Resection In High-risk Patients Research Articles

Is the Preoperative Prognostic Nutritional Index a Useful Marker for the Decision to Perform Limited Resection in High-risk Patients With Stage I Non-small Cell Lung Cancer?

The indications for limited resection in high-risk patients with stage I non-small cell lung cancer (NSCLC) remain controversial. The purpose of this study was to evaluate the prognostic impact of the preoperative prognostic nutritional index (PNI) in high-risk patients undergoing limited resection. High-risk patients undergoing limited resection for stage I NSCLC in our institution from 2005 to 2020 were retrospectively reviewed. Patients with clinical/pathological Tis/minimally invasive adenocarcinoma and multiple NSCLC were excluded. A multivariate Cox regression analysis was conducted to identify factors associated with overall survival (OS). Ninety eligible patients were included in this study. Grade ≥2 postoperative complications were significantly more frequent in the low-PNI group (6 cases, 16.6% vs. 7 cases, 12.9%; p=0.03). The rate of death due to other diseases was significantly higher in the low-PNI group than in the high-PNI group (14 cases, 50.0% vs. 11 cases, 25.0%; p=0.002). The multivariate analysis showed that male sex, Brinkman index ≥400, preoperative low PNI and pathological T factor ≥T1c/T2a were independent prognostic factors for OS. In high-risk patients undergoing limited resection for stage I NSCLC, low PNI was a poor prognostic factor, especially in relation to death from other diseases and lung cancer. The results may support thoracic surgeons in decision-making in relation to the indications for surgery.

[Enhanced recovery after lung resection in high-risk patients].

To study the possibilities of the ERAS program and immediate results in high-risk patients undergoing lung resection. The prospective study included 76 high-risk patients. All patients required lobar resection for various lung diseases. The risk of postoperative complications and mortality was stratified using the Thoracoscore and Thoracic Revised Cardiac Risk Index systems, as well as the American Society of Anesthesiologists Outcome Prediction Scale. At all perioperative stages, we assessed the possibilities for accelerated recovery and postoperative complications using the Thoracic Morbidity and Mortality System. Patients were characterized by multiple comorbidities requiring long-term and individual preoperative correction. This prevented adherence to a single protocol at the outpatient stage. We intraoperatively observed severe adhesive process up to complete obliteration of pleural cavity that complicated the use of minimally invasive technologies. Lung tissue was characterized by emphysematous lesions and reduced elasticity that caused prolonged air release and formation of residual cavities. These features required two pleural drains in 42 (52.3%) cases that increased hospital-stay. Multimodal analgesia and early activation with rehabilitation were optimal elements of ERAS. Various postoperative abnormalities developed in 31 (40.8%) patients, mortality rate was 7.9% (n=6). Minor and serious complications prevailed (21 (27.6%) cases). Their correction was effective and not accompanied by fatal outcomes. Critical complications occurred in 10 (13.1%) patients and caused fatal outcomes in 6 (7.9%) cases. ERAS protocol among high-risk patients in thoracic surgery is possible in the form of separate elements included in perioperative support.

Personalized pre-habilitation reduces anastomotic complications compared to up front surgery before ileocolic resection in high-risk patients with Crohn's disease: A single center retrospective study

BackgroundThe aim of this study was to analyze the effect of a personalized prehabilitation (PP) before ileocolic resection (ICR) on the postoperative anastomotic complications in patients with Crohn's Disease (CD) with high risk of post-operative complications. Materials and methodsAll high-risk patients who required ICR with primary anastomosis for CD between January 2010 and March 2020 were retrospectively analyzed. PP included nutritional support, antibiotic therapy or drainage of an abscess, stopping or decreasing corticosteroid treatments. Patients were considered as high risk for complications when they had at least one or more of these 3 risk factors (RF) (hypoalbuminemia <30 g/L or weight loss of >10% over the last 6 months, treatment with corticosteroids before surgery (within 4 weeks before surgery), or presence of preoperative intra-abdominal sepsis (abscess or enteral fistula)) according to ECCO guidelines 2020. ResultsNinety high-risk patients were included in our cohort and the anastomotic complication rate was 11.1%. Sixty-four (71.1%) had preoperative prehabilitation (median duration of 37 days), and the mean albumin level (34 g/L vs 37 g/L; p < 0.001) and the number of RF (1.21 vs 1.06; p = 0.001) were improved by PP during the preoperative period. The rate of anastomotic complications at 90 days from surgery (6.25% vs 23.1%; p = 0.031) as well as the re-operation rate (3.1% vs 19.2%; p = 0.019) were lower after PP. No difference was found on the rate of readmission and the length of stay in this subgroup analysis. Biological treatment administration within 3 months before surgery was not a risk factor for postoperative complication. ConclusionPP reduces the number of preoperative risk factors before ICR in high-risk patients with CD and allows primary anastomosis with a lower complication rate than in upfront operated patients.

