Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND: The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting. METHODS: Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups. RESULTS: Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005). CONCLUSION: Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery

How to deal with large airways stenosis

Institutul National de Pneumologie "Marius Nasta", București, România, Al XIII-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” și al III-lea Congres al Societății de Endoscopie, Chirurgie miniminvazivă și Ultrasonografie ”V.M.Guțu” din Republica MoldovaManagementul stenozelor traheale rămâne o provocare terapeutică, necesitând un abord multidisciplinar. Orice leziune simptomatica ce limitează activitatea curentă a unui pacient trebuie abordată chirurgical, cel mai eficient tratament fiind rezecția traheală cu anastomoză. Cauza principala a stenozelor benigne este lezarea traheală post-intubație. Tumorile primitive traheale sunt rare, iar abordul chirurgical este de elecție. În cancerul tiroidian cu invazie traheală se practică rezecția ”în bloc’’ cu anastomoză termino-terminală. Opțiunile de tratament non-chirurgical (dilatațiile repetate, tratamentul laser, stentarea prelungită) sunt indicate doar la pacienți atent selecționați și sunt folosite în principal doar pentru stabilizarea stenozei până la tratamentul chirurgical. Evaluarea preoperatorie a pacienților cu stenoză traheală include fibrobronhoscopia pentru a determina gradul de afectare a căilor aeriene si examenul CT toracic pentru decelarea metastazelor la distanță, în cazul neoplaziilor. Abordul chirurgical se face prin: cervicotomie simplă, cervicotomie cu sternotomie parțială superioară sau toracotomie. Pacienții sunt inițial intubați cu o sondă endotraheala de calibru mic, până când traheea este expusă în plagă și disecată circumferențial, cu păstrarea nervilor laringei recurenți. În timpul rezecției și anastomozei pacientul este ventilat prin plagă cu ajutorul unei sonde de intubație poziționată în traheea distală. În cazul unei leziuni la nivelul treimei medii sau inferioare a traheei, se folosește ventilatia în jet cu frecvență înalta. Este foarte important ca anastomoza să nu fie realizată în tensiune deoarece dehiscentele pot fi fatale. Manevrele de relaxare traheala precum disectia anterioara a traheei și flexia cervicală permit o rezecție de până la 8 cartilagii traheale (4 cm) fără complicații. * * * The management of tracheal stenosis remains a challenge, requiring a multidisciplinary team. Any lesion that produces symptoms that limit patient activity should be considered for surgery. The most effective treatment is the tracheal resection with reconstruction. The main cause of benign stenosis is postintubation tracheal injury. Primary tracheal tumors are rare, but surgery gives the best local control. In tracheal involvement by thyroid cancer we perform ‘en-bloc’ resection with primary end-to-end anastomosis. Non-operative treatments (dilation, laser treatment, prolonged stenting) are indicated in selected patients and are mainly used to stabilize the stenosis before surgery. Preoperative assessment included brobchoscopy and CT-scan to evaluate the extent of the airway involvement and distant metastases if present. We use as surgical approach: cervical collar incision, cervical incision with partial sternal split or thoracotomy. The patients are intubated initially with a small caliber endotracheal tube until the trachea is exposed and circumferentially dissected, sparing the inferior laryngeal nerves. During resection and anastomosis the patients are kept ventilated by means of a distal intubation tube. In cases with lesions of the middle and lower third of the trachea we use high frequency jet ventilation. It is very important to have a tension-free anastomosis as anastomotic leakage can be fatal in most cases. Releasing maneuvers such as anterior dissection of the trachea and cervical flexion allows a total length of eight tracheal cartilages (4 cm in length) to be resected with no complications

Molecular characterization of Echinococcus granulosus in south-eastern Romania: evidence of G1G3 and G6G10 complexes in humans

Clin Microbiol Infect Echinococcus granulosus is the aetiological agent of cystic echinococcosis (CE), which is a public health problem in many eastern European countries, particularly in Romania, where the infection causes a high number of human and animal cases. To shed light on the transmission patterns of the parasite, we performed a genotyping analysis on 60 cyst samples obtained from patients who live in south-eastern Romania and who underwent surgery for liver or lung CE. DNA was extracted from the endocysts or the cyst fluids, and fragments of cytochrome c oxidase subunit 1 and NADH dehydrogenase subunit 1 mitochondrial genes (cox1 and nd1, respectively) were amplified by PCR and sequenced. We found that most of the samples analysed (59/60) belonged to the G1-G3 complex (E. granulosus sensu stricto), which contains the most widespread and infective strains of the parasite. We also identified the first human patient infected by a non-G1-G3 genotype of E. granulosus in this country. As the DNA sequence of this cyst sample showed maximum homology with the G6-G10 complex (Echinococcus canadensis), this is, in all likelihood, a G7 genotype, which is often found in pigs and dogs in most countries of eastern and south-eastern Europe