Portal Vein Thrombosis After Hepatectomy

Background

Although various complications after hepatectomy have been reported, there have been no large studies on postoperative portal vein thrombosis (PVT) as a complication. This study evaluated the incidence, risk factors, and clinical outcomes of PVT after hepatectomy.

Methods

The preoperative and postoperative clinical characteristics of patients who underwent hepatectomy were retrospectively analyzed.

Results

A total of 208 patients were reviewed. The incidence of PVT after hepatectomy was 9.1 % (n = 19), including main portal vein (MPV) thrombosis (n = 7) and peripheral portal vein (PPV) thrombosis (n = 12). Patients with MPV thrombosis had a significantly higher incidence of right hepatectomy (p < 0.001), larger resection volume (p = 0.003), and longer operation time (p = 0.021) than patients without PVT (n = 189). Multivariate analysis identified right hepatectomy as a significant independent risk factor for MPV thrombosis (odds ratio 108.9; p < 0.001). Patients with PPV thrombosis had a significantly longer duration of Pringle maneuver than patients without PVT (p = 0.002). Among patients who underwent right hepatectomy, those with PVT (n = 6) had a significantly lower early liver regeneration rate than those without PVT (n = 13; p = 0.040), and those with PVT had deterioration of liver function on postoperative day 7. In all patients with MPV thrombosis who received anticoagulation therapy, PVT subsequently resolved.

Conclusions

Postoperative PVT after hepatectomy is not rare. It is closely related to delayed recovery of liver function and delayed liver regeneration.     

Postoperative Portomesenteric Venous Thrombosis: Lessons Learned From 1,069 Consecutive Laparoscopic Colorectal Resections

Background

Portomesenteric venous thrombosis (PVT) is a known complication after open and laparoscopic colorectal (LCR) surgery. Risk factors and the prognosis of PVT have been poorly described.

Methods

This study is a retrospective analysis of a prospectively collected database. Patients with new-onset postoperative abdominal pain were evaluated with a computed tomography scan of the abdomen. Patients found to have PVT were analyzed. A multivariate analysis was performed to identify predictors of PVT.

Results

A total of 1,069 patients undergoing LCR surgery for inflammatory bowel disease (IBD) or nonmetastatic cancer between June 2002 and June 2012 were included. Altogether, 37 (3.5 %) patients experienced symptomatic postoperative PVT. On univariate analysis, IBD (p < 0.001), ulcerative colitis (p = 0.016), preoperative therapy with steroids (p = 0.008), operative time ≥220 min (p = 0.004), total proctocolectomy (TPC) (p < 0.001), ileoanal pouch anastomosis (p = 0.006), and postoperative intraabdominal septic complications (p < 0.001) were found to be significant risk factors. By multivariate analysis, TPC (p = 0.026) and postoperative intraabdominal septic complications (p < 0.001) were independent predictors of PVT. In the PVT group, postoperative length of stay was longer (14.8 vs. 7.4 days, p < 0.001). Of the patients evaluated with a hematologic workup, 72.7 % were found to have a hypercoagulable condition. All patients were managed with oral anticoagulation for at least 6 months. No death or complications related to PVT occurred.

Conclusions

PVT is a potentially serious complication that is more likely to occur after TPC and in the presence of postoperative intraabdominal septic complications, particularly in patients with a coagulation disorder. Prompt diagnosis and treatment with oral anticoagulation are recommended to avoid long-term sequelae.     

Surgical Complications Following Liver Transplantation in Patients with Portal Vein Thrombosis—A Single-Center Perspective

Introduction

Portal vein thrombosis (PVT) was once considered a contraindication for liver transplantation (LTx) because of technical difficulties. Though no longer a contraindication, it remains a risk factor.

Aim

A study of surgical complications following LTx in patients with and without PVT.

Patients and methods

A retrospective review of 1,171 consecutive patients who underwent LTx between June 1995 and June 2007 was performed, and 78 recipients with PVT (study group) were compared with a stratified random sample of 78 contemporous recipients without PVT (control group) for postoperative complications. Both groups were comparable with respect to age, sex, race, and other confounding variables.

