ChemInform Research Articles

Does a surgical access for rectal cancer in older patients affect postoperative morbidity and oncological safety?

AIM: to evaluate the effect of a surgical access on postoperative morbidity and oncological safety in older patients.PATIENTS AND METHODS: a multicenter retrospective study included 179 patients aged 60–74 years who underwent surgery for middle and low rectal cancer (T1-3N0-N2bM0) in 2021-2023. The patients were divided into 3 groups: the first ones underwent robotic (ROB) surgery (n = 62), the second — laparoscopic (LAP) surgery (n = 55), and the third — open (OPEN) surgery (n = 62). Parameters of pre-, intra-, and postoperative periods and histopathological findings were evaluated. Neural network modeling was used to predict anastomotic leakage (AL).RESULTS: the blood loss was 150 (100; 200) ml with OPEN versus 100 (50; 100) with ROB and LAP, the operation time was 255 (210; 300) min with ROB versus 180 (150; 240) min with LAP and 140 (120; 150) min with OPEN. In ROB and LAP groups, anastomoses were formed in 61 (98.4%) and 54 (98.2%) cases compared with 45 (72.6%) cases in the OPEN group (p = 0.00001). The splenic flexure was mobilized in 54 (98.2%) cases in the LAP group, 55 (88.7%) cases in the OPEN group, and 50 (80.7%) cases in the ROB group (p = 0.01). Conversion rates were 10.9% (6/55) and 1.6% (1/62) in LAP and ROB groups, respectively (p = 0.00001). Postoperative complications in the OPEN group occurred in 48 (77.4%) cases compared with 31 (50%) and 12 (21.8%) in ROB and LAP groups (p = 0.02). Inflammatory complications predominated in the OPEN group. Distal and lateral margins, the quality of mesorectal excision, and the number of examined and affected lymph nodes did not differ. However, the good quality of mesorectal excision prevailed in ROB and OPEN groups, where as the satisfactory quality was more common in the LAP group. The most important predictors of AL were American Society of Anesthesiologists (ASA) physical status II, neoadjuvant chemoradiotherapy, stage I and IIa cancer, end-to-end anastomosis, Charlson Comorbidity Index scores of 3–4, and surgeon’s experience (20–40 operations for rectal cancer per year). The least important predictors were the level of mesenteric vessel ligation and the access.CONCLUSIONS: the surgical access does not affect the AL rate. The histology revealed that all the 3 approaches ensure compliance with principles of oncological safety. Compared with open surgery, robotic and laparoscopic surgery result in less blood loss and faster recovery of intestinal function; however, the operation time increases.

Urinary and sexual dysfunction after rectal cancer surgery: A surgical challenge

This manuscript focused on the surgical challenge of urinary and sexual dysfunction after rectal cancer surgery based on the interesting results demonstrated by the observational study of Chen et al , which was published in the World Journal of Gastrointestinal Surgery . Urinary dysfunction occurs in one-third of patients treated for rectal cancer. Surgical nerve damage is the main cause of urinary dysfunction. Radiotherapy seems to exacerbate sexual dysfunction. The role of Denonvilliers' fascia preservation vs resection when performing total mesorectal excision (TME), the impact of robotic and transanal TME, alternatives to open and laparoscopic TME, as well as intraoperative pelvic neuromonitoring are discussed in this report. In conclusion, exact knowledge of the highly complex pelvic neuroanatomy and the use of novel surgical techniques can lead to a reduction in urinary and sexual dysfunction after rectal cancer surgery.

Days at Home After Cancer Surgery: Impact of Area Deprivation and Association with Long-Term Outcomes.

Poor infrastructure in deprivedareas may hinder access to health care, and a lack of socioeconomic resources can prevent patients from remaining at home after discharge. This study sought to assess the association between the Area Deprivation Index (ADI) and days at home within 90days (DAH-90) after a complex operative procedure. Patients who underwent an elective operation for a gastrointestinal cancer between 2016 and 2020 were identified from the Medicare Standard Analytic Files. County-level ADI was calculated using a weighted average of ADI percentiles for each census block within a county. The association between ADI and DAH-90 and the impact of DAH-90 on 1-year expenditures and 1-year mortality were evaluated. Among 72,452 patients who underwent a surgical procedure, median patient age was 75years (interquartile range [IQR] 71-81) and 54.3% of patients had a Charlson Comorbidity Index higher than 2. A +0.2 increase in ADI was associated with 12.6% lower odds of achieving high DAH-90 (adjusted odds ratio [aOR], 0.874; 95% confidence interval [CI], 0.845-0.903) compared with low DAH-90. Notably, high DAH-90 (mean difference, -55,614$; 95% CI, -56,540$ to -54,687$) and medium DAH-90 (mean difference, -39,538$; 95% CI, -40,194$ to -38,882$) were associated with markedly decreased 1-year total expenditures, as well as lower 1-year mortality compared with patients who spent fewer days at home after surgery. Increasing area deprivation was associated with higher likelihood of spending fewer days at home after a complex cancer surgical procedure. Patients spending fewer days at home were far more likely to die within 1 year and experienced higher health care costs.

