Enhanced recovery after surgery for emergency colorectal surgery: Are there any differences between intra-abdominal infection and other indications?

AIM OF THE STUDY: Enhanced recovery after surgery (ERAS) has become the standard of care for elective colorectal operations. However, there are few data regarding ERAS in emergency setting. This study aimed to evaluate the results of ERAS protocol for emergency colorectal resection and to compare its difference between patients with intra-abdominal infection (IAI) and those without. PATIENTS AND METHODS: Patients undergoing emergency colectomy and/or proctectomy with ERAS protocol from 2011 to 2017 a university hospital was reviewed. Clinical outcomes and ERAS compliance were analyzed and compared depending on whether there was IAI. RESULTS: This study included 60 patients; 14 (23%) had IAI. Median ERAS compliance was 75% (IQR: 63-83). Rates of overall complication and severe complication were 35% and 15%, respectively. The 60-day mortality was 6.7%. Median length of postoperative stay was 5days (IQR: 4-8). Thirty-three patients (55%) achieved targeted discharge within postoperative day 5. High adherence to ERAS protocol was associated with lower morbidity (P<0.001) and shorter hospitalization (P=0.006). Patients with IAI had less ERAS compliance (50% vs. 78%; P<0.001), higher complication rates (64% vs. 26%; P=0.009), and higher mortality (21% vs. 2%; P=0.036), and longer time to first defecation (4days vs. 3days; P=0.049). Of note, patients with IAI had significant lower compliance with preoperative optimization, scheduled removal of urinary catheter and early mobilization than the other group. CONCLUSIONS: ERAS program is applicable for patients undergoing emergency colorectal surgery. In patients with intra-abdominal sepsis, the ERAS compliance was lower and the complications rate was higher.

The influence of preoperative nutritional status on the outcomes of an enhanced recovery after surgery (ERAS) programme for colorectal cancer surgery.

BACKGROUND: The aim of the present study was to evaluate the effects of preoperative nutritional status on the short-term outcomes of an enhanced recovery after surgery (ERAS) programme for colorectal cancer surgery. METHODS: This prospective observational study included 149 patients who underwent elective resection of colorectal cancer with ERAS from January 2011 to January 2014 in a university hospital. Subjective global assessment (SGA) was used to determine preoperative nutritional status. Primary outcomes included the length of postoperative stay, postoperative morbidity, gastrointestinal recovery, and 30-day readmission. RESULTS: The patients were divided into 3 groups according to the SGA classification. There were 96 patients (64.4 %) in SGA-A (well-nourished), 48 (32.2 %) in SGA-B (mild to moderately malnourished), and 5 (3.4 %) in SGA-C (severely malnourished). Patients in SGA-A had the median length of postoperative stay of 4 days (range 2-23), which was significantly shorter compared to SGA-B (5 days; range 2-16; p < 0.01) and SGA-C (7 days; range 4-17; p < 0.01). The overall complication rates of SGA-A, SGA-B, and SGA-C patients were 11, 31 % (adjusted OR 3.76; 95 % CI 1.36-10.36; p < 0.01) and 40 % (adjusted OR 2.15; 95 % CI 0.07-63.64; p = 0.66). Mean time to resumption of normal diet and time to first defecation were 1.6 ± 1.3 and 2.2 ± 0.9 days in SGA-A, 2.6 ± 1.7 and 3.1 ± 1.6 days in SGA-B (p < 0.01 compared to SGA-A) and 3.2 ± 2.4 days and 2.6 ± 1.5 days in SGA-C (p = 0.07 and p = 0.1 compared to SGA-A, respectively). No 30-day mortality occurred in any group. One patient in SGA-A (1 %), and 3 patients in SGA-B (6 %) had unplanned 30-day re-admission; p = 0.11. CONCLUSIONS: Within an ERAS programme for colorectal cancer surgery, malnourished patients were at risk for increased postoperative morbidity, delayed recovery of gastrointestinal function, and prolonged length of hospital stay.

Evaluation of fat grafting safety in patients with intraepithelial neoplasia: a matched-cohort study.

