Preoperative Chemotherapy Does Not Adversely Affect Pancreatic Structure and Short-Term Outcome after Pancreatectomy

Background

Preoperative chemotherapy (PCHT) has recently been proposed also in patients with resectable pancreatic adenocarcinoma. Few data are currently available on the impact of PCHT on short-term postoperative outcome after pancreatic resection. The objective of this study is to assess the impact of PCHT on pancreatic structure and short-term outcome after surgical resection.

Methods

Fifty consecutive patients successfully underwent resection after PCHT. Each patient was matched with two control patients with pancreatic adenocarcinoma selected from our prospective electronic database. Match criteria were age (±3 years), gender, American Society of Anesthesiologist score, type of resection, pancreatic duct diameter (±1 mm), and tumor size (±5 mm). Primary endpoint was morbidity rate. Secondary endpoints were pancreatic parenchymal structure, mortality rate, and length of hospital stay (LOS).

Results

Both degree of fibrosis and fatty infiltration of the pancreas were similar in the two groups. Overall morbidity rate was 48.0 % in the PCHT group vs. 54.0 % in the control group (p?=?0.37). Pancreatic fistula rate was 18.0 % in the PCHT group vs. 25.0 % in the control group (p?=?0.41). Mortality was 4.0 % in the PCHT group vs. 2.0 % in the control group (p?=?0.60). Mean LOS (days) was 12.7 in the PCHT group vs. 12.4 in the control group (p?=?0.74). There was no difference in resection margin status, while the rate of patients without nodal involvement was higher in the PCHT group (46.0 vs. 23.0 %, p?=?0.004).

Conclusion

PCHT did not induce significant structural changes in pancreatic parenchyma and did not adversely affect short-term outcome after surgery.     

Outcomes of Laparoscopic Sleeve Gastrectomy in Patients Older than 60 Years

Background

Morbidity and mortality following laparoscopic sleeve gastrectomy (LSG) occur at acceptable rates, but its safety and efficacy in the elderly are unknown.

Methods

A retrospective review was performed of all patients aged >60 years who underwent LSG from 2008 to 2012. These patients were 1:2 matched, by gender and body mass index (BMI) to young patients, 18?<?age?<?50. Data analyzed included demographics, preoperative and postoperative BMI, postoperative complications, and improvement or resolution of obesity-related comorbidities.

Results

Fifty-two morbid obese patients older than 60 years underwent LSG (mean age, 62.9?±?0.3 years). These were matched to 104 young patients, age 18–50 years (mean age, 35.7?±?0.8 years). Groups did not differ in male gender (44 vs. 43 %, p?=?0.9), preoperative BMI (42.6?±?0.7 vs. 42.6?±?0.6, p?=?0.97), and length of follow-up (17?±?2 vs. 22?±?1.4 months, p?=?0.06). Obesity-related comorbidities were significantly higher in the older group (96 vs. 65 %, p?<?0.001). Excess weight loss (EWL) was higher in the younger group (75?±?2.4 vs. 62?±?3 %, p?=?0.001). Older patients had a significantly higher rate of a concurrent hiatal hernia repair (23 vs. 1.9 %, p?<?0.001). Overall postoperative minor complication rate was higher in the older group (25 vs. 4.8 %, p?<?0.001). This included atrial fibrillation (9.5 %), urinary tract infection (7 %), trocar site hernia (4 %), dysphagia, surgical site infection, bleeding, bowel obstruction, colitis, and nutritional deficiency (2 %, each). No perioperative mortality occurred. Comorbidity resolution or improvement was comparable between groups (88 vs. 80 %, p?=?0.13).

Conclusions

LSG is safe and very efficient in patients aged >60, despite higher rates of perioperative comorbidities.     

Early Post-operative Complications: Incidence, Management, and Impact on Length of Hospital Stay. A Retrospective Comparison Between Laparoscopic Gastric Bypass and Sleeve Gastrectomy

Background

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are the most common obesity surgeries. Their early complications may prolong hospital stay (HS).

Methods

Data for patients who underwent LRYGB and LSG in our clinic from 2009 through August 2012 were collected. Early post-operative complications prolonging HS (>5 days) were retrospectively analyzed, highlighting their relative incidence, management, and impact on length of HS.

