Non-hiatal diaphragmatic hernias: results of transabdominal and transthoracic surgical approaches at a fourth-level hospital.

OBJECTIVE: The objective of this study is to elucidate the clinical and demographic profiles, as well as perioperative outcomes, of patients undergoing surgery for non-hiatal diaphragmatic hernias. Additionally, it aims to analyse these outcomes based on the surgical approach employed (transthoracic versus transabdominal). METHODS: This retrospective, observational study was conducted at a single center and involved patients diagnosed with non-hiatal diaphragmatic hernia who underwent either emergency or elective surgery between July 2007 and March 2023. Clinical characteristics and perioperative outcomes of these patients were compared using appropriate statistical tests.The research protocol for this observational, retrospective, and comparative study followed the Declaration of Helsinki's ethical requirements. The need for Clinical Research Ethics Committee approval was waived according to our institutional law because the study was a retrospective cohort study based on anonymous data of patients. Informed consent was waived because this study involved the secondary analysis of patient medical records. Additionally, this study followed the STROBE guidelines for reporting observational studies. RESULTS: The analysis included 22 patients being 59.1% men, with median age of 61 years. The predominant clinical presentation was restrictive lung disease (40.9%). The majority of cases (68%) had traumatic aetiology with a median defect size of 4 cm (range of 3-8 cm). Elective surgery was performed in 15 cases (68.1%) and transthoracic approach was employed in 13 patients (54.5%). Postoperative major morbidity reached 27.2% and mortality within 30 days was 9.1%. Emergency surgeries accounted for 44.4% of transabdominal interventions, compared to 23% in the transthoracic subgroup (p = 0.376). There were no statistically significant differences between the transabdominal and trasnthoracic approaches in terms of global postoperative complications (88.8% vs. 84.6%, p = 1), major complications (44.4% vs 15.4%, p = 0.734), mortality (11.1% v 7.6%, p = 1) and recurrence (11.1% vs 7.6%, p = 1). Postoperative stay was significantly shorter in the transthoracic subgroup (6 days vs. 14 days, p = 0.011). CONCLUSIONS: Non-hiatal diaphragmatic hernias are characterized by significant postoperative major morbidity and mortality rates, standing at 27.2% and 9.1%, respectively, accompanied by a recurrence rate of 9.1%. Both transthoracic and transabdominal approaches demonstrate comparable short- and long-term outcomes.

Outcomes of surgical resection after neoadjuvant chemoimmunotherapy in locally advanced stage IIIA non-small-cell lung cancer.

OBJECTIVES: This analysis aimed to evaluate perioperative outcomes of surgical resection following neoadjuvant treatment with chemotherapy plus nivolumab in resectable stage IIIA non-small-cell lung cancer. METHODS: Eligible patients received neoadjuvant chemotherapy (paclitaxel + carboplatin) plus nivolumab for 3 cycles. Reassessment of the tumour was carried out after treatment and patients with at least stable disease as best response underwent pulmonary resection. After surgery, patients received adjuvant treatment with nivolumab for 1 year. Surgical data were collected from the NADIM database and patient charts were reviewed for additional surgical details. RESULTS: Among 46 patients who received neoadjuvant treatment, 41 (89.1%) underwent surgery. Two patients rejected surgery and 3 did not fulfil resectability criteria. There were 35 lobectomies (85.3%), 3 of which were sleeve lobectomies (9.4%), 3 bilobectomies (7.3%) and 3 pneumonectomies (7.3%). Video-assisted thoracoscopy was the initial approach in 51.2% of cases, with a conversion rate of 19% (n = 4). There was no operative mortality at either 30 or 90 days. The most common complications were prolonged air leak (n = 8), pneumonia (n = 5) and arrhythmia (n = 4). Complete resection (R0) was achieved in all patients who underwent surgery, downstaging was observed in 37 patients (90.2%) and major pathological response in 34 patients (82.9%). CONCLUSIONS: Surgical resection following induction therapy with chemotherapy plus nivolumab appears to be safe and offers appropriate oncological outcomes. Perioperative morbidity and mortality rates in our study were no higher than previously reported in this setting. A minimally invasive approach is, therefore, feasible.

Management of cystic echinococcosis in the last two decades: what have we learned?

