Blumgart anastomosis for pancreaticojejunostomy minimizes severe complications after pancreatic head resection

Background:

Leakage from the pancreaticojejunostomy is the major cause of septic complications after partial pancreaticoduodenectomy. This study evaluated a new transpancreatic ‐suture technique (Blumgart anastomosis, BA), which aims to avoid shear forces during knot‐tying.

Methods:

Using a before–after study design, BA was compared with a modified Cattell–Warren anastomosis (CWA). Two patient cohorts (CWA, 90; BA, 92), which were similar with respect to primary diagnosis, age, sex and American Society of Anesthesiologists score, were compared retrospectively. Dependent variables were surgical and overall morbidity and mortality after partial pancreaticoduodenectomy.

Results:

Duration of operation (354 versus 328 min for CWA versus BA; P = 0·002), pancreatic leakage rate (13 versus 4 per cent; P = 0·032), postoperative haemorrhage (11 versus 3 per cent; P = 0·040), total surgical complications (31 versus 15 per cent; P = 0·011), general complications (36 versus 17 per cent; P = 0·005) and length of intensive care unit stay (median 5·4 versus 2·8 days; P = 0·015) were significantly reduced after BA. These effects were not related merely to an improvement over time.

Conclusion:

BA appears to be a fast, simple and safe technique for pancreaticojejunostomy. It might reduce leakage rates and surgical complications after partial pancreaticoduodenectomy. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Impact of postoperative morbidity on long‐term survival after oesophagectomy

Background:

Oesophageal malignancy is a disease with a poor prognosis. Oesophagectomy is the mainstay of curative treatment but associated with substantial morbidity and mortality. Although mortality rates have improved, the incidence of perioperative morbidity remains high. This study assessed the impact of postoperative morbidity on long‐term outcomes.

Methods:

A prospective database was designed for patients undergoing oesophagectomy for malignancy from 1998 to 2011. An observational cohort study was performed with these data, assessing intraoperative technical complications, postoperative morbidity and effects on overall survival.

Results:

Some 618 patients were included, with a median follow‐up of 51 months for survivors. The overall complication rate was 64·6 per cent (399 of 618), with technical complications in 124 patients (20·1 per cent) and medical complications in 339 (54·9 per cent). Technical complications were associated with longer duration of surgery (308 min versus 293 min in those with no technical complications; P = 0·017), greater operative blood loss (448 versus 389 ml respectively; P = 0·035) and longer length of stay (22 versus 13 days; P < 0·001). Medical complications were associated with greater intraoperative blood loss (418 ml versus 380 ml in those with no medical complications; P = 0·013) and greater length of stay (16 versus 12 days respectively; P < 0·001). Median overall and disease‐free survival were 41 and 43 months. After controlling for age, tumour stage, resection margin, length of tumour, adjuvant therapy, procedure type and co‐morbidities, there was no effect of postoperative complications on disease‐specific survival.

Conclusion:

Technical and medical complications following oesophagectomy were associated with greater intraoperative blood loss and a longer duration of inpatient stay, but did not predict disease‐specific survival. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Randomized clinical trial of duct‐to‐mucosa versus invagination pancreaticojejunostomy after pancreatoduodenectomy

Background

The postoperative pancreatic fistula (POPF) rate for duct‐to‐mucosa and invagination anastomosis after pancreatoduodenectomy is still debated. The aim of this RCT was to investigate the POPF rate for duct‐to‐mucosa versus invagination pancreaticojejunostomy.

Methods

Patients were stratified by pancreatic texture and diameter of the main pancreatic duct and randomized to the duct‐to‐mucosa or invagination group. The primary endpoint was the rate of clinically relevant POPF (defined as grade B or C). Secondary endpoints were suture material cost for pancreaticojejunostomy, drain insertion duration and duration of postoperative hospital stay.

