Postoperative monitoring with a mobile application after ambulatory lumbar discectomy: an effective tool for spine surgeons

Background

The rise of eHealth, with the increasing use of a Mobile application provides a new perspective for outpatient spine surgery follow-up.

Objective

Assess the feasibility of Mobile app for postoperative monitoring after outpatient lumbar discectomy.

Patients and methods

Sixty consecutive patients, who underwent an ambulatory lumbar discectomy, were proposed the use of Mobile app to optimize their home monitoring for 15 days. Contact was maintained with the clinic based on the level of symptom severity: pain, temperature, deficit, bleeding, to provide a suitable solution. Use of Mobile app compared to the standard follow-up procedure was evaluated daily and a satisfaction survey was carried-out 3 months after surgery.

Results

Thirty-six patients (60.0 %) completed the initial checklist within 48 h, with no triggered severity. Five patients (8.3 %) triggered a non-response alarm; no action was required in the follow-up of 41 patients. However, 19 patients (31.7 %) triggered a total of 29 alarms, automatically resulting in a neurosurgeon contact for: postoperative pain management and optimization of analgesics, 21 cases (72.4 %), low-grade fever <38.5°, 4 cases (13.8 %), voiding delay, 2 cases (6.9 %) and a problem related to dressing, 2 cases (6.9 %). The scale ranged from 1 (poor) to 4 (excellent), with a 3.5/4 overall satisfaction mean score for the mobile handheld-device. Most patients (91.6 %) responded that they would agree to repeat the postoperative experience.

Conclusion

Overall patient satisfaction was excellent. Mobile app provides an effective useful tool for outpatient spine surgery monitoring and minimizes the need for in-person visits for postoperative patients.

     

Facial nerve preservation with preoperative identification and intraoperative monitoring in large vestibular schwannoma surgery

Background

Microsurgery is an option of choice for large vestibular schwannomas (VSs). Anatomical and functional preservation of facial nerve (FN) is still a challenge in these surgeries. FNs are often displaced and morphologically changed by large VSs. Preoperative identification of FN with magnetic resonance (MR) diffusion tensor tracking (DTT) and intraoperative identification with facial electromyography (EMG) may be desirable for improving functional results of FN.

Method

In this retrospective study, eight consecutive cases with large VS (≥30 mm in maximal extrameatal diameter) were retrospectively studied. FN DTT was performed in each case preoperatively. All the cases underwent microsurgical resection of the tumor with intraoperative FN EMG monitoring. Correctness of prediction for FN location by DTT was verified by the surgeon’s inspection. Postoperative FN function of each patient was followed up.

Results

Preoperative identification of FN was possible in 7 of 8 (87.5 %) cases. FN location predicted by preoperative DTT agreed to surgical finding in all the 7 cases. FN EMG was helpful to locate and protect the FN. Total resection was achieved in 7 of 8 (87.5 %). All FNs were anatomically preserved. All cases had excellent facial nerve function (House–Brackmann Grade I–II).

Conclusions

FN DTT is a powerful technique in preoperatively identification of FN in large VS cases. Continuous intraoperative FN EMG monitoring is contributive to locating and protecting FNs. Radical resection of large VSs as well as favorable postoperative FN outcome is available with application of these techniques.     

The clinical and radiographic results of intertrochanteric curved varus osteotomy for idiopathic osteonecrosis of the femoral head

Purpose

In this study, postoperative results of intertrochanteric curved varus osteotomy (CVO) for idiopathic osteonecrosis of the femoral head (ION) were studied retrospectively and optimal indication of CVO was considered.

Methods

Between 1995 and 2011, CVO was performed in 51 patients (53 hips) for the treatment of ION in our department. The patients who had the potential to obtain acetabular coverage of more than one-third of the intact articular surface on pre-operative AP hip radiographs in maximum abduction were considered suitable for this operation. For radiological assessment, a ratio of necrotic volume, a ratio of postoperative intact surface on the weight-bearing area, progression of collapse, shortening length of the lower limb, and lateralization of great trochanter were evaluated.

