There is a need for a paradigm shift in laparoscopic surgical training: results of a nationwide survey among teaching hospitals in Switzerland.

BACKGROUND: Surgical training curricula have changed little over the past decades. Current advances in surgical techniques, especially in minimally invasive surgery, as well as the rapidly changing socioeconomic environment pose a major challenge for the training of young surgeons. The aim of this survey was to provide a representative overview of the surgical training landscape in Switzerland focusing on laparoscopic surgical training: How do department chairs of teaching hospitals deal with the above challenges, and what should a future training curriculum look like? METHODS: This is a prospective, questionnaire-based, cross-sectional study among the heads of departments of all certified surgical teaching hospitals in Switzerland. RESULTS: The overall response rate was 56% (48/86) and 86% (19/22) for tertiary centers. Two-thirds of the centers (32) organize themselves in training networks. Laparoscopic training courses are offered in 25 (52%) hospitals, mainly in tertiary centers. Self-training opportunities exist in 40 (83%) hospitals. In addition to commercial (27) and self-built (7) box trainers, high-fidelity trainers are available in 16 (33%) hospitals. A mandatory training curriculum exists in 7 (15%) facilities, and a training assessment is performed in 15 (31%) institutions. Thirty-two (65%) heads of departments indicated that residents have sufficient practical exposure in the operating room, but the ability to work independently with obtaining the specialist title is seen critically (71%). They state that the surgical catalog does not adequately reflect the manual skills of the resident (64%). The desire is for training to be restructured from a numbers-based to a performance-based curriculum (53%) and for tools to assess residents' manual skills (56%) to be introduced. CONCLUSIONS: Department chairs stated that the existing curriculum in Switzerland does not meet the requirements of a modern training curriculum. This study highlights the need to create an improved, competency-based curriculum that ensures the training of a new generation of surgeons, taking into account the growing evidence of the effectiveness of state-of-the-art training modalities such as simulation or proficiency-based training.

Is survival after transanal total mesorectal excision (taTME) worse than that after traditional total mesorectal excision? A retrospective propensity score-adjusted cohort study.

PURPOSE: Transanal total mesorectal excision (taTME) was developed to provide better vision during resection of the mesorectum. Conflicting results have shown an increase in local recurrence and shorter survival after taTME. This study compared the outcomes of taTME and abdominal (open, laparoscopic, robotic) total mesorectal excision (abTME). METHODS: Patients who underwent taTME or abTME for stages I-III rectal cancer and who received an anastomosis were included. A retrospective analysis of a prospectively conducted database was performed. The primary endpoints were overall survival (OS), cancer-specific survival (CSS), and disease-free survival (DFS). Risk factors were adjusted by propensity score matching (PSM). The secondary endpoints were local recurrence rates and combined poor pathological outcomes. RESULTS: From 2012 to 2020, a total of 189 patients underwent taTME, and 119 underwent abTME; patients were followed up for a mean of 54.7 (SD 24.2) and 78.4 (SD 34.8) months, respectively (p < 0.001). The 5-year survival rates after taTME and abTME were not significantly different after PSM: OS: 78.2% vs. 88.6% (p = 0.073), CSS: 87.4% vs. 92.1% (p = 0.359), and DFS: 69.3% vs. 80.9% (p = 0.104), respectively. No difference in the local recurrence rate was observed (taTME, n = 10 (5.3%); abTME, n = 10 (8.4%); p = 0.280). Combined poor pathological outcomes were more frequent after abTME (n = 36, 34.3%) than after taTME (n = 35, 19.6%) (p = 0.006); this difference was nonsignificant according to multivariate analysis (p = 0.404). CONCLUSION: taTME seems to be a good treatment option for patients with rectal cancer and is unlikely to significantly affect local recurrence or survival. However, further investigations concerning the latter are warranted. TRIAL REGISTRATION: ClinicalTrials.gov (NCT0496910).

Surgical site infections after kidney transplantation are independently associated with graft loss.

