Surgical Technology International
45th Edition
ISSN:1090-3941
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Major Risk Factors of Mortality in Adult and Elderly Patients Emergently Admitted for Intestinal Fistulas, Excluding the Rectum and Anus
Zachary Thomas, MS, Cailan Feingold, BS, New York Medical College, School of Medicine, Valhalla, New York, Abbas Smiley, MD, PhD, School of Medicine, University of Rochester, Rochester, New York, Rifat Latifi, MD, FACS, FICS, FKCS, Adjunct Professor , University of Arizona, Tucson, Arizona
1807
Introduction: In the United States, intestinal fistulas accounts for $500 million (USD) of healthcare expenditures and 28,000 admissions annually. They are also associated with significant morbidity and mortality. Despite the high prevalence of intestinal fistulas, risk factors of mortality have yet to be fully elucidated. The aim of this study was to identify risk factors of mortality in emergently admitted patients with fistulas of the intestine, excluding the rectum and anus.
Materials and Methods: Adult and elderly patients emergently admitted with intestinal fistulas, between 2004–2014 were investigated using the National Inpatient Sample Database, ICD-9-CM code 569.81. Clinical outcomes, therapeutic management, demographics, and comorbidities were collected. Associations between mortality and all other variables were established via univariable and multivariable logistic regression models. The final multivariable regression model elucidated the odds ratios (95% confidence interval, p-value) of pertinent mortality risk factors.
Results: A total of 7,377 patients were included, of which the average adult and elderly ages were 48.9 and 74.6 years, respectively. Of these patients, 4,241 (57.5%) were female and 3,136 (42.5%) were male. Elderly patients demonstrated a higher mortality rate than adult patients—4.5% and 1.7%, respectively. In the adult group, the odds ratio for mortality was 1.020 for hospital length of stay in days (95% CI: 1.015–1.026, p<0.001), 1.035 for age (95% CI: 1.011–1.060, p=0.004), and 1.033 for days to the first procedure (95% CI: 1.021–1.044, p<0.001), among others. For the elderly group, the odds ratio for mortality was 1.012 for hospital length of stay in days (95% CI: 1.005–1.019, p=0.001), 1.075 for age (95% CI: 1.050–1.101, p<0.001), and 1.026 for days to the first procedure (95% CI: 1.009–1.043, p=0.002), among others.
Conclusion: In adult and elderly patients emergently admitted for intestinal fistulas, multiple comorbidities were risk factors for in-hospital mortality. In the elderly cohort, increased age and increased days to operation were additional risk factors for in-hospital mortality.
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Cardiophrenic Lymph Node Resection Through Abdominal Subxiphoid Approach: Surgical Technique
Christian Mouawad, MD, MSc, Chetana Lim MD, PhD, Hôpital de la Pitié-Salpêtrière, Paris, France, Rui Bernardino, MD, Hospital de Santa Maria – Centro Hospitalar Lisboa Norte, Lisbon, Portugal
1820
While metastatic extension to the cardiophrenic lymph nodes (CPN) is relatively rare, cardiophrenic lymphadenectomy may be performed for diagnostic and/or therapeutic purposes. The subxiphoid approach is appropriate, especially for CPN in the prepericardiac area, offering adequate exposure while avoiding the morbidity associated with pleural or pericardial breach. In this article, we describe the surgical technique—detailing the retrosternal liberation section of the tranversus abdominis muscle, followed by cardiophrenic dissection and lymphadenectomy.
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Endo-Bag Retrieval Using the “Fishing Technique”
Christian Mouawad, MD, MSc, Centre Hospitalier Intercommunal de Villeneuve-Saint-Georges, Paris, France, Houssam Dahboul, MD, MSc, Centre Hospitalier de Saint-Denis, Paris, France, Michael Osseis, MD, MPH , Ghassan Chakhtoura, MD, Saint Joseph University’s Faculty of Medicine, Beirut, Lebanon
1831
In minimally invasive procedures, one of the surgeon’s goals is finalizing the surgery safely while using the minimum number and size of trocars. In this article, we present the “fishing technique” which helps to avoid using an extra 10mm trocar in order to deploy specimen retrieval bags.
