Background Laparoscopic gastrectomy could reduce pain and opioid consumption, compared to open gastrectomy. However, it is difficult to judge the clinical relevance of this reduction, since these... Show moreBackground Laparoscopic gastrectomy could reduce pain and opioid consumption, compared to open gastrectomy. However, it is difficult to judge the clinical relevance of this reduction, since these outcomes are reported in few randomized trials and in limited detail.Methods This secondary analysis of a multicenter randomized trial compared laparoscopic versus open gastrectomy for resectable gastric adenocarcinoma (cT1-4aN0-3bM0). Postoperative pain was analyzed by opioid consumption in oral morphine equivalents (OME, mg/day) at postoperative day (POD) 1-5, WHO analgesic steps, and Numeric Rating Scales (NRS, 0-10) at POD 1-10 and discharge. Regression and mixed model analyses were performed, with and without correction for epidural analgesia.Results Between 2015 and 2018, 115 patients in the laparoscopic group and 110 in the open group underwent surgery. Some 16 patients (14%) in the laparoscopic group and 73 patients (66%) in the open group received epidural analgesia. At POD 1-3, mean opioid consumption was 131, 118, and 53 mg OME lower in the laparoscopic group, compared to the open group, respectively (all p < 0.001). After correcting for epidural analgesia, these differences remained significant at POD 1-2 (47 mg OME, p = 0.002 and 69 mg OME, p < 0.001, respectively). At discharge, 27% of patients in the laparoscopic group and 43% patients in the open group used oral opioids (p = 0.006). Mean highest daily pain scores were between 2 and 4 at all PODs, < 2 at discharge, and did not relevantly differ between treatment arms.Conclusion In this multicenter randomized trial, postoperative pain was comparable between laparoscopic and open gastrectomy. After laparoscopic gastrectomy, this was generally achieved without epidural analgesia and with fewer opioids. Show less
Ozmen, I.; Grupa, V.E.M.; Bedrikovetski, S.; Dudi-Venkata, N.N.; Huisman, D.E.; Reudink, M.; ... ; LekCheck Study Grp 2022
Purpose Anastomotic leakage (AL) is a dreaded complication after colorectal surgery. Preoperatively identifying high-risk patients can help to reduce the incidence of this complication. For this... Show morePurpose Anastomotic leakage (AL) is a dreaded complication after colorectal surgery. Preoperatively identifying high-risk patients can help to reduce the incidence of this complication. For this reason, AL risk nomograms have been developed. The objective of this study was to test the AL risk nomogram developed by Frasson, et al. for validity and to identify risk-factors for AL. Methods From the international multi-center LekCheck study database, patients who underwent colonic surgery with the formation of an anastomosis were included. Data were prospectively collected between 2016 and 2019 at 14 hospitals. Univariate and multivariable regression analyses, and area under receiver operating characteristic curve analysis (AUROC) were performed. Results A total of 643 patients were included. The median age was 70 years and 51% were male. The majority underwent surgery for malignancies (80.7%). The overall AL rate was 9.2%. The risk nomogram was not predictive for AL in the population tested (AUROC 0.572). Low preoperative haemoglobin (p = 0.006), intraoperative hypothermia (p = 0.02), contamination of the operative field (p = 0.004), and use of epidural analgesia (p = 0.02) were independent risk-factors for AL. Conclusion The AL risk nomogram could not be validated using the international LekCheck study database. In the future, intraoperative predictive factors for AL, as identified in this study, should also be included in AL risk predictors. Show less
Background Synchronous colorectal cancer (CRC) has been associated with higher postoperative morbidity and mortality rates compared to solitary CRC. The influence of improved CRC care and... Show moreBackground Synchronous colorectal cancer (CRC) has been associated with higher postoperative morbidity and mortality rates compared to solitary CRC. The influence of improved CRC care and introduction of screening on these outcomes remains unknown. This study aimed to evaluate time trends in incidence, population characteristics, and short-term outcomes of synchronous CRC patients at the population level over a 10-year time period. Methods Data of all patients that underwent resection for primary CRC were extracted from the Dutch ColoRectal Audit (2010-2019). Analyses were stratified for solitary and synchronous colon and rectal cancer. Multilevel logistic regression analyses were used to determine factors associated with pathological and surgical outcomes. Results Among 100,474 patients, 3.1% underwent surgery for synchronous CRC. A screening-related decrease for surgically treated left-sided solitary and synchronous colon cancer and a temporary increase for exclusively right-sided colon cancer were observed. Synchronous CRC patients had higher rates of complicated postoperative course, failure to rescue, and mortality. Bilateral synchronous colon cancer was more often treated with subtotal colectomy (25.4%) and demonstrated higher rates of surgical complications, reinterventions, prolonged hospital stay, and mortality than other synchronous tumor locations. Discussion National bowel screening resulted in contradictory effects on surgical resections for synchronous CRCs depending on sidedness. Bilateral synchronous colon cancer required more often extended resection resulting in significantly worse outcomes than other synchronous tumor locations. Identification of low volume, high complex CRC subpopulations is relevant for individualized care and has implications for case-mix correction and benchmarking in clinical auditing. Show less
