Introduction: Carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 are widely used for treating various cancers, with cutoff values of 5.0 ng/mL and 37.0 IU/mL, respectively. However, these cutoff values are not for specific diseases or purposes but are uniformly used for any disease and any purpose. It is also unclear as to whether patients are at equal risk of recurrence if they are below the cutoff values. This study aimed to investigate the optimal cutoff of serum tumor markers in the stratification of recurrence risk after curative resection of gastric cancer.
Methods: We constructed a nine-center integrated database of patients who received gastrectomy between January 2010 and December 2014 with a 5-year follow-up period. We determined the cutoff value of preoperative serum tumor marker levels correlated with postoperative recurrences and evaluated its performance in risk stratification for recurrences in 948 patients with stage II/III gastric cancer who underwent radical resection.
Results: The hazard ratio for postoperative recurrences increased at two points of preoperative CEA levels, 3.6 ng/mL and 5.0 ng/mL, which were set as cutoffs. These two cutoffs stratified relapse-free survival into three levels.
Conclusions: By adding a second cutoff value for preoperative serum CEA, which was proposed specifically for the prediction of recurrences, patients can be stratified into low-, intermediate-, and high-risk recurrences after curative resection of gastric cancer.
{"title":"Proposal of the Second Cutoff of Serum Carcinoembryonic Antigen Levels to Stratify Patients into Low, Intermediate, and High Risks at Recurrences after Curative Resection of Gastric Cancer.","authors":"Bin Sato, Mitsuro Kanda, Seiji Ito, Yoshinari Mochizuki, Hitoshi Teramoto, Kiyoshi Ishigure, Toshifumi Murai, Takahiro Asada, Akiharu Ishiyama, Hidenobu Matsushita, Koki Nakanishi, Dai Shimizu, Chie Tanaka, Michitaka Fujiwara, Kenta Murotani, Yasuhiro Kodera","doi":"10.1159/000533143","DOIUrl":"10.1159/000533143","url":null,"abstract":"<p><strong>Introduction: </strong>Carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 are widely used for treating various cancers, with cutoff values of 5.0 ng/mL and 37.0 IU/mL, respectively. However, these cutoff values are not for specific diseases or purposes but are uniformly used for any disease and any purpose. It is also unclear as to whether patients are at equal risk of recurrence if they are below the cutoff values. This study aimed to investigate the optimal cutoff of serum tumor markers in the stratification of recurrence risk after curative resection of gastric cancer.</p><p><strong>Methods: </strong>We constructed a nine-center integrated database of patients who received gastrectomy between January 2010 and December 2014 with a 5-year follow-up period. We determined the cutoff value of preoperative serum tumor marker levels correlated with postoperative recurrences and evaluated its performance in risk stratification for recurrences in 948 patients with stage II/III gastric cancer who underwent radical resection.</p><p><strong>Results: </strong>The hazard ratio for postoperative recurrences increased at two points of preoperative CEA levels, 3.6 ng/mL and 5.0 ng/mL, which were set as cutoffs. These two cutoffs stratified relapse-free survival into three levels.</p><p><strong>Conclusions: </strong>By adding a second cutoff value for preoperative serum CEA, which was proposed specifically for the prediction of recurrences, patients can be stratified into low-, intermediate-, and high-risk recurrences after curative resection of gastric cancer.</p>","PeriodicalId":11241,"journal":{"name":"Digestive Surgery","volume":null,"pages":null},"PeriodicalIF":2.7,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10224137","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
We report a case of pathologic complete response after successful treatment for advanced hepatocellular carcinoma (HCC) complicated with portal venous tumor thrombus with atezolizumab and bevacizumab followed by radical resection. The patient was a male in his 60s. During follow-up for chronic hepatitis B, abdominal ultrasonography revealed a huge tumor located in the right lobe of the liver with the portal vein thrombosed by the tumor. The tumor thrombus extended to the proximal side of the left branch of the portal vein. The patient's tumor marker levels were elevated (alpha-phetoprotein, 14,696 ng/mL; PIVKA-II, 2,141 mAU/mL). Liver biopsy revealed poorly differentiated HCC. The lesion was categorized as advanced stage according to the BCLC staging system. As systemic therapy, atezolizumab plus bevacizumab was administered. Imaging showed marked shrinkage of the tumor and portal venous thrombus with a remarkable decrease of tumor marker levels after 2 courses of chemotherapy. After 3 additional courses of chemotherapy, radical resection was considered possible. The patient underwent right hemihepatectomy and portal venous thrombectomy. A pathological examination revealed a complete response. In conclusion, we experienced a case in which advanced HCC was curatively treated with atezolizumab plus bevacizumab, which was administered as systemic therapy with a view to conversion surgery.
