Pattern of Postoperative Mortality After Esophageal Cancer Resection According to Center Volume: Results from a Large European Multicenter Study.

BACKGROUND: High center procedural volume has been shown to reduce postoperative mortality (POM); however, the cause of POM has been poorly studied previously. The aim of this study was to define the pattern of POM and major morbidity in relation to center procedural volume. METHODS: Data from 2,944 consecutive adult patients undergoing esophagectomy for esophageal cancer in 30 centers between 2000 and 2010 were retrospectively collected. Data between patients who suffered 30-day POM were compared with those who did not. Factors associated with POM were identified using binary logistic regression, with propensity matching to compare low- (LV) and high-volume (HV) centers. RESULTS: The 30-day and in-hospital POM rates were 5.0 and 7.3 %, respectively. Pulmonary complications were the most common, affecting 38.1 % of patients, followed by surgical site infection (15.5 %), cardiovascular complications (11.2 %), and anastomotic leak (10.2 %). Factors that were independently associated with 30-day POM included American Society of Anesthesiologists grade IV, LV center, anastomotic leak, pulmonary, cardiovascular and neurological complications, and R2 resection margin status. Surgical complications preceded POM in approximately 30 % of patients compared to medically-related causes in 68 %. Propensity-matched analysis demonstrated LV centers were significantly associated with increased 30-day POM, and POM secondary to anastomotic leak, and pulmonary- and cardiac-related causes. CONCLUSIONS: The results of this large, multicenter study provide further evidence to support the centralization of esophagectomy to HV centers, with a lower rate of morbidity and better infrastructure to deal with complications following major surgery preventing further mortality.

The short- and long-term outcomes of pancreaticoduodenectomy for cancer in Child A patients are acceptable: a patient-control study from the Surgical French Association report for pancreatic surgery.

BACKGROUND: On the basis of now dated studies, cirrhosis is usually considered to be a contraindication in pancreatoduodenectomy (PD) for adenocarcinoma of the pancreatic head (APH). OBJECTIVE: Examine the outcomes of PD for APH in the presence of cirrhosis. METHODS: Retrospective, multicenter study of cirrhotic patients with APH having undergone PD between January 2004 and March 2012. Cirrhotic patients were matched 1:2 for demographic, surgical and histologic criteria with non-cirrhotic patients. Primary endpoint was morbidity and mortality. Secondary endpoints were surgical parameters, morbidity related to pancreatic surgery and cirrhosis, and follow-up. RESULTS: We included 35 patients with cirrhosis. Twenty-four patients (69%) were Child A and none were Child C. The Child A cirrhotic patients and non-cirrhotic patients respectively had complication rates of 79% vs. 43% (P = 0.002), major complication rates of 33% vs. 21% (P = 0.26), pancreatic fistula rates of 13% vs. 9% (P = 0.57), post-operative mortality of 4% vs. 5% (P = 0.94), 3-year overall survival rates of 44% vs. 50% (P = 0.46). All Child B cirrhotic patients experienced post-operative complications. CONCLUSION: Pancreatoduodenectomy for APH was possible in Child A cirrhotic patients with a mortality and long-term outcomes equivalent to non-cirrhotic patients. Child B cirrhosis remains a clear contraindication to surgery.

Impact of neoadjuvant chemoradiotherapy on postoperative outcomes after esophageal cancer resection: results of a European multicenter study.

OBJECTIVES: To assess the impact of neoadjuvant chemoradiotherapy (NCRT) on anastomotic leakage (AL) and other postoperative outcomes after esophageal cancer (EC) resection. BACKGROUND: Conflicting data have emerged from randomized studies regarding the impact of NCRT on AL. METHODS: Among 2944 consecutive patients operated on for EC between 2000 and 2010 in 30 European centers, patients treated by NCRT after surgery (n=593) were compared with those treated by primary surgery (n=1487). Multivariable analyses and propensity score matching were used to compensate for the differences in some baseline characteristics. RESULTS: Patients in the NCRT group were younger, with a higher prevalence of male sex, malnutrition, advanced tumor stage, squamous cell carcinoma, and surgery after 2005 when compared with the primary surgery group. Postoperative AL rates were 8.8% versus 10.6% (P=0.220), and 90-day postoperative mortality and morbidity rates were 9.3% versus 7.2% (P=0.110) and 33.4% versus 32.1% (P=0.564), respectively. Pulmonary complication rates did not differ between groups (24.6% vs 22.5%; P=0.291), whereas chylothorax (2.5% vs 1.2%; P=0.020), cardiovascular complications (8.6% vs 0.1%; P=0.037), and thromboembolic events (8.6% vs 6.0%; P=0.037) were higher in the NCRT group. After propensity score matching, AL rates were 8.8% versus 11.3% (P=0.228), with more chylothorax (2.5% vs 0.7%; P=0.030) and trend toward more cardiovascular and thromboembolic events in the NCRT group (P=0.069). Predictors of AL were high American Society of Anesthesiologists scores, supracarinal tumoral location, and cervical anastomosis, but not NCRT. CONCLUSIONS: Neoadjuvant chemoradiotherapy does not have an impact on the AL rate after EC resection (NCT 01927016).

