Inflammatory response in laparoscopic vs. open surgery for gastric cancer

Enhanced rehabilitation after surgery: principles in the treatment of emergency complicated colorectal cancers - a narrative review

Enhanced Recovery After Surgery (ERAS) protocols are used in elective colorectal surgeries and have shown improved recovery for many patients. However, using these protocols in emergency colorectal surgery, especially in complicated cases of obstructive colorectal cancer, is still debated. This review examined the ERAS principles that can be adapted for emergencies. We reviewed the literature on applying ERAS principles in emergency colorectal cancer surgery. We analyzed key strategies used before, during, and after surgery. The aim of ERAS in emergency colorectal surgery is to reduce physical stress from urgent surgical conditions. Before surgery, the focus should be on early patient recovery, managing blood sugar levels, and providing patient education when possible. Minimally invasive techniques, careful fluid management, and effective pain relief during surgery are intraoperative key points. After surgery, early feeding, patient mobilization, and minimizing the use of medical devices are encouraged. Studies have shown that using ERAS in emergencies can lower mortality, reduce hospital stays, and influence patient recovery rates, although it may lead to higher initial costs. Still, following ERAS in emergencies is inconsistent due to logistical issues and patient health changes. More people are starting to recognize the benefits of ERAS in obstructive colorectal cancer surgery. Although there is less evidence compared to elective procedures, new studies suggest that organized steps for care can improve patient outcomes. Further research is needed to improve ERAS emergency protocols and identify patients suitable for this approach so that healthcare resources can be used better.

Laparoscopic hepatectomy using indocyanine green attenuates postoperative inflammatory response for hepatocellular carcinoma: A propensity score matching analysis

BACKGROUND

Improving the intraoperative and postoperative performance of laparoscopic hepatectomy was quite a challenge for liver surgeons.

AIM

To determine the benefits of indocyanine green (ICG) fluorescence imaging in patients with hepatocellular carcinoma (HCC) who underwent laparoscopic hepatectomy during and after surgery.

METHODS

We retrospectively collected the clinicopathological data of 107 patients who successfully underwent laparoscopic hepatectomy at Zhongshan Hospital (Xiamen), Fudan University from June 2022 to June 2023. Whether using the ICG fluorescence imaging technique, we divided them into the ICG and non-ICG groups. To eliminate statistical bias, a 1:1 propensity score matching analysis was conducted. The comparison of perioperative outcomes, including inflammation-related markers and progression-free survival, was analyzed statistically.

RESULTS

Intraoperatively, the ICG group exhibited lower blood loss, a shorter surgical time, lower hepatic inflow occlusion (HIO) frequency, and a shorter total HIO time. Postoperatively, the participation of ICG resulted in a shorter duration of hospitalization (6.5 vs 7.6 days, P = 0.03) and postoperative inflammatory response attenuation (lower neutrophil-lymphocyte ratio on the first day after surgery and platelet-lymphocyte ratio on the third day, P < 0.05). Although the differences were not significant, the levels of all inflammation-related markers were lower in the ICG group. The rates of postoperative complications and the survival analyses, including progression-free and overall survivals showed no significant difference between the groups.

CONCLUSION

The involvement of ICG fluorescence imaging may lead to improved perioperative outcomes, especially postoperative inflammatory response attenuation, and ultimately improve HCC patients' recovery after surgery.

Recovery of gastrointestinal functional after surgery for abdominal tumors: A narrative review

Postoperative gastrointestinal dysfunction, including temporary nonmechanical suppression of gastrointestinal motility (known as postoperative ileus), occurs in about 10% surgeries of abdominal tumors. Since these complications can prolong hospitalization and affect eating, it is important to understand their risk factors and identify effective interventions to manage or prevent them. The present review comprehensively examined the relevant literature to describe risk factors for postoperative ileus and effective interventions. Risk factors include old age, open surgery, difficulty of surgery, surgery lasting longer than 3 hours, preoperative bowel treatment, infection, and blood transfusion. Factors that protect against postoperative ileus include early enteral nutrition, minimally invasive surgery, and multimodal pain treatment. Interventions that can shorten or prevent such ileus include minimally invasive surgery, early enteral nutrition as well as use of chewing gum, laxatives, and alvimopan. Most of these interventions have been integrated into current guidelines for enhanced recovery of gastrointestinal function after surgery. Future high-quality research is needed in order to clarify our understanding of efficacy and safety.

Short- and Long-Term Advantages of Laparoscopic Gastrectomy for Elderly Patients with Locally Advanced Cancer

Minimally invasive surgery has provided several clinical advantages in locally advanced gastric cancer (LAGC) care, although a consensus on its application criteria remains unclear. Surgery remains a careful choice in elderly patients, who frequently present with frailty, comorbidities, and other disabling diseases. This study aims to assess the possible advantages of laparoscopic gastric resections in elderly patients presenting with LAGC. This retrospective study analyzed a single-center series of elderly patients (≥75 years) undergoing curative resections for LAGC between 2015 and 2020. A comparative analysis of open versus laparoscopic approaches was conducted, focusing on postoperative complications, length of hospital stay (LOS), and long-term survival. A total of 62 patients underwent gastrectomy through an open or a laparoscopic approach (31 pts each). The study population did not show statistically significant differences in demographics, operative risk, and neoadjuvant chemotherapy. The laparoscopic group reported significantly minimized overall complications (45.2 vs. 71%, p = 0.039) and pulmonary complications (0 vs. 9.7%, p = 0.038) as well as a shorter LOS (8 vs. 12 days, p = 0.007). Lymph node harvest was equal between the groups, although long-term overall survival presented significantly better after laparoscopic gastrectomy (p = 0.048), without a relevant difference in terms of disease-free and disease-specific survivals. Laparoscopic gastrectomy proves effective in elderly LAGC patients, offering substantial short- and long-term postoperative benefits.

New immune phenotypes for treatment response in high-grade serous ovarian carcinoma patients

Despite advances in surgical and therapeutic approaches, high-grade serous ovarian carcinoma (HGSOC) prognosis remains poor. Surgery is an indispensable component of therapeutic protocols, as removal of all visible tumor lesions (cytoreduction) profoundly improves the overall survival. Enhanced predictive tools for assessing cytoreduction are essential to optimize therapeutic precision. Patients' immune status broadly reflects the tumor cell biological behavior and the patient responses to disease and treatment. Serum cytokine profiling is a sensitive measure of immune adaption and deviation, yet its integration into treatment paradigms is underexplored. This study is part of the IMPACT trial (NCT03378297) and aimed to characterize immune responses before and during primary treatment for HGSOC to identify biomarkers for treatment selection and prognosis. Longitudinal serum samples from 22 patients were collected from diagnosis until response evaluation. Patients underwent primary cytoreductive surgery or neoadjuvant chemotherapy (NACT) based on laparoscopy scoring. Twenty-seven serum cytokines analyzed by Bio-Plex 200, revealed two immune phenotypes at diagnosis: Immune High with marked higher serum cytokine levels than Immune Low. The immune phenotypes reflected the laparoscopy scoring and allocation to surgical treatment. The five Immune High patients undergoing primary cytoreductive surgery exhibited immune mobilization and extended progression-free survival, compared to the Immune Low patients undergoing the same treatment. Both laparoscopy and cytoreductive surgery induced substantial and transient changes in serum cytokines, with upregulation of the inflammatory cytokine IL-6 and downregulation of the multifunctional cytokines IP-10, Eotaxin, IL-4, and IL-7. Over the study period, cytokine levels uniformly decreased in all patients, leading to the elimination of the initial immune phenotypes regardless of treatment choice. This study reveals distinct pre-treatment immune phenotypes in HGSOC patients that might be informative for treatment stratification and prognosis. This potential novel biomarker holds promise as a foundation for improved assessment of treatment responses in patients with HGSOC. ClinicalTrials.gov Identifier: NCT03378297.

Pancreatectomy Induces Cancer-Promoting Neutrophil Extracellular Traps

BACKGROUND

Neutrophil extracellular traps (NETs) occur when neutrophil chromatin is decondensed and extruded into the extracellular space in a web-like structure. Originally described as an anti-microbial function, this process has been implicated in the pathogenesis of pancreatic disease. In addition, NETs are upregulated during physiologic wound-healing and coagulation. This study evaluated how the inflammatory response to pancreatic surgery influences NET formation.

METHODS

For this study, 126 patients undergoing pancreatectomy gave consent before participation. Plasma was collected at several time points (preoperatively and through the postoperative outpatient visit). Plasma levels of NET markers, including cell-free DNA (cfDNA), citrullinated histone H3 (CitH3), interleukin (IL)-8, IL-6, and granulocyte colony-stimulating factor (G-CSF) were measured using enzyme-linked immunosorbent assay (ELISA). Patient clinical data were retrospectively collected from a prospectively maintained database.

