Post-hepatectomy venous thromboembolism: a systematic review with meta-analysis exploring the role of pharmacological thromboprophylaxis.

PURPOSE: Patients undergoing hepatectomy are at moderate-to-high risk of venous thromboembolism (VTE). This study critically examines the efficacy of combining pharmacological (PTP) and mechanical thromboprophylaxis (MTP) versus only MTP in reducing VTE events against the risk of hemorrhagic complications. METHODS: A systematic review of major reference databases was undertaken, and a meta-analysis was performed using common-effects model. Risk of bias assessment was performed using Newcastle-Ottawa scale. Trial sequential analysis (TSA) was used to assess the precision and conclusiveness of the results. RESULTS: 8 studies (n = 4238 patients) meeting inclusion criteria were included in the analysis. Use of PTP + MTP was found to be associated with significantly lower VTE rates compared to only MTP (2.5% vs 5.3%; pooled RR 0.50, p = 0.03, I2 = 46%) with minimal type I error. PTP + MTP was not associated with an increased risk of hemorrhagic complications (3.04% vs 1.9%; pooled RR 1.54, p = 0.11, I2 = 0%) and had no significant impact on post-operative length of stay (12.1 vs 10.8 days; pooled MD - 0.66, p = 0.98, I2 = 0%) and mortality (2.9% vs 3.7%; pooled RR 0.73, p = 0.33, I2 = 0%). CONCLUSION: Despite differences in the baseline patient characteristics, extent of hepatectomy, PTP regimens, and heterogeneity in the pooled analysis, the current study supports the use of PTP in post-hepatectomy patients (grade of recommendation: strong) as the combination of PTP + MTP is associated with a significantly lower incidence of VTE (level of evidence, moderate), without an increased risk of post-hepatectomy hemorrhage (level of evidence, low).

Outcomes of level of ligation of inferior mesenteric artery in colorectal cancer: a systematic review and meta-analysis.

The level of ligation of the inferior mesenteric artery (IMA) is a critical factor that can influence outcomes. The aim of this meta-analysis was to compare outcomes following high or low ligation of IMA. A systematic search was performed for relevant articles published between 2000 and 2020. Meta-analysis was performed using fixed-effects or random-effects models; 31 studies were included. Results show significantly lower rates of anastomotic leak, postoperative morbidity and urinary dysfunction with low ligation compared with high ligation. Though recurrence rates were similar, 5-year overall survival was longer in the low ligation group. Low ligation of IMA decreases anastomotic leak rates and overall morbidity. Addition of IMA nodal clearance to low ligation appears to improve overall survival in colorectal cancer.

Challenges of cytoreduction in porta hepatis in surgery for advanced ovarian cancer.

Introduction: Advanced ovarian cancer often necessitates aggressive surgical intervention, including cytoreduction of the porta hepatis, which poses significant challenges due to the intricate anatomical structures involved. This surgical video aims to illustrate these challenges and demonstrate effective techniques for clearance of critical structures such as the portal vein (PV), common bile duct (CBD), accessory left hepatic artery (Acc. LHA), obliterated umbilical vein (OUV), inferior vena cava (IVC), and foramen of Winslow. Methods: The surgical procedure depicted in the video involved meticulous dissection and identification of anatomical landmarks to access the porta hepatis. Techniques for safe clearance of the PV, CBD, Acc. LHA, OUV, IVC, and foramen of Winslow were employed and are highlighted in detail. Emphasis was placed on preserving vascular integrity and minimizing intraoperative complications. Conclusions: The video demonstrates the complexities associated with cytoreduction of the porta hepatis in advanced ovarian cancer surgery and offers insights into overcoming these challenges. By utilizing precise surgical techniques and careful anatomical consideration, successful clearance of critical structures can be achieved, thereby optimizing patient outcomes and minimizing postoperative complications. This educational resource provides valuable guidance for surgeons encountering similar challenges in the management of advanced ovarian cancer.

The influence of socioeconomic status on access to cancer care and survival in resectable pancreatic cancer: a systematic review and meta-analysis.

