Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

Phosphorous and sulfur nutrition modulate antioxidant defenses in Myracrodruom urundeuva plants exposed to arsenic

We investigated if plant nutrition and antioxidant system activation are correlated features of arsenic (As)-tolerance in Myracrodruom urundeuva. Plants were grown for 120 days in substrates with 0, 10, 50 and 100mg Askg(-1) and its As-tolerance was demonstrated. As-concentrations greater than 10mgkg(-1) decreased plant growth and photosynthesis but did not induce plant death. Plants coupled alterations in stomatal conductance and transpiration to avoid As-deleterious effects to the photosynthetic apparatus. As-toxicity in M. urundeuva was due to lipid peroxidation induced by hydrogen peroxide accumulation. Ascorbate peroxidase (APX) and gluthatione peroxidase (GPX) had central roles in hydrogen peroxide (H2O2) scavenging in leaves, and their activities were linked to changes in redox potentials (ascorbate and glutathione pools). APX and GPX inactivation/degeneration led to H2O2 accumulation and related lipid peroxidation. Increased phosphorus (P) and sulfur (S) concentrations in leaves were related to increased APX and GPX activities by stimulating increases in glutathione biosynthesis. We concluded that P and S nutrition were directly linked to As-tolerance in M. urundeuva plants by increasing antioxidant system activities.

Bivalirudin for the treatment of patients with confirmed or suspected heparin-induced thrombocytopenia

BACKGROUND

Heparin-induced thrombocytopenia (HIT) is an adverse immune-mediated response to unfractionated heparin and, less commonly, low molecular weight heparin. It is associated with a high thrombotic risk and the potential for limb and life-threatening complications. Argatroban is the only approved and currently available anticoagulant for HIT treatment in the USA.

OBJECTIVES

To report safety and efficacy outcomes with bivalirudin for HIT treatment.

METHODS

We retrospectively examined records from our registry of patients with a suspected, confirmed or previous history of HIT and who had received bivalirudin for anticoagulation in a single tertiary-care center over a 9-year period.

RESULTS

We identified 461 patients who received bivalirudin: 220 (47.7%) were surgical patients, and 241 (52.3%) were medical patients. Of this population, 107 (23.2%) were critically ill, and 109 (23.6%) were dialysis-dependent. Suspected, confirmed and previous history of HIT were reported in 262, 124 and 75 patients, respectively. Of 386 patients with suspected or confirmed HIT, 223 patients (57.8%) had thrombosis at HIT diagnosis. New thrombosis was identified in 21 patients (4.6%) while they were on treatment with therapeutic doses of bivalirudin. No patient required HIT-related amputation. Major bleeding occurred in 35 patients (7.6%). We found a significant increase in major bleeding risk in the critically ill population (13.1%; odds ratio 2.4, 95% confidence interval 1.2-4.9, P = 0.014). The 30-day all-cause mortality rate was 14.5% (67 patients), and eight of 67 (1.7%) deaths were HIT-related.

CONCLUSION

Bivalirudin may be an effective and safe alternative option for the treatment of both suspected and confirmed HIT, and appears to reduce the rate of HIT-related amputation.

Zinc tolerance modulation in Myracrodruon urundeuva plants

We investigated Zn tolerance and related tolerance mechanisms of Myracrodruon urundeuva by evaluating the growth (biomass production, pigment content, and photosynthetic activity) and antioxidant systems (redox potential and antioxidant enzyme activities) of seedlings exposed to increasing Zn doses. Plants were grown for 120 days in substrates with 0, 50, 80, 120 and 200 mg Zn kg(-1) and demonstrated Zn-tolerance. Zn doses greater than 80 mg Zn kg(-1) were phytotoxic but not lethal, and Zn toxicity under these conditions was imposed by oxidative stress caused by hydrogen peroxide (H2O2) accumulation and related lipid peroxidation. Zn tolerance in M. urundeuva is linked to the activity of antioxidant systems in their leaves that are modulated by that metal: both superoxide dismutase (SOD) and catalase (CAT) were always higher in the presence of Zn; lower Zn doses stimulated ascorbate peroxidase (APX) and glutathione reductase (GR) activities, but enzyme activity was inhibited at high doses; APX appeared to be the main peroxidase in H2O2 scavenging as stimulated guaiacol peroxidase (GPX) activity was not sufficient to avoid H2O2 accumulation at higher Zn doses; the modulation of APX and GR activities was linked to changes in the redox status of leaves.

