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.

     

Operative Harnableitung bei Kindern aus Kriegs- und Krisengebieten – 20-jähriger Erfahrungsbericht

Background

Because sick and injured children from war and crisis areas can often only be helped to a limited extent in their countries of origin, those children with the most complex diseases often receive medical treatment in Europe.

Materials and methods

To evaluate the postoperative outcome of reconstructive interventions in children from war and crisis areas, an evaluation of the clinic’s internal database between 1997 and 2017 was carried out. The operative indication, the surgical procedure, any revisions or conversions and the overall mortality were analyzed.

Results

During the above-mentioned period a total of 44 (male: 32, female: 12) children aged 3–14 years from Afghanistan, Angola, Central Asia and the Caucasus were treated. Indications for the reconstructive procedures were bladder exstrophy (n?=?23), neurogenic bladder dysfunction (n?=?9), penile partial amputation (n?=?1) and traumatic bladder dysfunction (n?=?11). In 26 children, a conduit was created, 11 children received a sigma rectum pouch and 1 child an ileocecal pouch, while 5 other children received bladder augmentation and 1 child an oral mucosal urethroplasty. In total, 7 revisions or conversions due to ureteral implantation stenoses and recurrent acidosis had to be performed. Five children died in their home country due to acidosis, sepsis, end stage renal failure, accident and social exclusion.

Conclusion

In the long term 39 of the 44 (88.6%) children live socially integrated in their home country and are regularly monitored by local aid organizations. When choosing the reconstructive intervention, the local conditions must be considered.

     

Robotic Roux-en-Y Gastric Bypass,is it Safer than Laparoscopic Bypass?

Background

Along with the development of technology, robotic approach is being performed for laparoscopic Roux-en-Y gastric bypass (LRYGB). Some literatures reported same or better peri-operative outcomes with the robotic procedure. The aim of this study is to compare our experience in robot-assisted LRYGB (RA-LRYGB) with LRYGB in terms of peri-operative outcomes.

Methods

From January 1, 2012 to April 30, 2014, a total of 270 patients underwent LRYGB by one surgeon at a single institution. Of these, 64 cases were done robotically. A retrospective review was performed for these patients, noting the outcomes and complications of the procedure.

Results

The 64 RA-LRYGB patients had a mean age of 45.9?±?10.0 years (range, 23–67) and a mean preoperative body mass index (BMI) of 48.4?±?7.9 kg/m² (range, 33.8–76.4). The 207 LRYGB patients had a mean age of 45.0?±?10.7 years (range, 21–67) and a mean preoperative BMI of 48.4?±?8.1 kg/m² (range, 34.0–80.4). These two groups were clinically comparable. Mean length of hospital stay was 3.0?±?4.1 days (range, 1–19) in RA-LRYGB patients, significantly longer than 1.6?±?1.7 days (range, 1–17) in LRYGB patients (p?<?0.01). Thirty-day readmission rate was 9.3 % (n?=?6) in the RA-LRYGB group and 6.8 % (n?=?14) in the LRYGB group. Higher leak rate was noticed in RA-LRYGB patients at 7.8 % (n?=?5), compared to 0.5 % (n?=?1) in LRYGB patients (p?<?0.01). All the leaks occurred at the pouch level in the RA-LRYGB group, while one leak from the LRYGB group occurred at the gastrojejunal anastomosis site.

Conclusions

Robot-assisted Roux-en-Y gastric bypass may result in higher leak rate at the pouch level, when compared to that of laparoscopic procedures.

     

Assessment of the Double-Staple Technique for Esophagoenteric Anastomosis in Gastric Cancer

Introduction

Reports on outcomes after double-staple technique (DST) for total and proximal gastrectomy are limited, originating mostly from Asian centers. Our objective was to examine anastomotic leak and stricture with DST for esophagoenteric anastomosis in gastric cancer patients.

