Endoscopic Surgery: Ideal for Endocrine Surgery?

The laparoscopic approach of endocrine tumors is recent, the first reported resection of an adrenal gland in 1992. It represents a revolution in endocrine surgery equivalent to that observed in general surgery after the first cholecystectomy was performed in 1987. This new approach needs evaluation in terms of feasibility, indications, safety, and surgical procedure to define its potential advantages. The surgical technique and operative approaches of laparoscopic adrenalectomies are at the present time well defined and mostly accepted. Pancreatic approaches and resections, thyroidectomies, and parathyroidectomies are more confidential and performed only by rare teams. Nevertheless, the development of this technique is ineluctable. The spread of this technique, partly due to the increased quality of the technologies available, especially cameras, encounter a major brake that limits its generalization: If general surgeons commonly perform laparoscopy in their daily practice, they treat few patients presenting endocrine disorders. On the other hand, endocrine surgeons to whom many patients are referred do not have regular videoscopic practice. Endocrine surgery benefit few patients for these reasons. An analysis of the present state of the art allows us to imagine the evolution and future of videoscopic endocrine surgery.     

Is It Time to Lower the Bar for Bariatric Surgery?

A new position statement from the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) recommends that surgery be also considered for patients with class 1 obesity (BMI 30–35 kg/m²) with significant comorbidity, who have failed nonsurgical obesity treatments. These recommendations reflect the arbitrary nature of current BMI-based recommendations. However, it is essential that this new approach be carefully assessed with regard to outcomes, cost-effectiveness, and impact on access to care for those with more severe obesity.     

Does Time to Surgery Affect Outcomes for Periprosthetic Femur Fractures?

Background

Periprosthetic femur fractures around total hip (THA) and total knee (TKA) arthroplasties are difficult complications to manage. With native hip fractures, delay to fixation has been correlated with an increase in postoperative mortality. The effect of time to definitive fixation of periprosthetic femur fractures around THA and TKA is not well established. The aim of our study is to evaluate the effect of time to definitive fixation on postoperative length of stay and mortality for patients with periprosthetic femur fractures around THA and TKA.

Should We Deny Surgery for Malignant Hepato-Pancreatico-Biliary Tumors to Elderly Patients?

Malignant hepato-pancreatico-biliary (HPB) tumors have their highest incidence within the sixth to eighth decades of life. The aging of the world population has resulted in a dramatic increase in the number of elderly patients considered for resection of malignant HPB tumors. Because elderly patients are more likely to have more co-morbidities, cognitive impairment, and decreased life expectancy, the benefit and appropriateness of these procedures must be scrutinized for geriatric patients. Therefore, many surgeons have compared the perioperative and long-term outcome of hepatic and pancreatic resections for elderly and younger patients. In most series the elderly population was defined by an age of 70 years or older. The results demonstrate that hepatic resection for hepatocellular carcinoma and colorectal liver metastases can be safely performed in well-selected elderly patients with long-term outcome comparable to younger patients. Similar findings are also reported for pancreatic resection in elderly patients with either ampullary or pancreatic cancer. Although the survival benefit of pancreatico-duodenectomy is limited in all age groups, the absence of competitive therapy justifies this procedure as the sole curative option in younger as well as older patients. Data on resection of gallbladder cancer and hilar bile duct cancer in the elderly are sparse, but there is evidence from large series on resection of these types of tumors that advanced age per se is not a risk factor for reduced outcome. Therefore, surgical options should not be denied to elderly patients with a malignant HPB tumor, and the evaluation should include surgeons expert in HPB surgery.     

Endoscopic Surgery: Fit for Malignancy?

Neither experimental nor clinical data confirm the repeatedly published opinion that video-endoscopic surgery promotes tumor growth or the occurrence of implantation metastases in cancer patients. On the contrary, alterations due to pneumoperitoneum by the application of different gases, pressures, and temperatures might provide the basis for a new therapeutic approach to cancer surgery. Oncologically adequate resections defined by such terms as “no touch isolation” and “monobloc resection” can be performed video-endoscopically in a variety of intraabdominally or intrathoracically located cancers if a standardized technique is used. The benefit of video-endoscopic surgery is limited in large tumors, especially if they have reached the organ surface. There is still a major deficit in the clinical evaluation of video-endoscopic interventions in most oncologic diseases. Randomized studies comparing video-endoscopic and conventional surgery have been reported only for the resection of colorectal carcinoma. They show that laparoscopic resections can be performed with a minimum of postoperative complications to the same extent as conventional resections and offer several advantages during the early postoperative period. No reliable data from comparative trials are as yet available on the long-term results.     

Neoadjuvant Long-Course Chemoradiotherapy for Rectal Cancer: Does Time to Surgery Matter?

