Association between preoperative administration of gabapentinoids and 30-day hospital readmission: A retrospective hospital registry study.

Study objectiveTo evaluate the effectiveness of preoperative gabapentinoid administration.DesignRetrospective hospital registry study.SettingTertiary referral center (Boston, MA).Patients111,008 adult non-emergency, non-cardiac surgical patients between 2014 and 2018.InterventionsPreoperative administration of gabapentinoids (gabapentin or pregabalin).MeasurementsWe tested the primary hypothesis that preoperative gabapentinoid use was associated with lower odds of hospital readmission within 30 days. Contingent on this hypothesis, we examined whether lower intraoperative opioid utilization mediated this effect. Secondary outcome was postoperative respiratory complications.Main resultsGabapentinoid administration was associated with lower odds of readmission (adjusted odds ratio [OR_adj] 0.80 [95% CI, 0.75–0.85]; p < 0.001). This effect was in part mediated by lower intraoperative opioid utilization in patients receiving gabapentinoids (8.2% [2.4–11.5%]; p = 0.012). Readmissions for gastrointestinal disorders (OR_adj 0.74 [0.60–0.90]; p = 0.003), neuro-psychiatric complications (OR_adj 0.66 [0.49–0.87]; p = 0.004), non-surgical site infections (OR_adj 0.68 [0.52–0.88; p = 0.004) and trauma or poisoning (OR_adj 0.25 [0.16–0.41]; p < 0.001) occurred less frequently in patients receiving gabapentinoids. The risk of postoperative respiratory complications was lower in patients receiving gabapentinoids (OR_adj 0.77 [0.70–0.85]; p < 0.001). Lower doses of pregabalin (< 75 mg) and gabapentin (< 300 mg) compared to both, no and high-dose administration of gabapentinoids, were associated with a lower risk of postoperative respiratory complications (OR_adj 0.61 [0.50–0.75]; p < 0.001 and OR_adj 0.70 [0.53–0.92]; p = 0.012, respectively). These lower gabapentinoid doses prevented 30-day readmission (OR_adj 0.74 [0.65–0.85]; p < 0.001). The results were robust in several sensitivity analyses including surgical procedure defined subgroups and patients undergoing ambulatory surgery.ConclusionsThe preoperative use of pregabalin and gabapentin, up to doses of 75 and 300 mg respectively, mitigates the risks of hospital readmission and postoperative respiratory complications which can in part be explained by lower intraoperative opioid use. Further research is warranted to elucidate mechanisms of the preventive action.     

Systematic review and meta-analysis of safety and efficacy of early enteral nutrition as an isolated component of Enhanced Recovery After Surgery [ERAS] in children after bowel anastomosis surgery

BackgroundPostoperative feeding practices are not uniform in children undergoing bowel anastomosis surgery. Primary aim of this review was to evaluate the safety and efficacy of early enteral nutrition (EEN) as an isolated component of enhanced recovery in children undergoing bowel anastomosis surgery.MethodsMedical search engines (PubMed, CENTRAL, Google scholar) were accessed from inception to January 2021. Randomized Controlled Trials (RCT)s, non-randomized controlled trials, observational studies and retrospective studies comparing EEN, initiated within 48 h vs late enteral nutrition (LEN), initiated after 48 h in children ≤ 18 years undergoing bowel anastomosis surgery were included. Primary outcome measure was the incidence of postoperative complications (anastomotic leak, abdominal distension, surgical site infection, wound dehiscence, vomiting and septic complications). Secondary outcome measures were the time to passage of first feces and the length of hospital stay.ResultsTwelve hundred and eighty-six children from 10 studies were included in this review. No difference was seen between the EEN and LEN groups in the incidence of anastomotic leak (1.69% vs 4.13%; p = 0.06), abdominal distention (13.87% vs 12.31%; p = 0.57), wound dehiscence (3.07% vs 2.69%; p = 0.69) or vomiting (8.11% vs 8.67%; p = 0.98). The incidence of surgical site infections (7.51% vs 11.72%; p = 0.04), septic complications (14.02% vs 26.22%; p = 0.02) as well as pooled overall complications (8.11% vs 11.27%; RR 0.71; 95% CI = 0.56 to 0.89; p = 0.003; I² = 33%) were significantly lower in the EEN group. The time to passage of first feces (MD – 17.23 h; 95% CI -23.13 to -11.34; p < 0.00001; I² = 49%) and the length of hospital stay (MD -2.95 days; 95% CI -3.73 to -2.17; p < 0.00001; I² = 93%) were significantly less in the EEN group.ConclusionEEN is safe and effective in children following bowel anastomosis surgery and is associated with a lower overall incidence of complications as compared to LEN. EEN also promotes early bowel recovery and hospital discharge. However, further well designed RCTs are required to validate these findings.Level of evidence: V     

