Long term outcome of complex surgical resection and reconstruction for rare thoracic cancers.

BACKGROUND: Complex surgical resection and reconstruction for rare thoracic cancers (RTCs) represent a major challenge, given their very low frequency, extreme variability of presentation, multi-modality treatment options and inadequate outcome prediction. We analysed the experience of a tertiary referral centre on a consecutive series of patients with thoracic germ cell tumours, thymomas and sarcomas, with the aim of reporting the long-term outcome by cancer type and complexity of surgical procedures. METHODS: From Jan 2003 to Dec 2018, 768 surgical procedures were performed with curative intent on 644 RTC patients. Study endpoints were: post-operative hospital stay (Pod), 30-day and 90-day mortality, 5-year and 10-year overall survival (OS). Median follow-up of alive patients was 7.2 years. RESULTS: Median Pod was 7 days, with a 1.2% 30-day and 2.9% 90-day mortality. OS was 90.8% at one year, 74.2% at five years and 62.8% at 10 years. Ten-year OS was 73.0% in low, 65.3% in intermediate, and 55.6% in high complexity score (Log-rank tests p<0.0001); 66.6% in patients with one or two reconstructions and 46.4% in patients with three or more reconstructions (p<0.0001); 46.0% with vascular and 50.0% with chest wall reconstruction; 71.8% in germ cell tumours, 64.6% in thymoma and 51.3% in sarcoma (p<0.0001). CONCLUSION: Complex surgical resection and reconstruction was associated with acceptable 90-day mortality and good 10-year survival in all RTC types. A predictive score based on surgical complexity and cancer type can help the clinical decision making.

Strategies to decrease morbidity in surgical management of esophageal cancer: a single center experience.

BACKGROUND: In this study we described our experience in decreasing morbidity by performing a few changes during and after the Ivor Lewis esophagectomy. METHODS: This is a retrospective single center experience comparing a control period (group A) and a study period (group B) in patients who underwent esophagectomy for esophageal cancer (control group: 23; study group: 17). Control group had postero-lateral thoracotomy and a gastric tube without aspiration during postoperative period. Study group had limited lateral muscle sparing thoracotomy and postoperatively the gastric tube was routinely left for 1 week with intermittent aspiration (10 times every two hours for 1 week). RESULTS: Average operation time was 312±56 minutes in control period, in study period 189±36 min. Average ICU stay was 10 (7-32) days in the control group, in study group 4 (1-8) days. Anastomotic leak rate was significantly higher in control vs. study group (53.3% vs. 16.6%; P<0.05). Respiratory complications were significantly lower in the study group (47.8% vs. 17.6%). CONCLUSIONS: The combination of a limited lateral thoracotomy and postoperative intermittent aspiration seem to reduce the rate of respiratory and anastomotic complication after Ivor-Lewis' procedure.

Chest wall reconstruction, prosthesis and allografts: a narrative review.

Background and Objective: What is the best material in the case of prosthesis used to replace major chest wall resection is still unknown. We reviewed most significant literature focused on the type of prosthetic materials available by highlighting their relative pros and cons. Methods: We reviewed most significant articles, including clinical results of relevant case series (retrospective studies), published in English in the last 23 years: PubMed, Embase and Scopus databases were used in our search in the period between the 1st January 1999 and 31st December 2022. Key Content and Findings: Overall, our literature review revealed lack of uniformity or conformity in the surgical strategies described for chest wall reconstruction with no internationally accepted standard in terms of decisions and optimal prosthetic materials and type of prostheses (soft, rigid, biological). Despite the increased interest in chest wall reconstruction, we observed a general lack of substantial prospective and multicentric studies. Likewise, there are not substantial data which may guide to the choice of optimal prosthetics in terms of characteristics and biocompatibility. Conclusions: A variety of materials are available for reconstruction, including synthetic and biological meshes, flexible and rigid patches, and metal osteosynthesis systems. The material chosen should be optimized to each patient and damaged tissues to be restored. Prospective and multicentric studies are necessary to address current limits in this surgical field.