{"title":"Pathologic Complete Response after Chemotherapy with Atezolizumab plus Bevacizumab for Hepatocellular Carcinoma with Tumor Thrombus in the Main Portal Trunk.","authors":"Ken Kurisaki, Akihiko Soyama, Takanobu Hara, Hajime Matsushima, Hajime Imamura, Takayuki Tanaka, Tomohiko Adachi, Shinichiro Ito, Kengo Kanetaka, Masaaki Hidaka, Shinji Okano, Susumu Eguchi","doi":"10.1159/000529405","DOIUrl":"https://doi.org/10.1159/000529405","url":null,"abstract":"<p><p>We report a case of pathologic complete response after successful treatment for advanced hepatocellular carcinoma (HCC) complicated with portal venous tumor thrombus with atezolizumab and bevacizumab followed by radical resection. The patient was a male in his 60s. During follow-up for chronic hepatitis B, abdominal ultrasonography revealed a huge tumor located in the right lobe of the liver with the portal vein thrombosed by the tumor. The tumor thrombus extended to the proximal side of the left branch of the portal vein. The patient's tumor marker levels were elevated (alpha-phetoprotein, 14,696 ng/mL; PIVKA-II, 2,141 mAU/mL). Liver biopsy revealed poorly differentiated HCC. The lesion was categorized as advanced stage according to the BCLC staging system. As systemic therapy, atezolizumab plus bevacizumab was administered. Imaging showed marked shrinkage of the tumor and portal venous thrombus with a remarkable decrease of tumor marker levels after 2 courses of chemotherapy. After 3 additional courses of chemotherapy, radical resection was considered possible. The patient underwent right hemihepatectomy and portal venous thrombectomy. A pathological examination revealed a complete response. In conclusion, we experienced a case in which advanced HCC was curatively treated with atezolizumab plus bevacizumab, which was administered as systemic therapy with a view to conversion surgery.</p>","PeriodicalId":11241,"journal":{"name":"Digestive Surgery","volume":null,"pages":null},"PeriodicalIF":2.7,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9829306","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Simone Giacopuzzi, Lorena Torroni, Maria Bencivenga, Jacopo Weindelmayer, Maria Clelia Gervasi, Giuseppe Verlato, Michele Pavarana, Gabriella Rossi, Giovanni de Manzoni
Introduction: RCTs support neoadjuvant chemoradiotherapy (nCRT) followed by surgery in locally advanced esophago-gastric junction (LA-EGJ) adenocarcinoma. However, RCTs are performed in highly controlled settings with limited representativeness of real-life patients (RLS). The aim of the study was to compare the outcomes in RLS and clinical trial settings.
Methods: The outcomes of RLS, which comprised 125 patients consequently treated for LA-EGJ adenocarcinoma between 2012 and 2017, were compared with the phase II trial (PIIS), performed on 65 patients from 2003 to 2011.
Results: About half of RLS (51.2%) were treated with nCRT according to VR protocol, 20.8% with standard CRT according to CROSS/Al-Sarraf, 20% with chemotherapy (CT) alone. pCR was 36.8%, 28.6%, and 9.1% after VR protocol, standard CRT, and CT, respectively (p = 0.082), while 3-year overall survival (OS) was 58.6% (95% CI 43.2-71.1%), 32.8% (14.6-52.4%), and 44.8% (21.3-65.9%), respectively (p = 0.030). With respect to PIIS, RLS had a higher proportion of cN+ (94% vs. 54%; p < 0.001) and a lower proportion of pCR after CT/CRT (23% vs. 39%; p = 0.041). Three-year OS was slightly higher, although not significantly, in PIIS (58.9%, 45.1-70.2%) than RLS (47.9%, 37.4-57.7%) and nearly identical to 3-year OS in RLS treated with VR protocol.
Conclusion: Real-life patients with EGJ adenocarcinoma have more advanced cancer at baseline, lower pathologic response to neoadjuvant treatment than patients enrolled in clinical trials, but similar survival.