The objective of this paper was to evaluate whether delaying surgery following long-course chemoradiotherapy for rectal cancer correlates with pathologic complete response. Pre-operative chemoradiotherapy (CRT) is standard practice in the UK for the management of locally advanced rectal cancer. Optimal timing of surgery following CRT is still not clearly defined. All patients with a diagnosis of rectal cancer who had undergone long-course CRT prior to surgery between January 2008 and December 2011 were included. Statistical analysis was performed using Stata 11. Fifty-nine patients received long-course CRT prior to surgery in the selected period. Twenty-seven percent (16/59) of patients showed a complete histopathologic response and 59.3% (35/59) of patients had tumor down-staging from radiologically-assessed node positive to histologically-proven node negative disease. There was no statistically significant delay to surgery after completion of CRT in the 16 patients with complete response (CR) compared with the rest of the group [IR: incomplete response; CR group median: 74.5 days (IQR: 70–87.5) and IR group median: 72 days (IQR: 57–83), P = 0.470]. Although no statistically significant predictors of either complete response or tumor nodal status down-staging were identified in logistic regression analyses, a trend toward complete response was seen with longer delay to surgery following completion of long-course CRT.Key words: Interval to surgery, Rectal cancer, Long-course chemoradiotherapyIn the multimodal management of rectal cancer, surgical resection remains the mainstay of treatment. Total mesorectal excision (TME) has become the standard operative technique resulting in reduced rates of local recurrence compared with previous conventional surgery.^1,2 Apart from surgery, neoadjuvant radiotherapy is employed in resectable rectal cancer to reduce the risk of local recurrence, and in locally-advanced rectal cancer, to downsize the tumor and facilitate subsequent successful R0 resection or sphincter-preserving surgery.^3,4 Two meta-analyses have reported that preoperative radiotherapy plus surgery when compared with surgery alone significantly reduced the 5-year overall mortality rate, cancer-related mortality rate, and local recurrence rates in resectable rectal cancer.^5,6Preoperative radiotherapy is usually given either as a short- or long-course treatment schedule. Short-course radiotherapy typically involves 25 Gy in 5 fractions given in 1 week,⁷ whereas long-course treatment consists of 45 Gy given in 25 fractions over 5 weeks as standard⁸ with concomitant chemotherapy as a radiosensitizer. The Swedish Rectal Cancer Trial showed statistically significant reduction in the local recurrence rates and increase in the overall survival rates at a median follow-up of 13 years in the group receiving short-course preoperative radiotherapy compared with surgery alone.⁷ The Dutch trial also confirmed that short-course radiotherapy reduced the risk of local recurrence in patients who underwent a standardized TME.⁹ Although no chemotherapy was considered in the above studies, the EORTC Radiotherapy Group trial concluded that long-course preoperative radiotherapy with chemotherapy given either preoperatively or postoperatively conferred significant benefit in terms of local control, but did not improve survival.⁸ Finally, the German Rectal Cancer Study Group showed that preoperative chemoradiotherapy (CRT) compared with postoperative CRT improved local recurrence rates and was associated with reduced toxicity.¹⁰A 6 to 8 week interval to surgery from completion of neoadjuvant CRT has become standard practice since the results of the Lyons R90-01 study were published.¹¹ In this trial, a longer interval of 6 weeks when compared to 2 weeks post-CRT was associated with increased tumor down-staging.¹¹ However, it is not clear whether a yet longer delay before surgery might result in further tumor down-staging or in higher rates of pathologic complete response. The aim of our retrospective study was to evaluate whether a longer interval between completion of long-course CRT and surgery for locally-advanced rectal cancer might maximize the effectiveness of CRT in achieving complete response.     

Portal Hypertension: Contraindication to Liver Surgery?

Introduction In recent decades liver resection has become a safe procedure, mainly because of better patient selection. Despite this progress, however, outcomes of hepatectomy in cirrhotic patients with portal hypertension are still uncertain. The aim of this study was to elucidate early and long-term outcomes of liver resection in these patients. Methods Between 1985 and 2003, a total of 245 cirrhotic patients underwent hepatectomy for HCC. Altogether, 217 patients were eligible for this analysis and were divided into two groups according to the presence of portal hypertension at the time of surgery: 99 patients with portal hypertension and 118 without it. Results Patients with portal hypertension had worse preoperative liver function (Child-Pugh A class patients: 66.7% vs. 94.9%; P < 0.0001). No differences were encountered in terms of intraoperative and pathology data. Operative mortality was similar (11.1% vs. 5.1%; P = 0.100), but patients with portal hypertension had higher morbidity (43.4% vs. 30.5%; P = 0.049) and received a higher rate of blood and plasma transfusions (51.5% vs. 32.2%, P = 0.004; 77.8% vs. 57.6%, P = 0.0017). Considering only Child-Pugh A patients, short-term results were similar in the two groups in terms of mortality, morbidity, and transfusion rates. The 5-year survival rate was significantly higher in patients without portal hypertension (39.8% vs. 28.9%; P = 0.020), although when considering only Child-Pugh A patients no difference of survival was encountered. Multivariate analysis identified Child-Pugh classification, tumor diameter, and vascular invasion as independent predicting factors for survival. Conclusions Portal hypertension should not be considered an absolute contraindication to hepatectomy in cirrhotic patients. Child-Pugh A patients with portal hypertension have short- and long-term results similar to patients with normal portal pressure.