Systematic review and meta-analysis of minimally invasive versus open approach for pancreaticoduodenectomy

Backgrounds and objective

The technique of minimally invasive pancreatic surgeries has evolved rapidly, including minimally invasive pancreaticoduodenectomy (MIPD). However, controversy on safety and feasibility remains when comparing the MIPD with the open pancreaticoduodenectomy (OPD); therefore, we aimed to compare MIPD and OPD with a systemic review and meta-analysis.

Methods

Multiple electronic databases were systematically searched to identify studies (up to February 2016) comparing MIPD with OPD. Intra-operative outcomes, oncologic data, postoperative complications and postoperative recovery were evaluated.

Results

Twenty-two retrospective studies including 6120 patients (1018 MIPDs and 5102 OPDs) were included. MIPD was associated with a reduction in estimated blood loss (WMD ?312.00 ml, 95 % CI ?436.30 to ?187.70 ml, p < 0.001), transfusion rate (OR 0.41, 95 % CI 0.30–0.55, p < 0.001), wound infection (OR 0.37, 95 % CI 0.20–0.66, p < 0.001) and length of hospital stay (WMD ?3.57 days, 95 % CI ?5.17 to ?1.98 days, p < 0.001). Meanwhile, MIPD group has a higher R0 resection rate (OR 1.47, 95 % CI 1.18–1.82, p < 0.001) and more lymph nodes harvest (WMD 1.74, 95 % CI 1.03–2.45, p < 0.001). However, it had longer operation time (WMD 83.91 min, 95 % CI 36.60–131.21 min, p < 0.001). There were no significant differences between the two procedures in morbidities (p = 0.86), postoperative pancreatic fistula (p = 0.17), delayed gastric empting (p = 0.65), vascular resection (p = 0.68), reoperation (p = 0.33) and mortality (p = 0.90).

Conclusions

MIPD can be a reasonable alternative to OPD with potential advantages. However, further large-volume, well-designed RCTs with extensive follow-ups are suggested to confirm and update the findings of our analysis.

     

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.     

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.     

Effect of epidural analgesia in patients with traumatic rib fractures: a systematic review and meta-analysis of randomized controlled trials

Purpose

A consensus group recently proposed epidural analgesia as the optimal analgesic modality for patients with multiple traumatic rib fractures. However, its beneficial effects are not consistently recognized in the literature. We performed a systematic review and a meta-analysis of randomized controlled trials (RCT) of epidural analgesia in adult patients with traumatic rib fractures.

Methods

A systematic search strategy was applied to MEDLINE, EMBASE, the Cochrane Library and to the annual meeting of relevant societies (up to July 2008). All randomized controlled trials comparing epidural analgesia with other analgesic modalities in adult patients with traumatic rib fractures were included. Primary outcomes were mortality, ICU length of stay (LOS), hospital LOS and duration of mechanical ventilation.

Results

Eight studies (232 patients) met eligibility criteria. Epidural analgesia did not significantly affect mortality (odds ratio [OR] 1.6, 95% CI, 0.3, 9.3, 3 studies, n = 89), ICU LOS (weighted mean difference [WMD] ?3.7 days, 95% CI, ?11.4, 4.0, 4 studies, n = 135), hospital LOS (WMD ?6.7, 95% CI, ?19.8, 6.4, 4 studies, n = 140) or duration of mechanical ventilation (WMD ?7.5, 95% CI, ?16.3, 1.2, 3 studies, n = 101). Duration of mechanical ventilation was decreased when only studies using thoracic epidural analgesia with local anesthetics were evaluated (WMD ?4.2, 95% CI, ?5.5, ?2.9, 2 studies, n = 73). However, hypotension was significantly associated with the use of thoracic epidural analgesia with local anesthetics (OR 13.76, 95% CI, 2.89, 65.51, 3 studies, n = 99).

Conclusions

No significant benefit of epidural analgesia on mortality, ICU and hospital LOS was observed compared to other analgesic modalities in adult patients with traumatic rib fractures. However, there may be a benefit on the duration of mechanical ventilation with the use of thoracic epidural analgesia with local anesthetics. Further research is required to evaluate the benefits and harms of epidural analgesia in this population before being considered as a standard of care therapy.     