BACKGROUND: Fat grafting is widely carried out in breast cancer patients to improve quality in breast reconstruction. Recently, in vitro and animal studies have questioned the role of adipose tissues in cancer development. DESIGNS: Matched-cohort study. We analysed: (i) 59 intraepithelial neoplasia patients who had undergone lipofilling, with no recurrence between primary surgery and lipofilling. (ii) A control group of 118 matched patients (two controls per lipofilling patient) with the corresponding recurrence-free intervals. Both groups were also matched for main cancer criteria. A local event (LE) was the primary end point, with follow-up starting from the baseline. RESULTS: Median follow-up was 63 and 66 months from surgery, and 38 and 42 from baseline, for the lipofilling and control groups, respectively; the 5-year cumulative incidence of LE was 18% and 3% (P = 0.02). Ki-67 was the significant factor in univariate survival analysis. A subgroup analysis showed that lipofilling increased the risk of LE in women <50 years, with high grade neoplasia, Ki-67 ≥ 14 or who had undergone quadrantectomy. CONCLUSION: Higher risk of LE was observed in intraepithelial neoplasia patients following lipofilling. Although further studies are required to validate our conclusions, patients belonging to this subgroup should be informed of these results and the potential risks.

Breast cancer subtype approximations and loco-regional recurrence after immediate breast reconstruction.

BACKGROUND: A small but significant proportion of patients with breast cancer (BC) will develop loco-regional recurrence (LRR) after immediate breast reconstruction (IBR). The LRR also varies according to breast cancer subtypes and clinicopathological features. METHODS: We studied 1742 consecutive BC patients with IBR between 1997 and 2006. According to St Gallen conference consensus 2011, its BC approximations were applied to classify BC into five subtypes: estrogen receptor (ER) and/or progesterone receptor (PgR) positive, HER2 negative, and low Ki67 (<14%) [luminal A]; ER and/or PgR positive, HER2 negative and high Ki67(≥ 14%) [luminal B/HER2 negative]; ER and/or PgR positive, any Ki67 and HER2 positive [luminal B/HER2 positive]; ER negative, PgR negative and HER2 positive [HER2 positive/nonluminal]; and ER negative, PgR negative and HER2 negative [triple negative]. Cumulative incidences of LRR were compared across different subgroups by means of the Gray test. Multivariable Cox regression models were applied. RESULTS: Median follow up time was 74 months (range 3-165). The cumulative incidence of LRR was 5.5% (121 events). The 5-year cumulative incidence of LRR was 2.5% for luminal A; 5.0% for luminal B/HER2 negative; 9.8% for luminal B/HER2 positive; 3.8% for HER2 non luminal; and 10.9% for triple negative. On multivariable analysis, tumor size (pT) >2 cm, body mass index (BMI) ≥ 25, triple negative and luminal B/HER2 positive subtypes were associated with increased risk of LRR. CONCLUSION: Luminal B/HER2 positive, triple negative subtypes and BMI ≥ 25 are independent prognostic factors for risk of LRR after IBR.

Risk factors associated with recurrence after nipple-sparing mastectomy for invasive and intraepithelial neoplasia.

BACKGROUND: To identify risk factors of recurrence in a large series of patients with breast cancer who underwent a nipple-sparing mastectomy (NSM). PATIENTS AND METHODS: Breast-related recurrences and local recurrences (LR) in the breast and the nipple areola complex (NAC) were studied. Cumulative incidences of events were estimated through competing risk analysis. Multivariate Cox regression models were also applied. RESULTS: We identified 934 consecutive NSM patients during 2002-2007. Median follow-up was 50 months. In 772 invasive carcinoma patients, the rate of LR in the breast and in the NAC was 3.6% and 0.8%, respectively. In the 162 patients with intraepithelial neoplasia, the rate of LR in the breast and in the NAC was 4.9% and 2.9%, respectively. The significant risk factors of LR in the breast for the group A were grade, overexpression/amplification of HER2/neu and breast cancer molecular subtype Luminal B. In group B, the risk factors of LR in the breast and in the NAC were age (<45 years), absence of estrogen receptors, grade, HER2/neu overexpression and high Ki-67. CONCLUSIONS: The LR rate after NSM in our series was low. Biological features of disease and young age should be taken into account when considering NSM in breast cancer patients.

