Influence of splenectomy on morbidity of esophageal cancer surgery

Risk factors and outcomes associated with anastomotic leaks following esophagectomy: a systematic review and meta-analysis

Anastomotic leaks (AL) are a major complication after esophagectomy. This meta-analysis aimed to determine identify risks factors for AL (preoperative, intra-operative, and post-operative factors) and assess the consequences to outcome on patients who developed an AL. This systematic review was performed according to PRISMA guidelines, and eligible studies were identified through a search of PubMed, Scopus, and Cochrane CENTRAL databases up to 31 December 2018. A meta-analysis was conducted with the use of random-effects modeling and prospectively registered with the PROSPERO database (Registration CRD42018130732). This review identified 174 studies reporting outcomes of 74,226 patients undergoing esophagectomy. The overall pooled AL rates were 11%, ranging from 0 to 49% in individual studies. Majority of studies were from Asia (n = 79). In pooled analyses, 23 factors were associated with AL (17 preoperative and six intraoperative). AL were associated with adverse outcomes including pulmonary (OR: 4.54, CI95%: 2.99-6.89, P < 0.001) and cardiac complications (OR: 2.44, CI95%: 1.77-3.37, P < 0.001), prolonged hospital stay (mean difference: 15 days, CI95%: 10-21 days, P < 0.001), and in-hospital mortality (OR: 5.91, CI95%: 1.41-24.79, P = 0.015). AL are a major complication following esophagectomy accounting for major morbidity and mortality. This meta-analysis identified modifiable risk factors for AL, which can be a target for interventions to reduce AL rates. Furthermore, identification of both modifiable and non-modifiable risk factors will facilitate risk stratification and prediction of AL enabling better perioperative planning, patient counseling, and informed consent.

Great Vessel Injury in Thoracic Surgery

The potential for intraoperative bleeding is inherent to the practice of thoracic surgery due to the presence of multiple vital vascular structures, complex anatomy, and constant cardiorespiratory motion. Careful and detailed preoperative evaluation and planning, comprehensive review of imaging studies, and a thorough knowledge of the operative procedure, anatomic relationships, and potential complications are of the highest importance in prevention and avoidance of bleeding complications. Preparation with a clear crisis management plan ensures an effective and expedited response when intraoperative bleeding occurs.

Predictors of readmission after laparoscopic gastric bypass and sleeve gastrectomy: a comparative analysis of ACS-NSQIP database

BACKGROUND

Readmission rate is an indicator of quality in surgical practice. We aimed to determine the predictors of unplanned early readmissions following stapling bariatric surgeries.

METHODS

From the American College of Surgeons National Surgical Quality Improvement Program database, we identified morbidly obese patients, who underwent either laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) in 2012 and 2013. Demographic, comorbidities, operative and postoperative parameters of the readmitted (within 30 days) and non-readmitted patients were evaluated using a multivariate logistic regression analysis.

RESULTS

A total of 35,655 patients (17,101 LSG and 18,554 LRYGB) were analyzed. Of those, 1758 patients (4.9 %) were readmitted within 30 days of surgery. Multivariate analysis showed the following significant predictors for readmission: Non-Hispanic black ethnicity (OR: 1.56, 95 % CI:1.34-1.81), Hispanic ethnicity (OR: 1.29, 95 % CI:1.05-1.58), totally or partially dependent functional status (OR: 1.94, 95 % CI:1.06-3.55), higher preoperative creatinine (OR: 1.13, 95 % CI:1.04-1.22), lower serum albumin (OR: 0.78, 95 % CI:0.68-0.90), diabetes mellitus on insulin (OR: 1.28, 95 % CI:1.09-1.51), steroid or immunosuppressant use for a chronic condition (OR: 1.61, 95 % CI:1.11-2.33), history of cardiac disease with intervention (OR: 2.05, 95 % CI:1.10-3.83), bleeding disorders (OR: 1.71, 95 % CI:1.15-2.54), LRYGB versus LSG (OR: 1.63, 95 % CI:1.44-1.85), longer operative time (OR: 1.13, 95 % CI:1.07-1.20), concurrent splenectomy (OR: 4.10, 95 % CI:1.05-16.01), and occurrence of any postoperative complication during index admission (OR: 2.61, 95 % CI:1.99-3.42).