简介:随机对照试验支持局部晚期食管胃结(LA-EGJ)腺癌的新辅助放化疗(nCRT)后手术治疗。然而,随机对照试验是在高度控制的环境中进行的,对现实患者(RLS)的代表性有限。该研究的目的是比较RLS和临床试验环境的结果。方法:将2012年至2017年期间接受LA-EGJ腺癌治疗的125例RLS患者的结果与2003年至2011年进行的65例II期试验(PIIS)患者的结果进行比较。结果:约一半(51.2%)的RLS患者采用VR方案的nCRT治疗,20.8%的RLS患者采用CROSS/Al-Sarraf标准CRT治疗,20%的RLS患者采用单独化疗(CT)治疗。VR方案、标准CRT和CT后的pCR分别为36.8%、28.6%和9.1% (p = 0.082), 3年总生存率(OS)分别为58.6% (95% CI 43.2-71.1%)、32.8%(14.6-52.4%)和44.8% (21.3-65.9%)(p = 0.030)。相对于PIIS, RLS中cN+的比例更高(94% vs. 54%;p < 0.001), CT/CRT后pCR比例较低(23% vs. 39%;P = 0.041)。PIIS的3年OS(58.9%, 45.1-70.2%)略高于RLS(47.9%, 37.4-57.7%),但不显著,与VR方案治疗的RLS的3年OS几乎相同。结论:与临床试验患者相比,现实生活中的EGJ腺癌患者在基线时更晚期,对新辅助治疗的病理反应更低,但生存期相似。
{"title":"Treatment of EGJ Cancer within or outside Clinical Trials: Does the Setting Matter? A Monocentric Prospective Observational Study.","authors":"Simone Giacopuzzi, Lorena Torroni, Maria Bencivenga, Jacopo Weindelmayer, Maria Clelia Gervasi, Giuseppe Verlato, Michele Pavarana, Gabriella Rossi, Giovanni de Manzoni","doi":"10.1159/000529199","DOIUrl":"https://doi.org/10.1159/000529199","url":null,"abstract":"<p><strong>Introduction: </strong>RCTs support neoadjuvant chemoradiotherapy (nCRT) followed by surgery in locally advanced esophago-gastric junction (LA-EGJ) adenocarcinoma. However, RCTs are performed in highly controlled settings with limited representativeness of real-life patients (RLS). The aim of the study was to compare the outcomes in RLS and clinical trial settings.</p><p><strong>Methods: </strong>The outcomes of RLS, which comprised 125 patients consequently treated for LA-EGJ adenocarcinoma between 2012 and 2017, were compared with the phase II trial (PIIS), performed on 65 patients from 2003 to 2011.</p><p><strong>Results: </strong>About half of RLS (51.2%) were treated with nCRT according to VR protocol, 20.8% with standard CRT according to CROSS/Al-Sarraf, 20% with chemotherapy (CT) alone. pCR was 36.8%, 28.6%, and 9.1% after VR protocol, standard CRT, and CT, respectively (p = 0.082), while 3-year overall survival (OS) was 58.6% (95% CI 43.2-71.1%), 32.8% (14.6-52.4%), and 44.8% (21.3-65.9%), respectively (p = 0.030). With respect to PIIS, RLS had a higher proportion of cN+ (94% vs. 54%; p < 0.001) and a lower proportion of pCR after CT/CRT (23% vs. 39%; p = 0.041). Three-year OS was slightly higher, although not significantly, in PIIS (58.9%, 45.1-70.2%) than RLS (47.9%, 37.4-57.7%) and nearly identical to 3-year OS in RLS treated with VR protocol.</p><p><strong>Conclusion: </strong>Real-life patients with EGJ adenocarcinoma have more advanced cancer at baseline, lower pathologic response to neoadjuvant treatment than patients enrolled in clinical trials, but similar survival.</p>","PeriodicalId":11241,"journal":{"name":"Digestive Surgery","volume":null,"pages":null},"PeriodicalIF":2.7,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9819886","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Brenda Monaghan, Ann Monaghan, Qurat Ul Ain, Sinead N Duggan, Kevin C Conlon, John Gormley
Introduction: The beneficial effects of exercise and physical activity (PA) have been demonstrated in many chronic inflammatory diseases. Knowledge on PA levels is unknown in the chronic pancreatitis population, and there are currently no specific PA recommendations for this condition.
Methods: PA was measured objectively over a 7-day period in 17 individuals with chronic pancreatitis using an accelerometer (ActiGraph) and in 15 controls, matched for age, sex, and body mass index.
Results: Participants with chronic pancreatitis spent a significantly lower amount of time in moderate, light, and moderate/vigorous activity compared to the healthy control group. Mean time in light activity in the chronic pancreatitis group was 825.4 ± 972 (standard deviation [SD]) compared to 1,500 ± 958 (SD) in the healthy control group. Moderate activity mean minutes were 61.6 ± 85 in the chronic pancreatitis group compared to 161.4 ± 131.2 in the healthy control group. Moderate/vigorous mean minutes were 62.1 ± 86 (SD) in the chronic pancreatitis group compared to 164.3 ± 132 (SD) in the healthy control group. There was no significant difference found between the groups for either vigorous activity or time spent sedentary.