Methods

A single institution review was performed for patients who underwent total/proximal gastrectomy with DST between 2006 and 2015. DST was performed using transoral anvil delivery (OrVil?) with end-to-end anastomosis. Clinical characteristics and outcomes, including anastomotic leak and stricture, were recorded.

Results

Overall, DST was performed in 60 patients [total gastrectomy (81.7 %, n?=?49/60), proximal gastrectomy (10.0 %, n?=?6/60), and completion gastrectomy (8.3 %, n?=?5/60)]. Neoadjuvant chemotherapy was administered to 21 patients (35.0 %), and 6 patients (10.0 %) received external beam radiation therapy prior to completion gastrectomy. Operative approach was open (51.7 %, n?=?31/60), laparoscopic (43.3 %, n?=?26/60), or robotic (5.0 %, n?=?3/60). Anastomotic leak occurred in 6.7 % (n?=?4/60), while stricture independent of leak was identified in 19.0 % (n?=?11/58) of patients. Complications occurred in 38.3 % (n?=?23/60) of patients, of which 52 % were classified as Clavien-Dindo grades III–V complications.

Conclusion

In the largest Western series of DST for esophagoenteric anastomoses in gastric cancer surgery, our experience demonstrates that DST is safe and effective with low rates of leak and stricture.

     

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.

     

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.

     

Small-Volume,Fast-Emptying Gastric Pouch Leads to Better Long-Term Weight Loss and Food Tolerance After Roux-en-Y Gastric Bypass

Introduction

Anatomical and functional influences on gastric bypass (GBP) results are often poorly evaluated and not yet fully understood.

Purpose

The purpose of this study is to evaluate the influence of the gastric pouch volume and its emptying rate on long-term weight loss and food tolerance after GBP.

Materials and Methods

Weight loss, food tolerance, pouch volumetry (V) by three-dimensional reconstruction, and pouch emptying rate by 4 h scintigraphy were evaluated in 67 patients. Cutoffs were identified for V and retention percentage (%Ret) at 1 h (%Ret1). From these parameters, the sample was categorized, looking for associations between V, %Ret, weight loss, and food tolerance, assessed by a questionnaire for quick assessment of food tolerance (SS).

Results

PO median follow-up time was 47 months; median V was 28 mL; %Ret at 1, 2, and 4 h were 8, 2, and 1%, respectively. There were associations between V ≤ 40 mL and higher emptying rates up to 2 h (V ≤ 40 mL: %Ret1 = 6, %Ret2 = 2, p = 0.009; V > 40 mL: %Ret1 = 44, %Ret2 = 13.5, p = 0.045). An association was found between higher emptying speed in 1 h and higher late weight loss (WL), represented by lower percentage of excess weight loss (%EWL) regain (p = 0.036) and higher %EWL (p = 0.033) in the group with %Ret1 ≤ 12%, compared to the group %Ret1 ≥ 25%. Better food tolerance (SS > 24), was associated with lower %Ret1 (p = 0.003).

Conclusion

Smaller pouch size is associated with a faster gastric emptying, greater WL maintenance, and better food tolerance. These data suggest that a small pouch with rapid emptying rate is an important technical parameter for good outcomes in GBP.

     

Elevated Alkaline Phosphatase Prior to Transarterial Chemoembolization for Neuroendocrine Tumors Predicts Worse Outcomes

Introduction

We hypothesized that an elevated preoperative alkaline phosphatase (AP) predicted worse outcomes for patients undergoing transarterial chemoembolization (TACE) for neuroendocrine tumor (NET) liver metastases.

Methods

We reviewed all patients who underwent TACE for metastatic NET between 2009 and 2013. Survival was evaluated using preprocedure variables.

