Long-Term Impact of Severe Postoperative Complications after Esophagectomy for Cancer: Individual Patient Data Meta-Analysis.

BACKGROUND: Severe postoperative complications (SPCs) may occur after curative esophagectomy for cancer and are associated with prolonged hospital stay, augmented costs, and increased in-hospital mortality. However, the effect of SPCs on survival after esophagectomy is uncertain. AIM: To assess the impact of severe postoperative complications (SPCs) on long-term survival following curative esophagectomy for cancer, we conducted a systematic search of PubMed, MEDLINE, Scopus, and Web of Science databases up to December 2023. The included studies examined the relationship between SPCs and survival outcomes, defining SPCs as Clavien-Dindo grade > 3. The primary outcome measure was long-term overall survival (OS). We used restricted mean survival time difference (RMSTD) and 95% confidence intervals (CIs) to calculate pooled effect sizes. Additionally, we applied the GRADE methodology to evaluate the certainty of the evidence. RESULTS: Ten studies (2181 patients) were included. SPCs were reported in 651 (29.8%) patients. The RMSTD overall survival analysis shows that at 60-month follow-up, patients experiencing SPCs lived for 8.6 months (95% Cis -12.5, -4.7; p < 0.001) less, on average, compared with no-SPC patients. No differences were found for 60-month follow-up disease-free survival (-4.6 months, 95% CIs -11.9, 1.9; p = 0.17) and cancer-specific survival (-6.8 months, 95% CIs -11.9, 1.7; p = 0.21). The GRADE certainty of this evidence ranged from low to very low. CONCLUSIONS: This study suggests a statistically significant detrimental effect of SPCs on OS in patients undergoing curative esophagectomy for cancer. Also, a clinical trend toward reduced CSS and DFS was perceived.

Magnetic Sphincter Augmentation Outcomes in Severe Gastroesophageal Reflux Disease.

Introduction: Outcomes of laparoscopic procedures for gastroesophageal reflux disease (GERD) are variable depending on surgical expertise and/or patient-related factors. Some procedures may be inadequate in patients with severe disease. Effectiveness of laparoscopic magnetic sphincter augmentation (MSA) has not been extensively tested in patients with severe disease. Methods: A prospectively collected database was analyzed to identify patients who underwent MSA at a single institution. Individuals who had previous esophago-gastric surgery were excluded. Severe GERD was defined as lower esophageal sphincter pressure <5 mmHg, distal esophageal amplitude <30 mmHg, Barrett's metaplasia, stricture or grade C-D esophagitis, and/or DeMeester score >50. Clinical characteristics and outcomes of patients with severe GERD were compared with those of patients with mild to moderate GERD who served as control group. Results: Over the study period, a total of 336 patients met the inclusion criteria, and 102 (30.4%) had severe GERD. The median follow-up was 24 months (IQR = 75) in severe GERD patients and 32 months (IQR = 84) in those with non-severe GERD. Patients with severe GERD had a higher rate of dysphagia and higher GERD-HRQL scores. After the MSA procedure, symptoms, health-related quality of life scores, and proton-pump inhibitors consumption significantly decreased in both groups (p < 0.05). No difference between groups was found in the prevalence of severe post-operative dysphagia, the need for endoscopic dilation or device removal, and the DeMeester score. Conclusion: Laparoscopic MSA is safe and effective in reducing symptoms, PPI use, and esophageal acid exposure also in patients with severe GERD.

Modified National Early Warning Score as Early Predictor of Outcome in COVID-19 Pandemic.

COVID-19 represented an important challenge to the Italian healthcare system (IHCS). Our main aim was to obtain evidence to support the use of modified national early warning score (m-NEWS) as an interdisciplinary, common, and universal scoring scale to quickly recognize patients with a risk of clinical deterioration before admission and during hospitalization. As a secondary goal, we tried to find a score threshold that can trigger patients' immediate medical review as a part of an optimal triaging protocol for an emergency setting where healthcare resources are overloaded. We performed a retrospective observational study. We included in our study all patients treated for COVID-19 infection in surgical departments between 01 March 2020 and 16 April 2020. Patients with negative test results for SARS-COV-2 were excluded. m-NEWS was obtained twice a day. Patients' m-NEWS were analyzed in order to verify the correlation between m-NEWS (at admission and m-NEWS variation 24 h after admission) and outcome (positive outcome-survival, negative outcome-death, or intensive care unit (ICU) transfer). We included a population-based sample of 225 SARS-COV-2-infected patients. Overall, the average age at hospitalization was 71 (ranging from 40 to 95). 144 (64%) patients were males and 81 (36%) females. m-NEWS values lower or equal to 7 were associated with the majority of the "recovered" population (100/132 75.75%) and at the same time with the minority of the "non-recovered" population (25/93 26.88%). For our sample, age is statistically correlated to the outcome but a triage protocol based solely on this variable is less effective than m-NEWS, which showed to be a reliable and easy-to-use score for first patient evaluation. Our observations pave the way towards further studies aiming at optimizing territorial and community healthcare management protocols.

Minimally invasive surgical management of Boerhaave's syndrome: a narrative literature review.

