The State of Research and Development in Global Cancer Surgery.
Ann Surg. 2012 Jan 24;
Authors: Purushotham AD, Lewison G, Sullivan R
Abstract
OBJECTIVE:: The objective of this study was to perform an analysis of global cancer surgery research and development trends over the last 10 years across 21 countries. BACKGROUND:: Surgery is the main modality for cancer cure and control globally. Yet, in comparison to other areas such as cancer drugs, we know little about ongoing research activities to inform policymakers. METHODS:: Two subfield filters, surgery research and oncology, were developed and applied to Web of Science. The intersection of these 2 filters identified papers in surgical oncology, and their bibliographic details were downloaded for analysis. This included matching of 5-year citation counts to the papers, impact factor, geographical analysis by country, translational collaboration, involvement in clinical trials, citation on clinical guidelines, and percentage of reviews. RESULT:: Surgical oncology represents about 9% of all cancer research-low in comparison with surgery’s contribution to cancer treatment. The US published the most, followed by Japan which had a high relative commitment to surgery within cancer research, followed by the large West European countries. Although Sweden’s papers were relatively basic, it participated the most in clinical trials. Its papers were also the most cited on clinical guidelines, but contained relatively few reviews, where the UK, Greece, and Belgium scored best. Surgical oncology papers are generally not well cited compared with cancer research overall, but on this measure the Netherlands, the US, and Sweden scored best. International collaboration was measured relative to what might have been expected, on this indicator Canada, Switzerland, and the US were the best performers. CONCLUSIONS:: Globally, low activity-low funding cycle needs to be addressed by new national and supranational policies to support surgical oncology research.
PMID: 22281701 [PubMed - as supplied by publisher]
Morbidity Risk Factors After Low Anterior Resection With Total Mesorectal Excision and Coloanal Anastomosis: Retrospective Series of 483 Patients.
Ann Surg. 2012 Jan 26;
Authors: Bennis M, Parc Y, Lefevre JH, Chafai N, Attal E, Tiret E
Abstract
OBJECTIVE:: To report postoperative morbidity after low anterior resection (LAR) and coloanal anastomosis (CAA) for rectal cancer and identify possible risk factors of complications. BACKGROUND:: Coloanal anastomosis after total mesorectal excision (TME) is associated with significant morbidity. Precise data on the specific morbidity and the risk factors are lacking. METHODS:: We analyzed retrospectively 483 consecutive LARs with TME and CAA carried out in a single center between 1996 and 2005. All complications occurring up to 3 months after LAR and up to 3 months after closure of the diverting stoma were graded according to the Dindo classification. RESULTS:: Of 483 patients, 164 (33.9%) suffered at least 1 complication, leading to death in 2 (0.4%) patients. Grade III/IV complications occurred in 69 of 483 (14.2%) patients. Thirty-four (7.0%) patients developed leakage of the CAA and 3 patients had leakage of the small bowel anastomosis after stoma closure. Ileostomy closure was carried out after a mean of 88.7 days (36-630) after LAR. The stoma was not closed in 4 of 456 (0.6%) patients. In multivariate analysis, male sex (P = 0.0216) and postoperative transfusion (P = 0.0025) were associated with complications. Medical complications were furthermore associated with previous thrombembolic events (P = 0.0012) and associated surgery at the time of LAR (P = 0.0010). Circumferential tumor localization was predictive of surgical complications (P = 0.0015). The only factor associated with a risk of leakage was transfusion (P = 0.0216). CONCLUSIONS:: In this series morbidity occurred in 34% and dehiscence of the CAA in 7.0%. Transfusion requirement was an independent risk factor for postoperative complications and anastomotic leakage.