Results

Sixty-six patients (4.9 %) after 1,345 LRYGB operations vs. 49 patients (7.14 %) after 686 LSG operations developed early complications. This difference is statistically significant (p?=?0.039). Male gender percentage was significantly higher in complicated LSG group vs. complicated LRYGB group [23 patients (46.9 %) vs. 16 patients (24.2 %)] (p?=?0.042). Mean BMI was significantly higher in the complicated LSG group (54.2?±?8.3) vs. complicated LRYGB group (46.8?±?5.7; p?=?0.004). Median length of HS was not longer after complicated LSG compared with complicated LRYGB (11 vs. 10 days; p?=?0.287). Leakage and bleeding were the most common complications after either procedure. Leakage rate was not higher after LSG (12 patients, 1.7 %) compared with LRYGB (22 patients, 1.6 %; p?=?0.304). Bleeding rate was significantly higher after LSG (19 patients, 2.7 %) than after LRYGB (10 patients, 0.7 %; p?=?0.004). Prolonged elevation of inflammatory markers was the most common presentation for complications after LSG (18 patients, 36.7 %) and LRYGB (31 patients, 46.9 %).

Conclusions

LSG was associated with more early complications. This may be attributed to higher BMI and predominance of males in LSG group.     

Clinical Features and Outcome of Postoperative Peritonitis Following Bariatric Surgery

Background

We assessed the clinical features and outcome of morbidly obese patients admitted to the intensive care unit (ICU) for management of postoperative peritonitis (POP) following bariatric surgery (BS).

Methods

In a prospective, observational, surgical ICU cohort, we compared the clinical features, empiric antibiotic therapy, and prognosis of BS patients with those developing POP after conventional surgery (cPOP).

Results

Overall, 49 BS patients were compared to 134 cPOP patients. BS patients were younger (45?±?10 versus 63?±?16 years; p?<?0.0001), had lower rates of fatal underlying disease (39 vs 64 %; p?=?0.002), and the same SOFA score at the time of reoperation (8?±?4 vs 8?±?3; p?=?0.8) as the cPOP patients. BS patients had higher proportions of Gram-positive cocci (48 vs 35 %; p?=?0.007) and lower proportions of Gram-negative bacilli (33 vs 44 %; p?=?0.03), anaerobes (4 vs 10 %; p?=?0.04), and multidrug-resistant strains (20 vs 40 %; p?=?0.01). Despite higher rates of adequate empiric antibiotic therapy (82 vs 64 %; p?=?0.024) and high de-escalation rates (67 % in BS cases and 51 % in cPOP cases; p?=?0.06), BS patients had similar reoperation rates (53 vs 44 %; p?=?0.278) and similar mortality rates (24 vs 32 %; p?=?0.32) to cPOP patients. In multivariate analysis, none of the risk factors for death were related to BS.

Conclusions

The severity of POP in BS patients resulted in high mortality rates, similar to the results observed in cPOP. Usual empiric antibiotic therapy protocols should be applied to target multidrug-resistant microorganisms, but de-escalation can be performed in most cases.     

Postpancreatectomy hemorrhage (PPH): predictors and management from a prospective database

Background

Postpancreatectomy hemorrhage (PPH) is a dreaded complication in pancreatic surgery. Today, there is a definition and grading of PPH without therapeutic consensus. We reviewed our prospective database to identify predictors and assess therapeutic strategy.

Method

We included all patients who underwent pancreatectomy between 2005 and 2010. Data were collected prospectively. We used the International Study Group Of Pancreatic Surgery (ISGPS) definition for PPH to include patients in the PPH group.

Results

Forty-six of 285 patients showed a PPH (16.1 %). The ISGPS classification was graded A?=?3, B?=?26, and C?=?17. The average time to the onset of PPH was 7 days. CT-scan identified the origin of PPH in 43.5 % of the cases. PPH was responsible for a longer duration of hospital stay (p?=?0.004), a higher hospital mortality (21.7 vs 2.5 %, p?<?0.0001) and a lower survival (40 vs 70 % (p?=?0.05) at 36 months). The first-intention treatment of PPH was conservative in 32 % and interventional in 68 %: endoscopy (6.4 %), transcatheter arterial embolization (TAE, 30.4 %), and surgical (30.4 %). In multivariate analysis, predictors of PPH were: pancreatic fistula (24 vs 8 % p?=?0.028), pancreatoduodenectomy (70 vs 43 % p?=?0.029), age (61.6 vs 58.8 %, p?=?0.03), and nutritional risk index (NRI) (p?=?0.048).

Conclusion

In our series, risk factors for PPH were age, pancreatic fistula, pancreatoduodenectomy, and NRI. Its occurrence is associated with significantly higher hospital mortality and a lower survival rate. Our first-line treatment was radiological TAE. Surgical treatment is offered in case of failure of interventional radiology or in case of uncontrolled hemodynamic.     