Lung cancer resection in high-risk patients: a narrative review

Lung cancer resection in high-risk patients: a narrative review

Split stoma with delayed anastomosis may be preferred for 2-stage surgical resection in high-risk patients with Crohn's disease

BackgroundFecal diversion after bowel resection is a safe and effective procedure in high-risk patients with Crohn's disease, but the better approach between primary anastomosis with protective stoma and split stoma with delayed anastomosis has not yet been investigated. This study aimed to compare the outcomes of these approaches in high-risk patients with Crohn's disease. MethodsA retrospective investigation on consecutive high-risk patients with Crohn's disease was conducted at a tertiary referral hospital from August 2009 to March 2019. The primary outcomes were the overall early postoperative complications and overall anastomosis-related adverse events in an intention-to-treat approach. ResultsA total of 118 consecutive patients who underwent 121 surgeries (35 procedures with a protective stoma and 86 procedures with a split stoma) were enrolled. After a median follow-up period of 659 days and 728 days, respectively, 25 patients underwent a stoma-reversal procedure in the protective-stoma group, and 54 patients underwent delayed anastomosis in the split stoma group. Overall, early 30-day surgical morbidity and anastomosis-related adverse events were observed in more patients in the protective-stoma group than in the split-stoma group (51.4% [18/35] vs 30.2% [26/86]; P = .028 and 37.1% [13/35] vs 2.3% [2/86]; P < .001, respectively; intention-to-treat analysis). Similar results were found in the per-protocol analysis (44.0% [11/25] vs 20.4% [11/54]; P = .029 and 36.0% [12/25] vs 3.7% [2/54]; P < .001, respectively.) ConclusionSplit stoma with delayed anastomosis is associated with a reduction in anastomotic adverse events and overall early surgical complications and thus may be a better surgical option for high-risk patients with Crohn's disease.

Mesopancreas Excision and Triangle Operation During Robotic Pancreatoduodenectomy.

The retropancreatic space between the superior mesenteric artery, celiac axis, and portal vein is called the mesopancreas. Total mesopancreas excision and skeletonization of both celiac axis and superior mesenteric artery are used to reduce R1 resection in high-risk patients and in those with locally advanced disease. The aim of this study was to present a series of video clips from several patients showing the mesopancreas excision and the triangle operation with a detailed technical description of both techniques with different approaches. Video clips were compiled from several robotic pancreatoduodenectomies to demonstrate the total mesopancreas excision and triangle operation technique, as follows: (1) main steps for mesopancreas excision and triangle operation, (2) anterior approach for mesopancreas excision, and (3) triangle operation. A total of 87 patients underwent robotic PD at our center between March 2018 and March 2021. Of these, 22 patients underwent robotic mesopancreas excision. This technique was used for patients at high risk for R1 resection in 18 patients and triangle operation in four patients. Partial portal vein resection was necessary in 6 cases. One patient had R1 resection and was treated with adjuvant therapy. The remaining patients presented free surgical margins. The mean number of harvested lymph nodes was 40 (range: 27-77). The median interval between the operation and chemotherapy was 23 days. The robotic total mesopancreas excision and the triangle operation are feasible and safe for selected patients. The indication for this radical operation is the presence of a high risk for R1 resection and for those with locally advanced disease. The presented video may help oncological surgeons to perform these techniques.

