Category Archives: BJS

Perioperative lactate dynamics and value for prediction of clinically relevant post-hepatectomy liver failure (grade B or C) in the exploration cohort (509 patients) a Median lactate values (with interquartile range) before surgery (baseline), maximum value within 24 h (Max) and on the morning of postoperative day 1 (POD1; *all P 

Video: Early postoperative arterial lactate concentrations to stratify risk of post-hepatectomy liver failure

Post-hepatectomy liver failure (PHLF) represents the major determinant for death after liver resection. Early recognition is essential. Early postoperative lactate values are powerful, readily available markers for clinically relevant PHLF and associated complications after hepatectomy with potential for guiding postoperative care. This video explains the recent study published in BJS.

Cumulative incidence of retained common bile duct stones on postoperative endoscopic retrograde cholangiopancreatography Active intervention versus surveillance per common bile duct (CBD) stone size. IOC, intraoperative cholangiography; ECRP, endoscopic retrograde cholangiopancreatography.

Video: Intervention versus surveillance in patients with common bile duct stones detected by intraoperative cholangiography

Each year 13 000 patients undergo cholecystectomy in Sweden, and routine intraoperative cholangiography (IOC) is recommended to minimize bile duct injuries. IOC plus an intervention to remove CBD stones identified during cholecystectomy was associated with reduced risk for retained stones and unplanned ERCP, even for the smallest asymptomatic CBD stones in this BJS study.

Hernias in children

Guest blog in plain English: Hernias in children

Nathalie Auger, Francesca del Giorgio, Annie Le-Nguyen, Marianne Bilodeau-Bertrand, Nelson Piché

University of Montreal Hospital Research Centre, Montreal, Quebec, Canada

Are women who have inguinal hernias more likely to have a child with an inguinal hernia? Have you ever wondered why a child may develop an inguinal hernia? Inguinal hernias affect about 4% of children1,2, but the reasons why are very unclear. An inguinal hernia occurs when intestinal tissues push through a weak spot in the abdominal wall. Most children with inguinal hernias are thought to have developed this disorder while still in their mother’s womb1,3. Yet there has been little attention to the possibility that the characteristics of mothers could predict which children will develop inguinal hernias while growing up.

We studied whether women who were previously diagnosed or treated for an inguinal hernia were more likely to have a child with an inguinal hernia. To test our research question, we analyzed the health status of 795,590 children from the province of Quebec, Canada4. We collected information from their mothers including her age, pregnancy complications, diseases she may have had in the past, and whether she was ever treated for an inguinal hernia. We closely followed her child over time to find out if the child was ever hospitalized for an inguinal hernia between birth and 13 years of age. We used regression methods to determine how characteristics of the mothers were associated with the chance of having an inguinal hernia in the child, and made sure that we controlled for confounders that could lead to incorrect measurements.

Our findings were very enlightening. We confirmed that mothers with a history of inguinal hernia were more likely to have a child who develops an inguinal hernia. But we found that the risk was higher for daughters than sons. Girls whose mothers had an inguinal hernia were 5 times more likely to themselves have an inguinal hernia. Additionally, mothers with connective tissue disorders such as rheumatoid arthritis or lupus were more likely to have sons with inguinal hernias. The figure illustrates just how strong some of the associations were.

These results suggest that the characteristics of a mother may affect a child’s chance of having an inguinal hernia. The likelihood of having an inguinal hernia also depends on if the child is a girl or a boy. Some of this difference may be because the development of inguinal hernias in boys is not the same as in girls. But it is also possible that there is a genetically sex-linked component. Finally, the relationship between maternal connective tissue diseases and the risk of inguinal hernia in boys suggests that connective tissue architecture may be involved as well.

Although more research is needed to confirm these findings, doctors and patients should be aware that children with abdominal symptoms who have a mother with a history of an inguinal hernia or connective tissue disorder may themselves be more likely to have an inguinal hernia. For more information, we invite you to read our study that was recently published in British Journal of Surgery4.

References

1          Azarow K, Cusick R. Pediatric Surgery [Internet]. The Surgical clinics of North America, Vol. 92. 2012. Available from: http://www.sciencedirect.com/science/article/pii/S0039 610912000680 [accessed 11 February 2021]

2          Lao OB, Fitzgibbons RJ, Cusick RA. Pediatric inguinal hernias, hydroceles, and undescended testicles. Surgical Clinics of North America 2012; 92: 487–504.

3          Kapur P, Caty MG, Glick PL. Pediatric hernias and hydroceles. Pediatric Clinics of North America 1998; 45: 773–789.

4          Auger P, Del Giorgio F, Le-Nguyen A, Bilodeau-Bertrand M, Piché N. Pediatric hernias and hydroceles. British Journal of Surgery 2021.

Guest blog: Venous resection during pancreatoduodenectomy – there is still much to gain

J.V. Groen, Department of Surgery, Leiden University Medical Centre, Leiden, J.V.Groen@lumc.nl 

N. Michiels, Department of Surgery, Leiden University Medical Centre, Leiden, N.Michiels@lumc.nl        

J.S.D. Mieog, Department of Surgery, Leiden University Medical Centre, Leiden, J.S.D.Mieog@lumc.nl 

IMPORTANCE

The use of venous resection (portal or superior mesenteric vein [PV-SMV]) during pancreatoduodenectomy is increasing.1-4 In a recent international survey, we found that most pancreatic surgeons prefer a segmental resection with primary anastomosis over a partial wedge resection, because of a lower perceived risk of complications.5 The impact of the type of venous resection (wedge or segmental) on postoperative morbidity and survival is poorly understood in current literature.

QUESTION

Does type of venous resection during pancreatoduodenectomy for pancreatic cancer impact postoperative morbidity and overall survival?

FINDINGS

We performed a nationwide retrospective analysis of 1311 patients who underwent pancreatoduodenectomy for pancreatic cancer within the Dutch Pancreatic Cancer Group (2013-2017). A venous resection was performed in 27% patients (65% wedge resection; 35% segmental resection). Patients with segmental resection had more Clavien-Dindo ≥III complications (adjusted odds ratio 1.90, 95% confidence interval 1.22-2.98) and worse survival (adjusted hazard ratio 1.40, 95% confidence interval 1.10-1.78) compared to no venous resection. Patients with segmental resection had a higher rate of PV-SMV thrombosis (18%) as compared to patients with wedge resection (5%) and without venous resection (1%). Vascular complications (PV-SMV thrombosis or haemorrhage) were the indication for relaparotomy in 18 out of 23 (78%) patients with segmental resection. Tumour invasion in the resected PV-SMV did not differ between patients with segmental (67%) or wedge resection (69%).

