D1 vs D2 resection for gastric cancer

One discussion this week included a trial out of Denmark comparing D1 and D2 lymph-node dissection for gastric cancer.

Reference: Bonenkamp JJ, et al. Extended lymph-node dissection for gastric cancer. NEJM. 1999 Mar 25;340(12):908-914.

Summary: Curative resection is the treatment of choice for gastric cancer, but it is unclear whether this operation should include an extended (D2) lymph-node dissection or a limited (D1) dissection. The authors conducted a randomized trial in 80 Dutch hospitals in which they compared D1 with D2 lymph-node dissection for gastric cancer in terms of morbidity, postoperative mortality, long-term survival, and cumulative risk of relapse after surgery.

Between August 1989 and July 1993, 996 patients were enrolled. Of these, 711 underwent randomly assigned treatment (D1 = 380, D2 = 331) and 285 received palliative treatment.

General findings:

  • Complications: 43% in D2, 25% in D1
  • Postoperative deaths: 10% in D2, 4% in D1
  • Length of stay: 16 median days in D2, 14 days in D1
  • 5-year survival rates: 47% in D2, 45% in D1


d1 v d2

One of the arguments for D2 dissection is its ability to reduce rates of local recurrence, thereby increasing the quality of life. The distressing finding of local recurrence, usually in a terminal phase of the disease, often leads to second operations to restore gastrointestinal continuity. In this trial, there was a tendency toward a reduced cumulative risk of relapse after D2 dissection, but the rate of relapse remained high and the difference from D1 dissection was not significant. A subgroup analysis indicated a significant or marginally significant difference for patients with disease in UICC stages II and IIIA, but this difference was attributable largely to stage migration.

Are diabetic patients at greater risk for anastomotic leaks and mortality when undergoing colectomies?

One discussion this week included postoperative anastomotic leaks.

Reference: Ziegler MA, et al. Risk factors for anastomotic leak and mortality in diabetic patients undergoing colectomy: analysis from a statewide surgical quality collaborative. Archives of Surgery. 2012 Jul;147(7):600-605. doi: 10.1001/archsurg.2012.77.

Summary: In a database review of patients in Michigan who underwent colectomy, the study aimed to determine risk factors in diabetic patients that are associated with increased postcolectomy mortality and anastomotic leak.

Primary risk factors were diabetes mellitus, hyperglycemia, steroid use, and emergency surgery. Of the 5123 patients, 889 were diabetic, 4234 were nondiabetic.

Diabetes alone was not found to be a risk factor for anastomotic leak in this study.

  • 56% of diabetic patients had preoperative glucose levels of 140 mg/dL or higher
  • Preoperative steroid use led to increased rates of anastomotic leak in diabetic patients
  • Diabetic patients who had a leak had more than a 4-fold higher mortality (26.3% vs 4.5%, P<.001) compared with nondiabetic patients (6.0% vs 2.5%, P<.05).
  • Mortality was associated with hyperglycemia for nondiabetic patients only

The authors conclude that improved screening may identify high-risk patients who would benefit from perioperative intervention.

Enterocutaneous fistulas: causes, management, and Emory authors

One discussion this week involved enterocutaneous fistulas.

Reference: Haak CI, Galloway JR, Srinivasan J. Enterocutaneous fistulas: a look at causes and management. Current Surgery Reports. 2014 Oct;2:71.

Summary: Despite advances in medical technology and surgical care, the management of enterocutaneous fistulas (ECF) remains one of the most challenging problems faced by physicians. Success depends on an expert multidisciplinary team, access to long-term enteral and parenteral nutrition support, advanced wound care, optimal medical management and meticulous, methodical, surgical decision-making and technique.

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Meta-analysis, systematic review of carbonic anhydrase inhibitors in respiratory failure and metabolic alkalosis

One discussion this week involved carbonic anhydrase inhibitors (CAIs) in the setting of respiratory failure and metabolic alkalosisa.

Reference: Tanios BY, et al. Carbonic anhydrase inhibitors in patients with respiratory failure and metabolic alkalosis: a systematic review and meta-analysis of randomized controlled trials. Critical Care. 2018 Oct 29;22(1):275.  doi: 10.1186/s13054-018-2207-6

Summary: Metabolic alkalosis is common in patients with respiratory failure and may delay weaning in mechanically ventilated patientsCarbonic anhydrase inhibitors (such as acetazolamide, methazolamide, and dichlorphenamide) block renal bicarbonate reabsorption, and thus reverse metabolic alkalosis. However, uncertainty remains about
their effects in the setting of respiratory failure with concurrent metabolic alkalosis on duration of hospitalization, mechanical ventilation (MV), or noninvasive positive pressure ventilation (NIPPV), and mortality.

