Transdiaphragmatic herniation after transthoracic esophagectomy: an underestimated problem

2020 ◽  
Vol 33 (12) ◽  
Author(s):  
Hans F Fuchs ◽  
Laura Knepper ◽  
Dolores T Müller ◽  
Isabel Bartella ◽  
Christiane J Bruns ◽  
...  
Keyword(s):  
Hospital Mortality ◽  
Emergency Surgery ◽  
Locally Advanced ◽  
Treatment Algorithm ◽  
Laparoscopic Approach ◽  
High Rate ◽  
Neoadjuvant Radiochemotherapy ◽  
Left Hemithorax ◽  
Surgical Data ◽  
Diaphragmatic Herniation

Summary Diaphragmatic transposition of intestinal organs is a major complication after esophagectomy and can be associated with significant morbidity and mortality. This study aims of to analyze a large series of patients with this condition in a single high-volume center for esophageal surgery and to suggest a novel treatment algorithm. Patients who received surgery for postesophagectomy diaphragmatic herniation between October 2003 and December 2017 were included. Retrospective analysis of demographic, clinical and surgical data was performed. Outcomes of measure were initial clinical presentation, postoperative complications, in-hospital mortality and herniation recurrence. A total of 39 patients who had surgery for postesophagectomy diaphragmatic herniation were identified. Diaphragmatic herniation occurred after a median time of 259 days following esophagectomy with the highest prevalence between 1 and 12 months. A total of 84.6% of the patients had neoadjuvant radiochemotherapy prior to esophagectomy. The predominantly effected organ was the transverse colon (87.2%) prolapsing into the left hemithorax (81.6%). A total of 20 patients required emergency surgery. Surgery always consisted of reposition of the intestinal organs and closure of the hiatal orifice; a laparoscopic approach was used in 25.6%. Major complications (Dindo–Clavien ≥ IIIb) were observed in 35.9%, hospital mortality rate was 7.7%. Three patients developed recurrent diaphragmatic herniation during follow-up. Postesophagectomy diaphragmatic herniation is a functional complication of the late postoperative course and predominantly occurs in patients with locally advanced adenocarcinoma having chemoradiation before Ivor–Lewis esophagectomy. Due to a high rate of emergency surgery with life-threatening complications not a ‘wait-and-see’ strategy but early surgical repair may be indicated.

scholarly journals In-hospital recurrence in a Chinese large cohort with acute ischemic stroke

2019 ◽  
Vol 9 (1) ◽  
Author(s):  
Fan Yu ◽  
Xiaolu Liu ◽  
Qiong Yang ◽  
Yu Fu ◽  
Dongsheng Fan
Keyword(s):  
Risk Factors ◽  
Ischemic Stroke ◽  
Hospital Mortality ◽  
Hospital Stay ◽  
Acute Ischemic Stroke ◽  
Recurrent Events ◽  
Early Stage ◽  
High Rate ◽  
Large Artery ◽  
Stroke Event

Abstract Acute ischemic stroke (AIS) has a high risk of recurrence, particularly in the early stage. The purpose of this study was to assess the frequency and risk factors of in-hospital recurrence in patients with AIS in China. A retrospective analysis was performed of all of the patients with new-onset AIS who were hospitalized in the past three years. Recurrence was defined as a new stroke event, with an interval between the primary and recurrent events greater than 24 hours; other potential causes of neurological deterioration were excluded. The risk factors for recurrence were analyzed using univariate and logistic regression analyses. A total of 1,021 patients were included in this study with a median length of stay of 14 days (interquartile range,11–18). In-hospital recurrence occurred in 58 cases (5.68%), primarily during the first five days of hospitalization. In-hospital recurrence significantly prolonged the hospital stay (P < 0.001), and the in-hospital mortality was also significantly increased (P = 0.006). The independent risk factors for in-hospital recurrence included large artery atherosclerosis, urinary or respiratory infection and abnormal blood glucose, whereas recurrence was less likely to occur in the patients with aphasia. Our study showed that the patients with AIS had a high rate of in-hospital recurrence, and the recurrence mainly occurred in the first five days of the hospital stay. In-hospital recurrence resulted in a prolonged hospital stay and a higher in-hospital mortality rate.