Results

The rate of primary nonfunction (PNF) in the study and control groups was 9.0% and 1.3%, (p?=?0.063), while that of retransplantation was 17.9% and 7.7% (p?=?0.055), respectively. The mean donor risk index (DRI) among the patients with and without PNF in the study group was 2.58?±?0.44 and 2.08?±?0.42, respectively (p?=?0.014). A significantly higher number of packed red blood cells and fresh frozen plasma transfusions were observed in study group compared to controls (p?=?0.012, 0.007, respectively).

Conclusion

A higher rate of PNF was related to the complexity of the surgical procedure and the use of donor livers with a high DRI. Higher rates of PNF eventually led to a higher rate of retransplant. A strategy of offering donor livers with a low DRI might be helpful in decreasing the rate of PNF. Further, a PV interposition graft in difficult cases instead of thrombectomy could lead to a lower rethrombosis rate.     

Short-Term but Not Long-Term Loss of Patency of Venous Reconstruction During Pancreatic Resection Is Associated with Decreased Survival

Background

Pancreatic surgery with vascular reconstruction is increasingly performed to offer the benefits of surgical resection to patients with locally advanced disease. The short- and long-term patency rates and the clinical significance of thrombosis of such reconstructions are unknown.

Methods

We reviewed pancreatectomies requiring venous reconstruction from 1994 to 2011. We sought to identify predictors of acute (within 30 days) and late thrombosis. We compared survival of patients with thrombosis to patients with patent reconstructions.

Results

Of 203 pancreatectomies requiring venous reconstruction, acute thrombosis occurred in nine (4.4 %) cases and was associated with increased perioperative mortality (22.2 versus 4.6 %, p?=?0.023). Even when nonfatal, acute thrombosis was associated with decreased median survival (7.1 versus 15.9 months, p?=?0.011) and increased hazard of death (hazard ratio 8.6, confidence interval 3.7–19.9, p?<?0.001). A late loss of patency was seen in 31.2 % of cases at a median of 9.5 months. Later loss of patency was not associated with decreased median survival or increased hazard of death.

Conclusions

Acute thrombosis of the portal venous reconstructions after pancreatectomy is associated with increased perioperative mortality and, even when nonfatal, is associated with decreased survival. Late loss of patency occurs in one-third of patients but does not affect survival.     

Analysis of cerebrospinal fluid flow dynamics and morphology in Chiari I malformation with cine phase-contrast magnetic resonance imaging

Background

To determine cerebrospinal fluid (CSF) dynamics and morphology in Chiari I malformation (CMI) and assess the response to surgery of the posterior cranial fossa, we examined midsagittal imaging along with anterior cervical 2-3 (AC2-3), posterior cervical 2-3 (PC2-3), and aqueduct CSF flow hydrodynamics in axial imaging by using cine phase-contrast magnetic resonance imaging (PCMR).

Method

We examined 52 patients with CMI, both with and without syringomyelia (SM), pre-/post-surgery, and compared them to 17 healthy volunteers. Statistical analyses included paired t-tests, independent-samples t-tests, binary logistic regression, and crosstab with MedCalc software.

Results

Patients with CMI had significantly shorter clivus length and larger tentorial angle than the healthy controls (P?=?0.004, P?=?0.019, respectively). The AC2-3 cranial/caudal peak velocity (PV), PC2-3 cranial/caudal PV and aqueduct cranial peak PV of patients with CMI were significantly lower than healthy volunteers pre-surgery (P?=?0.034 AC2-3 cranial PV, P?=?0.000002 AC2-3 caudal PV; P?=?0.046 PC2-3 cranial PV, P?=?0.015 PC2-3 caudal PV; P?=?0.022 aqueduct cranial PV) and increased after surgery (P?=?0.024 AC2-3 cranial PV, P?=?0.002 AC2-3 caudal PV; P?=?0.001 PC2-3 cranial PV, P?=?0.032 PC2-3 caudal PV; P?=?0.003 aqueduct cranial PV). The aqueduct caudal PV of patients with CMI was higher than that of healthy controls (P?=?0.004) and decreased post-surgery (P?=?0.012). Patients with pre-surgery PC2-3 cranial PV >2.63 cm/s and aqueduct cranial PV >2.13 cm/s, respectively, experienced primary symptom improvement after surgery.