Disease-Free Survival after Simultaneous or Delayed Resection of Synchronous Colorectal Liver Metastasis and Primary Cancer.

BACKGROUND/AIMS: The purpose of our study was to compare disease-free survival in patients with synchronous colorectal liver metastasis who underwent delayed hepatic resection or simultaneous resection. METHODOLOGY: All patients who underwent a curative resection of synchronous colorectal liver metastasis between 2000 and 2006 in our tertiary care referral centre were retrospectively included in our study. Patients who underwent the first stage of a two-stage hepatectomy during the primary resection were included in the delayed resection group. Disease-free survival was studied using a Kaplan-Meier method. Prognostic factors for disease-free and overall survival were determined by multivariate analysis using Cox models. RESULTS: One hundred and five patients underwent 85 delayed resections and 20 simultaneous resections. Three and five-year disease-free survival did not differ significantly between simultaneous (50% and 40%) and delayed (65% and 34%) resection groups (P = 0.47). Preoperative carcinoembryonic antigen (HR = 2.05, 95% CI, 1.07-3.92) and presence of extra-hepatic metastasis (HR = 2.85, 95% CI, 1.08-7.54) were independent prognostic factors for disease-free survival. Three and five-year overall survival did not differ either (23% and 23%; 24% and 20%, P = 0.13). CONCLUSIONS: Simultaneous resection of synchronous colorectal liver metastasis and primitive cancer does not appear to impair long-term disease-free survival.

Pancreaticogastrostomy decreased relaparotomy caused by pancreatic fistula after pancreaticoduodenectomy compared with pancreaticojejunostomy.

HYPOTHESIS: Pancreaticogastrostomy (PG) is associated with a lower relaparotomy rate following pancreaticoduodenectomy (PD) than pancreaticojejunostomy (PJ). DESIGN: Retrospective clinical trial. SETTING: Department of digestive surgery and transplantation. PATIENTS: Between 1987 and 2001, 250 consecutive patients underwent PD in our institution. Among them, 83 patients underwent PJ and 167, PG. MAIN OUTCOME MEASURES: Preoperative clinicopathological features, intraoperative parameters, in-hospital mortality, postoperative morbidity, pancreatic fistula (PF), relaparotomy rates, and length of hospital stay were analyzed and compared between 2 reconstructive methods, PJ and PG, after PD. RESULTS: The morbidity rate, including PF, was lower in the PG group (38.3%) than in the PJ group (53.0%; P =.02). The mortality rate did not differ between the PG group (2.9%) and PJ group (2.4%). Conversely, the incidence of PF and the mean +/- SD length of hospital stay were significantly lower in the PG group (2.3% and 17.2 +/- 7.7 days) than in the PJ group (20.4% and 23.3 +/- 11.7 days; P<.001 for both variables). Moreover, the overall relaparotomy rate was significantly lower in the PG group (4.7%) than in the PJ group (18.0%; P =.001). Nine (52.9%) of 17 patients with PF in the PJ group underwent relaparotomy. These 9 patients underwent subsequent completion pancreatectomy (n = 7) or removal of peripancreatic necrotized tissue (n = 2) with a postoperative mortality rate of 22.2%. However, no patient required relaparotomy for PF in the PG group because medical therapy succeeded in all 4 patients with PF. Moreover, no mortality related to PF occurred in the PG group. CONCLUSION: The PG procedure is a safe method of reconstruction after PD, with a significantly lower rate of PF and relaparotomy.

Laparoscopic ventral rectopexy for the treatment of outlet obstruction associated with recto-anal intussusception and rectocele: a valid alternative to STARR procedure in patients with anal sphincter weakness.

OBJECTIVE: This study was designed to assess the safety and outcomes achieved with Stapled Trans-Anal Rectal Resection (STARR) vs laparoscopic ventral rectopexy (LVR) in obstructed defecation patients. METHOD: From 2002 to 2011, 52 patients (females) had a rectocele with outlet obstruction. After clinical assessment by an Obstructed Defecation Syndrome score (ODS), an anorectal manometry, a defecography and an endoanal ultrasound, the patients underwent either a STARR (n=25) or a LVR (n=27) according to the existence of an asymptomatic anal sphincter injury. Functional results were evaluated clinically and by the preoperative and 18 months postoperative ODS score and by an 18 months postoperative score of satisfaction. RESULTS: Average ages were 56 ± 10 years in the STARR and 60 ± 9 years in LVR. The 1-month postoperative complication rates were comparable for the 2 groups (25%). Mean length of stay was shorter for STARR than for LVR (5.6 ± 2.1 vs. 7.1 ± 2.9, P=0.009). After treatment, the ODS was lowered by 56% in LVR and 59% in the STARR (P=0.0001) but with no difference between the 2 groups. Eighty percent of patients were very or moderately satisfied after LVR, versus 84% after STARR. CONCLUSIONS: The 2 surgical procedures obtain good results with 80% of satisfied patients with a length of stay a little shorter in the STARR. BRIEF SUMMARY: In our retrospective study, Stapled Trans-Anal Rectal Resection (STARR) and laparoscopic ventral rectopexy improved the outlet obstruction associated with recto-anal intussusception and rectocele.

