The accordion severity grading system of surgical complications. Ann Surg. 2009;250:177-186. [PMID: 19638919 DOI: 10.1097/sla.0b013e3181afde41]

Factors predictive of postoperative morbidity and cost in patients with endometrial cancer

OBJECTIVE

To identify patient characteristics and perioperative factors predictive of 30-day morbidity and cost in patients with endometrial carcinoma.

METHODS

Data of consecutive patients treated with hysterectomy for endometrial carcinoma between 1999 and 2008 were collected prospectively. Thirty predictors were chosen from more than 130 collected based on anticipated clinical relevance and prevalence (more than 3%). Complications were graded per the Accordion Classification. Multivariable models were developed using stepwise and backward variable selection methods. Thirty-day cost analyses were expressed in 2010 Medicare dollars.

RESULTS

Of 1,369 patients, significant predictors (P<.01) of grade 2 and higher morbidity included American Society of Anesthesiologists physical status classification system class higher than 2 (odds ratio [OR] 2.1), preoperative white blood count (OR 2.1 per doubling), history of deep vein thrombosis (OR 2.1), pelvic and para-aortic lymphadenectomy (OR 2.3 compared with no lymphadenectomy), laparotomy (OR 2.8 compared with minimally invasive surgery), myometrial invasion more than 50% (OR 2.4), operating time (OR 1.9 per doubling), and grade 4 surgical complexity (OR 2.7 compared with grade 1). After controlling for patient factors in a multivariable model, laparotomy, pelvic, and para-aortic lymphadenectomy were associated with significant increases in cost compared with the use of minimally invasive surgery or hysterectomy alone.

CONCLUSION

This analysis identifies patient and perioperative care factors predictive of 30-day morbidity and cost. These data are useful for preoperative counseling, for defining equitable reimbursement and factors critical for risk-adjustment when comparing outcomes, and for identifying areas for quality improvement in patients with endometrial carcinoma. Given the marked increases in morbidity and cost associated with laparotomy and lymphadenectomy, minimally invasive surgery and selective lymphadenectomy should be standard treatment for patients with endometrial carcinoma.

Comparison of totally laparoscopic total gastrectomy and open total gastrectomy for gastric cancer

BACKGROUND

The technique of totally laparoscopic total gastrectomy (TLTG) has been developed for gastric cancer, but its feasibility and surgical outcomes remain unclear. This is the first study comparing the early surgical outcomes of TLTG with those of conventional open total gastrectomy (OTG) for gastric cancer.

PATIENTS AND METHODS

Between January 2011 and December 2011, 139 patients underwent TLTG, and 207 patients underwent OTG for gastric cancer; surgical procedures were selected by means of preoperative diagnostic tests under T3N2M0. Clinicopathologic characteristics and early surgical outcomes in the two groups were compared retrospectively.

RESULTS

There were no significant difference in preoperative characteristics between the two groups, and the durations of surgery were not significantly different. However, TLTG was superior to OTG in terms of time to first flatus, time to commencement of soft diet, pain score (visual analog scale), need for analgesics, length of hospital stay, and overall postoperative complications (each P<.05). The median number of lymph nodes harvested was significantly higher in the TLTG group (37 versus 34; P=.039). Resection margins were negative in all patients.

CONCLUSIONS

TLTG should be considered as a safe and practicable alternative to OTG for the treatment of gastric cancer. Moreover, it is less invasive and results in faster recovery than OTG.

Intracorporeal laparoscopic Roux-en-Y gastrojejunostomy after 95% gastrectomy for early gastric cancer in the upper third of the stomach: a report on 21 cases

BACKGROUND

Many reconstructive procedures have been developed in an effort to resolve complications after total gastrectomy (TG). However, anatomical disruption of the esophagogastric junction, especially the low esophageal sphincter, still occurs so that postoperative complications continue to arise. In this study, we developed a procedure for intracorporeal laparoscopic Roux-en-Y gastrojejunostomy (RYGJ) after 95% (near-total) gastrectomy, to reduce postoperative complications in early gastric cancer (EGC) of the upper third of the stomach.

PATIENTS AND METHODS

Laparoscopic RYGJ after 95% gastrectomy was performed on 21 patients with EGC in the upper third of the stomach between May 2011 and April 2012 in Asan Medical Center, Seoul, Korea. The resection line of the stomach was marked using metallic preoperative endoscopic clips and intraoperative laparascopic vessel clips together with a portable abdominal radiograph. Approximately 95% of the stomach was transected using an endoscopic linear stapler, and an antecolic side-to-side gastrojejunal anastomosis was created between the posterior side of the gastric remnant and the antimesenteric side of the jejunal limb, also using an endoscopic linear stapler. The entry hole was first closed in approximate fashion with three sutures, and closure was completed with an endoscopic linear stapler.

RESULTS

Intracorporeal laparoscopic RYGJ after 95% gastrectomy was successfully performed in all patients. No patients required conversion to open surgery or other laparoscopic anastomosis techniques. No postoperative complications occurred. All patients had tumor-free resection margins, and there was no mortality.

CONCLUSIONS

Intracorporeal laparoscopic RYGJ after 95% gastrectomy can be performed easily and safely. We recommend this method over laparoscopic TG or open TG for treatment of EGC in the upper third of the stomach.

Defining quality for distal pancreatectomy: does the laparoscopic approach protect patients from poor quality outcomes?

INTRODUCTION

Established systems for grading postoperative complications do not change the assigned grade when multiple interventions or readmissions are required to manage a complication. Studies using these systems may misrepresent outcomes for the surgical procedures being evaluated. We define a quality outcome for distal pancreatectomy (DP) and use this metric to compare laparoscopic distal pancreatectomy (LDP) to open distal pancreatectomy (ODP).

METHODS

Records for patients undergoing DP between January 2006 and December 2009 were reviewed. Clavien-Dindo grade IIIb, IV, and V complications were classified as severe adverse--poor quality--postoperative outcomes (SAPOs). II and IIIa complications requiring either significantly prolonged overall lengths of stay including readmissions within 90 days or more than one invasive intervention were also classified as SAPOs.

RESULTS

By Clavien-Dindo system alone, 91 % of DP patients had either no complication or a low/moderate grade (I, II, IIIa) complication. Using our reclassification, however, 25 % had a SAPO. Patients undergoing LDP demonstrated a Clavien-Dindo complication profile identical to that for SDP but demonstrated significantly shorter overall lengths of stay, were less likely to require perioperative transfusion, and less likely to have a SAPO.

CONCLUSIONS

Established systems undergrade the severity of some complications following DP. Using a procedure-specific metric for quality, we demonstrate that LDP affords a higher quality postoperative outcome than ODP.

Predictors of unsuccessful laparoscopic resection of gastric submucosal neoplasms

BACKGROUND

While laparoscopy has become integral to the performance of foregut surgery, its optimal use in resection of gastric submucosal neoplasms, including gastrointestinal stromal tumors (GISTs), remains uncertain. Concern exists for technical feasibility related to tumor size and location, as well as oncologic outcome.

METHODS

From 2002 to 2012, 106 patients underwent resection for gastric submucosal neoplasms, comprising 79 laparoscopic and 27 open resections. Median follow-up was 15 months.

