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Parmar C, Abi Mosleh K, Aeschbacher P, Halfdanarson TR, McKenzie TJ, Rosenthal RJ, Ghanem OM. The feasibility and outcomes of metabolic and bariatric surgery prior to neoplastic therapy. Surg Obes Relat Dis 2024:S1550-7289(24)00080-7. [PMID: 38594091 DOI: 10.1016/j.soard.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 02/18/2024] [Accepted: 02/25/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Metabolic and bariatric surgery (MBS) is a potent intervention for addressing obesity-related medical conditions and achieving sustainable weight loss. Beyond its conventional role, MBS has demonstrated potential to serve as a transitional step for patients requiring various interventions. However, the implications of MBS in the context of neoplasia remain understudied. OBJECTIVES To explore the feasibility of MBS as a possible attempt to reduce surgical and treatment risks in patients with benign tumors or low-grade cancers. SETTING Multicenter review from twelve tertiary referral centers spanning 8 countries. METHODS A retrospective review of patients with a diagnosis of primary neoplasia, deemed inoperable or high-risk due to obesity, and receiving primary MBS prior to neoplastic therapy. Data encompassed baseline characteristics, neoplasia characteristics, MBS outcomes, and neoplastic therapy outcomes. RESULTS Thirty-seven patients (median age 52 years, 75.7% female, median BMI of 49.1 kg/m2) were included. There were 9 distinct organs of origin of primary neoplasia, with the endometrium (43.2%) being the most common, followed by the pancreas, colon, kidney and breast. Sleeve gastrectomy (SG) was the most commonly performed MBS procedure (78.4%), with no MBS-related complications or mortalities reported over an average of 4.3 ± 3.9 years. Thirty-one patients (83.8%) eventually underwent neoplastic surgery, with a mean BMI decrease from 49.9 kg/m2 to 39.7 kg/m2 at surgery over an average of 5.8 ± 4.8 months. There were 2 (6.7%) documented mortalities associated with neoplastic surgical intervention. CONCLUSIONS This study highlights the potential feasibility of employing MBS prior to neoplastic therapy in patients with low-grade, less aggressive neoplasms in the context of obesity. This underscores the importance of providing a personalized, case-to-case multidisciplinary approach in the management of these patients.
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Affiliation(s)
- Chetan Parmar
- Department of Surgery, Whittington Hospital, London, UK; University College London, London, UK
| | | | - Pauline Aeschbacher
- Department of General Surgery and Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, Florida
| | | | | | - Raul J Rosenthal
- Department of General Surgery, Bariatric and Metabolic Institute, Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida
| | - Omar M Ghanem
- Department of Surgery, Mayo Clinic, Rochester, Minnesota.
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Rogers P, Dourado J, Delgado Z, De Stefano Hernandez F, Aeschbacher P, Wexner SD. Perineal rectosigmoidectomy (Altemeier) with colonic J pouch and levatorplasty: a technical demonstration - a video vignette. Colorectal Dis 2024; 26:583-584. [PMID: 38282101 DOI: 10.1111/codi.16890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 01/01/2024] [Indexed: 01/30/2024]
Affiliation(s)
- Peter Rogers
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
| | - Justin Dourado
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
| | | | - Felice De Stefano Hernandez
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
| | - Pauline Aeschbacher
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
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Dourado J, Garoufalia Z, Emile SH, Wignakumar A, Aeschbacher P, Rogers P, Delgado Z, Greer M, Wexner SD. Ostomy continence devices: a systematic review of the literature and meta-analysis. Colorectal Dis 2024. [PMID: 38358053 DOI: 10.1111/codi.16906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 01/11/2024] [Accepted: 01/14/2024] [Indexed: 02/16/2024]
Abstract