"Before skin incision" high-resolution ultrasound in primary hyperparathyroidism: a new imaging tool for surgeons?

PURPOSE: Various diagnostic methods have been utilized for localizing pathologic parathyroid glands to consequently provide the possibility of avoiding bilateral neck dissection in cases of primary hyperparathyroidism. Scintigraphy, combined with ultrasound, became established as the standard method of localization in the 2000s. The aim of this study was to evaluate the role of the "before skin incision" surgeon-performed ultrasound in determining the improvement in the diagnostic accuracy in a large case series. METHOD: The method used in this research is a retrospective observational study (study period: between 1-2014 and 12-2020) comparing two patient groups before (control group: 31 patients) and after (study group: 70 patients) the introduction of the ultrasonography surgical protocol: combined preoperative and "before skin incision" surgeon-performed ultrasound. RESULTS: The sensitivity of the combined preoperative "before skin incision" surgeon-performed ultrasound was 97%, and the positive predictive value was 93% in regard to detecting the number of diseased glands and the appropriate anatomic location (right versus left, upper versus lower). The sensitivity of the parathyroid scan (Tc-MIBI-scintigraphy) was 74%, and the positive predictive value was 92%. The duration of surgery was significantly shorter in the test group (84.7 vs. 66.4 min; Mann‒Whitney U: 0.006). No differences were detected between the two groups in regard to avoiding intraoperative or postoperative complications. CONCLUSION: The combination of the preoperative "before skin incision" surgeon-performed ultrasound could improve the efficiency of the preoperative location and anatomic classification using the standard literature-suggested diagnostic methods.

Are risk factors for anastomotic leakage influencing long-term oncological outcomes after low anterior resection of locally advanced rectal cancer with neoadjuvant therapy? A single-centre cohort study.

PURPOSE: Anastomotic leakage (AL) poses the most serious problem following low anterior resection in patients with rectal cancer independent of surgical approach or technique. The aim of this study was to evaluate risk factors for the occurrence of AL and how they affect the oncological long-term outcome of patients who received neoadjuvant therapy. METHODS: A single centre cohort study of 163 consecutive locally advanced rectal cancer patients (cT3, cT4, N +) that received neoadjuvant therapy followed by resection with primary anastomosis between January 1998 and December 2020 were included in this study. Short- and long-term findings were compared between patients with AL (Leakage +) and without AL (Leakage -). RESULTS: A complete follow-up was obtained from 163 patients; thereby, 33 patients (20%) developed an AL. We observed more patients with comorbidities (38% vs. 61%, p = 0.049) which developed a leakage in the course. Permanent stoma rate (36% vs. 18%, p = 0.03) was higher, and time between primary operation and stoma reversal was longer (219 days [172-309] vs. 93 days [50-182], p < 0.001) in this leakage group as well. Tumour distance lower than 6 cm from the anal verge (OR: 2.81 [95%CI: 1.08-7.29], p = 0.04) and comorbidities (OR: 2.22 [95%CI: 1.01-4.90], p = 0.049) was evaluated to be independent risk factors for developing an AL after rectal cancer surgery. Oncological outcome was not influenced by AL nor by other associated risk factors. CONCLUSION: We could clearly detect the distance of tumour from the anal verge and comorbidities independent risk factors for the occurrence of AL. Oncological findings and long-term outcome were not influenced by these particular risk factors.

Is Robotic Assisted Colorectal Cancer Surgery Equivalent Compared to Laparoscopic Procedures during the Introduction of a Robotic Program? A Propensity-Score Matched Analysis.

