Decompressive craniectomy and expansive duraplasty with evacuation of hypertensive intracerebral hematoma,a randomized controlled trial

Hypertensive intracerebral hemorrhage (ICH) has high morbidity and mortality rates. Decompressive craniectomy (DC) is generally used for the treatment of cases associated with refractory increased intracranial pressure (ICP). In this study, we investigated the beneficial effects of adding DC and expansive duraplasty (ED) to hematoma evacuation in patients who underwent surgery for large hypertensive ICH. A prospective randomized controlled clinical trial where 40 patients diagnosed having large hypertensive ICH was randomly allocated to either group A or B, each comprised 20 patients. Group A patients, the treatment group, were submitted to hematoma evacuation together with DC and ED, whereas group B patients, the control group, were submitted only to hematoma evacuation. Twenty-three (57.5 %) of the patients were males, with an overall age range of 34–79 years (mean 59.3 years). Preoperative Glasgow Coma Scale (GCS) scores in group A ranged from 4 to 13 (mean 7.1), while in group B it ranged from 4 to 12 (mean 6.8). Postoperative hydrocephalus occurred in 3 (15 %) patients in group A and in 4 (20 %) patients in group B, whereas meningitis occurred in one patient (5 %) in group A. The mortality rate was 2 (10 %) patients in group A as compared to 5 (25 %) patients in group B (p?=?0.407). High admission GCS (p?=?0.0032), younger age (p?=?0.0023), smaller hematoma volume (p?=?0.044), subcortical hematoma location (p?=?0.041), absent or minimal preoperative (p?=?0.0068), and postoperative (p?=?0.0031) midline shift as well as absent intraventricular extension of the hematoma (p?=?0.036) contributed significantly to a better outcome. Selected patients’ subgroups who benefited from adding DC and ED to ICH evacuation were age category of 30 to less than 50 (p?=?0.0015) and from 50 to less than 70 (p?=?0.00619) as well as immediate preoperative GCS from 6 to 8 (p?=?0.000436) and from 9 to 12 (p?=?0.00774). At 6 months’ follow-up, 14 (70 %) patients of group A had favorable outcome as compared to 4 (20 %) patients of group B (p?=?0.0015). Adding DC with ED to evacuation of a large hypertensive hemispheric ICH might improve the outcome in selected group of patients.     

Postpancreatectomy hemorrhage (PPH): predictors and management from a prospective database

Background

Postpancreatectomy hemorrhage (PPH) is a dreaded complication in pancreatic surgery. Today, there is a definition and grading of PPH without therapeutic consensus. We reviewed our prospective database to identify predictors and assess therapeutic strategy.

Method

We included all patients who underwent pancreatectomy between 2005 and 2010. Data were collected prospectively. We used the International Study Group Of Pancreatic Surgery (ISGPS) definition for PPH to include patients in the PPH group.

Results

Forty-six of 285 patients showed a PPH (16.1 %). The ISGPS classification was graded A?=?3, B?=?26, and C?=?17. The average time to the onset of PPH was 7 days. CT-scan identified the origin of PPH in 43.5 % of the cases. PPH was responsible for a longer duration of hospital stay (p?=?0.004), a higher hospital mortality (21.7 vs 2.5 %, p?<?0.0001) and a lower survival (40 vs 70 % (p?=?0.05) at 36 months). The first-intention treatment of PPH was conservative in 32 % and interventional in 68 %: endoscopy (6.4 %), transcatheter arterial embolization (TAE, 30.4 %), and surgical (30.4 %). In multivariate analysis, predictors of PPH were: pancreatic fistula (24 vs 8 % p?=?0.028), pancreatoduodenectomy (70 vs 43 % p?=?0.029), age (61.6 vs 58.8 %, p?=?0.03), and nutritional risk index (NRI) (p?=?0.048).

Conclusion

In our series, risk factors for PPH were age, pancreatic fistula, pancreatoduodenectomy, and NRI. Its occurrence is associated with significantly higher hospital mortality and a lower survival rate. Our first-line treatment was radiological TAE. Surgical treatment is offered in case of failure of interventional radiology or in case of uncontrolled hemodynamic.     

Resection for Hilar Cholangiocarcinoma: Analysis of Prognostic Factors and the Impact of Systemic Inflammation on Long-term Outcome

Introduction

Resection for hilar cholangiocarcinoma is the single hope for long-term survival.

