Pub Date : 2024-11-01DOI: 10.1016/j.gassur.2024.08.013
Mahdi Neshan , Vennila Padmanaban , Robert Connor Chick , Timothy M. Pawlik
Background
Whipple pancreaticoduodenectomy (PD) is a complex gastrointestinal surgery that is performed increasingly via minimally invasive approach through robotic platforms. We sought to provide a comparative review of available data regarding robot-assisted vs open PD in terms of cost-effectiveness, overall survival, and other perioperative and long-term oncologic outcomes.
Methods
Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria, PubMed, Scopus, and Web of Science databases were searched from 1980 to April 2024 using designated keywords. English-language studies comparing costs and oncologic outcomes of robotic vs open PDs were considered for inclusion. Reviews, abstracts, case reports, letters to the editor, and non-English articles were excluded.
Results
A total of 1733 studies were initially identified throughout the literature search. After the removal of duplicates, title and abstract screening identified 16 studies that were included in the review. No statistically significant differences were detected in terms of short-term complications (95% CI, 0.805–1.096; P = .42), mortality (95% CI, 0.599–1.123; P = .21), and readmission (95% CI, 0.959–1.211; P = .20) among patients undergoing open vs robotic PD. Robotic PDs was associated with a slightly better overall survival (95% CI, 1.020–1.233) and higher costs (95% CI, 0.134–1.139; P = .013). Mean length of stay (LOS) was higher in the open PD group (95% CI, −0.353 to 0.189; P < .001).
Conclusion
Robotic-assisted PD had a slightly shorter LOS and improved overall survival. There were no differences in short-term complications, mortality, or readmission. The use of cohort studies and residual potential selection bias necessitate randomized controlled trials to define the benefit of robotic PD.
{"title":"Open vs robotic-assisted pancreaticoduodenectomy, cost-effectiveness and long-term oncologic outcomes: a systematic review and meta-analysis","authors":"Mahdi Neshan , Vennila Padmanaban , Robert Connor Chick , Timothy M. Pawlik","doi":"10.1016/j.gassur.2024.08.013","DOIUrl":"10.1016/j.gassur.2024.08.013","url":null,"abstract":"<div><h3>Background</h3><div>Whipple pancreaticoduodenectomy (PD) is a complex gastrointestinal surgery that is performed increasingly via minimally invasive approach through robotic platforms. We sought to provide a comparative review of available data regarding robot-assisted vs open PD in terms of cost-effectiveness, overall survival, and other perioperative and long-term oncologic outcomes.</div></div><div><h3>Methods</h3><div>Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria, PubMed, Scopus, and Web of Science databases were searched from 1980 to April 2024 using designated keywords. English-language studies comparing costs and oncologic outcomes of robotic vs open PDs were considered for inclusion. Reviews, abstracts, case reports, letters to the editor, and non-English articles were excluded.</div></div><div><h3>Results</h3><div>A total of 1733 studies were initially identified throughout the literature search. After the removal of duplicates, title and abstract screening identified 16 studies that were included in the review. No statistically significant differences were detected in terms of short-term complications (95% CI, 0.805–1.096; <em>P</em> = .42), mortality (95% CI, 0.599–1.123; <em>P</em> = .21), and readmission (95% CI, 0.959–1.211; <em>P</em> = .20) among patients undergoing open vs robotic PD. Robotic PDs was associated with a slightly better overall survival (95% CI, 1.020–1.233) and higher costs (95% CI, 0.134–1.139; <em>P</em> = .013). Mean length of stay (LOS) was higher in the open PD group (95% CI, −0.353 to 0.189; <em>P</em> < .001).</div></div><div><h3>Conclusion</h3><div>Robotic-assisted PD had a slightly shorter LOS and improved overall survival. There were no differences in short-term complications, mortality, or readmission. The use of cohort studies and residual potential selection bias necessitate randomized controlled trials to define the benefit of robotic PD.</div></div>","PeriodicalId":15893,"journal":{"name":"Journal of Gastrointestinal Surgery","volume":"28 11","pages":"Pages 1933-1942"},"PeriodicalIF":2.2,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141995852","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 : 2024-11-01DOI: 10.1016/j.gassur.2024.08.030
Nicolas Mibelli , Florian Oehme , Olga Radulova-Mauersberger , Anne-Christin Selbmann , Felix Merboth , Sebastian Hempel , Marius Distler , Jürgen Weitz , Christian Teske
Background
Pancreatic head resection is associated with postoperative morbidity, primarily because of infectious complications. The microbiota in these infections is crucial, and selective decontamination of the digestive tract (SDD) aims to mitigate this risk by targeting pathogenic organisms while preserving beneficial flora. This study aimed to determine the effect of SDD on bacterial shifts and resistance patterns in pancreatic head resection.
Methods
All patients who underwent pancreatic head resection either between January 2012 and August 2018 (non-SDD group) or between January 2019 and December 2021 (SDD group) were included. Propensity score–matched analysis was performed to compare the bacterial presence and resistance patterns in bile duct smear tests and postoperative complications.
