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Grilo N, Crettenand F, Bohner P, Rodrigues Dias SC, Cerantola Y, Lucca I. Impact of Enhanced Recovery after Surgery ® Protocol Compliance on Length of Stay, Bowel Recovery and Complications after Radical Cystectomy. Diagnostics (Basel) 2024; 14:264. [PMID: 38337779 PMCID: PMC10855147 DOI: 10.3390/diagnostics14030264] [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: 09/28/2023] [Revised: 01/15/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Despite existing standardized surgical techniques and the development of new perioperative care protocols, radical cystectomy (RC) morbidity remains a serious challenge for urologists. Postoperative ileus (POI) is one of the most common postoperative complications, often leading to a longer length of stay (LOS). The aim of our study was to assess the impact of compliance to the Enhanced Recovery After Surgery (ERAS®) protocol on bowel recovery, 30-day complications and LOS after RC for bladder cancer (BC). METHODS Data from consecutive patients undergoing RC for BC within an ERAS® dedicated protocol were analyzed. Exclusion criteria were urinary diversion other than ileal conduit and palliative RC. Patients were divided into two groups according to their compliance (A: low-compliance and B: high-compliance). ERAS® compliance was extracted from the ERAS® Interactive Audit System (EIAS) database. Postoperative complications were prospectively recorded by a dedicated study nurse 30 days after RC. POI was defined as the placement of a nasogastric tube. Logistic regression analysis was used to identify predictors of 30-day complications and POI. RESULTS After considering the exclusion criteria, 108 patients were included for the final analysis. The median global compliance to the ERAS® protocol was 61%. A total of 78 (72%) patients had a compliance <65% (group A), while the remaining 30 (28%) had a compliance >65% (group B). No significant differences were found among the two groups regarding the 30-day complication rate (86% in group A versus 73% in group B, p = 0.82) and LOS (14 days in group A versus 15 days in group B, p = 0.82). The time to stool was significantly shorter in group B (4 days versus 6 days, p = 0.02), and the time to tolerate solid food was slightly faster in group B but not significant (8 versus 7 days, p = 0.23). The POI rate was significantly lower in patients with a higher ERAS® compliance (20% versus 46%, p = 0.01). A multivariate analysis showed that ERAS® compliance was not significantly associated with 30-day total complications. However, a lower compliance to the ERAS® protocol and age > 75 years were significant independent predictors of POI. CONCLUSIONS Our study provides further evidence to support the beneficial effect of the ERAS® protocol in patients undergoing RC, particularly in terms of facilitating a faster recovery of bowel function and preventing POI. Future research should focus on investigating novel approaches and interventions to improve compliance with the ERAS® protocol. This may involve patient education, multidisciplinary teamwork, and continuous quality improvement initiatives.
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Affiliation(s)
- Nuno Grilo
- Urology Department, Lausanne University Hospital, 1011 Lausanne, Switzerland
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Bohner P, Pal M, Crettenand F, Roth B, Lucca I. [Bladder cancer : a comprehensive follow-up for an efficient and personalized care]. Rev Med Suisse 2023; 19:2250-2253. [PMID: 38019542 DOI: 10.53738/revmed.2023.19.852.2250] [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: 11/30/2023]
Abstract
Bladder cancer is a common cancer in the Swiss population. The heterogeneous nature of the disease requires long-term oncological monitoring, as well as metabolic and functional follow-up. Patients' quality of life must also be considered during follow-up.
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Affiliation(s)
- Perrine Bohner
- Service d'urologie, Centre hospitalier universitaire vaudois, 1011 Lausanne
| | - Matyas Pal
- Service d'urologie, Centre hospitalier universitaire vaudois, 1011 Lausanne
| | | | - Beat Roth
- Service d'urologie, Centre hospitalier universitaire vaudois, 1011 Lausanne
| | - Ilaria Lucca
- Service d'urologie, Centre hospitalier universitaire vaudois, 1011 Lausanne
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Pal M, Bohner P, Crettenand F, Roth B, Lucca I. [A Swiss Urological Society register of cystectomies to improve surgical quality]. Rev Med Suisse 2023; 19:2254-2256. [PMID: 38019543 DOI: 10.53738/revmed.2023.19.852.2254] [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: 11/30/2023]
Abstract
In the era of highly specialised medicine, the Swiss Urological Society has set up a national register from January 2019 that will prospectively record all data relating to cystectomies. Doctors will be able to use this information to compare their activities at national level, refine surgical techniques and optimise the perioperative management of cystectomy patients. This article presents the register and provides an initial assessment of cystectomy surgery activity in Switzerland over the first four years of its set up.
