The Impact of Comprehensive Fetal Care on Mortality of Children With Congenital Diaphragmatic Hernia when Delivery is Co-located in a Pediatric Hospital

BACKGROUND

We evaluated the impact of delivery at a comprehensive fetal care center co-located in a pediatric hospital on extracorporeal membrane oxygenation (ECMO) exposure and survivorship of children with CDH.

METHODS

This retrospective study includes maternal-fetal dyads with a prenatal diagnosis of isolated CDH who received any prenatal care at a single fetal center between February 2006 and March 2021. The principal variables included: (1) delivery setting (children born in the pediatric hospital ["inborn"] vs. children who were delivered elsewhere ["outborn"]), (2) exposure to ECMO (yes vs. no), and (3) survival-at-discharge from birth hospitalization (yes vs. no). Multivariable logistic regression was used to evaluate the association between delivery setting and ECMO cannulation, and whether delivery setting moderates the association between exposure to ECMO and survival-at-discharge.

RESULTS

Among 418 maternal-fetal dyads, 77.0% of children were inborn and 32.0% of children were exposed to ECMO during their index hospitalization. Inborn children had more severe prenatal prognostic indicators but had a 57% lower odds of extracorporeal than outborn children. In multivariable logistic regression, delivery setting moderated the association between exposure to ECMO and survival-at-discharge. Although there was no statistically significant difference in mortality between inborn and outborn children who were not exposed to ECMO, inborn children exposed to ECMO had a 6.86 (1.98, 23.74) increased odds of death and outborn children exposed to ECMO had a 17.71 (4.69, 66.87) increased odds of death when both were compared to non-cannulated outborn children.

CONCLUSIONS

Comprehensive fetal care with delivery co-located in a pediatric hospital was associated with decreased exposure to ECMO and a survivorship advantage among children with CDH who required extracorporeal support.

LEVEL OF EVIDENCE

Level III.

Developments in pancreatic cancer surgery

Pancreatic cancer surgery, with one of the worst prognoses in oncology, is a challenge to the surgical community. Centralization of pancreatic surgery has led to the foundation of high-volume centers, thereby greatly facilitating the successful performance of more radical approaches. This review spotlights on recent advances in surgical approaches to pancreatic cancer and the risks and benefits of vascular reconstruction to improve resectability. Surgery being the only modality to achieve cure, multivisceral and vascular resections are being incorporated to improve dismal operability rates of < 10%. Great leaps have been made in neoadjuvant and adjuvant treatment, as targeted and specific chemotherapeutic agents are being continually added. The concept of borderline and locally advanced pancreatic tumors and the use of neoadjuvant chemorad has extended the indications of oncological resection in such tumors. Venous resections are being routinely performed so as to facilitate en bloc removal of tumors, while arterial resections, owing to the increased morbidity and mortality, are offered to highly selective cases. New techniques like the triangle operation and periarterial divestment have opened new viable surgical options. Although laparoscopic approach is time consuming, it offers reduced operative blood loss and a shortened hospital stay at specialized centers. Robotic surgery may produce better results in patients needing vascular resection and reconstruction, but the expenses involved and limited availability are major deterrents. Advanced techniques of surgical resection and vessel reconstruction provide a repository for curative-intent surgery in borderline resectable and locally advanced pancreatic cancer.

[Current approach in cases of persistence and recurrence of primary hyperparathyroidism]

Primary hyperparathyroidism (pHPT) is now diagnosed much earlier and is often asymptomatic. Biochemically mild pHPT is characterized by small parathyroid adenomas (NSDA) and the results of localization diagnostics as well as surgical treatment are poorer. The frequency of redo surgery is 3-14% in large registries. The planning of a reoperation is no different from the basic principles for the first intervention. Diagnosis and differential diagnoses must be checked. This is followed by a review of the first operation and the associated histology as well as imaging and the course of parathyroid hormone (PTH) values. The next step is to check whether the reoperation is necessary. Most patients still have comprehensible indications that correspond to the guidelines and also ex-post. In contrast to the first intervention, there is always a need to attempt to localize the NSDA. The first procedure is a surgically performed ultrasound. Other localization options are MIBI-SPECT scintigraphy, 4D-CT and FEC-PET-CT, with the latter having the highest sensitivity. There is a clear relationship between higher case numbers and better surgical outcomes. Personal experience is decisive and in terms of predicting success this is even more important than the results of localization procedures. The goal of maximizing the outcome and minimizing morbidity justifies what is from the perspective of those affected probably the most important requirement for the future: no redo surgery for HPT outside of a high-volume center.

