Impact of the introduction of laparoscopic cholecystectomy on the population aged 70 and over.

BACKGROUND/AIMS: Laparoscopic cholecystectomy is reported to be better tolerated than open cholecystectomy by patients aged 70 and over. We evaluate its impact on patients aged 70 and over, from one single center. METHODOLOGY: We review 427 cholecystectomies performed in one single centre, from November 1992 through November 1999. We consider 23 patients, 70 years old or older at the time of surgery. The following objective parameters were considered and compared with the younger population: length of stay in the hospital; mean preoperative stay; mean postoperative stay; incidence of risk factors; postoperative complications. A questionnaire was also mailed to all individual 427 patients. RESULTS: Length of stay in the hospital declined in both population, during the time interval considered. The incidence of risk factors, both major and minor, increases consistently with age from less than 1% below the age of 30 to about 62% in the eighth decade and over. Major postoperative complications were 4.34% in patients > or = 70 vs. 2.8% in patients < 70 years of age. Mortality was nil in both groups. Ninety percent reported complete disappearance of preoperative symptoms. CONCLUSIONS: Laparoscopic cholecystectomy in geriatric patients is safe and risks are reasonably low. Selection of patients must be done on strict indications.     

Use of Microvascular Flap Technique in Older Adults with Head and Neck Cancer: A Persisting Dilemma in Reconstructive Surgery?

OBJECTIVES: To compare perioperative problems and outcomes of reconstructive surgery with microvascular flaps of a group of older (≥70) and younger adults (20–69). DESIGN: Prospective clinical cohort study. SETTING: Maxillofacial surgical unit of a university teaching hospital in Munich, Germany. PARTICIPANTS: Two hundred fifteen people with head and neck carcinoma (older: n=54, mean age 75.8, range 70–96; younger: n=161, mean age 55.5, range 20–69) who underwent surgery between 2007 and 2009. MEASUREMENTS: Participant characteristics: age, sex, American Society of Anesthesiologists (ASA) status, tumor type, preoperative radiation or chemotherapy, medical comorbidities. Surgical variables: flap type, type of reconstruction (primary/secondary), length of operation (minutes). Postoperative variables: length of stay (minutes) on intensive care unit (ICU), reasons for ICU stay longer than 1,500 minutes (surgical or medical), length of hospitalization (days), and reasons for hospitalization longer than 20 days (surgical or /medical). Short‐term outcome within 30 days: revisions, flap success, overall complication rate, mortality. RESULTS: Older adults had a higher ASA class (P<.001) and shorter duration of surgery (P=.02). Age as an independent factor prolonged stay on ICU (P=.008) and was associated with a higher complication rate (P=.003) but had no influence on length of hospitalization, flap success, need for revisions, or mortality. CONCLUSION: Although higher rates of peri‐ and postoperative difficulties must be expected when microvascular reconstructive surgery is considered for older adults, careful surgical technique, adequate postoperative surveillance, and immediate management of complications can facilitate outcomes comparable with those for younger adults.     

Determinants of postoperative stay in patients with colorectal cancer

The easiest way to reduce the cost of hospital care for patients is to reduce the length of hospital stay. Multivariate analysis was used to identify potentially alterable factors affecting postoperative length of stay for 320 consecutive colorectal cancer patients undergoing elective surgery during a three-year period. Prolonged postoperative stays were noted for patients over age 69. Significantly longer stays were seen for men than for women (13.9vs. 11.9 days,P=.012). Operative procedure significantly influenced postoperative stay: left hemicolectomies, anterior resections with colostomy, abdominoperineal resections, and subtotal coloectomies were associated with significantly longer stays than right, transverse, sigmoid, and anterior resections without colostomy (P<.001). Complications increased the mean postoperative stay from 11.4 to 19.7 days (P<.001) and stay increased progressively with the number of blood transfusions received from 11.1 days for no blood to 21.6 days for more than four units (P<.001). Severity of disease, as reflected by Dukes' stage, tumor differentiation, and tumor size, was not related to postoperative stay. In the latter half of the study, postoperative stay declined, accompanied by a decline in the use of blood and a shift in the procedures performed for rectal carcinoma away from abdominoperineal resection toward anterior resection without colostomy. Diagnosis-related group (DRG) relative weights for procedure, age, and complications are at variance with these findings. Supported in part by NCI-NIH Grant 1 R01-CA-35558-01 and The Frieda and George Zinberg Foundation.     

