Skeletal Muscle Depletion and Major Postoperative Complications in Locally-Advanced Head and Neck Cancer: A Comparison between Ultrasound of Rectus Femoris Muscle and Neck Cross-Sectional Imaging.

Skeletal muscle mass (SMM) depletion has been validated in many surgical fields as independent predictor of complications through cross-sectional imaging. We evaluated SMM depletion in a stage III-IV head and neck cancer cohort, comparing the accuracy of CT/MRI at C3 level with ultrasound (US) of rectus femoris muscle (RF) in terms of prediction of major complications. Patients submitted to surgery were recruited from 2016 to 2021. SMM was estimated on CT/MRI by calculating the sum of the cross-sectional area (CSA) of the sternocleidomastoid and paravertebral muscles at C3 level and its height-indexed value (cervical skeletal muscle index, CSMI) and on US by computing the CSA of RF. Specific thresholds were defined for both US and CT/MRI according to ROC curve in terms of best prediction of 30-day major complications to detect sarcopenic subjects (40-53%). Sixty-five patients completed the study. At univariate analysis, major complications were associated to lower RF CSA, lower CSA at C3 level and lower CSMI, together with previous radiotherapy, higher ASA score and higher modified frailty index (mFI). At multivariate analysis RF CSA (OR 7.07, p = 0.004), CSA at C3 level (OR 6.74, p = 0.005) and CSMI (OR 4.02, p = 0.025) were confirmed as independent predictors in three different models including radiotherapy, ASA score and mFI. This analysis proved the value of SMM depletion as predictor of major complications in a head and neck cancer cohort, either defined on cross-sectional imaging at C3 or on US of RF.

Laparoscopic Witzel jejunostomy.

The placement of a feeding jejunostomy can be indicated in malnourished patients with gastric and oesophagogastric junction cancer to allow for enteral nutritional support. In these patients, the jejunostomy tube can be suitably placed at the time of staging laparoscopy. Several techniques of laparoscopic jejunostomy (LJ) have been described, yet the Witzel approach remains neglected, due to the perceived difficulty of suturing the bowel around the tube and securing them to the abdominal wall. Here, we describe a novel technique for LJ, using a single barbed suture for securing the bowel and tunnelling the jejunostomy catheter according to the Witzel approach.

Low skeletal muscle mass as predictor of postoperative complications and decreased overall survival in locally advanced head and neck squamous cell carcinoma: the role of ultrasound of rectus femoris muscle.

PURPOSE: Skeletal muscle mass (SMM) depletion and sarcopenia as predictors of postoperative complications and poorer overall survival (OS) have been validated in many surgical fields through cross-sectional imaging (CT, MRI), with potential limitations. We evaluated it in a stage III-IV head and neck squamous cell carcinoma (HNSCC) surgical cohort through ultrasound (US) of rectus femoris muscle (RF), a quick, cheap, repeatable alternative. METHODS: Patients submitted to surgical treatment with curative purpose were recruited and prospectively evaluated through clinical, biometric, biochemical, surgical, pathological and functional prognosticators and with preoperative US of RF with regards to 30-day complications and OS. RESULTS: Forty-seven patients completed the study. RF cross-sectional area (RF-CSA) was used to identify patients with low SMM (CSA ≤ 0.97 cm2: 18/47, 38.3%). RF-CSA was lower in complicated cases (0.95 ± 0.48 vs 1.41 ± 0.49 cm2; p = 0.003), remaining the only independent predictor of postoperative complications at multivariate analysis, with a model including ASA score and modified Frailty index (OR 9.84; p = 0.004). SMM depletion significantly impaired OS (13.6 ± 2.9 vs 26.3 ± 2.1 months; p = 0.017), being its only independent prognosticator at multivariate Cox regression analysis (OR 4.42; p = 0.033). CONCLUSION: RF-CSA, evaluated with US, seems a reliable method for identification of patients with low SMM in a stage III-IV HNSCC cohort, defining a subset at high-risk of 30-day complications and poorer OS.

Laparoscopic tubularized continent gastrostomy: an alternative to tube gastrostomies.

Gastrostomy tubes, placed either endoscopically or laparoscopically, are the most widely used method to deliver enteral feeding to patients unable to be fed by mouth. Tube gastrostomy is quick and low cost and allows the health care professionals for a convenient route to deliver enteral nutrition to their patients. Nevertheless, bearing an indwelling gastric tube could not be as convenient for patients. Complications, such as bowel perforation, tube dislodgement, peristomal infection or bleeding occur in up to 17% of patients, and some other drawbacks of gastric tubes, such as peristomal pain, are often understated. We present our technique for laparoscopic creation of a tubularized continent gastrostomy, originally conceived for the emergency treatment of patients with a dislodged percutaneous endoscopic gastrostomy, to provide them with a reliable new route for gastric feeding. After healing, this gastrostomy does not need an indwelling tube to stay patent, requires only a light gauze dressing and can be used by intermittent catheterization at conventional feeding times during the day. Laparoscopic tubularized continent gastrostomy can be offered to patients as a reliable alternative to tube gastrostomy.

Splenic flexure mobilization in rectal cancer surgery: do we always need it?