Psychiatric Predictors of Surgery Non-completion Following Suitability Assessment for Bariatric Surgery

Background

Bariatric surgery is recognized as a treatment for severe obesity; however, little is known about factors influencing patient surgery non-completion. This study explored the relationship between psychiatric factors and patient non-completion during the pre-bariatric surgery suitability assessment.

Methods

A total of 367 individuals underwent a structured psychiatric interview and were classified as either surgery completers (SC) or surgery non-completers (SNC) if they attended at least one pre-surgery assessment appointment but did not receive surgery.

Results

The results showed that in comparison to the SC group, the SNC group had significantly higher rates of overall past Axis I psychiatric disorders (58.1 vs. 46.6 %, p?=?0.035), past anxiety disorders (17.4 vs. 9.4 %, p?=?0.03), and past substance use disorders (8.7 vs. 3.7 %, p?=?0.03). For specific past psychiatric disorders, the SNC group exhibited significantly higher rates of a past post-traumatic stress disorder (PTSD) (5 vs. 1 %, p?=?0.029) and past substance dependence disorder (7 vs. 1 %, p?=?0.005). Although overall current psychiatric disorders did not significantly differ between groups, the SNC group had significantly higher rates of current PTSD (2 vs. 0 %, p?=?0.049) and current generalized anxiety disorder (4 vs. 0 %, p?=?0.005).

Conclusions

A past history of an anxiety or substance use disorder may play a role in patients not completing the assessment component of the bariatric surgery process. Additional psychosocial support, such as cognitive behavioral therapy or targeted psychoeducation, may help improve patient completion of the pre-surgery assessment phase.     

Craniotomy vs. craniectomy for posterior fossa tumors: a prospective study to evaluate complications after surgery

Background

Posterior fossa surgery traditionally implies permanent bone removal. Although suboccipital craniectomy offers an excellent exposure, it could lead to complications. Thus, some authors proposed craniotomy as a valuable alternative to craniectomy. In the present study we compare post-operative complications after craniotomy or craniectomy for posterior fossa surgery.

Methods

We prospectively collected data for a consecutive series of patients who underwent either posterior fossa craniotomy or craniectomy for tumor resection. We divided patients into two groups based on the surgical procedure performed and safety, complication rates and length of hospitalization were analyzed. Craniotomies were performed with Control-Depth-Attachment® drill and chisel, while we did craniectomies with perforator and rongeurs.

Results

One-hundred-fifty-two patients were included in the study (craniotomy n?=?100, craniectomy n?=?52). We detected no dural damage after bone removal in both groups. The total complication rate related to the technique itself was 7 % for the craniotomy group and 32.6 % for the craniectomy group (<0.0001). Pseudomeningocele occurred in 4 % vs. 19.2 % (p?=?0.0009), CSF leak in 2 % vs. 11.5 % (p?=?0.006) and wound infection in 1 % vs. 1.9 % (p?=?0.33), respectively. Post-operative hydrocephalus, a multi-factorial complication which could affect our results, was also calculated and occurred in 4 % of the craniotomy vs. 9.6 % of the craniectomy group (p?=?0.08). The mean length of in-hospital stay was 9.3 days for the craniotomy group and 11.8 days for the craniectomy group (p?=?0.10).

Conclusions

The present study suggests that fashioning a suboccipital craniotomy is as effective and safe as performing a craniectomy; both procedures showed similar results in preserving dural integrity, while post-operative complications were fewer when a suboccipital craniotomy was performed.     

Perioperative experience of pelvic organ prolapse repair with the Prolift® and Elevate® vaginal mesh procedures

Introduction and hypothesis

We compared the operative and immediate postoperative experience of the trocar-based Prolift® and non-trocar-based Elevate® techniques used to repair vaginal prolapse.

Methods

A retrospective review of Prolift and Elevate repairs was performed. Baseline characteristics and operative and postoperative variables evaluated included compartment(s) repaired, adjacent organ injury, operative time (OT), change in hemoglobin (ΔH), pain score, narcotic use, length of stay (LOS), and short-term complications. Categorical variables were assessed as counts and percent frequency. Data were compared using chi-squared analysis and paired t test.