Phosphorus improves arsenic phytoremediation by Anadenanthera peregrina by alleviating induced oxidative stress

Due to similarities in their chemical behaviors, studies examining interactions between arsenic (As)--in special arsenate--and phosphorus (P) are important for better understanding arsenate uptake, toxicity, and accumulation in plants. We evaluated the effects of phosphate addition on plant biomass and on arsenate and phosphate uptake by Anadenanthera peregrina, an important Brazilian savanna legume. Plants were grown for 35 days in substrates that received combinations of 0, 10, 50, and 100 mg kg(-1) arsenate and 0, 200, and 400 mg kg(-1) phosphate. The addition of P increased the arsenic-phytoremediation capacity of A. peregrina by increasing As accumulation, while also alleviating As-induced oxidative stress. Arsenate phytotoxicity in A. peregrina is due to lipid peroxidation, but not hydrogen peroxide accumulation. Added P also increased the activity of important reactive oxygen species-scavenging enzymes (catalase and ascorbate peroxidase) that help prevent lipid peroxidation in leaves. Our findings suggest that applying P represents a feasible strategy for more efficient As phytoremediation using A. peregrina.

Threshold photoelectron spectroscopy of ozone

Threshold photoelectron spectrum of ozone is presented for the first time at a resolution of 21-38 meV using synchrotron radiation in the energy region of 12-21 eV. The ionization energies of the first ionized states were determined and an interpretation of the O3 spectrum with respect to its first three ionic states, 1 2A1, 1 2B2, and 1 2A2, is presented. Above 16 eV the enhancement of the intensities of the 2 2B1, 3 2A1, and 4 2B2 band systems due to the contribution of indirect processes was observed, not accessible by conventional photoelectron spectroscopy. It was also resolved and assigned the extensive vibrational structures of ozone. Between 15.5 and 18.5 eV the main band contours are similar to those found in conventional photoelectron spectroscopy, except that our threshold photoelectron spectrum reveals extensive additional vibrational structures. The band 2 2B1 was found to present an irregular vibrational spacing DeltaE, with a minimum value of 80 meV at approximately 16.47 eV.

Mercury content in shark species from the South-Eastern Brazilian coast

We present here the first results of Hg concentrations in three small shark species (Rhizoprionodon lalandei, R. porosus and Mustelus higmani) from the SE Brazilian coast. Mercury concentrations in R. lalandei ranged from 21.5 to 280.0 ng.g-1 dry weight (d.w.) (average 74.6 ng.g-1 d.w.; 17.9 ng.g-1 wet weight). In R. porosus, concentrations ranged from 7.6 to 90.5 ng.g-1 d.w. (average 42.2 ng.g-1 d.w., 9.4 ng.g-1 wet weight), whereas in M. higmani, concentrations ranged from 13.0 to 162.8 ng.g-1 d.w. (average 54.9 ng.g-1 d.w., 13.4 ng.g-1 wet weight). These concentration ranges are very low compared with values reported for other large shark species of the Southwestern Atlantic Ocean. There was a significant positive correlation between Hg concentrations and individual size, suggesting that biomagnification is occurring in these animals.