Methods

Ninety patients underwent curative intent surgery for hilar cholangiocarcinoma between 1996 and 2012. The potential prognostic factors were assessed by univariate (Kaplan–Meier curves and log-rank test) and multivariate analyses (Cox proportional hazards model).

Results

The median overall and disease-free survivals were 26 and 17 months, respectively. The multivariate analysis identified R0 resection (HR?=?0.03, 95 % CI 0–0.19, p?<?0.001), caudate lobe invasion (HR?=?6.33, 95 % CI 1.31–30.46, p?=?0.021), adjuvant gemcitabine-based chemotherapy (HR?=?0.38, 95 % CI 0.15–0.94, p?=?0.037), and the neutrophil-to-lymphocyte ratio (HR?=?0.78, 95 % CI 0.62–0.98, p?=?0.036) as independent prognostic factors for disease-free survival. The independent prognostic factors for overall survival were R0 resection (HR?=?0.03, 95 % CI 0–0.22, p?<?0.001), caudate lobe invasion (HR?=?11.75, 95 % CI 1.65–83.33, p?=?0.014), and adjuvant gemcitabine-based chemotherapy (HR?=?0.19, 95 % CI 0.06–0.56, p?=?0.003).

Conclusions

The negative resection margin represents the most important prognostic factor. Adjuvant gemcitabine-based chemotherapy appears to benefit survival. The neutrophil-to-lymphocyte ratio may potentially be used to stratify patients for future clinical trials.     

Liver Resection in the Elderly: Significance of Comorbidities and Blood Loss

Objective

Liver resection is increasingly performed in elderly patients who are suspected of increased postoperative morbidity (PM) and reduced overall survival (OS). Patient selection based on the identification of age-adjusted risk factors may help to decrease PM and OS.

Design and Participants

Prospectively collected data of 879 patients undergoing elective hepatic resection were analyzed. This population was stratified into three age cohorts: >70 years (n?=?228; 26 %), 60–69 years (n?=?309; 35 %), and <60 years (n?=?342; 39 %). Multivariate survival analysis was performed.

Results

The incidence of severe (p?<?0.01) and non-surgical (p?<?0.001) postoperative complications was higher in older compared to younger patients. Major estimated blood loss (EBL; p?=?0.039) and comorbidities (p?=?0.002) independently increased PM. EBL was comparable between all age cohorts. However, preexisting comorbidities, major EBL, and postoperative complications markedly decreased OS in contrast to younger patients. Adjusted for age, independent predictors of OS were comorbidities (HR?=?1.51; p?=?0.001), major hepatectomy (HR?=?1.33; p?=?0.025), increased EBL (HR?=?1.32; p?=?0.031), and postoperative complications (HR?=?1.64; p?<?0.001).

Conclusion

Although increased age should not be a contraindication for liver resection, this study accents the avoidance of major blood loss in elderly patients and a stringent patient selection based on preexisting comorbidities.     

Perineal Wound Healing Following Ileoanal Pouch Excision

Introduction

There is paucity of information relating to perineal wound healing when pouch failure after ileal pouch anal anastomosis necessitates pouch excision (PE). The aim of this study is to evaluate perineal healing and factors associated with the development of persistent perineal sinus (PPS) after PE.

Methods

Perineal wound-related outcomes for patients who underwent PE from 1985–2009 were evaluated by type of closure (extrasphincteric, intersphincteric, and sphincter-preserving (SP)) and other factors (presence of Crohn's disease (CD) and/or perineal fistulae). Primary outcomes were PPS and delayed healing (healing after PPS development).

Results

One hundred ten patients (CD 48 %) underwent PE. PPS occurred in 39.8 % patients, 51 % had delayed perineal healing with further procedures, with an overall healing rate of 80.7 %. Closure technique was not associated with PPS (p?=?0.37) or eventual healing (p?=?0.94). For CD patients, risk of PPS (41 vs. 39 %, p?=?0.83) and delayed healing (44 vs. 59 %, p?=?0.61) was similar to non-CD patients, but uncomplicated healing took longer (p?=?0.04). Four of 15 (26.7 %) patients who underwent SP closure developed PPS; all eventually healed with secondary sphincter excision.

Conclusions

Perineal healing may be prolonged after pouch excision. Since eventual healing can be achieved in most patients, perineal dissection and closure can be tailored to the individual circumstance. Sphincter preservation may be used in non-CD patients if future reconstruction is possible. Extrasphincteric closure is preferable with cancer or perineal sepsis. Sphincter resection allows for complete healing in patients who undergo SP dissection and develop PPS.     