RESULTS

After pancreatic resection, NET markers (cfDNA and CitH3) were elevated, peaking on postoperative days 3 and 4. This increase in NETs was due to an inherent change in neutrophil biology. Postoperatively, NET-inducing cytokines (IL-8, IL-6, and G-CSF) were increased, peaking early in the postoperative course. The patients undergoing the robotic approach had a reduction in NETs during the postoperative period compared with those who underwent the open approach. The patients who experienced a pancreatic leak had an increase in NET markers during the postoperative period.

CONCLUSIONS

Pancreatectomy induces cancer-promoting NET formation. The minimally invasive robotic approach may induce fewer NETs, although the current analysis was limited by selection bias. Pancreatic leak resulted in increased NETs. Further study into the potential for NET inhibition during the perioperative period is warranted.

Role of vitamin D supplementation in modifying outcomes after surgery: a systematic review of randomised controlled trials

BACKGROUND

There is increasing evidence to suggest vitamin D plays a role in immune and vascular function; hence, it may be of biological and clinical relevance for patients undergoing major surgery. With a greater number of randomised studies being conducted evaluating the impact of vitamin D supplementation on surgical patients, it is an opportune time to conduct further analysis of the impact of vitamin D on surgical outcomes.

METHODS

MEDLINE, EMBASE and the Cochrane Trials Register were interrogated up to December 2023 to identify randomised controlled trials of vitamin D supplementation in surgery. The risk of bias in the included studies was assessed using the Cochrane Risk of Bias tool. A narrative synthesis was conducted for all studies. The primary outcome assessed was overall postoperative survival.

RESULTS

We screened 4883 unique studies, assessed 236 full-text articles and included 14 articles in the qualitative synthesis, comprising 1982 patients. The included studies were highly heterogeneous with respect to patient conditions, ranging from open heart surgery to cancer operations to orthopaedic conditions, and also with respect to the timing and equivalent daily dose of vitamin D supplementation (range: 0.5-7500 mcg; 20-300 000 IU). No studies reported significant differences in overall survival or postoperative mortality with vitamin D supplementation. There was also no clear evidence of benefit with respect to overall or intensive care unit length of stay.

DISCUSSION

Numerous studies have reported the benefits of vitamin D supplementation in different surgical settings without any consistency. However, this systematic review found no clear evidence of benefit, which warrants the supposition that a single biological effect of vitamin D supplementation does not exist. The observed improvement in outcomes in low vitamin D groups has not been convincingly proven beyond chance findings.

TRIAL REGISTRATION NUMBER

CRD42021232067.

The Intraoperative Administration of Dexmedetomidine Alleviates Postoperative Inflammatory Response in Patients Undergoing Laparoscopy-Assisted Gastrectomy: A Double-Blind Randomized Controlled Trial

Surgical stress can compromise the immune system of patients with cancer, affecting susceptibility to perioperative infections, tumor progression, treatment responses, and postoperative recovery. Perioperatively reducing inflammatory responses could improve outcomes. We determined the impact of intraoperative dexmedetomidine administration on the inflammatory response and postoperative recovery in patients undergoing elective laparoscopy-assisted gastrectomy. These patients were randomly assigned to the dexmedetomidine or control group (n = 42 each). The primary endpoint was the C-reactive protein (CRP) level on postoperative day 1. The secondary endpoints included the perioperative interleukin (IL)-6 levels, postoperative numerical rating scale (NRS) scores, and rescue analgesic doses. There were no significant between-group differences in terms of CRP levels. The IL-6 levels at the end of the surgery, NRS scores in the post-anesthesia care unit, and rescue pethidine requirements within the first hour postoperatively were significantly lower in the dexmedetomidine group than in the control group. The bolus deliveries-to-attempts ratio (via patient-controlled analgesia) at 2 h differed significantly between the two groups. However, IL-6 reduction was confined to a single timepoint, and the postoperative analgesic effects lasted for the first 2 h postoperatively. Low-dose dexmedetomidine infusion (0.4 µg kg-1 h-1) during laparoscopy-assisted gastrectomy exerts minimal anti-inflammatory effects.

Using complete blood count-derived inflammatory markers to compare postoperative inflammation in dogs undergoing open or laparoscopic ovariectomy

BACKGROUND

The inflammatory response triggered in dogs after laparoscopic ovariectomy (LapOV) or ovariectomy through mini-celiotomy (COV) has never been compared using the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and systemic inflammatory index (SII).

METHODS

Bitches underwent LapOV (n = 25) or COV (n = 25). NLR, PLR and SII were calculated 1 hour before ovariectomy (T0) and 2-3, 6-8 and 20-24 hours (T1-T3) after surgery.

RESULTS

Surgical time was longer in the LapOV group. Changes over time were observed in the NLR, PLR and SII in both groups (p < 0.001). PLR at baseline and T1 (p = 0.03 and 0.01) and NLR, PLR and SII at T2 (p = 0.01, 0.01 and 0.009) were higher in the LapOV group than in the COV group, but they did not differ at T3.

LIMITATIONS

The overrepresentation of Greyhounds in the LapOV group and the short-term follow-up are the study's main limitations.

CONCLUSION

Although an inflammatory peak was observed 6-8 hours after COV or LapOV, it was higher after the laparoscopy. However, there was no difference in the bitches' inflammatory status 24 hours after surgery.

The Impact of Acute Systemic Inflammation Secondary to Oesophagectomy and Anastomotic Leak on Computed Tomography Body Composition Analyses

This study aimed to longitudinally assess CT body composition analyses in patients who experienced anastomotic leak post-oesophagectomy. Consecutive patients, between 1 January 2012 and 1 January 2022 were identified from a prospectively maintained database. Changes in computed tomography (CT) body composition at the third lumbar vertebral level (remote from the site of complication) were assessed across four time points where available: staging, pre-operative/post-neoadjuvant treatment, post-leak, and late follow-up. A total of 20 patients (median 65 years, 90% male) were included, with a total of 66 computed tomography (CT) scans analysed. Of these, 16 underwent neoadjuvant chemo(radio)therapy prior to oesophagectomy. Skeletal muscle index (SMI) was significantly reduced following neoadjuvant treatment (p < 0.001). Following the inflammatory response associated with surgery and anastomotic leak, a decrease in SMI (mean difference: -4.23 cm²/m², p < 0.001) was noted. Estimates of intramuscular and subcutaneous adipose tissue quantity conversely increased (both p < 0.001). Skeletal muscle density fell (mean difference: -5.42 HU, p = 0.049) while visceral and subcutaneous fat density were higher following anastomotic leak. Thus, all tissues trended towards the radiodensity of water. Although tissue radiodensity and subcutaneous fat area normalised on late follow-up scans, skeletal muscle index remained below pre-treatment levels.

Improved survival after laparoscopic compared to open gastrectomy for advanced gastric cancer: a Swedish population-based cohort study

BACKGROUND

Laparoscopic gastrectomy is increasingly used for the treatment of locally advanced gastric cancer but concerns remain whether similar results can be obtained compared to open gastrectomy, especially in Western populations. This study compared the short-term postoperative, oncological and survival outcomes following laparoscopic versus open gastrectomy based on data from the Swedish National Register for Esophageal and Gastric Cancer.

METHODS

Patients who underwent surgery with curative intent for adenocarcinoma of the stomach or gastroesophageal junction Siewert type III from 2015 to 2020 were identified, and 622 patients with cT2-4aN0-3M0 tumors were included. The impact of surgical approach on short-term outcomes was assessed using multivariable logistic regression. Long-term survival was compared using multivariable Cox regression.

RESULTS

In total, 350 patients underwent open and 272 laparoscopic gastrectomy, of which 12.9% were converted to open surgery. The groups were similar regarding distribution of clinical disease stage (27.6% stage I, 46.0% stage II, and 26.4% stage III). Neoadjuvant chemotherapy was administered to 52.7% of the patients. There was no difference in the rate of postoperative complications, but laparoscopic approach was associated with lower 90 day mortality (1.8 vs 4.9%, p = 0.043). The median number of resected lymph nodes was higher after laparoscopic surgery (32 vs 26, p < 0.001), while no difference was found in the rate of tumor-free resection margins. Better overall survival was observed after laparoscopic gastrectomy (HR 0.63, p < 0.001).

CONCLUSIONS

Laparoscopic gastrectomy can be safely preformed for advanced gastric cancer and is associated with improved overall survival compared to open surgery.

