Elderly patients have increased perioperative morbidity and mortality from oesophagectomy for oesophageal cancer: A systematic review and meta-analysis.

BACKGROUND: Although oesophagectomy remains technically challenging and associated with high morbidity and mortality, it is now increasingly performed in an ever-ageing population with improvement in perioperative care. However, the risks in the elderly population are poorly quantified. The study aims to review the current evidence to quantify further the postoperative risk of oesophagectomy for cancer in the elderly population compared to younger patients. METHOD: A systematic literature search of PubMed, EMBASE and the Cochrane Library databases was conducted including studies reporting oesophagectomy for cancer in the elderly population. A meta-analysis was reported in accordance with the recommendations of the Cochrane Library and PRISMA guidelines. Primary outcome was overall complications and secondary outcomes were pulmonary and cardiac complications, anastomotic leaks, overall and disease-free survival. RESULTS: This review identified 37 studies incorporating 30,836 patients. Increasing age was significantly associated with increased rates of overall complications (OR 1.67, CI95%: 1.42-1.96), pulmonary complications (OR 1.87, CI95%: 1.48-2.35), and cardiac complications (OR: 2.22, CI95%: 1.95-2.53). However, there was no increased risk of anastomotic leak (OR: 0.98, CI95%: 0.85-1.18). Elderly patients were significantly more likely to have lower rates of 5-year overall survival (OR: 1.36, CI95%: 1.11-1.66) and 5-year disease-free survival (OR: 1.72, CI95%: 1.51-1.96). CONCLUSION: Elderly patients undergoing oesophagectomy for cancer are at increased risk of overall, pulmonary and cardiac complications, irrespective of age subgroups, albeit no difference in anastomotic leaks. Therefore, they represent high-risk patients warranting implementation of preoperative pathways such as prehabilitation to improve cardiopulmonary fitness prior to surgery, although benefit of prehabilitation is yet to be proven. This information will also aid future pre-operative counselling and informed consent.

Laparoscopic anterior versus posterior fundoplication for gastro-esophageal reflux disease: a meta-analysis and systematic review.

OBJECTIVES: Although laparoscopic posterior fundoplication (LPF) i.e., Nissen or Toupet have the proven efficacy for controlling gastro-esophageal reflux surgically, there remain problems with postoperative dysphagia and gas bloat syndrome. To decrease some of these postoperative complications, laparoscopic anterior fundoplication (LAF) was introduced. The aim of this study was to conduct a meta-analysis and systematic review of randomized controlled trials (RCTs) to investigate the merits and drawbacks of LPF versus LAF for the treatment of gastro-esophageal reflux disease (GERD). DATA SOURCES, STUDY SELECTION, AND REVIEW METHODS: A search of Medline, Embase, Science Citation Index, Current Contents, PubMed, ISI Web of Science, and the Cochrane Database identified all RCTs comparing different types of LPF and LAF published in the English Language between 1990 and 2013. The meta-analysis was prepared in accordance with the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) statement. Data was extracted and analyzed on ten variables which include dysphagia score, heartburn rate, redo operative rate, operative time, overall complications, rate of conversion to open, Visick grading of satisfaction, overall satisfaction, length of hospital stay, and postoperative 24-h pH scores. DATA SYNTHESIS: Nine trials totaling 840 patients (anterior = 425, posterior = 415) were analyzed. There was a significant reduction in the odds ratio for dysphagia in the LAF group compared to the LPF group. Conversely, significant reduction in the odds ratio for heartburn was observed for LPF compared to LAF. Comparable effects were noted for both groups for other variables which include redo surgery, operating time, overall complications, conversion rate, Visick's grading, patients' satisfaction, length of hospital stay, and postoperative 24-h pH scores. CONCLUSIONS: Based on this meta-analysis, LPF compared to LAF is associated with significant reduction in heartburn at the expense of higher dysphagia rate on a short- and medium-term basis. We therefore conclude that LPF is a better alternative to LAF for controlling GERD symptoms.

Delayed duodenal hematoma and pancreatitis from a seatbelt injury.

