Digestive Surgery最新文献

Introduction: The balance between potential oncological merits and surgical risks is unclear for the additional step of performing paratracheal lymphadenectomy during esophagectomy for cancer. This study aimed to investigate the impact of paratracheal lymphadenectomy on lymph node yield and short-term outcomes in patients who underwent this procedure in the Netherlands.

Methods: Patients who underwent neoadjuvant chemoradiotherapy followed by transthoracic esophagectomy were included from the Dutch Upper Gastrointestinal Cancer Audit (DUCA). After propensity score matching Ivor Lewis and McKeown approaches separately, lymph node yield and short-term outcomes were compared between patients who underwent paratracheal lymphadenectomy versus patients who did not.

Results: Between 2011 and 2017, 2,128 patients were included. Some 770 patients (n = 385 vs. n = 385) and 516 patients (n = 258 vs. n = 258) were matched for the Ivor Lewis and McKeown approaches, respectively. Paratracheal lymphadenectomy was associated with a higher lymph node yield in Ivor Lewis (23 vs. 19 nodes, p < 0.001) and McKeown (21 vs. 19 nodes, p = 0.015) esophagectomy. There were no significant differences in complications or mortality. After Ivor Lewis esophagectomy, paratracheal lymphadenectomy was associated with longer length of stay (12 vs. 11 days, p < 0.048). After McKeown esophagectomy, paratracheal lymphadenectomy was associated with more re-interventions (30% vs. 18%, p = 0.002).

Conclusions: Paratracheal lymphadenectomy resulted in a higher lymph node yield but also in longer length of stay after Ivor Lewis and more re-interventions following McKeown esophagectomy.

Introduction: Curative therapy for gastric cancer usually consists of perioperative chemotherapy combined with a radical (R0) gastrectomy. In addition to a modified D2 lymphadenectomy, a complete omentectomy is recommended. However, there is little evidence for a survival benefit of omentectomy. This study presents the follow-up data of the OMEGA study.

Methods: This multicenter prospective cohort study included 100 consecutive patients with gastric cancer undergoing (sub)total gastrectomy with complete en bloc omentectomy and modified D2 lymphadenectomy. Primary outcome of the current study was 5-year overall survival. Patients with or without omental metastases were compared. Pathological factors associated with locoregional recurrence and/or metastases were tested with multivariable regression analysis.

Results: Of 100 included patients, five had metastases in the greater omentum. Five-year overall survival was 0.0% in patients with omental metastases and 44.2% in patients without omental metastases (p = 0.001). Median overall survival time for patients with or without omental metastases was 7 months and 53 months. A (y)pT3-4 stage tumor and vasoinvasive growth were associated with locoregional recurrence and/or metastases in patients without omental metastases.

Conclusion: The presence of omental metastases in gastric cancer patients who underwent potentially curative surgery was associated with impaired overall survival. Omentectomy as part of radical gastrectomy for gastric cancer might not contribute to a survival benefit in case of undetected omental metastases.

Introduction: Body composition comprising low-skeletal muscle mass (LSMM) and subcutaneous and visceral adipose tissue (SAT and VAT) can be assessed by using cross-sectional imaging modalities. Previous analyses suggest that these parameters harbor prognostic relevance in various diseases. Aim of this study was to analyze possible associations of body composition parameters on mortality in patients with clinically suspected acute mesenteric ischemia (AMI).

Methods: All patients with clinically suspected AMI were retrospectively assessed between 2016 and 2020. Overall, 137 patients (52 female patients, 37.9%) with a median age of 71 years were included in the present analysis. For all patients, the preoperative abdominal computed tomography (CT) was used to calculate LSMM, VAT, and SAT.

Results: Overall, 94 patients (68.6%) of the patient cohort died within 30 days within a median of 2 days, range 1-39 days. Of these, 27 patients (19.7%) died within 24 h. According to the CT, 101 patients (73.7%) were classified as being visceral obese, 102 patients (74.5%) as being sarcopenic, and 69 patients (50.4%) as being sarcopenic obese. Skeletal muscle index (SMI) was lower in non-survivors compared to survivors (37.5 ± 12.4 cm2/m2 vs. 44.1 ± 13.9 cm2/m2, p = 0.01). There were no associations between body composition parameters with mortality in days (SMI r = 0.07, p = 0.48, SAT r = -0.03, p = 0.77, and VAT r = 0.04, p = 0.68, respectively). In Cox regression analysis, a nonsignificant trend for visceral obesity was observed (HR: 0.62, 95% CI: 0.36-1.05, p = 0.07).

