The influence of delayed gastric emptying on quality of life after partial duodenopancreatectomy.

PURPOSE: Quality of life (QoL) is temporarily compromised after pancreatic surgery, but no evidence for a negative impact of postoperative complications on QoL has been provided thus far. Delayed gastric emptying (DGE) is one of the most common complications after pancreatic surgery and is associated with a high level of distress. Therefore, the aim of this study was to analyse the influence of DGE on QoL. METHODS: This single-centre retrospective study analysed QoL after partial duodenopancreatectomy (PD) via the European Organization for Research and Treatment of Cancer core questionnaire (QLQ-C30). The QoL of patients with and without postoperative DGE was compared. RESULTS: Between 2010 and 2022, 251 patients were included, 85 of whom developed DGE (34%). Within the first postoperative year, compared to patients without DGE, those with DGE had a significantly reduced QoL, by 9.0 points (95% CI: -13.0 to -5.1, p < 0.001). Specifically, physical and psychosocial functioning (p = 0.020) decreased significantly, and patients with DGE suffered significantly more from fatigue (p = 0.010) and appetite loss (p = 0.017) than patients without DGE. After the first postoperative year, there were no significant differences in QoL or symptom scores between patients with DGE and those without DGE. CONCLUSION: Patients who developed DGE reported a significantly reduced QoL and reduced physical and psychosocial functioning within the first year after partial pancreatoduodenectomy compared to patients without DGE.

Systematic review on groove pancreatitis: management of a rare disease.

BACKGROUND: Groove pancreatitis is a focal form of chronic pancreatitis affecting the area of the paraduodenal groove. The aim of this systematic review was to assess the clinical presentation, diagnosis and treatment of patients with groove pancreatitis. METHODS: Medical literature databases (Embase, Medline via PubMed and Cochrane Central Register of Controlled Trials) were systematically searched for data recorded between 1 January 1990 and 31 August 2022 regarding patient characteristics, diagnosis, surgical treatment and outcomes. The following inclusion criteria were applied: RCTs, observational studies (cohort and case-control studies) and case studies with >3 cases including patients with groove pancreatitis undergoing medical, endoscopic or surgical treatment with available clinical and diagnostic data. Fisher's exact test for binary data and Mann-Whitney U test or Student t-test for continuous data were adopted for statistical analysis. RESULTS: Of 649 studies, 44 were included, involving reports on 1404 patients with a mean age of 49 years. In 41 of the 44 studies in which patient gender was described, 86 per cent (N = 1023) of patients were male. Information on the risk factors of alcohol and nicotine was available in 37 and 23 studies, respectively. Seventy-nine per cent (N = 886) of patients had a history of excessive alcohol consumption and 83 per cent (N = 595) were smokers. Information on clinical symptoms was available in 37 of the 44 included studies and 78.5 per cent (N = 870) presented with abdominal pain. Some 27 studies comprising 920 groove pancreatitis patients were treatment oriented. Seventy-four per cent (N = 682) of patients were treated conservatively, 26.4 per cent (N = 134) underwent endoscopic treatment and 54.7 per cent (N = 503) required surgery. There was complete relief of symptoms in 35.6 per cent (N = 243) after conservative treatment, 55.2 per cent (N = 74) after endoscopic treatment and 69.6 per cent (N = 350) after surgical treatment. The median follow-up time was 42 months (range, 1-161 months). CONCLUSION: Groove pancreatitis shows on imaging a typical triad: cystic lesions in the pancreatic duct or duodenal wall, calcifications, and thickenings of the duodenal wall. Surgery appears to be the most effective treatment modality.

Current Research and Development in Hyperthermic Intraperitoneal Chemotherapy (HIPEC)-A Cross-Sectional Analysis of Clinical Trials Registered on ClinicalTrials.gov.

