Leaks and obstruction after gastric resection

Postoperative gastric retention may be minimized by avoiding the use of the Billroth I reconstruction when a large duodenal ulcer must be retained. Postoperative gastric retention is more likely to remit with conservative therapy if the procedure was a Billroth I reconstruction with a vagotomy. In other instances where there is difficulty in gastric emptying, a mechanical cause should be strongly suspected. The optimum duration of a conservative trial with suction for postoperative gastric retention may be debatable, and contrast radiography or endoscopy may be helpful; however, patience and suction are not long-term substitutes for a needed operation.     

Pulmonary resection after pneumonectomy

Patients who have a lung cancer in the residual lung after pneumonectomy should not be automatically excluded for surgical consideration. These patients should be carefully staged and evaluated physiologically. The most important initial differentiation is to distinguish a true second primary lung cancer from metastatic recurrent lung cancer. Meticulous staging with chest CT, PET, brain MRI, and mediastinoscopy should be able to successfully exclude metastatic disease, multifocal disease, or locally advanced tumors. Only patients who have stage I disease are candidates for this type of extended resection. Ideally, these patients should have small peripheral tumors that can be encompassed with a low-volume wedge resection. More extended resections, such as segmentectomy or right middle lobectomy, may be considered in some patients but seem to bear a higher operative morbidity and mortality. The need for an upper or lower lobectomy after contralateral pneumonectomy is probably an absolute contraindication to surgical resection. To tolerate pulmonary resection after pneumonectomy, and to obtain the desired survival benefit, patients should have a good to excellent performance status, no serious comorbidities, and a ppoFEV1 greater than 1.0 L/second. In these highly selected patients, pulmonary resection after pneumonectomy can be accomplished with an acceptable operative morbidity and mortality and, in true cases of metachronous second primary lung cancers, may achieve a 5-year survival rate of up to 50%.     

Transurethral resection syndrome after transurethral resection of bladder tumours

The transurethral resection syndrome has not previously been described after bladder surgery. This article reports four patients who developed signs of this syndrome after transurethral resection of bladder tumours (TURB). Symptoms included abdominal pain, arterial hypotension, nausea and vomiting. There was evidence in all cases that the cause was absorption of irrigating fluid by the extravascular route. Fluid absorption was detected by ethanol in two patients and the urologist noted a perforation during the third operation. The most complicated clinical course occurred in the case where there was a delay of three hours before the diagnosis was made. Medical treatment consisted of antiemetics and volume expansion of the extracellular fluid compartment as extravasation is associated with hypovolaemia. Diuretics were not given until the circulation had been restored.     

Early discharge and readmission after colorectal resection

Background

Emphasis on the provision of high quality, cost-effective healthcare has meant increasing efforts at reducing postoperative length of stay while reducing 30-d readmission rates. The aim of this study was to identify factors associated with early discharge (ED) and to evaluate the effectof ED on readmission after colorectal resection.

Materials and methods

We identified all inpatients aged ≥18 y who underwent a colorectal resection in the American College of Surgeons National Surgical Quality Improvement Program Participant Use File, 2011. ED was defined as a length of stay ≤25th percentile by procedure (rectal resection, open colectomy, and laparoscopic colectomy). Multivariate logistic regression was used to identify factors significantly associated with ED and readmission. A subset analysis was performed by procedure type.

Results

Of 28,532 patients, 2171 (7%) underwent rectal resection, 14,976 (52%) underwent open colectomy, and 11,385 (40%) underwent laparoscopic colectomy with an ED on or before postoperative days 5, 5, and 3, respectively. The overall cohort included patients with a mean age of 61 y. A total of 52% were women and 37% were colorectal cancer patients. Age >65 y, recent steroid use, simultaneous ostomy creation, nonelective surgery, need for reoperation, and a postoperative occurrence before discharge were significantly associated with a reduced likelihood of ED. The overall rate of readmission was 12%. Patients who were discharged early were significantly less likely to be readmitted (odds ratio, 0.77; 95% confidence interval, 0.70–0.84).

Conclusions

In the appropriate patient population, ED after colorectal surgery may be implemented without any adverse effect on readmission rates.     

Outcome and complications after resection of hepatoblastoma

Purpose

The aim of this study was to review the outcome and complications after resection of hepatoblastoma treated over 2 decades in our institution.

