Evolución de la calidad de vida tras cirugía radical o conservadora en cáncer de mama

Introducción: De todos los factores que pueden influir en la calidad de vida relacionada con la salud (CVRS), el tratamiento quirúrgico puede ser uno de los más importantes. Las características sociodemográficas o aspectos clínicos relacionados con el cáncer de mama o sus tratamientos también pueden modificar la CVRS. Objetivos: Analizar las relaciones entre el tipo de intervención (cirugía conservadora (CC) o radical) y la CVRS al año. Describir las características de las pacientes y la evolución de su CVRS al mes, a los 6 meses y al año de la intervención. Se analizan las asociaciones entre las características sociodemográficas o clínicas de las pacientes y las puntuaciones de CVRS al año de la intervención. Adicionalmente se analiza la capacidad predictiva de los instrumentos de medida de CVRS. Material y métodos: Estudio multicéntrico, observacional, prospectivo, en el que una cohorte de pacientes intervenidas de cáncer de mama fue seguida durante un año. Se midió su CVRS al mes, a los 6 meses y al año de la intervención mediante una escala general de CVRS (EuroQol-5D), una escala específica de CVRS en cáncer (EORTC QLQC30) y una escala específica de CVRS en cáncer de mama (EORTC QLQ-BR23). Resultados: Se incluyeron 551 pacientes, de las que participaron 446. La edad media fue 59,09 años (Rango: 20-91). La CVRS fue mejorando a lo largo del año de seguimiento. Respecto al EuroQol, las puntuaciones de la Escala Visual Analógica (EVA) mejoraron (p<0,0001); sin embargo, la tarifa no mostró cambios significativos (p=0,1323). En cambio, la puntuación global del EORTC QLQ-C30 mejoró (p<0,0001), así como todas las dimensiones funcionales y de síntomas y la mayoría de ítems independientes del EORTC QLQ-C30. Las dimensiones del EORTC QLQ-BR23 mostraron mejoría, salvo el funcionamiento sexual y la preocupación por el futuro, que presentaron un discreto empeoramiento. La CC ofreció mejores actividades diarias, mejor funcionamiento físico, emocional y social, menos fatiga, dolor, insomnio o impacto económico al año de la intervención. Adicionalmente, proporcionó mejor imagen corporal, menos molestias en el brazo y menos efectos secundarios del tratamiento sistémico, pero a expensas de mayores preocupaciones por el futuro y más síntomas locales en la mama que la cirugía radical. Entre los factores sociodemográficos y de acceso, la edad comprendida entre los 60 y 69 años y la menor de 50 años, así como ser soltera o ama de casa se asociaron con una mejor CVRS. En relación con los factores clínicos y de tratamiento, las pacientes con estadios I y II, con tipo histológico carcinoma ductal infiltrante (CDI) papilar, así como las intervenidas de forma conservadora o aquellas que no requirieron linfadenectomía axilar presentaron mejor CVRS. En el análisis multivariable, una edad mayor de 70 años, estar casada, separada o viuda, el estadio III o no recibir QT fueron factores independientes predictivos de peor CVRS al año. Sin embargo, ser ama de casa, la CC, el CDI papilar, provenir de la consulta o no recibir RT fueron factores independientes predictivos de una mejor CVRS al año. Adicionalmente, la CVRS medida al mes mediante los tres cuestionarios fue predictiva de la CVRS al año. Conclusiones: La CVRS de las pacientes fue buena y mejoró con el seguimiento. Existen diferencias en la CVRS según la modalidad de intervención, puesto que la CC ofreció beneficios en múltiples ítems frente a la radical, aunque mostró mayores preocupaciones por el futuro y más síntomas locales. Determinados factores sociodemográficos y clínicos pueden influir en la CVRS, y algunos de ellos independientemente. Los instrumentos de medida de CVRS utilizados precozmente pueden predecir la CVRS al año de la intervención.Introduction: Multiple factors could affect Health Related Quality of Life (HRQoL) of breast cancer patients. Objectives: Assess associations between HRQoL and type of intervention (Breast Conserving Surgery (BCS) or mastectomy). Describe HRQoL evolution over one year after surgery. Analyze associations between sociodemographic or clinical factors and HRQoL scores. And finally, analyze the predictive ability of HRQoL measurement instruments. Methods: Observational, multicenter and prospective study of a cohort of patients with breast cancer that was followed one year after surgery. HRQoL was assessed at one month, six months and one year after surgical intervention using three questionnaires: EuroQol-5D, EORTC QLQ-C30 and its breast cancer specific module BR-23. Results: Of 551 patients included in the study, 446 participated. Mean age was 59.09 years (range: 20-91). Visual Analogue Scale (VAS) from EuroQol improved; however, EuroQol Score showed no significant change. In contrast, Global Health Status of EORTC QLQ-C30 improved, as well as all its scales and most of its independent items. Dimensions of EORTC QLQ-BR23 experienced improvement, except for sexual functioning and future perspective, that experienced a slight worsening. BCS provided better rol, physical, social and emotional functioning, better body image and less fatigue, pain, insomnia, financial difficulties, arm symptoms and systemic therapy side-effects, but increased concerns about the future and more breast symptoms than mastectomy one year after surgery. Age between 60-69 years and under 50 years, being single or housewife, stage I-II, invasive papillary carcinoma, BCS or lack of axillary dissection were associated with better HRQoL. Howerver, age over 70 years, being married, separated or widowed, stage III or not receive adyuvant chemotherapy were independent predictors of worse HRQoL. In contrast, being housewife, BCS, invasive papillary carcinoma, come from outpatient clinic or not receive radiotherapy were independent predictive factors of better HRQoL after one year. Moreover, HRQoL measured at one month was predictive of HRQoL at one year. Conclusions: HRQoL was good and improved during the follow-up. Differences in HRQoL according to the type of intervention were found in favour of BCS. Demographic and clinical factors can influence HRQoL and some of them independently. HRQoL measurement instruments can predict early HRQoL

