Use and outcome of minimally invasive pancreatic surgery in the European E-MIPS registry.

BACKGROUND: The European registry for minimally invasive pancreatic surgery (E-MIPS) collects data on laparoscopic and robotic MIPS in low- and high-volume centers across Europe. METHODS: Analysis of the first year (2019) of the E-MIPS registry, including minimally invasive distal pancreatectomy (MIDP) and minimally invasive pancreatoduodenectomy (MIPD). Primary outcome was 90-day mortality. RESULTS: Overall, 959 patients from 54 centers in 15 countries were included, 558 patients underwent MIDP and 401 patients MIPD. Median volume of MIDP was 10 (7-20) and 9 (2-20) for MIPD. Median use of MIDP was 56.0% (IQR 39.0-77.3%) and median use of MIPD 27.7% (IQR 9.7-45.3%). MIDP was mostly performed laparoscopic (401/558, 71.9%) and MIPD mostly robotic (234/401, 58.3%). MIPD was performed in 50/54 (89.3%) centers, of which 15/50 (30.0%) performed ≥20 MIPD annually. This was 30/54 (55.6%) centers and 13/30 (43%) centers for MIPD respectively. Conversion rate was 10.9% for MIDP and 8.4% for MIPD. Overall 90 day mortality was 1.1% (n = 6) for MIDP and 3.7% (n = 15) for MIPD. CONCLUSION: Within the E-MIPS registry, MIDP is performed in about half of all patients, mostly using laparoscopy. MIPD is performed in about a quarter of patients, slightly more often using the robotic approach. A minority of centers met the Miami guideline volume criteria for MIPD.

Laparoscopic versus open right posterior sectionectomy: an international, multicenter, propensity score-matched evaluation.

BACKGROUND: Although laparoscopic liver resection has become the standard for minor resections, evidence is lacking for more complex resections such as the right posterior sectionectomy (RPS). We aimed to compare surgical outcomes between laparoscopic (LRPS) and open right posterior sectionectomy (ORPS). METHODS: An international multicenter retrospective study comparing patients undergoing LRPS or ORPS (January 2007-December 2018) was performed. Patients were matched based on propensity scores in a 1:1 ratio. Primary endpoint was major complication rate defined as Accordion ≥ 3 grade. Secondary endpoints included blood loss, length of hospital stay (LOS) and resection status. A sensitivity analysis was done excluding the first 10 LRPS patients of each center to correct for the learning curve. Additionally, possible risk factors were explored for operative time, blood loss and LOS. RESULTS: Overall, 399 patients were included from 9 centers from 6 European countries of which 150 LRPS could be matched to 150 ORPS. LRPS was associated with a shorter operative time [235 (195-285) vs. 247 min (195-315) p = 0.004], less blood loss [260 (188-400) vs. 400 mL (280-550) p = 0.009] and a shorter LOS [5 (4-7) vs. 8 days (6-10), p = 0.002]. Major complication rate [n = 8 (5.3%) vs. n = 9 (6.0%) p = 1.00] and R0 resection rate [144 (96.0%) vs. 141 (94.0%), p = 0.607] did not differ between LRPS and ORPS, respectively. The sensitivity analysis showed similar findings in the previous mentioned outcomes. In multivariable regression analysis blood loss was significantly associated with the open approach, higher ASA classification and malignancy as diagnosis. For LOS this was the open approach and a malignancy. CONCLUSION: This international multicenter propensity score-matched study showed an advantage in favor of LRPS in selected patients as compared to ORPS in terms of operative time, blood loss and LOS without differences in major complications and R0 resection rate.

The current state of robotic-assisted pancreatic surgery.

Pancreatic surgery is challenging for both surgeon and patient. With the advent of minimally invasive surgical techniques, patient morbidity could be reduced. However, these techniques must conform to established principles of open pancreatic surgery with regards to meticulous dissection, haemostasis and oncologic results. The robotic platform is utilized in all facets of surgery, and is being increasingly applied in pancreatic surgery. As with the introduction of any new technology, this approach must undergo rigorous examination before widespread adoption of the technique. In this article, we review the techniques and outcomes of robotic-assisted pancreatic resections, focusing on robotic-assisted pancreaticoduodenectomy, robotic-assisted distal pancreatectomy and robotic-assisted central pancreatectomy. As the outcomes of robotic-assisted surgery have yet to be rigorously evaluated against the gold standard of open surgery, this Review also highlights major laparoscopic pancreatic series in an effort to summarize the available literature on minimally invasive pancreatic surgery.

Has the quality of abstracts for randomised controlled trials improved since the release of Consolidated Standards of Reporting Trial guideline for abstract reporting? A survey of four high-profile anaesthesia journals.