PMID: 22281734 [PubMed - as supplied by publisher]
OBJECTIVE:: To assess whether semiquantitative terms (eg, “often” or “rare”), which are often used for achieving informed consent, have the same meaning for laypersons and physicians. BACKGROUND:: To obtain informed consent, physicians have to make their patients aware of the risks of an operation. Thereby, semiquantitative terms are often used. METHODS:: Questionnaire interview among surgeons and randomly approached laypersons. A set of semiquantitative terms was presented to participants for quantification. Pertinent to 8 exemplary complications of common operations, these values were compared among the 2 interviewed groups and corresponding rates in scientific literature. RESULTS:: The questionnaire was completed by 48 surgeons and 582 laypersons in Switzerland. Confronted with corresponding complication rates in literature, laypersons underestimated the risk significantly in 6 of 8 cases. After a simulated informed consent conversation with a surgeon by using semiquantitative terms, laypersons overestimated the complication rate significantly in 7 of 8 cases. An interaction analysis did not show any significant difference between correct estimations of complication rates of respondents who graduated, who had a professional medical background or who had had prior contact with the health care system (eg, medical consultation, hospitalization, operation) compared with the others. CONCLUSIONS:: Laypersons overestimate probabilities of semiquantitative terms named by surgeons. We recommend using “percentages” or “odds ratios” to achieve a more reliable preoperative informed consent.
PMID: 22281735 [PubMed - as supplied by publisher]
Isoflurane Post-conditioning Protects Against Intestinal Ischemia-Reperfusion Injury and Multiorgan Dysfunction via Transforming Growth Factor-β1 Generation.
Ann Surg. 2012 Jan 19;
Authors: Kim M, Park SW, Kim M, Dʼagati VD, Lee HT
Abstract
OBJECTIVE:: This study examined volatile anesthetic-mediated protection against intestinal ischemia-reperfusion injury (IRI). BACKGROUND:: Intestinal IRI is a devastating complication in the perioperative period leading to systemic inflammation and multiorgan dysfunction. Volatile anesthetics, including isoflurane, have anti-inflammatory effects. We aimed to determine whether isoflurane, given after intestinal ischemia, protects against intestinal IRI and the mechanisms involved in this protection. METHODS:: After IACUC approval, mice were anesthetized with pentobarbital and subjected to 30 minutes of superior mesenteric artery ischemia, followed by 4 hours of equianesthetic doses of pentobarbital or isoflurane. Five hours after reperfusion, small intestine tissues were analyzed for morphological injury, apoptosis, neutrophil infiltration, proinflammatory mRNAs, and TGF-(Transforming Growth Factor-)β1 levels. We also assessed hepatic and renal injury after intestinal IRI. RESULTS:: Intestinal IRI with pentobarbital led to significant small intestinal dysfunction with increased mucosal injury, TUNEL (transferase biotin-dUTP nick end-labeling)-positive cells, neutrophil infiltration, and proinflammatory mRNAs as well as elevated plasma alanine aminotransferase and creatinine levels. Isoflurane exposure after IRI led to significant attenuation of intestinal, hepatic, and renal injuries. Furthermore, the protective effects of isoflurane were abolished by treatment with a TGF-β1 neutralizing antibody before induction of IRI. Finally, isoflurane exposure led to increased TGF-β1 levels in intestinal epithelial cells and in plasma. CONCLUSIONS:: Our findings demonstrate that isoflurane post-conditioning protects against small intestinal injury and hepatic and renal dysfunction after severe intestinal IRI via induction of intestinal epithelial TGF-β1. Our findings support therapeutic applications of volatile anesthetics during the intraoperative and postoperative periods and imply an important role of TGF-β1 signaling in modulating multiorgan injury.
PMID: 22266638 [PubMed - as supplied by publisher]
Systematic Review of the Clinical Effectiveness of Wound-edge Protection Devices in Reducing Surgical Site Infection in Patients Undergoing Open Abdominal Surgery.