Results

One hundred and nine patients underwent 210 TACE procedures. The average age was 57.7 years (range 20–78). Primary sites included pancreas (N?=?20), other gastrointestinal (N?=?52), lung (N?=?9), and unknown (N?=?28). The tumor was grade 1 in 68 (62 %), grade 2 in 21 (19 %), and grade 3 in 3 (3 %). Extrahepatic disease was present in 54 (50 %) and greater than 50 % hepatic tumor burden by imaging in 63 (58 %). Elevated bilirubin occurred in 8 (7 %), elevated AP in 22 (20 %), elevated ALT in 21 (19 %), and elevated AST in 41 (38 %). Univariate predictors included tumor grade (43 vs 27 vs 21 months, p?=?0.015), hepatic tumor burden (59 vs 37 months, p?=?0.009), and elevated AP (59 vs 23 months, p?<?0.001). On multivariate analysis, only elevated AP (p?=?0.001) predicted worse survival.

Conclusions

Elevated AP prior to TACE for metastatic NET portends a worse survival outcome, even more so than tumor grade or extent of hepatic disease.

     

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.

     

Bariatric Surgery in Patients with Cirrhosis and Portal Hypertension

Introduction

Studies on bariatric patients with cirrhosis and portal hypertension are limited. The aim of this study was to review our experience in cirrhotic patients with portal hypertension who had bariatric surgery.

Method

All cirrhotic patients with portal hypertension who underwent laparoscopic bariatric surgery, from 2007 to 2017, were retrospectively reviewed.

Results

Thirteen patients were included; eight (62%) were female. The median age was 54 years (interquartile range, IQR 49–60) and median BMI was 48 kg/m² (IQR 43–55). Portal hypertension was diagnosed based on endoscopy (n?=?5), imaging studies (n?=?3), intraoperative increased collateral circulation (n?=?2), and endoscopy and imaging studies (n?=?3). The bariatric procedures included sleeve gastrectomy (n?=?10, 77%) and Roux-en-Y gastric bypass (n?=?3, 23%). The median length of hospital stay was 3 days (IQR 2–4). Three 30-day complications occurred including wound infection (n?=?1), intra-abdominal hematoma (n?=?1), and subcutaneous hematoma (n?=?1). No intraoperative or 30-day mortalities. There were 11 patients (85%) at 1-year follow-up and 9 patients (69%) at 2-year follow-up. At 2 years, the median percentage of excess weight loss (EWL) and total weight loss (TWL) were 49 and 25%, respectively. There was significant improvement in diabetes (100%), dyslipidemia (100%), and hypertension (50%) at 2 years after surgery.

Conclusion

Bariatric surgery in selected cirrhotic patients with portal hypertension is relatively safe and effective.

     

Early Weight Recidivism Following Laparoscopic Sleeve Gastrectomy: A Prospective Observational Study

Background

Although weight loss following laparoscopic sleeve gastrectomy (LSG) can be substantial, weight recidivism is still a major concern. The aim of our work is to study early weight recidivism following LSG and to evaluate the role of gastric computed tomography volumetry (GCTV) in the assessment of patients experiencing early weight regain.

Methods

One-hundred and one morbidly obese patients undergoing LSG were prospectively studied. Patients were followed up for 2 years. Those who presented with weight recidivism were counseled for dietary habits and assessed for the amount of weight regain. Patients who regained weight were scheduled for GCTV.

Results

Twelve patients were excluded from the study. Weight recidivism was reported in 9/89 patients (10.1 %) [weight loss failure (n?=?1), weight regain (n?=?8)] and was almost always first recognized 1½–2 years after LSG. The amount of weight regain showed negative correlations with preoperative body weight and body mass index (r?=??0.643, P?=?0.086 and r?=??0.690, P?=?0.058; respectively) and positive correlations with the distance between the pylorus and the beginning of the staple line (r?=?0.869, P?=?0.005), as well as with the residual gastric volume (RGV) on GCTV 2 years after LSG (r?=?0.786, P?=?0.021).