Management of Esophageal Perforation in 120 Consecutive Patients: Clinical Impact of a Structured Treatment Algorithm

Introduction

The therapy of esophageal perforation is still challenging. The aim of this study was to assess the etiology, specific treatment, and outcome of esophageal disruption in order to generate an optimal therapeutic approach to improve patient’s outcome.

Methods

We reviewed the cases of 120 consecutive patients with esophageal perforation treated within 10 years.

Results

Iatrogenic perforation was the most frequent cause of esophageal perforation (58.3 %); Boerhaave’s syndrome was detected in 15 cases (6.8 %). Surgery was performed in 66 patients (55 %), 17 (14 %) patients received conservative treatment and 37 (31 %) patients underwent endoscopic stenting after tumorous perforation. Statistically significant impact on mean survival had Boerhaave’s syndrome (p?=?0.005), initial sepsis (p?=?0.002), pleural effusion/empyema (p?=?0.001), mediastinitis (p?=?0.003), peritonitis (p?=?0.001), and redo-surgery (p?=?0.000). Overall mortality rate was 11.7 %, in the esophagectomy group 17 % and in the patients with Boerhaave’s syndrome 33.3 %.

Conclusions

An approach considering etiology and extent of perforation, diagnostic delay, and septic status is required to improve patient’s outcome. Primary repair is feasible in patients without intrinsic esophageal disease and evidence of sepsis. The greater the diagnostic delay, the more the destruction of the esophageal wall especially in the case of septic esophageal disease, thus the stronger the argument for esophagectomy if anatomically and/or oncologically possible.     

Reoperations for primary hyperparathyroidism—improvement of outcome over two decades

Purpose

Reoperations (R-PTX) for primary hyperparathyroidism (pHPT) are challenging, since they are associated with increased failure and morbidity rates. The aim was to evaluate the results of reoperations over two decades, the latter considering the implementation of Tc^99msestamibi-SPECT (Mibi/SPECT), intraoperative parathormone (IOPTH) measurement, and intraoperative neuromonitoring (IONM).

Patients and methods

Data of 1,363 patients who underwent surgery for pHPT were retrospectively analyzed regarding reoperations. Causes of persistent (p) pHPT or recurrent (r) pHPT, preoperative imaging studies, surgical findings, and outcome were analyzed. Data of patients who underwent surgery between 1987 and 1997 (group 1; G1) and between 1998 and 2008 (group 2; G2) with the use of Mibi/SPECT, IOPTH, and IONM were evaluated.

Results

One hundred twenty-five patients with benign ppHPT (n?=?108) or rpHPT (n?=?17) underwent reoperations (R-PTX). Group 1 included 54, group 2 71 patients. Main cause of ppHPT (G1?=?65 % vs. G2?=?53 %) and rpHPT (G1?=?80 % vs. G2?=?60 %) was the failed detection of a solitary adenoma (p?=?0.2). Group 1 patients had significantly less unilateral/focused neck re-explorations (G1?=?23 % vs. G2?=?57 %, p?=?0.0001), and more sternotomies (G1?=?35 vs. G2?=?14 %, p?=?0.01). After a median follow-up of 4 (range 0.9–23.4) years, reversal of hypercalcemia was achieved in 91 % (G1) and in 98.6 % in group 2 (p?=?0.08, OR 7.14 [0.809–63.1]). The rates of permanent recurrent laryngeal nerve palsy (G1?=?G2?=?9 %, p?=?1) and of postoperative permanent hypoparathyroidism (G1?=?9 % vs. G2?=?6 %, p?=?0.5) were not significantly different. Other complications such as wound infection, postoperative bleeding, and pneumonia were significantly lower in group 2 (p?<?0.001).

Conclusion

Nowadays, cure rates of R-PTX are nearly the same as in primary operations for pHPT. These results can be achieved in high-volume centers by routine use of well-established preoperative Mibi/SPECT and US in combination with IOPTH. However, morbidity is still considerably high.     

Preoperative therapy of esophagogastric cancer: the problem of nonresponding patients

Introduction

Preoperative treatment is nowadays standard for locally advanced esophagogastric cancer in Europe. Surprisingly, little attention has been paid to nonresponders so far. The aim of our retrospective exploratory study was the comparison of responder, nonresponder, and primary resected patients in respect of outcome considering the tumor entity.

