A systematic review of surgical site infections following day surgery: a frequentist and a Bayesian meta-analysis of prevalence.

BACKGROUND: Since 1990, several studies have focused on safety and patient satisfaction in connection with day surgery. However, to date, no meta-analysis has investigated the overall prevalence of surgical site infections (SSI). AIM: To estimate the overall prevalence of SSI following day surgery, regardless of the type of surgery. METHOD: A systematic review and a meta-analysis of the prevalence of SSI following day surgery, regardless of the type of surgery, was conducted, seeking all studies before June 2016. A pooled random effects model using the DerSimonian and Laird approach was used to estimate overall prevalence. A double arcsine transformation was used to stabilize the variance of proportions. After performing a sensitivity analysis to validate the robustness of the method, univariate and multi-variate meta-regressions were used to test the effect of date of publication, country of study, study population, type of specialty, contamination class, time of postoperative patient visit after day surgery, and duration of hospital care. FINDINGS: Ninety articles, both observational and randomized, were analysed. The estimated overall prevalence of SSI among patients who underwent day surgery was 1.36% (95% confidence interval 1.1-1.6), with a Bayesian probability between 1 and 2% of 96.5%. The date of publication was associated with the prevalence of SSI (coefficient -0.001, P = 0.04), and the specialty (digestive vs non-digestive surgery) tended to be associated with the prevalence of SSI (coefficient 0.03, P = 0.064). CONCLUSION: The meta-analysis showed a low prevalence of SSI following day surgery, regardless of the surgical procedure.

Same-day discharge in benign esophageal surgery: a prospective cohort study.

Day-case esophageal surgery has been demonstrated to be safe in small prospective cohorts and only for laparoscopic fundoplication. The aims of this study are to assess the feasibility and safety of a large series of esophageal day-case surgeries, including laparoscopic Nissen fundoplication (LNF), Zenker diverticulectomy (ZD), and laparoscopic Heller myotomy (LHM) and to compare the outcomes among three procedures.This was a prospective, observational study of selected patients who underwent day-case LNF, ZD, and LHM between 2003 and 2013. Postoperative outcomes, the patients' satisfaction, and functional results were evaluated with dedicated scores and compared.Of the 427 patients who underwent surgery for those indications during the study period, 168 (39.3%) eligible patients underwent day-case procedures (134 LNF, 14 LHM, and 20 ZD). The overnight unplanned admission rate was 16.2% and was similar among the groups (P = 0.681). Ten patients were readmitted during the first postoperative week because of dysphagia (n = 6, all in the LNF group), flu-like syndrome (n = 1), and secondary perforation (n = 3, all in the LHM group). The unplanned seven-day readmission rate was significantly higher in the LHM group than in the ZD and LNF groups (P = 0.042). The 30-day rates of unplanned readmission and consultation were 8.9% (P = 0.300) and 4.8%, respectively. At follow-up, 87.5% of the patients were satisfied with day-case treatment, and the functional results were good for 81.4% of the patients.Day-case esophageal surgery is feasible for LNF and seems to be feasible for ZD. Safety criteria have not yet been met for LHM, requiring further adaptations.

Patterns of recurrence in early-stage oesophageal cancer after chemoradiotherapy and surgery compared with surgery alone.

BACKGROUND: Patterns of disease recurrence in patients with oesophageal cancer following treatment with neoadjuvant chemoradiotherapy and surgery (nCRTS) or surgery alone are poorly reported. An understanding of patterns of disease recurrence is important for subsequent treatment planning. METHODS: An analysis was undertaken of patterns of disease recurrence from a phase III multicentre randomized trial (FFCD9901) comparing nCRTS with surgery alone in patients with stage I and II oesophageal cancer. RESULTS: Some 170 patients undergoing surgical resection were included in the study. R0 resection rates were similar in the two groups: 94 per cent following nCRTS versus 92 per cent after surgery alone (P = 0·749). After a median follow-up of 94·2 months, recurrent disease was found in 39·4 per cent of the overall cohort (31 per cent after nCRTS versus 47 per cent following surgery alone; P = 0·030). Locoregional recurrence was diagnosed in 41 patients (17 versus 30 per cent respectively; P = 0·047) and distant metastatic recurrence in 47 (23 versus 31 per cent respectively; P = 0·244). Metastatic recurrence was more frequent in patients with adenocarcinoma than in those with squamous cell cancer (40 versus 23·1 per cent respectively; P = 0·032). ypT0 N0 category was associated with prolonged time to mixed locoregional and metastatic recurrence (P = 0·009), and time to locoregional (P = 0·044) and metastatic (P = 0·055) recurrence. In multivariable analysis, node-positive disease predicted both locoregional (P = 0·001) and metastatic (P < 0·001) recurrence. CONCLUSION: Locoregional disease control following nCRTS indicated a local field effect not related solely to completeness of resection. pN+ disease was strongly predictive of time to locoregional and metastatic disease recurrence.