RESULTS

Patients were 62 ± 14 years and 56 % male. Mean tumor size was 5.5 ± 4.3 cm, with 76 % being GISTs. A total of 8 (10 %) conversions occurred in the laparoscopic cohort. On multivariate analysis, conversion was predicted by size greater than 8 cm, while recurrence was predicted by mitotic index (p < 0.05). Laparoscopic resection resulted in better perioperative outcomes, with less morbidity, operative time, blood loss, and length of stay (p < 0.05). No significant difference was seen in survival, with 90 % and 81 % alive 3 years after laparoscopic and open resection, respectively (HR 0.4; 95 % CI 0.1-1.3; p = 0.13).

CONCLUSIONS

Laparoscopic resection is feasible and effective in the management of gastric submucosal neoplasms, including GISTs. Caution should be reserved for tumors greater than 8 cm. Oncologic outcome appears to be predicted by tumor biology as opposed to surgical approach.

A contemporary analysis of survival for resected pancreatic ductal adenocarcinoma

INTRODUCTION

Survival after a resected pancreatic ductal adenocarcinoma (PDAC) appears to be improving. Yet, in spite of advancements, prognosis remains disappointing. This study analyses a contemporary experience and identifies features associated with survival.

METHODS

Kaplan-Meier analysis was conducted for 424 PDAC resections performed at two institutions (2001-2011). Multivariate analysis was performed to elicit characteristics independently associated with survival.

RESULTS

The median, 1-, and 5-year survivals were 21.3 m, 76%, and 23%, with 30/90-day mortalities of 0.7%/1.7%. 76% of patients received adjuvant therapy. Patients with major complications (Clavien Grade IIIb-IV) survived equivalently to patients with no complications (P = 0.33). The median and 5-year survival for a total pancreatectomy was 32.2 m/49%; for 90 'favourable biology' patients (R0/N0/M0) was 37.3 m/40%; and for IPMN (9% of series) was 21.2 m/46%. Elderly (>75 yo) and nonelderly patients had similar survival. Favorable prognostic features by multivariate analysis include lower POSSUM physiology score, R0 resection, absence of operative transfusion, G1/G2 grade, absence of lymphovascular invasion, T1/T2 stage, smaller tumor size, LN ratio <0.3, and receipt of adjuvant therapy.

CONCLUSION

This experience with resected PDAC shows decreasing morbidity and mortality rates along with modestly improving long-term survival, particularly for certain subgroups of patients. Survival is related to pathological features, pre-operative physiology, operative results and adjuvant therapy.

The pelvic floor complication scale: a new instrument for reconstructive pelvic surgery

OBJECTIVE

The purpose of this study was to develop and test a unique, new pelvic floor surgery complication scale and compare it with an existing validated measure.

STUDY DESIGN

Surgeons from 2 clinical trials networks rated complications based on perceived patient bother, severity, and duration of disability to develop a pelvic floor complication scale (PFCS). PFCS scores were calculated for subjects in 2 multicenter pelvic floor surgical trials. The PFCS and modified Clavien-Dindo scores were evaluated for associations with length of hospitalization, satisfaction, and quality-of-life measures (health utilities index, short form-36, urogenital distress inventory, and incontinence impact questionnaire).

RESULTS

We calculated PFCS scores for 977 subjects. Higher PFCS and Clavien-Dindo scores similarly were associated with longer length of hospitalization (P < .01), lower satisfaction (P < .01), lower Health Utilities Index scores (P = .02), lower short form-36 scores (P = .02), higher urogenital distress Inventory scores (P < .01), and incontinence impact questionnaire scores (P < .01) at 3 months. No associations were present at 1 year.

CONCLUSION

The PFCS compares favorably to the validated modified Clavien-Dindo instrument.

[Reporting and grading of complications after urologic surgical procedures: an ad hoc EAU guidelines panel assessment and recommendations]

CONTEXT

The incidence of postoperative complications is still the most frequently used surrogate marker of quality in surgery, but no standard guidelines or criteria exist for reporting surgical complications in the area of urology.

OBJECTIVE

To review the available reporting systems used for urologic surgical complications, to establish a possible change in attitude towards reporting of complications using standardised systems, to assess systematically the Clavien-Dindo system when used for the reporting of complications related to urologic surgical procedures, to identify shortcomings in reporting complications, and to propose recommendations for the development and implementation of future reporting systems that are focused on patient-centred outcomes.

EVIDENCE ACQUISITION

Standardised systems for reporting and classification of surgical complications were identified through a systematic review of the literature. To establish a possible change in attitude towards reporting of complications related to urologic procedures, we performed a systematic literature search of all papers reporting complications after urologic surgery published in European Urology, Journal of Urology, Urology, BJU International, and World Journal of Urology in 1999-2000 and 2009-2010. Data identification for the systematic assessment of the Clavien-Dindo system currently used for the reporting of complications related to urologic surgical interventions involved a Medline/Embase search and the search engines of individual urologic journals and publishers using Clavien, urology, and complications as keywords. All selected papers were full-text retrieved and assessed; analysis was done based on structured forms.

EVIDENCE SYNTHESIS

The systematic review of the literature for standardised systems used for reporting and classification of surgical complications revealed five such systems. As far as the attitude of urologists towards reporting of complications, a shift could be seen in the number of studies using most of the Martin criteria, as well as in the number of studies using either standardised criteria or the Clavien-Dindo system. The latter system was not properly used in 72 papers (35.3%).

CONCLUSIONS

Uniformed reporting of complications after urologic procedures will aid all those involved in patient care and scientific publishing (authors, reviewers, and editors). It will also contribute to the improvement of the scientific quality of papers published in the field of urologic surgery. When reporting the outcomes of urologic procedures, the committee proposes a series of quality criteria.

Laparoscopic primary repair with omentopexy for duodenal ulcer perforation: a single institution experience of 21 cases

PURPOSE

Despite the great advances in laparoscopic techniques, most active general surgeons do not apply laparoscopic surgery in the treatment of duodenal ulcer perforation when facing a real-life emergency. Therefore, our study was designed to evaluate the feasibility of laparoscopic surgery in duodenal ulcer perforation, and provide a step-by-step protocol with tips and recommendations for less experienced surgeons.

MATERIALS AND METHODS

Between March, 2011 and May, 2012, 21 patients presenting with duodenal ulcer perforation underwent laparoscopic primary repair with omentopexy. There were no contraindications to perform laparoscopic surgery, and the choice of primary repair was decided according to the size of the perforation. The procedure for laparoscopic primary repair with omentopexy consisted of peritoneal lavage, primary suture, and omentopexy using a knot pusher.

RESULTS

During the operation, no conversion to open surgery or intra-operative events occurred. The median operation time was 45.0 minutes (20~80 minutes). Median day of commencement of a soft diet was day 6 (4~17 days). After surgery, the median hospital stay was 8.0 days (5~27 days). Postoperative complications occurred in one patient, which included a minor leakage. This complication was resolved by conservative management.

CONCLUSIONS

Although our study was carried out on a small number of patients at a single institution, we conclude that laparoscopic primary repair can be an effective surgical method in the treatment of duodenal ulcer perforation. We believe that the detailed explanation of our procedure will help beginners to perform laparoscopic primary repair more easily.