Advanced age—indication or contraindication for laparoscopic colorectal surgery?

PURPOSE: It has been proposed that laparoscopic colorectal surgery offers several benefits to patients. The aim of this study was to evaluate particularly whether older patients can benefit by laparoscopic colorectal procedures or if minimally invasive procedures are contraindicated. METHODS: All patients who underwent elective surgery were divided into age-related groups: patients 50 years of age or younger, patients ranging from 51 to 70 years of age, and patients older than 70 years. The groups by age were compared with each other relative to their cardiopulmonary status, indication, procedure, conversion, morbidity, mortality, duration of surgery, perioperative blood transfusion, stay on the intensive care unit, and hospitalization. Statistical analysis included univariate analysis by chi-squared tests and Student'st-tests comparing patients older than 70 years with patients 50 years of age or younger and with patients ranging from 51 to 70 years of age (statistical significance was defined asP<0.05). RESULTS: Within five years 298 patients (male/female ratio, 0.38) underwent a laparoscopic or laparoscopic-assisted colorectal procedure. Of these, 95 (31.9 percent) patients were older than 70 years, 138 (46.3 percent) patients ranged from 51 to 70 years of age, and 65 (21.8 percent) patients were 50 years of age or younger. Pathologic findings in cardiopulmonary function increased with age. There were no statistically significant differences among the younger, middle-aged, and older patients relative to the incidence of conversion (3.1vs. 9.4vs. 7.4 percent, respectively), major complications (4.6vs. 10.1vs. 9.5 percent, respectively), minor complications (12.3vs. 15.2vs. 12.6 percent, respectively) or total laparotomy rate (7.7vs. 12.3vs. 12.6 percent, respectively).P>0.05 for all comparisons. However, duration of surgery, stay on the intensive care unit, and postoperative hospitalization were significantly prolonged in patients older than 70 years (P<0.05 for all comparisons) but were reduced during the five years of experience with these procedures. CONCLUSIONS: If preoperative assessment of comorbid conditions and perioperative care was ensured, laparoscopic procedures were shown to be safe options in the elderly. The outcome of laparoscopic colorectal surgery in patients older than 70 years is similar to that noted in younger patients. Advanced age is no contraindication for laparoscopic colorectal surgery.Poster presentation at the 115th Congress of The German Society of Surgery, Berlin, Germany, April 28 to May 2, 1998.     

Short-term postoperative outcomes after liver resection in the elderly patient: a nationwide population-based study

BackgroundLiver resection is high-risk surgery in particular in elderly patients. The aim of this study was to explore postoperative outcomes after liver resection in elderly patients.MethodsIn this nationwide study, all patients who underwent liver resection for primary and secondary liver tumours in the Netherlands between 2014 and 2019 were included. Age groups were composed as younger than 70 (70-), between 70 and 80 (septuagenarians), and 80 years or older (octogenarians). Proportion of liver resections per age group and 30-day major morbidity and 30-day mortality were assessed.ResultsIn total, 6587 patients were included of whom 4023 (58.9%) were younger than 70, 2135 (32.4%) were septuagenarians and 429 (6.5%) were octogenarians. The proportion of septuagenarians increased during the study period (aOR:1.06, CI:1.02–1.09, p < 0.001). Thirty-day major morbidity was higher in septuagenarians (11%) and octogenarians (12%) compared to younger patients (9%, p = 0.049). Thirty-day mortality was higher in septuagenarians (4%) and octogenarians (4%) compared to younger patients (2%, p < 0.001). Cardiopulmonary complications occurred more frequently with higher age, liver-specific complications did not. Higher age was associated with higher 30-day morbidity and 30-day mortality in multivariable logistic regression.ConclusionThirty-day major morbidity and 30-day mortality are higher after liver resection in elderly patients, attributed mainly to non-surgical cardiopulmonary complications.     