INTRODUCTION: Over the past two decades, cytoreductive surgery and HIPEC has improved outcomes for selected patients with peritoneal metastasis from various origins. This is a cross-sectional study with descriptive analyses of HIPEC trials registered on ClinicalTrials.gov. This study aimed to characterize clinical trials on HIPEC registered on ClinicalTrials.gov with the primary objective of identifying a trial focus and to examine whether trial results were published. METHODS: The search included trials registered from 1 January 2001 to 14 March 2022. We examined the associations of exposure variables and other trial features with two primary outcomes: therapeutic focus and results reporting. RESULTS: In total, 234 clinical trials were identified; 26 (11%) were already published, and 15 (6%) trials have reported their results but have not been published as full papers. Among ongoing nonpublished trials, 81 (39%) were randomized, 30 (14%) were blinded, n = 39 (20%) were later phase trials (i.e., phases 3 and 4), n = 152 (73%) were from a single institution, and 91 (44%) had parallel groups. Most of the trials were recruiting at the time of this analysis (75, 36%), and 39 (20%) were completed but had yet to publish results. In total, 68% of the trials focused on treatment strategies, and 53% investigated the oncological outcome. The most studied neoplasms for HIPEC trials were peritoneally metastasized colorectal cancer (32%), gastric cancer (29%), and ovarian cancer (26%). Twenty different drugs were analyzed in these clinical trials. CONCLUSIONS: Many study results are awaited from ongoing HIPEC trials. Most HIPEC trials focused on gastric, colorectal, or ovarian cancer. Many clinical trials were identified involving multiple entities and chemotherapeutic agents.

Hiatus hernia repair with a new-generation biosynthetic mesh: a 4-year single-center experience.

BACKGROUND: Mesh augmentation is a highly controversial adjunct of hiatus hernia (HH) surgery. The current scientific evidence remains unclear and even experts disagree on indications and surgical techniques. With an aim to avoid the downsides of both non-resorbable synthetic and biological materials, biosynthetic long-term resorbable meshes (BSM) have recently been developed and are becoming increasingly popular. In this context, we aimed at assessing outcomes after HH repair with this new generation of mesh at our institution. METHODS: From a prospective database, we identified all consecutive patients that underwent HH repair with BSM augmentation. Data was extracted from electronic patient charts of our hospital information system. Endpoints of this analysis included perioperative morbidity, functional results and recurrence rates at follow-up. RESULTS: Between December 2017 and July 2022, 97 patients (elective primary cases n = 76, redo cases n = 13, emergency cases n = 8) underwent HH with BSM augmentation. Indications in elective and emergency cases were paraesophageal (Type II-IV) HH in 83%, and large Type I HH in 4%. There was no perioperative mortality, and overall (Clavien-Dindo ≥ 2) and severe (Clavien-Dindo ≥ 3b) postoperative morbidity was 15% and 3%, respectively. An outcome without postoperative complications was achieved in 85% of cases (elective primary surgery 88%, redo cases 100%, emergencies cases 25%). After a median (IQR) postoperative follow-up of 12 months, 69 patients (74%) were asymptomatic, 15 (16%) reported improvement, and 9 (10%) had clinical failure, of which 2 patients (2%) required revisional surgery. CONCLUSION: Our data suggest that HH repair with BSM augmentation is feasible and safe with low perioperative morbidity and acceptable postoperative failure rates at early to mid-term follow-up. BSM may be a useful alternative to non-resorbable materials in HH surgery.

Quality of Surgical Outcome Reporting in Randomised Clinical Trials of Multimodal Rectal Cancer Treatment: A Systematic Review.

INTRODUCTION: Randomised controlled trials (RCTs) continue to provide the best evidence for treatment options, but the quality of reporting in RCTs and the completeness rate of reporting of surgical outcomes and complication data vary widely. The aim of this study was to measure the quality of reporting of the surgical outcome and complication data in RCTs of rectal cancer treatment and whether this quality has changed over time. METHODS: Eligible articles with the keywords ("rectal cancer" OR "rectal carcinoma") AND ("radiation" OR "radiotherapy") that were RCTs and published in the English, German, Polish, or Italian language were identified by reviewing all abstracts published from 1982 through 2022. Two authors independently screened and analysed all studies. The quality of the surgical outcome and complication data was assessed based on fourteen criteria, and the quality of RCTs was evaluated based on a modified Jadad scale. The primary outcome was the quality of reporting in RCTs and the completeness rate of reporting of surgical results and complication data. RESULTS: A total of 340 articles reporting multimodal therapy outcomes for 143,576 rectal cancer patients were analysed. A total of 7 articles (2%) met all 14 reporting criteria, 13 met 13 criteria, 27 met from 11 to 12 criteria, 36 met from 9 to 10 criteria, 76 met from 7 to 8 criteria, and most articles met fewer than 7 criteria (mean 5.5 criteria). Commonly underreported criteria included complication severity (15% of articles), macroscopic integrity of mesorectal excision (17% of articles), length of stay (18% of articles), number of lymph nodes (21% of articles), distance between the tumour and circumferential resection margin (CRM) (26% of articles), surgical radicality according to the site of the primary tumour (R0 vs. R1 + R2) (29% of articles), and CRM status (38% of articles). CONCLUSION: Inconsistent surgical outcome and complication data reporting in multimodal rectal cancer treatment RCTs is standard. Standardised reporting of clinical and oncological outcomes should be established to facilitate comparing studies and results of related research topics.

