Diagnosis and management of postoperative pancreatic fistula

Background

Postoperative pancreatic fistula (POPF) is the leading complication after partial pancreatic resection and is associated with increased length of hospital stay and resource utilization. The introduction of a common definition in 2005 by the International Study Group of Pancreatic Surgery (ISGPS), which has been since employed in the vast majority of reports, has allowed a reliable comparison of surgical results. Despite the systematic investigation of risk factors and of surgical techniques, the incidence of POPF did not change in recent years, whereas the associated mortality has decreased.

Purpose

The purposes of this review article were to summarize the current evidence on the diagnosis and management strategies of POPF and to provide a concise reference for the practicing surgeons and physicians.

Conclusion

The high incidence of POPF was accompanied by a shift from operative to non-operative management. However, the current management strategy is driven by the patient’s condition and local expertise and is generally based on poor evidence. A randomized trial showed that enteral nutrition is superior to total parenteral nutrition, and pooled data of randomized trials failed to show any advantage of somatostatin analogs for accelerating fistula closure. The choice of percutaneous versus endoscopic drainage of peripancreatic collections remains arbitrary, and—when re-operation is needed—there are very few comparative data regarding local drainage with or without main pancreatic stenting as opposed to anastomotic revision or salvage re-anastomosis. The continuous development of specialist, high-volume units with appropriate resources and multidisciplinary experience in complication management might further improve the evidence and the outcomes.     

Small bowel enterocutaneous fistulae: the merits of early surgery

Background

The treatment of patients with small bowel enterocutaneous fistulas is complex and a challenge for every surgeon. The mortality and morbidity associated with only conservative management is often high and expensive because most patients cannot afford prolonged parenteral nutrition which itself carries a high incidence of complications. Although operations are difficult if performed early they may be lifesaving in our situation. The focus of our study was to determine whether, in patients with fistulae, early intervention resulted in low mortality and morbidity rates and to identify prognostic factors for fistula closure and mortality.

Patients and methods

Between August 1996 and July 2008 we treated 64 consecutive patients with small bowel enterocutaneous fistulae. There were 28 females and 36 males patients who had a mean age of 42.4 years. 49 (77%) of the fistulae resulted from surgical complications. Our policy was to intervene early once the patient was fit for a procedure.

Results

In 4 patients (6.2%) the fistulae arose from the jejunum and in the remaining 94% from the ileum. Octreotide was administered in 49 (77%) patients. To maintain the nutrition of the patients enteral feeding was used in 47 (73%) while re-feeding of the proximal gut fistula output into the distal stoma was used in 7 patients. Spontaneous closure occurred in 10 patients (16%). There were 9 deaths (14%). Fifty-two patients (81%) required surgical intervention at some stage. A strong relationship was found between their preoperative albumin levels and and mortality.

Conclusion

Aggressive early surgical treatment with the judicious use of nutritional support, stoma care, octreotide, and control of sepsis results in a low mortality in patients with small intestinal fistulae. Preoperative hypoalbuminaemia is an important prognostic variable.     

Laparoscopic Roux limb Placement over a Fistula Defect Without Mucosa-to-Mucosa Anastomosis: a Modified Technique for Surgical Management of Chronic Proximal Fistulas After Laparoscopic Sleeve Gastrectomy

Background

Laparoscopic sleeve gastrectomy (LSG) is an increasingly popular bariatric procedure. A chronic fistula at the esophago-gastric junction (EGJ) is a rare but life-threatening complication of this procedure whose causes are still unclear and management is still controversial.

Methods

A 41-year-old woman with a body mass index (BMI) of 38 developed an EGJ leak 6 days post-LSG. Despite initial control with conservative measures, the leak persisted and resulted in a left pleural abscess and a broncho-pleural fistula requiring thoracotomy with resection of the abscessed lung parenchyma. Endoscopic and drainage procedures failed to prevent subdiaphragmatic recurring collection due to the persistent fistula. Nineteen months after LSG, a Roux limb was placed on the EGJ and sutured side to side around the fistula defect, without mucosa-to-mucosa anastomosis.

Results

The postoperative course was uneventful and, 20 months later (39 months post-LSG), the patient is well with a BMI of 27.