Results
Positive bile duct smear tests were observed more often in the non-SDD group (63.5%) than in the SDD group (51.0%). Moreover, the SDD group exhibited a significant reduction in the median number of bacterial species in the bile ducts compared with the non-SDD group (P = .04). However, a notable increase in gram-negative species was observed in the SDD group. The SDD group experienced higher rates of postoperative complications, including relevant pancreatic fistulas (24.8% in the SDD group vs 11.6% in the non-SDD group; P < .01) and delayed gastric emptying (33.8% in the SDD group vs 21.9% in the non-SDD group; P < .01). No significant difference in antibiotic resistance patterns was observed.
Conclusion
SDD in pancreatic head resection reduces bacterial load in the biliary tract, but it is associated with a shift toward more gram-negative species and higher rates of severe postoperative complications. Our findings suggest that SDD may negatively affect postoperative outcomes and should be carefully considered in clinical practice.
{"title":"Bacterial shift and resistance pattern in pancreatic head resections after selective decontamination of the digestive tract – a propensity score-matched analysis","authors":"Nicolas Mibelli , Florian Oehme , Olga Radulova-Mauersberger , Anne-Christin Selbmann , Felix Merboth , Sebastian Hempel , Marius Distler , Jürgen Weitz , Christian Teske","doi":"10.1016/j.gassur.2024.08.030","DOIUrl":"10.1016/j.gassur.2024.08.030","url":null,"abstract":"<div><h3>Background</h3><div>Pancreatic head resection is associated with postoperative morbidity, primarily because of infectious complications. The microbiota in these infections is crucial, and selective decontamination of the digestive tract (SDD) aims to mitigate this risk by targeting pathogenic organisms while preserving beneficial flora. This study aimed to determine the effect of SDD on bacterial shifts and resistance patterns in pancreatic head resection.</div></div><div><h3>Methods</h3><div>All patients who underwent pancreatic head resection either between January 2012 and August 2018 (non-SDD group) or between January 2019 and December 2021 (SDD group) were included. Propensity score–matched analysis was performed to compare the bacterial presence and resistance patterns in bile duct smear tests and postoperative complications.</div></div><div><h3>Results</h3><div>Positive bile duct smear tests were observed more often in the non-SDD group (63.5%) than in the SDD group (51.0%). Moreover, the SDD group exhibited a significant reduction in the median number of bacterial species in the bile ducts compared with the non-SDD group (<em>P</em> = .04). However, a notable increase in gram-negative species was observed in the SDD group. The SDD group experienced higher rates of postoperative complications, including relevant pancreatic fistulas (24.8% in the SDD group vs 11.6% in the non-SDD group; <em>P</em> < .01) and delayed gastric emptying (33.8% in the SDD group vs 21.9% in the non-SDD group; <em>P</em> < .01). No significant difference in antibiotic resistance patterns was observed.</div></div><div><h3>Conclusion</h3><div>SDD in pancreatic head resection reduces bacterial load in the biliary tract, but it is associated with a shift toward more gram-negative species and higher rates of severe postoperative complications. Our findings suggest that SDD may negatively affect postoperative outcomes and should be carefully considered in clinical practice.</div></div>","PeriodicalId":15893,"journal":{"name":"Journal of Gastrointestinal Surgery","volume":"28 11","pages":"Pages 1844-1852"},"PeriodicalIF":2.2,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142145745","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Dysphagia caused by tumor strictures is a major symptom in patients with advanced esophageal cancer. However, the prognostic effect of dysphagia in resectable cases is insufficiently investigated. This study aimed to investigate the prognostic value of dysphagia scores in resectable advanced esophageal cancer who underwent radical esophagectomy after preoperative treatment.
Methods
This retrospective study enrolled 302 consecutive patients with advanced resectable esophageal cancer who received preoperative treatment. The preoperative dysphagia score was used to assess the relationship between tumor stricture and clinical outcomes.
Results
Almost half of the patients had dysphagia scores of 2 to 4 (n = 152 [50.3%]). Lower body mass index, circumferential tumors, and noncurative resection were significantly more common as dysphagia scores worsened. Patients with dysphagia had significantly more advanced ypT stage and worse histopathologic response than those without dysphagia. The 5-year disease-free survival and overall survival (OS) rates for dysphagia scores of 0 to 1, 2 to 3, and 4 were 52.9%, 35.3%, and 26.7% and 60.7%, 40.4%, and 26.7%, respectively. Multivariate analysis identified dysphagia score as an independent factor of OS, similar to surgical curability and ypN stage. The postoperative recurrence rate was significantly higher among patients with dysphagia scores of 2 to 3 (56%) and 4 (67%) than among those with dysphagia scores of 0 to 1 (36%) (P < .001 and P = .037, respectively). Furthermore, distant recurrence in dysphagia scores of 2 to 3 and 4 was higher than in dysphagia scores of 0 to 1 (26%, 46%, and 42%, respectively).
Conclusion
The dysphagia score before initial treatment is associated with postoperative survival in patients with resectable advanced esophageal cancer.
