Laparoscopy-assisted gastrectomy versus open gastrectomy for resectable gastric cancer: an update meta-analysis based on randomized controlled trials

Background

We carry out a meta-analysis to evaluate the effectiveness and safety of laparoscopy-assisted gastrectomy (LAG) versus open gastrectomy for resectable gastric cancer.

Methods

We searched EMBASE, the Cochrane Library, PubMed, Science Citation Index (SCI), Chinese biomedicine literature database to identify randomized controlled trials (RCTs) from their inception to April 2012. Meta-analyses were performed using RevMan 5.0 software. It was in line with the preferred reporting items for systematic reviews and meta-analyses statement. The quality of evidence was assessed by GRADEpro 3.6.

Results

Eight RCTs totaling 784 patients were analyzed. Compared with open gastrectomy group, no significant differences were found in postoperative mortality (OR = 1.49; 95 % CI 0.29–7.79), anastomotic leakage (OR = 1.02; 95 % CI 0.24–4.27) , overall mean number of harvested lymph nodes [weighed mean difference (MD) = ?3.17; 95 % CI ?6.39 to 0.05]; the overall postoperative complication morbidity (OR = 0.54; 95 % CI 0.36–0.82), estimated blood loss (MD = ?107.23; 95 % CI ?148.56 to ?65.89,) frequency of analgesic administration (MD = ?1.69; 95 % CI ?2.18 to ?1.21, P < 0.00001), incidence of pulmonary complications (OR = 0.43, 95 % CI 0.20–0.93, P = 0.03) were significantly less in LAG group; LAG had shorter time to start first flatus (MD = ?0.23; 95 % CI ?0.41 to ?0.05) and decreased hospital stay (MD = ?1.72; 95 % CI ?3.40 to 0.04), but, LAG still had longer operation time (MD = 76.70; 95 % CI 51.54–101.87).

Conclusions

On the basis of this meta-analysis we conclude that although LAG was still a time-consuming and technically dependent procedure, it has the advantage of better short-term outcome. Long term survival data from other studies are urgently needed to estimate the survival benefit of this technique.     

Progression from laparoscopic-assisted to totally laparoscopic distal gastrectomy: comparison of circular stapler (i-DST) and linear stapler (BBT) for intracorporeal anastomosis

Background

Billroth I (B-I) gastroduodenostomy is an anastomotic procedure that is widely performed after gastric resection for distal gastric cancer. A circular stapler often is used for B-I gastroduodenostomy in open and laparoscopic-assisted distal gastrectomy. Recently, totally laparoscopic distal gastrectomy (TLDG) has been considered less invasive than laparoscopic-assisted gastrectomy, and many institutions performing laparoscopic-assisted distal gastrectomy are trying to progress to TLDG without markedly changing the anastomosis method. The purpose of this report is to introduce the technical details of new methods of intracorporeal gastroduodenostomy using either a circular or linear stapler and to evaluate their technical feasibility and safety.

Methods

Seventeen patients who underwent TLDG with the intracorporeal double-stapling technique using a circular stapler (n = 7) or the book-binding technique (BBT) using a linear stapler (n = 10) between February 2010 and April 2011 were enrolled in the study. Clinicopathological data, surgical data, and postoperative outcomes were analyzed.

Results

There were no intraoperative complications or conversions to open surgery in any of the 17 patients. The usual postoperative complications following gastroduodenostomy, such as anastomotic leakage and stenosis, were not observed. Anastomosis took significantly longer to complete with DST (64 ± 24 min) than with BBT (34 ± 7 min), but more stapler cartridges were needed with BBT than with DST.

Conclusions

TLDG using a circular or linear stapler is feasible and safe to perform. DST will enable institutions performing laparoscopic-assisted distal gastrectomy with circular staplers to progress to TLDG without problems, and this progression may be more economical because fewer stapler cartridges are used during surgery. However, if an institution has already been performing δ anastomosis in TLDG but has been experiencing certain issues with δ anastomosis, converting from δ anastomosis to BBT should be beneficial.     

