Selective decontamination of the digestive tract in upper gastrointestinal surgery: systematic review with meta-analysis of randomized clinical trials.

BACKGROUND: Infectious complications are common after gastrointestinal surgery. Selective decontamination of the digestive tract (SDD) might reduce their incidence. SDD is used widely in colorectal resections, but its role in upper gastrointestinal resection is less clear. The aim of this study was to investigate the impact of SDD on postoperative outcome in upper gastrointestinal surgery. METHODS: Studies investigating SDD in upper gastrointestinal surgery were included after search of medical databases (PubMed, Ovid, Cochrane Library and Google Scholar). Results were analysed according to predefined criteria. The incidence of perioperative overall complications and death was pooled. Risk of bias was assessed using the revised Cochrane risk-of-bias tool. RESULTS: Some 1384 studies were identified, of which four RCTs were included in the final analysis. These studies included 415 patients, of whom 213 (51·3 per cent) received standard treatment/placebo and 202 (48·7 per cent) had SDD. The incidence of anastomotic leakage (odds ratio (OR) 0·39, 95 per cent c.i. 0·19 to 0·80; P = 0·010) and pneumonia (OR 0·42, 0·23 to 0·78; P = 0·006) was reduced in patients receiving SDD. Rates of surgical-site infection (P = 0·750) and mortality (P = 0·130) were not affected by SDD. CONCLUSION: SDD seems to be associated with reduction of anastomotic leakage and pneumonia following upper gastrointestinal resection, without affecting postoperative mortality.

ANTECEDENTES: Las complicaciones infecciosas son frecuentes tras la cirugía gastrointestinal. La descontaminación selectiva del tracto digestivo (Selective Decontamination of the Digestive tract, SDD) podría reducir su incidencia. Mientras que la SDD es ampliamente utilizada en las resecciones colorrectales, su papel en las resecciones del tracto gastrointestinal superior está menos definido. El objetivo de este estudio fue investigar el impacto de la SDD en el resultado postoperatorio en cirugía del tracto gastrointestinal superior. MÉTODOS: Se incluyeron estudios que investigasen la SDD en cirugía del tracto gastrointestinal superior después de una búsqueda de bases de datos médicas (Pubmed, Ovid, Cochrane-Library y Google/Scholar). Los resultados se analizaron de acuerdo con criterios predefinidos. Se agrupó la incidencia de complicaciones perioperatorias globales y mortalidad. El riesgo de sesgo se analizó utilizando la herramienta de la colaboración Cochrane revisada para la evaluación del riesgo de sesgo. RESULTADOS: Se identificaron 1.380 estudios, de los cuales cuatro ensayos controlados aleatorizados fueron incluidos en el análisis final. Estos estudios incluían a 415 pacientes de los cuales 213 (51,3%) recibieron tratamiento estándar/placebo y 202 (48,7%) recibieron SDD. La incidencia de fugas anastomóticas (razón de oportunidades, odds ratio, OR: 0,39 (0,19-0,80); P = 0,010)) y neumonía (OR: 0,42 (0,23-0,78); P = 0,006)) se redujo en pacientes que recibieron SDD. Infecciones del sitio quirúrgico (P = 0,750) y la mortalidad (P = 0,130) no se relacionaron con la SDD. CONCLUSIÓN: SDD parece asociarse con reducción de fuga anastomótica y neumonía tras resecciones del tracto gastrointestinal superior, sin afectar a la mortalidad postoperatoria.

Influence of the surgical technique on survival in the treatment of carcinomas of the true cardia (Siewert Type II) - Right thoracoabdominal vs. transhiatal-abdominal approach.

INTRODUCTION: It is still a matter of debate whether subtotal esophagectomy via a right thoracoabdominal approach (RTA) or extended gastrectomy using a transhiatal-abdominal approach (TH) is the favorable technique in the treatment of Siewert type II esophago-gastric junction adenocarcinoma (EJA). MATERIALS AND METHODS: Patients undergoing RTA or TH for EJA at our institution between 2000 and 2013 were extracted from a prospective database. Of 270 patients 91 (33.7%) underwent RTA and 179 (66.3%) were treated by TH. Differences in baseline characteristics, 30d mortality and complications were investigated using the χ2-test or exact testing. Survival analysis was performed using the Kaplan-Meier method and log rank testing. Median survival and hazard ratios were calculated and multivariable analysis of predictors was performed using a Cox model. Confounders were balanced using propensity score matching (PSM). RESULTS: No significant difference between the two procedures was detected regarding overall-survival (OS) and disease-free survival (DFS). 30d mortality rates were 1.1% in the RTA group and 4.5% in the TH group (p = 0.134). Morbidity was 34.1% in the RTA and 24.6% in the TH group (p = 0.006). Cox regression analysis identified age, ASA class and UICC stage as independent prognostic factors for OS. After PSM survival curves (OS + PFS) showed no significant difference. CONCLUSION: The present study could not detect a difference between RTA and TH from the oncologic point of view; RTA was not associated with higher 30d mortality. RTA for Siewert Type II EJA is justified whenever the oral tumor margin cannot be safely reached via a transhiatal approach.

