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PURPOSE: To reduce perioperative risks among patients with a preoperative diabetes mellitus (DM) a total pancreatectomy (TP) might be a alternative to pancreatoduodenectomy (PD). This study aimed to compare the postoperative quality of life (QoL) of patients with preoperative DM undergoing PD or TP. METHODS: A single-centre retrospective study was conducted, all consecutive patients with preoperative DM undergoing PD or TP between 2011 and 2023 were identified in a prospective database. The primary endpoint was QoL, prospectively assessed using EORTC QLQ-C30 questionnaires at 3, 6, and 12 months after surgery and then annually until death. Secondary endpoints were morbidity and mortality. RESULTS: Seventy-one patients were included, 17 after TP and 54 after PD. Insulin-dependent DM occurred in 21 (39%) of the PD patients. QoL was worse after TP, especially in terms of physical functioning (-31.7 points; 95% CI: -50.0 to -13.3; P < 0.001), role functioning (-41.3 points; 95% CI: -61.3 to -21.3; P < 0.001), emotional functioning (-27.5 points; 95% CI: -50.4 to -4.6; P = 0.019), fatigue symptoms (20 points; 95% CI: 2.7 to 37.4; P = 0.024) and pain symptoms (30.2 points; 95% CI: 4.1 to 56.3; P = 0.024). The rates of postoperative major complications (29% vs. 35%; P = 0.853) and mortality (11% vs. 7%; P = 0.857) were similar between TP and PD. CONCLUSION: Postoperative morbidity and mortality were comparable between PD and TP, however QoL is significantly lower after TP. Importantly, patients with preoperative DM have a 60% chance of remaining noninsulin-dependent after PD.
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Pancreatectomia , Neoplasias Pancreáticas , Pancreaticoduodenectomia , Qualidade de Vida , Humanos , Masculino , Feminino , Pancreaticoduodenectomia/efeitos adversos , Pancreaticoduodenectomia/métodos , Pancreatectomia/métodos , Pancreatectomia/efeitos adversos , Pessoa de Meia-Idade , Estudos Retrospectivos , Idoso , Neoplasias Pancreáticas/cirurgia , Neoplasias Pancreáticas/mortalidade , Resultado do Tratamento , Diabetes Mellitus/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , AdultoRESUMO
BACKGROUND: The aim of this study was to assess the predictive value of discharge C-reactive protein (CRP) and white blood cell (WBC) levels for 90-day readmission after pancreatoduodenectomy (PD). METHODS: A two-centre, retrospective study was performed between 2008 and 2022. Receiver operating characteristic (ROC) curve analysis was used to determine the predictive value of CRP level and WBC count at discharge. A conditional inference tree (CTREE) was constructed to identify combined risks within subgroups using variables associated with readmission. RESULTS: Of 438 patients, 54 (12%) were readmitted. The median WBC count at discharge was comparable between the readmitted and not readmitted groups (9.1 vs. 8.5 G/l). The CRP levels at discharge were predictive of 90-day readmission, with an area under the ROC curve (AUC) of 0.63 (95% CI: 0.55-0.63). A CRP concentration below 105 mg/l ruled out 90-day readmission, with a negative predictive value (NPV) of 90% (95% CI: 81%-95%). CTREE confirmed the diagnostic value of CRP at discharge (AUC = 0.68, 95% CI 0.60-0.68). CTREE additionally identified previous wound infection as a second risk factor for readmission in patients with CRP levels less than 101 mg/l (P = 0.003). CONCLUSION: CRP levels below 105 mg/l at discharge allow for a safe discharge with a low 90-day readmission rate. Wound infection, but not WBC count, was a positive predictor of 90-day readmission with moderate accuracy, suggesting the need for predischarge imaging for undetected complications in this patient cohort. TRIAL REGISTRATION: Our retrospective analysis did not require registration with a publicly accessible registry.