Conclusions

Laparoscopic apposition of a Roux-en-Y limb without mucosa-to-mucosa anastomosis as an efferent path to drain the undebrided fistula defect can effectively treat chronic leaks at the EGJ after LSG.     

Disease-specific nutrition therapy: one size does not fit all

Introduction

The delivery of adequate nutrition is an integral part of the care of the critically ill surgical patient, and the provision of nutrition may have a greater impact on outcome than many other therapies commonly employed in the treatment of certain disease states.

Methods

A review of the existing literature was performed to summarize the evidence for utilizing disease-specific nutrition in critically ill surgical patients.

Results

Enteral nutrition, unless specifically contraindicated, is always preferable to parenteral nutrition. Methodological heterogeneity and conflicting results plague research in immunonutrition, and routine use is not currently recommended in critically ill patients.

Conclusion

There is currently insufficient evidence to recommend the routine initial use of most disease-specific formulas, as most patients with the disease in question will tolerate standard enteral formulas. However, the clinician should closely monitor for signs of intolerance and utilize disease-specific formulas when appropriate.     

Unterkiefergelenkfortsatzfrakturen

Background

The discussion about the therapy of condyloid process fractures is still controversial even after 90 years.

Methods

After 80 years of using the same modalities for conservative therapy, the situation has changed dramatically with the introduction of functionally stable osteosynthesis of condyloid process fractures.

Results

Prospective randomized studies have shown better or comparable results for operative compared to conservative therapy. The current rule for the complete mandible is that the greater the displacement, the greater the indications for operative therapy. After informed consent both patient and physician must jointly decide on the form of treatment.     

Kindliche Ureterabgangsstenose in einem Zuweisungszentrum

Background

Ureteropelvic junction obstruction is the most frequent malformation of the upper urinary tract and treatment with conservative or operative management remains controversial. In this study we present the retrospective analysis of 129 children with ureteropelvic junction obstruction who underwent conservative or operative management.

Material and methods

A total of 129 children with ureteropelvic junction obstruction, who were treated in the department of pediatric nephrology at the University of Essen from 1998–2005, were included into the analysis. Clinical charts were reviewed for the parameters urinary tract infections (total number, severity, bacteriology), antibiotics, ultrasound, Tc-99 diuresis renography, and management (conservative or operative). Statistical analysis was performed using the SPSS software (Version 11.0)

Results

A total of 89 urinary tract infections was observed in 52 children. The mean width of renal pelvis was 3.04±1.33 cm in the operative group and 1.98±1.2 cm in the conservative group (p=0.001, ANOVA test). Tc-99 diuresis renography was performed in 70 children of which 46 children received primarily conservative management and 24 children were operated. In the conservative group 6 children underwent pyeloplasty later on due to aggravation of renal function. In 59 out of 129 cases diuresis nephrography was not performed due to only mild ectasia.

Conclusions

This study demonstrates that conservative management is safe in children with ureteropelvic junction obstruction with no or only little constricted renal function, if a close-meshed surveillance protocol is followed and parental compliance is given.     

Wirbelsäulenverletzung im Sport

Background

The management of patients with sport-related injuries of the spine is a challenging issue with regard to the ability to resume former sport activities. The current study analyses the rate of resumption of sports participation after conservative and operative treatment.

Methods

In a 2-year period, 96 patients with sport-related injuries of the thoracic and lumbar spine were included in this prospective study. Conservative (19%) or operative treatment (81%) was performed depending on the extent, severity and instability of the trauma. The reduction, the loss of reduction over time and the VAS and Odom scores were assessed. A questionnaire was included to estimate the rate of resumption of sports participation.

Results

Of the patients 91% resumed sports participation and 9% had to abandon all sport activities mostly due to neurological deficits. Minor loss of correction was found in patients with 360° short segment fusions and major loss was found after conservative treatment.

Conclusion

The current management of injuries of the spine effectuates a high rate of resumption of sports activity following conservative or operative treatment.     

Operative vs. konservative Therapie nichtdislozierter Skaphoidfrakturen

Purpose

Within a prospective, multicenter cohort study we investigated whether operative treatment of scaphoid bone fractures leads to earlier return to previous activity levels.