Conclusion: This exploratory study offers early objective evidence that activity levels in the chronic pancreatic group are not meeting current international recommendations. Further investigation of this chronic illness population is strongly recommended.
{"title":"Significantly Lower Physical Activity Participation in Individuals with Chronic Pancreatitis Compared to Controls: An Exploratory Study of Objectively Assessed Physical Activity Levels.","authors":"Brenda Monaghan, Ann Monaghan, Qurat Ul Ain, Sinead N Duggan, Kevin C Conlon, John Gormley","doi":"10.1159/000530543","DOIUrl":"https://doi.org/10.1159/000530543","url":null,"abstract":"<p><strong>Introduction: </strong>The beneficial effects of exercise and physical activity (PA) have been demonstrated in many chronic inflammatory diseases. Knowledge on PA levels is unknown in the chronic pancreatitis population, and there are currently no specific PA recommendations for this condition.</p><p><strong>Methods: </strong>PA was measured objectively over a 7-day period in 17 individuals with chronic pancreatitis using an accelerometer (ActiGraph) and in 15 controls, matched for age, sex, and body mass index.</p><p><strong>Results: </strong>Participants with chronic pancreatitis spent a significantly lower amount of time in moderate, light, and moderate/vigorous activity compared to the healthy control group. Mean time in light activity in the chronic pancreatitis group was 825.4 ± 972 (standard deviation [SD]) compared to 1,500 ± 958 (SD) in the healthy control group. Moderate activity mean minutes were 61.6 ± 85 in the chronic pancreatitis group compared to 161.4 ± 131.2 in the healthy control group. Moderate/vigorous mean minutes were 62.1 ± 86 (SD) in the chronic pancreatitis group compared to 164.3 ± 132 (SD) in the healthy control group. There was no significant difference found between the groups for either vigorous activity or time spent sedentary.</p><p><strong>Conclusion: </strong>This exploratory study offers early objective evidence that activity levels in the chronic pancreatic group are not meeting current international recommendations. Further investigation of this chronic illness population is strongly recommended.</p>","PeriodicalId":11241,"journal":{"name":"Digestive Surgery","volume":null,"pages":null},"PeriodicalIF":2.7,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9832617","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-01-01Epub Date: 2023-07-26DOI: 10.1159/000533186
Cassandra Mohr, Hailie Ciomperlik, Naila Dhanani, Oscar A Olavarria, Craig Hannon, William Hope, Scott Roth, Mike K Liang, Julie L Holihan
Introduction: Hiatal hernia repair is associated with substantial recurrence of both hiatal hernia and symptoms of gastroesophageal reflux (GER). While small randomized controlled trials demonstrate limited differences in outcomes with use of mesh or fundoplication type, uncertainty remains.
Methods: A multicenter, retrospective review of patients undergoing surgical treatment of hiatal hernias between 2015 and 2020 was performed. Patients with mesh and with suture-only repair were compared, and partial versus complete fundoplication was compared. Primary outcomes were hernia recurrence and occurrence of postoperative GER symptoms and dysphagia. Multivariable regression was performed to assess the effect of each intervention on clinical outcomes.
Results: A total of 453 patients from four sites were followed for a median (IQR) of 17 (13) months. On multivariate analysis, mesh had no impact on hernia recurrence (odds ratio 0.993, 95% CI: 0.53-1.87, p = 0.982), and fundoplication type did not impact recurrence of postoperative GER symptoms (complete: odds ratio 0.607, 95% CI: 0.33-1.12, p = 0.112) or dysphagia (complete: odds ratio 1.17, 95% CI: 0.56-2.43, p = 0.677).
Conclusion: During hiatal hernia repair, mesh and fundoplication type do not appear to have substantial impact on GER symptoms, dysphagia, or hernia recurrence. This multicenter study provides real-world evidence to support the findings of small RCTs.
