Identification of Patients at Risk for Development of Tertiary Peritonitis on a Surgical Intensive Care Unit

Background  Tertiary peritonitis (TP) is defined as a severe recurrent or persistent intra-abdominal infection after adequate surgical source control of secondary peritonitis (SP). The aim of this study was to analyze the characteristics of patients with SP who will further develop TP in order to define early diagnostic markers for TP. Study Design  Over a 1-year period, all patients on the surgical intensive care unit (ICU) with SP were prospectively assessed for the development of TP applying the definition of the ICU consensus conference. The Mannheim Peritonitis Index (MPI), C-reactive protein (CRP) and Simplified Acute Physiology Score II (SAPS II) were assessed at the initial operation (IO) that was diagnostic for SP and in the postoperative period. Results  Among 69 patients with SP, 15 patients further developed TP, whereas 54 patients did not develop TP. Compared to SP, patients with transition to TP had significantly higher MPI at IO (28.6 vs. 19.8; p < 0.001), relaparotomy rate (2.00 vs. 0.11; p < 0.001), mortality (60% vs. 9%; p < 0.001), duration of ICU stay (14 vs. 4 days; p < 0.005), as well as SAPS II (45.1 vs. 28.4; p < 0.005) and CRP (265 mg/dL vs. 217 mg/dL; p < 0.05) on the second postoperative day after IO. Conclusions  The MPI at IO as well as CRP and SAPS II at the second postoperative day helps to identify patients at risk for tertiary peritonitis. This paper was presented by the principal author (A.M. Chromik) at the “Papers Session GS71 Trauma and Critical Care” of the 94th Annual Clinical Congress of the American College of Surgeons, October 12–16, 2008, San Francisco, (Abstract # NP2008-1246). Ansgar M. Chromik and Andreas Meiser contributed equally to this publication.     

Organ dysfunction and long term outcome in secondary peritonitis

Background and aims Secondary peritonitis is still associated with high mortality, especially when multiorgan dysfunction complicates the disease. Good prognostic tools to predict long term outcome in individual patients are lacking and therefore require further study. Patients and methods 163 consecutive patients with secondary peritonitis were included, except those with postoperative or traumatic peritonitis. In 58 patients treated in the intensive care unit (ICU), organ dysfunction was quantified using Sequential Organ Failure Assessment (SOFA) score in the first 4 days. Predictive factors for poor outcome were evaluated in all patients. Hospital and 1-year mortality was assessed. Results Hospital mortality was 19% and 1-year mortality 23%. Acute physiology and chronic health evaluation II (APACHE II), previous functional status, and sepsis category were predictive of fatal outcome in the total cohort (p = 0.034, p < 0.001, and p < 0.001). In patients treated in the ICU, advanced age and admission SOFA score were independent predictors of death (p = 0.014, p < 0.0001). The SOFA score showed the best discriminative ability for poor outcome (AuROC 0.78). Conclusion Degree of organ dysfunction measured using SOFA score was the best predictor of hospital mortality in patients suffering from secondary peritonitis. This study was supported by the Helsinki University Hospital HUS-EVO funding.     