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Affiliation(s)
- Matyas Pal
- Service d'urologie, Centre hospitalier universitaire vaudois, 1011 Lausanne
| | - Perrine Bohner
- Service d'urologie, Centre hospitalier universitaire vaudois, 1011 Lausanne
| | | | - Beat Roth
- Service d'urologie, Centre hospitalier universitaire vaudois, 1011 Lausanne
| | - Ilaria Lucca
- Service d'urologie, Centre hospitalier universitaire vaudois, 1011 Lausanne
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Reale S, Bohner P, Crettenand F, Roth B, Lucca I. [Radical cystectomy in the geriatric population. Tools for screening postoperative complications]. Rev Med Suisse 2023; 19:2247-2249. [PMID: 38019541 DOI: 10.53738/revmed.2023.19.852.2247] [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: 11/30/2023]
Abstract
Radical cystectomy is the gold standard for the treatment of muscle-invasive bladder cancer. Advanced age is only a relative criterion when selecting patients eligible for radical cystectomy, and to reduce post-operative complications, the management of an elderly patient requires a multidisciplinary approach. The role of the geriatrician is therefore essential, in collaboration with the urologist, to ensure appropriate follow-up. A series of preoperative screening tests should be used to identify frailer patients who are at high risk of developing complications, so that appropriate follow-up can be carried out.
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Affiliation(s)
- Sofia Reale
- Service d'urologie, Centre hospitalier universitaire vaudois, 1011 Lausanne
| | - Perrine Bohner
- Service d'urologie, Centre hospitalier universitaire vaudois, 1011 Lausanne
| | | | - Beat Roth
- Service d'urologie, Centre hospitalier universitaire vaudois, 1011 Lausanne
| | - Ilaria Lucca
- Service d'urologie, Centre hospitalier universitaire vaudois, 1011 Lausanne
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Crettenand F, Assayed-Leonardi N, Rohrer F, Martinez Carrique S, Roth B. Reply to Beilstein, C.M.; Wuethrich, P.Y. Comment on "Crettenand et al. Is Continuous Wound Infiltration a Better Option for Postoperative Pain Management after Open Nephrectomy Compared to Thoracic Epidural Analgesia? J. Clin. Med. 2023, 12, 2974". J Clin Med 2023; 12:5918. [PMID: 37762859 PMCID: PMC10531563 DOI: 10.3390/jcm12185918] [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: 08/29/2023] [Revised: 09/06/2023] [Accepted: 09/08/2023] [Indexed: 09/29/2023] Open
Abstract
We appreciate your comprehensive comment [...].