Background: Management options for cystic echinococcosis (CE) remain a serious problem. The main aim of this study was to examine the selection and complications of treatment applied in patients with CE. The second aim was to evaluate the mortality rate and causative factors. Methods: A retrospective descriptive study of patients diagnosed with CE between 1998 and 2015 was conducted, according to ICD-9 (code 122·0 to 122·9) criteria in the Complejo Asistencial Universitario of Salamanca, Spain. Results: Four-hundred-ninety-one (491) patients were diagnosed with CE disease and the treatment applied in these patients were: 166 (33.8%) patients received only surgery, 176 (35.8%) surgery and drugs, 17 (3.5%) drugs alone, in 131 (26.7%) patients the strategy was 'watch and wait', and only one patient (0.2%) was applied puncture-aspiration-injection-respiration (PAIR). Thus, a total of 342 patients received surgery, either alone (166) or combined with drugs (176), and a total of 193 (39.4%) patients were medically treated, either alone (17) or combined with surgery (176); 123 (63.7%) patients used albendazole alone; and 70 (36.3%) patients used a combination of albendazole and praziquantel. Sixty-five patients (19.0%) had complications after surgery and seven of them (2%) died. Only 15 (7.8%) cases had side effects from anthelmintics. Throughout the study period, 80 (16.3%) patients died, 14 (2.9%) of them due to CE disease. Conclusions: Complications of CE are one of the most common causes of mortality in CE patients, with size, location, and number of cysts, and the 'watch and wait' treatment strategy being the main factors associated with mortality.

Recurrence of cystic echinococcosis in an endemic area: a retrospective study.

BACKGROUND: Cystic echinococcosis (CE) is a chronic, complex and neglected zoonotic disease. CE occurs worldwide. In humans, it may result in a wide spectrum of clinical manifestations, ranging from asymptomatic infection to fatal disease. Clinical management procedures have evolved over decades without adequate evaluation. Despite advances in surgical techniques and the use of chemotherapy, recurrence remains one of the major problems in the management of hydatid disease. The aim of this study was to determine the frequency of CE recurrence and the risk factors involved in recurrence. METHODS: A descriptive longitudinal-retrospective study was designed. We reviewed all patients diagnosed with CE according to ICD-9 (code 122-0 to 122-9) criteria admitted at Complejo Asistencial Universitario de Salamanca, Spain, between January 1998 and December 2015. RESULTS: Among the 217 patients studied, 25 (11.5%) had a hydatid recurrence after curative intention treatment. Median duration of recurrence's diagnosis was 12.35 years (SD: ±9.31). The likelihood of recurrence was higher [OR = 2.7; 95% CI, 1.1-7.1; p < 0.05] when the cyst was located in organs other than liver and lung, 22.6% (7/31) vs 14.2% (31/217) in the cohort. We detected a chance of recurrence [OR = 2.3; 95% CI, 1.4-6.5; p > 0.05] that was two times higher in those patients treated with a combination of antihelminthic treatments and surgical intervention (20/141, 14.2%) than in patients treated with surgical intervention alone (5/76, 6.6%). CONCLUSIONS: Despite advances in diagnosis and therapeutic techniques in hydatid disease, recurrence remains one of the major problems in the management of hydatid disease. The current management and treatment of recurrences is still largely based on expert opinion and moderate-to-poor quality of evidence. Consequently, large prospective and multicenter studies will be needed to provide definitive recommendations for its clinical management.

An alternative method for predicting the risk of postoperative complications in lung resection.

OBJECTIVES: The aims of this study were to design a best fit linear regression model to estimate VO2max (estimated VO2) and to compare the ability of VO2 values (measured and estimated) predicting cardiorespiratory complications in a series of patients undergoing lung resection for lung cancer. METHOD: This was a prospective, observational study performed in 83 patients. Variables analyzed were: demographic characteristics, comorbidity, body mass index (BMI), FEV1%, FVC%, diffusion capacity (DLCO%), mean daily distance walked in kilometers, VO2max measured by cardio-pulmonary exercise test (CPET) and postoperative complications. Descriptive and comparative statistical analysis of the variables was performed using the Mann-Whitney test for categorical variables and the Student's t-test for continuous variables. A new linear regression model was designed, where the dependent variable (measured VO2max) was estimated by the distance, DLCO% and age, resulting in the estimated VO2. The predictive power of the measured and estimated consumption was analyzed using the Student's t-test, grouping by the occurrence or absence of cardiorespiratory complications. RESULTS: Both groups were homogeneous for age, sex, BMI, FEV1%, DLCO%, comorbidity, type of resection performed and mean distance walked per day. Estimated VO2 and measured VO2 were normally distributed (K-Smirnov test, P>.32). VO2 means estimated by the model (age, DLCO% and mean distance walked per day) were significantly different between patients with and without complications (Student's t test, P=.037) compared with measured VO2 values, which did not differentiate groups (Student's t test, P=.42). CONCLUSION: The VO2max estimated by the model is more predictive in this case series than the VO2max measured during a standard exercise test.