Laparoscopic Versus Open Surgery for Gastric Gastrointestinal Stromal Tumors: What Is the Impact on Postoperative Outcome and Oncologic Results?

OBJECTIVES: The aim of the study was to compare the postoperative and oncologic outcomes of laparoscopic versus open surgery for gastric gastrointestinal stromal tumors (gGISTs). BACKGROUND: The feasibility of the laparoscopic approach for gGIST resection has been demonstrated; however, its impact on outcomes, particularly its oncologic safety for tumors greater than 5 cm, remains unknown. METHODS: Among 1413 patients treated for a GIST in 61 European centers between 2001 and 2013, patients who underwent primary resection for a gGIST smaller than 20 cm (N = 666), by either laparoscopy (group L, n = 282) or open surgery (group O, n = 384), were compared. Multivariable analyses and propensity score matching were used to compensate for differences in baseline characteristics. RESULTS: In-hospital mortality and morbidity rates in groups L and O were 0.4% versus 2.1% (P = 0.086) and 11.3% vs 19.5% (P = 0.004), respectively. Laparoscopic resection was independently protective against in-hospital morbidity (odds ratio 0.54, P = 0.014). The rate of R0 resection was 95.7% in group L and 92.7% in group O (P = 0.103). After 1:1 propensity score matching (n = 224), the groups were comparable according to age, sex, tumor location and size, mitotic index, American Society of Anesthesiology score, and the extent of surgical resection. After adjustment for BMI, overall morbidity (10.3% vs 19.6%; P = 0.005), surgical morbidity (4.9% vs 9.8%; P = 0.048), and medical morbidity (6.2% vs 13.4%; P = 0.01) were significantly lower in group L. Five-year recurrence-free survival was significantly better in group L (91.7% vs 85.2%; P = 0.011). In tumors greater than 5 cm, in-hospital morbidity and 5-year recurrence-free survival were similar between the groups (P = 0.255 and P = 0.423, respectively). CONCLUSIONS: Laparoscopic resection for gGISTs is associated with favorable short-term outcomes without compromising oncologic results.

Advanced age remains an achilles heel for liver resections.

BACKGROUND: As the general population is aging, surgery in elderly patients has become a major public health issue. This basic question is especially true for liver resection (LR). The aim of this study was to evaluate the operative risks of LR in the elderly. METHODS: Retrospective analysis of a large recent and monocentric database of LR was performed between January 1, 2005 and May 31, 2011. Patients were categorized into three groups (<60, 60-74, and ≥75 years old) to analyze postoperative outcomes and 1-year mortality. Clinicopathologic factors likely to influence outcomes were assessed by univariate and multivariate analysis. RESULTS: Altogether, 1,001 consecutive LRs were performed in 912 patients (mean age 62 ± 13 years). The distribution of the LR by age was 372 (37.2 %), 477 (47.6 %), and 152 (15.2 %) in patients <60, 60-74, and ≥75 years, respectively. The overall morbidity and mortality rates were 33.3 and 2.5 %, respectively. Age ≥75 years was independently associated with postoperative mortality [odds ratio (OR) 4.75, 95 % confidence interval (CI) 1.5-15.1; p = 0.008] and 1-year mortality (OR 2.8, 95 % CI 1.2-6.6; p = 0.015). The postoperative complication rate (p = 0.216) was not increased, even for major complications (p = 0.09). The other independent risk factors for mortality were a cirrhotic liver (p = 0.017), preoperative arterial chemoembolization (p = 0.001), caval vein clamping (p = 0.001), and intraoperative blood transfusion (p = 0.044). CONCLUSIONS: Age beyond 75 years represent a risk factor of death after LR and should be avoided after chemoembolization or in cirrhotic patients. A specific assessment using geriatric indexes might be the key to success in this population.

Incidence and predictive factors of clinically relevant bile leakage in the modern era of liver resections.

OBJECTIVE: To evaluate the incidence, the impact on survival and the predictive factors of bile leakage (BL) in a recent large monocentric series of liver resections performed in a referral tertiary care centre. BACKGROUND: Previous reports dealing with bile leakage (BL) after liver resection are rare and have displayed conflicting results regarding incidence, impact on follow-up and predictive factors. METHODS: A retrospective review of the records of 912 patients who underwent a total of 1001 consecutive liver resections without biliary reconstruction, performed between January 2005 and May 2011. BL was defined by the presence of bile in the abdominal drains, a radiologically or surgically drained bilioma or biliary peritonitis. BL severity was established according to the Clavien-Dindo classification. Fifty-eight pre-, per- and post-resection variables were analysed and the independent BL predictive factors were identified using logistic regression. RESULTS: The incidence of BL was 8%. Clavien-Dindo I-II, IIIa, IIIb or IV rates were 29%, 35%, 32.5% and 2.5%, respectively. BL did not increase in-hospital mortality (2.5% versus 2.9%, P = 1.0), but doubled the median duration of hospital stay (16 versus 9 days, P < 0.001) and increased 1-year mortality (11% versus 5%, P = 0.03). Multivariate analysis identified that pre-operative bevacizumab [odds ratio (OR) = 2.9, confidence interval (CI) 95% = 1.58-5.41] P = 0.001], a major hepatectomy [OR = 2.6 (CI 95% = 1.48-4.76) P = 0.001], a two-stage hepatectomy [OR = 2.5 (CI 95% = 1.17-5.52) P = 0.018], the selective clamping technique [OR = 2.6 (CI 95% = 1.03-6.78) P = 0.042], R1 or R2 resection [OR = 2.6 (CI 95% = 1.52-4.64) P = 0.001] and the absence of a methylene blue test [OR = 2.6 (IC 95% = 1.43-4.65) P = 0.002] were independent risk factors of BL. CONCLUSION: BL remains frequent after liver resection. It has a dramatic impact on patient survival and care costs. Its incidence could be reduced by avoiding the pre-operative use of bevacizumab, avoiding selective clamping and performing a blue dye test in all resections.

Gastrobronchial Fistula: A Serious Complication of Sleeve Gastrectomy. Results of a French Multicentric Study.

BACKGROUND: Gastrobronchial fistula (GBF) is a complication of esophageal, splenic, or antireflux surgeries and was recently described as a complication of bariatric surgery. Our aim was to study all cases of GBF after laparoscopic sleeve gastrectomy (LSG) managed in five French university bariatric centers in order to establish the incidence and to evaluate the different treatments of this complication. METHODS: We retrospectively studied 13 patients which developed GBF after LSG performed between March 2007 and August 2012. Patients were separated into two groups: patients who had early gastric fistula which has evolved into a GBF (group 1) and patients who had a late gastric fistula, either directly GBF or a late gastric fistula evolved in GBF (group 2). RESULTS: Group 1 consisted of five patients and group 2 of eight patients. All patients were undernourished at diagnosis. Management of GBF was a combined thoraco-abdominal surgery with gastrojejunal anastomosis (n = 5) or total gastrectomy (n = 1), multiple endoscopic treatment and thoracic surgery (n = 3), an endobronchial valve (n = 1), total gastrectomy and thoracic drainage (n = 1), and transorificial intubation with thoracic surgery or drainage (n = 2). There was no mortality. All GBF healed. CONCLUSIONS: GBF after LSG is a serious complication which is not anecdotal. Most of the early gastric fistulas occuring after LSG become chronic and can evolve into a GBF. Surgical approach is an effective treatment. Endobronchial valve is a novel alternative.