Benchmarks in colorectal surgery: multinational study to define quality thresholds in high and low anterior resection.

BACKGROUND: Benchmark comparisons in surgery allow identification of gaps in the quality of care provided. The aim of this study was to determine quality thresholds for high (HAR) and low (LAR) anterior resections in colorectal cancer surgery by applying the concept of benchmarking. METHODS: This 5-year multinational retrospective study included patients who underwent anterior resection for cancer in 19 high-volume centres on five continents. Benchmarks were defined for 11 relevant postoperative variables at discharge, 3 months, and 6 months (for LAR). Benchmarks were calculated for two separate cohorts: patients without (ideal) and those with (non-ideal) outcome-relevant co-morbidities. Benchmark cut-offs were defined as the 75th percentile of each centre's median value. RESULTS: A total of 3903 patients who underwent HAR and 3726 who had LAR for cancer were analysed. After 3 months' follow-up, the mortality benchmark in HAR for ideal and non-ideal patients was 0.0 versus 3.0 per cent, and in LAR it was 0.0 versus 2.2 per cent. Benchmark results for anastomotic leakage were 5.0 versus 6.9 per cent for HAR, and 13.6 versus 11.8 per cent for LAR. The overall morbidity benchmark in HAR was a Comprehensive Complication Index (CCI®) score of 8.6 versus 14.7, and that for LAR was CCI® score 11.9 versus 18.3. CONCLUSION: Regular comparison of individual-surgeon or -unit outcome data against benchmark thresholds may identify gaps in care quality that can improve patient outcome.

Trends in pancreatic surgery in Switzerland: a survey and nationwide analysis over two decades.

BACKGROUND: Centralisation of highly specialised medicine (HSM) has changed practice and outcome in pancreatic surgery (PS) also in Switzerland. Fewer hospitals are allowed to perform pancreatic surgery according to nationally defined cut-offs. OBJECTIVE: We aimed to examine trends in PS in Switzerland. First, to assess opinions and expected trends among Swiss pancreatic surgeons in regard of PS practice and second, to assess the evolution of PS performance in Switzerland by a nationwide retrospective analysis. METHODS: First, a 26-item survey among all surgeons who performed PS in 2016 in Switzerland was performed. Then, nationwide data from 1998 to 2018 from all hospitals performing PS was analysed including centre volume, perioperative morbidity and mortality, surgical indications and utilisation of minimally invasive pancreatic surgery (MIPS). The national cut-off for regulatory accredited volume centres (AVC) was ≥ 12. Additionally, an international benchmark definition for high volume (≥ 20 surgeries/year) was used. RESULTS: Among 25 surgeons from 15 centres (response rate 51%), the survey revealed agreement that centralisation is important to improve perioperative outcomes. Respondents agreed on a minimum case load per surgeon or centre. Within the nationwide database, 8534 pancreatic resections were identified. Most resections were performed for pancreatic ductal adenocarcinoma (58.9%). There was a significant trend towards centralisation of PS with fewer non-accredited volume centres (nAVC) (36 in 1998 and 17 in 2018, p < 0.001) and more AVC (2 in 1998 and 18 in 2018, p < 0.001). A significantly higher adjusted mortality after pancreatoduodenectomy (PD) was observed in low-volume compared to high-volume hospitals (OR 1.45 [95% CI 1.15-1.84], p = 0.002) and a similar trend compared among AVC and nAVC (OR 1.25 [95% CI 0.98-1.60], p = 0.072), while mortality after distal pancreatectomy (DP) was not influenced by centre volume. CONCLUSIONS: Over the last two decades, centralisation of PS towards higher-volume centres was observed in Switzerland with a decrease of mortality after PD and low mortality after DP. Further centralisation is supported by most pancreatic surgeons. However, the ideal metric and outcome measures for the allocation of highly specialised medicine need further discussion to allow a fair and outcome-focused allocation.

Advanced Lymph Node Staging With Ex Vivo Intra-arterial Indigo Carmine Injection After Transanal Total Mesorectal Excision for Rectal Cancer: A Retrospective Cohort Study.

