Featured Articles in Apr 2018

Enhanced Recovery After Surgery for Low- and Middle-Income Countries

 

Author list: K. McQueen, R. Oodit, M. Derbew, P. Banguti, O. Ljungqvist 

 

Abstract:

The revolution of Enhanced Recovery After Surgery (ERAS) is sweeping high-income countries (HICs), improving surgical and anesthesia complication rates and outcomes, and saving healthcare dollars due to fewer complications and decreased length of stay in the hospital [1]. But ERAS is not only for HICs. We propose that a modified approach to ERAS would extend protocols to improving all types of surgery in low- and lower-middle-income countries (LMICs) and would proactively create responsible anesthesia, perioperative, and surgical systems that are cost and technology appropriate, and limit complications and hospital stays.

 

URL: http://rdcu.be/ImBm

 


Robot-Assisted Transaxillary Thyroidectomy (RATT): A Series Appraisal of More than 250 Cases from Europe

 

Author list: Gabriele Materazzi, Lorenzo Fregoli, Piermarco Papini, Sohail Bakkar, Malince Chicas Vasquez, Paolo Miccoli

 

Abstract:

Background

Robot-assisted transaxillary thyroidectomy (RATT) is widely accepted in Asian countries. However, concerns regarding the balance between its real advantages and safety and cost have been raised by North American authorities. In Europe, assessments have been limited by small numbers since now. The purpose here is to report a large European experience with RATT.

 

Methods

A retrospective analysis was conducted of 257 patients who underwent RATT for nodular disease between February 2012 and September 2016. Data collected included patient demographics, diagnosis, ultrasound-estimated mean thyroid volume and nodule size, type of resection, operative time, postoperative pain and morbidity, and the hospital length of stay. Pain was assessed by visual analog scale score 12 h postoperatively (on the first postoperative day, before discharge). Feasibility, effectiveness, and safety were the outcomes of interest. Follow-up of thyroid carcinoma patients was carried out measuring thyroglobulin levels and ultrasound examination (median follow-up 24 months (6–48 months)). First control after 12 months and successively once a year.

 

Results

There were 253 women and 4 men, with a mean age of 37.3 years. Indications included benign disease in 116, papillary carcinoma in 56, and indeterminate nodule in 85. Mean thyroid volume was 16.8 mL, and nodule size was 25.3 mm. A hemithyroidectomy was performed in 138 patients and total thyroidectomy in 118. The mean operative time was 77.5 min for the former and 99.7 min for the latter. One conversion was required. Complications included transient hypoparathyroidism in 7/118 (total thyroidectomy) patients (5.9%), transient vocal fold palsy in 3/257 (1.1%), 1 delayed tracheal injury (0.4%), and 3 postoperative hematoma (1.1%). Mean visual analog scale score was 1.79, and the mean length of stay was 1.6 days for hemithyroidectomy and 1.9 days for total thyroidectomy.

 

Conclusion

RATT is safe and effective and could serve as a viable treatment modality in selected cases.

 

URL: http://rdcu.be/ImB6

 


Postoperative Bleeding After Laparoscopic Pancreaticoduodenectomy: the Achilles’ Heel?

 

Author list: Sophie Chopinet, David Fuks, Mathieu Rinaudo, Julien Massol, Emilie Gregoire, Christian Lamer, Ajay Belgaumkar, Jean Hardwigsen, Yves-Patrice Le Treut, Brice Gayet

 

Abstract:

Background

Laparoscopic pancreaticoduodenectomy (LPD) is technically demanding, and its impact on postoperative outcomes remains controversial.

 

Methods

From 2002 to 2014, all consecutive patients undergoing LPD or OPD at two tertiary centers were retrospectively analyzed. Patients were matched for demographics, comorbidities, pathological diagnosis, and pancreatic texture. Results for the two groups were compared for postoperative outcomes.

