An update on the incidence of perioperative outcomes after carotid endarterectomy, stratified by type of preprocedural neurologic symptom

Objective: Perioperative complications after carotid endarterectomy (CEA) have decreased over time. Therefore, we aimed to provide an update on 30-day outcomes after CEA, stratified by type of preprocedural neurologic symptom. Methods: We included all CEAs from the Targeted Vascular module of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP, 2011-2015) and stratified patients based on type of preprocedural neurologic symptom, that is, asymptomatic, ocular transient ischemic attack (TIA), hemispheric TIA, and stroke. We compared 30-day outcomes across the groups, with 30-day stroke/death as our primary endpoint. Results: Of 16,739 CEA patients, 9784 were asymptomatic (58%). Among the 6955 symptomatic patients, 1216 (17%) had a preprocedural ocular TIA, 2635 (38%) a preprocedural hemispheric TIA, and 3104 (45%) a preprocedural stroke. Preprocedural stroke patients had higher 30-day stroke/death rates compared with those with a preprocedural hemispheric TIA, or ocular TIA, or asymptomatic patients (5.0% vs 3.3%, 1.9%, and 1.8%, respectively; all P <.001), primarily owing to differences in perioperative 30-day stroke rates, with 4.1% vs 2.5%, 1.4%, and 1.3%, respectively (all P <.001). Conclusions: Among symptomatic CEA patients, those with a preprocedural stroke had a high perioperative 30-day stroke/death rate, compared with those patients with either a preprocedural hemispheric or ocular TIA. Therefore, the common stratification applied to CEA patients, which groups all symptomatic patients, should be avoided, especially as the relative proportion of symptomatic patients with a preprocedural stroke vs those with a hemispheric or ocular TIA will affect the overall outcome for all symptomatic patients after CEA

The measured distance between tumor cells and the peritoneal surface predicts the risk of peritoneal metastases and offers an objective means to differentiate between pT3 and pT4a colon cancer

Substantial variability exists in what pathologists consider as pT4a in colorectal cancer when tumor cells are within 1 mm of the free peritoneal surface. This study aimed to determine if the measured sub-millimeter distance between tumor cells and the free peritoneal surface would offer an objective means of stratifying patients according to the risk of developing peritoneal metastases. Histological slides of patients included in the COLOPEC trial, with resectable primary c/pT4N0-2M0 colon cancer, were centrally reassessed. Specific tumor morphological variables were collected, including distance from tumor to free peritoneal surface, measured in micrometers (mu m). The primary outcome, 3-year peritoneal metastasis rate, was compared between four groups of patients stratified for relation of tumor cells to the peritoneum: 1) Full peritoneal penetration with tumor cells on the peritoneal surface, 2) 0-99 mu m distance to the peritoneum, 3) 100-999 mu m to the peritoneum, and 4) >= 1000 mu m to the peritoneum, by using Kaplan-Meier analysis. In total, 189 cases were included in the present analysis. Cases with full peritoneal penetration (n = 89), 0-99 mu m distance to the peritoneal surface (n = 34), 100-999 mu m distance (n = 33), and >= 1000 mu m distance (n = 33), showed significantly different 3-year peritoneal metastases rates of 25% vs 29% vs 6% vs 12%, respectively (Log Rank, p = 0.044). N-category did not influence the risk of peritoneal metastases in patients with a tumor distance beyond 100 mu m, while only the N2 category seemed to result in an additive risk in patients with a distance of 0-99 mu m. The findings of this study suggest that the measured shortest distance between tumor cells and the free peritoneal surface is useful as an objective means of stratifying patients according to the risk of developing peritoneal metastases. This simple measurement is practical and may help in providing a precise definition of pT4a. Trial registration: NCT02231086 (Clinicaltrials.gov)

Laparoscopic versus open colorectal surgery in the emergency setting: A systematic review and meta-analysis

Objective: This systematic review and meta-analysis aimed to compare published outcomes of patients undergoing laparoscopic versus open emergency colorectal surgery, with mortality as primary outcome. Background: In contrast to the elective setting, the value of laparoscopic emergency colorectal surgery remains unclear. Methods: PubMed, Embase, the Cochrane Library, and CINAHL were searched until January 6, 2021. Only comparative studies were included. Meta-analyses were performed using a random-effect model. The Cochrane Risk of Bias Tool and the Newcastle-Ottawa Scale were used for quality assessment. Results: Overall, 28 observational studies and 1 randomized controlled trial were included, comprising 7865 laparoscopy patients and 55,862 open surgery patients. Quality assessment revealed ‘good quality’ in 16 of 28 observational studies, and low to intermediate risk of bias for the randomized trial. Laparoscopy was associated with significantly lower postoperative mortality compared to open surgery (odds ratio [OR] 0.44; 95% confidence interval [CI], 0.35–0.54). Laparoscopy resulted in significantly less postoperative overall morbidity (OR, 0.53; 95% CI, 0.43–0.65), wound infection (OR, 0.63; 95% CI, 0.45–0.88), wound dehiscence (OR, 0.37; 95% CI, 0.18–0.77), ileus (OR, 0.68; 95% CI 0.51–0.91), pulmonary (OR, 0.43; 95% CI, 0.24–0.78) and cardiac complications (OR, 0.56; 95% CI, 0.35–0.90), and shorter length of stay. No meta-analyses were performed for long-term outcomes due to scarcity of data. Conclusions: The systematic review and meta-analysis suggest a benefit of laparoscopy for emergency colorectal surgery, with a lower risk of postoperative mortality and morbidity. However, the almost exclusive use of retrospective observational study designs with inherent biases should be taken into account