Results

The mean ratio of necrotic volume was 16.9 %. The mean ratio of postoperative intact surface on the weight-bearing area of the femoral head was 51.7 %. The progression of collapse was observed in two hips (ratio of necrotic volume 10.4, 39.8 %; ratio of postoperative intact area 36.5, 38.1 %). The mean shortening length of the lower limb was 9 mm, and the mean lateralization of great trochanter was 3 mm. One hip (ratio of necrotic volume 11.6 %, ratio of intact area 35.8 %) was converted to THA because of the progression of osteoarthritis at 55 months after CVO.

Conclusion

The results of CVO for ION were successful, if this procedure was indicated for cases with intact load-bearing area more than 40 %.     

Long-term surgical outcomes of cervical dumbbell neurinomas

Study design

Retrospective case series.

Objective

To evaluate our treatment strategy for cervical dumbbell neurinoma.

Summary of background data

In treating cervical dumbbell neurinoma, possible difficulties include reoperation due to recurrent tumor, denervation due to nerve root resection, and postoperative spinal deformity due to extensive bony removal.

Methods

We reviewed 75 cases of cervical dumbbell neurinoma that were treated surgically between 1985 and 2006. Postoperative neurological deficits, effects of surgical margins on tumor recurrence, and surgical complications were investigated retrospectively.

Results

Sensory and motor deficits due to resection of specific nerve roots appeared temporarily in 33 and 23 % of all cases, and persisted in 8 and 8 % at final evaluation, respectively. Total, subtotal, and partial resection was performed in 57, 13, and 5 cases, respectively. The total resection rate was low in the tumors that had large extraforaminal components. Of the subtotally resected 13 cases, only two cases of high tumor-growth rate required re-operation or showed tumor growth. Among the five partially resected cases, re-operation was necessary in two cases 13 and 15 years later because of aggravated neurological symptoms due to tumor growth. Two patients who underwent C2 laminectomy developed kyphosis, and three patients who underwent facet joint resection and curettage of vertebral body lesions developed scoliosis.

Conclusion

Total resection should be attempted for cervical dumbbell tumors. In cases where total resection was potentially of high risk, however, subtotal resection (within the capsule) was found to be a practical choice yielding favorable long-term outcome when the tumor growth rate (MIB-1 index) was low.     

Comparison of Cases Captured in the National Cancer Data Base with Those in Population-based Central Cancer Registries

Background

The National Cancer Data Base (NCDB) is a large, geographically diverse hospital-based cancer registry that has been used to study factors related to cancer diagnosis, treatment, and survival. The primary purpose of this study was to compare the case counts and characteristics of patients in NCDB with population-based registries reported in the United States Cancer Statistics (USCS).

Methods

Cancer case counts from NCDB were compared to case counts from USCS to measure NCDB’s case coverage, or the percentage of cases captured. Case coverage was examined by a variety of characteristics, including state of residence, race/ethnicity, age, and primary cancer site.

Results

The overall NCDB case coverage was 67.4 %, ranging from a high of 88.7 % for Delaware to a low of 27.1 % for Arizona. Case coverage for white, black, and Asian/Pacific Islander cases was high (64.7 % to 67.4 %), but it was much lower for American Indians/Alaskan Natives (32.8 %) and those of Hispanic ethnicity (51.1 %). Among the elderly (aged 65 + years), case coverage is much lower compared to persons younger than 65 (63.0 % and 73.0 %, respectively). Case coverage also varied widely by site, with the highest being cervix (77.9 %) and the lowest being melanoma (50.6 %).

Conclusions

This study highlights the geographic- and site-specific variation in NCDB case coverage, primarily as a result of NCDB facility presence and data collection and processing protocols. These findings illustrate the strengths and limitations of NCDB as a resource for nationwide data on cancer diagnosis, treatment, and survival.     

Effectiveness of C5 or C6-Cz assembly in predicting immediate post operative facial nerve deficit

Background

Intraoperative neurophysiology monitoring (IOM) is a valuable tool in cerebellopontine angle (CPA) surgeries posing risk to the cranial nerves. Transcranial electrical stimulation (TES) for cranial nerves has been performed in the last 7 years, for obtaining the facial nerve motor evoked potential (MEP), using either C3/C4-Cz or C3-C4 (or inverse) stimulating points, which have been correlated with facial nerve functional outcome.