BACKGROUND: Robotic surgery represents a novel approach for the treatment of colorectal cancers and has been established as an important and effective method over the last years. The aim of this work was to evaluate the effect of a robotic program on oncological findings compared to conventional laparoscopic surgery within the first three years after the introduction. METHODS: All colorectal cancer patients from two centers that either received robotic-assisted or conventional laparoscopic surgery were included in a comparative study. A propensity-score-matched analysis was used to reduce confounding differences. RESULTS: A laparoscopic resection (LR Group) was performed in 82 cases, and 93 patients were treated robotic-assisted surgery (RR Group). Patients' characteristics did not differ between groups. In right-sided resections, an intracorporeal anastomosis was significantly more often performed in the RR Group (LR Group: 5 (26.31%) vs. RR Group: 10 (76.92%), p = 0.008). Operative time was shown to be significantly shorter in the LR Group (LR Group: 200 min (150-243) vs. 204 min (174-278), p = 0.045). Conversions to open surgery did occur more often in the LR Group (LR Group: 16 (19.51%) vs. RR Group: 5 (5.38%), p = 0.004). Postoperative morbidity, the number of harvested lymph nodes, quality of resection and postoperative tumor stage did not differ between groups. CONCLUSION: In this study, we could clearly demonstrate robotic-assisted colorectal cancer surgery as effective, feasible and safe regarding postoperative morbidity and oncological findings compared to conventional laparoscopy during the introduction of a robotic system.

Short- and Long-Term Outcome of Laparoscopic- versus Robotic-Assisted Right Colectomy: A Systematic Review and Meta-Analysis.

Background: There is a rapidly growing literature available on right hemicolectomy comparing the short- and long-term outcomes of robotic right colectomy (RRC) to that of laparoscopic right colectomy (LRC). The aim of this meta-analysis is to revise current comparative literature systematically. Methods: A systematic review of comparative studies published between 2000 to 2021 in PubMed, Scopus and Embase was performed. The primary endpoint was postoperative morbidity, mortality and long-term oncological results. Secondary endpoints consist of blood loss, conversion rates, complications, time to first flatus, hospital stay and incisional hernia rate. Results: 25 of 322 studies were considered for data extraction. A total of 16,099 individual patients who underwent RRC (n = 1842) or LRC (n = 14,257) between 2002 and 2020 were identified. Operative time was significantly shorter in the LRC group (LRC 165.31 min ± 43.08 vs. RRC 207.38 min ± 189.13, MD: −42.01 (95% CI: −51.06−32.96), p < 0.001). Blood loss was significantly lower in the RRC group (LRC 63.57 ± 35.21 vs. RRC 53.62 ± 34.02, MD: 10.03 (95% CI: 1.61−18.45), p = 0.02) as well as conversion rate (LRC 1155/11,629 vs. RRC 94/1534, OR: 1.65 (1.28−2.13), p < 0.001) and hospital stay (LRC 6.15 ± 31.77 vs. RRC 5.31 ± 1.65, MD: 0.84 (95% CI: 0.29−1.38), p = 0.003). Oncological long-term results did not differ between both groups. Conclusion: The advantages of robotic colorectal procedures were clearly demonstrated. RRC can be regarded as safe and feasible. Most of the included studies were retrospective with a limited level of evidence. Further randomized trials would be suitable.

Current Medical Care Situation of Patients in Germany Undergoing Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC).

OBJECTIVE: Tailored approaches in gastrointestinal oncology have been more frequently introduced in past years and for patients with peritoneal metastases. This article attempts to overview the current strategies in surgical gastrointestinal oncology, with a focus on gastrointestinal peritoneal metastases. METHODS: In 2019, all patients undergoing PIPAC therapy in Germany were retrospectively analyzed regarding morbidity and in-hospital mortality rates. Furthermore, patients with chemotherapy-refractory peritoneal metastases from gastric cancer undergoing PIPAC-therapy at our institution were analyzed. RESULTS: In 2019, 534 patients received PIPAC treatment in german hospitals. The in-hospital mortality rate was 0%. In total, 36 patients suffered from postoperative complications (8%). From April 2016 to September 2021, a total of 44 patients underwent 93 PIPAC applications at our institution. The non-access-rate was 0%. The median PRGS was two (range, 1-4). Eleven patients (44%) showed histologically stable disease, whereas six patients (24%) showed histological regression. Median survival, calculated from the date of the first PIPAC application, was 181 days (range, 43-636 days). CONCLUSIONS: PIPAC is a safe and feasible procedure with a low in-hospital morbidity and mortality. Furthermore, PIPAC in the palliative and chemorefractory setting and is an appealing approach for patient management in the future.