Splenic flexure (SFM) in rectal cancer surgery is a crucial step which may increase the difficulty of the operation. The aim of this retrospective single-center study is to demonstrate if the selective omission of SFM during anterior rectal resection can reduce the complexity of the operation, without affecting post-operative and oncologic outcomes. Data of 112 consecutive rectal resections for cancer from March 2010 to March 2017 were analyzed and divided into two groups: SFM and No-SFM. A sub-analysis was then performed for laparoscopy and traditional cases. Post-operative and oncologic outcomes, including overall (OS) and cancer-related survival (CRS), were analyzed and compared. SFM was performed in 42% of cases and laparoscopy was used in 73.2%. Operative time resulted significantly lower in the No-SFM group (190 vs. 225 min, p = 0.01). In laparoscopy in the No-SFM group, operative time and post-operative stay were significantly lower (205.5 vs. 222.5 min, p = 0.04; 9 vs. 10 days, p = 0.01). Most of the open resections were performed without SFM (35.4% vs. 14.9%, p = 0.02). No statistical significant differences were found in OS and CRS in the two groups. We support the hypothesis that every surgeon should carry out an accurate intra-operative evaluation to perform a selective SFM. When possible, SFM can be safely avoided with no additional risks in terms of post-operative and oncologic outcomes.

Association Between Changes in Body Composition and Neoadjuvant Treatment for Pancreatic Cancer.

Importance: Sarcopenia and sarcopenic obesity have been associated with poor outcomes in unresectable pancreatic cancer (PC). Neoadjuvant treatment (NT) is used increasingly to improve resectability; however, its effects on fat and muscle body composition have not been characterized. Objectives: To evaluate whether NT affects muscle mass and adipose tissue in patients with borderline resectable PC (BRPC) and locally advanced PC (LAPC) and determine whether there were potential differences between patients who ultimately underwent resection and those who did not. Design, Setting, and Participants: In this retrospective cohort study conducted at 4 academic medical centers, 193 patients with BRPC and LAPC undergoing surgical exploration after NT who had available computed tomographic scans (both at diagnosis and preoperatively) and confirmed pancreatic ductal adenocarcinoma were evaluated. The study was conducted from January 2013 to December 2015. Data analysis was performed from September 2016 to May 2017. Measurement of body compartments was evaluated with volume assessment software before and after NT. A radiologist blinded to the patient outcome assessed the areas of skeletal muscle, total adipose tissue, and visceral adipose tissue through a standardized protocol. Exposures: Receipt of NT. Main Outcomes and Measures: Achievement of pancreatic resection at surgical exploration after the receipt of NT. Results: Of the 193 patients with complete radiologic imaging available after NT, 96 (49.7%) were women; mean (SD) age at diagnosis was 64 (11) years. Most patients received combined therapy with fluorouracil, irinotecan, oxaliplatin, leucovorin, and folic acid (124 [64.2%]) and 86 (44.6%) received chemoradiotherapy as well. The median interval between pre-NT and post-NT imaging was 6 months (interquartile range [IQR], 4-7 months). All body compartments significantly changed. The adipose compound decreased (median total adipose tissue area from 284.0 cm2; IQR, 171.0-414.0 to 250.0 cm2; IQR, 139.0-363.0; P < .001; median visceral adipose tissue area from 115.2 cm2; IQR, 59.9-191.0 to 97.7 cm2; IQR, 48.0-149.0 cm2; P < .001), whereas the lean mass slightly improved (median skeletal muscle from 122.1 cm2; IQR, 99.3-142.0 to 123 cm2; IQR 104.8-152.5 cm2; P = .001). Surgical resection was achievable in 136 (70.5%) patients. Patients who underwent resection had experienced a 5.9% skeletal muscle area increase during NT treatment, whereas those who did not undergo resection had a 1.7% decrease (P < .001). Conclusions and Relevance: Patients with PC experience a significant loss of adipose tissue during neoadjuvant chemotherapy, but no muscle wasting. An increase in muscle tissue during NT is associated with resectability.

Failure to Rescue, Rescue Surgery and Centralization of Postoperative Complications: A Challenge for General and Acute Care Surgeons.

PURPOSE OF REVIEW: To explore the current literature on the failure to rescue and rescue surgery concepts, to identify the key items for decreasing the failure to rescue rate and improve outcome, to verify if there is a rationale for centralization of patients suffering postoperative complications. RECENT FINDINGS: There is a growing awareness about the need to assess and measure the failure to rescue rate, on institutional, regional and national basis. Many factors affect failure to rescue, and all should be individually analyzed and considered. Rescue surgery is one of these factors. Rescue surgery assumes an acute care surgery background. SUMMARY: Measurement of failure to rescue rate should become a standard for quality improvement programs. Implementation of all clinical and organizational items involved is the key for better outcomes. Preparedness for rescue surgery is a main pillar in this process. Centralization of management, audit, and communication are important as much as patient centralization.

Preoperative sarcopenia determinants in pancreatic cancer patients.

BACKGROUND & AIMS: Recent studies report that muscle depletion can impair short and long-term results after abdominal surgery. The aim of the present study is to quantify sarcopenia rate in patients undergoing pancreatic resection for cancer and to identify possible determinants of muscle waste. METHODS: Total abdominal muscle area (TAMA) and visceral fat area (VFA) were measured by preoperative CT scan imaging at the level of the third lumbar vertebra in 273 patients undergoing pancreas resection for cancer. Demographics, preoperative parameters, and cancer stage were prospectively collected in our Institutional electronic database. An adjusted regression model was used to identify independent predictors for low TAMA. RESULTS: 176 (64.5%) patients were sarcopenic, with only 52 of them showing weight loss > 10%. Patients with cancer stage II and III had lower TAMA compared to patients with stage I (p = 0.002). The magnitude of weight loss was inversely correlated with VFA (p = 0.001), while no correlation with TAMA was found. Multivariate analysis showed that cancer stage was an independent predictor of low TAMA. Patients aged over 75 had the highest probability of having both low TAMA (p = 0.031) and high VFA (p < 0.0001). CONCLUSIONS: Most of patients undergoing oncologic pancreatic surgery are sarcopenic. Cancer stage was an independent determinant of sarcopenia while nutritional factors seem less important. An age of over 75 years was significantly correlated with both muscle compartment depletion and visceral fat increase.