Strategies to decrease morbidity in surgical management of esophageal cancer: a single center experience.

BACKGROUND: In this study we described our experience in decreasing morbidity by performing a few changes during and after the Ivor Lewis esophagectomy. METHODS: This is a retrospective single center experience comparing a control period (group A) and a study period (group B) in patients who underwent esophagectomy for esophageal cancer (control group: 23; study group: 17). Control group had postero-lateral thoracotomy and a gastric tube without aspiration during postoperative period. Study group had limited lateral muscle sparing thoracotomy and postoperatively the gastric tube was routinely left for 1 week with intermittent aspiration (10 times every two hours for 1 week). RESULTS: Average operation time was 312±56 minutes in control period, in study period 189±36 min. Average ICU stay was 10 (7-32) days in the control group, in study group 4 (1-8) days. Anastomotic leak rate was significantly higher in control vs. study group (53.3% vs. 16.6%; P<0.05). Respiratory complications were significantly lower in the study group (47.8% vs. 17.6%). CONCLUSIONS: The combination of a limited lateral thoracotomy and postoperative intermittent aspiration seem to reduce the rate of respiratory and anastomotic complication after Ivor-Lewis' procedure.

Does intraoperative flexible endoscopy offer any benefit compared to conventional air leak testing after circular stapled left-sided laparoscopic colon surgery?

BACKGROUND: Anastomotic leakage is still a feared complication after left-sided colonic resections. Various types of "anastomotic leak testing methods" are described in current literature. In this study we evaluated the use of intraoperative flexible endoscopy in comparison to conventional air leak testing after performing a circular stapled anastomosis in left-sided laparoscopic colon surgery. METHODS: A retrospective database consisting of 130 patients with left sided colonic resections between 01/2015 and 12/2019 at our hospital was evaluated. After performing a circular stapled anastomosis flexible endoscopy was done in 69 cases, 61 patients were controlled with a conventional air leak test. Intraoperative and postoperative complications were recorded and retrospectively evaluated. RESULTS: In the flexible endoscopy group, we observed complications in 13,04%, in the conventional air leak testing group in 9.83%. Postoperative anastomotic leakage was observed in 10,14% in the flexible endoscopy group and 4.91% in the conventional air leak test group. In 10.14% a positive air leak test was seen in the flexible endoscopy group and 11.47% in the conventional air leak testing group. In those cases, we observed no postoperative complications in the first group, in the conventional group we had two anastomotic leakages and one infected haematoma. CONCLUSIONS: In the case of a positive air leak, flexible endoscopy offered a more exact detection of the leak. In those cases, no anastomotic leakage was observed postoperatively. In our opinion, flexible endoscopy should be recommended for testing the anastomosis intraoperatively in every left-sided colon surgery.

Reduced port versus open right hemicolectomy for colorectal cancer: a retrospective comparison study of two centers.

PURPOSE: The concept of complete mesocolic excision (CME) in right-sided colorectal cancer is well known for open and laparoscopic surgery. The aim of this study was to evaluate and compare perioperative and oncological outcomes of reduced port and open surgery for right-sided colorectal cancer. METHODS: One hundred forty-one patients received elective surgery for right-sided colonic cancer between January 2015 and December 2019 and were included in a retrospective database. RESULTS: We observed longer operation time in the RP-CME group (145 min vs. 119.43 min, p<0.01). Hospital stay (8 days vs. 14 days, p<0.01) and time to first intestinal passage (42 h. vs. 59 h, p<0.01) were significantly shorter in the reduced port group. Postoperative complications were more likely to be observed in the O-CME group (7.2% vs. 14.1%, p=0.28); anastomotic leakage rate was low in both groups (1.8% vs. 2.4%, p=1.00). Specimen scores (score 1= good: 93.8% vs. 91.7%, p=1.00) and average number of retrieved lymph nodes were comparable (24 vs. 23 p=0.69). In O-CME patients, we observed more advanced tumor stages (UICC III: 21.4% vs. 45.9%, p<0.01). CONCLUSION: To our knowledge, this is the first study comparing reduced port to open surgery for right-sided colorectal cancer. We could demonstrate that this technique is feasible for oncological right hemicolectomy with observation of shorter hospital stay and lower morbidity rates compared to open surgery. The oncological outcome did not differ in the present study.