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PURPOSE: Quality of life (QoL) is temporarily compromised after pancreatic surgery, but no evidence for a negative impact of postoperative complications on QoL has been provided thus far. Delayed gastric emptying (DGE) is one of the most common complications after pancreatic surgery and is associated with a high level of distress. Therefore, the aim of this study was to analyse the influence of DGE on QoL. METHODS: This single-centre retrospective study analysed QoL after partial duodenopancreatectomy (PD) via the European Organization for Research and Treatment of Cancer core questionnaire (QLQ-C30). The QoL of patients with and without postoperative DGE was compared. RESULTS: Between 2010 and 2022, 251 patients were included, 85 of whom developed DGE (34%). Within the first postoperative year, compared to patients without DGE, those with DGE had a significantly reduced QoL, by 9.0 points (95% CI: -13.0 to -5.1, p < 0.001). Specifically, physical and psychosocial functioning (p = 0.020) decreased significantly, and patients with DGE suffered significantly more from fatigue (p = 0.010) and appetite loss (p = 0.017) than patients without DGE. After the first postoperative year, there were no significant differences in QoL or symptom scores between patients with DGE and those without DGE. CONCLUSION: Patients who developed DGE reported a significantly reduced QoL and reduced physical and psychosocial functioning within the first year after partial pancreatoduodenectomy compared to patients without DGE.
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Esvaziamento Gástrico , Neoplasias Pancreáticas , Pancreaticoduodenectomia , Complicações Pós-Operatórias , Qualidade de Vida , Idoso , Feminino , Masculino , Pessoa de Meia-Idade , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/efeitos adversos , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , HumanosRESUMO
STUDY DESIGN: We performed a comprehensive cadaveric biomechanical study to compare the fixation strength of primary screws, screws augmented with bone allograft, and screws augmented with polymethylmethacrylate cement. OBJECTIVE: To evaluate a novel technique for screw augmentation using morselized cortico-cancellous bone allograft to fill the widened screw track of failed pedicle screws. BACKGROUND: To date, there are no known biological methods available for failed pedicle screw augmentation or fixation. MATERIALS AND METHODS: Biomechanical tests were performed using 2 different testing modalities to quantify fixation strength including axial screw pullout and progressive cyclic displacement tests. RESULTS: Fifty vertebrae were instrumented with pedicle screws. Our study showed that bone allograft augmentation using the same diameter screw was noninferior to the fixation strength of the initial screw. In the axial pullout test, screws undergoing bone allograft repair failed at 25% lower loads compared with native screws, and screws augmented with cement showed approximately twice as much strength compared with native screws. In the cyclic displacement test, screws fixed with cement resisted loosening the best of all the groups tested. However, screws augmented with bone graft were found to have an equal strength to native screw purchase. our study did not find a correlation with bone mineral density as a predictor for failure in axial pullout or cyclic displacement tests. CONCLUSION: Bone allograft augmentation for pedicle screw fixation was noninferior to the initial screw purchase in this biomechanical study. This bone allograft technique is a viable option for screw fixation in the revision setting when there is significant bone loss in the screw track.
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INTRODUCTION: Marginal ulcers are an acid-related complication of laparoscopic Roux-en-Y gastric bypass. Few cases of acute perforation have been described, and there are few reports on viable surgical management. This case report demonstrates a two-step surgical procedure for treating a perforated late marginal ulcer in a patient with sepsis. PRESENTATION OF CASE: A 39-year-old smoker presented to the emergency department six years after undergoing a Roux-en-Y gastric bypass. Diagnostic findings revealed ascites and changes in intestinal calibre, indicating the need for surgery. Intraoperatively, a perforated marginal ulcer covered by the liver was observed. Given the extent of the perforation and the patient's increased instability, discontinuity resection was performed. After stabilisation and improvement in the nutritional status, the gastrojejunostomy was restored nine weeks later. DISCUSSION: Treatment of Marginal ulcers is controversial, with no clear guidelines. However, severe complications require endoscopic or surgical treatment. The literature considers three main surgical treatment options for perforated marginal ulcers: surgical repair, surgical anastomotic revision, and gastric bypass reversal. Complicated situations, significant intraoperative findings, and unstable patients require tailored approaches. CONCLUSION: A two-step procedure with discontinuity resection for damage control surgery, patient stabilisation, and improvement of nutritional status, followed by elective continuity restoration with a new gastrojejunostomy, is considered feasible in critically ill patients.
