Gastrectomy for Cancer: A 15-Year Analysis of Real-World Data from the University of Athens.

Background and Objectives: Encouraging data have been reported from referral centers following gastrointestinal cancer surgery. Our goal was to retrospectively review patient outcomes following gastrectomy for gastric or gastroesophageal junction (GEJ) cancer at a high-volume unit of the University of Athens. Methods: The enrollment period was from June 2003 to September 2018. Disease-free survival (DFS) and overall survival (OS) were estimated using the Kaplan-Meier method. Cox proportional hazard models were constructed to identify variables independently associated with time-to-event outcomes. Results: A total of 205 patients were analyzed. R0 resection was achieved in 183 (89.3%) patients and was more likely to occur following neoadjuvant chemotherapy (p = 0.008). Recurrence developed in 46.6% of our cohort and the median disease-free survival was 31.2 months. On multivariate analysis, only staging (HR = 2.15; 95% CI: 1.06-4.36) was independently associated with increased risk of recurrence. All-cause mortality was 57.2% and the median time of death was 40.9 months. On multivariate regression, staging (HR: 1.35; 95% CI: 1.11-1.65) and recurrence (HR: 2.87; 95% CI: 1.32-6.22) predicted inferior prognosis. Conclusions: Gastrectomy at the University of Athens has yielded favorable outcomes for patients with GEJ cancer.

Venous Thromboembolism Following Major Abdominal Surgery for Cancer: A Guide for the Surgical Intern.

BACKGROUND: Venous thromboembolism (VTE) is a term used to compositely describe deep vein thrombosis (DVT) and pulmonary embolism (PE). Overall, the incidence of VTE after major abdominal and pelvic surgery has been reported to be between 10% and 40%. OBJECTIVE: The aim of this study is to estimate the incidence of post-operative VTE in patients undergoing major abdominal surgery for cancer, to identify risk factors associated with VTE, and to assess available thromboprophylaxis tools. METHODS: A Medline and Cochrane literature search from database inception until February 1st, 2021 was performed according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. RESULTS: Thirty-one studies met our eligibility criteria and were included in the current review. In total, 435,492 patients were identified and the overall incidence of VTE was 2.19% (95% CI: 1.82-2.38). Τhe following risk factors were associated with VTE: smoking, advanced age (>70 years), a history of diabetes mellitus, American Society of Anesthesiologists' (ASA) classification of Physical Health class III or IV, a history of cardiovascular or pulmonary disease, a history of DVT or PE, elevated plasma fibrinogen level, c-reactive protein (CRP) level, cancer stage III or IV, postoperative acute respiratory distress syndrome (ARDS), prolonged postoperative hospital stay, previous steroid use, history of Inflammatory Bowel Disease (IBD), heart failure and neoadjuvant and adjuvant chemotherapy. CONCLUSION: VTE remains an important complication after major abdominal surgery for cancer and seems to increase mortality rates.

Venous thromboembolism after esophagectomy for cancer: a systematic review of the literature to evaluate incidence, risk factors, and prophylaxis.

PURPOSE: Although esophagectomy remains the preferred treatment for esophageal cancer, it is still associated with a number of complications, including post-operative venous thromboembolism (VTE). The aim of this study was to summarize the reported incidence of VTE after esophagectomy, its risk factors, and prevention strategies. METHODS: We conducted a systematic search of the literature in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: Fourteen studies met our inclusion criteria and were selected in the present review. Overall, we identified 9768 patients who underwent esophagectomy, with a post-operative VTE rate of 4% (440 patients). The reported risk factors for VTE included advanced age, American Society of Anesthesiologists (ASA) class III or IV, a history of cardiovascular or pulmonary disease, and the implementation of preoperative chemo-radiotherapy. Postoperative acute respiratory distress syndrome was also associated with VTE. No universally applied prevention strategies for VTE after esophagectomy were identified in the literature. CONCLUSIONS: Despite advances in perioperative care, VTE after esophagectomy still represents a source of morbidity for about 4% of patients. Low molecular weight heparin is suggested as the routine standard prophylactic regimen after esophageal cancer surgery.

Newer-generation antihistamines and the risk of adverse events in children: A systematic review.