scholarly journals Recurrent Sigmoid Volvulus – Early Resection may Obviate Later Emergency Surgery and Reduce Morbidity and Mortality

2009 ◽  
Vol 91 (3) ◽  
pp. 205-209 ◽  
Author(s):  
JO Larkin ◽  
TB Thekiso ◽  
R Waldron ◽  
K Barry ◽  
PW Eustace
Keyword(s):  
Emergency Surgery ◽  
Hospital Admissions ◽  
Elective Surgery ◽  
Postoperative Mortality ◽  
Operative Management ◽  
Sigmoid Volvulus ◽  
High Rate ◽  
Colonoscopic Decompression ◽  
Non Operative Management ◽  
Overall Mortality

INTRODUCTION Acute sigmoid volvulus is a well recognised cause of acute large bowel obstruction. PATIENTS AND METHODS We reviewed our unit's experience with non-operative and operative management of this condition. A total of 27 patients were treated for acute sigmoid volvulus between 1996 and 2006. In total, there were 62 separate hospital admissions. RESULTS Eleven patients were managed with colonoscopic decompression alone. The overall mortality rate for non-operative management was 36.4% (4 of 11 patients). Fifteen patients had operative management (five semi-elective following decompression, 10 emergency). There was no mortality in the semi-elective cohort and one in the emergency surgery group. The overall mortality for surgery was 6% (1 of 15). Five of the seven patients managed with colonoscopic decompression alone who survived were subsequently re-admitted with sigmoid volvulus (a 71.4% recurrence rate). The six deaths in our overall series each occurred in patients with established gangrene of the bowel. With early surgical intervention before the onset of gangrene, however, good outcomes may be achieved, even in patients apparently unsuitable for elective surgery. Eight of the 15 operatively managed patients were considered to be ASA (American Society of Anesthesiologists) grade 4. There was no postoperative mortality in this group. CONCLUSIONS Given the high rate of recurrence of sigmoid volvulus after initial successful non-operative management and the attendant risks of mortality from gangrenous bowel developing with a subsequent volvulus, it is our contention that all patients should be considered for definitive surgery after initial colonoscopic decompression, irrespective of the ASA score.

Pathological prognostic factors in locally advanced rectal carcinoma after neoadjuvant radiochemotherapy: analysis of 113 cases

2014 ◽  
Vol 65 (5) ◽  
pp. 623-630 ◽  
Author(s):  
Aurélie Sannier ◽  
Jérémie H Lefèvre ◽  
Yves Panis ◽  
Dominique Cazals-Hatem ◽  
Pierre Bedossa ◽  
...  
Keyword(s):  
Prognostic Factors ◽  
Rectal Carcinoma ◽  
Locally Advanced ◽  
Neoadjuvant Radiochemotherapy

scholarly journals Who profits from neoadjuvant radiochemotherapy for locally advanced esophageal carcinoma?

2009 ◽  
Vol 24 (5) ◽  
pp. 886-895 ◽  
Author(s):  
Stephan Kersting ◽  
Ralf Konopke ◽  
Dag Dittert ◽  
Marius Distler ◽  
Felix Rückert ◽  
...  
Keyword(s):  
Esophageal Carcinoma ◽  
Locally Advanced ◽  
Neoadjuvant Radiochemotherapy

Phase-II study of toripalimab combined with neoadjuvant chemotherapy for the treatment of resectable esophageal squamous cell carcinoma.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. e16029-e16029
Author(s):  
Delin Liu ◽  
Qin Zhang ◽  
Jinghua Zhu ◽  
Ting Qian ◽  
Rong Yin ◽  
...  
Keyword(s):  
Squamous Cell Carcinoma ◽  
Esophageal Squamous Cell Carcinoma ◽  
Cell Carcinoma ◽  
Neoadjuvant Therapy ◽  
Squamous Cell ◽  
Phase Ii Study ◽  
Locally Advanced ◽  
Neoadjuvant Treatment ◽  
Neoadjuvant Radiochemotherapy ◽  
Grade 3

