Postoperative complications after transthoracic esophagectomy for cancer of the esophagus and gastroesophageal junction are correlated with early cancer recurrence: role of systematic grading of complications using the modified Clavien classification. Ann Surg. 2009;250:798-807. [PMID: 19809297 DOI: 10.1097/sla.0b013e3181bdd5a8]

Intraoperative events and their outcome: data from 4007 laparoscopic interventions by the French "Club Cœlio"

AIM

To assess the operative and postoperative course of intraoperative events occurring in laparoscopic surgery according to the classification of Clavien. This evaluation aims at ascertaining morbidity and mortality of abdominal laparoscopic operations, thus serving as a reference for future comparative studies.

METHOD

Twenty-nine senior surgeons, all of them members of the Cœlio Club prospectively and consecutively summarized all their laparoscopic activity over a period of 6 months.

RESULTS

Of 4007 patients, 373 (9.31%) developed complications, 69 (1.72%) requiring surgery. Establishing the pneumoperitoneum and trocar placement caused 15 vascular (0.37%) and six visceral (0.15%) injuries; seven vascular (0.17%) and 22 visceral (0.55%) injuries occurred intraoperatively. Surgery of the colon and especially the rectum were associated with the highest morbidity with Clavien grades III, IV and V reported in 8, 10 and 15.97% of patients, respectively; 1.2% occurred in biliary surgery and 0.67% in inguinal/femoral hernia repair.

CONCLUSION

The prevalence of surgical intraoperative events and postoperative complications is higher than reported in the literature. Clavien's classification is applicable to abdominal laparoscopic surgery; further information is necessary to assess intraoperative surgical events as well as conversions.

Negative impact of leakage on survival of patients undergoing curative resection for advanced gastric cancer

BACKGROUND AND OBJECTIVES

Leakage has been shown to adversely affect survival in patients undergoing surgery for gastrointestinal malignancies. However, the effect of leakage following radical gastrectomy in patients with gastric cancer remains unclear.

METHODS

In total, 478 patients with advanced gastric cancer who underwent surgery with curative intent were reviewed. Anastomosis or duodenal stump leakage was diagnosed clinically or radiologically. Risk factors for leakage were evaluated by univariate and multivariate analyses. The impact of leakage on patient survival was analyzed using the Kaplan-Meier method.

RESULTS

Leakage was diagnosed in 32 of 478 patients (6.7%); 14 patients (2.9%) exhibited esophagojejunal anastomotic leakage, 14 (2.9%) showed duodenal stump leakage, and four (0.8%) showed gastroduodenal anastomotic leakage. Poor performance status [odds ratio (OR): 4.01, 95% confidence interval (CI): 1.80-8.93] and tumor location (OR: 3.74, 95% CI: 1.56-8.89) were risk factors for postoperative leakage. Overall mean survival of patients with leakage was significantly lower than that of patients without leakage (30.5 vs. 96.2 months; P < 0.001). Leakage was one of the independent predictive factor for overall survival [hazard ratio (HR): 3.58, 95% CI: 2.29-5.59].

CONCLUSIONS

Postoperative inflammation due to leakage is a negative prognostic factor for patients with advanced gastric cancer.

Prognostic value of an inflammation-based score in patients undergoing pre-operative chemotherapy followed by surgery for esophageal cancer

Recent studies have shown that the presence of systemic inflammation is associated with poor outcome in patients with malignancy. However, whether systemic inflammation affects the response to pre-operative therapy and survival of patients undergoing multimodal treatment for esophageal cancer is not clear. We studied 152 patients who underwent pre-operative chemotherapy followed by surgery for esophageal cancer. The correlation between various clinicopathological factors, including hematological markers of systemic inflammatory response, and survival or response to chemotherapy was examined. Among various hematological factors, leucocyte count, hemoglobin level, albumin level, neutrophil-lymphocyte ratio and CEA, but not serum concentration of C-reactive protein, were significantly associated with survival. Multivariate analysis revealed that the clinical response to chemotherapy, number of metastatic lymph nodes, operative complications and systemic inflammation score (SI score), comprising leucocyte count, albumin and hemoglobin levels, were independent prognostic factors, and identified the SI score as the most significant prognostic factor. There was no significant relationship between hematological markers of systemic inflammation, including the SI score, and the response to chemotherapy. In conclusion, in patients scheduled for chemotherapy followed by surgery for esophageal cancer, systemic inflammation, reflected by SI, predicts poor outcome, but not the response to chemotherapy.