Methods

Only isolated, acute, complete, stable and non-displaced fractures of the mid-third of the scaphoid bone were included. A total of 94 patients with the same number of fractures were recruited. In the operative group, fractures were fixed with a cannulated screw and had postoperative splint immobilization for a maximum of 1 week. In the conservative group a short arm cast was applied until fracture union was achieved. Both groups were followed for 6 months.

Results

By 15 weeks patients receiving surgical treatment had returned significantly earlier to their full time work and home activities and achieved significantly better results for functional status, pain, and overall satisfaction. However, after screw fixation, complication rates concerning union and secondary operative management were higher.

Conclusion

Operative treatment primarily facilitates earlier return to previous activity levels, as well as better functional status, less pain and higher patient satisfaction, but conservative treatment seems to be safer and associated with a lower complication rate.     

Konservative Therapie mit einem Brace bei periprothetischer Humerusfraktur

Background

Due to the increasing number of implanted shoulder prostheses following trauma or omarthritis in the recent past, an increase in the occurrence of periprosthetic humeral fractures is to be expected in the future.

Problem

For type B fractures according to Worland the current literature clearly recommends operative treatment with fixed angle plate osteosynthesis or a long-stemmed cement-free revision endoprosthesis. This article presents a case study on the clinical and radiological results of a conservatively treated periprosthetic humeral fracture (Wright type B or type B2 according to Worland) and a discussion of the current literature.

Material and methods

A 70-year-old woman was diagnosed with a periprosthetic humeral fracture with an enclosed fracture endoprosthesis (Wright type B). The operative treatment with fixed angle plate osteosynthesis and the alternative conservative therapy with a brace construct were discussed with the patient. The patient decided on the conservative therapy with regular radiological course control.

Results

The conservative therapy of periprosthetic type B2 humeral fractures according to Worland using retention in an upper arm brace can lead to excellent radiological and functional results     

Predictive factors for pancreatic fistula following pancreatectomy

Background

Postoperative pancreatic fistula is a significant contributor to morbidity following proximal and distal pancreatic resections. In recent decades, the incidence of fistula has ranged from 2 to 33 %; however, the consistent identification of risk factors has been difficult due to significant variability in the definition of pancreatic fistula.

Purpose

The purpose of this study was to use the highest level evidence available in the literature to present risk factors thus far identified as significant predictors of fistula occurrence. Another endpoint will address those risk factors which have been shown to have a clinical impact on the patient. This review will conclude by discussing comprehensive risk models that interpret the aggregate fistula risk for a patient based on the presence of weighted risk factors.

Conclusion

The contemporary surgical literature suggests many risk factors for fistula development, which can be categorized as either endogenous, operative, or perioperative. The advent of the International Study Group of Pancreatic Fistula (ISGPF) scheme created universal definitions for fistula that delineate between biochemical and clinically relevant fistulas. This classification system has allowed for the elucidation of risk factors for clinically impactful fistula and enabled the development of risk scores for predicting fistula occurrence after major pancreatic resections, which are useful in clinical management and comparative research.     

Role of CT angiography with three-dimensional reconstruction of mesenteric vessels in laparoscopic colorectal resections: a randomized controlled trial

Background

Laparoscopic surgery, despite its well-known advantages and continuous technological innovations, still has limitations such as the lack of tactile sensation and reduced view of the operative field. These limitations are particularly evident when performing laparoscopic colorectal resection due to the variability of the number and course of mesenteric vessels. Today, the patient’s vascular anatomy can be mapped using computed tomography (CT) angiography and processing of the images with rendering software to reconstruct a three-dimensional model of the mesenteric vessels. To assess how prior knowledge of the patient’s mesenteric vascular anatomy represents an advantage when performing laparoscopic colorectal resections, we conducted a randomized, parallel, single-blinded controlled trial.

Methods

From January 2010 to January 2012, all patients with surgical indication to undergo standardized right or left hemicolectomy and anterior rectal resections were randomly assigned to two groups and subjected to CT angiography with three-dimensional reconstruction of mesenteric vessels. In the first group the surgeon was able to view the 3D reconstruction before and during surgery, while in the second group the surgeon was only able to view the 3D reconstruction after surgery.

Results

Evaluation of data from 112 patients shows statistically significantly lower operative time, episodes of difficult identification of right anatomy, and incidence of intraoperative and postoperative complication related to difficult or erroneous identification of mesenteric vessels in the group in which the surgeon was able to view the 3D reconstruction before and during surgery compared with the control group.