e16029 Background: Compared with neoadjuvant chemotherapy alone，Neoadjuvant radiochemotherapy can significantly increase pCR rate in esophageal squamous cell carcinoma and improve patient overall survival. However, the addition of radiotherapy increases the risk of adverse reactions and surgery. Neoadjuvant radiochemotherapy is currently used in < 5% of Chinese patients.The purpose of this phase II study is to assess the efficacy and safety of toripalimab combined with paclitaxel and cisplatin as neoadjuvant treatment for resectable locally advanced esophageal squamous cell carcinoma(clinical trial registration number: ChiCTR1900025318). Methods: Patients 18–75 years old with esophageal squamous cell carcinoma confirmed by endoscopic biopsy, assessed to be locally advanced esophageal squamous cell carcinoma (cT1–cT2, N+; cT3–cT4 a, any N), and expected to be resectable were given toripalimab (240 mg d1 + PTX 175 mg/m2 + PDD 75 mg/m2 q3w) before surgery for two treatment cycles, followed by efficacy assessment. A consultation meeting with thoracic surgeons was held to assess radical surgery for patients with resectable lesions 4–6 weeks after neoadjuvant therapy was completed. pCR and postoperative-stage statistical analysis were conducted based on postoperative pathology test results. These results were used to determine the efficacy and safety of PD-1 monoclonal antibody combined with chemotherapy as neoadjuvant therapy for locally advanced esophageal cancer. Results: By December 2020, 23 subjects were enrolled. Of the subjects, five withdrew without undergoing surgery (three subjects refused surgery and switched to radical radiochemotherapy, one subject progressed to PD after two cycles of neoadjuvant therapy and switched to palliative treatment, and one subject could not undergo surgery after neoadjuvant treatment and gave up the treatment) and 18 evaluable patients underwent surgery. The R0 resection rate was 100%, and T0–Tis 33.3% (6/18) achieved pCR. Among these patients, 61.1% (11/18) achieved T0–T1 after surgery, and 72.2% (13/18) achieved N0. Moreover, stage reduction effects were significant compared with preoperative TN staging. Common side-effects include nausea, vomiting, neutropenia, thrombocytopenia, rash, asthenia, constipation, and muscle soreness. Most adverse events were grades 1–2, and grades 3/4 adverse events include one case of grade 3 neutropenia and one case of grade 3 diarrhea (suspected immune-related colitis), which improved after symptomatic treatment. Conclusions: Toripalimab combined with the TP scheme showed preliminary efficacy and controllable safety in the treatment of resectable locally advanced esophageal squamous cell carcinoma and is worthy of further exploration. Clinical trial information: ChiCTR1900025318.

Abstract 2399: Low Hospital Mortality Of Acute Myocardial Infarction In Cslinical Practice Due To Optimized Guideline Oriented Treatment: Results Of The Optami-registry

Circulation ◽  
2007 ◽  
Vol 116 (suppl_16) ◽  
Author(s):  
Anselm K Gitt ◽  
Harm Wienbergen ◽  
Uwe Zeymer ◽  
Frank Towae ◽  
Martin G Gottwik ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Clinical Practice ◽  
Hospital Mortality ◽  
Randomized Trials ◽  
Patient Characteristics ◽  
High Rate ◽  
Internal Quality ◽  
Acute Therapy ◽  
Early Invasive Strategy

Background: Hospital mortality of STEMI in recent randomized trials as ASSENT IV ranges between 3.5 and 6.0%. Although registry data have shown a constant improvement of myocardial infarction outcome over the past years due to better implementation of guidelines for the management of acute myocardial infarction, hospital mortality in clinical practice still was much higher than in the selected patient population of randomized trials. Can ongoing registries in clinical practice as quality assurance programmes further reduce hospital mortality of acute myocardial infarction? Methods: The OPTAMI Register (Optimized Therapy of Acute Myocardial Infarction) enrols consecutive patients with STEMI or NSTEMI in 33 Centres (27 with cathlab facilities) in Germany to document patient characteristics, acute therapy as well as hospital outcome. All centres are provided benchmark reports for internal quality control. Results: Out of 1139 enrolled patients, 629 (55%) presented with STEMI and 510 (45%) with NSTEMI. Patients with NSTEMI were older, more often female and had a significantly higher prevalence of relevant comorbidities. OPTAMI documented an extraordinary high rate of primary PCI in STEMI as well as a high rate of early invasive strategy with PCI <48h in NSTEMI. In both groups, adherence to guidelines for the acute adjunctive medical treatment including antiplatelet therapy, betablockers, ACE-inhibitors and statins was higher than ever documented in any German MI registry. Hospital mortality was 4.0% in consecutive patients with STEMI and 3.9% in consecutive patients with NSTEMI. Conclusion: Preliminary data of the ongoing OPTAMI Registry demonstrate that in selected cnetres (mainly with cath lab facilities) hospital mortality in clinical practice can be reduced to levels of randomised controlled trials by adherence to practice guidelines for the management of acute myocardial infarctions.