Surgical site infections (SSIs) are common health care-associated infections. SSIs after kidney transplantation (K-Tx) can endanger patient and allograft survival. Multicenter studies on this early posttransplant complication are scarce. We analyzed consecutive adult K-Tx recipients enrolled in the Swiss Transplant Cohort Study who received a K-Tx between May 2008 and September 2020. All data were prospectively collected with the exception of the categorization of SSI which was performed retrospectively according to the Centers for Disease Control and Prevention criteria. A total of 58 out of 3059 (1.9%) K-Tx recipients were affected by SSIs. Deep incisional (15, 25.9%) and organ/space infections (34, 58.6%) predominated. In the majority of SSIs (52, 89.6%), bacteria were detected, most frequently Escherichia coli (15, 28.9%), Enterococcus spp. (14, 26.9%), and coagulase-negative staphylococci (13, 25.0%). A BMI ≥25 kg/m2 (multivariable OR 2.16, 95% CI 1.07-4.34, P = .023) and delayed graft function (multivariable OR 2.88, 95% CI 1.56-5.34, P = .001) were independent risk factors for SSI. In Cox proportional hazard models, SSI was independently associated with graft loss (multivariable HR 3.75, 95% CI 1.35-10.38, P = .011). In conclusion, SSI was a rare complication after K-Tx. BMI ≥25 kg/m2 and delayed graft function were independent risk factors. SSIs were independently associated with graft loss.

The Impact of Age in the Treatment of Non-comorbid Patients with Rectal Cancer: Survival Outcomes from the National Cancer Database.

BACKGROUND: Multimodal therapy has improved survival outcomes for rectal cancer (RC) significantly with an exemption for older patients. We sought to assess whether older non-comorbid patients receive substandard oncological treatment for localized RC referring to the National Comprehensive Cancer Network (NCCN) guidelines and whether it affects survival outcomes. METHODS: This is a retrospective study using patient data from the National Cancer Data Base (NCDB) for histologically confirmed RC from 2002 to 2014. Non-comorbid patients between ≥50 and ≤85 years and defined treatment for localized RC were included and assigned to a younger (<75 years) and an older group (≥75 years). Treatment approaches and their impact on relative survival (RS) were analyzed using loess regression models and compared between both groups. Furthermore, mediation analysis was performed to measure the independent relative effect on age and other variables on RS. Data were assessed using the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) checklist. RESULTS: Of 59,769 included patients, 48,389 (81.0%) were assigned to the younger group (<75 years). Oncologic resection was performed in 79.6% of the younger patients compared to 67.2% of the older patients (p < 0.001). Chemotherapy (74.3% vs. 56.1%) and radiotherapy (72.0% vs. 58.1%) were provided less often in older patients, respectively (p < 0.001). Increasing age was associated with enhanced 30- and 90-day mortality with 0.6% and 1.1% in the younger and 2.0% and 4.1% in the elderly group (p < 0.001) and worse RS rates [multivariable adjusted HR: 1.93 (95% CI 1.87-2.00), p < 0.001]. Adherence to standard oncological therapy resulted in a significant increase in 5-year RS (multivariable adjusted HR: 0.80 (95% CI 0.74-0.86), p < 0.001). Mediation analysis revealed that RS was mainly affected by age itself (84%) rather than the choice of therapy. CONCLUSIONS: The likelihood to receive substandard oncological therapy increases in the older population and negatively affects RS. Since age itself has a major impact on RS, better patient selection should be performed to identify those that are potentially eligible for standard oncological care regardless of their age.

Surgical approach for appendicitis in neutropenia: a case report and review of the literature.

BACKGROUND: Acute appendicitis is a common abdominal pathology, particularly in younger patients presenting with abdominal pain. The clinical presentation is typically characterized by right lower quadrant pain (with local peritonitis) accompanied by fever and nausea. In neutropenic patients it is challenging to diagnose acute appendicitis. It is much more challenging because the characteristic symptoms are different, and diagnosis may be delayed or missed. CASE PRESENTATION: We present the case of a 33-year-old Caucasian male patient with fever, abdominal pain, and an absolute granulocyte count of 0 × 109/L. Abdominal CT demonstrated an uncomplicated acute appendicitis. We initiated a conservative in-hospital treatment with intravenous antibiotic therapy and simultaneous bone marrow stimulation, with close monitoring. On day three, there was evidence of monocyte increase, one of the first signs of bone marrow regeneration, and delayed laparoscopic appendectomy was performed. The perioperative and postoperative course was uneventful. CONCLUSION: We discuss the different treatment strategies in patients with neutropenia presenting with acute appendicitis (i.e., conservative management, delayed appendectomy, and immediate appendectomy) based on our experience and a review of the literature. In summary, delayed laparoscopic appendectomy at the onset of granulocyte regeneration under antibiotic and G-CSF therapy represents a viable surgical option for adults as well as for children and should be discussed compared with conservative therapy.