Thyroid doses for the Chornobyl Tissue Bank: improved estimates based on revised methodology and individual residence and diet history.

Increased thyroid cancer incidence has been one of the principal adverse health effects of the Chornobyl (Chernobyl) nuclear power plant accident. Accurate dose estimation is critical for assessing the radiation dose-response relationship. Current dosimetry estimates for individuals from the Chornobyl Tissue Bank (CTB) are based only on the limited information on their places of residence at the time of the accident and/or at the time of surgery for thyroid cancer. The present study aimed to assess whether additional residential and dietary history data collected during personal interviews would substantially impact dose estimates. This paper presents an assessment of thyroid doses from 131I intake for the 197 exposed individuals from the CTB with pathologically confirmed papillary thyroid cancer. Thyroid doses, which had been calculated for these individuals in 2010, were revised in this study using the recently substantially revised 'Thyroid Dosimetry 2020 system for Ukraine' (TDU20). In addition, residence and diet history data were collected during personal interviews with individuals for whom dosimetry-related data were scarce. The arithmetic mean of thyroid doses estimated in this study was 510 mGy (previously 700 mGy), while the median was 81 mGy (previously 120 mGy). A rather wide range of thyroid doses from zero to 11.9Gy (previously up to 15.0Gy) was observed among study participants. The uncertainties in doses were characterized by the geometric standard deviation of 1,000 individual stochastic doses. As a result, the geometric standard deviation varied from 1.3 to 5.3 with an overall arithmetic mean of 2.7 and a median of 2.9. This study clearly showed that the use of individual questionnaire data in dose assessment of individuals who completed personal dosimetry interviews had a noticeable impact on the thyroid dose values: the thyroid doses changed by more than 100 mGy in 31 out of 104 (29.8% of the total) individuals, while such changes due to the use of TDU20 were observed in 18 out of 104 (17.3%) individuals. Clearly, future focused studies using samples from the CTB would benefit from personal interviews to improve dose estimates. Another lesson learned from this study is that whenever a radiation accident occurs, it is important to ask affected people by health and radiation safety authorities to keep records of their own behavior and diet, and, if possible, those of their children.

The Pediatric Influence of Cooling Duration on Efficacy in Cardiac Arrest Patients (P-ICECAP): Statistical Methods Planned in the Bayesian, Adaptive, Duration Finding Trial.

To determine the optimal cooling duration for children after out-of-hospital cardiac arrest (OHCA) using an adaptive Bayesian trial design. The Pediatric Influence of Cooling duration on Efficacy in Cardiac Arrest Patients (P-ICECAP) trial is a randomized, response-adaptive duration/dose-finding clinical trial with blinded outcome assessment. Participants are randomized to one of several cooling durations (0, 12, 18, 24, 36, 48, 60, 72, 84, or 96 hr). The first 150 participants are randomized 1:1:1 to 24-, 48-, and 72-hour durations. Response-adaptive randomization is used thereafter to allocate participants based on emerging duration-response data. PICUs. Up to 900 pediatric patients 2 days to younger than 18 years old who have survived OHCA and been admitted to an ICU. Duration of targeted temperature management using a surface temperature control device. The primary outcome is the Vineland Adaptive Behavior Scales-Third Edition mortality composite score, assessed at 12 months. Secondary outcomes include changes in the Pediatric Cerebral Performance Category and Pediatric Resuscitation after Cardiac Arrest scores, as well as survival at 12 months. Bayesian modeling is employed to evaluate the duration-response curve and determine the optimal cooling duration. The trial is designed to adaptively update randomization probabilities every 10 weeks, maximizing the allocation of participants to potentially optimal cooling durations. Over 90% power is achieved for the hypothesized scenarios. The P-ICECAP trial aims to identify the shortest cooling duration that provides the maximum treatment effect for pediatric OHCA patients. The adaptive design allows for flexibility and efficiency in handling various clinical scenarios, potentially transforming pediatric cardiac arrest care by optimizing hypothermia treatment protocols.