Conclusion

This study shows that prior knowledge of the patient’s mesenteric vascular anatomy represents an advantage when performing laparoscopic colorectal resection. Registration number NCT01540448 (http://www.clinicaltrials.gov).     

Totally implantable venous access devices in surgical patients: Our 3-year experience

Aim-Background

Totally implantable central venous access devices (TIVADs) are commonly used in patients to administer chemotherapy or long-term parenteral nutrition. In the present article, we report our experience with TIVADs.

Patients-Methods

In the period between 1 January 2009 and 31 December 2011, a total of 64 patients (18 men, 46 women) with an average age of 57 years (41–79 years) underwent implantation of a central vein catheter in an outpatient or inpatient setting. The indications were chemotherapy (n=60) and total parenteral nutrition (n=4).

Results

The cancer patients had been operated on for cancer of the colon (n=26), cancer of breast (n=23), stomach cancer (n=8) and haematologic malignancies (n=3). The other 4 patients had small intestine syndrome after extensive resection of the small intestine for mesenteric ischaemia. The median follow-up duration was 8.8 months (range 0.2–33 months). All intraports were inserted via the subclavian vein by the same surgical team using the aseptic percutaneous access technique. The complications included thrombosis in two cases (3.1%), followed by infection of the tip in one case (1.6%). No other complications or deaths were reported.

Conclusions

We confirm that the use of subcutaneous ports in adults with cancer or malnutrition is feasible for the majority of patients with low morbidity and absence of mortality. To avoid complications, the surgery team needs to be very experienced in regard to the positioning of the catheters. Furthermore, daily management of the catheters is of paramount importance.     

Endoscopic treatment of Roux-en-Y gastric bypass-related gastrocutaneous fistulas using a novel biomaterial

Background

Roux-en-Y gastric bypass (RYGB) is amongst the commonest surgical intervention for weight loss in obese patients. Gastrocutaneous fistula, which usually occurs along the vertical staple line of the pouch, is amongst its most alarming complications. Medical management comprised of wound drainage, nutritional support, acid suppression, and antibiotics may be ineffective in as many as a third of patients with this complication. We present outcomes after endoscopic application of SurgiSIS^®, which is a novel biomaterial for the treatment of this complication.

Design

A case series of 25 patients.

Methods

Twenty-five patients who had failed conservative medical management of gastrocutaneous fistula after RYGB underwent endoscopic application of SurgiSIS^®—an acellular fibrogenic matrix biomaterial to help fistula healing.

Main outcome measures

Fistula closure as assessed by upper gastrointestinal imaging and endoscopic examination.

Results

In patients who had failed medical management lasting 4–25 (median, 7) weeks, closure of the fistulous tract was successful after one application in six patients (30%), two applications in 11 patients (55%), and three applications in three patients (15%). There were no procedure-related complications.

Conclusions

Endoscopic application of SurgiSIS^®—an acellular fibrogenic matrix—is safe and effective for the treatment of gastrocutaneous fistula after RYGB.     

Anesthesia and the patient with pericardial disease

Purpose

Pericardial diseases present unique perioperative considerations for the anesthesiologist. The purpose of this review is to provide a summary of the pertinent issues related to the etiology, diagnosis, pathophysiology, and perioperative management of patients presenting for operative treatment of pericardial disease.

Source

A selective search of the anesthesia, cardiology, and cardiothoracic surgical literature was carried out with particular emphasis on acute pericarditis, effusion, tamponade, and constrictive pericarditis

Principal findings

The anesthesiologist needs to be well versed in the etiology (i.e., differential diagnosis), pathophysiology, and diagnostic modalities in order to best prepare the patient for surgery. Diagnosis and guidance of management requires a working knowledge of the specific associated hemodynamic consequences, particularly of the impaired diastolic function that can occur. Echocardiography is essential in the diagnosis and management of these patients.

Conclusions

Patients with acute and chronic pericardial diseases often require the need for surgical intervention. Several unique features of acute tamponade and constrictive pericarditis require careful perioperative consideration. With proper preparation and pre-anesthetic optimization, patients with a variety of pericardial diseases can be safely managed before, during, and after their surgical intervention.     