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BACKGROUND: Groove pancreatitis is a focal form of chronic pancreatitis affecting the area of the paraduodenal groove. The aim of this systematic review was to assess the clinical presentation, diagnosis and treatment of patients with groove pancreatitis. METHODS: Medical literature databases (Embase, Medline via PubMed and Cochrane Central Register of Controlled Trials) were systematically searched for data recorded between 1 January 1990 and 31 August 2022 regarding patient characteristics, diagnosis, surgical treatment and outcomes. The following inclusion criteria were applied: RCTs, observational studies (cohort and case-control studies) and case studies with >3 cases including patients with groove pancreatitis undergoing medical, endoscopic or surgical treatment with available clinical and diagnostic data. Fisher's exact test for binary data and Mann-Whitney U test or Student t-test for continuous data were adopted for statistical analysis. RESULTS: Of 649 studies, 44 were included, involving reports on 1404 patients with a mean age of 49 years. In 41 of the 44 studies in which patient gender was described, 86 per cent (N = 1023) of patients were male. Information on the risk factors of alcohol and nicotine was available in 37 and 23 studies, respectively. Seventy-nine per cent (N = 886) of patients had a history of excessive alcohol consumption and 83 per cent (N = 595) were smokers. Information on clinical symptoms was available in 37 of the 44 included studies and 78.5 per cent (N = 870) presented with abdominal pain. Some 27 studies comprising 920 groove pancreatitis patients were treatment oriented. Seventy-four per cent (N = 682) of patients were treated conservatively, 26.4 per cent (N = 134) underwent endoscopic treatment and 54.7 per cent (N = 503) required surgery. There was complete relief of symptoms in 35.6 per cent (N = 243) after conservative treatment, 55.2 per cent (N = 74) after endoscopic treatment and 69.6 per cent (N = 350) after surgical treatment. The median follow-up time was 42 months (range, 1-161 months). CONCLUSION: Groove pancreatitis shows on imaging a typical triad: cystic lesions in the pancreatic duct or duodenal wall, calcifications, and thickenings of the duodenal wall. Surgery appears to be the most effective treatment modality.
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Pancreatite , Doenças Raras , Humanos , Masculino , Pessoa de Meia-Idade , Feminino , Dor Abdominal/etiologia , Estudos de Casos e Controles , Tratamento Conservador , Pancreatite/diagnóstico por imagem , Pancreatite/terapiaRESUMO
BACKGROUND: Postoperative ileus is common after gastrointestinal surgery. This network meta-analysis aimed to compare the effectiveness of gum chewing and coffee and caffeine intake on ileus-related outcomes. METHODS: A systematic literature review was performed to identify randomized controlled trials (RCTs) comparing noninvasive treatments for ileus after gastrointestinal surgery. The main analyses included random effects network meta-analyses using frequentist methods with simultaneous direct and indirect comparisons of time to first flatus, time to first defecation, and length of stay. Bayesian network meta-analysis using Markov chains was also used. RESULTS: A total of 32 RCTs comparing 4999 patients were included in this network meta-analysis. Time to flatus was reduced by gum chewing (mean difference compared to control (MD): -11 h, 95% confidence interval (95% CI) - 16 to - 5 h, P < 0.001). Time to defecation was reduced by gum chewing and coffee, with MDs of -18 h (95% CI - 23 to - 13 h, P < 0.001) and -13 h (95% CI - 24 to - 1 h, P < 0.001), respectively. Length of stay was reduced by coffee and gum chewing with MDs of - 1.5 days (95% CI: - 2.5 to - 0.6 days, P < 0.001) and - 0.9 days (95% CI: - 1.3 to - 0.4 days, P < 0.001), respectively. CONCLUSION: Coffee and gum chewing were proven to be effective noninvasive approaches for shortening the postoperative length of hospital stay and time to first defecation, especially in open gastrointestinal surgery; thus these actions should be recommended after gastrointestinal surgery.