The best surgical approach for left colectomy: a comparative study between transverse laparotomy, midline laparotomy and laparoscopy.

AIM: To compare the early and late complications after left colectomy (LC) by left transverse laparotomy (LTL), midline laparotomy (ML) and laparoscopy (La). METHODS: From 1998 to 2003, 328 patients underwent an LC by LTL, ML or La. After matching patients for age, ASA score and indication, 159 patients were divided into three groups of 53 patients each according to the surgical approach performed. The median follow-up was 8 years. Early and late complications were compared by univariate and multivariate analysis. RESULTS: Early morbidity rates after LTL, ML and La were 52%, 45% and 21%, respectively (p = 0.002). Extra digestive complication rates after LTL, ML and La were 36%, 34% and 13.2%, respectively (p = 0.02). Respiratory complication rates were 15%, 21% and 2% (p = 0.01). The rate of wound infection was higher after LTL (15% vs. 6% and 6%, p = 0.06). Length of stay was significantly shorter after La (median: LTL, 10 days; ML, 9 days; La, 6 days; p < 0.0001). At a median follow-up of 8 years, the obstruction rate was 6.3%, regardless of the surgical approach. The rates of incisional hernia after LTL, ML and La were 8%, 23% and 3% (p = 0.004), respectively, with odds ratio (OR) = 4.47 (1.2 to 16). CONCLUSION: Our study shows that although La has a significant lower rate of complications, LTL, with fewer respiratory complications and hernia than ML, should be considered as the reference incision in case of conversion or contra-indication for laparoscopy.

Have French recommendations had an impact on the treatment and survival of middle and lower rectal cancer patients?

OBJECTIVE: Compare the survival of middle and lower rectal cancer (MLRC) patients before and after the 1994 issue of rectal cancer (RC) consensus conference recommendations. METHODS: Cases of MLRC noted in the Hérault department of France in 1992 (n=58) and 2000 (n=93) yielded exhaustive epidemiological, clinical-pathological and treatment data that were used to compare MLRC patient management and survival in these two periods. RESULTS: Significantly more lymph nodes (≥ 8) were harvested in 2000 (≥ 8, 47%) than in 1992. In all, 45 patients (77.6%) received radiotherapy in 1992, and 74 (82%) in 2000. Chemotherapy was employed in 15 patients (25.9%) in 1992 and in 39 patients (43%) in 2000. Chemotherapy and radiotherapy, together with sphincter conservation, were dependent upon the year. Overall 5-year relative survival for rectal cancer in the Hérault department did not vary between 1992 (56%) and 2000 (56%). Independent poor prognostic factors were the same in both years: age over 75 years, lymph node involvement and metastases. Management place and year had no significant impact on prognosis. CONCLUSION: The recommendations made have had little impact on disease management and the quality of anatomic pathology reports, and have not improved 5-year relative survival.

Small hepatocellular carcinoma in Child A cirrhotic patients: hepatic resection versus transplantation.

Hepatic resection (HR) is the treatment of choice for small hepatocellular carcinoma (HCC) in a noncirrhotic liver, whereas liver transplantation (LT) offers better results in patients with impaired hepatic function (Child B and C). However, it is still debated whether HR or LT is the best strategy for patients with Child A cirrhosis. We conducted a retrospective study on 37 consecutive patients with Child A cirrhosis and small HCC, treated between 1991 and 1999. Seventeen of these patients, who underwent LT, were compared with 20 patients who underwent HR, and prognostic factors for survival and tumor recurrence were analyzed. The primary endpoints were the intention-to-treat, 3- and 5-year survival, and 3- and 5-year recurrence-free survival. Three- and 5-year patient survival rate both were significantly (P =.04) higher in the LT group (87% and 71%, respectively) than in the HR group (67 and 36% respectively). Similarly, the 3- and 5- year recurrence-free survival rates were 87% and 80% for the LT group, and 52% and 40% for the HR group (P =.03). Absence of microscopic vascular invasion was the only other prognostic factor correlated with significantly better recurrence-free survival (P =.02). Therefore, we concluded that in patients with Child A cirrhosis and small HCC, liver transplantation resulted in better overall and disease-free survival than HR.