The value of preoperative lung spirometry test for predicting the operative risk in patients undergoing gastric cancer surgery

PURPOSE

We evaluated the predictive value of preoperative lung spirometry test for postoperative morbidity and the nature of complications related to an abnormal pulmonary function after gastric cancer surgery.

METHODS

Between February 2009 and March 2010, 538 gastric cancer patients who underwent laparoscopic (n = 247) and open gastrectomy (n = 291) were divided into the normal (forced expiratory volume in 1 second [FEV(1)]/forced vital capacity [FVC] ≥ 0.7, n = 441) and abnormal pulmonary function group (FEV(1)/FVC < 0.7, n = 97), according to the preoperative lung spirometry test. The predictive value of lung spirometry for postoperative morbidity was evaluated using the univariate and multivariate analysis.

RESULTS

After surgery, the abnormal pulmonary function group showed a significantly increased incidence of local (29.9% vs. 18.1%, P = 0.009) and systemic complications (8.2% vs. 2.0%, P = 0.005) than the normal group. Of local complications, anastomosis leakage and wound complication were found to be more common in the abnormal pulmonary function group. In the univariate and multivariate analysis, an abnormal pulmonary function was an independent predictor for postoperative local complication (odds ratio, 1.75; 95% confidence interval, 1.03 to 2.97) after adjusted by old age, total gastrectomy, open surgery, and tumor-node-metastasis stage. Meanwhile, an old age and a history of pulmonary disease were independent predictors for systemic complication.

CONCLUSION

Preoperative lung spirometry is a simple and useful means to predict postoperative morbidity after gastric cancer surgery. In view of its simplicity and low cost, we recommend adding preoperative lung spirometry test to assess the operative risk and aid in proper perioperative treatment planning.

Neoadjuvant chemotherapy improves survival rate in advanced urothelial carcinoma

Radical surgery (RS) with adjuvant chemotherapy (AC) or radiotherapy has been conventionally used for patients with advanced urothelial carcinoma (AUC). Recent research has indicated that systemic neoadjuvant chemotherapy (NC) with RS yields better outcomes than RS alone for patients with locally advanced bladder cancer. However, there are no reports indicating whether NC or AC would be beneficial for patients with AUC. The present study compared the survival rate for AUC patients receiving NC or AC. A retrospective analysis was conducted using data for 64 patients with AUC who underwent RS and systemic chemotherapy at our institution between March 2002 and March 2011. Of the 64 patients, 30 received NC before RS and 34 received RS followed by systemic AC. Pathologic stages (p=0.002), grades (p=0.018) and lymphovascular invasion (p=0.047) were significantly lower in the patients who received NC first than in those who received RC first. Furthermore, analysis of the surgical specimens revealed that 26.7% of patients who received NC before RS had complete remission. There were no significant differences in demographic data, surgical complications, and chemotoxicity between the two patient groups. The progression-free survival (PFS) and overall survival (OS) of patients who received initial NC were significantly better than those of patients who received initial RC (p=0.002 and 0.018, respectively). Our results indicate that NC administration before RS significantly improved the PFS and OS of AUC patients, without increasing surgical complications and chemotoxicity. Further prospectively controlled trials need to be conducted to confirm the effectiveness of NC for AUC patients.

Laparoscopic surgery for submucosal tumor near the esophagogastric junction

BACKGROUND

Laparoscopic surgery is widely accepted as a treatment for gastric submucosal tumors (SMTs). However, laparoscopy is not easily applied to tumors near the esophagogastric junction (EGJ). This study was conducted to evaluate laparoscopic techniques for treating SMTs near the EGJ.

SUBJECTS AND METHODS

Between March 2008 and August 2012 at the Asan Medical Center, Seoul, Korea, we performed laparoscopic surgery on 71 patients who had SMTs located within 3 cm of the EGJ. The laparoscopic approach chosen depended on the position of the tumor, which was located accurately by preoperative diagnosis.

RESULTS

None of the patients required conversion to open surgery. Of the 71 patients in the study, 66 had laparoscopic wedge resection (LAPWR), 4 had laparoscopic enucleation, and 1 had laparoscopic proximal gastrectomy. Two patients had intraoperative events during LAPWR. One had EGJ stricture, which required laparoscopic esophagogastrostomy. The other had a muscle defect of the posterior wall of the distal esophagus, and the defect was covered using fundus-like fundoplication. All patients had tumor-free resection margins, and there were no deaths.

CONCLUSIONS

Laparoscopic resection of SMTs near the EGJ may be performed safely. The laparoscopic approach used depends on the location and size of the tumor and on the extent of gastric resection.

Surgical stress after robot-assisted distal gastrectomy and its economic implications

BACKGROUND

There is a lack of reports evaluating the outcomes of robotic gastrectomy and conventional laparoscopic surgery. The aim of this study was to compare the surgical stress response and costs of robot-assisted distal gastrectomy (RADG) with those of laparoscopy-assisted distal gastrectomy (LADG).

METHODS

This prospective study compared a cohort of patients who had RADG with a cohort that underwent conventional LADG for early gastric cancer between March 2010 and May 2011. The surgical outcomes including Eastern Cooperative Oncology Group performance status and complications, surgical stress response and overall costs were compared between the two groups.

RESULTS

Thirty patients were enrolled in the RADG group and 120 in the LADG group. There were no conversions. Median duration of operation was longer in the RADG group (218 (interquartile range 200-254) versus 140 (118-175) min; P < 0·001). Postoperative abdominal drain production was less (P = 0·001) and postoperative performance status was worse (P < 0·001) in the RADG group. C-reactive protein (CRP) levels on postoperative days 1 and 3, and interleukin (IL) 6 level on the third postoperative day, were lower in the LADG compared with the RADG group (CRP: P = 0·002 and P = 0·014 respectively; IL-6: P < 0·001). Costs for robotic surgery were much higher than for laparoscopic surgery (difference €3189).

CONCLUSION

RADG did not reduce surgical stress compared with LADG. The substantial RADG costs due to robotic system expenses may not be justified.

Robotic versus laparoscopic anterior resection of sigmoid colon cancer: comparative study of long-term oncologic outcomes

BACKGROUND

Robotically assisted colon resection is a new type of surgery for colon cancer. However, the evidence is inadequate for the general adaptation of robotic colon surgery. This study aimed to show the oncologic and perioperative clinical results of robotically assisted anterior resection (R-AR) compared with those of laparoscopically assisted anterior resection (L-AR) for sigmoid colon cancer.

METHODS

A total of 180 patients (sigmoid colon cancer stages 1-3) were assigned to receive either R-AR (n = 34) or L-AR (n = 146) between April 2006 and September 2008. Patient characteristics, perioperative clinical results, and long-term oncologic outcomes were compared between the two groups.