In patients treated with neoadjuvant therapy, survival was comparable between types of venous resection, although patients with segmental resection had more Clavien-Dindo ≥III complications (52%) compared to venous wedge (19%) and without venous resection (21%).

MEANING

In contrast with the found preference for a segmental resection in the international survey, most patients underwent a wedge resection. Little is known what exactly drives the surgeon’s preference regarding choice of type of venous reconstruction.5 The results of this study implicate that an upfront segment resection is associated with both poor postoperative morbidity and poor survival. These findings are in line with a recent large international cohort study6 and contribute to the growing evidence that neoadjuvant chemotherapy should be considered in borderline resectable disease and suspected venous involvement. 

FUTURE

This study, and other studies from our group5,7, on venous resection during pancreatoduodenectomy demonstrated that there is much to gain with regards to patient selection (~30% of patients with venous resection do not have tumour invasion in the resected PV-SMV), surgical technique (variation in clamping techniques, heparinization, types of reconstruction and use of grafts and flow measurements), postoperative management (e.g. vascular complications as PV-SMV thrombosis, haemorrhages and portal hypertension) and pathological assessment (lack of internationally accepted grossing techniques of venous resections). We believe this is especially relevant for the future since venous resection will be even more common with the increasing use of neoadjuvant therapy. 

Several imaging tools are being investigated which can help selecting the right patients who need a venous resection to achieve a radical resection. Intraoperative ultrasound provides real-time imaging and feedback about the tumour, vascular involvement and resectability in patients with pancreatic cancer.8,9 We are currently analysing the data of our ULTRAPANC study which assesses the added value of intraoperative ultrasound in patients with pancreatic cancer and vascular involvement (https://www.trialregister.nl/trial/7621). A recent study showed the utility of computed tomography coupled with 3-dimensional image reconstruction in the assessment of superior mesenteric artery involvement after neoadjuvant therapy, the authors distinguish a “halo sign” (not involved) from a  “string sign” (involved).10 An interesting topic would be if these ‘’halo and string signs’’,  are also useful in the assessment of venous involvement with intraoperative ultrasound (or analogous ‘’signs’’, as the venous wall does not have an tunica adventitia). 

Recently defined benchmark outcomes for pancreatoduodenectomy with venous resection can be used to assess outcomes and identify areas for improvement on a hospital, regional or national level.11 The PREOPANC-4 trial (protocol in preparation) within the Dutch Pancreatic Cancer Group will investigate the implementation of a best-practice algorithm for patients with locally advanced pancreatic cancer. This study has the potential to improve surgical technique and management of patients undergoing arterial/venous resection during pancreatoduodenectomy in the Netherlands. 

In the present study, no data were available on the diagnosis, treatment and outcome of patients with PV-SMV thrombosis. We are currently collecting data for a successive study in which we will provide an overview of the current clinical practice in the Netherlands regarding the prevention, diagnosis, treatment and outcome of PV-SMV thrombosis following venous resection during pancreatoduodenectomy. A group from Japan recently performed an impressive study among 40 centres which showed that venous resection during pancreatoduodenectomy with splenic vein division frequently causes variceal formation, bleeding, and thrombocytopenia.12

Within the Dutch Pancreatic Cancer Group, pathological assessment of venous involvement have recently been standardized. The location of deepest invasion in the resected PV-SMV is assessed and all edges of the resected PV-SMV are assessed for radicality. A prospective study with this standardized pathological assessment is needed in to investigate the true prognostic value of (depth of) tumour invasion in the resected PV-SMV.