 

Results

Sixty-five LPD were performed and compared to 290 OPD. In the whole population, postoperative pancreatic fistula (PF) was higher in the LPD group, but the proportion of ampullary adénocarcinoma (25 vs. 10%, p = 0.004) and soft pancreatic parenchyma (52 vs. 38%, p = 0.001) were higher in the LDP group. After matching (n = 65), LPD was associated with longer operative time (429 vs. 328 min, p < 0.001) and lower blood loss (370 vs. 515 mL, p = 0.047). The PF rate and its severity were similar (33 vs. 27%, p = 0.439, p = 0.083) in the two groups. However, both complications (78 vs. 71%, p = 0.030) and major complications (40 vs. 23%, p = 0.033) were more frequent in the LPD group. LPD patients experience more postoperative bleeding (21 vs. 14%, p = 0.025) compared to their open counterparts. In multivariate analysis, perioperative transfusion (OR = 5 IC 95% (1.5–16), p = 0.008), soft pancreas (OR = 2.5 IC 95% (1.4–4.6), p = 0.001), and ampullary adenocarcinoma (OR = 2.6 IC 95% (1.2–5.6), p = 0.015) were independent risks factors of major complications.

 

Conclusion

Despite lower blood loss and lower intraoperative transfusion, LPD leads to higher rate of postoperative complications with postoperative bleeding in particular.

 

URL: http://rdcu.be/ImC9

 


Repeated Resections of Hepatic and Pulmonary Metastases from Colorectal Cancer Provide Long-Term Survival

 

Author list: Jocelyn Bellier, Julien De Wolf, Mohamed Hebbar, Mehdi El Amrani, Christophe Desauw, Emmanuelle Leteurtre, Francois-Rene Pruvot, Henri Porte, Stephanie Truant

 

Abstract:

Background

Liver and lungs are the two most frequent sites of metastatic spread of colorectal cancer (CRC). Complete resection of liver and/or lung metastases is the only chance of cure, and several studies have reported an improved survival after an aggressive treatment. Nevertheless, CRC liver metastases (CLM) have been recognized as a pejorative factor for patients undergoing pulmonary metastasectomy. We report our experience with patients successively operated on for CRC hepatic and pulmonary metastasis (CPM) and seek to identify prognostic factors.

 

 

 

Methods

All consecutive patients who had resection of CPM and CLM between 2001 and 2014 were enrolled in the study. Clinicopathological and survival data were retrospectively analysed.

 

Results

Forty-six patients underwent resections of both CLM and CPM. Hepatic resection preceded pulmonary resection in most cases (91.3%). The median intervals between the resection of the primary tumour and the hepatic recurrence and between hepatic and pulmonary recurrences were 12 months [0–72] and 21.5 months [1–84], respectively. The mortality rate following CPM resection was 4.3%. After a median follow-up of 41.5 months [0–126], 35 patients recurred of whom 14 (40%) and 11(31.4%) could benefit from repeated resection of recurrent CLM and CPM, respectively. The median and 5-year overall survivals (OS) were 53 months and 49%, respectively. No prognostic factor was identified.

 

Conclusions

An aggressive management of CLM and CPM, including repeated resections, may provide a long-term survival comparable to survival of patients with unique metastasectomy. The absence of prognostic factor may reflect the highly selected pattern of the eligible patients.

 

URL: http://rdcu.be/ImEc

 


Incidence of Clinically Relevant Incisional Hernia After Colon Cancer Surgery and Its Risk Factors: A Nationwide Claims Study

 

Author list: Gi Hyeon Seo, Eun Kyung Choe, Kyu Joo Park, Young Jun Chai

 

Abstract:

Background

As there is scant literature focusing on incisional hernia for which hospital care is sought, the aim of this study was to elucidate the incidence and risk factors of overt incisional hernia (OIH) after colon cancer surgery using nationwide claims data.

 

Methods

Claims data of colon cancer patients who underwent regional colectomy were obtained from the Health Insurance Review and Assessment Service database of South Korea. Data from 2010 to 2012 were collected to ensure adequate follow-up. OIH was considered to be present when either the diagnosis code for IH or the claim code for IH repair was entered after index colectomy for colon cancer.