{"title":"Prognostic impact of dysphagia scores in patients with advanced resectable esophageal cancer who underwent radical esophagectomy after preoperative treatment","authors":"Takahito Sugase, Takashi Kanemura, Norihiro Matsuura, Yuki Ushimaru, Yasunori Masuike, Yoshitomo Yanagimoto, Ryota Mori, Masatoshi Kitakaze, Masataka Amisaki, Masahiko Kubo, Yosuke Mukai, Hisateru Komatsu, Toshinori Sueda, Yoshinori Kagawa, Junichi Nishimura, Hiroshi Wada, Masayoshi Yasui, Takeshi Omori, Hiroshi Miyata","doi":"10.1016/j.gassur.2024.08.031","DOIUrl":"10.1016/j.gassur.2024.08.031","url":null,"abstract":"<div><h3>Background</h3><div>Dysphagia caused by tumor strictures is a major symptom in patients with advanced esophageal cancer. However, the prognostic effect of dysphagia in resectable cases is insufficiently investigated. This study aimed to investigate the prognostic value of dysphagia scores in resectable advanced esophageal cancer who underwent radical esophagectomy after preoperative treatment.</div></div><div><h3>Methods</h3><div>This retrospective study enrolled 302 consecutive patients with advanced resectable esophageal cancer who received preoperative treatment. The preoperative dysphagia score was used to assess the relationship between tumor stricture and clinical outcomes.</div></div><div><h3>Results</h3><div>Almost half of the patients had dysphagia scores of 2 to 4 (n = 152 [50.3%]). Lower body mass index, circumferential tumors, and noncurative resection were significantly more common as dysphagia scores worsened. Patients with dysphagia had significantly more advanced ypT stage and worse histopathologic response than those without dysphagia. The 5-year disease-free survival and overall survival (OS) rates for dysphagia scores of 0 to 1, 2 to 3, and 4 were 52.9%, 35.3%, and 26.7% and 60.7%, 40.4%, and 26.7%, respectively. Multivariate analysis identified dysphagia score as an independent factor of OS, similar to surgical curability and ypN stage. The postoperative recurrence rate was significantly higher among patients with dysphagia scores of 2 to 3 (56%) and 4 (67%) than among those with dysphagia scores of 0 to 1 (36%) (<em>P</em> < .001 and <em>P</em> = .037, respectively). Furthermore, distant recurrence in dysphagia scores of 2 to 3 and 4 was higher than in dysphagia scores of 0 to 1 (26%, 46%, and 42%, respectively).</div></div><div><h3>Conclusion</h3><div>The dysphagia score before initial treatment is associated with postoperative survival in patients with resectable advanced esophageal cancer.</div></div>","PeriodicalId":15893,"journal":{"name":"Journal of Gastrointestinal Surgery","volume":"28 11","pages":"Pages 1853-1860"},"PeriodicalIF":2.2,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142145748","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 : 2024-11-01DOI: 10.1016/j.gassur.2024.09.002
Jin-soo Park , Maxwell Colby , Jarrah Spencer , Nazim Bhimani , Steven Leibman , Jerome M. Laurence , Garett Smith , Gregory L. Falk , Charbel Sandroussi
Background
Myosteatosis is a measure of skeletal muscle quality that is readily identifiable on computed tomography (CT). The effect of preoperative myosteatosis on outcomes after radical esophagectomy remains unclear. This study aimed to correlate the presence of myosteatosis on CT scan with perioperative morbidity, mortality, and survival outcomes after esophagectomy in an Australian population across 3 esophageal cancer centers.
Methods
A retrospective analysis was performed for all patients undergoing radical esophagectomy for cancer across 3 centers. Radiologic assessment of preoperative CT images was performed to determine the presence of myosteatosis. The outcomes measured included perioperative complication rate, overall survival (OS), and disease-free survival (DFS).
Results
A total of 462 patients were included in the analysis (male patients, 78.4%; median age, 67 years). Moreover, 353 patients (76.4%) had myosteatosis on CT. Compared to patients with normal skeletal muscle attenuation, patients with myosteatosis had a higher rate of major (Clavien-Dindo grade ≥ IIIb) complication (14.7% vs 24.9%, respectively; P = .026) and a higher rate of 30-day mortality (0.0% vs 4.0%, respectively; P = .048). Myosteatosis was associated with a major complication on multivariate analysis (hazard ratio, 1.906; 95% CI, 1.057–3.437; P = .032). There was no difference in OS and DFS between patients with and without myosteatosis (OS: 59 vs 56 months, respectively [P = .465]; DFS: 39 vs 42 months, respectively; P = .172).
Conclusion
The presence of myosteatosis on radiologic imaging was associated with an increased risk of major complications and 30-day mortality. Identifying myosteatosis can be an adjunct to preoperative nutritional assessment and prognostication, facilitating early recognition of patients at risk of complications.
