Overall Survival Following Anastomotic Leakage After Surgery for Carcinoma of the Esophagus and Gastroesophageal Junction: A Systematic Review.

The effect of anastomotic leakage, in patients who underwent surgery for carcinoma of the esophagus and gastroesophageal junction, on overall survival (OS) is a debated and controversial topic. The aim of this systematic review was to clarify the impact of anastomotic leakage on long-term survival of patients with esophageal cancer undergoing esophagectomy. A systematic literature review was carried out from 2000 to 2022. We chose articles reporting data from patients who underwent surgery for carcinoma of the esophagus and gastroesophageal junction. Data regarding 1-, 3- and 5-year OS were analyzed. Twenty studies met the inclusion criteria, yielding a total of 9,279 patients. Analyzing data from selected studies, anastomotic leakage was found to be associated with decreased OS in 5,456 cases while in the remaining 3,823 it had no impact on long term survival (p<0.05). However, this result did not emerge from the other studies considered in the systematic review. Anastomotic leakage is a severe postoperative complication, which seems to have an impact on overall survival. However, the topic remains debated and not supported by all case series included in this systematic review.

Splenic artery steal syndrome after liver transplantation - prophylaxis or treatment?: A case report and literature review.

Splenic artery steal syndrome (SASS) is a cause of graft hypoperfusion leading to the development of biliary tract complications, graft failure, and in some cases to retransplantation. Its management is still controversial since there is no universal consensus about its prophylaxis and consequently treatment. We present a case of SASS that occurred 48 hours after orthotopic liver transplantation (OLTx) in a 56-year-old male patient with alcoholic cirrhosis and severe portal hypertension, and who was successfully treated by splenic artery embolization. A literature search was performed using the PubMed database, and a total of 22 studies including 4,789 patients who underwent OLTx were relevant to this review. A prophylactic treatment was performed in 260 cases (6.2%) through splenic artery ligation in 98 patients (37.7%) and splenic artery banding in 102 (39.2%). In the patients who did not receive prophylaxis, SASS occurred after OLTx in 266 (5.5%) and was mainly treated by splenic artery embolization (78.9%). Splenic artery ligation and splenectomies were performed, respectively, in 6 and 20 patients (2.3% and 7.5%). The higher rate of complications registered was represented by biliary tract complications (9.7% in patients who received prophylaxis and 11.6% in patients who developed SASS), portal vein thrombosis (respectively, 7.3% and 6.9%), splenectomy (4.8% and 20.9%), and death from sepsis (4.8% and 30.2%). Whenever possible, prevention is the best way to approach SASS, considering all the potential damage arising from an arterial graft hypoperfusion. Where clinical conditions do not permit prophylaxis, an accurate risk assessment and postoperative monitoring are mandatory.

Is Complete Pathologic Response in Pancreatic Cancer Overestimated? A Systematic Review of Prospective Studies.

BACKGROUND: In literature, percentages of pathologic complete response (pCR) in patients presenting with resectable (RES), borderline resectable (BLR) or locally advanced (LA) pancreatic cancer (PaC) after neoadjuvant treatment (NADT) are variable, ranging 0-33%. Those data come mostly from retrospective reviews of single centres. The objective of this systematic review is to assess the incidence of pCR. METHODS: Following the criteria of the PRISMA statement, a literature search was conducted looking for prospective papers focusing on neoadjuvant treatment in PaC. Retrospective papers, other than ductal carcinoma histologies and trials including metastatic patients, were excluded from the present review. Data extraction was carried out by 3 independent investigators. Meta-analysis was performed with ProMeta3 Software (Internovi, 2015). PROSPERO registry: CRD42018095641. RESULTS: The literature search of Embase, Cochrane and Medline with the terms "neoadjuvant OR preoperative", "pancreatic OR pancreas" and "cancer OR adenocarcinoma OR tumor" led to the identification of 3128 papers. We restricted the search to humans, last 10 years and English language articles resulting in 1158 eligible articles to review. Extended paper revision led to the inclusion of 27 papers. Complete pathologic response ranged 0-11.11%, at the meta-analysis 4% (95% CI 3-5%), in prospective studies 0-9.09% and in prospective databases 1.63-11.11%. CONCLUSIONS: Pathologic complete response in pancreatic cancer is actually infrequent: high-quality studies provide a more reliable picture of neoadjuvant effects, high rates of pCR are reported in selected retrospective studies but it is overestimated.

