Featured Articles in Nov 2018

Risk Factors for Surgical Complications in Ventral Hernia Repair

 

Author list: Mikael Lindmark, Karin Strigard, Thyra Lowenmark, Ursula Dahlstrand, Ulf Gunnarsson

 

Abstract:

Background

The aim of this study was to identify risk factors for an adverse event, i.e. early surgical complication, need for ICU care and readmission, following ventral hernia repair. Our hypothesis was that there is an association between an increased complication rate following ventral hernia repair and specific factors, including hernia size, BMI > 35, concomitant bowel surgery, ASA-class, age, gender and method of hernia repair.

 

Methods

Data from a hernia database with prospectively entered data on 408 patients operated for ventral hernia between 2007 and 2014 at two Swedish university hospitals were analysed. A 3-month follow-up of complications, need for intensive care and readmission, was performed by reviewing the medical records.

 

Results

Eighty-one of 408 patients (20%) had a registered complication. Fifty-eight (14%) of these were classed as Clavien I–IIIa, and in 19 cases a Clavien IIIb–IV complication was reported. Large hernia size was associated with increased risk for early complication. A Kendall Tau test analysis revealed a proportional relationship between hernia size and modified Clavien outcome class (p < 0.001). Morbid obesity, ASA-class, method, hernia recurrence, age and concomitant bowel surgery were not statistically significant predictors of adverse events.

 

Conclusion

Assessment of hernia aperture size is of great importance in the preoperative evaluation of ventral hernia patients to consider risk for post-operative complications. These results suggest a careful attitude when applying watchful waiting concepts and when postponing hernia surgery to achieve weight loss. A delaying attitude may result in increased risk of complications caused by increasing hernia size.

 

URL: https://rdcu.be/8jJK

 

 


The Updated AJCC/TNM Staging System for Papillary Thyroid Cancer (8th Edition): From the Perspective of Genomic Analysis

 

Author list: Kyubo Kim, Jin Hwan Kim, Il Seok Park, Young Soo Rho, Gee Hwan Kwon, Dong Jin Lee

 

Abstract:

Background

Recently, the American Joint Committee on Cancer published the 8th edition of its Cancer Staging Manual with major changes regarding the staging of thyroid cancer, including the raising of the age cutoff from 45 to 55 years. Using the clinical and genetic data of 505 papillary thyroid cancer (PTC) cases, we aimed to compare overall survival (OS) and recurrence-free survival (RFS) with different age cutoff values, and also investigate the efficacy of the new staging system on a genomic level.

 

Methods

We downloaded gene expression data, somatic mutation profile, copy number alteration data and clinical data of 505 PTC patients from The Cancer Genome Atlas data portal. We used multiple statistical analysis and multiplatform genomic analysis to evaluate the efficacy of the 8th edition.

 

 

Results

When using 55 years as the cutoff value for analyzing RFS, the Kaplan–Meier plot showed a significant p value but not when using 45 years (p = 0.006 vs. p = 0.493), but both cutoff values were significant when analyzing OS (p = 1.1 × 10−9 with age 55 vs. p = 4.4 × 10−5 with age 45). When looking at stage-dependent survival, both the 7th and 8th edition had significant p values (p = 0.048 vs. p = 3.1 × 10−9 in RFS and p = 5.9 × 10−10 vs. p = 2.2 × 10−10 in OS). Multiplatform genomic analysis showed patients ≥55 years had 103 differently expressed genes when compared with other age groups. Signaling pathway analysis revealed that patients ≥55 years had altered pathways associated with aggressiveness of thyroid cancer.

 

Conclusion

In conclusion, this is the first study to show clinical and genetic evidence supporting the altered age cutoff point of 55 years in the AJCC 8th edition for PTC patients.

 

URL: https://rdcu.be/8jJW

 

 


The Video-Assisted Thoracic Surgery for Mediastinal Bronchogenic Cysts: A Single-Center Experience

 

Author list: Xun Wang, Kezhong Chen, Yun Li, Fan Yang, Hui Zhao, Jun Wang

 

Abstract:

Background

The aim of this study was to evaluate the outcomes of video-assisted thoracic surgery (VATS) for mediastinal bronchogenic cyst (MBC) excision and investigate the surgical indication for MBC.

 

Methods

We retrospectively reviewed all consecutive MBC patients who underwent surgical excision between April 2001 and June 2016. One hundred and nineteen patients were enrolled with a median age of 45.4 years and divided into two groups: anterior mediastinum group (n = 48), and middle and posterior mediastinum group (n = 71). VATS technique was initially performed for each patient. The cyst should be resected completely as far as possible. Follow-up was completed by telephone or outpatient clinic every year. The deadline of follow-up was June 2017.