Conclusions

In the small group of patients who regained weight, a longer distance between the pylorus and the beginning of the staple line, as well as a higher RGV on GCTV 2 years after LSG, were both associated with increased weight regain. Gastric computed tomography volumetry with RGV measurement holds promise as a useful research tool after LSG.

     

Robotic or laparoscopic sacrohysteropexy versus open sacrohysteropexy for uterus preservation in pelvic organ prolapse

Introduction and hypothesis

The aim of this study was to compare robotic or laparoscopic sacrohysteropexy (RLSH) and open sacrohysteropexy (OSH) as a surgical treatment for pelvic organ prolapse (POP).

Methods

Among 111 consecutive patients who had undergone sacrohysteropexy for POP, surgical outcomes and postoperative symptoms were compared between the RLSH (n?=?54; robotic 14 cases and laparoscopic 40 cases) and OSH (n?=?57). groups The medical records of enrolled patients were reviewed retrospectively.

Results

Compared with the OSH group, the RLSH group had shorter operating time (120.2 vs 187.5 min, p?<?0.0001), less operative bleeding (median estimated blood loss 50 vs 150 ml; p?<?0.0001; mean hemoglobin drop 1.4 vs 2.0 g/dl; p?<?0.0001), and fewer postoperative symptoms (13 vs 45.6 %; p?<?0.0001). Patients’ overall satisfaction (94.4 vs 91.2 %; p?=?0.717) and required reoperation due to postoperative complications (3.7 vs 1.8 %; p?=?0.611) did not differ between groups.

Conclusions

RLSH could be a feasible and safe procedure in patients with POP and should be considered as a surgical option that allows preservation of the uterus. Prospective randomized trials will permit the evaluation of potential benefits of RLSH as a minimally invasive surgical approach.

     

Are radiographic indices reliable indicators for quantitative bone mineral density and vitamin D status after femoral neck fractures? A retrospective study in 112 elderly patients

Background

Radiographic parameters and indices obtained from hip x-rays are a potential tool to promptly estimate bone quality in elderly hip fracture patients. Preoperative decision in whether to use cemented or cement augmented implants might be supported by this information and thus improve patient safety. Subsequently, this study was conducted to evaluate radiographic parameters as a prescreening tool for bone quality.

Methods

A retrospective analysis of 112 elderly patients with a femoral neck fracture after low-energy trauma was performed (81 % female, 19 % male). Three radiological indices were calculated on hip x-rays: cortical index antero-posterior CTI (ap), cortical index lateral CTI (lat) and canal to calcar ratio CCR. These indices were analyzed for correlations with DXA T-Scores and serum 25-hydroxyvitamin D (25(OH)D) using the Spearman test.

Results

Median age of patients was 80 (IQR 72–86) years. A linear correlation was found for CTI (lat) and T-Score at the total hip (p?<?0.001, r?=?0.589), femoral neck (p?=?0.005, r?=?0.405) and the lumbar spine (p?=?0.002, r?=?0.299). A significant correlation was also indicated between CTI (lat) and 25(OH)D (p?=?0.002, r?=?0.293). CTI (lat) at a cut-off level of 0.4 showed a sensitivity of 79 % and a specificity of 56 % in predicting a T-score?≤??2.5 at the total hip. Gender specific analysis revealed a higher sensitivity (100 %) and specificity (73 %) of CTI (lat) at a cut-off level of 0.4 for men. For severe vitamin D deficiency (<10 ng/ml) sensitivity and specificity were 75 % and 65 %.

Conclusion

Radiographic indices as the CTI (lat) exhibit a direct correlation to BMD and serum 25OH vitamin D levels. A CTI (lat) cut-off level of 0.4 is recommended for identifying patients at risk of osteoporosis expressed by T-Scores?≤??2.5 and severe vitamin D deficiency.

     

Laparoscopic Sleeve Gastrectomy and Gastric Bypass for The Aging Population

Background

Laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are the two most common bariatric surgeries for treating morbid obesity. The purpose of this study is to determine differences in outcomes from RYGB or SG between patients ages?≥?60 years and?<?60 years.