CONCLUSIONS

Ethnicity, baseline functional status, comorbidities, type and duration of surgical procedure, and postoperative complications occurred in the index admission can predict risk of early readmission following LRYGB and LSG.

Is it worthwhile to preserve adult spleen in laparoscopic distal pancreatectomy? Perioperative and patient-reported outcome analysis

BACKGROUND

Despite the emphasis on its role, the spleen has commonly been removed in distal pancreatectomy. We designed this study to evaluate the efficacy of spleen salvage during laparoscopic distal pancreatectomy for patients with benign and borderline malignant tumors.

MATERIALS AND METHODS

From February 2005 to December 2010, 40 patients underwent spleen-preserving laparoscopic distal pancreatectomy (Sp-Lap DP) and 32 patients underwent laparoscopic distal pancreatosplenectomy (Lap DPS). Medical records were retrospectively reviewed, and a specially designed questionnaire was administered to the patients for the follow-up study.

RESULTS

The demographics and final diagnoses were similar between the two groups. The operative time was significantly longer in the Sp-Lap DP group (303.9 ± 136.0 versus 239.0 ± 94.9 min, p = 0.024). Patients in the Lap DPS group had more postoperative pancreatic fistulas of higher grade (p = 0.026). A higher grade of postoperative complications occurred more frequently in the Lap DPS group (p = 0.003). Consequently, postoperative hospital stay was significantly shorter for Sp-Lap DP than for Lap DPS patients (7.1 ± 2.3 versus 12.5 ± 10.8 days, p = 0.004). On the follow-up survey, episodes of common cold or flu were apparently more frequent in the Lap DPS group (p = 0.026). Despite the similar recovery period between the two groups, significantly more patients who underwent Lap DPS felt fatigue (p = 0.014) and poorer health condition (p = 0.042).

CONCLUSIONS

In addition to frequent higher-grade complications and prolonged hospital stays, Lap DPS appeared to impair patient quality of life based on follow-up survey. Even an effort to preserve adult spleen in distal pancreatectomy is worthwhile.

Significance of platelet count in esophageal carcinomas

BACKGROUND/AIM

Thrombocytosis is found to be associated with unfavorable prognosis in esophageal carcinoma. Platelets produce thymidine phosphorylase which is a platelet-derived endothelial cell growth factor with angiogenic activity. Increased platelet count may be translated into enhanced tumor growth. We examined the relation between platelet count and several prognostic variables in patients with esophageal cancer.

PATIENTS AND METHODS

Three hundred and eighty-one cases with esophageal cancer that underwent esophagectomy in a referral cancer institute during a 5-year period were studied retrospectively. The relation between preoperative platelet count and patient age, gender, site of tumor, presence of multiple cancers and clinicopathological characteristics including histological type, tumor size, depth of penetration (T), lymph node involvement (N), distant metastasis (M), degree of differentiation, presence of vascular, lymphatic and perineural invasion was examined.

RESULTS

Squamous cell carcinoma (SCC) constituted 93% and adenocarcinoma 7% of cases. Most of patients were in stage III, followed by stage II. The mean platelet count was 245±76 (Χ 10(9)/L). There was no statistically significant correlation between platelet counts with prognostic factors except a weak linear correlation between platelet count and and tumor size (P = 0.03, Pearson correlation coefficient: 0.16). Patients with adenocarcinoma had a higher platelet count than those with SCC (P = 0.003).

CONCLUSION

Platelet count does not correlate with prognostic factors in esophageal cancer. However, it is significantly different between SCC and adenocarcinoma of esophagus.