Conversion surgery after gemcitabine and cisplatin plus durvalumab for advanced intrahepatic cholangiocarcinoma:A case report

BACKGROUND The combination of immune checkpoint inhibitors and chemotherapy has shown promising results for the treatment of advanced biliary tract cancer(BTC).Based on the results of the TOPAZ-1 trial,a gemcitabine and cisplatin plus durvalumab(GCD)regimen was recently approved as first-line therapy for patients with advanced BTC.However,post-GCD conversion surgery has not been previously studied.Herein,we describe a case of advanced intrahepatic cholangiocarcinoma(ICC)successfully treated with radical surgery after GCD.CASE SUMMARY A 65-year-old female diagnosed with advanced ICC with periductal infiltration into the hepatic hilum underwent eight cycles of GCD,followed by durvalumab maintenance treatment,with mild adverse events.Partial response was obtained.Subsequently,a conversion surgery with extended left hepatectomy and bile duct resection was performed.The resection margins were negative,and the pathological diagnosis was compatible with small duct type ICC.The patient remained disease-free for 8 months without adjuvant chemotherapy.CONCLUSION We describe the case of a patient who received successful conversion surgery after GCD treatment for advanced ICC.

Pulmonary embolism after shoulder surgery:Is it a real threat?

Pulmonary embolism(PE)is a rare but devastating complication of shoulder surgery.Apart from increased morbidity and mortality rates,it may significantly impair postoperative recovery and functional outcome.Its frequency accounts for up to 5.7%of all shoulder surgery procedures with a higher occurrence in women and patients older than 70 years.It is most commonly associated with thrombophilia,diabetes mellitus,obesity,smoking,hypertension,and a history of malignancy.PE usually occurs secondary to upper or lower-extremity deep vein thrombosis(DVT).However,in rare cases,the source of the thrombi cannot be determined.Prophylaxis for PE following shoulder surgery remains a topic of debate,and the standard of care does not routinely require prophylactic medication for DVT prophylaxis.Early ambulation and elastic stockings are important preventative measures for DVT of the lower extremity and medical agents such as aspirin,low-molecular-weight heparin,and vitamin K antagonists are indicated for high-risk patients,long-lasting operations,or concomitant severe acute respiratory syndrome coronavirus 2 infection.The most common symptoms of PE include chest pain and shortness of breath,but PE can also be asymptomatic in patients with intrinsic tolerance of hypoxia.Patients with DVT may also present with swelling and pain of the respective extremity.The treatment of PE includes inpatient or outpatient anticoagulant therapy if the patient is hemodynamically unstable or stable,respectively.Hemodynamic instability may require transfer to the intensive care unit,and cardiovascular arrest can be implicated in fatal events.An important issue for patients with PE in the postoperative period after shoulder surgery is residual stiffness due to a delay in rehabilitation and a prolonged hospital stay.Early physiotherapy and range-of-motion exercises do not adversely affect the prognosis of PE and are highly recommended to preserve shoulder mobility and function.

Albumin-to-alkaline phosphatase ratio: A novel prognostic index of overall survival in cholangiocarcinoma patients after surgery

AIM To clarify the prognostic significance of preoperative albumin-to-alkaline phosphatase ratio(AAPR) in cholangiocarcinoma(CCA) subjects receiving surgery.METHODS In this retrospective study, we included 303 CCA patients receiving surgery without preoperative therapy between 2002 and 2014. Clinicopathological characteristics(including AAPR) were analyzed to determine predictors of postoperative overall survival and recurrence-free survival(RFS). In addition,univariate and multivariate Cox proportional hazards models were conducted,followed by application of time-dependent receiver operating curves to identify the optimal cut-off.RESULTS Univariate and multivariate analyses revealed both decreased overall survival[hazard ratio(HR): 2.88, 95%CI: 1.19-5.78] and recurrence-free survival(HR: 2.31,95%CI: 1.40–3.29) in patients with AAPR < 0.41 compared to those with AAPR ≥0.41. The optimal cut-off of AAPR was 0.41. Of the 303 subjects, 253(83.5%) had an AAPR over 0.41. The overall 1-, 3- and 5-year survival rates were 70.2%, 38.0% and 16.5%, respectively in the low(< 0.41) AAPR group, which were significantly lower than those in the high(≥ 0.41) AAPR group(81.7%, 53.9%, and 33.4%,respectively)(P < 0.0001). Large tumor size, multiple tumors, and advanced clinical stage were also identified as significant predictors of poor prognosis.CONCLUSION Our outcomes showed that AAPR was a potential valuable prognostic indicator in CCA patients undergoing surgery, which should be further confirmed by prospective studies. Moreover, it is necessary to investigate the mechanisms concerning the correlation of low AAPR with poor post-operative survival in CCA patients.

