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Markar S.R.,Imperial College London | Karthikesalingam A.,St Georges Vascular Institute | Jackson D.,MRC Biostatistic Unit | Hanna G.B.,Imperial College London
Annals of Surgical Oncology | Year: 2013

Background: The presence of mixed evidence about the value of lymphadenectomy in gastric cancer surgery coupled with the difference in patients' demographics and tumor stage between the West and East have doubted the needs to standardize surgical techniques in Western clinical practice. The purpose of this study was to compare survival rates between the West and East following gastrectomy in randomized, controlled, oncological trials with appropriate adjustment for confounding variables. Methods: Systematic search revealed 25 trials that have randomization into surgery and chemotherapy versus surgery alone between 1995 and 2012 (n = 7 (East) and n = 18 (West)). End points were 5-year survival and cancer recurrence. Results: There was association between gastrectomy performed in the East and improved 5-year survival (pooled odds ratio (OR) 4.83; 95 % confidence interval (CI) 3.27-7.12) and reduced cancer recurrence (pooled OR 0.33; 95 % CI 0.2-0.54). Association of improved 5-year survival with surgery in the East remained when meta-regression adjusted for the effect of age, sex, chemotherapy, tumor depth and nodal status, and gastrectomy type. Association of reduced cancer recurrence also persisted with meta-regression adjusting for age, chemotherapy, nodal status, and gastrectomy type. However, when adjustment for the percentage of patients with tumor depth T1 or 2 was made statistical significance was lost. Conclusions: This analysis shows association between gastrectomy performed in Eastern countries and improved survival. The known difference in surgical techniques between the East and the West is one potential unexamined variable that may be responsible in part for such discrepancy in outcomes. © 2013 Society of Surgical Oncology. Source


Paraskevas K.I.,St Georges Vascular Institute | Kalmykov E.L.,Royal Infirmary | Naylor A.R.,Royal Infirmary
European Journal of Vascular and Endovascular Surgery | Year: 2016

Background Randomised trials have reported higher stroke/death rates after carotid artery stenting (CAS) versus carotid endarterectomy (CEA). Despite this, the 2011 American Heart Association (AHA) guidelines expanded CAS indications, partly because of the Carotid Revascularization Endarterectomy versus Stenting Trial, but also because of improving outcomes in industry sponsored CAS Registries. The aim of this systematic review was: (i) to compare stroke/death rates after CAS/CEA in contemporary dataset registries, (ii) to examine whether published stroke/death rates after CAS fall within AHA thresholds, and, (iii) to see if there had been a decline (over time) in procedural risk after CAS/CEA. Methods PubMed/Medline, Embase, and Cochrane databases were systematically searched according to the recommendations of the PRISMA statement from January 1, 2008 until February 23, 2015 for administrative dataset registries reporting outcomes after both CEA and CAS. Results Twenty-one registries reported outcomes involving more than 1,500,000 procedures. Stroke/death after CAS was significantly higher than after CEA in 11/21 registries (52%) involving "average risk for CEA" asymptomatic patients and in 11/18 registries (61%) involving "average risk for CEA" symptomatic patients. In another five registries, CAS was associated with higher stroke/death rates than CEA for both symptomatic and asymptomatic patients, but formal statistical comparison was not reported. CAS was associated with stroke/death rates that exceeded risk thresholds recommended by the AHA in 9/21 registries (43%) involving "average risk for CEA" asymptomatic patients and in 13/18 registries (72%) involving "average risk for CEA" symptomatic patients. In 5/18 registries (28%), the procedural risk after CAS in "average risk" symptomatic patients exceeded 10%. Conclusions Data from contemporary administrative dataset registries suggest that stroke/death rates following CAS remain significantly higher than after CEA and often exceed accepted AHA thresholds. There was no evidence of a sustained decline in procedural risk after CAS. © 2015 European Society for Vascular Surgery. Source


Thompson M.,St Georges Vascular Institute
European Journal of Vascular and Endovascular Surgery | Year: 2011