Acute Abdominal Pain in Patients with Systemic Lupus Erythematosus

Background  Patients with Systemic Lupus Erythematosus (SLE) that present with acute abdominal pain (AAP) represent a challenge for the general surgeon. The purpose of this study was to identify the major causes of AAP among these patients and to define the role of disease activity scores and the APACHE II score in identifying patients with an increased perioperative risk. Methods  We conducted a prospective study of patients admitted to the ER with AAP and SLE in an 11-year period. Demographic, diagnostic, and treatment data were recorded. Systemic lupus erythematosus disease activity index (SLEDAI), systemic lupus international collaboration clinics damage index (SLICC/DI), and APACHE II Score were analyzed. The main outcome variables were morbidity and mortality within 30 days of admission. Results  Seventy-three patients were included. Ninety-three percent were female. Most common causes of AAP were: pancreatitis (29%), intestinal ischemia (16%), gallbladder disease (15%), and appendicitis (14%). Most causes of AAP in patients with LES were not related to the disease. APACHE II score > 12 was statistically associated with the diagnosis of intestinal ischemia compared to other causes. No relationship was observed between SLEDAI and outcome. Furthermore, this index did not have impact on diagnosis or decision making. Overall morbidity was 57% and overall mortality 11%. On multivariate analysis, only APACHE II > 12 was associated with mortality (P = 0.0001). Conclusion  This is one of the largest series of AAP and SLE. Most common causes of AAP were pancreatitis and intestinal ischemia. APACHE II score in patients with intestinal ischemia was higher than those with serositis; further studies are needed to examine whether this score may help to differentiate these ethiologies when CT findings are inconclusive. APACHE II score was the most important factor associated with mortality. Furthermore, a prompt diagnosis and an appropriate surgical management are essential in order to improve patient outcome.     

Risk factors affecting morbidity in typhoid enteric perforation

Introduction  Typhoid enteric perforation is a cause of high morbidity and mortality. This study aim is to determine the factors affecting morbidity in patients with typhoid enteric perforation. Materials and methods  Ninety-six patients with typhoid enteric perforation were reviewed. The variables are defined as follows: Age, gender, complaints, perforation–operation interval, typhoid fever treatment before the perforation or not, white blood cell (WBC) count, hemoglobin level (Hgb), intraoperative peritonitis intensity, the number of perforations, and type of surgery were examined. To determine the independent risk factors that might affect morbidity in typhoid enteric perforation, we made use of multivariate logistic regression analysis. Results  Nine variables were applied the univariate analysis, which were greater than 30 years (P = 0.218), male gender (P = 0.02), preoperative treatment (P = 0.147), less than or equal to 48 h perforation–operation interval (P = 0.013), greater than 4,000 K/UL WBC (P = 0.388), less than 8 g/dL Hgb (P = 0.026), greater than 29 Mannheim Peritonitis Index (P < 0.0001), multiple perforation number (P = 0.614), and primary repair (P = 0.105). Logistic regression analysis showed that Mannheim Peritonitis Index (P = 0.014) and perforation–operation interval (P = 0.047) were defined as independent risk factors affecting morbidity. Conclusions  If liquid electrolyte, blood, antibiotics, and parenteral nutrition are applied in typhoid enteric perforation cases adequately, then severe peritonitis becomes an independent risk factor that affects morbidity. Early diagnosis and appropriate surgery type would decrease morbidity and mortality.     

Laparoscopic-assisted vs. Open Colectomy for Cancer: Comparison of Short-term Outcomes from 121 Hospitals

Background  Overall postoperative morbidity and mortality after laparoscopic-assisted colectomy (LAC) and open colectomy (OC) have been shown to be generally comparable; however, differences in the occurrence of specific complications are unknown. The objective of this study was to determine whether certain complications occurred more frequently after LAC vs. OC for colon cancer. Methods  Using the American College of Surgeons-National Surgical Quality Improvement Project’s (ACS-NSQIP) participant-use file, patients were identified who underwent colectomy for cancer at 121 participating hospitals in 2005–2006. Multiple logistic regression models including propensity scores were developed to assess the risk-adjusted association between surgical approach (LAC vs. OC) and 30-day outcomes. Patients were excluded if they underwent emergent procedures, were ASA class 5, or had metastatic disease. Results  Of the 3,059 patients who underwent elective colectomy for cancer, 837 (27.4%) underwent LAC and 2,222 (72.6%) underwent OC. There were no significant differences in age, comorbidities, ASA class, or body mass index (BMI) between patients undergoing LAC vs. OC. Patients undergoing LAC had a lower likelihood of developing any adverse event compared to OC (14.6% vs. 21.7%; OR 0.64, 95% CI 0.51–0.81, P < 0.0001), specifically surgical site infections, urinary tract infections, and pneumonias. Mean length of stay was significantly shorter after LAC vs. OC (6.2 vs. 8.7 days, P < 0.0001). There were no differences between LAC and OC in the reoperation rate (5.5% vs. 5.8%, P = 0.79) or 30-day mortality (1.4% vs. 1.8%, P = 0.53). Conclusions  Laparoscopic-assisted colectomy was associated with lower morbidity compared to OC in select patients, specifically for infectious complications. This study was presented in part at the 2008 Annual Meeting of the Society for Surgery of the Alimentary Tract in San Diego, CA on May 21, 2008.     