Method

Intraoperative surgical and electrophysiological findings were documented prospectively. Patient files were reviewed for clinical data. We studied 23 patients undergoing CPA tumor resection using C5 or C6-Cz montage for TES, and were able to determine the correlation between facial nerve functional outcome and the amplitude drop of facial MEP above 50 %. Patients were evaluated for immediate facial nerve outcome and 6 months after the surgery. Follow-up was performed by structured telephone interviews with local physicians.

Results

The sensibility of the studied parameters was 92.8 % for amplitude drop of facial nerve MEP, with positive predictive value of 81.2 %. The absence of changes during IOM has shown a negative predictive value of 100 %.

Conclusion

In this series, the used montage was effective in predicting new facial deficit.     

Volume and densities of chronic subdural haematoma obtained from CT imaging as predictors of postoperative recurrence: a prospective study of 107 operated patients

Background

Chronic subdural haematoma (CSDH) is a common entity in neurosurgery with a considerable postoperative recurrence rate. Computerised tomography (CT) scanning remains the most important diagnostic test for this disorder. The aim of this study was to characterise the relationship between the recurrence of CSDH after treatment with burr-hole irrigation and closed-system drainage technique and CT scan features of these lesions to assess whether CT findings can be used to predict recurrence.

Methods

We investigated preoperative and postoperative CT scan features and recurrence rate of 107 consecutive adult surgical cases of CSDH and assessed any relationship with univariate and multivariate regression analyses.

Results

Seventeen patients (15.9 %) experienced recurrence of CSDH. The preoperative haematoma volume, the isodense, hyperdense, laminar and separated CT densities and the residual total haematoma cavity volume on the 1st postoperative day after removal of the drainage were identified as radiological predictors of recurrence. If the preoperative haematoma volume was under 115 ml and the residual total haematoma cavity volume postoperatively was under 80 ml, the probability of no recurrence was very high (94.4 % and 97.4 % respectively).

Conclusions

These findings from CT imaging may help to identify patients at risk for postoperative recurrence.     

Improvement in intraoperative transcranial electrical motor-evoked potentials in tethered cord surgery: an analysis of 45 cases

Background

Improvement of transcranial electrical motor-evoked potentials (TeMEPs) following untethering during tethered cord surgery (TCS) and its clinical significance have not been analyzed in the literature.

Methods

Forty-five consecutive cases of tethered cord were operated on with multimodality intraoperative neurophysiological monitoring (IONM) between February 2005 and January 2012. Intraoperative TeMEP change was classified as improvement, worsening or no change. Motor, sensory, bladder and bowel symptoms and signs were evaluated preoperatively, in the first week post-surgery and at the last follow-up (maximum of 2 years).

Results

Patient age ranged from 5 to 44 years (mean, 16?±?10 years), with 30 children. Intraoperative MEPs improved in 23 (51 %), remained the same in 21 (46.7 %) and worsened in 1 (2 %) patient. Motor improvement occurred in 7 patients and clinical improvement in 17 patients in the immediate postoperative period. Postoperative neurological worsening occurred in one patient (2.2 %). Improved and stable MEPs correlated with the motor (p?=?0.002) and clinical improvement (p?=?0.02) in the immediate postoperative period. Follow-up was available in 35 patients (77.7 %), ranging from 5 to 24 months (median, 21 months; mean, 17.7?±?6.8 months). There was late clinical improvement in 73.5 % of the patients in whom the intraoperative MEP had remained the same or improved. However, there was no statistically significant correlation between MEP change and long-term outcome.

Conclusions

Intraoperative MEP improvement occurs in about 50 % of the patients following successful untethering. This finding probably provides support to the ischemic theory of tethered cord syndrome.     

Contemporary monopolar and bipolar transurethral resection of the prostate: prospective assessment of complications using the Clavien system

Purpose

A modified version of the Clavien system has been recently suggested to allow a standardized assessment of complications associated with transurethral resection of the prostate (TURP). Aim of this multicentre study was to validate the use of this assessment tool in a contemporary cohort of patients undergoing monopolar or bipolar TURP.

Methods

Consecutive patients undergoing TURP in five Italian institutions from April 2011 to March 2012 were prospectively included in this study. Complications occurring within first postoperative month were recorded and graded according to the modified Clavien system. Univariate and binary logistic regression analysis were used for statistical analysis.