Clinicopathological features and prognosis of combined hepatocellular carcinoma and cholangiocarcinoma after surgery

BACKGROUND： Combined hepatocellular carcinoma and cholangiocarcinoma （cHCC-CC） is a rare subtype of primary liver cancer consisting of both hepatocellular carcinoma （HCC） and cholangiocarcinoma （CC）. Because of the rarity of this tumor, its feature is poorly understood. The present study aimed to evaluate the clinicopathological features and long-term prognosis of patients with cHCC-CC after surgery and to compare with those of the patients with stage-matched HCC and CC. METHODS： The dinicopathological features of the patients who underwent surgery for cHCC-CC at our center during the period of 2001-2010 were retrospectively analyzed and compared with those of stage-matched HCC and CC patients. Cancer staging was performed according to the AJCC Cancer Staging Manual （6th ed.）. Overall survival and disease-free survival were compared among the groups and prognostic factors of cHCC-CC were evaluated. RESULTS： Significant differences were observed in clinico- pathological features among 42 patients with cHCC-CC, 90 patients with HCC and 45 patients with CC. Similar to HCC patients, cHCC-CC patients had frequent hepatitis B virus antigen positivity, microscopic vessel invasion, cirrhosis and high level of serum alpha-fetoprotein. Similar to CC patients, cHCC-CC patients showed increased bile duct invasion and decreased capsule. The 1-, 3-, and 5-year overall survival and disease- free survival of patients with cHCC-CC were not significantly different from those with stage-matched patients with CC;but significantly poorer than those with HCC. In subanalysis of patients with stage Ⅱ, the overall survival in patients with cHCC-CC or CC was significantly poorer than that in patients with HCC. We did not find the difference in patients with other stages. Univariate analysis of overall and disease-free survival of patients with cHCC-CC showed that the vascular invasion and intrahepatic metastasis were the significant predictive factors. CONCLUSION： Patients with cHCC-CC showed similar dinico- pathological features as those with HCC or CC, and patients with cHCC-CC or CC had a poorer prognosis compared with those with HCC, especially at matched stage Ⅱ.

Surgery and chemotherapy for intrahepatic cholangiocarcinoma

Cholangiocarcinoma, arising from bile duct epithelium, is categorized into intrahepatic cholangiocarcinoma (ICC) and extrahepatic cholangiocarcinoma (ECC), including hilarcholangiocarcinoma. Recently, there has been a worldwide increase in the incidence and mortality from ICC. Complete surgical resection is the only approach to cure the patients with ICC. However, locoregional extension of these tumors is usually advanced with intrahepatic and lymph-node metastases at the time of diagnosis. Resectability rates are quite low and variable (18%-70%). The five-year survival rate after surgical resection was reported to be 20%-40%. Median survival time after ICC resection was 12-37.4 mo. Only a small number of ICC cases, accompanied with ECC, gall bladder carcinoma, and ampullary carcinoma, have been reported in the studies of chemotherapy due to the rarity of the disease. However, in some reports, significant anti-cancer effects were achieved with a response rate of up to 40% and a median survival ofone year. Although recurrence rate after hepatectomy is high for the patients with ICC, the residual liver and the lung are the main sites of recurrence after tentative curative surgical resection. Several patients in our study had a long-term survival with repeated surgery and chemotherapy. Repeated surgery, combined with new effective regimens of chemotherapy, could benef it the survival of ICC patients.