Congenital heart disease and arrhythmia disorders in newborns with congenital diaphragmatic hernia: a 23-year experience at a UK university pediatric surgical centre

PurposeCongenital diaphragmatic hernia (CDH) is associated with congenital heart disease (CHD) and index newborns reportedly may experience cardiac arrhythmia disorders [Tella et al.—Pediatric Critical Care Medicine 2022]. This study analyses, details and reports contemporary outcome metrics of CHD and cardiac rhythm disease (CRD) in CDH babies attending a university surgical centre.MethodsRetrospective analysis of medical records of all newborns undergoing Bochdalek CDH repair between 1999 and 2021 at a university paediatric surgical centre. CDH newborns with CHD and neonatal arrythmias were identified from echocardiogram and electrocardiogram (ECG) investigative studies. Operative native diaphragm and / or use of patch repair(s) was documented. Outcome(s) measured—(i) mortality and (ii) cardiopulmonary interventions including ventilatory strategies—ECMO (%), inotropes and anti-arrhythmic therapy(s).ResultsOf 173 CDH neonates, 95 (55%) had CHD of which 9 babies (10%) had cardiac arrhythmias. CDH and co-existing CHD was linked with (a) lower infant birth weights (3130 g vs 3357 g, p = 0.05), (b) increased use of inotrope agents (48.4% vs 39.3%, p = 0.03) and (c) greater use of high-frequency oscillatory ventilation (38.9% vs 23%, p = 0.004). CDH babies experiencing arrythmias were at higher risk (%) of developing pulmonary hypertension (66.7% vs 28.7%, p = 0.01). No significant differences were observed in ECMO utilisation (12% vs 6%, p = 0.46) or patch repair(s) (53% vs 46%, p = 0.06) in CDH patients with and without CHD. CHD was not associated with increased risk(s) of mortality (OR 2.58, 95% CI 0.81–8.24, p = 0.11). Of 9 index CDH patients with arrhythmias—4 babies (44%) required interventional treatments.ConclusionCHD was prevalent in a high percentage (%) of CDH newborns treated at this university centre and associated with increased use (%) of cardiovascular respiratory support including patch repair. A minority of patients (2.3%) had cardiac rhythm disorders requiring treatment(s). In those developing arrhythmias pulmonary hypertension may be a risk-linked event. Optimising outcomes to offset pulmonary hypertension requires further appraisal. Future large-scale population studies may help underscore the ‘real apparent incidence’ of cardiac rhythm disorders in CDH.

Best practice peri-extubation bundle reduces neonatal and infant extubation failure after cardiac surgery.

Extubation failure after neonatal cardiac surgery is associated with increased intensive care unit length of stay, morbidity, and mortality. We performed a quality improvement project to create and implement a peri-extubation bundle, including extubation readiness testing, spontaneous breathing trial, and high-risk criteria identification, using best practices at high-performing centers to decrease neonatal and infant extubation failure by 20% from a baseline of 15.7% to 12.6% over a 2-year period. Utilising the transparency of the Pediatric Cardiac Critical Care Consortium database, five centres were identified as high performers, having better-than-expected neonatal extubation success rates with the balancing metric of as-expected or better-than-expected mechanical ventilation duration. Structured interviews were conducted with cardiac intensive care unit physician leadership at the identified centers to determine centre-specific extubation practices. Data from those interviews underwent qualitative content analysis which was used to develop a peri-extubation bundle. The bundle was implemented at a single-centre 17-bed cardiac intensive care unit. Extubation failure, defined as reintubation within 48 hours of extubation for anything other than a procedure, ventilator days and bundle compliance was tracked. There was a 41.4% decrease in extubation failure following bundle implementation (12 failures of 76 extubations pre-implantation; 6 failures of 65 extubations post-implementation). Bundle compliance was 95.4%. There was no difference in ventilator days (p = 0.079) between groups. Implementation of a peri-extubation bundle created from best practices at high-performing centres reduced extubation failure by 41.4% in neonates and infants undergoing congenital heart surgery.

