Jennifer Straatman

Predictive Value of C-Reactive Protein for Major Complications after Major Abdominal Surgery: A Systematic Review and Pooled-Analysis

Background Early diagnosis and treatment of complications after major abdominal surgery can decrease associated morbidity and mortality. Postoperative CRP levels have shown a strong correlation with complications. Aim of this systematic review and pooled-analysis was to assess postoperative values of CRP as a marker for major complications and construct a prediction model. Study design A systematic review was performed for CRP levels as a predictor for complications after major abdominal surgery (MAS). Raw data was obtained from seven studies, including 1427 patients. A logit regression model assessed the probability of major complications as a function of CRP levels on the third postoperative day. Two practical cut-offs are proposed: an optimal cut-off for safe discharge in a fast track protocol and another for early identification of patients with increased risk for major complications. Results A prediction model was calculated for major complications as a function of CRP levels on the third postoperative day. Based on the model several cut-offs for CRP are proposed. For instance, a two cut-off system may be applied, consisting of a safe discharge criterion with CRP levels below 75 mg/L, with a negative predictive value of 97.2%. A second cut-off is set at 215 mg/L (probability 20%) and serves as a predictor of complications, indicating additional CT-scan imaging. Conclusions The present study provides insight in the interpretation of CRP levels after major abdominal surgery, proposing a prediction model for major complications as a function of CRP on postoperative day 3. Cut-offs for CRP may be implemented for safe early-discharge in a fast-track protocol and, secondly as a threshold for additional examinations, such as CT-scan imaging, even in absence of clinical signs, to confirm or exclude major complications. The prediction model allows for setting a cut-off at the discretion of individual surgeons or surgical departments.

Systematic review of patient-reported outcome measures in the surgical treatment of patients with esophageal cancer.

Esophageal cancer is currently the eighth most common cancer worldwide. Improvements in operative techniques and neoadjuvant therapies have led to improved outcomes. Resection of the esophagus carries a high risk of severe complications and has a negative impact on health-related quality of life (QOL). The aim of this study was to assess which patient-reported outcome measures (PROMs) are used to measure QOL after esophagectomy for cancer. A comprehensive search of original articles was conducted investigating QOL after surgery for esophageal carcinoma. Two authors independently selected relevant articles, conducted clinical appraisal, and extracted data (PJ and JS). Out of 5893 articles, 58 studies were included, consisting of 41 prospective and 17 retrospective cohort studies, including a total of 6964 patients. These studies included 11 different PROMs. The existing PROMs could be divided into generic, symptom-specific, and disease-specific questionnaires. The European Organisation for Research and Treatment of Cancer (EORTC) QOL Questionnaire Core 30 (QLQ C-30) along with the EORTC QLQ-OESophagus module OES18 was the most widely used; in 42 and 32 studies, respectively. The EORTC and the Functional Assessment of Cancer Therapy (FACT) questionnaires use an oncological module and an organ-specific module. One validation study was available, which compared the FACT and EORTC, showing moderate to poor correlation between the questionnaires. A great variety of PROMs are being used in the measurement of QOL after surgery for esophageal cancer. A questionnaire with a general module along with a disease-specific module for assessment of QOL of different treatment modalities seem to be the most desirable, such as the EORTC and the FACT with their specific modules (EORTC QLQ-OES18 and FACT-E). Both are developed in different treatment modalities, such as in surgical patients. With regard to reproducibility of current results, the EORTC is recommended.

Hospital Cost-Analysis of Complications after Major Abdominal Surgery

Background: Complications after major abdominal surgery (MAS) are associated with increased morbidity and mortality. Rising costs in health care are of increasing interest and a major factor affecting hospital costs are postoperative complications. In this study, the costs associated with complications are assessed. Methods: Retrospective cohort study of 399 consecutive patients that underwent MAS. Analysis of total costs for hospital stay, complications and treatment was performed, including bootstrapping; allowing for subtraction of data with 95% confidence intervals. Results: For a single patient who underwent MAS the average costs, adjusted for ASA-classification and surgery type, adds up to EUR 8,584.81 (95% CI EUR 8,332.51 - EUR 8,860.81) in patients without complications. EUR 15,412.96 (95% CI EUR 14,250.22 - EUR 16,708.82) after minor complications, and EUR 29,198.23 (95% CI EUR 27,187.13 - EUR 31,295.78) after major complications (p < 0.001). Conclusion: The results provide an insight into the scope of hospital costs associated with complications. Major complications occur in 20% of patients undergoing MAS and account for 50% of the total costs of care. Implementation of a protocol aimed at early diagnosis and treatment of complications might lead to a decrease in morbidity and mortality, but also prove to be cost effective.