Fast-track surgery in gastrectomy for gastric cancer: a systematic review and meta-analysis

Purpose

Fast-track surgery aims to attenuate the surgical stress response, reduce complications, and shorten hospital stay. The goal of the present meta-analysis is to assess the safety and effectiveness of fast-track surgery in patients undergoing gastrectomy for gastric cancer compared with conventional perioperative care.

Methods

PubMed, Embase, the Cochrane Central Register of Controlled Trials, and reference lists of the identified studies were searched to identify randomized clinical trials that compared fast-track surgery with conventional perioperative care in patients undergoing gastrectomy for gastric cancer.

Results

Five studies with a total of 400 patients were included in the meta-analysis. Meta-analysis shows that postoperative hospital stay (weighted mean difference (WMD) ?1.87 days, 95 % confidence interval (CI), ?2.46 to ?1.28 days, P?<?0.00001), time to first passage of flatus (WMD ?0.71 days, 95 % CI, ?1.03 to ?0.39 days, P?<?0.0001), and hospital costs (WMD ?505.87 dollars, 95 % CI, ?649.91 to ?361.84 dollars, P?<?0.00001) were significantly reduced for fast-track surgery. No significant differences were found for readmission rates (relative risk (RR), 1.97 95 % CI, 0.37 to 10.64, P?=?0.43) and total postoperative complications (RR, 0.99 95 % CI, 0.56 to 1.76, P?=?0.97).

Conclusions

Fast-track surgery is safe and effective in gastrectomy for gastric cancer. Further randomized trials are needed to strengthen the conclusions.     

A Body Shape Index Has a Good Correlation with Postoperative Complications in Gastric Cancer Surgery

Background

The relationship between obesity and surgical complications has been controversial. A Body Shape Index (ABSI) is a newly developed anthropometric index based on waist circumference adjusted for height and weight. The aim of this study was to investigate the relationship between ABSI and surgical complications.

Methods

From November 2001 to September 2012, 4,813 patients underwent curative resection for gastric cancer. ABSI was defined as waist circumference divided by (BMI^2/3height^1/2). Data of clinicopathologic characteristics and morbidity were collected by retrospective review. Binary logistic regression was used for multivariable analyses to determine whether ABSI was independently associated with postoperative complications.

Results

The incidence of overall surgical complications was 13.4 %, and the most common complication was ileus (2.8 %). In the multivariable analysis, ABSI was an independent factor for overall complications [odds ratio (OR), 1.22; 95 % confidence interval (CI) 1.01–1.48; P = 0.041). However, BMI showed no statistical significance (OR, 1.03; 95 % CI 1.00–1.06; P = 0.063). In the subgroup analyses, ABSI was significantly associated with overall complications regarding open gastrectomy (OR, 1.26; 95 % CI 1.01–1.57; P = 0.039). Regarding laparoscopy-assisted gastrectomy, ABSI had no significant effect on overall complications (P = 0.844).

Conclusions

ABSI shows good correlation with surgical complications in patients with gastric cancer. Further studies are needed for the various clinical roles of ABSI, and the results could be helpful to determine the effect of abdominal obesity on gastric cancer surgery and the clinical usefulness of ABSI.     

Systematic review with meta-analysis of prospective randomized trials comparing minimally invasive video-assisted thyroidectomy (MIVAT) and conventional thyroidectomy (CT)

Background

Minimally invasive video-assisted thyroidectomy (MIVAT) has gained acceptance among surgeons as its feasibility has been well documented. The aim of this systematic review with meta-analysis has been to assess and validate the safety and feasibility of MIVAT when compared to conventional thyroidectomy (CT) and to verify other potential benefits and drawbacks.

Methods

A literature search for prospective randomized trials comparing MIVAT and CT was performed. Trials were reviewed for the primary outcome measures: overall morbidity, recurrent laryngeal nerve palsy, postoperative hypocalcemia, and postoperative hematoma; and for the secondary outcome measures: operative time, conversion to standard procedure, intraoperative blood loss, intraoperative drain insertion, nodule size and thyroid weight, postoperative pain evaluation, length of hospital stay, patient satisfactory score, and cosmetics results. Standardized mean difference (SMD) was calculated for continuous variables and odds ratio for qualitative variables.