Results

Some 120 patients undergoing pancreatoduodenectomy were included following consent. Clinically relevant POPF developed in six of 59 patients (10 per cent) in the invagination group and in 14 of 61 patients (23 per cent) in the duct‐to‐mucosa group (P = 0·077). Duration of drain insertion (6 versus 7 days respectively; P = 0·027) and postoperative hospital stay (19 versus 24 days; P = 0·015) were shorter in the invagination group. Subgroup analysis for 61 patients with a soft pancreas revealed a lower rate of clinically relevant POPF in the invagination group (10 per cent versus 42 per cent in the duct‐to‐mucosa group; P = 0·010). Among 20 patients with a clinically relevant POPF, the six patients in the invagination group had a shorter duration of drain insertion (38·5 days versus 49 days for 14 patients in the duct‐to‐mucosa group; P = 0·028) and postoperative hospital stay (42 versus 54·5 days respectively; P = 0·028).

Conclusion

This study did not demonstrate a superiority of invagination over duct‐to‐mucosa pancreaticojejunostomy in the risk of POPF. However, in high‐risk patients with a soft pancreas, invagination may reduce the risk of clinically relevant POPF compared with duct‐to‐mucosa. Registration number: UMIN000005890 ( http://www.umin.ac.jp ).     

Changing trends in surgery for acute appendicitis

Background:

Laparoscopic appendicectomy (LA) offers faster recovery times and a reduced rate of wound infection compared with open appendicectomy (OA) but may be associated with more intra‐abdominal abscesses. This study examines the changing trends in management of appendicitis in a regional setting during service reorganization and compares infective complication rates for each procedure.

Methods:

Data were retrieved from the Lothian Surgical Audit database on 1824 patients treated for appendicitis by OA or LA during equal 31‐month periods before and after service reorganization in August 2002. Outcome measures were duration of admission, recovery time from operation to discharge and reintervention for infective complications. Analysis was by intention to treat.

Results:

The rate of LA in Lothian increased from 29·9 to 39·4 per cent (P < 0·001) after subspecialist service reorganization. Recovery time from operation to discharge was significantly shorter after LA than OA when results were stratified with respect to sex (mean 2·5 versus 4·4 days respectively in women, P < 0·001; 2·7 and 3·1 days in men, P = 0·023), timing of surgery (2·7 versus 3·3 days before subspecialization, P = 0·007; 2·5 versus 3·6 days after subspecialization, P < 0·001) and whether appendicitis was associated with peritoneal contamination (2·2 versus 3·0 days for uncontaminated surgery, P < 0·001; 4·3 versus 5·1 days for contaminated surgery, P = 0·060). Peritoneal contamination at primary operation was the only independent risk factor that predicted reintervention for infective complications.

Conclusion:

LA is associated with a shorter hospital stay from operation to discharge than OA, with no evidence of an increased rate of intra‐abdominal infective complications. Copyright © 2007 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Effectiveness of a written clinical pathway for enhanced recovery after transthoracic (Ivor Lewis) oesophagectomy

Background:

This study assessed the feasibility of a protocol‐driven written clinical pathway for multidisciplinary postoperative management after oesophagectomy for oesophageal neoplasia, and examined whether the application of such a protocol could shorten hospital stay and reduce postoperative morbidity and mortality.

Methods:

Consecutive patients undergoing transthoracic oesophagectomy for oesophageal neoplasia were divided into those treated between 2003 and 2008 to whom a clinical pathway was applied for postoperative management (group 1), and a control group treated between 1998 and 2002 when no clinical pathway was applied (group 2).

Results:

There were 74 patients in each group. Morbidity rates were similar in the two groups: 31 per cent in group 1 and 38 per cent in group 2. There were more pulmonary complications in group 2 (23 versus 14 per cent; P = 0·025). One patient (1 per cent) in group 1 and four (5 per cent) in group 2 died after surgery (P = 0·010). The median (range) length of hospital stay was 9 (5–98) days for group 1 and 13 (8–106) days in group 2 (P = 0·012).