Sphincter damage during fistulotomy for perianal fistulae and its relationship with faecal incontinence

Background The length of sphincter which can be divided during fistulotomy for perianal fistula is unclear. The aim was to quantify sphincter damage during fistulotomy and determine the relationship between such damage with symptoms and severity of faecal incontinence and long-term quality of life (QOL). Methods A prospective cohort study was performed over a 2-year period. Patients with intersphincteric and mid to low transsphincteric perianal fistulas without risk factors for faecal incontinence were scheduled for fistulotomy. All patients underwent 3D endoanal ultrasound (3D-EAUS) pre-operatively and 8 weeks postoperatively. Measurements were taken of pre- and postoperative anal sphincter involvement and division. Anal continence was assessed using the Jorge-Wexner scale and QOL scores pre, 6 and 12 months postoperatively. Results Forty-nine patients were selected. A strong correlation between pre- and postoperative measurements was found p < 0.001. A median length of 41% of the external anal sphincter and 32% of the internal anal sphincter was divided during fistulotomy. Significant differences in mild symptoms of anal continence were found with increasing length of external anal sphincter division. But there was no significant deterioration in continence, soiling, or quality of life scores at the 1-year follow-up. Division of over two-thirds of the external anal sphincter was associated with the highest incontinence rates. Conclusions 3D-EAUS is a valuable tool for quantifying the extent of sphincter involvement pre- and postoperatively. Post-fistulotomy faecal incontinence is mild and increases with increasing length of sphincter division but does not affect long-term quality of life

Incidence of anastomotic leakage using powered circular staplers versus manual circular staplers for left colorectal anastomosis: a cost-effectiveness analysis

Background: Colorectal anastomotic leakage causes severe consequences for patients and healthcare system as it will lead to increased consumption of hospital resources and costs. Technological improvements in anastomotic devices could reduce the incidence of leakage and its economic impact. The aim of the present study was to assess if the use of a new powered circular stapler is cost-effective. Method: This observational study included patients undergoing left-sided circular stapled colorectal anastomosis between January 2018 and December 2021. Propensity score matching was carried out to create two comparable groups depending on whether the anastomosis was performed using a manual or powered circular device. The rate of anastomotic leakage, its severity, the consumption of hospital resources, and its cost were the main outcome measures. A cost-effectiveness analysis comparing the powered circular stapler versus manual circular staplers was performed. Results: A total of 330 patients were included in the study, 165 in each group. Anastomotic leakage rates were significantly different (p = 0.012): 22 patients (13.3%) in the manual group versus 8 patients (4.8%) in the powered group. The effectiveness of the powered stapler and manual stapler was 98.27% and 93.69%, respectively. The average cost per patient in the powered group was ¿6238.38, compared with ¿9700.12 in the manual group. The incremental cost-effectiveness ratio was - ¿74,915.28 per patient without anastomotic complications. Conclusion: The incremental cost of powered circular stapler compared with manual devices was offset by the savings from lowered incidence and cost of management of anastomotic leaks

Prognostic value of routine blood biomarkers in 3-year survival of resectable colorectal cancer patients: a prognostic nomogram for clinical practice