Is Perineural Invasion More Accurate Than Other Factors to Predict Early Recurrence after Pancreatoduodenectomy for Pancreatic Head Adenocarcinoma?

Background

Some patients operated by pancreaticoduodenectomy for resectable pancreatic head adenocarcinoma will present with a recurrence during the first year (early recurrence).

Objective

The aim of this study was to determine prognostic factors associated with early recurrence in a large retrospective study.

Methods

From January 1995 to November 2010, all patients operated by pancreaticoduodenectomy for pancreatic head adenocarcinoma in our institution were retrospectively included. Univariate and multivariate analyses were performed to determine factors associated with early recurrence.

Results

A total of 166 patients were included; 57 patients (34 %) developed early recurrence. In univariate analysis, factors associated with early recurrence were perineural invasion (p = 0.0002), preoperative bilirubin (p = 0.01), lymph node ratio (LNR) ≥0.2 (p = 0.009), and T stage (p = 0.02). In multivariate analysis, perineural invasion (odds ratio [OR] 3.31; 95 % confidence interval [CI] 1.42–7.72; p = 0.005), LNR ≥0.2 (OR 2.55; 95 % CI 1.17–5.52; p = 0.02), and preoperative bilirubin (OR 1.04; 95 % CI 1.01–1.07; p = 0.03) were independent factors associated with early recurrence. Perineural invasion was also associated with poor overall survival (p = 0.001) and poor disease-free survival (p = 0.07).

Conclusion

In our study, perineural invasion (OR 3.31) is more accurate than T stage and lymph node status (OR 2.55) to predict early recurrence after pancreatoduodenectomy for pancreatic head adenocarcinoma.     

Identifying causes for high readmission rates after stoma reversal

Background

Unplanned readmissions after colorectal surgery impact patient and financial outcomes. Our goal was to identify factors related to readmission in ostomy reversal patients.

Methods

Review of a prospective department database was performed from 2006 to 2012 to identify patients who underwent an ostomy reversal. Patients were stratified into nonreadmitted and readmitted within 30 days of ostomy reversal. The main outcome measures were predictors of readmission and characteristics of patients readmitted and not readmitted.

Results

A total of 351 ostomy reversals (86 % ileostomy and 14 % colostomy) were analyzed; 44 patients were readmitted (12.5 %). Readmitted and nonreadmitted patients were similar in age, body mass index, gender, comorbidities, indications for the index operation, and time to ostomy reversal. Readmitted patients had longer operative times (p = 0.002) and length of stay (p = 0.001), more intraoperative blood loss (p = 0.003), intraoperative complications (p = 0.005), ICU requirements (p < 0.0001), need for temporary nursing at discharge (p < 0.001), and higher total hospital costs than nonreadmitted patients (p = 0.0162). Longer operative time [odds ratio (OR) 1.006, 95 % confidence interval (CI) 1.001–1.012], intraoperative complications (OR 7.334, 95 % CI 1.23–43.761), ICU stay (OR 1.291, 95 % CI 1.18–1.893), delayed discharge (OR 1.085, 95 % CI 1.003–1.173), and discharge to skilled nursing facility (OR 6.936, 95 % CI 1.531–31.332) were independent predictors of readmission. Ostomy type had no independent effect on readmission.

Conclusions

Differences in perioperative and outcomes variables exist between readmitted and nonreadmitted patients after ostomy reversal. Longer operative times, intraoperative complications, intensive care unit care, longer length of stay, and skilled nursing at discharge were independently predictive of readmission. These findings can be used to identify high-risk patients prospectively, potentially improving clinical outcomes and healthcare utilization.     

A systematic review and meta-analysis evaluating the role of laparoscopic surgical resection of transverse colon tumours

Objectives

A meta-analysis of published literature comparing outcomes after laparoscopic resection (LR) with open resection (OR) for transverse colon tumours.

Methods

Medline, PubMed, CINAHL, EMBASE and Cochrane were searched from inception to October 2013. The text words “minimally invasive”, “keyhole surgery” and “transverse colon” were used in combination with the medical subject headings “laparoscopy” and “colon cancer”. Outcome variables were chosen based upon whether the included articles reported results. A meta-analysis was performed to obtain a summative outcome.