Phosphodiesterase-5 gene (PDE5A) polymorphisms are associated with progression of childhood IgA nephropathy

The phosphodiesterase-5 (PDE-5) gene is highly specific to cyclic GMP (cGMP) and several experimental studies have shown that the nitric oxide/cGMP pathway plays an important role in the pathogenesis of glomerulonephritis, including IgA nephropathy (IgAN). The present study was conducted to investigate the association among 16 single nucleotide polymorphisms (SNPs) of PDE5A and childhood IgAN. The genotyping data from 160 patients with childhood IgAN and 454 controls showed a significant difference in rs13124532 (codominant, P = 0.005; dominant, P = 0.005). Furthermore, patient subgroup analysis revealed an association between the development of proteinuria (>4 and ≤4 mg/m²/h) and rs13124532 (codominant, P = 0.008; dominant, P = 0.011), and between the nephrotic range proteinuria (> 40 mg/m²/h) and rs11734241 (dominant, P = 0.035), rs12510138 (dominant, P = 0.028), rs13134665 (dominant, P = 0.025), rs3822192 (dominant, P = 0.027), rs10013305 (dominant, P = 0.020), rs1480940 (dominant, P = 0.020), rs1480936 (dominant, P = 0.019), rs11947234 (dominant, P = 0.019), and rs2127823 (dominant, P = 0.026). The pathological findings showed that rs13124532 had an association with podocyte foot process effacement (codominant, P = 0.035; dominant, P = 0.044) and with pathological progression (codominant, P = 0.046). Our results suggest that PDE5A is associated with increased disease susceptibility, pathological progression, and development of proteinuria in childhood IgAN.     

Infectiological diagnostic problems in tertiary peritonitis

Background The tertiary peritonitis causes the highest mortality in intraabdominal infections. Surgical interventions and antibiotic therapy may only provide an incomplete impact on nosocomial infections acquired at an intensive care unit (ICU) [Nathens et al., World J Surg 22:158–163, 28]. To open up new resources in the management, in particular, in the previous infectious diagnostic, the aim was to investigate the infectious course as well as the diagnostic value of laboratory parameters and microbiological monitoring.Materials and methods In this retrospective patient cohort study from the Surgical ICU of a University Hospital (capacity, n=12), overall, 60 patients with a tertiary peritonitis were enrolled.Results Approximately 20% of the patients with an intraabdominal infection developed a tertiary peritonitis. A tertiary peritonitis can more frequently develop in nosocomial intraabdominal infections, in particular, in case of necrotizing pancreatitis. The device-associated infection rate in the spectrum of nosocomial infections is sevenfold higher than in all ICU patients. Compared with the secondary peritonitis, its mortality is double as high: 35%. In the diagnostic characterizing the course of the nosocomial, prognosis-relevant infections, usual inflammatory parameters show a considerable loss of their sensitivity with a range from 35–57%. By the mean of a routine microbiological monitoring, 47.3% of the analysed subsequent infections could be identified at an early stage.Conclusion In patients with a severe infection, an early diagnostic and treatment of infectious “second hits” can improve the complication rate and prognosis. During the prolonged and complicated septic course of tertiary peritonitis, an additional routine microbiological monitoring contributed effectively to early detection and diagnostic of nosocomial infections. Further studies to investigate the value and efficacy of such monitoring, which have been abandoned, should be undertaken in infectious high-risk patients.     