Results

Prolift (n?=?143) and Elevate (n?=?77) patients were similar in age (p?=?0.19). Concurrent hysterectomy was done in 22 (15.4 %) and 24 (31.2 %), respectively, and concurrent midurethral sling placed in 100 (70 %) and 50 (65 %), respectively. LOS (median, 25th,75th) after anterior/apical compartment repairs was shorter with Elevate, whether with (1.0; 1.0,1.5 vs. 2.0 days;1.0, 2.0; p?=?0.003) or without (2.0; 1.0, 2.0 vs. 2.0 days; 2.0, 3.0; p?=?0.024) hysterectomy, but no differences in OT, ΔH, pain score, or narcotic use occurred. Posterior compartment mean pain scores were lower with Prolift (3.6 ± 2.2 vs. 1.7 ± 1.5, p?=?0.035), and three-compartment-repair pain scores were lower with Elevate (0.6 ± 1.3 vs 2.5 ± 1.9; p?=?0.013). Three bladder injuries occurred with Prolift but none with Elevate.

Conclusions

Operative and postoperative experiences were similar between groups; however, Elevate anterior/apical repairs had shorter LOS, which might reflect more aggressive discharge planning. There were no bowel or major vascular injuries, and the Prolift trocar bladder injuries did not alter the surgical procedure.     

Weight Loss and Weight Regain—5-Year Follow-Up for Circular- vs. Linear-Stapled Gastrojejunostomy in Laparoscopic Roux-en-Y Gastric Bypass

Background

Weight regain (WR) occurs in some patients after laparoscopic Roux-en-Y gastric bypass (LRYGBP). Loss of restriction due to dilation of the gastrojejunostomy (GJS) or the gastric pouch might be the main cause for WR. With different techniques available for the establishment of the GJS, the surgical technique might influence long-term success.

Methods

We present a 5-year follow-up for weight loss and WR of a matched-pair study comparing circular stapled (CSA) to linear stapled (LSA) GJS in a series of 150 patients who underwent primary antecolic antegastric LRYGBP. Complete 5-year follow-up was obtained for 79 % of the patients.

Results

Excess BMI loss (EBL) at 3 months was better with the CSA (p?=?0.02) and comparable thereafter. The 5-year %EBL was 67.3?±?23.2 vs. 73.3?±?24.3 % (CSA vs. LSA, p?=?0.19) WR of?>?10 kg from nadir was found in 24 patients (16 %) with higher incidence in CSA than in LSA patients (20 % vs. 12 %). The %WR was comparable for both groups, 16?±?13 vs. 15?±?19 % (CSA vs. LSA, p?=?0.345). Eleven patients underwent surgical re-intervention for WR by placement of a non-adjustable band (n?=?2), adjustable band (n?=?7) and conversion to distal gastric bypass (n?=?2).

Conclusions

CSA and LSA lead to comparable weight loss in this 5-year follow-up. More patients in the CSA group had WR. Weight regain of more than 10 kg was found in one out of seven patients within 5 years postoperatively.     

Pure laparoscopic liver resection reduces surgical site infections and hospital stay. Results of a case-matched control study in 50 patients

Background

Laparoscopic resection is an emerging tool in surgical oncology, but its role in liver tumors is far from being universally accepted.

Methods

We designed a case-matched control study, comparing laparoscopic (LAP) vs. open hepatectomies (OP) performed in the same center during the same period of time. Fifty LAP were performed (34 liver metastases, 7 hepatocellular carcinomas, 2 hydatid cysts, and 5 benign tumors). Cases were compared with 100 OP matched according to: diagnosis, number of lesions, type of resection, age, ASA score, and ECOG performance status. We evaluated intraoperative and postoperative parameters, focusing on morbidity and mortality.

Results

Preoperative data were comparable in both groups. Operative features were similar in terms of overall morbidity 18 (36 %) vs. 36 (36 %), p?=?1; intraoperative bleeding, 401 (18–2192) vs. 475 (20–2000) mL, p?=?0.89; pedicle clamping, 37 (74 %) vs. 88 (88 %), p?=?0.55; margin, 0.6 (0–5) vs. 0.65 (0–5) cm, p?=?0.94, and mortality p?=?0.65 for the LAP and OP groups, respectively. There was a significant decrease in surgical site infections 1 (2 %) vs. 18 (18 %) p?=?0.007 in the LAP group. Operative time was longer: 295 (120–600) vs. 200 (70–450) min (p?=?0.0001), and hospital stay significantly shorter: 4 (1–60) vs. 7 (3–44) days, p?=?0.0001 with less readmissions (0 vs. 7 %) in the LAP.

Discussion

In adequately selected patients, laparoscopic hepatectomy is feasible, safe, shortens hospital stay, and decreases surgical site infections.     

Single-incision mesh repair versus traditional native tissue repair for pelvic organ prolapse: results of a cohort study

Introduction and hypothesis

To compare the efficacy and safety of the Elevate? anterior and posterior prolapse repair system and traditional vaginal native tissue repair in the treatment of stage 2 or higher pelvic organ prolapse.