Results

Nine prospective randomized studies comparing MIVAT and CT were analyzed. Overall, 581 patients were randomized to either MIVAT (289, 49.7 %) or CT (292, 50.3 %). The primary outcome measures of MIVAT were comparable with those of CT without statistically significant difference. Patients who underwent MIVAT experienced significantly less pain than those operated on conventionally during the whole postoperative period. Patient satisfactory score significantly favored MIVAT (9.0 vs. 6.8, SMD?=??3.388, 95 % CI?=??5.720 to ?1.057). Operative time was significantly longer in MIVAT (75.2 vs. 59.2 min, SMD?=?1.246, 95 % CI?=?0.227–2.266).

Conclusions

MIVAT is a safe and feasible alternative for the removal of small-volume benign thyroid disease and low-risk papillary thyroid carcinomas showing better cosmetics results and less postoperative pain but significantly longer operative time when compared to CT. New multicenter randomized studies are needed to evaluate the technique in more complex circumstances such as intermediate-risk thyroid cancer, lymph node removal, thyroiditis, and Graves’ disease.     

External Stent Versus No Stent for Pancreaticojejunostomy: A Meta-analysis of Randomized Controlled Trials

Background

The effectiveness of an external pancreatic duct stent for reduction of the pancreatic fistula after pancreaticoduodenectomy remains controversial.

Methods

MEDLINE, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials were searched for eligible randomized controlled trials (RCTs). Reviews of each trial were conducted and data were extracted. The primary outcome was pancreatic fistula. Statistical pooling used the fixed or random effects model and reported as risk ratio (RR) or mean difference (MD) with the corresponding 95 % confidence intervals (CI).

Results

Four RCTs including a total of 416 patients were detected. Methodological quality assessment revealed a better quality of all analyzed trials. Placing an external stent across pancreaticojejunal anastomosis could significantly reduce the incidence of pancreatic fistula (RR?=?0.57, 95 % CI?=?0.41–0.80, P?=?0.001, I ²?=?0 %), overall morbidity (RR?=?0.79, 95 % CI?=?0.64–0.98, P?=?0.03), and the length of hospital stay (MD?=??3.98 days, 95 % CI?=??6.42 to ?1.54, P?=?0.001, I ²?=?13 %). No significant difference was found in terms of hospital mortality, delayed gastric emptying, operation time, operative blood loss, blood replacement, and reoperation rate.

Conclusions

This meta-analysis provides compelling evidence that the application of an external pancreatic duct stent after pancreaticoduodenectomy can decrease the incidence of pancreatic leakage when compared with no stent. Moreover, the external drainage of pancreatic juice is associated with lower postoperative overall morbidity and shorter hospital stay.     

Laparoscopic total gastrectomy versus open total gastrectomy for cancer: a systematic review and meta-analysis

Background

The possible advantages of laparoscopic (assisted) total gastrectomy (LTG) versus open total gastrectomy (OTG) have not been reviewed systematically. The aim of this study was to systematically review the short-term outcomes of LTG versus OTG in the treatment of gastric cancer.

Methods

A systematic search of PubMed, Cochrane, CINAHL, and Embase was conducted. All original studies comparing LTG with OTG were included for critical appraisal. Data describing short-term outcomes were pooled and analyzed.

Results

A total of eight original studies that compared LTG (n = 314) with OTG (n = 384) in patients with gastric cancer fulfilled quality criteria and were selected for review and meta-analysis. LTG compared with OTG was associated with a significant reduction of intraoperative blood loss (weighted mean difference = 227.6 ml; 95 % CI 144.3–310.9; p < 0.001), a reduced risk of postoperative complications (risk ratio = 0.51; 95 % CI 0.33–0.77), and shorter hospital stay (weighted mean difference 4.0 = days; 95 % CI 1.4–6.5; p < 0.001). These benefits were at the cost of longer operative time (weighted mean difference = 55.5 min; 95 % CI 24.8–86.2; p < 0.001). In-hospital mortality rates were comparable for LTG (0.9 %) and OTG (1.8 %) (risk ratio = 0.68; 95 % CI 0.20–2.36).