Automated feedback modestly improves perioperative treatment adherence of postoperative nausea and vomiting

Study objectiveExtensive evidence demonstrates that medical record modernization and a vast amount of available data have not overcome the gap between recommended and delivered care. This study aimed to evaluate the use of clinical decision support (CDS) in conjunction with feedback (post-hoc reporting) to improve PONV medication administration compliance and postoperative nausea and vomiting (PONV) outcomes.DesignSingle center, prospective observational study between January 1, 2015, and June 30, 2017.SettingPerioperative care at a university-affiliated tertiary care center.Patients57,401 adult patients who received general anesthesia in a non-emergency setting.InterventionA multi-phased intervention that consisted of post-hoc reporting for individual providers by email about PONV occurrences in their patients, followed by directive CDS through preoperative daily case emails that provided therapeutic PONV prophylaxis recommendations based on patients' PONV risk scores.MeasurementCompliance with PONV medication recommendations, as well as hospital rates of PONV were measured.Main resultOver the study period, there was a 5.5% (95% CI, 4.2% to 6.4%; p < 0.001) improvement in the compliance of PONV medication administration along with an 8.7% (95% CI, 7.1% to 10.2%, p < 0.001) reduction in PONV rescue medication administration in the PACU. However, there was no statistically or clinically significant reduction in the prevalence of PONV in the PACU. The prevalence of PONV rescue medication administration decreased during the Intervention Rollout Period (odds ratio 0.95 [per month]; 95% CI, 0.91 to 0.99; p = 0.017), and during the Feedback with CDS Recommendation Period (odds ratio, 0.96 [per month]; 95% CI, 0.94 to 0.99; p = 0.013).ConclusionPONV medication administration compliance modestly improves with CDS in conjunction with post-hoc reporting; however, no improvement in PACU rates of PONV occurred.     

Clinical outcomes of manual bowel decompression (milking) in the mechanical small bowel obstruction: a prospective randomized clinical trial

BackgroundThe aim of this prospective randomized study was to investigate the effects of manual bowel decompression in patients who were operated on for mechanical small bowel obstruction.MethodsBetween March 2008 and February 2010, 40 consecutive patients with mechanical small bowel obstruction were randomized into 2 clinically comparable groups. The intestinal content of the dilated small bowel was caressed to the stomach (by milking) and aspirated via a nasogastric tube in the milking group (group M, n = 20) and left uncaressed in the control Group (group C, n = 20). Patients' characteristics and general operative outcomes were compared and analyzed.ResultsThe resumption of a regular diet and postoperative hospital stay (P = .68) were not significantly different in groups M and group C. Similarly, there were no differences between the 2 groups regarding respiratory complications (P = .34), bacterial translocation (P = 1), or wound infection (P = 1).ConclusionsThe findings suggest that routine milking is unnecessary in mechanical small bowel obstruction.     

The Importance of the ileocecal valve and colon in achieving intestinal independence in infants with short bowel syndrome

PurposeInfants with short bowel syndrome (SBS) wean from parenteral nutrition (PN) support at variable rates. Small bowel length is a predictor, but the importance of the ileocecal valve (ICV) and colon are unclear. We aim to determine if the ICV and/or colon predict enteral autonomy.MethodsInfants from a single intestinal rehabilitation program were retrospectively reviewed. Etiology of SBS, intestinal anatomy, and duration of nutritional support were collected for three years. The primary outcome was time to full enteral nutrition. ANCOVA and Cox proportional hazards model were used, with p < 0.05 significant.Results55 infants with SBS were included. After accounting for the effect of small bowel, PN duration was shorter for infants with the ICV compared to those without (mean 218 vs. 538 days, p = 0.003), and had a more significant effect on infants with ≤50% of small bowel. Increased small bowel length was a positive predictor of weaning. Patients with ≤50% of colon spent less time on PN with the ICV, compared to without (mean 220 vs 715 days, p = 0.009).ConclusionsPreservation of the ICV was associated with shorter duration of PN support, while colon was not. Small bowel length is a positive predictor of enteral autonomy.Level of EvidenceLevel III retrospective comparative studyType of StudyRetrospective review     

Factors influencing enteral autonomy after autologous gastrointestinal reconstructive surgery: A two-centre UK perspective

Background and AimsThe implementation of multidisciplinary care and improvements in parenteral nutrition (PN) in patients with short bowel syndrome (SBS) have led to better outcomes and higher survivability. Autologous gastrointestinal reconstructive (AGIR) surgery can reduce the duration on PN and lead to earlier enteral autonomy (EA). Our aim was to investigate the effect of SBS aetiology and other predictors on the achievement of enteral autonomy following AGIR surgery.MethodsRetrospective review of all patients undergoing AGIR surgery in two tertiary paediatric surgical units, between 2010 and 2021. Continuous data is presented as median (range).ResultsTwenty-seven patients underwent 29 AGIR procedures (20 serial transverse enteroplasties (STEP), 9 longitudinal intestinal lengthening and tailoring (LILT)) at an age of 6.6 months (1.5 – 104.5). EA rate was 44% at 13.6 months after surgery (1 – 32.8). AGIR procedures achieved an increase in small bowel length of 70% (pre-operative 46.5 vs 77 cm, p = 0.003). No difference was found between STEP and LILT (p = 0.84). Percentage of expected small bowel length (based on the child's weight) was a strong predictor of EA (bowel length >15% – EA 80% vs bowel length ≤15% – EA 17%, p = 0.008). A diagnosis of gastroschisis showed a negative non-significant correlation with the ability to achieve EA (25% vs 60%, p = 0.12). Overall survival rate was 96%.ConclusionAGIR surgery is an important tool in the multidisciplinary management of children with SBS. Percentage of expected small length and aetiology of SBS are likely predictors of achievement of EA in patients undergoing AGIR surgery.Level of Evidence: IVRetrospective Case-Series     

Variability in the management of adhesive small bowel obstruction in children

BackgroundThis study assessed inter-hospital variability in operative-vs-nonoperative management of pediatric adhesive small bowel obstruction (ASBO).MethodsA multi-institutional retrospective study was performed examining patients 1–21 years-of-age presenting with ASBO from 2010 to 2019 utilizing the Pediatric Health Information System. Multivariable mixed-effects logistic regression was performed assessing inter-hospital variability in operative-vs-nonoperative management of ASBO.ResultsAmong 6410 pediatric ASBO admissions identified at 46 hospitals, 3,239 (50.5%) underwent surgery during that admission. The hospital-specific rate of surgery ranged from 35.3% (95%CI: 28.5–42.6%) to 74.7% (66.3–81.6%) in the unadjusted model (p < 0.001), and from 35.1% (26.3–45.1%) to 73.9% (66.7–79.9%) in the adjusted model (p < 0.001). Factors associated with operative management for ASBO included admission to a surgical service (OR 2.8 [95%CI: 2.4–3.2], p < 0.001), congenital intestinal and/or rotational anomaly (OR 2.5 [2.1–3.1], p < 0.001), diagnostic workup including advanced abdominal imaging (OR 1.7 [1.5–1.9], p < 0.001), non-emergent admission status (OR 1.5 [1.3–1.8], p < 0.001), and increasing number of complex chronic comorbidities (OR 1.3 [1.2–1.4], p < 0.001). Factors associated with nonoperative management for ASBO included increased hospital-specific annual ASBO volume (OR 0.98 [95%CI: 0.97–0.99], p = 0.002), older age (OR 0.97 [0.96–0.98], p < 0.001), public insurance (OR 0.87 [0.78–0.96], p = 0.008), and presence of coinciding non-intestinal congenital anomalies, neurologic/neuromuscular disease, and/or medical technology dependence (OR 0.57 [95%CI: 0.47–0.68], p < 0.001).ConclusionsRates of surgical intervention for ASBO vary significantly across tertiary children's hospitals in the United States. The variability was independent of patient and hospital characteristics and is likely due to practice variation.Level of evidenceIII     

Delayed versus early repair of inguinal hernia in preterm infants: A systematic review and meta-analysis

ObjectivesTo evaluate the clinical outcomes of herniotomy in preterm infants undergoing early versus delayed repair, the risk factors for complications, and to identify best timing of surgery.MethodsMedline, Embase and Central databases were searched from inception until 25 Jan 2021 to identify publications comparing the timing of neonatal inguinal hernia repair between early intervention (before discharge from first hospitalization) and delayed (after first hospitalisation discharge) intervention. Inclusion criteria was preterm infants diagnosed with inguinal hernia during neonatal intensive care unit admission. Results were analyzed using fixed and random effects meta-analysis (RevManv5.4).ResultsOut of 721 articles found, six studies were included in the meta-analysis. Patients in the early group had lower odds of developing incarceration [odds ratio (OR) 0.43, 95% confidence interval (CI) 0.34–0.55, I² = 0%, p < 0.001]; but higher risk of post-operative respiratory complications (OR 4.36, 95% CI 2.13–8.94, I² = 40%, p < 0.001). No significant differences were reported in recurrence rate (OR 3.10, 95% CI 0.90–10.64, I² = 0%, p = 0.07) and surgical complication rate (OR 0.94, 95% CI 0.18–4.83, I² = 0%, p = 0.94) between early and delayed groups.ConclusionWhile early inguinal hernia repair in preterm infants reduces the risk of incarceration, it increases the risk of post-operative respiratory complications compared to delayed repair. Surgeons should discuss the risks and benefits of delaying inguinal hernia repair with the caregivers to make an informed decision best suited to the patient physiology and circumstances.Level of evidenceTreatment study, level 3.     

Does the timing of pouch creation in 2-stage operations for pediatric patients with ulcerative colitis matter?

IntroductionChildren with fulminant ulcerative colitis(UC) traditionally undergo 2-stage operations: restorative-proctocolectomy(RP/IPAA) and ileostomy followed by ostomy closure. In the biologic era, surgeons have modified their strategy: initial subtotal-colectomy/diversion, followed by RP/IPAA without diversion. Yet, evidence on efficacy and functional outcomes with the “modified 2-stage” approach is limited in children. We sought to compare the timing of pouch creation in 2-stage operations to determine outcomes.MethodsThis is a retrospective study of children with UC undergoing either a traditional 2-stage RP/IPAA or modified 2-stage RP/IPAA between 2010 and 2019. Complications (leak, stricture, wound-infection) were recorded at 90-days and 1 year from 2nd operation.ResultsN = 57 (Traditional n = 40, Modified n = 17). Median time to surgery from consultation was shorter in the modified-group (7 vs.25 days, p = 0.01). Preoperatively, the modified-group had lower albumin(p = 0.01), higher CRP(p = 0.01), and more frequently took biologics within 90-daysp=0.001). After re-establishing intestinal continuity, stricture requiring dilation was higher in the traditional-group (59% vs.18%, p = 0.008). No difference in pouch leak (p = 0.38), bowel obstruction(p = 0.35), loperamide dose(p = 0.21), or incontinence(p = 0.38) was observed.ConclusionDelaying pouch creation to the second operation without a protective ileostomy as a modified 2-stage is safe in a sicker and more acute pediatric population.     

Stapled intestinal anastomoses are more cost effective than hand-sewn anastomoses in a diagnosis related group system

PurposeCreation of an optimal bowel anastomosis with low postoperative leakage rate is an immanent part of colorectal surgery contributing to recovery, length of hospital stay and overall hospital costs. We aimed to investigate costs of small and large bowel resection, length of hospital stay, anastomotic leakage rate and its risk factors depending on the anastomotic technique.MethodsRetrospective analysis of 198 patients (67 stapled and 131 hand-sewn anastomoses) undergoing elective bowel resection with a single anastomosis without protective ileostomy either stapled or in double-rowed running suture technique between 1st October 2012 and 30th September 2018 at Charité University Hospital Berlin, Campus Benjamin Franklin. We analyzed costs of treatment, total length of hospital stay, rate of anastomotic leakage and possible risk factors for anastomotic leak.ResultsNo significant difference between both anastomotic techniques could be detected for hospital stay (p = 0.754), 30-day-readmission rate (p = 0.827), or anastomotic leakage (p = 606). Neither comorbidities (p = 0.449), underlying disease (p = 0.132), experience of the surgical team (p = 0.828) nor scheduling of the operation (p = 0.531) were associated with anastomotic leakage. Stapled anastomoses took 22 min less operation time than sutured anastomoses (130 vs. 152 min. Median) (p = 0.001). Operations with stapled anastomoses saved 183 € in operation costs and 496 € in overall hospital costs.ConclusionStapled and hand-sewn bowel anastomoses can be performed equally safe without differences in postoperative outcome. No patient, procedure or surgeon related risk factors for anastomotic leakage could be detected. Bowel resections with stapled anastomoses take less time and save operation and overall hospital costs.     

Influence of bacteriobilia on postoperative complications in patients with periampullary tumors

BackgroundPeriampullary tumours (PAT) may cause obstruction of distal choledochus. The bile stasis is a risk factor for microbial colonisation of bile (bacteriobilia), cholangitis, hepatic insufficiency and coagulopathy. PAT obstruction can be managed surgically or non-operatively - by inserting a biliary drain or stent (BDS). Although BDS allows for adequate bile drainage, liver function restitution and coagulopathy, increased bacteriobilia has been reported and this is associated with an increased incidence of postoperative complications.MethodsA monocentric, prospective, comparative study including 100 patients operated with PAT. The effects of bacteriobilia and the presence of a drain in the biliary tract on the development of postoperative complications were evaluated.ResultsPositive microbial findings in bile were found in 67% of patients. It was 98% in the biliary drain group vs. 36% in non-drained patients (p = 0.0001). In 68% 2 or more different bacterial strains were simultaneously present (p = 0.0001). Patients with a positive microbial finding in bile had more frequent incidence of infectious complications 40.2% (27) vs. 9.1% (3); p = 0.0011. The most frequent infectious complication was wound infection 29.8% (20) vs. 3.03% (1); p = 0.0014. Similarly, a higher incidence of postoperative infectious complications occurred in patients with BDS - 36% (18) vs. 24% (12); p = 0.2752.ConclusionThe presence of a drain or stent in the biliary tract significantly increases the microbial colonisation of bile. It is associated with a significant increase in infectious complications, especially infections in the wound.     

Reduced complication rate after modified binding purse-string-mattress sutures pancreatogastrostomy versus duct-to-mucosa pancreaticojejunostomy

Background and PurposeA 2011 metaanalysis demonstrated no difference in postoperative complications between pancreatogastrostomy and pancreaticojejunostomy after pancreaticoduodenectomy with the limitation of heterogeneity among the analysed studies. The present study compares postoperative complications after duct-to-mucosa pancreaticojejunostomy with a modified binding purse-string-mattress sutures pancreatogastrostomy in a teaching hospital.MethodsOne-hundred consecutive pancreaticoduodenectomies were reconstructed either by pancreaticojejunostomy (n = 50, 2004–2008) or modified pancreatogastrostomy (n = 50, 2008–2011). Prospective patients' data was retrospectively analysed for postoperative complications.Main findingsComplications occurred significantly less after modified pancreatogastrostomy compared to pancreaticojejunostomy (p = 0.016). This was mainly due to a significantly lower rate of pancreatic fistula (p = 0.029), especially a lower rate of clinically relevant B and C fistulas (p = 0.011). In particular, the fistula rate was reduced in patients with a soft, non-fibrotic pancreas (p = 0.0231). Postoperative mortality was also lower after modified pancreatogastrostomy (p = 0.042). Uni- and multivariate analyses revealed a soft, non-fibrotic pancreatic texture (odds ratio 5.4, p = 0.028), a non-dilatated pancreatic duct (p = 0.047) and pancreaticojejunostomy (odds ratio 10.7, p = 0.026) as independent, negative factors for pancreatic fistula.ConclusionIn a teaching hospital, modified pancreatogastrostomy seems to be superior to pancreaticojejunostomy regarding pancreatic fistula, especially in patients with a soft, non-fibrotic pancreas and/or a small duct. An ongoing prospective randomised multicentre trial (RECOPANC) might confirm these results.     

Frailty as a predictor of negative outcomes in trauma patients with rib fractures

BackgroundIn patients with rib fractures, adverse outcomes are associated with number of rib fractures; however, studies suggest an association with frailty. We assessed whether frailty, measured using the Canadian Study of Health and Aging clinical frailty scale, was associated with adverse outcomes in this population.MethodsPatients ≥50 years admitted for rib fractures from July 2015 to June 2020 were retrospectively scored for frailty. Demographics, comorbidities, injury information, hospital course, and complications were collected. Univariate analyses were performed to assess significant differences between the fit, prefrail, and frail groups. The association between number of rib fractures and frailty with outcomes was determined.ResultsControlling for age, sex, Injury Severity Score, preadmission anticoagulant, injury mechanism, and comorbidities and nonchest Abbreviated Injury Scores showing significant differences, the number of rib fractures was associated with developing pneumonia (odds ratio = 1.197 [1.076–1.332]; P = .001), hospital length of stay (odds ratio = 1.066 [1.033–1.100], P < .001), mortality (odds ratio = 1.157 [1.048–1.278], P = .004), and discharge to long-term acute care facilities (odds ratio = 1.295 [1.084–1.546], P = .004). Frailty was associated with hospital length of stay (odds ratio = 1.659 [1.059–2.598], P = .027) and discharge to skilled nursing facilities (odds ratio = 5.282 [1.567–17.802], P = .007).ConclusionIn our population, the number of rib fractures was associated with respiratory complications and mortality. Frailty was associated with longer hospitalization and discharge to higher level of care.     

Assessment of care timelines in intestinal malrotation with volvulus: A retrospective chart review

BackgroundPatients with intestinal malrotation with volvulus (MWV) may suffer bowel ischemia, which can be correlated with the timing of surgical intervention. The purpose of this study was to identify and assess time-blocks in the care of patients from initial physician assessment (IPA) to surgical intervention to highlight potential opportunities for improvement.MethodsRetrospective chart review of patients with MWV presenting to McMaster Children's Hospital between January 1st, 2000 and December 31st, 2020 (n = 31). Demographic data and time-blocks of care were identified and analyzed (p < 0.05 considered significant). All times were reported as medians.Results22 males (71%) and 9 females (29%) were identified; median age was 9.8 d. IPA to incision was 10.7hrs and surgical consult to incision was 3.4hrs. Time to incision for patients <1 y was not significantly different than those >1 y (10.5hrs vs 10.7hrs, p = 0.737). The use of ultrasound did not significantly affect time to incision (7.9hrs vs 12.0hrs, p = 0.128). For patients requiring resection or having pan-necrosis there was no significant difference in time from IPA (10.9hrs vs 10.5hrs, p = 0.238) or surgical consult to incision (4.0hrs vs 3.3hrs, p = 0.808).ConclusionTime from IPA to surgical consult and time from surgical consult to surgical intervention represented the largest proportions of time. Age, use of ultrasound, and need for resection or having pan-necrosis did not significantly affect the time to incision. This data may be used to inform opportunities for expediting the management of patients with MWV once they have presented to a physician.Level of EvidenceIII.     

Postoperative delirium: An independent risk factor for poorer quality of life with long-term cognitive and functional decline after cardiac surgery

Study objectiveTo evaluate the influence of delirium on the functional and cognitive capacity of patients included in the DELIPRECAS study, as well as on their quality of life, in the 3–4 years after cardiac surgery.DesignProspective observational study.SettingAssessment of cognitive and functional status from hospital discharge to the present, 3 years after cardiac surgery.Patients313 patients undergoing cardiac surgery consecutively, aged 18 years or over.MeasurementsThe primary outcome measure was the cognitive and functional status of the patients 3 years after cardiac surgery, evaluated by telephone interview, and the possible influence on them of delirium diagnosed by the Confusion Assessment Method in Intensive Care Units (CAM-ICU) during their stay in the intensive care unit after cardiac surgery.Main resultsPostoperative delirium acts as an independent risk factor for the long-term development of memory problems (OR 6.11, 95% CI 2.54 to 14.68, p < 0.001), concentration (OR 11.20, 95% CI 3.58 to 35.09, p > 0.001), confusion/disorientation (OR 10.93, 95% CI 3.61 to 33.12, p > 0.001), sleep problems (OR 5.21, 95% CI 2 0.29 to 11.84, p < 0.001), nightmares (OR 8.99, 95% CI 1.98 to 40.90, p = 0.004), emotional problems (OR 4.30, 95% CI 1.87 to 9.91, p = 0.001) and poorer mobility after hospital discharge (OR 2.436, 95% CI 1.06 to 5.61, p = 0.037). The number of hospital readmissions was also significantly higher in those patients who developed delirium after cardiac surgery (27% vs 13.8%, p = 0.022).ConclusionPostoperative delirium is a risk factor for decreased quality of life in patients 3 years after heart surgery, being associated with greater cognitive and functional deterioration, as well as greater risk of hospital readmission. Therefore, emphasis should be placed on both prevention and early recognition and treatment of delirium to improve long-term outcomes for patients after cardiac surgery.     

Effect of allopurinol drug use on GFR and proteinuria in patients with renal transplant recipients (ADOPTR study)

BackgroundHyperuricemia has been associated with the development of hypertension, cardiovascular, and renal disease. However, there is no data about the effect of lowering uric acid level on renal functions and proteinuria in renal transplant recipients. This study aimed to investigate the effect of allopurinol treatment on renal functions in renal transplant recipients (RTR).MethodsA total of 245 patients with renal transplantation were included in this randomized, placebo-controlled study. Patients were randomized to receive either placebo (121 patients) or 300 mg/day allopurinol (124 patients). We have examined uric acid, urinary protein creatinin ratio, MDRD (the modification of diet in renal diseases) and CRP (C-reactive protein) before and 24 weeks after treatment in both group.ResultsIn the allopurinol group, the mean serum uric acid levels, eGFR (estimated glomerular filtration rate), and creatinine urinary albumin creatinin ratio (UACR) significantly improved (p < 0.001). Also uric acid level was positively correlated with the UACR (r = 0,645 p < 0.001) and negatively correlated with MDRD (r = −0,387 p < 0.05) in allopurinol treatment group. A statistically significant increase in CRP level was observed (p < 0,05) in plasebo group. Multivariate regression analysis showed that uric acid was positively correlated with UACR (r = 0,473, β = 0.021, p = 0.002) and negatively correlated with MDRD (r = −0554 β = 0.016, P = 0.001) in allopurinol treatment RTR.ConclusionUrate, a salt of uric acid, is lowered by allopurinol treatment resulting in improved eGFR and decreased proteinuria, when compared to the placebo group. Therefore, we suggest that allopurinol therapy should be part of the management of kidney transplant patients with normal kidney function. Long-term follow-up studies will be useful in revealing the effect of uric acid management on kidney functions and proteinuria.     

Cryptorchidism as an obscure cause of adhesive small bowel obstruction in an adult,a case report

Introduction and importanceCryptorchidism is seen in 3% of fullterm neonates. Rarely, it may cause small bowel obstruction. Knowledge of this presentation of cryptorchidism is essential to treat bowel obstruction arising due to cryptorchidism before the patient suffers complications.Case presentationWe present a case of a patient who underwent exploratory laparotomy for small bowel obstruction that did not resolve with conservative management. At laparotomy, on initial exploration, this patient had adhesive bands causing the small bowel obstruction. On further exploration, the bands were found to arise from a cryptorchid testis.Clinical discussionCryptorchidism is a common finding among newborns and needs to be corrected by 1 year of age. Failure to correct cryptorchidism in a timely manner can result in complications such as bowel obstruction.ConclusionThorough intraoperative exploration is key at operation for all cases of small bowel obstruction, so as to find and treat anatomic causes of obstruction. Congenital causes of bowel obstruction should be suspected in all unexplained cases of bowel obstruction and may be revealed by careful physical examination and thorough intraoperative exploration.     

Early investigations into improving bowel and bladder function in fetal ovine myelomeningocele repair

IntroductionFetal myelomeningocele (MMC) repair improves lower extremity motor function. We have previously demonstrated that augmentation of fetal MMC repair with placental mesenchymal stromal cells (PMSCs) seeded on extracellular matrix (PMSC-ECM) further improves motor function in the ovine model. However, little progress has been made in improving bowel and bladder function, with many patients suffering from neurogenic bowel and bladder. We hypothesized that fetal MMC repair with PMSC-ECM would also improve bowel and bladder function.MethodsMMC defects were surgically created in twelve ovine fetuses at median gestational age (GA) 73 days, followed by defect repair at GA101 with PMSC-ECM. Fetuses were delivered at GA141. Primary bladder function outcomes were voiding posture and void volumes. Primary bowel function outcome was anorectal manometry findings including resting anal pressure and presence of rectoanal inhibitory reflex (RAIR). Secondary outcomes were anorectal and bladder detrusor muscle thickness. PMSC-ECM lambs were compared to normal lambs (n = 3).ResultsEighty percent of PMSC-ECM lambs displayed normal voiding posture compared to 100% of normal lambs (p = 1). Void volumes were similar (PMSC-ECM 6.1 ml/kg vs. normal 8.8 ml/kg, p = 0.4). Resting mean anal pressures were similar between cohorts (27.0 mmHg PMSC-ECM vs. normal 23.5 mmHg, p = 0.57). RAIR was present in 3/5 PMSC-ECM lambs that underwent anorectal manometry and all normal lambs (p = 0.46). Thicknesses of anal sphincter complex, rectal wall muscles, and bladder detrusor muscles were similar between cohorts.ConclusionOvine fetal MMC repair augmented with PMSC-ECM results in near-normal bowel and bladder function. Further work is needed to evaluate these outcomes in human patients.     

Laparoscopic management of mechanical small bowel obstruction

Background: Laparoscopy is used increasingly for the management of acute abdominal conditions. For many years, previous abdominal surgery and intestinal obstruction have been regarded as contraindications to laparoscopy because there is an increased risk of iatrogenic bowel perforation. The role of laparoscopy in acute small bowel obstruction remains unclear. Methods: Since 1995, data from patients undergoing laparoscopic surgery have been entered prospectively into a database. Patients who underwent surgery before 1995 were added retrospectively to the same database. The charts of all patients treated surgically for mechanical small bowel obstruction were reviewed. Univariate analysis was performed to identify factors associated with success or failure, especially intraoperative complications, conversion, and postoperative morbidity. Stepwise logistic regression was used to assess for independent variables. Results: This study included 83 patients (56 women and 27 men) with a mean age of 56 years (range, 17–91 years). Conversion was necessary in 36 cases (43%). Laparoscopy alone was successful in 47 patients (57%). Intraoperative complications were noted in 16% and postoperative complications in 31% of the patients. Eight reoperations (9%) were necessary. Mortality was 2.4%. Duration of surgery (p < 0.001) and a bowel diameter exceeding 4 cm (p= 0.02) were predictors of conversion. No risk factor for intraoperative complication was identified. Accidental bowel perforation (p= 0.008) and the need for conversion (p= 0.009) were the only independent factors associated with an increased risk of postoperative complications. Conclusions: Laparoscopic management of small bowel obstruction is possible in roughly 60% of the patients selected for this approach. Morbidity is lower, resumption of a normal diet is faster, and hospital stay is shorter than with patients requiring conversion. No clear predictor of success or failure was identified, but intraoperative complications must be avoided. If the surgeon is widely experienced in advanced laparoscopic surgery and there is a liberal conversion policy, laparoscopy is a valuable alternative to conventional surgery in the management of acute small bowel obstruction. Received: 20 July 1999/Accepted: 22 November 1999/Online publication: 17 April 2000     

Changes in pediatric trauma during COVID-19 stay-at-home epoch at a tertiary pediatric hospital

BackgroundTrauma is the leading cause of morbidity and mortality in the pediatric population. However, during the societal disruptions secondary to the coronavirus (COVID-19) stay-at-home regulations, there have been reported changes to the pattern and severity of pediatric trauma. We review our two-institution experience.MethodsPediatric trauma emergency department (ED) encounters from the National Trauma Registry for a large, tertiary, metropolitan level 1 pediatric trauma center and pediatric burn admission at the regional burn center were extracted for children less than 19 years from March 15th thru May 15th during the years 2015–2020. The primary outcome was the difference in encounters during the COVID-19 (2020) epoch versus the pre-COVID-19 epoch (2015–2019).ResultsThere were 392 pediatric trauma encounters during the COVID-19 epoch as compared to 451, 475, 520, 460, 432 (mean 467.6) during the pre-COVID-19 epoch. Overall trauma admissions and ED trauma encounters were significantly lower (p < 0.001) during COVID-19. Burn injury admissions (p < 0.001) and penetrating trauma encounters (p = 0.002) increased during the COVID-19 epoch while blunt trauma encounters decreased (p < 0.001). Trauma occurred among more white (p = 0.01) and privately insured (p < 0.001) children, but no difference in suspected abuse, injury severity, mortality, age, or gender were detected. Sub-analysis showed significant decreases in motor vehicle crashes (p < 0.001), pedestrians struck by automobile (p < 0.001), all-terrain vehicle (ATV)/motorcross/bicycle/skateboard involved injuries (p = 0.02), falls (p < 0.001), and sports related injuries (p < 0.001). Fewer injuries occurring in the playground or home play equipment such as trampolines neared significance (p = 0.05). Interpersonal violence (assault, NAT, self-harm) was lower during the COVID-19 era (p = 0.04). For burn admissions, there was a significant increase in flame burns (p < 0.001).ConclusionsStay-at-home regulations alter societal patterns, leading to decreased overall and blunt traumas. However, the proportion of penetrating and burn injuries increased. Owing to increased stressors and time spent at home, healthcare professionals should keep a high suspicion for abuse and neglect.