Day-case versus inpatient laparoscopic fundoplication: outcomes, quality of life and cost-analysis.

BACKGROUND: Day-case laparoscopic Nissen-Rossetti fundoplication (LF) has been demonstrated to be safe in small, prospective cohorts. The purpose of the study was to compare postoperative course, functional results, quality of life, and healthcare costs in patients undergoing LF in a day-case surgical unit with same-day discharge and patients undergoing LF as an inpatient. METHODS: All consecutive patients in our department who underwent a primary LF for symptomatic uncomplicated gastroesophageal reflux disease from 2004 to 2011 were entered into a prospective database (n = 292). From 101 same-day discharge patients (day-case group), control inpatient procedures were randomly matched by age, gender, body mass index, American Society of Anesthesiologists classification, and presence of a hiatal hernia (inpatient group, n = 101). RESULTS: No postoperative deaths occurred and postoperative morbidity occurred in 9.4% of patients. When comparing day-case and inpatient groups, postoperative morbidity rates were 9.9 vs. 8.9% (p = 0.81) with median hospital stays and readmission rates of 1 vs. 4 days (p < 0.001) and 7.9 vs. 0% (p < 0.001), respectively. Gastrointestinal Quality of Life Index was significantly enhanced due to surgery (p < 0.001) and comparable in the two groups. Estimated direct healthcare costs per patient were 2,248 euros in the day-case group vs. 6,569 euros in the inpatient group (p < 0.001), equivalent to a cost saving of 3,921 euros. CONCLUSIONS: Day-case and inpatient approaches after LF give similar results in terms of postoperative mortality and morbidity, functional outcomes and quality of life, with a substantial cost saving in favor of a day-case procedure.

Effects of hybrid minimally invasive oesophagectomy on major postoperative pulmonary complications.

BACKGROUND: Morbidity after oesophageal cancer surgery remains high, mainly due to major postoperative pulmonary complications (MPPCs). The aim of this study was to test the hypothesis that hybrid minimally invasive oesophagectomy (HMIO) decreases the 30-day MPPC rate without compromising oncological outcomes. METHODS: Consecutive patients undergoing curative oesophagectomy for cancer by laparoscopic gastric mobilization and open thoracotomy (HMIO) between January 2004 and December 2009 were matched to randomly selected patients undergoing a totally open approach during the same study interval. Matching variables were age, sex, cancer stage, location of the primary tumour, histological subtype, American Society of Anesthesiologists grade, malnutrition, neoadjuvant chemoradiation and epidural analgesia. RESULTS: MPPCs at 30 days were significantly less frequent after HMIO compared with open surgery (15·7 versus 42·9 per cent; P < 0·001). Postoperative in-hospital mortality and overall morbidity rates were 4·3 and 47·5 per cent respectively, again significantly lower in the HMIO group: 1·4 versus 7·1 per cent (P = 0·018) and 35·7 versus 59·3 per cent (P < 0·001). In multivariable analysis, HMIO, adenocarcinoma subtype, epidural analgesia and surgery after 2006 were independent protective factors against MPPCs, and HMIO was independently protective against acute respiratory distress syndrome (ARDS). Lymph node yields and survival were similar in the two groups. CONCLUSION: HMIO for oesophageal cancer, using laparoscopic gastric mobilization and open right thoracotomy, offered a substantial and independent protective effect against MPPCs, including ARDS, without compromising oncological outcomes.

Outcome of day-case laparoscopic fundoplication for gastro-esophageal reflux disease.