Results

Six comparatives involving 444 patients were analysed. Of them 245 patients were in the LR group and 199 in the OR group. There was a significant increase in operative time in the LR group compared with the OR group [random effects model: SMD = ?0.65, 95 % CI (?1.01, ?0.30), z = ?3.60, p < 0.001] but there was significant heterogeneity amongst trials (Q = 15.51, df = 5, p = 0.008, I ² = 68). There was less blood loss in the LR group [fixed effects model: SMD = 0.70, 95 % CI (0.47, 0.93), z = 6.01, p < 0.001] and patients returned to oral diet earlier [random effects model: SMD = 0.78, 95 % CI (0.40, 1.16), z = 4.01, p < 0.001] and had a reduced time to functioning bowel [fixed effects model: SMD = 0.86, 95 % CI (0.60, 1.11), z = 6.63, p < 0.001]. No difference was seen for overall morbidity (p = 0.76) or mortality (p = 0.58).

Conclusions

LR of transverse colon tumours is a safe and effective technique. Although there is an increase in operating time, operative and clinical outcomes of intraoperative blood loss and faster recovery are seen with laparoscopic procedures.     

Impact of Routine Cavity Shave Margins on Breast Cancer Re-excision Rates

Purpose

Breast-conserving therapy (BCT) is an accepted method of treating early breast cancer. We hypothesized that routine excision of additional cavity shave margins (CSM) at time of initial partial mastectomy reduces the need for additional surgery.

Methods

A single-institution retrospective review was performed of women, 18 years or older, with a new diagnosis of breast cancer who underwent partial mastectomy between 1 January 2004 and 1 October 2009. Five hundred thirty-three charts were reviewed. Of those, 69 patients underwent CSM at time of initial operation. These 69 patients were matched with patients who had undergone partial mastectomy without CSM by tumor size, presence of extensive intraductal component, and primary histology.

Results

The two groups were well matched for age, nuclear grade, associated lymphovascular invasion (LVI), receptor status, and multifocality. We found that 31.9% (44/138) required return to the operating room (OR) for re-excision of margins. Rate of return to the OR was 21.7% (15/69) in the CSM group and 42.0% (29/69) in the matched group (p = 0.011). Multivariate analysis found factors significantly associated with need for additional operation included lack of CSM (odds ratio 9.2, 95% CI 2.8–30.5, p = 0.0003), larger extent of intraductal component (odds ratio 7.0, 95% CI 1.8–27.0, p = 0.005), and lack of directed re-excision (odds ratio 6.4, 95% CI 1.7–25.1, p = 0.007).

Conclusions

CSM at time of initial partial mastectomy decreases rate of re-excision by as much as ninefold. CSM should be considered at time of initial operation to reduce the need for subsequent reoperation.     

Predictors of Lower Extremity Amputation and Reamputation Associated With the Diabetic Foot

In the present study, we aimed to identify the comorbidities that would be predictive of requiring lower extremity amputation or reamputation for diabetic foot wounds. We performed a retrospective review of 132 consecutive patients who had undergone lower extremity amputations (110 patients) or reamputations (22 patients) for diabetic wounds from January 2013 to March 2016. We used multivariate logistic regression to calculate the odds ratios (ORs) for amputation and reamputation for various comorbidities. The ORs of undergoing amputation were greatest for adult males (OR 5.12, 95% confidence interval [CI] 1.56 to 13.04; p = .05) and those with longer term diabetes (OR 4.22, 95% CI 2.01 to 12.95; p = .05), wound infection (OR 3.94, 95% CI 1.04 to 9.00; p = .05), diabetic neuropathy (OR 3.53, 95% CI 1.07 to 9.11; p = .05), and a positive history of smoking (OR 3.04, 95% CI 1.55 to 9.89; p = .05). Similarly, the ORs of undergoing reamputation were greatest for adult males (OR 4.06, 95% CI 1.02 to 12.08; p = .05) and those with longer term diabetes (OR 3.67, 95% CI 1.94 to 11.42; p = .05), wound infection (OR 3.12; 95% CI 0.9 to 8.32; p = .05), diabetic neuropathy (OR 3.01, 95% CI 0.92 to 8.54; p = .05), and a positive history of smoking (OR 2.89, 95% CI 1.09 to 9.42; p = .05). The early identification of these comorbidities could help determine which patients are most likely to require amputation or reamputation.     