Caffeine for intestinal transit after laparoscopic colectomy: randomized clinical trial (CaCo trial).

BACKGROUND: Coffee has been suggested to help postoperative gastrointestinal motility but the mechanism is not known. This trial assessed whether caffeine shortened time to bowel activity after laparoscopic colectomy. METHODS: This was a single-centre, randomized, double-blinded, placebo-controlled superiority trial (October 2015 to August 2020). Patients aged at least 18 years undergoing elective laparoscopic colectomy were assigned randomly to receive 100 mg or 200 mg caffeine, or a placebo (250 mg corn starch) three times a day orally. The primary endpoint was the time to first bowel movement. Secondary endpoints included colonic transit time, time to tolerance of solid food, duration of hospital stay, and perioperative morbidity. RESULTS: Sixty patients were assigned randomly to either the 200-mg caffeine group (20 patients), the 100-mg caffeine group (20) or the placebo group (20). In the intention-to-treat analysis, the mean(s.d.) time to first bowel movement was 67.9(19.2) h in the 200-mg caffeine group, 68.2(32.2) h in the 100-mg caffeine group, and 67.3(22.7) h in the placebo group (P = 0.887). The per-protocol analysis and measurement of colonic transit time confirmed no measurable difference with caffeine. CONCLUSION: Caffeine was not associated with reduced time to first bowel movement. REGISTRATION NUMBER: NCT02510911 (http://www.clinicaltrials.gov).

Impact of precoding on reimbursement in diagnosis-related group systems: Randomized controlled trial.

BACKGROUND: Complete and correct documentation of diagnosis and procedures is essential for adequate health provider reimbursement in diagnosis-related group (DRG) systems. The objective of this study was to investigate whether daily monitoring and semiautomated proposal optimization of DRG coding (precoding) is associated with higher reimbursement per hospitalization day. MATERIALS AND METHODS: This parallel-group, unblinded, randomized clinical trial randomized patients 1:1 into intervention (precoding) and control groups. Between June 12 and December 6, 2019 all hospitalized patients (1566 cases) undergoing elective or emergency surgery at the department of surgery in a Swiss hospital were eligible for this study. By random sample selection, cases were assigned to the intervention (precoding) and control groups. The primary outcome was the total reimbursement, divided by the length of stay. RESULTS: Of the 1205 randomized cases, 1200 (precoding group: 602) remained for intention-to-treat, and 1131 (precoding group: 564) for per-protocol analysis. Precoding increased reimbursement per hospitalization day by 6.5% (160 US dollars; 95% confidence interval 31 to 289; P = 0.015). In a regression analysis patients hospitalized 7 days or longer, precoding increased reimbursement per day by 10.0% (246 US dollars; 95% confidence interval -12 to 504; P = 0.021). More secondary diagnoses (mean [SD]: 5.16 [5.60] vs 4.39 [5.34]; 0.77; 95% confidence interval 0.15 to 1.39; P = 0.015) and nonsurgical postoperative complications (mean [SD]: 0.68 [1.45] vs 0.45 [1.12]; 0.23; 95% confidence interval 0.08 to 0.38; P = 0.002) were documented by precoding. No associated was observed regarding the length of stay, total reimbursement, or case mix index. The mean (SD) precoding time effort was 37 (27) minutes per case. CONCLUSION: Physician-led precoding increases DRG-based reimbursement. Precoding is time consuming and should be focused on cases with a longer hospital stay to increase efficiency.

Diagnostic role of the 'white test' with lipidic solution in the early intraoperative identification of open bile ducts for the prevention of bile leakage after liver resection: study protocol for a randomised controlled multicentric superiority trial (BiLe-Trial).

