Does neoadjuvant chemotherapy for carcinoma in the thoracic esophagus increase postoperative morbidity?

The Effect of Intraoperative Fentanyl Consumption on Prognosis of Colorectal Liver Metastasis treated by Simultaneous Resection: A Propensity Score Matching Analysis

Background: No previous studies have reported the effect of intraoperative opioid consumption in colorectal liver metastasis (CRLM).

Methods: Medical records of patients who received simultaneous resection of CRLM were retrospectively reviewed. Patients with epidural anesthesia, intraoperative morphine, or intraoperative oxycodone were excluded. Patients were separated into high- and low-dose groups by median intraoperative equianalgesic fentanyl dose. Short-term outcomes, progression-free surcical (PFS) and overall survival (OS) were compared between groups before and after 1:1 propensity score matching (PSM). Univariable and multivariable Cox regression analysis were performed to identify independent predictors of survival.

Results: The final study population included 343 patients. Patients were separated into the low dose group (n=172) and the high dose group (n=171) by median intraoperative equianalgesic fentanyl dose (8.33 μg/kg). After PSM, 55 patients in the low dose group were matched to 55 patients in the high dose group and the baseline characteristics of the two groups were balanced. The two groups had no statistically significance difference in severity and categories of postoperative complications before and after PSM. Before PSM, the two groups had similar PFS (median 10.2 vs. 12.4 months, P=0.54) and OS (median 59.0 vs. 58.3 months, P=0.76). Univariate and multivariate Cox regression analyses revealed no statistically significant association between intraoperative equianalgesic fentanyl and PFS (multivariate HR=0.852, 95% CI 0.655-1.11, P=0.235) and OS (multivariate HR=1, 95% CI 0.68-1.49, P = 0.981). After PSM, the two groups also had similar PFS (median 9.2 vs. 10.7 months, P=0.98) and OS (median 51.0 vs. 46.0 months, P=0.39). Univariate and multivariate Cox regression analyses revealed no statistically significant association between intraoperative equianalgesic fentanyl and PFS (multivariate HR=1.05, 95% CI 0.632-1.73, P=0.861) and OS (multivariate HR=1.74, 95% CI 0.892-3.38, P = 0.105).

Conclusion: Intraoperative opioids consumption was not correlated with outcomes of CRLM patients treated with simultaneous resection.

Outcomes of simultaneous resection for elderly patients with colorectal liver metastasis: A propensity score matching analysis

BACKGROUND

Evidence on simultaneous resection for elderly patients (age ≥ 70 years) with colorectal liver metastasis (CRLM) is lacking.

METHODS

Four hundred and eighty-two CRLM patients treated by simultaneous resection were categorised into young group (age < 70 years) and elderly group (age ≥ 70 years). Propensity score matching (PSM1) was performed to adjust for differences in baseline characteristics and compare short-term outcomes. An additional propensity score matching (PSM2) including short-term outcomes was performed to analyse survival. Subgroup analysis was performed in patients stratified by the Clinical Risk Score (CRS).

RESULTS

After PSM1, 87 young group patients were matched to 50 elderly group patients. Patients in the elderly group had a significantly higher rate of overall post-operative complications (68.0% vs. 46.0%, p = 0.013). After PSM2, 89 young group patients were matched to 47 elderly group patients. Progression-free survival (PFS) was comparable between the two groups (median 11.0 months vs. 9.8 months, p = 0.346). Age ≥ 70 independently predicted worse overall survival (OS) (Hazard ratio, HR = 2.57, 95% confidence interval, CI 1.37-4.82) in multivariate analysis. In the subgroup multivariate analysis of patients with CRS score 3-5, age ≥ 70 was independently associated with worse PFS (HR = 1.62, 95% CI 1.01-2.62) and OS (HR = 2.34, 95% CI 1.26-4.35).

CONCLUSIONS

Simultaneous resection for elderly CRLM patients is acceptable. Further studies are required to determine the optimal treatment for elderly CRLM patients with high CRS scores.