Factors associated with a protracted hospital stay after hip fracture surgery in Japan

Aim: Hip fracture is a major injury in the elderly and has a high impact on quality of life and use of health‐care resources. In this study, we aimed to identify the factors related to prolonged hospital stay and poor outcome after hip fracture surgery. Methods: We evaluated data from 8920 cases at 398 acute‐care hospitals in Japan. Multivariate logistic regression analysis was used to determine the factors associated with the length of postoperative hospital stay. Results: A shorter postoperative hospital stay was associated with admission to a high surgical volume hospital (P < 0.001). On the other hand, a longer postoperative hospital stay was associated with infective complications, admission to a private hospital, an interval of more than 3 days between admission and surgery (P < 0.001 for all), and an interval of more than 1 day between surgery and start of rehabilitation (P = 0.01). Further analysis revealed that infective complications were more likely in older patients (P = 0.003) and patients with comorbidities (P = 0.03). Conclusion: The results imply that hospital stay, and, therefore, use of medical resources, can be decreased by performing surgeries shortly after patients are admitted, preventing postoperative infections, and starting rehabilitation on the next day of the surgery. One of the limitations of our study was that data of the length of hospital stay at transferred hospitals were not available. Therefore, further prospective studies will be needed to address significance of early surgery and rehabilitation. Geriatr Gerontol Int 2011; 11: 474–481.     

Complications of care in a medical intensive care unit

Objective:To determine the frequency and nature of complications of care in the medical intensive care unit (MICU). Design:Prospective, observational study. Setting:Seven-bed MICU in a teaching and referral VA hospital. Patients:295 consecutive patients admitted to the MICU during a ten-month study period. Interventions:None. Measurements and main results:Forty-two patients (14%, 95% confidence interval 13%, 16%) experienced one or more complications during their MICU stays. Compared with other MICU patients, those experiencing complications tended to be older (mean age ± SD: 63.6±10.1 years vs 59.3±14.0 years, p<0.02) and more acutely ill (mean Acute Physiology Score ± SD: 18.3±8.0 vs 12.5±8.0, p=0.0001). These patients also had significantly longer MICU lengths of stay (mean ± SD: 12.3±14.7 days vs 3.1±4 days, p<0.0001) and higher hospital mortality rates (67% vs 27%, p<0.001). The 67% mortality rate among patients with complications significantly exceeded the expected mortality rate of 46% (calculated from the APACHE risk equation). Conclusion:Complications of care in the MICU are not rare and may independently contribute to in-hospital mortality. The potential for complications must be recognized when considering ICU care.     

Localized gallbladder perforation: a systematic review of treatment and prognosis

BackgroundThe optimal management of localized gallbladder perforation (Neimeier type II) has yet to be defined. The aim of this systematic review was to identify factors associated with improved patient outcomes.MethodsSystematic review of studies that described the management of Neimeier type II perforation, reported complications of the first intervention, necessity of added interventions, resolution of the pathology, and days of hospital stay were included. The search strategy was conducted in EMBASE, Mayo Journals, MEDLINE, SCOPUS, and Web of Science (December 2020)ResultsA total of 122 patients (53% male) from case reports, series, and cohorts were included for analysis. In total 56 (46%) and 44 (36%)patients were treated with open and laparoscopic cholecystectomy respectively. Overall risk of bias was moderate. The need for another intervention was higher in the laparoscopic group (5 vs 17, p=<0.001) as well as prevalence of complications (4 vs 16, p=<0.001), but lower for days of hospital stay (median days 5. vs 15, p = 0.008) against open cholecystectomy. Preoperative percutaneous catheter drainage did not influence outcome.ConclusionOpen cholecystectomy has a lower need for further surgical procedures and postoperative complications, but a longer hospital stay. These outcomes did not vary with preoperative percutaneous drainage. The effect of timing of cholecystectomy did not influence the outcomes.     