Sublobar resection in high-risk patients for lobectomy: current and future strategy

Surgical resection by lobectomy is the gold standard of therapy for early stage non-small cell lung cancer. However, not all patients are medically fit to undergo surgery. In patients considered high-risk for lobectomy, alternative strategies have been developed including radiofrequency ablation, cryoablation, microwave ablation, stereotactic radiation therapy, wedge resection, and segmentectomy. This work reviews the definition of high-risk, and the outcomes that have been associated with each treatment technique. Some technical points regarding wedge resection versus segmentectomy are noted. Future directions are discussed in the context of treatment for patients considered at high-risk for lobectomy.

Percutaneous lung microwave ablationversus lung resectionin high-risk patients. A monocentric experience.

Background and aim of work:Lung microwave ablation (MWA) is considered an alternative treatment in high-risk patients, not suitable for surgery. The aim of our study is to compare MWA and pulmonary lobectomy in high-risk, lung cancer patients.Methods:This was a single-center, propensity score-weighted cohort study. All adult patients who underwent CT guided MWA for stage I NSCLC between June 2009-October 2014 were included in the study and were compared with a cohort of patients submitted to lung lobectomy in the same period of time. Outcomes were overall survival (OS) and disease-free survival (DFS).Results:32 patients underwent MWA, and 35 high-risk patients submitted to lung lobectomy in the same period were selected. Median follow-up time was 51.1 months (95% CI: 43.8-62.3). Overall survival was 43.8 (95% CI: 26.1-55) and 55.8 months (95% CI: 49.9-76.8) in the MWA group and Lobectomy group, respectively. Negative prognostic factors were MWA procedure (HR:2.25, 95% CI: 1.20-4.21, p= 0.0109) and nodule diameter (HR: 1.04, 95% CI: 1.01-1.07; p= 0.007) for OS, while MWA procedure (HR: 5.2; 95% CI: 2.1-12.8: p < 0.001), ECOG 3 (HR: 5.0; 95% CI: 1.6-15.6; p = 0.006) and nodule diameter (HR: 1.1; 95% CI: 1.0-1.1; p = 0.003) for DFS.Conclusions:Our study demonstrated a high percentage of local relapse in the MWA group but a comparable overall survival. Although lung lobectomy remains the gold standard treatment for stage I NSCLC, we can consider the MWA procedure as valid alternative local treatment in high-risk patients for stage I NSCLC. (www.actabiomedica.it)

Indocyanine green fluorescence/thermography evaluation of intercostal muscle flap vascularization.

BackgroundDuring anatomical lung resection in high‐risk patients, the bronchial stump is covered with tissue flaps (e.g. pericardial fat tissue and intercostal muscle) to prevent bronchopleural fistula development. This is vital for reliable reinforcement of the bronchial stump. We evaluated the blood supply of the flap using indocyanine green fluorescence (ICG‐FL) and thermography intraoperatively in 27 patients at high risk for developing a bronchopleural fistula.MethodsBefore reinforcing the stump with a flap, the fluorescence agent was intravenously injected and the blood supply was evaluated. The surface temperature of the flap was measured with thermography. The two modalities were then compared.ResultsICG‐FL intensity and surface temperature on the distal compared to the proximal side of the flap decreased by 32.6 ± 29.4% (P < 0.0001) and 3.5 ± 2.0°C (P < 0.0001), respectively. In patients with a higher ICG‐FL intensity value at the tip than the median, the surface temperature at the tip decreased by 2.7 ± 1.7°C compared to the proximal side. In patients with a lower ICG‐FL value at the tip, the surface temperature decreased by 4.6 ± 1.7°C (P = 0.0574). The bronchial stump reinforced the part of the flap with adequate blood supply; none of the patients developed a bronchopleural fistula.ConclusionsICG‐FL confirmed variation in the blood supply of the intercostal muscle flap, even if prepared using the same surgical procedure. Thermography analysis tends to correlate with the fluorescence method, but may be influenced by the state of flap preservation during surgery.

