[Fast track recovery protocols for extended pelvic surgery]

OBJECTIVE

To compare the immediate results of extended pelvic surgery before and after introduction of standardized fast track surgery (FTS) protocol into routine clinical practice.

MATERIAL AND METHODS

The study included 111 patients with pelvic tumors who underwent extended pelvic surgery. The control group included 59 patients whose perioperative management implied traditional approaches (2018-2019), the main group - 52 patients with FTS protocol (2020-2021). Age, BMI and ECOG status were similar. In the main group, females (90.4% vs. 74.6%; p=0.046), patients with recurrent (46.2% vs. 22.0%; p=0.009) and complicated tumors (26.9% vs. 11.9%; p=0.054) prevailed. Obstructive resection without anastomosis was less common in the main group (28.8% vs. 47.5%; p=0.068).

RESULTS

Surgery time was higher (319±125 min vs. 236±79 min, p<0.001) in the main group, but blood loss (238±154 ml vs. 282±150 ml, p=0.029) and incidence of blood transfusions (23.1% vs. 42.4%, p=0.043) were lower. Moreover, complications (36.6% vs. 54.3%; p=0.086), mild complications (Clavien-Dindo class I-II) (11.6% vs. 28.8%; p=0.034) and local infectious complications (19.2% vs. 42.4%; p=0.009) were less common in the main group. Two patients died in the control group due to sepsis following colonic anastomosis and bladder suture failure, respectively. Postoperative hospital-stay was similar (14±9.1 days vs. 14.4±9 days; p=0.89).

CONCLUSION

FTS protocol is possible and safe in patients with locally advanced and recurrent malignant pelvic tumors. This approach reduces blood loss, the number of blood transfusions and risk of postoperative infections.

Patient blood management in oncology in the Russian Federation: resolution to improve oncology care

The huge global burden of oncological diseases is growing and measures to counter this complex challenge are high on national health agendas. The Russian National Long-Term Oncology Strategy 2030 defines priorities, goals and directions in the fight against cancer. Italso contains action plans for more effective prevention, earlier and more specific diagnosis and more effective treatment options. Against this backdrop, experts now suggest to complement standard oncology treatment strategies by adding Patient Blood Management (PBM). For many clinical disciplines where a low blood count and considerable blood loss are commonly encountered, this bundle of care is the new standard. Based on clinical and scientific evidence, it aims to optimise medical and surgical patient outcomes by clinically managing and preserving a patients blood. The principles of this comprehensive concept can and must be transferred to oncology, thus offering value in improving cancer care and the efficacy of medical institutions. Accumulating evidence demonstrates that anaemia and iron deficiency, but also thrombocytopenia, blood loss and coagulopathy are independent risk factors for adverse patient outcomes including morbidity, mortality, reduced quality of life and prolonged average length of hospital stay in both surgical and medical patients. For the timely and effective detection and correction of these risk factors, an international network of multi-disciplinary clinicians and researchers has developed PBM. The rapidly growing body of evidence for PBM not only shows improved patient outcomes, but also reduced resource utilisation including the use of allogeneic blood components. The reduction of allogeneic blood transfusion further improves patient safety and outcomes, since transfusion is another independent risk factor for adverse outcomes. Supported by WHO endorsements and following the recommendations of an increasing number of state or national health authorities, PBM is about to become a new standard of care. However, even though the aforementioned risk factors are highly prevalent in oncology settings due to chemo-/radiotherapy and the pathology of the disease, the integration of PBM in standard oncology treatment pathways is lagging behind. Thus, and in support of the Russian National Long-Term Oncology Strategy 2030 to improve quality of oncological care, with the support of the National Association of Specialists in PBM (NASPBM), the PBM Oncology Working Group of the Russian Federation was created, consisting of national and international experts in oncology and PBM. On July 9, 2020, the Working Group met to discuss the rationale for PBM in oncology and to assess the need to implement PBM in Russian oncology care. As a result, the Group recommended to include PBM as an integral part of standard oncology treatment pathways, delineated the action required from facilitating stakeholders in the Russian Federation, determined a roadmap for implementation and developed a national resolution as a call to action on the matter. Presented herein, this resolution acknowledges the global and local impetus to reduce cancer mortality, and the rationale for PBM interventions to improve patient outcomes and alleviate the social and economic burden of cancer on the healthcare system.