Adjuvant surgery for advanced extrahepatic cholangiocarcinoma

Patients with StageⅣcholangiocarcinoma are currently not considered to be surgical candidates and are typically offered systemic chemotherapy.Recently,several novel systemic chemotherapy regimens have allowed an initially unresectable cholangiocarcinoma to be resectable.The aim of this article is to present the usefulness of adjuvant surgery in a case of advanced cholangiocarcinoma that was successfully treated with gemcitabine.A 72-year-old man was diagnosed with distal cholangiocarcinoma with liver metastases(cT2N0M1,StageⅣ).He underwent metal stent placement in the duodenum to alleviate jaundice.After 18courses of chemotherapy using gemcitabine without severe drug toxicities,a computed tomography scan showed that the liver metastases in S6 and S7 had disappeared.The patient underwent subtotal stomachpreserving pancreaticoduodenectomy and lymph node dissection.The pathological stage was pT2N0M0,StageⅠB.The patient underwent 6 cycles of adjuvant chemotherapy using gemcitabine.The patient is alive and well 6 years and 9 mo after the diagnosis.

Compliance with enhanced recovery after surgery predicts long-term outcome after hepatectomy for cholangiocarcinoma

BACKGROUND Enhanced recovery after surgery(ERAS)program has been proved to improve postoperative outcome for many surgical procedures,including liver resection.There was limited evidence regarding the feasibility and benefit of ERAS in patients who underwent liver resection for cholangiocarcinoma.AIM To evaluate the feasibility of ERAS in patients who underwent liver resection for cholangiocarcinoma and its association with patient outcomes.METHODS We retrospectively analyzed 116 cholangiocarcinoma patients who underwent hepatectomy at Srinagarind Hospital,Khon Kaen University between January 2015 and December 2016.The primary outcome was the compliance with ERAS.To determine the association between ERAS compliance and patient outcomes.the patients were categorized into those adhering more than and equal to 50%(ERAS≥50),and below 50%(ERAS<50)of all components.Details on type of surgical procedure,preoperative and postoperative care,tumor location,postoperative laboratory results,and survival time were evaluated.The compliance with ERAS was measured by the percentage of ERAS items achieved.The Kaplan-Meier curve was used for survival analysis.RESULTS The median percentage of ERAS goals achieved was 40%(±12%).Fourteen patients(12.1%)were categorized into the ERAS≥50 group,and 102 patients were in the ERAS<50 group.Postoperative hospital stay was significantly shorter in the ERAS≥50 group[8.9 d,95%confidence interval(CI):7.3-10.4 d]than in the ERAS<50 group(13.7 d,95%CI:12.2-15.2 d)(P=0.0217).No hepatobiliary-related complications or in-hospital mortality occurred in the ERAS≥50 group.Overall survival was significantly higher in the ERAS≥50 group.The median survival of the patients in the ERAS<50 group was 1257 d(95%CI:853.2-1660.8 d),whereas that of the patients in the ERAS≥50 group was not reached.CONCLUSION Overall ERAS compliance for patients who underwent liver resection for cholangiocarcinoma is poor.Greater ERAS compliance could predict in-hospital,short-term,and long-term outcomes of the patients.

Prognostic factors in patients with advanced cholangiocarcinoma: Role of surgery, chemotherapy and body mass index

AIM： To study the factors that may affect survival of cholangiocarcinoma in Lebanon. METHODS： A retrospective review of the medical records of 55 patients diagnosed with cholangio- carcinoma at the American University of Beirut between 1990 and 2005 was conducted. Univariate and multivariate analyses were performed to determine the impact of surgery, chemotherapy, body mass index, bilirubin level and other factors on survival. RJ^SULTS： The median survival of all patients was 8.57 mo （0.03-105.2）. Univariate analysis showed that low bilirubin level （〈 10 mg/dL）, radical surgery and chemotherapy administration were significantly associated with better survival （P = 0.012, 0.038 and 0.038, respectively）, in subgroup analysis on patients who had no surgery, chemotherapy administration prolonged median survival significantly （17.0 mo vs 3.5 mo, P = 0.001）. Multivariate analysis identified only low bilirubin level 〈 10 mg/dL and chemotherapy administration as independent predictors associated with better survival （P 〈 0.05）. CONCLUSION： Our data show that palliative and postoperative chemotherapy as well as a bilirubin level 〈 10 mg/dL are independent predictors of a significant increase in survival in patients with cholangiocarcinoma.