{"title":"Radiologic myosteatosis predicts major complication risk following esophagectomy for cancer: a multicenter experience","authors":"Jin-soo Park , Maxwell Colby , Jarrah Spencer , Nazim Bhimani , Steven Leibman , Jerome M. Laurence , Garett Smith , Gregory L. Falk , Charbel Sandroussi","doi":"10.1016/j.gassur.2024.09.002","DOIUrl":"10.1016/j.gassur.2024.09.002","url":null,"abstract":"<div><h3>Background</h3><div>Myosteatosis is a measure of skeletal muscle quality that is readily identifiable on computed tomography (CT). The effect of preoperative myosteatosis on outcomes after radical esophagectomy remains unclear. This study aimed to correlate the presence of myosteatosis on CT scan with perioperative morbidity, mortality, and survival outcomes after esophagectomy in an Australian population across 3 esophageal cancer centers.</div></div><div><h3>Methods</h3><div>A retrospective analysis was performed for all patients undergoing radical esophagectomy for cancer across 3 centers. Radiologic assessment of preoperative CT images was performed to determine the presence of myosteatosis. The outcomes measured included perioperative complication rate, overall survival (OS), and disease-free survival (DFS).</div></div><div><h3>Results</h3><div>A total of 462 patients were included in the analysis (male patients, 78.4%; median age, 67 years). Moreover, 353 patients (76.4%) had myosteatosis on CT. Compared to patients with normal skeletal muscle attenuation, patients with myosteatosis had a higher rate of major (Clavien-Dindo grade ≥ IIIb) complication (14.7% vs 24.9%, respectively; <em>P</em> = .026) and a higher rate of 30-day mortality (0.0% vs 4.0%, respectively; <em>P</em> = .048). Myosteatosis was associated with a major complication on multivariate analysis (hazard ratio, 1.906; 95% CI, 1.057–3.437; <em>P</em> = .032). There was no difference in OS and DFS between patients with and without myosteatosis (OS: 59 vs 56 months, respectively [<em>P</em> = .465]; DFS: 39 vs 42 months, respectively; <em>P</em> = .172).</div></div><div><h3>Conclusion</h3><div>The presence of myosteatosis on radiologic imaging was associated with an increased risk of major complications and 30-day mortality. Identifying myosteatosis can be an adjunct to preoperative nutritional assessment and prognostication, facilitating early recognition of patients at risk of complications.</div></div>","PeriodicalId":15893,"journal":{"name":"Journal of Gastrointestinal Surgery","volume":"28 11","pages":"Pages 1861-1869"},"PeriodicalIF":2.2,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142145749","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 : 2024-11-01DOI: 10.1016/j.gassur.2024.08.007
Sven E. Eriksson , Margaret Gardner , Inanc S. Sarici , Ping Zheng , Naveed Chaudhry , Blair A. Jobe , Shahin Ayazi
<div><h3>Background</h3><div>Pyloroplasty is an effective surgery for gastroparesis. However, some patients fail to improve after pyloric drainage and may require subsequent gastric electric stimulation. There is a paucity of data on the efficacy of gastric stimulator as an adjunct to failed pyloroplasty. This study aimed to describe our experience with pyloroplasty, determine the efficacy of gastric stimulator for failed pyloroplasty, and compare the final outcomes of those who required pyloroplasty with and without gastric stimulator for gastroparesis.</div></div><div><h3>Methods</h3><div>Records of patients who underwent primary pyloroplasty for gastroparesis at our institution were reviewed. Patients with poor symptomatic improvement after pyloroplasty underwent subsequent gastric stimulator. Symptoms were assessed using the gastroparesis cardinal symptom index (GCSI) preoperatively and after each surgery. Severe gastroparesis was defined as GCSI total score ≥3. Outcomes were assessed after pyloroplasty in all patients and after stimulator in patients who failed pyloroplasty. Final outcomes were then compared between those who did and did not require adjunct gastric stimulator.</div></div><div><h3>Results</h3><div>The study population consisted of 104 patients (89.4% females) with a mean (SD) age of 42.2 years (11) and body mass index of 26.9 kg/m<sup>2</sup> (7). Gastroparesis etiologies were 71.2% idiopathic, 17.3% diabetic, and 11.5% postsurgical. At 18.7 months (12) after pyloroplasty, there was a decrease in the GCSI total score (3.5 [1] to 2.7 [1.2]; <em>P</em> = .0012) and the rate of severe gastroparesis (71.9%−29.3%; <em>P</em> < .0001). Gastric emptying scintigraphy (GES) 4-hour retention decreased (36.5 [24] to 15.3 [18]; <em>P</em> = .0003).</div><div>Adjunct gastric stimulator was required by 30 patients (28.8%) owing to suboptimal outcomes with no improvement in GCSI (<em>P</em> = .201) or GES (<em>P</em> = .320). These patients were younger (40.5 [10.6] vs 49.6 [15.2] years; <em>P</em> = .0016), with higher baseline GCSI total scores (4.3 [0.7] vs 3.7 [1.1]; <em>P</em> < .001) and more severe gastroparesis (100% vs 55.6%; <em>P</em> < .001). All other preoperative characteristics were similar. At 21.7 months (15) after gastric stimulator, there was improvement in GCSI (4.1 [0.7] to 2.6 [1.1]; <em>P</em> < .0001), severe gastroparesis (100%−33.3%; <em>P</em> < .0001), and GES 4-hour retention (21.2 [22] to 7.6 [10]; <em>P</em> = .054). Before gastric stimulator, those who failed pyloroplasty had significantly worse GCSI (<em>P</em> = .0009) and GES (<em>P</em> = .048). However, after gastric stimulator, GCSI and GES improved and were comparable with those who only required pyloroplasty (<em>P</em> > .05).</div></div><div><h3>Conclusion</h3><div>Pyloroplasty improved gastroparesis symptoms and gastric emptying, yet 28% failed, requiring gastric stimulator. Younger patients and those with preoperative GCSI scores