Conclusion

LTG shows better short term outcomes compared with OTG in eligible patients with gastric cancer. Future studies should evaluate 30- and 60-day mortality, radicality of resection, and long-term follow-up in LTG versus OTG, preferably in randomized trials.     

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.     

Does using comprehensive preoperative bowel preparation offer any advantage for urinary diversion using ileum? A meta-analysis

Purpose

The aim of this study was to compare the efficacy of comprehensive bowel preparation to that of limited bowel preparation in prevention of postoperative complications in elective urinary diversion surgery by using ileum.

Methods

Literature search of PubMed, EMBASE and the Cochrane Library was done to identify randomized controlled trials (RCTs) and cohort studies involving comparison of postoperative complications after comprehensive bowel preparation and limited bowel preparation. A meta-analysis was carried out to distinguish overall differences between the two groups.

Results

Our literature search yielded two randomized controlled trials and two cohort studies, involving a total of 346 patients, which met our inclusion criteria. There was no significant difference between the comprehensive bowel preparation and limited bowel preparation in wound infection [relative risk (RR) 95 % confidence interval (CI), 1.05(0.46–2.40); P = 0.86], mortality [RR 95 % CI, 1.06 (0.32–3.55); P = 0.76], ileus [RR 95 % CI, 0.86 (0.37, 2.00); P = 0.40], sepsis [RR 95 % CI, 0.71 (0.20, 2.52); P = 0.78], anastomotic leakage [RR 95 % CI, 0.81 (0.15, 4.21); P = 0.83], wound dehiscence [RR 95 % CI, 0.92 (0.40, 2.13); P = 0.67], peritonitis [RR 95 % CI, 0.64 (0.08, 5.10); P = 0.63] or fistula [RR 95 % CI, 0.71 (0.18,2.75); P = 0.63].

Conclusions

The limited evidence available demonstrated that the use of comprehensive bowel preparation for urinary diversion surgery using ileum does not offer any significant advantage over limited bowel preparation. Future work should target more high-quality RCTs to confirm this.     

Nephrolithiasis,bone mineral density,osteoporosis, and fractures: a systematic review and comparative meta-analysis

Summary

Our meta-analysis demonstrates that people with nephrolithiasis have decreased bone mineral density, an increased odds of osteoporosis, and potentially an elevated risk of fractures.

Introduction

People with nephrolithiasis might be at risk of reduced bone mineral density (BMD) and fractures, but the data is equivocal. We conducted a meta-analysis to investigate if patients with nephrolithiasis have worse bone health outcomes (BMD), osteoporosis, and fractures versus healthy controls (HCs).

Methods

Two investigators searched major databases for articles reporting BMD (expressed as g/cm² or a T- or Z-score), osteoporosis or fractures in a sample of people with nephrolithiasis, and HCs. Standardized mean differences (SMDs), 95 % confidence intervals (CIs) were calculated for BMD parameters; in addition odds (ORs) for case-control and adjusted hazard ratios (HRs) in longitudinal studies for categorical variables were calculated.

Results

From 1816 initial hits, 28 studies were included. A meta-analysis of case-control studies including 1595 patients with nephrolithiasis (mean age 41.1 years) versus 3402 HCs (mean age 40.2 years) was conducted. Patients with nephrolithiasis showed significant lower T-scores values for the spine (seven studies; SMD?=??0.69; 95 % CI?=??0.86 to ?0.52; I ²?=?0 %), total hip (seven studies; SMD?=??0.82; 95 % CI?=??1.11 to ?0.52; I ²?=?72 %), and femoral neck (six studies; SMD?=??0.67; 95 % CI?=???1.00 to ?0.34; I ²?=?69 %). A meta-analysis of the case-controlled studies suggests that people with nephrolithiasis are at increased risk of fractures (OR?=?1.15, 95 % CI?=?1.12–1.17, p?<?0.0001, studies?=?4), while the risk of fractures in two longitudinal studies demonstrated trend level significance (HR?=?1.31, 95 % CI?=?0.95–1.62). People with nephrolithiasis were four times more likely to have osteoporosis than HCs (OR?=?4.12, p?<?0.0001).