(P58) Multiple Recurrences of Granular Cell Tumor in the Skin: A Case Report and Review of the Literature

Granular cell tumors are rare tumors of Schwann cell origin. Rapid growth, aggressiveness, and histological markers characterize these tumors. Granular cell tumors (GCTs) are very uncommon (0.5% of all soft tissue tumors) and malignant granular cell tumors are even rarer. We present the clinical, pathologic, and radiographic features of a submental granular cell tumor of the skin that recurred multiple times in a 51-year-old African American man. The patient was a 51-year-old male who presented with swelling underneath his chin. He had a history of “keloids”; treatment included multiple surgeries and short-course radiotherapy. Eventually, an excisional biopsy was completed, showing granular cell tumor with positive margins. He was treated at our institution to 66Gy in 33 fractions via IMRT to the surgical bed with a treatment margin. The patient did well with treatment with minimal toxicity and had no evidence of disease for 10 months. Unfortunately, he developed new soft-tissue nodules in the surgical bed and radiation treatment field. On biopsy, recurrent granular cell tumor was confirmed. Given the complexity of his case, he was referred to an oncologic otolaryngologist for further evaluation and treatment. He was recommended surgery but on preoperative evaluation, he was noted to have lung metastases; he was started on chemotherapy. Discussion: Surgical excision has been the primary treatment strategy used in the treatment of GCTs. However, the prognosis remains poor, particularly with malignant granular cell tumor where > 50% of patients develop metastases. Given our patient’s multiple local recurrences and positive margins, we felt adjuvant radiotherapy was a reasonable treatment option for him to maximize local control. Radiation therapy was intended to decrease locoregional failure. There is not much published literature on the role of radiotherapy for GCTs. Case reports where adjuvant radiotherapy was used have demonstrated good disease control. Granular cell tumors are rare tumors that sometimes present in the soft tissues of the head and neck. Based on the existing literature, adding adjuvant radiotherapy after surgical resection in high risk patients is a reasonable treatment approach. Our case report highlights that these tumors can recur locally multiple times and demonstrates the importance of proper upfront diagnosis and management. Local treatment with surgical excision and radiation is a reasonable treatment approach.

Feasibility of Prophylactic Pancreatojejunostomy in Possible High-Risk Patients for Prevention of Pancreatic Fistula during Enucleation or Limited Pancreatic Resection

The aim of this study was to assess the feasibility of prophylactic pancreatojejunostomy after enucleation or limited pancreatic resection regarding the risk of postoperative pancreatic fistula (PF). We retrospectively reviewed the medical records of 32 patients who underwent enucleation or limited pancreatic resection and compared the clinical parameters between patients with (n = 10) and without (n = 22) prophylactic pancreatojejunostomy. Prophylactic pancreatojejunostomy was performed in patients with a possible high risk ofPF. No operation-related mortality occurred. Operation time was significantly longer (P < 0.01) and blood loss significantly greater (P < 0.01) in patients with pancreatojejunostomy. Overall complications were more frequent (P = 0.02) and postoperative hospital stay was significantly longer (P = 0.02) in patients with pancreatojejunostomy. However, other assessed factors including the prevalence of postoperative PF did not differ between groups. In conclusion, prophylactic pancreatojejunostomy is feasible, and its efficacy in preventing PF after enucleation or limited pancreatic resection in high-risk patients will require further study.