BACKGROUND: H1-antihistamines (AHs) are widely used for the treatment of allergic diseases, being one of the most commonly prescribed classes of medications in pediatrics. Newer-generation AHs are associated with fewer adverse effects compared with first-generation AHs. However, their relative harms in the pediatric population still need scrutiny. METHODS: We performed a systematic review of randomized controlled trials (RCTs), which included comparisons of safety parameters between an orally administered newer-generation AH and another AH (first- or second-generation), montelukast, or placebo in children aged ≤12 years. We searched MEDLINE and CENTRAL, independently extracted data on study population, interventions, adverse events (AEs), and treatment discontinuations, and assessed the methodologic quality of the included RCTs using the Cochrane's risk of bias tool. RESULTS: Forty-five RCTs published between 1989 and 2017 met eligibility criteria. The majority of RCTs included school-aged children with allergic rhinitis and had a follow-up period of up to a month. Four RCTs reported serious AEs in patients receiving a newer-generation AH, but only two patients experienced a possibly drug-related serious AE. The occurrence of AEs, drug-related AEs, and treatment discontinuations due to AEs varied between RCTs. Most AEs reported were of mild intensity. Indirect evidence indicates that cetirizine is more sedating than the other newer-generation AHs. CONCLUSION: Our findings confirm that newer-generation AHs have a favorable safety and tolerability profile. However, we could not draw firm conclusions regarding the comparative safety profile of the newer-generation AHs due to the paucity of head-to-head RCTs, variation in definitions and reporting of AEs, and short follow-up duration.

Carcinomas of the hypopharynx and cervical esophagus: A systematic review and quality of evidence assessment.

PURPOSE: Hypopharyngeal cervical esophageal carcinoma (HPCEC) is a group of highly malignant entities usually presenting at an advanced stage. Our purpose was to systematically review and synthesize all available data on the management and outcomes of patients with these upper gastrointestinal malignancies. METHODS: A systematic literature search of the PubMed and Cochrane databases was performed with respect to the PRISMA statement (end-of-search date: May 1st, 2017). Data on the study design, interventions, participants, and outcomes were extracted by two independent reviewers. Quality assessment of included studies was performed using the tool developed by the National Heart, Lung, and Blood Institute. RESULTS: Thirty-four observational studies were included in this review. Overall, 20,409 patients with HPCECs were included. Mean patient age was 61.3 years. The most widely implemented therapeutic modalities were chemoradiation (38%), radiation alone (16%), and surgery plus radiation (13%). Overall, mean relapse rates were 15±2.6% for local recurrence, 14.7±2.6% for regional recurrence. and 10±2.3% for distant metastases. Cumulative mean 5- and 3-year survival rates were 20±2.6% and 22±2.6%, respectively, while mean 5-year disease-free survival rates were 22±2.3%. The most common complications were fistulae and pulmonary complications. Mean 30-day mortality rate was 7±2.2% and the mean long-term mortality rate was 22±3.3%. CONCLUSIONS: Multimodal approaches are typically needed for the management of HPCECs. Radiotherapy is the mainstay of treatment for local tumors. Locally advanced non-metastatic tumors are typically managed with chemoradiation or a combination of pharyngolaryngoesophagectomy and chemoradiation. For metastatic carcinomas, an arsenal of surgical and medical treatment options can help relieve tumor burden and improve quality of life.

Esophageal cancer surgery in Greece during the era of the financial crisis.

The aim of this study is to describe outcomes of esophageal cancer surgery in a quaternary upper gastrointestinal (GI) center in Athens during the era of the Greek financial crisis. We performed a retrospective analysis of patients that underwent esophagectomy for esophageal or gastroesophageal junction (GEJ) cancer at an upper GI unit of the University of Athens, during the period January 2004-June 2019. Time-to-event analyses were performed to explore trends in survival and recurrence. A total of 146 patients were identified. Nearly half of the patients (49.3%) underwent surgery during the last 4 years of the financial crisis (2015-2018). Mean age at the time of surgery was 62.3 ± 10.3 years, and patients did not present at older ages during the recession (P = 0.50). Most patients were stage III at the time of surgery both prior to the recession (35%) and during the financial crisis (39.8%, P = 0.17). Ivor-Lewis was the most commonly performed procedure (67.1%) across all eras (P = 0.06). Gastric conduit was the most common form of GI reconstruction (95.9%) following all types of surgery (P < 0.001). Pre-recession anastomoses were usually performed using a circular stapler (65%). Both during (88.1%) and following the recession (100%), the vast majority of anastomoses were hand-sewn. R0 resection was achieved in 142 (97.9%) patients. Anastomosis technique did not affect postoperative leak (P = 0.3) or morbidity rates (P = 0.1). Morbidity rates were not significantly different prior to (25%), during (46.9%), and after (62.5%) the financial crisis, P = 0.16. Utilization of neoadjuvant chemotherapy (26.9%, P = 0.90) or radiation (8.4%, P = 0.44) as well as adjuvant chemotherapy (54.8%, P = 0.85) and irradiation (13.7%, P = 0.49) was the same across all eras. Disease-free survival (DFS) and all-cause mortality rates were 41.2 and 47.3%, respectively. Median DFS and observed survival (OS) were 11.3 and 22.7 months, respectively. The financial crisis did not influence relapse (P = 0.17) and survival rates (P = 0.91). The establishment of capital controls also had no impact on recurrence (P = 0.18) and survival (P = 0.94). Austerity measures during the Greek financial crisis did not influence long-term esophageal cancer outcomes. Therefore, achieving international standards in esophagectomy may be possible in resource-limited countries when centralizing care.