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Affiliation(s)
- François Crettenand
- Department of Urology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Nady Assayed-Leonardi
- Department of Urology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Felix Rohrer
- Department of Anesthesiology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Silvia Martinez Carrique
- Department of Urology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Beat Roth
- Department of Urology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
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Crettenand F, Assayed-Leonardi N, Rohrer F, Martinez Carrique S, Roth B. Is Continuous Wound Infiltration a Better Option for Postoperative Pain Management after Open Nephrectomy Compared to Thoracic Epidural Analgesia? J Clin Med 2023; 12:jcm12082974. [PMID: 37109313 PMCID: PMC10143069 DOI: 10.3390/jcm12082974] [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: 03/02/2023] [Revised: 04/10/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Despite increasingly advanced minimally invasive percutaneous ablation techniques, surgery remains the only evidence-based therapy in curative intent for larger (>3-4 cm) renal tumors. Although minimally invasive surgery using (robotic-assisted) laparoscopic or retroperitoneoscopic approaches has gained popularity, open nephrectomy (ON) is still performed in 25% of cases, especially in tumors with central localization (partial ON) or large tumors with/without cava thrombus (total ON). As postoperative pain is one of the drawbacks of ON, our study aims to assess recovery and post-operative pain management using continuous wound infiltration (CWI) compared to thoracic epidural analgesia (TEA). METHODS Since 2012, all patients undergoing ON at our tertiary cancer center at CHUV have been included in our prospective ERAS® (enhanced recovery after surgery) registry that is centrally stored in ERAS® Interactive Audit System (EIAS) secured server. This study represents an analysis of all patients operated on with partial or total ON at our center between 2012 and 2022. An additional analysis was performed for the estimations of the total cost of CWI and TEA, based on the diagnosis-related group method. RESULTS 92 patients were included and analyzed in this analysis (n = 64 (70%) with CWI; n = 28 (30%) with TEA). Adequate oral pain control was earlier achieved in the CWI group compared to the TEA group (median 3 vs. 4 days; p = 0.001), whereas immediate postoperative pain relief was better in the TEA group (p = 0.002). Consequently, opioid use was higher in the CWI group (p = 0.004). Still, reported nausea was lower in the CWI group (p = 0.002). Median time to bowel recovery was similar in both groups (p = 0.03). A shorter LOS (0.5 days) was observed in patients managed with CWI, although this was not statistically significant (p = 0.06). The use of CWI has reduced total hospital costs by nearly 40%. CONCLUSIONS TEA has better results in terms of postoperative pain management compared to CWI following ON. However, CWI is better tolerated, and causes less nausea and earlier recovery, which leads to a shorter length of stay. Given its simplicity and cost-effectiveness, CWI should be encouraged for ON.
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Affiliation(s)
- François Crettenand
- Department of Urology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Nady Assayed-Leonardi
- Department of Urology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Felix Rohrer
- Department of Anesthesiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Silvia Martinez Carrique
- Department of Urology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Beat Roth
- Department of Urology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
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Crettenand F, Assayed Leonardi N, Martinez Carrique S, Roth B. Comparing continuous wound infiltration with thoracic epidural analgesia for postoperative pain management in open nephrectomy. Eur Urol 2023. [DOI: 10.1016/s0302-2838(23)01054-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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Lucca I, Derré L, Cesson V, Bohner P, Crettenand F, Rodrigues-Dias S, Dartiguenave F, Masnada A, Texeira-Pereira C, Benmerzoug S, Chevalier M, Domingos-Pereira S, Nguyen S, Polak L, Schneider A, Roth B, Jichlinski P, Nardelli-Haefliger D. Intravesical Ty21a Treatment of Non-muscle-invasive Bladder Cancer Shows a Good Safety Profile. EUR UROL SUPPL 2022; 45:55-58. [PMID: 36212980 PMCID: PMC9539774 DOI: 10.1016/j.euros.2022.09.004] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2022] [Indexed: 11/05/2022] Open
Abstract
Standard-of-care immunotherapy for non–muscle-invasive bladder cancer (NMIBC) with intravesical Bacillus Calmettte-Guérin (BCG) is associated with adverse events (AEs), disease recurrence/progression, and supply shortages. Preclinical data have shown that intravesical instillation of Ty21a/Vivotif, the oral vaccine against typhoid fever, may be an effective and safer alternative to BCG. We assessed the safety of intravesical Ty21a in NMIBC. For ethical reasons, patients with low- or intermediate-risk NMIBC not requiring BCG immunotherapy were enrolled. To determine the maximum tolerated dose, escalating doses of Ty21a/Vivotif were intravesically instilled in three patients once a week for 4 wk in phase 1a. In phase 1b, ten patients received the selected dose (1 × 108 CFU) once a week for 6 wk, as for standard BCG therapy. At this dose, all patients completed their treatment. Most patients experienced minor systemic AEs, while half reported mild local bladder AEs. AEs only occurred after one or two instillations for 40% of the patients. Ty21a bacteria were only recovered in three out of 72 urinary samples at 1 wk after instillation. Intravesical Ty21a might be well tolerated with no cumulative side effects, no fever >39 °C, and lower risk of bacterial persistence than with BCG. Ty21a treatment thus warrants clinical trials to explore its safety and antitumor efficacy in high-risk NMIBC. This trial is registered on ClinicalTrials.gov as NCT03421236. Patient summary We examined the safety of a new intra-bladder immunotherapy for non–muscle-invasive bladder cancer as an alternative to the standard BCG treatment. Our data show that the Ty21a vaccine might be well tolerated. Further studies are needed to determine the safety and antitumor efficacy of this treatment.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Denise Nardelli-Haefliger
- Corresponding author. Department of Urology, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Bugnon 48, 1011 Lausanne, Switzerland. Tel. 021 3144081; Fax: 021 3144060.