ES 05.05 Lung Cancer Surgery for High Risk Patients

High risk lung cancer patients represent a challenge in thoracic oncology, they are often related to heavy smoke habit with increased cardiovascular or respiratory diseases that prevents for getting optimal results in their lung cancer treatment. In the other hand it is widely accepted that lobectomy and lymphadenectomy is the standard treatment for younger patients with adequate cardiopulmonary function, especially in solid lung cancer patients.1 High risk patients with early stage lung cancer, often undergo sublobar resections, regardless of histology or tumor size, which increases the risk of local recurrence and may decrease long-term survival. However, a significant group of these patients have a good prognosis, either because their histology or tumor size are favorable, they present slow growing tumors or because they can undergo anatomical sublobar resections and a lymphadenectomy that provides an adequate disease control. In patients without respiratory or cardiovascular impairment it is accepted that sublobar resections have the same possibility of controlling the disease than lobectomy for ground glass opacity lesions, partially solid lesions (<50%) or with invasion area less than 5mm.2-4 The biggest problem appears in high-risk patients with solid lesions, in whom sublobar resections have not demonstrated the same oncological performance compared to lobectomy. This group will face the dilemma of decreasing operative morbimortality and the risk of postoperative respiratory disability versus decreased global and disease-free survival.5 Reports and our own experience with the treatment of T1 and T2 patients with segmentectomies and wedge resections suggests that it is appropriate to try these patients with economical resections to improve the quality of life and survival in a group of patients whose survival curve does not depend only on cancer, but it is also important the competitive causes of mortality (ex. cardiovascular disease, pulmonary fibrosis, emphysema).5 In our group, we evaluate cardiovascular risk with echocardiography and provocative test for myocardial ischemia, preferably exercise stress test. Respiratory risk is evaluated with spirometry, DLCO and cardiopulmonary exercise testing (peak VO2 and ventilatory equivalent VE/VCO2).6,7 If ppoFEV1 <60%, ppoDLCO <60%, V02 <10-15ml/kg/min and/or CO2 equivalent >35, values that show that the patient is high-risk or inoperable, we incorporate the patient to an exercise training program. Our protocol considers 1-1.5 hours/day of training, with progressive load to improve muscular strength, cardiovascular and respiratory capacity, associated with full medical treatment (LABA/LAMA inhalers plus inhaled and eventually systemic corticosteroids). After completing the training period, the patient is reevaluated and the treatment plan is defined: 1. If he leaves the high-risk group (VO2 >15ml/kg/min with VE/VCO2 <35), he will receive standard oncological surgery, according to tumor size and radiological/histological findings (TNM, GGO vs solid component, invasion). 2. If the surgical contraindication persists (VO2 <10ml/kg/min with VE/VCO2 >35), we prefer non-surgical treatments (like SBRT). In our institution, less than 5% of patients that enter the training program remain inoperable. 3. If the patient persists in the high or moderate-risk group (VO2 10-15ml/kg/min with VE/VCO2 <35), we prefer sublobar resections. In patients where the tumor is pure GGO or predominantly GGO (<50% solid) and measure less than 2 cms, we perform a VATS wide wedge resection plus hilar and mediastinal sampling. Frozen section must confirm that less than 50% is invasive or invasion area is smaller than 5mm. Margins should be larger than 1cm to persevere with wedge resection. If these requirements are not met: solid tumors larger than 10mm or mostly solid/GGO tumors, or GGO tumors greater than 2 cm with >25% solid, or has an invasive component larger than 5mm, we perform an anatomic segmental resection, by VATS or thoracotomy, associated with hilar and mediastinal lymphadenectomy.2,8-10 4. Even in larger tumors, we will attempt segmental resection in high-risk patients. We consider that although the risk of local recurrence is high, the lower morbidity and mortality rate of sublobar resections justifies this approach in high-risk patients. We believe that a sublobar resection with margins larger than 1 cm, grant better quality of life than a patient who becomes oxygen dependent, dies in the postoperative period or has not been resected due to the impossibility of lobectomy. In our institution, we have a prospective registry of morbidity that allows us to evaluate M&M rate and the relation with VO2 in patients with lobar and sublobar resections (Fig 1).5,9 Finally, in those patients with solid tumors and lymphovascular invasion, that are staged as clinically an pathological N0, the problem is that the intralobar lymph nodes are not completely accessible or evaluable. This implies that actually the N1 barrier is not adequately studied with sublobar resections, especially in those patients undergoing a training program and become candidates to wedge or even anatomical segmental resections as a treatment choice. This lack of information may be acceptable in AIS or MIA tumors, but constitute a greater risk in patients with solid or partially solid tumors, and even greater risk in those with lymphovascular invasion in the paraffin section. Should we consider these patients as potential N1 and add treatment to avoid the risk of relapse? There is no evidence to support this approach yet, but we feel it should be considered. 1.De Zoysa MK et al. Is limited pulmonary resection equivalent to lobectomy for surgical management of stage I non-small-cell lung cancer? Interactive CardioVascular and Thoracic Surgery 14(2012) 816-20 2.Asamura H et al. Radiographically determined noninvasive adenocarcinoma of the lung: Survival outcomes of Japan Clinical Oncology Group 0201. J Thorac Cardiovasc Surg 2013;146:24-30 3. Sakurai H, Asamura H. Sublobar resection for early stage lung cancer. Transl Lung Cancer Res 2014;3(3):164-172 4. Suzuki K, Asamura H et al. “Early” peripheral lung cancer: prognostic significance of Ground Glass Opacity on thin-section computed tomographic scan. Ann thorac Surg 2002;74:1635-9 5. Nakamura H et al. Comparison of the surgical outcomes of thoracoscopic lobectomy, segmentectomy, and wedge resection for clinical stage I non-small-cell lung cancer. 2011 Apr;59(3):137-41. 6. Shafiek et al. Risk of postoperative complications in chronic obstructive lung disease patients considered fit for lung surgery: beyond oxygen consumption. Eur J Cardiothorac Surg 2016; http://dx.doi.org/10/1093/ejcts/ezw104 7. Salati M, Brunelli A. Risk stratification in lung resection. Curr Surg Rep. 2016; 4:37 8. Hattori A et al. Prognostic impact of the findings on thin section computed tomography in patients with subcentimetric non-small cell lung cancer. JTO 2017;12(6):954-962 9. Valenzuela R et al. Long term survival of lung cancer in Chile. JTO2017;12(1):S745-S746 10. Aokage K et al. Limited resection for early-stage non-small cell lung cancer as function-preserving radical surgery: a review. Jpn J Clin Oncol,2017,47(1):7-11. High risk patients, lung cancer