REFERENCES

  1. Kantor O, Talamonti MS, Wang CH, Roggin KK, Bentrem DJ, Winchester DJ, Prinz RA, Baker MS. The extent of vascular resection is associated with perioperative outcome in patients undergoing pancreaticoduodenectomy. HPB (Oxford) 2018;20(2): 140-146.
  2. Kleive D, Sahakyan MA, Berstad AE, Verbeke CS, Gladhaug IP, Edwin B, Fosby B, Line PD, Labori KJ. Trends in indications, complications and outcomes for venous resection during pancreatoduodenectomy. Br J Surg 2017;104(11): 1558-1567.
  3. van Roessel S, Mackay TM, Tol J, van Delden OM, van Lienden KP, Nio CY, Phoa S, Fockens P, van Hooft JE, Verheij J, Wilmink JW, van Gulik TM, Gouma DJ, Busch OR, Besselink MG. Impact of expanding indications on surgical and oncological outcome in 1434 consecutive pancreatoduodenectomies. HPB (Oxford) 2019;21(7): 865-875.
  4. Worni M, Castleberry AW, Clary BM, Gloor B, Carvalho E, Jacobs DO, Pietrobon R, Scarborough JE, White RR. Concomitant vascular reconstruction during pancreatectomy for malignant disease: a propensity score-adjusted, population-based trend analysis involving 10,206 patients. JAMA Surg 2013;148(4): 331-338.
  5. Groen JV, Stommel MWJ, Sarasqueta AF, Besselink MG, Brosens LAA, van Eijck CHJ, Molenaar IQ, Verheij J, de Vos-Geelen J, Wasser MN, Bonsing BA, Mieog JSD, Dutch Pancreatic Cancer G. Surgical management and pathological assessment of pancreatoduodenectomy with venous resection: an international survey among surgeons and pathologists. HPB (Oxford) 2021;23(1): 80-89.
  6. Machairas N, Raptis DA, Velázquez PS, Sauvanet A, de Leon AR, Oba A, Koerkamp BG, Lovasik B, Chan C, Yeo C, Bassi C, Ferrone CR, Kooby D, Moskal D, Tamburrino D, Yoon DS, Barroso E, de Santibañes E, Kauffmann EF, Vigia E, Robin F, Casciani F, Burdío F, Belfiori G, Malleo G, Lavu H, Hartog H, Hwang HK, Han HS, Marques HP, Poves I, Rosado ID, Park JS, Lillemoe KD, Roberts K, Sulpice L, Besselink MG, Abuawwad M, Del Chiaro M, de Santibañes M, Falconi M, D’Silva M, Silva M, Hilal MA, Qadan M, Sell NM, Beghdadi N, Napoli N, Busch OR, Mazza O, Muiesan P, Müller PC, Ravikumar R, Schulick R, Powell-Brett S, Abbas SH, Mackay TM, Stoop TF, Gallagher TK, Boggi U, van Eijck C, Clavien PA, Conlon KCP, Fusai GK. The Impact of Neoadjuvant Treatment on Survival in Patients Undergoing Pancreatoduodenectomy with Concomitant Portomesenteric Venous Resection: An International Multicenter Analysis. Ann Surg 2021.
  7. Groen, Jesse V. MD∗; van Manen, Labrinus MD∗; van Roessel, Stijn MD, PhD†; van Dam, Jacob L. MD‡; Bonsing, Bert A. MD, PhD∗; Doukas, Michael MD, PhD§; van Eijck, Casper H.J. MD, PhD‡; Farina Sarasqueta, Arantza MD, PhD∥; Putter, Hein MD, PhD¶; Vahrmeijer, Alexander L. MD, PhD∗; Verheij, Joanne MD, PhD∥; Besselink, Marc G. MD, PhD†; Groot Koerkamp, Bas MD, PhD‡; Mieog, J. Sven D. MD, PhD∗ Resection of the Portal-Superior Mesenteric Vein in Pancreatic Cancer, Pancreas: September 2021 – Volume 50 – Issue 8 – p 1218-1229 doi: 10.1097/MPA.0000000000001897
  8. Sibinga Mulder BG, Feshtali S, Farina Sarasqueta A, Vahrmeijer AL, Swijnenburg RJ, Bonsing BA, Mieog JSD. A Prospective Clinical Trial to Determine the Effect of Intraoperative Ultrasound on Surgical Strategy and Resection Outcome in Patients with Pancreatic Cancer. Ultrasound Med Biol 2019;45(8): 2019-2026.
  9. van Veldhuisen E, Walma MS, van Rijssen LB, Busch OR, Bruijnen RCG, van Delden OM, Mohammad NH, de Hingh IH, Yo LS, van Laarhoven HW, van Leeuwen MS, Nio CY, van Santvoort HC, de Vries J, Wessels FJ, Wilmink JW, Molenaar IQ, Besselink MG, van Lienden KP, Dutch Pancreatic Cancer G. Added value of intra-operative ultrasound to determine the resectability of locally advanced pancreatic cancer following FOLFIRINOX chemotherapy (IMAGE): a prospective multicenter study. HPB (Oxford) 2019.
  10. Habib JR, Kinny-Köster B, van Oosten F, Javed AA, Cameron JL, Lafaro KJ, Burkhart RA, Burns WR, He J, Thompson ED, Fishman EK, Wolfgang CL. Periadventitial dissection of the superior mesenteric artery for locally advanced pancreatic cancer: Surgical planning with the “halo sign” and “string sign”. Surgery 2020.
  11. Raptis DA, Sánchez-Velázquez P, Machairas N, Sauvanet A, Rueda de Leon A, Oba A, Groot Koerkamp B, Lovasik B, Chan C, Yeo CJ, Bassi C, Ferrone CR, Kooby D, Moskal D, Tamburrino D, Yoon DS, Barroso E, de Santibañes E, Kauffmann EF, Vigia E, Robin F, Casciani F, Burdío F, Belfiori G, Malleo G, Lavu H, Hartog H, Hwang HK, Han HS, Poves I, Rosado ID, Park JS, Lillemoe KD, Roberts KJ, Sulpice L, Besselink MG, Abuawwad M, Del Chiaro M, de Santibañes M, Falconi M, D’Silva M, Silva M, Abu Hilal M, Qadan M, Sell NM, Beghdadi N, Napoli N, Busch ORC, Mazza O, Muiesan P, Müller PC, Ravikumar R, Schulick R, Powell-Brett S, Abbas SH, Mackay TM, Stoop TF, Gallagher TK, Boggi U, van Eijck C, Clavien PA, Conlon KCP, Fusai GK. Defining Benchmark Outcomes for Pancreatoduodenectomy With Portomesenteric Venous Resection. Ann Surg 2020;272(5): 731-737.
  12. Mizuno S, Kato H, Yamaue H, Fujii T, Satoi S, Saiura A, Murakami Y, Sho M, Yamamoto M, Isaji S. Left-sided Portal Hypertension After Pancreaticoduodenectomy With Resection of the Portal Vein/Superior Mesenteric Vein Confluence in Patients With Pancreatic Cancer: A Project Study by the Japanese Society of Hepato-Biliary-Pancreatic Surgery. Ann Surg 2021;274(1): e36-e44.
Cerebral microbleed

Guest blog: Cerebral microbleeds following thoracic endovascular aortic repair

W. Eilenberg a,b**, M. Bechstein d**, P. Charbonneauc, F. Rohlffs a, A. Eleshra a, G. Panuccio a, J. Bhangu b, J. Fiehler d, R. Greenhalgh e, S. Haulon c, T. Kölbel a*

German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany

Department of General Surgery, Division of Vascular Surgery, Medical University of Vienna, Vienna, Austria

Centre de l’Aorte, Hôpital Marie Lannelongue, Groupe hospitalier Paris Saint Joseph, Université Paris Saclay, France

Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Vascular Surgical Research Group, Imperial College, London, UK.

** both authors contributed equally

E-mail: wolf.eilenberg@meduniwien.ac.at

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article. 

Stroke and cerebral damage are frequent findings after thoracic endovascular aortic repair (TEVAR) with a postoperative clinical stroke rate of 3-4% and silent brain infarcts (SBI) in about 80%.(1-4) However, the mechanism of stroke and subclinical cerebral damage in TEVAR is under-investigated. Current clinical research-efforts such as the STEP-registry (strokes from thoracic endovascular procedures) aim to better understand incidence of, and risk factors for stroke and cerebral damage after TEVAR, and to develop strategies for prevention.(5, 6) More than 60% of patients undergoing arch-TEVAR were reported to have SBIs on diffusion weighted magnetic resonance imaging (DW-MRI) despite protective efforts such as carbon dioxide (CO2) flushing of the endografts.(5, 6) The aim of the current study is to examine the occurrence of CMBs in patients after TEVAR within the STEP-registry and to evaluate their association with patient- and procedural factors.

Ninety-one patients treated with TEVAR in proximal landing zone (PLZ) 0-3 from September 2018 to January 2020 at the German Aortic Center (Hamburg, Germany) and Marie Lannelongue Hospital (Paris, France) were included in the study.(5) The location and number of CMBs were identified and analyzed with regards to procedural aspects, clinical outcome and Fazekas-score as indicator of preexisting vascular leukoencephalopathy.