Laparoscopic Fundoplication in Patients with a Hypertensive Lower Esophageal Sphincter

Background  A small proportion of patients evaluated with manometry prior to a fundoplication have a high-pressure lower esophageal sphincter (LES). This paper examines the outcome of laparoscopic fundoplication for these patients. Material and Methods  Between October 1991 and December 2006, 1,886 patients underwent primary laparoscopic fundoplication. Those with a high-pressure LES on preoperative manometry (LESP ≥30 mm Hg at end expiration) were identified from a prospective database. Long-term outcomes were determined using analogue symptom scores (0–10) for heartburn, dysphagia, and patient satisfaction and compared to those of a matched control group. Results  Thirty patients (1.6%), nine men and 21 women, median age 51 years, had a hypertensive LES (mean, 36 mmHg; range, 30–55). Median follow-up after fundoplication was 99 (12–182) months. These patients had similar mean symptom scores to 30 matched controls for heartburn (2.3 vs. 2.2, P = 0.541), dysphagia (2.7 vs. 3.1, P = 0.539), and satisfaction (7.4 vs. 7.6, P = 0.546). Five patients required revision for dysphagia compared to no control patients (P = 0.005). These patients had a higher preoperative dysphagia score (6.6 vs. 3.1, P = 0.036). Conclusion  Laparoscopic fundoplication can be performed with good long-term results for patients with reflux and a hypertensive LES. However, those with preoperative dysphagia have a higher failure rate.     

Efficacy of tolterodine on overactive bladder symptoms and sexual and emotional quality of life in sexually active women

We evaluated overactive bladder (OAB) symptoms and sexual and emotional health in sexually active women with OAB/urgency urinary incontinence (UUI) treated with tolterodine extended release (ER). Sexually active women with OAB symptoms were randomized to placebo or tolterodine ER. Five-day bladder diaries, Sexual Quality of Life Questionnaire—Female (SQOL-F), Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ), and Hospital Anxiety and Depression Scale (HAD) were completed at baseline and week 12. Tolterodine ER (n = 201; mean ± SD age, 49 ± 12 years) reduced UUI episodes (P = 0.0029), total (P = 0.0006) and OAB (P < 0.0001) micturitions, and pad use per 24 h (P = 0.0024), and was associated with improvements in SQOL-F (P = 0.004), PISQ total (P = 0.009), and HAD Anxiety (P = 0.03) scores versus placebo (n = 210; mean ± SD age, 47 ± 12 years). OAB symptoms improved with tolterodine ER as did the scores of sexual health and anxiety measures in sexually active women with OAB.     

Effects of A-Line Autoregression Index (AAI) Monitoring on Recovery After Sevoflurane Anesthesia for Bariatric Surgery

Monitoring depth of anesthesia may improve anesthetic dosing and postanesthetic recovery in obese patients. Sixty morbidly obese patients undergoing laparoscopic adjustable gastric bandage (LAGB) were randomly assigned to receive anesthesia with sevoflurane titrated by either standard clinical parameters (SCP) (target = baseline hemodynamic parameters ± 20%) or by A-line ARX index (AAI) (target = 20 ± 5). Heart rate, arterial blood pressure, inspiratory and expiratory gas concentrations, and AAI were recorded in all patients at 5-min intervals, but AAI was made available only to the anesthesiologist assigned to AAI-monitored patients. Emergence times in surgery room and recovery times in postanesthesia care unit (PACU) were recorded at 1- and 30-min intervals. Mean intraoperative values of AAI were higher in AAI-monitored than in SCP-monitored patients (22.5 vs 15.0, p = 0.001). Compared to SCP monitoring, AAI monitoring reduced consumption of sevoflurane by 20% (p = 0.014), times to eye opening by 2.4 min (p = 0.001) and to extubation by 2.5 min (p = 0.009) and to achieve SpO₂ 92% in room air by 17 min (p = 0.001). Aldrete scores were higher in AAI- than in SCP-monitored patients at arrival in PACU (p = 0.035), but Aldrete scores ≥9 were attained in similar times. AAI monitoring can improve titration of and recovery from sevoflurane for LAGB.     