[C-reactive protein as early predictor of anastomotic leakage after surgery for colorectal cancer. Systematic review and meta-analysis]

OBJECTIVE

Systematic review and meta-analysis of data on C-reactive protein (CRP) as a predictor of anastomotic leakage (AL) after surgery for colorectal cancer.

MATERIAL AND METHODS

Literature searching was performed in Medline, Elibrary, Scopus, Web of Science databases. Literature request consisted of keywords «CRP», «colorectal surgery», «anastomotic leakage» for the period 2008-2018. Meta-analysis included 2 manuscripts for the second postoperative day, 7 articles for the third postoperative day and 6 articles for the fourth postoperative day. ROC-analysis was made to determine optimal prognostic values.

RESULTS

ROC-curve for the second postoperative day - AUC 0.758; optimal CRP value - 154 mg/l (sensitivity 70.1%, specificity 55.6%), 95% confidence interval 0.698-0.819. ROC-curve for the third postoperative day - AUC 0.715; optimal CRP value - 144.5 mg/l (sensitivity 79.1% specificity 60.3%), 95% confidence interval 0.68-0.75. ROC-curve for the fourth postoperative day - AUC 0.767; optimal CRP value - 122.91 mg/l (sensitivity 72.3% specificity 60%), 95% confidence interval 0.73-0.804.

CONCLUSION

Increased CRP is an early predictor of AL after surgery for colorectal cancer. CRP level ≥144.5 mg/l on the third postoperative day can predict AL (sensitivity 79%, specificity 60%).

[Application of the standardized protocol for fast track recovery after lung cancer surgery]

OBJECTIVE

To assess standardized protocol for fast track recovery after lung cancer surgery.

MATERIAL AND METHODS

There were 201 patients. Patients underwent VATS lung resection, VATS lobectomy and various open resections of lungs. Patients had either primary lung cancer or metastatic lung lesion with indications for surgical treatment. Management of patients was divided into 3 periods: preoperative, intraoperative and postoperative. The protocol of fast track recovery was developed considering literature data and own experience. Requirements of this protocol were applied in perioperative management.

RESULTS

Application of the protocol was successful in all patients. Minimum number of complications (6%) and length of postoperative hospital-stay of 4 days were observed after VATS resection of lung. VATS lobectomy was followed by complication rate 25% and postoperative hospital-stay of 6 days. In the group of open resections these values were 29% and 7 days.

Russian consensus on exo- and endocrine pancreatic insufficiency after surgical treatment

The Russian consensus on exo- and endocrine pancreatic insufficiency after surgical treatment was prepared on the initiative of the Russian "Pancreatic Club" on the Delphi method. His goal was to clarify and consolidate the opinions of specialists on the most relevant issues of diagnosis and treatment of exo- and endocrine insufficiency after surgical interventions on the pancreas. An interdisciplinary approach is provided by the participation of leading gastroenterologists and surgeons.

[Thoracoscopic pulmonary resection for metastatic lesion without pleural drainage: initial experience]

AIM

To analyze the possibility of thoracoscopic pulmonary resection for metastatic lesion without pleural drainage.

MATERIAL AND METHODS

There were 10 patients aged 53.8 years. Most of patients had solitary lung injury within 3 cm from the visceral pleura on the average. Surgical treatment was performed in standard fashion: hardware atypical pulmonary resection within healthy tissues. Pleural cavity was drained with 24 Fr tube. After that lung was inflated under visual control. Since wounds were closured residual air was evacuated by active aspiration and drainage tube was removed. Control chest X-ray was performed in 2 hours and 1 day after surgery.

RESULTS

The technique was successful in all patients. Mean surgery time was 52 minutes. There was no blood loss in all patients. Pneumo- and/or hydrothorax were absent according to control chest X-ray in postoperative period. Mean length of postoperative hospital-stay was 3 days (median 2 days). There were no cases of repeated hospitalization.