Acute esophageal necrosis: A systematic review and pooled analysis.

BACKGROUND: Acute esophageal necrosis (AEN) is a rare entity with multifactorial etiology, usually presenting with signs of upper gastrointestinal bleeding. AIM: To systematically review all available data on demographics, clinical features, outcomes and management of this medical condition. METHODS: A systematic literature search was performed with respect to the PRISMA statement (end-of-search date: October 24, 2018). Data on the study design, interventions, participants and outcomes were extracted by two independent reviewers. RESULTS: Seventy-nine studies were included in this review. Overall, 114 patients with AEN were identified, of whom 83 were males and 31 females. Mean patient age was 62.1 ± 16.1. The most common presenting symptoms were melena, hematemesis or other manifestations of gastric bleeding (85%). The lower esophagus was most commonly involved (92.9%). The most widely implemented treatment modality was conservative treatment (75.4%), while surgical or endoscopic intervention was required in 24.6% of the cases. Mean overall follow-up was 66.2 ± 101.8 d. Overall 29.9% of patients died either during the initial hospital stay or during the follow-up period. Gastrointestinal symptoms on presentation [Odds ratio 3.50 (1.09-11.30), P = 0.03] and need for surgical or endoscopic treatment [surgical: Odds ratio 1.25 (1.03-1.51), P = 0.02; endoscopic: Odds ratio 1.4 (1.17-1.66), P < 0.01] were associated with increased odds of complications. A sub-analysis separating early versus late cases (after 2006) revealed a significantly increased frequency of surgical or endoscopic intervention (9.7 % vs 30.1% respectively, P = 0.04). CONCLUSION: AEN is a rare condition with controversial pathogenesis and unclear optimal management. Although the frequency of surgical and endoscopic intervention has increased in recent years, outcomes have remained the same. Therefore, further research work is needed to better understand how to best treat this potentially lethal disease.

Pseudoachalasia: a systematic review of the literature.

Pseudoachalasia, also known as secondary achalasia, is a clinical condition mimicking idiopathic achalasia but most commonly caused by malignant tumors of gastroesophageal junction (GEJ). Our aim was to systematically review and present all available data on demographics, clinical features, and diagnostic modalities involved in patients with pseudoachalasia. A systematic search of literature published during the period 1978-2019 was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (end-of-search date: June 25th, 2019). Two independent reviewers extracted data with regards of study design, interventions, participants, and outcomes. Thirty-five studies met our inclusion criteria and were selected in the present review. Overall, 140 patients with pseudoachalasia were identified, of whom 83 were males. Mean patient age was 60.13 years and the mean weight loss was 13.91 kg. A total of 33 (23.6%) patients were wrongly 'treated' at first for achalasia. The most common presenting symptoms were dysphagia, food regurgitation, and weight loss. The median time from symptoms' onset to hospital admission was 5 months. Most common etiology was gastric cancer (19%). Diagnostic modalities included manometry, barium esophagram, endoscopy, and computed tomography (CT). Pseudoachalasia is a serious medical condition that is difficult to be distinguished from primary achalasia. Clinical feature assessment along with the correct interpretation of diagnostic tests is nowadays essential steps to differentiate pseudoachalasia from idiopathic achalasia.

Pericardial hernias in adults: a systematic review of the literature.

OBJECTIVES: A pericardial hernia is defined as the protrusion of abdominal viscera through the central tendon of the diaphragm into the pericardial sac. It is a rare clinical entity whose symptoms vary considerably. The objective of this study was to evaluate the clinical manifestations of and the optimal surgical treatments for pericardial hernias. METHODS: PubMed and the Cochrane bibliographical databases were searched (last search: 20 April 2019) for studies on pericardial diaphragmatic hernias in the adult population. RESULTS: Eighty studies met our inclusion criteria and reported on 85 patients (62 men and 23 women) with a mean age of 55.86 ± 15.79 years (mean ± standard deviation) presenting with a pericardial hernia at health care facilities. The leading aetiology was trauma (56.5%) followed by iatrogenic interventions (30.6%). The most common herniated organs were the transverse colon (49.4%) and the greater omentum (48.2%). Seventy-one patients (83.5%) underwent an open surgical repair, whereas 14 (16.5%) had a laparoscopic approach. Mesh or a patch was applied in 41.9% of cases. A postoperative morbidity rate of 16.9% was recorded, whereas the mortality rate reached 2.4%. CONCLUSIONS: Pericardial hernia is a rare disease characterized by abdominal organs herniating into the pericardium. It requires a high degree of suspicion for early diagnosis, and all medical professionals should be encouraged to report such cases to clarify the best available therapeutic approach.