Patients and methods

From 2001–2011, 607 patients with locally advanced esophagogastric carcinoma (adenocarcinoma of the esophagogastric junction (AEG), n?=?293; squamous cell cancer (SCC), n?=?111; gastric cancer, n?=?203) after preoperative treatment (n?=?281) or primary resection (n?=?326) were included. Histopathological response evaluation (Becker criteria) was available for 263.

Results

A total of 76/263 (28.9 %) were responders (<10 % residual tumor). There was an association of response with increased R0 resections (p?<?0.001) but also with a higher complication rate (p?=?0.008) compared to nonresponse and primary surgery. Mortality was not influenced. Increased R0 resections after response were confirmed in every tumor entity (AEG, p?=?0.010; SCC, p?=?0.023; gastric cancer, p?=?0.006). Median survival was best for responders with 43.5 months [95 % confidence interval (CI), 27.9–59.1], followed by nonresponders with 24.3 months (95 % CI, 21.6–27.0) and primary resected patients with 20.8 months (95 % CI, 17.7–23.9; p?=?0.002). AEG (p?=?0.012) and gastric cancer (p?=?0.017) revealed identical results, but in the subgroup of SCC, the survival of nonresponders (median, 11.6 months; 95 % CI, 6.9–16.3) was even worse than for primary resected patients (median, 23.8 months; 95 % CI, 1.7–46.0; p?=?0.012).

Conclusion

The histopathological response rate was low. Generally, nonresponding patients with AEG or gastric cancer seem not to have a disadvantage compared to primary resected patients, but nonresponders with SCC have a worse prognosis, which strengthens the demand for a critical patient selection in surgery for this tumor entity.     

Efficacy and safety of postoperative early mobilization for chronic subdural hematoma in elderly patients

Background

The incidences of chronic subdural hematoma (CSDH) will probably increase with the aging of the population; thus, postoperative care of elderly CSDH patients may play a more important role in surgical management. The aim of this study was to evaluate the efficacy of and adverse effects after postoperative early mobilization (EM) for elderly CSDH patients.

Methods

This is a single-institution historical control study. One hundred eighty-two patients with CSDH aged 65 years and older underwent one burr-hole surgery between 2001 and 2008. This institution has prospectively conducted an EM protocol after surgery since 2005. The emphasis of the EM was helping patients not only to an upright position but also to walk beginning the day of operation. The incidences of postoperative complications and recurrence of CSDH were compared between the EM group (n?=?91; 76.5?±?6.5 years old) and a delayed mobilization (DM) group (n?=?91; 77.9?±?7.5 years old).

Results

Postoperative complications, such as pneumonia and urinary tract infection, was observed in 24 (26.4%) in the DM group and 11 (12.1%) in the EM group (p?<?0.05). The rate of recurrence did not differ between the two groups (6.6% and 8.8%, respectively; p?=?0.58).

Conclusions

The results suggest that EM after one burr-hole surgery prevents postoperative complications without increasing the risk of recurrence in CSDH patients ≥65 years of age.     

Gastrectomy in Advanced Gastric Cancer Effectively Palliates Symptoms and May Improve Survival in Select Patients

Background

The role of gastrectomy in the face of incurable gastric cancer is evolving. We sought to evaluate our experience with incomplete (i.e., R2) gastrectomy in advanced gastric cancer.

Methods

We reviewed 210 locally advanced or metastatic gastric cancers (1992–2008). Patient characteristics and outcomes were compared between three groups: gastrectomy (N?=?99), exploration without resection (N?=?66), and no surgery (N?=?45).

Results

Clinicopathologic characteristics were similar between groups. Symptoms successfully resolved after gastrectomy in 48 % with a complication rate of 32 % and mortality of 6 %. Overall median survival for all patients was 6.2 months: 10.0 months after gastrectomy, 4.1 months after exploration without resection, and 5.3 months for no surgery (p?<?0.001). Perioperative complications were the only predictor of symptom resolution following resection (OR?=?0.175). Resolution of symptoms (p?<?0.001, Hazards Ratio (HR)?=?0.09) and preoperative nausea/vomiting (p?=?0.017, HR?=?0.55) improved survival, while linitis plastica (p?=?0.035, HR?=?4.05) and spindle cell morphology (p?=?0.011, HR?=?1.98) were predictors of poor survival in patients undergoing resection.