RESULTS

The patient characteristics did not differ significantly between the two groups. The mean operation time was 217.6 ± 70.7 min for L-AR versus 252.5 ± 94.9 min for R-AR (p = 0.016). The total postoperative complication rate was 10.3 % for R-AR versus 5.9 % for L-AR (p = 0.281). The 3-year overall survival rate for all the patients was 93.4 % for L-AR versus 92.1 % for R-AR (p = 0.723). The 3-year overall survival rate was 100 % for both L-AR and R-AR in stage 1, 95.5 % for L-AR versus 100 % for R-AR (p = 0.386) in stage 2, and 88.4 % for L-AR versus 72.9 % (p = 0.881) for R-AR in stage 3.

CONCLUSION

In this study, R-AR showed safety and feasibility in terms of perioperative clinical and long-term oncologic outcomes. However, the advanced technologies of R-AR did not translate into better long-term oncologic outcomes compared with L-AR.

Impact of postoperative morbidity on long-term survival after oesophagectomy

Background

Oesophageal malignancy is a disease with a poor prognosis. Oesophagectomy is the mainstay of curative treatment but associated with substantial morbidity and mortality. Although mortality rates have improved, the incidence of perioperative morbidity remains high. This study assessed the impact of postoperative morbidity on long-term outcomes.

Methods

A prospective database was designed for patients undergoing oesophagectomy for malignancy from 1998 to 2011. An observational cohort study was performed with these data, assessing intraoperative technical complications, postoperative morbidity and effects on overall survival.

Results

Some 618 patients were included, with a median follow-up of 51 months for survivors. The overall complication rate was 64·6 per cent (399 of 618), with technical complications in 124 patients (20·1 per cent) and medical complications in 339 (54·9 per cent). Technical complications were associated with longer duration of surgery (308 min versus 293 min in those with no technical complications; P = 0·017), greater operative blood loss (448 versus 389 ml respectively; P = 0·035) and longer length of stay (22 versus 13 days; P &lt; 0·001). Medical complications were associated with greater intraoperative blood loss (418 ml versus 380 ml in those with no medical complications; P = 0·013) and greater length of stay (16 versus 12 days respectively; P &lt; 0·001). Median overall and disease-free survival were 41 and 43 months. After controlling for age, tumour stage, resection margin, length of tumour, adjuvant therapy, procedure type and co-morbidities, there was no effect of postoperative complications on disease-specific survival.

Conclusion

Technical and medical complications following oesophagectomy were associated with greater intraoperative blood loss and a longer duration of inpatient stay, but did not predict disease-specific survival.

Hospital morbidity rankings and complication severity in vascular surgery

INTRODUCTION

The American College of Surgeons National Surgical Quality Improvement Program ranks hospitals according to risk-adjusted rates of postoperative complications. However, this approach does not consider the severity or number of complications that occurred. We sought to determine whether incorporating this information would alter hospital rankings.

METHODS

The study examined data for the 39,519 patients who underwent major vascular surgery in 206 National Surgical Quality Improvement Program hospitals during 2008 to 2009. We categorized postoperative complications as minor or severe and evaluated the extent to which minor and severe complications increased a patient's risk of death and prolonged length of stay. We then ranked hospitals on two alternative approaches that included severity or number of complications. We determined the effect of these alternative methods by assessing the proportion of hospitals that moved out of the top and bottom 20% of hospitals compared with standard rankings.

RESULTS

Compared with patients with minor complications, patients with severe complications had a higher mortality rate (16.2% vs 3.6%; P<.001) and prolonged length of stay (66.7% vs 53.3%; P<.001). Patients with two or more complications also had a higher mortality rate (23.7% vs 6.0%; P<.001) and prolonged length of stay (77.0% vs 50.1%; P<.001) than patients with only one complication. Compared with the current approach for assessing morbidity, ranking hospitals by severe complications resulted in 12 hospitals (29%) moving out of the top 20% and 10 hospitals (24%) moving out of the bottom 20%. A similar degree of reclassification was found when the current rankings were compared with an alternative approach that considered the number of different complications.

CONCLUSIONS

Although the severity and number of postoperative complications affect mortality and length of stay, and subsequently, hospital rankings, existing measurement systems do not take this into account. Quality measurement platforms should consider weighting complications according to severity and number.

Reporting of short-term clinical outcomes after esophagectomy: a systematic review

OBJECTIVE

This review summarizes reporting of complications of esophageal cancer surgery.

BACKGROUND

Accurate assessment of morbidity and mortality after surgery for cancer is essential to compare centers, allow data synthesis, and inform clinical decision-making. A lack of defined standards may distort clinically relevant treatment effects.

METHODS

Systematic literature searches identified articles published between 2005 and 2009 reporting morbidity and mortality after esophagectomy for cancer. Data were analyzed for frequency of complication reporting and to check whether outcomes were defined and classified for severity and whether a validated system for grading complications was used. Information about reporting outcomes adjusting for baseline risk factors was collated, and a descriptive summary of the results of included outcomes was undertaken.

RESULTS

Of 3458 abstracts, 224 full papers were reviewed and 122 were included (17 randomized trials and 105 observational studies), reporting outcomes of 57,299 esophagectomies. No single complication was reported in all papers, and 60 (60.6%) did not define any of the measured complications. Anastomotic leak was the most commonly reported morbidity, assessed in 80 (80.1%) articles, defined in 28 (28.3%), but 22 different descriptions were used. Five papers (5.1%) categorized morbidity with a validated grading system. One hundred fifteen papers reported postoperative mortality rates, 25 defining the term using 10 different definitions. In-hospital mortality was the most commonly used term for postoperative death, with 6 different interpretations of this phrase. Eighteen papers adjusted outcomes for baseline risk factors and 60 presented baseline measures of comorbidity.

CONCLUSIONS

Outcome reporting after esophageal cancer surgery is heterogeneous and inconsistent, and it lacks methodological rigor. A consensus approach to reporting clinical outcomes should be considered, and at the minimum it is recommended that a "core outcome set" is defined and used in all studies reporting outcomes of esophageal cancer surgery. This will allow meaningful cross study comparisons and analyses to evaluate surgery.

Variable impact of complications in general surgery: a prospective cohort study

BACKGROUND

Registering complications is important in surgery, since complications serve as outcome measures and indicators of quality of care. Few studies have addressed the variation in severity and consequences of complications. We hypothesized that complications show much variation in consequences and severity.

METHODS

We conducted a prospective observational cohort study to evaluate consequences and severity of complications in surgical practice. All recorded complications of patients admitted to our hospital between June 1, 2005, and Dec. 31, 2007, were prospectively recorded in an electronic database. Complications were classified according to the system of the Trauma Registry of the American College of Surgeons. We graded the severity of complications according to the system proposed by Clavien and colleagues, and the consequences of each complication were registered.

RESULTS

During the study period, 3418 complications were recorded; consequences and severity were recorded in 89% of them. Of 3026 complications, 987 (33%) were grade I, 781 (26%) were grade IIa, 1020 (34%) were grade IIb, 150 (5%) were grade III and 88 (3%) were grade IV. The consequences and severity of identically registered complications showed a large degree of variation, best illustrated by wound infections, which were grade I in 50%, grade IIa in 22%, grade IIb in 28% and grade III and IV in 0.3% of patients.

CONCLUSION

Severity should be routinely presented when reporting complications in clinical practice and surgical research papers to adequately compare quality of care and results of clinical trials.