Postoperative outcomes and complications after laparoscopy-assisted pylorus-preserving gastrectomy for early gastric cancer

OBJECTIVE

Laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) was introduced as a function-preserving and minimally invasive operation for early gastric cancer (EGC) in Japan. This study investigated the postoperative outcomes, complications, and associated risk factors of the procedure.

METHODS

From January 2005 to December 2009, 307 patients with EGC diagnosed before surgery underwent LAPPG. The postoperative outcomes and complications were assessed in this study. Postoperative complications were classified according to the Clavien-Dindo classification of surgical complications, and risk factors related to complications were analyzed.

RESULTS

The mean operation time for LAPPG was 229.4 ± 47.5 minutes and estimated blood loss was 49.1 ± 62.0 mL. The mean total number of dissected lymph nodes was 31.6 ± 10.4, with nodal involvement observed in 25 patients (8.5%). The preoperative diagnostic accuracy of EGC was 93.2%. Complications developed in 53 patients (17.3%), and major complications, classified as grades greater than Clavien-Dindo classification IIIa, were observed in 4 patients (1.3%). The most frequent complication was gastric stasis, occurring in 19 patients (6.2%). Body mass index (BMI) and surgical experience of LAPPG were identified as significant risk factors of postoperative complications. Body mass index was related to severity of the complications. The patients' serum total protein and albumin did not change significantly after surgery.

CONCLUSIONS

Laparoscopy-assisted pylorus-preserving gastrectomy is a safe operation with excellent postoperative outcomes in terms of minimized major complications based on the Clavien-Dindo classification in patients with EGC in the middle third of the stomach. To prevent postoperative complications, surgeons need to ensure an extra leaning period for LAPPG, and LAPPG should be performed cautiously in patients with high BMI.

Survival factors in patients with recurrence after curative resection of esophageal squamous cell carcinomas

BACKGROUND

Approximately half of patients who undergo curative resection for esophageal cancers develop recurrence postoperatively. The factors affecting survival after such recurrence remain largely unknown.

METHODS

To investigate factors affecting survival after recurrence in patients who had undergone curative resection for esophageal cancer, we retrospectively reviewed data for 461 patients who underwent curative esophagectomy with or without preoperative therapy for esophageal squamous cell carcinoma from January 1996 to December 2007. The correlations between several clinicopathological factors and survival after recurrence were examined.

RESULTS

Recurrence occurred in 196 of 461 patients (42.5%), with a median survival time after recurrence of 8.2 months. Multivariate analysis identified advanced tumor stage, preoperative chemoradiotherapy (CRT), number of recurrent tumors, and the presence of recurrence at the local site and liver as associated with shortened survival after recurrence. The analysis also indicated that treatment of the recurrence prolonged survival regardless of the treatment type. Although the pattern of recurrence did not significantly differ according to type of preoperative therapy, patients who underwent preoperative CRT were less often treated with radiotherapy for recurrence. Patients with multiple recurrent tumors less often received radiotherapy or surgery than those with a solitary recurrence. Chemotherapy for recurrence was not associated with either preoperative therapy or the number of recurrences.

CONCLUSIONS

Our retrospective study showed that multiple recurrent tumors and preoperative CRT limit the available treatment for recurrence and thereby are associated with poor prognosis. Vigorous treatment for recurrence can extend survival after recurrence in patients who undergo esophagectomy.

[Effect of postoperative complications on late recurrence and distant metastasis in patients previously treated with elective, curative resection of colorectal carcinoma]

BACKGROUND

The aim of the present study is to investigate whether severe postoperative complications following elective colorectal surgery increase local recurrence or distant metastasis rate.

METHODS

332 patients underwent elective, curative colorectal carcinoma resection in the period between 01.01.2000 and 31.12.2004. Postoperative complications were classified according to the modified Clavien Scale. Complications occurring up to postoperative day 30 were recorded. All complications were analyzed but the most severe one was considered for each patient and included in further analysis. Patients were followed up until 31.12.2009. Univariate and multivariate statistical analyses were performed.

RESULTS

The mean age of patients was 64 years, 187 (56%) were male. 84 patients (25.3%) received preoperative oncological treatment. We included patients only with R0 resections. 182 patients (56.3%) recovered after the surgery without any complications. Mortality rate was 3.3%. Grade 4 complication developed in 5 (1.5%) patients, while Grade 3 in 26 (8%) patients, Grade 2 in 83 (25.8%) patients, and Grade 1 in 25 (7.7%) patients. During the follow up period 75 (23.3%) patients developed local tumor recurrence and/or distant metastasis. Tumor grade (p = 0.008), stage (p = 0.0001) and histological lympho-vascular invasion of the tumor (p = 0.0001) were associated with increased local and distant tumor recurrence rates. Further, Grade 3 postoperative complications were associated with increased tumor recurrence rate (p = 0.0039) and tumor related mortality (p = 0.05%).