A computer-assisted training/monitoring system for TURP structure and design

A generic framework for a computer-assisted system for both soft tissue endoscopic surgery and surgical training is being researched and developed. The concept demonstrator is a specific system for transurethral prostatic resection (TURP). The main novelty of the research is that it is not confined to an in vitro trainer system. An in vivo monitoring version of the system, for use in the operating theater, is also being researched. This paper presents the framework's structure and design using the United Modeling Language. It also discusses and justifies the underlying information technologies chosen to implement this approach. Object-oriented concepts and well-proven mathematical tools have been adopted as the foundation of this research and development. The rationale for having chosen such tools is presented. The objectives are to arrive at a system which is modular, general, and reusable.

Regional odontodysplasia: report of a case involving two separate affected areas

The purpose of this study was to report in a 12-year old white child a rare clinical condition called regional odontodysplasia. The diagnosis was based on clinical and radiographic findings. Due to the patient's concern over appearance, the treatment involved extracting the affected teeth and subsequently placing partial removable prostheses, thus providing the patient better function and appearance. The teeth that were removed were examined histologically, both in routine preparation stained by hematoxyline and eosin, and in ground sections.

Asymptomatic perianal shedding of herpes simplex virus in patients with acquired immunodeficiency syndrome

OBJECTIVE

To determine the frequency of asymptomatic perianal shedding of herpes simplex virus (HSV) in adult patients with acquired immunodeficiency syndrome (AIDS).

DESIGN

Cross-sectional study.

SETTING

A 1000-bed, state-supported hospital in Brazil that provides comprehensive health care.

PATIENTS

Eighty-two consecutively hospitalized patients with AIDS (Centers for Disease Control and Prevention class C).

MAIN OUTCOME MEASUREMENT

Specimens for HSV culture were obtained with premoistened swabs of the perianal region at approximately 7-day intervals during the hospitalization of each patient. After the specimens were inoculated into cultures of human foreskin and Vero cells, supernatants of cultures showing the cytopathic effect characteristic of HSV infection were tested for virus in a confirmatory immunoenzymatic assay. Typing of HSV was performed by polymerase chain reaction amplification of HSV-1- and HSV-2-specific DNA polymerase sequences.

RESULTS

On early into the study, 12 (15%) of 82 patients had perianal ulceration and 70 did not. None of the patients in the latter group developed perianal ulcers during the study period, but HSV was isolated at least once from 17 (24%) of them. Nine of the 17 asymptomatic perianal shedders had a mean of 3 perianal swabs collected before the first HSV isolation, and 11 (65%) of 17 had a total of 18 perianal swabs collected 8 to 62 days after the HSV isolation. All postpositive samples were negative for HSV except 1 obtained from a patient 13 days after the first positive sample. Twelve of the 17 asymptomatic perianal shedders of HSV were followed up clinically for 8 to 62 days after the first episode of shedding and none developed perianal ulceration.

CONCLUSIONS

We conclude that asymptomatic perianal shedding of HSV is common in patients with AIDS, even among those without a history of perianal HSV lesions. This shedding appears to be short-lived, intermittent, and not associated with early subsequent development of perianal ulcers. These findings present a new perspective on the natural course of perianal HSV infection in patients with AIDS.

Beta-thalassemia mutations in the Portuguese population

In this study we have carried out haplotype analysis on the beta-globin gene cluster and characterized the beta-thalassemia mutation by oligonucleotide hybridization in 14 patients with thalassemia major and 5 with sickle cell/beta-thalassemia originating from southern Portugal. We found that three mutations, namely the beta(0)-39, beta(0) IVS-1 nt 1 and beta(+) IVS-1 nt 110 are prevalent accounting for 53%, 32% and 10% of the beta-thalassemia chromosomes respectively. In general each mutation was associated with a specific chromosomal haplotype; the beta(0)-39 mutation, however, was linked to three different haplotypes. These results indicate that three oligo-probes complementary to the most common mutations allow prenatal diagnosis by oligonucleotide analysis in 96% of the couples at risk of having offspring with thalassemia major in southern Portugal.

Familial inv(1)(p36.3q12) associated with sterility

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