BACKGROUND: Exact lymph node staging is essential in rectal cancer therapy. OBJECTIVE: The aim of the study was to assess the impact of intra-arterial indigo carmine injection after transanal total mesorectal excision on the number of retrieved lymph nodes. DESIGN: This was a retrospective, nonrandomized study. SETTINGS: The study was conducted at a tertiary hospital by a multidisciplinary team. PATIENTS: Patients who underwent transanal total mesorectal excision for suspected rectal cancer between 2013 and 2019 were included. INTERVENTIONS: Rectal cancer specimens received ex vivo intra-arterial indigo carmine injection to stain lymph nodes. MAIN OUTCOME MEASURES: Outcome measures included the number of retrieved lymph nodes with or without staining. RESULTS: Specimens of 189 patients were analyzed, of which 108 (57.1%) were stained with indigo carmine. A mean of 19.8 ± 6.1 lymph nodes was identified in stained samples compared to 16.0 ± 4.9 without staining ( p < 0.001). Multivariable analysis showed that 3.2 additional lymph nodes were found in stained specimens (95% CI: 1.0 to 5.3; p = 0.02). In stained specimens the adequate lymph node count (≥12) was increased in univariable (odds ratio: 3.24, 95% CI: 1.13 to 10.65; p = 0.03) but not in multivariable analysis. Indigo carmine injection had no effect on the number of positive lymph nodes or the nodal stage. Chemoradiotherapy reduced the lymph node count by 2.5 ( p = 0.008). After staining, 95.0% of patients with chemoradiotherapy had ≥12 lymph nodes retrieved. The median follow-up of patients was 24.2 months with a local recurrence rate of 3.3%. LIMITATIONS: The study is limited by its retrospective design and the nonrandomized allocation. CONCLUSIONS: Ex vivo intra-arterial indigo carmine injection increases the number of isolated lymph nodes after transanal total mesorectal excision regardless of neoadjuvant chemoradiotherapy. Indigo carmine injection is not associated with nodal upstaging or an increased number of tumor-positive lymph nodes. See Video Abstract at http://links.lww.com/DCR/B839 . ESTADIFICACIN AVANZADA DE LOS GANGLIOS LINFTICOS CON INYECCIN INTRAARTERIAL EX VIVO,DE NDIGO CARMN,DESPUS DE LA ESCISIN TOTAL DEL MESORRECTO POR VA TRANSANAL PARA CNCER DE RECTO UN ESTUDIO DE COHORTE RETROSPECTIVO: ANTECEDENTES:La estadificación exacta de los ganglios linfáticos es esencial en la tratamiento del cáncer de recto.OBJETIVO:El objetivo del estudio fue evaluar el impacto de la inyección intraarterial de índigo carmín después de la escisión total del mesorrecto por vía transanal con relación al número de ganglios linfáticos recuperados en el espécimen quirúrgico..DISEÑO:Estudio retrospectivo no aleatorizado.AJUSTE:El estudio se llevó a cabo en un hospital de tercer nivel por un equipo multidisciplinario.PACIENTES:Pacientes a quienes se les practicó escisión total del mesorrecto por vía transanal por sospecha de cáncer de recto entre 2013 y 2019.INTERVENCIONES:Al espécimen quirúrgico que se obtuvo, se le practicó inyección intraarterial ex vivo, de índigo carmín para teñir los ganglios linfáticos.PRINCIPALES MEDIDAS DE RESULTADO:El número de ganglios linfáticos recuperados con o sin tinción.RESULTADOS:Se analizaron muestras de 189 pacientes, de los cuales 108 (57,1%) fueron teñidos con índigo carmín. Se identificó una media de 19,8 ± 6,1 ganglios linfáticos en las muestras teñidas en comparación con 16,0 ± 4,9 sin tinción ( p < 0,001). El análisis multivariado mostró que se encontraron 3.2 ganglios linfáticos adicionales en las muestras teñidas (intervalo de confianza del 95%: 1,0 a 5,3; p = 0,02). En las muestras teñidas, el recuento adecuado de ganglios linfáticos (≥12) aumentó en el análisis univariado (razón de posibilidades: 3,24, intervalo de confianza del 95%: 1,13 a 10,65; p = 0,03) pero no en el multivariado. La inyección de índigo carmín no tuvo ningún efecto sobre el número de ganglios linfáticos positivos o el estadio ganglionar. La quimiorradioterapia redujo el recuento de ganglios linfáticos en 2,5 ( p = 0,008). Después de la tinción, en el 95,0% de los pacientes con quimiorradioterapia se recuperaron ≥12 ganglios linfáticos. La mediana de seguimiento de los pacientes fue de 24,2 meses con una tasa de recurrencia local del 3,3%.LIMITACIONES:El estudio está limitado por su diseño retrospectivo y la asignación no aleatoria.CONCLUSIONES:La inyección ex vivo de índigo carmín intraarterial aumenta el número de ganglios linfáticos aislados después de la escisión total del mesorrectal por vía transanal a pesar de la quimiorradioterapia neoadyuvante. La inyección de índigo carmín no se asocia con un aumento del estadio de los ganglios ni con un mayor número de ganglios linfáticos positivos para tumor. Consulte Video Resumen en http://links.lww.com/DCR/B839 . (Traducción-Eduardo Londoño-Schimmer ).