Management of lymph fistulas in thyroid surgery

Purpose

Postoperative lymphatic leakage following thyroid surgery represents a management problem with considerate potential morbidity, psychological, and economical impact. Conservative and surgical management strategies for high- and low-output lymph fistulas are inconsistent. Reliable criteria to predict outcome of conservative versus surgical treatment in clinically evident lymph fistula are lacking.

Material and methods

A retrospective single-center chart review of consecutively quality-control-documented thyroid surgeries from January 1998 to December 2009 was performed to identify reported postoperative lymph fistulas. Documentation of surgical procedures, drainage, medical, and nutritional management was analyzed to identify risk factors for occurrence and criteria for management of evident lymph fistulas.

Results

There were 29 patients identified with postoperative clinical evidence of lymph fistulas following thyroid surgery; incidence was 0.5%. Indication to surgery comprised benign nodular goiter, recurrent nodular goiter, and thyroid carcinoma or local and lymphonodal carcinoma recurrences. There were 12 (41%) primary and 17 (59%) redo surgeries performed. Surgical procedures performed included thyroidectomy, completion thyroidectomy, and primary and redo central and lateral systematic microdissection of lymphatic compartments. All patients were initially submitted to fasting diet and medical treatment, successfully in 19 (66%), whereas ten (34%) patients underwent surgical intervention for fistula closure after failure of conservative treatment. Complications were one wound infection and fistula recurrence in five (26%) patients in the conservative group and two (20%) in the surgical group. Hospital stay was exceedingly prolonged in both groups with a median of 21 and 11 versus 6 days in patients with regular postoperative course following thyroid surgery.

Conclusions

Data of this series support definition of the two categories of high- and low-output fistulas according to drainage collection with >300 versus <200 ml/day. Fasting in low-output fistula facilitates conservative treatment with closed drainage, whereas in high-output fistulas surgical intervention should be sought. Attendant criteria for treatment stratification are equally important, like patient’s compliance, nutritional, and general health status as well as evidence for wound infection. Surgical closure of lymph fistula may be demanding when identification of the secreting fistula is limited and even muscle flap fortification may fail. Ultimately, in unsuccessfully reoperated fistula recurrences, open drainage may become necessary. Lymph fistulas cause significantly prolonged hospital stay, possible critical clinical decay, and unfavorable cosmetic and oncologic outcome while the superior management remains to be defined.     

Robotic total pelvic exenteration

Introduction

Pelvic exenteration is now becoming widely acceptable as a curative procedure rather than a palliative one. Performing these surgeries by minimally invasive techniques helps to improve the quality of life and decrease the morbidity of these extensive procedures.

Aims and objectives

To demonstrate the feasibility of performing a total pelvic exenteration robotically, and to study the morbidity associated with such extensive surgery.

Materials and methods

A 35-year-old female with advanced cervical cancer presented with a vesicovaginal fistula and a rectovaginal fistula. In view of these, we performed a total robotic pelvic exenteration with colo-anal anastomosis and uretero-sigmoidostomy. The patient refused an ileal-loop conduit for urinary tract diversion due to social reasons associated with a stoma.

Results

The total operative time was 240 min and the console time was 120 min. The estimated blood loss was 300 ml and the intensive care unit stay was 2 days. Post-operatively, the patient had good faecal and urinary continence and good quality of life.     

Significance of Computed Tomography Finding of Intra-Abdominal Free Fluid Without Solid Organ Injury after Blunt Abdominal Trauma: Time for Laparotomy on Demand

Background

Optimal management of patients with intra-abdominal free fluid found on computed tomography (CT) scan without solid organ injury remains controversial.

Objective

The purpose of this study was to determine the significance of CT scan findings of free fluid in the management of blunt abdominal trauma patients who otherwise have no indications for laparotomy.

Methods

During the 3-year study period, all patients presenting with blunt abdominal trauma who underwent abdominal CT examination were retrospectively reviewed. All hemodynamically stable patients who presented with abdominal free fluid without solid organ injury on CT scan were analyzed for radiological interpretation, clinical management, operative findings, and outcome.