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Textbook Outcome Following Liver Transplantation: A Systematic Review
Christian Mouawad, MD, MSc,Chetana Lim, MD, PhD, Hôpital de la Pitié-Salpêtrière, Paris, France
1832
Introduction: Despite advances in perioperative care and immunosuppressive therapy in liver transplantation (LT), and the broadening of eligibility criteria and indications for LT, the complexity of this procedure makes the configuration of a textbook outcome (TO) rather difficult to define an optimal postoperative follow up. In this article, we evaluate and summarize the data in the literature concerning textbook outcome in liver transplantation (TOLT).
Materials and Methods: Four studies discussing TOLT were included and evaluated in our literature review. Three studies had, as inclusion criteria, adult patients who had undergone elective primary LT, without association with another organ transplant, with a deceased donor. The fourth study included patients who had undergone an enhanced recovery after surgery (ERAS) protocol prior to their LT during the study period, with no other selection criteria.
Results: The frequency of TOLT in the four studies described ranged from 31 to 37.5%. The definition of TOLT was variable between the different authors, with an “all or nothing” rule. Three criteria were rather predominant: length of hospital stay, mortality, and need for hospital readmission, with variability in the times adopted by the authors for each criterion.
Conclusion: Our systematic review summarizes the international experience regarding the conceptualization of the TOLT to date. The impact of TOLT on graft and patient survival is debated, especially with the complexity of this surgery and its postoperative follow up. Multicenter studies are needed to achieve a standardization of TOLT on a global scale.
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Importance of Lymph Node Metastasis to the Pancreatic Head Region in Patients with Ampulla of Vater Carcinoma
Motoyasu Tabuchi, MD, Shinya Sakamoto, MD, Teppei Tokumaru, MD, Takehiro Okabayashi, MD, Jun Iwata, MD, Manabu Matsumoto, MD, Rika Yoshimatsu, MD, Kochi Health Sciences Center, Kochi, Japan , Yasuhiro Shimada, MD, Tatsuo Iiyama, MD, National Center for Global Health and Medicine,Kochi, Japan
1841
Introduction: Owing to their rarity, clinicopathologic variables and postoperative outcomes in patients with ampulla of Vater carcinoma (AVC) have not been fully elucidated.
Materials and Methods: A retrospective review of the clinical records of patients who underwent surgical exploration for AVC was performed using univariate and multivariate analyses.
Results: One-, three-, and five-year overall survival rates after surgery were 97.4%, 71.8%, and 63.0%, respectively. The most frequently observed sites of recurrence were lymph nodes in 11 patients (52%), followed by the liver in eight (38%), lung in six (29%), local in three (14%), and peritoneal dissemination in three (14%). On multivariate analysis, only the presence of lymph node metastasis extending to the pancreatic head region predicted inferior relapse-free survival. A significant correlation between postoperative recurrence and pathological lymph node metastasis was observed.
Conclusions: Lymph node metastasis, especially that extends to the pancreatic head region, was clearly identified as a prognostic indicator of reduced relapse-free survival in patients with AVC.
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Two Cases of Pylorus-Preserving Pancreatoduodenectomy with Remnant Stomach Preservation in Patients Who Have Undergone Proximal Gastrectomy
Motoyasu Tabuchi, MD, Shinya Sakamoto, MD, Teppei Tokumaru MD, Takehiro Okabayashi, MD, Rika Yoshimatsu, MD, Dean of Radiology, Manabu Matsumoto, MD, Jun Iwata, MD, Kochi Health Sciences Center, Kochi, Japan
1842
Introduction: Pancreaticoduodenectomy after proximal gastrectomy (PG) presents technical challenges owing to the need to preserve blood flow in the remnant stomach. Considering the oncological factors and preservation of the remnant stomach blood supply, it is crucial to preserve or reconstruct the right gastric artery (RGA) and/or right gastroepiploic artery (RGEA). In cases where the RGEA is preserved, technical considerations for reconstruction arise owing to the poor motility of the remnant stomach.