Conclusions

Gastrectomy in the setting of advanced gastric cancer may be useful in up to half of patients with an acceptable perioperative mortality rate. Symptom resolution offers a potential survival advantage but is dependent upon a complication-free course, so should only be considered selectively.     

Carotid intima media thickness, oxidative stress, and inflammation in children with chronic kidney disease

Objective

We evaluated the association between inflammation and oxidative stress with carotid intima media thickness (cIMT) and elasticity increment module (E_inc) in pediatric patients with chronic kidney disease (CKD).

Methods

This analytical, cross-sectional study assessed 134 children aged 6–17 years with CKD. Anthropometric measurements and biochemistry of intact parathyroid hormone (iPTH), high-sensitivity C-reactive protein (CRP), interleukin (IL)-6, IL-1β, reduced glutathione (GSH), malondialdehyde, nitric oxide, and homocysteine were recorded. Bilateral carotid ultrasound (US) was taken. Patients were compared with controls for cIMT and E_inc using?≥?75  percentile (PC).

Results

Mean cIMT was 0.528?±?0.089 mm; E_inc was 0.174?±?0.121 kPa × 10³; cIMT negatively correlated with phosphorus (r ?0.19, p?=?0.028) and the calcium × phosphorus (Ca × P) product (r ?0.26, p?=?0.002), and positively with iPTH (r 0.19,p?=?0.024). After adjusting for potential confounders, hemodialysis (HD) (β?=?0.111, p?=?<0.001), automated peritoneal dialysis (APD) (β?=?0.064, p?=?0.026), and Ca x P product (β?=??0.002, p?=?0.015) predicted cIMT (R ²?=?0.296). In patients on dialysis, HD (β?=?0.068, p?=?0.010), low-density lipoprotein cholesterol (LDL-C) (β?=?0.001, p?=?0.048), and GSH (β?=??0.0001, p?=?0.041) independently predicted cIMT (R ²?=?0.204); HD, hypoalbuminemia, and high iPTH increased the risk of increased cIMT. In dialysis, E_inc was inversely associated with GSH, and in predialysis, Ca × P correlated with/predicted E_inc (β?=?0.001, p?=?0.009).

Conclusions

cIMT and E_inc strongly associate with several biochemical parameters and GSH but not with other oxidative stress or inflammation markers.     

Evolution of Glycolipid Profile After Sleeve Gastrectomy vs. Roux-en-Y Gastric Bypass: Results of a Prospective Randomized Clinical Trial

Background

This study aims to report glycolipid changes after sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) in the setting of a prospective randomized clinical trial.

Methods

One hundred patients were randomly assigned to RYGB (n?=?45) and SG (n?=?55). Fasting glucose, insulin, glycated hemoglobin (HbA1c%), triglycerides, and serum cholesterol (total, HDL, and LDL) were evaluated at inclusion and after 1, 3, 6, and 12 months. The index for homeostasis model assessment of insulin resistance (HOMA-IR) and β cell function (HOMA-B) were assessed.

Results

Mean postoperative 1-, 3-, 6-, and 12-month excess weight loss was 25.39, 43.47, 63.75, and 80.38 % after RYGB and 25.25, 51.32, 64.67, and 82.97 % after SG, respectively. Mean fasting glucose and fasting serum insulin were similarly and statistically significantly reduced in both RYGB and SG. Mean HOMA-IR improved in both groups, particularly in case of high preoperative values, and mean HOMA-B improved at 1 year after RYGB. HbA1c% dropped from 5.66 % (SD?=?0.61) to 5.57 % (SD?=?0.32) after RYGB and from 5.64 % (SD?=?0.43) to 5.44 % (SD?=?0.43) after SG. Total cholesterol was significantly higher at 1 month (p?=?0.04), 3 months (p?=?0.03), and 1 year (p?=?0.005) after SG as compared to RYGB. LDL cholesterol decreased significantly after RYGB at 1 month (p?=?0.03), 3 months (p?=?0.0001), and 1 year (p?=?0.0004) as compared to SG. HDL cholesterol was increased at 1 year in the RYGB group but not in the SG group. Triglycerides decreased similarly in both groups.

Conclusions

Short-term glycemic control was comparable after SG and RYGB. An improved lipid profile was noted after RYGB in patients with abnormal preoperative values.     