AIM: To assess the acceptability, feasibility and results of day-case laparoscopic fundoplication for gastro-esophageal reflux disease (GERD) in an university tertiary care center. METHODS: Day-case surgery for GERD was proposed routinely to all patients with proven asymptomatic, uncomplicated GERD fulfilling predetermined inclusion criteria from September 2003 and January 2007. All patients underwent standard anesthetic, surgical, analgesic and antiemetic protocols. Patients had a 360° Nissen-Rosetti laparoscopic fundoplication. Evaluation, according to intent-to-treat analysis, included inclusion criteria, admission to conventional hospital facilities, unplanned post-operative consultation or readmission, complication and reoperation rates as well as patient satisfaction at 12 months, using the validated Visick score and Gastro-Intestinal Quality of Life Index (GIQLI) questionnaire. RESULTS: Of 152 patients undergoing laparoscopic fundoplication for GERD during the study period, 49 (32.2%) had day-case procedures. Forty patients (81.6%) were discharged 6 to 8h after operation. Nine patients were converted to in-patient hospitalization because of nausea (n=5), inadequate pain control (n=3) or anxiety (n=1), seven (77.8%) of these were discharged within 23h. Unplanned consultation or hospitalization was necessary in 14.3% and 4.1% of cases respectively, mainly for dysphagia. The postoperative complication rate was 6.1%. At 12 months, 89.6% of patients were Visick 1 to 3 (excellent to satisfactory results). Reoperation was needed in three cases. Patient quality of life, evaluated by GIQLI, was significantly enhanced by surgery (88.9±27.3 preoperatively versus 111.2±24.0 postoperatively, P<0.001). CONCLUSIONS: Day-case laparoscopic fundoplication for GERD is feasible and well tolerated in selected patients.

FOLFIRI chemotherapy in patients with advanced non resectable esophageal or junctional adenocarcinoma: a pilot study.

In this prospective pilot study, we assessed the efficacy and safety of the FOLFIRI regimen (irinotecan 180 mg/m², leucovorin 200 mg/m² d1 followed by bolus 400 mg/m² 5-fluorouracil (5-FU) and by a 46-h 2400 mg/m² 5-FU infusion, every 2 weeks) in patients with advanced esophageal or junctional adenocarcinoma. Twenty-nine patients were included. A complete response was obtained in 2 patients, a partial response in 7 patients (objective response rate 31.0%). Stable disease was obtained in 13 patients (disease control rate 75.9%). The median progression-free and overall survivals were 5.9 and 8.6 months, respectively. One patient died from chemotherapy-related diarrhea after one cycle but this patient presented concomitant disease progression with cerebral metastases. We observed one additional grade 4 diarrhea, one grade 3 vomiting, and two grade 3 neutropenias. To conclude, FOLFIRI regimen appears quite active, with an acceptable safety profile in patients with advanced esophageal or junctional adenocarcinoma.

Reconstruction after gastrectomy: which technique is best?

Several reconstruction techniques are possible after gastrectomy. The best reconstruction is one, that maintains satisfactory nutritional status and quality of life while keeping postoperative morbidity as low as possible. The aim of this study was to describe the different reconstruction techniques that can be proposed after distal and total gastrectomy, heeding to the French guidelines on the use of mechanical sutures in these indications. We then conducted a review of randomized trials dealing with reconstruction techniques after distal and total gastrectomy. After distal gastrectomy, Roux-en-Y reconstruction seems superior to Billroth I and Billroth II reconstructions in terms of functional outcomes and long-term endoscopic results and should be chosen in patients with benign disease or superficial tumors. Otherwise, Billroth II should be preferred over Billroth I reconstruction because of lower postoperative morbidity and better oncologic margins. After total gastrectomy, Roux-en-Y reconstruction remains the easiest solution, with satisfactory functional results. Addition of a pouch reservoir after Roux-en-Y reconstruction seems to improve short-term functional outcome after total gastrectomy with better potential for nutritional intake. In the long-term, quality of life seems better mainly in patients with small-resected tumors associated with a good prognosis.

Clinical impact of MUC1 and MUC4 expression in Barrett-associated oesophageal adenocarcinoma.