{"title":"The Role of Biologic Mesh and Fundoplication in the Surgical Management of Hiatal Hernias: A Multicenter Evaluation.","authors":"Cassandra Mohr, Hailie Ciomperlik, Naila Dhanani, Oscar A Olavarria, Craig Hannon, William Hope, Scott Roth, Mike K Liang, Julie L Holihan","doi":"10.1159/000533186","DOIUrl":"10.1159/000533186","url":null,"abstract":"<p><strong>Introduction: </strong>Hiatal hernia repair is associated with substantial recurrence of both hiatal hernia and symptoms of gastroesophageal reflux (GER). While small randomized controlled trials demonstrate limited differences in outcomes with use of mesh or fundoplication type, uncertainty remains.</p><p><strong>Methods: </strong>A multicenter, retrospective review of patients undergoing surgical treatment of hiatal hernias between 2015 and 2020 was performed. Patients with mesh and with suture-only repair were compared, and partial versus complete fundoplication was compared. Primary outcomes were hernia recurrence and occurrence of postoperative GER symptoms and dysphagia. Multivariable regression was performed to assess the effect of each intervention on clinical outcomes.</p><p><strong>Results: </strong>A total of 453 patients from four sites were followed for a median (IQR) of 17 (13) months. On multivariate analysis, mesh had no impact on hernia recurrence (odds ratio 0.993, 95% CI: 0.53-1.87, p = 0.982), and fundoplication type did not impact recurrence of postoperative GER symptoms (complete: odds ratio 0.607, 95% CI: 0.33-1.12, p = 0.112) or dysphagia (complete: odds ratio 1.17, 95% CI: 0.56-2.43, p = 0.677).</p><p><strong>Conclusion: </strong>During hiatal hernia repair, mesh and fundoplication type do not appear to have substantial impact on GER symptoms, dysphagia, or hernia recurrence. This multicenter study provides real-world evidence to support the findings of small RCTs.</p>","PeriodicalId":11241,"journal":{"name":"Digestive Surgery","volume":null,"pages":null},"PeriodicalIF":1.8,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10013964","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-01-01Epub Date: 2023-09-25DOI: 10.1159/000533794
Amitai Bickel, Ron Lagrissi, Jacqueline Jerushalmi, Wisam Sbeit, Michael Weiss, Moshe Shiller, Samer Ganam, Eli Kakiashvili
Introduction: Currently, the rate of bile duct injury and leak following laparoscopic cholecystectomy (LC) is still higher than for open surgery. Diverse investigative algorithms were suggested for bile leak, shifting from hepatobiliary scintigraphy (HBS) toward invasive and more sophisticated means. We aimed to analyze the use of biliary scan as the initial modality to investigate significant bile leak in the drain following LC, attempting to avoid potential unnecessary invasive means when the scan demonstrate fair passage of nuclear substance to the intestine, without leak.
Methods: We have conducted a prospective non-randomized study, mandating hepatobiliary scintigraphy first, for asymptomatic patients harboring drain in the gallbladder fossa, leaking more than 50 mL/day following LC. Analysis was done based on medical data from the surgical, gastroenterology, and the nuclear medicine departments.
Results: Among 3,124 patients undergoing LC, significant bile leak in the drain was seen in 67 subjects, of whom we started with HBS in 50 patients, presenting our study group. In 27 of whom, biliary scan was the only investigative modality, showing fair passage of the nuclear isotope to the duodenum and absence of leak in the majority. The leak stopped spontaneously within a mean of 3.6 days, and convalescence as well as outpatient clinic follow-up was uneventful. In 23 patients, biliary scan that was interpreted as abnormal was followed by endoscopic retrograde cholangio-pancreatography (ERCP). However, ERCP did not demonstrate any bile leak in 13 subjects. In 17 patients, ERCP was used initially, without biliary scan, suggesting the possibility of avoiding invasive modalities in 7 patients.
Conclusions: Based on a negative predictive value of 91%, we suggest that in cases of asymptomatic significant bile leak through a drain following LC, a normal HBS as the initial modality can safely decrease the rate of using invasive modalities.