Timing of Intervention in Necrotizing Pancreatitis

Background

The best available evidence suggests that surgical intervention should be delayed where possible until four weeks after the onset of pancreatitis. Subgroups that may benefit from early or delayed intervention have not been identified.

Methods

This study reviewed a prospective database with 223 patients of necrotizing pancreatitis who received intervention. A subgroup analysis was performed to compare the results of different surgical timing.

Results

The median timing of intervention was 32 days. The mortality rates in the early (≤30 days) intervention and delayed intervention (>30 days) groups were 21 % (28/136) and 10 % (9/87), respectively (P?=?0.04). In patients with persistent early organ failure, mortality and re-intervention rates were higher in the early group compared with the delayed group (23/61 vs. 3/21, P?=?0.04; 17/61 vs. 2/21, P?=?0.01). In patients without persistent early organ failure who underwent treatment, mortality rates, and re-intervention rates were similar between the early group and delayed group (5/75 vs. 6/66, P?=?0.59; 7/75 vs. 3/66, P?=?0.27). In patients with infected necrosis, mortality rate was similar with the early group and delayed group (17/77 vs. 7/57, P?=?0.14).

Conclusion

Early intervention in patients without persistent organ failure showed similar outcomes with patients who received delayed intervention.     

Feeding Jejunostomy Tube Placement in Patients Undergoing Pancreaticoduodenectomy: An Ongoing Dilemma

Background

Concomitant placement of feeding jejunostomy tubes (FJT) during pancreaticoduodenectomy is common, yet there are limited data regarding catheter-specific morbidity and associated outcomes. This information is crucial to appropriately select patients for feeding tube placement and to optimize perioperative nutrition strategies.

Methods

A review of all patients undergoing pancreaticoduodenectomy with FJT placement was completed. Patients were grouped by the occurrence of FJT-related morbidity. Multivariable logistic regression was performed to identify predictors of FJT morbidity; these complications were then further defined. Finally, associated postoperative outcomes were compared between groups.

Results

In total, 126 patients were included, of which 18 (14 %) had complications directly related to their FJT, including pericatheter infection (n?=?6), pneumatosis intestinalis (n?=?4), severe tube feed intolerance (n?=?3), and primary catheter malfunction (n?=?7). Following adjustment with logistic regression, preoperative hypoalbuminemia was identified as the only independent predictor of FJT complications (OR 2.23, p?=?0.035). Patients with FJT complications were more likely to be initiated on total parenteral nutrition (TPN; 55.6 vs. 7.4 %, p??0.035) and to require TPN at discharge (16.7 vs. 0 %, p?=?0.003). Correspondingly, these patients resumed an oral diet later (14 vs. 8 days, p?=?0.06). Both reoperation (50.0 vs. 6.5 %, p?p?=?0.041) rates were higher among patients with FJT complications.

Conclusions

FJT-related morbidity is common among patients undergoing pancreaticoduodenectomy and is associated with inferior outcomes and other performance metrics. Preoperative malnutrition appears to predict FJT complications, creating an ongoing dilemma regarding FJT placement. In the future, it will be important to better define criteria for FJT placement during pancreaticoduodenectomy.     

Prevalence of Nonalcoholic Steatohepatitis Among Patients with Resectable Intrahepatic Cholangiocarcinoma

Background and Aims

The objective of this report was to determine the prevalence of underlying nonalcoholic steatohepatitis in resectable intrahepatic cholangiocarcinoma.

Methods

Demographics, comorbidities, clinicopathologic characteristics, surgical treatments, and outcomes from patients who underwent resection of intrahepatic cholangiocarcinoma at one of eight hepatobiliary centers between 1991 and 2011 were reviewed.

Results

Of 181 patients who underwent resection for intrahepatic cholangiocarcinoma, 31 (17.1 %) had underlying nonalcoholic steatohepatitis. Patients with nonalcoholic steatohepatitis were more likely obese (median body mass index, 30.0 vs. 26.0 kg/m², p?<?0.001) and had higher rates of diabetes mellitus (38.7 vs. 22.0 %, p?=?0.05) and the metabolic syndrome (22.6 vs. 10.0 %, p?=?0.05) compared with those without nonalcoholic steatohepatitis. Presence and severity of hepatic steatosis, lobular inflammation, and hepatocyte ballooning were more common among nonalcoholic steatohepatitis patients (all p?<?0.001). Macrovascular (35.5 vs. 11.3 %, p?=?0.01) and any vascular (48.4 vs. 26.7 %, p?=?0.02) tumor invasion were more common among patients with nonalcoholic steatohepatitis. There were no differences in recurrence-free (median, 17.0 versus 19.4 months, p?=?0.42) or overall (median, 31.5 versus 36.3 months, p?=?0.97) survival after surgical resection between patients with and without nonalcoholic steatohepatitis.