Locoregional recurrence risk after lipofilling in breast cancer patients.

BACKGROUND: Lipofilling has been indicated for postmastectomy and postlumpectomy breast reconstruction. The clinical literatures underline its technical efficacy but experimental studies raise important questions about the potential detrimental effect of adipocytes on the stimulation of cancer growth and reappearance. DESIGN: We collected 321 consecutive patients operated for a primary breast cancer between 1997 and 2008 who subsequently underwent lipofilling for reconstructive purpose. For each patient, we selected two matched patients with similar characteristics who did not undergo a lipofilling. RESULTS: Eighty-nine percent of the tumors were invasive. Median follow-up was 56 months from the primary surgery and 26 months from the lipofilling. Eight and 19 patients had a local event in the lipofilling and control group, respectively, leading to comparable cumulative incidence curves [P = 0.792; Hazard Ratio(Lipo vs No lipo) = 1.11 (95% confidence interval 0.47-2.64)]. These results were confirmed when patients undergoing quadrantectomy and mastectomy were analyzed separately and when the analysis was limited to invasive tumors. Based on 37 cases, the lipofilling group resulted at higher risk of local events when the analysis was limited to intraepithelial neoplasia. CONCLUSIONS: Lipofilling seems to be a safe procedure in breast cancer patients. Longer follow-up and further experiences from oncological series are urgently required to confirm these findings.

Nipple sparing mastectomy: can we predict the factors predisposing to necrosis?

BACKGROUND: Nipple sparing mastectomy (NSM) is an accepted surgical approach in selected breast cancer and prophylactic mastectomy, nevertheless post-mastectomy skin necrosis is one of the frequent complications. This study aimed to analyze the factors that may lead to skin necrosis after NSM. PATIENTS AND METHODS: From May 2010 to July 2010, we prospectively registered 50 consecutive NSM from 45 patients. There were 40 mastectomies for cancer, and 10 prophylactic mastectomies. The various patient's and surgical factors were registered during pre-, intra- and postoperative period. RESULTS: No total necrosis of the nipple areola complex (NAC) was observed. There were thirteen cases with partial necrosis (26.0%) of the areola or the adjacent skin. All these necrosis were partial both for the surface and the thickness. Surgical debridement was performed in 9 (18.0%) cases. The significant risk factors are smoking, young age, type of incision and NAC involvement with areola flap thickness less than 5 mm. CONCLUSION: NSM should be done with high caution in smokers. Young patients, periareolar incision and superior circumareolar incision have also a higher risk of necrosis. We recommend keeping areolar flap thickness more than 5 mm in areola region.

Safety of fat grafting in secondary breast reconstruction after cancer.

BACKGROUND: Fat grafting is largely used to correct soft-tissue defects in any region of the human body. This study analysed its safety when the technique is used to correct defects after breast-cancer reconstruction. METHODS: A total of 158 patients who underwent 194 breast fat grafting procedures were analysed. Almost all patients (98%) had a personal history of breast cancer: conservative surgery or mastectomy with breast reconstruction. In all cases, fat grafting was performed according to the Coleman's technique by a single surgeon. RESULTS: Immediate complications included liponecrosis and infection in seven cases (3.6%) that required only daily dressings and oral antibiotics administration. In cases of fat grafting after conservative surgery, only four patients (5.9%) showed minor alterations in the postoperative mammograms, consisting of the appearance of benign images. CONCLUSION: Breast fat grafting can be a good solution to repair defects after breast-cancer treatment and reconstruction, and can reduce the indication for more extensive surgeries such as myocutaneous flaps. Postoperative complication rates are very low and there is little alteration in follow-up mammograms. Two points remain unclear--how much of the fat is absorbed after grafting and the potential risk of local 'dormant' tumour cells being stimulated to induce a local recurrence.

Acute radiation dermatitis in breast cancer: topical therapy with vitamin E acetate in lipophilic gel base.

