Minimally invasive colectomies can be performed with similar outcomes to open counterparts for colorectal cancer emergencies: a propensity score matching analysis utilizing ACS-NSQIP

PURPOSE

The safety and feasibility of minimally invasive surgery (MIS) in the setting of colorectal cancer emergencies have been debated. We sought to compare postoperative outcomes of MIS with open techniques in the setting of colorectal cancer emergencies from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

METHODS

We included patients undergoing colectomy for colorectal cancer emergency between 2012 and 2019 "2012-2019" from the ACS-NSQIP dataset. We compared short-term morbidity, mortality, short-term oncological outcomes, and secondary outcomes for MIS vs open colectomies using propensity score matching. We then evaluated the trends of MIS versus open colectomies using linear regression analysis.

RESULTS

We examined a total of 5544 patients (open n = 4070; MIS n = 1474) and included 1352 patients for our postoperative outcome analyses after propensity score matching 1:1 (open n = 676; MIS n = 676). Within the matched cohort, mortality was significantly higher in the open group (open 6.95% vs MIS 3.99%, OR 1.8, p = 0.023). Anastomotic leak rates were comparable between the  two groups (open 4.46% vs MIS 4.02%, OR 1.12, p = 0.787). Pulmonary complications were significantly higher after open surgery (open 10.06% vs MIS 4.73%, OR 2.25, p < 0.001). Rates of ileus were significantly higher amongst open patients (open 29.08% vs MIS 19.94%, p < 0.001). Patients stayed on average 1 day longer in the hospital after open surgery (p < 0.001). Rates of MIS for early tumors (N0 and T1/T2, n = 289) did not significantly change over 7 years (p = 0.597, rate = - 0.065%/year); however, utilization of MIS for late tumors (N1 or T3/T4, n = 4359) increased by 2.06% per year (p < 0.001).

CONCLUSIONS

This study demonstrates that MIS was associated with superior postoperative outcomes compared to open surgery without compromising oncological outcomes in patients undergoing emergency colectomy for colon cancer. Within the matched cohort, MIS was associated with lower rates of mortality, pulmonary complications, ileus, and shorter postoperative length of stay.

The role of bilirubin and its protective function against coronary heart disease

BACKGROUND

Atherosclerotic cardiovascular disease is the leading cause of morbidity and mortality both in industrialized and developing countries. Atherosclerosis is a chronic inflammatory disease of the arterial wall, which also involves deposition and peroxidation of lipids. Bilirubin, an important endogenous antioxidant, may limit lipid peroxidation and retard the progression of atherosclerosis. Previous studies have reported an inverse relationship between serum bilirubin levels and the risk of coronary artery disease (CAD). Taking into account that atherosclerosis is a complex process that is initiated and accelerated by diverse risk factors, we aimed to test the antiatherosclerotic effects of bilirubin in a population with multiple risk factors for CAD.

METHODS

The study included 221 patients who underwent coronary angiography owing to symptoms suggestive of ischemia and/or positive noninvasive stress test results. Of the patients, 76 had normal coronary angiograms and served as the control group. The remaining 145 patients with documented CAD and two or more cardiovascular risk factors constituted the study group. The study group (n=145) was further classified according to the Gensini score as follows: group 1 if Gensini score was 1-19 (minimal CAD, n=82), and group 2 if Gensini score was 20 or higher (significant CAD, n=63). Biochemical assessments including total and direct serum bilirubin levels were carried out using standard methods in automated systems.

RESULTS

All of the cardiovascular risk factors were found significantly more frequently in the study group (groups 1 and 2) than in the control group. Total and direct serum bilirubin levels did not differ significantly between the control group, group 1, and group 2. There was a moderate and significant positive correlation between direct bilirubin levels and the Gensini score (r = 0.158, p = 0.019). There was no significant correlation between total bilirubin levels and the Gensini score.

CONCLUSION

In conclusion, our findings suggest that in the presence of multiple risk factors, similar concentrations of serum bilirubin may not confer the same level of protection against CAD as in an individual with a more favorable risk profile. The relationship between direct bilirubin levels and the Gensini score is unlikely to be causative, given the established antiatherosclerotic effects of bilirubin.

