Ambiguity about the volume of colloids administered in a clinical study of thoracic esophagectomy precludes conclusions on the renal safety of hydroxyethyl starch

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Current status of robot-assisted thoracoscopic surgery for lung cancer Abstract The robotic surgical system was designed to overcome the drawbacks of conventional endoscopic surgery. Since national health insurance in Japan began covering robotic-assisted thoracoscopic surgery (RATS) for malignant lung and mediastinal tumors in 2018, the number of RATS procedures being performed domestically has increased rapidly. This review evaluates the advantages and disadvantages of RATS for patients with lung cancers, based on an electronic literature search of PubMed. The main advantages of RATS are its ability to achieve excellent lymph-node removal with low morbidity and mortality, and minimal postoperative pain. Conversely, its disadvantages include a long operation time and the need for specialized instruments. However, the learning curve for RATS is reported to be shorter than that for VATS: some studies recommend that a surgeon needs to perform 18–22 robotic operations to attain sufficient skill. RATS for lung cancer is more expensive than VATS and the cost of training is high. Although the main disadvantage of RATS is that it reduces operator’s tactile senses, the endoscope, which is directly manipulated by the surgeon at the console, using various magnifications, and 3D HD images on the monitor, may compensate for this. Ultimately, RATS offers better maneuverability, accuracy, and stability over VATS.

Predicting mortality in patients admitted to the intensive care unit after open vascular surgery Abstract Purposes Vascular surgery (VS) has a higher perioperative mortality than other types of surgery. We compared different scores for predicting mortality in patients admitted to the intensive care unit (ICU) after open VS. Methods Patients admitted to the ICU after open VS from 2006 to 2013 were included. We calculated the Acute Physiology and Chronic Health Evaluation (APACHE), Simplified Acute Physiology Score (SAPS), Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) and Preoperative Score to Predict Postoperative Mortality (POSPOM). We performed multivariate logistic regression to assess independent factors with the calculation of odds ratios (ORs) and 95% confidence intervals (CIs). We tested the predictive ability of the scores using the area under the receiver operating characteristics curve (AUROC). Results A total of 833 consecutive patients were included. Hospital mortality was 5.1% (1.3% after intermediate-risk and 8.4% after high-risk surgery). In the multivariate analysis, the age (OR 1.04, 95% CI 1.01–1.08, p = 0.013), smoking status (OR 2.46, 95% CI 1.16–5.21, p = 0.019), surgery risk (OR 2.92, 95% CI 1.05–8.08, p = 0.040), serum sodium level (OR 1.17, 95% CI 1.10–1.26, p < 0.001), urea (OR 1.01, 95% CI 1.01–1.02, p = 0.001) and leukocyte count (OR 1.05, 95% CI 1.01–1.10, p = 0.009) at admission were considered independent predictors. Hematocrit (0.86, 95% CI 0.80–0.93, p < 0.001) was considered an independent protective factor. The AUROC of our model was 0.860, compared to SAPS (0.752), APACHE (0.774), POSPOM (0.798) and POSSUM (0.829). Conclusion The observed mortality was within the predicted range (1–5% after intermediate-risk and > 5% after high-risk surgery). POSSUM and POSPOM had slightly better predictive capacity than SAPS or APACHE.

Super-elderly patient-specific perioperative complications in breast cancer surgery Abstract Purpose Geriatric surgery poses specific challenges due to patient vulnerability in relation to aging. We analyzed perioperative challenges concerning super-elderly patients with breast cancer. Methods Between 2013 and 2018, 908 patients with breast cancer were treated surgically. Of these, two patient groups were compared: Group A (≥ 85 years old, n = 34, 3.7%) and Group B (75–84 years old, n = 136, 15%). Results In Groups A and B, 26.4% and 36.8% of patients lived alone, respectively. Group A patients had higher rates of psychiatric and cardiovascular disease (32.4% and 41.2%) than Group B (8.8% and 16.2%) (p = 0.0009 and p = 0.0031, respectively). There was no marked difference in the type of surgery or length of hospital stay between groups, and most complications involved surgical site disorders. Postoperatively, Group A had a higher rate of delirium (29.4%) than Group B (3.7%) (p < 0.0001). The 30-day postoperative mortality rate was 0, and 76.5% of Group A and 45.6% of Group B patients received no adjuvant therapy (p = 0.0024). Conclusions Age alone does not constitute a contraindication for appropriate surgery, although there are some challenges necessary to consider for super-elderly patients.

Score of the preoperative absolute number of lymphocytes, monocytes, and neutrophils as a prognostic indicator for patients with gastric cancer Abstract Purpose The association between the preoperative absolute neutrophil count (NC), lymphocyte count (LC), and monocyte count (MC) in the peripheral blood and the prognosis of gastric cancer (GC) patients has not been investigated widely. Methods We enrolled 445 patients who underwent surgery for GC between January, 2005 and April, 2013 to analyze the correlations among NC, LC, and MC and their prognoses. Results Based on cut-off values calculated by ROC analysis, patients were sub grouped as having: NC ≥ 4477 (NCHigh), NC < 4477 (NCLow); and as LC ≥ 1447 (LCHigh), LC < 1447 (LCLow); and as MC ≥ 658.5 (MCHigh), MC < 658.5 (MCLow). Each group was assigned as follows; NCHigh group = 1, NCLow group = 0, LCHigh group = 0, LCLow group = 1, MCHigh group = 1, MCLow group = 0, and the sum of each score was defined as the lymphocyte–monocyte–neutrophil score (LMN score). The overall 5-year survival rates were 89%, 74%, 57.8%, and 53.3% for LMN scores of 0, 1, 2, and 3, respectively (P = 0.0004). Multivariate analysis indicated that the LMN score was an independent prognostic indicator. Conclusions The combination of preoperative NC, LC, and MC appears to be a useful indicator of GC prognosis.