Conclusion:

Use of a written clinical pathway in patients undergoing oesophageal resection significantly reduced pulmonary complications, postoperative mortality and hospital stay. Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Two‐year results of the randomized clinical trial DILALA comparing laparoscopic lavage with resection as treatment for perforated diverticulitis

Background

Traditionally, perforated diverticulitis with purulent peritonitis was treated with resection and colostomy (Hartmann's procedure), with inherent complications and risk of a permanent stoma. The DILALA (DIverticulitis – LAparoscopic LAvage versus resection (Hartmann's procedure) for acute diverticulitis with peritonitis) and other randomized trials found laparoscopic lavage to be a feasible and safe alternative. The medium‐term follow‐up results of DILALA are reported here.

Methods

Patients were randomized during surgery after being diagnosed with Hinchey grade III perforated diverticulitis at diagnostic laparoscopy. The primary outcome was the proportion of patients with one or more secondary operations from 0 to 24 months after the index procedure in the laparoscopic lavage versus Hartmann's procedure groups. The trial was registered as ISRCTN82208287.

Results

Forty‐three patients were randomized to laparoscopic lavage and 40 to Hartmann's procedure. Patients in the lavage group had a 45 per cent reduced risk of undergoing one or more operations within 24 months (relative risk 0·55, 95 per cent c.i. 0·36 to 0·84; P = 0·012) and had fewer operations (ratio 0·51, 95 per cent c.i. 0·31 to 0·87; P = 0·024) compared with those in the Hartmann's group. No difference was found in mean number of readmissions (1·37 versus 1·50; P = 0·221) or mortality between patients randomized to laparoscopic lavage or Hartmann's procedure. Three patients in the lavage group and nine in the Hartmann's group had a colostomy at 24 months.

Conclusion

Laparoscopic lavage is a better option for perforated diverticulitis with purulent peritonitis than open resection and colostomy.     

Recovery after ultrasound‐guided foam sclerotherapy compared with conventional surgery for varicose veins

Background:

The advantages of minimally invasive alternatives such as ultrasound‐guided foam sclerotherapy (UGFS) over conventional surgery for the treatment of varicose veins include lower morbidity and faster recovery times. The aim was to compare morbidity, analgesia use, and time to return to driving and work following UGFS with those reported after conventional surgery for varicose veins.

Methods:

Patients who had UGFS or surgery for varicose veins were sent a questionnaire 4 weeks after treatment.

Results:

A total of 332 (84·9 per cent) of 391 patients who had UGFS and 53 (56 per cent) of 94 who had surgery returned a questionnaire. The groups were similar in terms of age, sex, and the proportion who had treatment of bilateral or recurrent veins. Patients who had surgery were more likely to have significant bruising (44 versus 7·2 per cent; P < 0·001) and pain (17 versus 5·5 per cent; P = 0·001). After UGFS, 43·2 per cent of patients returned to work within 24 h compared with none who had surgery (P < 0·001). Patients who had UGFS were more likely to return to driving within 4 days (P = 0·014).

Conclusion:

UGFS was associated with less pain and analgesia requirement, time off work and quicker return to driving. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Meta‐analysis comparing upfront surgery with neoadjuvant treatment in patients with resectable or borderline resectable pancreatic cancer

Background

Studies comparing upfront surgery with neoadjuvant treatment in pancreatic cancer may report only patients who underwent resection and so survival will be skewed. The aim of this study was to report survival by intention to treat in a comparison of upfront surgery versus neoadjuvant treatment in resectable or borderline resectable pancreatic cancer.

Methods

MEDLINE, Embase and the Cochrane Library were searched for studies reporting median overall survival by intention to treat in patients with resectable or borderline resectable pancreatic cancer treated with or without neoadjuvant treatment. Secondary outcomes included overall and R0 resection rate, pathological lymph node rate, reasons for unresectability and toxicity of neoadjuvant treatment.

Results

In total, 38 studies were included with 3484 patients, of whom 1738 (49·9 per cent) had neoadjuvant treatment. The weighted median overall survival by intention to treat was 18·8 months for neoadjuvant treatment and 14·8 months for upfront surgery; the difference was larger among patients whose tumours were resected (26·1 versus 15·0 months respectively). The overall resection rate was lower with neoadjuvant treatment than with upfront surgery (66·0 versus 81·3 per cent; P < 0·001), but the R0 rate was higher (86·8 (95 per cent c.i. 84·6 to 88·7) versus 66·9 (64·2 to 69·6) per cent; P < 0·001). Reported by intention to treat, the R0 rates were 58·0 and 54·9 per cent respectively (P = 0·088). The pathological lymph node rate was 43·8 per cent after neoadjuvant therapy and 64·8 per cent in the upfront surgery group (P < 0·001). Toxicity of at least grade III was reported in up to 64 per cent of the patients.