The objective of this systematic review is to assess the benefits and harms of carbonic anhydrase inhibitor therapy in patients with respiratory failure and metabolic alkalosis.

Randomized clinical trials were included if they assessed at least one of the following outcomes: mortality, duration of hospital stay, duration of mechanical ventilation, adverse events, and blood gas parameters. Six eligible studies were identified with a total of 564 patients.

There were no definitive results for the effects of CAI therapy on clinically important outcomes such as mortality and duration of hospital stay in patients with respiratory failure and metabolic alkalosis. The results suggest that CAI therapy may decrease the duration of mechanical ventilation. There was a trend towards increased incidence of adverse events in the CAI group; however, most of these adverse events were mild.

On the other hand, the results suggest that CAI therapy has favorable effects on arterial blood gas parameters (PaCO2, PaO2, bicarbonate and pH), with decreased PaCO2, increased PaO2, and, as expected, decreased bicarbonate and pH levels.


In patients with respiratory failure and metabolic alkalosiscarbonic anhydrase inhibitor therapy may have favorable effects on blood gas parameters. The authors note that this analysis did not provide conclusive results for clinically important outcomes.

In mechanically ventilated patientscarbonic anhydrase inhibitor therapy may decrease the duration of mechanical ventilation. A major limitation was that only two trials assessed this clinically important outcome.

Ureteral catheters and injury during colectomy: A NSQIP study

One discussion this week included ureteral injuries during colectomy.

Reference: Coakley KM, et al. Prophylactic ureteral catheters for colectomy: A National Surgical Quality Improvement Program-based analysis. Diseases of the Colon and Rectum. 2018 Jan;61(1):84-88. doi:10.1097/DCR.0000000000000976.

Summary: Despite improvement in technique and technology, using prophylactic ureteral catheters to avoid iatrogenic ureteral injury during colectomy remains controversial. The aim of this retrospective study was to evaluate outcomes and costs attributable to prophylactic ureteral catheters with colectomy. Conducted at a signle tertiary care center, the authors pulled clinical data, 2012-2014, from ACS NSQIP database.

A total of 51,125 patients were identified with a mean age of 60.9 ± 14.9 years and a BMI of 28.4 ± 6.7 k/m; 4.90% (n = 2486) of colectomies were performed with prophylactic catheters, and 333 ureteral injuries (0.65%) were identified.

  • Prophylactic ureteral catheters were most commonly used for diverticular disease (42.2%; n = 1048), with injury occurring most often during colectomy for diverticular disease (36.0%; n = 120).
  • Univariate analysis of outcomes demonstrated higher rates of ileus, wound infection, urinary tract infection, urinary tract infection as reason for readmission, superficial site infection, and 30-day readmission in patients with prophylactic ureteral catheter placement.
  • On multivariate analysis, prophylactic ureteral catheter placement was associated with a lower rate of ureteral injury (OR = 0.45 (95% CI, 0.25-0.81)).
  • Additional research is needed to delineate patient populations most likely to benefit from prophylactic ureteral stent placement.

Open vs closed hemorrhoidectomy: a systematic review and meta-analysis of RCTs

One discussion this week included open versus closed hemorrhoidectomy.

Reference: Bhatti M, Sajid MS, Baig MK. Milligan-Morgan (open) versus Ferguson haemorrhoidectomy (closed): A systematic review and meta-analysis of published randomized, controlled trails. World Journal of Surgery. 2016 Jun;40(6):1509-1519. doi:10.1007/s00268-016-3419-z.

Summary: In Europe, the Milligan-Morgan procedure or open haemorrhoidectomy (OH) is more frequently practised, whereas in the United States of America the closed haemorrhoidectomy (CH) procedure, as described by Ferguson and Heaton, is the most popular. CH is purported to be a less painful procedure and associated with faster wound healing due to primary wound closure. However, the conflicting outcomes following both procedures have been debated in the published literature and several controversies around post-operative pain still need clarification.

Relevant prospective randomized, controlled trials (irrespective of type, language, gender, blinding, sample size or publication status) on CH versus OH for the management of HD until May 2014 were included in this review.

Ultimately, 11 RCTs encompassing 1326 patients were included in the systematic review and meta-analysis. Significant heterogeneity was found among included trials.

CONCLUSIONS: Variables of pain on defecation, length of hospital stay, post-operative complications, HD recurrence and risk of surgical site infection were similar in both groups.

Based upon the findings of this review, CH was associated with a reduced post-operative pain, faster wound healing, lesser risk of post-operative bleeding but prolonged duration of operation.

Findings of this review are contradictory to a 2007 meta-analysis of six randomized, controlled trials.


To view full data analyses (3 tables and 11 figures!) click on the link in the reference at the top of this post.