Prospective assessment of survival, morbidity, and cost associated with lymphadenectomy in low-risk endometrial cancer

OBJECTIVE

Since 1999, patients with low risk endometrial cancer (EC) as defined by the Mayo criteria have preferably not undergone lymphadenectomy (LND) at our institution. Here we prospectively assess survival, sites of recurrence, morbidity, and cost in this low risk cohort.

METHODS

Cause-specific survival (CSS) was estimated using the Kaplan-Meier method and compared using the log-rank test. Complications were graded per the Accordion Classification. Thirty-day cost analyses were expressed in 2010 Medicare dollars.

RESULTS

Among 1393 consecutive surgically managed cases, 385 (27.6%) met inclusion criteria, accounting for 34.1% of type I EC. There were 80 LND and 305 non-LND cases. Complications in the first 30 days were significantly more common in the LND cohort (37.5% vs. 19.3%; P<0.001). The prevalence of lymph node metastasis was 0.3% (1/385). Over a median follow-up of 5.4 years only 5 of 31 deaths were due to disease. The 5-year CSS in LND and non-LND cases was 97.3% and 99.0%, respectively (P=0.32). None of the 11 total recurrences occurred in the pelvic or para-aortic nodal areas. Median 30-day cost of care was $15,678 for LND cases compared to $11,028 for non-LND cases (P<0.001). The estimated cost per up-staged low-risk case was $327,866 to $439,990, adding an additional $1,418,189 if all 305 non-LND cases had undergone LND.

CONCLUSION

Lymphadenectomy dramatically increases morbidity and cost of care without discernible benefits in low-risk EC as defined by the Mayo criteria. In these low-risk patients, hysterectomy with salpingo-oophorectomy alone is appropriate surgical management and should be standard of care.

Accordion severity grading system: assessment of relationship between costs, length of hospital stay, and survival in patients with complications after esophagectomy for cancer

BACKGROUND

The ability to assess and compare the impact of postoperative complications in major cancer surgery is currently limited. The Accordion Severity Grading System provides the opportunity to categorize complications according to treatment responses and resource use.

STUDY DESIGN

A retrospective review of patient demographics, perioperative outcomes, and costs was performed using a prospective IRB-approved database of patients undergoing esophagectomy from 2000 to 2008.

RESULTS

This study included 285 consecutive patients, 83% were male, and mean age was 63.7 years. Histology was predominantly adenocarcinoma (80%). For patients with invasive cancer, overall survival at 5 years was 50%. Mean overall cost and length of stay were $23,419 and 10.4 days, respectively. Neoadjuvant therapy was used in 156 patients (54.7%) and operative mortality rate was 0.7%. Complications were documented in 144 patients (50.5%), with Accordion grades assigned as 1 (29%), 2 (59%), 3 (3%), 4 (6%), 5 (2%), and 6 (0.7%). Accordion grade was significantly related to costs and length of stay in univariate (p < 0.005) and multivariate analyses (p < 0.005). There was a statistically significant difference in survival between those patients who did and did not experience complications; however, no significant differences were noted among individual Accordion grades. Cox regression multivariate analysis demonstrated a significant relationship between overall survival and occurrence of postoperative complications.

CONCLUSIONS

The Accordion Severity Grading System provides a meaningful approach to classifying complications according to resource use, which also directly correlates with treatment costs and length of stay. Survival is affected by overall occurrence of complications, but was not related to individual Accordion grades in this study. The Accordion Severity Grading System should be a component of prospective data collections and can be used in major cancer surgery to study areas appropriate for quality improvement and cost containment.

Short-term surgical outcomes and operative risks of laparoscopic total gastrectomy (LTG) for gastric carcinoma: experience at a large-volume center

BACKGROUND

Despite the popularity of laparoscopic distal gastrectomy (LDG), laparoscopic total gastrectomy (LTG) remains a challenging procedure because of its technical difficulties and possible complications. In this study, the authors evaluated the short-term surgical outcomes and operative risks of LTG.

METHODS

The records of 118 patients who underwent LTG for middle or upper gastric cancer were retrieved from a prospectively constructed database of 1,064 patients who underwent laparoscopic gastrectomy between 2007 and 2011. Surgical outcomes of LTG, such as operative results, postoperative courses, morbidities, and mortality, were investigated and compared with those of LDG patients.

RESULTS

Of the 118 LTG patients, one underwent open conversion and three experienced an intraoperative complication. Mean operating time was 292 ± 88 min, and the mean total number of harvested lymph nodes was 41 ± 16. As compared with the LDG group, the LTG group had a significantly longer operation time (292 vs. 220 min, p < 0.001), and significantly more intraoperative blood loss (256 vs. 191 ml, p = 0.002). The overall morbidity rate after LTG was 22.9%, which was significantly higher than after LDG (12.7%, p = 0.002). There were two postoperative mortalities in the LTG group. The most common complications after LTG were anastomosis leakage (n = 9) and luminal bleeding (n = 9), which were followed by anastomosis stricture (n = 4) and abdominal infection (n = 3). Univariate and multivariate analysis revealed that old age [≥60 years, odds ratio (OR) = 2.55, 95% confidence interval (CI) = 0.95-6.84], intraoperative blood loss >200 ml (OR = 3.33, 95% CI = 1.14-9.70), and D2 lymphadenectomy (OR = 3.87, 95% CI = 1.30-11.55) were independent risk factors for postoperative complications after LTG.

CONCLUSIONS

LTG is a feasible and acceptable procedure for treatment of middle or upper early gastric cancer. Further refinement of anastomosis techniques and considerable experience of laparoscopic gastrectomy are required for proper application of LTG in gastric carcinoma.

Hepatic resection for huge (>15 cm) multinodular HCC with macrovascular invasion

BACKGROUND

Surgical resection has routinely not been recommended for patients with huge (>15 cm) multinodular lesions and macrovascular invasion (advanced-stage hepatocellular carcinoma [HCC] patients) because of high operative mortality, recurrence rate, and lack of survival benefit.

METHODS

A retrospective study of 1425 patients was carried out, of which 1245 patients met EASL/AASLD criteria for hepatic resection (HR-EA group), 116 were surgically treated advanced-stage HCC patients (HR-AS group), and 64 were advanced-stage HCC patients receiving nonsurgical treatments (N-AS group).

CONCLUSION

HR may still be suitable for the HCC patients with huge (>15 cm) multinodular lesions and macrovascular invasion in selected cases. Advanced-stage HCC patients without liver cirrhosis and with a tumor-free resection margin could enjoy longer survival and lower recurrence. Preoperative and/or postoperative TACE provides no survival benefits for advanced-stage HCC patients.

Interrater reliability of the International Continence Society and International Urogynecological Association (ICS/IUGA) classification system for mesh-related complications

OBJECTIVE

We sought to assess interrater reliability of the International Continence Society (ICS)/International Urogynecological Association (IUGA) classification system of vaginal mesh-related complications and compare this with several other available complication classification systems.

STUDY DESIGN

This was a retrospective analysis of mesh-related complications in patients presenting after pelvic organ prolapse or incontinence surgery. The complications were classified by 2 independent reviewers using the ICS/IUGA classification system as well as 3 other available classification systems. Interrater reliability was assessed using percent agreement and the weighted κ statistic.

