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Introduced more than 20 years ago, laparoscopic pancreatic surgery (LAPS) has not reached a uniform acceptance among HPB surgeons. As a result, there is no consensus regarding its use in patients with pancreatic neoplasms. This st...
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Introduced more than 20 years ago, laparoscopic pancreatic surgery (LAPS) has not reached a uniform acceptance among HPB surgeons. As a result, there is no consensus regarding its use in patients with pancreatic neoplasms. This study, organized by the European Association for Endoscopic Surgery (EAES), aimed to develop consensus statements and clinical recommendations on the application of LAPS in these patients.
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Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition an...
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Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover both nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include the inte-gration of nutrition into the overall management of the patient, avoidance of long periods of preoperative fasting, re-establishment of oral feeding as early as possible after surgery, the start of nutritional therapy immediately if a nutritional risk becomes apparent, metabolic control e.g. of blood glucose, reduction of factors which exacerbate stress-related catabolism or impaired gastrointestinal function, minimized time on paralytic agents for ventilator management in the postoperative period, and early mobilization to facilitate protein synthesis and muscle function. (c) 2021 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.
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Este artigo discute as rela??es entre ciência e arte, principalmente entre física e pintura, com o objetivo de apresentar uma abordagem cultural para a ciência. Dessa forma, entendemos que a compreens?o dos conteúdos da ciênc...
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Este artigo discute as rela??es entre ciência e arte, principalmente entre física e pintura, com o objetivo de apresentar uma abordagem cultural para a ciência. Dessa forma, entendemos que a compreens?o dos conteúdos da ciência torna-se mais significativa. Abordamos diferentes momentos da história desde a revolu??o científica até o século XX. As rela??es aqui salientadas n?o buscam uma rela??o causal entre ciência e arte, mas sim uma vis?o mais significativa do que é o processo de constru??o do conhecimento. Assim, a ciência se desnuda para nós como parte da cultura e pode nos ajudar a compreender melhor o processo histórico que nos trouxe até aqui.
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Background: ECCO essential requirements for quality cancer care (ERQCC) are checklists and explanations of organisation and actions that are necessary to give high-quality care to patients who have a specific type of cancer. They ...
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Background: ECCO essential requirements for quality cancer care (ERQCC) are checklists and explanations of organisation and actions that are necessary to give high-quality care to patients who have a specific type of cancer. They are written by European experts representing all disciplines involved in cancer care. ERQCC papers give oncology teams, patients, policymakers and managers an overview of the elements needed in any healthcare system to provide high quality of care throughout the patient journey. References are made to clinical guidelines and other resources where appropriate, and the focus is on care in Europe.
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Recent studies show contrasting data on the impact of laparoscopy on long-term complications such as the occurrence of small bowel obstruction (SBO) and incisional hernia (IH). The objective of the study was to assess the impact o...
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Recent studies show contrasting data on the impact of laparoscopy on long-term complications such as the occurrence of small bowel obstruction (SBO) and incisional hernia (IH). The objective of the study was to assess the impact of the laparoscopic approach on the occurrence of SBO and IH after colorectal resection.
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Background Previous Enhanced Recovery After Surgery (ERAS (R)) studies have not always taken into account that ERAS interventions depend on baseline covariates and that several confounding variables affect the composite outcomes. ...
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Background Previous Enhanced Recovery After Surgery (ERAS (R)) studies have not always taken into account that ERAS interventions depend on baseline covariates and that several confounding variables affect the composite outcomes. Method A causal latent variable model is proposed to analyze data obtained prospectively concerning 1261 patients undergoing elective colorectal surgery within the ERAS protocol. Primary outcomes (composite of any complication, surgical site infection, medical complications, early ready for discharge (TRD), early actual discharge) and secondary outcomes (composite of late bowel function recovery, IV fluid resumption, nasogastric tube replacement, postoperative nausea and vomiting, re-intervention, re-admission, death) are considered along with their multiple dimensions. Results Concerning the primary outcomes, our results evidence three subpopulations of patients: one with probable good outcome, one with possibly prolonged TRD and discharge without complications, and the other one with probable complications and prolonged TRD and discharge. Epidural anesthesia, waiving surgical drainage, and early ambulation, IV fluid stop and urinary catheter removal act favorably, while preoperative hospital stay and blood transfusion act negatively. Concerning the secondary outcomes our results evidence two subpopulations of patients: one with high probability of good outcome and one with high probability of complications. Epidural anesthesia, waiving surgical drainage, early ambulation and IV fluid stop act favorably, while blood transfusion acts negatively also with respect to these secondary outcomes. Conclusion The multivariate causal latent class two-parameter logistic model, a modern statistical method overcoming drawbacks of traditional models to estimate the average causal effects on the treated, allows us to disentangle subpopulations of patients and to evaluate ERAS interventions.
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Aim: To establish the correlation between changes in body composition after neoadjuvant chemoradiotherapy (nCRT) and postoperative outcomes, in patients with advanced low rectal cancer. Methods: Patients with clinical stage T >= 3...
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Aim: To establish the correlation between changes in body composition after neoadjuvant chemoradiotherapy (nCRT) and postoperative outcomes, in patients with advanced low rectal cancer. Methods: Patients with clinical stage T >= 3 or N+ rectal cancer who underwent nCRT and surgical resection were studied. Skeletal muscle, visceral, and subcutaneous fat cross-sectional area were measured by computed tomography before and after nCRT. Postoperative morbidity, pathologic response to nCRT, overall and disease-free survival was assessed. Results: Fifty-two patients, median age 62 (range 32-79) were studied. A skeletal muscle loss >2% significantly correlated with a shorter disease-free survival both in the overall population (P = 0.048) and in the subgroup of N0 patients (P = 0.048). A subcutaneous fat loss >5% was also associated with a shorter disease-free survival (P = 0.012) in the whole population. Conclusions: Skeletal muscle loss, after neoadjuvant chemoradiotherapy, negatively impacts on disease-free survival in surgically treated rectal cancer patients. (C) 2019 Elsevier Inc. All rights reserved.