AIM Colostomy complication rates range widely from 10% to 70%. The psychological burden on patients, leading to lifestyle changes and decreased quality of life (QoL), is one of the largest factors. The aim of this work was to assess the history and efficacy of ostomy continence devices in improving continence and QoL. METHOD In this PRISMA-compliant systematic review and meta-analysis, we searched PubMed, Scopus, Google Scholar and clinicaltrials.gov for studies on continence devices for all ostomies up to April 2023. Primary outcomes were continence and improvement in QoL. Secondary outcomes were leakage, patient's device preference and complications. Risk of Bias 2 and the revised tool to assess risk of bias in non-randomized studies of interventions (ROBINS-1) were used to assess risk of bias. Certainty of evidence was graded using GRADE. RESULTS Twenty-two studies assessed devices from 1978 to 2022. The two main types identified were ball-valve devices and plug systems. Conseal and Vitala were the two main devices with significant evidence allowing for pooled analyses. Conseal, the only currently marketed device, had a pooled rate of continence of 67.4%, QoL improvement was 74.9%, patient preference over a traditional appliance was 69.1%, leakage was 10.1% and complications was 13.7%. Since 2011, five studies have investigated experimental devices on both human and animal models. CONCLUSION Ostomy continence has been a long-standing goal without a consistently reliable solution. We propose that selective and short-term usage of continence devices may lead to improved continence and QoL in ostomy patients. Further research is needed to develop a reliable daily device for ostomy continence. Future investigation should include the needs of ileostomates.
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Affiliation(s)
- Justin Dourado
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - Anjelli Wignakumar
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Pauline Aeschbacher
- Department of General Surgery and Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, Florida, USA
- Department for Visceral Surgery and Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Peter Rogers
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Zachary Delgado
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Matthew Greer
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida, USA
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Emile SH, Garoufalia Z, Aeschbacher P, Horesh N, Gefen R, Wexner SD. Endorectal advancement flap compared to ligation of inter-sphincteric fistula tract in the treatment of complex anal fistulas: A meta-analysis of randomized clinical trials. Surgery 2023:S0039-6060(23)00178-2. [PMID: 37198039 DOI: 10.1016/j.surg.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/22/2023] [Accepted: 04/04/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Rectal advancement flap and ligation of intersphincteric fistula tract are common procedures for treating complex anal fistula. The present meta-analysis aimed to compare the surgical outcomes of advancement flap and ligation of intersphincteric fistula tract. METHODS A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review of randomized clinical trials comparing the ligation of intersphincteric fistula tract and advancement flap was conducted. PubMed, Scopus, and Web of Science were searched through January 2023. The risk of bias was assessed using the Risk of Bias 2 tool and certainty of evidence with the Grading of Recommendations Assessment, Development and Evaluation approach. The primary outcomes were healing and recurrence of anal fistulas, and secondary outcomes were operative time, complications, fecal incontinence, and early pain. RESULTS Three randomized clinical trials (193 patients, 74.6% male) were included. The median follow-up was 19.2 months. Two trials had a low risk of bias, and 1 had some risk of bias. The odds of healing (odds ratio: 1.363, 95% confidence interval: 0.373-4.972, P = .639), recurrence (odds ratio: 0.525, 95% confidence interval: 0.263-1.047, P = .067), and complications (odds ratio: 0.356, 95% confidence interval: 0.085-1.487, P = .157) were similar between the 2 procedures. Ligation of intersphincteric fistula tract was associated with a significantly shorter operation time (weighted mean difference: -4.876, 95% confidence interval: -7.988 to -1.764, P = .002) and less postoperative pain (weighted mean difference: -1.030, 95% confidence interval: -1.418 to -0.641, 0.198, P < .001, I2 = 3.85%) than advancement flap. Ligation of intersphincteric fistula tract was associated with marginally lower odds of fecal incontinence than advancement flap (odds ratio: 0.27, 95% confidence interval: 0.069-1.06, P = .06). CONCLUSION Ligation of intersphincteric fistula tract and advancement flap had similar odds of healing, recurrence, and complications. The odds of fecal incontinence and extent of pain after ligation of intersphincteric fistula tract were lower than after advancement flap.