Heart injuries related to cardiopulmonary resuscitation: a risk often overlooked.

BACKGROUND: Current studies focus primarily on skeletal injuries following cardiopulmonary resuscitation (CPR). Few studies report on intrathoracic injuries (ITI) and none, to our knowledge, focus exclusively on cardiovascular injuries related to cardiac massage. This study was based on autopsy findings and assessed the incidence of non-skeletal CPR related injuries related to chest compression. METHODS: This was a retrospective forensic autopsy cohort study conducted in a single institution after resuscitation. Pathologists recorded autopsy data using standardized protocol contained information from external and internal examination of the body. RESULTS: Thirty-eight autopsy reports (21 males and 17 females), post- CPR-failure were studied. Heart lesions were reported in 19 patients (group A). The average age was 65.7 years (69.05 group A and 66.5 group B). Median weight was 75.2 Kg and was significantly higher in group B (p = 0.01). Pericardial lesions were identified in 6 patients in group A and 2 in group B (p = 0.2 ns). No significant difference was observed among the two groups (Table 4) with the exception of the average number of rib fractures which was higher in group A (p = 0.04). Autopsy findings revealed heart injuries in 50% of patients with a high prevalence (52.6%) of left ventricle injuries. CONCLUSION: Cardiac lesions represent frequent and serious complications of unsuccessful CPR. Correct performance of chest compressions according to guidelines is the best way to avoid these complications.

Thoracoscopic resympathectomy for persistent or recurrent palmar hyperhidrosis: single-center experience.

BACKGROUND: In case of recurrence or persistent palmar hyperhidrosis, a sympathetic chain resection is suggested, however, many surgeons are still reluctant to offer further intervention because of the inability to predict the efficacy of such a procedure. We analyzed our large series of resympathectomy. METHODS: Substantive retrospective analysis of 39 patients underwent a resympathectomy (minimally invasive bilaterally sympathetic chain Th2-3 resection). Patients referred from other hospitals or primarily operated at our institution for recurrence or persistence palmar hyperhidrosis were included in the study group. RESULTS: No intraoperative complications were detected. Reoperation or chest tube positioning was necessary in 2 patients. Twenty-eight patients had a positive response (excellent or good results). Seven patients described a substantial, but not sufficient, reduction of the symptomatology. Four patients were very unsatisfied and regretted the operation. CONCLUSIONS: Resympathectomy is highly effective procedure for patients who have persistent or recurrent symptoms. However, the indication of the operations should be more dissuasive as possible to avoid the risk of any undesirable psychologically side effects.

Incidence and risk factors for umbilical incisional hernia after reduced port colorectal surgery (SIL + 1 additional port)-is an umbilical midline approach really a problem?

PURPOSE: Umbilical midline incisions for single incision- or reduced port laparoscopic surgery are still discussed controversially because of a higher rate of incisional hernia compared to conventional laparoscopic techniques. The aim of this study was to evaluate incidence and risk factors for incisional hernia after reduced port colorectal surgery. METHODS: A total 241 patients underwent elective reduced port colorectal surgery between 2014 and 2020. Follow-up was achieved through telephone interview or clinical examination. The study collective was examined using univariate and multivariate analysis. RESULTS: A total of 150 patients with complete follow-up were included into this study. Mean follow-up time was 36 (IQR 24-50) months. The study collective consists of 77 (51.3%) female and 73 (48.7%) male patients with an average BMI of 26 kg/m2 (IQR 23-28) and an average age of 61 (± 14). Indication for surgery was diverticulitis in 55 (36.6%) cases, colorectal cancer in 65 (43.3%) patients, and other benign reasons in 30 (20.0%) cases. An incisional hernia was observed 9 times (6.0%). Obesity (OR 5.8, 95% CI 1.5-23.1, p = 0.02) and pre-existent umbilical hernia (OR 161.0, 95% CI 23.1-1124.5, p < 0.01) were significant risk factors for incisional hernia in the univariate analysis. Furthermore, pre-existent hernia is shown to be a risk factor also in multivariate analysis. CONCLUSION: We could demonstrate that reduced port colorectal surgery using an umbilical single port access is feasible and safe with a low rate of incisional hernia. Obesity and pre-existing umbilical hernia are significant risk factors for incisional hernia.