INTRODUCTION: Bile leakage is a frequent complication after liver resection associated with the need of interventional drainage, endoscopic retrograde cholangio pancreatography (ERCP) or reoperation. The intraoperative application of the white test could be a promising strategy to reduce the occurrence of bile leakages. Therefore, we propose to conduct the first multicentric randomised controlled trial with rate of postoperative bile leakage as primary endpoint with and without the white test. METHODS AND ANALYSIS: The Bile-Leakage Trial trial is an investigator-initiated randomised controlled, parallel group, double-blinded, multicentric, superiority trial in four Swiss centres. A total of 210 patients undergoing a resection of at least 2 liver segments will be randomly allocated intraoperatively to either the intervention (identification of open bile ducts with administration of 20-40 mL SMOFlipid5% in the bile tract) or the control group (identification with a white gauze on the liver resection surface).Primary outcome will be the comparison of the postoperative bile leakage rate in both groups within 30 days after liver resection, defined according to the classification of the International Study Group of Liver Surgery. Secondary outcomes will be operative and postoperative complication, including severity grade of the bile leakage, rate of ERCP, interventional drainage, morbidity, intensive care unit stay, and mortality. ETHICS AND DISSEMINATION: The cantonal ethics committees of all participating centres and Swissmedic approved the study. SMOFlipid20% consists of a mixture of oils, no side effects resulting from the intraoperative application of 20-40 mL in the biliary tract with consecutive enteral absorption are expected nor are side effects described in the literature. SMOFlipid20% will be diluted intraoperatively with isotonic saline solution to a concentration of 5%. The results of the BiLe-Trial will be submitted to a peer-reviewed journal regardless of the outcome. As this is an investigator-initiated trial, data are property of the sponsor investigator and can be obtained on request. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov, ID: NCT04523701. Registered on 25 August 2020.Swiss National Clinical Trials Portal (SNCTP), ID: SNCTP000004200. Registered on 20 January 2021. PROTOCOL VERSION: V3.2_14-12-2020_clean.pdf.

[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.

Indeterminate dendritic cell tumor in the pancreas.

Indeterminate dendritic cell tumor (IDCT) is an extremely rare hematologic neoplastic disorder with proliferation of indeterminate dendritic cells. In the vast majority of cases, IDCTs are restricted to the skin or lymph nodes. To our knowledge, we report the first case of IDCT in the pancreas. Due to the rarity of extracutaneous IDCT, guidelines or treatment recommendations addressing their management are missing. We performed a review of literature to compare our experience to the management of other extracutaneous IDCT. Histopathological examination confirms the diagnosis of IDCT in electron microscopy and/or immunohistochemistry. Specific features are the lack of Birbeck granules and the nonreaction to Langerin antibodies. Concerning the aftercare of extracutaneous IDCT, we recommend a dermatological examination to rule out an additional cutaneous manifestation as well as annual blood examinations due to the association between IDCT and hematologic malignancies.

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.

Role of lymphadenectomy, adjuvant chemotherapy, and treatment at high-volume centers in patients with resected pancreatic cancer-a distinct view on lymph node yield.

PURPOSE: While the importance of lymphadenectomy is well-established for patients with resectable pancreatic cancer, its direct impact on survival in relation to other predictive factors is still ill-defined. METHODS: The National Cancer Data Base 2006-2015 was queried for patients with resected pancreatic adenocarcinoma (stage IA-IIB). Patients were dichotomized into the following two groups, those with 1-14 resected lymph nodes and those with ≥ 15. Optimal number of resected lymph nodes and the effect of lymphadenectomy on survival were assessed using various statistical modeling techniques. Mediation analysis was performed to differentiate the direct and indirect effect of lymph node resection on survival. RESULTS: A total of 21,912 patients were included; median age was 66 years (IQR 59-73), 48.9% were female. Median number of resected lymph nodes was 15 (IQR 10-22), 10,163 (46.4%) had 1-14 and 11,749 (53.6%) had ≥ 15 lymph nodes retrieved. Lymph node positivity increased by 4.1% per lymph node up to eight examined lymph nodes, and by 0.6% per lymph node above eight. Five-year overall survival was 17.9%. Overall survival was better in the ≥ 15 lymph node group (adjusted HR 0.91, CI 0.88-0.95, p < 0.001). On a continuous scale, survival improved with increasing LNs collected. Patients who underwent adjuvant chemotherapy and were treated at high-volume centers had improved overall survival compared with their counterparts (adjusted HR 0.59, CI 0.57-0.62, p < 0.001; adjusted HR 0.86, CI 0.83-0.89, p < 0.001, respectively). Mediation analysis revealed that lymphadenectomy had only 18% direct effect on improved overall survival, while 82% of its effect were mediated by other factors like treatment at high-volume hospitals and adjuvant chemotherapy. DISCUSSION: While higher number of resected lymph nodes increases lymph node positivity and is associated with better overall survival, most of the observed survival benefit is mediated by chemotherapy and treatment at high-volume centers.

No Difference in Survival between Neo-Adjuvant Chemotherapy and Neo-Adjuvant Chemoradiation Therapy in Gastric Cardia Cancer Patients: A Contemporary View from the National Cancer Database.