Results

Two hundred and ninety-five patients were included in the study. Overall, 47 complications were recorded in 44 patients. There was no difference in terms of postoperative complications between those who underwent monopolar TURP (27 pts; 9.2 %) versus those who underwent bipolar TURP (17 pts; 5.2 %, p = 0.142). Overall perioperative morbidity rate was 15.5 %. Most of the complications were Clavien type I (37 cases; 78 %) and II (6 cases; 12 %). High-grade complications were few as follows: Clavien type IIIb in two cases (4 %) and IV in two cases (4 %). No TURP-related deaths were reported. In the monopolar TURP group, a longer-operative time (OR 1.024; 95 % CI 1.007–1.040, p = 0.004) is an independent predictors of postoperative complications.

Conclusions

A modified Clavien system can be considered a practical and easily applicable tool in grading postoperative complications in patients undergoing TURP. Our findings confirm that TURP is a safe procedure associated with minimal perioperative morbidity.     

Role of Intraoperative Esophagogastroenteroscopy in Minimizing Gastrojejunostomy-Related Morbidity: Experience with 2,311 Laparoscopic Gastric Bypasses with Linear Stapler Anastomosis

Background

Anastomotic leaks and strictures of the gastrojejunostomy are a cause of major morbidity following laparoscopic Roux-en-Y gastric bypass (LRYGB). Reported rates of leaks vary between 0 and 5.2 %. This has led bariatric surgeons to use a variety of intraoperative methods to detect incompetent suture lines. The aim of the study was to evaluate the role of intraoperative endoscopy in reducing the rate of postoperative anastomotic complications. The setting of this study is in a community teaching hospital.

Methods

Medical records of 2,311 patients who underwent a LRYGB from 2002 to 2011 were retrospectively reviewed utilizing the hospitals’ bariatric surgery database. Demographics, weight, body mass index, intraoperative endoscopy results, and postoperative outcomes within 90 days after surgery were analyzed.

Results

Endoscopy was attempted in 2,311 patients and completed in 2,308 (99.9 %). Intraoperative leak was detected in 80 (3.5 %) patients; suture line was reinforced in 46 patients (2 %), while in the other 34 patients the leak was transient at only high insufflation pressure. Postoperative clinical leaks were detected in four cases (0.2 %) two of which had initial leaks intraoperatively. In two cases, the anastomosis was too tight and required reconstruction. Twenty-five patients (1.1 %) developed early postoperative strictures requiring endoscopic dilatation within 90 days. Three patients (0.1 %) had iatrogenic injury at the time of intraoperative endoscopy, all three healed without delayed morbidity.

Conclusions

The routine use of intraoperative endoscopy in LRYGB with the linear stapler anastomosis technique is associated with a complication/failure rate of 0.3 % and low gastrojejunostomy-related morbidity after LRYGB within 90 days (leak rate of 0.2 % and stricture rate of 1.1 %).     

Transient neurological deficit following midthoracic decompression for severe stenosis: a series of three cases

Purpose

To report three cases of transient perioperative neurological deficit in the absence of direct cord insult following decompression of the severely stenotic thoracic spine.

Methods

The clinical and radiographic electronic medical records of three patients who underwent decompression for severe midthoracic stenosis with transient neurological deficits perioperatively were reviewed. The cases are presented with consideration of possible underlying mechanisms and multimodality intraoperative monitoring (IOM) findings.

Results

Two patients had neurologic changes on IOM and Stagnara wake-up test, the remaining patient had absent motor and sensory potentials at baseline and throughout the case. IOM changes were observed immediately following decompression in the absence of direct cord insult or displacement. Postoperatively all patients experienced neurological motor deficits which presented as complete paralysis of the right lower extremity in two of the patients and the left lower extremity in one patient. The deficit was transient—improvement of motor strength occurred between 1 and 13 months of follow-up in all patients.