Conclusions

The innate bony dysontogenesis in patients with CMI contributes to tonsilar ectopia and exacerbates CSF flow obstruction. A pressure gradient that existed between SM and SAS supports the perivascular space theory that is used to explain SM formation. Our findings demonstrate that PCMR maybe a useful tool for predicting patient prognosis.     

Risk Factors of Portal Vein Thrombosis in Crohn’s Disease Patients

Introduction

Patients with inflammatory bowel disease, such as Crohn??s disease (CD), suffer from a threefold increase in the risk of venous thromboembolism. Small bowel, segmental bowel, or ileocolonic resection to treat Crohn??s disease can lead to rare complications of portal vein thrombosis (PVT), which can lead to further poor health outcomes, such as small bowel ischemia. The study attempts to find different risk factors that may be associated with postoperative complications of PVT in Crohn??s disease patients.

Methods

In a 1 to 3 case?Ccontrol study following Institutional Review Board approval, 13 Crohn??s disease patients with documented radiological postoperative diagnosis of PVT from 2004 to 2011 and 39 CD patients who did not have postoperative PVT were matched by retrospective chart review for patient demographics, preoperative course and workup, anticoagulant use, and operative procedure. Univariate analysis was performed to draw correlations on risk factors for the development of PVT.

Results

In the 13 CD patients with PVT, concurrent cancer, liver disease, and dyslipidemia were present in 23.1%, 23.1%, and 15.4% of the population, respectively. Compared to the 39 CD only patients, concurrent cancer, liver disease, and dyslipidemia were present in only 2.6%, 2.6%, and 0% of the population, respectively. Of the CD patients with PVT, 61.5% were on preoperative steroids compared to 28.9% of the CD only patients. PVT development in CD patients is correlated with concurrent cancer (p?=?0.016), liver disease (p?=?0.016), dyslipidemia (p?=?0.012), and preoperative steroid usage (p?=?0.036).

Conclusions

Concurrent cancer, liver disease, dyslipidemia, and preoperative steroid usage were risk factors associated with the development of PVT in Crohn??s patients. Since there is limited literature on PVT in CD, more data needs to be collected, and additional studies should be done to further assess the prevention, diagnosis, and management of the disease.     

Perioperative Outcomes of Pancreaticoduodenectomy Compared to Total Pancreatectomy for Neoplasia

Purpose

Total pancreatectomy (TP) eliminates the risk and morbidity of pancreatic leak after pancreaticoduodenectomy (PD). However, TP is a more extensive procedure with guaranteed endocrine and exocrine insufficiency. Previous studies conflict on the net benefit of TP.

Methodology

A comparison of patients undergoing non-emergent, curative-intent TP or PD for pancreatic neoplasia using the National Surgical Quality Improvement Project data from 2005–2011 was done. Main outcome measures were mortality and major and minor morbidities.

Results

Of the 6,314 (97 %) who underwent PD and the 198 (3 %) who underwent TP, malignancy was present in 84 % of patients. The two groups were comparable at baseline. Mortality was higher after TP (6.1 %) than DP (3.1 %), p?=?0.02. Adjusting for differences on multivariable analysis, TP carried increased mortality (OR 2.64, 95 % CI 1.3–5.2, p?=?0.005). TP was also associated with increased rates of major morbidity (38 vs. 30 %, p?=?0.02) and blood transfusion (16 vs. 10 %, p?=?0.01). Infectious and septic complications occurred equally in both groups.

Conclusion

The morbidity of a pancreatic fistula can be eliminated by TP. However, based on our findings, TP is associated with increased major morbidity and mortality. TP cannot be routinely recommended for to reduce perioperative morbidity when pancreaticoduodenectomy is an appropriate surgical option.     