Surgical treatment of piles

PURPOSE: The present prospective, randomized clinical trial compares the outcome of surgical hemorrhoidectomy according to Parks and Milligan-Morgan in terms of hospital stay, duration of incapacity to work, symptom relief, length of morbidity, and patient convenience. METHODS: Thirty-four consecutive patients with third or fourth degree internal hemorrhoids were randomly allocated to the two groups. Before surgery, all patients were interviewed using a standard questionnaire, followed by rectal examination. All patients underwent a follow-up interview and examinations 1, 2, 4, 8, and 12 weeks after the operation. RESULTS: No serious postoperative complications were seen. Length of hospital stay (3.2 days for Parks hemorrhoidectomyvs. 4.6 days for Milligan-Morgan hemorrhoidectomy; 95 percent confidence interval, 0.2 and 2.6, respectively;P=0.02) and mean duration of incapacity to work (12.3 days for Parks hemorrhoidectomyvs. 20.2 days for Milligan-Morgan hemorrhoidectomy; 95 percent confidence interval, 5.7 and 10.2, respectively;P<0.001) differed significantly between the Milligan-Morgan and Parks patients. Until two weeks after the operation, Milligan-Morgan hemorrhoidectomy patients experienced significantly more pain. CONCLUSIONS: Our study confirms that both operations are safe, easy to perform, and lead to satisfactory results. However, the Parks procedure is the preferred option, because it minimizes patients' postoperative discomfort, is more economic, has a significantly reduced hospital stay, and has a shorter time for return to work.     

Randomised trial comparing LigaSure haemorrhoidectomy with the diathermy dissection operation

The study was designed to compare LigaSure haemorrhoidectomy with open haemorrhoidectomy performed by means of diathermy excision. Fifty-sixty consecutive patients with third- and fourth-degree haemorrhoids were randomly allocated to undergo either LigaSure haemorrhoidectomy (29 patients) or diathermy haemorrhoidectomy (27 patients). All patients were evaluated for operative time, pain, post-operative analgesic requirements, time to first bowel movement, length of hospital stay, wound healing period, time to return to work, and occurrence of early postoperative complications (such as urinary dysfunction, bleeding, soiling, seepage, continence disorders) and late complications (such as stenosis). A statisticallysignificant advantage was observed in the patients who received the LigaSure technique as far as concerns length of operative time (9.2 vs. 12.2 min, p<0.001), post-operative analgesic requirements (14.1 vs. 16.8 administrations, p<0.001), wound healing period (16.3 vs. 37.5 days, p< 0.0001), and time to return to work (8.3 vs. 18.3 days, p<0.01). No significant difference was seen in the postoperative pain score, complications rate, first bowel motion or hospital stay. No recurrence was observed at the 6-month follow-up. In conclusion, our experience shows that the LigaSure haemorrhoidectomy offers definite advantages over the classic diathermy technique. This procedure is easier, safer, and more rapid to perform and is followed by a faster wound healing time, a significantly shorter hospital stay, less postoperative pain and faster wound healing. Received: 18 September 2002 / Accepted: 20 October 2002     