Purpose: This study aimed to develop a prognostic model for colorectal cancer (CRC) patients using biomarkers from routine preoperative peripheral blood examinations combined with clinical factors. Methods: This observational study comprised CRC patients (stages I-III) who underwent curative surgery between January 2011 and December 2019. Study variables included patient demographics, tumour characteristics, and immune/inflammatory markers from preoperative blood tests. Cut-off thresholds for continuous variables were determined using maximally selected rank statistics. Univariate and multivariate analyses identified variables associated with 3-year cancer-specific survival (CSS) and disease-free survival (DFS). Cox regression models were developed and validated using a random split-sample approach. Nomograms based on these models were constructed, and receiver operating characteristic (ROC) curves were generated for 12, 24 and 36 months. Results: A total of 764 patients were included. Independent factors for 3-year DFS included laparoscopic surgery, prognostic nutritional index (PNI), neutrophil count, lymphocyte count, and Charlson comorbidity index. The DFS prediction model showed AUC values of 66.6%, 64.8%, and 69% for years 1, 2, and 3, respectively. For CSS, independent factors included age, systemic immune-inflammation index (SII), serum albumin, and platelet count, with AUC values of 89.2%, 76.8%, and 71% for years 1, 2, and 3. The most significant contributors to the CSS model were SII and platelet cut-off values. Conclusion: Inflammatory biomarkers combined with clinical parameters robustly predict 3-year survival outcomes in CRC patients undergoing curative resection. These findings highlight the importance of systemic inflammation in CRC prognosis and support its inclusion in preoperative risk stratification

Prognostic implications of surgical specimen quality on the oncological outcomes of open and laparoscopic surgery in mid and low rectal cancer

Purpose: Determine differences in pathologic outcomes between laparoscopic (LAP) and open surgery (OPEN) for mid and low rectal cancer and its influence in long-term oncological outcomes. Methods: Retrospective case matched study at a tertiary institution. Adults with rectal cancer below 12 cm from the anal verge operated between January 2005 and September 2018 were included. Primary outcomes were quality of specimen, overall survival (OS), disease-free survival (DFS), and local recurrence (LR). Results: The study included 311 patients, LAP = 108 (34.7%), OPEN = 203 (65,3%). A successful resection was accomplished in 81% of the LAP group and in 84.5% of the OPEN (p = 0.505). No differences in free distal margin (LAP = 100%, OPEN = 97.5%; p = 0.156) or circumferential resection margin (LAP = 95.2%, OPEN = 93.2%; p = 0.603) were observed. However, mesorectum quality was incomplete in 16.2% for LAP and in 8.1% for OPEN (p = 0.048). OS was 91.1% for LAP and 81.1% for OPEN (p = 0.360). DFS was 81.4% for LAP and 77.5% for OPEN (p = 0.923). Overall, LR was 2.3% without differences between groups. Conclusions: Laparoscopic approach could affect the quality of surgical specimen due to technical aspects. However, if principles of surgical oncology are respected, minor pathologic differences in the quality of the mesorectum may not influence on the long-term oncologic outcomes

Current evidence on powered versus manual circular staplers in colorectal surgery: a systematic review and meta-analysis

Purpose: This meta-analysis aims to evaluate the efficacy of powered circular staplers (PCS) compared to manual circular staplers (MCS) in reducing anastomotic leakage (AL) and postoperative bleeding (AB) in colorectal surgery. Methods: Extensive searches were performed in the Embase, PubMed, and SCOPUS electronic bibliographic databases. Most studies were of an observational nature, and only one randomized clinical trial was identified. Results: Twelve studies met the inclusion criteria for anastomotic leakage and five for anastomotic hemorrhage. The number of patients included for AL analysis was 4524. The leakage rate was 4.6% (208 cases). The number of patients with AB was 2868 with a bleeding rate of 4.99% (143 patients). After identifying outliers and studies with possible selection bias, the odds ratio (OR) for leaks and PCS was 0.38 (95% CI 0.26-0.55), the relative risk was - 0.05 (95% CI - 0.07 to 0.03), and the number needed to treat to prevent one leak was 20. For bleeding, the PCS OR for PCS was 0.20 (95% CI 0.0772-0.5177). Conclusion: Powered circular staplers could be associated with a significantly lower risk of leakage and anastomotic bleeding than two-row manual circular staplers. Further prospective randomized trials are needed to validate these findings

Short-term outcomes of colorectal cancer surgery in older patients : a novel nomogram predicting postoperative morbi-mortality