Methods

A cohort study was conducted between January 2010 and July 2012. Patients who underwent transvaginal pelvic reconstruction surgery for prolapse were recruited. The primary outcome was anatomical success 1 year after surgery. The secondary outcome included changes in the quality of life and surgical complications. Recurrence of prolapse was defined as stage 2 or higher prolapse based upon the pelvic organ prolapse qQuantification system.

Results

Two hundred and one patients (100 in the Elevate? repair group and 101 in the traditional repair group) were recruited and analyzed. The anatomical success rate of the anterior compartment was significantly higher in the Elevate? repair group than in the traditional repair group (98 % vs 87 %, p?=?0.006), but not for the apical (99 % vs. 6 %, p?=?0.317) or posterior (100 % vs 97 %, p?=?0.367) compartments after a median 12 months of follow-up. Both groups showed significant improvements in the quality of life after surgery with no statistical difference. Mesh-related complications included extrusion (3 %) and the need for revision of the vaginal wound (1 %). Those in the mesh repair group had a longer hospital stay (p?=?0.04), operative time (p?<?0.001), and greater estimated blood loss (p?=?0.05). Other complications were comparable with no statistical difference.

Conclusions

The Elevate? prolapse repair system had a better 1-year anatomical cure rate of the anterior compartment than traditional repair, with slightly increased morbidity.     

Stapled Hemorrhoidopexy Versus Milligan–Morgan Hemorrhoidectomy in Circumferential Third-Degree Hemorrhoids: Long-Term Results of a Randomized Controlled Trial

Background

The literature indicates higher recurrence rates for stapled hemorrhoidopexy than for conventional techniques. This could be due to inappropriate patient selection.

Objective

The aim of this study was to evaluate the short- and long-term outcome after stapled hemorrhoidopexy compared with the Milligan–Morgan procedure in a homogeneous patient population with circumferential third-degree hemorrhoids.

Design and Patients

One hundred thirty patients were enrolled into a randomized controlled study, of which 122 were clinically evaluated at weeks 1, 2, and 4, and thereafter each year for a minimum of 3 years. Patients completed a questionnaire for symptoms, function, and pain. Pain was assessed using a visual analog scale. Recurrences were determined by anoscopy and self-report.

Settings

The study was performed at the University Hospital Hamburg.

Main Outcome Measures

Endpoints were pain, recurrence, bleeding, itching/burning, urinary retention, incontinence symptoms, and prolonged rate of wound healing.

Results

The cumulative recurrence rates after 5 years were 18 % (n?=?11) in the stapled hemorrhoidopexy group and 23 % (n?=?14) in the Milligan–Morgan group (p?=?0.65). Patients who underwent stapled hemorrhoidopexy had significantly less postoperative pain with mean VAS scores at week 1: 3.1 vs. 6.2; week 2: 0.5 vs. 3; week 4: 0.05 vs. 0.6 (p?<?0.001), and demonstrated less burning/itching sensation 4 weeks after surgery compared with the Milligan–Morgan group (4.9 vs. 19.7 %; p?<?0.001). The postoperative bleeding rate was 4.9 % in both groups and the rate of urinary retention did not differ significantly (4.9 % vs. 1.6 %; p?=?0.309). Postoperative incontinence symptoms (6.6 % versus 3.3 %; p?=?0.40) resolved within the first 6 months.

Limitations

Detailed measurement of incontinence was not possible because postoperative symptoms resolved between consultations, and pathological results were examined retrospectively.

Conclusions

The results show a similar rate of recurrence in the long term and suggest increased patient comfort in the early postoperative course after stapled hemorrhoidopexy. In patients with circumferential third-degree hemorrhoids, stapled hemorrhoidopexy is as effective as the Milligan–Morgan procedure.     

Perioperative Outcome After Pancreatic Head Resection: a 10-Year Series of a Specialized Surgeon in a University Hospital and a Community Hospital

Introduction

Hospital and surgeon volume are potential factors influencing postoperative mortality and morbidity after pancreatic resection. Data on perioperative outcome of individual surgeons in different institutions, however, are scarce. We evaluated the perioperative outcome after pancreatic head resections (PHR) performed by a high-volume pancreatic surgeon in a high-volume university department and (later) in a community hospital with low prior experience in major pancreatic surgery.

Methods

We compared the results after PHR were performed by a single experienced surgeon between 2001 and October 2006 in a specialized unit of a German university hospital (n?=?83; group A) with the results after PHR were performed in a community hospital between November 2006 and 2011 (n?=?145; group B). Before the study period (?2001), the surgeon already had a personal caseload of >200 PHR. In addition to the 228 PHR analyzed here, the surgeon also had taught further >150 PHR to residents and consulting surgeons. Comparable surgical and perioperative techniques were applied in both series (e.g., types of resection and reconstruction, abdominal drains, early enteral feeding). The data of both series were prospectively recorded in SPSS databases.