Impact of Anastomotic Leakage on Overall and Disease-free Survival After Surgery for Gastric Carcinoma: A Systematic Review.

BACKGROUND/AIM: Gastric cancer is the fifth most frequently diagnosed cancer and the second most common cause of cancer-related death. The only potentially curative treatment is surgical resection, which is associated with potentially severe complications, such as anastomotic leakage. The aim of this systematic review was to evaluate the relationship between anastomotic leakage and overall and disease-free survival after surgery for gastric cancer. MATERIALS AND METHODS: A systematic literature search was performed and 7 articles published between 2010 and 2019 were included, including a total of 7,167 patients. RESULTS: Among the included studies the frequency of anastomotic leakage ranged from 6 to 41%. Patients affected by anastomotic leakage had an overall survival ranging between 4.1 and 97.6 months, whereas patients who did not experience anastomotic leakage had an overall survival between 23 and 109.5 months. CONCLUSION: Closer follow-up or even more aggressive oncological therapy may be considered for patients affected by anastomotic leakage after surgery for gastric cancer.

Recurrence Following Anastomotic Leakage After Surgery for Carcinoma of the Distal Esophagus and Gastroesophageal Junction: A Systematic Review.

BACKGROUND: Esophageal cancer is the ninth most common cancer. The only potentially curative treatment is surgical resection, which unfortunately is still associated with major complications, the most important being anastomotic leakage, currently with an overall rate of up to 26% morbidity. The aim of this systematic review was to evaluate the relationship between anastomotic leakage and recurrence of disease. MATERIALS AND METHODS: A literature search was systematically performed. Seven out of 312 articles dated between 2009 and 2018 fulfilled the selection for a total of 5,433 patients. RESULTS: The frequency of anastomotic leakage ranged from 7.2 to 11.2%. Patients affected by anastomotic leakage had a recurrence rate of 9-56%. CONCLUSION: Closer follow-up or even more aggressive oncological therapy should be considered for patients affected by anastomotic leakage after surgery for carcinoma of the distal esophagus and gastroesophageal junction.

Indocyanine green fluorescence angiography: a new ERAS item.

ERAS protocol and indocyanine green fluorescence angiography (ICG-FA) represent the new surgical revolution minimizing complications and shortening recovery time in colorectal surgery. As of today, no studies have been published in the literature evaluating the impact of the ICG-FA in the ERAS protocol for the patients suitable for colorectal surgery. The aim of our study was to assess whether the systematic evaluation of intestinal perfusion by ICG-FA could improve patients outcomes when managed with ERAS perioperative protocol, thus reducing surgical complication rate. This is a retrospective case-control study. From March 2014 to April 2017, 182 patients underwent laparoscopic colorectal surgery for benign and malignant diseases. All the patients were enrolled in ERAS protocol. Two groups were created: Group A comprehended 107 patients managed within the ERAS pathway only and Group B comprehended 75 patients managed as well as with ERAS pathway plus the intraoperative assessment of intestinal perfusion with ICG-FA. Two board-certified laparoscopic colorectal surgeons jointly performed all procedures. Six (5.6%) clinically relevant anastomotic leakages (AL) occurred in Group A, while there was none in Group B, demonstrating that ICG-FA integrated in the ERAS protocol can lead to a statistically significant reduction of the AL. Mean operative time between the two groups was not statistically significant. In five cases (6.6%), the demarcation line set by the fluorescence made the surgeon change the resection line previously marked. The prevalence of all other complications did not differ statistically between the two groups. Our study confirms that combination between ICG and ERAS protocol is feasible and safe and reduces the anastomotic leakage, possibly leading to consider ICG-FA as a new ERAS item.