BACKGROUND: Socioeconomic status (SES) is an important factor affecting access to cancer care and survival. Its role in pancreatic cancer warrants scrutiny. METHODS: A systematic review of major reference databases was undertaken. Categorization of the study population into low SES (LSES) and high SES (HSES) was based on the criteria employed in the individual studies. The outcome measures studied were stage of cancer presentation, access to care and overall survival. Meta-analysis was performed using random-effects models and trial sequential analysis (TSA) was used to assess the precision and conclusiveness of the results. RESULTS: Thirteen studies meeting inclusion criteria were included in the meta-analysis, which demonstrated that LSES was associated with significantly lower rates of presentation at a non-metastatic stage and poorer access to cancer care, viz. surgery, chemotherapy and radiation therapy. Despite heterogeneity, TSA supported the findings, displaying minimal type I error. CONCLUSION: As LSES is associated with delayed presentation, poorer access to care and poorer survival, SES should be considered a modifiable risk factor for poor outcomes in pancreatic cancer.

Systematic review and meta-analysis of the impact of deviations from a clinical pathway on outcomes following pancreatoduodenectomy.

BACKGROUND: Enhanced recovery after surgery is steadily gaining importance in patients undergoing pancreatic surgery, including pancreatoduodenectomy (PD). While clinical pathways targeting enhanced-recovery can achieve their intended outcome in reducing length of stay, compliance to these pathways, and their relevance is poorly understood. The aim of this systematic review was to assess the impact of deviations from/non-compliance to a clinical pathway on post-PD outcomes. AIM: To assess the impact of deviations from/non-compliance to a clinical pathway on post-PD outcomes. METHODS: A systematic review of major reference databases was undertaken, according to preferred reporting items for systematic reviews and meta-analysis guidelines, between January 2000 and November 2020 relating to compliance with clinical pathways and its impact on outcomes in patients undergoing PD. A meta-analysis was performed using fixed-effects or random-effects models. RESULTS: Eleven studies including 1852 patients were identified. Median overall compliance to all components of the clinical pathway was 65.7% [interquartile range (IQR): 62.7%-72.3%] with median compliance to post-operative parameters of the clinical pathway being 44% (IQR: 34.5%-52.25%). Meta-analysis using a fixed-effects model showed that ≥ 50% compliance to a clinical pathway predicted significantly fewer post-operative complications [pooled odds ratio (OR): 9.46, 95% confidence interval (CI): 5.00-17.90; P < 0.00001] and a significantly shorter length of hospital stay [pooled mean difference (MD): 4.32, 95%CI: -3.88 to -4.75; P < 0.0001]. At 100% compliance which was associated with significantly fewer post-operative complications (pooled OR: 11.25, 95%CI: 4.71-26.84; P < 0.00001) and shorter hospital stay (pooled MD of 4.66, 95%CI: 2.81-6.51; P < 0.00001). CONCLUSION: Compliance to post-PD clinical pathways remains low. Deviations are associated with an increased risk of complications and length of hospital stay. Under-standing the relevance of deviations to clinical pathways post-PD presents pancreatic surgeons with opportunities to actively pursue an enhanced-recovery of their patients.

Prevalence of Molecular Subtypes of Breast Cancer in India: a Systematic Review and Meta-analysis.

In the last two decades, India has witnessed a substantial increase in the incidence of breast cancer and associated mortality. Studies on the prevalence of molecular subtypes of breast cancer in India have reported inconsistent results. Therefore, we conducted a systematic review of observational studies to document the prevalence of molecular subtypes of breast cancer. A complete literature search for observational studies was conducted in MEDLINE and EMBASE databases using key MeSH terms ((molecular classification) OR (molecular subtypes)) AND (breast cancer)) OR (breast carcinoma)) AND (prevalence)) AND (India). Two reviewers independently reviewed the retrieved studies. The screened studies satisfying the eligibility were included. The quality of included studies was assessed using the selected STROBE criteria. The overall pooled prevalence of luminal A, luminal B, HER2-enriched, and triple-negative breast cancer (TNBC) subtypes of breast cancer were 0.33 (95% CI 0.23-0.44), 0.17 (95% CI 0.12-0.23), 0.15 (95% CI 0.12-0.19), and 0.30 (95% CI 0.27-0.33), respectively. Subgroup analyses were performed by mean age of patients, time period, region, and sample size of the study. Among molecular subtypes of breast cancer, luminal A was the most prevalent subtype followed by TNBC, luminal B, and HER2-enriched subtypes. The overall prevalence of TNBC in India is high compared to other regions of the world. Additional research is warranted to identify the determinants of high TNBC in India. Differentiating TNBC from other molecular subtypes is important to guide therapeutic management of breast cancer.