EORTC Nomograms and Risk Groups for Predicting Recurrence, Progression, and Disease-specific and Overall Survival in Non–Muscle-invasive Stage Ta–T1 Urothelial Bladder Cancer Patients Treated with 1–3 Years of Maintenance Bacillus Calmette-Guérin

BackgroundThere are no prognostic factor publications on stage Ta–T1 non–muscle-invasive bladder cancer (NMIBC) treated with 1–3 yr of maintenance bacillus Calmette-Guérin (BCG). ObjectiveTo determine prognostic factors in NMIBC patients treated with 1–3 yr of BCG after transurethral resection of the bladder (TURB), to derive nomograms and risk groups, and to identify high-risk patients who should be considered for early cystectomy. Design, setting, and participantsData for 1812 patients were merged from two European Organization for Research and Treatment of Cancer randomized phase 3 trials in intermediate- and high-risk NMIBC. InterventionPatients received 1–3 yr of maintenance BCG after TURB and induction BCG. Outcome measurements and statistical analysisPrognostic factors for risk of early recurrence and times to late recurrence, progression, and death were identified in a training data set using multivariable models and applied to a validation data set. Results and limitationsWith a median follow-up of 7.4 yr, 762 patients recurred; 173 progressed; and 520 died, 83 due to bladder cancer (BCa). Statistically significant prognostic factors identified by multivariable analyses were prior recurrence rate and number of tumors for recurrence, and tumor stage and grade for progression and death due to BCa. T1G3 patients do poorly, with 1- and 5-yr disease-progression rates of 11.4% and 19.8%, respectively, and 1- and 5-yr disease-specific death rates of 4.8% and 11.3%. Limitations include lack of repeat transurethral resection in high-risk patients and exclusion of patients with carcinoma in situ. ConclusionsNMIBC patients treated with 1–3 yr of maintenance BCG have a heterogeneous prognosis. Patients at high risk of recurrence and/or progression do poorly on currently recommended maintenance schedules. Alternative treatments are urgently required. Patient summaryNon–muscle-invasive bladder cancer patients at high risk of recurrence and/or progression do poorly on currently recommended bacillus Calmette-Guérin maintenance schedules, and alternative treatments are urgently required. Trial registrationStudy 30911 was registered with the US National Cancer Institute clinical trials database (protocol ID: EORTC 30911). Study 30962 was registered at ClinicalTrials.gov, number NCT00002990; http://clinicaltrials.gov/ct2/show/record/NCT00002990.

[Necessity of defunctioning stoma in low anterior resection for rectal cancer: a meta-analysis].