Short- and Long-term Outcomes After Laparoscopic Emergency Resection of Left-Sided Obstructive Colon Cancer:A Nationwide Propensity Score-Matched Analysis

BACKGROUND: The role of laparoscopy for emergency resection of left-sided obstructive colon cancer remains unclear, especially regarding impact on survival. OBJECTIVE: This study aimed to determine short- and long-term outcomes after laparoscopic versus open emergency resection of left-sided obstructive colon cancer. DESIGN: This observational cohort study compared patients who underwent laparoscopic emergency resection to those who underwent open emergency resection between 2009 and 2016 by using 1:3 propensity-score matching. Matching variables included sex, age, BMI, ASA score, previous abdominal surgery, tumor location, cT4, cM1, multivisceral resection, small-bowel distention on CT, and subtotal colectomy. SETTING: This was a nationwide, population-based study. PATIENTS: Of 2002 eligible patients with left-sided obstructive colon cancer, 158 patients who underwent laparoscopic emergency resection were matched with 474 patients who underwent open emergency resection. INTERVENTIONS: The intervention was laparoscopic versus open emergency resection. MAIN OUTCOME MEASURES: The main outcome measures were 90-day mortality, 90-day complications, permanent stoma, disease recurrence, overall survival, and disease-free survival. RESULTS: Intentional laparoscopy resulted in significantly fewer 90-day complications (26.6% vs 38.4%; conditional OR, 0.59; 95% CI, 0.39-0.87) and similar 90-day mortality. Laparoscopy resulted in better 3-year overall survival (81.0% vs 69.4%; HR, 0.54; 95% CI, 0.37-0.79) and disease-free survival (68.3% vs 52.3%; HR, 0.64; 95% CI, 0.47-0.87). Multivariable regression analyses of the unmatched 2002 patients confirmed an independent association of laparoscopy with fewer 90-day complications and better 3-year survival. LIMITATIONS: Selection bias was the limitation that cannot be completely ruled out because of the retrospective nature of this study. CONCLUSIONS: This population-based study with propensity score-matched analysis suggests that intentional laparoscopic emergency resection might improve outcomes in patients with left-sided obstructive colon cancer compared to open emergency resection. Management of those patients in the emergency setting requires proper selection for intentional laparoscopic resection if relevant expertise is available, thereby considering other alternatives to avoid open emergency resection (ie, decompressing stoma).</p

Short- and Long-term Outcomes After Laparoscopic Emergency Resection of Left-Sided Obstructive Colon Cancer:A Nationwide Propensity Score-Matched Analysis

BACKGROUND: The role of laparoscopy for emergency resection of left-sided obstructive colon cancer remains unclear, especially regarding impact on survival. OBJECTIVE: This study aimed to determine short- and long-term outcomes after laparoscopic versus open emergency resection of left-sided obstructive colon cancer. DESIGN: This observational cohort study compared patients who underwent laparoscopic emergency resection to those who underwent open emergency resection between 2009 and 2016 by using 1:3 propensity-score matching. Matching variables included sex, age, BMI, ASA score, previous abdominal surgery, tumor location, cT4, cM1, multivisceral resection, small-bowel distention on CT, and subtotal colectomy. SETTING: This was a nationwide, population-based study. PATIENTS: Of 2002 eligible patients with left-sided obstructive colon cancer, 158 patients who underwent laparoscopic emergency resection were matched with 474 patients who underwent open emergency resection. INTERVENTIONS: The intervention was laparoscopic versus open emergency resection. MAIN OUTCOME MEASURES: The main outcome measures were 90-day mortality, 90-day complications, permanent stoma, disease recurrence, overall survival, and disease-free survival. RESULTS: Intentional laparoscopy resulted in significantly fewer 90-day complications (26.6% vs 38.4%; conditional OR, 0.59; 95% CI, 0.39-0.87) and similar 90-day mortality. Laparoscopy resulted in better 3-year overall survival (81.0% vs 69.4%; HR, 0.54; 95% CI, 0.37-0.79) and disease-free survival (68.3% vs 52.3%; HR, 0.64; 95% CI, 0.47-0.87). Multivariable regression analyses of the unmatched 2002 patients confirmed an independent association of laparoscopy with fewer 90-day complications and better 3-year survival. LIMITATIONS: Selection bias was the limitation that cannot be completely ruled out because of the retrospective nature of this study. CONCLUSIONS: This population-based study with propensity score-matched analysis suggests that intentional laparoscopic emergency resection might improve outcomes in patients with left-sided obstructive colon cancer compared to open emergency resection. Management of those patients in the emergency setting requires proper selection for intentional laparoscopic resection if relevant expertise is available, thereby considering other alternatives to avoid open emergency resection (ie, decompressing stoma).</p