Methods

Clinical, radiologic, and pathologic data were reviewed retrospectively, focusing on the outcome and complications.

Results

Between January 1978 and December 2002, 56 children were treated for hepatoblastoma. The age range was 0.08 to 8.74 years (median, 1 year). The right lobe was involved in 48%, the left lobe in 22%, and in 29% the main bulk of the tumour was centrally located. Surgical procedures included the following: hemihepatectomy in 62%, trisegmentectomy in 18%, extended hemihepatectomy in 16%, and liver transplantation and laparotomy in one patient each. Intraoperative complications occurred in 5(9%)—rupture of the tumour (1), haemorrhage from the contralateral lobe (1), a defect in the left hepatic duct (1), cardiac arrest from tumour embolus (1), and bleeding from the inferior vena cava (1). The mean blood loss was 280 mL (50 to 2,000 mL). Postoperative complications occurred in 12 patients (22%) including subphrenic abscess (3), adhesion obstruction (2), ischaemic stenosis of the bile duct (1), abdominal wound dehiscence (1), pyloric obstruction (1), and pleural effusion (2). Fifteen patients died, 14 as a result of tumour recurrence (mortality rate, 27%).     

Local recurrence after abdomino-perineal resection

Objective  Local recurrence of rectal cancer is a major cause of morbidity and mortality following curative resection. The published rates vary after abdomino-perineal resection (APR) from 5% to 47%. The aim of this study was to evaluate local recurrence following curative APR for low rectal cancer in our unit.
Method  The medical notes of patients treated between 1st January 1996 and 31st December 2000 were retrieved. Local recurrence was defined as the presence of tumour within the pelvis confirmed by clinical findings, pathological specimen or radiological reports. A curative resection was defined as excision of tumour in the absence of macroscopic metastatic disease and whose resection margins were greater than 1 mm circumferentially and 10 mm distally. Outcomes and survival were compared using Fisher's exact test and Kaplan–Meier method.
Results  Two hundred consecutive cases with a diagnosis of rectal cancer were identified of which 139 underwent a curative resection (69.5%). Of these 40 patients (28%) underwent APR with curative intent. Two patients (5%) developed local recurrence at 18 and 24 months respectively. The overall local recurrence rate for all curative rectal cancer surgery, in the same period was 2.6%. Eleven patients have died in the follow-up period of which nine were cancer-related deaths.
Conclusion  The local recurrence rates achieved with APR were not significantly different from those achieved with restorative operations. Tumours at the ano-rectal junction should not be dissected off the pelvic floor, but radically excised en bloc with the surrounding levator ani, as a cylinder, as originally described by Miles.     

Bile leakage after hepatic resection

OBJECTIVE: To identify the perioperative risk factors for postoperative bile leakage after hepatic resection, to evaluate the intraoperative bile leakage test as a preventive measure, and to propose a treatment strategy for postoperative bile leakage according to the outcome of these patients. SUMMARY BACKGROUND DATA: Bile leakage remains a common cause of major complications after hepatic resection. METHODS: Between January 1985 and June 1999, 781 hepatic resections without bilioenteric anastomosis were performed at the authors' institution. Perioperative risk factors related to postoperative bile leakage were identified using univariate and multivariate analysis. The characteristics of patients with intractable bile leakage and the effect of intraoperative bile leakage test were also examined. Management was evaluated in relation to the outcomes and the clinical characteristics of the patients with bile leakage. RESULTS: Bile leakage developed in 31 (4.0%) of 781 hepatic resections. This complication carried high risks for surgical death (two patients [6.5%] died). The stepwise logistic regression analysis identified high-risk surgical procedure, in which the cut surface exposed the major Glisson's sheath and included the hepatic hilum (i.e., anterior segmentectomy, central bisegmentectomy, or total caudate lobectomy), as the independent predictor of the development of postoperative bile leakage. None of the 102 cases in which an intraoperative bile leakage test was performed were subsequently complicated by postoperative bile leakage, and the preventive effect of the test was statistically significant. Patients with fisterographically demonstrable leakage from the hepatic hilum and with postoperative uncontrollable ascites had poor outcomes. CONCLUSION: Patients with bile leakage from the hepatic hilum and postoperative uncontrollable ascites tend to have a poor prognosis. Therefore, especially when a high-risk surgical procedure is performed in patients with liver cirrhosis, more careful surgical procedures and use of an intraoperative bile leakage test are recommended.