Retrospective case-control study on the outcomes of early minimally invasive pleural lavage for pleural empyema in oncology patients.

BACKGROUND: Oncology patients carry a substantial risk of developing pleural empyema. Here, we report the preliminary results of our early video-assisted thoracoscopic surgery (VATS) lavage strategy in cases of empyema occurring in patients undergoing (radio-) chemotherapy. METHODS: This was a retrospective case-control study comparing early VATS lavage (test group, current therapy since January 2018, n = 46) versus VATS pleurectomy (historical control; before January 2018, n = 46). RESULTS: Five patients in the control group and one in the test group developed recurrence of empyema within 30 days. Complications were more severe and more frequently observed in the historical control group than in the test group (30/46 vs. 12/46 CI: 5%-95%, p = < 0.05). Early VATS lavage saved operating time, allowed a shorter ICU stay (2.6 days CI: 5%-95% vs. 5.1 days CI: 5%-95%, p = ns) and an earlier hospital discharge (6.1 days CI: 5%-95% vs. 13.5 days CI: 5%-95%, p < 0.05). Moreover, radio and/or chemotherapy could be reinitiated earlier (15 ± 20.5 days CI: 5%-95% vs. 40 ± 12 days CI: 5%-95%, p < 0.05). CONCLUSIONS: In this retrospective cohort study, early VATS lavage was found to have a beneficial effect especially on hospital stay and enabling an earlier restart of radio- and/or chemotherapy.

Prosthetic-free ribs stabilization technique in critical complex chest wall traumas: first results and experiences.

BACKGROUND: Surgical stabilization in complex chest wall traumas, especially in case of posterior ribs arch destruction and flail chest, still remains a challenge for thoracic and trauma surgeons. Throughout the years different techniques and materials developed to address the complex anatomy of the ribs and reach an adequate fixation. Our aim is to present a prosthetic-free ribs stabilization technique which is easily reproducible and can achieve an efficient mechanical stabilization of the chest wall. METHODS: This surgical technique can be summarized in three steps: muscle sparing thoracotomy following modified "Shaw-Paulson's" technique (complete section of the latissimus dorsi muscle along the transverse processes of vertebral spine to rich the serratus muscles plane), prosthetic-free ribs fixation with single stiches (Maxon™ 1) and muscles repositioning. RESULTS: Between January 2018 and June 2020, we retrospectively evaluated ten consecutive patients (six male and four female) which underwent a chest wall stabilization because of a posterior ribs destruction and flail chest. No chest wall deformities were observed during follow-up with CT-scan after 4, 30 and 90 days and no patient underwent additional early or late stabilization procedures. CONCLUSIONS: In the case of severe thoracic trauma with chest wall destruction and flail chest, modified "Shaw-Paulson approach" and prosthetic-free fixation technique with Maxon thread should be considered as a valuable option allowing an adequate stabilization of the chest with optimal respiratory function.

Does intraoperative flexible endoscopy offer any benefit compared to conventional air leak testing after circular stapled left-sided laparoscopic colon surgery?