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Affiliation(s)
- Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Egypt. https://twitter.com/dr_samehhany81
| | - Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL
| | - Pauline Aeschbacher
- Department of General Surgery and Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, FL
| | - Nir Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Department of Surgery and transplantation, Sheba Medical Center, Ramat-Gan, Israel
| | - Rachel Gefen
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL; Department of General Surgery, Faculty of Medicine, Hadassah Medical Organization, Hebrew University of Jerusalem, Israel
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL.
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Katou S, Wenning AS, Aeschbacher P, Morgul H, Becker F, Pascher A, Gloor B, Strücker B, Andreou A. Resection margin status at the portomesenteric axis may not determine oncologic outcome after pancreaticoduodenectomy for lymph node-positive pancreatic ductal adenocarcinoma. Surgery 2023:S0039-6060(23)00129-0. [PMID: 37121858 DOI: 10.1016/j.surg.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/19/2023] [Accepted: 03/11/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Lymph node and resection margin status are associated with oncologic outcomes after pancreaticoduodenectomy for pancreatic ductal adenocarcinoma. However, surgical radicality at the portomesenteric axis in case of suspected infiltration remains controversial. METHODS Clinicopathological data of patients who underwent a partial or total pancreaticoduodenectomy for PDAC between 2012 to 2019 in 2 major hepato-pancreato-biliary centers in Germany and Switzerland were assessed. We evaluated the impact of positive resection margins at the vascular, parenchymal, and retropancreatic surfaces on overall survival in patients with and without lymph node involvement. Margin-positive vascular resection included both patients with positive margins at the vascular groove and the resected venous wall. RESULTS During the study period, 217 patients underwent partial/total pancreaticoduodenectomy for pancreatic ductal adenocarcinoma. After excluding 7 patients suffering postoperative complications resulting in mortality within 90 days after surgery (3%), 169 patients had lymph node involvement (80%). In the entire study cohort, margin-positive resection (33%) was significantly associated with worse overall survival (3-year overall survival: margin-positive resection: 27% vs margin-negative resection: 43%, P = .014). Among patients with positive lymph nodes, margin-positive vascular resection (n = 48, 28%) was not significantly associated with impaired overall survival (3-year overall survival: margin-positive vascular resection: 28% vs margin-negative vascular resection: 36%, P = .065). On the contrary, margin-positive parenchymal resection (n = 7, 4%) (3-year overall survival: margin-positive parenchymal resection: 0% vs margin-negative parenchymal resection: 35%, P < .0001) and margin-positive retropancreatic resection (n = 21, 12%) (3-year overall survival: margin-positive retropancreatic resection: 6% vs margin-negative retropancreatic resection: 39%, P < .0001) significantly diminished overall survival in univariate and multivariate analysis in all patients. Among patients without lymph node involvement (n = 41, 20%), there were no margin-positive parenchymal or margin-positive retropancreatic resections. In contrast, only 5 patients had margin-positive vascular resection (12%), with overall survival compared to those with margin-negative vascular resection. CONCLUSIONS In patients with pancreatic ductal adenocarcinoma and lymph nodal positivity, resection status at the parenchymal and retropancreatic surface but probably not at the portal and/or superior mesenteric vein is a determinant of survival. Therefore, margin-negative resection should be pursued during pancreaticoduodenectomy. However, radical venous resection and/or reconstruction for suspected tumor infiltration may not be necessary for patients with intraoperatively detected lymph node metastases.