{"title":"Efficacy of gastric stimulator as an adjunct to pyloroplasty for gastroparesis: characterizing patients suitable for single procedure vs dual procedure approach","authors":"Sven E. Eriksson , Margaret Gardner , Inanc S. Sarici , Ping Zheng , Naveed Chaudhry , Blair A. Jobe , Shahin Ayazi","doi":"10.1016/j.gassur.2024.08.007","DOIUrl":"10.1016/j.gassur.2024.08.007","url":null,"abstract":"<div><h3>Background</h3><div>Pyloroplasty is an effective surgery for gastroparesis. However, some patients fail to improve after pyloric drainage and may require subsequent gastric electric stimulation. There is a paucity of data on the efficacy of gastric stimulator as an adjunct to failed pyloroplasty. This study aimed to describe our experience with pyloroplasty, determine the efficacy of gastric stimulator for failed pyloroplasty, and compare the final outcomes of those who required pyloroplasty with and without gastric stimulator for gastroparesis.</div></div><div><h3>Methods</h3><div>Records of patients who underwent primary pyloroplasty for gastroparesis at our institution were reviewed. Patients with poor symptomatic improvement after pyloroplasty underwent subsequent gastric stimulator. Symptoms were assessed using the gastroparesis cardinal symptom index (GCSI) preoperatively and after each surgery. Severe gastroparesis was defined as GCSI total score ≥3. Outcomes were assessed after pyloroplasty in all patients and after stimulator in patients who failed pyloroplasty. Final outcomes were then compared between those who did and did not require adjunct gastric stimulator.</div></div><div><h3>Results</h3><div>The study population consisted of 104 patients (89.4% females) with a mean (SD) age of 42.2 years (11) and body mass index of 26.9 kg/m<sup>2</sup> (7). Gastroparesis etiologies were 71.2% idiopathic, 17.3% diabetic, and 11.5% postsurgical. At 18.7 months (12) after pyloroplasty, there was a decrease in the GCSI total score (3.5 [1] to 2.7 [1.2]; <em>P</em> = .0012) and the rate of severe gastroparesis (71.9%−29.3%; <em>P</em> < .0001). Gastric emptying scintigraphy (GES) 4-hour retention decreased (36.5 [24] to 15.3 [18]; <em>P</em> = .0003).</div><div>Adjunct gastric stimulator was required by 30 patients (28.8%) owing to suboptimal outcomes with no improvement in GCSI (<em>P</em> = .201) or GES (<em>P</em> = .320). These patients were younger (40.5 [10.6] vs 49.6 [15.2] years; <em>P</em> = .0016), with higher baseline GCSI total scores (4.3 [0.7] vs 3.7 [1.1]; <em>P</em> < .001) and more severe gastroparesis (100% vs 55.6%; <em>P</em> < .001). All other preoperative characteristics were similar. At 21.7 months (15) after gastric stimulator, there was improvement in GCSI (4.1 [0.7] to 2.6 [1.1]; <em>P</em> < .0001), severe gastroparesis (100%−33.3%; <em>P</em> < .0001), and GES 4-hour retention (21.2 [22] to 7.6 [10]; <em>P</em> = .054). Before gastric stimulator, those who failed pyloroplasty had significantly worse GCSI (<em>P</em> = .0009) and GES (<em>P</em> = .048). However, after gastric stimulator, GCSI and GES improved and were comparable with those who only required pyloroplasty (<em>P</em> > .05).</div></div><div><h3>Conclusion</h3><div>Pyloroplasty improved gastroparesis symptoms and gastric emptying, yet 28% failed, requiring gastric stimulator. Younger patients and those with preoperative GCSI scores","PeriodicalId":15893,"journal":{"name":"Journal of Gastrointestinal Surgery","volume":"28 11","pages":"Pages 1769-1776"},"PeriodicalIF":2.2,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141912921","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 : 2024-11-01DOI: 10.1016/j.gassur.2024.08.014
Erin E. Isenberg , Nicholas Kunnath , Pasithorn A. Suwanabol , Andrew Ibrahim , Renuka Tipirneni , Calista M. Harbaugh
Background
The Social Vulnerability Index (SVI) has previously been demonstrated to correlate with worse postoperative outcomes after surgery, but the association of SVI with short- and long-term outcomes after colon cancer surgery has been underexplored.
Methods
This is a retrospective cross-sectional study of Medicare patients aged 65 to 99 years who underwent colectomy for colon cancer between 2016 and 2020, merged with SVI at the census tract level. We tested the association between SVI with emergent colectomy and 30-day and 1-year mortality using a multivariable logistic regression model adjusted for patient demographics and hospital characteristics.
Results
The cohort included 169,498 patients who underwent colectomy for colon cancer. Medicare patients living in areas in the highest quintile of social vulnerability were more likely to undergo unplanned colectomy for colon cancer than those in the lowest quintile (35.6% vs 28.9%; adjusted odds ratio [aOR], 1.36; 95% CI, 1.31–1.41; P < .001). Similarly, patients living in areas in the highest quintile of social vulnerability experienced higher risk-adjusted rates of 30-day mortality (3.4% vs 2.9%; aOR, 1.20; 95% CI, 1.12–1.29; P < .001) and 1-year mortality (10.8% vs 8.6%; aOR, 1.30; 95% CI, 1.22–1.37; P < .001) than patients living in the lowest quintile of social vulnerability. When evaluating the elective and unplanned cohorts separately, these differences persisted.