BACKGROUND AND OBJECTIVE: Randomised controlled trial (RCT) abstracts published in journal articles have traditionally been deficient of crucial information. To improve the quality of RCT abstracts, in January 2008, the Consolidated Standards of Reporting Trial (CONSORT) group published a checklist of essential information for inclusion. The current study assessed whether there has been an improvement in the quality of RCT abstracts published in main anaesthesia journals since this new guideline was introduced. METHODS: Articles involving human RCTs published in four high-profile anaesthesia journals (Anaesthesia, Anesthesia & Analgesia, Anesthesiology and the European Journal of Anaesthesiology) were reviewed, comparing those published from October 2005 to September 2006 (pre-CONSORT abstracts) with those published from October 2008 to September 2009 (post-CONSORT abstracts). Trials involving healthy volunteers or cadavers, cost-effectiveness studies, meta-analyses and letters were excluded. Abstracts from remaining RCTs were randomly assigned to four reviewers in a blinded fashion and reviewed for content using the new CONSORT checklist. RESULTS: In total, 527 RCT abstracts (pre-CONSORT RCTs, n = 275 and post-CONSORT RCTs, n = 252) were analysed. The majority of abstracts in both groups provided an appropriate description of study interventions (73.1 and 73.8%, pre-CONSORT abstracts versus post-CONSORT abstracts, respectively), objective (91.3 and 90.1%) and conclusions (72.4 and 66.3%). From pre-CONSORT to post-CONSORT guidelines for abstract reporting, there were significant improvements in correctly identifying blinding (18.2-29%) and harmful effects (31.6-42.1%). The improvement in reporting the nature of the trial in abstract titles (20.1-29%) and primary outcome measure in the methods section (22.9-30.6%) did not reach significance. There was no clear improvement in the already poor reporting of trial design, participants, randomisation, recruitment, outcomes, trial registration and funding sources. CONCLUSIONS: Despite some promising improvements and inter-journal differences, the overall quality of RCT abstracts and adherence to the CONSORT checklist for abstracts remains poor.

Idiopathic granulomatous mastitis.

OBJECTIVE: To discuss the clinical and radiological features and treatment approaches in 14 patients diagnosed with idiopathic granulomatous mastitis (GM). METHODS: We retrospectively evaluated the clinical features, radiological findings, and treatment approaches in 14 patients with idiopathic GM in the General Surgery Department, Gulhane School of Medicine, Ankara, Turkey between April 2000 and June 2006. RESULTS: The mean age of the patients was 34.5 years (range 27-41 years). The complaints at admission were a mass in the breast in 7 (50%) patients, an abscess and a mass in 6 (42.8%), and a skin fistula in one (7.2%). Granulomatous mastitis was unilateral in all subjects (on the right in 5 patients and on the left in 9). All of the patients underwent ultrasonographic evaluation. Mammography was performed in 8 and magnetic resonance imaging in 5 patients. Seven patients (50%) were suspected to have breast carcinoma according to radiological findings. We performed large excision in 11, incisional biopsy plus abscess drainage in one, and incisional biopsy plus abscess drainage plus medical treatment (prednisolone, methotrexate) in 2 patients. Due to the development of abscess after 9 months, drainage and large excision were also performed in one patient who received medical treatment. CONCLUSION: Idiopathic GM is a disease that generally affects young women of reproductive age and may be mistaken for breast carcinoma in clinical and radiological evaluations. The gold standard for the diagnosis is histopathologic evaluation.

Can SAPS II predict operative mortality more accurately than POSSUM and P-POSSUM in patients with colorectal carcinoma undergoing resection?

BACKGROUND: This study assessed the APACHE II (Acute Physiology and Chronic Health Evaluation II), SAPS II (Simplified Acute Physiology Score-II), POSSUM (Physiologic and Operative Severity Score for Enumeration of Morbidity and Mortality), and P-POSSUM (Portsmouth-POSSUM) in patients with colorectal cancer undergoing curative or palliative resection. METHODS: Predicted mortality rates and the observed/expected mortality ratio were computed by means of each scoring system. The results were compared between survivors and nonsurvivors and between elective and emergency operations. Each model was assessed for its accuracy to predict the risk of death using receiver operator characteristic (ROC) curve analysis, and risk stratification was generated as well. RESULTS: Some 224 patients were enrolled in the study. The overall 30-day mortality rate was 3.6% (n = 8). Predicted mortality rates generated by APACHE II, SAPS II, POSSUM, and P-POSSUM were 9.1%, 3.7%, 13.4%, and 5.2%, respectively. All the scoring systems assigned higher scores to those patients who died than to those who survived. Areas under the curve calculated by ROC curve analysis for APACHE II, SAPS II, POSSUM, and P-POSSUM were 0.786, 0.854, 0.793, and 0.831, respectively. Best stratification was achieved by the SAPS II score. CONCLUSIONS: SAPS II and P-POSSUM were determined to be better predictors for patients with colorectal cancer undergoing resection. SAPS II also was found to have a higher degree of discriminatory power in colorectal resection for carcinoma. The predictive value of this useful severity score in several surgical subgroups must be examined to evaluate its routine use in risk-adjusted audit.

Extracapsular extension is associated with increased ratio of metastatic to examined lymph nodes in axillary node-positive breast cancer.

BACKGROUND: Extracapsular extension of nodal tumor cells, although it is not a parameter of staging, has recently been shown to be correlated with the high number of metastatic lymph nodes in patients with axillary-positive breast cancer. It is suggested that the use of involved/examined lymph node ratio instead of the number of metastatic lymph nodes in axillary evaluation would obtain standardized prognostic data for patient management. This study investigated the association of the extracapsular extension with the lymph node ratio in a node-positive group of patients. PATIENTS AND METHODS: Medical records of 170 patients with positive axillary status were retrospectively reviewed. Of these, 54 were extracapsular extension positive, and the remaining were extracapsular extension negative. A comparison was made between extracapsular extension-positive and extracapsular extension-negative groups with respect to some potential prognostic indicators. RESULTS: Number of metastatic lymph nodes, number of examined lymph nodes, and involved/examined lymph node ratio were found to be significantly higher in patients with a presence of extracapsular extension. CONCLUSION: The results suggest that the presence of extracapsular extension might force physicians to perform more aggressive adjuvant therapies and that the extracapsular extension could be a valuable parameter in the management of breast cancer because it has a strong relationship with the proven prognostic factors.