Sinovenous thrombosis associated with skull fracture in the setting of blunt head trauma

Background

Emerging literature suggests that closed head injuries may be an important etiology of cerebral venous sinus thrombosis (CVST). Fractures over the dural sinuses, in particular, may predispose such patients to this secondary complication. The purpose of this study was to determine the incidence and characteristics of CVST resulting from skull fractures overlying cerebral venous sinuses at a single tertiary care center.

Methods

A retrospective review of consecutive patients presenting to our institution with skull fractures from blunt head trauma between 1 January 2009 and 31 December 2011 who underwent either a computed tomography (CT) or magnetic resonance (MR) venogram. Patient demographics, associated intracranial injuries, admission Glasgow Coma Scale (GCS), presence of CVST, and post-hospital disposition were recorded.

Results

Overall, 908 patients with skull fractures presented to the institution. Of those, 63 had fractures over a sinus and a venogram satisfying inclusion criteria. Twenty-two (34.9 %) patients demonstrated a thrombus in at least one sinus. There was no statistical difference in patient demographics, presenting GCS, length of stay (LOS), or outcome between patients with or without a thrombus. Pediatric patients had significantly shorter LOS (11 vs. 4 days, p?<?0.01) compared to adults. Adults had a greater incidence of total sinus occlusions while children had more non-occlusive thrombus formations; both were statistically significant (p?=?0.035 and p?=?0.037, respectively).

Conclusions

This report suggests that over 10 % of skull fractures involve cerebral venous sinuses, thus emphasizing the need to rule out CVST in patients suffering blunt head trauma. We propose including a venogram as part of the initial trauma work-up for these patients. Moreover, our data suggest that pediatric patients may be predisposed to less severe injuries than their adult counterparts.     

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.     

Pyogenic Liver Abscess Following Pancreaticoduodenectomy: Risk Factors,Treatment, and Long-Term Outcome

Background

Pancreaticoduodenectomy (PD) remains a challenging operation with a 40 % postoperative complication rate. Pyogenic liver abscess (PLA) is an uncommon complication following PD with little information on its incidence or treatment. This study was done to examine the incidence, risk factors, treatment, and long-term outcome of PLA after PD.

Methods

We retrospectively reviewed 1,189 patients undergoing PD (N?=?839) or distal pancreatectomy (DP) (N?=?350) at a single institution over a 14-year period (January 1, 1994–January 1, 2008). Pancreatic databases (PD and DP) were queried for postoperative complications and cross-checked through a hospital-wide database using ICD-9 codes 572.0 (PLA) and 006.3 (amebic liver abscess) as primary or secondary diagnoses. No PLA occurred following DP. Twenty-two patients (2.6 %) developed PLA following PD. These 22 patients were matched (1:3) for age, gender, year of operation, and indication for surgery with 66 patients without PLA following PD.

Results

PLA occurred in 2.6 % (22/839) of patients following PD, with 13 patients (59.1 %) having a solitary abscess and 9 (40.9 %) multiple abscesses. Treatment involved antibiotics and percutaneous drainage (N?=?15, 68.2 %) or antibiotics alone (N?=?7, 31.8 %) with a mean hospital stay of 12 days. No patient required surgical drainage, two abscesses recurred, and all subsequently resolved. Three patients (14 %) died related to PLA. Postoperatively, patients with biliary fistula (13.6 vs. 0 %, p?=?0.014) or who required reoperation (18.2 vs. 1.5 %, p?=?0.013) had a significantly higher rate of PLA than matched controls. Long-term follow-up showed equivalent 1-year (79 vs.74 %), 2-year (50 vs. 57 %), and 3-year (38 vs. 33 %) survival rates and hepatic function between patients with PLA and matched controls.

Conclusions

Postoperative biliary fistula and need for reoperation are risk factors for PLA following PD. Antibiotics and selective percutaneous drainage was effective in 86 % of patients with no adverse effects on long-term hepatic function or survival.     