Meta-analysis of the impact of neoadjuvant therapy on patterns of recurrence in pancreatic ductal adenocarcinoma.

BACKGROUND: Neoadjuvant therapy may increase the rate of radical tumour resection in patients with pancreatic cancer. Its impact on tumour recurrence has not been investigated fully. This study aimed to assess the impact of neoadjuvant therapy on patterns of recurrence. METHODS: A systematic review was performed of articles identified through the PubMed, Scopus, Embase, Ovid and Google Scholar databases that analysed the relationship between neoadjuvant therapy and recurrence published to January 2016. The main endpoint was overall tumour recurrence. Other endpoints included local recurrence, any kind of distant, hepatic, pulmonary or peritoneal metastasis. RESULTS: A total of 4257 citations were reviewed. Twelve observational studies comprising 1365 patients were analysed. Neoadjuvant therapy significantly reduced the risk of overall (risk ratio (RR) 0·82, 95 per cent c.i. 0·74 to 0·90; P < 0·001) and local (RR 0·42, 0·32 to 0·55; P < 0·001) recurrence. Neoadjuvant therapy did not reduce the risk of any kind of distant (RR 1·02, 0·91 to 1·14; P = 0·78), hepatic (RR 0·86, 0·68 to 1·10; P = 0·23), pulmonary (RR 0·99, 0·37 to 2·66; P = 0·98) or peritoneal (RR 0·88, 0·57 to 1·38; P = 0·58) metastasis. CONCLUSION: Neoadjuvant therapy reduced the risk of local recurrence but not that of distant metastasis.

[Watchful waiting vs surgical repair of oligosymptomatic incisional hernias: Current status of the AWARE study]. / Beobachtung vs. Operation oligosymptomatischer Narbenhernien : Aktueller Stand der AWARE-Studie.

INTRODUCTION: Incisional hernias are one of the the most frequent complications in visceral surgery and incisional hernia repair has a relevant complication rate. Therefore, there have to be solid indications before carrying out incisional hernia repair. To date, there is a lack of evidence concerning the correct indications for surgical repair of incisional hernias. The AWARE trial compares watchful waiting to surgical repair of incisional hernias. MATERIAL AND METHODS: The AWARE trial is a prospective randomized multicenter trial. Patients with asymptomatic or oligosymptomatic incisional hernia are randomized into the watchful waiting or the surgical repair group with a follow-up of 2 years. The primary endpoint is pain during normal activities due to the hernia or the hernia repair after 2 years measured on the hernia-specific surgical pain scale (SPS). RESULTS: In this study 36 centers are participating throughout Germany, more than 1600 patients had been screened up to 31 December 2014 and 234 (14.6%) of the screened patients could be recruited. CONCLUSION: The AWARE study will provide evidence concerning the two therapeutic options of watchful waiting and surgical repair of incisional hernia.

[Further technical and digital development in minimally invasive and conventional surgery]. / Technische und digitale Weiterentwicklung in der laparoskopischen/offenen Chirurgie.

Technological innovations have initiated a fundamental change in invasive therapeutic approaches which has led to a welcome reduction of surgical trauma but was also associated with a declining role of conventional surgery. Active utilization of future technological developments is decisive to promote new therapeutic strategies and to avoid a further loss of importance of surgery. This includes individualized preoperative therapy planning as well as intraoperative diagnostic work-up and navigation and the use of new functional intelligent implants. The working environment "surgical operating room" has to be refurbished into an integrated cooperating functional system. The impact of new technological developments is particularly obvious in minimally invasive surgery. There is a clear tendency towards further reduction in trauma in the surgical access. The incision will become smaller and the number of ports will be further reduced, with the aim of ultimately having just one port (monoport surgery) or even via natural access routes (scarless surgery). Among others, improved visualization including, e.g. autostereoscopy, digital image processing and intelligent support systems, which are able to assist in a cooperative way, will enable these goals to be achieved.