Conclusion

Neoadjuvant treatment appears to improve overall survival by intention to treat, despite lower overall resection rates for resectable or borderline resectable pancreatic cancer. PROSPERO registration number: CRD42016049374.     

Surgical treatment of hepatocellular carcinoma associated with the metabolic syndrome

Background:

The incidence of metabolic syndrome‐associated hepatocellular carcinoma (MS‐HCC) is increasing. However, the results following liver resection in this context have not been described in detail.

Methods:

Data for all patients with metabolic syndrome as a unique risk factor for HCC who underwent liver resection between 2000 and 2011 were retrieved retrospectively from an institutional database. Pathological analysis of the underlying parenchyma included fibrosis and non‐alcoholic fatty liver disease activity score. Patients were classified as having normal or abnormal underlying parenchyma. Their characteristics and outcomes were compared.

Results:

A total of 560 resections for HCC were performed in the study interval. Sixty‐two patients with metabolic syndrome, of median age 70 (range 50–84) years, underwent curative hepatectomy for HCC, including 32 major resections (52 per cent). Normal underlying parenchyma was present in 24 patients (39 per cent). The proportion of resected HCCs labelled as MS‐HCC accounted for more than 15 per cent of the entire HCC population in more recent years. Mortality and major morbidity rates were 11 and 58 per cent respectively. Compared with patients with normal underlying liver, patients with abnormal liver had increased rates of mortality (0 versus 18 per cent; P = 0·026) and major complications (13 versus 42 per cent; P = 0·010). In multivariable analysis, a non‐severely fibrotic yet abnormal underlying parenchyma was a risk factor for major complications (hazard ratio 5·66, 95 per cent confidence interval 1·21 to 26·52; P = 0·028). The 3‐year overall and disease‐free survival rates were 75 and 70 per cent respectively, and were not influenced by the underlying parenchyma.

Conclusion:

HCC in patients with metabolic syndrome is becoming more common. Liver resection is appropriate but carries a high risk, even in the absence of severe fibrosis. Favourable long‐term outcomes justify refinements in the perioperative management of these patients. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Long‐term follow‐up of the Medical Research Council CLASICC trial of conventional versus laparoscopically assisted resection in colorectal cancer

Background:

Laparoscopic resection is used widely in the management of colorectal cancer; however, the data on long‐term outcomes, particularly those related to rectal cancer, are limited. The results of long‐term follow‐up of the UK Medical Research Council trial of laparoscopically assisted versus open surgery for colorectal cancer are presented.

Methods:

A total of 794 patients from 27 UK centres were randomized to laparoscopic or open surgery in a 2:1 ratio between 1996 and 2002. Long‐term follow‐up data were analysed to determine differences in survival outcomes and recurrences for intention‐to‐treat and actual treatment groups.

Results:

Median follow‐up of all patients was 62·9 (interquartile range 22·9 ? 92·8) months. There were no statistically significant differences between open and laparoscopic groups in overall survival (78·3 (95 per cent confidence interval (c.i.) 65·8 to 106·6) versus 82·7 (69·1 to 94·8) months respectively; P = 0·780) and disease‐free survival (DFS) (89·5 (67·1 to 121·7) versus 77·0 (63·3 to 94·0) months; P = 0·589). In colonic cancer intraoperative conversions to open surgery were associated with worse overall survival (hazard ratio (HR) 2·28, 95 per cent c.i. 1·47 to 3·53; P < 0·001) and DFS (HR 2·20, 1·31 to 3·67; P = 0·007). In terms of recurrence, no significant differences were observed by randomized procedure. However, at 10 years, right colonic cancers showed an increased propensity for local recurrence compared with left colonic cancers: 14·7 versus 5·2 per cent (difference 9·5 (95 per cent c.i. 2·3 to 16·6) per cent; P = 0·019).