Treatment of Boerhaave's syndrome is controversial. Formal thoracotomy and laparotomy were considered the gold standard treatment in the past. However, these approaches are associated with significant surgical trauma, stress, and postoperative pain. Recently published studies reported the application of minimally invasive surgery in the setting of such esophageal emergency. However, the application of minimally invasive surgery in the setting of Boerhaave's syndrome is debated and evidence is puzzled. The aim of this study was to summarize the current knowledge on minimally invasive treatment of Boerhaave's syndrome. PubMed, EMBASE, and Web of Science databases were consulted. All articles that described the management of Boerhaave's syndrome in the setting of minimally invasive surgery (thoracoscopy or laparoscopy) were included. Sixteen studies and forty-eight patients were included. The age of the patient population ranged from 37 to 81 years old and 74% were males. The time shift period from symptoms onset to surgical treatment ranged from 5 to 240 hours with 10 patients (20.8%) having surgery more than 24 hours from symptoms onset. Vomiting (100%), chest/epigastric pain (88%), and dyspnea (62%) were the most commonly reported symptoms. The perforation size ranged from 6 to 30 mm with 96% of patients suffering from distal esophageal tear. Video-assisted thoracoscopy (VATS) was the most commonly reported surgical approach (75%), followed by laparoscopy (16.7%), and combined thoraco-laparoscopy (6.2%). In case of VATS, a left approach was adopted in 91% of patients with selective lung ventilation. Primary suture was the most commonly performed surgical procedure (60%) with interrupted single or dual-layer repair. Surgical debridement (25%), primary repair reinforced with gastric or omental patch (8%), esophageal repair over T-tube (6%), and endoscopic stenting combined with laparoscopic debridement (2%) were also reported. The postoperative morbidity was 64.5% with pneumonia (42%), pleural empyema (26%), and leak (19%) being the most commonly reported complications. The overall mortality was 8.3%. Boerhaave's syndrome is a rare entity. Minimally invasive surgical treatment seems promising, feasible, and safe in selected patients with early presentation and stable vital signs managed in referral centers. In the management algorithm of Boerhaave's syndrome, a definitive indication to adopt minimally invasive surgery is lacking and its potential role mandates further analysis.

Intracorporeal Versus Extracorporeal Anastomosis in Laparoscopic Right Colectomy: An Updated Systematic Review and Cumulative Meta-Analysis.

Purpose: The effect of intracorporeal anastomosis (IA) versus extracorporeal anastomosis (EA) in laparoscopic right hemicolectomy is controversial. The aim of this study was to evaluate the safety, effectiveness, and functional outcomes of IA compared with EA and to explore the timely tendency variations favoring one treatment over another. Materials and Methods: PubMed, EMBASE, and Web of Science were consulted. A systematic review, pairwise meta-analysis, and cumulative meta-analysis were conducted. Results: Twenty-three studies (3755 patients) were included: 45.7% underwent IA, whereas 54.3% underwent EA. The estimated pooled postoperative infectious complications, anastomotic leak, and overall complications risk ratios were 0.51 (95% confidence interval [CI]: 0.31 to 0.84; P = .009), 0.64 (95% CI: 0.40 to 1.03; P = .063), and 0.78 (95% CI: 0.62 to 0.97; P = .028), respectively. The cumulative meta-analysis showed a statistically significant timely tendency in favor of IA while considering infectious and overall complications. The estimated pooled mean difference of time to first flatus, first defecation, first oral diet, and hospital stay were -16.68 (P < .001), -25.94 (P < .001), -16.35 (P < .001), and -0.72 (P < .001), respectively. Again, the cumulative meta-analysis showed a statistically significant timely trend in favor of IA. No differences were found in term of operative time, conversion rate, ileus, bleeding, reoperation, 30-day readmission, and 30-day mortality. Conclusions: Compared with EA, IA seems to be associated with reduced postoperative infectious and overall complications. The time to first flatus, time to defecation, time to liquid diet, and hospital length of stay were estimated to be lower. A statistically significant timely trend favoring IA was noticed for postoperative infectious complications, overall complications, and recovery parameters. Further studies are warranted to confirm these results and to deeply investigate the supposed timely tendency convergence in favor of IA.

Remnant Gastric Cancer After Roux-en-Y Gastric Bypass: Narrative Review of the Literature.

BACKGROUND: The Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed procedures for surgical weight loss. It has been shown that overweight may be associated with an increased risk of gastric cancer. However, the risk of remnant gastric cancer after RYGB has not been defined yet and the development of neoplasm in the excluded stomach remains a matter of concern. METHODS: PubMed, EMBASE, and Web of Science databases were consulted. Articles that described the diagnosis and management of remnant gastric cancer after RYGB were considered. RESULTS: Seventeen patients were included. The age of the patient population ranged from 38 to 71 years. The most commonly reported symptoms were abdominal pain, nausea/vomiting, and anemia. Abdominal computed tomography was used for diagnosis in the majority of patients. The neoplasm was located in the antrum/pre-pyloric region in 70% of cases and adenocarcinoma was the most common tumor histology (80%). An advanced tumor stage (III-IV) was diagnosed in almost 70% of patients and 40% were considered unresectable. Gastrectomy with lymphadenectomy was performed in 9 cases (53%). Post-operative morbidity was 12%. The follow-up ranged from 3 to 26 months and the overall disease-related mortality rate was 33.3%. CONCLUSION: The development of remnant gastric cancer after RYGB is rare. Surgeons should be aware of this potential event and the new onset of epigastric pain, nausea, and anemia should raise clinical suspicion. Further epidemiologic studies are warranted to deeply investigate the post-RYGB-related risk of remnant gastric cancer development in high-risk populations.