Laparoscopic subtotal cholecystectomy; change in practice over a 10-year period

BackgroundLaparoscopic subtotal cholecystectomy is a recognised safe, alternative strategy when a critical view of safety cannot be obtained. This study audits the change in practice at a District General Hospital following the adoption of subtotal cholecystectomy in 2013.MethodsRetrospective case series included consecutive cholecystectomies over a ten-year period in a single institution. Cases were divided into subgroups based on operation date. Primary outcome was the proportion of patients undergoing laparoscopic total cholecystectomy, laparoscopic subtotal and laparoscopic converted to open cholecystectomy. Secondary outcomes included incidence of bile leak, complication rate, return to theatre, and length of stay.ResultsThere were 4217 cases: 1381 in Group A (pre-adoption of subtotal cholecystectomy 2009–2012), and 2836 in Group B (post-adoption of subtotal cholecystectomy 2013–2019). The rate of laparoscopic total cholecystectomy was higher in Group A than Group B (95.4% vs. 92.8%, p < 0.001). In the subtotal group (n = 114, 14 (12.3%) patients had bile leak, 6 (5.3%) underwent re-laparoscopy, and median length of stay was 2 days.ConclusionLaparoscopic subtotal cholecystectomy appears to be an acceptable alternative technique at this centre, reducing the rate of open conversion and length of stay, with a low reintervention rate for bile leak.     

Laparoscopic cholecystectomy in the elderly: Analysis of pre-operative risk factors and postoperative complications

A retrospective study was conducted of two groups of patients over (group 1, n= 57) and under (group 2, n= 655) the age of 70 years who underwent laparoscopic cholecystectomy (LC). The pre-operative physical status and systemic complications, operation time, postoperative complications, postoperative hospital stay and other clinical features of the two groups were compared. The incidence of pre-operative complications in group 1 was significantly higher than that in group 2 (P < 0.05). Postoperatively no severe complication was found in any patient. Group 1 showed significantly prolonged operation time and postoperative hospital stay compared with group 2 (P < 0.05). The difference between the groups in the intra-operative treatment time and postoperative treatment is attributed to the greater prevalence of common bile duct stone in group 1 as there was little difference between the groups in the postoperative recovery after exclusion of these patients. No pulmonary complications, which are associated with LC, were observed; the postprocedure pain was slight and the period of bedrest was short. If complications associated with pneumoperitoneum can be prevented, this surgery is an excellent measure to improve the quality of life of even elderly patients with cholecystolithiasis.     

Incidence and hospital stay for cardiac and pulmonary complications after abdominal surgery

OBJECTIVE: Internists frequently evaluate preoperative cardiopulmonary risk and comanage cardiac and pulmonary complications, but the comparative incidence and clinical importance of these complications are not clearly delineated. This study evaluated incidence and length of stay for both cardiac and pulmonary complications after elective laparotomy. DESIGN: Nested case-control. SETTING: University-affiliated Department of Veterans Affairs Hospital. PATIENTS: Computerized registry of all 2,291 patients undergoing elective abdominal operations from 1982 to 1991. MEASUREMENT AND MAIN RESULTS: Strategy for ascertainment and verification of complications was systematic and explicit. The charts of all 116 patients identified by the registry as having complications and 412 (19%) randomly selected from 2,175 remaining patients were reviewed to verify presence or absence of cardiac or pulmonary complications, using explicit criteria and independent abstraction of pre- and postoperative components of charts. From these 528 validated cases and controls (23% of the cohort), 96 cases and 96 controls were matched by operation type and age within ten years. Hospital and intensive care unit stays were significantly longer (p<0.0001) for the cases than for the controls (24.1 vs 10.3 and 5.8 vs 1.5 days, respectively). All 19 deaths occurred among the cases. Among the cases, pulmonary complications occurred significantly more often than cardiac complications (p<0.00001) and were associated with significantly longer hospital stays (22.7 vs 10.4 days, p=0.001). Combined cardiopulmonary complications occurred among 26% of the cases. Misclassification-corrected incidence rates for the entire cohort were 9.6% (95% CI 7.2–12.0) for pulmonary and 5.7% (95% CI 3.8–7.7) for cardiac complications. CONCLUSIONS: For noncardiac surgery, previous research has focused on cardiac risk. In this study, pulmonary complications were more frequent, were associated with longer hospital stay, and occurred in combination with cardiac complications in a substantial proportion of cases. These results suggest that further research is needed to fully characterize the clinical epidemiology of postoperative cardiac and pulmonary complications and better guide preoperative risk assessment. Supported by Veterans Affairs Health Services Research and Development, Grant # IIR 88-166. Reprints are not available.     