Mesenteric traction syndrome - Incidence, impact, and treatment: A systematic scoping review of the literature

BACKGROUND

Mesenteric traction syndrome (MTS) is commonly seen during major abdominal surgery and is characterised by facial flushing, hypotension, and tachycardia 15 min into surgery. MTS also impacts the postoperative course, as severe MTS has been associated with increased postoperative morbidity. However, despite MTS being common and severe MTS causing increased postoperative morbidity, the gaps in the literature are not clearly defined. We aimed to examine the diagnostic criteria, incidence, intraoperative and postoperative impact, and potential preventative measures of MTS while highlighting potential gaps in the literature.

METHODS

We followed the Prisma guidelines and performed a systematic literature search. We included only human studies examining MTS. All hits were screened for title and abstract, followed by a full-text review by at least two authors for determining eligibility for inclusion. Data were extracted and risk of bias was assessed by two independent reviewers.

RESULTS

A total of 37 studies, comprising 1102 patients were included in the review. The combined incidence of MTS during open abdominal surgery was found to be 76%, with 35% developing severe MTS. It was found that the development of MTS was associated with marked haemodynamic changes. It was also found that several different subjective diagnostic criteria exist and that severe MTS was associated with increased postoperative morbidity. Furthermore, several preventative measures for protecting against MTS have been examined, but only on the incidence of MTS and not on the postoperative course.

CONCLUSION

MTS occurs in 76% of patients undergoing major abdominal surgery and is associated with deleterious haemodynamic effects, which are more pronounced in patients developing severe MTS. Severe MTS is also associated with a worse postoperative outcome. However, gaps are still present in the current literature on MTS.

Short- and Long-Term Outcomes in Laparoscopic Versus Open Hepatectomy for Hepatocellular Carcinoma in Elderly Patients: A Systematic Review and Meta-Analysis

Background: Laparoscopic hepatectomy (LH) is considered a safe and feasible treatment for patients with hepatocellular carcinoma (HCC) in recent studies. However, in elderly patients, application of LH still remains controversial, and the outcomes of LH versus open hepatectomy (OH) have not been fully evaluated. Our objective is to compare the short- and long-term outcomes of LH with OH in elderly patients with HCC. Materials and Methods: All studies comparing LH and OH in elderly patients with HCC were systematically searched in the databases of PubMed, EmBase, and Web of Science. Statistical analysis was conducted using Review Manager 5.3 (Cochrane Collaboration, 2014). The last search was performed on March 20, 2022. Short-term outcomes include blood loss, operation time, blood transfusion, overall and major postoperative complications, mortality, hospital stay, tumor size, and surgical margin. Long-term outcomes include 1-, 3-, and 5-year overall survival (OS); 1-, 3-, and 5-year disease-free survival (DFS); and 1-, 3-, and 5-year recurrence-free survival (RFS). Results: Fourteen studies involving 1596 patients were included in this meta-analysis. The short-term outcomes of LH were a shorter postoperative hospital stay and fewer overall and major postoperative complications (all P < .00001). However, there were no significant differences in operation time, blood loss, blood transfusion rate, surgical margin, tumor size, and mortality. For the long-term outcomes, LH is comparable with OH in terms of 1-, 3-, and 5-year OS; 1-, 3-, and 5-year DFS; and 1-, 3-, and 5-year RFS. Conclusions: Compared with OH, LH is a safe and feasible treatment for elderly patients with HCC.

Impact of postoperative intra-abdominal infectious complications on survival outcomes in patients with gastric cancer who underwent laparoscopic surgery

BACKGROUND

Postoperative intra-abdominal infection is known to adversely affect survival outcomes in patients with gastric cancer; however, previous reports have investigated this complication only in open surgery. This adverse effect is expected to be weakened by less invasive surgery, such as a laparoscopic approach, by way of maintaining immune function.

METHODS

This study included 1223 patients with gastric cancer who underwent open (n = 439) or laparoscopic (n = 784) curative surgery between 2010 and 2015. For each approach, patients were divided into two groups based on presence or absence of postoperative intra-abdominal infection of Clavien-Dindo grade II or higher (C-group and NC-group, respectively). Survival outcomes were compared in propensity-matched cohorts to evaluate the impact of the complication.

RESULTS

The incidences of Clavien-Dindo ≥ grade II postoperative intra-abdominal infectious complications were 9.7% (43/439) in open surgery and 9.8% (70/714) in laparoscopic surgery. After propensity score matching, 86 patients in open surgery and 138 in laparoscopic surgery were extracted for analysis. The 5-year overall survival rate in the open C-group (n = 43) was worse than that in the open NC-group (n = 43) but with no significant difference (70.9% vs. 82.8%, log-rank P = 0.18). The 5-year overall survival rates were equivalent between the laparoscopic C-group (n = 69) and the laparoscopic NC-group (n = 69) (90.5% vs. 90.4%, log-rank P = 0.99).

CONCLUSION

In general, postoperative intra-abdominal infection adversely affects survival outcomes; however, its impact may be weakened by less invasive surgery. Further evaluation using larger datasets is necessary before reaching definitive conclusions.

C-reactive protein identifies patients at low risk of anastomotic leak after esophagectomy

PURPOSE

Fast-track protocols are increasingly used after digestive surgery. After esophagectomy, the gravity and the fear of anastomotic leak may be an obstacle to generalization of such protocols. C-reactive protein (CRP) might be a reliable tool to identify patients at low risk of anastomotic leak after esophagectomy, so that they can be safely included in a fast-track program. The aim of our retrospective bicentric study is to evaluate the interest of C-reactive protein measurement for the early diagnosis of anastomotic leak after esophagectomy.

METHODS

Patients having undergone Ivor-Lewis procedure between January 2009 and September 2017 were included in this bicentric retrospective study. CRP values were recorded between postoperative day 3 (POD 3) and postoperative day 5 (POD 5). All postoperative complications were recorded, and the primary endpoint was anastomotic leak.

RESULTS

We included 585 patients. Among them, 241 (41.2%) developed infectious complications and 69 patients (11.8%) developed anastomotic leak. CRP had the best predictive value on POD 5 (AUC = 0.74; 95% CI: 0.67-0.81). On POD 5, a cut-off value of 130 mg/L yielded a sensitivity of 87%, a specificity of 51%, and a negative predictive value of 96% for the detection of anastomotic leak.

CONCLUSIONS

CRP may help in identifying patients at very low risk of anastomotic leak after esophagectomy. Patients with CRP values < 130 mg/L on POD 5 can safely undertake an enhanced recovery protocol.

Antimicrobial Challenge in Acute Care Surgery

The burden of infections in acute care surgery (ACS) is huge. Surgical emergencies alone account for three million admissions per year in the United States (US) with estimated financial costs of USD 28 billion per year. Acute care facilities and ACS patients represent boost sanctuaries for the emergence, development and transmission of infections and multi-resistant organisms. According to the World Health Organization, healthcare-associated infections affected around 4 million cases in Europe and 1.7 million in the US alone in 2011 with 39,000 and 99,000 directly attributable deaths, respectively. In this scenario, antimicrobial resistance arose as a public-health emergency that worsens patients' morbidity and mortality and increases healthcare costs. The optimal patient care requires the application of comprehensive evidence-based policies and strategies aiming at minimizing the impact of healthcare associated infections and antimicrobial resistance, while optimizing the treatment of intra-abdominal infections. The present review provides a snapshot of two hot topics, such as antimicrobial resistance and systemic inflammatory response, and three milestones of infection management, such as source control, infection prevention, and control and antimicrobial stewardship.

A good preoperative immune prognostic index is predictive of better long-term outcomes after laparoscopic gastrectomy compared with open gastrectomy for stage II gastric cancer in elderly patients

BACKGROUND

It remains inconclusive whether laparoscopic gastrectomy (LG) has better long-term outcomes when compared with open gastrectomy (OG) for elderly gastric cancer (EGC). We attempted to explore the influence of the immune prognostic index (IPI) on the prognosis of EGCs treated by LG or OG to identify a population among EGC who may benefit from LG.

METHODS

We included 1539 EGCs treated with radical gastrectomy from January 2007 to December 2016. Propensity score matching was applied at a ratio of 1:1 to compare the LG and OG groups. The IPI based on dNLR ≥ cut-off value (dNLR) and sLDH ≥ cut-off value (sLDH) was developed, characterizing two groups (IPI = 0, good, 0 factors; IPI = 1, poor, 1 or 2 factors).