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Procedimentos Cirúrgicos do Sistema Digestório , Íleus , Humanos , Defecação , Café , Metanálise em Rede , Mastigação , Flatulência , Íleus/etiologia , Íleus/prevenção & controle , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Goma de Mascar , Tempo de Internação , Motilidade GastrointestinalRESUMO
INTRODUCTION: Over the past two decades, cytoreductive surgery and HIPEC has improved outcomes for selected patients with peritoneal metastasis from various origins. This is a cross-sectional study with descriptive analyses of HIPEC trials registered on ClinicalTrials.gov. This study aimed to characterize clinical trials on HIPEC registered on ClinicalTrials.gov with the primary objective of identifying a trial focus and to examine whether trial results were published. METHODS: The search included trials registered from 1 January 2001 to 14 March 2022. We examined the associations of exposure variables and other trial features with two primary outcomes: therapeutic focus and results reporting. RESULTS: In total, 234 clinical trials were identified; 26 (11%) were already published, and 15 (6%) trials have reported their results but have not been published as full papers. Among ongoing nonpublished trials, 81 (39%) were randomized, 30 (14%) were blinded, n = 39 (20%) were later phase trials (i.e., phases 3 and 4), n = 152 (73%) were from a single institution, and 91 (44%) had parallel groups. Most of the trials were recruiting at the time of this analysis (75, 36%), and 39 (20%) were completed but had yet to publish results. In total, 68% of the trials focused on treatment strategies, and 53% investigated the oncological outcome. The most studied neoplasms for HIPEC trials were peritoneally metastasized colorectal cancer (32%), gastric cancer (29%), and ovarian cancer (26%). Twenty different drugs were analyzed in these clinical trials. CONCLUSIONS: Many study results are awaited from ongoing HIPEC trials. Most HIPEC trials focused on gastric, colorectal, or ovarian cancer. Many clinical trials were identified involving multiple entities and chemotherapeutic agents.
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INTRODUCTION: Randomised controlled trials (RCTs) continue to provide the best evidence for treatment options, but the quality of reporting in RCTs and the completeness rate of reporting of surgical outcomes and complication data vary widely. The aim of this study was to measure the quality of reporting of the surgical outcome and complication data in RCTs of rectal cancer treatment and whether this quality has changed over time. METHODS: Eligible articles with the keywords ("rectal cancer" OR "rectal carcinoma") AND ("radiation" OR "radiotherapy") that were RCTs and published in the English, German, Polish, or Italian language were identified by reviewing all abstracts published from 1982 through 2022. Two authors independently screened and analysed all studies. The quality of the surgical outcome and complication data was assessed based on fourteen criteria, and the quality of RCTs was evaluated based on a modified Jadad scale. The primary outcome was the quality of reporting in RCTs and the completeness rate of reporting of surgical results and complication data. RESULTS: A total of 340 articles reporting multimodal therapy outcomes for 143,576 rectal cancer patients were analysed. A total of 7 articles (2%) met all 14 reporting criteria, 13 met 13 criteria, 27 met from 11 to 12 criteria, 36 met from 9 to 10 criteria, 76 met from 7 to 8 criteria, and most articles met fewer than 7 criteria (mean 5.5 criteria). Commonly underreported criteria included complication severity (15% of articles), macroscopic integrity of mesorectal excision (17% of articles), length of stay (18% of articles), number of lymph nodes (21% of articles), distance between the tumour and circumferential resection margin (CRM) (26% of articles), surgical radicality according to the site of the primary tumour (R0 vs. R1 + R2) (29% of articles), and CRM status (38% of articles). CONCLUSION: Inconsistent surgical outcome and complication data reporting in multimodal rectal cancer treatment RCTs is standard. Standardised reporting of clinical and oncological outcomes should be established to facilitate comparing studies and results of related research topics.