Improving asthma care in children: revealing needs and bottlenecks through in-depth interviews

Asthma affects 7% of Dutch children and poses an increasing challenge, highlighting the need for effective paediatric asthma care. Achieving optimal asthma control is crucial given the potentially negative long-term effects of bad asthma control on lung development and quality of life in young children. The aim was to understand the challenges and requirements of existing asthma management practices in children. In a qualitative explorative study design, semi-structured, in-depth interviews were held among 37 Dutch stakeholders. A total of 15 patients/parents, 10 general practitioners (GPs), 5 paediatricians/paediatric pulmonologists and 7 nursing specialist/pulmonary nurses participated. Analysis was based on a thematic inductive analysis, using open and axial coding. GPs tended to emphasise the treatment of patients/parents with acute symptoms and underestimate the diagnosis and management of chronic symptoms, leading to possible over- and undertreatment. Asthma care between primary and secondary healthcare is fragmented and worsens these challenges. Moreover, the absence of well-established follow-up structures in primary care contributes to insufficient self-management skills among patients. Shared Decision-Making in children lacks a tailored approach, with variable engagement levels among healthcare providers. Limited focus on preventive strategies leads to little attention to, for example, promoting healthy lifestyles. Moreover, children are often not actively involved in decision-making. The study provides valuable insights to improve the quality and continuity of care for children with asthma and their parents. It underlines the need for a comprehensive and integrated care pathway to minimise the long-term negative effects of uncontrolled asthma.

Factors associated with post acute care utilization after mastectomy for breast cancer patients.

Although the demand for care immediately after mastectomy is rising, and such medical services are referred to as post-acute care (PAC), there is limited evidence on the factors influencing PAC choices among these patients in Korea. A total of 106,670 patients diagnosed with breast cancer and undergoing mastectomy were extracted from the Central Cancer Registry data from 2012 to 2019 using Public Cancer Library data of KCURE. PAC was defined as utilization of long-term care hospital (LTCH), hospital-based nursing care (HBNC), or HBC (hospital-based care) within 2 months post-surgery. Multinomial logistic regression was used to identify factors associated with different types of PAC utilization. The utilization patterns of different types of PAC within 2 months after mastectomy were associated with age, income, cancer severity, and particularly the region of residence (Metropolitan; HBNC, OR 0.16, 95% CI 0.10-0.26; LTCH, OR 2.35, 95% CI 2.21-2.50; HBC, OR 2.17, 95% CI 1.97-2.39), as well as the location (capital areas; HBNC, OR 12.46, 95% CI 4.97-31.25; LTCH, OR 1.21, 95% CI 1.15-1.28; HBC, OR 1.90, 95% CI 1.74-2.07) and type of the hospital (tertiary hospital; HBNC, OR 13.70, 95% CI 7.86-23.86; LTCH, OR 1.45, 95% CI 1.37-1.53; HBC, OR 3.38, 95% CI 3.00-3.80) where the surgery was performed. In this study, we found the factors associated with PAC utilization on mastectomy patients. Our study found that middle-aged breast cancer patients, residents of metropolitan or rural areas, and those who underwent surgery at hospitals in capital area were particularly associated with higher utilization of inpatient-related PAC services. Breast cancer patients with higher income, older adults, metropolitan residents, patients who underwent breast cancer surgery at metropolitan hospitals, and those treated at tertiary hospitals were strongly associated with higher utilization of HBNC services. Identifying factors that determine the use of PAC has meaningful implications for patients and healthcare systems.

Reconstruction of the pelvic floor and perineal wound after extralevator abdominoperineal resection of the rectum.

This article presents an innovative technique for perineal wound reconstruction following extralevator abdominoperineal excision (ELAPE) in rectal cancer surgery. The authors trace the evolution of surgical methods for rectal cancer treatment, from W.E. Miles' abdominoperineal resection (APR) to T. Holm's ELAPE technique introduced in 2007. The proposed metod's primary advantage lies in its ability to completely fill the extensive deep and superficial perineal wound defect by moving two flaps from both sides of the wound and overlapping them. This approach potentially reduces postoperative complications and improves patients' quality of life following ELAPE. The authors describe the procedure in detail, including specific measurements and angles for flap creation. They also present a case study of a 52-year-old female patient with lower rectal ampulla cancer, demonstrating the practical application of this technique. This innovative reconstruction method addresses the current lack of consensus on perineal wound plastic surgery techniques following ELAPE and offers a promising solution to reduce postoperative morbidity in rectal cancer patients undergoing this procedure.