{"title":"The Role of Hepatobiliary Scintigraphy as the Initial Investigative Modality for Significant Bile Leak following Laparoscopic Cholecystectomy.","authors":"Amitai Bickel, Ron Lagrissi, Jacqueline Jerushalmi, Wisam Sbeit, Michael Weiss, Moshe Shiller, Samer Ganam, Eli Kakiashvili","doi":"10.1159/000533794","DOIUrl":"10.1159/000533794","url":null,"abstract":"<p><strong>Introduction: </strong>Currently, the rate of bile duct injury and leak following laparoscopic cholecystectomy (LC) is still higher than for open surgery. Diverse investigative algorithms were suggested for bile leak, shifting from hepatobiliary scintigraphy (HBS) toward invasive and more sophisticated means. We aimed to analyze the use of biliary scan as the initial modality to investigate significant bile leak in the drain following LC, attempting to avoid potential unnecessary invasive means when the scan demonstrate fair passage of nuclear substance to the intestine, without leak.</p><p><strong>Methods: </strong>We have conducted a prospective non-randomized study, mandating hepatobiliary scintigraphy first, for asymptomatic patients harboring drain in the gallbladder fossa, leaking more than 50 mL/day following LC. Analysis was done based on medical data from the surgical, gastroenterology, and the nuclear medicine departments.</p><p><strong>Results: </strong>Among 3,124 patients undergoing LC, significant bile leak in the drain was seen in 67 subjects, of whom we started with HBS in 50 patients, presenting our study group. In 27 of whom, biliary scan was the only investigative modality, showing fair passage of the nuclear isotope to the duodenum and absence of leak in the majority. The leak stopped spontaneously within a mean of 3.6 days, and convalescence as well as outpatient clinic follow-up was uneventful. In 23 patients, biliary scan that was interpreted as abnormal was followed by endoscopic retrograde cholangio-pancreatography (ERCP). However, ERCP did not demonstrate any bile leak in 13 subjects. In 17 patients, ERCP was used initially, without biliary scan, suggesting the possibility of avoiding invasive modalities in 7 patients.</p><p><strong>Conclusions: </strong>Based on a negative predictive value of 91%, we suggest that in cases of asymptomatic significant bile leak through a drain following LC, a normal HBS as the initial modality can safely decrease the rate of using invasive modalities.</p>","PeriodicalId":11241,"journal":{"name":"Digestive Surgery","volume":null,"pages":null},"PeriodicalIF":2.7,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41119121","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Matteo De Pastena, Elisa Bannone, Elena Andreotti, Chiara Filippini, Marco Ramera, Alessandro Esposito, Roberto Salvia
Robot-assisted pancreatoduodenectomy (R-PD) may provide challenges but potential benefits for pancreatic-enteric anastomosis fashioning. Despite numerous trials comparing different pancreatic-enteric anastomosis techniques, an ideal method is still missing. This study aims to describe different management strategies and surgical techniques of standardized pancreatic-enteric anastomoses during an R-PD. This study reported the robotic technical steps of the modified end-to-side Blumgart pancreaticojejunostomy, the Cattel-Warren duct-to-mucosa pancreatojejunostomy, with internal or external pancreatic duct stent, and the modified end-to-side, double-layer pancreogastrostomy. A dual-console da Vinci Xi Surgical System® (Intuitive Surgical Xi, Sunnyvale, CA) was used to perform all the R-PD. Different robotic pancreatic-enteric anastomosis techniques can be used during the reconstruction phase, possibly reproducing the open technique. The type of anastomosis and applied mitigation strategies should balance surgical strategy adaptability and operative technique standardization. R-PD should be performed in high-volume centers by surgeons with extensive experience in pancreatic and advanced MI surgery, enabling different but standardized anastomotic techniques based on patients' risk factors and intraoperative findings. Future studies on robotic pancreatic anastomosis should focus on personalized approaches after adequate risk stratification.
{"title":"Pancreatic Anastomosis in Robotic-Assisted Pancreaticoduodenectomy: Different Surgical Techniques.","authors":"Matteo De Pastena, Elisa Bannone, Elena Andreotti, Chiara Filippini, Marco Ramera, Alessandro Esposito, Roberto Salvia","doi":"10.1159/000528646","DOIUrl":"https://doi.org/10.1159/000528646","url":null,"abstract":"<p><p>Robot-assisted pancreatoduodenectomy (R-PD) may provide challenges but potential benefits for pancreatic-enteric anastomosis fashioning. Despite numerous trials comparing different pancreatic-enteric anastomosis techniques, an ideal method is still missing. This study aims to describe different management strategies and surgical techniques of standardized pancreatic-enteric anastomoses during an R-PD. This study reported the robotic technical steps of the modified end-to-side Blumgart pancreaticojejunostomy, the Cattel-Warren duct-to-mucosa pancreatojejunostomy, with internal or external pancreatic duct stent, and the modified end-to-side, double-layer pancreogastrostomy. A dual-console da Vinci Xi Surgical System® (Intuitive Surgical Xi, Sunnyvale, CA) was used to perform all the R-PD. Different robotic pancreatic-enteric anastomosis techniques can be used during the reconstruction phase, possibly reproducing the open technique. The type of anastomosis and applied mitigation strategies should balance surgical strategy adaptability and operative technique standardization. R-PD should be performed in high-volume centers by surgeons with extensive experience in pancreatic and advanced MI surgery, enabling different but standardized anastomotic techniques based on patients' risk factors and intraoperative findings. Future studies on robotic pancreatic anastomosis should focus on personalized approaches after adequate risk stratification.</p>","PeriodicalId":11241,"journal":{"name":"Digestive Surgery","volume":null,"pages":null},"PeriodicalIF":2.7,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9832161","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Jacopo Weindelmayer, Valentina Mengardo, Lorena Torroni, Maria Clelia Gervasi, Selma Hetoja, Carlo Alberto De Pasqual, Davide Simion, Simone Giacopuzzi
Introduction: While enhanced recovery after surgery (ERAS) protocol demonstrated to improve outcomes after gastrectomy, some papers evidenced a detrimental effect on postoperative morbidity related to the "weekday effect." We aimed to understand whether the day of gastrectomy could affect postoperative outcomes and compliance with ERAS items.