RESULTS

The ICS/IUGA mesh complication classification system was found to have poor interrater reliability (κ = 0.15-0.78). The other systems yielded a κ that ranged from 0.18-0.60, but were too general or could only be applied to 68% of the complications.

CONCLUSION

The complexity of the ICS/IUGA mesh complication system, the large number of categories, and lack of clarity likely contribute to its poor interrater reliability.

Oncologic Outcomes of a Laparoscopic Right Hemicolectomy for Colon Cancer: Results of a 3-Year Follow-up

PURPOSE

The purpose of the study is to evaluate the oncologic outcomes of a laparoscopic-assisted right hemicolectomy for the treatment of colon cancer and compare the results with those of previous randomized trials.

METHODS

From June 2006, to December 2008, 156 consecutive patients who underwent a laparoscopic right hemicolectomy with a curative intent for colon cancer were evaluated. The clinicopatholgic outcomes and the oncologic outcomes were evaluated retrospectively by using electronic medical records.

RESULTS

There were 84 male patients and 72 female patients. The mean possible length of stay was 7.0 ± 1.5 days (range, 4 to 12 days). The conversion rate was 3.2%. The total number of complications was 30 (19.2%). Anastomotic leakage was not noted. There was no mortality within 30 days. The 3-year overall survival rate of all stages was 93.3%. The 3-year overall survival rates according to stages were 100% in stage I, 97.3% in stage II, and 84.8% in stage III. The 3-year disease-free survival rate of all stages was 86.1%. The 3-year disease-free survival rates according to stage were 96.2% in stage I, 90.3% in stage II, and 75.6% in stage III. The mean follow-up period was 36.3 (3 to 60) months.

CONCLUSION

A laparoscopic right hemicolectomy for the treatment of colon cancer is technically feasible and safe to perform in terms of oncologic outcomes. The present data support previously reported randomized trials.

Impact of Body Mass Index on Outcomes of Laparoscopic Adrenal Surgery

Objective. The aim of this article is to define the relationship between body mass index (BMI) and outcomes of laparoscopic adrenalectomy. Method. A total of 172 patients were eligible for inclusion in the study. The patients were divided into 3 groups: group I, normal weight; group II, overweight; and group III, obesity. Perioperative outcomes were compared between the groups. Results. The median operative time was 72, 75, and 90 minutes in groups I, II, and III, respectively. The median blood loss was <50 mL in all groups. There were no intraoperative blood transfusions. There was no statistical difference in the rate of intraoperative incidences and postoperative complications. Moderately increased operative time was the only perioperative parameter that statistically differed from nonobese patients. The regression analysis found significant but weak correlation between BMI and operative time. The BMI did not correlate with other surgical outcomes. Conclusions. Laparoscopic adrenal surgery for obese patients can be done as safely as for nonobese patients.

Reporting and grading of complications after urologic surgical procedures: an ad hoc EAU guidelines panel assessment and recommendations

CONTEXT

The incidence of postoperative complications is still the most frequently used surrogate marker of quality in surgery, but no standard guidelines or criteria exist for reporting surgical complications in the area of urology.

OBJECTIVE

To review the available reporting systems used for urologic surgical complications, to establish a possible change in attitude towards reporting of complications using standardised systems, to assess systematically the Clavien-Dindo system when used for the reporting of complications related to urologic surgical procedures, to identify shortcomings in reporting complications, and to propose recommendations for the development and implementation of future reporting systems that are focused on patient-centred outcomes.

EVIDENCE ACQUISITION

Standardised systems for reporting and classification of surgical complications were identified through a systematic review of the literature. To establish a possible change in attitude towards reporting of complications related to urologic procedures, we performed a systematic literature search of all papers reporting complications after urologic surgery published in European Urology, Journal of Urology, Urology, BJU International, and World Journal of Urology in 1999-2000 and 2009-2010. Data identification for the systematic assessment of the Clavien-Dindo system currently used for the reporting of complications related to urologic surgical interventions involved a Medline/Embase search and the search engines of individual urologic journals and publishers using Clavien, urology, and complications as keywords. All selected papers were full-text retrieved and assessed; analysis was done based on structured forms.

EVIDENCE SYNTHESIS

The systematic review of the literature for standardised systems used for reporting and classification of surgical complications revealed five such systems. As far as the attitude of urologists towards reporting of complications, a shift could be seen in the number of studies using most of the Martin criteria, as well as in the number of studies using either standardised criteria or the Clavien-Dindo system. The latter system was not properly used in 72 papers (35.3%).

CONCLUSIONS

Uniformed reporting of complications after urologic procedures will aid all those involved in patient care and scientific publishing (authors, reviewers, and editors). It will also contribute to the improvement of the scientific quality of papers published in the field of urologic surgery. When reporting the outcomes of urologic procedures, the committee proposes a series of quality criteria.

Postoperative morbidity index: a quantitative measure of severity of postoperative complications

BACKGROUND

Postoperative complications are key outcomes of surgical procedures, but currently there is no uniform quantitative measure of complication severity. The purpose of this study was to evaluate and establish feasibility of quantitative morbidity scores for several common abdominal surgical procedures.

STUDY DESIGN

Using American College of Surgeons' National Surgical Quality Improvement Program data, complications were identified in 5 common abdominal procedures for one institution in 2005-2008, including inguinal hernia, appendectomy, laparoscopic colectomy, hepatectomy, and pancreaticoduodenectomy. Complications were graded by the 6-level "expanded" Accordion Severity Grading System. Quantification was performed using severity scores described previously.

RESULTS

Six hundred and seventy-six procedures were identified, including 88 patients (13.84%) who had complications and 5 patients (0.79%) who died. After severity weighting, the postoperative morbidity index (PMI) for each procedure was derived. An index of 0 would indicate no complication in any patient and an index of 1.000 would indicate that all operated patients died. PMIs were hernia repair 0.005; appendectomy 0.031; laparoscopic colectomy 0.082; hepatectomy 0.145; and pancreaticoduodenectomy 0.150. PMI of hepatectomy was greatly affected by the presence of a second procedure, ie, 0.070 without a second procedure and 0.427 with a second procedure. Weighted severity spectragrams were developed, portraying the impact of each grade of complication on overall morbidity.

CONCLUSIONS

Quantification of severity of postoperative complications is possible using American College of Surgeons' National Surgical Quality Improvement Program methods and the Accordion Severity Grading System. Procedural PMI can be useful in assessing surgical outcomes. Certain limitations, particularly the need for risk adjustment, still need to be addressed.

Comparative evaluation of laparoscopic liver resection for posterosuperior and anterolateral segments

Background

Totally laparoscopic liver resection of lesions located in the posterosuperior segments is reported to be technically challenging. This study aimed to define whether these technical difficulties affect the surgical outcome.

