Featured Articles in Mar 2019

Guidelines for Perioperative Care in Elective Colorectal Surgery: ERAS® Society Recommendations 2018

 

 

 Author list  U. O. Gustafsson, M. J. Scott, M. Hubner, J. Nygren, N. Demartines, N. Francis, T. A. Rockall, T. M. Young-Fadok, A. G. Hill, M. Soop, H. D. de Boer, R. D. Urman, G. J. Chang, A. Fichera,H. Kessler, F. Grass, E. E. Whang, W. J. Fawcett, F. Carli, D. N. Lobo, K. E. Rollins, A. Balfour, G. Baldini, B. Riedel, O. Ljungqvist

 

Abstract:

Background

This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol.

Methods

A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

Results

All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly.

Conclusions

The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

 

URL https://rdcu.be/bjp2L



Bariatric Surgery Versus Lifestyle Intervention in Class I Obesity

 

Author list: Antonio Vitiello, Luigi Angrisani, Antonella Santonicola, Paola Iovino, Vincenzo Pilone, Pietro Forestieri

 

Abstract:

Introduction

The American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation of Surgery for Obesity (IFSO) have both stated that bariatric surgery (BS) should not be denied in Class I patients. However, lifestyle intervention (LI), such as diet plus gym programs, is still considered the preferred approach for subjects with a BMI ranging from 30 to 35 kg/m2. The aim of this study was to retrospectively compare results of LI and BS in patients in Class I obesity.

 

Methods

Retrospective analysis of prospective maintained databases of two centers for the “Interdisciplinary Treatment of Obesity” was performed. All patients in Class I obesity and follow-up >7 years were included in the study. Subjects were divided into two groups: BS group that included patients who had undergone surgery and LI group that included patients who underwent lifestyle intervention (LI). Percentage of excess body mass index loss (%EBMIL) and comorbidities remission were recorded.

 

Results

Seventy-six patients were included in the study. Fifty-six subjects were submitted to surgery (BS group); 20 subjects were treated with nonsurgical approach (LI group). In BS group, 34 underwent laparoscopic adjustable gastric band, 13 laparoscopic sleeve gastrectomy (LSG), and 9 laparoscopic Roux-en-Y gastric bypass. EWL% resulted significantly higher in BS group at 1, 3, 5, 7 and 10 years (p < 0.01).

 

Conclusion

Bariatric surgery is more effective than LI for patients in Class I obesity. Due to its versatility, low-risk profile and high-effectiveness LSG could be the standard intervention for these patients.

 

URL https://rdcu.be/bjp4E

 


Risk Factors for Skin Flap Necrosis in Breast Cancer Patients Treated with Mastectomy and Immediate Breast Reconstruction

 

Author list: Hiroki Ito, Takayuki Ueno, Hirotaka Suga, Tomohiro Shiraishi, Hirotsugu Isaka, Kentaro Imi, Kaisuke Miyamoto, Manami Tada, Yoshiharu Ishizaka, Shigeru Imoto

 

Abstract:

Background

Skin-sparing mastectomy (SSM) and nipple-sparing mastectomy (NSM) are the standard techniques for achieving a cosmetic outcome, but necrosis of a cutaneous flap including the nipple–areolar complex (NAC) is a serious complication. To analyze the risk factors for skin flap necrosis, we retrospectively evaluated a clinical database of breast cancer patients treated with mastectomy followed by immediate breast reconstruction.

 

Methods

Four hundred and twelve cases were consecutively recorded between 2006 and 2016. Body weight (BW), body mass index (BMI), distance from NAC to referent tumor, distance from overlying skin to the tumor and weight of breast resection (WBR) as measured in the operating theater were included in the statistical analysis.

 

Results

NSM, SSM and total mastectomy were performed in 123 (30%), 96 (23%) and 193 cases (47%), respectively. A tissue expander was used in 379 cases (92%), a silicone implant in 8 (2%) and autologous breast reconstruction in 25 (6%). Skin flap necrosis was found in 7% of all cases and NAC necrosis in 13% of NSM cases. In a univariate analysis, BW, NSM and WBR were risk factors for skin flap necrosis, and BW, BMI and WBR were risk factors for NAC necrosis. In a multivariate analysis, NSM and WBR remained significant risk factors for skin flap necrosis, and WBR was a significant risk factor for NAC necrosis.

 

Conclusions

WBR is an important risk factor for skin flap necrosis. Especially, NAC necrosis should be considered for patients with large-volume breasts who undergo NSM and immediate breast reconstruction.

 

URL https://rdcu.be/bjp9u

 


Diagnostic Laparoscopy in Patients with Pancreatic Cancer

 

Author list: Munizay Paracha, Kathryn Van Orden, Gregory Patts, Jennifer Tseng, David McAneny, Teviah Sachs

 

Abstract:

Background

Routine preoperative staging in pancreas cancer is controversial. We sought to evaluate the rates of diagnostic laparoscopy (DLAP) for pancreatic cancer.