Palliative surgery for hilar cholangiocarcinoma

OBJECTIVE: To evaluate the results of palliative surgical treatment of hilar cholangiocarcinoma in terms of quality of life, survival period and cholangitis rate. MFTHODS: The clinical data on 232 patients with hilar cholangiocarcinoma in the last 22 years were analyzed retrospectively. Palliative operations included extrahepatic or intrahepatie choledochojejunostomy (123 patients), bridge internal drainage (15), endoscopic biliary drainage (49), percutaneous transhepatic biliary drainage or celiotomy biliary drainage (29), and exploratory celiotomy external drainage (16). RESULTS: In this series, the operative mortality rate was 9.1%, and no significant difference was observed between groups. The rate of cholangitis after operation was significantly lower in Roux-en-Y choledochojejunostomy group (16.2%) and bridge internal drainage group (15.4%) than in internal drainage group (35.5%, P<0.01), including percutaneous transhepatic biliary drainage (PTBD), endoscopic retrograde biliary drainage (ERBD), and celiotomy (or PTBD) external biliary drainage group (39.1%, P<0.01). No significant difference in survival was observed between the Roux-en-Y choledcthojejunostomy group (9.3±1.8 months) and PTBD (or ERBD) internal drainage group (8.7±2.2 months), but the survivals of the above groups were significantly longer than those of the bridge internal drainage group (6.5±1.7 months, P<0.05) and celiotomy (or PTBD) external biliary drainage group (4.4±2.1 months, P<0.01). CONCLUSIONS: In unresectable cholangiocarcinomas, either operative bilioenteric bypass or percutaneous transhepatic biliary drainage can achieve significant palliation. Roux-en-Y choledochojejunostomy is the best choice for palliative operation. The use of U-tube is recommended for internal radiation therapy.

New direction for surgery:Super minimally invasive surgery

The top goal of modern medicine is treating disease without destroying organ structures and making patients as healthy as they were before their sickness.Minimally invasive surgery(MIS)has dominated the surgical realm because of its lesser invasiveness.However,changes in anatomical structures of the body and reconstruction of internal organs or different organs are common after traditional surgery or MIS,decreasing the quality of life of patients post-operation.Thus,I propose a new treatment mode,super MIS(SMIS),which is defined as“curing a disease or lesion which used to be treated by MIS while preserving the integrity of the organs”.In this study,I describe the origin,definition,operative channels,advantages,and future perspectives of SMIS.

Late recurrence after surgery for cholangiocarcinoma:implications for follow-up?

BACKGROUND:Biliary tract cancer is uncommon,but has a high rate of early recurrence and a poor prognosis. There is only limited information on patients surviving more than 5 years after resection. METHODS:We report a patient who developed recurrence 8 years after resection of cholangiocarcinoma.Descriptions of late recurrence after excision of cholangiocarcinoma are reviewed. RESULTS:Few long-term survivors with biliary tract cancer have been reported.The survivors tend to have well differentiated or papillary tumors.The present case had no recurrence for 8 years despite poor prognostic factors including poor differentiation,invasion through the muscle wall and perineural invasion.It has been suggested that tumor cells left after the first operation grow and present as late recurrence.There is a need to differentiate a new primary and field change from recurrence of the previous tumor. CONCLUSIONS:Long-term follow-up after resection of cholangiocarcinoma is needed because late recurrence after 5 years occurs.The mortality rate between 5 and 10 years after resection of cholangiocarcinoma ranges from 6%to 43%in different series.Early detection of local recurrence may give an opportunity for further surgical resection.