A systematic review and meta-analysis on the effect of neoadjuvant chemotherapy on complications following immediate breast reconstruction

BACKGROUND

The impact of neoadjuvant chemotherapy (NACT) on surgical outcomes following immediate breast reconstruction (IBR) remains unclear. While it is generally considered safe practice to perform an IBR post NACT, reported complication rates in published data are highly variable with the majority of studies including fewer than 50 patients in the NACT and IBR arm. To evaluate this further, we conducted a systematic review and meta-analysis on the effect of NACT on autologous and implant based immediate breast reconstructions. We aimed to assess for differences in the post-operative course following IBR between patients who received NACT with those who did not.

METHODS

PubMed, EMBASE, and Cochrane Library were searched from 1995 to Sept 2, 2020 to identify articles that assessed the impact of NACT on IBR. All included studies assessed outcomes following IBR. Only studies comparing reconstructed patients receiving NACT to a control group of women who did not receive NACT were included. Unadjusted relative risk of outcomes between patients who received or did not receive NACT were synthesized using a fixed-effect meta-analysis. The evidence was assessed using the Newcastle Ottawa Scale scores and GRADE. Primary effect measures were risk ratios (RRs) with 95% confidence intervals.

RESULTS

A total 17 studies comprising 3249 patients were included in the meta-analyses. Overall, NACT did not increase the risk of complications after immediate breast reconstructions (risk ratio [RR]: 0.91, 95% CI 0.74 to 1.11, p = 0.34). There was a moderate, but not significant, increase in flap loss following NACT compared with controls (RR: 1.23, 95% CI 0.70 to 2.18, p = 0.47; I² = 0%). Most notably, there was a statistically significant increase in implant/expander loss after NACT (RR: 1.54, 95% CI 1.04 to 2.29, p = 0.03; I² = 34%). NACT was not shown to significantly increase the incidence of hematomas, seromas or wound complications, or result in a significant delay to commencing adjuvant therapy (RR: 1.59, 95% CI 0.66 to 3.87, p = 0.30).

CONCLUSION

Immediate breast reconstruction after NACT is a safe procedure with an acceptable post-operative complication profile. It may result in a slight increase in implant loss rates, but it does not delay commencing adjuvant therapy.

Impact of pretreatment asymptomatic renal dysfunction on clinical course after esophagectomy

PURPOSE

Recent large-scale clinical studies have shown that preoperative renal insufficiency is associated with an increased risk of postoperative complications after esophagectomy; however, it remains unclear whether asymptomatic renal dysfunction affects the postoperative course after esophagectomy.

METHODS

The subjects of this retrospective study were 177 patients who underwent esophagectomy between May, 2009 and December, 2018. Renal function was evaluated based on the pretreatment estimated glomerular filtration rate (eGFR). Patients were divided into two groups according to the eGFR cut-off value of 55 ml/min per 1.73 m².

RESULTS

There were 17 patients in the low eGFR group and 160 patients in the normal group eGFR group. The rate of severe complications was significantly higher in the low eGFR than in the normal eGFR group. A low eGFR was the only significant complication risk factor identified; however, there were no marked differences in mortality or survival between the low and normal eGFR groups.

CONCLUSION

Our findings demonstrate that pretreatment asymptomatic renal dysfunction may be a significant risk factor for severe morbidity after esophagectomy.

Development of Novel Prognostic Prediction Models including the Prognostic Nutritional Index for Patients with Colorectal Cancer after Curative Resection

Objectives: It has been reported that there is an association between the nutritional condition and the prognosis of cancer. Here, we evaluated the relation between the prognostic nutritional index (PNI) and colorectal cancer (CRC). Methods: A total of 184 patients with CRC who underwent curative surgery from October 2011 to December 2012 at the Osaka University Hospital were investigated. According to the median PNI value of our data set, patients were classified into a high-PNI (≥46) group and a low-PNI (<46) group. The relationship between the PNI and the disease-free survival (DFS) and overall survival (OS) was analyzed by a Cox regression model. Results: A low PNI was significantly associated with poor DFS (P = 0.006) and OS (P < 0.001). A multivariate analysis showed that low PNI, venous invasion (present), and tumor location (rectum) were independent risk factors for recurrence. Low PNI, advanced age, and venous invasion were found to be independent risk factors for mortality. Using these clinicopathological factors, we developed nomograms to predict DFS and OS. The concordance index was 0.828 for DFS and 0.756 for OS. Conclusions: A low PNI is a prognostic indicator for recurrence and mortality in CRC. Nomograms constructed by clinicopathological factors including the PNI can provide individual prognostic outcomes.