Usefulness of Contrast-Enhanced Intraoperative Ultrasonography (CE-IOUS) in Patients with Colorectal Liver Metastases after Preoperative Chemotherapy

Aims

The aim of this study was to evaluate the ability of contrast-enhanced intraoperative ultrasonography to detect colorectal liver metastases after preoperative chemotherapy compared with intraoperative ultrasound and preoperative imaging techniques.

Methods

From January 2010 to December 2011, 28 patients with colorectal liver metastases underwent intraoperative ultrasonography and contrast-enhanced intraoperative ultrasonography during hepatectomy following preoperative chemotherapy. The findings were compared to preoperative imaging using contrast-enhanced ultrasonography, computed tomography, magnetic resonance imaging, and/or fluorodeoxyglucose positron emission tomography.

Results

Preoperative imaging techniques detected 58 metastatic lesions in 28 patients. In 32 % of patients (n?=?9), intraoperative ultrasound detected 24 missed hepatic nodules. In 14 % of patients (n?=?4), contrast-enhanced intraoperative ultrasonography detected an additional six nodules and change in operative management occurred in 18 % of patients. Using univariate analysis, we found three factors significantly related to detection of additional metastases with contrast-enhanced intraoperative ultrasonography: three or more metastases before chemotherapy (p?=?0.047), resolution of at least one metastasis (p?=?0.011), and small liver metastases (largest lesion size ≤20 mm) after chemotherapy (p?=?0.007).

Conclusion

In patients undergoing surgery for colorectal liver metastases after chemotherapy, contrast-enhanced intraoperative ultrasonography improved both the sensitivity of intraoperative ultrasonography to detect liver metastases and the R0 hepatic resection rate.     

Outcomes of Laparoscopic Sleeve Gastrectomy in Patients Older than 60 Years

Background

Morbidity and mortality following laparoscopic sleeve gastrectomy (LSG) occur at acceptable rates, but its safety and efficacy in the elderly are unknown.

Methods

A retrospective review was performed of all patients aged >60 years who underwent LSG from 2008 to 2012. These patients were 1:2 matched, by gender and body mass index (BMI) to young patients, 18?<?age?<?50. Data analyzed included demographics, preoperative and postoperative BMI, postoperative complications, and improvement or resolution of obesity-related comorbidities.

Results

Fifty-two morbid obese patients older than 60 years underwent LSG (mean age, 62.9?±?0.3 years). These were matched to 104 young patients, age 18–50 years (mean age, 35.7?±?0.8 years). Groups did not differ in male gender (44 vs. 43 %, p?=?0.9), preoperative BMI (42.6?±?0.7 vs. 42.6?±?0.6, p?=?0.97), and length of follow-up (17?±?2 vs. 22?±?1.4 months, p?=?0.06). Obesity-related comorbidities were significantly higher in the older group (96 vs. 65 %, p?<?0.001). Excess weight loss (EWL) was higher in the younger group (75?±?2.4 vs. 62?±?3 %, p?=?0.001). Older patients had a significantly higher rate of a concurrent hiatal hernia repair (23 vs. 1.9 %, p?<?0.001). Overall postoperative minor complication rate was higher in the older group (25 vs. 4.8 %, p?<?0.001). This included atrial fibrillation (9.5 %), urinary tract infection (7 %), trocar site hernia (4 %), dysphagia, surgical site infection, bleeding, bowel obstruction, colitis, and nutritional deficiency (2 %, each). No perioperative mortality occurred. Comorbidity resolution or improvement was comparable between groups (88 vs. 80 %, p?=?0.13).

Conclusions

LSG is safe and very efficient in patients aged >60, despite higher rates of perioperative comorbidities.     

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.     

Pancreatic thickness as a predictive factor for postoperative pancreatic fistula after distal pancreatectomy using an endopath stapler

Purpose

No consistent risk factor has yet been established for the development of pancreatic fistula (PF) after distal pancreatectomy (DP) with a stapler.

Methods

A total of 31 consecutive patients underwent DP with an endopath stapler between June 2006 and December 2010 using a slow parenchymal flattening technique. The risk factors for PF after DP with an endopath stapler were identified based on univariate and multivariate analyses.