Outcomes of liver transplantation for non-alcoholic steatohepatitis: A European Liver Transplant Registry study.

BACKGROUND & AIMS: Little is known about outcomes of liver transplantation for patients with non-alcoholic steatohepatitis (NASH). We aimed to determine the frequency and outcomes of liver transplantation for patients with NASH in Europe and identify prognostic factors. METHODS: We analysed data from patients transplanted for end-stage liver disease between January 2002 and December 2016 using the European Liver Transplant Registry database. We compared data between patients with NASH versus other aetiologies. The principle endpoints were patient and overall allograft survival. RESULTS: Among 68,950 adults undergoing first liver transplantation, 4.0% were transplanted for NASH - an increase from 1.2% in 2002 to 8.4% in 2016. A greater proportion of patients transplanted for NASH (39.1%) had hepatocellular carcinoma (HCC) than non-NASH patients (28.9%, p <0.001). NASH was not significantly associated with survival of patients (hazard ratio [HR] 1.02, p = 0.713) or grafts (HR 0.99; p = 0.815) after accounting for available recipient and donor variables. Infection (24.0%) and cardio/cerebrovascular complications (5.3%) were the commonest causes of death in patients with NASH without HCC. Increasing recipient age (61-65 years: HR 2.07, p <0.001; >65: HR 1.72, p = 0.017), elevated model for end-stage liver disease score (>23: HR 1.48, p = 0.048) and low (<18.5 kg/m2: HR 4.29, p = 0.048) or high (>40 kg/m2: HR 1.96, p = 0.012) recipient body mass index independently predicted death in patients transplanted for NASH without HCC. Data must be interpreted in the context of absent recognised confounders, such as pre-morbid metabolic risk factors. CONCLUSIONS: The number and proportion of liver transplants performed for NASH in Europe has increased from 2002 through 2016. HCC was more common in patients transplanted with NASH. Survival of patients and grafts in patients with NASH is comparable to that of other disease indications. LAY SUMMARY: The prevalence of non-alcoholic fatty liver disease has increased dramatically in parallel with the worldwide increase in obesity and diabetes. Its progressive form, non-alcoholic steatohepatitis, is a growing indication for liver transplantation in Europe, with good overall outcomes reported. However, careful risk factor assessment is required to maintain favourable post-transplant outcomes in patients with non-alcoholic steatohepatitis.

High incidence of hepatocellular carcinoma and postoperative complications in patients with nonalcoholic steatohepatitis as a primary indication for deceased liver transplantation.

BACKGROUND AND AIMS: Nonalcoholic steatohepatitis (NASH) is an increasingly prevalent indication for liver transplantation (LT) across the world. The relative outcomes following transplantation are poorly described in this cohort. We aimed to analyze the incidence and outcome of LT for NASH as compared with other indications. PATIENTS AND METHODS: This is a retrospective analysis of 513 patients who underwent deceased-donor, adult LT between 2002 and 2012 as recorded at the Medical University of Innsbruck, Austria. RESULTS: The prevalence of NASH cirrhosis as indication for liver transplantation was 12.7% (65/513). Patient survival in patients with NASH was comparable to other indications, including alcohol-induced liver steatosis (ALD) and hepatitis C virus (HCV) (P=0.208). Patients with NASH were older, had a higher model of end-stage liver disease score and a higher BMI, but patient survival and graft survival were equivalent to other indications. Patients with hepatocellular carcinoma (HCC) as primary indication for liver transplantation showed significantly inferior overall survival as compared with the other indications (P=0.003). Patients with NASH had coexisting HCC in 53.7% of cases, whereas HCC in ALD, HCV and other indications was prevalent in 31.2, 47.7, and 34.5%, respectively (P<0.0001). Patients with NASH had a higher incidence of advanced HCCs (outside the Milan criteria) than patients with ALD, HCV, and other indications (P=0.034). Postoperative complications were significantly higher in the NASH cohort (P=0.048). CONCLUSION: In this single-center LT database analysis, patients with NASH have a higher incidence and a more rapid progression of HCC as well as an increased incidence of postoperative complications. Our findings warrant confirmation by others.