Conclusions

Nephrolithiasis is associated with lower BMD, an increased risk of osteoporosis, and possibly, fractures. Future screening/preventative interventions targeting bone health might be indicated.

     

Risk Factors Associated with Complication Following Gastrectomy for Gastric Cancer: Retrospective Analysis of Prospectively Collected Data Based on the Clavien–Dindo System

Background

Most studies about complication after gastric cancer surgery have been performed without consideration of the severity of each complication. The purposes of this study were to prospectively analyze all postgastrectomy complications according to severity using Clavien–Dindo classification and to identify risk factors related to postoperative complications.

Methods

Complication data were collected prospectively through weekly conferences with all gastric adenocarcinoma patients who underwent gastrectomy between March 2011 and February 2012 at Seoul National University Hospital. Complications were categorized according to the Clavien–Dindo classification.

Results

Out of the 881 patients who underwent gastrectomy, there were 254 events in 197 patients (22.4 %). The numbers of grade I, II, IIIa, IIIb, IVa, and V complications according to the Clavien–Dindo classification were 71 (8.1 %), 58 (6.6 %), 108 (12.3 %), 8 (0.9 %), 5 (0.6 %), and 4 (0.5 %), respectively. Extended gastrectomy (odds ratio [OR], 3.92; 95 % confidence interval [CI], 1.96–7.82, p?<?0.001), total gastrectomy (OR, 1.97; 95 % CI, 1.24–3.14, p?=?0.004), and age of 60 years or more (OR, 1.66; 95 % CI, 1.15–2.38, p?=?0.007) were found to be significant independent risk factors for overall complications of gastrectomy. These three factors were also risk factors for the complications of grade IIIa or over and local and systemic complications. In addition, ASA 3 or 4 and moderate or severe malnutrition as well as those three factors were risk factors for systemic complications.

Conclusion

Age and the extent of gastrectomy were revealed as the prognostic factors for overall complications and the complications of grade IIIa or over according to the Clavien–Dindo classification following gastrectomy for gastric cancer.     

Poor Survival Rate in Patients with Postoperative Intra-Abdominal Infectious Complications Following Curative Gastrectomy for Gastric Cancer

Background

The impact of postoperative complications on recurrence rate and long-term outcome has been reported in patients with colorectal and esophageal cancer, but not in patients with gastric cancer. This study evaluated the impact of postoperative intra-abdominal infectious complications on long-term survival following curative gastrectomy.

Methods

This study included 765 patients who underwent curative gastrectomy for gastric cancer between 2002 and 2006. Patients were divided into 2 groups: with (C-group, n = 81) or without (NC-group, n = 684) intra-abdominal infectious complications. Survival curves were compared between the groups, and multivariate analysis was conducted to identify independent prognostic factors.

Results

Male patients were dominant, and total gastrectomy was frequently performed in the C-group. The pathological stage was more advanced and D2 lymph node dissection and splenectomy were preferred in the C-group. The 5-year overall survival (OS) rate was better in the NC-group (86.8 %) than in the C-group (66.4 %; P < .001). The 5-year relapse-free survival (RFS) rate was also better in the NC-group (84.5 %) than in the C-group (64.9 %; P < .001). This trend was still observed in stage II and III patients after stratification by pathological stage. Multivariate analysis identified intra-abdominal infectious complication as an independent prognostic factor for OS (hazard ratio, 2.448; 95 % confidence interval [95 % CI], 1.475–4.060) and RFS (hazard ratio, 2.219; 95 % CI, 1.330–3.409) in patients with advanced disease.

Conclusions

Postoperative intra-abdominal infectious complications adversely affect OS and RFS. Meticulous surgery is needed to decrease the complication rate and improve the long-term outcome of patients following curative gastrectomy.     

Robotic versus Open Pancreatectomy: A Systematic Review and Meta-analysis

Background

Robotic surgery is gaining momentum with advantages for minimally invasive management of pancreatic diseases. The objective of this meta-analysis is to compare the clinical and oncologic safety and efficacy of robotic versus open pancreatectomy.