 

Results

One hundred and eighteen patients underwent VATS, and only one patient converted to open thoracotomy. The average operative time was 103.8 ± 41.6 min (40–360 min). The average intraoperative blood loss was 56.6 ± 86.6 ml (5–600 ml). The intraoperative complication rate was 3.4%, and the incomplete excision rate was 5.9%. The multivariate logistic analysis showed that maximal diameter >5 cm was significantly associated with risk of operation time extension (OR = 3.968; 95% CI 1.179–13.355, p = 0.026) and bleeding loss increasing (OR = 12.242; 95% CI 2.420–61.933, p = 0.002). No serious postoperative complications were observed. Follow-up was performed in 102 patients, and the mean follow-up time was 45 months (12–194 months). There was no local recurrence.

 

Conclusion

The maximal diameter >5 cm increased risk of operation time extension and bleeding loss increasing. Early surgical excision of MBC by VATS is recommended to establish histopathological diagnosis, relieve symptoms, and prevent surgery-related complications.

 

URL: https://rdcu.be/8jKe

 


Afferent Loop Decompression Technique is Associated with a Reduction in Pancreatic Fistula Following Pancreaticoduodenectomy

 

Author list: Jie Yin, Zipeng Lu, Pengfei Wu, Junli Wu, Wentao Gao, Jishu Wei, Feng Guo, Jianmin Chen, Kuirong Jiang, Yi Miao

 

Abstract:

Background

Postoperative pancreatic fistula (POPF) is a major complication and main cause of mortality after pancreaticoduodenectomy (PD). Afferent loop decompression technique (ALDT) has theoretical feasibility to reduce the rate of POPF. The aim of this study is to determine whether ALDT is a protective factor for POPF.

 

Methods

A total of 492 consecutive patients who underwent PD between January 2012 and December 2014 were identified from a prospective database. All data were extracted and events were judged based on medical records. Propensity score matching was conducted to balance several variables. Univariate and multivariate analyses were performed, respectively, to investigate the independent risk factors for pancreatic fistula. ALDT required a nasogastric tube with multiple side holes to be placed deep into the afferent jejunal limb. The rationale for this technique was to prevent pancreatic fistula by decreasing intraluminal pressure in the afferent jejunal loop by placement of the nasogastric tube and the application of continuous low-pressure suction after surgery.

 

Results

The total rate of POPF for the entire cohort was 30.7%, and ISGPS grade-A/B/C POPF rates were 18.1, 10.6 and 2.0%, respectively. In-hospital mortality was 1.6%. Among the 331 patients who received ALDT, 89 developed pancreatic leakage (26.9 vs. 38.5% for non-ALDT; P = 0.009) and eight developed biliary leakage (2.4 vs. 6.2% for non-ALDT; P = 0.035). Apart from ALDT, decreased preoperative ALT, soft pancreas, long operative time and tumour presence in the lower common bile duct (as opposed to the pancreas) were identified as other independent risk factors for POPF following multivariate logistic regression analysis.

 

Conclusion

ALDT may reduce the incidence of POPF after PD.

 

URL: https://rdcu.be/8jKx

 


Defunctioning Stomas Result in Significantly More Short-Term Complications Following Low Anterior Resection for Rectal Cancer

 

Author list: Andrew Emmanuel, Ezzat Chohda, Christo Lapa, Andrew Miles, Amyn Haji, Joe Ellul

 

Abstract:

Background

Studies suggest that defunctioning stomas reduce the rate of anastomotic leakage and urgent reoperations after anterior resection. Although the magnitude of benefit appears to be limited, there has been a trend in recent years towards routinely creating defunctioning stomas. However, little is known about post-operative complication rates in patients with and without a defunctioning stoma. We compared overall short-term post-operative complications after low anterior resection in patients managed with a defunctioning stoma to those managed without a stoma.

 

Methods

A retrospective cohort study of patients undergoing elective low anterior resection of the rectum for rectal cancer. The primary outcome was overall 90-day post-operative complications.

 

 

Results

Two hundred and three patients met the inclusion criteria for low anterior resection. One hundred and forty (69%) had a primary defunctioning stoma created. 45% received neoadjuvant radiotherapy. Patients with a defunctioning stoma had significantly more complications (57.1 vs 34.9%, p = 0.003), were more likely to suffer multiple complications (17.9 vs 3.2%, p < 0.004) and had longer hospital stays (13.0 vs 6.9 days, p = 0.005) than those without a stoma. 19% experienced a stoma-related complication, 56% still had a stoma 1 year after their surgery, and 26% were left with a stoma at their last follow-up. Anastomotic leak rates were similar but there was a significantly higher reoperation rate among patients managed without a defunctioning stoma.