A systematic review on the efficacy and safety of PA21 versus sevelamer in dialysis patients

Aim

To evaluate the efficacy and safety of PA21 versus sevelamer in dialysis patients.

Methods

We searched Medline, Embase, Science Citation Index, Cochrane Central Register of Controlled Trials, and Clinical Trial Registries for randomized controlled trials comparing PA21 and sevelamer in dialysis patients.

Results

Four studies were included. Compared with sevelamer group, PA21 needed fewer mean daily number of tablets (WMD, ? 7.97 pill; 95% CI, ? 11.28 to ? 4.65, p < 0.00001), developed fewer all adverse events (RR = 1.05; 95% CI, 1.00 to 1.11, p = 0.05), and developed fewer gastrointestinal adverse events (RR = 1.32; 95% CI, 1.15 to 1.53, p = 0.0001). There was no significant difference in serum phosphorus between two groups (WMD, ? 0.07 mmol/L; 95% CI, ? 0.15 to 0.02, p = 0.12). As for serum calcium, there was also no significant difference between two groups (WMD, 0.27 mmol/L; 95% CI, ? 0.63 to 1.17, p = 0.55).

Conclusion

PA21 can effectively control serum phosphorus with lower pill burden and less side effects than sevelamer. PA21 might be another valuable choice for dialysis patients with hyperphosphatemia when patients are unable to tolerate sevelamer.

     

Does Preoperative Neutrophil Lymphocyte Ratio Predict Risk of Recurrence and Occult Central Nodal Metastasis in Papillary Thyroid Carcinoma?

Background

Preoperative neutrophil to lymphocyte ratio (NLR) might be prognostic in papillary thyroid carcinoma (PTC). Given the controversy of prophylactic central neck dissection (pCND) in clinically nodal-negative (cN0) PTC, our study evaluated whether preoperative NLR predicted disease-free survival (DFS) and occult central nodal metastasis (CNM) in cN0 PTC.

Methods

A total of 191 patients who underwent pCND were analyzed. Complete blood counts with differential counts were taken before operation. NLR was calculated by dividing preoperative neutrophil count with lymphocyte count. Patients were categorized into NLR tertiles: first (NLR < 1.93; n = 63), second (NLR = 1.93–2.79; n = 64), and third tertile (NLR > 2.79; n = 64). Four other patient types, namely, benign nodular goiter, clinically nodal-positive (cN1) PTC, poorly differentiated thyroid carcinoma, and anaplastic thyroid carcinoma (ATC), were used as references.

Results

Age at operation (p < 0.001) and tumor size (p = 0.037) significantly increased with higher NLR. First tertile had significantly more TNM stage I tumors (p = 0.01) and lowest MACIS score (p = 0.002). Tumor size [hazard ratio (HR) 1.422, 95% confidence interval (CI) 1.119–1.809, p = 0.004] and multicentricity (HR = 2.545, 95% CI 1.073–6.024, p = 0.034) independently predicted DFS, whereas old age [odds ratio (OR) 1.026, 95% CI 1.006–1.046, p = 0.009), male (OR 2.882, 95% CI 1.348–6.172, p = 0.006), and large tumor (OR 1.567, 95% CI 1.209–2.032, p = 0.001) independently predicted occult CNM. NLR was not significantly associated with DFS or occult CNM. ATC had significantly higher NLR than cN1 PTC (7.28 vs. 2.74, p < 0.001).

Conclusions

Although a higher NLR may imply a poorer tumor profile, it was not significantly associated with a worse DFS or higher risk of occult CNM in cN0 PTC. Perhaps, future research should focus on the prognostic value in other thyroid cancer types with a poorer prognosis.     

Sentinel Node Location in Trunk and Extremity Melanomas: Uncommon or Multiple Lymph Drainage Does Not Affect Survival

Background

Patients with cutaneous melanoma (CM) on the trunk have a worse prognosis than those with extremity CM. One reason could be multiple or uncommon (outside axilla or groin) sentinel node locations (SNLs).

Methods

We identified 859 patients who underwent sentinel node biopsy for trunk (n = 465) or extremity (n = 394) CM in three Swedish healthcare regions from 2000 to 2008. We collected patient, tumor, and sentinel node characteristics through clinical registers and medical records. We investigated the distribution of SNLs in a logistic regression model, and risk of overall and melanoma-specific death through 2011 in a multivariable Cox regression model.