Prognostic significance of preoperative prognostic nutritional index in colorectal cancer: results from a retrospective cohort study and a meta-analysis

The preoperative prognostic nutritional index (PNI) may forecast colorectal cancer (CRC) outcomes, but the evidence is not conclusive. Here, we retrospectively analyzed a cohort of patients from the Department of Surgical Oncology at the First Hospital of China Medical University (CMU-SO). We also conducted a meta-analysis of eleven cohort studies. Bayesian Information Criterion (BIC) was used to determine the optimal PNI cut-off values for classifying prognosis in the patients from the CMU-SO. The result from CMU-SO and meta-analysis both confirmed that low PNI was significantly associated with a poor prognosis and advanced TNM stages. Among the patients from the CMU-SO, the optimal cut-off values were “41-45-58” (PNI < 41, 41 ≤ PNI < 45, 45 ≤ PNI < 58, PNI ≥ 58), which divided patients into 4 stages. The BIC value for TNM staging combined with the PNI was smaller than that of TNM staging alone (−325.76 vs. −310.80). In conclusion, low PNI was predictive of a poor prognosis and was associated with clinicopathological features in patients with CRC, and the 41-45-58 four-stage division may be suitable for determining prognosis. PNI may thus provide an additional index for use along with the current TNM staging system to determine more accurate CRC prognoses.

Complications after microvascular breast reconstruction: experience with 1195 flaps

BACKGROUND

Reconstruction is an important adjunct to breast cancer management. This study evaluated the frequency of major and minor complications in the largest reported series of consecutive mastectomy patients treated with free tissue transfer for breast reconstruction.

METHODS

All patients treated with microvascular breast reconstruction at the University of California, Los Angeles, Medical Center over an 11-year period were identified using a retrospective analysis. Frequency of complications was assessed.

RESULTS

A total of 1195 breast reconstructions were performed in 952 patients. Transverse rectus abdominis musculocutaneous flaps were used in most cases (81.8 percent), whereas the superior gluteal musculocutaneous flap (10.1 percent) and other free flaps were used in the remaining patients. The overall complication rate was 27.9 percent and consisted primarily of minor complications (21.7 percent). Major complications were noted in 7.7 percent, including six total flap losses (0.5 percent). Obesity was a major predictor of complications. Smoking was not associated with increased rates of overall or microsurgical complications. Neoadjuvant chemotherapy was also an independent predictor of complications and was associated with wound-healing problems and fat necrosis. Prior abdominal surgery in transverse rectus abdominis musculocutaneous flap patients increased the risk of partial flap loss, fat necrosis, and donor-site complications.

CONCLUSIONS

Microsurgical breast reconstruction is a safe and highly effective technique. Complications tend to be minor and do not affect postreconstruction adjuvant therapy. Obesity is a major predictor of flap and donor-site complications, and these patients should be appropriately counseled. Similarly, neoadjuvant preoperative chemotherapy and prior abdominal surgery increase the rates of minor complications.

Risk analysis in resection of thoracic esophageal cancer in the era of endoscopic surgery

BACKGROUND

Surgical outcomes after thoracoscopic esophagectomy were compared with those after open esophagectomy, and the prognostic values of factors potentially related to mortality and morbidity were evaluated.

METHODS

We performed a retrospective chart review of 153 patients who underwent esophagectomy for thoracic esophageal cancer. The thoracic surgical procedures were categorized into the following three groups: esophagectomy under standard thoracotomy (n = 37), assisted thoracoscopic esophagectomy with utility minithoracotomy (n = 38), and complete thoracoscopic esophagectomy (n = 78). Mortality and morbidity were compared among the three groups. Then, in a separate multivariate analysis, data on 14 potentially prognostic variables were extracted, and the relation to postoperative outcomes was examined.

RESULTS

Respiratory complications were the most frequent complications in all three groups, and their rate of occurrence was not significantly among the three groups. The 30-day and in-hospital mortality rates were significantly higher in the open group than in the other groups. Multivariate analysis demonstrated that patient age, sex, induction chemoradiation, and forced expiratory volume were independently significant contributing factors for respiratory complications, while the serum total protein concentration and open esophagectomy were significant factors for in-hospital mortality.

