Laparoscopic versus Open Adrenalectomy for localised/ locally advanced primary Adrenocortical Carcinoma (ENSAT I-III) in adults. Is the Margin-free (R0) resection the predominant key which designates the surgical technique? - A review of the literature

Σκοπός της εργασίας ήταν η μελέτη και ανασκόπηση της βιβλιογραφίας ως προς τη θέση της λαπαροσκοπικής επινεφριδεκτομής στην αντιμετώπιση του πρωτοπαθούς τοπικού/ τοπικά προχωρημένου αδενοκαρκινώματος των επινεφριδίων (ENSAT I-III) στους ενήλικες. Μη τυχαιοποιημένες μελέτες που δημοσιεύτηκαν από τον Ιανουάριο του 1999 έως τον Φεβρουάριο του 2017 αναγνωρίστηκαν μέσω αναζήτησης στις βάσεις δεδομένων Pubmed, EMBASE, Cochrane Library και Google Scholar. Οι πρωταρχικές και οι δευτερεύουσες παράμετροι περιέλαβαν: χειρουργικές και παθολογικές μεταβλητές (ηλικία ασθενών, μέγεθος όγκου, στάδιο ENSAT, είδος χειρουργικής προσέγγισης, περίοδος παρακολούθησης), περιεγχειρητικά αποτελέσματα (χειρουργικός χρόνος, εκτιμώμενη απώλεια αίματος, διάρκεια νοσηλείας, ποσοστό μετατροπής σε ανοικτή μέθοδο , εκτομή R0, μικροσκοπικά όρια εκτομής χειρουργικού παρασκευάσματος) και ογκολογικά αποτελέσματα (ποσοστό συνολικής υποτροπής, ποσοστό υγιούς επιβίωσης/ ελεύθερης νόσου και συνολικό ποσοστό επιβίωσης), τα οποία αναλύθηκαν διεξοδικά στην παρούσα εργασία. Συνολικά 13 μελέτες με συνολικό αριθμό 1171 ασθενών περιλήφθηκαν στην ανασκόπηση. Σε σύγκριση με την ανοιχτή προσπέλαση, η λαπαροσκοπική επινεφριδεκτομή ανέδειξε επιλογή ασθενών με μικρότερο μέγεθος όγκου, παρουσίασε βραχύτερο χειρουργικό χρόνο με μικρότερη διεγχειρητική απώλεια αίματος και βραχύτερη μετεγχειρητική νοσηλεία, αλλά και υψηλότερα ποσοστά τοπικής υποτροπής. Δεν παρατηρήθηκαν σημαντικές διαφορές μεταξύ των ομάδων στις οποίες διενεργήθηκε ανοικτή ή λαπαροσκοπική μέθοδος για τις ακόλουθες μεταβλητές: R0 εκτομή με αρνητικά μικροσκοπικά χειρουργικά όρια, συνολική υποτροπή, συνολική ελεύθερης νόσου επιβίωση και ολική επιβίωση. Συμπερασματικά, αναδεικνύεται μέσω της παρούσας μελέτης, ότι η R0 εκτομή με αρνητικά μικροσκοπικά όρια εκτομής στο χειρουργικό παρασκεύασμα, μέσω του αδιαμφισβήτητου αντίκτυπού της στις μεταβλητές της συχνότητας υποτροπής (RR), της ελεύθερης νόσου επιβίωσης (DFS) και της ολικής επιβίωσης (OS), αποτελεί τον κυρίαρχο βασικό παράγοντα- κλειδί που υποδεικνύει την επιλογή της κατάλληλης χειρουργικής τεχνικής στη θεραπεία του πρωτοπαθούς αδενοκαρκίνωματος των επινεφριδίων (ENSAT I-III) σε ενήλικες. Αν και είναι τεχνικά απαιτητική, η λαπαροσκοπική επινεφριδεκτομή φαίνεται να είναι ασφαλής και εφικτή μέθοδος στα χέρια ενός έμπειρου χειρουργού (που εκτελεί> 10/ έτος), που διεξάγεται σε ειδικό κέντρο παραπομπής με επαρκή εμπειρία σε τέτοιες περιπτώσεις, υπό την αιγίδα μιας διεπιστημονικής ομάδας και πάντα με σεβασμό στις γενικές χειρουργικές ογκολογικές αρχές. Διεξαγωγή πολυκεντρικών τυχαιοποιημένων μελετών ελέγχου με σκοπό τη διερεύνηση των μακροχρόνια ογκολογικών αποτελεσμάτων των δύο τεχνικών, απαιτείται για να προσδιοριστούν τα πιθανά οφέλη της λαπαροσκοπικής σε σχέση με την ανοιχτή προσέγγιση στην χειρουργική αντιμετώπιση του αδενοκαρκινώματος των επινεφριδίων των ενηλίκων.Background: The aim of this study was to review the current literature on the role of laparoscopic adrenalectomy in the treatment of primary adrenocortical carcinoma (ENSAT I-III) in adults. Materials and Methods: Non-randomized control trials published between January 1999 to February 2017 were identified by searching the Pubmed, EMBASE, Cochrane Library and Google Scholar databases. Primary and secondary endpoints included surgical and pathological parameters (patients age, tumor size, ENSAT stage, type of surgical approach, period of follow-up), surgical outcomes (operative time, estimated blood loss, length of hospital stay, conversion rate to laparotomy, R0 resection, surgical margin’s status) and oncological outcomes (rate of recurrence, disease free survival and overall survival rates)were analysed. Results: A total of 13 studies with a total number of 1171 patients were included in the review. Compared with open approach, laparoscopic adrenalectomy demonstrated lower tumor size, shorter operative time, lower intraoperative blood loss, shorter postoperative hospital stay and higher local recurrence rates. No significant differences were observed between groups treated with an open or laparoscopic approach for the following criteria: R0 surgical resection status, tumor overall recurrence, postoperative disease free survival and overall survival rates. Conclusion: R0 Resection Status via its undeniable impact on Recurrence Rate (RR), Disease Free Survival (DFS) and Overall Survival (OS), is the actual predominant key factor which designates the selection of the appropriate surgical technique in the treatment of primary adrenocortical carcinoma (ENSAT I-III) in adults. Although a technically demanding procedure, laparoscopic adrenalectomy appears to be secure and feasible in the management of adrenocortical cancer in the hands of an experienced surgeon (performing >10 LAs/year), held in a referral specialised centre with sufficient experience in such cases, under the auspices of a multidisciplinary team, with respect to general surgical oncological principles.. Multicentre randomized controlled trials exploring its long-term oncological outcomes are required to determine the benefits of this procedure over the open approach. Key Words: "adrenocortical cancer", "laparoscopy" or laparoscopic", "open", "laparoscopic versus open", "adrenalectomy", "R0 resection", "margin status" and "oncological outcome"