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Grilo N, Crettenand F, Dartiguenave F, Dias S, Blanc C, Roth B, Lucca I. Impact of ERAS® protocol compliance on length of stay, bowel recovery and complications after radical cystectomy. Clin Nutr ESPEN 2022. [DOI: 10.1016/j.clnesp.2022.06.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Crettenand F, M’Baya O, Grilo N, Valerio M, Dartiguenave F, Cerantola Y, Roth B, Rouvé JD, Blanc C, Lucca I. ERAS® protocol improves survival after radical cystectomy: A single-center cohort study. Medicine (Baltimore) 2022; 101:e30258. [PMID: 36107599 PMCID: PMC9439815 DOI: 10.1097/md.0000000000030258] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION To evaluate Enhanced recovery after surgery (ERAS®) protocol on oncological outcomes for patients treated with radical cystectomy (RC) for urothelial carcinoma of the bladder (UCB). METHODS A prospectively maintained single-institutional database comprising 160 consecutive UCB patients who underwent open RC from 2012 to 2020 was analyzed. Patients receiving chemotherapy and those with a urinary diversion other than ileal conduit were excluded. Patients were divided into two groups according to the perioperative management (ERAS® and pre-ERAS®). The study aimed to evaluate the impact of the ERAS® protocol on survival at five years after surgery using a Kaplan-Meier log-rank test. A multivariable Cox proportional hazards model was used to identify prognostic factors for cancer-specific (CSS) and overall survival (OS). RESULTS Of the 107 patients considered for the final analysis, 74 (69%) were included in the ERAS® group. Median follow-up for patients alive at last follow-up was 28 months (interquartile range [IQR] 12-48). Five-years CSS rate was 74% for ERAS® patients, compared to 48% for the control population (P = 0.02), while 5-years OS was 31% higher in the ERAS® (67% vs. 36%, P = .003). In the multivariable analysis, ERAS® protocol and tumor stage were independent factors of CSS, while ERAS®, tumor stage so as total blood loss were independent factors for OS. DISCUSSION A dedicated ERAS® protocol for UCB patients treated with RC has a significant impact on survival. Reduction of stress after a major surgery and its potential improvement of perioperative patient's immunity may explain these data.
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Affiliation(s)
- François Crettenand
- Department of Urology, University Hospital CHUV, Lausanne, Switzerland
- * Correspondence: François Crettenand, Department of Urology, University Hospital CHUV, Rue du Bugnon 46, 1011 Lausanne, Switzerland (e-mail: )
| | - Olivier M’Baya
- Department of Urology, University Hospital CHUV, Lausanne, Switzerland
| | - Nuno Grilo
- Department of Urology, University Hospital CHUV, Lausanne, Switzerland
| | - Massimo Valerio
- Department of Urology, University Hospital CHUV, Lausanne, Switzerland
| | | | - Yannick Cerantola
- Department of Urology, University Hospital CHUV, Lausanne, Switzerland
| | - Beat Roth
- Department of Urology, University Hospital CHUV, Lausanne, Switzerland
| | - Jean-Daniel Rouvé
- Department of Anaesthesiology, University Hospital CHUV, Lausanne, Switzerland
| | - Catherine Blanc
- Department of Anaesthesiology, University Hospital CHUV, Lausanne, Switzerland
| | - Ilaria Lucca
- Department of Urology, University Hospital CHUV, Lausanne, Switzerland
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Crettenand F, M’Baya O, Jichlinski P, Martel P, Dartiguenave F, Blanc C, Rouvé JD, Valerio M, Cerantola Y, Lucca I. ERAS protocol improves cancer-specific and overall survival after elective radical cystectomy: A retrospective cohort study. Clin Nutr ESPEN 2019. [DOI: 10.1016/j.clnesp.2019.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Martel P, Crettenand F, M'baya O, Cerantola Y, Jichlinski P, Lucca I. [Improved rehabilitation after major urological surgery : what role for the general practitioner ?]. Rev Med Suisse 2018; 14:2150-2153. [PMID: 30484971] [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: 06/09/2023]
Abstract
Enhanced recovery after surgery (ERAS) is a multimodal concept aiming to reduce surgical stress and prevent postoperative complications. Once adapted to urologic patients in 2013, this protocol evolves continuously and many international centers have now implemented it. This article resumes ERAS key principles for general practitioners as they can have a significant impact on patient's optimization before surgery.