Enhanced recovery pathway after open pancreaticoduodenectomy reduces postoperative length of hospital stay without reducing composite length of stay

Background/PurposeThere is no data regarding the impact of enhanced recovery pathways (ERP) on composite length of stay (CLOS) after procedures with increased risk of morbidity and mortality, such as pancreaticoduodenectomy.MethodsPatients undergoing open pancreaticoduodenectomy before and after implementation of ERP were prospectively followed for 90 days after surgery and complications were severity graded using the Modified Accordion Grading System. A retrospective analysis of patient outcomes were compared before and after instituting ERP. 1:1 propensity score matching was used to compare ERP patient outcomes to those of matched pre-ERP patients. CLOS is defined as postoperative length of hospital stay (PLOS) plus readmission length of hospital stay within 90 days after surgery.Results494 patients underwent open pancreaticoduodenectomy – 359 pre-ERP and 135 ERP. In a 1:1 propensity-score-matched analysis of 110 matched pairs, ERP patients had significantly decreased superficial surgical site infections (5.5% vs 15.5% p = 0.015) and significantly increased rates of urinary retention (29.1% vs 7.3% p < 0.0001) compared to matched pre-ERP patients. However, overall complication rate and 90-day readmission rate were not significantly different between matched groups. Propensity score-matched ERP patients had significantly decreased PLOS (7 days vs 8 days p = 0.046) compared to matched pre-ERP patients, but CLOS was not significantly different (9 days vs 9.5 days p = 0.615).ConclusionERP may reduce PLOS but might not impact the total postoperative time spent in the hospital (i.e. CLOS) within 90 days after pancreaticoduodenectomy.     

Complications of LVAD utilization in older adults

BackgroundYearly rate and mean patient age of left ventricular assist device (LVAD) implantation increased from 2009 to 2014. Data are lacking regarding trends of LVAD implantation in older adults.ObjectivesTo describe the trends of LVAD implantation in older adults and the clinical impact of associated procedural complications.MethodsWe retrospectively analyzed the National Inpatient Sample from 2005 to 2014, calculated the percentage of older adults (>65 years of age) among those who underwent LVAD implantation, and compared their clinical characteristics. Primary outcomes were in-hospital mortality and discharge home.ResultsIn total, 4491 patients were included. The percentage of older adults among those receiving LVAD increased from 12.53% to 31.65% (p<0.01). Older adults were more likely to develop postoperative delirium (17.90% vs. 11.92% in younger patients; p<0.01), which portended lesser odds of discharge home.ConclusionsDelirium develops with greater incidence in older adults undergoing LVAD implantation, which decreases odds of favorable discharge disposition.     

Perioperative blood transfusions increase infectious complications after ileoanal pouch procedures (IPAA)

Background and purpose Assessment of risk factors associated with the use of perioperative allogeneic blood transfusion and the effect of transfusion on infectious complications after ileal pouch-anal anastomosis (IPAA).Methods All patients included had IPAA with ileostomy. They were divided into two groups: transfused (TRAN); nontransfused (NON). Data included age, gender, preoperative anemia (Hgb <9 l g/dl), operative blood loss, transfusion volume, incidence of postoperative infectious or anastomotic complications, and length of stay (LOS).Results The 1,202 patients eligible for the study were divided into: TRAN = 240 patients and NON = 962 patients. The patient age, sex, and preoperative steroid use were similar in both groups. Significantly, more patients in the TRAN group were anemic preoperatively (32 vs 11%; p<0.05) and the preoperative Hgb level was significantly lower in the TRAN (12.07; p<0.05 vs 13.34 g/dl). Transfusion was required more frequently in anemic patients (p<0.001). The overall infection rate was significantly higher in the TRAN (48.75 vs 11.22%, p<0.001), Anastomotic separation (10.83 vs 3.32%, TRAN and NON, respectively; p<0.001) and fistula formation percentage (20.8 vs 4.46%, TRAN and NON, respectively; p<0.001) was significantly higher in the TRAN group. Pelvic sepsis also occurred more frequent in TRAN (22.9 vs 4.2%, TRAN and NON, respectively; p<0.001). The incidence of any infectious complication at any site was higher in anemic patients irrespective of transfusion status (18.2 vs 2.8%, p<0.05). Transfusion was the only significant independent risk factor for postoperative infections. LOS was adversely affected by an infectious complication (9 vs 7 days, p<0.001).Conclusions Preoperative anemia is a significant risk factor for perioperative transfusion with significant increase in postoperative infectious complications and anastomotic complications after IPAA. Strategies to correct preoperative anemia, refine indications for transfusion, and define the use of blood salvage techniques may be helpful in decreasing this risk.     