RESULTS

Of the 528 EGCs (LG: 264 and OG: 264), 271 were in the IPI = 0 group, and 257 were in the IPI = 1 group. In the entire cohort, the IPI = 0 group was associated with good 5-year overall survival (OS) (p = 0.001) and progression-free survival (PFS) (p = 0.003) compared to the IPI = 1 group; no significant differences in 5-year OS and PFS between the LG and OG groups were observed. In the IPI = 1 cohort, there was no significant difference in OS or PFS between the LG and OG groups across all tumor stages. However, in the IPI = 0 cohort, LG was associated with longer OS (p = 0.015) and PFS (p = 0.018) than OG in stage II EGC, but not in stage I or III EGC. Multivariate analysis showed that IPI = 0 was an independent protective factor for stage II EGC receiving LG, but not for those receiving OG.

CONCLUSION

The IPI is related to the long-term prognosis of EGC. Compared with OG, LG may improve the 5-year survival rate of stage II EGC with a good IPI score. This hypothesis needs to be further confirmed by prospective studies.

Mini-laparotomy radical cystectomy with limited bowel externalization during ileal conduit urinary diversion reduces the rate of postoperative complications: a match-paired, single centered analysis

OBJECTIVE

To assess the feasibility and functional outcomes of mini-laparotomy radical cystectomy (RC) in association with limited bowel externalization during ileal conduit urinary diversion.

METHODS

Between January 2018 and March 2020, 53 patients underwent RC plus pelvic lymph node dissection (PLND) for invasive carcinoma of the urinary bladder. This group of patients was intentionally treated utilizing the mini-laparotomy approach, with the addition of limited bowel externalization during conduit preparation and match-paired with 46 examinees from a historical series of patients who underwent conventional open RC plus PLND and ileal conduit diversion. Clinicopathological features and perioperative outcomes were examined from medical records, while postoperative pain was evaluated through the Visual Analog Scale for Pain (VAS). Mean pain scores were evaluated on postoperative days (POD) 1-3.

RESULTS

There was no difference in specific intraoperative complications between groups, with a median (range) incision length of 8 (5-10) cm within the first group and 16.3 (12-22.6) cm within the second group. The first group had less postoperative pain compared with patients in the second group, with mean pain scores significantly lower across POD 1-3, 3.8 (IQR: 0-6) versus 6.7 (IQR: 3.8-8.1) and 2.5 (IQR: 1-3.7) versus 4.6 (IQR: 3-6), respectively (p = .012 and .002).

CONCLUSIONS

By using this technique, we were able to significantly reduce patients' postoperative pain, time to bowel restitution, and hospital stay, which are major issues in minimizing short-term postoperative complications of conventional open surgery.

The pre- and postoperative neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios: The comparison of laparoscopy and laparotomy in colorectal cancer patients

INTRODUCTION

The management of inflammation after colorectal surgery is important to decrease the susceptibility to postoperative complications. Platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) in the peripheral blood are known as two important inflammatory markers. In this study we evaluated and compared colorectal laparoscopy and laparotomy based on the PLR and NLR.

METHODS

Totally, 76 patients were divided into two groups including patients who underwent laparoscopy (45 cases) or laparotomy (31 cases). The PLR and NLR were calculated based on cell blood count analysis of preoperative and postoperative day (POD) one and three in both groups. Statistical analysis was performed using SPSS software version 22.

RESULTS

The PLR and NLR have no significant association with age, gender and tumor site (p > 0.05). However, both ratios were significantly increased in laparotomy patients at POD1 compared with the laparoscopy patients (p < 0.05). According to the two by two comparisons, the preoperative and postoperative PLR were significantly different in the laparotomy group (p < 0.05) but not in the laparoscopy group (p > 0.05). However, the preoperative and postoperative NLR were significantly different in both laparoscopy and laparotomy groups (p < 0.05).

CONCLUSION

The NLR and PLR markers indicated that laparoscopy can be a better choice for colorectal surgery due to lower induction of inflammation compared with laparotomy.

Impact of intravenous dexmedetomidine on postoperative bowel movement recovery after laparoscopic nephrectomy: A consort-prospective, randomized, controlled trial

BACKGROUND

Postoperative ileus is a frequent postoperative complication, especially after abdominal surgery. Sympathetic excitation is the primary factor for postoperative ileus. Sympathetic activation becomes increased by surgical stress, postoperative pain, and inflammation. Dexmedetomidine (DEX) can inhibit sympathetic nerve activity, inflammation, and pain.

AIM

To observe whether DEX promotes bowel movements in patients after laparoscopic nephrectomy.

METHODS

One hundred and twenty patients undergoing laparoscopic nephrectomy were assigned to three groups: C (normal saline infusion), D1 (DEX 0.02 µg/kg/h), and D2 (DEX 0.04 µg/kg/h). The primary outcomes were the recorded times to first flatus, defecation, and eating after surgery. The secondary outcomes were postoperative pain, assessed using the numerical rating scale (NRS), adverse effects, and the duration of the postoperative hospital stay.

RESULTS

The times to first flatus, defecation, and eating in groups D1 and D2 were significantly shorter than those in group C (P < 0.01). The NRS scores at 8 h and 24 h after surgery were significantly lower in groups D1 and D2 than in group C (P < 0.05). No adverse effects were observed (P > 0.05).

CONCLUSION

Postoperative infusion of DEX at 0.04 µg/kg/h facilitates bowel movements in patients undergoing laparoscopic nephrectomy.

Postoperative C-reactive protein concentrations to predict infective complications following gastrectomy for cancer

BACKGROUND AND OBJECTIVES

Gastrectomy for gastric cancer is associated with significant infective postoperative complications. C-reactive protein (CRP) is a useful biomarker in the early detection of infective complications following major abdominal surgery. This single-centre retrospective study aimed to determine the relationship between postoperative CRP levels and development of postoperative infective complications after gastrectomy.

METHODS

Daily postoperative CRP levels were analyzed to determine a CRP threshold associated with infective complications. ROC curve analysis was used to determine which postoperative day (POD) gave the optimal cutoff. Multivariate analysis was performed to determine significant factors associated with complications.

RESULTS

One hundred and forty-four patients were included. A total of 61 patients (42%) had at least one infective complication. A CRP level of 220 mg/L was associated with the highest AUC (0.765) with a sensitivity of 70% and specificity of 76% (positive predictive value, 67%; negative predictive value, 78%). More patients with a CRP > 220 mg/L on POD 3 developed infective complications (67% vs. 21%, p < 0.001).

CONCLUSIONS

A CRP of more than 220 mg/L on POD 3 may be useful to alert clinicians to the increased risk of a postoperative infective complication or enable earlier safe discharge from critical care for those with a lower value.

Impact of Immune Response in Short-term and Long-term Outcomes After Minimally Invasive Surgery for Colorectal Liver Metastases: Results From a Randomized Study

BACKGROUND

The potential benefit related to laparoscopic liver surgery (LLS) for colorectal liver metastases outcomes is not well known.

MATERIALS AND METHODS

Serum cytokines associated with Th1 (tumor necrosis factor-α) and Th2 [interleukin (IL)-10 and IL-6] phenotypes were measured in 36 patients operated on for colorectal liver metastases by open liver surgery (OLS) and LLS. Measurements were performed at 3 time points: 1 day before surgery, day 3 postoperative, and 1 month postoperative. We compared the postoperative inflammatory response influence between LLS and OLS on long-term outcomes.

RESULTS

In both groups, only IL-6 levels on day 3 postoperative were higher than those measured preoperatively and at 1 month. Comparing the tumor necrosis factor-α levels between the LLS and OLS groups, preoperative (7.28 vs. 2.36), day 3 (7.99 vs. 4.08) and 1 month (7.39 vs. 1.99) postoperative levels were higher in the OLS group (P<0.01, <0.01, and <0.01, respectively). In contrast, IL-10 levels were higher in the LLS group preoperatively (7.51 vs. 4.57) and on day 3 postoperative (13.40 vs. 4.57) (P=0.03 and 0.01, respectively). A cut-off IL-6 level of ≥4.41 in the first month was associated with a higher risk of recurrence (logrank=4.8, P=0.02).

CONCLUSIONS

Both LLS and OLS induce an initial increase in IL-6 that normalizes one month after surgery, showing a similar pattern. In addition, a cut-off IL-6 value of 4.41 pg/mL was established, with a higher concentration at 1 month postoperative possibly related to a higher risk or recurrence.

How Much Benefit Can Patients Acquire from Enhanced Recovery After Surgery Protocols with Percutaneous Endoscopic Lumbar Interbody Fusion?

Purpose

We aimed to explore the role of enhanced recovery after surgery (ERAS) in patients who underwent percutaneous endoscopic lumbar interbody fusion (PELIF).

Patients and Methods

We performed a retrospective, observational, cohort study on 91 patients who underwent PELIF for degenerative disc disease. The primary outcomes were postoperative opioid consumption, hospital length of stay (LOS), and hospital cost.