Conclusion
Among Medicare patients undergoing colectomy for colon cancer, high social vulnerability was associated with an increased risk of unplanned operations and worse short- and long-term postoperative outcomes in both the emergent and elective settings. Providers should seek to mitigate disparate surgical outcomes by addressing structural inequities in social resources.
背景：社会脆弱性指数（SVI）曾被证明与手术后较差的术后预后相关，但 SVI 与结肠癌手术后短期和长期预后的关联还未得到充分探讨：这是一项回顾性横断面研究，研究对象是在 2016 年至 2020 年间因结肠癌接受结肠切除术的 65-99 岁医疗保险患者，并在人口普查区层面合并了 SVI。我们使用多变量逻辑回归模型检验了 SVI 与急诊结肠切除术以及 30 天和 1 年死亡率之间的关系，并对患者人口统计学特征和医院特征进行了调整：研究对象包括 169,498 名因结肠癌接受结肠切除术的患者。与生活在社会脆弱性最高五分位数地区的患者相比，生活在社会脆弱性最低五分位数地区的医保患者更有可能因结肠癌而接受非计划性结肠切除术（35.6% 对 28.9%；调整赔率比 (aOR) 1.36 [95% CI 1.31-1.41]，p）：在接受结肠癌结肠切除术的医疗保险患者中，社会脆弱性高与意外手术风险增加以及急诊和择期手术的短期和长期术后效果较差有关。医疗服务提供者应设法通过解决社会资源结构性不平等问题来缓解不同的手术结果。
{"title":"Social vulnerability and perioperative outcomes after colectomy for colon cancer","authors":"Erin E. Isenberg , Nicholas Kunnath , Pasithorn A. Suwanabol , Andrew Ibrahim , Renuka Tipirneni , Calista M. Harbaugh","doi":"10.1016/j.gassur.2024.08.014","DOIUrl":"10.1016/j.gassur.2024.08.014","url":null,"abstract":"<div><h3>Background</h3><div>The Social Vulnerability Index (SVI) has previously been demonstrated to correlate with worse postoperative outcomes after surgery, but the association of SVI with short- and long-term outcomes after colon cancer surgery has been underexplored.</div></div><div><h3>Methods</h3><div>This is a retrospective cross-sectional study of Medicare patients aged 65 to 99 years who underwent colectomy for colon cancer between 2016 and 2020, merged with SVI at the census tract level. We tested the association between SVI with emergent colectomy and 30-day and 1-year mortality using a multivariable logistic regression model adjusted for patient demographics and hospital characteristics.</div></div><div><h3>Results</h3><div>The cohort included 169,498 patients who underwent colectomy for colon cancer. Medicare patients living in areas in the highest quintile of social vulnerability were more likely to undergo unplanned colectomy for colon cancer than those in the lowest quintile (35.6% vs 28.9%; adjusted odds ratio [aOR], 1.36; 95% CI, 1.31–1.41; <em>P</em> < .001). Similarly, patients living in areas in the highest quintile of social vulnerability experienced higher risk-adjusted rates of 30-day mortality (3.4% vs 2.9%; aOR, 1.20; 95% CI, 1.12–1.29; <em>P</em> < .001) and 1-year mortality (10.8% vs 8.6%; aOR, 1.30; 95% CI, 1.22–1.37; <em>P</em> < .001) than patients living in the lowest quintile of social vulnerability. When evaluating the elective and unplanned cohorts separately, these differences persisted.</div></div><div><h3>Conclusion</h3><div>Among Medicare patients undergoing colectomy for colon cancer, high social vulnerability was associated with an increased risk of unplanned operations and worse short- and long-term postoperative outcomes in both the emergent and elective settings. Providers should seek to mitigate disparate surgical outcomes by addressing structural inequities in social resources.</div></div>","PeriodicalId":15893,"journal":{"name":"Journal of Gastrointestinal Surgery","volume":"28 11","pages":"Pages 1783-1790"},"PeriodicalIF":2.2,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141995853","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 : 2024-11-01DOI: 10.1016/j.gassur.2024.08.019
Kurt S. Schultz, Miranda S. Moore, Haddon J. Pantel, Anne K. Mongiu, Vikram B. Reddy, Eric B. Schneider, Ira L. Leeds
Background
Failure to rescue after elective surgery is associated with increased healthcare costs. These costs are poorly understood and have not been reported for colorectal surgery. This study aimed to assess the incremental costs of failure to rescue after elective colorectal surgery.
Methods
This was a retrospective study of adult patients identified in the National Inpatient Sample from 2016 to 2019 who underwent an elective colectomy or proctectomy. Patients were stratified into 4 groups: uneventful recovery, successfully rescued, failure to rescue, and died without rescue attempts. “Rescue” was defined as admissions with ≥1 procedure code ≥1 day after the initial procedure. The primary outcome was total admission costs.