Conclusion

Decompression of a severely stenotic region of the thoracic spinal cord may lead to a complete yet transient motor deficit in the perioperative period in the absence of direct mechanical cord insult. Potential etiologies include ischemia-reperfusion injury, microthrombi, and altered perfusion due to internal recoil of spinal cord architecture following decompression. IOM may show conspicuous findings in such events, however, may not be relied upon when baseline potentials are sub-optimal. Recognition of this short-lived neurological deficit following decompression of the severely stenotic thoracic spine will improve preoperative patient counseling and merits further study for determination of the precise pathophysiology.     

Survey of compartment syndrome of the lower extremity after gynecological operations

Purpose

This study was aimed to investigate incidence, circumstances and consequences of acute compartment syndrome (CS) of the lower extremity after gynecological operations in lithotomy position by collecting data from departments of Obstetrics and Gynecology in Germany.

Design

Retrospective observational study.

Setting

Departments of Obstetrics and Gynecology in the area of North Rhine (Germany)

Methods

A 24-item questionnaire was sent to 168 gynecological departments. In addition, cases anonymously reported to the Expert Committee for Medical Malpractice Claims of the Medical Association of North Rhine between 2002 and 2012 were analyzed.

Main outcome measure

Incidence of acute CS after gynecological operations.

Results

A total of 59 questionnaires (35 %) were returned for analysis, reporting 21 cases of CS. Based on the collected data, we calculated an incidence of postoperative CS ranging between 0.067 % and 0.28 %. All reported cases of postoperative CS occurred after surgeries in lithotomy position, 57.1 % of cases occurred after laparoscopic procedures and 76.2 % after procedures longer than 4 h. Overall, 61.0 % of departments do not routinely inform about the risk of this complication when they get patients’ informed consent. Reported prevention strategies were inconsistent and ranged from none to multiple measures.

Conclusion

CS is a complication clearly associated with long lasting gynecological operations in Lithotomy position. Despite a relatively high incidence, so far no guidelines on perioperative management and medicolegal aspects exist and preventive measures are heterogeneous among institutions. The need for guidelines and recommendations by an expert committee has been identified.     

The Use of Short Segment Free Jejunal Transfer as Salvage Surgery for Cervical Esophageal and Hypopharyngeal Cancer

Background

Salvage surgery after definitive chemoradiotherapy for cervical esophageal cancer and hypopharyngeal cancer remains a challenge because of the high rate of complications. The purpose of this study was to evaluate the safety and efficacy of free jejunal transfer as salvage surgery for cervical esophageal cancer and hypopharyngeal cancer after definitive chemoradiotherapy.

Methods

We enrolled eight patients with cervical esophageal cancer and 11 patients with hypopharyngeal cancer who underwent free jejunal transfer as salvage surgery following radiotherapy or chemoradiotherapy. In this study, we reviewed the surgical procedures, perioperative complications, and survival rates.

Results

The median duration of surgery was 514 min, and the median blood loss was 439 ml. In surgical procedures, the recipient vessels for the anastomosis of the free jejunum consisted of one artery and one vein (63 %), one artery and two veins (5 %), and two arteries and two veins (31 %). The postoperative morbidity rate was 57.9 % (11 patients), with six cases of partial necrosis of the tracheal margin and no cases of graft necrosis or postoperative in-hospital death. The overall 5-year survival rate after surgery was 58.1 %.

Conclusions

Our findings suggest that with careful attention to the potential development of necrosis of the tracheal margin, pharyngolaryngoesophagectomy and free jejunal transfer can be safely performed, even in patients who received radiotherapy or chemoradiotherapy.     

Total knee arthroplasty of the stiff knee: three hundred and four cases

Purpose

The purpose of this study was to analyse the results of total knee arthroplasty (TKA) in stiff knees (flexion ≤90° and/or flexion contracture ≥20°). Our hypothesis was that despite having poorer results than those obtained in a “standard” population and a high rate of complications, TKA was a satisfactory treatment in patients with osteoarthritis of the knee associated with significant stiffness.

Methods

Three hundred and four consecutive primary HLS TKAs (Tornier), whose data were prospectively collected between October 1987 and October 2012, were retrospectively analysed at a mean of 60 months (range, 12–239) postoperatively. Two groups, those with a “flexion contracture” and those with a “flexion deficit”, were assessed for postoperative range of motion (as integrated to the Knee Society score [KSS]), physical activity level and patient satisfaction.