Methods

A retrospective review of patients who underwent RYGB and SG at our institution from 01/2008 to 05/2012 was conducted. Forty patients from each group (≥60 years and?<?60 years) were matched based on gender, body mass index (BMI), co-morbidities, and type of bariatric surgery performed, and their charts were reviewed up to 1 year post-operatively. Primary end points measured were mean length of stay, operative time, incidence of complications, and readmissions in the first post-operative year. A secondary end point measured was percent total weight loss (%TWL) and excess weight loss (%EWL).

Results

There were no significant differences between group?<?60 and group?≥?60 in operative time (210 vs. 229 min; p?=?0.177), in-hospital post-operative complication rates (2.5 vs. 5 %; p?=?1.0), long-term complication rates (2.5 vs. 10 %; p?=?0.359), and 30-day readmission rates (2.5 vs. 12.5 %; p?=?0.2). Patients in group?<?60 had shorter lengths of stay (2.2 vs. 2.7 days; p?=?0.031), but this difference is not clinically significant. Both groups achieved similar %TWL (21.4 vs. 20.5 %; p?=?0.711) and %EWL (50.6 vs. 50.7 %; p?=?0.986).

Conclusions

Advanced age (≥60 years) is not a significant predictor of a worse outcome for SG and RYGB.

     

The investigation of the survival time after recurrence in patients with pancreatic ductal adenocarcinoma for individualization of adjuvant chemotherapy

Purpose

Pancreatic ductal adenocarcinoma (PDAC) is a lethal disease; however, the frequency of recurrence can be reduced if curative surgery following adjuvant chemotherapy is applied. At present, adjuvant chemotherapy is uniformly performed in all patients, as it is unclear which tumor types are controlled best or worst. We investigated patients with recurrence to establish the optimum treatment strategy.

Methods

Of 138 patients who underwent curative surgery for PDAC, 85 developed recurrence. Comprehensive clinicopathological factors were investigated for their association with the survival time after recurrence (SAR).

Results

The median SAR was 12.6 months. Treatments for recurrence included best supportive care, GEM-based therapy and S-1. The performance status [hazard ratio (HR) 0.12, P?<?0.001], histological invasion of lymph vessels (HR 0.27, P?<?0.001), kind of treatment for recurrence (HR 5.0, P?<?0.001) and initial recurrence site (HR 2.9, P?<?0.001) were independent significant risk factors for the SAR. The initial recurrence sites were the liver (n?=?21, median SAR 8.8 months), lung (n?=?10, 14.9 months), peritoneum (n?=?6, 1.7 months), lymph nodes (n?=?6, 14.7 months), local site (n?=?17, 13.9 months) and multiple sites (n?=?25, 10.1 months). A shorter recurrence-free survival (<?1 year) and higher postoperative CA19-9 level were significantly associated with critical recurrence (peritoneal/liver).

Conclusions

Several risk factors for SAR were detected in this study. Further investigations are needed to individualize the adjuvant chemotherapy for each patient with PDAC.

     

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.

     

Outcome and functional prognosis of pelvic sepsis after ileal pouch-anal anastomosis in patients with ulcerative colitis

Purpose

Restorative proctocolectomy with ileal pouch-anal anastomosis is a surgical procedure for ulcerative colitis, but pouch failure or pelvic sepsis still occurs in some patients. We conducted this study to investigate the cause of pouch failure and evaluate defecatory function after pelvic sepsis.

Methods

A total of 234 patients who underwent restorative proctocolectomy were enrolled. We analyzed the cause of pouch failure, as well as defecatory function and manometric outcomes, with and without the complication of pelvic sepsis.