Conclusion:

Long‐term results continue to support the use of laparoscopic surgery for both colonic and rectal cancer. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Similar liver transplantation survival with selected cardiac death donors and brain death donors

Background:

The outcome of orthotopic liver transplantation (OLT) with controlled graft donation after cardiac death (DCD) is usually inferior to that with graft donation after brain death (DBD). This study compared outcomes from OLT with DBD versus controlled DCD donors with predefined restrictive acceptance criteria.

Methods:

All adult recipients in the Netherlands in 2001–2006 with full‐size OLT from DCD (n = 55) and DBD (n = 471) donors were included. Kaplan–Meier, log rank and Cox regression analyses were used.

Results:

One‐ and 3‐year patient survival rates were similar for DCD (85 and 80 per cent) and DBD (86·3 and 80·8 per cent) transplants (P = 0·763), as were graft survival rates (74 and 68 per cent versus 80·4 and 74·5 per cent; P = 0·212). The 3‐year cumulative percentage of surviving grafts developing non‐anastomotic biliary strictures was 31 per cent after DCD and 9·7 per cent after DBD transplantation (P < 0·001). The retransplantation rate was similar overall (P = 0·081), but that for biliary stricture was higher in the DCD group (P < 0·001). Risk factors for 1‐year graft loss after DBD OLT were transplant centre, recipient warm ischaemia time and donor with severe head trauma. After DCD OLT they were transplant centre, donor warm ischaemia time and cold ischaemia time. DCD graft was a risk factor for non‐anastomotic biliary stricture.

Conclusion:

OLT using controlled DCD grafts and restrictive criteria can result in patient and graft survival rates similar to those of DBD OLT, despite a higher risk of biliary stricture. Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Systematic review and meta‐analysis of randomized clinical trials comparing single‐incision versus conventional laparoscopic cholecystectomy

Background:

Single‐incision laparoscopic cholecystectomy (SILC) may offer advantages over conventional laparoscopic cholecystectomy (LC).

Methods:

MEDLINE, Embase, PubMed, CINAHL, Cochrane Central Register of Controlled Trials and the Cochrane Library were searched for randomized clinical trials on SILC versus LC until May 2012. Odds ratio (OR) and weight mean difference (WMD) were calculated with 95 per cent confidence intervals (c.i.) based on intention‐to‐treat analysis.

Results:

Thirteen randomized clinical trials included a total of 923 procedures. SILC had a higher procedure failure rate than LC (OR 8·16, 95 per cent c.i. 3·42 to 19·45; P < 0·001), required a longer operating time (WMD 16·55, 95 per cent c.i. 9·95 to 23·15 min; P < 0·001) and was associated with greater intraoperative blood loss (WMD 1·58, 95% of c.i. 0·44 to 2·71 ml; P = 0·007). There were no differences between the two approaches in rate of conversion to open surgery, length of hospital stay, postoperative pain, adverse events, wound infections or port‐site hernias. Better cosmetic outcomes were demonstrated in favour of SILC as measured by Body Image Scale questionnaire (WMD ? 0·97, 95% of c.i. ? 1·51 to ? 0·43; P < 0·001) and Cosmesis score (WMD ? 2·46, 95% of c.i. ? 2·95 to ? 1·97; P < 0·001), but this was based on comparison with procedures in which multiple and often large ports (10 mm) were used.

Conclusion:

SILC has a higher procedure failure rate with more blood loss and takes longer than LC. No trial was adequately powered to assess safety. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Randomized clinical trial of goal‐directed fluid therapy within an enhanced recovery protocol for elective colectomy

Background:

Goal‐directed fluid therapy (GDFT) has been compared with liberal fluid administration in non‐optimized perioperative settings. It is not known whether GDFT is of value within an enhanced recovery protocol incorporating fluid restriction. This study evaluated GDFT under these circumstances in patients undergoing elective colectomy.