Antimicrobial prophylaxis for 1 day versus 3 days in liver cancer surgery: a randomized controlled non-inferiority trial Abstract Purposes This study compared the effectiveness of 1-day vs 3-days antibiotic regimen to prevent surgical site infection (SSI) in open liver resection. Method We performed a randomized controlled non-inferiority trial in 480 patients at 39 hospitals across Japan (registered as UMIN000002852). Patients with hepatocellular carcinoma scheduled to undergo resection were randomly assigned to receive either a 1-day regimen for antimicrobial prophylaxis, or a 3-day regimen. The primary endpoint was the incidence of SSI. Results Among 480 randomized patients, 232 assigned to the 1-day regimen and 235 to the 3-day regimen were included in the full analysis set. Baseline characteristics of the two groups were well balanced. SSI was diagnosed in 22 patients (9.5%) in the 1-day group vs 23 patients (9.8%) in the 3-day group (difference, – 0.30; 90% CI – 4.80 to 4.19% [95% CI – 5.66% to 5.05%]; one-sided P = 0.001 for non-inferiority), meeting the non-inferiority hypothesis. In both groups, remote site infection (16 [6.9%] vs 22 [9.4%], P ˂ 0.001 for non-inferiority) and drain-related infection (5 [2.2%] vs 4 [1.7%], P ˂ 0.001 for non-inferiority) were comparable. Conclusion To prevent SSI in liver cancer surgery, a 1-day regimen of flomoxef sodium is recommended for antimicrobial prophylaxis because of confirming the non-inferiority to longer usage.

A comparison between 2- and 3-dimensional approaches to solid component measurement as radiological criteria for sublobar resection in lung adenocarcinoma ≤ 2 cm in size Abstract Purpose We compared three-dimensional (3D) and two-dimensional (2D) measurements of the solid component to determine radiological criteria for sublobar resection of lung adenocarcinoma ≤ 2 cm in size. Methods We included 233 surgical cases. The maximum size of the solid component for 3D measurement was calculated by delineating the solid component on successive axial images and reconstructing the 3D surface model. Results The predictive performance for adenocarcinoma in situ (n = 43) and minimally invasive adenocarcinoma (n = 77) were equivalent to areas under the curve of 0.871 and 0.857 for 2D and 3D measurements (p = 0.229), respectively. A solid component of 5 mm had a prognostic impact on both measurements ( ≤ 5 mm versus > 5 mm; p = 0.003 for 2D and p = 0.002 for 3D, log-rank test). Survival rates at 5 years were 94.7–96.9% following lobectomy and sublobar resection among patients with a solid component ≤ 5 mm in size. Sublobar resection resulted in worse survival rates, with declines at 5 years of 15.8% on 2D and 11.5% on 3D measurements, than lobectomy in patients with a solid component > 5 mm in size. Conclusions A solid component ≤ 5 mm in size is an appropriate criterion for sublobar resection for both measurements. In addition, 2D measurement is justified because of its simple implementation.

A prospective multi-center registry concerning the clinical performance of laparoscopic colorectal surgery using an absorbable adhesion barrier (INTERCEED ® ) made of oxidized regenerated cellulose Abstract Purpose The aim of this prospective multi-center registry was to evaluate the safety and clinical performance of INTERCEED® in laparoscopic colorectal surgery. Methods This study was a prospective, multi-center, single-arm registry wherein patients who received INTERCEED® in laparoscopic colorectal surgery were registered consecutively (UMIN-CTR 00001872). The primary outcome was the incidence rate of postoperative adhesive small intestinal obstruction within 6 months. The secondary outcomes were reoperation related to postoperative bleeding and anastomotic leak, surgical site infection (SSI) and anastomotic leak. Results Between March 2012 and March 2015, a total of 202 patients were enrolled from six institutions. INTERCEED® was not applied in two patients, so 200 patients were analyzed using the full analysis set population. The incidence rate of postoperative adhesive intestinal obstruction was 1.0% (2/200). The total SSI rate was 3.5% (7/200), the deep incisional SSI rate was 0.0% (0/200), and the organ SSI rate was 0.0% (0/200). The incidence of anastomotic leak was 1.0% (2/200). Reoperation was performed in two cases: one for anastomotic leak and the other as cardiac surgery due to heart disease. Conclusions Using INTERCEED® in laparoscopic colorectal surgery is safe and may be useful for preventing postoperative adhesive small intestinal obstruction.

Etiology and management of low anterior resection syndrome based on the normal defecation mechanism Abstract Low anterior resection syndrome (LARS) commonly develops after an anal sphincter-preserving operation (SPO). The etiology of LARS is not well understood, as the anatomical components and physiological function of normal defecation, which may be damaged during the SPO, are not well established. SPOs may damage components of the anal canal (such as the internal anal sphincter, longitudinal conjoint muscle, or hiatal ligament), either mechanically or via injury to the nerves that supply these organs. The function of the rectum is substantially impaired by resection of the rectum, division of the rectococcygeus muscle, and/or injury of the nervous supply. When the remnant rectum is small and does not function properly, an important functional role may be played by the neorectum, which is usually constructed from the left side of the colon. Hypermotility of the remnant colon may affect the manifestation of urge fecal incontinence. To develop an SPO that minimizes the risk of LARS, the anatomy and physiology of the structures involved in normal defecation need to be understood better. LARS is managed similarly to fecal incontinence. In particular, management should focus on reducing colonic motility when urge fecal incontinence is the dominant symptom.