Results

Pelvic sepsis developed in 29 (12.3%) of the 234 patients who underwent restorative proctocolectomy (pelvic sepsis group). The pelvic sepsis led to pouch failure in two of these patients (as a vaginal fistula in one and ileo-anal anastomotic leakage in one). Of the remaining majority of patients who did not suffer pelvic sepsis (control group), nine suffered pouch failure (as vaginal fistula in four, perianal abscess in two, pouch-spinal marrow fistula in one, and chronic pouchitis in two). There were no significant differences in defecatory function or manometric outcomes between the two groups. In the pelvic sepsis group, stool frequency was significantly correlated with white blood cell count (P = 0.01) and the duration until onset of pelvic sepsis (P < 0.01).

Conclusions

Pelvic sepsis after restorative proctocolectomy for ulcerative colitis does not affect defecatory and manometric function, but control of the inflammation caused by pelvic sepsis is integral for defecatory function.

     

The effectiveness of FloSeal® matrix hemostatic agent in thyroid surgery: a prospective,randomized, control study

Background

The objective of this study was to compare the effectiveness of FloSeal® matrix hemostatic agent with hemostatic surgical procedures and Tabotamp® in thyroid surgery.

Methods

One hundred fifty-five consecutive total thyroidectomy patients were recruited at our institution between January 2005 and December 2007. Exclusion criteria were applied. Patients were randomized to one of three hemostatic approaches: 49 received surgical procedures only, and 52 received oxidized regenerated cellulose patch (Tabotamp Fibrillar 2.5?×?5 cm) and 54 FloSeal (5,000 U/5 mL). The same surgeon performed all operations.

Results

Mean operating time was reduced in the FloSeal group (105 min) vs. surgical (133 min, p?=?0.02) and vs. Tabotamp (122 min, p?=?0.0003). Also, wound drain removal occurred earlier with FloSeal (p?=?0.006 vs. surgical; p?=?0.008 vs. Tabotamp) resulting in shorter postoperative hospital stay in the FloSeal group (p?=?0.02 vs. surgical; p?=?0.002 vs. Tabotamp).

Conclusions

FloSeal matrix is an effective additional agent to conventional haemostatic procedures in thyroid surgery.

     

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.

     

Bariatric Surgery in Patients on Chronic Anticoagulation Therapy

Background

Perioperative management of chronically anti-coagulated patients undergoing bariatric surgery requires a balance of managing hemorrhagic and thromboembolic risks. The aim of this study is to evaluate the incidence of hemorrhagic complications and their management in chronically anticoagulated (CAT) patients undergoing bariatric surgery.

Methods

A retrospective review of CAT patients undergoing bariatric surgery at an academic center from 2008 to 2015 was studied.

Results

A total of 153 patients on CAT underwent surgery [Roux-en-Y gastric bypass (n?=?79), sleeve gastrectomy (n?=?63), and adjustable gastric banding (n?=?11)] during the study period: 85 patients (55%) were females; median age was 56 years (interquartile range [IQR] 49–64), and median BMI was 49 kg/m² (IQR 43–56). The most common indications for CAT were venous thromboembolism (n?=?87) and atrial fibrillation (n?=?83). Median duration of procedure and estimated intraoperative blood loss was 150 min (IQR 118–177) and 50 ml (IQR 25–75), respectively. Thirty-day postoperative complications were reported in 33 patients (21.6%) including postoperative bleeding (n?=?19), anastomotic leak (n?=?3), and pulmonary embolism (n?=?1). Nineteen patients (12%) with early postoperative bleeding were further categorized to intra-abdominal (n?=?10), intraluminal (n?=?6), and at the port site or abdominal wall (n?=?3). All-cause readmissions within 30 days of surgery occurred in 19 patients (12%). There was no 30-day mortality.

Conclusion

In our experience, patients who require chronic anticoagulation medication are higher than average risk for postoperative complications and all-cause readmission rates. Careful surgical technique and close attention to postoperative anticoagulation protocols are essential to decrease perioperative risk in this high-risk cohort.