Conclusions

Nonalcoholic steatohepatitis affects up to 20 % of patients with resectable intrahepatic cholangiocarcinoma.     

Circulating activin-A is elevated in postmenopausal women with low bone mass: the three-month effect of zoledronic acid treatment

Summary

Activin-A is expressed in bone and seems to regulate osteoclastogenesis. In this study, serum activin-A was increased in postmenopausal women with low bone mass and was positively correlated to age and negatively to lumbar spinal bone mineral density (BMD). Serum activin-A levels did not change 3 months after zoledronic acid infusion.

Introduction

The aims of the study were to evaluate prospectively the circulating activin-A levels in postmenopausal women with low bone mass and explore possible correlations with clinical and laboratory data, as well as the 3-month effect of zoledronic acid infusion.

Methods

Postmenopausal women with low bone mass assigned to receive zoledronic acid infusion (Patients, n?=?47) and age-matched, postmenopausal women with normal bone mass (Controls, n?=?27) were recruited on an outpatient basis. Main outcome measurement was serum activin-A levels.

Results

Serum activin-A was higher in patients at baseline compared to controls (p?<?0.001) and activin-A in the serum of patients and controls was positively correlated with age (Spearman’s coefficient of correlation [rs]?=?0.325; p?=?0.005) and negatively with lumbar spinal (LS) BMD (rs?=??0.425; p?<?0.001). In multiple linear regression analysis, only age (B?=?8.93; 95 % CI?=?4.39–13.46; p?<?0.001) was associated with serum activin-A levels at baseline, independent from group (patients or controls), previous anti-osteoporotic treatment, LS BMD and follicle-stimulating hormone. Circulating activin-A levels were not affected 3 months after zoledronic acid infusion.

Conclusions

Serum activin-A is increased in postmenopausal women with low bone mass compared with postmenopausal women with normal bone mass and is positively correlated to age and negatively to LS BMD.     

Outcome Analysis of Single Incision vs Traditional Multiport Sleeve Gastrectomy: A Matched Cohort Study

Background

Single incision laparoscopy remains controversial due to technical challenges which may cause suboptimal outcomes. This study aims to evaluate the feasibility and equivalency of the single incision sleeve gastrectomy (SISG) when compared to the traditional multiport sleeve gastrectomy (MPSG) approach in a matched cohort evaluating technical aspects and postoperative results.

Methods

This is a retrospective analysis of prospectively collected data in a consecutive cohort of 113 SG (MPSG?=?77, SISG?=?36). The 36 patients who underwent SISG were included as the case group. Thirty-six MPSG patients were included in the control group, in 1:1 ratio with cases after matching for BMI, age, race, gender, and additional demographic data. Operative time (OT) in minutes and length of stay (LOS) in days was measured and excess weight loss (EWL) at 6 months and 1 year was collected and evaluated.

Results

Mean BMI was equivalent (SISG 43.06, MPSG 43.72, p?=?0.36). Mean OT for the SISG was 116.78 and 118.25 for the MPSG (p?=?0.84), and mean LOS was 1.80 for the SISG and 1.75 for the MSPG (p?=?0.75). EWL at 6 months was 58.4 % for the SISG and 58.5 % for the MPSG (p?=?0.98) and 72.3 and 74.1 % (p?=?0.77) for 1 year, respectively. There were no leaks in either group. There was one reoperation for postoperative bleeding in the MPSG group.

Conclusions

Sleeve gastrectomy can be performed safely using single incision techniques with equivalent outcomes for weight loss.     

Clinical features and surgical outcomes of primary cauda equina tumours

Background

To identify clinical features, radiological findings and surgical outcomes of primary cauda equina tumours.

Methods

A consecutive series of 64 operations in 60 patients with primary cauda equina tumours from April 1999 to May 2009 at one institution comprised the study. The cases were divided into tumours of neural sheath origin (TNS, n?=?48) and tumours of non-neural sheath origin (TNNS, n?=?22). We analysed pain intensity, neurological abnormalities, MRI findings, surgical extent and functional outcome.