INTRODUCTION: Both neo-adjuvant chemoradiation therapy (NACRT) and neo-adjuvant chemotherapy (NAC), in addition to surgical resection of gastric cardia cancer, improves survival outcomes. We assessed whether NACRT or NAC had superior overall survival (OS) and relative survival (RS) outcomes using the National Cancer Database (NCDB). METHODS: The NCDB from 2006 to 2014 was reviewed to identify non-metastatic adult gastric cardia cancer patients who underwent surgical resection and received NACRT or NAC. Advanced statistical models were applied to assess survival outcomes. RESULTS: Of the 5,371 patients included, 4,520 (84.2%) were male, the mean age was 61.2 years (SD 10.0), 4,229 (78.7%) underwent NACRT, and 1,142 (21.3%) underwent NAC. NACRT patients more often had an R0 resection compared to NAC (91.4 vs. 86.6%, p < 0.001, respectively). Univariate 5-year OS rates were 40.0% (95% CI 38.2-41.8) for NACRT and 40.1% (37.0-43.6) for NAC (p = 0.302). No differences in OS for NAC vs. NACRT were found after multivariable analysis (hazard ratio [HR] 0.95, 95% CI 0.86-1.05, p = 0.290). There were no survival differences after stepwise, propensity score, RS analyses, nor after near-far-matching (HR 0.94, 95% CI 0.82-1.07, p = 0.332). CONCLUSIONS: NAC or NACRT yield the same survival outcome for patients with resectable gastric cardia cancer. These data support the need for randomized controlled trials comparing the 2 regimens head-to-head.

Is There a Role for Surgery in Patients with Neuroendocrine Tumors of the Esophagus? A Contemporary View from the NCDB.

BACKGROUND: Esophageal neuroendocrine tumors (eNETs) are exceedingly rare, aggressive and have a poor prognosis. Treatment guidelines are ill-defined and mainly based on evidence from case reports and analogous experiences drawn from similar disease sites. METHODS: The NCDB was reviewed for histologically confirmed stage I-III, primary eNETs from 2006 to 2014. Patients were grouped into whether or not they underwent primary tumor resection. Univariate, multivariable, and full bipartite propensity score (PS) adjusted Cox regression analyses were used to assess overall and relative survival differences. RESULTS: A total of 250 patients were identified. Mean age was 65.0 (standard deviation [SD] 11.9) years, and 174 (69.6%) patients were male. Most patients had stage III disease (n = 136, 54.4%), and the most common type of NET was small cell eNET (n = 111, 44.4%). Chemotherapy was used in 186 (74.4%), radiation therapy in 178 (71.2%), and oncological resection was performed in 69 (27.6%) patients. Crude 2-year survival rates were higher in the operated (57.3%) compared with the nonoperated group (35.2%; p < 0.001). The survival benefit held true after multivariable adjustment (hazard ratio [HR] 0.47, 95% confidence interval [CI] 0.32-0.69, p < 0.001). After full bipartite PS adjustment analysis, survival was longer for patients who received a surgical resection compared with those who did not (HR 0.48, 95% CI 0.31-0.75, p = 0.003) with a corresponding 2-year overall survival rate of 63.3% (95% CI 52.0-77.2) versus 38.8% (95% CI 30.9-48.8), respectively. CONCLUSIONS: Multimodal treatment that includes surgery is associated with better overall survival for eNETs. Additional research is needed to more definitively identify patients who benefit from esophagectomy and to establish an appropriate treatment algorithm.

Peridural analgesia does not impact survival in patients after colon cancer resection: a retrospective propensity score-adjusted analysis.