Results

The median age of the patients was lower in group A (58 vs. 66 years in B; p?<?0.01). Indications for PHR were pancreatic cancer (A 39 % vs. B 45 %), other periampullary cancer (A 18 % vs. B 12 %), chronic pancreatitis (A 33 % vs. B 28 %), and others (A 10 % vs. B 15 %). Most PHR were pylorus preserving (64 vs. 75 %), with oncologically indicated portal vein resections in 24 % (A) or 33 % (B). The percentage of duodenum-preserving PHR was lower in group B (14 vs. 26 % in A). Mortality of PHR was 3.6 % in group A and 2.8 % in B (p?=?0.72). Overall morbidity rate was 49 % (A) or 57 % (B; p?=?0.25). Using the expanded Accordion classification, complications classified as grade 4 or higher occurred in 9 % (A) and 11 % (B; p?=?0.74). Postoperative pancreatic leak (any grade) was documented in 26 % (A) and 25 % (B; p?=?0.87).

Conclusions

Surgeon volume and a high individual experience, respectively, contribute to acceptable complication rates and low mortality rates after pancreatic head resection. An experienced surgeon can provide a good perioperative outcome after pancreatic resection even after a change of hospital or medical staff.     

Prevalence of Nonalcoholic Steatohepatitis Among Patients with Resectable Intrahepatic Cholangiocarcinoma

Background and Aims

The objective of this report was to determine the prevalence of underlying nonalcoholic steatohepatitis in resectable intrahepatic cholangiocarcinoma.

Methods

Demographics, comorbidities, clinicopathologic characteristics, surgical treatments, and outcomes from patients who underwent resection of intrahepatic cholangiocarcinoma at one of eight hepatobiliary centers between 1991 and 2011 were reviewed.

Results

Of 181 patients who underwent resection for intrahepatic cholangiocarcinoma, 31 (17.1 %) had underlying nonalcoholic steatohepatitis. Patients with nonalcoholic steatohepatitis were more likely obese (median body mass index, 30.0 vs. 26.0 kg/m², p?<?0.001) and had higher rates of diabetes mellitus (38.7 vs. 22.0 %, p?=?0.05) and the metabolic syndrome (22.6 vs. 10.0 %, p?=?0.05) compared with those without nonalcoholic steatohepatitis. Presence and severity of hepatic steatosis, lobular inflammation, and hepatocyte ballooning were more common among nonalcoholic steatohepatitis patients (all p?<?0.001). Macrovascular (35.5 vs. 11.3 %, p?=?0.01) and any vascular (48.4 vs. 26.7 %, p?=?0.02) tumor invasion were more common among patients with nonalcoholic steatohepatitis. There were no differences in recurrence-free (median, 17.0 versus 19.4 months, p?=?0.42) or overall (median, 31.5 versus 36.3 months, p?=?0.97) survival after surgical resection between patients with and without nonalcoholic steatohepatitis.

Conclusions

Nonalcoholic steatohepatitis affects up to 20 % of patients with resectable intrahepatic cholangiocarcinoma.     

Thoracic endovascular aortic repair with left subclavian artery coverage without prophylactic revascularisation—early and midterm results

Background

The management of the left subclavian artery when coverage is necessary during thoracic aorta endografting remains a matter of debate.

Materials and methods

A retrospective analysis of a single-centre experience with thoracic endovascular aorta repair (TEVAR) was performed. Between April 2004 and October 2012, 125 cases of TEVAR were performed. The analysis focused on patients who required coverage of the left subclavian artery (LSA). We analysed mortality and morbidity with special attention to the rates of cerebrovascular accidents (CVAs) and spinal cord ischaemia (SCI) in the early and midterm.

Results

Of the 125 patients, 53 (42 %, group A) required an intentional coverage of the LSA to obtain an adequate proximal seal for the endograft; the remaining patients constituted group B. None of the patients in group A had protective LSA revascularisation prior to TEVAR. The primary technical success rate was 79.2 vs. 90.3 % (group A vs. group B, p?=?0.08), and the primary clinical success rate was 77.4 vs. 82 % (group A vs. group B, p?=?0.53). The 30-day mortality rate was 11.3 vs. 11.1 % (group A vs. group B, p?=?0.97). The 30-day morbidity was 7.5 vs. 13.9 % (group A vs. group B, p?=?0.4). CVA occurred in 1.9 % of group A patients, compared to 1.4 % of patients from group B (p?=?0.82). The SCI incidence rate was 0 vs. 1.4 % (p?=?0.39). The mean follow-up of group A was 24.1 months (range 2–64.6 months, SD?=?19). Additionally, the 1-year estimated survival was 85.5 %, and the 3-year estimated survival was 78 %. There were no midterm CVAs; one event of SCI occurred in the seventh post-operative month in group A.