The prehospital paediatric emergency care burden managed by a public ambulance service in the Western Cape, South Africa

BackgroundPaediatric mortality rates in low- and middle-income countries account for over 80% of the global burden. In South Africa, one in every 33 children will not reach the age of five. Despite the high mortality rate, there is a paucity of data describing the prehospital paediatric under-five emergency care burden in South Africa. Such data are essential to inform the development of local prehospital emergency care guidelines and targeted prevention strategies.AimThis study describes the prehospital paediatric under-five emergency care burden managed by the Western Cape Government Health and Wellness (WCGHW) Emergency Medical Services (EMS) in South Africa.MethodsA retrospective review of the prehospital records was conducted, extracting epidemiological and clinical data from the WCGHW EMS patient record database. The review included all paediatric cases under-five, managed between 1 January 2022 and 31 December 2023, in the Western Cape of South Africa.ResultsIn the 87 457 cases, there was a similar distribution between the primary cases (50.7%) and interfacility transfers (49.3%). Most activations emanated from rural areas (47 980, 54.9%), with respiratory emergencies (30 934, 35.4%), non-cardiac pain (11 381, 13.0%) and trauma (10 831,12.4%) being the most common presenting complaints. Most cases were prioritised as priority 2 (46 034, 52.6%), with most of these being older children between one and five years old (29 008, 63.0). Low acuity cases accounted for 67.2% (58 818) of the sample, with the highest mortality occurring between 29 days and 12 months (190, 52.9.%). Most patients spent less than one hour in the prehospital setting (64 431, 73.7%), with advanced airway management (748, 43.1%) being the most common airway intervention.ConclusionThis first description of the prehospital paediatric under-five emergency care burden managed by the WCGHW EMS reveals a unique burden, particularly regarding the high interfacility transfer rates. As illustrated in graphical abstract, these findings underscore critical considerations for healthcare planners and the prehospital training environment. Future research among this population should focus on characterising the reasons for the high interfacility transfer rates through assessments of healthcare access, EMS care quality and post-EMS follow-up.Graphical

The Role of Pharmacogenetic Testing in Optimizing Antipsychotic Therapy

Antipsychotic therapy in psychiatric practice can last from several months to many years, which requires the selection of drugs with the greatest effectiveness and the lowest risk of adverse drug reactions for the patient. According to experts, about a quarter of the total variability in response to antipsychotics is of genetic origin. This review analyzes and summarizes the results of domestic and foreign studies of the role of hereditary risk factors that cause a decrease in hepatic metabolism and efflux of antipsychotics due to polymorphism of genes encoding cytochrome P450 isoenzymes and transporter proteins. The key enzymes of antipsychotic metabolism registered for use in Russia and abroad are presented. The prospects of various options for pharmacogenetic testing in reducing the risk of potentially fatal complications in the selection of antipsychotic therapy in clinical practice are assessed.

Assessing caregiver stress and resource needs in pediatric cancer care

BackgroundCaregivers of pediatric cancer patients often face significant stress and emotional strain, which can negatively impact their well-being and the quality of care provided to their children. Understanding the socio-demographic factors influencing caregiver stress and identifying the specific needs and resources required by caregivers are crucial for improving support systems in pediatric cancer care.Aim of the studyThis study aimed to analyze the levels of caregiver stress and their resource needs within pediatric cancer care.MethodsA cross-sectional descriptive design was used, and the study was conducted at El-Minia Oncology Center outpatient clinics, Egypt. The sample included 258 pediatric cancer caregivers selected based on predefined eligibility criteria. Data were collected using the Caregiver Needs and Resources Assessment (CNRA) and the King Stone Caregiver Stress Scale (KCSS), both of which demonstrated strong reliability and validity. Descriptive statistics, t-tests, ANOVA, and Pearson correlation coefficients were employed for data analysis using SPSS version 29, with a significance level set at p < 0.05.ResultsCaregivers reported moderate to high stress levels, with an average stress score of 34.59 (SD = 7.649). Age, education level, marital status, and income were significant predictors of caregiver stress (p < 0.001), with lower income and higher educational levels contributing to increased stress. The number of children, child’s age, and duration since cancer diagnosis also significantly impacted stress levels (p < 0.001). Correlation analysis revealed that psychological needs were positively related to stress (r = 0.488, p < 0.001), while spirituality was negatively associated with stress (r = -0.241, p < 0.001). Regression analysis indicated that physiological needs (ß = 0.331) and role conflict (ß = 0.294) were the strongest predictors of stress (R² = 0.636).Conclusion and implicationsThis study emphasizes the impact of socio-demographic factors on caregiver stress in pediatric cancer care. Targeted interventions that address caregivers’ psychological, social, and financial needs are essential to alleviate stress. Implementing caregiver-centered support programs in pediatric oncology can enhance the well-being of both caregivers and patients. Future research should explore sustainable strategies to further reduce caregiver burden.Clinical trial numberNot applicable.