Results
Of 451,490 admissions for elective colorectal resection, 94.6% had an uneventful recovery, 4.8% were successfully rescued, 0.4% were failure to rescue, and 0.3% died without rescue attempts. The median total hospital cost for the uneventful recovery cohort was $16,751 (IQR, $12,611-$23,116), for the successfully rescued cohort was $42,295 (IQR, $27,959-$67,077), for the failure-to-rescue cohort was $53,182 (IQR, $30,852-$95,615), and for the died without attempted rescue cohort was $29,296 (IQR, $19,812-$45,919). When comparing cost quantiles by regression analysis, failure-to-rescue patients had significantly higher costs than the successfully rescued patients for the last 3 quantiles (fifth quantile [90th percentile], $163,963 vs $106,521; P < .001).
Conclusion
Across a nationally representative cohort, the median total hospital costs for patients who failed to be rescued were $10,887 more than for those who were successfully rescued. These findings emphasize the importance of shared decision making and medical futility and highlight opportunities for resource optimization after postoperative complications.
{"title":"For whom the bell tolls: assessing the incremental costs associated with failure to rescue after elective colorectal surgery","authors":"Kurt S. Schultz, Miranda S. Moore, Haddon J. Pantel, Anne K. Mongiu, Vikram B. Reddy, Eric B. Schneider, Ira L. Leeds","doi":"10.1016/j.gassur.2024.08.019","DOIUrl":"10.1016/j.gassur.2024.08.019","url":null,"abstract":"<div><h3>Background</h3><div>Failure to rescue after elective surgery is associated with increased healthcare costs. These costs are poorly understood and have not been reported for colorectal surgery. This study aimed to assess the incremental costs of failure to rescue after elective colorectal surgery.</div></div><div><h3>Methods</h3><div>This was a retrospective study of adult patients identified in the National Inpatient Sample from 2016 to 2019 who underwent an elective colectomy or proctectomy. Patients were stratified into 4 groups: uneventful recovery, successfully rescued, failure to rescue, and died without rescue attempts. “Rescue” was defined as admissions with ≥1 procedure code ≥1 day after the initial procedure. The primary outcome was total admission costs.</div></div><div><h3>Results</h3><div>Of 451,490 admissions for elective colorectal resection, 94.6% had an uneventful recovery, 4.8% were successfully rescued, 0.4% were failure to rescue, and 0.3% died without rescue attempts. The median total hospital cost for the uneventful recovery cohort was $16,751 (IQR, $12,611-$23,116), for the successfully rescued cohort was $42,295 (IQR, $27,959-$67,077), for the failure-to-rescue cohort was $53,182 (IQR, $30,852-$95,615), and for the died without attempted rescue cohort was $29,296 (IQR, $19,812-$45,919). When comparing cost quantiles by regression analysis, failure-to-rescue patients had significantly higher costs than the successfully rescued patients for the last 3 quantiles (fifth quantile [90th percentile], $163,963 vs $106,521; <em>P</em> < .001).</div></div><div><h3>Conclusion</h3><div>Across a nationally representative cohort, the median total hospital costs for patients who failed to be rescued were $10,887 more than for those who were successfully rescued. These findings emphasize the importance of shared decision making and medical futility and highlight opportunities for resource optimization after postoperative complications.</div></div>","PeriodicalId":15893,"journal":{"name":"Journal of Gastrointestinal Surgery","volume":"28 11","pages":"Pages 1812-1818"},"PeriodicalIF":2.2,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142055789","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}
This study aimed to investigate the effect of remote ischemic preconditioning (RIPC) on the healing of small intestinal anastomoses, evaluated by tensile strength and histologic wound healing on postoperative day 5.
Methods
A total of 22 female pigs were randomized 1:1 into either an intervention or control group. The intervention group received 5 cycles of 3-minute ischemia followed by 3-minute reperfusion on the right forelimb. Two end-to-end anastomoses, a distal and a proximal, were created in the small intestine 30 and 60 min after RIPC, respectively. On postoperative day 5, the anastomoses were harvested and underwent a maximal anastomotic tensile strength (MATS) test (MATS 1–3) followed by histologic analyses.
Results
MATS 1, when a tear became visible in the serosa, was significantly increased in the proximal anastomoses of the RIPC group compared with the control group (4.91 N vs 3.83 N; P = .005). No other significant differences were found when comparing these 2 groups.
Conclusion
Our study showed no convincing results of RIPC on intestinal anastomotic healing to recommend its use in a general clinical setting. Further animal studies on RIPC’s effect after relative or absolute intestinal ischemia may be recommended.