To evaluate the necessity of defunctioning stoma in low anterior resection for rectal cancer below peritoneal reflection. The databases of Medline, Embase, Cochrane Library, Wanfang and CNKI were searched. The eligible studies were identified for pooled analyses. Six randomized controlled trials with 648 cases(332 patients with defunctioning stoma and 316 without stoma) and 25 retrospective controlled trials with 10,722 cases(4,470 patients with defunctioning stoma and 6,252 without stoma) were included. Combined analyses showed that defunctioning stoma was effective for decreasing risk of postoperative anastomotic leakage (RR=0.33 and 95% CI:0.21-0.53 for RCTs, OR=0.60 and 95% CI:0.42-0.85 for retrospective studies), reoperation (RR=0.30, 95% CI:0.16-0.53 for RCTs, OR=0.26 and 95% CI:0.21-0.32 for retrospective studies) and mortality(OR=0.41, 95% CI:0.27-0.62 for retrospective studies). Defunctioning stoma should be routinely performed in low anterior resection for high-risk patients.

Efficacy of Laparoscopic Colorectal Resection for Risk Patients with Severe Comorbidity

This study assessed the short term results of laparoscopic colorectal resection for high risk patients. Five hundred and fifty seven consecutive patients underwent an elective laparoscopic colorectal cancer resection by the same surgical team between April 2007 and December 2010. No risk patients in ASA class 1 (Group N, n=222), low risk patients with the systemic disease under the control in ASA class 2 and 3 (Group L, n=320), high risk patients with severe comorbidities in ASA class 4 (Group H, n=15) were respectively compared. The median blood loss count was significantly higher than the other group (N: 26 g, L: 22 g) in group H (59 g; p<0.05). On the other hands, the less lymphadenectomy was performed and a reconstruction with anastomosis was denied in group H. The incidence of postoperative complications was not significantly different in each group (N: 12%, L: 18%, H: 26%; p>0.05). There was the significant difference of the incidence with systemic complication (respiratory failure, ascites and delirium) in group H. The median postoperative hospital stay was not significantly different in each group (POD7; p>0.05). Hospitalization death occurred in three patients (0.5%) by uncontrollability of the systemic disease, two patients in group L and one patient in group H. Laparoscopic colorectal resection for high risk patients was performed safely without increasing complications and postoperative hospital stay.

Non-Invasive Pressure Support Ventilation in Major Lung Resection for High Risk Patients: Does It Matter?

Background and purpose: Patients with severely impaired pulmonary function have an increased operative risk for major lung resection. The clinical benefits of pre- and perioperative, non-invasive pressure support ventilation (NIPSV) have up to now not been extensively evaluated. Patients with severely reduced pulmonary function were investigated in this prospective and randomised single centre clinical trial. Methods: Standard pulmonary evaluation was performed in all patients before major lung resection. To predict postoperative pulmonary function, a lung perfusion-ventilation scan was carried out. All patients enrolled in the study were instructed preoperatively on how to use a NIPSV respirator. Af-ter lung resection patients were randomised either for continuation of NIPSV or for standard treatment. Results: Of the 52 patients assessed, 21 patients met the inclusion criteria for the study protocol. Predicted mean postoperative FEV1 was 1.10 L (range 0.92 - 1.27 L). Lobectomy was performed in 14 patients, pneumonectomy in 6 patients and a segmentectomy in 1 patient. No inhospital deaths occurred. Pulmonary complications (reintubation, pneumonia) were more frequent in the NIPSV group than in the control group (3 patients versus 1 patient), without statistical significance (p = 0.31). Conclusions: We observed no mortality and a low morbidity in this high risk group. Postoperative continuation of NIPSV had no beneficial effect on the clinical outcome. Preoperative conditioning with NIPSV, however, seems to be a suitable tool for patients with severely impaired pulmonary function. This study may serve therefore as basis for further investigations for the potential clinical benefits of prophylactic NIPSV in major lung surgery.

Non-invasive pressure support ventilation in major lung resection for high risk patients: does it matter?

Non-invasive pressure support ventilation in major lung resection for high risk patients: does it matter?

Laparoscopic Colorectal Surgery Produces Better Outcomes for High Risk Cancer Patients Compared to Open Surgery