Conclusion

Our analysis, although retrospective and based on one institution experience, shows a realistic population of TEVAR patients. We prove that TEVAR with coverage of LSA origin can be accomplished with minimal neurological morbidity in this patient population. The study shows that LSA revascularisation is not mandatory before endograft deployment, especially in emergency settings. We also prove that although zone 2 TEVAR extends the proximal landing zone, it does not prevent type IA endoleaks from appearing. A multicentre randomised control trial with higher number of patients is necessary for proper, robust conclusion to be established.     

Surgical outcomes of pancreaticoduodenectomy for periampullary tumors in elderly patients

Backgrounds

Pancreaticoduodenectomy (PD) is an aggressive surgery with considerable operative risks, but offers the only chance for cure in patients with periampullary tumors. A growing number of elderly patients are being offered PD because of the aging of populations in developed countries. We examined surgical outcomes of PD in patients aged 75 years and older (≥75 years).

Methods

A retrospective cohort study was performed in 65 consecutive patients who underwent PD for periampullary tumors at a single medical center during the 5 years from 2006 to 2010. We analyzed surgical outcomes such as mortality and morbidity after PD in patients aged ≥75 years (n?=?21) compared to those in patients aged <75 years (n?=?44).

Results

The positive rate of comorbidities such as hypertension was significantly higher in patients aged ≥75 years than in patients aged <75 years (76 vs. 48 %; p?=?0.03). The incidence of wound infection was significantly higher in patients aged ≥75 years than in patients aged <75 years (19 vs. 0 %; p?<?0.01). However, there was no significant difference in the mortality rate (0 vs. 2 %; p?=?0.49) or the overall morbidity rate (33 vs. 32 %; p?=?0.90). There was no significant difference in changes in body weight or serum albumin levels during the 3 months after PD between the two groups, but the recovery of serum prealbumin levels from 1 to 3 months after PD in patients aged ≥75 years was significantly delayed compared to that in patients aged <75 years (p?=?0.04). There was no statistically significant difference in long-term survival between the two groups.

Conclusions

Advanced age alone should not discourage surgeons from offering PD, although nutritional supports after PD for elderly patients aged ≥75 years are needed.     

Colorectal Surgery After Kidney Transplantation: Characteristics of Early vs. Late Posttransplant Interventions

Background

The majority of colorectal complications after kidney transplantation reportedly occur <1 year of transplant. We aimed to identify differences in complications in the early and late posttransplant period.

Methods

We retrospectively reviewed kidney transplant recipients undergoing colorectal resection from 1 June 2000 to 1 June 2012 at a single institution, comparing patients by posttransplant year (<1 vs. >1 year). Measured outcomes included major complications, postoperative length of stay, perioperative mortality, reoperations, and readmissions.

Results

We identified 45 patients aged 31–77 (median 55). Gastrointestinal malignancy (31 %), diverticular disease (24 %), and ischemic colitis (16 %) were the most common indications for surgery. The early group (n?=?9) had more cases of ischemic colitis (44 vs. 6 %, p?=?0.01), emergent operations (100 vs. 33 %, p?=?0.0003), blood transfusion (78 vs. 31 %, p?=?0.02), longer length of stay (23.2?±?12 vs. 11.7?±?10 days, p?=?0.02), and higher mortality rate (33 vs. 6 %, p?=?0.05 compared to the late group (n?=?36)). There were no significant differences in major complications, reoperations, or readmissions.

Conclusions

Kidney transplant recipients undergoing colorectal resection <1 year of transplant have a higher incidence of emergency surgery and ischemic colitis compared with those with >1 year posttransplant. Despite these findings, patients with grafts <1 year had a similar postoperative complication rate to patients with grafts >1 year.     

Multicenter Study of Short- and Long-Term Outcomes of Laparoscopic Palliative Resection for Incurable, Symptomatic Stage IV Colorectal Cancer in Japan

Background

This Japanese multicenter retrospective study evaluated short- and long-term outcomes of palliative laparoscopic procedures for symptomatic stage IV colorectal cancer compared with conventional open procedures.