Pressurized Intraperitoneal Aerosol Chemotherapy-Related Clinical Trials in the Treatment of Peritoneal Metastases.

INTRODUCTION: Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a treatment option for patients with peritoneal metastases. We evaluated the current status of ongoing prospective clinical trials investigating PIPAC to provide an overview and predict trends in this field. METHODS: All 367,494 records of clinical trials registered at ClinicalTrials.gov were searched for trials dealing with PIPAC. Active or unpublished trials were further analyzed. RESULTS: In total, 22 clinical trials were identified and selected for further analyses. Most trials had a single-arm design and were phase I or II. No phase III trials were registered. Academic centers were recorded as primary sponsors in the majority of trials (63.6%). Every year, between 2 and 5 new trials were initiated. In 17 trials (81.8%), PIPAC was used in a palliative setting only, 2 trials performed PIPAC in a neoadjuvant setting, and 2 trials performed PIPAC in an adjuvant setting. Six different drugs (doxorubicin, cisplatin, oxaliplatin, nab-paclitaxel, 5-fluorouracil, and docetaxel) were used in these clinical trials. Most trials investigated the efficacy (n = 15) or safety (n = 7) of PIPAC therapies. CONCLUSIONS: The results of ongoing clinical trials will bring specific information on indications for PIPAC as well as the impact of PIPAC on quality of life and overall survival.

Functional syndromes and symptom-orientated aftercare after esophagectomy.

BACKGROUND: Surgery is the cornerstone of esophageal cancer treatment but remains burdened with significant postoperative changes of gastrointestinal function and quality of life. PURPOSE: The aim of this narrative review is to assess and summarize the current knowledge on postoperative functional syndromes and quality of life after esophagectomy for cancer, and to provide orientation for the reader in the challenging field of functional aftercare. CONCLUSIONS: Post-esophagectomy syndromes include various conditions such as dysphagia, reflux, delayed gastric emptying, dumping syndrome, weight loss, and chronic diarrhea. Clinical pictures and individual expressions are highly variable and may be extremely distressing for those affected. Therefore, in addition to a mostly well-coordinated oncological follow-up, we strongly emphasize the need for regular monitoring of physical well-being and gastrointestinal function. The prerequisite for an effective functional aftercare covering the whole spectrum of postoperative syndromes is a comprehensive knowledge of the pathophysiological background. As functional conditions often require a complex diagnostic workup and long-term therapy, close interdisciplinary cooperation with radiologists, gastroenterologists, oncologists, and specialized nutritional counseling is imperative for successful management.

[Diagnosis and treatment of acute cholecystitis]. / Diagnostik und Behandlung der akuten Cholezystitis.

Diagnosis and treatment of acute cholecystitis Abstract. Acute cholecystitis is one of the most common acute surgical diseases. Typical clinical symptoms are pain in the upper abdomen, fever and leucocytosis. Ultrasonography may often be used to confirm the clinical diagnosis. There is a consensus that laparoscopic cholecystectomy is recommended as the treatment of choice and should be performed immediate after diagnosis independent of the onset of symptoms. The risk of complications is prevented by surgery. Surgery is the treatment of choice for acute cholecystits also in elderly patients with severe comorbidities. Conventional laparoscopic 3 - 4 port cholecystectomy is considered as a standard for removing the gallbladder. Laparoscopic cholecystectomy has become established as a safe standard procedure in the treatment of symptomatic cholecystolithiasis and cholecystitis with low mortality and morbidity. Nevertheless, this procedure is associated with typical complications. Bile duct injuries are among the most serious injuries. Most complications are the consequence of lack of experience or technical causes. By reasonably indication for laparoscopic cholecystectomy and a low inhibition rate of conversion, combined with adequate training (laparoscopy courses), the complication rate can be kept very low.

Effect of lymphadenectomy in curative gallbladder cancer treatment: a systematic review and meta-analysis.