Screening of the nutritional risk of patients with gastric carcinoma before operation by NRS 2002 and its relationship with postoperative results

Aim: To evaluate the nutritional risk of patients with gastric carcinoma using the methodologies of European Nutritional Risk Screening 2002 (NRS 2002) and its relationship with postoperative results. Methods: We prospectively evaluated the nutritional risk of 314 cases of gastric carcinoma patients in one center from 2004 to 2007 with NRS 2002, in accordance with China's normal body mass index (BMI), and observed its relationship with postoperative complications, mortality and length of hospital stay. Results: Of 337 cases, 314 (93.1%) were suitable for assessment by NRS 2002.The number of patients with a score ≥ 3 was 125 before operation, comprising 39.8% of patients with gastric carcinoma. The rate of complications (26.2%) of the preoperative nutritional risk group (NRS 2002 score ≥ 3) was higher than those in the preoperative nutritional normal group (NRS 2002 score < 3) (P < 0.05). Assessed by multivariate logistics regression analysis, the odds ratio of developing complications was 2.366 (P < 0.05) and 2.277 (P < 0.05) by NRS 2002 score and clinicopathological stage, respectively. The correlation between length of hospital stay and nutritional risk was also assessed by Pearson correlation analysis. The Pearson coefficient was 0.177 (P = 0.002). Conclusion: Preoperative nutrition score (NRS 2002) ≥ 3 predicted more postoperative complications and longer length of hospital stay. It indicated that preoperative nutritional support was necessary in patients with a preoperative nutritional score (NRS 2002) ≥ 3.     

Laparoscopic-assisted right hemicolectomy in inflammatory versus noninflammatory conditions of the large bowel

The most common indications for laparoscopic-assisted right hemicolectomy are terminal ileal Crohn's disease (TICD) and noninflammatory conditions such as polyps or cancer. While patients in the former category are usually younger and require immunosuppressive medications, patients in the latter category are older and may have significant comorbidity. The aim of this study was to compare and contrast the results of this operation performed on these two very different groups of patients. Between August 1991 and September 1998, 85 patients underwent laparoscopic-assisted right hemicolectomy. Statistical analysis was performed using Mann-Whithney test. A total of 31 patients (19 F / 12 M) of mean age 40 years (range, 15–74), were operated upon for TICD while 54 patients (22 F /32 M) of mean age 70 years (range, 30–87) (p<0.01) were operated upon for noninflammatory bowel disease (NIBD) including polyps (n=29), adenocarcinoma (n=19), and other reasons (n=6). In the TICD group, 18 were operated on for strictures, 3 for fistulas, 2 for abscesses, and 8 for two or more of these reasons. Overall there were 7 intraoperative complications reported: 4 in the TICD group and 3 in the NIBD group (p=70). The total operative time was 144 min (range, 90–260) in the TICD vs. 153 min (range, 70–270) in the NIBD group (p=0.40). Hospital stay was 6.4 days (range, 3–18) in the TICD group vs. 7.7 days (range, 3–19) in the NIBD group (p=0.0175). Six of the TICD patients and 6 of the NIBD patients had their procedure converted to laparotomy (p=0.34). In the TICD group, 12 patients (39%) had a total of 16 postoperative complications, 3 of which were wound related and 8 of which were general medical complications. One patient had an anastomotic leak while 4 patients had prolonged postoperative ileus. In the NIBD group, 23 (43%) patients had a total of 28 complications of which 7 were wound related; 11 patients had prolonged postoperative ileus and 10 were general medical complications (p=NS between groups). During a mean follow-up of 41 months (range, 3–89), 3 patients in the TICD group and 4 in the NIBD group developed incisional hernia. Despite the inflammatory nature of inflammatory bowel disease with related septic conditions such as fistulae and consequent abscesses, the overall operative complication rate was not significantly different from complication rates in patients with noninflammatory conditions. One factor contributing to this finding may be the younger age in the TICD group. Thus, laparoscopic right hemicolectomy can be safely performed for both inflammatory and noninflammatory conditions. Received: 10 September 2000 / Accepted: 12 October 2000     