Results

Trunk CM was associated with multiple SNLs (31 vs. 7 %; odds ratio [OR] 7.1; 95 % confidence interval [CI] 4.6–11.5; p < 0.001) but not uncommon SNLs (8 vs. 7 %; OR 1.1; 95 % CI 0.6–1.9; p = 0.75) compared with extremity CM. The increased risk of melanoma-specific death was confirmed for trunk CM (hazard ratio [HR] 1.9; 95 % CI 1.3–2.9; p = 0.003), especially on the upper back (HR 2.3; 95 % CI 1.4–3.6; p < 0.001) compared with extremity CM. Uncommon SNLs (HR 0.5; 95 % CI 0.2–1.4; p = 0.21) or multiple SNLs (HR 1.1; 95 % CI 0.4–2.9; p = 0.81) were not associated with melanoma-specific death compared with those with common/single SNL.

Conclusions

Trunk melanomas were associated with multiple lymph drainage, but the worse prognosis of trunk melanomas could not be explained by the increased frequency of multiple or uncommon SNLs.     

The effect of low concentrations versus high concentrations of local anesthetics for labour analgesia on obstetric and anesthetic outcomes: a meta-analysis

Introduction

The influence that different concentrations of labour epidural local anesthetic have on assisted vaginal delivery (AVD) and many obstetric outcomes and side effects is uncertain. The purpose of this meta-analysis was to determine whether local anesthetics utilized at low concentrations (LCs) during labour are associated with a decreased incidence of AVD when compared with high concentrations (HCs).

Methods

We searched PubMed, Ovid EMBASE, Ovid MEDLINE, CINAHL, Scopus, clinicaltrials.gov, and Cochrane databases for randomized controlled trials of labouring patients that compared LCs (defined as ≤ 0.1% epidural bupivacaine or ≤ 0.17% ropivacaine) of epidural local anesthetic with HCs for maintenance of analgesia. The primary outcome was AVD and secondary outcomes included Cesarean delivery, duration of labour, analgesia, side effects (nausea and vomiting, motor block, hypotension, pruritus, and urinary retention), and neonatal outcomes. The odds ratios (OR) or weighted mean differences (WMD) and 95% confidence intervals (CI) were calculated using random effects modelling. An OR < 1 or a WMD < 0 favoured LCs.

Results

Eleven studies met our criteria (eight bupivacaine and three ropivacaine studies), providing 1,145 patients in the LCs group and 852 patients in the HCs group for analysis of the primary outcome. Low concentrations were associated with a reduction in the incidence of AVD (OR = 0.70; 95% CI 0.56 to 0.86; P < 0.001). There was no difference in the incidence of Cesarean delivery (OR 1.05; 95% CI 0.82 to 1.33; P = 0.7). The LCs group had less motor block (OR 3.9; 95% CI 1.59 to 9.55; P = 0.003), greater ambulation (OR 2.8; 95% CI 1.1 to 7.14; P = 0.03), less urinary retention (OR 0.42; 95% CI 0.23 to 0.73; P = 0.002), and a shorter second stage of labour (WMD ?14.03; 95% CI ?27.52 to ?0.55; P = 0.04) compared with the HCs group. There were no differences between groups in pain scores, maternal nausea and vomiting, hypotension, fetal heart rate abnormalities, five-minute Apgar scores, and need for neonatal resuscitation. One-minute Apgar scores < 7 favoured the HCs group (OR 1.53; 95% CI 1.07 to 2.21; P = 0.02), and there was more pruritus in the LCs group (OR 3.36; 95% CI 1.00 to 11.31; P = 0.05).

Conclusion

When compared with HCs of local anesthetics, the use of LCs for labour epidural analgesia reduces the incidence of AVD. This may be due to a reduction in the amount of local anesthetic used and the subsequent decrease in motor blockade. We therefore recommend the use of LCs of local anesthetics for epidural analgesia to optimize obstetric outcome.     

Off-pump versus on-pump coronary surgery in patients with chronic kidney disease: a meta-analysis

Background

Patients with chronic kidney disease (CKD) have worse adverse cardiovascular outcomes after coronary artery bypass grafting (CABG). However, the adverse cardiovascular outcomes between off-pump coronary artery bypass grafting (OPCAB) versus on-pump coronary artery bypass grafting (ONCAB) in these patients have been a subject of debate.