Surgical Resection Versus Radiofrequency Ablation in the Treatment of Small Unifocal Hepatocellular Carcinoma

Background  Hepatocellular carcinoma (HCC) has a high worldwide prevalence and mortality. While surgical resection and transplantation offers curative potential, donor availability and patient liver status and comorbidities may disallow either. Interventional radiological techniques such as radiofrequency ablation (RFA) may offer acceptable overall and disease-free survival rates. Materials and Methods  Sixty-eight cirrhotic patients matched for age, sex, tumor size, and Child–Pugh grade with small (1–5 cm) unifocal HCC were studied retrospectively to find determinants of overall and disease-free survival in those treated with surgical resection and RFA between 1991 and 2003. Results  Multivariate analysis using Cox proportional regression modeling showed that overall survival was related to tumor recurrence (p = 0.010), tumor diameter (p = 0.002), and treatment modality (p = 0.014); overall p = 0.008. Recurrence was independently related to the use of RFA over surgery (p = 0.023) on multivariate analysis; overall p = 0.034. Conclusion  Surgical resection offers longer disease-free survival and potentially longer overall survival than RFA in patients with small unifocal HCC.     

Relief of Dysphagia after Laparoscopic Heller Myotomy Improves Long-Term Quality of Life

Background and Objective  Quality of life (QoL) is getting more attention in the medical literature. Treatment outcomes are now gauged by their effect on the QoL along with their direct effect on the diseases they are targeting. The aim of the study was to assess the impact of residual dysphagia on QoL after laparoscopic Heller myotomy for achalasia. Methods  QoL was evaluated using the short-form-36 (SF-36) and postoperative dysphagia was assessed using a dysphagia score. The score (range 0–10) was calculated by combining the frequency of dysphagia (0=never, 1 = < 1 day/wk, 2 = 1 day/wk, 3 = 2–3 days/wk, 4 = 4–6 days/wk, 5=daily) with the severity (0=none, 1=very mild, 2=mild, 3=moderate, 4=moderately severe, 5=severe). Patients were classified in the Nonresponder group when their dysphagia score was in the upper quartile. Results  Questionnaires were mailed to 110 patients. The overall response rate was 91% with 100 patients (54 female) returning the questionnaires. The average follow-up was 3.3 years. There was a significative inverse correlation between dysphagia score and mental component (P = 0.0001) and total SF-36 (P = 0.001) scores. According to their postoperative dysphagia scores, 77 patients were assigned to the Responder Group and 23 patients to the Nonresponder Group. The two groups were similar in terms of age, gender, rate of fundoplication, and length of follow-up. Mental component and total SF-36 scores were significantly (P < 0.05) higher in the Responder group. Successful relief of dysphagia after Heller myotomy was associated with health-related quality of life scores that were 13 higher in Vitality (P < 0.05), 11 points higher in mental health (P < 0.05), and 12 points higher in General Health (P < 0.05). Overall patient satisfaction with surgical outcome was 92%, with only eight patients not satisfied with the surgery. Conclusion  Laparoscopic Heller myotomy offers excellent long-term relief of achalasia-related symptoms, namely dysphagia, and this was projected on a significant improvement in quality of life and patient satisfaction. Presented at the 47th annual meeting at Digestive Disease Week 2006     

Treatment of Thoracic Esophageal Anastomotic Leaks and Esophageal Perforations with Endoluminal Stents: Efficacy and Current Limitations