AIMS: To study the expression of MUC1 and MUC4 mucins in Barrett-associated oesophageal adenocarcinoma and coexisting lesions of the carcinogenic sequence (normal mucosa, metaplasia, dysplasia) if present, and to investigate their prognostic significance. METHODS: The expression profiles of MUC1 and MUC4 were investigated by immunohistochemistry in tissue samples obtained from consecutive patients with primary surgically resected lower third oesophageal adenocarcinoma (OA) between 1997 and 2002. Histopathological parameters, recurrence and long-term survival were correlated with the number of cells stained. RESULTS: All 52 patients exhibited OA, with 25 patients (48.1%) having associated Barrett oesophagus lesions (metaplasia or/and dysplasia). MUC1 and MUC4 were expressed in 52 and 41 of the 52 patients with adenocarcinoma (100% and 78%), respectively. All samples expressed MUC1 strongly. The prevalence of MUC4 staining was significantly decreased in metaplasia compared with normal mucosa (53% versus 92%, p<0.001). No correlation was found between the level of MUC1 or MUC4 expression in OA and histopathological variables, recurrence or survival. CONCLUSIONS: MUC1 and MUC4 are strongly expressed in OA. The results do not support a role for these two membrane-bound mucins as either a phenotypic or a prognostic marker for the development of Barrett OA. There are several other membrane-bound mucins that have not yet been evaluated in this situation.

[Treatment of thoracic anastomotic leaks after oesophagectomy with self-expanding and extractible covered stent]. / Traitement des fistules anastomotiques intrathoraciques apres esophagectomie par prothese couverte autoexpansive extractible.

We report a case of a thoracic anastomotic leak after oesophagectomy for cancer treated by surgical debridement, drainage and an endoscopically placed self-expanding stent. Intrathoracic, covered oesophageal stents appears to reduce leak-morbidity after oesophagectomy and may be considered as a cost-effective treatment alternative.

Acute respiratory disease syndrome with preoperative chronomodulated chemoradiotherapy in patients with esophageal cancer. Early termination of a phase I trial.

A phase I trial was initiated to establish the dose-limiting toxicities (DLTs) and the maximum tolerated dose (MTD) of chronomodulated 5-fluorouracil and cisplatin given concurrently with preoperative radiotherapy in patients with esophageal cancer. Patients with stage I or II esophageal cancer received preoperative radiation therapy (28-30 daily 1.8-Gy fractions for a total of 50.4 or 54 Gy) and concurrent three fortnightly cycles of chronomodulated 5-fluorouracil (700-835 mg/m2 per day, d1-d4, with peak delivery at 4.00 am) and cisplatin (50 mg/m2, d1, with peak delivery at 4.00 pm) administered by a time-programmable pump. Ten patients were treated on this study. Two of six patients treated at the starting dose-level experienced acute DLTs (esophagitis, asthenia) which required de-escalation of 5-fluorouracil. Five patients out of ten experienced seven DLTs (severe esophagitis, asthenia, vomiting: 5/1/1) at any dose-level. The MTD was not assessed because the study was halted due to slow accrual. Finally, two patients deceased from an Acute Respiratory Distress Syndrome due to inadequate radiation therapy planning. Without definitively ruling out any possible impact of chronomodulation in that setting, our data reinforce the need of a better selection of patients aimed to be treated by CRT plus surgery.

Peptic ulcer of the gastric tube after esophagectomy for cancer: clinical implications.

The use of the stomach as an esophageal substitute has become a well-established treatment procedure after esophagectomy for cancer. During the procedure, a bilateral truncal vagotomy is performed, which should prevent the occurrence of acid-related diseases in the gastric tube and in the remaining esophagus. We report the case of a man who presented a plugged perforated peptic ulcer that subsequently decompensated following endoscopic examination 1 year after a transthoracic esophagectomy with neoadjuvant chemo-radiation for a middle third squamous cell carcinoma. Resection of the ulcer and suture with a pleural patch was performed. There was no evidence of recurrent malignancy at time of surgery. The pathophysiology of gastric tube ulcer is multifactorial. Long-term treatment with an anti-secretory proton pump inhibitor may decrease esophageal complications of duodeno-gastric-esophageal reflux and could prevent the recurrence of gastric tube ulcers.

[Ovarian dermoid cyst complicated by chemical peritonitis. Case report]. / Kyste dermoïde de l'ovaire compliqué d'une péritonite chimique. A propos d'un cas.