Methods: We included all patients that underwent gastrectomy for cancer between January 2017 and September 2021. Cohort was divided considering the day of surgery: Early group (Monday-Wednesday) and Late group (Thursday-Friday). Compliance with protocol and postoperative outcomes were compared.
Results: Two hundred twenty-seven patients were included in Early group, while 154 were in Late group. The groups were comparable in preoperative characteristics. No significant difference in pre/intraoperative and postoperative ERAS items' compliance was apparent between Early and Late groups, with most items exceeding the 70% threshold. Median length of stay was 6.5 days and 6 days in Early and Late groups (p = 0.616), respectively. Morbidity was 50% in both groups, with severe complications that occurred in 13% of Early patients and 15% of Late patients. Ninety-day mortality was 2%, and it was similar between the two groups.
Conclusions: In a center with a standardized ERAS protocol, the weekday of gastrectomy has no significant impact on the success of each ERAS item and on postoperative surgical and oncological outcomes.
导论:虽然ERAS方案被证明可以改善胃切除术后的预后,但一些论文证明了与“工作日效应”相关的对术后发病率的不利影响。我们的目的是了解胃切除术的日期是否会影响术后结果和ERAS项目的依从性。方法:我们纳入了2017年1月至2021年9月期间因癌症接受胃切除术的所有患者。根据手术日期将队列分为早组(周一-周三)和晚组(周四-周五)。比较方案依从性和术后结果。结果:早期组227例,晚期组154例。两组术前特征具有可比性。早期组和晚期组术前/术中及术后ERAS项目的依从性无明显差异,多数项目超过70%阈值。早期组和晚期组的中位住院时间分别为6.5 d和6 d (p = 0.616)。两组的发病率均为50%,早期和晚期患者中分别有13%和15%出现严重并发症。90天死亡率为2%,两组之间相似。结论:在采用标准化ERAS方案的中心,胃切除术的工作日对ERAS各项目的成功及术后手术和肿瘤预后无显著影响。
{"title":"The \"Weekday Effect\" on Enhanced Recovery after Surgery Protocol for Gastrectomy.","authors":"Jacopo Weindelmayer, Valentina Mengardo, Lorena Torroni, Maria Clelia Gervasi, Selma Hetoja, Carlo Alberto De Pasqual, Davide Simion, Simone Giacopuzzi","doi":"10.1159/000531022","DOIUrl":"https://doi.org/10.1159/000531022","url":null,"abstract":"<p><strong>Introduction: </strong>While enhanced recovery after surgery (ERAS) protocol demonstrated to improve outcomes after gastrectomy, some papers evidenced a detrimental effect on postoperative morbidity related to the \"weekday effect.\" We aimed to understand whether the day of gastrectomy could affect postoperative outcomes and compliance with ERAS items.</p><p><strong>Methods: </strong>We included all patients that underwent gastrectomy for cancer between January 2017 and September 2021. Cohort was divided considering the day of surgery: Early group (Monday-Wednesday) and Late group (Thursday-Friday). Compliance with protocol and postoperative outcomes were compared.</p><p><strong>Results: </strong>Two hundred twenty-seven patients were included in Early group, while 154 were in Late group. The groups were comparable in preoperative characteristics. No significant difference in pre/intraoperative and postoperative ERAS items' compliance was apparent between Early and Late groups, with most items exceeding the 70% threshold. Median length of stay was 6.5 days and 6 days in Early and Late groups (p = 0.616), respectively. Morbidity was 50% in both groups, with severe complications that occurred in 13% of Early patients and 15% of Late patients. Ninety-day mortality was 2%, and it was similar between the two groups.</p><p><strong>Conclusions: </strong>In a center with a standardized ERAS protocol, the weekday of gastrectomy has no significant impact on the success of each ERAS item and on postoperative surgical and oncological outcomes.</p>","PeriodicalId":11241,"journal":{"name":"Digestive Surgery","volume":null,"pages":null},"PeriodicalIF":2.7,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10209083","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Siri Rønholdt Henriksen, Jacob Rosenberg, Siv Fonnes
Background: Diagnostic laparoscopy is often used when a patient is suspected of having acute appendicitis. The aim of this study was to assess the rate of other pathologies found during diagnostic laparoscopy for suspected acute appendicitis.