Indication for TEVAR was type B dissection, degenerative aneurysm or other aortic disease in 44/91 (48.4%), 34/91 (37.3%) and 13/91 (14.3%) patients, respectively. Anatomical details have been described in detail previously.(5)

PLZ were 0, 1, 2 and 3 in 23/91 (25.3%), 10/91 (11.0%), 47/91 (51.6%) and 11/91 (12.1%) patients, respectively. Seventy-one/91 (78.0%) patients were treated in an elective setting. 23 (25%) patients received branched-TEVAR (B-TEVAR), 15 (17%) patients fenestrated-TEVAR (F-TEVAR) of which 4 (4%) patients had in-situ laser fenestrations. Fifty-three/91 (58%) patients received tubular endografts. The median proximal diameter of the aortic endoprosthesis was 38 (34-46) mm and 37/91 (40.7%) patients received a proximal bare stent. Technical success was reported in all cases. Intraoperative complications, such as prolonged hypotension, iatrogenic dissection of the left subclavian artery, aortic rupture during deployment of a stent-graft and proximal common iliac rupture, were reported in 4/91 (4.4%) patients. No periprocedural ischemic stroke or death occurred within 30 postoperative days (POD). 

On MRI performed within 7 POD (Median 4 (2-7)), a total of 1531 CMBs were detected in 58 (63.7%) patients by two neuroradiological experts; bilateral CMBs were identified in 46/58 (79.3%) patients (P=0.078). CMBs were present unilaterally in the right or left hemisphere in 9/58 (15.5%) and 3/58 (5.2%) patients (P=0.0001) respectively. 

More CMBs were found in the middle cerebral territory vs. the posterior territory and the anterior territory ((3.35 (5.56 SD) vs. 2.26 (4.05 SD) vs. 0.966 CMBs (2.87 SD) (P=0.045)),  Procedural factors associated with the presence of CMBs were deployment in zone 0/1 vs. 2/3 (P=0.001), placement of a branched or fenestrated endograft (P=0.025) and longer procedure time (≥120 min) (P=0.019). Proximal diameter of the endoprosthesis ≥40mm (P=0.016), reoperations linked to primary operation (P=0.017) and atheroma grade 4 and 5 (P=0.048) were significantly associated with CMB in a multivariate logistic binary regression model, whereas compliant balloon (P=0.053) use showed only a tendency.  

Multiple linear regression with Firth regression showed more CMBs in TEVAR with proximal diameter ≥40mm OR 6.8 (95% CI 1.65-41.59; P=0.007) and higher DWM Fazekas-score in postoperative MRI OR 2.6 (95% CI 1.06-7.92; P=0.037, indicator of pre-existing vascular leukoencephalopathy). There was no significant correlation between CMBs and SBIs (P=0.376). 

Since there is no pre-operative MRI data to compare to, a causal association between CMBs and TEVAR cannot be proven by the study design. Nevertheless, the observed rate of CMBs after TEVAR (63,7%) was increased compared to rates reported in the literature among a general population of similar mean age (28%).(7) Although the rate among elderly patients with preexisting cardiovascular diseases may generally be higher, a causal linkage between TEVAR and CMBs can therefore also not be ruled by our findings. With the multi-territorial pattern, an embolic and secondary hemorrhagic origin caused by TEVAR may be hypothesized. The middle cerebral artery territory was most frequently affected due to its higher volume and share of blood.(8), (9) CMBs may be of various origin. As SW-MRI is sensitive to para-, dia- and ferromagnetic compounds, the susceptible MRI lesions referred to as “CMBs” may in this postoperative state also result from embolic micromaterial originating from endovascular devices or dispersed microcalcifications from the aortic arch.

We could not identify a significant correlation between SBI and CMBs (P=0.376). In contrast to SBI, which were found predominantly in the left hemisphere, CMBs were detected bilaterally in the vast majority of patients (79.3 %) and unilateral occurrence was more frequent in the right hemisphere (P=0.0001). While cerebral microbleeds are known to occur predominantly in deep or infratentorial regions in the presence of cardiovascular risk factors, and in the temporal lobe in patients with cerebral amyloid angiopathy, a spatial predilection for the right hemisphere in case of unilateral occurrence has so far not been described.(10, 11)

We found an association of CMBs with the PLZ and atheroma grade of the aortic arch matching previously described associations of stroke, SBI and high-intensity transient signals on transcranial doppler with atheroma grade and PLZ. (12, 13)

Although the occurrence of CMBs after TEVAR did not lead to clinically apparent stroke, a potential long-term effect on cognitive function cannot be ruled out. 

The limitations of this study include its retrospective nature and the non-consecutive patient cohort. Pre-operative MRI weren´t available to safely differentiate between procedure-related and preexisting CMBs.  Multivariable and subgroup analysis are limited by low patient numbers and third error in multivariable analysis. Results should be interpreted with caution and only be used to generate hypotheses for future studies. 

CMBs are present bi-hemispherical in the majority of patients after endovascular arch TEVAR and associated with morphological and procedural factors. The clinical importance of this finding needs to be further examined.

References

1.         Kahlert P, Eggebrecht H, Jánosi RA, Hildebrandt HA, Plicht B, Tsagakis K, et al. Silent cerebral ischemia after thoracic endovascular aortic repair: a neuroimaging study.  Ann Thorac Surg. 98. Netherlands: © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc; 2014. p. 53-8.

2.         Perera AH, Rudarakanchana N, Monzon L, Bicknell CD, Modarai B, Kirmi O, et al. Cerebral embolization, silent cerebral infarction and neurocognitive decline after thoracic endovascular aortic repair. Br J Surg. 2018;105(4):366-78.

3.         Ullery BW, McGarvey M, Cheung AT, Fairman RM, Jackson BM, Woo EY, et al. Vascular distribution of stroke and its relationship to perioperative mortality and neurologic outcome after thoracic endovascular aortic repair.  J Vasc Surg. 56. United States: © 2012 Society for Vascular Surgery. Published by Mosby, Inc; 2012. p. 1510-7.

4.         Varkevisser RRB, Swerdlow NJ, de Guerre L, Dansey K, Li C, Liang P, et al. Thoracic Endovascular Aortic Repair With Left Subclavian Artery Coverage Is Associated With a High 30-Day Stroke Incidence With or Without Concomitant Revascularization. J Endovasc Ther. 2020;27(5):769-76.

5.         Charbonneau P, Kölbel T, Rohlffs F, Eilenberg W, Planche O, Bechstein M, et al. Silent Brain Infarction After Endovascular Arch Procedures: Preliminary Results from the STEP Registry.  Eur J Vasc Endovasc Surg. England: © 2020 European Society for Vascular Surgery. Published by Elsevier B.V; 2020.