PURPOSE: Only a small fraction of resectable gallbladder cancer (GBC) patients receive a thorough lymphadenectomy. The aim of this systematic review and meta-analysis was to investigate the effect of lymphadenectomy on survival in GBC surgery. METHODS: On May 19, 2019, MEDLINE, EMBASE, and the Cochrane Library were searched for English or German articles published since 2002. Studies assessing the effect of lymphadenectomy on survival in GBC surgery were included. Fixed effect and random effects models were used to summarise the hazard ratio (HR). RESULTS: Of the 530 identified articles, 18 observational studies (27,570 patients, 10 population-based, 8 cohort studies) were reviewed. In the meta-analysis, lymphadenectomy did not show a significant benefit for T1a tumours (n = 495; HR, 1.37; 95%CI, 0.65-2.86; P = 0.41). Lymphadenectomy showed a significant survival benefit in T1b (n = 1618; HR, 0.69; 95%CI, 0.50-0.94; P = 0.02) and T2 (n = 6204; HR, 0.68; 95%CI, 0.56-0.83; P < 0.01) tumours. Lymphadenectomy improved survival in the 2 studies assessing T3 tumours (n = 1961). A conclusive analysis was not possible for T4 tumours due to a low case load. Among patients undergoing lymphadenectomy, improved survival was observed in patients with a higher number of resected lymph nodes (HR, 0.57; 95%CI, 0.45-0.71; P < 0.01). CONCLUSIONS: Regional lymphadenectomy improves survival in T1b to T3 GBC. A minimum of 6 retrieved lymph nodes are necessary for adequate staging, indicating a thorough lymphadenectomy. Patients with T1a tumours should be evaluated for lymphadenectomy, especially if lymph node metastases are suspected.

Impact of intraoperative noise measurement on the surgeon stress and patient outcomes. A prospective, controlled, single-center clinical trial with 664 patients.

BACKGROUND: The impact of sound-activated noise meters to decrease the noise level in the operating room is not clear. The aim of this study was to determine whether a sound-activated, visual noise meter would decrease noise levels, decrease postoperative morbidity, and improve surgeons' feelings of well-being. METHODS: This prospective, single-center study proceeded in 2 phases. First, sound levels were compared during a 6-month period with noise measurement only and without a visual feedback function. Second, we conducted a subsequent 6-month phase with noise meters providing direct feedback. Surgeon disturbance during the operation was assessed by a questionnaire after each procedure. RESULTS: Of the 664 procedures included in this analysis, 447 (67.3%) were in phase 1 and 217 (32.7%) in phase 2. The noise levels in the operating room were decreased by 3.8 dB(A) from 54.6 ± 4.5 dB(A) in phase 1 to 50.8 ± 2.8 dB(A) in phase 2 after intervention with the feedback device (P < .001). During the procedures, there was an increase of 0.7 dB(A) (P < .001), with mean noise levels of 53.5 dB(A) at the beginning of the procedures and 54.2 dB(A) at the end. There was a correlation between the disturbance of the surgeon and the noise level (P < .001). CONCLUSION: The application of a visual noise warning device in an operating room decreased both the noise levels and surgeon stress and may offer sustained decreases in ambient and peak sound levels, potentially leading to improved quality outcomes in visceral surgery.

Baseline mortality-adjusted survival in colon cancer patients.

BACKGROUND: This investigation assessed the baseline mortality-adjusted survival after colon cancer resection. MATERIAL AND METHODS: In total, 523 patients with adenocarcinoma of the colon who underwent primary colon resection at Kantonsspital St. Gallen, Switzerland, between 1996 and 2008 were included. RESULTS: The median follow-up was 25 months for all patients and 39 months for those who survived until the end of the follow-up. The 5-year relative survival rate was 63.2 % (95 % CI 57.3-69.6 %), and the overall survival rate was 52 % (95 % CI 47.6-57.7 %). After curative resection of stage I-III colon cancer, 40 % of the observed deaths were cancer-related and 60 % reflected the baseline mortality. In stage I, the 5-year relative survival was 103.2 % (95 % CI 91.4-116.5 %) and was not different from a matched population (p = 0.820). In multivariate analysis, good general health and less advanced cancer stages were associated with better relative and overall survival rates. A more advanced age was associated with better relative survival, but worse overall survival. CONCLUSIONS: The analysis of relative survival of patients exclusively with colon cancer revealed that prognosis of patients suffering from stage I colon cancer does not differ significantly from that of the general population. In more advanced stages, a relevant fraction of deaths is not cancer-related. As the stage determines a patient's survival, early diagnosis is crucial for prognosis.