Results

Forty-six patients comprised the ERAS group, and 45 patients comprised the pre-ERAS group (control group). The groups had comparable demographic characteristics. Good compliance with the ERAS pathway was observed in the ERAS group. Patients in the ERAS group used significantly fewer morphine equivalents compared with the pre-ERAS group (25.0 vs 33.3, respectively; p = 0.017). Hospital LOS did not decrease significantly in the ERAS group compared with the pre-ERAS group (3.1days vs 3.4 days, respectively; p = 0.096). Likewise, there was no significant difference in hospital cost between the pre-ERAS group and the ERAS group ($10,598.60 vs $10,384.50, respectively; p = 0.468).

Conclusion

In the present study, the benefit of ERAS in the context of PELIF was limited. Although a multidisciplinary ERAS protocol can improve analgesia and decrease opioid consumption, no significant reduction in hospital LOS and cost was observed.

Transpyloric optic navigation of tumor using a laparoscope during totally laparoscopic distal gastrectomy for gastric cancer

Purpose

Methods

Results

Conclusion

Safety of Breast Cancer Mastoscopic Surgery from the Perspective of Immunity and Adipokines

Background: This study was performed to explore the safety of breast cancer (BC) mastoscopic surgery from the perspective of immunity and adipokines. Method: A single-center, prospective, randomized controlled trial was carried out among 42 patients who had undergone surgery from December 2018 to July 2019. All patients were randomly divided into an open surgery group (n = 21) and a mastoscopic surgery group (n = 21). Flow cytometry was used to detect natural killer (NK), CD4⁺ T cells, CD8⁺ T cells, and regulatory T (Treg) cells in each group 1 d before surgery, 1 h after operation, and 1, 5, and 7 d after operation. The levels of serum leptin and adiponectin were detected by enzyme-linked immunosorbent assay before and after operation. Results: There were no significant differences in the percentages of NK (p = 0.984), CD4⁺ T (p = 0.591), Treg (p = 0.676), and CD8 ⁺ T (p = 0.341) lymphocytes between the two groups during the perioperative period. There were no significant differences in the levels of serum leptin and adiponectin before and after operation between the two groups (all p > 0.05). There were no significant differences between patients undergoing open surgery and mastoscopic surgery from the perspective of immunity and adipokines. Conclusion: Mastoscopic surgery is a suitable surgical choice for patients with BC.

Laparoscopic left hemihepatectomy combined with right lateral hepatic lobectomy in pigs: surgical approach and comparative study of the inflammatory response versus open surgery

This study describes a left hemihepatectomy combined with a right lateral hepatic lobectomy. It compares the inflammatory response associated with laparoscopic hepatectomy (LH group, n = 7) with conventional open hepatectomy (OH group, n = 7). Blood was collected before surgery as well as 1, 2, 3, 5, and 7 days after surgery to determine the white blood cell count and levels of serum cortisol (COR), interleukin-6 (IL-6), and C-reactive protein (CRP). The left hemi-hepatectomy combined with a right lateral hepatic lobectomy was completed in miniature pigs. The average operative time was 139.00 ± 9.07 min, which was longer than that in the OH group (121.67 ± 3.02 min). The length of surgical incision associated with the OH group was 17.93 ± 1.09 cm, significantly longer than that related to the LH group (5.10 ± 0.17 cm). The estimated mean blood loss in the LH group was 136.43 ± 63.24 mL, which was significantly lower than that in the OH group. No severe complications (e.g., massive bleeding, bile leakage, and air embolism) were reported. The CRP levels, COR, and IL-6, increased significantly in the OH group and then slowly returned to their preoperative levels. A postoperative laparoscopic exploration revealed that the incised portion of the liver adhered to the omentum, but no additional abnormalities were observed. These findings indicate that a 4-trocar method for laparoscopic left hemihepatectomy combined with a right lateral hepatic lobectomy is safe and feasible. The inflammatory response for those receiving LH are lower than that for those receiving OH. This porcine model can be used as a research analog for liver disease and regeneration.

The immunomodulatory effect of ketamine in colorectal cancer surgery: a randomized-controlled trial

PURPOSE

Ketamine's inhibitory action on the N-methyl-D-aspartate receptor and anti-inflammatory effects may provide beneficial immunomodulation in cancer surgery. We investigated the effect of subanesthetic-dose ketamine as an adjunct to desflurane anesthesia on natural killer (NK) cell activity and inflammation in patients undergoing colorectal cancer surgery.

METHODS

A total of 100 patients were randomly assigned to a control or ketamine group. The ketamine group received a bolus of 0.25 mg·kg^-1 ketamine five minutes before the start of surgery, followed by an infusion 0.05 mg·kg^-1·hr^-1 until the end of surgery; the control group received a similar amount of normal saline. We measured NK cell activity and proinflammatory cytokines (interleukin-6 [IL-6] and tumour necrosis factor-α [TNF-α]) before surgery and one, 24, and 48 hr after surgery. C-reactive protein (CRP) was measured before surgery and one, three, and five days after surgery. Carcinoembryonic antigen and cancer recurrence/metastasis were assessed two years after surgery.

RESULTS

The NK cell activity was significantly decreased after surgery in both groups, but the change was not different between groups in the linear mixed model analysis (P = 0.47). Changes in IL-6, TNF-α, CRP, and carcinoembryonic antigen levels were not different between groups (P = 0.27, 0.69, 0.99, and 0.97, respectively). Cancer recurrence within 2 years after surgery was similar between groups (10% vs 8%, P = 0.62).

CONCLUSIONS

Intraoperative low-dose ketamine administration did not convey any favourable impacts on overall postoperative NK cell activity, inflammatory responses, and prognosis in colorectal cancer surgery patients.

TRIAL REGISTRATION

www.clinicaltrial.gov (NCT03273231); registered 6 September 2017.

Short-term Outcomes of Single-port Versus Multiport Laparoscopic Surgery for Colon Cancer: The SIMPLE Multicenter Randomized Clinical Trial

OBJECTIVE

To compare short-term perioperative outcomes of single-port laparoscopic surgery (SPLS) and multiport laparoscopic surgery (MPLS) for colon cancer.

SUMMARY BACKGROUND DATA

Although many studies reported short- and long-term outcomes of SPLS for colon cancer compared with MPLS, few have reported results of randomized controlled trials.

METHODS

This was a multicenter, prospective, randomized controlled trial with a noninferiority design. It was conducted between August 2011 and June 2017 at 7 sites in Korea. A total of 388 adults (aged 19-85 yrs) with clinical stage I, II, or III adenocarcinoma of the ascending or sigmoid colon were enrolled and randomized. The primary endpoint was 30-day postoperative complication rates. Secondary endpoints were the number of harvested lymph nodes, length of the resection margin, postoperative pain, and time to functional recovery (bowel movement and diet). Patients were followed for 30 days after surgery.

RESULTS

Among 388 patients, 359 (92.5%) completed the study (SPLS, n = 179; MPLS, n = 180). The 30-day postoperative complication rate was 10.6% in the SPLS group and 13.9% in the MPLS group (95% confidence interval, -10.05 to 3.05 percentage points; P < 0.0001). Total incision length was shorter in the SPLS group than in the MPLS group (4.6 cm vs 7.2 cm, P < 0.001), whereas the length of the specimen extraction site did not differ (4.4 cm vs 4.6 cm, P = 0.249). There were no significant differences between groups for all secondary endpoints and all other outcomes.

CONCLUSIONS

Even though there was no obvious benefit to SPLS over MPLS when performing colectomy for cancer, our data suggest that SPLS is noninferior to MPLS and can be considered an option in selected patients, when performed by experienced surgeons.Trial registration: ClinicalTrials.gov Identifier: NCT01480128.

Effect of volatile and total intravenous anesthesia on syndecan-1 shedding after minimally invasive gastrectomy: a randomized trial

This study aimed to compare the effects of volatile anesthesia and total intravenous anesthesia (TIVA) on syndecan-1 shedding in patients with gastric cancer undergoing minimally invasive gastrectomy. Patients were randomly assigned to either the Volatile (n = 68) or the TIVA (n = 68) group. Anesthesia was maintained with sevoflurane/remifentanil or propofol/remifentanil in the Volatile and TIVA groups, respectively. Serum syndecan-1 was evaluated at pre-operation, end of operation, and postoperative day (POD) 1. Inflammatory markers including white blood cell (WBC) count, neutrophil-to-lymphocyte ratio (NLR), and C-reactive protein (CRP), were also measured at pre-operation, end of operation, and POD 1, 2, 3, and 5. The TIVA group showed significantly lower levels of syndecan-1 at the end of the operation compared to the Volatile group; however, no difference was seen between the groups at POD 1. The WBC count and NLR were significantly lower in the TIVA group at the end of the operation than the Volatile group, but there were no differences between the groups at POD 1, 2, 3, and 5. CRP levels were similar between the groups at all time points. In conclusion, despite TIVA being superior to volatile anesthesia in protecting endothelial glycocalyx during the operation, both did not prevent postoperative syndecan-1 shedding after gastrectomy.