6.         Rohlffs F, Haulon S, Kolbel T, Greenhalgh R, Collaborators S. Stroke From Thoracic Endovascular Procedures (STEP) Collaboration. Eur J Vasc Endovasc Surg. 2020;60(1):5-6.

7.         Poels MM, Ikram MA, van der Lugt A, Hofman A, Krestin GP, Breteler MM, et al. Incidence of cerebral microbleeds in the general population: the Rotterdam Scan Study. Stroke. 2011;42(3):656-61.

8.         Naylor AR. Translating Evidence into Practice: Surveillance after Carotid Interventions. Eur J Vasc Endovasc Surg. 2018;56(2):298-9.

9.         Kim DE, Park JH, Schellingerhout D, Ryu WS, Lee SK, Jang MU, et al. Mapping the Supratentorial Cerebral Arterial Territories Using 1160 Large Artery Infarcts. JAMA Neurol. 2019;76(1):72-80.

10.       Mesker DJ, Poels MM, Ikram MA, Vernooij MW, Hofman A, Vrooman HA, et al. Lobar distribution of cerebral microbleeds: the Rotterdam Scan Study.  Arch Neurol. 68. United States2011. p. 656-9.

11.       Vernooij MW, van der Lugt A, Ikram MA, Wielopolski PA, Niessen WJ, Hofman A, et al. Prevalence and risk factors of cerebral microbleeds: the Rotterdam Scan Study.  Neurology. 70. United States2008. p. 1208-14.

12.       Feezor RJ, Martin TD, Hess PJ, Klodell CT, Beaver TM, Huber TS, et al. Risk factors for perioperative stroke during thoracic endovascular aortic repairs (TEVAR). J Endovasc Ther. 2007;14(4):568-73.

13.       Morita Y, Kato T, Okano M, Suu K, Kimura M, Minamino-Muta E, et al. Incidence and Predictors of Catheterization-Related Cerebral Infarction on Diffusion-Weighted Magnetic Resonance Imaging. Biomed Res Int. 2016;2016:6052125.

St Gallen

Guest blog: Invasive lobular cancer of the breast remains a surgical challenge

U Narbe, P -O Bendahl, M Fernö, C Ingvar, L Dihge, L Rydén

Invasive lobular breast cancer is the second most common histological subtype and constitutes around 10-15% of all breast cancer. It is recognized by a peculiar diffuse growth pattern and disseminated spread of cancer cells contributing to diagnostic delay and difficulties in detecting the primary tumors by mammography and nodal metastasis by axillary ultrasound. Consequently, although invasive lobular breast cancer mainly displays a favorable luminal A molecular subtype, it is often diagnosed at a higher stage than invasive cancer of no special type. Despite these characteristics, histopathological subtype is not accounted for in Clinical Guidelines, in contrast to the molecular subtypes. In the BJS publication “The St. Gallen 2019 Guidelines understage the Axilla in Lobular Breast Cancer: a Population-Based Study” by Ulrik Narbe and co-authors, we have elaborated on the consequences for patients with invasive lobular cancers if completion axillary clearance would be omitted in patients with 1-2 nodal metastases.

For the breast surgeon, lobular cancer poses a challenge to surgery of the breast and to the axilla. Large tumor size and diffuse infiltrating margins are associated with an increased risk of positive margins after breast conserving surgery and in breast centers where MRI is available, complementary imaging is recommended ahead of primary surgery. Still a larger proportion of patients (66%) with lobular cancer undergo a mastectomy compared to other histological subtypes (43%) according to our registry study, supporting previous publications. So the dogma of de-escalating breast surgery from mastectomy to partial mastectomy in lobular cancer is challenging, keeping in mind that positive resection margins is a mandatory quality criteria in most centers pushing the choice of initial surgery towards upfront mastectomy.

Axillary surgery is moving towards de-escalation of surgical interventions for patients with 1-2 sentinel node metastases after the results of the Z0011 trial have been implemented worldwide and clearly supports that omission of completion axillary dissection is non-inferior provided the inclusion criteria for the trial is fulfilled. The Z0011 criteria for omission of completion axillary dissection is restricted to patients undergoing breast-conserving surgery, and is thus not applicable for lobular cancers operated by mastectomy. The St. Gallen 2019 guidelines extended the indication for abstaining completion axillary dissection to all patients of any tumor size irrespective of type of breast surgery. In addition, the guidelines recommended that the decision on adjuvant chemotherapy for luminal A-like tumors should include nodal staging and patients with 4 or more nodal metastasis (nodal stage II) were recommended adjuvant chemotherapy. For these patients there is hitherto no data on the role of genomic tests for risk stratification until the results of OPTIMA trial are presented. In this paper, we present data from the National Swedish Quality Registry with prospectively collected data retrieved from the period when a completion axillary clearance for patients with sentinel node metastases was recommended. We found a strong association between invasive lobular breast cancer and nodal stage II disease independent of other determinants such as tumour size.

Moreover, we validated the predominance of luminal A-like subtype in lobular cancer and among those the risk of nodal stage II disease was higher than for the corresponding group of invasive cancers of no specific type (19% compared with 3%). Importantly, patients with lobular cancer retained a predominance (60%) for luminal A-like subtype in the nodal stage II subgroup. In contrast, patients with nodal stage II disease and non-lobular cancers had a lower fraction of luminal A-like tumors (23%) compared with patients with a lower nodal status implicating that for most patients with nodal stage II and non-lobular cancers, the molecular subtype would guide adjuvant treatment decisions rather than nodal stage.

The biological mechanism behind the prevalence of a higher nodal burden in lobular cancer is today speculative. Hormone responsive tumors (ER positive) of all histological subtypes are characterized by a slightly increased risk of nodal metastasis, probably linked to a lower immunologic reaction in the primary tumor facilitating lymphatic spread. Moreover, the cornerstone of lobular cancers – loss of E-cadherin – facilitates detachment of cancer cells which might be of importance for metastatic spread. In the present study, we clearly present data on the independent association of lobular cancer with nodal spread underscoring that this association is not solely explained by a hormone responsive phenotype or a larger tumor size. 