BACKGROUND: Anastomotic leakage is still a feared complication after left-sided colonic resections. Various types of "anastomotic leak testing methods" are described in current literature. In this study we evaluated the use of intraoperative flexible endoscopy in comparison to conventional air leak testing after performing a circular stapled anastomosis in left-sided laparoscopic colon surgery. METHODS: A retrospective database consisting of 130 patients with left sided colonic resections between 01/2015 and 12/2019 at our hospital was evaluated. After performing a circular stapled anastomosis flexible endoscopy was done in 69 cases, 61 patients were controlled with a conventional air leak test. Intraoperative and postoperative complications were recorded and retrospectively evaluated. RESULTS: In the flexible endoscopy group, we observed complications in 13,04%, in the conventional air leak testing group in 9.83%. Postoperative anastomotic leakage was observed in 10,14% in the flexible endoscopy group and 4.91% in the conventional air leak test group. In 10.14% a positive air leak test was seen in the flexible endoscopy group and 11.47% in the conventional air leak testing group. In those cases, we observed no postoperative complications in the first group, in the conventional group we had two anastomotic leakages and one infected haematoma. CONCLUSIONS: In the case of a positive air leak, flexible endoscopy offered a more exact detection of the leak. In those cases, no anastomotic leakage was observed postoperatively. In our opinion, flexible endoscopy should be recommended for testing the anastomosis intraoperatively in every left-sided colon surgery.

Reduced port versus open right hemicolectomy for colorectal cancer: a retrospective comparison study of two centers.

PURPOSE: The concept of complete mesocolic excision (CME) in right-sided colorectal cancer is well known for open and laparoscopic surgery. The aim of this study was to evaluate and compare perioperative and oncological outcomes of reduced port and open surgery for right-sided colorectal cancer. METHODS: One hundred forty-one patients received elective surgery for right-sided colonic cancer between January 2015 and December 2019 and were included in a retrospective database. RESULTS: We observed longer operation time in the RP-CME group (145 min vs. 119.43 min, p<0.01). Hospital stay (8 days vs. 14 days, p<0.01) and time to first intestinal passage (42 h. vs. 59 h, p<0.01) were significantly shorter in the reduced port group. Postoperative complications were more likely to be observed in the O-CME group (7.2% vs. 14.1%, p=0.28); anastomotic leakage rate was low in both groups (1.8% vs. 2.4%, p=1.00). Specimen scores (score 1= good: 93.8% vs. 91.7%, p=1.00) and average number of retrieved lymph nodes were comparable (24 vs. 23 p=0.69). In O-CME patients, we observed more advanced tumor stages (UICC III: 21.4% vs. 45.9%, p<0.01). CONCLUSION: To our knowledge, this is the first study comparing reduced port to open surgery for right-sided colorectal cancer. We could demonstrate that this technique is feasible for oncological right hemicolectomy with observation of shorter hospital stay and lower morbidity rates compared to open surgery. The oncological outcome did not differ in the present study.

Colorectal resection in endometriosis patients: correlation between histopathological findings and postoperative outcome.

INTRODUCTION: Endometriosis is associated with a high number of chronic pelvic pain and reduced quality of life. Colorectal resections in case of bowel involvement of endometriosis are associated with an unneglectable morbidity in young and healthy patients. There is no linear correlation established between the degree of symptoms and stage of endometriosis. The aim of this study was to correlate the histological findings to preoperative pain scores in colorectal resected patients with endometriosis. METHODS: Twenty-five patients who underwent laparoscopic colorectal resection for endometriosis between 2014 and 2019 were included in this retrospective study. Pain level was assessed preoperatively and postoperatively via phone call in May 2020. Histopathology was correlated to preoperative symptoms and postoperative outcome. RESULTS: Average follow-up time was 38.68 months (± 19.92). Preoperative VAS-score was 8.32 (± 1.70). We observed a significant reduction of pain level in all patients after surgery (p ≤ 0.005). Pain levels were equal regarding the presence of satellite spots and various degrees of infiltration depth. The resection margins were clear in all patients. Postoperative complications occurred in 6 cases (24%) and anastomotic leakage was observed in 3 patients (12%). Average VAS-score at time of follow-up was 1.70 (± 2.54). CONCLUSION: Our data demonstrate that adequate colorectal resection leads to reduction of pain and an increase of quality of life irrespective of histopathological findings. An experienced team is necessary to improve intraoperative outcome and to reduce postoperative morbidity in case of complication.