A type of neoplasia deadlier than gastric adenocarcinoma? Report of a case of primary gastric squamous cell carcinoma

BackgroundPrimary gastric squamous cell carcinoma is an extremely rare malignancy with few case reports reported so far in the current medical literature. Its incidence varies between 0.04 and 0.07% of all gastric malignancies with a male predominance in the sixth decade of life. It has been found that this type of malignancy has a more aggressive behavior and associated poorer prognosis, when compared to gastric adenocarcinoma. Thus, the most appropriate management of this kind of neoplasia is still debatable due to the small number of reported cases.Case presentationWe report the case of a 66-year-old man who underwent total gastrectomy with D2 lymphadenectomy for an ulcerative lesion in the fundus of the stomach that turned out to be primary gastric squamous cell carcinoma.ConclusionsUpon confirmation of this specific malignancy, the affected patients should be enrolled in strict follow-up protocols after curative surgery, since the risk for metastasis is high. Physicians should maintain high clinical suspicion in order to diagnose these tumors at an early stage, along with the need to rule out any other possible primary sites of squamous malignancy

The CLEAR (Considering Leading Experts' Antithrombotic Regimes around peripheral angioplasty) survey: an international perspective on antiplatelet and anticoagulant practice for peripheral arterial endovascular intervention

Background: Antiplatelet and anticoagulant therapy are commonly used before, during and after peripheral arterial endovascular intervention. This survey aimed to establish antiplatelet and anticoagulant choice for peripheral arterial endovascular intervention in contemporary clinical practice. Methods: Pilot-tested questionnaire distributed via collaborative research networks. Results: One hundred and sixty-two complete responses were collected from responders in 22 countries, predominantly the UK (48%) and the rest of the European Union (44%). Antiplatelet monotherapy was the most common choice pre-procedurally (62%). In the UK, there was no difference between dual and single antiplatelet therapy use post procedure (50% vs. 37% p = 0.107). However, a significant majority of EU respondents used dual therapy (68% vs. 20% p < 0.001). There was variation in choice of antiplatelet therapy by the device used and the anatomical location of the intervention artery. The majority (82%) of respondents believed there was insufficient evidence to guide antithrombotic therapy after peripheral endovascular intervention and most (92%) would support a randomised trial. Conclusions: There is widespread variation in the use of antiplatelet therapy, especially post peripheral arterial endovascular intervention. Clinicians would support the development of a randomised trial comparing dual antiplatelet therapy with monotherapy

Global impact of the first coronavirus disease 2019 (COVID-19) pandemic wave on vascular services

This online structured survey has demonstrated the global impact of the COVID-19 pandemic on vascular services. The majority of centres have documented marked reductions in operating and services provided to vascular patients. In the months during recovery from the resource restrictions imposed during the pandemic peaks, there will be a significant vascular disease burden awaiting surgeons. One of the most affected specialtie

Global attitudes in the management of acute appendicitis during COVID-19 pandemic: ACIE Appy Study

Background: Surgical strategies are being adapted to face the COVID-19 pandemic. Recommendations on the management of acute appendicitis have been based on expert opinion, but very little evidence is available. This study addressed that dearth with a snapshot of worldwide approaches to appendicitis. Methods: The Association of Italian Surgeons in Europe designed an online survey to assess the current attitude of surgeons globally regarding the management of patients with acute appendicitis during the pandemic. Questions were divided into baseline information, hospital organization and screening, personal protective equipment, management and surgical approach, and patient presentation before versus during the pandemic. Results: Of 744 answers, 709 (from 66 countries) were complete and were included in the analysis. Most hospitals were treating both patients with and those without COVID. There was variation in screening indications and modality used, with chest X-ray plus molecular testing (PCR) being the commonest (19\ub78 per cent). Conservative management of complicated and uncomplicated appendicitis was used by 6\ub76 and 2\ub74 per cent respectively before, but 23\ub77 and 5\ub73 per cent, during the pandemic (both P < 0\ub7001). One-third changed their approach from laparoscopic to open surgery owing to the popular (but evidence-lacking) advice from expert groups during the initial phase of the pandemic. No agreement on how to filter surgical smoke plume during laparoscopy was identified. There was an overall reduction in the number of patients admitted with appendicitis and one-third felt that patients who did present had more severe appendicitis than they usually observe. Conclusion: Conservative management of mild appendicitis has been possible during the pandemic. The fact that some surgeons switched to open appendicectomy may reflect the poor guidelines that emanated in the early phase of SARS-CoV-2

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P &lt; 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research