Use of human fibrin glue (Tisseel) versus staples for mesh fixation in laparoscopic transabdominal preperitoneal hernioplasty (TISTA): a randomized controlled trial (NCT01641718).

BACKGROUND: Inguinal hernia repair is one of the most common surgical procedures worldwide. This procedure is increasingly performed with endoscopic techniques (laparoscopy). Many surgeons prefer to cover the hernia gap with a mesh to prevent recurrence. The mesh must be fixed tightly, but without tension. During laparoscopic surgery, the mesh is generally fixed with staples or tissue glue. However, staples often cause pain at the staple sites, and they can cause scarring of the abdominal wall, which can lead to chronic pain. We designed a trial that aims to determine whether mesh fixation with glue might cause less postoperative pain than fixation with staples during a transabdominal preperitoneal patch plastic repair. METHODS/DESIGN: The TISTA trial is a prospective, randomized, controlled, single-center trial with a two-by-two parallel design. All patients and outcome-assessors will be blinded to treatment allocations. For eligibility, patients must be male, ≥18 years old, and scheduled for laparoscopic repair of a primary inguinal hernia. One group comprises patients with a unilateral inguinal hernia that will be randomized to receive mesh fixation with either tissue glue or staples. The second group comprises patients with bilateral inguinal hernias. They will be randomized to receive mesh fixation with tissue glue either on the right or the left side and with staples on the other side. The primary endpoint will be pain under physical stress, measured at 24 h after surgery. Pain will be rated by the patient based on a numeric rating scale from 0 to 10, where 10 equals the worst pain imaginable. A total of 82 patients will be recruited (58 patients with unilateral inguinal hernias and 24 patients with bilateral hernias). This number is estimated to provide 90% power for detecting a pain reduction of one point on a numeric rating scale, with a standard deviation of one. DISCUSSION: Patients with bilateral hernias will receive two meshes, one fixed with glue, and the other fixed with staples. This design will eliminate the inter-individual bias inherent in comparing pain measurements between two groups of patients. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01641718.

Blood transfusion does not adversely affect survival after elective colon cancer resection: a propensity score analysis.

PURPOSE: The aim of this study was to assess the putative impact of perioperative blood transfusions on overall survival in patients undergoing curative resection for stage III colon cancer by applying propensity scoring methods. METHODS: In a single-center study, a total of 309 patients who underwent open curative resection for stages I-III colon cancer from 1996-2008 were assessed. The mean follow-up period was 47 ± 38 months. Transfused and non-transfused patients were compared using both Cox regression and propensity score analyses. RESULTS: Overall, 148 patients (47.9 %) received blood transfusions. The patient characteristics were highly biased toward transfusions (propensity score 0.68 ± 0.22 vs. 0.30 ± 0.22, p <0.001). In the unadjusted analysis, blood transfusions were associated with a 90 % increased risk of overall mortality (hazard ratio 1.90, 95 % CI: 1.19-3.04, p = 0.001). The 5-year survival for patients receiving blood transfusions was 64.5 % (95 % CI: 56.0-74.3 %) compared with 80.1 % (95 % CI: 72.8-88.2 %) in those not receiving blood transfusions. In the propensity score-adjusted Cox regression analysis (hazard ratio: 0.85, 95 % CI = 0.53-1.37, p = 0.501), blood transfusions did not increase the risk of overall mortality. After risk adjustment, the 5-year survival rate for patients receiving blood transfusions was 66.6 % (95 % CI: 57.4-77.3 %) compared with 61.8 % (95 % CI: 51.9-73.7 %) for those who did not. CONCLUSION: This study is the first propensity score-based analysis that provides evidence that poor oncological outcomes after curative colon cancer resection in patients receiving perioperative blood transfusions are due to the clinical circumstances that require the transfusions and are not due to the blood transfusions.

Concomitant cholecystectomy during laparoscopic Roux-en-Y gastric bypass in obese patients is not justified: a meta-analysis.