Targeted Directed Evolution of an α-L-Rhamnosidase on Hesperidin Through Six-Codon Combinatorial Mutagenesis

Targeted saturation mutagenesis at the residues located at the substrate-binding pocket for generating focused libraries has emerged as the technique of choice for enzyme engineering, but choosing the optimal residue number of the randomization site and the reduced amino acid alphabet to minimize the labor-determining screening effort remains a challenge. Herein, we propose the six-codon combinatorial mutagenesis (SCCM) strategy by using the BMT degeneracy codons encoding six amino acids with different chemical properties as the building blocks for the randomization of the amnio acid motif. SCCM requires only a small library of 646 clones for 95% coverage at the three-residue motif compared to conventional NNK degeneracy codons encoding all 20 canonical amino acids and requiring the screening of nearly 100,000 clones. SCCM generates a suitable number of mutant libraries, providing a new strategy for reducing the screening workload of saturated combination mutations in enzyme engineering. Using this approach, the α-L-rhamnosidase BtRha78A from Bacteroides thetaiotaomicron had been successfully engineered for improving the hydrolytic activity on natural flavonoid diglycoside hesperidin via targeted directed evolution at the motifs positioning the entrance of the substrate-binding pocket. The results indicate that the conversion rates of the four mutants on hesperidin were increased by more than 30% compared with the wild type using whole-cell biotransformation. Moreover, the catalytic efficiency kcat/KM value of the mutant TM1-6-F5 was 1.4-fold higher than that of the wild type.

Assessing the continuum of care in Sub-Saharan African hospitals performing surgery for breast cancer: a secondary analysis of the GlobalSurg 3 study

BackgroundWhile breast cancer incidence rates in Sub-Saharan Africa (SSA) are among the lowest worldwide, mortality rates remain among the highest, reflecting particularly poor survival. Only a few studies in SSA have investigated the capabilities of treatment services to adequately provide a continuum of care for breast cancer. Our aim was to assess the availability of diagnostic facilities and adjuvant therapies in hospitals performing breast cancer surgery in SSA.MethodsWe performed a secondary analysis of the GlobalSurg3 study data collected in the SSA region. The GlobalSurg 3 study is a multicenter, international, prospective, observational study of hospitals providing surgical services for cancer patients (including breast cancer) around the world. A total of 47 hospitals from 15 SSA countries and 43 cities were included between April 1, 2018, and Jan 31, 2019.ResultsOne-third of hospitals covered a population greater than two million (n = 17; 36.2%). Ultrasound was available in all hospitals; however, it was not consistently functional in 11 hospitals (23.4%). Only half of the included hospitals (n = 26, 55.3%) had access to a full-time pathologist, whilst the multidisciplinary team (MDT) approach was absent in 42.4% of hospitals. Radiotherapy equipment was only available in nine hospitals (19.1%). Only half of the hospitals (n = 25, 53.1%) had chemotherapy drugs available on site. In nine hospitals (19.1%), patients had to travel more than 50 km to access chemotherapy drugs.ConclusionsOutcomes for breast cancer patients in SSA cannot be improved without significant investments in pathology, surgical and oncological treatment pathways to provide timely diagnostic and effective treatment.