CONCLUSIONS

application of the modified Clavien Scale is suitable to classify the severity of postoperative complications. Grade 3 complications following elective curative resection of colorectal carcinoma increase local and distant tumor recurrence rates as well as tumor related mortality. Complications developing after colorectal surgery endanger not only the immediate postoperative period, but long term survival is also threatened due to its oncological effect.

Superficial adenocarcinoma of the esophagogastric junction: long-term results of endoscopic submucosal dissection

BACKGROUND

Endoscopic submucosal dissection (ESD) was recently introduced as a treatment option for superficial adenocarcinoma of the esophagogastric junction (EGJ); however, its long-term clinical outcomes have not been fully evaluated.

OBJECTIVE

To assess the long-term outcomes of ESD for patients with superficial adenocarcinoma of the EGJ.

DESIGN

Retrospective review from a single institution.

SETTING

University hospital.

PATIENTS

Fifty-eight patients, 46 men and 12 women (mean 69.3 years), with 39 T1m and 19 T1sm adenocarcinomas of the EGJ treated from June 2000 to May 2009.

INTERVENTIONS

ESD procedures were performed with typical sequences.

MAIN OUTCOME MEASUREMENTS

Complications, en bloc resection rate, curative resection rate, local recurrence, and distant metastases after ESD were evaluated. Curative resection is histologically defined as being free of resection margins and any evidence of deep submucosal invasion, undifferentiated carcinoma, and lymphovascular invasion.

RESULTS

There were no major complications except for 3 patients with ulcer bleeding without the need for blood transfusion and 1 patient with esophageal stenosis. The rates of en bloc resection and curative resection were 100% and 79%, respectively. Twelve resections were histologically considered noncurative; these patients underwent additional ESD (n = 1) or surgical resection (n = 8). Local or distant recurrences were not observed in any patient achieving curative resection during follow-up (median 36.6 months, range 4-94 months).

LIMITATIONS

Retrospective design and single-site data collection.

CONCLUSIONS

Long-term outcomes after ESD are favorable. ESD may be adopted as a treatment of choice for superficial adenocarcinoma of the EGJ.

Proposed follow up programme after curative resection for lower third oesophageal cancer

The incidence of oesophageal adenocarcinoma has risen throughout the Western world over the last three decades. The prognosis remains poor as many patients are elderly and present with advanced disease. Those patients who are suitable for resection remain at high risk of disease recurrence. It is important that cancer patients take part in a follow up protocol to detect disease recurrence, offer psychological support, manage nutritional disorders and facilitate audit of surgical outcomes. Despite the recognition that regular postoperative follow up plays a key role in ongoing care of cancer patients, there is little consensus on the nature of the process. This paper reviews the published literature to determine the optimal timing and type of patient follow up for those after curative oesophageal resection.

Impact of anastomotic leakage on long-term survival after total gastrectomy for carcinoma of the stomach

BACKGROUND

Recent studies suggest that anastomotic leak may adversely affect long-term survival in patients undergoing surgery for gastrointestinal malignancies. Data relating to total gastrectomy for gastric cancer are scarce.

METHODS

An electronic database of all patients with resectable gastric cancer treated between January 1999 and December 2004 at seven university surgical centres cooperating in the Polish Gastric Cancer Study Group was reviewed.

RESULTS

Anastomotic leakage was diagnosed in 41 (5.9 per cent) of 690 patients who underwent total gastrectomy. The prevalence of surgical and general complications, and mortality rates were significantly higher in patients diagnosed with anastomotic leakage. The only two independent risk factors for leakage were Eastern Cooperative Oncology Group performance status of 2 or 3 (odds ratio 5.09, 95 per cent confidence interval (c.i.) 2.29 to 11.32) and splenectomy (odds ratio 2.58, 95 per cent c.i. 1.08 to 6.13). Two Cox proportional hazards models including all the patients and excluding in-hospital deaths identified anastomotic leakage as an independent predictor of survival with hazard ratios of 3.47 (95 per cent c.i. 1.82 to 6.64) and 3.14 (1.51-6.53) respectively.

CONCLUSION

The occurrence of anastomotic leakage was a major independent prognostic factor for long-term survival.