[Surgical Treatment of Esophageal Cancer-New Technologies, Modern Concepts]

Das Ösophaguskarzinom wird in Deutschland meist in spezialisierten Zentren entsprechend den Leitlinien multimodal und interdisziplinär therapiert. In den kommenden Jahren wird die Zentralisierung der Ösophaguschirurgie in Deutschland durch die Festlegung neuer Mindestmengen weiter voranschreiten. Dieser Artikel soll neue Technologien für die chirurgische Therapie des Ösophaguskarzinoms und zudem aktuelle onkologische Konzepte aus der Sicht eines High-volume-Centers vorstellen.

[Surgical treatment of esophageal cancer-New technologies, modern concepts]

In Germany esophageal cancer is mostly treated in specialized centers according to national and international guidelines in a multimodal and interdisciplinary setting. In the next few years centralization of esophageal surgery will continue in Germany due to new national regulations on minimum case volumes. This article highlights new technologies for surgical treatment of esophageal cancer and also depicts the current oncological concepts from the perspective of a high-volume center.

Socio-economic factors do not affect overall survival in soft tissue sarcoma when patients treated at a single high-volume center

BACKGROUND

Treatments for soft tissue sarcoma (STS) include extensive surgical resection, radiation and chemotherapy, and can necessitate specialized care and excellent social support. Studies have demonstrated that socioeconomic factors, such as income, marital status, urban/rural residence, and educational attainment as well as treatment at high-volume institution may be associated with overall survival (OS) in STS.

METHODS

In order to explore the effect of socio-economic factors on OS in patients treated at a high-volume center, we performed a retrospective analysis of STS patients treated at a single institution.

RESULTS

Overall, 435 patients were included. Thirty-seven percent had grade 3 tumors and 44% had disease larger than 5 cm. Patients were most commonly privately insured (38%), married (67%) and retired or unemployed (43%). Median distance from the treatment center was 42 miles and median area deprivation index (ADI) was 5 (10 representing most deprived communities). The majority of patients (52%) were treated with neoadjuvant therapy followed by resection. As expected, higher tumor grade (HR 3.1), tumor size > 5 cm (HR 1.3), and involved lymph nodes (HR 3.2) were significantly associated with OS on multivariate analysis. Demographic and socioeconomic factors, including sex, age at diagnosis, marital status, employment status, urban vs. rural location, income, education, distance to the treatment center, and ADI were not associated with OS.

CONCLUSIONS

In contrast to prior studies, we did not identify a significant association between socioeconomic factors and OS of patients with STS when patients were treated at a single high-volume center. Treatment at a high volume institution may mitigate the importance of socio-economic factors in the OS of STS.

Locally Advanced Oral Tongue Cancer: Is Organ Preservation a Safe Option in Resource-Limited High-Volume Setting?

Background

Oral tongue is found to be the most common intraoral subsite with worse prognosis despite the use of multimodality treatments. Extensive resections have resulted in loss of form and function of tongue in advanced tumors. The objective of the study was to analyze the role of induction chemotherapy (IC) in intermediate to advanced staged oral tongue cancer for organ preservation and survival outcome in a developing country.

Materials and Methods

The records of oral tongue cancer patients treated from 2007 to 2016 were retrospectively analyzed.

Results

Eighty-one oral tongue cancer patients with advanced stage were treated using induction arm in 10 years. The median follow-up was 24 months with 3- and 5-year survival of 77% and 58%, respectively. IC has an overall response in 87% of the patients at primary site. The chemotherapy has completely resolved the nodal disease in 17% of the patients, but 23% of the patients had failed to respond. Only 21% of the patients received reconstruction using local or regional flaps.

Conclusion

IC has shown encouraging results in advanced staged oral tongue cancers with function preservation and improved survival outcome in less privileged high-volume centers.

Twelve-Year Experience with Roux-en-Y Gastric Bypass as a Conversional Procedure for Vertical Banded Gastroplasty: Are We on the Right Track?

BACKGROUND

Vertical banded gastroplasty (VBG) has high rates of long-term complications. Conversion to Roux-en-Y gastric bypass (RYGB) is considered optimal; however, there are limited data on the late results of these conversions. We aimed to analyze our single-center long-term outcomes of patients requiring conversional RYGB for a failed VBG.

METHODS

The records of patients who underwent RYGB as a conversional procedure after VBG from November 2004 to December 2016 were reviewed. Follow-up data were obtained by direct telephone calls with patients, electronic files, and general practitioner reports. Characteristics, indications of conversion, long-term (> 30 days) morbidities, weight records, obesity-related comorbidities, and overall patient satisfaction were analyzed.