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Affiliation(s)
- Shadi Katou
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, Germany.
| | - Anna Silvia Wenning
- Department of Visceral Surgery und Medicine, lnselspital, Bern University Hospital, University of Bern, Switzerland
| | - Pauline Aeschbacher
- Department of Visceral Surgery und Medicine, lnselspital, Bern University Hospital, University of Bern, Switzerland
| | - Haluk Morgul
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, Germany
| | - Felix Becker
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, Germany
| | - Andreas Pascher
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, Germany
| | - Beat Gloor
- Department of Visceral Surgery und Medicine, lnselspital, Bern University Hospital, University of Bern, Switzerland
| | - Benjamin Strücker
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, Germany
| | - Andreas Andreou
- Department of General, Visceral and Transplant Surgery, University Hospital Münster, Germany
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Karamitopoulou E, Wenning AS, Acharjee A, Zlobec I, Aeschbacher P, Perren A, Gloor B. Spatially restricted tumour-associated and host-associated immune drivers correlate with the recurrence sites of pancreatic cancer. Gut 2023:gutjnl-2022-329371. [PMID: 36792355 DOI: 10.1136/gutjnl-2022-329371] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 02/06/2023] [Indexed: 02/17/2023]
Abstract
OBJECTIVE Most patients with pancreatic ductal adenocarcinoma (PDAC) will experience recurrence after resection. Here, we investigate spatially organised immune determinants of PDAC recurrence. DESIGN PDACs (n=284; discovery cohort) were classified according to recurrence site as liver (n=93/33%), lung (n=49/17%), local (n=31/11%), peritoneal (n=38/13%) and no-recurrence (n=73/26%). Spatial compartments were identified by fluorescent imaging as: pancytokeratin (PanCK)+CD45- (tumour cells); CD45+PanCK- (leucocytes) and PanCK-CD45- (stromal cells), followed by transcriptomic (72 genes) and proteomic analysis (51 proteins) for immune pathway targets. Results from next-generation sequencing (n=194) were integrated. Finally, 10 tumours from each group underwent immunophenotypic analysis by multiplex immunofluorescence. A validation cohort (n=109) was examined in parallel. RESULTS No-recurrent PDACs show high immunogenicity, adaptive immune responses and are rich in pro-inflammatory chemokines, granzyme B and alpha-smooth muscle actin+ fibroblasts. PDACs with liver and/or peritoneal recurrences display low immunogenicity, stemness phenotype and innate immune responses, whereas those with peritoneal metastases are additionally rich in FAP+ fibroblasts. PDACs with local and/or lung recurrences display interferon-gamma signalling and mixed adaptive and innate immune responses, but with different leading immune cell population. Tumours with local recurrences overexpress dendritic cell markers whereas those with lung recurrences neutrophilic markers. Except the exclusive presence of RNF43 mutations in the no-recurrence group, no genetic differences were seen. The no-recurrence group exhibited the best, whereas liver and peritoneal recurrences the poorest prognosis. CONCLUSIONS Our findings demonstrate distinct inflammatory/stromal responses in each recurrence group, which might affect dissemination patterns and patient outcomes. These findings may help to inform personalised adjuvant/neoadjuvant and surveillance strategies in PDAC, including immunotherapeutic modalities.
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Affiliation(s)
- Eva Karamitopoulou
- Institute for Tissue Medicine and Pathology, University of Bern, Bern, Switzerland
| | - Anna Silvia Wenning
- Department of Visceral Surgery, Insel University Hospital, University of Bern, Bern, Switzerland
| | - Animesh Acharjee
- University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Inti Zlobec
- Institute for Tissue Medicine and Pathology, University of Bern, Bern, Switzerland
| | - Pauline Aeschbacher
- Department of Visceral Surgery, Insel University Hospital, University of Bern, Bern, Switzerland
| | - Aurel Perren
- Institute for Tissue Medicine and Pathology, University of Bern, Bern, Switzerland
| | - Beat Gloor
- Department of Visceral Surgery, Insel University Hospital, University of Bern, Bern, Switzerland
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Lunger F, Aeschbacher P, Nett PC, Peros G. The impact of bariatric and metabolic surgery on cancer development. Front Surg 2022; 9:918272. [PMID: 35910464 PMCID: PMC9334768 DOI: 10.3389/fsurg.2022.918272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/30/2022] [Indexed: 12/21/2022] Open
Abstract
Obesity (BMI ≥ 30 kg/m2) with related comorbidities such as type 2 diabetes mellitus, cardiovascular disease, sleep apnea syndrome, and fatty liver disease is one of the most common preventable risk factors for cancer development worldwide. They are responsible for at least 40% of all newly diagnosed cancers, including colon, ovarian, uterine, breast, pancreatic, and esophageal cancer. Although various efforts are being made to reduce the incidence of obesity, its prevalence continues to spread in the Western world. Weight loss therapies such as lifestyle change, diets, drug therapies (GLP-1-receptor agonists) as well as bariatric and metabolic surgery are associated with an overall risk reduction of cancer. Therefore, these strategies should always be essential in therapeutical concepts in obese patients. This review discusses pre- and post-interventional aspects of bariatric and metabolic surgery and its potential benefit on cancer development in obese patients.