Results

The TNS group showed more leg pain (76 % vs. 44 %, p?=?0.019) with higher intensity (6.1?±?1.5 vs. 4.6?±?1.9, p?=?0.04). Motor weakness and bladder dysfunction were more common in the TNNS group (p?=?0.028 and p?=?0.00 in each). Flow voids of MRI were more frequently observed in TNNS (50 % vs. 4 %, p?=?0.01). The TNS group achieved total removal in all operations compared with total removal in 77 % in the TNNS group (p?=?0.001). The TNNS group showed higher recurrence rates (18 % vs. 0 %, p?=?0.009). The TNS group showed higher improvement of JOA scores postoperatively (p?=?0.049). Surgical complications were observed less frequently in the TNS group (19 % vs. 78 %, p?=?0.000).

Conclusions

TNS differs from TNNS by causing more frequent leg pain, higher pain intensity and more frequent flow voids. TNS has better surgical outcomes than TNNS in terms of higher rates of total removal, fewer surgical complications, better functional outcomes and less recurrence.     

Predictors of early mortality after hip fracture surgery

Purpose

The aim of this study was to examine causes and potential risk factors for 30-day mortality after hip fracture surgery (HFS) at a high-volume tertiary-care hospital.

Methods

We retrospectively reviewed 467 patients who underwent HFS at our institution. Multivariate analysis was undertaken to identify potential predictors of early mortality.

Results

The 30-day mortality rate was 7.5 % (35/467). The most common causes of death were pneumonia (37.1 %, 13/35), acute coronary syndrome (31.4 %, 11/35) and sepsis (14.3 %, 5/35). Surgery after 48 hours of admission had a significantly higher 30-day mortality rate (11 % versus 4 %, p?=?0.006). There was a significant difference in age (p?=?0.034), admission source (p??<?0.001), preoperative haemoglobin (p?<?0.001), walking ability (p ?=?0.004), number of comorbidities (p ?=?0.004) and pre-existing dementia (p ?=?0.01), cardiac disease (p ?<?0.001), chronic obstructive pulmonary disorder (COPD) (p ?=?0.036) and renal failure (p ?=?0.007) between the 30-day mortality group and the rest of the cohort. Surgical delay greater than 48 hours, admission source and pre-existing cardiac disease were identified as the strongest predictors of 30-day mortality.

Conclusion

Surgical delay is an important but avoidable determinant of early mortality after HFS. Respiratory and cardiac function needs to be optimised postoperatively with early intervention in patients with signs of cardiovascular compromise or infection.     

Clinical Features and Outcome of Postoperative Peritonitis Following Bariatric Surgery

Background

We assessed the clinical features and outcome of morbidly obese patients admitted to the intensive care unit (ICU) for management of postoperative peritonitis (POP) following bariatric surgery (BS).

Methods

In a prospective, observational, surgical ICU cohort, we compared the clinical features, empiric antibiotic therapy, and prognosis of BS patients with those developing POP after conventional surgery (cPOP).

Results

Overall, 49 BS patients were compared to 134 cPOP patients. BS patients were younger (45?±?10 versus 63?±?16 years; p?<?0.0001), had lower rates of fatal underlying disease (39 vs 64 %; p?=?0.002), and the same SOFA score at the time of reoperation (8?±?4 vs 8?±?3; p?=?0.8) as the cPOP patients. BS patients had higher proportions of Gram-positive cocci (48 vs 35 %; p?=?0.007) and lower proportions of Gram-negative bacilli (33 vs 44 %; p?=?0.03), anaerobes (4 vs 10 %; p?=?0.04), and multidrug-resistant strains (20 vs 40 %; p?=?0.01). Despite higher rates of adequate empiric antibiotic therapy (82 vs 64 %; p?=?0.024) and high de-escalation rates (67 % in BS cases and 51 % in cPOP cases; p?=?0.06), BS patients had similar reoperation rates (53 vs 44 %; p?=?0.278) and similar mortality rates (24 vs 32 %; p?=?0.32) to cPOP patients. In multivariate analysis, none of the risk factors for death were related to BS.

Conclusions

The severity of POP in BS patients resulted in high mortality rates, similar to the results observed in cPOP. Usual empiric antibiotic therapy protocols should be applied to target multidrug-resistant microorganisms, but de-escalation can be performed in most cases.