Perioperative Management of Antiplatelet Therapy in Patients With History of Coronary Artery Disease Undergoing Surgery for Esophageal Cancer: A Single-center Experience.

AIM: To present the experience of the upper Gastrointestinal Unit of the Surgical Department of National and Kapodistrian University of Athens in order to inform surgeons of the exact harms and benefits associated with their decisions concerning management of antiplatelet therapy. MATERIALS AND METHODS: This was a single-center study of patients who underwent surgery for esophageal cancer and had concomitant coronary artery disease from 1/1/2005 to 31/7/2017. Patients were divided into two cohorts based on when their antiplatelet therapy was stopped (<7 vs. ≥7 days). Esophageal cancer was classified as esophageal only or as Siewert type I, II, or III based on tumor location at the gastroesophageal junction. A univariate logistic regression model was developed to assess the relationship between baseline variables and myocardial infraction, mortality, bleeding and stroke after the operation. For all tests, differences with a value of p<0.05 were considered significant. RESULTS: During the study period, 135 esophagectomies were performed for esophageal cancer. Almost 17% of them had concomitant coronary artery disease medically managed with antiplatelet therapy. No difference was found in terms of myocardial infarction, stroke or severe bleeding events between patients that stopped antiplatelet therapy for more or less than 7 days before esophagectomy. CONCLUSION: It is a reasonable approach to discontinue antiplatelet therapy for more than 7 days before surgery, especially in such a population of patients with esophageal cancer that require complex operations with high bleeding risk.

Fluoroquinolone-based versus ß-lactam-based regimens for complicated intra-abdominal infections: a meta-analysis of randomised controlled trials.

Complicated intra-abdominal infections (cIAIs) are common and confer significant morbidity, mortality and costs. In this era of evolving antimicrobial resistance, selection of appropriate empirical antimicrobials is paramount. This systematic review and meta-analysis of randomised controlled trials compared the effectiveness and safety of fluoroquinolone (FQ)-based versus ß-lactam (BL)-based regimens for the treatment of patients with cIAIs. Primary outcomes were treatment success in the clinically evaluable (CE) population and all-cause mortality in the intention-to-treat (ITT) population. Subgroup analyses were performed based on specific antimicrobials, infection source and isolated pathogens. Seven trials (4125 patients) were included. FQ-based regimens included moxifloxacin (four studies) or ciprofloxacin/metronidazole (three studies); BL-based regimens were ceftriaxone/metronidazole (three studies), carbapenems (two studies) or piperacillin/tazobactam (two studies). There was no difference in effectiveness in the CE (2883 patients; RR = 1.00, 95% CI 0.95-1.04) or ITT populations (3055 patients; RR = 0.97, 95% CI 0.94-1.01). Mortality (3614 patients; RR = 1.04, 95% CI 0.75-1.43) and treatment-related adverse events (2801 patients; RR = 0.97, 95% CI 0.70-1.33) were also similar. On subset analysis, moxifloxacin was slightly less effective than BLs in the CE (1934 patients; RR = 0.96, 95% CI 0.93-0.99) and ITT populations (1743 patients; RR = 0.94, 95% CI 0.91-0.98). Although FQ- and BL-based regimens appear equally effective and safe for the treatment of cIAIs, limited data suggest slightly inferior results with moxifloxacin. Selection of empirical coverage should be based on local bacterial epidemiology and patterns of resistance as well as antimicrobial stewardship protocols.

Antibiotics exposure and risk of inflammatory bowel disease: a systematic review.

AIM: The aim of this study was to critically assess all available evidence suggesting an association between antibiotic exposure and new onset of inflammatory bowel disease (IBD). MATERIALS AND METHODS: This systematic review was conducted according to the PRISMA statement and eligible studies were identified through search of PubMed, Embase and the Cochrane Library. Data on patient demographics, antibiotic exposure and confounding factors were analyzed. The Newcastle-Ottawa Scale (NOS) was used to assess the quality of eligible studies. RESULTS: A total of 15 observational studies (10 case control and five cohort) including 8748 patients diagnosed with IBD were systematically reviewed. Antibiotic exposure was mostly associated with Crohn's disease but not with ulcerative colitis. In particular, penicillin's, cephalosporins, metronidazole and fluoroquinolones were most commonly associated with the onset of Crohn's disease. The impact of tetracycline-family antibiotics on the pathogenesis of IBD was not clear. CONCLUSION: There may be an association between antibiotic exposure and the development of IBD; especially Crohn's disease. Even though, clinicians should be cautious when prescribing certain antibiotic regimens to patients with a strong family history of IBD, it should be emphasized that available data are not granular enough to reach any definitive conclusions.