The electrophysiology of thyroid surgery: electrophysiologic and muscular responses with stimulation of the vagus nerve, recurrent laryngeal nerve, and external branch of the superior laryngeal nerve.

OBJECTIVES/HYPOTHESIS: Correlation of physiologically important electromyographic (EMG) waveforms with demonstrable muscle activation is important for the reliable interpretation of evoked waveforms during intraoperative neural monitoring (IONM) of the vagus nerve, recurrent laryngeal nerve (RLN), and external branch of the superior laryngeal nerve (EBSLN) in thyroid surgery. STUDY DESIGN: Retrospective chart review. METHODS: Data were reviewed retrospectively for thyroid surgery patients with laryngeal nerve IONM from January to December, 2015. EMG responses to monopolar stimulation of the vagus/RLN and EBSLN were recorded in bilateral vocalis, cricothyroid (CTM), and strap muscles using endotracheal tube-based surface and intramuscular hook electrodes, respectively. Target muscles for vagal/RLN and EBSLN stimulation were the ipsilateral vocalis and CTM, respectively. All other recording channels were nontarget muscles. RESULTS: Fifty surgical sides were identified in 37 subjects. All target muscle mean amplitudes were significantly higher than in nontarget muscles. With vagal/RLN stimulation, target ipsilateral vocalis mean amplitude was 1,095.7 µV (mean difference range = -814.1 to -1,078 µV, P < .0001). For EBSLN stimulation, target ipsilateral CTM mean amplitude was 6,379.3 µV (mean difference range = -6,222.6 to -6,362.3 µV, P < .0001). Target muscle large-amplitude EMG responses correlated with meaningful visual or palpable muscular responses, whereas nontarget EMG responses showed no meaningful muscle activation. CONCLUSIONS: Target and nontarget laryngeal muscles are differentiated based on divergence of EMG response directly correlating with presence or absence of visual and palpable muscle activation. Low-amplitude EMG waveforms in nontarget muscles with neural stimulation can be explained by the concept of far-field artifactual waveforms and do not correspond to a true muscular response. The surgeon should be aware of these nonphysiologic waveforms when interpreting and applying IONM during thyroid surgery. LEVEL OF EVIDENCE: 4 Laryngoscope, 127:764-771, 2017.

Changes in electromyographic amplitudes but not latencies occur with endotracheal tube malpositioning during intraoperative monitoring for thyroid surgery: Implications for guidelines.

OBJECTIVES/HYPOTHESIS: During intraoperative neural monitoring (IONM) in thyroid and parathyroid surgery, endotracheal (ET) tube migration can result in a decrease in vocalis electromyographic (EMG) amplitude without a concordant latency elevation during stimulation of the recurrent laryngeal nerve (RLN). STUDY DESIGN: Retrospective review. METHODS: Data were reviewed retrospectively for thyroid and parathyroid surgery patients with IONM of the laryngeal nerves from January 2015 to December 2015. Recordings of vocalis EMG amplitudes and latencies with RLN stimulation were obtained with the neuromonitoring ET tube surface electrodes in optimal baseline position, with vertical displacement away from the vocalis, and with rotational change away from baseline. RESULTS: ET tube surface electrode EMG recordings were obtained with stimulation of seven left and three right RLNs in a total of 10 patients. Mean vocalis EMG amplitudes were reduced with vertical displacement 1 and 2 cm both inferior and superior to baseline and with rotational change (45° and 90° clockwise and counterclockwise, 180°), although amplitude change with 45° clockwise and 180° rotation did not meet statistical significance. Mean EMG latency values did not change significantly from baseline with either rotation or vertical displacement of the ET tube. CONCLUSIONS: An isolated decrease in EMG amplitude without concordant latency elevation should warrant re-evaluation of ET tube position during thyroid and parathyroid surgery and is in contrast to a combined event, with both EMG amplitude decrease and concordant latency increase, which is more suggestive of a true neuropraxic injury. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:2182-2188, 2017.