While LRYGB has become a cornerstone in the surgical treatment of morbidly obese patients, concomitant cholecystectomy during LRYGB remains a matter of debate. The aim of this meta-analysis was to estimate the rate and morbidity of subsequent cholecystectomy after laparoscopic Roux-en-Y gastric bypass (LRYGB) in obese patients. A meta-analysis was performed analyzing the rate and morbidity of subsequent cholecystectomy in patients who underwent LRYGB without concomitant cholecystectomy. Thirteen studies met the inclusion criteria. The rate of subsequent cholecystectomy was 6.8 % (95 % CI, 5.0-8.7 %) based on 6,048 obese patients who underwent LRYGB without concomitant cholecystectomy. The rate of subsequent cholecystectomy due to biliary colic or gallbladder dyskinesia was 5.3 %; due to cholecystitis, 1.0 %; choledocholithiasis, 0.2 %; and biliary pancreatitis, 0.2 %. The mortality after subsequent cholecystectomy was 0 % (95 % CI, 0-0.1 %). The surgery-related complication rate after subsequent cholecystectomy was 1.8 % (95 % CI, 0.7-3.4 %) resulting in a risk of 0.1 % (95 % CI, 0.03-0.3 %) to suffer from a cholecystectomy-related complication in patients undergoing LRYGB without concomitant cholecystectomy. A prophylactic concomitant cholecystectomy during LRYGB should be avoided in patients without cholelithiasis and exclusively be performed in patients with symptomatic biliary disease.

Diagnostic study and meta-analysis of C-reactive protein as a predictor of postoperative inflammatory complications after gastroesophageal cancer surgery.

PURPOSE: This study assessed the diagnostic accuracy of C-reactive protein (CRP) after gastroesophageal cancer resection for postoperative inflammatory complications (PIC). METHODS: The clinical data and CRP values of patients operated on for gastroesophageal cancer surgery between 1997 and 2009 were retrospectively analyzed. The results of this study were compared with published data using a meta-analytic approach for diagnostic outcomes. RESULTS: Of 210 patients included in the study, 59 developed PIC (28.1 %; 95 % CI: 22.5-34.5 %). On the postoperative day (POD) 4 and 7, CRP had the best diagnostic accuracy for PIC (AUC 0.77; 95 % CI, 0.64-0.91, AUC 0.81; 95 % CI, 0.71-0.91). Using a cut-off value of 141 mg/L (95 % CI, 131-278 mg/L) for CRP on POD 4, the sensitivity was 0.78 (95 % CI, 0.55-0.91), the specificity was 0.70 (95 % CI, 0.53-0.83) and the NPV was 0.89 (95 % CI, 0.77-0.95). The in-hospital mortality rate was 3.3 % (95 % CI, 1.5-6.9 %). In a diagnostic meta-analysis that included two additional studies, CRP had a significant predictive value after POD 3. CONCLUSION: There is limited evidence for the diagnostic accuracy of CRP levels for PIC after gastroesophageal cancer surgery. CRP levels on POD 4 might be useful to rule out PIC, but its diagnostic accuracy is moderate at best. For clinical routine use CRP levels are clearly not sufficient to predict PIC and have to be interpreted in the context of the whole clinical picture.

Loss of secreted frizzled-related protein 4 correlates with an aggressive phenotype and predicts poor outcome in ovarian cancer patients.

BACKGROUND: Activation of the Wnt signaling pathway is implicated in aberrant cellular proliferation in various cancers. In 40% of endometrioid ovarian cancers, constitutive activation of the pathway is due to oncogenic mutations in ß-catenin or other inactivating mutations in key negative regulators. Secreted frizzled-related protein 4 (SFRP4) has been proposed to have inhibitory activity through binding and sequestering Wnt ligands. METHODOLOGY/PRINCIPAL FINDINGS: We performed RT-qPCR and Western-blotting in primary cultures and ovarian cell lines for SFRP4 and its key downstream regulators activated ß-catenin, ß-catenin and GSK3ß. SFRP4 was then examined by immunohistochemistry in a cohort of 721 patients and due to its proposed secretory function, in plasma, presenting the first ELISA for SFRP4. SFRP4 was most highly expressed in tubal epithelium and decreased with malignant transformation, both on RNA and on protein level, where it was even more profound in the membrane fraction (p<0.0001). SFRP4 was expressed on the protein level in all histotypes of ovarian cancer but was decreased from borderline tumors to cancers and with loss of cellular differentiation. Loss of membrane expression was an independent predictor of poor survival in ovarian cancer patients (p = 0.02 unadjusted; p = 0.089 adjusted), which increased the risk of a patient to die from this disease by the factor 1.8. CONCLUSIONS/SIGNIFICANCE: Our results support a role for SFRP4 as a tumor suppressor gene in ovarian cancers via inhibition of the Wnt signaling pathway. This has not only predictive implications but could also facilitate a therapeutic role using epigenetic targets.