PURPOSE: To assess the putative impact of peridural analgesia on oncological outcome in patients undergoing resection of stages I-IV colon cancer. METHODS: In a single-center study, 876 patients undergoing resection for primary colon cancer (AJCC stages I-IV) between 2001 and 2014 were analyzed. Mean follow-up of the entire cohort was 4.2 ± 3.5 years. Patients who did and did not receive peridural analgesia were compared using Cox regression and propensity score analyses. RESULTS: Overall, 208 patients (23.7%) received peridural analgesia. Patients' characteristics were biased with regard to the use of peridural analgesia (propensity score 0.296 ± 0.129 vs. 0.219 ± 0.108, p < 0.001). After propensity score matching, the use of peridural analgesia had no impact on overall (HR 0.81, 95% CI 0.59-1.11, p = 0.175), cancer-specific (HR 0.72, 95% CI 0.48-1.09, p = 0.111), and disease-free survival (HR 0.89, 95% CI 0.66-1.19, p = 0.430). The 5-year overall survival after propensity score matching was 60.9% (95% CI 54.8-67.7%) for patients treated with peridural analgesia compared with 54.1% (95% CI 49.5-59.1%) for patients not treated with peridural analgesia. Cancer-specific and disease-free survival showed similar non-significant results. CONCLUSIONS: Peridural analgesia in patients after colon cancer resection was not associated with a better oncological outcome after risk adjusting in multivariable Cox regression and propensity score analyses. Hence, oncological outcome should not serve as a reason for the use of peridural analgesia in patients with colon cancer.

Urgent surgery in colon cancer has no impact on survival.

BACKGROUND AND OBJECTIVES: Despite advances in early detection of colon cancer, a minority of patients still require urgent surgery. Whether such urgent conditions result in poor outcome remains a topic of debate. METHODS: Using a prospectively maintained database, patients suffering exclusively from colon cancer and receiving either elective or emergent resection between 2001 and 2014 were analyzed with respect to overall, disease-specific, and relative survival using Cox regression and propensity score analyses. RESULTS: From a total of 877 patients analyzed, 2.7% (24) presented with complications requiring urgent surgery. Propensity-scoring identified strongly biased patient characteristics (0.097 ± 0.069 vs 0.028 ± 0.043; P < 0.001). An unadjusted Cox proportional hazards regression analysis revealed urgent surgery as a statistically significant prognostic factor with an approximately 207% increased risk of mortality (hazard ratio [HR] = 3.07; 95% confidence interval [CI]: 1.62-5.81; P = 0.003). After adjusting the data according to the propensity score analysis, urgent surgery was not associated with a decreased overall (HR = 1.67; 95%CI; 0.84-3.36; P = 0.174), disease-specific (HR = 1.62; 95% CI; 0.81-3.24; P = 0.201) or relative survival (HR = 1.86; 95% CI: 0.92-3.79; P = 0.086). CONCLUSIONS: After risk-adjustment, using multivariable Cox regression and propensity score analyses, no significant disadvantage could be noted with regard to overall, disease-specific, or relative survival in patients with exclusively colon cancer who received emergent oncological resection.

Success and Complication Rates After Sacral Neuromodulation for Fecal Incontinence and Constipation: A Single-center Follow-up Study.

BACKGROUND/AIMS: The aim of this study was to evaluate the sustainability of sacral neuromodulation (SNM) success in patients with fecal incontinence (FI) and/or constipation. METHODS: This is a retrospective analysis of a prospective database of patients who received SNM therapy for FI and/or constipation between 2006 and 2015. Success rates, complications and reintervention rates were assessed after up to 10 years of follow-up. RESULTS: Electrodes for test stimulation were implanted in 101 patients, of whom 79 (78.2%) received permanent stimulation. The mean follow-up was 4.4 ± 3.0 years. At the end of follow-up, 57 patients (72.2%) were still receiving SNM. The 5-year success rate for FI and isolated constipation was 88.2% (95% confidence interval [CI], 80.1-97.0%) and 31.2% (95% CI, 10.2-95.5%), respectively (P ＜ 0.001). In patients with FI, involuntary evacuations per week decreased ＞ 50% in 76.1% of patients (95% CI, 67.6-86.2%) after 5 years. A lead position at S3 was associated with an improved outcome (P = 0.04). Battery exchange was necessary in 23 patients (29.1%), with a median battery life of 6.2 years. Reinterventions due to complications were necessary in 24 patients (30.4%). For these patients, the 5-year success rate was 89.0% (95% CI, 75.3-100.0%) compared to 78.4% (95% CI, 67.2-91.4%) for patients without reintervention. CONCLUSIONS: SNM offers an effective sustainable treatment for FI. For constipation, lasting success of SNM is limited and is thus not recommended. Reinterventions are necessary but do not impede treatment success.

The prognostic value of signet ring cell histology in stage I/II colon cancer-a population-based, propensity score-matched analysis.