Results

Clinical PF developed in 7 of 31 (22 %) patients who underwent DP with a stapler. The pancreata were significantly thicker at the transection line in patients with PF (19.4 ± 1.47 mm) in comparison to patients without PF (12.6 ± 0.79 mm; p = 0.0003). A 16-mm cut-off for pancreatic thickness was established based on the receiver operating characteristic (ROC) curve; the area under the ROC curve was 0.875 (p = 0.0215). Pancreatic thickness (p = 0.0006) and blood transfusion (p = 0.028) were associated with postoperative PF in a univariate analysis. Pancreatic thickness was the only significant independent factor (odds ratio 9.99; p = 0.036) according to a multivariate analysis with a specificity of 72 %, and a sensitivity of 85 %.

Conclusion

Pancreatic thickness is a significant independent risk factor for PF development after DP with an endopath stapler. The stapler technique is thus considered to be an appropriate modality in patients with a pancreatic thicknesses of <16 mm.     

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.     

Is it worthwhile to preserve adult spleen in laparoscopic distal pancreatectomy? Perioperative and patient-reported outcome analysis

Background

Despite the emphasis on its role, the spleen has commonly been removed in distal pancreatectomy. We designed this study to evaluate the efficacy of spleen salvage during laparoscopic distal pancreatectomy for patients with benign and borderline malignant tumors.

Materials and methods

From February 2005 to December 2010, 40 patients underwent spleen-preserving laparoscopic distal pancreatectomy (Sp-Lap DP) and 32 patients underwent laparoscopic distal pancreatosplenectomy (Lap DPS). Medical records were retrospectively reviewed, and a specially designed questionnaire was administered to the patients for the follow-up study.

Results

The demographics and final diagnoses were similar between the two groups. The operative time was significantly longer in the Sp-Lap DP group (303.9?±?136.0 versus 239.0?±?94.9?min, p?=?0.024). Patients in the Lap DPS group had more postoperative pancreatic fistulas of higher grade (p?=?0.026). A higher grade of postoperative complications occurred more frequently in the Lap DPS group (p?=?0.003). Consequently, postoperative hospital stay was significantly shorter for Sp-Lap DP than for Lap DPS patients (7.1?±?2.3 versus 12.5?±?10.8?days, p?=?0.004). On the follow-up survey, episodes of common cold or flu were apparently more frequent in the Lap DPS group (p?=?0.026). Despite the similar recovery period between the two groups, significantly more patients who underwent Lap DPS felt fatigue (p?=?0.014) and poorer health condition (p?=?0.042).

Conclusions

In addition to frequent higher-grade complications and prolonged hospital stays, Lap DPS appeared to impair patient quality of life based on follow-up survey. Even an effort to preserve adult spleen in distal pancreatectomy is worthwhile.     

Laparoscopic Gastric Bypass Versus Laparoscopic Sleeve Gastrectomy as a Definitive Surgical Procedure for Morbid Obesity. Mid-Term Results

Background

Laparoscopic sleeve gastrectomy (LSG) has been gaining acceptance because it has shown good short- and mid-term results as a single procedure for morbid obesity. The aim of this study was to compare short- and mid-term results between laparoscopic Roux-en-Y gastric bypass (LRYGB) and LSG.

Methods

Observational retrospective study from a prospective database of patients undergoing LRYGB and LSG between 2004 and 2011, where 249 patients (mean age 44.7 years) were included. Patients were followed at 1, 3, 6, 12, and 18 months, and annually thereafter. Short- and mid-term weight loss, comorbidity improvement or resolution, postoperative complications, re-interventions, and mortality were evaluated.