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Affiliation(s)
- Fabian Lunger
- Department for Visceral Surgery and Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Visceral and Thoracic Surgery, Cantonal Hospital of Winterthur, Winterthur, Switzerland
| | - Pauline Aeschbacher
- Department for Visceral Surgery and Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Philipp C. Nett
- Department for Visceral Surgery and Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
- Correspondance: Philipp C. Nett
| | - Georgios Peros
- Department of Visceral and Thoracic Surgery, Cantonal Hospital of Winterthur, Winterthur, Switzerland
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8
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Aeschbacher P, Kollár A, Candinas D, Beldi G, Lachenmayer A. The Role of Surgical Expertise and Surgical Access in Retroperitoneal Sarcoma Resection – A Retrospective Study. Front Surg 2022; 9:883210. [PMID: 35647004 PMCID: PMC9133808 DOI: 10.3389/fsurg.2022.883210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/22/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundRetroperitoneal sarcoma (RPS) is a rare disease often requiring multi-visceral and wide margin resections for which a resection in a sarcoma center is advised. Midline incision seems to be the access of choice. However, up to now there is no evidence for the best surgical access. This study aimed to analyze the oncological outcome according to the surgical expertise and also the incision used for the resection.MethodsAll patients treated for RPS between 2007 and 2018 at the Department of Visceral Surgery and Medicine of the University Hospital Bern and receiving a RPS resection in curative intent were included. Patient- and treatment specific factors as well as local recurrence-free, disease-free and overall survival were analyzed in correlation to the hospital type where the resection occurred.ResultsThirty-five patients were treated for RPS at our center. The majority received their primary RPS resection at a sarcoma center (SC = 23) the rest of the resection were performed in a non-sarcoma center (non-SC = 12). Median tumor size was 24 cm. Resections were performed via a midline laparotomy (ML = 31) or flank incision (FI = 4). All patients with a primary FI (n = 4) were operated in a non-SC (p = 0.003). No patient operated at a non-SC received a multivisceral resection (p = 0.004). Incomplete resection (R2) was observed more often when resection was done in a non-SC (p = 0.013). Resection at a non-SC was significantly associated with worse recurrence-free survival and disease-free survival after R0/1 resection (2 vs 17 months; Log Rank p-value = 0.02 respectively 2 vs 15 months; Log Rank p-value < 0.001).ConclusionsResection at a non-SC is associated with more incomplete resection and worse outcome in RPS surgery. Inadequate access, such as FI, may prevent complete resection and multivisceral resection if indicated and demonstrates the importance of surgical expertise in the outcome of RPS resection.