Long-Term Survival After Complications Following Major Abdominal Surgery

IntroductionPostoperative complications have been associated with decreased long-term survival in cardiac, orthopedic, and vascular surgery. For major abdominal surgery research, conflicting evidence is reported in smaller studies. The aim of this study was to assess the effect of complications on long-term survival in major abdominal surgery.Material and MethodsAn observational cohort study was conducted of 861 consecutive patients that underwent major abdominal surgery between January 2009 and March 2014, with prospective assessment of the survival status. The effect of postoperative complications on survival was assessed.ResultsPostoperative complications were associated with decreased survival, even after applying correction for 30-day mortality (p < 0.001). Stratified Cox regression analysis depicted postoperative complications to be an important predictor for survival in upper gastrointestinal and female hepatopancreaticobiliary patients. Correction was applied for age, gender, BMI, ASA classification, radicality, and positive lymph node status.ConclusionThese results further indicate the importance of prevention and early diagnosis and treatment of complications. Etiological factors are believed to be both sustained levels of inflammatory markers, as well as attenuated immune response in malignancy with subsequent cancer cell seeding. Future research should aim to prevent and early diagnose postoperative complications to prevent morbidity and mortality not only in the early postoperative phase, but also in the long term.

Surgical anatomy of the supracarinal esophagus based on a minimally invasive approach : vascular and nervous anatomy and technical steps to resection and lymphadenectomy

BackgroundDuring esophageal dissection and lymphadenectomy of the upper mediastinum by thoracoscopy in prone position, we observed a complex anatomy in which we had to resect the esophagus, dissect vessels and nerves, and take down some of these in order to perform a complete lymphadenectomy. In order to improve the quality of the dissection and standardization of the procedure, we describe the surgical anatomy and steps involved in this procedure.MethodsWe retrospectively evaluated twenty consecutive and unedited videos of thoracoscopic esophageal resections. We recorded the vascular anatomy of the supracarinal esophagus, lymph node stations and the steps taken in this procedure. The resulting concept was validated in a prospective study including five patients.ResultsSeventy percent of patients in the retrospective study had one right bronchial artery (RBA) and two left bronchial arteries (LBA). The RBA was divided at both sides of the esophagus in 18 patients, with preservation of one LBA or at least one esophageal branch in all cases. Both recurrent laryngeal nerves were identified in 18 patients. All patients in the prospective study had one RBA and two LBA, and in four patients the RBA was divided at both sides of the esophagus and preserved one of the LBA. Lymphadenectomy was performed of stations 4R, 4L, 2R and 2L, with a median of 11 resected lymph nodes. Both recurrent laryngeal nerves were identified in four patients. In three patients, only the left recurrent nerve could be identified. Two patients showed palsy of the left recurrent laryngeal nerve, and one showed neuropraxia of the left vocal cord.ConclusionsKnowledge of the surgical anatomy of the upper mediastinum and its anatomical variations is important for standardization of an adequate esophageal resection and paratracheal lymphadenectomy with preservation of any vascularization of the trachea, bronchi and the recurrent laryngeal nerves.

The role of tissue adhesives in esophageal surgery, a systematic review of literature

BACKGROUND Anastomotic leakage following esophageal surgery is a major contributor to mortality. According to the national database leakage occurs in 20% of esophagectomies carried out in the Netherlands. Therefore anastomotic leakage has been the topic of many studies. However, studies discussing application of tissue adhesives for either prevention or management of anastomotic leakage are limited. This article systematically reviewed all available literature on the potential use of tissue adhesives in esophageal surgery. METHODS Medline, Embase and Cochrane were searched to identify studies that used tissue adhesives as anastomotic sealants to prevent esophageal anastomotic leakage or used tissue adhesives to treat esophageal anastomotic leakage. Two authors independently selected nineteen out of 3107 articles. RESULTS Eight articles, of which five were experimental and three clinical, discussed prevention of anastomotic leakage. Eleven articles, of which one was experimental and ten clinical, discussed treatment of anastomotic leakage. Most articles reported positive results, however overall quality was low due to a high degree of bias and lack of homogeneity. CONCLUSION This study shows mainly positive results for the use of tissue adhesives for the esophageal anastomosis both in prevention of leakage as treating anastomotic leakage. However, the quality of current literature is poor.

Major abdominal surgery in octogenarians: should high age affect surgical decision-making?