RESULTS

Overall, 305 VBG patients (82% female) underwent conversional RYGB during the study period. The mean pre-RYGB body mass index (BMI) was 35.6 (23-66) kg/m². Conversions were indicated in 61% of patients because of simultaneous VBG complications and weight regain. After a median follow-up of 74.3 (5-151) months, 225 (73.8%) patients agreed to participate. The mean BMI and percentage of total weight loss (%TWL) were 28.6 (18-45) kg/m² and 17.4%, respectively. Nearly all conversion indications were addressed effectively. Surgical reintervention was mandatory in 28 of 225 patients (12.4%) due to complications. Approximately 85% of patients reported complete remission of obesity-related comorbidities, and four-fifths were fully satisfied.

CONCLUSION

RYGB resolves VBG complications, improves quality of life, and results in prolonged stable weight loss. It has a key role in the management of obesity-related comorbidities and in expert hands is the preferred conversional procedure for patients with failed VBG.

Conversion of both Versions of Vertical Banded Gastroplasty to Laparoscopic Roux-en-Y Gastric Bypass: Analysis of Short-term Outcomes

BACKGROUND

Conversional bariatric surgery has relatively high rates of complications. We aimed to analyze our single-center experience with patients requiring conversional laparoscopic Roux-en-Y gastric bypass (LRYGB) following a failed primary open or laparoscopic vertical banded gastroplasty (OVBG or LVBG, respectively).

METHODS

The records of patients who underwent LRYGB as a conversional procedure after VBG between November 2004 and December 2017 were reviewed. Characteristics, body mass index (BMI), operation time, intraoperative problems, length of hospitalization, and early (< 30 days) morbidity and mortality were analyzed. Data were expressed as mean ± standard deviation or frequency.

RESULTS

A total of 329 patients (81.76% females) who underwent conversional RYGB were included. For the LVBG group (224 patients) and OVBG group (105 patients), respectively, BMI was 34.15 ± 6.38 and 37.79 ± 6.31 kg/m2 (p < 0.05), the operation time was 96.00 ± 31.40 and 123.15 ± 40.26 min (p < 0.05), hospitalization duration was 2.96 ± 1.13 and 3.20 ± 1.20 days (p = 0.08), the early complication rate was 7.14 and 11.43% (p = 0.19), and the reoperation rate was 2.23 and 2.86% (p = 0.73). There were no major intraoperative problems. Three patients with OVBG were converted to open RYGB (2.86%). There was no mortality.

CONCLUSION

The conversion of OVBG and LVBG to laparoscopic RYGB is technically feasible and provides comparably low early morbidity rates and length of hospitalization. However, compared to LVBG, conversional laparoscopic RYGB following OVBG is technically more challenging and time-consuming, with a slightly higher risk of conversion to open surgery. We support the use of such conversional bariatric surgery in specialized, high-volume bariatric centers.

Surgical management of pediatric thyroid disease: Complication rates after thyroidectomy at the Children's Hospital of Philadelphia high-volume Pediatric Thyroid Center

BACKGROUND

Recent studies suggest improved outcomes for children undergoing thyroidectomy at high-volume pediatric surgery centers. We present outcomes after thyroid surgery at a single center and advocate for referral to high-volume centers for multidisciplinary management of these children.

METHODS

Medical records were reviewed for all pediatric patients undergoing thyroid surgery at a single institution from 2009 through 2017. Routine recurrent laryngeal nerve and parathyroid hormone monitoring was used. Lymph node dissections were performed in appropriately selected cancer patients. Data collection focused on pathologic diagnosis, surgical technique, and surgical complications, including postoperative hematoma, neurapraxia, permanent nerve damage, hypocalcemia, and transient and permanent hypoparathyroidism.

RESULTS

From 2009 through 2017, 464 patients underwent thyroid surgery. Median age of the cohort was 15 years (range 2-24). Thirty-three percent were diagnosed with benign nodules (n=151), 36% with papillary or follicular thyroid cancer (n=168), 27% with Graves' disease (n=124), 3% with medullary thyroid cancer (n=14), and 1.5% underwent prophylactic thyroidectomy for MEN2a (n=7). Six patients required return to the OR for hematoma evacuation including 5 patients after surgery for Graves' disease (RR 8.7, 95% CI 1.06-71.85). In sixteen cases, concern about neurapraxia resulted in laryngoscopy, revealing eleven patients with vocal cord paresis. Two of these patients demonstrated a persistent deficit at 6 months postoperatively (0.4%). Thirty-seven percent of patients had transient hypoparathyroidism (n=137), and two patients had persistent hypoparathyroidism 6 months after total thyroidectomy (0.6%). There was no significant difference in either hypocalcemia or hypoparathyroidism after total thyroidectomy based on age or diagnosis.

CONCLUSIONS

Characterizing outcomes for pediatric patients based on diagnosis will assist in preoperative counseling for patients and their families. This high-volume center reports low complication rates after pediatric thyroid surgery, highlighting that referral to high-volume centers should be considered for children and adolescents with thyroid disease requiring surgery.