Dermoid cyst is the most frequent benign ovarian tumor. Its spontaneous or more frequently iatrogenic intraperitoneal rupture may lead to a chemical peritonitis. This is a rare complication but with a potentially dangerous issue. We report a case of a patient who developed chemical peritonitis after laparoscopic management of ovarian dermoid cysts. Three further interventions, associated with systemic anti-inflammatory treatment, were necessary to resolve symptoms completely. On the basis of this case, we aim to re-access the characteristics of dermoid cysts and highlight in particular the potential complication of chemical peritonitis and the following attitude to avoid this.

[Interest in agents for adhesion prevention after gynecologic surgery]. / Intérêt des produits antiadhérentiels en chirurgie gynécologique.

Adhesion barriers are intraperitoneal agents, solid or fluid, developed in order to prevent postoperative adhesions. In this article, we evaluate the efficiency of these new barrier agents for adhesion prevention in gynaecologic surgery, undertaking a review of controlled clinical trials published. Several human clinical trials demonstrated the safety and efficiency of both Interceed and Seprafilm. As far as other barrier agents are concerned, data are still insufficient to recommend them for clinical use. There is a need for other randomised controlled trials in order to evaluate functional efficiency of anti adhesion agents.

[Oesophageal squamous cell carcinoma stade III. State of surgery after radiochemotherapy (RCT)]. / Carcinomes malpighiens de l'oesophage de stade III, place de la chirurgie après chimioradiothérapie.

Neoadjuvant chemoradiotherapy is the gold standard of the treatment of advanced oesophageal squamous cell carcinoma. The role of surgery after chemoradiotherapy is still debated. Feasibility of curative resection depends on dose of radiotherapy, morbimortality rates, and nutrition status at the end of the protocol especially for non-responders patients. Adding surgery to radiochemotherapy improves local tumour control but does not increase overall survival of patients with advanced oesophageal squamous cell carcinoma. According to the two randomised trials published on the subject, surgery is not recommended after chemoradiotherapy for responders. Recommendations of French National Thesaurus are: exclusive chemoradiotherapy as reference, esophagectomy for residual tumour as alternative for operable patients. Surgery may be proposed for selected non-responders patients and some complete pathology response in expert center.

Impact of preoperative radiochemotherapy on postoperative course and survival in patients with locally advanced squamous cell oesophageal carcinoma.

BACKGROUND: The aim of this study was to determine the effect of neoadjuvant radiochemotherapy (RCT) on postoperative complications and survival after surgery for locally advanced oesophageal squamous cell carcinoma. METHODS: Postoperative course and survival were compared in 144 patients who had neoadjuvant RCT and 80 control patients who had surgery alone for locally advanced oesophageal squamous cell carcinoma (radiological stage T3, N0 or N1, M0). RESULTS: The two groups were comparable in terms of American Society of Anesthesiologists grade, age, sex, weight loss, tumour location, presence of lymph node metastasis and surgical approach. Postoperative mortality rates were 6.3 and 9 per cent (P=0.481), with morbidity rates of 40.3 and 41 percent (P=0.887) in the RCT and control group respectively. Complete resection (R0) rates were 74.3 and 48 percent respectively (P<0.001). Significant downstaging was observed in the RCT group (P<0.001), with 16.0 percent of patients having a complete pathological response. Median survival was 29 versus 15 months, and the 5-year survival rate 37 versus 17 percent (P=0.002) in RCT and control groups respectively. CONCLUSION: Neoadjuvant RCT significantly enhanced R0 resection and survival rates in patients with stage T3 oesophageal squamous cell carcinoma, with no increase in postoperative mortality and morbidity rates.

[Barrett's oesophagus: the rationale for surgical resection]. / Endobrachyoesophage: place de la résection.

Surgical resection has a limited place in the management of Barrett's oesophagus with high-grade dysplasia, except when failure of endoscopic mucosectomy is likely (extended Barrett's oesophagus, nodular or ulcerated lesions at endoscopy). For superficial carcinoma, it is often difficult to differentiate mucosal carcinoma (carrying a risk of nodal metastasis less than 7%) from submucosal carcinoma (carrying a risk of nodal metastasis ranging from 16 to 47%), oesophagectomy is routinely indicated if operative risk is low. When operative risk is not minimal, endoscopic mucosectomy is indicated for lesions limited to the mucosa and the proximal third of submucosa; for lesions extending beyond, an oesophagectomy must be discussed. These indications must take into account both age and general condition of the patient, as well as the expertise in oesophageal surgery of the group.