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BACKGROUND: The cause, extent, and role of muscle edema for muscle degeneration are unknown and not considered in the current literature. In vivo experiments were designed to prove muscle edema formation in the early period in a sheep model of acute rotator cuff tears. HYPOTHESIS: Muscle edema occurs after tendon release with or without additional stretching trauma and may be associated with muscle retraction and subsequent muscle degeneration. STUDY DESIGN: Controlled laboratory study. METHODS: A sheep model with acute release of the infraspinatus tendon was used. An osteotomy of the greater tuberosity, including the insertion of the infraspinatus tendon, was performed in 14 sheep. To demonstrate presence of edema, magnetic resonance imaging scans were performed at 0, 2, and 4 weeks using T1-weighted, T2-weighted, proton density-weighted, and Dixon sequences. Excisional biopsy specimens were taken at 0, 3, and 4 weeks (histological results will be reported in a later publication). Two injury models were created: a nontrauma group that consisted of muscle release alone and a trauma group that included additional standardized traction to the musculotendinous unit. Evaluation of T1- and T2-weighted images included calculation of pennation angle, muscle fiber length, signal intensity (edema), and muscle volume. Muscle wet weight and volume were measured at sacrifice. RESULTS: Edema formation was shown in all sheep and slightly more pronounced in the trauma group, where muscle intensity increased significantly between time point 0 (200 Grey Value (GV)) and weeks 2, 3, and 4 (300 GV). Edema formation started early after tendon release with a plateau between 3 and 4 weeks. Deterioration of muscle fiber bundles began also after tendon release with a peak at 4 weeks. Muscle volume decreased steadily over time. CONCLUSION: Muscle edema appeared early after rotator cuff tendon release, was more pronounced in the trauma group, and reached a plateau after 3 to 4 weeks. Muscle fatty content decreased within the short period of 4 weeks owing to a dilution effect. Muscle edema seems to be an essential factor in cuff tears and subsequent muscle retraction and degeneration. CLINICAL RELEVANCE: This study demonstrates a new type of muscle edema of retraction and describes the characteristics of edema associated with a retracted rotator cuff tear.
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Lesões do Manguito Rotador , Animais , Modelos Teóricos , Projetos de Pesquisa , Ovinos , Modelos Animais de DoençasRESUMO
Peritoneal cancer (PC) is a dire finding, yet in selected patients, long-term survival is possible. Complete cytoreductive surgery (CRS) together with combination immunochemotherapy is essential to achieve cure. Hyperthermic intraperitoneal chemotherapy (HIPEC) and pressurized intraperitoneal aerosol chemotherapy (PIPAC) are increasingly added to the multimodal treatment. The Swiss Peritoneal Cancer Group (SPCG) is an interdisciplinary group of expert clinicians. It has developed comprehensive treatment algorithms for patients with PC from pseudomyxoma peritonei, peritoneal mesothelioma, gastric, and colorectal origin. They include multimodal neoadjuvant treatment, surgical resection, and palliative care. The indication for and results of CRS HIPEC and PIPAC are discussed in light of the current literature. Institutional volume and clinical expertise required to achieve best outcomes are underlined, while inclusion of patients considered for CRS HIPEC and PIPAC in a clinical registry is strongly advised. The present recommendations are in line with current international guidelines and provide the first comprehensive treatment proposal for patients with PC including intraperitoneal chemotherapy. The SPCG comprehensive treatment algorithms provide evidence-based guidance for the multimodal care of patients with PC of gastrointestinal origin that were endorsed by all Swiss clinicians routinely involved in the multimodal care of these challenging patients.
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BACKGROUND: Coffee has been suggested to help postoperative gastrointestinal motility but the mechanism is not known. This trial assessed whether caffeine shortened time to bowel activity after laparoscopic colectomy. METHODS: This was a single-centre, randomized, double-blinded, placebo-controlled superiority trial (October 2015 to August 2020). Patients aged at least 18 years undergoing elective laparoscopic colectomy were assigned randomly to receive 100â mg or 200â mg caffeine, or a placebo (250â mg corn starch) three times a day orally. The primary endpoint was the time to first bowel movement. Secondary endpoints included colonic transit time, time to tolerance of solid food, duration of hospital stay, and perioperative morbidity. RESULTS: Sixty patients were assigned randomly to either the 200-mg caffeine group (20 patients), the 100-mg caffeine group (20) or the placebo group (20). In the intention-to-treat analysis, the mean(s.d.) time to first bowel movement was 67.9(19.2)â h in the 200-mg caffeine group, 68.2(32.2)â h in the 100-mg caffeine group, and 67.3(22.7)â h in the placebo group (P = 0.887). The per-protocol analysis and measurement of colonic transit time confirmed no measurable difference with caffeine. CONCLUSION: Caffeine was not associated with reduced time to first bowel movement. REGISTRATION NUMBER: NCT02510911 (http://www.clinicaltrials.gov).