BACKGROUND: Previous research associated signet ring cell histology in colon cancer patients with poor survival outcomes. The aim of this study was to analyze the prognostic significance of signet ring cell histology on overall and cancer-specific survival in patients with localized colon cancer. METHODS: Stage I and II colon cancer patients treated with surgical resection between 2004 and 2015 were identified in the Surveillance, Epidemiology, and End Results (SEER) database. Overall survival (OS) and cancer-specific survival (CSS) were assessed using risk-adjusted Cox proportional hazards regression models and propensity score methods. RESULTS: Eighty-eight thousand nine hundred fifty-eight stage I-II colon cancer patients were identified. Overall, 446 (0.5%) showed signet ring cell histology. In unadjusted analyses, the 5-year OS and CSS rates of patients with signet ring cell histology were 65.8 and 83.1%, respectively, compared with 74.3 and 88.7% in patients with non-signet ring cell adenocarcinoma (p values: OS, p < 0.001; CSS, p < 0.001). Neither in risk-adjusted Cox proportional hazard regression analysis (OS: hazard ratio (HR), 0.96 (95% CI, 0.82-1.12%) p = 0.616; CSS: HR, 1.01 (95% CI, 0.79-1.28%) p = 0.946) nor with propensity score matching (OS: HR, 0.96 (95% CI, 0.82-1.14%) p = 0.669 and CSS: HR: 1.09 (95% CI: 0.84-1.40%) p = 0.529), a survival disadvantage was found for signet ring cell histology. CONCLUSION: This is the first propensity score-adjusted population-based investigation on exclusively stage I and II colon cancer patients providing compelling evidence that signet ring cell histology does not negatively impact survival in stage I and II colon cancer after risk-adjusting for known prognostic factors. Therefore, standard treatment strategies can be applied in these patients.

High rate of positive lymph nodes in T1a gallbladder cancer does not translate to decreased survival: a population-based, propensity score adjusted analysis.

BACKGROUND: Current consensus guidelines suggest that gallbladder cancer (GBC) patients with resected T1a disease can be observed while patients with T1b or greater lesions should undergo lymphadenectomy (LNE). The primary aim of this study was to critically explore the impact of LNE in early-stage GBC on overall survival (OS) on a population-based level. METHOD: The 2004-2014 National Cancer Database was reviewed to identify non-metastatic GBC patients with T1a, T1b, or T2 disease and grouped whether a dedicated LNE was performed. OS and relative survival were assessed using Cox proportional hazard regression analyses before and after propensity score adjustments. RESULTS: 4015 patients were included, 246 (6%) had T1a, 654 (16%) T1b, and 3115 (78%) T2 GBC. The rate of positive lymph nodes was 13%, 12%, and 40% for T1a, T1b, and T2 tumors, respectively. Even after propensity score adjustment, no OS benefit was found if LNE was performed for T1a disease (HR:0.63, 95%CI:0.35-1.13) while OS was improved for T1b (HR:0.65, 95%CI:0.49-0.87) and T2 tumors (HR:0.65, 95%CI:0.57-0.73). CONCLUSION: Despite a higher rate of nodal positivity among patients with T1a disease compared to previous reports, there was no impact on survival and current treatment guidelines appear appropriate for the management of T1a disease.

Prognostic impact of anastomotic leakage after elective colon resection for cancer - A propensity score matched analysis of 628 patients.

BACKGROUND: There is limited information regarding the impact of anastomotic leakage on oncologic outcome in exclusively colon cancer patients. METHODS: The colorectal database of the Department of Surgery of the University of Heidelberg was used to assess the impact of anastomotic leakage on oncologic outcome in patients undergoing curative resection for Stage I-III colon cancer. Risk-adjusted Cox regression analysis and propensity score methods were used to assess overall, disease-free, and relative survival. RESULTS: 628 patients of which 26 (4.1%) experienced anastomotic leakage were analysed. Anastomotic leakage was associated with significantly worse overall, disease-free and relative survival in univariate and multivariate analysis. The analysis after exact propensity score matching confirmed the negative impact of anastomotic leakage on overall (HR 2.62, 95% CI 1.33-5.18, p = .011), disease-free (HR 2.28, 95% CI 1.16-4.47, p = .027) and relative survival (HR 3.70, 95% CI 1.82-7.52, p < .001). 5-year overall survival was 51.6% (95% CI 34.5-77.2%) for patients with anastomotic leakage compared to 77.7% (95% CI 73.0-82.8%) for patients without anastomotic leakage. CONCLUSIONS: All conceivable efforts should be made to avoid anastomotic leakage after colon resection for cancer not only to evade short-term consequences but also to allow for adequate long-term outcome.