Methods

We undertook a comprehensive literature search of PubMed, Embase, and the Cochrane Library database to identify all relevant studies comparing techniques between OPCAB and ONCAB in CKD patients. We pooled the odds ratios (ORs) and hazard ratios (HRs) from individual studies and conducted heterogeneity, quality assessment, and publication bias analyses.

Results

This meta-analysis includes 17 studies with 201,889 patients. In CKD patients, OPCAB was associated with significantly lower early mortality as compared to ONCAB (OR 0.88; 95% CI 0.82–0.93; p < 0.0001). OPCAB was associated with decreased risk of atrial fibrillation (OR 0.57; 95% CI 0.34–0.97; p = 0.04), cerebrovascular accident (OR 0.46; 95% CI 0.22–0.95; p = 0.04), blood transfusion (OR 0.20; 95% CI 0.08–0.49; p = 0.0005), pneumonia, prolonged ventilation, and shorter hospital stays. No difference was found regarding long-term survival (HR 1.08; 95% CI 0.86–1.36; p = 0.51) or myocardial infarction (OR 0.65; 95% CI 0.30–1.38; p = 0.26).

Conclusions

Compared with ONCAB, OPCAB is associated with superior postoperative morbidity and the early mortality in CKD patients. Long-term survival is comparable between the two surgical revascularizations.

     

Clinical Outcomes of Open Versus Arthroscopic Broström Procedure for Lateral Ankle Instability: A Meta-analysis

Arthroscopic repair of the anterior talofibular ligament is becoming increasingly popular as a surgical option for lateral ankle instability. However, studies directly comparing outcomes of open and arthroscopic anterior talofibular ligament repair continue to present conflicting conclusions. This review aims to compare the clinical outcomes of arthroscopic and open Broström procedure. A systematic literature review was performed using MEDLINE, Cochrane Library, and EMBASE from January 2010 to March 2020 to identify all clinical studies (level of evidence I-III) comparing outcomes of arthroscopic versus open Broström procedure for chronic lateral ankle instability. Six studies were included in this review. The arthroscopic technique, compared to the open technique, resulted in higher American Orthopaedic Foot and Ankle Society scores (weighted mean difference [WMD] = 1.20, 95% confidence interval [CI]: 0.05-2.34, p= .04), higher Karlsson scores (WMD = 1.86, 95% CI: 0.46-3.25, p= .009) and lower Visual Analog Scale pain scores (WMD = ?0.31, 95% CI: ?0.51 to ?0.10, p= .003). There were no differences between the groups in terms of postoperative anterior drawer test (WMD = ?0.10, 95% CI: ?0.60 to 0.39, p= .68), talar tilt (WMD = 0.31, 95% CI: ?0.10 to 0.72, p= .14) or overall complication rates (odds ratio [OR] = 0.78, 95% CI: 0.37-1.64, p= .51). The odds of wound-related complications in arthroscopic Broström procedures was significantly lower than that of open Broström procedures (OR = 0.25, 95% CI: 0.07-0.95, p= .04). Current evidence shows that arthroscopic repairs offer comparable clinical outcomes with a lower wound complication rate, compared to traditional open repairs.     

Outcome of laparoscopic cholecystectomy conversion: is the surgeon’s selection needed?

Background

Risk factors for conversion in cholecystectomy may be of clinical value. This study aimed to investigate whether a set of risk factors, including the surgeon’s specialization, can be used for the development of a preoperative strategy to optimize conversion outcome.

Methods

The data for all patients who underwent laparoscopic cholecystectomy at a single institution between January 2004 and December 2008 were retrospectively reviewed. Factors predictive for conversion were identified, and a preoperative strategy model was deduced.

