Background The Oesophago-Gastric Anastomosis Audit (OGAA) is an international collaborative group set up to study anastomotic leak outcomes after oesophagectomy for cancer. This Delphi study aimed to prioritize future research areas of unmet clinical need in RCTs to reduce anastomotic leaks. Methods A modified Delphi process was overseen by the OGAA committee, national leads, and engaged clinicians from high-income countries (HICs) and low/middle-income countries (LMICs). A three-stage iterative process was used to prioritize research topics, including a scoping systematic review (stage 1), and two rounds of anonymous electronic voting (stages 2 and 3) addressing research priority and ability to recruit. Stratified analyses were performed by country income. Results In stage 1, the steering committee proposed research topics across six domains: preoperative optimization, surgical oncology, technical approach, anastomotic technique, enhanced recovery and nutrition, and management of leaks. In stages 2 and stage 3, 192 and 171 respondents respectively participated in online voting. Prioritized research topics include prehabilitation, anastomotic technique, and timing of surgery after neoadjuvant chemo(radio)therapy. Stratified analyses by country income demonstrated no significant differences in research priorities between HICs and LMICs. However, for ability to recruit, there were significant differences between LMICs and HICs for themes related to the technical approach (minimally invasive, width of gastric tube, ischaemic preconditioning) and location of the anastomosis. Conclusion Several areas of research priority are consistent across LMICs and HICs, but discrepancies in ability to recruit by country income will inform future study design.
IntroductionGastric cancer (GC) is a significant and unsolved problem, despite a slight decrease in its morbidity. Globally, 952,000 new GC cases were registered in 2012. In South Korea and Japan, because of screening for GC, the 5-year survival rate is more than 60%. In most other countries, this value is 2-3 times lower (1,2). In Ukraine, GC is a serious problem. Annually, the country registers more than 8,000 new GC cases. The disease is usually diagnosed at stage III-IV (65% of cases) and 62.2% of patients die within 1 year. About 70% of patients with GC need chemotherapy, and for most of them, this is the only way to increase their life expectancy. Morbidity and death rateAccording to the national cancer register of Ukraine, there were 8,350 new cases of GC in 2014 (5,104 in men and 3,246 in women). Thus, the morbidity rate is 23.0 cases per 100,000 people (30.3 for men and 16.7 for women), which puts the disease in fourth place for men and eighth place for women for morbidity as a result of malignant tumors in Ukraine. During the period under investigation, 6,414 patients diagnosed with GC died. The death rate was 17.7 cases per 100,000 people (23.8 for men and 12.3 for women), which means that, for men and women respectively, GC has the second and third highest death rates from malignant tumors in Ukraine.People diagnosed with GC for the first time are diagnosed at the following stages according to the TNM classification: stage I-II, 37.6%; stage III, 22.5%; stage IV, 33.9%; and indistinct stage, 5%. Thus, advanced GC is diagnosed for the first time in as many as 60% of all patients, which leads to a high death rate of more than 50% during the first year.The above information allows us to conclude that the early diagnosis of GC, as well as combined methods of treating it with neo-adjuvant and adjuvant therapy, is of paramount importance in Ukraine.Despite the gradual decline in GC morbidity, there are still some serious associated problems. Namely, in the last 10 years, the following was noted ( Table 1): (I) very few changes in the morbidity rate for women; (II) decrease in the diagnosis of stage I-II disease in spite of the necessary endoscopic equipment; (III) high death rate within 1 year.Given this information, we should define the most of patients with GC need chemotherapy, and for most of them, this is the only way to increase their lifeexpectancy. An unsolved problem of nationwide importance is achieving the early diagnosis of GC, which predetermines the treatment outcome. The 5-year survival rate for GC patients in Ukraine is only 13%, while early diagnosed GC is almost totally curable using surgery. Another important task is the development of national diagnosis and treatment standards, which will be based on national breakthroughs and will meet modern international requirements.
There are many studies of single lung ventilation (SLV), which are mostly limited to reducing lung damage by changing ventilation strategies or comparing differences in lung damage caused by different lung isolation devices. There is no study comparing the morphological changes of ventilated lungs using different strategies of artificial lung ventilation. The aim of the study was to examine pathomorphological changes in the ventilated lung during thoracic surgery using SLV. A randomized study was performed on 40 patients who underwent thoracic surgery using SLV. After signing the informed consent, the patients were divided into two groups. In the control group (40 patients) with ventilation “by volume” (VCV), in the study group – ventilation “by pressure” (PCV) with the addition of PEEP 5 mm. During surgery in the thoracic cavity with the help of SLV performed transbronchial biopsy of the parenchyma of the ventilated lung to study the pathomorphological changes after ventilation with different modes. The biopsy was performed using a bronchoscope, which was inserted through the endotracheal tube into the lung, opposite the side of the operation (after the end of SLV and “inclusion” of the collapsed lung). The morphological changes caused by the ventilator were investigated. Pathomorphological examination of the non-collapsed lung (which participated in gas exchange during SLV) was as follows: the control group found significant changes in the alveolar wall with its edema, thickening of the interstitial lung, vascular occlusion, severe inflammatory cell infiltration and damage to alveolar structures. The alveoli collapsed and disappeared. The alveolar structures of the study group were better than the control group: pulmonary interstitial and alveolar exudates, as well as inflammatory cell infiltration were significantly reduced compared to those in the control group. The results of the study suggest that the use of PCV with “moderate” PEEP can significantly improve oxygenation and reduce acute ventilatory injury of the lungs compared to VCV during SLV.
Annotation. One lung ventilation (OLV) is one of the most difficult intraoperative methods of respiratory support for anesthesiologists. OLV should provide the most comfortable surgical field, maintaining proper gas exchange and minimizing damage to both lungs. This anesthetic procedure has a significant inflammatory response, so using perioperative corticosteroid therapy to suppress inflammatory mediators is recommended as an approach to improving prognosis. Therefore, the aim of this study was to determine how the preoperative administration of methylprednisolone affects the systemic proinflammatory response of cytokines during thoracic surgery. The analysis was performed for 80 patients who underwent surgeries in the thoraco-abdominal department of the Shalimov National Institute of Surgery and Transplantology. Patients were divided into 2 groups (study – 40 patients who were administered methylprednisolone 10 mg / kg intravenously during induction of anesthesia and control – 40 patients without methylprednisolone). Before surgery and in the postoperative period on days 1, 3 and 5, the surface phenotype of peripheral blood lymphocytes and the expression of IL-6 by monocytes were determined by flow cytofluorometry. The author's MedStat package was used for statistical analysis (Lyakh Yu.E., Guryanov V.G., 2004–2012). Postoperative indicators of IL-6 monocyte expression in the blood of patients administered methylprednisolone were significantly lower on the 1st and 3rd postoperative day (p<0.001). Thus, preoperative administration of methylprednisolone reduces the release of pro-inflammatory cytokines and improves the condition of patients after thoracic surgery. We consider it expedient to conduct further research on the administration of methylprednisolone for several days in the postoperative period.
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