Clinical trial registration number: NCT04183296 (ClinicalTrial.gov, 03/12/2019).

Impact of postoperative complications on survival outcomes in patients with gastric cancer: exploratory analysis of a randomized controlled JCOG1001 trial

BACKGROUND

Recent studies have found a negative impact of postoperative complications on long-term survival outcomes, but it has not been confirmed by data obtained from a prospective study with a large sample size. This study investigated the impact of postoperative complications on long-term survival outcomes, and considered the optimal definition of complication, using data from JCOG1001, which compared bursectomy and non-bursectomy for patients with cT3/4a locally advanced gastric cancer.

METHODS

This study included 1191 of 1204 patients enrolled in the JCOG1001 trial. Complications were graded by Clavien-Dindo (C-D) classification. Impact of the grade (≥ C-D grade II or ≥ grade III) or type (any or intra-abdominal infectious) of complication on survival outcome was evaluated by univariate and multivariable analyses using the Cox proportional hazard model.

RESULTS

The incidence of any ≥ C-D grade II and ≥ grade III complication was 23.0% and 9.7%, respectively, and that of ≥ grade II and ≥ grade III intra-abdominal infectious complication was 13.4% and 6.9%, respectively. Multivariable analysis showed all four definitions of complications were independent prognostic factors for overall survival. Conversely, only  any ≥ C-D grade III complication was found to be an independent prognostic factor for relapse-free survival (hazard ratio, 1.445; 95% confidence interval, 1.026-2.036; P = 0.035).

CONCLUSIONS

Postoperative complications adversely affect the long-term survival outcomes of patients with cT3/4a gastric cancer. Any ≥ C-D grade III complication seems to be the most suitable definition of complication for predicting negative long-term survival outcomes.

Systemic Inflammatory Response Syndrome After Surgery: Mechanisms and Protection

The immune system is an evolutionary hallmark of higher organisms that defends the host against invading pathogens and exogenous infections. This defense includes the recruitment of immune cells to the site of infection and the initiation of an inflammatory response to contain and eliminate pathogens. However, an inflammatory response may also be triggered by noninfectious stimuli such as major surgery, and, in case of an overshooting, still not comprehensively understood reaction, lead to tissue destruction and organ dysfunction. Unfortunately, in some cases, the immune system may not effectively distinguish between stimuli elicited by major surgery, which ideally should only require a modest inflammatory response, and those elicited by trauma or pathogenic infection. Surgical procedures thus represent a potential trigger for systemic inflammation that causes the secretion of proinflammatory cytokines, endothelial dysfunction, glycocalyx damage, activation of neutrophils, and ultimately tissue and multisystem organ destruction. In this review, we discuss and summarize currently available mechanistic knowledge on surgery-associated systemic inflammation, demarcation toward other inflammatory complications, and possible therapeutic options. These options depend on uncovering the underlying mechanisms and could include pharmacologic agents, remote ischemic preconditioning protocols, cytokine blockade or clearance, and optimization of surgical procedures, anesthetic regimens, and perioperative inflammatory diagnostic assessment. Currently, a large gap between basic science and clinically confirmed data exists due to a limited evidence base of translational studies. We thus summarize important steps toward the understanding of the precise time- and space-regulated processes in systemic perioperative inflammation.

Laparoscopic hepatectomy enhances recovery for small hepatocellular carcinoma with liver cirrhosis by postoperative inflammatory response attenuation: a propensity score matching analysis with a conventional open approach

BACKGROUND

The concurrent presence of liver cirrhosis and hepatocellular carcinoma (HCC) poses a challenge for laparoscopic surgeons to establish a routine practice. The aim of this study was to gather evidence and produce recommendations on the safe and effective practice of laparoscopic hepatectomy for patients with solitary HCC (≤ 5 cm) and liver cirrhosis.

METHODS

Between October 2013 and October 2014, 356 curative hepatectomies were performed for patients pathologically diagnosed with solitary HCC (≤ 5 cm) accompanied by cirrhosis (stage 4 fibrosis). To overcome selection bias, a 1:2 match using propensity score matching analysis was conducted between laparoscopic and open hepatectomy. Perioperative outcomes were compared between the groups, including hospitalization, operation time, blood loss, and surgical complications. Perioperative inflammation-based markers, including systemic immune-inflammation index (SII), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR) were collected from medical records and analyzed.

RESULTS

There were 43 and 77 patients in the laparoscopic and open groups, respectively. The laparoscopic group had less hepatic inflow occlusion (16.3% vs. 61%; P < 0.001), shorter operation time (155 vs. 170 min; P = 0.004), and shorter postoperative hospital stay (4 vs. 7 days; P < 0.001). Although the difference was not significant (P = 0.154), the rate of postoperative complications tended to be lower in the laparoscopic group (2.3%) compared with the open group (9.1%). The increase in postoperative SII, NLR, and LMR for laparoscopic hepatectomy were significantly lower than for open hepatectomy. NLR < 5.8 on postoperative day 3 was significantly correlated with shorter hospital stay (P < 0.001).

CONCLUSIONS

Compared with open hepatectomy, laparoscopic hepatectomy for selected HCC patients, even in the presence of cirrhosis, might result in better perioperative outcomes and postoperative inflammatory response attenuation, and ultimately promote faster recovery. This provides evidence for considering routine laparoscopic hepatectomy through careful selection of patients with HCC.

Combination of sufentanil, dexmedetomidine and ropivacaine to improve epidural labor analgesia effect: A randomized controlled trial

Opioids and α2-agonists have been used as epidural adjuvants in local anesthetics for a long time, but the effect of the combination of opioids and α2-agonists as epidural adjuvants is not completely understood. In the present study, the combination of dexmedetomidine (Dex) and sufentanil as adjuvants to ropivacaine for epidural labor analgesia was investigated. A total of 108 parturient women receiving labor epidural analgesia were randomly divided into three groups: i) Group RD received 0.1% ropivacaine + 0.5 µg/ml Dex; ii) Group RS received 0.1% ropivacaine + 0.5 µg/ml sufentanil; and iv) Group RDS received 0.1% ropivacaine + 0.25 µg/ml Dex + 0.25 µg/ml sufentanil. Patients received a 10 ml loading dose followed by a maintenance by patient controlled epidural analgesia. The visual analog scale scores, onset time, local anesthetic requirements, motor blockage and adverse effects were recorded. Group RDS displayed an improved labor analgesia effect compared with Groups RD and RS. Group RDS displayed a shorter onset time compared with Groups RD and RS, and a reduced local anesthetic requirement compared with Group RS. The motor blockage in Groups RDS and RS was significantly lower compared with Group RD, and the incidence of pruritus in Groups RDS and RD was lower compared with Group RS. In conclusion, the combined use of 0.25 µg/ml Dex and 0.25 µg/ml sufentanil as adjuvants to 0.1% ropivacaine for epidural labor analgesia displayed an improved analgesia effect compared with the use of either 0.5 µg/ml sufentanil or 0.5 µg/ml Dex alone. The present study was registered with the Chinese Clinical Trial Registry Center on 23 February, 2018 (registration no. ChiCTR-IOR-1800014943).

The Impact of Minimally Invasive Gastrectomy on Survival in the USA

BACKGROUND

Minimally invasive surgical approaches for gastric adenocarcinoma are increasing in prevalence. Although recent studies suggest such approaches are associated with improvements in short-term outcomes, long-term outcomes have not been well studied. This study aimed to evaluate the impact of minimally invasive gastrectomy on long-term survival.

METHODS

The National Cancer Database (NCDB) was used to identify patients who underwent gastrectomy for adenocarcinoma between 2010 and 2015. Patient characteristics were stratified by open and minimally invasive approaches and compared using chi-square and t tests. Unadjusted survival functions were estimated using Kaplan-Meier methodology. Multivariable modeling of risks factors for survival was analyzed with Cox proportional hazard models. Covariate imbalance was controlled using propensity score matching.

RESULTS

The study included 17,449 patients who underwent gastrectomy. Cox proportional hazard modeling demonstrated that minimally invasive surgery improved survival (hazard ratio = 0.86, P < 0.0001). Predictors of worsened survival included community facility type, comorbidities, tumor size, extent of gastrectomy, clinical T and N staging (P < 0.0060 for all). After propensity score matching, minimally invasive surgery had a significantly improved survival at 5 years compared to an open approach, 51.9% versus 47.7% (P < 0.0001). Survival was not significantly different between propensity score-matched patients who received laparoscopic and robotic approaches (P = 0.2611).