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Crettenand F, Martin D, Cherix S, Demartines N, Matter M. Occurrence and prognosis of lymph node metastases in patients selected for isolated limb perfusion with soft tissue sarcoma. J Cancer 2018; 9:3311-3315. [PMID: 30271491 PMCID: PMC6160681 DOI: 10.7150/jca.25696] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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: 02/23/2018] [Accepted: 08/03/2018] [Indexed: 12/13/2022] Open
Abstract
Background and Objectives:Extensive surgery is often required for advanced soft tissue sarcoma (STS) of the limb. In the 1980s, a new approach was developed: isolated limb perfusion (ILP). This study aimed to assess incidence and impact on patient survival based on lymph node metastasis with systematic radical lymphadenectomy during ILP. Methods: Retrospective study of 57 consecutive patients treated by ILP for limb STS with simultaneous radical lymph node dissection in our tertiary referral center between 1992 and 2015. Results: Median age was 62 years (19-87) and 30 patients were male (53%). Lymph node involvement was observed in 13 patients (N1, 23%), regarded as metastatic spreading in 4 angiosarcomas, 3 epithelioid sarcomas, 2 leiomyosarcomas, 2 undifferentiated sarcomas and 2 synovial sarcomas. For the N0 patient group, median survival was 73.9 months (CI 95% 41.9-105.9) compared to 15.1 months (CI 95% 7.4-22.6) in case of metastatic lymph node (p=0.002). The median disease-free survival was 33,0 months (CI 95% 12,5-53.5) in N0 group and 8.0 months (CI 95% 4.0-11.9) in N1 (p=0.006). Conclusions: Lymph node metastases of STS patients selected for ILP seemed to have a negative impact on both overall and disease-free survival. Radical lymph node dissection should be included in ILP procedure.
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Affiliation(s)
| | - David Martin
- Department of Visceral Surgery, University Hospital CHUV, Lausanne, Switzerland
| | - Stéphane Cherix
- Department of Orthopaedics and Traumatology, University Hospital CHUV, Lausanne, Switzerland.,Sarcoma Center, University Hospital CHUV, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, University Hospital CHUV, Lausanne, Switzerland.,Sarcoma Center, University Hospital CHUV, Lausanne, Switzerland
| | - Maurice Matter
- Department of Visceral Surgery, University Hospital CHUV, Lausanne, Switzerland.,Sarcoma Center, University Hospital CHUV, Lausanne, Switzerland
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Seifert L, Komar J, Crettenand F, Dadashi F, Aminian K, Millet G. Inter-limb coordination and energy cost in swimming. J Sci Med Sport 2014; 17:439-44. [DOI: 10.1016/j.jsams.2013.07.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Revised: 05/17/2013] [Accepted: 07/14/2013] [Indexed: 11/26/2022]
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Fontannaz B, Genin A, Crettenand F. [Sleep: a hospital survey]. Krankenpfl Soins Infirm 1980:349-55. [PMID: 6249966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Fontannaz B, Genin A, Crettenand F. [Sleep: physiology, disorders, treatment]. Krankenpfl Soins Infirm 1980:319-31. [PMID: 6247566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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