Methods

Of 968 eligible patients with stage IV colorectal cancer enrolled during January 2006–December 2007 from 41 participating surgical units (Japan Society of Laparoscopic Colorectal Surgery Group), we studied 409 patients who underwent palliative resection of symptomatic primary colorectal tumor.

Results

Data from patients with laparoscopic resection (n?=?98) and open colorectal resection (n?=?311) were analyzed. Eleven (11.2 %) laparoscopic operations were converted to an open procedure. Fewer complications were reported for laparoscopic resections than for open procedures (13.3 vs. 26.7 %; p?=?0.0042). Postoperative hospital stay was significantly shorter in the laparoscopic vs. open resection group (median, 14 vs. 17 days; p?=?0.0242). Postoperative chemotherapy treatment was administered to 245 (78.9 %) patients in the open and 78 (79.6 %) patients in the laparoscopic resection group. Time from surgery to start of postoperative chemotherapy was significantly shorter in the laparoscopic vs. open resection group (median, 32 vs. 27 days; p?=?0.0487). Median survival time between the two groups was not significantly different (22.0 vs. 22.2 months; p?=?0.948).

Conclusions

Laparoscopic palliative resection results in reduced postoperative complications and earlier recovery with acceptable long-term outcomes comparable with open surgery. When performed by experienced surgeons in selected patients, it may be a safe and feasible option. Because of the potential of significant bias arising from the included studies, further randomized controlled trials should be undertaken to confirm this bias.     

The effect of age on complications in women undergoing minimally invasive sacral colpopexy

Introduction and hypothesis

Previous research has demonstrated similar complication rates in older and younger women undergoing abdominal sacral colpopexy via laparotomy. The objective of this study was to compare perioperative complications in older and younger women undergoing minimally invasive sacral colpopexy.

Methods

This was a retrospective study of laparoscopic and robotic sacral colpopexies performed from January 2009 to May 2012 at a large academic center. Patient demographics, surgical data, and perioperative complications were compared in women Results A total of 302 women underwent minimally invasive sacral colpopexy during the study period. Mean age was 58.5?±?8.8 years and 84 subjects (27.8 %) were ≥65 years. Older women were more likely to have had a prior hysterectomy (60.7 vs 39.0 %, p?=?0.001) and had more severe preoperative prolapse (86.9 % vs 71.9 %?≥ POPQ stage III, p?=?0.01). There was no significant difference in duration of hospitalization (1.4 vs 1.4 days, p?=?0.54). Overall, there were significantly more major complications in women ≥?65 years (unadjusted OR 1.84, 95 % CI 1.02–3.35, p?=?0.04). After controlling for BMI, route of surgery, estimated blood loss (EBL), and operating room time, age ≥?65 remained a significant predictor of complications (adjusted OR 2.28, 95 % CI 1.21–4.29, p?=?0.01).

Conclusions

Our findings suggest that older women have a higher rate of major complications following minimally invasive sacral colpopexy, even after controlling for BMI, route of surgery, EBL, and operating room time. This increased risk should be addressed during preoperative counseling and may influence surgical planning.     

Long-Term Outcomes of Laparoscopic Surgery for Advanced Transverse Colon Cancer

Background

The role of laparoscopic surgery for advanced transverse colon cancer (TCC) remains controversial, especially in terms of long-term oncologic outcomes.

Methods

This retrospective cohort study enrolled 157 consecutive patients who underwent curable resections for advanced TCC between January 2002 and June 2011 (laparoscopic-assisted colectomy (LAC), n?=?74; open colectomy (OC), n?=?83). Short-term outcomes and oncologic long-term outcomes were compared between the two groups.

Results

Compared to the OC group, patients in the LAC group had less blood loss (LAC vs. OC, 79.6?±?70.3 vs. 158.4?±?89.3 ml, p?<?0.001), faster return of bowel function (2.6?±?0.7 vs. 3.8?±?0.8 days, p?<?0.001), and shorter postoperative hospital stay (10.3?±?3.7 vs. 12.6?±?6.0 days, p?=?0.007). Conversions were required in four (5.4 %) patients. Rates of short-term complication, mortality, and long-term complication were comparable between the two groups. The median follow-up time was 54 (26–106) months in the LAC group and 58 (29–113) months in the OC group (p?=?0.407). There were no statistical differences in the rates of 5-year overall survival (73.6 vs. 71.1 %, p?=?0.397) and 5-year disease-free survival (70.5 vs. 66.7 %, p?=?0.501) between the two groups.

Conclusions

Laparoscopic surgery for advanced TCC yield short-term benefits while achieving equivalent long-term oncologic outcomes.