Results

Of the 1,126 patients analyzed, 106 (9%) underwent laparoscopic cholecystectomy in an emergency setting. Delayed surgery was performed for 63 (46%) of 138 patients (12%) with acute cholecystitis. Preoperative endoscopic retrograde cholangiography was achieved for 161 of the patients (14%). Risk factors predictive of conversion (for 65 patients) were male gender [odds ratio (OR), 2.3; 95% confidence interval (CI), 1.3–3.9; p = 0.004], age older than 65 years (OR, 2.6; 95% CI, 1.4–4.8; p = 0.002), body mass index (BMI) exceeding 25 kg/m² (OR, 3.4; 95% CI, 1.7–7.1; p < 0.001), history of complicated biliary disease (HCBD) (OR, 5.6; 95% CI, 3.2–9.8; p = < 0.001), and surgery by a non-gastrointestinal (non-GI) surgeon (OR, 4.9; 95% CI, 2.2–10.6; p < 0.001). The conversion rate for patients with a history of no complications who had two or more risk factors (gender, age, BMI > 25) and for patients with a HCBD who had one or more risk factors was significantly higher if the surgery was performed by non-GI rather than GI surgeons.

Conclusion

Male gender, age older than 65 years, BMI exceeding 25 kg/m², HCBD, and surgery by a non-GI surgeon are predictive for conversion. A preoperative triage for surgeon selection based on risk factors and a HCBD is proposed to optimize conversion outcome.     

A Systematic Review and Meta-analysis Comparing Pancreaticoduodenectomy Versus Limited Resection for Duodenal Gastrointestinal Stromal Tumors

Purpose

This study was designed to compare the clinical outcomes of patients who underwent limited resection (LR) versus pancreaticoduodenectomy (PD) for duodenal gastrointestinal stromal tumors (GISTs).

Methods

A systematic review of the literature was performed to identify studies analyzing the clinical outcomes of LR and PD for duodenal GISTs.

Results

Eleven studies were included, of which 7 that compared 162 patients who underwent LR versus 98 patients who underwent PD were suitable for meta-analysis. Patients who underwent PD were more likely to have tumors which were large (≥ 5 cm) [76.0 vs. 36.6 %, odds ratio (OR) 5.49, 95 % confidence interval (CI) 1.8–16.76], with high mitotic count ≥5/50 high-power field (HPF) (33.7 vs. 18.5 %, OR 2.23, 95 % CI 1.22–4.08), classified as high risk (60.3 vs. 32.0 %, OR 3.23, 95 % CI 1.65–6.34), and which were located at D2 (80.5 vs. 28.6 %, OR 10.33, 95 % CI 5.22–20.47) compared with LR. PD was associated with a higher postoperative morbidity rate than LR [48.3 vs. 20.7 %, relative risk (RR) 2.34, 95 % CI 1.61–3.42]. LR was not associated with an increased local recurrence rate, had a better DFS [hazard ratio (HR) 2.07, 95 % CI 1.07–4.01], and lower rate of distant metastasis (8.9 vs. 25.8 %, OR 0.28, 95 % CI 0.13–0.59) compared with PD.

Conclusions

LR should be the procedure of choice for duodenal GIST whenever technically feasible, because it is associated with good oncologic outcomes and lower morbidity compared with PD. The oncologic outcome of GIST is more likely to be dependent on tumor biology rather that the type of surgical resection. The use of Imatinib in patients with duodenal GIST may potentially allow a proportion of patients who would otherwise require a PD to undergo LR instead.     

A systematic review of robotic-assisted liver resection and meta-analysis of robotic versus laparoscopic hepatectomy for hepatic neoplasms

Background

Robotic-assisted liver resection (RALR) was introduced as procedures of overcoming the limitations of traditional laparoscopic liver resection (LLR). The aim of this review was to evaluate the surgical results of RALR from all published studies and the results of comparative studies of RALR versus LLR for hepatic neoplasm.

Methods

Eligible studies involved RALR that published between January 2001 and December 2014 were reviewed systematically. Comparisons between RALS and LLR were pooled and analyzed by meta-analytical techniques using random- or fixed-effects models, as appropriate.

Results

In total, 29 studies, involving 537 patients undergoing RALR, were identified. The most common RALR procedure was a wedge resection and segmentectomy (28.67 %), followed by right hepatectomy (17.88 %), left lateral sectionectomy (13.22 %), and bisegmentectomy (9.12 %). The conversion and complication rates were 5.59 and 11.36 %, respectively. The most common reasons for conversion were bleeding (46.67 %) and unclear tumor margin (33.33 %). Intracavitary fluid collections and bile leaks (40.98 %) were the most frequently occurring morbidities. Nine studies, involving 774 patients, were included in meta-analysis. RALR had a longer operative time compared with LLR [mean difference (MD) 48.49; 95 % confidence interval (CI) 22.49–74.49 min; p = 0.0003]. There were no significant differences between the two groups in blood loss [MD 31.53; 95 % CI ?14.74 to 77.79 mL; p = 0.18], hospital stay [MD 0.13; 95 % CI ?0.54 to 0.80 days; p = 0.18], postoperative overall morbidity [odds ratio (OR) 0.76; 95 % CI 0.49–1.19; p = 0.23], and surgical margin status (OR 0.61; 95 % CI 0.33–1.12; p = 0.11); cost was greater than robotic surgery (p = 0.001).