BACKGROUND Over the last decades longevity has increased significantly, with more octogenarians undergoing surgery. Here, we assess surgical outcomes after major abdominal surgery in octogenarians. METHODS Observational cohort of 874 patients undergoing major abdominal elective surgery between January 2009 and March 2014. Seventy-six octogenarians were propensity matched to 76 younger patients, corrected for sex, body mass index, American Society of Anesthesiologists classification, comorbidity, indication, and type of surgery. RESULTS Minor complications were more prevalent in octogenarians (P = .01) and consisted mainly of respiratory complications; progressing to respiratory insufficiency requiring intubation in 28.6%. Preoperative weight loss (odds ratio 3 [1.1 to 8.3]) and upper gastrointestinal surgery (odds ratio 11 [2 to 60]) were associated with minor complications. CONCLUSIONS Octogenarians are at increased risk of minor complications after major abdominal surgery. Major complication rates were similar, indicating the importance of preoperative assessment and standardized surgical techniques. Taking into account preoperative morbidities and type of surgery and techniques. Implementation of quality control algorithms may further improve outcomes in octogenarians.

Short-term outcomes in minimally invasive versus open gastrectomy: the differences between East and West. A systematic review of the literature

ObjectiveMinimally invasive surgical techniques for gastric cancer are gaining more interest worldwide. Several Asian studies have proven the benefits of minimally invasive techniques over the open techniques. Nevertheless, implementation of this technique in Western countries is gradual. The aim of this systematic review is to give insight in the differences in outcomes and patient characteristics in Asian countries in comparison to Western countries.MethodologyAn extensive systematic search was conducted using the Medline, Embase, and Cochrane databases. Analysis of the outcomes was performed regarding operative results, postoperative recovery, complications, mortality, lymph node yield, radicality of the resected specimen, and survival. A total of 12 Asian and 8 Western studies were included.ResultsMinimally invasive gastrectomy shows faster postoperative recovery, fewer complications, and similar outcomes regarding mortality in both the Eastern and Western studies. However, patient characteristics such as age and BMI differ between these populations. Comparison of overall outcomes in minimally invasive and open procedures between East and West showed differences in complications, mortality, and number of resected lymph nodes in favor of the Asian population.ConclusionImproved outcomes are observed following minimally invasive gastrectomy in comparison to open procedures in both Western and Asian studies. There are differences in patient characteristics between the Western and Asian populations. Overall outcomes seem to be in favor of the Asian population. These differences may fade with centralization of care for gastric cancer patients in the West and increasing surgical experience.

Systematic Review of Exocrine Pancreatic Insufficiency after Gastrectomy for Cancer

Background: Survival rates after a total gastrectomy with adequate lymphadenectomy are improving, leading to a shift in outcomes of interest from survival to postoperative outcomes and symptoms. In this systematic review, we investigate gastrointestinal symptoms that occur after a gastrectomy in relation to exocrine pancreatic insufficiency and the effect of pancreatic exocrine enzyme supplementation on these symptoms. Methods: Online databases PubMed, Embase, and Cochrane Library were systematically searched in accordance with the PRISMA guidelines. Studies that researched gastrointestinal symptoms, exocrine pancreatic function, and enzyme supplementation were identified and assessed. Results: The search resulted in a total of 1,023 articles after exclusion of duplicates. After performing a thorough assessment, 4 studies were included for systematic review. Exocrine pancreatic insufficiency was investigated by 2 studies; the results showed a significant decrease of total exocrine pancreatic function of up to 76%. The other 2 studies investigated the effect of pancreatic enzyme supplementation and found minor improvement in fecal consistency and a decrease in high-degree steatorrhea. No differences in individual symptom scores were reported. Conclusion: Gastrointestinal symptoms such as steatorrhea, bloating, and dumping syndrome may be related to exocrine pancreatic function, initiated by total gastrectomy. Treatment with pancreatic enzymes had a minor positive effect on patients. It should be noted that these studies were of a small sample size and low quality. New and larger RCTs are necessary to either prove or disprove the benefit of pancreatic enzyme replacement therapy in the treatment of the gastrointestinal symptoms after total gastrectomy.

Mastering minimally invasive esophagectomy requires a mentor; experience of a personal mentorship

Since the first laparoscopic procedure, there has been an steady increase in advanced minimally invasive surgery. These procedures include oncological colorectal, hepatobiliary and upper gastrointestinal surgery. Implementation of these procedures requires different and new skills for the surgeons who wish to perform these procedures. To accomplish this surgical teaching program, a mentorship seems the most ideal method to teach the apprentice surgeon these specific skills. At the VU medical center a teaching program for a minimally-invasive esophagectomy for esophageal cancer started in 2009. At first it started in different centers in the Netherlands and later on we also started mentoring other institutes throughout Europe, Latin America and India. In this article we describe our experience and the outcomes of this mentorship in advanced minimally invasive surgery.