CONCLUSIONS

Minimally invasive approaches for gastric carcinoma are associated with improved long-term survival. There was no significant difference in survival when comparing laparoscopic to robotic gastrectomy. The mechanisms that drive these improvements deserve further investigation.

Development of a severe mesenteric traction syndrome during major abdominal surgery is associated with increased postoperative morbidity: Secondary data analysis on prospective cohorts

PURPOSE

MTS is elicited during open abdominal surgery and is characterized by facial flushing, hypotension, and tachycardia in response to the release of prostacyclin (PGI₂) to plasma. MTS seems to affect postoperative morbidity, but data from larger cohorts are lacking. We aimed to determine the impact of severe mesenteric traction syndrome (MTS) on postoperative morbidity in patients undergoing open upper gastrointestinal surgery.

METHODS

The study was a secondary analysis of data from three cohorts (n = 137). The patients were graded for severity of MTS intraoperatively, and hemodynamic variables and blood samples for plasma 6-keto-PGF_1α, a stable metabolite of PGI₂, were obtained at defined time points. Postoperative morbidity was evaluated by the comprehensive complication index (CCI) and the Dindo-Clavien classification (DC).

RESULTS

Patients undergoing either esophagectomy (n = 70), gastrectomy (n = 22), liver- (n = 23), or pancreatic resection (n = 22) were included. Severe MTS was significantly associated with increased postoperative morbidity, i.e., CCI ≥ 26.2 (OR 3.06 [95% CI 1.1-6.6]; p = 0.03) and risk of severe complications, i.e., DC ≥3b (OR 3.1 [95% CI 1.2-8.2]; p = 0.023). Furthermore, patients with severe MTS had increased length of stay (OR 10.1 [95% CI 1.9-54.3]; p = 0.007) and were more likely to be admitted to the intensive care unit (OR = 7.3 [95% CI 1.3-41.9]; p = 0.027), but there was no difference in 1-year mortality.

CONCLUSION

Occurrence of severe MTS during upper gastrointestinal surgery is associated with increased postoperative morbidity as indicated by an increased rate of severe complications, length of stay, and admission to the ICU. It remains to be determined whether inhibition of MTS enhances postoperative recovery.

Immune capacity determines outcome following surgery or trauma: a systematic review and meta-analysis

Purpose

Immunological functions are altered following physical injury. The magnitude of the immunological response is dependent on the initial injury. However, variability in the immune response exists within and between patients where only some patients are at risk of developing complications such as systemic inflammatory response syndrome after injury. This systematic review and meta-analysis assessed whether lipopolysaccharide (LPS) induced cytokine production capacity of leucocytes can be used as a functional test to predict the risk of developing complications after injury.

Methods

Medline, Embase and Web of Science were systematically searched to identify articles that investigated the association between LPS induced cytokine production capacity in leucocytes and any clinical outcome after surgery or trauma. Where sufficient information was supplied, a meta-analysis was performed to determine the overall clinical outcomes.

Results

A total of 25 articles out of 6765 abstracts identified through the literature search were included in this review. Most articles described a positive association between cytokine production capacity and the development of inflammatory complications (n = 15/25). Coincidingly, the meta-analysis demonstrated that TNFα (Hedges g: 0.63, 95% CI 0.23, 1.03), IL-6 (Hedges g: 0.76, 95% CI 0.41, 1.11) and IL-8 (Hedges g: 0.93, 95% CI 0.46, 1.39) production capacity was significantly higher, one day after injury, in patients who developed inflammatory complications compared to patients who did not following trauma or surgical intervention. No significant difference was observed for IL-1β.

Conclusion

The associations of elevated LPS-induced cytokine production capacity with the risk of developing inflammatory complications are consistent with previous theories that proposed excessive inflammation is accompanied by anti-inflammatory mechanisms that results in a period of immunosuppression and increased risk of secondary complications. However, immunological biomarkers for risk stratification is still a developing field of research where further investigations and validations are required.

Electronic supplementary material

The online version of this article (10.1007/s00068-019-01271-6) contains supplementary material, which is available to authorized users.

Systematic Review of the Role of Biomarkers in Predicting Anastomotic Leakage Following Gastroesophageal Cancer Surgery

Anastomotic leakage (AL) following gastroesophageal cancer surgery remains a serious postoperative complication. This systematic review aims to provide an overview of investigated biomarkers for the early detection of AL following esophagectomy, esophagogastrectomy and gastrectomy. All published studies evaluating the diagnostic accuracy of biomarkers predicting AL following gastroesophageal resection for cancer were included. The Embase, Medline, Cochrane Library, PubMed and Web of Science databases were searched. Risk of bias and applicability were assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) 2 tool. Twenty-four studies evaluated biomarkers in the context of AL following gastroesophageal cancer surgery. Biomarkers were derived from the systemic circulation, mediastinal and peritoneal drains, urine and mediastinal microdialysis. The most commonly evaluated serum biomarkers were C-reactive protein and leucocytes. Both proved to be useful markers for excluding AL owing to its high specificity and negative predictive values. Amylase was the most commonly evaluated peritoneal drain biomarker and significantly elevated levels can predict AL in the early postoperative period. The associated area under the receiver operating characteristic (AUROC) curve values ranged from 0.482 to 0.994. Current biomarkers are poor predictors of AL after gastroesophageal cancer surgery owing to insufficient sensitivity and positive predictive value. Further research is needed to identify better diagnostic tools to predict AL.

Retrospective analysis of 1-year mortality after gastric cancer surgery: Total intravenous anesthesia versus volatile anesthesia

BACKGROUND

It remains controversial whether propofol-based total intravenous anesthesia (TIVA) or inhalation anesthesia is associated with better outcomes after cancer surgery. We investigated whether there is a difference in the 1-year overall or cancer-related mortality between propofol-based TIVA and inhalation anesthesia in patients who underwent gastric cancer surgery.

METHODS

This retrospective cohort study was based on medical records of ll patients aged ≥18 years who underwent elective gastric cancer surgery with curative intent between January 2005 and December 2015 at a single tertiary academic hospital. Propensity score (PS) matching and Cox proportional hazard models were used for analyses.

RESULTS

After PS matching, 1538 patients (769 patients in each group) were included in the final analysis. The 1-year overall mortality risk was not significantly different between the TIVA and inhalation groups in either the PS-matched analysis [hazard ratio (HR): 0.92, 95% confidence interval (CI): 0.52-1.64; P = 0.774] or entire cohorts (HR: 0.82 95% CI: 0.52-1.33; P = 0.417) after multivariable adjustment. The 1-year cancer-related mortality risk was similar between the groups in both the PS-matched cohort (HR: 0.91, 95% CI: 0.50-1.67; P = 0.764) and the entire cohort after multivariable adjustment (HR: 0.82, 95% CI: 0.50-1.33; P = 0.406).

CONCLUSIONS

We show that propofol-based TIVA was not significantly associated with a decrease in the 1-year overall or cancer-related mortality after gastric cancer surgery, as compared with inhalation anesthesia. Further studies are required to ascertain the optimal anesthetic choice for gastric cancer surgery.

A Combination of Robotic Approach and ERAS Pathway Optimizes Outcomes and Cost for Pancreatoduodenectomy

OBJECTIVE

To determine the impact of enhanced recovery after surgery (ERAS) pathway implementation on outcomes, and cost of robotic and open pancreatoduodenectomy.

BACKGROUND

ERAS pathways have shown benefit in open pancreatoduodenectomy (OPD). The impact of ERAS on robotic pancreatoduodenectomy (RPD) is unknown.

METHODS

Retrospective review of consecutive RPD and OPDs in the pre-ERAS (July, 2014-July, 2015) and ERAS (July, 2015-July, 2016) period. Univariate and multivariate logistic regression was used to determine impact of ERAS and operative approach alone, or in combination (pre-ERAS + OPD, pre-ERAS + RPD, ERAS + OPD, ERAS + RPD) on length of hospital stay (LOS) and overall cost.

RESULTS

In all, 254 consecutive pancreatoduodenectomies (RPD 62%, OPD 38%) were analyzed (median age 67, 47% female). ERAS patients had shorter LOS (6 vs 8 days; P = 0.004) and decreased overall cost (USD 20,362 vs 24,277; P = 0.001) compared with non-ERAS patients, whereas RPD was associated with decreased LOS (7 vs 8 days; P = 0.0001) and similar cost compared with OPD. On multivariable analysis (MVA), RPD was predictive of shorter LOS [odds ratio (OR) 0.33, confidence interval (CI) 0.16-0.67, P = 0.002), whereas ERAS was protective against high cost (OR 0.57, CI 0.33-0.97, P = 0.037). On MVA, when combining operative approach with ERAS pathway use, a combined ERAS + RPD approach was associated with reduced LOS and optimal cost compared with other combinations (pre-ERAS + OPD, pre-ERAS + RPD, ERAS + OPD).