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Affiliation(s)
- P. Aeschbacher
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - A. Kollár
- Department of Medical Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - D. Candinas
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - G. Beldi
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - A. Lachenmayer
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Correspondence: A. Lachenmayer
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Aeschbacher P, Nguyen TL, Dorn P, Kocher GJ, Lutz JA. Surgical Site Infections Are Associated With Higher Blood Loss and Open Access in General Thoracic Practice. Front Surg 2021; 8:656249. [PMID: 34250005 PMCID: PMC8267000 DOI: 10.3389/fsurg.2021.656249] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 05/18/2021] [Indexed: 12/23/2022] Open
Abstract
Background: Surgical site infections (SSIs) are the most costly and second most frequent healthcare-associated infections in the Western world. They are responsible for higher postoperative mortality and morbidity rates and longer hospital stays. The aim of this study is to analyze which factors are associated with SSI in a modern general thoracic practice. Methods: Data were collected from our department's quality database. Consecutive patients operated between January 2014 and December 2018 were included in this retrospective study. Results: A total of 2430 procedures were included. SSIs were reported in 37 cases (1.5%). The majority of operations were video-assisted (64.6%). We observed a shift toward video-assisted thoracic surgery in the subgroup of anatomical resections during the study period (2014: 26.7%, 2018: 69.3%). The multivariate regression analysis showed that blood loss >100 ml (p = 0.029, HR 2.70) and open surgery (p = 0.032, HR 2.37) are independent risk factors for SSI. The latter was higher in open surgery than in video-assisted thoracic procedures (p < 0.001). In the subgroup of anatomical resection, we found the same correlation (p = 0.043). SSIs are also associated with significantly longer mean hospital stays (17.7 vs. 7.8 days, p < 0.001). Conclusion: As SSIs represent higher postoperative morbidity and costs, efforts should be made to maintain their rate as low as possible. In terms of prevention of SSIs, video-assisted thoracic surgery should be favored over open surgery whenever possible.
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Affiliation(s)
- Pauline Aeschbacher
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thanh-Long Nguyen
- Department of Thoracic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Patrick Dorn
- Department of Thoracic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Gregor Jan Kocher
- Department of Thoracic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jon Andri Lutz
- Department of Thoracic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Andreou A, Aeschbacher P, Wenning AS, Candinas D, Gloor B. Major postoperative complications increase tumor recurrence rate and diminish long-term survival following resection for pancreatic ductal adenocarcinoma. Br J Surg 2021. [DOI: 10.1093/bjs/znab202.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Objective
Major complications have been associated with worse oncologic outcomes following resection for several gastrointestinal malignancies. However, the impact of major postoperative morbidity on the survival of patients undergoing resection for pancreatic ductal adenocarcinoma (PDAC) remains unclear.
Methods
Clinicopathological data of patients who underwent resection for PDAC between 2014 and 2019 in a major swiss hepatopancreatobiliary center were assessed. We evaluated the disease-free (DFS) and overall survival (OS) of patients suffering a major postoperative complication (grade-3 or higher within 90 days according to Clavien-Dindo classification) in comparison to those of patients without any major postoperative adverse events.
Results
During the study period, 186 patients underwent resection for PDAC with curative intent. Pancreatoduodenectomy, distal pancreatectomy, and total pancreatectomy were performed in 66%, 12%, and 22% of patients, respectively. Major 90-day postoperative morbidity and mortality rate were 21.5% and 4.3%, respectively. After excluding patients who died within 90 days, major postoperative morbidity significantly increased the length of hospital stay [median 22 (8-66) days vs. 13 (5-26) days, p < 0.0001] resulting in a delay of returning to intended oncologic treatment and reducing the likelihood of receiving adjuvant chemotherapy (56% vs. 83%, p = 0.001). Postoperative major complications were associated with significantly worse DFS (median DFS 10 vs. 16 months, hazard ratio 1.9, 95% confidence interval 1.91-2.96, p = 0.004) and worse OS (median OS 14 vs. 37 months, hazard ratio 1.7, 95% confidence interval 1.02-2.75, p = 0.04) in multivariate analysis.
Conclusion
Major postoperative complications promote tumor recurrence following resection for PDAC, thus limiting long-term survival. Careful patient selection and optimized complication management may reduce postoperative morbidity, thereby lowering its negative impact on oncologic prognosis.