Liver transplantation as an alternative for the treatment of perihilar cholangiocarcinoma: A critical review

Background:Perihilar cholangiocarcinoma(phCCC)is a dismal malignancy.There is no consensus regard-ing the best treatment for patients with unresectable phCCC.The present review aimed to gather the current pieces of evidence for liver transplantation and liver resection as a treatment for phCCC and to build better guidance for clinical practice.Data sources:The search was conducted in PubMed,Embase,Cochrane,and LILACS.The related references were searched manually.Inclusion criteria were:reports in English or Portuguese literature that a)patients with confirmed diagnosis of phCCC;b)patients treated with a curative intent;c)patients with the outcomes of liver resection and liver transplantation.Case reports,reviews,letters,editorials,conference abstracts and papers with full-text unavailability were excluded from the analysis.Results:Most of the current literature is based on observational retrospective studies with low grades of evidence.Liver resection has better long-term outcomes than systemic chemotherapy or palliation ther-apy and liver transplantation is a good alternative for selected patients with unresectable phCCC.All candidates for resection or transplantation should be medically fit and free of intrahepatic or extrahep-atic diseases.As a general rule,patients presenting with a tumor having a longitudinal size>3 cm or extending below the cystic duct,lymph node disease,confirmed extrahepatic dissemination;intraoper-atively diagnosed metastatic disease;a history of other malignancies within the last five years,and did not complete chemoradiation regimen and were medically unfit should not be considered for transplan-tation.Some of these criteria should be individually assessed.Liver transplantation or resection should only be considered in highly experienced hepatobiliary centers,and any decision-making must be based on a multidisciplinary evaluation.Conclusions:phCCC is a complex condition with high morbidity.Surgical therapies,including hepatec-tomy and liver transplantation,are the best option for better long-term disease-free survival.

Liver transplantation as an alternative for the treatment of intrahepatic cholangiocarcinoma: Past, present, and future directions

Intrahepatic cholangiocarcinoma(iCCA)is a rare biliary tract cancer with high mortality rate.Complete resection of the iCCA lesion is the first choice of treatment,with good prognosis after margin-negative resection.Unfortunately,only 12%-40% of patients are eligible for resection at presentation due to cirrhosis,portal hypertension,or large tumor size.Liver transplantation(LT)offers margin-negative iCCA extirpation for patients with unresectable tumors.Initially,iCCA was a contraindication for LT until size-based selection criteria were introduced to identify patients with satisfied post-LT outcomes.Recent studies have shown that tumor biology-based selection can yield high post-LT survival in patients with locally advanced iCCA.Another selection criterion is the tumor response to neoadjuvant therapy.Patients with response to neoadjuvant therapy have better outcomes after LT compared with those without tumor response to neoadjuvant therapy.Another index that helps predict the treatment outcome is the biomarker.Improved survival outcomes have also opened the door for living donor LT for iCCA.Patients undergoing LT for iCCA now have statistically similar survival rates as patients undergoing resection.The combination of surgery and locoregional and systemic therapies improves the prognosis of iCCA patients.

Cholangiocarcinoma after flow diversion surgery for congenital biliary dilatation: A case report and review of literature

BACKGROUND Pancreaticobiliary maljunction(PBM)can be classified into two categories,PBM with congenital biliary dilatation(CBD)or PBM without biliary dilatation,and the management of PBM is often controversial.The treatment for PBM with CBD is prophylactic flow diversion surgery,and some authors have reported that the incidence of cancer after extrahepatic bile duct excision is less than 1%.A very rare case of intrahepatic cholangiocarcinoma 6 years after flow diversion surgery for PBM with CBD is reported.CASE SUMMARY A 30-year-old man was diagnosed as having PBM with CBD,Todani classification type IVA,because of abnormal liver enzyme profiles.He underwent flow diversion surgery and cholecystectomy,and the specimen showed adenocarcinoma foci,pT1,pStage IA.Five and a half years passed without any recurrence of bile duct cancer.However,6 years after his operation,computed tomography showed a gradually growing nodule in the bile duct.Fluorodeoxyglucose positron emission tomography showed high uptake,and magnetic resonance imaging showed restricted diffusion signals.On double balloon enteroscopy,the nodule at the posterior bile duct-jejunum anastomosis was directly visualized,and its biopsy specimen showed adenocarcinoma.The patient underwent right lobectomy and biliary reconstruction.The pathological diagnosis was intraductal papillary neoplasm with high-grade intraepithelial neoplasia,pTis,pN0,pStage 0.The patient’s postoperative course was uneventful,and he has had no recurrence up to the present time.CONCLUSION This case suggests the necessity of careful observation after flow diversion surgery,especially when PBM with CBD is detected in adulthood.