Results

At the latest follow-up, range of motion was significantly improved, as was the KSS. Ninety-four percent of patients were satisfied or very satisfied, and activity levels were increased after surgery. The complication rate, however, was high in patients with a preoperative flexion deficit (17 %). Pain and residual stiffness were the most common complications.

Conclusion

TKA provides satisfactory results in patients with knee osteoarthritis associated with significant pre-operative stiffness. The surgical plan should be adapted to anticipate complications, which are particularly frequent in the presence of a flexion deficit.     

Transcerebellomedullary fissure approach to lesions of the fourth ventricle: less is more?

Background

The transcerebellomedullary fissure (trans-CMF) approach is safe and effective. Nevertheless, previous research documented a few differences in the use of this approach with regard to the opening portion of the fissure and roof of the ventricle. Here, we present a series of patients with fourth ventricular lesions and our experience using the trans-CMF approach.

Methods

Fifty patients who underwent the trans-CMF approach were analyzed. The tela choroidea was simply incised in 32 patients: 27 unilaterally and 5 bilaterally. Both the tela and inferior medullary velum were cut in 18 patients: 16 unilaterally and 2 bilaterally. Unless the tumor extended below the C1 level, C1 was preserved intact. Brainstem mapping (BSM) and corticobulbar tract (CBT) motor-evoked potential (MEP) monitoring were used.

Results

Gross total removal was achieved in 41 (82 %) cases, and sub-total removal was achieved in 9 (18 %) cases. Two deaths occurred 1–2 months postoperatively because of pulmonary complications. Four patients developed temporary mutism, all of whom underwent the bilateral trans-CMF approach (this rate is significantly higher than that of the unilateral approach, P?<?0.05). No permanent neurological deficit occurred.

Conclusion

The trans-CMF approach provides excellent access to fourth ventricular lesions without splitting the vermis. The opening portion of the fissure and roof of the ventricle should be determined by the location, extension and size of the lesion. In most cases, the unilateral trans-CMF approach with only a tela choroidea incision is adequate; this procedure is mini-invasive and possibly prevents postoperative mutism.     

Neurolysis for secondary sciatic nerve entrapment: evaluation of surgical feasibility and functional outcome

Background

The study included 11 patients; seven males and four females with mean age of 68.3?±11 years. All patients had sciatic nerve entrapment: three had a penetrating injury, three suffered postoperative trauma, two had a crush injury, two had inadvertent injections and one was trapped in a machine belt. Clinical examination included: an evaluation of the extent of motor and sensory impacts according to the British Medical Research Council (BMRC) scale and the Semmes-Weinstein monofilament test; assessment of pain sensation using the visual analogue scale (VAS); electromyography; and nerve conduction velocitiey determination. The applied operative procedure for sciatic neurolysis was modulated according to the suspected site of sciatic nerve entrapment. At 6 and 12 months after surgery all patients were evaluated for recovery of motor and sensory function.

Results

All patients passed the smooth intraoperative course within a mean operative time of 77.7?±21 min. The mean duration of wound drainage and postoperative hospital stay was 2.6?±0.7 and 4.8?±0.8 days, respectively. Pain sensation showed progressive significant improvement in nine patients but decreased at time of discharge and remained stationary till 12-m post-operative (PO). Recovery of motor function showed progressive significant improvement at 6 and 12 months after sciatic nerve neurolysis. The frequency of patients having muscle power recovery and regained sensation was significantly higher at 6-m and 12-m PO as compared to preoperative grading with a significantly higher frequency at the 6-m grading compared to preoperative grading. Two patients showed no change of their muscle strength grade, while nine patients showed improvement for a total success rate of motor strength recovery of 81.8%. At 6- m PO five patients showed no change of their sensory group, while six patients showed improvement for a total success rate of sensation recovery of 54.5%. At 12-m PO ten patients had fullly recovered protective sensation for a success rate of 90.9%.

Conclusion

Surgical exploration and neurolysis of cases with sciatic nerve entrapment is a safe and effective therapeutic modality with significant improvement of both motor and sensory functions without risk of additional deficit secondary to neurolysis.     