Methods:

Patients undergoing elective laparoscopic or open colectomy within an established enhanced recovery protocol (including fluid restriction) were randomized to GDFT or no GDFT. Bowel preparation was permitted for left colonic operations at the surgeon's discretion. Exclusion criteria included rectal tumours and stoma formation. The primary outcome was a patient‐reported surgical recovery score (SRS). Secondary endpoints included clinical outcomes and physiological measures of recovery.

Results:

Eighty‐five patients were randomized, and there were 37 patients in each group for analysis. Nine patients in the GDFT and four in the fluid restriction group received oral bowel preparation for either anterior resection (12) or subtotal colectomy (1). Patients in the GDFT group received more colloid during surgery (mean 591 versus 297 ml; P = 0·012) and had superior cardiac indices (mean corrected flow time 374 versus 355 ms; P = 0·018). However, no differences were observed between the GDFT and fluid restriction groups with regard to surgical recovery (mean SRS after 7 days 47 versus 46 respectively; P = 0·853), other secondary outcomes (mean aldosterone/renin ratio 9 versus 8; P = 0·898), total postoperative fluid (median 3750 versus 2400 ml; P = 0·604), length of hospital stay (median 6 versus 5 days; P = 0·570) or number of patients with complications (26 versus 27; P = 1·000).

Conclusion:

GDFT did not provide clinical benefit in patients undergoing elective colectomy within a protocol incorporating fluid restriction. Registration number: NCT00911391 ( http://www.clinicaltrials.gov ). Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Long‐term outcomes of revisional surgery following laparoscopic fundoplication

Background:

A small proportion of patients who have laparoscopic antireflux procedures require revisional surgery. This study investigated long‐term clinical outcomes.

Methods:

Patients requiring late revisional surgery following laparoscopic fundoplication for gastro‐oesophageal reflux were identified from a prospective database. Long‐term outcomes were determined using a questionnaire evaluating symptom scores for heartburn, dysphagia and satisfaction.

Results:

The database search found 109 patients, including 98 (5·6 per cent) of 1751 patients who had primary surgery in the authors' unit. Indications for surgical revision were dysphagia (52 patients), recurrent reflux (36), mechanical symptoms related to paraoesophageal herniation (16) and atypical symptoms (five). The median time to revision was 26 months. Outcome data were available for 104 patients (median follow‐up 66 months) and satisfaction data for 102, 88 of whom were highly satisfied (62·7 per cent) or satisfied (23·5 per cent) with the outcome. Patients who had revision for dysphagia had a higher incidence of poorly controlled heartburn (20 versus 2 per cent; P = 0·004), troublesome dysphagia (16 versus 6 per cent; P = 0·118) and a lower satisfaction score (P = 0·023) than those with recurrent reflux or paraoesophageal herniation.

Conclusion:

Revisional surgery following laparoscopic fundoplication can produce good long‐term results, but revision for dysphagia has less satisfactory outcomes. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Minimal‐access colorectal surgery is associated with fewer adhesion‐related admissions than open surgery

Background:

This study aimed to describe national intermediate‐term admission rates for incisional hernia or clinically apparent adhesions following colorectal surgery, and to compare rates following laparoscopic and open approaches.

Methods:

Patients undergoing primary colorectal resection between 2002 and 2008 were included from the Hospital Episode Statistics database. Subsequent inpatient admissions were extracted for up to 3 years after the initial operation or to the end of the study period. Outcomes examined were admissions with a diagnosis of, or operative interventions for, incisional hernia or adhesions.

Results:

A total of 187 148 patients were included between 2002 and 2008, with median follow‐up of 31·8 (interquartile range 13·1–35·3) months. Some 8885 (4·7 per cent) of these patients were admitted with a diagnosis of, or underwent a repair of, an incisional hernia. In multiple regression analysis, use of laparoscopy was not a predictor of operative intervention for incisional hernia (odds ratio 1·09, 95 per cent confidence interval (c.i.) 0·99 to 1·21; P = 0·083). Some 15 125 (8·1 per cent) of the patients were admitted with a diagnosis of adhesions or had a procedure for division of adhesions. Overall, 3·5 per cent (6637 of 187 148) of patients underwent adhesiolysis. Patients selected for a laparoscopic procedure had lower rates of admission for adhesions (6·3 per cent (692 of 11 013) for laparoscopic versus 8·2 per cent (14 433 of 176 135) for open surgery; P < 0·001) and reintervention for adhesions (2·8 per cent (305 of 11 013) versus 3·6 per cent (6325 of 176 135) respectively; P < 0·001) than those undergoing an open procedure. In multiple regression analysis, patients selected for a laparoscopic procedure had lower subsequent intervention rates for adhesions (odds ratio 0·80, 95 per cent c.i. 0·71 to 0·90; P < 0·001).