Ann Surg. 2012 Jan 20;
Authors: Gheorghe A, Calvert M, Pinkney TD, Fletcher BR, Bartlett DC, Hawkins WJ, Mak T, Youssef H, Wilson S
Abstract
OBJECTIVE:: Assess the existing evidence on the clinical effectiveness of wound-edge protection devices (WEPDs) in reducing the surgical site infection (SSI) rate in patients undergoing open abdominal surgery. BACKGROUND:: Surgical site infections are a common postoperative complication associated with considerable morbidity, extended hospital stay, increased health care costs, and reduced quality of life. Wound-edge protection devices have been used in surgery to reduce SSI rates for more than 40 years; however, they are yet to be cited in major clinical guidelines addressing SSI management. METHODS:: A review protocol was prespecified. A variety of sources were searched in November 2010 for studies containing primary data on the use of WEPDs in reducing SSI compared with standard care in patients undergoing open abdominal surgery. The outcome of interest was a well-specified, clinically based definition of an SSI. No language or time restrictions were applied. The quality assessment of the studies and the quantitative analyses were performed in line with the principles of the Cochrane Collaboration. RESULTS:: Twelve studies reporting primary data from 1933 patients were included in the review. The quality assessment found all of them to be at considerable risk of bias. An exploratory meta-analysis was performed to provide a quantitative indication on the effect of WEPDs. The pooled risk ratio under a random effects model was 0.60 (95% confidence interval, 0.41-0.86), indicating a potentially significant benefit from the use of WEPDs. No indications of significant between-study heterogeneity or publication bias, respectively, were identified. CONCLUSIONS:: Evidence to date suggests that WEPDs may be efficient in reducing SSI rates in patients undergoing open abdominal surgery. However, the poor quality of the existing studies and their small sample sizes raise the need for a large, good quality randomized controlled trial to validate this indication.
PMID: 22270692 [PubMed - as supplied by publisher]
Cost-Effectiveness of Early Colectomy With Ileal Pouch-Anal Anastamosis Versus Standard Medical Therapy in Severe Ulcerative Colitis.
Ann Surg. 2012 Jan 20;
Authors: Park KT, Tsai R, Perez F, Cipriano LE, Bass D, Garber AM
Abstract
BACKGROUND:: Inflammatory bowel diseases are costly chronic gastrointestinal diseases. We aimed to determine whether immediate colectomy with ileal pouch-anal anastamosis (IPAA) after diagnosis of severe ulcerative colitis (UC) was cost-effective compared to the standard medical therapy. METHODS:: We created a Markov model simulating 2 cohorts of 21-year-old patients with severe UC, following them until 100 years of age or death, comparing early colectomy with IPAA strategy to the standard medical therapy strategy. Deterministic and probabilistic analyses were performed. RESULTS:: Standard medical care accrued a discounted lifetime cost of $236,370 per patient. In contrast, early colectomy with IPAA accrued a discounted lifetime cost of $147,763 per patient. Lifetime quality-adjusted life-years gained (QALY-gained) for standard medical therapy was 20.78, while QALY-gained for early colectomy with IPAA was 20.72. The resulting incremental cost-effectiveness ratio (Δcosts/ΔQALY) was approximately $1.5 million per QALY-gained. Results were robust to one-way sensitivity analyses for all variables in the model. Quality-of-life after colectomy with IPAA was the most sensitive variable impacting cost-effectiveness. A low utility value of less than 0.7 after colectomy with IPAA was necessary for the colectomy with IPAA strategy to be cost-ineffective. CONCLUSIONS:: Under the appropriate clinical settings, early colectomy with IPAA after diagnosis of severe UC reduces health care expenditures and provides comparable quality of life compared to exhaustive standard medical therapy.
PMID: 22270693 [PubMed - as supplied by publisher]
Laparoendoscopic Rendezvous Versus Preoperative ERCP and Laparoscopic Cholecystectomy for the Management of Cholecysto-Choledocholithiasis: Interim Analysis of a Controlled Randomized Trial.