This study highlights that lobular cancer is associated with a higher nodal burden than non-lobular cancer and omission of completion axillary clearance in sentinel node positive patients could thus understage the axilla. The consequence of this is that some 19% of all patients with invasive lobular cancer and luminal A-like subtype would be dismissed from recommendation of adjuvant chemotherapy. Today, the updated St. Gallen 2021 guidelines states that completion axillary clearance is recommended for patients where staging is necessary for adjuvant treatment recommendations and would largely correspond to lobular cancers with a luminal A-like molecular subtype. The challenge of de-escalating axillary surgery in lobular cancer is thus unresolved.

The consequence of understaging of the axilla in lobular cancer in terms of clinical outcome is, however, unclear while the responsiveness of chemotherapy in lobular cancer is considered poorer than the corresponding effect in non-lobular cancer. Despite the findings from neoadjuvant trials, lobular cancer is included in general recommendations on adjuvant chemo-endocrine therapy due to the lack of data specific for lobular cancer. The ongoing randomized trial SENOMAC holds some promise to shed light on the outcome for lobular cancers in the experimental arm in which adjuvant recommendations are not based on complete axillary staging. A strong recommendation for the future is to always include data on histological subtype in clinical trials to be able to stratify the cohort in future analysis. The small but aggressive molecular subtypes, triple-negative and HER2-positive, represent subgroups as small as the lobular histological subtype and today clin.trials.gov is overloaded by adjuvant and neoadjuvant treatment protocols specific for these molecular subtypes. So isn´t it time to reconsider protocols on invasive lobular breast cancer with luminal A-like subtypes? The phenotype indicates cancers at low-risk of distant spread which is balanced by a higher stage at diagnosis associated with a substantial risk of recurrence and death after long-term follow-up. The role of neoadjuvant endocrine therapy in this subgroup is far from settled and might open up for de-escalating surgery of the breast and axilla and shed light on the fascinating biology of lobular breast cancer.

Tsunami of systematic reviews and meta-analyses

Guest blog: A tsunami of overlapping reviews in surgery

Morihiro Katsura, Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan and Department of Surgery, Okinawa Chubu Hospital, Okinawa, Japan
Yasushi Tsujimoto, Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan and Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan
Shingo Fukuma, Associate Professor – Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
Toshi A Furukawa, Professor – Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan

As systematic review papers on the same topic continue to be published, a massive amount of information pours down on the readers, a trend that gradually amplifies like a tsunami every year1. This phenomenon is still not well unknown in our field for surgeons. A meta-epidemiological study conducted by our research team showed that considerable variability in results and methodological quality can be found among multiple systematic reviews and meta-analyses (SRs/MAs) on the same topic. Additionally, high methodological quality in the systematic review evaluation is independently associated with increased citation counts in the subsequent five years after adjusting for journal impact factors and other covariates. These results highlight the current situation wherein surgeons seeking high-quality “evidence-based surgery do not know which review results to believe in the clinical setting, even though SRs/MAs are central to evidence-based medicine. To reduce the burden on busy surgeons in finding the most relevant evidence, this study suggests that quality evaluations should play a complementary role, and researchers and journal editors should concentrate their efforts on reviews of more limited quantity but higher quality. 

These results highlight the current situation wherein surgeons seeking high-quality “evidence-based surgery do not know which review results to believe in the clinical setting

Many clinicians and researchers have felt the wastefulness of the recent explosion of similar review articles1,2. Several descriptive studies regarding duplicate review articles on pharmacological intervention have been reported3,4 but particularly in surgery, this is rarely discussed. Therefore, we hypothesized that there are many redundant overlapping SR/MA publications with conflicting results and variable qualities, even in the field of surgery5. We first identified all SRs/MAs focusing on surgical interventions published in 2015 via PubMed. We then searched for SRs/MAs of similar RCTs published within the preceding five years (between 2011 and 2015). As the research progressed, an interesting idea arose among our research team to examine the number of citations as a measure of scientific impact after publication; therefore, we decided to investigate factors associated with the number of five-year citations through 2020 (Figure 1). This research was conducted in collaboration with the Research Group on Meta-epidemiology at Kyoto University School of Public Health.The results of this study were published online in the British Journal of Surgery on 17th November 2021.

Figure 1. Study schema outlining the steps of our search

Omission and commission phenomenon

Figure 2. Image of omission and commission phenomena (Blue circle, publication year of each RCT; Green circle, previous systematic review published in 2013; Red circle, recent systematic review published in 2015)

Ideally, all randomized controlled trials (RCTs) included in previous SRs/MAs should also be included in subsequently published SRs/MAs. In the real world, however, some of them have been omitted (Figure 2). We attempted to visualize this omission and commission phenomenon and compared the coverage probabilities of all RCTs that were published until the publication year of each SR/MA (one example is shown in Table 2). As a result, we found that there was considerable variability in coverage probability for relevant RCTs, and this was observed on almost every topic except the Cochrane update review.

Table 1. Coverage probabilities of 5 overlapping systematic reviews and meta-analyses on a single topic (‘Early vs. Delayed laparoscopic cholecystectomy for acute cholecystitis’) between 2011 and 2015

Discrepant results among overlapping systematic reviews

We found discrepancies among overlapping SRs/MAs on the same topic, such as different effect sizes, different statistical precisions, and even different directions of effect for many topics. Of course, although this is only the result of a sample within a wide surgical field, we believe that it is highly representative.

We show some examples of the discrepancies of pooled effect estimates among overlapping SRs/MAs in Table 2. For the topic ‘Appendectomy vs. Antibiotic treatment for acute appendicitis’, while the largest odds ratio (OR) was 8.13, the smallest was 0.54, a difference by a factor of 15.06 (Table 2), which was the largest difference among the 29 surgical topics which we reviewed in this study. We hypothesize that the major reasons why the pooled effect estimates are so different among overlapping SRs/Mas are related to differences in coverage probability for relevant RCTs (Table 1) and differences among the study subjects. Of course, there could be many other reasons, so we expect further research to shed light on some of them. Interestingly, overlapping publications have continued to increase since 2015, according to an updated PubMed search, particularly for topics with a large discrepancy in the study results.

Table 2. Differences in pooled effect estimates among overlapping systematic reviews between 2011 and 2015: Five representative examples from the 29 topics
(PCI, Percutaneous coronary intervention; CABG, Coronary artery bypass graft; PD, Pancreaticoduodenectomy)

How do you select a systematic review paper for citation?