Effect of Preoperative Body Composition on Postoperative Anastomotic Leakage in Oncological Ivor Lewis Esophagectomy—A Retrospective Cohort Study

Background: Surgery for esophageal cancer has an associated high rate of postoperative complications such as anastomotic leakage (AL) and fistulas. Pre-operative sarcopenia as a loss of skeletal muscle mass and function is identified as a potential prognostic factor in determining the outcomes of oncological surgical resections for esophageal cancers. In this study, we evaluated the impact of body composition on postoperative complications in esophageal cancer surgery. Methods: In this cohort study, we analyzed patients’ body composition at the level of the third lumbar vertebra on CT scans before Ivor Lewis resections for esophageal cancers between January 2015 and December 2022. Patients with a skeletal muscle index (SMI) ≤ 38.5 cm2/m2 in women and ≤52.4 cm2/m2 in men were classified as sarcopenic. Postoperative complications were categorized following the Dindo–Clavien classification and included AL, postoperative pneumonia, length of hospital stay, and failure-to-rescue which were compared between the sarcopenic and non-sarcopenic patients. Results: From a group of 111 patients with Ivor Lewis esophagectomy, 70 patients (63.1%) were classified as sarcopenic based on the SMI and the previously published gender-specific cut-off values. AL occurred at 12.6% (5.6% in adenocarcinoma). Within the whole cohort, patients with AL had a significantly low SMI of 43.487 ± 8.088 vs. 48.668 ± 7.514; p = 0.012. Additionally, the SMI showed a negative correlation to the length of postoperative hospital stay (r = −0.204; p = 0.032; N = 111). The failure-to-rescue rate was higher in the group of sarcopenic patients (12.8% vs. 8%). Conclusions: Our data showed a correlation between SMI and AL. This effect could not be seen in gender-specific SMI. This study showed a lower failure-to-rescue rate in non-sarcopenic patients after Ivor Lewis esophagectomy. These findings underscore the crucial role of determining the preoperative nutritional and body composition status as measured by the preoperative CT scans.

Immunonutrition in Operated-on Gastric Cancer Patients: An Update

Enteral immune nutrition has attracted considerable attention over the past few years regarding its perioperative role in patients undergoing major surgery for digestive cancer. Today, the term enteral immune nutrition refers to the perioperative administration of nutritional preparations containing, among others, specific ingredients such as glutamine, omega-3 polyunsaturated fatty acids, and arginine. They provide nutritional support and exert pharmacological effects through the substances contained in these preparations. Their administration to patients with gastric cancer is necessary as malnutrition and other metabolic disorders are frequent symptoms with effects on the level of immune responses, affecting the function of intestinal permeability and, therefore, the effectiveness of chemotherapy. Existing clinical data and data from all meta-analyses published so far support the view that enteral immune nutrition enhances the immune responses of gastric cancer patients, and reduces the rate of postoperative complications, and the duration of hospitalization without, however, improving patient survival. The content of enteral immune nutrition, dose, administration interval, and the effect on patient survival should be more precisely determined through relevant extensive multicenter studies. This systematic review describes and analyses the clinical results and the findings of relevant meta-analyses of the application of enteral immune nutrition in gastric cancer patients, emphasize the importance of this therapeutic intervention for disease progression, and attempts to provide practical guidelines for applying enteral immune nutrition in daily clinical practice.

Exploring the effect of carbon nanoparticle tracing technique on five-year overall survival and disease-free survival in patients undergoing radical surgery for colorectal cancer: a retrospective study

BackgroundTo investigate the effect of preoperative carbon nanoparticle tracing technique via colonoscopy on the five-year overall survival and disease-free survival rates in patients undergoing radical resection for colorectal cancer.MethodsA retrospective cohort study was conducted to collect data from patients diagnosed with colorectal cancer who underwent radical resection with complete postoperative pathological information at the First Affiliated Hospital of Chongqing Medical University from March 2013 to February 2017. Patients with multiple primary cancers were excluded, resulting in 2,237 eligible patients in the study. Of these, 368 patients were lost to follow-up within five years after surgery, resulting in a final sample of 1,869 patients. These patients were then divided into two groups: 758 patients who underwent preoperative carbon nanoparticle tracing technique via colonoscopy (CAS group) and 1,111 patients who did not undergo carbon nanoparticle tracing (non-CAS group). Survival curves for both overall survival and disease-free survival were plotted for both groups based on follow-up results. Univariate and multivariate analyses were performed to investigate the effect of carbon nanoparticle tracing technique on the 5-year overall survival and disease-free survival rates in patients, as well as to explore the factors influencing these outcomes.ResultsThe results showed that the total number of lymph nodes detected in the tracing group 15(11,19) was significantly higher than that in the non-tracing group 11(7,15), with a statistically significant difference (p&amp;lt;0.05). The 5-year overall survival rates were 90.8% in the CAS group and 87.4% in the non-CAS group, and, while the disease-free survival rate were 88.5% and 83.4%, respectively. However, the differences between 5-year overall survival and disease-free survival between the two groups were not statistically significant (p&amp;gt;0.05). Both univariate and multivariate cox regression analyses demonstrated that patient age, tumor stage, postoperative chemoradiotherapy, postoperative radiotherapy, and postoperative tumor recurrence were independent factors influencing the 5-year overall survival and disease-free survival rates in colorectal cancer patients.ConclusionCarbon nanoparticle tracing technique can effectively increase the total detected number of lymph nodes in patients with radical resection for colorectal cancer, but it does not significantly impact the 5-year overall survival and disease-free survival rates in these patients.