 

Conclusion

Patients selected to have a defunctioning stoma had an absolute increase of 22% in overall post-operative complications compared to those managed without a stoma. These findings support the more selective use of defunctioning stomas.

 

URL: https://rdcu.be/8jKT

 


Enhanced Recovery After Surgery Programs for Laparoscopic Abdominal Surgery: A Systematic Review and Meta-analysis

 

Author list: Zhengyan Li, Qingchuan Zhao, Bin Bai Gang Ji, Yezhou Liu

 

Abstract:

Background

Enhanced recovery after surgery (ERAS) protocols or laparoscopic technique has been applied in various surgical procedures. However, the clinical efficacy of combination of the two methods still remains unclear. Thus, our aim was to assess the role of ERAS protocols in laparoscopic abdominal surgery.

 

Methods

We performed a systematic literature search in various databases from January 1990 to October 2017. The results were analyzed according to predefined criteria.

 

Results

In the present meta-analysis, the outcomes of 34 comparative studies (15 randomized controlled studies and 19 non-randomized controlled studies) enrolling 3615 patients (1749 in the ERAS group and 1866 in the control group) were pooled. ERAS group was associated with shorter hospital stay (WMD − 2.37 days; 95% CI − 3.00 to − 1.73; P 0.000) and earlier time to first flatus (WMD − 0.63 days; 95% CI − 0.90 to − 0.36; P 0.000). Meanwhile, lower overall postoperative complication rate (OR 0.62; 95% CI 0.51–0.76; P 0.000) and less hospital cost (WMD 801.52 US dollar; 95% CI − 918.15 to − 684.89; P 0.000) were observed in ERAS group. Similar readmission rate (OR 0.73, 95% CI 0.52–1.03, P 0.070) and perioperative mortality (OR 1.33; 95% CI 0.53–3.34; P 0.549) were found between the two groups.

 

Conclusions

ERAS protocol for laparoscopic abdominal surgery is safe and effective. ERAS combined with laparoscopic technique is associated with faster postoperative recovery without increasing readmission rate and perioperative mortality.

 

URL: https://rdcu.be/8jK8

 


Three-Dimensional Versus Two-Dimensional Video-Assisted Endoscopic Surgery: A Meta-analysis of Clinical Data

 

Author list: Hengrui Liang, Wenhua Liang, Zhao Lei, Zhichao Liu, Wei Wang, Jiaxi He, Yuan Zeng, Weizhe Huang, Manting Wang, Yuehan Chen, Jianxing He

 

Abstract:

Background

There have been no studies to systematically evaluate the two display (3D vs. 2D) systems regarding both laparoscopic and thoracoscopic surgeries in clinical settings; thus, we conducted one to evaluate the safety and efficacy of different visualization systems (two-dimensional and three-dimensional) during endoscopic surgery (laparoscopy or thoracoscopy) in clinical settings.

 

Methods

A comprehensive search of online databases was performed. Perioperative outcomes were synthesized. Cumulative meta-analysis was performed to evaluate the temporal trend of pooled outcomes. Specific subgroups (laparoscopy vs. thoracoscopy, prospective vs. retrospective study, malignant vs. benign diseases) were examined. Meta-regression was conducted to explore the source of heterogeneity.

 

Results

Twenty-three articles were considered in this analysis, of which 7 were thoracoscopic and 16 were laparoscopic surgeries. A total of 2930 patients were recorded, of which 1367 underwent 3D video-assisted surgery and 1563 underwent 2D display. Overall, significantly shorter operating time (SMD −0.69; p = <0.001), less blood loss (SMD −0.26; p = 0.028) and shorter hospital stays (SMD −0.16; p = 0.016) were found in the 3D display group. Meanwhile, the perioperative morbidity (OR 0.92; p = 0.487), retrieved lymph nodes (SMD 0.09; p = 0.081), drainage duration (SMD −0.15; p = 0.105) and drainage volume (SMD 0.00; p = 0.994) were similar between the two groups. Comparison of the overall outcomes in each subset showed consistency in all groups.

 

Conclusions

This up-to-date meta-analysis reveals that the 3D display system is superior to the 2D system in clinical settings with significantly shorter operating time, less blood loss and shorter hospital stay. These findings suggest that, in laparoscopic or thoracoscopic surgeries, 3D endoscopic system is preferable when condition permits. Future efforts should be made on decreasing the side effects of 3D display and increasing its cost-effectiveness.

 

URL: https://rdcu.be/8jLz

 


 

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