CONCLUSION

ERAS implementation is independently associated with cost savings for pancreatoduodenectomy. A combination of ERAS and robotic approach synergistically decreases hospital stay and overall cost compared with other strategies.

The systemic impact of a surgical procedure in older oncological patients

BACKGROUND

An excessive inflammatory response accounts partially for the increased morbidity and mortality seen in elderly surgical patients. The aim of this study was to investigate the association between a range of pre- and peroperative factors and the extent of the inflammatory response, and to identify patients at risk of a greater inflammatory response following surgery.

METHODS

Patients 65 years and older undergoing a surgical procedure for a solid malignant tumour were prospectively included in an observational cohort study. Inflammatory markers were measured in plasma samples pre- and postoperatively: C-reactive protein (CRP), Interleukin-1 beta (IL-1β), IL-6, IL-10, IL-12, and Tumour necrosis factor alpha (TNF-α). Preoperative and postoperative inflammatory factor assay results were compared, and associations between inflammatory markers and pre- and peroperative factors were explored using multivariate linear regression analysis.

RESULTS

Between July 2010 and April 2014, plasma samples of 224 patients were obtained. Median age was 72 (65-89) years and 108 (48.2%) patients were male. The predominant diagnosis was carcinoma, 156 (69.6%). Anaesthesia duration was associated with increase in CRP, IL-1β and IL-6; intracavitary surgery with increase in IL-6; blood loss with decrease in CRP and IL-1β; total fluid volume administered with a decrease in IL-1β and disease stage was associated with increase in IL-6.

CONCLUSIONS

The perioperative inflammatory response is related more to surgical characteristics rather than to preoperative factors (with the exception of disease stage). Elderly oncological patients undergoing longer lasting, intracavitary surgical procedures for more advanced disease stages develop the most intense inflammatory response.

Laser speckle contrast imaging for quantitative assessment of facial flushing during mesenteric traction syndrome in upper gastrointestinal surgery

The mesenteric traction syndrome (MTS) is associated with prostacyclin (PGI₂) facilitated systemic vasodilatation during surgery and is identified by facial flushing. We hypothesized that severe facial flushing would be related to the highest concentrations of plasma PGI₂ and accordingly to the highest levels of skin blood flow measured by laser speckle contrast imaging (LSCI). Patients scheduled for major upper abdominal surgery were consecutively included. Within the first hour of the procedure, facial flushing was scored according to a standardized scale, and skin blood flow (LSPU) was continuously measured on the forehead and the cheeks by LSCI. Arterial blood samples for 6-keto-PGF_1α (stable metabolite of PGI₂) and hemodynamic variables were obtained at defined time points. Overall, 66 patients were included. After 15 min of surgery, patients with severe flushing demonstrated the highest plasma 6-keto-PGF_1α concentration and the most significant decrease in systemic vascular resistance. Accordingly, the skin blood flow on the forehead (238 [201-372] to 562 LSPU [433-729]) and the cheeks (341 [239-355] to 624 LSPU [468-917]) increased and were significantly higher than for patients with moderate or no flushing (both, P = 0.04). A cut-off value for skin blood flow could be defined for both the cheeks and the forehead for patients with severe flushing vs. no flushing (425/456 LSPU, sensitivity 75/76% and specificity 80/85%). MTS is linked to an increase in facial skin blood flow during upper gastrointestinal surgery. By applying LSCI, it is possible to quantitatively register facial blood flow, and thereby provide an objective tool for intraoperative verification of MTS.

The Length of Surgical Skin Incision in Postoperative Inflammatory Reaction

BACKGROUND AND OBJECTIVES

Surgery provokes inflammatory and immune responses, so efforts have been made to reduce host response by using less invasive techniques. The purpose of this experimental study was to investigate the surgical stress induced by skin incision and the role of liver response in this process.

METHODS

Seventy male anesthetized Wistar rats were subjected to a midline incision confined strictly to the skin (dermis) of either 1 cm long (n = 20), 10 cm long (n = 20), or no incision (n = 20) or served as controls (n = 10). Skin trauma was left open for a 20-minutes period, and then was meticulously sutured. At 3 and 24 hours later, laparotomy was performed on half the rats of each group, for blood and liver sampling. In serum and liver homogenates, cytokine-induced neutrophil chemoattractant (CINC)1/interleukin (IL)-8 and tumor necrosis factor (TNF)-α levels were measured with enzyme-linked immunosorbent assays and nitric oxide (NO) using a Griess reaction.

RESULTS

Skin trauma was found to significantly (P < .01) increase all inflammatory mediators tested (CINC1/IL-8, TNF-α, NO) in serum of operated rats versus controls, the increase being proportionally dependent on the length of skin incision. In liver homogenates, CINC1/IL-8 was significantly (P < .01) increased in operated animals versus controls, similarly to serum levels. In contrast, liver TNF-α levels were inversely related to serum levels, and a significant (P < .01) decrease in TNF-α was observed in liver homogenates of operated animals compared with the controls, indicating that the increased TNF-α in blood reflects liver TNF-α secretion.

CONCLUSION

Our findings suggest that inflammatory and immune reactions induced by skin-only surgical trauma are closely correlated to the length of skin incision.

Comparison of postoperative lymphocytes and interleukins between laparoscopy-assisted and open radical gastrectomy for early gastric cancer

OBJECTIVE

This study aimed to study the effects of laparoscopic-assisted radical gastrectomy (LAG) and open radical gastrectomy (OG) on immune function and inflammatory factors in patients with early gastric cancer.

METHODS

Seventy-five patients with pT1N0M0 gastric cancer in Ren Ji Hospital from August 2017 to January 2018 were studied. Lymphocytes subsets and interleukins were compared preoperatively and on the third postoperative day (POD3) and seventh postoperative day (POD7).

RESULTS

There were no significant differences in age, sex, body mass index, duration of the operation, estimated blood loss, total gastrectomy rate, postoperative first fluid diet, and the levels of preoperative lymphocytes subsets and interleukins between the two groups. The number of CD4+ T cells and the CD4+/CD8+ ratio in the LAG group were significantly higher than those in the OG group on POD3. However, the number of CD8+ T cells, and interleukin-6 and interleukin-8 levels in the LAG group were significantly lower than those in the OG group on POD3.

CONCLUSIONS

Laparoscopy can effectively reduce the levels of inflammatory factors and has less effect on the immune system than OG.

Robot-assisted laparoscopic cystectomy with intracorporeal urinary diversion vs. open mini-laparotomy cystectomy: evaluation of surgical inflammatory response and immunosuppressive ability of CO2-pneumoperitoneum in an experimental porcine study

OBJECTS

To compare surgical inflammatory response (SIR) after radical cystectomy (RC) in a porcine model using minimal invasive techniques. Additionally we aimed to investigate the potential immunosuppressive ability of preoperative CO₂-pneumoperitoneum (CO₂P).

MATERIALS AND METHODS

Forty female landrace pigs were randomized to five groups: Three intervention groups all having a cystectomy and an ileal conduit either done by robot-assisted laparoscopic technique with intracorporeal urinary diversion (RALC) or an open mini-laparotomy with or without prior CO₂P (OMC ± CO₂P). Two control sham groups with or without prior CO₂P (S ± CO₂P). Serum samples were obtained preoperatively, immediately postoperative, 24, 48 and 72 hours postoperatively, and the inflammatory mediators CRP, Haptoglobin, Ceruloplasmin, Albumin, Cortisol, IL-4, IL-6, IL-12 and IFN-α were measured.

RESULTS

Operative time was significantly longer in RALC compared to open groups (OMC ± CO₂P) (p's < .0001). CRP and Haptoglobin levels were significantly higher for surgical intervention groups (SIG) compared to controls 24, 48 and 72 hours postoperatively (p's < .001). At 48 hours, CRP was higher for RALC vs OMC + CO₂P (p = .029). At 72 hours, Haptoglobin was higher for RALC vs open groups (p's < .024). Ceruloplasmin, cortisol, albumin, IL-4, IL-6, IL-12 and IFN-α, revealed no significant differences between SIG.

CONCLUSIONS

No major differences were found between RALC and OMC regarding the degree of tissue trauma quantified by inflammatory markers. Thirty minutes of CO_2-insufflation preoperative appears to have a transient immunosuppressive effect of the innate postoperative SIR, whereas prolonged CO₂P apparently diminishes this effect.