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Cafeína , Laparoscopia , Humanos , Adolescente , Adulto , Cafeína/uso terapêutico , Resultado do Tratamento , Colectomia/métodos , Procedimentos Cirúrgicos EletivosRESUMO
OBJECTIVE: To assess the impact of surgical technique in regard to morbidity and mortality after neoadjuvant treatment for esophageal cancer. BACKGROUND: The SAKK trial 75/08 was a multicenter phase III trial (NCT01107639) comparing induction chemotherapy followed by chemoradiation and surgery in patients with locally advanced esophageal cancer. METHODS: Patients in the control arm received induction chemotherapy with cisplatin and docetaxel, followed by concomitant chemoradiation therapy with cisplatin, docetaxel, and 45Gy. In the experimental arm, the same regimen was used with addition of cetuximab. After completion of neoadjuvant treatment, patients underwent esophagectomy. The experimental arm received adjuvant cetuximab. Surgical outcomes and complications were prospectively recorded and analyzed. RESULTS: Total of 259 patients underwent esophagectomy. Overall complication rate was 56% and reoperation rate was 15% with no difference in complication rates for transthoracic versus transhiatal resections (56% vs 54%, P = 0.77), nor for video assisted thoracic surgeries (VATS) versus open transthoracic resections (67% vs 55%, P = 0.32). There was a trend to higher overall complication rates in squamous cell carcinoma versus adenocarcinoma (65% vs 51%, P = 0.035), and a significant difference in ARDS in squamous cell carcinoma with 14% versus 2% in adenocarcinoma (P = 0.0002). For patients with involved lymph nodes, a lymph node ratio of ≥0.1 was an independent predictor of PFS (HR 2.5, P = 0.01) and OS (HR 2.2, P = 0.03). CONCLUSIONS: This trial showed no difference in surgical complication rates between transthoracic and transhiatal resections. For patients with involved lymph nodes, lymph node ratio was an independent predictor of progression free survival and overall survival.
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Adenocarcinoma , Carcinoma de Células Escamosas , Neoplasias Esofágicas , Adenocarcinoma/patologia , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/terapia , Cetuximab/uso terapêutico , Cisplatino/uso terapêutico , Docetaxel/uso terapêutico , Esofagectomia/métodos , Humanos , Terapia Neoadjuvante/métodos , Estadiamento de Neoplasias , Taxa de Sobrevida , Resultado do TratamentoRESUMO
BACKGROUND: Complete and correct documentation of diagnosis and procedures is essential for adequate health provider reimbursement in diagnosis-related group (DRG) systems. The objective of this study was to investigate whether daily monitoring and semiautomated proposal optimization of DRG coding (precoding) is associated with higher reimbursement per hospitalization day. MATERIALS AND METHODS: This parallel-group, unblinded, randomized clinical trial randomized patients 1:1 into intervention (precoding) and control groups. Between June 12 and December 6, 2019 all hospitalized patients (1566 cases) undergoing elective or emergency surgery at the department of surgery in a Swiss hospital were eligible for this study. By random sample selection, cases were assigned to the intervention (precoding) and control groups. The primary outcome was the total reimbursement, divided by the length of stay. RESULTS: Of the 1205 randomized cases, 1200 (precoding group: 602) remained for intention-to-treat, and 1131 (precoding group: 564) for per-protocol analysis. Precoding increased reimbursement per hospitalization day by 6.5% (160 US dollars; 95% confidence interval 31 to 289; P = 0.015). In a regression analysis patients hospitalized 7 days or longer, precoding increased reimbursement per day by 10.0% (246 US dollars; 95% confidence interval -12 to 504; P = 0.021). More secondary diagnoses (mean [SD]: 5.16 [5.60] vs 4.39 [5.34]; 0.77; 95% confidence interval 0.15 to 1.39; P = 0.015) and nonsurgical postoperative complications (mean [SD]: 0.68 [1.45] vs 0.45 [1.12]; 0.23; 95% confidence interval 0.08 to 0.38; P = 0.002) were documented by precoding. No associated was observed regarding the length of stay, total reimbursement, or case mix index. The mean (SD) precoding time effort was 37 (27) minutes per case. CONCLUSION: Physician-led precoding increases DRG-based reimbursement. Precoding is time consuming and should be focused on cases with a longer hospital stay to increase efficiency.