 

Results

A total of 24,645 patients underwent regional colectomy for colon cancer during the study period. Of these, 376 (1.5%) patients had an OIH within 3 years after surgery, and 50.3% of OIHs developed within the first year after the index colectomy (883.7 cases/10,000 patient-years). The Cox proportional hazard model showed that age >65 years, female gender, open colectomy, and institution volume <100 colectomies per year were statistically significant risk factors for OIH. The 3-year cumulative OIH incidence rates according to age >65 years, female gender, open colectomy, and institution volume <100 colectomies per year were 2.1, 2.1, 2.0, and 2.1%, respectively.

 

Conclusion

Several risk factors for OIH and its incidence after regional colectomy for colon cancer were identified. These findings are helpful for classifying patients undergoing segmental colectomy who have increased the likelihood of developing IH and are informative for patients and medical providers performing the surgery.

 

URL: http://rdcu.be/ImED

 


Clinicopathological Risk Factors for Distant Metastasis in Differentiated Thyroid Carcinoma: A Meta-analysis

 

Author list: Huy Gia Vuong, Uyen N. P. Duong, Thong Quang Pham, Hung Minh Tran, Naoki Oishi, Kunio Mochizuki, Tadao Nakazawa, Lewis Hassell, Ryohei Katoh, Tetsuo Kondo

 

Abstract:

Background

Distant metastasis (DM) is not a frequent event in differentiated thyroid carcinoma (DTC) but has an adverse impact on mortality of patients with DTC. In the current study, we aimed to conduct a comprehensive systematic review and meta-analysis to investigate the risk factors for DM in DTCs and for each histological subtype.

 

Methods

Five electronic databases were searched from inception to December 2016 for relevant articles. Pooled odd ratios and 95% confidence interval were calculated using random-effect model.

 

Results

Thirty-four articles with 73,219 patients were included for meta-analyses. In DTCs, male gender, age ≥45 years, tumor size ≥4 cm, multifocality, vascular invasion (VI), extrathyroidal extension (ETE), lymph node metastasis (LNM), and lateral LNM were demonstrated to be associated with significant risks for DM. In addition, several clinicopathological factors such as age ≥45 years, VI, ETE, and LNM were shown to be significant risk factors for DM in both PTC and FTC subgroups.

 

Conclusions

Our study demonstrated the promising value of several clinicopathological factors such as male gender, older age, VI, ETE, and LNM in predicting DM in PTCs and FTCs. Our study affirms the value of the selected clinicopathological factors for tumor risk stratification and assessment of patients’ prognosis.

 

URL: http://rdcu.be/ImFD

 


Unraveling Pancreatic Segmentation

 

Author list: Yohann Renard, Louis de Mestier, Manuela Perez, Claude Avisse, Philippe Levy, Reza Kianmanesh

 

Abstract:

Background

Limited pancreatic resections are increasingly performed, but the rate of postoperative fistula is higher than after classical resections. Pancreatic segmentation, anatomically and radiologically identifiable, may theoretically help the surgeon removing selected anatomical portions with their own segmental pancreatic duct and thus might decrease the postoperative fistula rate. We aimed at systematically and comprehensively reviewing the previously proposed pancreatic segmentations and discuss their relevance and limitations.

 

Methods

PubMed database was searched for articles investigating pancreatic segmentation, including human or animal anatomy, and cadaveric or surgical studies.

 

Results

Overall, 47/99 articles were selected and grouped into 4 main hypotheses of pancreatic segmentation methodology: anatomic, vascular, embryologic and lymphatic. The head, body and tail segments are gross description without distinct borders. The arterial territories defined vascular segments and isolate an isthmic paucivascular area. The embryological theory relied on the fusion plans of the embryological buds. The lymphatic drainage pathways defined the lymphatic segmentation. These theories had differences, but converged toward separating the head and body/tail parts, and the anterior from posterior and inferior parts of the pancreatic head. The rate of postoperative fistula was not decreased when surgical resection was performed following any of these segmentation theories; hence, none of them appeared relevant enough to guide pancreatic transections.

 

Conclusions

Current pancreatic segmentation theories do not enable defining anatomical–surgical pancreatic segments. Other approaches should be explored, in particular focusing on pancreatic ducts, through pancreatic ducts reconstructions and embryologic 3D modelization.

 

URL: http://rdcu.be/ImGd

 

 

 

 


 

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