Methods

A systematic review of the literature was performed to identify studies comparing robotic pancreatectomy and open pancreatectomy. Postoperative outcomes, intraoperative outcomes, and oncologic safety were evaluated. Meta-analysis was performed using a random-effect model.

Results

Seven studies matched the selection criteria, including 137 (40 %) cases of robotic pancreatectomy and 203 (60 %) cases of open pancreatectomy. None of the included studies were randomized. Overall complication rate was significantly lower in robotic group [risk difference (RD) = ?0.12, 95 % confidence interval (CI) ?0.22 to ?0.01, P = 0.03], as well as reoperation rate (RD = ?0.12; CI ?0.2 to ?0.03, P = 0.006) and margin positivity (RD = ?0.18; 95 % CI ?0.3 to ?0.06, P = 0.003). There was no significant difference in postoperative pancreatic fistula (POPF) incidence and mortality. The median (range) conversion rate was 10 % (0–12 %).

Conclusions

The results of this meta-analysis suggest that robotic pancreatectomy is as safe and efficient as, if not superior to, open surgery for patients with benign or malignant pancreatic diseases. However, the evidence is limited and more randomized controlled trials are needed to further clearly define this role.     

Laparoscopic-assisted versus open total mesorectal excision with anal sphincter preservation for mid and low rectal cancer: a prospective, randomized trial

Background

This single-center, prospective, randomized trial was designed to compare the short-term clinical outcome between laparoscopic-assisted versus open total mesorectal excision (TME) with anal sphincter preservation (ASP) in patients with mid and low rectal cancer. Long-term morbidity and survival data also were recorded and compared between the two groups.

Methods

Between August 2001 and August 2007, 80 patients with mid and low rectal cancer were randomized to receive either laparoscopic-assisted (40 patients) or open (40 patients) TME with ASP. The median follow-up time for all patients was 75.7 (range 16.9–115.7) months for the laparoscopic-assisted group and 76.1 (range 4.7–126.6) months for the open group. The primary endpoint of the study was short-term clinical outcome. Secondary endpoints included long-term morbidity rate and survival. Data were analyzed by intention-to-treat principle.

Results

The demographic data of the two groups were comparable. Postoperative recovery was better after laparoscopic surgery, with less analgesic requirement (P < 0.001), earlier mobilization (P = 0.001), lower short-term morbidity rate (P = 0.043), and a trend towards shorter hospital stay (P = 0.071). The cumulative long-term morbidity rate also was lower in the laparoscopic-assisted group (P = 0.019). The oncologic clearance in terms of macroscopic quality of the TME specimen, circumferential resection margin involvement, and number of lymph nodes removed was similar between both groups. After curative resection, the probabilities of survival at 5 years of the laparoscopic-assisted and open groups were 85.9 and 91.3 %, respectively (P = 0.912). The respective probabilities of being disease-free were 83.3 and 74.5 % (P = 0.114).

Conclusions

Laparoscopic-assisted TME with ASP improves postoperative recovery, reduces short-term and long-term morbidity rates, and seemingly does not jeopardize survival compared with open surgery for mid and low rectal cancer (http://ClinicalTrials.gov Identifier: NCT00485316).     

Baseline Mortality-Adjusted Survival in Resected Rectal Cancer Patients

Background

This investigation assessed the baseline mortality-adjusted 5-year survival after open rectal cancer resection.

Methods

The 5-year survival rate was analyzed in 885 consecutive American Joint Committee on Cancer (AJCC) stage I–IV rectal cancer patients undergoing open resection between 2002 and 2011 using risk-adjusted Cox proportional hazards regression models adjusted for population-based baseline mortality.