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Background Liver tumors invading the distal part of the umbilical portion of the left portal vein usually require left hepatectomy. The recent introduction of the concept of left anterior sector, an independent anatomo-functional ...
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Background Liver tumors invading the distal part of the umbilical portion of the left portal vein usually require left hepatectomy. The recent introduction of the concept of left anterior sector, an independent anatomo-functional unit including the anterior portion of the left liver and supplied by the distal part of the umbilical portion of the left portal vein, could represent the rational for an alternative surgical approach. The aim of this study was to introduce the novel surgical procedure of ultrasound-guided left anterior sectorectomy. Methods Among 92 consecutive patients who underwent hepatectomy, 3 patients with tumor invading the distal part of the umbilical portion of the left portal (two with colorectal liver metastases and one with neuroendocrine tumor liver metastases) underwent left anterior sectorectomy alone or in association with liver multiple metastasectomies. Results Mean operation time was 393 min; post-operative morbidity and mortality were not observed. After a mean FU of 23 months (range 19–28), no local recurrence occurred. Conclusions In presence of tumors invading the distal part of the umbilical portion of the left portal, left anterior sectorectomy could be considered as an anatomic radical surgical option that is safe but more conservative than a left hepatectomy.
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Background This individual-patient data meta-analysis investigated the effects of enhanced recovery after surgery (ERAS) protocols compared with conventional care on postoperative outcomes in patients undergoing pancreatoduodenect...
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Background This individual-patient data meta-analysis investigated the effects of enhanced recovery after surgery (ERAS) protocols compared with conventional care on postoperative outcomes in patients undergoing pancreatoduodenectomy. Methods The Cochrane Library, MEDLINE, Embase, Scopus, and Web of Science were searched systematically for articles reporting outcomes of ERAS after pancreatoduodenectomy published up to August 2020. Comparative studies were included. Main outcomes were postoperative functional recovery elements, postoperative morbidity, duration of hospital stay, and readmission. Results Individual-patient data were obtained from 17 of 31 eligible studies comprising 3108 patients. Time to liquid (mean difference (MD) -3.23 (95 per cent c.i. -4.62 to -1.85) days; P < 0.001) and solid (-3.84 (-5.09 to -2.60) days; P < 0.001) intake, time to passage of first stool (MD -1.38 (-1.82 to -0.94) days; P < 0.001) and time to removal of the nasogastric tube (3.03 (-4.87 to -1.18) days; P = 0.001) were reduced with ERAS. ERAS was associated with lower overall morbidity (risk difference (RD) -0.04, 95 per cent c.i. -0.08 to -0.01; P = 0.015), less delayed gastric emptying (RD -0.11, -0.22 to -0.01; P = 0.039) and a shorter duration of hospital stay (MD -2.33 (-2.98 to -1.69) days; P < 0.001) without a higher readmission rate. Conclusion ERAS improved postoperative outcome after pancreatoduodenectomy. Implementation should be encouraged. Lay Summary Enhanced recovery protocols consist of interdisciplinary interventions aimed at standardizing care and reducing the impact of surgical stress. They often include a short period of preoperative fasting during the night before surgery, early removal of lines and surgical drains, early food intake and mobilization out of bed on the day of surgery. This study gives a summary of reports assessing such care protocols in patients undergoing pancreatic head surgery, and assesses the impact of these protocols on functional recovery in an analysis of individual-patient data. The study revealed the true benefits of enhanced recovery protocols, including shorter time to food intake, earlier bowel activity, fewer complications after surgery, and a shorter hospital stay compared with conventional care.
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Background The benefit of anatomic (AR) versus parenchyma-sparing resection (PSR) in hepatocarcinoma (HCC) is still debated. The aim of the study was to compare AR vs. PSR in terms of overall survival (OS) and disease-free surviva...
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Background The benefit of anatomic (AR) versus parenchyma-sparing resection (PSR) in hepatocarcinoma (HCC) is still debated. The aim of the study was to compare AR vs. PSR in terms of overall survival (OS) and disease-free survival (DFS). Methods A systematic review was conducted using Medline and Google Scholar. To reduce intra- and inter-study heterogeneity, only propensity-matched studies and randomized clinical trials (RCT) were evaluated and a generic inverse variance meta-analysis was run. A sub-analysis was performed in case of tumor microvascular invasion (MVI). Results Eleven propensity-matched and one RCT were evaluated, with a total of 3445 patients (AR = 1776 and PSR = 1669). Tumor burden and liver function were comparable among studies (I-2 0.5). OS was similar between AR and PSR (HR 0.93; 95%CI, 0.75-1.15; p = 0.50, I-2 = 41%). DFS was improved in AR at 1 year (RR 0.84; 95%CI, 0.72-0.97; p = 0.02; I-2 = 36%) and 3 years (RR 0.90; 95%CI, 0.83-0.98; p = 0.02; I-2 = 40%) but not at 5 years (RR 0.94; 95%CI, 0.87-1.01; p = 0.07; I-2 = 41%). Furthermore, in the presence of MVI, no difference in OS and DFS was observed between AR and PSR. Conclusion When liver function and tumor burden are comparable, AR and PSR achieved similar overall survival. AR improved local control in the early period after surgery. Furthermore, in the presence of MVI, the extension of surgery was not associated with better OS and DFS.
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