Evaluation of the Learning Curve Threshold in Robot-Assisted Lung Cancer Surgery: A Nationwide Population-Based Study

Background: Recent publications suggest that the threshold for validation of the learning curve is 25 procedures. The aim of this study was to evaluate this threshold using another rarely used method, based on a composite quality indicator. Methods: We included all patients from the French medico-administrative database receiving robot-assisted surgery for lung cancer, with a focus on hospitals performing at least 25 procedures over the period 2019–2022. For postoperative complication analysis, we used the Clavien–Dindo classification. We used the sequential probability ratio test to estimate the number of procedures at which a hospital achieved its learning curve. Results: In France, the number of robotic-assisted procedures has risen steadily in the past few years: 195 in 2019 and 1567 in 2022 (overall, 3706 Robot-Assisted surgeries). The total number of patients with Clavien–Dindo classification &gt; II was 833 (24.7%). Among the 28 hospitals performing at least 25 procedures, eight achieved their learning curve with thresholds ranging from 94 to 174 procedures, and the median was 110. Severe complications such as acute respiratory distress syndrome, respiratory failure, heart failure, acute ischemia of the lower limbs, or pulmonary embolism were significantly more frequent in the group of hospitals that did not validate the learning curve threshold. Conclusions: This study suggests that the threshold of 25 procedures may not be sufficient to validate the robot-assisted surgery learning curve in lung cancer surgery. To significantly reduce postoperative complications, a hospital would need to perform 94 to 174 procedures to guarantee patient safety.

Personalized decision making of neoadjuvant chemotherapy vs. upfront surgery in pancreatic cancer by a simple blood collection?

SummaryPancreatic cancer still has dismal survival rates and high rates of early recurrence despite improvements of multimodal treatment options and more and more aggressive surgical approaches in recent years. Thus, precise and personalized management strategies to improve patient outcomes are needed. Circulating tumor DNA (ctDNA), a component of cell-free DNA (cfDNA) in body fluids, harbors genetic and epigenetic signatures of tumors and can be detected noninvasively for example through simple blood collections or peritoneal fluid during staging laparoscopy (liquid biopsies). This biomarker provides real-time insights into systemic tumor burden, heterogeneity, and genetic profile and has been proven to be of significant prognostic relevance for several gastrointestinal malignancies. Furthermore, the testing of ctDNA has emerged as a pivotal prognostic biomarker to indicate patients with high biological risk for recurrence and worse overall survival. Especially in pancreatic cancer, it has been shown that preoperative ctDNA detectability in peripheral blood is associated with systemic tumor burden (even volumetric). This indicates potential micrometastatic or subclinical disseminated disease, suggesting a benefit from neoadjuvant chemotherapy to address the systemic component of the disease prior to surgery. Furthermore, dynamic changes in ctDNA during systemic treatment can predict therapeutic response and guide adjustments in treatment regimens. Postoperatively, ctDNA presence could assist in detecting minimal residual disease which also predicts early relapse, facilitating timely intervention (or immediate adjuvant chemotherapy as already shown in colorectal cancer, e.g., Dynamic trial). Therefore, perioperative ctDNA detection has the potential to refine the management of pancreatic cancer, enhancing decision-making processes and optimizing personalized treatment approaches in serving as an additional highly sensitive biomarker for guiding treatment decisions between upfront surgery and neoadjuvant chemotherapy in patients with resectable pancreatic cancer. The first ever personalized change of treatment decision from upfront surgery (by current gold standard staging) to neoadjuvant chemotherapy based on additional liquid biopsy results was documented in March 2024 (Linz, Austria).