Methods

A total of 220 patients underwent laparoscopic liver resection during 244 procedures from August 1998 to December 2010. The patients who underwent primary minor single liver resection for malignant tumors affecting either posterosuperior segments 1, 7, 8, and, 4a (group 1) or anterolateral segments 2, 3, 5, 6, and 4b (group 2) were included in the study. Seventy-five procedures found to be eligible for the study, including 28 patients in group 1 and 47 patients in group 2. Intraoperative unfavorable incidents were graded on the basis of the Satava approach and postoperative complications were graded in agreement with the Accordion classification.

Results

The operative time (median, 127 min) and blood loss (median, 200 ml) were equivalent in the two groups. The rates for blood transfusions and intraoperative accidents did not differ statistically between the groups. A tumor-free margin resection was achieved in 94.7% of the procedures, equivalently in both groups. The postoperative course was similar in the two groups. Postoperative complications developed in 2 cases (7.1%) in group 1 and 2 cases (4.3%) in group 2 (p = 0.626). The median hospital stay was 2 days in both groups.

Conclusions

Laparoscopic liver resection for lesions located in posterosuperior segments represents certain technical challenges. However, appropriate adjustment of surgical techniques and optimal patient positioning enables the laparoscopic technique to provide safe and effective parenchyma-sparing resections for lesions located in both posterosuperior and anterolateral segments.

A practical way to overcome the learning period of laparoscopic gastrectomy for gastric cancer

BACKGROUND

Although laparoscopic gastrectomy is widely performed in patients with gastric cancer, it requires a learning period for surgeons. Few methods are known to reduce or overcome this learning period. We tested a method to reduce or overcome this learning period in the beginner surgeon.

METHODS

Between April 2009 and March 2010, a total of 139 patients underwent laparoscopic gastrectomy by a beginner surgeon. During their training period of 6 months, the beginner had been the first assistant during 200 laparoscopic gastrectomies. To evaluate surgical outcomes as the surgeon started to perform laparoscopic gastrectomy, outcomes were assessed in 79 patients who underwent laparoscopic-assisted distal gastrectomy with extracorporeal gastroduodenostomy (LADG); the first 30 were performed by the surgeon and 49 were performed subsequently. Outcomes of LADG and totally laparoscopic distal gastrectomy with intracorporeal gastroduodenostomy (TLDG) were compared to evaluate the beginner's ability to adapt to intracorporeal reconstruction. The learning period was assessed by dividing patients who underwent LADG and TLDG into sequential groups of five each by time.

RESULTS

No patient was converted to open surgery and none died. There were no significant differences between the first 30 patients and the next 49 who underwent LADG in surgical outcomes. The only significantly different outcome between LADG and TLDG was in operation time (95.9 min vs. 115.6 min, P < 0.001). There were no significant differences in mean operation times of sequential groups (LADG, P = 0.069; TLDG, P = 0.212).

CONCLUSIONS

The beginning surgeon examined in this work obtained satisfactory surgical outcomes during the early period of performing laparoscopic gastrectomy. We speculate that participation in laparoscopic gastrectomy team of experts improved the beginner's surgical outcomes, suggesting that such participation may reduce or overcome the learning period of beginners.

Safety of hepatic resection in overweight and obese patients with cirrhosis

Background

The simultaneous incremental increase in incidence of both obesity and hepatocellular carcinoma (HCC) will soon lead to more overweight and obese patients with cirrhosis needing surgery. At present, little is known about postoperative mortality and morbidity in such patients. This study investigated outcomes after hepatectomy in relation to obesity in a homogeneous cohort of patients with cirrhosis.

Methods

Perioperative data from 235 patients with cirrhosis who had hepatectomy for HCC were related to the presence of normal bodyweight (body mass index (BMI) 18·5–24·9 kg/m2), overweight (BMI 25·0–29·9 kg/m2) and obesity (BMI at least 30 kg/m2). Complications after surgery were graded according to the expanded Accordion Severity Classification of Postoperative Complications (T92).

Results

One hundred and one patients (43·0 per cent) were of normal bodyweight, 88 (37·4 per cent) were overweight and 46 (19·6 per cent) were obese; none was underweight. Overweight and obese groups showed a male preponderance (P = 0·024), and metabolic disorders were frequently the cause of cirrhosis in these patients (P &lt; 0·001 and P = 0·014 for non-B non-C hepatitis and alcoholic cirrhosis respectively). Liver function tests, tumour stage and extent of hepatectomy did not significantly differ between BMI groups. The intraoperative course and postoperative mortality were unaffected by BMI. Overweight and obese patients had significantly more mild respiratory complications (P = 0·044). Severe complications and organ system (including liver) failure were not significantly affected by BMI.

Conclusion

Hepatic resection can be performed safely in overweight and obese patients with cirrhosis, although morbidity is increased in these patients.

Major liver resection in elderly patients: a multi-institutional analysis

BACKGROUND

Because of the aging United States population, increase in overall life expectancy, and rising incidence of hepatobiliary tumors, more elderly patients are considered for hepatic resection. The objective of this study was to assess the influence of age on postoperative outcomes after major hepatectomy among a contemporary cohort from 2 high volume centers.

STUDY DESIGN

Demographics, diagnoses, surgical treatments, and postoperative outcomes of patients who underwent major hepatic resection were reviewed.

RESULTS

There were 856 patients who underwent major hepatectomy (resection of 3 or more segments) from 2002 to 2009. Postoperative mortality and morbidity occurred in 53 (6.2%) and 403 (47.1%) patients, respectively. Increasing age was independently associated with postoperative mortality (p = 0.0345). Each 1-year and 10-year increase in age resulted in an odds ratio of mortality after major hepatic resection of 1.036 (95% CI [1.003-1.071]) and 1.426 (95% CI [1.026-1.982]), respectively. This relationship was independent of American Society of Anesthesiology (ASA) score. Increasing age was associated with postoperative sepsis (p = 0.0224, odds ratio for each year 1.025 [range 1.003 to 1.048]) after major hepatic resection, but not overall postoperative morbidity.

CONCLUSIONS

In the contemporary era, increasing age is independently associated with postoperative mortality after major hepatic resection at high volume academic centers.

Defining higher-risk surgery

PURPOSE OF REVIEW

Defining the contemporary high-risk noncardiac surgical population using objective clinical outcomes data is paramount for the rational allocation of healthcare resources, truly informed patient consent and improving patient-centered outcomes.

RECENT FINDINGS

Data from independent healthcare systems have identified that the development, and consequences, of postoperative morbidity extend beyond the immediate postoperative hospital period and confer substantially increased risk of death. Cardiac insufficiency, rather than the relatively heavily explored paradigm of perioperative cardiac ischemia, is emerging as the dominant factor associated with excess risk of prolonged postoperative morbidity. The development of prospective, validated, time-sensitive morbidity data collection tools has also helped define patients at higher risk of noncardiac morbidities and short-term perioperative outcomes.

SUMMARY

Higher risk surgical patients present an increasingly major challenge for healthcare resource utilization. Detailed outcome studies using validated morbidity tools are urgently required to establish the extent to which postoperative morbidity may be predicted. Robust identification of patients at the highest risk of perioperative morbidity may permit further clinic-to-bench translational understanding of the pathophysiologic mechanisms underlying postoperative organ dysfunction. Defining the high-risk surgical patient population is as critically important for global public health planning as it is for the perioperative team.