Results

A total of 122 patients were included in the study, 91 % of whom were males. The mean age of the patients was 33 ± 12 years. A total of 34 patients underwent exploratory laparotomy, 31 of whom had therapeutic interventions. Small bowel injuries were found in 12 patients, large bowel injuries in ten, and mesenteric injuries in seven patients. One patient had combined small and large bowel injury, and one had traumatic gangrenous appendix. In the remaining three patients, laparotomy was non-therapeutic. A total of 36 patients had associated pelvic fractures and 33 had multiple lumbar transverse process fractures.

Conclusion

Detection of intra-peritoneal fluid by CT scan is inaccurate for prediction of bowel injury or need for surgery. However, the correlation between CT scan findings and clinical course is important for optimal diagnosis of bowel and mesenteric injuries.     

Perioperative Immunonutrition in Surgical Cancer Patients: A Summary of a Decade of Research

Background

Immunonutrition is assumed to enhance immune system function. In surgical patients, it is supposed to reduce postoperative complications. However, results of recent clinical trials have been puzzling and have not supported this theory.

Aim

The aim of our study was to evaluate the value of enteral and parenteral postoperative immunonutrition.

Methods

After initial evaluation of 969 patients, the intent-to-treat analysis included 776 patients (female 407, male 466, mean age 61.1 years) undergoing gastric or pancreatic resections between 2001 and 2009. All patients were randomly assigned after surgery to one of the following groups: standard enteral nutrition (SEN), immunomodulating enteral nutrition (IMEN), standard parenteral nutrition (SPN), or immunomodulating parenteral nutrition (IMPN). All malnourished patients received preoperative parenteral nutrition. Number and type of postoperative complications, length of hospitalization (length of stay [LOS]), and vital organ function were assessed.

Results

No statistically significant differences were observed in well-nourished patients, during either enteral or parenteral intervention, independent of the type of intervention (standard or immunomodulating). However, analysis of the malnourished group revealed the positive impact of enteral immunonutrition on reduction of postoperative complications (28.3 vs. 39.2 %, respectively; p = 0.043) and LOS (17.1 and 13.1 days, respectively; p < 0.05) compared with a standard enteral diet. The cross-analysis of SEN, IMEN, SPN, and IMPN was insignificant.

Conclusions

The type of postoperative nutrition was of no importance in well-nourished patients. However, in malnourished patients, enteral immunonutrition helped to improve treatment outcome. These findings suggest its use as a method of choice during the postoperative period.     

Management of Enterocutaneous Fistula: Outcomes in 276 Patients

Objective

To assess the outcomes of patients with type II intestinal failure due to enterocutaneous fistulae in a tertiary referral centre over a 15 year period.

Summary background

Intestinal failure secondary to enterocutaneous fistula (ECF) requires multidisciplinary management at significant cost. Mortality and morbidity are high.

Methods

Patients were identified from a prospectively collected database of patients requiring inpatient parenteral nutrition (1998–2013). Data collected included: demographics, mode of admission, pathological grouping and outcome.

Results

A total of 286 ECF were identified in 278 patients, mean age 64 years (20–96 years) with an equal gender distribution. In total, 112 fistulas developed following an emergency admission, 89 fistulas following an elective admission, and the remainder 85 were transferred from outlying district hospitals. In total, 246 ECF were as a result of previous surgery, 11 occurred following endoscopic procedures, with the remainder occurring spontaneously. All patients received parenteral nutrition (PN). Forty-seven patients overall died from sepsis/multiorgan failure. A total of 154 ECF resolved with aggressive non-operative management and 46 died prior to resolution of their fistula or surgery. 74.8% of patients with ECF proximal to the duodenal-jejunal flexure closed without surgery compared to 35.4% with disease distal to the flexure (p = 0.001). Nineteen early operations were performed, with 51 patients undergoing definitive surgery. In-hospital mortality was 19.1% (53/278), with 30-day post-operative mortality from definitive surgery being 9.8% (5/51).

Conclusion

Mortality remains high and is associated with sepsis. Fistulas proximal to the duodeno-jejunal flexure are more likely to close spontaneously. If the fistula fails to close spontaneously care is often prolonged and complex, requiring a dedicated nutrition team. In this series, spontaneous closure was more common in upper GI fistulas. Patients who are not able to be discharged in the interval between fistula formation and definitive surgery have a higher mortality risk.