When we write a scientific paper, what important factors are considered when picking systematic review articles to cite for our research? Many researchers may answer that it is the journal’s name recognition or impact factor. We used a mixed-effects regression model with a random intercept for surgical topics, which has been used as an analytical method in previous meta-epidemiological studies6, to investigate factors associated with the five-year citation counts of each SR/MA. As expected, a high journal impact factor (5.50 counts more per 1-point increment; 95% CI, 3.97 to 7.03; P <.001) was associated with a greater 5-year citation count. In addition, after adjusting for journal impact factors and other covariates, a high quality score (AMSTAR score 8-11) was independently associated with greater 5-year citation counts with a low quality score (AMSTAR score of 0-3) used as a reference (33.36 counts more; 95% CI, 16.20 to 50.51; P <.001). It is natural for researchers to evaluate the quality of the papers they would cite.

Implication for research and practice

Surgical SRs/MAs rarely include RCTs but instead focus on many nonrandomized trial designs. In this study, we evaluated SRs/MAs with only RCTs, which means that most SRs/MAs were excluded, and therefore, the situation is expected to be more serious in the real world. Surgical SRs/MAs may also be conducted predominantly by surgeons, lacking the involvement of methodologists or evidence synthesis experts, which could limit the quality of the research. There may be a significant risk of accepted wisdom concerning the hierarchy of evidence levels if numerous SRs/MAs on the same topic show high variability in the results and methodological quality. To prevent unnecessary duplication, the international Prospective Register for Systematic Reviews (PROSPERO) was launched in 2011; today, however, it may rarely work properly in practice and may only be considered as a courtesy7. Another novel approach, the “Living systematic review“, has been proposed: SRs are continually updated, incorporating relevant new evidence as it becomes available. It may be time to seek such new and more efficient methods8. Prior to initiating a project in surgical SRs/MAs, adequate communication and team building between surgeons and methodologists are critical in preventing duplication of research efforts and ensuring methodological rigor and currency. While further study is needed to discuss the problems of overlapping publications in surgical SRs/MAs, findings from our study may help guide clinicians, researchers and journal editors.

Researchers and journal editors should concentrate their efforts on reviews of more limited quantity but higher quality.

References

  1. Ioannidis JP. The mass production of redundant, misleading, and conflicted systematic reviews and meta-analyses. Milbank Q 2016;94:485-514.
  2. Créquit P, Trinquart L, Yavchitz A, Ravaud P. Wasted research when systematic reviews fail to provide a complete and up-to-date evidence synthesis: the example of lung cancer. BMC Med 2016;14:8.
  3. Siontis KC, Hernandez-Boussard T, Ioannidis JP. Overlapping meta-analyses on the same topic: survey of published studies. BMJ 2013;347:f4501.
  4. Hacke C, Nunan D. Discrepancies in meta-analyses answering the same clinical question were hard to explain: a meta-epidemiological study. J Clin Epidemiol 2020;119:47-56
  5. Katsura M, Kuriyama A, Tada M, Yamamoto K, Furukawa TA. Redundant systematic reviews on the same topic in surgery: a study protocol for a meta-epidemiological investigation. BMJ Open 2017;7(8):e017411.
  6. Tsujimoto Y, Fujii T, Onishi A, Omae K, Luo Y, Imai H, et al. No consistent evidence of data availability bias existed in recent individual participant data meta-analyses: a meta-epidemiological study. J Clin Epidemiol 2020;118:107-114.
  7. Moher D, Booth A, Stewart L. How to reduce unnecessary duplication: use PROSPERO. BJOG 2014;121:784-786.
  8. Hilton J, Tovey D, Shemilt I, Thomas J; Living Systematic Review Network. Living systematic review: 1. Introduction-the why, what, when, and how. J Clin Epidemiol 2017;91:23-30.

The illustration was created by the Tsuchimochi design office. Image source: hand drawing/Shutterstock.com under license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

European Hernia Society RD classification

European Hernia Society guidelines on management of rectus diastasis

Eight surgeons came together to review the available evidence on the management of rectus diastasis and produce evidence-based guidelines. Sadly the evidence quality ranged from very low to moderate. Despite this, the team were able to provide nine recommendations, with the strength of the recommendation ranging from weak to strong.

The nine key questions were:

KQ1 What is the definition of RD?

KQ2 Which modalities are most suitable for diagnosis and assessment of RD?

KQ3 What are the classification systems for RD?

KQ4 What symptoms are associated with RD?

KQ5 Which outcome measures should be used to evaluate treatment for RD?

KQ6 Are there non-operative treatment options for RD?

KQ7 What are the surgical treatment options in patients without concomitant hernias?

KQ8 What is the optimal treatment of rectus diastasis with concomitant umbilical or epigastric hernias?

KQ9 Is there a role for specific postoperative management of RD repair?

This is clearly an area of surgery where higher-quality research is needed; until that is achieved, these guidelines, together with detailed, honest, and open discussions with patients, offer the best pathway towards shared, evidence-based, decision making.

Calculator

Guest blog: “Are you a gambler or an accountant?”

Permanent stoma rates after anterior resection for rectal cancer

Authors: E Back, J Häggström, K Holmgren, M M Haapamäki, P Matthiessen, J Rutegård, M Rutegård

Anterior resection for rectal cancer is a beautiful operation. Whether with hand-held electrocautery or robotic scissors, uncovering the mesorectal package in embryological planes is a most satisfying moment, especially when followed up by a nice, tension-free and well-perfused anastomosis; when all goes well, of course. Unfortunately, anastomotic breakdown is a far too common and dangerous event, tripling the risk of early death1. Quite often, such an event also leads to reoperation and a permanent stoma2. No wonder then that, after decades of research on the merits of defunctioning stomas preventing anastomotic leakage3, there’s a near ubiquitous use in low anterior resection4 (though recent reports challenge this dogma5). The caveat, it seems, is that even temporary stomas cause problems6 and might never be reversed7, questioning the sphincter-saving procedure itself. Moreover, the spectre of severe low anterior resection syndrome rears its ugly head even when a textbook outcome is accomplished8; on the other hand, quality of life might be worse for patients with a permanent stoma9, and this was reported even in the stoma-friendly Scandinavian environment.

The problem is insurmountable, it seems. Do you choose bowel dysfunction and the risk of a leak, or do you opt for a permanent stoma at the get go? Would you dare omit the defunctioning stoma? In short, are you a gambler or an accountant?

In any case, information on an individual patient level is sorely needed for such an important discussion. We’ve recently published a prediction study using pre-operative variables collected from the Swedish Colorectal Cancer Registry, where an attempt has been made at forecasting the risk of a permanent stoma at two years after anterior resection for rectal cancer. While close to five thousand patients contributed data in the analysis, using the ensemble method SuperLearner to develop and validate a moderately accurate prediction model, the real thrust from this study lies in the on-line calculator. The input is shown in Figure 1, where the key predictors can be varied to reflect the patient at hand.