Background  Intra-thoracic esophageal leakage after esophageal resection or esophageal perforation is a life-threatening event. The objective of this non-randomized observational study was to evaluate the effects of endoluminal stent treatment in patients with esophageal anastomotic leakages or perforations in a single tertiary care center. Methods  Thirty-two consecutive patients with an intrathoracic esophageal leak, caused by esophagectomy (n = 19), transhiatal gastrectomy (n = 3), laparoscopic fundoplication (n = 2), and iatrogenic or spontaneous perforation (n = 8), undergoing endoscopic stent treatment were evaluated. Hospital stay, mortality and morbidity, sealing rate, extraction rates, complications, and long-term effects were measured. Results  Median time interval between diagnosis and stent treatment was 3 and 5 days, respectively. Eighteen patients had futile surgical closure of the defect before stenting, while in 14 patients, stent placement was the primary treatment for leakage. Stent placement was technically correct in all patients. Functional sealing was achieved in 78%. Mortality was 15.6%. Stent extraction rate was 70%. Overall method-related complications occurred in nine patients (28%). Conclusions  Implantation of self-expanding stents after esophageal resection or perforation is a feasible and safe procedure with an acceptable morbidity even if used as last-choice treatment. Dirk Tuebergen and Emile Rijcken contributed equally to this work.     

Risk Prediction Scores for Postoperative Mortality After Esophagectomy: Validation of Different Models

Background  Different prediction models for operative mortality after esophagectomy have been developed. The aim of this study is to independently validate prediction models from Philadelphia, Rotterdam, Munich, and the ASA. Methods  The scores were validated using logistic regression models in two cohorts of patients undergoing esophagectomy for cancer from Switzerland (n = 170) and Australia (n = 176). Results  All scores except ASA were significantly higher in the Australian cohort. There was no significant difference in 30-day mortality or in-hospital death between groups. The Philadelphia and Rotterdam scores had a significant predictive value for 30-day mortality (p = 0.001) and in-hospital death (p = 0.003) in the pooled cohort, but only the Philadelphia score had a significant prediction value for 30-day mortality in both cohorts. Neither score showed any predictive value for in-hospital death in Australians but were highly significant in the Swiss cohort. ASA showed only a significant predictive value for 30-day mortality in the Swiss. For in-hospital death, ASA was a significant predictor in the pooled and Swiss cohorts. The Munich score did not have any significant predictive value whatsoever. Conclusion  None of the scores can be applied generally. A better overall predictive score or specific prediction scores for each country should be developed. No score generally applicable     

Long-term Outcomes and Prognostic Factors of Elderly Patients with Hepatocellular Carcinoma Undergoing Hepatectomy

Objective  The present study aimed to evaluate the long-term outcomes and prognostic factors of elderly patients with hepatocellular carcinoma (HCC) undergoing hepatectomy. Material and Methods  From January 1983 to December 2006, 2,283 patients with HCC received hepatectomy in Sun Yat-sen University Cancer Center. The clinicopathological data and treatment outcomes of 67 elderly HCC patients (elderly group, ≥70 years of age) and 268 patients (control group, <70 years of age) who were selected randomly from the 2216 younger patients were compared retrospectively. Results  The elderly HCC patients had lower hepatitis B surface antigen-positive rate (P < 0.001), lower rate of marked α-fetoprotein elevation (P = 0.004), higher infection rate of hepatitis C virus (P = 0.010), more preoperative comorbidities (P < 0.001), higher rate of tumor encapsulation (P = 0.040), and better overall survival rate (P = 0.017); whereas there were no significant differences between these two groups in other factors, including gender ratio, liver function, accompanying cirrhosis, pathological tumor–node–metastasis (pTNM) staging, satellite nodules, vascular invasion, tumor rupture, resection margin, intraoperative blood loss, incidence of postoperative complications, hospital mortality, and disease-free survival rate. Multivariate analysis showed that pTNM staging was an independent prognostic factor of long-term survival in elderly patients with HCC. Conclusion  HCC in the elderly was less HBV-associated, less advanced, and less aggressive. Hepatectomy for selected elderly patients with HCC possibly have a better curative effect compared with younger patients. For the elderly patients without preoperative comorbidities or with controlled comorbidities, hepatectomy is a safe and effective treatment. pTNM staging is the only independent predictor of postoperative overall survival in elderly HCC patients.     