Current interventional options for palliative care for patients with advanced-stage cholangiocarcinoma

Primary biliary tract tumors are malignancies that originate in the liver,bile ducts,or gallbladder.These tumors often present with jaundice of unknown etiology,leading to delayed diagnosis and advanced disease.Currently,several palliative treatment options are available for primary biliary tract tumors.They include percutaneous transhepatic biliary drainage(PTBD),biliary stenting,and surgical interventions such as biliary diversion.Systemic therapy is also commonly used for the palliative treatment of primary biliary tract tumors.It involves the administration of chemotherapy drugs,such as gemcitabine and cisplatin,which have shown promising results in improving overall survival in patients with advanced biliary tract tumors.PTBD is another palliative treatment option for patients with unresectable or inoperable malignant biliary obstruction.Biliary stenting can also be used as a palliative treatment option to alleviate symptoms in patients with unresectable or inoperable malignant biliary obstruction.Surgical interventions,such as biliary diversion,have traditionally been used as palliative options for primary biliary tract tumors.However,biliary diversion only provides temporary relief and does not remove the tumor.Primary biliary tract tumors often present in advanced stages,making palliative treatment the primary option for improving the quality of life of patients.

Bariatric surgery and diabetes:Current challenges and perspectives

Diabetes mellitus(DM)and obesity have become public issues of global concern.Bariatric surgery for the treatment of obesity combined with type 2 DM has been shown to be a safe and effective approach;however,there are limited studies that have systematically addressed the challenges of surgical treatment of obesity combined with DM.In this review,we summarize and answer the most pressing questions in the field of surgical treatment of obesity-associated DM.I believe that our insights will be of great help to clinicians in their daily practice.

Artificial Intelligence and Computer Vision during Surgery: Discussing Laparoscopic Images with ChatGPT4—Preliminary Results

Introduction: Ultrafast latest developments in artificial intelligence (ΑΙ) have recently multiplied concerns regarding the future of robotic autonomy in surgery. However, the literature on the topic is still scarce. Aim: To test a novel AI commercially available tool for image analysis on a series of laparoscopic scenes. Methods: The research tools included OPENAI CHATGPT 4.0 with its corresponding image recognition plugin which was fed with a list of 100 laparoscopic selected snapshots from common surgical procedures. In order to score reliability of received responses from image-recognition bot, two corresponding scales were developed ranging from 0 - 5. The set of images was divided into two groups: unlabeled (Group A) and labeled (Group B), and according to the type of surgical procedure or image resolution. Results: AI was able to recognize correctly the context of surgical-related images in 97% of its reports. For the labeled surgical pictures, the image-processing bot scored 3.95/5 (79%), whilst for the unlabeled, it scored 2.905/5 (58.1%). Phases of the procedure were commented in detail, after all successful interpretations. With rates 4 - 5/5, the chatbot was able to talk in detail about the indications, contraindications, stages, instrumentation, complications and outcome rates of the operation discussed. Conclusion: Interaction between surgeon and chatbot appears to be an interesting frontend for further research by clinicians in parallel with evolution of its complex underlying infrastructure. In this early phase of using artificial intelligence for image recognition in surgery, no safe conclusions can be drawn by small cohorts with commercially available software. Further development of medically-oriented AI software and clinical world awareness are expected to bring fruitful information on the topic in the years to come.

Fully automatic AI segmentation of oral surgery-related tissues based on cone beam computed tomography images

Accurate segmentation of oral surgery-related tissues from cone beam computed tomography(CBCT)images can significantly accelerate treatment planning and improve surgical accuracy.In this paper,we propose a fully automated tissue segmentation system for dental implant surgery.Specifically,we propose an image preprocessing method based on data distribution histograms,which can adaptively process CBCT images with different parameters.Based on this,we use the bone segmentation network to obtain the segmentation results of alveolar bone,teeth,and maxillary sinus.We use the tooth and mandibular regions as the ROI regions of tooth segmentation and mandibular nerve tube segmentation to achieve the corresponding tasks.The tooth segmentation results can obtain the order information of the dentition.The corresponding experimental results show that our method can achieve higher segmentation accuracy and efficiency compared to existing methods.Its average Dice scores on the tooth,alveolar bone,maxillary sinus,and mandibular canal segmentation tasks were 96.5%,95.4%,93.6%,and 94.8%,respectively.These results demonstrate that it can accelerate the development of digital dentistry.