Figure 1. Variables included in the logistic forward-backward selection model can be varied, reflecting the individual patient.

There are certainly more variables of importance out there, and the experienced surgeon will surely add some data to a mental recalculation; smoking, on-going inflammation, continuous immunosuppressive medication, as well as a weak sphincter might decrease the chances of a stoma-free outcome even more. The output can be seen in Figure 2, where the risk of a permanent stoma is depicted in a cross-tabulation of defunctioning stoma use and laparoscopy use; those factors are the only ones that can be altered at a preoperative consultation. Importantly, the output is a predicted risk with measures of uncertainty, providing lower and upper bounds of the permanent stoma risk. Consistently, there is a higher risk of a permanent stoma with the use of a defunctioning stoma, which recently was shown using mediation analysis4.

Figure 2. Output from the prediction model with corresponding measures of uncertainty.

We urge all fellow surgeons to play around with the calculator – it’s actually quite addictive. Perhaps it can be informative in a patient-centred approach to anterior resection, as it seems that, stoma avoidance has the same priority as cure of cancer in some patient populations10. While at it, we can also recommend the internationally validated prediction model for low anterior resection syndrome, POLARS11. While all these prediction models can be improved, it is certainly worthwhile for both surgeon and patient to have some idea of the expected results after anterior resection. 

References

1 Boström P, Haapamäki MM, Rutegård J, Matthiessen P, Rutegård M. Population-based cohort study of the impact on postoperative mortality of anastomotic leakage after anterior resection for rectal cancer. BJS Open. 2019 Feb; 3: 106–111. 

2 Holmgren K, Kverneng Hultberg D, Haapamäki MM, Matthiessen P, Rutegård J, Rutegård M. High stoma prevalence and stoma reversal complications following anterior resection for rectal cancer: a population-based multicentre study. Colorectal Dis. 2017 Dec; 19: 1067–1075. 

3 Matthiessen P, Hallböök O, Rutegård J, Simert G, Sjödahl R. Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg. 2007 Aug; 246: 207–214. 

4 Holmgren K, Häggström J, Haapamäki MM, Matthiessen P, Rutegård J, Rutegård M. Defunctioning stomas may reduce chances of a stoma-free outcome after anterior resection for rectal cancer. Colorectal Dis. 2021 Jul 26; 

5 Talboom K, Vogel I, Blok RD, Roodbeen SX, Ponsioen CY, Bemelman WA, et al. Highly selective diversion with proactive leakage management after low anterior resection for rectal cancer. Br J Surg. 2021 Jun 22; 108: 609–612.

6 Gessler B, Haglind E, Angenete E. A temporary loop ileostomy affects renal function. Int J Colorectal Dis. 2014 Sep; 29: 1131–1135. 

7 Jørgensen JB, Erichsen R, Pedersen BG, Laurberg S, Iversen LH. Stoma reversal after intended restorative rectal cancer resection in Denmark: nationwide population-based study. BJS Open. 2020 Dec 2; 4: 1162–1171. 

8 Emmertsen KJ, Laurberg S, Rectal Cancer Function Study Group. Impact of bowel dysfunction on quality of life after sphincter-preserving resection for rectal cancer. Br J Surg. 2013 Sep; 100: 1377–1387. 

9 Näsvall P, Dahlstrand U, Löwenmark T, Rutegård J, Gunnarsson U, Strigård K. Quality of life in patients with a permanent stoma after rectal cancer surgery. Qual Life Res. 2017 Jan; 26: 55–64. 

10        Wrenn SM, Cepeda-Benito A, Ramos-Valadez DI, Cataldo PA. Patient Perceptions and Quality of Life After Colon and Rectal Surgery: What Do Patients Really Want? Dis Colon Rectum. 2018 Aug; 61: 971–978. 

11        Battersby NJ, Bouliotis G, Emmertsen KJ, Juul T, Glynne-Jones R, Branagan G, et al. Development and external validation of a nomogram and online tool to predict bowel dysfunction following restorative rectal cancer resection: the POLARS score. Gut. 2018 Apr; 67: 688–696. 

Guest blog: Keyhole versus open surgery for oesophageal cancer

Authors: B. P. Müller-Stich, P. Probst, H. Nienhüser, S. Fazeli, J. Senft, E. Kalkum, P. Heger, R. Warschkow, F. Nickel, A.T. Billeter, P. P. Grimminger, C. Gutschow, T. S. Dabakuyo-Yonli, G. Piessen, M. Paireder, S. F. Schoppmann, D. L. van der Peet, M. A. Cuesta, P. van der Sluis, R. van Hillegersberg, A. H. Hölscher, M. K. Diener, T. Schmidt

Minimally invasive resection of esophageal cancer might be less traumatic than open resection and has the potential to reduce complications and even improve survival. In contrast, oncological radicality might be negatively affected by the minimal-invasive approach. The aim of this BJS study was to generate 1A level of evidence on the question whether a minimally invasive approach for oncological esophagectomy is advantageous. A systematic literature search was performed and exclusively randomized-controlled trials (RCTs) comparing minimally invasive to open oncological esophagectomy were included in a meta-analysis.

Among 3219 articles six RCTs (four trials from Europe, two from Asia) were found including 822 patients. Survival data and short-term postoperative outcome data was analyzed. From the four European trials (Biere et al. Lancet 2012; Paireder et al. Eur Surg 2018; van der Sluis et al. Ann Surg 2019; Mariette et al. NEJM 2019) individual patient data was retrieved to analyze survival according to the different surgical approaches. Overall survival (56% minimally invasive) vs. (52% open) and disease-free survival (54% vs. 50%) after three years were comparable. Strikingly, the risk of postoperative complications was significantly reduced to one third in the minimal invasive group mainly due to the reduction of pulmonary complications and, in particular, pneumonia. Other parameters, especially those indicating oncological quality of the resection as number of harvested lymph nodes, did not differ between the two groups while the operation time was shorter in the open group. There was no significant difference in the rate of anastomotic leakage, length of stay in the intensive care unit or in the hospital and in the perioperative mortality while total blood loss was lower in the minimal invasive group.

As this meta-analysis included only high-quality randomized controlled trials, it generates high level evidence for the perioperative advantages of minimal invasive esophagectomy. The minimally invasive approach significantly reduces the risk of complications compared to open surgery and does not impair long-term oncological outcome. It should therefore be the preferred approach for cancer-related oesophagectomy.