Conclusion: SMI might be a valuable CT-based parameter, which could help discriminate between survivors and non-survivors. Further studies are needed to elucidate the associations between body composition and survival in patients with AMI.

Introduction: The identification of patients with low risk of clinically relevant postoperative pancreatic fistula (CR-POPF) and postoperative hemorrhage (PPH) can guide drain removal after pancreatoduodenectomy (PD). However, drain fluid amylase (DFA) ≤5,000 U/L on postoperative day (POD) 1 does not robustly predict the absence of CR-POPF.

Methods: Consecutive patients undergoing PD at Sun Yat-sen University Cancer Center between July 2018 and October 2021 were analyzed. Recursive partitioning analysis was used to classify patients into groups with different risks of CR-POPF and PPH.

Results: Among 288 consecutive patients included, 99 patients (34.38%) developed CR-POPF (86 grade B and 13 grade C). Patients with CR-POPF had increased levels of preoperative creatinine (CRE) and POD1 CRE. The combination of POD1 CRE (>104 μmol/L or not) and POD1 DFA (>5,000 U/L or not) stratified patients into subgroups with the maximum difference in CR-POPF risk. The CR-POPF rates were 17.82% (36/202) in group A (POD1 CRE ≤104 μmol/L and POD1 DFA ≤5,000 U/L), 53.33% (8/15) in group B (POD1 CRE >104 μmol/L and POD1 DFA ≤5,000 U/L), and 77.46% (55/71) in group C (POD1 DFA >5,000 U/L). The PPH rates were 1.98% (4/202), 20.00% (3/15), and 19.72% (14/71) in groups A, B, and C, respectively.

Conclusion: Patients with POD1 DFA ≤5,000 U/L and POD1 CRE >104 μmol/L have a high risk of CR-POPF and may not benefit from early drain removal. Patients with POD1 DFA ≤5,000 U/L and POD1 CRE ≤104 μmol/L have low risk of CR-POPF and PPH.

Introduction: Thyroid incidentalomas are often encountered during imaging performed for the workup of esophageal cancer. Their oncological significance is unknown. This study aimed to establish incidence and etiology of thyroid incidentalomas found during the diagnostic workup of esophageal cancer.

Methods: All esophageal cancer patients referred to or diagnosed at the Amsterdam UMC between January 2012 and December 2016 were included. Radiology and multidisciplinary team meeting reports were reviewed for presence of thyroid incidentalomas. When present, the fluorodeoxyglucose-positron emission tomography/computed tomography (18FDG-PET/CT) or CT was reassessed by a radiologist. Primary outcome was the incidence and etiology of thyroid incidentalomas.

Results: In total, 1,110 esophageal cancer patients were included. Median age was 66 years, most were male (77.2%) and had an adenocarcinoma (69.4%). For 115 patients (10.4%), a thyroid incidentaloma was reported. Two thyroidal lesions proved malignant. One was an esophageal cancer metastasis (0.9%) and one was a primary thyroid carcinoma (0.9%). Only the primary thyroid carcinoma resulted in treatment alteration. The other malignant thyroid incidentaloma was in the context of disseminated esophageal disease and ineligible for curative treatment.

Conclusion: In this study, thyroid incidentalomas were only very rarely oncologically significant. Further etiological examination should only be considered in accordance with the TI-RADS classification system and when clinical consequences are to be expected.

Introduction: Sarcopenia is often observed in patients with esophageal cancer (EC). However, the influence of sarcopenia during neoadjuvant chemotherapy (NAC) on complications has not been fully investigated. Thus, we aimed to investigate the best way of evaluating sarcopenia for predicting complications, especially postoperative pneumonia (PP), in patients with EC undergoing NAC and esophagectomy.

Methods: We retrospectively reviewed 113 patients. The skeletal muscle mass index (SMI) was evaluated by bioelectrical impedance analysis and/or computed tomography. Patients were diagnosed with sarcopenia at pre-NAC and preoperative timing. Different criteria were compared in terms of the predictability of PP. Next, we evaluated which factors were related to sarcopenia with the best PP predictability.

Results: Fifteen (13.2%) patients developed grade III or higher PP. Pre-NAC modified European Working Group on Sarcopenia in Older People (EWGSOP) criteria showed the highest sensitivity (100%) and acceptable specificity (75.8%) for predicting PP. Low pre-NAC body mass index and %VC were significantly associated with sarcopenia by the modified EWGSOP criteria.

Conclusion: Pre-NAC sarcopenia by modified EWGSOP was a significant predictor of PP after esophagectomy. Appropriate interventions for these patients should be explored to prevent PP.