Role of Prophylactic Antibiotics in Laparoscopic Cholecystectomy: A Meta-Analysis

Background   The role of prophylactic antibiotics in laparoscopic cholecystectomy in low-risk patients is controversial. We conducted a meta-analysis to evaluate the efficacy of prophylactic antibiotics in low-risk patients (those without cholelithiasis or cholangitis) undergoing laparoscopic cholecystectomy. Methods   Multiple databases and abstracts were searched. Randomized controlled trials (RCTs) comparing prophylactic antibiotics to placebo or no antibiotics in low-risk laparoscopic cholecystectomy were included. The effects of prophylactic antibiotics were analyzed by calculating pooled estimates of overall infections, superficial wound infections, major infections, distant infections, and length of hospital stay. Separate analyses were performed for each outcome by using odds ratio or weighted mean difference. Both random and fixed effects models were used. Publication bias was assessed by funnel plot. Heterogeneity among studies was assessed by calculating I ² measure of inconsistency. Results   Nine RCTs (N = 1,437) met the inclusion criteria. No statistically significant reduction was noted for those receiving prophylactic antibiotics and those who did not for overall infectious complications (p = 0.20), superficial wound infections (p = 0.36), major infections (p = 0.97), distant infections (p = 0.28), or length of hospital stay (p = 0.77). No statistically significant publication bias or heterogeneity were noted. Conclusions   Prophylactic antibiotics do not prevent infections in low-risk patients undergoing laparoscopic cholecystectomy. Scientific Meeting: Data presented at Digestive Disease Week on 19 May 2008 at San Diego, CA.     

Improvement in respiratory function after vertebroplasty and kyphoplasty

Our objective was to study the changes in respiratory function of patients with osteoporotic vertebral compression fractures (OVCFs) after vertebroplasty and kyphoplasty. Thoracic kyphotic angle, local kyphotic angle, pain scores and pulmonary function parameters were measured in 38 older women with OVCFs before, three days after and three months after operation. Vital capacity, forced vital capacity and maximum voluntary ventilation significantly increased three days after operation (P < 0.01), but only maximum voluntary ventilation went on to improve three months later (P < 0.01); the thoracic kyphotic angle had a significantly negative correlation with vital capacity (vertebroplasty: r = −0.832; kyphoplasty: r = −0.546). In thoracic subgroups, the improvement of the local kyphotic angle and vital capacity had a remarkably positive correlation (vertebroplasty: r = 0.778; kyphoplasty: r = 0.637), and kyphoplasty could improve vital capacity more than vertebroplasty (P < 0.01). Vertebroplasty and kyphoplasty improve the lung function impaired by OVCFs, and kyphoplasty has a better effect in improving vital capacity for thoracic OVCFs.     

Clinicopathological Feature and Surgical Outcome of Choledochal Cyst in Different Age Groups: The Implication of Surgical Timing

Background/aims  Surgical resection of choledochal cysts (CC) has become standard treatment. However, surgery is not universally recommended in early infancy and/or asymptomatic patients. In order to investigate the optimal timing of CC excision, we analyzed clinicopathological data and surgical results from different age groups. Material and methods  This retrospective review included 107 patients (77 females, 30 males) who underwent CC resection at the National Taiwan University Hospital between January 1988 and December 2005. Patient demographic, clinical, and surgical data were collected and analyzed. Results  The patients were divided into three groups according to age at the time of surgery: <1 year old (group I, n = 26), 1−16 years old (group II, n = 48), and >16 years old (group III, n = 33). About two thirds of the patients in group I had jaundice, while abdominal pain related to inflammation was the commonest symptom in groups II and III. Group I suffered significantly fewer surgical complications and less severe liver fibrosis than groups II or III. Conclusion  CC surgery in infancy and in asymptomatic patients is safe and may prevent the complications of this condition. The results support a recommendation for early excision.     