Epidural magnesium reduces postoperative analgesic requirement

BACKGROUND

Magnesium has antinociceptive effects in animal and human models of pain. Our hypothesis was that the addition of magnesium to postoperative epidural infusion of fentanyl may decrease the need for fentanyl.

METHODS

Fifty patients undergoing hip surgery were enrolled to receive either fentanyl (Group F) or fentanyl plus magnesium sulphate (Group FM) for 24 h for epidural analgesia. All patients were equipped with a patient-controlled epidural analgesia device and the initial settings of a demand bolus dose of fentanyl 25 microg. In Group FM, patients received 50 mg magnesium sulphate epidurally as an initial bolus dose followed by a continuous infusion of 100 mg day(-1). Ventilatory frequency, heart rate, blood pressure, pain assessment using a visual analogue scale (VAS), sedation scores and fentanyl consumption were recorded in the postoperative period.

RESULTS

There was no significant difference between groups in the time to first analgesic requirement. Compared with Group F, patients in Group FM received smaller doses of epidural fentanyl (P < 0.05). The cumulative fentanyl consumption in 24 h was 437 (SD110) microg in Group F and 328 (121) microg in Group FM (P < 0.05). Patients in Group F showed a higher VAS score in the first hour of the postoperative period (P < 0.05). The groups were similar with respect to haemodynamic and respiratory variables, sedation, pruritus, and nausea.

CONCLUSION

Co-administration of magnesium for postoperative epidural analgesia results in a reduction in fentanyl consumption without any side-effects.

Behcet's disease with a large and free right atrial thrombus

We present a case of a 27-year-old male patient with Behcet's disease who presented with dyspnoea and haemoptysis in whom further investigation revealed a large and free right atrial thrombus and pulmonary thromboembolism. Considering the absence of haemodynamic compromise and the risk of recurrence after surgical treatment for cardiac thrombus, we preferred medical management which consisted of immunosuppression and anticoagulation. On a follow-up period of 12 months we observed complete dissolution of the thrombus and dramatic improvement of clinical status.

In situ prone ESWL for the treatment of lower ureteral stones: experience with 28 patients

Twenty-eight patients with lower ureteral stones underwent in situ extracorporeal shock wave lithotripsy (ESWL) in the prone position over the period of 7 months between March 1990 and September 1990. For stone disintegration the spark gap shock wave lithotripter Tripter XI (Direx) was used. Satisfactory disintegration was achieved in 93 per cent of patients. The stone-free rate at 12 weeks was 82 per cent, and 11 per cent had residual fragments less than or equal to 4 mm in diameter. Twenty-one per cent of patients required repeat treatments. For only 2 patients general anaesthesia was required (7 per cent). There were no remarkable complications except for haemospermia which resolved spontaneously 15 days after treatment. It was concluded that in situ prone ESWL is an effective and safe procedure for the treatment of lower ureteral stones.

In situ extracorporeal shock wave lithotripsy for upper ureteral stones: experience with 65 patients

A total of 65 patients with 67 upper ureteral stones underwent in situ extracorporeal shock wave lithotripsy (ESWL) between March 1990 and September 1990. For stone disintegration the electrohydraulic shock wave lithotripter Tripter XI (Direx) was used. Eighty-seven per cent of stones showed satisfactory disintegration after the first treatment and a further 9 per cent after repeat treatments. The stone-free rate at 12 weeks was 85 per cent. General anaesthesia was needed in only 12 per cent of patients. The retreatment rate was 13 per cent. It was concluded that in situ ESWL is an effective procedure with negligible morbidity for treating upper ureteral stones.

A report on extracorporeal shock wave lithotripsy results on 1,569 renal units in an outpatient clinic

We report our experience with extracorporeal shock wave lithotripsy (ESWL*) treatment of 1,569 renal units in an outpatient clinic with a small focused piezoelectric lithotriptor. A stone-free rate of 93% was achieved. In 3.6% of the patients, mainly those with a history of surgery and/or anatomical caliceal deformations, fragments smaller than 3 mm. in diameter remained despite multiple ESWL sessions and intensive upside down physiotherapy. Of the cases 3.4%, including those without sufficient data, were considered unsuccessful. We treated 58 renal units in children 14 years old and younger, 55 patients had a single kidney and 7 had a horseshoe kidney.