Results

One hundred thirty-five LRYGB and 114 LSG were included. Significant statistical differences between LRYGB and LSG were found in operative time (153 vs. 93 min. p?<?0.001), minor postoperative complications (21.5 % vs. 4.4 %, p?=?0.005), blood transfusions (8.8 % vs. 1.7 %, p?=?0.015), and length of hospital stay (4 vs. 3 days, p?<?0.001). There were no differences regarding major complications and re-interventions. There was no surgery-related mortality. The percentage of excess weight loss up to 4 years was similar in both groups (66?±?13.7 vs. 65?±?14.9 %). Both techniques showed similar results in comorbidities improvement or resolution at 1 year.

Conclusions

There is a similar short- and mid-term weight loss and 1-year comorbidity improvement or resolution between LRYGB and LSG, although minor complication rate is higher for LRYGB. Results of LSG as a single procedure need to be confirmed after a long-term follow-up.     

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.     

Perioperative Strategies and Thrombophilia in Children with Extrahepatic Portal Vein Obstruction Undergoing the Meso-Rex Bypass

Background/Purpose

Extrahepatic portal vein obstruction (EHPVO) is an important cause of chronic portal hypertension in children. Although usually idiopathic in etiology, genetic and acquired thrombophilia have been implicated in EHPVO. Meso-Rex bypass is increasingly used to treat EHPVO in children.

Objective

The objective of this study is to assess the relationship of postoperative anticoagulation strategies and thrombophilic risk factors to the development of bypass thrombosis following the meso-Rex bypass.

Methods

Records of children who underwent meso-Rex bypass for EHPVO at a single institution from 1999 to 2009 were reviewed, and preoperative thrombophilia testing, perioperative anticoagulation strategies, and postoperative bypass patency based on imaging at last follow-up were examined.

Results

Sixty-five children with EHPVO underwent a first time meso-Rex bypass during the study period, and 9 of 65 (14 %) developed bypass thrombosis. The use of warfarin in the postoperative period was more common among children with thrombosed shunts than among those with open shunts [63 % vs. 20 %; OR, 6.5 (95 % CI, 1.3–31.5), p?=?0.022]. The contribution of genetic or acquired thrombophilia to shunt thrombosis was inconclusive given variability in testing.

Conclusions

Choice of anticoagulation following meso-Rex bypass may affect postoperative incidence of bypass thrombosis. Role of thrombophilic risk factors in the development of shunt thrombosis remains unclear.     

Simultaneous Versus Staged Bilateral Total Knee Arthroplasty

Background

An important source of debate in many orthopaedic practices is the choice of performing simultaneous or staged bilateral total knee arthroplasty.

Questions/Purpose

The objective of this meta-analysis is to compare simultaneous bilateral with staged bilateral total knee arthroplasty for peri-operative complication rates, infection rates and mortality outcomes.

Methods

All relevant citations were retrieved from MEDLINE, EMBASE, COCHRANE databases and the unpublished literature. Included studies were assessed for methodological quality and abstracted data was conducted independently by two reviewers. Data was categorized into subgroups and pooled using the DerSimonian and Laird’s random effects model.

Results

A total of 18 articles were identified from 873 potentially relevant titles and selected for inclusion in the primary meta-analyses. The incidence of mortality was significantly higher in the simultaneous group at 30 days (RR [relative risk] 3.67, 95% confidence interval [CI] 1.68–8.02, p?=?0.001, I ²?=?59%, n?=?67,691 patients), 3 months (RR 2.45, 95% CI 2.15–2.79, p?<?0.00001, I ²?=?0%, n?=?66,142 patients) and 1 year (RR 1.85, 95% CI 1.66–2.06, p?<?0.001, I ²?=?0%, n?=?65,322 patients) after surgery. However, there were no significant differences between the two groups in regards to in-hospital mortality rates (R 1.18, 95% CI 0.74–1.88, p?=?0.48, I ²?=?0%, n?=?33,814 patients). In addition, there was no increased risk of deep vein thrombosis, cardiac complication, and pulmonary embolism or infection rates in either comparison group.

Conclusions

The results of the analysis suggest that simultaneous bilateral total knee arthroplasty has a significantly higher rate of mortality at 30 days, 3 months and 1 year after surgery, but similar infection and complication rates in comparison to staged bilateral total knee arthroplasty.