[A change in the expression of membrane-associated proteins and cytoplasmic actin isoforms in the progression of human colon tumors]

Tumor progression is a complex process that also involves the restructuring of the actin cytoskeleton and the weakening of intercellular adhesive contacts due to the tumor cells that pass through the epithelial-mesenchymal transition (EMT).

AIM

Тo identify correlations between clinical features, risk of progression and/or recurrence of human colon adenocarcinomas (CAC), and EMT-related tumor markers.

MATERIAL AND METHODS

Descending colon and sigmoid colon adenocarcinoma samples were examined immunohistochemically. Formalin-fixed paraffin-embedded tissue sections were incubated with antigen-specific antibodies, then secondary antibodies labeled with fluorochromes, and the fluorescence intensity of microscopy images was analyzed.

RESULTS

The cells of a tumor compared to those of intact colon tissue showed a weak staining of E-cadherin in the cell-cell contact areas. The reduced membrane staining and nuclear localization of β-catenin were detected in moderately (G2) and poorly (G3) differentiated tumors. There were substantially decreased β-actin levels in almost all tumor samples and increased γ-actin ones, mainly in the samples belonging to stage IV disease.

CONCLUSION

A correlation was found between stage, tumor differentiation grade, risk for relapse or progression of disease, and the impaired expression of different EMT markers: total or partial loss of E-cadherin expression, β-catenin reorganization in cell-cell contacts, and a change in the ratio of cytoplasmic actin isoforms in the late stages of CAC development. We believe that these molecular markers may have a prognostic potential.

[Accelerated postoperative rehabilitation in patients undergoing pancreatoduodenectomy]

AIM

To assess safety and clinical-economic effectiveness of complex postoperative rehabilitation after pancreatoduodenectomy.

MATERIAL AND METHODS

73 patients were included in the study. Main group consisted of 39 patients who underwent accelerated postoperative rehabilitation that was developed in our clinic. In the control group of 34 patients this protocol was not applied. The main components of rehabilitation were multicomponent analgesia, early enteral nutrition, physical rehabilitation by using of exercise therapy and physiotherapy.

RESULTS

There were no significant differences in the incidence of postoperative complications and mortality (58.8% and 74.3%; p=0.213, 5.8% and 7.7%; p=0.678, respectively). Median of postoperative hospital-stay in the study group was 13 days (9; 16), in the control group - 15 days (9; 24). An estimated economic effect in the study group was 558 764, 84 rubles.

CONCLUSION

Accelerated postoperative rehabilitation after pancreatoduodenectomy is safe and does not lead to increased number of postoperative complications and mortality. Developed protocol has clinical advantages and is cost-effective.

[Radical oncological stomach, liver and pancreatic surgery in patients over 80 years old]

AIM

To analyze the results of radical surgery for upper GI cancer in patients ≥80 years old.

MATERIAL AND METHODS

For the period November 2010 - June 2015 there were 14 radical operations in elderly (≥80 years) patients with gastric, liver and pancreatic tumors. There were 4 Whipple procedures, 4 total and 2 distal gastrectomies, 1 total pancreatectomy as well as a central liver resection, one laparoscopic 5 segment resection and one 2, 3, 7 segment resection. We analyzed blood loss, duration of surgery, 90-day mortality, morbidity (Dindo-Clavien scoring), length of hospital-stay.

RESULTS

Blood loss ranged from 0 to 1500 ml, mean duration of surgery - from 150 to 560 min. There was one case of in-hospital mortality: one patient after a Whipple procedure died in 17 days after surgery due to massive arrosive bleeding. Complications developed in 8 patients, 3 of them required reoperation. Mean hospital-stay was 15±6 (8-29) days.

CONCLUSION

Advanced upper GI surgery for cancer is feasible in octagenarians and does not lead to inappropriate mortality and morbidity. Comprehensive preoperative examination alongside with enhanced recovery protocol are prerequisites for this type of surgery.