Discussion:

Patients undergoing colorectal resection who are selected for the laparoscopic approach have a lower risk of developing clinically significant adhesions. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Differences in outcomes of oesophageal and gastric cancer surgery across Europe

Background:

In several European countries, centralization of oesophagogastric cancer surgery has been realized and clinical audits initiated. The present study was designed to evaluate differences in resection rates, outcomes and annual hospital volumes between these countries, and to analyse the relationship between hospital volume and outcomes.

Methods:

National data were obtained from cancer registries or clinical audits in the Netherlands, Sweden, Denmark and England. Differences in outcomes were analysed between countries and between hospital volume categories, adjusting for available case‐mix factors.

Results:

Between 2004 and 2009, 10 854 oesophagectomies and 9010 gastrectomies were registered. Resection rates in England were 18·2 and 21·6 per cent for oesophageal and gastric cancer respectively, compared with 28·5–29·9 and 41·4–41·9 per cent in the Netherlands and Denmark (P < 0·001). The adjusted 30‐day mortality rate after oesophagectomy was lowest in Sweden (1·9 per cent). After gastrectomy, the adjusted 30‐day mortality rate was significantly higher in the Netherlands (6·9 per cent) than in Sweden (3·5 per cent; P = 0·017) and Denmark (4·3 per cent; P = 0·029). Increasing hospital volume was associated with a lower 30‐day mortality rate after oesophagectomy (odds ratio 0·55 (95 per cent confidence interval 0·42 to 0·72) for at least 41 versus 1–10 procedures per year) and gastrectomy (odds ratio 0·64 (0·41 to 0·99) for at least 21 versus 1–10 procedures per year).

Conclusion:

Hospitals performing larger numbers of oesophagogastric cancer resections had a lower 30‐day mortality rate. Differences in outcomes between several European countries could not be explained by differences in hospital volumes. To understand these differences in outcomes and resection rates, with reliable case‐mix adjustments, a uniform European upper gastrointestinal cancer audit with recording of standardized data is warranted. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Outcomes of simultaneous pancreas-kidney transplantation from brain-dead and controlled circulatory death donors

Background:

Organ scarcity has prompted increased use of organs from donation after circulatory death (DCD) donors. An early single‐centre experience of simultaneous pancreas–kidney (SPK) transplantation from controlled DCD donors is described here.

Methods:

Outcomes of SPK transplants from DCD and donation after brain death (DBD) donors between August 2008 and January 2011 were reviewed retrospectively.

Results:

SPK transplants from 20 DCD and 40 DBD donors were carried out. Donor and recipient characteristics were similar for both groups, although pancreas cold ischaemia times were shorter in DCD recipients: median (range) 8·2 (5·9–10·5) versus 9·5 (3·8–12·5) h respectively (P = 0·004). Median time from treatment withdrawal to cold perfusion was 24 (range 16–110) min for DCD donors. There were no episodes of delayed pancreatic graft function in either group; the graft thrombosis rates were both 5 per cent. Similarly, there were no differences in haemoglobin A1c level at 12 months: median (range) 5·4 (4·9–7·7) per cent in DCD group versus 5·4 (4·1–6·2) per cent in DBD group (P = 0·910). Pancreas graft survival rates were not significantly different, with Kaplan–Meier 1‐year survival estimates of 84 and 95 per cent respectively (P = 0·181).