Methods: This systematic search included studies with ≥100 patients who received laparoscopy for suspected acute appendicitis and reported on the histopathologic and other intra-abdominal findings. We performed a meta-analysis estimating the rate of other pathologies, and a sensitivity analysis excluding smaller cohorts (≤500 patients). Age groups, sex, specific findings, and geographic regions were investigated. Certainty of evidence was assessed with GRADE.
Results: A total of 27 studies were included covering 25,547 patients and of these 793 had an unexpected pathology. The findings were benign pathology in the appendix (34%), malignancy (30%), gynecologic pathology (5%), gastrointestinal pathology (4%), or unspecified (27%). Meta-analysis showed an overall rate of unexpected findings of 3.5% (95% CI 2.7-4.3; moderate certainty), and the sensitivity analysis showed similar results. Malignancy found in the appendix when treating suspected acute appendicitis was 1.0% (95% CI 0.8-1.3%; high certainty).
Conclusion: The rate of other histopathological findings in patients with suspected acute appendicitis was low and a malignancy in appendix was found in 1% of patients.
背景:诊断性腹腔镜检查常用于怀疑患有急性阑尾炎的患者。本研究的目的是评估在疑似急性阑尾炎的诊断性腹腔镜检查中发现的其他病理的比率。方法:本系统检索纳入了≥100例因疑似急性阑尾炎接受腹腔镜检查并报告了组织病理学和其他腹腔内发现的患者。我们进行了一项荟萃分析,估计了其他病理的发生率,并进行了敏感性分析,排除了较小的队列(≤500例患者)。调查了年龄组、性别、具体结果和地理区域。用GRADE评价证据的确定性。结果:共纳入27项研究,涵盖25,547例患者,其中793例患者有意想不到的病理。结果为阑尾良性病理(34%)、恶性病理(30%)、妇科病理(5%)、胃肠道病理(4%)或未明确病理(27%)。meta分析显示意外发现的总发生率为3.5% (95% CI 2.7-4.3;中等确定性),敏感性分析也显示了类似的结果。疑似急性阑尾炎治疗时阑尾肿瘤发生率为1.0% (95% CI 0.8-1.3%;高确定性)。结论:疑似急性阑尾炎患者其他病理表现的发生率较低,阑尾恶性肿瘤发生率为1%。
{"title":"Other Pathologies Were Rarely Reported after Laparoscopic Surgery for Suspected Appendicitis: A Systematic Review and Meta-Analysis.","authors":"Siri Rønholdt Henriksen, Jacob Rosenberg, Siv Fonnes","doi":"10.1159/000531283","DOIUrl":"https://doi.org/10.1159/000531283","url":null,"abstract":"<p><strong>Background: </strong>Diagnostic laparoscopy is often used when a patient is suspected of having acute appendicitis. The aim of this study was to assess the rate of other pathologies found during diagnostic laparoscopy for suspected acute appendicitis.</p><p><strong>Methods: </strong>This systematic search included studies with ≥100 patients who received laparoscopy for suspected acute appendicitis and reported on the histopathologic and other intra-abdominal findings. We performed a meta-analysis estimating the rate of other pathologies, and a sensitivity analysis excluding smaller cohorts (≤500 patients). Age groups, sex, specific findings, and geographic regions were investigated. Certainty of evidence was assessed with GRADE.</p><p><strong>Results: </strong>A total of 27 studies were included covering 25,547 patients and of these 793 had an unexpected pathology. The findings were benign pathology in the appendix (34%), malignancy (30%), gynecologic pathology (5%), gastrointestinal pathology (4%), or unspecified (27%). Meta-analysis showed an overall rate of unexpected findings of 3.5% (95% CI 2.7-4.3; moderate certainty), and the sensitivity analysis showed similar results. Malignancy found in the appendix when treating suspected acute appendicitis was 1.0% (95% CI 0.8-1.3%; high certainty).</p><p><strong>Conclusion: </strong>The rate of other histopathological findings in patients with suspected acute appendicitis was low and a malignancy in appendix was found in 1% of patients.</p>","PeriodicalId":11241,"journal":{"name":"Digestive Surgery","volume":null,"pages":null},"PeriodicalIF":2.7,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10567863","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}