Practice points for surgical oncology

2016 ◽  
pp. 163-172
Author(s):  
Petra G. Boelens ◽  
C.B.M. van den Broek ◽  
Cornelis J.H. van de Velde
Keyword(s):  
Locally Advanced ◽  
Laparoscopic Approach ◽  
Oncologic Outcome ◽  
Surgical Oncology ◽  
Infectious Complications ◽  
Minimal Invasive ◽  
Locoregional Recurrence Rate ◽  
Cancer Types ◽  
Minimal Invasive Techniques ◽  
Invasive Techniques

Cancer surgery remains the cornerstone of curative cancer treatment for most solid cancers. Staging, resectability and timing of surgery should be discussed in a multidisciplinary team. Complete resection offers the best prognosis at many stages. Anatomical planes of surgery need to be taught and respected to reduce locoregional recurrence rate. Age, comorbidities, and patient preferences are important to consider before surgical treatment is advised. Minimal invasive techniques have shown equivalence in oncologic outcome for certain cancer types and established benefits in short-term outcomes. A laparoscopic approach is even sometimes possible. It remains important to select patients for these techniques according to medical history, staging, and fitness. In specialized centres locally advanced disease can be treated by a multimodal approach. The quality of surgery can be improved using standardized audit structures to monitor and feed back on outcome of surgery such as resected margins, infectious complications, and disease-free and overall survival.

scholarly journals Preoperative Risk Assessment: A Poor Predictor of Outcome in Critically ill Elderly with Sepsis After Abdominal Surgery

2020 ◽  
Vol 44 (12) ◽  
pp. 4060-4069
Author(s):  
Anne C. M. Cuijpers ◽  
Marielle M. E. Coolsen ◽  
Ronny M. Schnabel ◽  
Susanne van Santen ◽  
Steven W. M. Olde Damink ◽  
...  
Keyword(s):  
Risk Assessment ◽  
Abdominal Surgery ◽  
Hospital Mortality ◽  
Emergency Surgery ◽  
Outcome Prediction ◽  
Elective Surgery ◽  
Perioperative Risk ◽  
Physical Status ◽  
Icu Admission ◽  
Apache Iv

Abstract Background Postoperative outcome prediction in elderly is based on preoperative physical status but its predictive value is uncertain. The goal was to evaluate the value of risk assessment performed perioperatively in predicting outcome in case of admission to an intensive care unit (ICU). Methods A total of 108 postsurgical patients were retrospectively selected from a prospectively recorded database of 144 elderly septic patients (>70 years) admitted to the ICU department after elective or emergency abdominal surgery between 2012 and 2017. Perioperative risk assessment scores including Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality (P-POSSUM) and American Society of Anaesthesiologists Physical Status classification (ASA) were determined. Acute Physiology and Chronic Health Evaluation IV (APACHE IV) was obtained at ICU admission. Results In-hospital mortality was 48.9% in elderly requiring ICU admission after elective surgery (n = 45), compared to 49.2% after emergency surgery (n = 63). APACHE IV significantly predicted in-hospital mortality after complicated elective surgery [area under the curve 0.935 (p < 0.001)] where outpatient ASA physical status and P-POSSUM did not. In contrast, P-POSSUM and APACHE IV significantly predicted in-hospital mortality when based on current physical state in elderly requiring emergency surgery (AUC 0.769 (p = 0.002) and 0.736 (p = 0.006), respectively). Conclusions Perioperative risk assessment reflecting premorbid physical status of elderly loses its value when complications occur requiring unplanned ICU admission. Risks in elderly should be re-assessed based on current clinical condition prior to ICU admission, because outcome prediction is more reliable then.

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