Introduction: Endovascular procedures for repair of Type B aortic dissection have become increasingly common and are often considered to be first line therapy for acute complicated dissections. The long term durability of these repairs is largely undefined. Methods: The Virtue Registry is a prospective, non-randomised, multi centre European Clinical Registry designed to inform on the clinical and morphological outcomes of 100 patients with Type B aortic dissection treated with the Medtronic Valiant thoracic stent graft. Patients with acute, sub-acute and chronic Type B dissections will be prospectively followed for three years. Clinical outcomes and aortic morphology will be defined. Results: Fifty patients had an acute dissection, 24 a sub-acute dissection and 26 a chronic lesion. The 30-day mortality for the acute, sub-acute and chronic lesions was 8%, 0% and 0%. The in hospital composite outcome (mortality, stroke or paraplegia) for the three groups was 16%, 0% and 3.8% respectively. The effect of left subclavian artery (LSCA) revascularisation was defined with the composite endpoint of patients with a covered, non-revascularised LSCA being 20% as compared to 5.8% in the covered, revascularised group. Conclusion: The early outcomes for the treatment of Type B aortic dissection are reported in the Virtue Registry. Longer term follow-up is planned to report on clinical and morphological outcomes up to 36 months post-procedure. © 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. Source


Patterson B.,St Georges Vascular Institute | Holt P.,St Georges Vascular Institute | Nienaber C.,University of Rostock | Cambria R.,Massachusetts General Hospital | And 2 more authors.
Circulation | Year: 2013

Background-Endovascular repair of the thoracic aorta has become an increasingly utilized therapy. Although the short-term mortality advantage over open surgery is well documented, late mortality and the impact of presenting pathology on long-term outcomes remain poorly reported. Methods and Results-A database was built from 5 prospective studies and a single institutional series. Rates of perioperative adverse events were calculated, as were midterm death and reintervention rates. Multivariate analysis was performed with the use of logistic regression modeling. Kaplan-Meier survival curves were drawn for midterm outcomes. The database contained 1010 patients: 670 patients with thoracic aortic aneurysm, 195 with chronic type B aortic dissection, and 114 with acute type B aortic dissection. Lower elective mortality was observed in patients with chronic dissections (3%) compared with patients with aneurysms (5%). Multivariate analysis identified age, mode of admission, American Society of Anesthesiologists grade, and pathology as independent predictors of 30-day death (P < 0.05). In the midterm, the all-cause mortality rate was 8, 4.9, and 3.2 deaths per 100 patient-years for thoracic aortic aneurysm, acute type B aortic dissection, and chronic type B aortic dissection, respectively. The rates of aortic-related death were 0.6, 1.2, and 0.4 deaths per 100 patient-years for thoracic aortic aneurysm, acute type B aortic dissection, and chronic type B aortic dissection, respectively. Conclusions-This study indicated that the midterm outcomes of endovascular repair of the thoracic aorta are defined by presenting pathology, associated comorbidities, and mode of admission. Nonaortic mortality is high in the midterm for patients with thoracic aortic aneurysm, and managing modifiable risk factors appears vital. Endovascular repair of the thoracic aorta results in excellent midterm protection from aortic-related mortality, regardless of presenting pathology. © 2013 American Heart Association, Inc. Source


Markar S.R.,St Marys Hospital | Arya S.,St Marys Hospital | Karthikesalingam A.,St Georges Vascular Institute | Hanna G.B.,St Marys Hospital
Annals of Surgical Oncology | Year: 2013

Background. Due to the significant contribution of anastomotic leak, with its disastrous consequences to patient morbidity and mortality, multiple parameters have been proposed and individually meta-analyzed for the formation of the ideal esophagogastric anastomosis following cancer resection. The purpose of this pooled analysis was to examine the main technical parameters that impact on anastomotic integrity. Methods. Medline, Embase, trial registries, and conference proceedings were searched. Technical factors evaluated included hand-sewn versus stapled esophagogastric anastomosis (EGA), cervical versus thoracic EGA, minimally invasive versus open esophagectomy, anterior versus posterior route of reconstruction and ischemic conditioning of the gastric conduit. The outcome of interest was the incidence of anastomotic leak, for which pooled odds ratios were calculated for each technical factor. Results. No significant difference in the incidence of anastomotic leak was demonstrated for the following technical factors: hand-sewn versus stapled EGA, minimally invasive versus open esophagectomy, anterior versus posterior route of reconstruction and ischemic conditioning of the gastric conduit. Four randomized, controlled trials comprising 298 patients were included that compared cervical and thoracic EGA. Anastomotic leak was seen more commonly in the cervical group (13.64 %) than in the thoracic group (2.96 %). Pooled analysis demonstrated a significantly increased incidence of anastomotic leak in the cervical group (pooled odds ratio = 4.73; 95 % CI 1.61- 13.9; P = 0.005). Conclusions. A tailored surgical approach to the patient's physiology and esophageal cancer stage is the most important factor that influences anastomotic integrity after esophagectomy. © Society of Surgical Oncology 2013. Source

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