Surgical vs percutaneous radiofrequency ablation for hepatocellular carcinoma in dangerous locations

AIM: To compare the long-term outcome of percutaneous vs surgical radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) in dangerous locations.

METHODS: One hundred and sixty-two patients with HCC in dangerous locations treated with percutaneous or surgical RFA were enrolled in this study. The patients were divided into percutaneous RFA group and surgical RFA group. After the patients were regularly followed up for a long time, their curative rate, hospital stay time, postoperative complications and 5-year local tumor progression were compared and analyzed.

RESULTS: No significant difference was observed in curative rate between the two groups (91.3% vs 96.8%, P = 0.841). The hospital stay time was longer and more analgesics were required while the incidence of bile duct injury and RFA-related hemorrhage was lower in surgical RFA group than in percutaneous RFA group (P < 0.05). The local progression rate of HCC in dangerous locations was significantly lower in surgical RFA group than in percutaneous RFA group (P = 0.05). The relative risk of local tumor progression was 14.315 in percutaneous RFA group.

CONCLUSION: The incidence of severe postoperative complications and local tumor progression is lower after surgical RFA than after percutaneous RFA.

Prognostic impact of underlying liver fibrosis and cirrhosis after curative resection of hepatocellular carcinoma

BACKGROUND

In the case of hepatocellular carcinoma (HCC), underlying liver pathology may not only determine the feasibility of surgery but may also affect the postsurgical outcome. We report our experience after curative liver resection for HCC in patients with normal liver, liver fibrosis, and liver cirrhosis.

METHODS

A total of 72 patients after liver resection with curative intention were analyzed. Histopathologic findings of tumor-unaffected liver tissue were used for retrospective classification: group A (normal liver); group B (liver fibrosis); group C (liver cirrhosis). The groups were compared for differences in short-term surgical results, total survival, and recurrence-free survival.

RESULTS

The rate of major complications was 34.7% and did not significantly differ among groups. The overall perioperative mortality rate was 9.7%, with one patient dying in group A and three patients dying in each of the other two groups. Including perioperative mortality, the median overall survival for the whole group was 37.3 months (95% confidence interval 29.3-45.2 months). The respective 1-, 2-, and 5-year survival rates for group A (n = 21) were 86%, 71%, and 50% and for group C (n = 24) 62%, 50%, and 17%. The overall survival of group B (n = 27) was intermediate (log-rank, P = 0.032). The respective recurrence-free survival rates were 76%, 42%, and 20% for group A and 39%, 13%, and 4% for group C, with group B being intermediate (log-rank, P = 0.016).

CONCLUSIONS

Our data demonstrate that liver resection in the presence of compensated liver cirrhosis is feasible but associated with a significantly impaired prognosis for overall and recurrence-free survival. The management of cirrhotic patients with compensated liver function and HCC therefore also requires the opportunity for transplantation.

Laparoscopic vs open resection for patients with rectal cancer: comparison of perioperative outcomes and long-term survival

PURPOSE

The aim of the study is to assess the safety and oncologic feasibility of laparoscopic-assisted resection for rectal cancer vs open rectal resection as a phase II pilot study for a planned randomized control trial.

METHODS

A case-matched controlled prospective analysis of 54 patients who underwent laparoscopic-assisted resection for stage I to III (no T4) rectal cancer within 12 cm of the anal verge from 2002 to 2005 was performed. Patients were matched with contemporary patients who underwent open rectal cancer surgery (n = 108) in a 1 to 2 fashion. The perioperative clinical outcomes, postoperative pathology, and oncologic outcomes were compared between the groups.

RESULTS

The demographic data did not differ significantly between the groups. The laparoscopic group manifested early return of bowel function (P = .003). The complication rate was 22.2% in the laparoscopic group and 32.4% in the open group (P = .178). Local recurrence was similar (2.0% laparoscopic, 4.2% open, P = .417). The 5-year overall and disease-free survival rate also were similar (overall survival, 90.8% laparoscopic, 88.5% open, P = .261; disease-free survival, 80.8% laparoscopic, 75.8% open. P = .390).

CONCLUSION

The laparoscopic-assisted resection for rectal cancer was acceptable in terms of oncologic outcomes and perioperative clinical outcomes. The present data are the basis for a large-scale randomized trial for comparison of laparoscopic and open rectal cancer surgeries (American College of Surgeons Oncology Group Z6051).

Effect of a comprehensive surgical safety system on patient outcomes

BACKGROUND

Adverse events in patients who have undergone surgery constitute a large proportion of iatrogenic illnesses. Most surgical safety interventions have focused on the operating room. Since more than half of all surgical errors occur outside the operating room, it is likely that a more substantial improvement in outcomes can be achieved by targeting the entire surgical pathway.

METHODS

We examined the effects on patient outcomes of a comprehensive, multidisciplinary surgical safety checklist, including items such as medication, marking of the operative side, and use of postoperative instructions. The checklist was implemented in six hospitals with high standards of care. All complications occurring during admission were documented prospectively. We compared the rate of complications during a baseline period of 3 months with the rate during a 3-month period after implementation of the checklist, while accounting for potential confounders. Similar data were collected from a control group of five hospitals.

RESULTS

In a comparison of 3760 patients observed before implementation of the checklist with 3820 patients observed after implementation, the total number of complications per 100 patients decreased from 27.3 (95% confidence interval [CI], 25.9 to 28.7) to 16.7 (95% CI, 15.6 to 17.9), for an absolute risk reduction of 10.6 (95% CI, 8.7 to 12.4). The proportion of patients with one or more complications decreased from 15.4% to 10.6% (P<0.001). In-hospital mortality decreased from 1.5% (95% CI, 1.2 to 2.0) to 0.8% (95% CI, 0.6 to 1.1), for an absolute risk reduction of 0.7 percentage points (95% CI, 0.2 to 1.2). Outcomes did not change in the control hospitals.

CONCLUSIONS

Implementation of this comprehensive checklist was associated with a reduction in surgical complications and mortality in hospitals with a high standard of care. (Netherlands Trial Register number, NTR1943.).

Systematic review and meta-analysis of steatosis as a risk factor in major hepatic resection

Background

The risk of major hepatic resection in patients with hepatic steatosis remains controversial. A meta-analysis was performed to establish the best estimate of the impact of steatosis on patient outcome following major hepatic surgery.

Methods

A systematic search was performed following Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. Risk ratios (RRs) for complication and mortality rates were calculated for patients with no, less than 30 per cent and at least 30 per cent steatosis, and a meta-analysis was carried out.

Results

Of six observational studies identified, four including a total of 1000 patients were subjected to meta-analysis; two others were tabulated separately. Compared with patients without steatosis, those with less than 30 per cent and at least 30 per cent steatosis had a significantly increased risk of postoperative complications, with a RR of 1·53 (95 per cent confidence interval (c.i.) 1·27 to 1·85) and 2·01 (1·66 to 2·44) respectively. Patients with at least 30 per cent steatosis had an increased risk of postoperative death (RR 2·79, 95 per cent c.i. 1·19 to 6·51).

Conclusion

Patients with steatosis had an up to twofold increased risk of postoperative complications, and those with excessive steatosis had an almost threefold increased risk of death.