Conclusion:

DCD SPK grafts had comparable short‐term outcomes to DBD grafts, even when procured from selected donors with a prolonged agonal phase. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Mild hepatic macrovesicular steatosis may be a risk factor for hyperbilirubinaemia in living liver donors following right hepatectomy

Background:

The aim of this study was to evaluate the effects of mild macrovesicular steatosis on the outcome of living liver donors following right hepatectomy.

Methods:

The medical records of 46 living liver donors who underwent right hepatectomy were studied. Ten donors had mild macrovesicular steatosis (5–10 per cent in seven and 11–20 per cent in three patients). Five donors with other liver pathology were excluded. Outcome in these ten donors (group 1) was compared with that in the remaining 31 donors with normal liver histology (group 2).

Results:

The median duration until normalization of total bilirubin levels was 14 and 5 days in groups 1 and 2 respectively (P = 0·028). The peak total bilirubin level was significantly higher in group 1 than in group 2 (80·4 versus 49·6 µmol/l; P = 0·033). Multivariable analysis showed mild macrovesicular steatosis to be an independent risk factor for hyperbilirubinaemia (odds ratio 7·94 (95 per cent confidence interval 1·17 to 54·03); P = 0·034).

Conclusion:

Mild macrovesicular steatosis may be related to adverse outcome in living liver donors who undergo right hepatectomy and, in terms of donor safety, is of potential concern in donor selection. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Peritoneal lavage cytology in patients with oesophagogastric adenocarcinoma

Background:

The aim of the study was to determine the value of performing peritoneal lavage cytology during laparoscopy in the management of oesophagogastric adenocarcinoma.

Methods:

Laparoscopy combined with peritoneal cytology was performed in patients with potentially resectable oesophagogastric adenocarcinoma. Macroscopic peritoneal findings at laparoscopy and the presence of free peritoneal tumour cells were recorded. All patients were followed to death or the census point. Patients with overt peritoneal disease or positive cytology were offered palliative chemotherapy, subject to performance status.

Results:

Forty‐eight (18·8 per cent) of 255 patients had overt peritoneal metastases at staging laparoscopy. Fifteen (7·2 per cent) of the remaining 207 patients had positive cytology; these patients had a median (95 per cent confidence interval) survival of 13 (3·1 to 22·9) months, versus 9 (7·4 to 10·6) months for those with overt peritoneal metastases (P = 0·517). Of patients receiving chemotherapy, those without overt metastases had a slight survival advantage over patients with metastases (median 15 (10·8 to 19·2) versus 9 (7·4 to 10·7) months; P = 0·045).

Conclusion:

Positive peritoneal cytology in the absence of overt peritoneal metastases is not uncommon in oesophagogastric adenocarcinoma. It is a marker of poor prognosis even in the absence of overt peritoneal metastases. Copyright © 2008 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Multicentre analysis of oncological and survival outcomes following anastomotic leakage after rectal cancer surgery

Background:

The association between diverting stomas and symptomatic anastomotic leakage after rectal cancer surgery was studied, as well as the impact of leakage on local recurrence, distant metastasis, and disease‐free, overall and cancer‐specific survival.

Methods:

Data from the Swedish Rectal Cancer Trial, Dutch TME trial, CAO/ARO/AIO‐94 trial, EORTC 22921 trial and Polish Rectal Cancer Trial were pooled (n = 5187). All eligible patients without distant metastases at the time of low anterior resection were selected (n = 2726); overall survival was studied in patients aged 75 years or less (n = 2480). Multivariable models were used to study the association between diverting stomas and anastomotic leakage, and between leakage and recurrence or survival.

Results:

Some 9·7 per cent of patients were diagnosed with a symptomatic anastomotic leak; diverting stomas were negatively associated with leakage (11·6 per cent without and 7·8 per cent with a stoma; P = 0·002). Anastomotic leakage was negatively associated with overall survival in the multivariable analysis (hazard ratio (HR) 1·29 (95 per cent confidence interval 1·02 to 1·63); P = 0·034), but not with cancer‐specific survival (HR 1·12 (0·83 to 1·52); P = 0·466).

Conclusion:

Diverting stomas were associated with less symptomatic anastomotic leakage. Oncological outcome was not significantly influenced by leakage, but overall survival was reduced. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.