Results

The 5-year relative and overall survival rates were 80.9 %(95 % confidence interval (CI): 77.0–85.0 %) and 71.9 %(95 % CI, 68.4–75.5 %), respectively. The 5-year relative survival rates for stage I, II, III, and IV cancer were 97.8 % (95 % CI, 93.1–102.8 %), 90.9 %(95 % CI, 84.3–98.1 %), 72.0 % (95 % CI, 64.7–80.1 %), and 24.4 % (95 % CI: 16.0–37.0 %), respectively. After the curative resection of stage I–III rectal cancer, fewer than every other observed death was cancer-related. The 5-year relative survival rate for stage I cancer did not differ from the matched average national baseline mortality rate (P?=?0.419). Higher age (hazard ratio (HR) 0.94, 95 % CI: 0.92–0.95, P?P?P?=?0.014).

Conclusion

The analysis of relative survival in a large cohort of rectal cancer patients revealed that stage I rectal cancer is fully curable. The findings regarding age and gender may explain the conflicting results obtained to date from studies based on overall survival.     

Feasibility and Nutritional Impact of Laparoscopy-assisted Subtotal Gastrectomy for Early Gastric Cancer in the Upper Stomach

Background

Laparoscopy-assisted total gastrectomy (LATG) is commonly performed for early gastric cancer (EGC) in the upper stomach; however, the incidence of anastomotic complications remains high, and postoperative nutritional status is not satisfactory. This study aimed to evaluate the feasibility and nutritional impact of a novel surgical procedure, laparoscopy-assisted subtotal gastrectomy (LAsTG).

Methods

This was a retrospective study of 167 patients with EGC in the upper stomach. Of these, 57 patients underwent LAsTG, while 110 patients underwent LATG. Postoperative change in body weight, and serum concentration of albumin (Alb) and total protein (TP) were compared between the LAsTG and LATG groups. Analysis of covariance (ANCOVA) was used to assess the influence of potential confounding factors.

Results

Frequency of anastomotic complications was significantly higher in the LATG group (16.3 %) than in the LAsTG group (5.3 %, P = 0.040). Postoperative recovery of body weight at 12 months after surgery was significantly better in the LAsTG group (89.8 ± 1.4 %) than in the LATG group (82.1 ± 1.0 %, P < 0.001). By ANCOVA, adjusted mean differences of Alb and TP at 12 months after surgery between the LAsTG and LATG groups were 0.226 g/dl (95 % CI 0.141–0.312; P < 0.001) and 0.380 g/dl (95 % CI 0.265–0.495; P < 0.001); thus, the surgical procedure was significantly associated with the postoperative Alb and TP levels.

Conclusions

LAsTG could be a better choice than LATG for EGC in the upper stomach as a result of improvements in the incidence of anastomotic complications and postoperative nutritional status.     

Impact of positive surgical margins and their locations after radical prostatectomy: comparison of biochemical recurrence according to risk stratification and surgical modality

Purpose

We investigated the influence of positive surgical margins (PSMs) and their locations on biochemical recurrence (BCR) according to risk stratification and surgical modality.

Methods

A total of 1,874 post-radical-prostatectomy (RP) patients of pT2–T3a between 2000 and 2010 at three tertiary centers, and who did not receive neoadjuvant/adjuvant therapy, were included in this study. Patients were stratified according to BCR risk: low risk (PSA <10, pT2a-b, and pGS ≤6), intermediate risk (PSA 10–20 and/or pT2c and/or pGS 7), and high risk (PSA >20 or pT3a or pGS 8–10). The median follow-up was 43 months.

Results

PSMs were a significant predictor of BCR in both the intermediate- and high-risk-disease groups (P = .001, HR 2.1, 95 % CI 1.3–3.4; P < .001, HR 2.8, 95 % CI 2.0–4.1). Positive apical margin was a significant risk factor for BCR in high-risk disease (P = .003, HR 2.0, 95 % CI 1.2–3.3), but not in intermediate-risk disease (P = .06, HR 1.7, 95 % CI 0.9–3.1). Positive bladder neck margin was a significant risk factor for BCR in both intermediate- and high-risk disease (P < .001, HR 5.4, 95 % CI 2.1–13.8; P = .001, HR 4.5, 95 % CI 1.8–11.4). In subgroup analyses, robotic RP provided comparable BCR-free survival regardless of risk stratification. Patients with PSMs showed similar BCR-free survival between open and robotic RP (log-rank, P = .897).