Atrial fibrillation after esophageal cancer surgery: an analysis of 207 consecutive patients

Purpose

The aim of this study was to identify perioperative risk factors that are associated with postoperative atrial fibrillation (AF) and the outcomes of different pharmacological interventions in esophageal cancer patients who underwent transthoracic esophagectomy.

Methods

This study included 207 patients who underwent a transthoracic esophagectomy for esophageal cancer resection by a single surgeon from January 1, 2004, through December 31, 2010.

Results

Postoperative AF occurred in 19 patients (9.2 %), all of whom received antiarrhythmic drug therapy at the early stage. Antiarrhythmic treatment was effective in 12 cases (63.2 %). In this study, landiolol hydrochloride, an ultrashort-acting β₁-selective β-blocker, was the first-line therapy for postoperative AF. A multivariate logistic regression analysis showed that postoperative AF was significantly associated with the use of an ileo-colon for reconstruction after esophagectomy (P = 0.0023, odds ratios [OR] = 13.6) and with the presence of tachycardia with a heart rate of >100 bpm on postoperative day (POD) 1 (P = 0.0004, OR = 18.4).

Conclusions

Postoperative AF is associated with the use of a colon conduit for reconstruction after esophagectomy and with tachycardia with a heart rate >100 bpm on POD 1. Identifying patients at high risk for postoperative AF will allow for more direct application of pharmacological methods of prophylaxis.     

Closing the gap: medialization of fascia with laparoscopic incisional hernia repair

Purpose

Laparoscopic incisional hernioplasty (LIH) bridges the fascial gap between the rectus muscles with a posteriorly placed mesh, and is a low recurrence alternative to other reconstructions. It is unclear if this repair optimizes the function of the abdominal wall. We hypothesize that significant medialization of the fascial edges occurs in patients who undergo LIH.

Methods

Two hundred fifty-eight patients underwent LIH by a single surgeon between 2004 and 2012. 44 of these had pre- and postoperative CT scans that illustrated the gap between the rectus muscles. All 44 patients underwent LIH with polyester composite mesh, with suture and tack fixation. The distance between the fascial edges on the pre- and postoperative CT scans was compared. Percent medialization was calculated for each defect.

Results

Average fascial separation reduction was 0.8 cm (6.56–5.76 cm, 12.2 % medialization, p < 0.0001). 36 of 44 patients demonstrated a reduction in hernia defect width (81.8 %): these defects reduced 1.09 cm (6.47–5.38 cm, 16.9 % medialization, p < 0.0001). In defects wider than 5 cm, the width reduced by 0.94 cm (8.48–7.54 cm, n = 26, 10.6 % medialization, p = 0.004). The use of meshes ≥500 cm² reduced the defect by 0.95 cm (8.42–7.47 cm, 11.23 % medialization, n = 22, p = 0.005).

Conclusions

Significant medialization of the rectus muscles is evident in most patients undergoing LIH. Although the rectus muscles are not ideally approximated, this may help improve the function of the anterior abdominal wall. Further technical refinements and material improvements may improve the reconstructive results of the LIH.     

Factors influencing the outcome of image-guided percutaneous drainage of intra-abdominal abscess after gastrointestinal surgery

Purpose

To improve the selection of patients for percutaneous abscess drainage (PAD) to treat postoperative intra-abdominal abscess after gastrointestinal surgery, we investigated the factors predictive of outcome.

Methods

Of 143 consecutive patients with symptomatic postoperative intra-abdominal abscess after a gastrointestinal tract resection, 104 who underwent image-guided PAD as the initial treatment were reviewed. We assessed the possible associations between successful PAD and patient-, abscess-, surgical-, and drainage-related variables, and investigated the success rates of PAD for patients with vs. those without the factors related to successful outcome.

Results

Based on monitoring for 1 year after PAD, the success rate of this procedure was 85.6 % (89/104). Multivariate analysis revealed that the interval between surgery and the onset of abscess (p = 0.0234) and a single abscess (p = 0.0038) were independently associated with a successful outcome. Single late-onset abscess resolved completely within 10 weeks in 91.4 % of these patients.

Conclusions

Despite new strategies aimed at preventing surgical site infection, PAD remains an important factor in the postoperative management of gastrointestinal surgery in Japan. Initial recognition of the day of onset and the number of abscesses are important prognostic factors.