Werf, L.R. van der; Eshuis, W.J.; Draaisma, W.A.; Etten, B. van; Gisbertz, S.S.; Harst, E. van der; ... ; Dutch Upper Gastrointestinal Canc 2019
Background Radical gastrectomy is the cornerstone of the treatment of gastric cancer. For tumors invading the pancreas, en-bloc partial pancreatectomy may be needed for a radical resection. The aim... Show moreBackground Radical gastrectomy is the cornerstone of the treatment of gastric cancer. For tumors invading the pancreas, en-bloc partial pancreatectomy may be needed for a radical resection. The aim of this study was to evaluate the outcome of gastrectomies with partial pancreatectomy for gastric cancer.Methods Patients who underwent gastrectomy with or without partial pancreatectomy for gastric or gastro-oesophageal junction cancer between 2011 and 2015 were selected from the Dutch Upper GI Cancer Audit (DUCA). Outcomes were resection margin (pR0) and Clavien-Dindo grade >= III postoperative complications and survival. The association between partial pancreatectomy and postoperative complications was analyzed with multivariable logistic regression. Overall survival of patients with partial pancreatectomy was estimated using the Kaplan-Meier method.Results Of 1966 patients that underwent gastrectomy, 55 patients (2.8%) underwent en-bloc partial pancreatectomy. A pR0 resection was achieved in 45 of 55 patients (82% versus 85% in the group without additional resection, P = 0.82). Clavien-Dindo grade = III complications occurred in 21 of 55 patients (38% versus 17%, P < 0.001). Median overall survival [95% confidence interval] was 15 [6.8-23.2] months. For patients with and without perioperative systemic therapy, median survival was 20 [12.3-27.7] and 10 [5.7-14.3] months, and for patients with pR0 and pR1 resection, it was 20 [11.8-28.3] and 5 [2.4-7.6] months, respectively.Conclusions Gastrectomy with partial pancreatectomy is not only associated with a pR0 resection rate of 82% but also with increased postoperative morbidity. It should only be performed if a pR0 resection is feasible. Show less
Background The use of epidural analgesia (EA) in pancreatic surgery remains under debate. This study compares patients treated with EA versus non-EA after open pancreatectomy in a tertiary referral... Show moreBackground The use of epidural analgesia (EA) in pancreatic surgery remains under debate. This study compares patients treated with EA versus non-EA after open pancreatectomy in a tertiary referral center.Methods All patients undergoing open pancreatectomy from 2013 to 2017 were retrospectively reviewed. (Non-)EA was terminated on postoperative day (POD) 3 or earlier if required.Results In total, 190 (72.5%) patients received EA and 72 (27.5%) patients received non-EA (mostly intravenous morphine). EA was terminated prematurely in 32.6% of patients and non-EA in 10.5% of patients. Compared with non-EA patients, EA patients had significantly lower pain scores on POD 0 (1.10 (0-3.00) versus 3.00 (1.67-5.00), P < 0.001) and POD 1 (2.00 (0.50-3.41) versus 3.00 (2.00-3.80), P = 0.001), though significantly higher pain scores on POD 3 (3.00 (2.00-4.00) versus 2.33 (1.50-4.00), P < 0.001) and POD 4 (2.50 (1.50-3.67) versus 2.00 (0.50-3.00), P = 0.007). EA patients required more vasoactive medication perioperatively and had higher cumulative fluid balances on POD 1-3. Postoperative complications were similar between groups.Conclusions In our cohort, patients with EA experienced significantly lower pain scores in the first PODs compared with nonEA, yet higher pain scores after EA had been terminated. Although EA patients required more vasoactive medication and fluid therapy, the complication rate was similar. Show less
IntroductionGastric cancer is decreasing nationally but remains pervasive globally. We evaluated our experience with gastric cancer at a safety-net hospital with a substantial immigrant population... Show moreIntroductionGastric cancer is decreasing nationally but remains pervasive globally. We evaluated our experience with gastric cancer at a safety-net hospital with a substantial immigrant population.MethodsDemographics, pathology, and treatment were analyzed for gastric adenocarcinoma at our institution (2004–2017). Chi-square analyses were performed for dependence of staging on demographics. Survival was evaluated with Kaplan-Meier and Cox regression analyses.ResultsWe identified 249 patients (median age 65 years). Patients were predominantly born outside the USA or Canada (74.3%), non-white (70.7%), and federally insured (71.4%), and presented with late-stage disease (52.2%). Hispanic ethnicity, Central American birthplace, Medicaid insurance, and zip code poverty > 20% were associated with late-stage presentation (all p < 0.05). Univariate analyses showed decreased survival for patients with late-stage disease, highest zip code poverty, and age ≥ 65 (all p < 0.05). On multivariate analysis, survival was negatively associated with late-stage presentation (HR 4.45, p < 0.001), age ≥ 65 (1.80, p = 0.018), and H. pylori infection (2.02, p = 0.036).ConclusionHispanic ethnicity, Central American birthplace, Medicaid insurance, and increased neighborhood poverty were associated with late-stage presentation of gastric cancer with poor outcomes. Further study of these populations may lead to screening protocols in order to increase earlier detection and improve survival. Show less