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Grupos Diagnósticos Relacionados , Documentação , Procedimentos Cirúrgicos Eletivos , Humanos , Tempo de Internação , Complicações Pós-OperatóriasRESUMO
INTRODUCTION: Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a treatment option for patients with peritoneal metastases. We evaluated the current status of ongoing prospective clinical trials investigating PIPAC to provide an overview and predict trends in this field. METHODS: All 367,494 records of clinical trials registered at ClinicalTrials.gov were searched for trials dealing with PIPAC. Active or unpublished trials were further analyzed. RESULTS: In total, 22 clinical trials were identified and selected for further analyses. Most trials had a single-arm design and were phase I or II. No phase III trials were registered. Academic centers were recorded as primary sponsors in the majority of trials (63.6%). Every year, between 2 and 5 new trials were initiated. In 17 trials (81.8%), PIPAC was used in a palliative setting only, 2 trials performed PIPAC in a neoadjuvant setting, and 2 trials performed PIPAC in an adjuvant setting. Six different drugs (doxorubicin, cisplatin, oxaliplatin, nab-paclitaxel, 5-fluorouracil, and docetaxel) were used in these clinical trials. Most trials investigated the efficacy (n = 15) or safety (n = 7) of PIPAC therapies. CONCLUSIONS: The results of ongoing clinical trials will bring specific information on indications for PIPAC as well as the impact of PIPAC on quality of life and overall survival.
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Aerossóis/uso terapêutico , Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Neoplasias Peritoneais/secundário , Humanos , Infusões Parenterais , Neoplasias Peritoneais/tratamento farmacológico , Pressão , Estudos ProspectivosRESUMO
BACKGROUND: Postoperative aspiration pneumonia is a feared complication contributing significantly to postoperative morbidity and mortality. Over decades, there has been little progress in reducing incidence and mortality of postoperative aspiration pneumonia. Here, we assessed risk factors for postoperative aspiration pneumonia in general and abdominal surgery patients. METHODS: Patients undergoing surgery between January 2012 and December 2018 were included in this exact matched and weighted case-control study. Data from a prospectively acquired clinical database were retrospectively analyzed. RESULTS: Among 23,647 patients undergoing 32,901 operations, 144 (0.44%, 95% Confidence Interval: 0.37%-0.52%) cases of postoperative aspiration pneumonia were identified. Ninety-day mortality was 27.8% (n = 40). Major risk factors for postoperative aspiration pneumonia were emergency surgery in patients with prolonged preoperative fasting (>6 hours; odds ratio: 3.25, 95% confidence interval: 1.46-7.26; P < .001), older age with increasing risk in octogenarians compared to seniors (65-80 years: n = 69; odds ratio 5.23, 95% confidence interval: 2.18-12.51; >80 years: n = 50; odds ratio 13.72, 95% confidence interval: 4.94-38.09; P < .001), American Society of Anesthesiologists scores >II (American Society of Anesthesiologists III: n = 90; odds ratio 3.38, 95% confidence interval: 1.08-16.01; American Society of Anesthesiologists IV/V: n = 18; odds ratio 5.20, 95% confidence interval: 1.48-27.61; P < .001), and body mass index <18 kg/m2 (n = 9; odds ratio: 2.53; 95% confidence interval: 1.04-6.11; P = .029). Laparoscopies (odds ratio 0.45, 95% confidence interval: 0.23-0.88; <0.001) and female sex were associated with a decreased risk for postoperative aspiration pneumonia (odds ratio 0.40, 95% confidence interval: 0.23-0.69; P < .001). CONCLUSION: Preventive measures to reduce postoperative aspiration pneumonia should focus on older patients with American Society of Anesthesiologists scores ≥III undergoing open surgery. Cachectic patients and patients undergoing emergency surgery with prolonged preoperative fasting require increased attention. Laparoscopy was associated with a lower risk for postoperative aspiration pneumonia and should be preferred whenever appropriate.