Survival of Patients with Synchronous and Metachronous Colorectal Liver Metastases—is there a Difference?

Background  The aim of this study was to compare outcomes in patients with synchronous and metachronous colorectal liver metastases, with special emphasis on prognostic determinants. Study design  We analyzed prospectively collected data on 101 patients with synchronous metastases (group A) who were treated surgically during the time period from April 1998 to December 2006 in regard to overall and disease-free survival, impact of chemotherapy, as well as several serum parameters. A group of patients with metachronous colorectal liver metastases (group B) was considered for baseline comparison. Results  Twenty-three patients in group A received only an explorative laparotomy. Surgical treatment included right hepatectomy (n = 7), left hepatectomy (n = 5), right trisectionectomy (n = 10), left trisectionectomy (n = 1), left lateral resection (n = 11), and sectionectomy (n = 44). Thirty-day mortality was 3%. Morbidity was observed in 10% of the patients. One-, 3-, and 5-year overall survival rates for synchronous metastases were 86%, 68%, and 47%, respectively. The corresponding rates for metachronous metastases were 94%, 68%, and 39% (p > 0.05). Disease free survival was 74%, 42%, and 33% in group A versus 84%, 62%, and 13% in group B (p = 0.28). There was no difference in survival between patients receiving neoadjuvant chemotherapy and no chemotherapy (p > 0.05). Out of all serum parameters, carcinoembryonic antigen levels were a negative predictor for overall and disease-free survival only. Conclusions  Patients with synchronous colorectal liver metastases had a similar 5-year overall and disease-free survival, which corresponds to patients with metachronous metastases. The impact of neoadjuvant chemotherapy in patients with synchronous metastases needs to be further clarified.     

Factors Predictive of Recurrence and Mortality after Surgical Repair of Enterocutaneous Fistula

Many enterocutaneous fistulas (ECF) require operative treatment. Despite recent advances, rates of recurrence have not changed substantially. This study aims to determine factors associated with recurrence and mortality in patients submitted to surgical repair of ECF. Consecutive patients submitted to surgical repair of ECF during a 5-year period were studied. Several patient, disease, and operative variables were assessed as factors related to recurrence and mortality through univariate and multivariate analysis. There were 35 male and 36 female patients. Median age was 52 years (range, 17–81). ECF recurred in 22 patients (31%), 18 of them (82%) eventually closed with medical and/or surgical treatment. Univariate analyses disclosed noncolonic ECF origin (p = 0.04), high output (p = 0.001), and nonresective surgical options (p = 0.02) as risk factors for recurrence; the latter two remained significant after multivariate analyses. A total of 14 patients died (20%). Univariate analyses revealed risk factors for mortality at diagnosis or referral including malnutrition (p = 0.03), sepsis (p = 0.004), fluid and electrolyte imbalance (p = 0.001), and serum albumin <3 g/dl (p = 0.02). Other significant variables were interval from last abdominal operation to ECF operative treatment ≤20 weeks (p = 0.03), preoperative serum albumin <3 g/dl (p = 0.001), and age ≥55 years (p = 0.03); the latter two remained significant after multivariate analyses. Interestingly, recurrence after surgical treatment was not associated with mortality (p = 0.75). Among several studied variables, recurrence was only independently associated with high output and type of surgical treatment (operations not involving resection of ECF). Interestingly, once ECF recurred its management was as successful as non-recurrent fistulas in our series. Mortality was associated to previously-reported bad prognostic factors at diagnosis or referral.