Ann Surg. 2012 Jan 18;
Authors: Tzovaras G, Baloyiannis I, Zachari E, Symeonidis D, Zacharoulis D, Kapsoritakis A, Paroutoglou G, Potamianos S
Abstract
BACKGROUND:: Although the ideal management of cholecysto-choledocholi-thiasis is controversial, the 2-stage approach [endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy, and common bile duct (CBD) clearance followed by laparoscopic cholecystectomy] remains the standard way of management worldwide. One-stage approach using the so-called laparoendoscopic rendezvous (LERV) technique offers some advantages, mainly by reducing the hospital stay and the risk of post-ERCP pancreatitis. OBJECTIVE:: To compare the LERV 1-stage approach with the standard 2-stage approach consisting of preoperative ERCP followed by laparoscopic cholecystectomy for the treatment of cholecysto-choledocholithiasis. SETTING:: Controlled randomized trial, University/Teaching Hospital. METHODS:: Patients with cholecysto-choledocholithiasis were randomized either to LERV or to the 2-stage approach. Both elective and emergency cases were included in the study. Primary endpoint was to detect difference in overall hospital stay, whereas secondary endpoints were (i) to detect differences in morbidity (especially post-ERCP pancreatitis) and (ii) success of CBD clearance. This is an interim analysis of the first 100 randomized patients. RESULTS:: Hospital stay was significantly shorter in the LERV group; median 4 (2-19) days versus 5.5 (3-22) days, P = 0.0004. There was no difference in morbidity and success of CBD clearance between the 2 groups. Post-ERCP amylase value was found significantly lower in the LERV group: median 65 (16-1159) versus 91 (30-1846), P = 0.02. CONCLUSIONS:: Interim analysis of the results suggests the superiority of the LERV technique in terms of hospital stay and post-ERCP hyperamylasemia.
PMID: 22261836 [PubMed - as supplied by publisher]
Resection of Hepatocellular Carcinoma Without Cirrhosis.
Ann Surg. 2012 Jan 17;
Authors: Shrager BJ, Jibara G, Schwartz M, Roayaie S
Abstract
OBJECTIVE:: The aim of this study was to examine the features and outcomes of noncirrhotic patients undergoing resection for hepatocellular carcinoma. BACKGROUND:: Ten percent to 40% of hepatocellular carcinoma cases arise within a noncirrhotic liver parenchyma. Resection is the standard therapy, yet the published resection series from the West are small. METHODS:: From January 1987 to December 2009, our center performed 206 partial liver resections for noncirrhotic hepatocellular carcinoma. We retrospectively reviewed these cases and performed univariate and multivariate analyses for predictors of long-term outcomes. RESULTS:: Eighty-one patients (39.3%) had chronic hepatitis B infection and 23 patients (11.2%) had chronic hepatitis C. The remaining 83 (39.8%) had no underlying liver disease. Average age was 60.2 years, and 68.4% of the patients were male. Average tumor size was 8.2 cm. Overall survival at 5 years was 46.3%. Recurrence at 5 years was 50.0%. Independent predictors for decreased survival were tumor size larger than 7.0 cm, creatinine more than 1.0 mg/dL, satellite nodules, albumin less than 3.5 gm/dL, alpha-fetoprotein more than 100 ng/mL, and any vascular invasion. Chronic hepatitis B virus infection predicted longer survival. Independent predictors for decreased time to recurrence were albumin less than 3.5 gm/dL, any vascular invasion, age more than 60 years, tumor size larger than 7.0 cm, and alpha-fetoprotein more than 100 ng/mL. Treatment of recurrence with either repeat resection or ablation was associated with a median survival of 50.4 months from time of recurrence. CONCLUSIONS:: Hepatocellular carcinoma can develop in a precirrhotic hepatitis C patient. Tumor-related factors such as vascular invasion primarily determine long-term outcomes. Hepatitis B virus-associated tumors seem to have a better prognosis in the noncirrhotic population. Aggressive treatment of recurrence is warranted.
PMID: 22258064 [PubMed - as supplied by publisher]
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