Short- and Long-term Outcomes After Laparoscopic Emergency Resection of Left-Sided Obstructive Colon Cancer:A Nationwide Propensity Score-Matched Analysis

BACKGROUND: The role of laparoscopy for emergency resection of left-sided obstructive colon cancer remains unclear, especially regarding impact on survival. OBJECTIVE: This study aimed to determine short- and long-term outcomes after laparoscopic versus open emergency resection of left-sided obstructive colon cancer. DESIGN: This observational cohort study compared patients who underwent laparoscopic emergency resection to those who underwent open emergency resection between 2009 and 2016 by using 1:3 propensity-score matching. Matching variables included sex, age, BMI, ASA score, previous abdominal surgery, tumor location, cT4, cM1, multivisceral resection, small-bowel distention on CT, and subtotal colectomy. SETTING: This was a nationwide, population-based study. PATIENTS: Of 2002 eligible patients with left-sided obstructive colon cancer, 158 patients who underwent laparoscopic emergency resection were matched with 474 patients who underwent open emergency resection. INTERVENTIONS: The intervention was laparoscopic versus open emergency resection. MAIN OUTCOME MEASURES: The main outcome measures were 90-day mortality, 90-day complications, permanent stoma, disease recurrence, overall survival, and disease-free survival. RESULTS: Intentional laparoscopy resulted in significantly fewer 90-day complications (26.6% vs 38.4%; conditional OR, 0.59; 95% CI, 0.39-0.87) and similar 90-day mortality. Laparoscopy resulted in better 3-year overall survival (81.0% vs 69.4%; HR, 0.54; 95% CI, 0.37-0.79) and disease-free survival (68.3% vs 52.3%; HR, 0.64; 95% CI, 0.47-0.87). Multivariable regression analyses of the unmatched 2002 patients confirmed an independent association of laparoscopy with fewer 90-day complications and better 3-year survival. LIMITATIONS: Selection bias was the limitation that cannot be completely ruled out because of the retrospective nature of this study. CONCLUSIONS: This population-based study with propensity score-matched analysis suggests that intentional laparoscopic emergency resection might improve outcomes in patients with left-sided obstructive colon cancer compared to open emergency resection. Management of those patients in the emergency setting requires proper selection for intentional laparoscopic resection if relevant expertise is available, thereby considering other alternatives to avoid open emergency resection (ie, decompressing stoma).</p

Laparoscopic Versus Open Colorectal Surgery in the Emergency Setting

Objective:. This systematic review and meta-analysis aimed to compare published outcomes of patients undergoing laparoscopic versus open emergency colorectal surgery, with mortality as primary outcome. Background:. In contrast to the elective setting, the value of laparoscopic emergency colorectal surgery remains unclear. Methods:. PubMed, Embase, the Cochrane Library, and CINAHL were searched until January 6, 2021. Only comparative studies were included. Meta-analyses were performed using a random-effect model. The Cochrane Risk of Bias Tool and the Newcastle-Ottawa Scale were used for quality assessment. Results:. Overall, 28 observational studies and 1 randomized controlled trial were included, comprising 7865 laparoscopy patients and 55,862 open surgery patients. Quality assessment revealed ‘good quality’ in 16 of 28 observational studies, and low to intermediate risk of bias for the randomized trial. Laparoscopy was associated with significantly lower postoperative mortality compared to open surgery (odds ratio [OR] 0.44; 95% confidence interval [CI], 0.35–0.54). Laparoscopy resulted in significantly less postoperative overall morbidity (OR, 0.53; 95% CI, 0.43–0.65), wound infection (OR, 0.63; 95% CI, 0.45–0.88), wound dehiscence (OR, 0.37; 95% CI, 0.18–0.77), ileus (OR, 0.68; 95% CI 0.51–0.91), pulmonary (OR, 0.43; 95% CI, 0.24–0.78) and cardiac complications (OR, 0.56; 95% CI, 0.35–0.90), and shorter length of stay. No meta-analyses were performed for long-term outcomes due to scarcity of data. Conclusions:. The systematic review and meta-analysis suggest a benefit of laparoscopy for emergency colorectal surgery, with a lower risk of postoperative mortality and morbidity. However, the almost exclusive use of retrospective observational study designs with inherent biases should be taken into account