Annals of surgery最新文献

Objective: To investigate the correlation between positive resection margins and outcomes in patients with pancreatic ductal adenocarcinoma who underwent surgery and adjuvant chemotherapy according to the pivotal trial PRODIGE 24-CCTG PA-6.

Background: The primary focus is on elucidating the prognostic significance of specific resection margins, including those associated with the superior-mesenteric vein, medial, and posterior pancreas.

Methods: The analysis involved 400 patients across multiple centers in France and Canada. Surgical resection and subsequent adjuvant chemotherapy were core interventions. This study assessed the prognostic impact of resection margins, highlighting the significance of standardized pathology assessments. In addition, the influence of chemotherapy regimen choice, comparing gemcitabine to mFOLFIRINOX, on the implications of positive resection margins was examined.

Results: Only 3 margins, superior-mesenteric vein [hazard ratio (HR) = 1.48 (95% CI: 1.11; 1.96); P < 0.001], medial [HR = 1.92 (95% CI: 1.36; 2.73); P < 0.001] and posterior [HR = 1.65 (95% CI: 1.21; 2.24); P = 0.002], had a significant prognostic impact on disease-free survival and were sufficient compared with the 7 recommended margins (Kappa = 0.90; 95% CI: 0.87; 0.94). R1 status was a significant independent prognostic factor for poorer survival in gemcitabine-treated patients [HR = 1.97 (95% CI: 1.23; 3.16); P = 0.005] but lost its significance with mFOLFIRINOX [HR = 1.46 (95% CI: 0.91; 2.35); P = 0.114].

Conclusions: All efforts should be made to evaluate the 3 margins of the highest prognostic value, with the others being secondary. A key finding of this study is the likely effect of mFOLFIRINOX on local invasion in operated patients, which seems to correct the impairment related to margin involvement, probably explaining the improvements in disease-free survival and overall survival.

Objective: To evaluate all mesh-related problems during reoperations after mesh reinforcement of the abdominal wall 15 years after the start of the PRIMA trial.

Background: Prophylactic mesh reinforcement during closure of a midline laparotomy has proven to reduce the incidence of incisional hernia, especially in high-risk patients, but long-term mesh-related morbidity is largely unknown.

Methods: Patients receiving a prophylactic onlay or retrorectus mesh in the PRIMA trial between 2009 and 2012 were included on an as-treated basis from participating centers that made reoperation notes available. The main outcomes were the incidences of complications requiring mesh explantation, mesh-related ileus, and mesh-related problems during laparotomy for other diagnoses.

Results: Out of 373 patients randomized to prophylactic mesh reinforcement, 242 were included: 127 with onlay and 115 patients with retrorectus mesh. Median follow-up is 27 months (interquartile range: 12-78). Thirty-four patients underwent reoperation for any reason during the entire follow-up, 22 after onlay (17.3%), and 12 after retrorectus mesh (10.4%). The reoperation rate for complications that required mesh explantation was 4/127 (3.1%) after onlay and 0/115 (0%) after retrorectus mesh. Mesh-related ileus occurred in none of the onlay group, and 3/115 (2.6%) in the retrorectus group. During subsequent laparotomies for other primary diagnoses, adhesions to the mesh were noted in 3/10 patients in the onlay group and 1/5 patients in the retrorectus group. Overall, the mesh was removed in 10/127 (7.9%) in the onlay group and 7/115 (6.1%) patients in the retrorectus group.

Conclusions: In high-risk patients receiving a prophylactic mesh during midline laparotomy closure, low incidences of mesh-related complications requiring reoperation and mesh-related problems during unrelated subsequent laparotomies were found, for both the onlay and retrorectus techniques.

Objective: Complications after esophagectomy are associated with poor long-term outcomes; however, the prognostic impacts of postoperative complications in patients receiving intensive neoadjuvant chemotherapy remain unclear. This study aimed to investigate the association between postoperative complications and the prognosis of patients receiving intensive neoadjuvant treatment.

Summary background data: This study is a supplementary analysis of JCOG1109, which is a phase III randomized trial that assessed the efficacy of neoadjuvant doublet chemotherapy (cisplatin plus 5-fluorouracil [CF]), triplet chemotherapy (docetaxel plus cisplatin plus 5-FU [DCF]), and chemoradiotherapy (radiation with CF [CF-RT]) in patients with locally advanced esophageal cancer.

Methods: Patients were randomly assigned to one of the three preoperative therapies, followed by open esophagectomy (OE) or thoracoscopic esophagectomy (TE) with regional lymphadenectomy. Postoperative complications (Grade ≥2) and their impacts on overall survival (OS) and progression-free survival (PFS) were assessed within each arm.

Results: A total of 601 patients were randomized (CF/DCF/CF-RT: 199/202/200) and 541 underwent esophagectomy (CF/DCF/CF-RT: 183/181/177) between 2012 and 2018. Postoperative complications, including pneumonia, anastomotic leakage, recurrent laryngeal nerve paralysis, and infectious complications, exhibited no significant impact on OS in any treatment arm. TE introduction appeared to attenuate the prognostic impact of complications: hazard ratios for OS shifted from 1.557 to 0.802, from 1.151 to 0.703, and from 1.548 to 1.186 in the CF, DCF, and CF-RT arms, when comparing OE with TE, respectively.

Conclusion: In this exploratory analysis of JCOG1109, postoperative complications were not significantly associated with prognosis. Minimally invasive esophagectomy, such as TE and intensified neoadjuvant therapy, may reduce the negative prognostic impact of complications.