Purpose To analyze short-term outcomes of curative-intent cancer surgery in all adult patients diagnosed with colorectal cancer undergoing surgery from January 2010 to December 2019 and determine risk factors for postoperative complications and mortality. Methods Retrospective study conducted at a single tertiary university institution. Patients were stratified by age into two groups: < 75 years and ≥ 75 years. Primary outcome was the influence of age on 30-day complications and mortality. Inde- pendent risk factors for postoperative adverse events or mortality were analyzed, and two novel nomograms were constructed. Results Of the 1486 patients included, 580 were older (≥ 75 years). Older subjects presented more comorbidities and tumors were located mainly in right colon (45.7%). After matching, no between-group differences in surgical postoperative com- plications were observed. The 30-day mortality rate was 5.3% for the older and 0.8% for the non-older group (p < 0.001). In multivariable analysis, the independent risk factors for postoperative complications were peripheral vascular disease, chronic pulmonary disease, severe liver disease, postoperative transfusion, and surgical approach. Independent risk factors for 30-day mortality were age ≥ 80 years, cerebrovascular disease, severe liver disease, and postoperative transfusion. The model was internally and externally validated, showing high accuracy. Conclusion Patientsaged≥75yearshadsimilarpostoperativecomplicationsbuthigher30-daymortalitythantheiryounger counterparts. Patients with peripheral vascular disease, chronic pulmonary disease, or severe liver disease should be informed of higher postoperative complications. But patients aged ≥ 80 suffering cerebrovascular disease, severe liver disease, or need- ing postoperative transfusion should be warned of significantly increased risk of postoperative mortality

Evolving trends in the management of acute appendicitis during COVID-19 waves. The ACIE appy II study

Background: In 2020, ACIE Appy study showed that COVID-19 pandemic heavily affected the management of patients with acute appendicitis (AA) worldwide, with an increased rate of non-operative management (NOM) strategies and a trend toward open surgery due to concern of virus transmission by laparoscopy and controversial recommendations on this issue. The aim of this study was to survey again the same group of surgeons to assess if any difference in management attitudes of AA had occurred in the later stages of the outbreak. Methods: From August 15 to September 30, 2021, an online questionnaire was sent to all 709 participants of the ACIE Appy study. The questionnaire included questions on personal protective equipment (PPE), local policies and screening for SARS-CoV-2 infection, NOM, surgical approach and disease presentations in 2021. The results were compared with the results from the previous study. Results: A total of 476 answers were collected (response rate 67.1%). Screening policies were significatively improved with most patients screened regardless of symptoms (89.5% vs. 37.4%) with PCR and antigenic test as the preferred test (74.1% vs. 26.3%). More patients tested positive before surgery and commercial systems were the preferred ones to filter smoke plumes during laparoscopy. Laparoscopic appendicectomy was the first option in the treatment of AA, with a declined use of NOM. Conclusion: Management of AA has improved in the last waves of pandemic. Increased evidence regarding SARS-COV-2 infection along with a timely healthcare systems response has been translated into tailored attitudes and a better care for patients with AA worldwide

Global disparities in surgeons’ workloads, academic engagement and rest periods: the on-calL shIft fOr geNEral SurgeonS (LIONESS) study

: The workload of general surgeons is multifaceted, encompassing not only surgical procedures but also a myriad of other responsibilities. From April to May 2023, we conducted a CHERRIES-compliant internet-based survey analyzing clinical practice, academic engagement, and post-on-call rest. The questionnaire featured six sections with 35 questions. Statistical analysis used Chi-square tests, ANOVA, and logistic regression (SPSS® v. 28). The survey received a total of 1.046 responses (65.4%). Over 78.0% of responders came from Europe, 65.1% came from a general surgery unit; 92.8% of European and 87.5% of North American respondents were involved in research, compared to 71.7% in Africa. Europe led in publishing research studies (6.6 ± 8.6 yearly). Teaching involvement was high in North America (100%) and Africa (91.7%). Surgeons reported an average of 6.7 ± 4.9 on-call shifts per month, with European and North American surgeons experiencing 6.5 ± 4.9 and 7.8 ± 4.1 on-calls monthly, respectively. African surgeons had the highest on-call frequency (8.7 ± 6.1). Post-on-call, only 35.1% of respondents received a day off. Europeans were most likely (40%) to have a day off, while African surgeons were least likely (6.7%). On the adjusted multivariable analysis HDI (Human Development Index) (aOR 1.993) hospital capacity &gt; 400 beds (aOR 2.423), working in a specialty surgery unit (aOR 2.087), and making the on-call in-house (aOR 5.446), significantly predicted the likelihood of having a day off after an on-call shift. Our study revealed critical insights into the disparities in workload, access to research, and professional opportunities for surgeons across different continents, underscored by the HDI

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries