The optimal treatment of patients with mild and moderate acute cholecystitis: time for a revision of the Tokyo Guidelines

Introduction

According to the Tokyo Guidelines, severity of acute cholecystitis is divided into three grades based on the degree of inflammation and the presence of organ dysfunction. These guidelines recommend grade I (mild) acute cholecystitis to be treated with early laparoscopic cholecystectomy and grade II (moderate) acute cholecystitis with delayed cholecystectomy. Yet, several studies have shown that, for acute cholecystitis in general, early cholecystectomy is superior to delayed cholecystectomy in terms of complication rate, duration of hospital stay and costs. The aim of this study was to determine the clinical outcomes of emergency cholecystectomy in patients with grade II acute cholecystitis. Based on our findings, we propose a revision of the Tokyo Guidelines.

Methods

We performed a retrospective observational cohort study of 589 consecutive patients undergoing emergency cholecystectomy for acute calculous cholecystitis in a large teaching hospital between January 2002 and January 2015. Patients were classified according to the severity assessment criteria of the Tokyo Guidelines. Patients with grade I and grade II acute cholecystitis were compared for perioperative outcomes.

Results

Emergency cholecystectomy was performed in 270 patients with grade I acute cholecystitis and 187 patients with grade II acute cholecystitis. There was no difference in conversion rate (6 vs. 6%, p = 0.985) and operating time (60 min [25–255] vs. 70 min [30–255], p = 0.421). Also the perioperative complication rate (7 vs. 9%, p = 0.517), 30-day mortality (1 vs. 1%, p = 0.648) and length of hospital stay (4 days [1–42] vs. 4 days [1–62], p = 0.327) were similar between grade I and grade II acute cholecystitis.

Conclusion

The clinical outcomes of emergency cholecystectomy did not differ between patients with grade I and grade II acute cholecystitis. The findings support a revision of the Tokyo Guidelines with respect to the recommendation of performing emergency cholecystectomy in both grade I and grade II acute cholecystitis.

     

Emergent laparoscopic cholecystectomy for acute acalculous cholecystitis revisited

Purpose

To compare the safety of emergent laparoscopic cholecystectomy for acute acalculous cholecystitis (AAC) with surgery for acute calculous cholecystitis (ACC).

Methods

We retrospectively reviewed the perioperative records of 111 patients who underwent emergent laparoscopic cholecystectomy for acute cholecystitis under the care of the Department of Digestive Surgery, Kawasaki Medical School, Kurashiki, between January 2010 and April 2014. Patients were divided into the AAC group (27 patients) and the ACC group (84 patients), and their perioperative outcomes were compared.

Results

Patients in the AAC group had significantly higher disease severity and American Society of Anesthesiologists physical status scores (p = 0.001 and 0.037, respectively), lower blood hemoglobin and albumin concentrations (p = 0.0005 and 0.017, respectively), and lower hematocrit and platelet count (p < 0.0001 and 0.040, respectively) than those in the ACC group. When we compared perioperative outcomes, we also found that patients in the AAC group were more likely to have received a blood transfusion (p = 0.002) and to have required conversion to open surgery (p = 0.008). There were no significant differences in morbidity, mortality or length of hospital stay.

Conclusions

Early laparoscopic cholecystectomy is safe in acute acalculous as well as acute calculous cholecystitis.

     

Is the plasma endocan level a reliable predictor for the severity of erectile dysfunction?

Purpose

The aim of our study was to assess the correlation between serum endocan level and erectile dysfunction (ED).

Methods

A total of 92 patients were reviewed in this study after institutional review board approval. The patients’ characteristics were recorded, including age, body mass index, blood pressure, smoking history, serum creatinine, glucose, lipid profile, total testosterone, and Beck Depression Inventory scores. ED was evaluated with the Sexual Health Inventory for Men (SHIM) questionnaire and classified as severe, moderate, or mild. Scores of >?18 indicate normal erectile function and were recruited for the control group.

Results

Sixty-three patients with a median age of 56 years in the ED group and 29 patients with a median age of 55 years in the control group were compared. ED was classified as severe in 20, moderate in 25, and mild in 18 patients. A significant difference was determined between the severe ED group and the control group for serum endocan levels (p?<?0.001). A significant negative correlation between the SHIM score and endocan levels (rho ? 0.65; p?<?0.01), age and SHIM score (rho ? 0.32; p?=?0.04), BMI and SHIM score (rho ? 0.25; p?=?0.03), and BMI and total testosterone (rho ? 0.16; p?=?0.04) was determined upon Spearman’s correlation analysis. A positive correlation was also determined between total testosterone and SHIM score (rho 0.50; p?=?0.04). Patients’ age (p?=?0.037) and serum endocan level (p?=?0.029) were determined as significant in the multivariate analysis.

Conclusion

This study demonstrated the presence of an association between plasma endocan levels and ED. Endocan may be used as a new diagnostic marker for the severity of ED.

     

Cholecystectomy Causes Ultrasound Evidence of Increased Hepatic Steatosis

Background

Cholecystectomy might contribute to the development of hepatic steatosis through metabolic changes. The biologic alteration of the enterohepatic circulation of bile acids and the alteration of the metabolic activity of bile acid that follows cholecystectomy may contribute to hepatic steatosis. This prospective study was conducted to clarify the possibility of steatosis development after cholecystectomy.

Methods

From October 2013 to July 2014, 82 consecutive patients with a presumptive diagnosis of gallbladder disease were cholecystectomized. Liver parenchymal steatosis was measured using ultrasound and the hepatic steatosis index.

Results

In all 82 patients, the hepatic steatosis index was found to be significantly correlated with the US fatty liver grade (Spearman’s correlation r ² = 0.331, P < 0.001). A total of 62 patients were followed up for 3 months. Comparison with the initial grade showed that 12 (18.5 %) patients had worsened from normal to mild (n = 10), from mild to moderate (n = 1), and from mild to severe (n = 1). The other patients stayed at their initial grade except one patient who improved (from moderated to mild). Analysis of laboratory findings showed that white blood cell count, aspartate transaminase, alanine transaminase level, and total bilirubin level were decreased. However, serum albumin and high-density lipoprotein cholesterol levels significantly increased.

Conclusions

Hepatic steatosis significantly developed 3 months after cholecystectomy. Therefore, cholecystectomy might be considered a risk factor for hepatic steatosis, but the relationship should be confirmed with long-term follow-up from a large group of patients.

     

Surgical treatment of symptomatic cerebral cavernous malformations in eloquent brain regions

Background

Despite the increased risk of hemorrhage and deteriorating neurological function of once-bled cerebral cavernous malformations (CM), the management of eloquently located CMs remains controversial.

Methods

All eloquently located CMs (n?=?45) surgically treated between 03/2006 and 04/2011 in our department were consecutively evaluated. Eloquence was characterized according to Spetzler and Martin's definition. The following locations were approached: brainstem, n?=?16; sensorimotor, n?=?8; visual pathway, n?=?7; cerebellum (deep nuclei and peduncles), n?=?7; basal ganglia, n?=?4, and language, n?=?3. Follow-up data was available for 41 patients (91 %) with a median interval of 14 months. Outcomes were evaluated according to the Glasgow outcome and the modified Rankin scale.

Results

Immediately after surgery, 47 % (n?=?21) had a new deficit. At follow-up, 80 % (n?=?36) recovered to at least preoperative status or were better than before surgery, 9 % (n?=?4) exhibited a slight, and 7 % (n?=?3) had a moderate neurological impairment. Only two cases (4 %) with a new permanent severe deficit were observed, both related to dorsal brainstem surgery. The outcome after the surgery of otherwise located brainstem CMs was as beneficial as that for non-brainstem CMs. Patients with initially poor neurological performance fared worse than oligosymptomatic patients.

Conclusions

Despite the high postoperative transient morbidity, the majority improved profoundly during follow-ups. Compared with natural history, surgical treatment should be considered for all eloquent symptomatic CMs. Dorsal brainstem location and poor preoperative neurological status are associated with an increased postoperative morbidity.

     

Acute Pancreatitis After Laparoscopic Transcystic Common Bile Duct Exploration: An Analysis of Predisposing Factors in 447 Patients

Introduction

In laparoscopic transcystic common bile duct exploration (LTCBDE), the risk of acute pancreatitis (AP) is well recognized. The present study assesses the incidence, risk factors, and clinical impact of AP in patients with choledocholithiasis treated with LTCBDE.

Methods

A retrospective database was completed including patients who underwent LTCBDE between 2007 and 2017. Univariate and multivariate analyses were performed by logistic regression.

Results

After exclusion criteria, 447 patients were identified. There were 70 patients (15.7%) who showed post-procedure hyperamylasemia, including 20 patients (4.5%) who developed post-LTCBDE AP. Of these, 19 were edematous and one was a necrotizing pancreatitis. Patients with post-LTCBDE AP were statistically more likely to have leukocytosis (p?<?0.004) and jaundice (p?=?0.019) before surgery and longer operative times (OT, p?<?0.001); they were less likely to have incidental intraoperative diagnosis (p?=?0.031) or to have biliary colic as the reason for surgery (p?=?0.031). In the final multivariate model, leukocytosis (p?=?0.013) and OT (p?<?0.001) remained significant predictors for AP. Mean postoperative hospital stay (HS) was significantly longer in AP group (p?<?0.001).

Conclusion

The risk of AP is moderate and should be considered in patients with preoperative leukocytosis and jaundice and exposed to longer OT. AP has a strong impact on postoperative HS.

     

Impact of Jaundice on Outcomes Following Emergency Laparoscopic Cholecystectomy in Patients with Choledocholithiasis

Introduction

Traditional teaching dictates that it may not be prudent to take the jaundiced patient to theatre for emergency laparoscopic cholecystectomy as they may experience worse outcomes following surgery.

Methods

A prospective cohort of 104 patients undergoing emergency laparoscopic cholecystectomy was stratified into two groups using a serum total bilirubin of above 50 μmol/L (2.9 mg/dL) to define the jaundiced group. Primary outcomes were morbidity and mortality rate. The Clavien–Dindo classification and the novel Comprehensive Complication Index (CCI) were applied to the grading of surgical complications. Multivariate analysis to identify possible predictors of morbidity and length of stay was also performed.

Results

Overall morbidity rate in the jaundiced group was 28 versus 36% (control), p?=?0.405. Mean CCI in the jaundiced group was 5.28 versus 8.00 in the control group, p?=?0.229. Mean length of stay was shorter in the jaundiced group, 4.65 versus 6.51 days, p?=?0.036. There were no peri-operative mortalities or conversions to open surgery. Only male gender and the presence of retained stones were found to be associated with morbidity. Serum total bilirubin was not associated with increased morbidity.

Conclusion

Amongst patients undergoing laparoscopic cholecystectomy who are found to have choledocholithiasis on IOC, the presence of jaundice does not appear to contribute towards increased morbidity.

     

Risk factors for complications after diverting ileostomy closure in patients who have undergone rectal cancer surgery

Purpose

To clarify the risk factors for complications after diverting ileostomy closure in patients who have undergone rectal cancer surgery.

Methods

The study group comprised 240 patients who underwent a diverting ileostomy at the time of lower anterior resection or internal anal sphincter resection, in our department, between 2004 and 2015. Univariate and multivariate analyses of 18 variables were performed to establish which of these are risk factors for postoperative complications.

Results

The most common complications were intestinal obstruction and wound infection. Univariate analysis showed that an age of 72 years or older (p?=?0.0028), an interval between surgery and closure of 6 months or longer (p?=?0.0049), and an operation time of 145 min or longer (p?=?0.0293) were significant risk factors for postoperative complications. Multivariate analysis showed that age (odds ratio, 3.4236; p?=?0.0025), the interval between surgery and closure (odds ratio, 3.4780; p?=?0.0039), and operation time (odds 2.5179; p?=?0.0260) were independent risk factors.

Conclusions

Age, interval between surgery and closure, and operation time were independent risk factors for postoperative complications after diverting ileostomy closure. Thus, temporary ileostomy closure should be performed within 6 months after surgery for rectal cancer.

     

Postoperative Complications of Laparoscopic Cholecystectomy for Acute Cholecystitis: A Comparison to the ACS-NSQIP Risk Calculator and the Tokyo Guidelines

Background

We compared observed postoperative outcomes from laparoscopic cholecystectomy performed for acute cholecystitis (AC) to outcomes predicted by the ACS-NSQIP risk calculator.We also noted and compared any differences in observed outcomes across the different Tokyo Guidelines (TG) levels of AC severity.We hypothesized that ACS-NSQIP would accurately predict complications and length of stay (LOS) and that increased TG severity levels would correlate with more complications, increased conversion to open surgery, and longer LOS.

Methods

A review of all patients who underwent laparoscopic cholecystectomy for acute cholecystitis over eighteen months was performed.

Results

ACS-NSQIP predicted a complication rate of 4.6% (11% found) and LOS of 0.73 days (2.5 found), p < 0.05. Increased TG severity had LOS of 1.89, 2.75, and 5.33, respectively, p < 0.05. The complication numbers and conversion to open cholecystectomy were insignificant between the TG classes.

Conclusion

ACS-NSQIP did not accurately predict complications or LOS. TG classifications did not show a significant difference in complications or conversion to open surgery, but positively correlated with LOS. ACS-NSQIP may not accurately predict patient outcomes and the TG, originally created with the purpose of differentiating levels of inflammation and severity, may only be useful for predicting LOS.

     

YouTube provides irrelevant information for the diagnosis and treatment of hip arthritis

Purpose

YouTube is increasingly becoming a key source for people to satisfy the need for additional information concerning their medical condition. This study analyses the completeness of accurate information found on YouTube pertaining to hip arthritis.

Methods

The present study analyzed 133 YouTube videos using the search terms: hip arthritis, hip arthritis symptoms, hip arthritis diagnosis, hip arthritis treatment and hip replacement. Two quality assessment checklists with a scale of 0 to 12 points were developed to evaluate available video content for the diagnosis and the treatment of hip arthritis. Videos were grouped into poor quality (grade 0–3), moderate quality (grade 4–7) and excellent quality (grade 8–12), respectively. Three independent observers assessed all videos using the new grading system and independently scored all videos. Discrepancies regarding the categories were clarified by consensus discussion. For intra-observer reliabilities, grading was performed at two occasions separated by four weeks.

Results

Eighty-four percent (n?=?112) had a poor diagnostic information quality, 14% (n?=?19) a moderate quality and only 2% (n?=?2) an excellent quality, respectively. In 86% (n?=?114), videos provided poor treatment information quality. Eleven percent (n?=?15) of videos had a moderate quality and only 3% (n?=?4) an excellent quality, respectively.

Conclusions

The present study demonstrates that YouTube is a poor source for accurate information pertaining to the diagnosis and treatment of hip arthritis. These finding are of high relevance for clinicians as videos are going to become the primary source of information for patients. Therefore, high quality educational videos are needed to further guide patients on the way from the diagnosis of hip arthritis to its proper treatment.

     

Eradication of Barrett Esophagus with Early Neoplasia by Radiofrequency Ablation,with or without Endoscopic Resection

Background

Radiofrequency ablation is safe and effective for complete eradication of nondysplastic Barrett esophagus (BE). The aim was to report the combined results of two published and two ongoing studies on radiofrequency ablation of BE with early neoplasia, as presented at SSAT presidential plenary session DDW 2008.

Methods

Enrolled patients had BE ≤12 cm with early neoplasia. Visible lesions were endoscopically resected. A balloon-based catheter was used for circumferential ablation and an endoscope-based catheter for focal ablation. Ablation was repeated every 2 months until the entire Barrett epithelium was endoscopically and histologically eradicated.

Results

Forty-four patients were included (35 men, median age 68 years, median BE 7 cm). Thirty-one patients first underwent endoscopic resection [early cancer (n?=?16), high-grade dysplasia (n?=?12), low-grade dysplasia (n?=?3)]. Worst histology remaining after resection was high-grade (n?=?32), low-grade (n?=?10), or no (n?=?2) dysplasia. After ablation, complete histological eradication of all dysplasia and intestinal metaplasia was achieved in 43 patients (98%). Complications following ablation were mucosal laceration at resection site (n?=?3) and transient dysphagia (n?=?4). After 21 months of follow-up (interquartile range 10–27), no dysplasia had recurred.

Conclusions

Radiofrequency ablation, with or without prior endoscopic resection for visible abnormalities, is effective and safe in eradicating BE and associated neoplasia.

     

Serum Arginase II level can be a novel indicator for erectile dysfunction in patients with vasculogenic erectile dysfunction: a comparative study

Purpose

The purpose of the study was to compare serum level of Arginase II in patients with vasculogenic erectile dysfunction (ED) versus healthy controls and to assess if its level is affected by severity of ED.

Methods

This is a prospective study that compared Arginase II in 40 patients with ED versus 40 healthy controls. Patients were excluded if they had any pelvic trauma or pelvic surgery, hormonal disorders, Peyronie’s disease, smoking, drug addiction or systemic illnesses. ED was evaluated by the validated Arabic version of the abbreviated five-item form of the international index of erectile function (IIEF-5). Serum arginase II level was assayed using ELIZA. Mann–Whitney, Kruskal–Wallis and Chi-square tests and Spearman correlation were used as appropriate and confirmed by logistic regression model.

Results

22 (55%) patients had DM. 15 (37.5%), 7 (17%), 6 (15%) and 12 (30%) patients suffered from severe, moderate, mild to moderate and mild ED, respectively. The level of serum Arginase II was significantly higher in patients than controls (p?<?0.001) and confirmed by multivariate logistic regression analysis. It also correlated significantly with age (r²?=?0.22; p?<?0.001) and IIEF-5 score (r²?=?0.8; p?<?0.001). Serum Arginase II increased significantly with more severe ED (p?<?0.001). Arginase II was also significantly higher in diabetic patients (p?<?0.001).

Conclusion

Serum level of Arginase II is significantly higher in patients with vasculogenic ED compared to healthy controls. It correlates significantly with age and IIEF-5 and was significantly affected by the severity of ED.

     

A Randomized,Double-Blind,Placebo-Controlled Trial of Intravenous Acetaminophen on Hospital Length of Stay in Obese Individuals Undergoing Sleeve Gastrectomy

Background

Retrospective studies indicate that acetaminophen iv administration reduces hospital length of stay (LoS) and opiate consumption in patients undergoing bariatric surgery.

Objective

This study sought to determine whether using acetaminophen iv in morbidly obese subjects undergoing sleeve gastrectomy decreased LoS and total hospital charges as compared to patients receiving saline placebo.

Setting

Single-center university hospital

Methods

Using a randomized, double-blind, placebo-controlled design, subjects were assigned to receive either acetaminophen iv (group A) or saline placebo iv (group P). Data were collected between Jan 1 and Dec 31, 2016. Group A received acetaminophen every 6 h for a total of four doses. The first dose was administered following the induction of general anesthesia; group P received saline iv on the same schedule. Anesthetic management and prophylactic antiemetic regimen were standardized in all subjects. Postoperative pain management consisted of hydromorphone via patient-controlled infusion pump. Primary outcomes include hospital LoS and associated hospital costs. Secondary outcomes include patient satisfaction and postoperative nausea and pain scores.

Results

Subject demographics (n?=?127) and intraoperative management were similar in the two groups. Across all subjects, median hospital LoS in group A (n?=?63) was 1.87 vs. 1.97 days in group P (n?=?64) (p?=?0.03, Wilcoxon rank-sum test). Postoperatively, daily quality-of-recovery (QoR-15) scores, narcotic consumption, and the use of rescue antiemetics were not significantly different between groups. Median hospital costs were as follows: group A, $12,885 vs. group P, $12,977 (n?=?64).

Conclusions

Acetaminophen iv may reduce hospital LoS in subjects undergoing sleeve gastrectomy.

     

Investigating Transitional Care to Decrease Post-pancreatectomy 30-Day Hospital Readmissions for Dehydration or Failure to Thrive

Background

Current literature emphasizes post-operative complications as a leading cause of post-pancreatectomy readmissions. Transitional care factors associated with potentially preventable conditions such as dehydration and failure to thrive (FTT) may play a significant role in readmission after pancreatectomy and have not been studied.

Methods

Thirty-one post-pancreatectomy patients, who were readmitted for dehydration or FTT between 2009 and 2014, were compared to 141 nonreadmitted patients. Medical record review and a questionnaire-based survey, specifically designed to assess transitional care, were used to identify predictors of readmissions for dehydration or FTT. Logistic regression models were used to evaluate outcomes.

Results

On multivariable analysis, the strongest predictors of readmission for dehydration and FTT were the patient’s lower educational level (P?=?0.0233), the absence of family during the delivery of discharge instructions (P?=?0.0098), episodic intermittent nausea at discharge (P?=?0.0019), uncertainty about quantity, quality, or frequency of fluid intake (P?=?0.0137), and the inability or failure to adhere to the clinician’s instructions in the outpatient setting (P?=?0.0048).

Conclusion

Transitional-care-related factors are found to be associated with post-pancreatectomy readmission for dehydration and FTT. Using these results to identify high-risk patients and implement focused preventive measures combining efficient communication and optimal inpatient and outpatient management could potentially decrease readmission rates.

     

Results of the treatment of first carpometacarpal joint osteoarthritis: trapeziectomy alone versus trapeziectomy associated with suspensionplasty

Backgrounds

The goal of this study was to compare trapeziectomy alone to trapeziectomy associated with a technique of suspensionplasty using the abductor pollicis longus with a minimum of 6 years of follow-up in the treatment of osteoarthritis of the first carpometacarpal joint.

Methods

Our series included 46 trapeziectomies in 35 patients, aged 69 years in average, among which 27 were women. In 27 cases group I, a trapeziectomy alone was performed, and in 19 cases group II, a trapeziectomy associated with an abductor pollicis longus suspensionplasty was performed.

Results

At the last follow-up, the difference between pre- and postoperative Quick DASH was ??36.104 in average in group I and ??38.877 in average in group II p?=?0.7717. The difference between pre- and postoperative pain was ??3.926 in average in group I and ??4.368 in average in group II p?=?0.35. The difference of pre- and postoperative thumb opposition was 0.630 in group I and 0.421 in group II p?=?0.3033. The average difference of pre- and postoperative key pinch was 0.389 in group I and 0.842 in group II p?=?0.3303. No complication was reported.

Conclusions

Our results suggest that it is unnecessary to perform a ligamentoplasty when a trapeziectomy is indicated.

     

Long term outcomes in the use of ileal ureter for radiation-induced ureteral strictures

Purpose

Radiation-induced ureteral stricture disease poses significant surgical challenges. Ureteral substitution with ileum has long been a versatile option for reconstruction. We evaluated outcomes in patients undergoing ileal ureter replacement for ureteral reconstruction due to radiation-induced ureteral stricture versus other causes.

Methods

Between July 1989 and June 2013, 155 patients underwent consecutive ileal ureter creation. The study cohort included 104 patients with complete data sets and at least 7 months of follow up. Records were retrospectively reviewed with regard to demographics, indications, complications, and renal deterioration.

Results

Surgical indications included radiation-induced stricture in 23 (22%) and non-radiation-induced stricture in 81 (78%). Comparing ileal ureter substitution due to radiation versus other stricture etiologies, no statistical significance was observed in regard to age (45.6 vs. 51.2, p?=?0.141), hospital length of stay in days (8.8 vs. 7.7, p?=?0.216), percent GFR loss (MDRD-4 vs. -5%, p?=?0.670 and CKD-EPI-7 vs. -6%, p?=?0.914), 30-day surgical complications (26.1 vs. 30.1%, p?=?0.658), metabolic acidosis (8.7 vs. 1.2%, p?=?0.059), and renal failure requiring dialysis (4.3 vs. 1.2%, p?=?0.337). Fistula formation (13.0 vs. 3.7%, p?=?0.095), partial small bowel obstructions (21.7 vs. 7.4%, p?=?0.063), and small bowel obstructions requiring reoperation (13.0 vs. 1.2%, p?=?0.033) approached or reached statistical significance. Using Kaplan–Meier methodology, there was no difference in time to worsening renal outcome between the radiation and non-radiation groups (p?>?0.05).

Conclusion

Ureteral substitution with ileum is an effective reconstructive option for radiation-induced ureteral strictures in carefully selected patients.

     

Complications in hepatic arterial infusion chemotherapy: retrospective comparison of catheter tip placement in the right/left hepatic artery vs. the gastroduodenal artery

Purpose

To compare the complication rates associated with hepatic arterial infusion chemotherapy (HAIC) for unresectable hepatocellular carcinoma (HCC) using two different catheter tip locations, the right/left hepatic artery (group 1) and the gastroduodenal artery (group 2).

Methods

Between April 2001 and March 2015, 88 patients (group 1, n?=?36; group 2, n?=?52) with unresectable HCC, underwent HAIC via a transfemorally placed infusion catheter. The incidence of complications related to catheter placement (including hepatic arterial occlusion, catheter dislocation, non-target embolization and port-catheter system infection) as well as catheter patency and patient survival were evaluated.

Results

The technical success rate was 100%. The overall complication rate was 17% (15/88 patients). The specific complications were as follows: hepatic artery occlusion, n?=?1 (group 2, n?=?1), gastroduodenal ulcer, n?=?6 (group 1, n?=?2; group 2, n?=?4); catheter dislocation, n?=?1 (group 2, n?=?1); port-catheter system infection, n?=?3 (group 2, n?=?3); and bleeding at the puncture site, n?=?4 (group 1, n?=?1; group 2, n?=?3).

Conclusions

The complication rates in groups 1 and 2 did not differ to a statistically significant extent.

     

The unresolved problem of beta-2 microglobulin amyloid deposits in the intervertebral discs of long-term dialysis patients

Background

Dialysis-related destructive spondyloarthropathy caused by beta-2 microglobulin (β2M) amyloid deposits in intervertebral discs is a major burden for patients undergoing long-term dialysis. This study aimed to quantify the presence of β2M amyloid deposits in the intervertebral disc tissue of such patients and analyze whether there was a significant correlation between β2M accumulation and the duration of dialysis.

Methods

Two groups of patients who had undergone surgery for degenerative spinal pathologies were selected: the dialysis group (n?=?29) with long-term dialysis and the control group (n?=?10) with no renal impairment. Tissue sections were prepared from specimens of intervertebral disc tissue obtained during spinal surgery and analyzed via histological staining, including immunohistochemistry (IHC) and Congo red.

Results

There was a statistically significant multifold increase of β2M expression in the disc tissue of long-term dialysis patients when compared to non-dialysis patients, as shown by both IHC (0.019?±?0.023 μm² vs. 0.00020?±?0.00033 μm², respectively; p?=?0.012) and Congo red staining (0.027?±?0.041 μm² vs. 9.240?×?10^?5?±?5.261?×?10^?5 μm², respectively; p?=?0.047). We also note a moderate strength positive correlation between the duration of dialysis and positive IHC (r?=?0.39; p?=?0.015) and Congo-red staining (r?=?0.42; p?=?0.007).

Conclusions

The problem of β2M amyloidosis in long-term dialysis patients remains unresolved even with predominant use of high-flux dialysis membranes. This highlights the insufficiency of current dialysis modalities to effectively filter β2M.

     

Exploration of Fluid Dynamics in Perioperative Patients Using Bioimpedance Analysis

Introduction

Perioperative fluid restriction is advocated to reduce complications after major surgeries. Current methods of monitoring body fluids rely on indirect volume markers that may at times be inadequate. In our study, bioimpedance analysis (BIA) was used to explore fluid dynamics, in terms of intercompartmental shift, of perioperative patients undergoing operation for hepato-pancreato-biliary (HPB) diseases.

Methods

A retrospective review was conducted, examining 36 patients surgically treated for HPB diseases between March 2010 and August 2012. Body fluid compartments were estimated via BIA at baseline (1 day prior to surgery), immediately after surgery, and on postoperative day 1, recording fluid balance during and after procedures. Patients were stratified by net fluid status as balanced (≤500 mL) or imbalanced (>550 mL) and outcomes of BIA compared.

Results

Mean net fluid balance volumes in balanced (n?=?16) and imbalanced (n?=?20) patient subsets were 231.41?±?155.44 and 1050.18?±?548.77 mL, respectively. Total body water (TBW) (p?=?0.091), extracellular water (ECW) (p?=?0.125), ECW/TBW (p?=?0.740), and intracellular water (ICW) (p?=?0.173) did not fluctuate significantly in fluid-balanced patients. Although TBW (p?=?0.069) in fluid-imbalanced patients did not change significantly (relative to baseline), ECW (p?=?0.001), ECW/TBW (p?=?0.019), and ICW (p?=?0.012) showed significant postoperative increases.

Conclusion

The exploration of fluid dynamics using BIA has shown importance of balanced fluid management during perioperative period. Increased ECW/TBW in fluid-imbalanced patients suggests possible causality for the development of ascites or fluid collections during postoperative period in patients undergoing HPB operations.

     

Externalized Stents for Pancreatoduodenectomy Provide Value Only in High-Risk Scenarios

Background

Evidence suggests externalized trans-anastomotic stents may be beneficial as a fistula mitigation strategy for pancreatoduodenectomy (PD); however, previous studies have not been rigorously risk-adjusted.

Methods

From 2001 to 2015, PDs were performed at three institutions, with externalized stents placed at the surgeon’s discretion. The Fistula Risk Score (FRS) and the Modified Accordion Severity Grading System were used to analyze occurrence and severity of clinically relevant postoperative pancreatic fistula (CR-POPF) across various risk scenarios.

Results

Of 729 PDs, externalized stents were placed during 129 (17.7 %). Overall, CR-POPFs occurred in 77 (10.6 %) patients. The median FRS of patients who received externalized stents was significantly higher compared with patients who did not (6 vs. 3, p?<?0.0001). Patients with negligible, low, or moderate CR-POPF risk (FRS 0–6) did not demonstrate improved outcomes with externalized stents; however, among high-risk patients (FRS 7–10), stents were associated with significantly reduced rates of CR-POPF (14.0 vs. 36.4 %, p?=?0.031), severe complications (p?=?0.039), and hospital stay (p?=?0.014) compared with no stents. The average complication burden of CR-POPF was significantly lower for patients with externalized stents (p?=?0.035).

Conclusion

This multicenter study, the largest comparative analysis of externalized trans-anastomotic stents versus no stent for PD, demonstrates a risk-stratified benefit to externalized stents.