 

Methods

We queried the National Surgical Quality Improvement Program for patients with pancreas cancer (2005–2013) and compared groups who underwent DLAP, exploratory laparotomy (XLAP), pancreas resection (RSXN) or therapeutic bypass (THBP). We compared demographics, comorbidities, postoperative complications, 30-day mortality (Chi-square P < 0.05) and trends over time (R2 0–1).

 

Results

We identified 17,138 patients (RSXN 81.8%, XLAP 16.5%, THBP 8.2%, and DLAP 12.9%), with some having multiple CPT codes. Only 10.3% (n = 1432) of RSXN patients underwent DLAP prior to resection. XLAP occurred in 49.5% of non-RSXN patients, of whom 67.1% had no other operation. The percentage of patients undergoing RSXN increased 20.3% over time (R2 0.81), while DLAP decreased 52.6% (R2 0.92). XLAP patients without other operations decreased from 4.2 to 2.4%, although not linearly (R2 0.31). Only 10.3% of XLAP had a diagnostic laparoscopy as well, leaving nearly 90% of these patients with an exploratory laparotomy without RSXN or THBP.

 

Discussion

Diagnostic laparoscopy for pancreas malignancy is becoming less common but could benefit a subset of patients who undergo open exploration without resection or therapeutic bypass.

 

URL https://rdcu.be/bjqc8

 


Lung Adenocarcinoma Has a Higher Risk of Lymph Node Metastases than Squamous Cell Carcinoma

 

Author list: Han-Yu Deng, Miao Zeng, Gang Li, Guha Alai, Jun Luo, Lun-Xu Liu, Qinghua Zhou, Yi-Dan Lin

 

Abstract:

Background

Controversy still exists in which subtype of non-small-cell lung cancer [squamous cell carcinoma (SCC) or adenocarcinoma] is more likely to have lymph node (LN) metastasis. The aim of this study is to compare the pattern of LN metastasis in two cohorts of matched patients surgically treated for SCC or adenocarcinoma.

 

Methods

A retrospective analysis of patients undergoing lobectomy or segmentectomy with systematic lymphadenectomy without preoperative treatment for lung SCC or adenocarcinoma was conducted in this study. Data for analysis consisted of age, gender, tumor size, lobe-specific tumor location, tumor location (peripheral or central), and pathologic findings. We conducted the propensity score-matched (PSM) analysis to eliminate potential bias effects of possible confounding factors.

 

Results

From January 2015 to December 2016 in our department, we finally included a total of 387 patients (including 63 patients with SCC and 324 patients with adenocarcinoma) for analysis. For the unmatched cohort, there was no sufficient evidence of significantly different number of positive LNs (P = 0.90) and rate of LN metastasis (P = 0.23) between SCC patients and adenocarcinoma patients. However, potential confounding factors, for example gender, tumor size, tumor location, tumor differentiation, and total number of dissected LNs, were significantly different between patients with SCC and those with adenocarcinoma. In the analysis of matched cohort after PSM analysis, those above confounding factors were comparable between the two groups. However, patients with adenocarcinoma had significantly more mean positive LNs (2.2 and 0.7; P = 0.008) and a higher rate of LN metastasis (53% and 29%; P = 0.016) than those with SCC.

 

Conclusions

Lung adenocarcinoma had a higher risk of LN metastasis than SCC, suggesting that different therapeutic modalities may be indicated for the two different subtypes of lung cancer.

 

URL https://rdcu.be/bjqd7

 


Microdialysis in Postoperative Monitoring of Gastrointestinal Organ Viability: A Systematic Review

 

Author list: Jonas Emil Sabroe, Niels Qvist,Mark Bremholm Ellebæk

 

Abstract:

Background

Microdialysis is a technique for continuous measurement of extracellular substances. It may be used to monitor tissue viability. The clinical implications of using microdialysis as a tool in gastrointestinal surgery have yet to be defined. The aim of the present study was to evaluate the clinical significance of microdialysis with special attention to different markers measured to predict the clinical outcome of surgical patients.

 

Methods

Embase, MEDLINE, and the Cochrane Library were searched systematically for human studies written in English. Study selection, data extraction, and quality assessment were performed independently by two authors. We included studies in which the microdialysis technique was used for postoperative monitoring of patients undergoing gastrointestinal surgery. To be eligible, studies had to compare patients with and without postoperative complications.

 

Results

Twenty-six studies were included in this review. MINORS score ranged from 3 to 12 (median 10.5). Most studies showed that levels of biomarkers obtained by microdialysis correlated with the postoperative clinical course. Lactate, pyruvate, glucose, and glycerol were the most frequently measured biomarkers. Several studies found that changes in biomarkers in complicated patients preceded symptoms of complications and/or changes in conventional paraclinical methods of postoperative monitoring.

 

Conclusions

Studies show that microdialysis may have the potential to become a tool in postoperative surveillance of surgical patients. Larger randomized studies are needed to define the clinical implications of microdialysis.

 

URL https://rdcu.be/bjqg2

 

 


 

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