{"title":"Short cycles of remote ischemic preconditioning had no effect on tensile strength in small intestinal anastomoses: an experimental animal study","authors":"Mei-Yun Zheng , Paula Thrane Dybro , Sören Möller , Gunvor Iben Madsen , Mie Dilling Kjær , Niels Qvist , Mark Bremholm Ellebæk","doi":"10.1016/j.gassur.2024.08.008","DOIUrl":"10.1016/j.gassur.2024.08.008","url":null,"abstract":"<div><h3>Purpose</h3><div>This study aimed to investigate the effect of remote ischemic preconditioning (RIPC) on the healing of small intestinal anastomoses, evaluated by tensile strength and histologic wound healing on postoperative day 5.</div></div><div><h3>Methods</h3><div>A total of 22 female pigs were randomized 1:1 into either an intervention or control group. The intervention group received 5 cycles of 3-minute ischemia followed by 3-minute reperfusion on the right forelimb. Two end-to-end anastomoses, a distal and a proximal, were created in the small intestine 30 and 60 min after RIPC, respectively. On postoperative day 5, the anastomoses were harvested and underwent a maximal anastomotic tensile strength (MATS) test (MATS 1–3) followed by histologic analyses.</div></div><div><h3>Results</h3><div>MATS 1, when a tear became visible in the serosa, was significantly increased in the proximal anastomoses of the RIPC group compared with the control group (4.91 N vs 3.83 N; <em>P</em> = .005). No other significant differences were found when comparing these 2 groups.</div></div><div><h3>Conclusion</h3><div>Our study showed no convincing results of RIPC on intestinal anastomotic healing to recommend its use in a general clinical setting. Further animal studies on RIPC’s effect after relative or absolute intestinal ischemia may be recommended.</div></div>","PeriodicalId":15893,"journal":{"name":"Journal of Gastrointestinal Surgery","volume":"28 11","pages":"Pages 1777-1782"},"PeriodicalIF":2.2,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141916904","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-01DOI: 10.1016/j.gassur.2024.08.012
Hassan Aziz , Ye In Christopher Kwon , Andrew Min-Gi Park , Alan Lai , Kerry Yi Chen Lee , Dean Zhang , Yeseo Kwon , Timothy M. Pawlik
Background
Owing to the heterogeneity of underlying primary tumors, noncolorectal, nonneuroendocrine metastases to the liver (NCNNMLs), although relatively rare, pose major challenges to treatment and long-term management. Despite being considered the gold standard for colorectal cancer liver metastases, the role of surgical resection for NCNNML remains controversial. Furthermore, advancements in locoregional treatment modalities, such as ablation and various chemotherapeutic modalities, have contributed to the treatment of patients with NCNNML.
Methods
This was a comprehensive review of literature that used Medline/PubMed, Google Scholar, the Cochrane Library, and the Web of Science, which were accessed between 2014 and 2024.
Results
NCNNMLs are rare tumor entities with varied presentation and outcomes. A multidisciplinary approach, which includes chemotherapy, surgery, and interventional radiologic techniques, can be implemented with good results.
Conclusion
Given the complex nature of NCNNML, its management should be highly individualized and multidisciplinary. Locoregional treatments, such as surgical resection and/or ablation, may be more appropriate for select patients and should be offered as a viable therapeutic option for a subset of individuals.
简介：由于潜在原发肿瘤的异质性，肝脏非结直肠、非神经内分泌转移瘤（NCNNML）虽然相对罕见，但对治疗和长期管理构成了重大挑战。虽然手术切除被认为是治疗结直肠癌肝转移的金标准，但对 NCNNML 的作用仍存在争议。此外，局部治疗模式（如消融和各种化疗模式）的进步也促进了 NCNNML 患者的治疗：我们使用 Medline/PubMed、Google Scholar、Cochrane Library 和 Web of Science 对 2014 年至 2024 年间的文献进行了全面回顾：NCNNML是罕见的肿瘤实体，表现和预后各不相同。包括化疗、手术和介入放射学技术在内的多学科方法可取得良好效果：鉴于NCNNML的复杂性，必须注意NCNNML的治疗应高度个体化和多学科化。手术切除和/或消融等局部治疗可能更适合特定患者，应将其作为一部分患者的可行治疗方案。
{"title":"Recent advancements in management for noncolorectal, nonneuroendocrine hepatic metastases","authors":"Hassan Aziz , Ye In Christopher Kwon , Andrew Min-Gi Park , Alan Lai , Kerry Yi Chen Lee , Dean Zhang , Yeseo Kwon , Timothy M. Pawlik","doi":"10.1016/j.gassur.2024.08.012","DOIUrl":"10.1016/j.gassur.2024.08.012","url":null,"abstract":"<div><h3>Background</h3><div>Owing to the heterogeneity of underlying primary tumors, noncolorectal, nonneuroendocrine metastases to the liver (NCNNMLs), although relatively rare, pose major challenges to treatment and long-term management. Despite being considered the gold standard for colorectal cancer liver metastases, the role of surgical resection for NCNNML remains controversial. Furthermore, advancements in locoregional treatment modalities, such as ablation and various chemotherapeutic modalities, have contributed to the treatment of patients with NCNNML.</div></div><div><h3>Methods</h3><div>This was a comprehensive review of literature that used Medline/PubMed, Google Scholar, the Cochrane Library, and the Web of Science, which were accessed between 2014 and 2024.</div></div><div><h3>Results</h3><div>NCNNMLs are rare tumor entities with varied presentation and outcomes. A multidisciplinary approach, which includes chemotherapy, surgery, and interventional radiologic techniques, can be implemented with good results.</div></div><div><h3>Conclusion</h3><div>Given the complex nature of NCNNML, its management should be highly individualized and multidisciplinary. Locoregional treatments, such as surgical resection and/or ablation, may be more appropriate for select patients and should be offered as a viable therapeutic option for a subset of individuals.</div></div>","PeriodicalId":15893,"journal":{"name":"Journal of Gastrointestinal Surgery","volume":"28 11","pages":"Pages 1922-1932"},"PeriodicalIF":2.2,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142000089","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}
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