Is recovery enhancement after gastric cancer surgery really a safe approach for elderly patients?

BACKGROUND This study aimed to evaluate the safety of enhanced recovery after surgery(ERAS)in elderly patients with gastric cancer(GC).AIM To evaluate the safety of ERAS in elderly patients with GC.METHODS The PubMed,EMBASE,and Cochrane Library databases were used to search for eligible studies from inception to April 1,2023.The mean difference(MD),odds ratio(OR)and 95%confidence interval(95%CI)were pooled for analysis.The quality of the included studies was evaluated using the Newcastle-Ottawa Scale scores.We used Stata(V.16.0)software for data analysis.RESULTS This study consists of six studies involving 878 elderly patients.By analyzing the clinical outcomes,we found that the ERAS group had shorter postoperative hospital stays(MD=-0.51,I2=0.00%,95%CI=-0.72 to-0.30,P=0.00);earlier times to first flatus(defecation;MD=-0.30,I²=0.00%,95%CI=-0.55 to-0.06,P=0.02);less intestinal obstruction(OR=3.24,I2=0.00%,95%CI=1.07 to 9.78,P=0.04);less nausea and vomiting(OR=4.07,I2=0.00%,95%CI=1.29 to 12.84,P=0.02);and less gastric retention(OR=5.69,I2=2.46%,95%CI=2.00 to 16.20,P=0.00).Our results showed that the conventional group had a greater mortality rate than the ERAS group(OR=0.24,I2=0.00%,95%CI=0.07 to 0.84,P=0.03).However,there was no statistically significant difference in major complications between the ERAS group and the conventional group(OR=0.67,I2=0.00%,95%CI=0.38 to 1.18,P=0.16).CONCLUSION Compared to those with conventional recovery,elderly GC patients who received the ERAS protocol after surgery had a lower risk of mortality.

Enhanced recovery after surgery in elderly patients with non-small cell lung cancer who underwent video-assisted thoracic surgery

BACKGROUND This study was designed to investigate the clinical outcomes of enhanced recovery after surgery(ERAS)in the perioperative period in elderly patients with nonsmall cell lung cancer(NSCLC).AIM To investigate the potential enhancement of video-assisted thoracic surgery(VATS)in postoperative recovery in elderly patients with NSCLC.METHODS We retrospectively analysed the clinical data of 85 elderly NSCLC patients who underwent ERAS(the ERAS group)and 327 elderly NSCLC patients who received routine care(the control group)after VATS at the Department of Thoracic Surgery of Peking University Shenzhen Hospital between May 2015 and April 2017.After propensity score matching of baseline data,we analysed the postoperative stay,total hospital expenses,postoperative 48-h pain score,and postoperative complication rate for the 2 groups of patients who underwent lobectomy or sublobar resection.RESULTS After propensity score matching,ERAS significantly reduced the postoperative hospital stay(6.96±4.16 vs 8.48±4.18 d,P=0.001)and total hospital expenses(48875.27±18437.5 vs 55497.64±21168.63 CNY,P=0.014)and improved the satisfaction score(79.8±7.55 vs 77.35±7.72,P=0.029)relative to those for routine care.No significant between-group difference was observed in postoperative 48-h pain score(4.68±1.69 vs 5.28±2.1,P=0.090)or postoperative complication rate(21.2%vs 27.1%,P=0.371).Subgroup analysis showed that ERAS significantly reduced the postoperative hospital stay and total hospital expenses and increased the satisfaction score of patients who underwent lobectomy but not of patients who underwent sublobar resection.CONCLUSION ERAS effectively reduced the postoperative hospital stay and total hospital expenses and improved the satisfaction score in the perioperative period for elderly NSCLC patients who underwent lobectomy but not for patients who underwent sublobar resection.