The excellent outcomes reported for laparoscopic colorectal surgery in selected patients could also be potentially advantageous for high risk patients. This prospective study was designed to examine the feasibility and safety of laparoscopic resection in high risk patients with colorectal cancer. Between 2006 and 2008 consecutive patients undergoing elective surgery for colorectal cancer were stratified into high and low risk groups. High risk was defined as >or=80 years, American Society of Anesthesiologists >or=3, preoperative radiotherapy, T4 tumor and BMI >or=30. Outcomes included median length of stay, lymph node yield, resection margins, 30-day hospital readmission, postoperative mortality and major postoperative complications requiring reoperation within 30 days of surgery. A total of 424 patients underwent elective laparoscopic (224) and open (200) resections. Overall mortality rate for laparoscopic resection was 1 of 224 (0.4%) versus 4 of 200 (2%) for open resection. Median length of stay was 4 (2-33) versus 10 (1-69) days (P < 0.0001), and rate of complications requiring reoperation was 2 of 224 (0.8%) compared with 10 of 200 (5%) (P = 0.02).Among the 280 (66%) "high risk" patients, 146 had laparoscopic resection (8 conversions; 5%) and 134 had open resections. Median hospital stay was 4 (2-33) days in the laparoscopic group versus 11 (1-69) days in the open group (P < 0.0001). Complications requiring reoperation were 2 of 146 (1.4%) after laparoscopic resection versus 7 of 134 (5.2%) after open resection (P < 0.09). Readmission rate after laparoscopic resection was 12.3% versus 5.2% after open resection (P = 0.06). Laparoscopic resection of colorectal cancer can achieve excellent results even in "high risk" patients and is associated with significant reductions in length of stay compared with open resection.

Fibrin Glue Administration to Support Bronchial Stump Line

Bronchopleural fistula is an important cause of mortality and morbidity after pulmonary resection. The use of fibrin glue to reduce the tension and number of sutures in the bronchial stump was assessed in this prospective study of 20 patients between June 2002 and May 2003. They all had a high risk of bronchopleural fistula development because of bronchiectasis, tuberculosis, lung abscess, diabetes mellitus, preoperative neoadjuvant radiotherapy, or residual tumor at the surgical margin. After pulmonary resection, the bronchial stump was closed with separate nonabsorbable sutures supported with fibrin glue. Bronchopleural fistula was observed in only 1 (5%) patient during 6.45 +/- 3.09 months of follow-up. There was no postoperative mortality. Closing the bronchial stump with an appropriate technique and supporting it with fibrin glue were considered effective in preventing bronchopleural fistula development after pulmonary resection in high-risk patients.

Aerosolized Salbutamol Accelerates the Resolution of Pulmonary Edema After Lung Resection

Ischemia-reperfusion injuries, fluid overload, and cardiac insufficiency may all contribute to alveolar and interstitial lung edema. We hypothesized that aerosolized salbutamol would reduce extravascular lung water and improve oxygenation after lung resection by stimulating epithelial fluid clearance and cardiovascular function. Blinded, randomized, cross-over trial. We selected 24 patients with risk factors for lung edema. Aerosolized drugs (salbutamol, 5 mg; vs ipratropium, 0.5 mg) were administered on two consecutive trials, with a 6-h washout period, on the day of surgery (postoperative day [POD]-0) as well as on POD-1. Before and 50 min after the end of drug administration, we determined the oxygenation index (Pao(2)/fraction of inspired oxygen [Fio(2)] ratio), the extravascular lung water index (EVLWI), the pulmonary vascular permeability index (PVPI), and the cardiac index (CI) using the single-indicator thermal dilution technique. Complete data were obtained in 21 patients. On POD-0, the EVLWI was increased compared with preoperative values (13.0 +/- 3.8 vs 9.1 +/- 4.4, p < 0.001); salbutamol treatment induced significant increases in Pao(2)/Fio(2) ratio (+ 25 +/- 13%) that were associated with decreases in EVLWI (- 18 +/- 10%, p < 0.05) and in PVPI (- 19 +/- 10%, p < 0.05) along with increased CI (+ 23 +/- 11%, p < 0.05). On POD-1, repeated nebulization of salbutamol induced significant increases in Pao(2)/Fio(2) ratio and CI (+ 22 +/- 10% and 19 +/- 11%, respectively), whereas both EVLWI and PVPI remained unchanged. Nebulization of ipratropium bromide did not produce significant hemodynamic and respiratory changes on POD-0 and POD-1. Aerosolized salbutamol accelerates the resolution of lung edema, improves blood oxygenation, and stimulated cardiovascular function after lung resection in high-risk patients. This protocol trial (CER03-160) has been registered at (Clinicaltrials.gov) under NCT00498251.