BACKGROUND: Radiotherapy can cause adverse skin reactions over the course of their treatment. Currently, management is based on several tropical products although there is no gold-standard approach to prevention and management of radiation toxicity. METHOD: We report our experience of vitamin E acetate in the treatment of radiation dermatitis in breast cancer patients who experienced grade 4 side effects (according to Radiation Therapy Oncology Group criteria). RESULTS: Clinical management consisted of oral antibiotics and local application of vitamin E acetate and local escarectomy. All of the patients achieved complete re-epithelialization within 40 days. CONCLUSION: Skin ulceration and necrosis post-radiation may interrupt oncological treatment in breast cancer patients. In acute radiodermatitis with skin necrosis, we propose the use of oral antibiotics together with escarectomy and the application of vitamin E acetate to facilitate the healing process in order to minimize the interruption to the oncological treatment.

The learning curve for safety and success of precut sphincterotomy for therapeutic ERCP: a single endoscopist's experience.

STUDY AIMS: The aims of this study were to evaluate the efficacy and safety of precut sphincterotomy in relation to the experience of a single endoscopist, and to establish the number of procedures required before achieving an effective and safe precut sphincterotomy. METHODS: A total of 200 consecutive patients underwent precut sphincterotomy carried out by a single endoscopist (T.A.) between January 2003 and December 2005. All of the procedures were divided into four chronological groups of 50 (Group I, II, III, and IV). Medical records and patient data were retrospectively reviewed and included procedure indications, outcomes, and complications. All patients were admitted for observation after the procedure in case of complications. RESULTS: A total of 200 patients (23.3%) (mean age 58.5 years; 101 men) underwent precut sphincterotomy (161 with needle-knife technique, 32 with septotomy technique, and seven with Erlangen technique). There was no mortality. The success rates of prompt bile duct cannulation after precut sphincterotomy were 88%, 86%, 94%, and 82%, respectively ( P > 0.05). Immediate bleeding requiring a submucosal adrenaline injection was observed in combined group I - II (28%) and combined group III - IV (7%) ( P < 0.05). One patient (2%) from each of group I, III, and IV required further endoscopic treatment for rebleeding. Duodenal perforation (2%) was detected and conservatively treated in one patient from group II. Mild pancreatitis was found in one patient (2%) in group III. CONCLUSIONS: The success rates of bile duct cannulation by precut sphincterotomy were not associated with the experience of the endoscopist. The postprocedural complications significantly decreased after the first 100 procedures. An experience of at least 100 procedures is suggested to achieve a safe precut sphincterotomy.

Long-term results of large diameter hepaticojejunostomy for treatment of Bile Duct Injuries following cholecystectomy.

OBJECTIVE: Bile Duct Injury (BDI) is one of the most serious complications of cholecystectomy. The authors analyzed the clinical presentation, surgical management and long-term outcome of 19 patients presenting with iatrogenic major BDIs (Straburg type E) following cholecystectomy who underwent Roux-en-Y hepaticojejunostomy. MATERIAL AND METHOD: Between 1992 and 2005, 19 patients with major BDIs (Strasberg type E) following cholecystectomy were included. Operative notes and charts of all patients were reviewed systematically. A follow-up examination of each patient was performed after a median of 22 months (range 1-120). RESULTS: Twelve patients presented with ascending cholangitis, two patients were referred to the hospital with biliary-cutaneous fistula and five patients (26.3%) were identified at the time of operations. All patients were treated with Roux-en-Y hepaticojejunostomy with at least 2 cm of the diameter of the biliary-enteric anastomosis. There was no postoperative mortality. Postoperative complication was found in 5 patients (26.3%). Until now, during the follow-up, neither clinical nor biochemical evidence of recurrent cholangitis has been found. CONCLUSION: Major BDIs are associated with high morbidity rate and prolonged hospitalization. Early detection and referral to an experienced center is crucial in the management of these patients. Roux-en-Y hepaticojejunostomy with large diameter of the biliary-enteric anastomosis is the surgical procedure of choice with good long-term outcome.