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Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Pneumonia Aspirativa/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Medição de Risco/métodos , Idoso , Idoso de 80 Anos ou mais , Áustria/epidemiologia , Feminino , Humanos , Incidência , Masculino , Pneumonia Aspirativa/etiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco , Suíça/epidemiologiaRESUMO
INTRODUCTION AND IMPORTANCE: Near infrared fluorescence imaging with indocyanine green (ICG) can facilitate the intraoperative tumour localization and therefore a complete resection. Cholangiocarcinoma is an aggressive tumour and complete resection improves the outcome. Therefore, it is necessary to localize the tumour exactly but the translation of the preoperative imaging into the intraoperative setting can be difficult based only on sonography, computed tomography or magnetic resonance imaging. CASE PRESENTATION/CLINICAL FINDINGS AND INVESTIGATIONS/INTERVENTIONS AND OUTCOME: In this case a hepatic lesion suspicious for cholangiocarcinoma was discovered accidentally. Further diagnostics were unable to prove the diagnosis, therefore right hepatectomy was recommended and performed. Preoperatively ICG was administered and near infrared imaging was used intraoperatively clearly localizing the tumour, thus facilitating the resection. The intra- and postoperative course was uneventful. RELEVANCE AND IMPACT: This case report supports the very promising intraoperative use of fluorescence imaging for the localization of superficial hepatic tumours. Timing and correct administration of ICG is important.
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BACKGROUND: The COVID-19 pandemic has rapidly spread worldwide. As it is a novel disease, we have less experience in its possible appearances. Predominantly affecting the respiratory tract, about 20-43% patients also present with extrapulmonary manifestations such as coagulation disorders with thrombotic angiopathy. CASE PRESENTATION: In our institution, a patient presented to the emergency department with acute abdominal pain which was caused by portal vein thrombosis. As a COVID-19 nasopharyngeal antigen swab few days earlier was negative, we performed several tests to find out its etiology. After all tests were inconclusive and the patient suffered flu-like symptoms 2 weeks before, we repeated COVID-19 molecular testing and received a positive test result. The patient was treated symptomatically and received therapeutic anticoagulation. CONCLUSION: A COVID-19 infection can also be present without typical pulmonary symptoms. In patients with severe abdominal pain and new diagnosed portal vein thrombosis, it is important to think of a COVID-19 infection. Also, the reliability of antigen nasopharyngeal swab should be considered critically, especially if performed wrongly. We recommended to perform molecular tests when in doubt. After the diagnosis of portal vein thrombosis, immediate anticoagulation is recommended to reduce the risk of further complications like intestinal infarction.
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BACKGROUND: Multimodal treatment, including systemic treatment and surgery, improved the prognosis of peritoneal metastasis (PM). Despite all efforts, recurrence rates remain high, and little data are available about clinical behavior or molecular patterns of PM in comparison to hematogenous metastasis. Here, we aimed to analyze recurrence patterns after multimodal treatment for PM from colorectal cancer. METHODS: Patients with colorectal PM undergoing multimodal treatment including systemic chemotherapy and cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) between 2005 and 2017 at 4 centers were analyzed retrospectively. RESULTS: A total of 505 patients undergoing CRS/HIPEC were analyzed. Of the patients, 82.1% received preoperative chemotherapy. Median peritoneal cancer index was 6 (interquartile range = 3-11). Median disease-free and overall survival was 12 (95% confidence interval [CI] = 11 to 14) months and 51 (95% CI = 43 to 62) months, respectively. Disease recurred in 361 (71.5%) patients, presenting as isolated peritoneal recurrence in 24.6%, isolated hematogenous recurrence in 28.3%, and mixed recurrence in 13.9% of patients. Recurrence to the peritoneum was associated with an impaired time from recurrence to death of 21 (95% CI = 18 to 31) months for isolated peritoneal and 22 (95% CI = 16 to 30) months for mixed recurrence, compared with 43 (95% CI = 31 to >121) months for hematogenous recurrence (hazard ratio [HR] = 1.79, 95% CI = 1.27 to 2.53; P = .001; and HR = 2.44, 95% CI = 1.61 to 3.79; P < .001). On multiple logistic regression analysis, RAS mutational status (odds ratio [OR] = 2.42, 95% CI = 1.11 to 5.47; P = .03) and positive nodal stage of the primary (OR = 3.88, 95% CI = 1.40 to 11.86; P = .01) were identified as predictive factors for peritoneal recurrence. CONCLUSIONS: This study highlights the heterogeneity of peritoneal metastasis in patients with colorectal cancer. Recurrent peritoneal metastasis after radical treatment represents a more aggressive subset of metastatic colorectal cancer.