Case presentation: A 79-year-old man was diagnosed with pancreatic head cancer and underwent pylorus-preserving pancreatoduodenectomy (PPPD) three years after PG for gastric cancer. The second patient, a 64-year-old man with a history of PG for esophagogastric junction cancer two years prior, was diagnosed with distal cholangiocarcinoma and underwent PPPD. In both cases, preserving the RGEA while ensuring adequate oncological resection margins was considered feasible. We were able to safely preserve the RGA, RGEA, and remnant stomach. The jejunum was mobilized from the right mesocolon, and all anastomoses (pancreatojejunostomy, choledochojejunostomy, and duodenojejunostomy [D-J]) were performed on the proximal side of the transverse mesocolon to minimize the tension on the D-J anastomosis.
Conclusion: Pancreatoduodenectomy after PG requires careful consideration of curability and surgical invasiveness. It is crucial to devise reconstruction techniques that minimize tension on the D-J anastomosis.
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Short-Term Outcomes Following Operative Repair of the Burst Abdomen: A Retrospective Review of Different Techniques
Vincent van Grinsven, MD, Stan A.M. Bessems, MD, PhD, Andreas Renders, MD, Joop Konsten, MD, Frits Aarts, MD, PhD, VieCuri Medical Center, Venlo, Netherlands, Johannes A. Wegdam, MD, PhD, Elkerliek Hospital, Helmond, Netherlands
1839
Introduction: Abdominal wall closure in postoperative burst abdomen remains challenging. Different techniques vary between definitive closure and temporary closure. The aim of this study was to examine the short-term outcomes for different closure techniques.
Materials and Methods: A multicenter single-arm observational retrospective cohort study examined all patients who underwent emergency operative repair for burst abdomen between January 2010 and May 2020 in two hospitals situated in the Netherlands. Patients underwent definitive closure, static closure with inlay mesh, or dynamic closure with negative pressure wound therapy (NPWT). We evaluated patient and treatment characteristics, length of stay, complications, and survival.
Results: 119 patients were assessed. Definitive closure was performed in 68 patients (57%), with mesh augmentation in 23 (33%). When temporary closure was performed, 45 patients (88%) underwent mesh bridging. Six patients underwent dynamic closure with NPWT. Mesh bridging resulted in a shorter hospital stay (29 ± 16 days vs. 93 ± 46 days; p<0.001), less severe complications (46% vs. 100%; p=0.001), and less reoperations (20% vs. 100%; p<0.001) when compared to NPWT. There was no significant difference in 30-day and one-year mortality between all patient groups.
Conclusion: Definitive closure of the burst abdomen should be performed if possible, depending on intraoperative findings. Our data suggest that mesh bridging for burst abdomen is a valuable alternative in terms of hospital stay, severe complications, and reoperations when compared to NPWT. It can be considered in cases where definitive closure is not feasible.
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Assessment of Hemostatic Powder in Order to Prevent Staple Line Bleeding After Sleeve Gastrectomy in High-Risk Patients: A Multicentric Randomized Controlled Trial
Vincenzo Salsano, MD, Clinique Clementville, Montpellier, France, Vincenzo Consalvo, MD, Clinica San Gaudenzio, Novara, Italy, Iphigenie Chaze, MD, Clinique Clementville, Montpellier, France
1846
Introduction: Preventing staple line bleeding (SLB) is still a main issue in bariatric surgery procedures, especially after laparoscopic sleeve gastrectomy (LSG). Staple line reinforcements (SLR), mattress sutures, or titanium clip application did not show any statistical superiority compared to other methods. In this randomized controlled trial, we tested hemostatic powder (HP) in order to assess a possible role in the prevention of active bleeding, hematoma formation, the need for transfusions, and the increased risk for hospitalization.
Materials and Methods: Centers involved started the enrollment of patients from September 2023 to August 2024. Two groups of 96 and 98 patients were created after randomization and application of the inclusion and exclusion criteria. Patients in the first group underwent LSG with application of HP, while the second group went with standard hemostasis with bipolar coagulation and titanium clip application.
Results: There was no difference between the two groups. Overall bleeding was found to be similar between the two groups (p=1.00). Diffuse bleeding was superior in group 2 (p=0.02), while large hematoma formation was superior in group 1 (p=0.02).
Conclusion: The use of HaemoCer™ (BioCer Entwicklungs, GmbH, Bayreuth, Germany) does not reduce staple line bleeding but helps reduce the incidence of hemoperitoneum as well as the reoperation rate, even though hospitalization was similar between the two groups.
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