Conclusion

RALR and LLR display similar safety, feasibility, and effectiveness for hepatectomies, but further studies are needed before any final conclusion can be drawn, especially in terms of oncologic and cost-effectiveness outcomes.

     

Deprivation and Colorectal Cancer Surgery: Longer-Term Survival Inequalities are Due to Differential Postoperative Mortality Between Socioeconomic Groups

Background

Deprivation is associated with poorer survival after surgery for colorectal cancer, but determinants of this socioeconomic inequality are poorly understood.

Methods

A total of 4,296 patients undergoing surgery for colorectal cancer in 16 hospitals in the West of Scotland between 2001 and 2004 were identified from a prospectively maintained regional audit database. Postoperative mortality (<30 days) and 5-year relative survival by socioeconomic circumstances, measured by the area-based Scottish Index of Multiple Deprivation 2006, were examined.

Results

There was no difference in age, gender, or tumor characteristics between socioeconomic groups. Compared with the most affluent group, patients from the most deprived group were more likely to present as an emergency (23.5 vs 19.5 %; p = .033), undergo palliative surgery (20.0 vs 14.5 %; p < .001), have higher levels of comorbidity (p = .03), have <12 lymph nodes examined (56.7 vs 53.1 %; p = .016) but were more likely to receive surgery under the care of a specialist surgeon (76.3 vs 72.0 %; p = .001). In multivariate analysis, deprivation was independently associated with increased postoperative mortality [adjusted odds ratio 2.26 (95 % CI, 1.45–3.53; p < .001)], and poorer 5-year relative survival [adjusted relative excess risk (RER) 1.25 (95 % CI, 1.03–1.51; p = .024)] but not after exclusion of postoperative deaths [adjusted RER 1.08 (95 %, CI .87–1.34; p = .472)].

Conclusions

The observed socioeconomic gradient in long-term survival after surgery for colorectal cancer was due to higher early postoperative mortality among more deprived groups.     

Predictors for underestimated pathology in forceps biopsy compared with resection specimen of colorectal neoplasia; focus on surface appearance

Background

There have been substantial differences in pathologic results between forceps biopsies (FB) and resection specimen (RS) of the colorectal neoplasm. The aim of this study was to investigate predictive factors of the underestimated pathology in FB compared with RS.

Methods

Data from 248 consecutive patients with colorectal intraepithelial neoplasm ≥10 mm, which was removed by endoscopic mucosal resection or endoscopic submucosal dissection, were reviewed retrospectively. We excluded patients with no FB on the neoplasm before the resection. Demographic data and tumor characteristics including size, locations, surface appearances, and the number of FB fragments were evaluated as potential factors associated with the discrepancies by logistic regression analysis.

Results

Overall, 179 lesions from 171 patients were included in the study (size, 28.37 ± 12.00 mm; range 10–80 mm). The overall number of discrepancy cases was 103 (57.5 %), where 90 (50.3 %) were underestimated in FB and 13 (7.2 %) downgraded in their RS. In the multivariate analysis, round [odds ratio (OR) 4.46, 95 % confidence interval (CI) 1.76–11.30, p = 0.002], depressed (OR 3.23, 95 % CI 1.11–9.39, p = 0.031), and mixed type of surface appearance (OR 5.47, 95 % CI 2.38–12.60, p < 0.001), and tumor size ≥30 mm (OR 2.14, 95 % CI 1.12–4.10, p = 0.021) were significant predictive factors for underestimated pathology in FB.

Conclusions

Underestimation in FB is remarkable in colorectal tumors ≥10 mm in size. This discrepancy is associated with the tumor characteristics, such as surface appearance and size. Endoscopic characteristics of tumor should be carefully examined for an adequate management strategy of colorectal epithelial neoplasm.