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Affiliation(s)
- A Andreou
- Department of Visceral Surgery und Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - P Aeschbacher
- Department of Visceral Surgery und Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - A S Wenning
- Department of Visceral Surgery und Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - D Candinas
- Department of Visceral Surgery und Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - B Gloor
- Department of Visceral Surgery und Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
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Aeschbacher P, Andreou A, Wenning AS, Christen S, Wiest R, Maubach J, Candinas D, Gloor B. Endoscopic ultrasound-guided hepaticogastrostomy vs. ERCP for preoperative biliary drainage in patients undergoing pancreatic resection. Br J Surg 2021. [DOI: 10.1093/bjs/znab202.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Objective
Preoperative bile drainage in patients with obstructive jaundice due to pancreatic head malignancy is needed, if pancreatic head resection cannot be performed in a timely fashion. The safety and efficacy of ultrasound-guided hepaticogastrostomy (HGS) as an alternative to the established endoscopic retrograde cholangio-pancreatography (ERCP) with stent placement needs further investigation.
Methods
Clinicopathological data of patients who underwent partial or total pancreaticoduodenectomy between January 2017 and December 2019 in a major swiss hepatopancreatobiliary center were assessed. We compared the HGS with ERCP/stent regarding the kinetics of bilirubin decrease, the procedure-related morbidity, and the postoperative surgical outcomes.
Results
During the study period, 102 patients underwent pancreaticoduodenectomy or total pancreatectomy for pancreatic malignancy. Preoperative bile drainage was performed in 65 patients (20 HGS, 45 ERCP). HGS was associated with a faster (6 vs. 10 days, P = 0.042) and more effective (133 µmol/L vs. 101 µmol/L, P = 0.037) reduction of the serum bilirubin levels. HGS was safe and did not differ from ERCP with stent placement concerning post-interventional complications (P = 0.565), postoperative mortality (P = 0.996) and postoperative morbidity (P = 0.896), including infectious complications (wound infection, P = 0.662/ intra-abdominal abscess, P = 0.587), severe pancreatic fistula (P = 0.587), bile leak (P = 0.131), and postoperative hemorrhage (P = 0.886).
Conclusion
HGS performed in a specialized multidisciplinary hepatopancreatobiliary center is feasible and safe and may result in more accelerated and effective bile drainage compared to the established ERCP. In patients with obstructive jaundice related to pancreatic malignancy unable to undergo adequate bile drainage by ERCP, HGS may be an effective alternative method enabling surgery in a timely manner.
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Affiliation(s)
- P Aeschbacher
- Department of Visceral Surgery und Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - A Andreou
- Department of Visceral Surgery und Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - A S Wenning
- Department of Visceral Surgery und Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - S Christen
- Department of Visceral Surgery und Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - R Wiest
- Department of Visceral Surgery und Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - J Maubach
- Department of Visceral Surgery und Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - D Candinas
- Department of Visceral Surgery und Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - B Gloor
- Department of Visceral Surgery und Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
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Zane RS, Aeschbacher P, Moll C, Fisch U. Carotid occlusion without reconstruction: a safe surgical option in selected patients. Am J Otol 1995; 16:353-9. [PMID: 8588630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Complete resection of extensive skull base tumors can be difficult when the disease involves or is closely related to the carotid artery. Detachable balloons have been used effectively to permanently occlude the carotid artery prior to anticipated surgical resection, but their use involves risk of significant cerebral complications. To better define the risks and benefits of this procedure, 52 patients who underwent balloon occlusion of the carotid artery followed by surgery with resection of a portion of the carotid artery were retrospectively reviewed. Pathologic findings are presented demonstrating the infiltrative nature of many of these tumors and the difficulty in separating histologically benign tumors from the carotid artery when they are closely related to it. Although vascular reconstruction can be considered whenever carotid occlusion or resection is planned, balloon occlusion without reconstruction can be safely performed in selected patients, avoiding unnecessary and hazardous additional surgery.
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Affiliation(s)
- R S Zane
- Department of Pathology, University of Zürich, Switzerland
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