Traumatic duodenal hematoma is a rare condition that is encountered in the paediatric age group following blunt abdominal trauma. It poses both a diagnostic and therapeutic challenge. The main concern is increased morbidity secondary to delayed diagnosis and associated occult injuries to the adjacent structures. Most of these hematomas resolve spontaneously with conservative management, and the prognosis is good. We present a case of a 15-year-old boy who had a delayed presentation of duodenal hematoma and acute pancreatitis, which was treated conservatively with complete resolution.

Meta-analysis of D1 versus D2 gastrectomy for gastric adenocarcinoma.

OBJECTIVES: To conduct a meta-analysis of randomized controlled trials evaluating the efficacy and drawbacks of limited (D1) versus extended lymphadenectomy (D2) for proven gastric adenocarcinoma. METHODS: A search of Cochrane, Medline, PubMed, Embase, Science Citation Index and Current Contents electronic databases identified randomized controlled trials published in the English language between 1980 and 2008 comparing the outcomes of D1 versus D2 gastrectomy for gastric adenocarcinoma. The meta-analysis was prepared in accordance with the Preferred Reporting Items for Systematic reviews and Meta-analyses statement. The 6 outcome variables analyzed included length of hospital stay; overall complication rate; anastomotic leak rate; reoperation rate; 30-day mortality rate and 5-year survival rate. Random effects meta-analyses were performed using odds ratios (OR) and weighted mean differences (WMD). RESULTS: Six trials totaling 1876 patients (D1 = 946, D2 = 930) were analyzed. In 5 of the 6 outcomes the summary point estimates favored D1 over D2 group with a statistically significant reduction of (i) 6.37 days reduction in hospital stay (WMD -6.37, confidence interval [CI] -10.66, -2.08, P = 0.0036); (ii) 58% reduction in relative odds of developing postoperative complications (OR 0.42, CI 0.27, 0.66, P = 0.0002); (iii) 60% reduction in anastomotic breakdown (OR 0.40, CI 0.25, 0.63, P = 0.0001); (iv) 67% reduction in reoperation rate (OR 0.33, CI 0.15, 0.72, P = 0.006); and (v) 41% reduction in 30-day mortality rate (OR 0.59, CI 0.40, 0.85, P = 0.0054). Lastly there was no significant difference in the 5-year survival (OR 0.97, CI 0.78, 1.20, P = 0.7662) between D1 and D2 gastrectomy patients. CONCLUSIONS: On the basis of this meta-analysis we conclude that D1 gastrectomy is associated with significant fewer anastomotic leaks, postoperative complication rate, reoperation rate, decreased length of hospital stay and 30-day mortality rate. Finally, the 5-year survival in D1 gastrectomy patients was similar to the D2 cohort.

Assessing the surgeon's technical skills: analysis of the available tools.

The concept of assessing competency in surgical practice is not new and has taken on an added urgency in view of the recent high-profile inquiries into "botched cases" involving surgeons of various levels in different parts of the world. Until very recently, surgeons in the United Kingdom and other parts of the world, although required to undergo formal and compulsory examinations to test their factual knowledge and decision making, were not required to demonstrate technical ability. Therefore, there existed (and still exist) no objective assessment criteria to test trainees' surgical skill, especially during the exit examination, which, if passed, provides unrestricted license to surgeons to practice their specialties. However, with the introduction of a new curriculum by various surgical societies and a demand from the lay community for better standards, new assessment tools are emerging that focus on technical competency and that could objectively and reliably measure surgical skills. Furthermore, training authorities and hospitals are keen to embrace these changes for satisfactory accreditation and reaccreditation processes and to assure the public of the safety of the public and private health care systems. In the United Kingdom, two new surgical tools (Surgical Direct Observation of Procedural Skill, and Procedure Based Assessments) have been simultaneously introduced to assess surgical trainees. The authors describe these two assessment methods, provide an overview of other assessment tools currently or previously used to assess surgical skills, critically analyze the two new assessment tools, and reflect on the merit of simultaneously introducing them.