Conclusions

Post-RP PSMs were a significantly independent predictor of disease progression in high-risk disease as well as intermediate-risk disease. Both positive apical and bladder neck margins are also significant risk factors of BCR in high-risk disease. Patients with PSMs showed similar BCR-free survival between open and robotic surgery.     

Effect of a multifactorial fall-and-fracture risk assessment and management program on gait and balance performances and disability in hospitalized older adults: a controlled study

Summary

This controlled intervention study in hospitalized oldest old adults showed that a multifactorial fall-and-fracture risk assessment and management program, applied in a dedicated geriatric hospital unit, was effective in improving fall-related physical and functional performances and the level of independence in activities of daily living in high-risk patients.

Introduction

Hospitalization affords a major opportunity for interdisciplinary cooperation to manage fall-and-fracture risk factors in older adults. This study aimed at assessing the effects on physical performances and the level of independence in activities of daily living (ADL) of a multifactorial fall-and-fracture risk assessment and management program applied in a geriatric hospital setting.

Methods

A controlled intervention study was conducted among 122 geriatric inpatients (mean?±?SD age, 84?±?7 years) admitted with a fall-related diagnosis. Among them, 92 were admitted to a dedicated unit and enrolled into a multifactorial intervention program, including intensive targeted exercise. Thirty patients who received standard usual care in a general geriatric unit formed the control group. Primary outcomes included gait and balance performances and the level of independence in ADL measured 12?±?6 days apart. Secondary outcomes included length of stay, incidence of in-hospital falls, hospital readmission, and mortality rates.

Results

Compared to the usual care group, the intervention group had significant improvements in Timed Up and Go (adjusted mean difference [AMD]?=??3.7s; 95 % CI?=??6.8 to ?0.7; P?=?0.017), Tinetti (AMD?=??1.4; 95 % CI?=??2.1 to ?0.8; P?<?0.001), and Functional Independence Measure (AMD?=?6.5; 95 %CI?=?0.7–12.3; P?=?0.027) test performances, as well as in several gait parameters (P?<?0.05). Furthermore, this program favorably impacted adverse outcomes including hospital readmission (hazard ratio?=?0.3; 95 % CI?=?0.1–0.9; P?=?0.02).

Conclusions

A multifactorial fall-and-fracture risk-based intervention program, applied in a dedicated geriatric hospital unit, was effective and more beneficial than usual care in improving physical parameters related to the risk of fall and disability among high-risk oldest old patients.     

Antiviral Therapy Decreases Recurrence of Hepatitis B Virus-related Hepatocellular Carcinoma after Curative Resection: A Meta-analysis

Background

The long-term outcome after curative resection of hepatocellular carcinoma (HCC) remains unsatisfactory because of the high incidence of recurrence. The present study was intended to assess the impact of hepatitis B virus (HBV) DNA level and nucleos(t)ide analog therapy on posthepatectomy recurrence of HBV-related HCC.

Methods

Eligible studies were identified through a computerized literature search. The pooled relative risk ratio (RR) with 95 % confidence interval (CI) was calculated using Review Manager 5.1 Software.

Results

Twenty studies with a total of 8,204 participants were included for this meta-analysis. Pooled analysis showed that high viral load was significantly associated with risk of recurrence (RR: 1.85, 95 % CI: 1.41–2.42; P < 0.001), poorer disease-free survival (DFS) (RR: 1.96, 95 % CI: 1.62–2.38; P < 0.001), and poorer overall survival (OS) (RR: 1.47, 95 % CI: 1.22–1.77; P < 0.001) of HBV-related HCC after surgical resection. Nucleos(t)ide analog therapy significantly decreased the recurrence risk (RR: 0.69, 95 % CI: 0.59–0.80; P < 0.001) and improved both DFS (RR: 0.70, 95 % CI: 0.58–0.83; P < 0.001) and OS (RR: 0.46, 95 % CI: 0.32–0.68; P < 0.001).

Conclusions

High DNA level is associated with posthepatectomy recurrence of HBV-related HCC. Nucleos(t)ide analog therapy improves the prognosis of HBV-related HCC after resection.