[Experience of transaxillary endoscopic thyroid surgery]

AIM

To compare the outcomes after open and endoscopic interventions on thyroid gland.

MATERIAL AND METHODS

We have retrospectively analyzed 158 interventions on thyroid gland for the period March 2014 - January 2016. Herewith, 21 interventions were performed endoscopically with transaxillary removal of specimen.

RESULTS

The study was designed in 2 groups - main (endoscopic surgery) and control (open surgery). There were 2 complications in the main group: intraoperative injury of cricoid cartilage by harmonic scalpel and unilateral subcutaneous emphysema of the neck and face. In the control group one patient had transient hypocalcemia.

CONCLUSION

Endoscopic thyroid surgery is technically feasible in certain patients, adequate technical equipment and sufficient experience of surgical team.

[No-touch pancreatectomy and radical antegrade modular pancreatosplenectomy: a systematic review]

AIM

To summarize the data of 'no-touch isolation technique' (NIT) for pancreatoduodenectomy and radical antegrade modular pancreato-splenectomy (RAMPS) for pancreatic malignancies.

MATERIAL AND METHODS

We looked through Pubmed and Cochrane databases for scientific papers published from January 2000 until September 2014.

RESULTS

Eight studies were included. There were 7 retrospective cohort studies and one randomized controlled trial (RCT). Mean operation time and blood loss were 267 min (198-386 min) and 132 ml (331-744 ml) respectively. Mean morbidity rate was 35% (17-58%). There was no 30-day mortality. Mean incidence of R0-resection varied from 50% to 97% with average value 84%. Median survival was reported in 3 studies (17, 18 and 26 months). Five-year actuarial overall survival was reported in 4 studies (31, 36, 40 and 53%).

CONCLUSION

Positive results of NIT and RAMPS might justify further evaluation of the method in pancreatic cancer. Prospective randomized controlled trials needs to be done to demonstrate the oncological value of this novel surgical technique.

[Radical surgical treatment of elderly patients with gastric cancer]

To analyze the early results of radical surgery for gastric cancer in patients > 75 years. In the period between Jan. 2013 and June 2015 there were 25 radical operations in elderly (≥ 75 years) patients with gastric cancer. The following outcomes are presented: bloodloss, duration of surgery, mortality and morbidiy according to Dindo-Clavien classification, length of stay. There were 12 total and 13 distal gastrectomies, including 8 laparoscopic procedures (2 - total laparoscopic gastrectomies), all with D2 lymph node dissection. Mean bloodloss constituted 50±64 ml (0-300 ml), mean duration of surgery 220±70 min (140-360 min). There was no in-hospital mortality, but one patient died 2 weeks after discharge because of an unclear intraluminal bleeding. Mild complications (Dindo-Clavien I-II) were found in 6 patients, severe in 11 patients. In 6 patients repeated laparotomies were necessary. Mean length-of-stay constituted 13±17 (5-63) days. Radical gastric cancer surgery in the elderly patients is feasible. A prerequisite is a thorough pre-operative examination. This type of surgery shall be practiced in highly specialized centers after detailled control of patients’ comorbidity.

[Experience of 100 transthoracic needle biopsies of the lung under CT navigation]

The aim of this study was to investigate and analyze the results of transthoracic needle biopsy of lung tumors under CT navigation. There were carried out more than 100 transthoracic needle biopsies of lung tumors. The analysis of immediate results of the applicability of this technique was performed. The average period of hospitalization after the puncture was 1.4 days (1-7). A number of pneumothorax that required drain- ing the pleural cavity was 8. The median of duration of drain- ing the pleural cavity was 6 of 8 patients (5-6.5) days. More severe complications and deaths were not. The histological conclusion was obtained in 100% of cases, in 72 patients the diagnosis of a malignant lung tumor was firstly verified, 12 cases showed a false-negative result. Diagnosis of lung cancer was excluded in 16 patients. The sensitivity of the method was 86%, specificity - 100% and accuracy - 88%. Therefore transthoracic needle biopsy of lung tumors with minimal risk to the patient allows receiving the morphological verification of peripheral lung tumors.