CONCLUSIONS

Our results demonstrated that respiratory complications are still the main cause of operative morbidity when using the thoracoscopic esophagectomy protocol and that use of the thoracoscopic procedure does not decrease the risk of respiratory complications. The use of the thoracoscopic procedure improved postoperative in-hospital mortality. The advantages of thoracoscopic esophagectomy should be investigated further. At this point in time, however, thoracoscopic esophagectomy can be considered a feasible, safe, and advantageous surgical option.

Induction therapy does not increase surgical morbidity after esophagectomy for cancer

BACKGROUND

A complete pathological response after induction therapy for esophageal cancer offers survival benefits, but induction therapy may increase the risk of postoperative complications and mortality.

METHODS

We performed a retrospective review of consecutive patients who underwent esophagectomy for esophageal cancer to identify preoperative predictors of complications and assess the possible influence of induction therapy on surgical outcomes.

RESULTS

Between 1988 and 2003, 170 esophagectomies were performed on our service; 95 (55.9%) underwent surgery alone and 75 (44.1%) received preoperative chemotherapy, 35 of whom also had preoperative radiation therapy. Based on multivariable regression analyses, independent covariates for complication categories included performance status (pulmonary, cardiovascular, total complications, and death), age (cardiovascular and other complications), and FEV(1)% (pulmonary complications). Whether patients received induction therapy was unrelated to the incidence of postoperative complications.

CONCLUSIONS

We found no evidence that induction therapy adversely influences the incidence of postoperative morbidity or mortality after esophagectomy for cancer.

Multiple Management Modalities in Esophageal Cancer: Combined Modality Management Approaches

The overall success rate nationally in treating esophageal carcinomas remains poor, with over 90% of patients succumbing to the disease. In part I of this two-part series, we explored epidemiology, presentation and progression, work-up, and surgical approaches. In part II, we explore the promising suggestions of integrating chemotherapy and radiation therapy into the multimodal management of esophageal cancers. Alternative approaches to resection alone have been sought because of the overall poor survival rates of esophageal cancer patients, with failures occurring both local-regionally and distantly. Concomitant chemotherapy and radiation therapy (XRT) have been shown, by randomized trial, to be more effective than XRT alone in treating unresectable esophageal cancers and also have shown promise as a neoadjuvant treatment when combined with surgery in the multimodal treatment of this disease. Various studies have also addressed issues such as preoperative chemotherapy, radiation dose escalation, chemotherapy/XRT as a definitive treatment versus use as a surgical adjuvant, and alternative chemotherapy regimens. There are suggestions of some progress, but this remains a difficult problem area in which management is continuing to evolve.

Expense and benefit of neoadjuvant treatment in squamous cell carcinoma of the esophagus

BACKGROUND

The effectiveness of neoadjuvant treatment (NT) prior to resection of squamous cell carcinoma of the esophagus (SCCE) in terms of prolonged survival has not been proven by randomized trials. Facing considerable financial expenses and with concerns regarding the consumption of the patient's remaining survival time, this study aims to provide rationales for pretreating resection candidates.

METHODS

From March 1986 to March 1999, patients undergoing resection for SCCE were documented prospectively. Since 1989, NT was offered to patients with mainly upper and middle third T3 or T4 tumors or T2 N1 stage who were fit for esophagectomy. Until 1993, NT consisted of chemotherapy. Since that time chemoradiation has also been applied. The parameters for expense and benefit of NT are costs, pretreatment time required, postoperative morbidity and mortality, clinical and histopathological response, and actuarial survival.

RESULTS

Two hundred and three patients were treated, 170 by surgery alone and 33 by NT + surgery. Postoperative morbidity and mortality were 52% to 30% and 12% to 6%, respectively (p = n.s.). The response to NT was detected in 23 patients (70%). In 11 instances (33%), the primary tumor lesion was histopathologically eradicated. Survival following NT + surgery was significantly prolonged in node-positive patients with a median survival of 12 months to 19 months (p = 0.0193). The average pretreatment time was 113 +/- 43 days, and reimbursement for NT to the hospital amounted to Euro 9.834.

CONCLUSIONS

NT did not increase morbidity and mortality. Expenses for pretreatment, particularly time and costs, are considerable. However, taking into account that the results are derived from a non-randomized study, patients with regionally advanced tumor stages seem to benefit, as seen by their prolonged survival.