LEVEL OF EVIDENCE

Level IV.

Strengths, Weaknesses, Opportunities, and Threats of Centralized Pancreatic Surgery: a Single-Center Analysis of 3000 Consecutive Pancreatic Resections

BACKGROUND

Pancreatic surgery at high-volume centers has undergone major changes over the last decades. However, the quality of surgery remains to be considered as one important factor for achieving long-term survival especially in patients at advanced stages of disease.

METHODS

Between January 1990 and June 2017, 3000 consecutive patients have undergone pancreatic resections at our institution. Relevant postoperative data and histopathological findings as well as overall survival were analyzed. In addition, a SWOT (strengths, weaknesses, opportunities, threats) analysis of pancreatic surgery at high-volume centers was performed.

RESULTS

A total of 2218 pancreatic head resections (74%), 494 distal pancreatectomies (16%), 200 total pancreatectomies (7%), and 88 other resections (3%) were performed within our study period. Despite additional vascular resections in 265 patients (9%) and additional liver resections in 167 patients (6%), overall perioperative mortality did not exceed 3%. Overall survival strongly depended on the underlying disease, as well as on lymph node stage (p = < 0.001) and surgical radicality (p = < 0.001).

CONCLUSIONS

The decentralization of pancreatic surgery over the last decades has led to a focus on high-volume centers to perform extended procedures in complex patients. The present SWOT analysis underlines the significance of a centralization of pancreatic surgery for patient safety and to increase the chance of long-term survival.

Safety-related outcomes of the Japanese Society of Hepato-Biliary-Pancreatic Surgery board certification system for expert surgeons

BACKGROUND

We investigated safety-related outcomes of hepatobiliary pancreatic (HBP) surgeries performed after establishment of the Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHBPS) board certification system for expert surgeons.

METHODS

We analyzed post-HBP surgery mortality data obtained from annual safety reports provided by board-certified training institutions between 2012 and 2015.

RESULTS

The 90-day mortality rate for the 53,929 high-level HBP surgeries performed at board-certified training institutions was 1.7%. The 30-day mortality rates for 2012, 2013, 2014, and 2015 were 0.9%, 0.7%, 0.6%, and 0.6%, respectively, and the 90-day mortality rates were 2.1%, 1.8%, 1.6%, and 1.3%, respectively, with significant decreases in both. The surgeries with high 4-year cumulative mortality rates were left hepatic trisectionectomy (10.3%), hepatopancreatectomy (7.6%), liver transplant recipient surgery (6.7%), hepatectomy with extrahepatic bile duct resection (4.6%), and right hepatic trisectionectomy (4.5%). Over the 4-year period, the number of operations increased, but the 90-day mortality rates for these surgeries, with the exception of right trisectionectomy, decreased.

CONCLUSIONS

The JSHBPS board certification system for expert surgeons has significantly decreased mortality subsequent to high-level HBP surgeries. Reducing mortality associated with high-risk HBP surgeries will be our next challenge.

Influence of high- and low-volume liver surgery in gallbladder carcinoma

AIM: To clarify whether the performance of liver resections (LR) for incidental gallbladder carcinoma (IGBC)’s depends more on the experience of the hospitals in liver surgery than on complying with the guidelines in Germany.

METHODS: For data analysis, we used the Surgical Association of Endoscopy and Ultrasound and Minimally Invasive Surgery Central Registry of “IGBC” of the German Society of Surgery (the German Registry). In 2010, we started a second form by requesting the frequency of LR at the various hospitals in Germany. The indication for LR was irrelevant. The aim was to determine the overall frequency of liver resections at the hospitals. We divided the hospitals according to their experience in liver surgery into high- (HV), mid- (MV), and low-volume (LV) LR hospitals.

RESULTS: This study includes 487 IGBC’s from 167 centers. There were 36 high-volume, 32 mid-volume, and 99 low-volume centers. In the high-volume centers, the mean (range) number of liver resections was 101 (40-300). In the mid-volume centers, the mean (range) number of liver resections was 26 (20-39). In the low-volume centers, the mean (range) number of liver resections was 6.5 (0-19) (P < 0.001). LV’s perform LR for T2-3 gallbladder carcinomas significantly less often than high-volume or mid-volume centers (χ² = 13.78, P = 0.001). In HV’s and MV’s, 61% of the patients with an indication for liver resection underwent LR, but in LV centers, only 41% with an indication for LR underwent LR (P < 0.001). In cases of T1b carcinomas, LR was performed significantly more often in HV’s (P = 0.009).

CONCLUSION: The central problem is that the performance of the required liver resection in IGBC in Germany depends on the hospital experience in liver surgery and not on the recommendations of the German guidelines.