Neoadjuvant chemoradiotherapy followed by esophagectomy does not increase morbidity in patients over 70

Esophagectomy in elderly esophageal carcinoma patients is correlated with a high morbidity and even mortality. Studies on neoadjuvant chemoradiotherapy (NT) in elderly patients are scarce. The aim of this study was to evaluate the effect of advanced age in combination with NT in esophageal carcinoma patients who underwent an esophagectomy. Patients who underwent NT prior to esophagectomy between 1993 and 2010 were divided into three groups: <70, 70–74, and ≥75 years. Toxicity of NT and postoperative morbidity were compared between groups. Primary endpoints were toxicity, complication rate, and survival. Two hundred thirteen patients underwent NT during the study period, 26 were aged 70–74 years, and 17 were ≥70 years. Toxicity of NT was comparable for younger and elderly patients (46% vs. 54% vs. 47%, P = 0.263). Overall complications occurred in 62% of younger patients versus 73% and 71% among patients aged 70–74 years and ≥75 years, respectively (P = 0.836). Cardiac complications occurred in 14% of younger patients versus 27% and 41% of elderly patients (P = 0.021). Three‐year survival rates were 59% versus 44% versus 31% among patients aged <70, 70–74, and ≥75 years, respectively (P = 0.237). Higher age (odds ratio 1.750, P < 0.001) was an independent risk factor for development of cardiac complications. Toxicity of NT and postoperative complications are comparable for patients aged <70, 70–74, and ≥75 years, with the exception of cardiac complications. Therefore, we consider NT followed by esophagectomy in elderly patients a safe treatment modality in our center.     

Laparoscopic or open cholecystectomy in cirrhosis: a systematic review of outcomes and meta-analysis of randomized trials

BackgroundCholecystectomy is associated with increased risks in patients with cirrhosis. The well-established advantages of laparoscopic surgery may be offset by the increased risk for complications relating particularly to portal hypertension and coagulopathy.MethodsA systematic search was undertaken to identify studies comparing open cholecystectomy (OC) and laparoscopic cholecystectomy (LC) in patients with cirrhosis. A meta-analysis was performed of the available randomized controlled trials (RCTs).ResultsForty-four studies were analysed. These included a total of 2005 patients with cirrhosis who underwent laparoscopic (n= 1756) or open (n= 249) cholecystectomy, with mortality rates of 0.74% and 2.00%, respectively. A meta-analysis of three RCTs involving a total of 220 patients was conducted. There was a reduction in the overall incidences of postoperative complications and infectious complications and a shorter length of hospital stay in LC. However, frequencies of postoperative hepatic insufficiency did not differ significantly.ConclusionsThere are few RCTs comparing OC and LC in patients with cirrhosis. These studies are small, heterogeneous in design and include almost exclusively patients with Child–Pugh class A and B disease. However, LC appears to be associated with shorter operative time, reduced complication rates and reduced length of hospital stay.