Featured Articles in Aug 2019

Spontaneous Retroperitoneal and Rectus Sheath Hemorrhage—Management, Risk Factors and Outcomes

 

Author list  

Josefine S. Baekgaard, Trine G. Eskesen, Jae Moo Lee, D. Dante Yeh, Haytham M. A. Kaafarani, Peter J. Fagenholz, Laura Avery, Noelle Saillant, David R. King, George C. Velmahos

 

Abstract

Background

Spontaneous retroperitoneal and rectus sheath hemorrhage (SRRSH) is associated with high mortality in the literature, but studies on the subject are lacking. The objective of this study was to identify early predictors of the need for angiographic or surgical intervention (ASI) in patients with SRRSH and define risk factors for mortality.

 

Methods

We conducted a retrospective cohort study at a tertiary academic hospital. All patients with computed tomography-identified SRRSH between 2012 to 2017 were included. Exclusion criteria were age below 18 years, possible mechanical cause of SRRSH, aortic aneurysm rupture or dissection, and traumatic or iatrogenic sources of SRRSH. The primary outcome was the incidence of ASI and/or mortality.

 

Results

Of 100 patients included (median age 70 years, 52% males), 33% were transferred from another hospital, 82% patients were on therapeutic anticoagulation, and 90% had serious comorbidities. Overall mortality was 22%, but SRRSH-related mortality was only 6%. Sixteen patients underwent angiographic intervention (n = 10), surgical intervention (n = 5), or both (n = 1). Flank pain (OR 4.15, 95% CI 1.21–14.16, p = 0.023) and intravenous contrast extravasation (OR 3.89, 95% CI 1.23–12.27, p = 0.020) were independent predictors of ASI. Transfer from another hospital (OR 3.72, 95% CI 1.30–10.70, p = 0.015), age above 70 years (OR 4.24, 95% CI 1.25–14.32, p = 0.020), and systolic blood pressure below 110 mmHg at the time of diagnosis (OR 4.59, 95% CI 1.19–17.68, p = 0.027) were independent predictors of mortality.

 

Conclusions

SRRSH is associated with high mortality but is typically not the direct cause. Most SRRSHs are self-limited and require no intervention. Pattern identification of ASI is hard.

 

URL https://rdcu.be/bKr1m

 


Low Preoperative Mental and Physical Health is Associated with Poorer Postoperative Recovery in Patients Undergoing Day Surgery

 

Author list 

Ulrica Nilsson, Karuna Dahlberg, Maria Jaensson

 

Abstract

Background

Day surgical procedures are increasing both in Sweden and internationally. Day surgery patients prepare for and handle their recovery on their own at home. The aim of this study was to investigate patients’ preoperative mental and physical health and its association with the quality of their recovery after day surgery.

 

Method

This was a secondary analysis of a randomized controlled trial. Data were collected at four-day surgery units in Sweden. Health-related quality of life was measured using the Short Form 36 (SF-36) Health Survey, and postoperative recovery was assessed using the Swedish web version of the Quality of Recovery (SwQoR) scale.

 

Result

This study included 756-day surgery patients. A low, compared with a high, preoperative mental component score was associated with poorer recovery as shown by responses to 21/24 and 22/24 SwQoR items, respectively, on postoperative days (PODs) 7 and 14. A low compared with a high preoperative physical component score was associated with poorer recovery in 18/24 SwQoR items on POD 7 and 13/24 on POD 14.

 

Conclusion

A clear message from this study is for surgeons, anaesthetists and nurses to consider the fact that postoperative recovery largely depends on patients’ preoperative mental and psychical status. A serious attempt must be made, as a part of the routine preoperative assessment, to assess and document not only the physical but also the mental status of patients undergoing anaesthesia and surgery.

 

Trial registration

Clinicaltrials.gov Identifier: NCT0249219.

 

URL https://rdcu.be/bKr1F

 


Timing of Parathyroidectomy Does Not Influence Renal Function After Kidney Transplantation

 

Author list 

Willemijn Y. van der Plas, Mostafa El Moumni, Philipp J. von Forstner, Ezra Y. Koh, Roderick R. Dulfer, Tessa M. van Ginhoven, Joris I. Rotmans, Natasha M. Appelman-Dijkstra, Abbey Schepers, Ewout J. Hoorn, John Th. M. Plukker, Liffert Vogt, Anton F. Engelsman, Els J. M. Nieveen van Dijkum, Schelto KruijffRobert A. Pol, Martin H. de Borst, The Dutch Hyperparathyroidism Study Group

Abstract

Background

Parathyroidectomy (PTx) is the treatment of choice for end-stage renal disease (ESRD) patients with therapy-resistant hyperparathyroidism (HPT). The optimal timing of PTx for ESRD-related HPT—before or after kidney transplantation (KTx)—is subject of debate.

 

Methods

Patients with ESRD-related HPT who underwent both PTx and KTx between 1994 and 2015 were included in a multicenter retrospective study in four university hospitals. Two groups were formed according to treatment sequence: PTx before KTx (PTxKTx) and PTx after KTx (KTxPTx). Primary endpoint was renal function (eGFR, CKD-EPI) between both groups at several time points post-transplantation. Correlation between the timing of PTx and KTx and the course of eGFR was assessed using generalized estimating equations (GEE).

 

Results

The PTxKTx group consisted of 102 (55.1%) and the KTxPTx group of 83 (44.9%) patients. Recipient age, donor type, PTx type, and pre-KTx PTH levels were significantly different between groups. At 5 years after transplantation, eGFR was similar in the PTxKTx group (eGFR 44.5 ± 4.0 ml/min/1.73 m2) and KTxPTx group (40.0 ± 6.4 ml/min/1.73 m2, p = 0.43). The unadjusted GEE model showed that timing of PTx was not correlated with graft function over time (mean difference −1.0 ml/min/1.73 m2, 95% confidence interval −8.4 to 6.4, p = 0.79). Adjustment for potential confounders including recipient age and sex, various donor characteristics, PTx type, and PTH levels did not materially influence the results.

 

Conclusions

In this multicenter cohort study, timing of PTx before or after KTx does not independently impact graft function over time.

 

URL https://rdcu.be/bKr13

 


The Clinical Implications of Peripancreatic Fluid Collection After Distal Pancreatectomy

 

Author list 

Jun Yoshino, Daisuke Ban, Toshiro Ogura, Kosuke Ogawa, Hiroaki Ono, Yusuke Mitsunori, Atsushi Kudo, Shinji Tanaka, Minoru Tanabe

 

Abstract

Objectives

Pancreatic fistula after distal pancreatectomy (DP) remains an unsolved problem, and postoperative CT imaging often demonstrates fluid collection (FC) around the pancreatic remnant. This study sought to clarify the clinical implications of FC.

 

Methods

This study enrolled 146 patients who underwent DP. FC was defined as a cyst-like lesion ≥ 10 mm in diameter on CT imaging at postoperative day (POD) 7. FC size, irregularity of FC margin, and air bubbles in FC were investigated. In addition, clinical data were retrospectively collected, and useful predictive factors for postoperative pancreatic fistula (POPF) were analyzed.

 

Results

Clinically relevant POPF was observed in 26 patients (17.8%), and FC was detected in 136 patients (94.4%). Multivariate analysis identified FC size and drain amylase levels on POD3 as significant risk factors for POPF. Cutoff values were determined by ROC analyses, and the levels of the FC size and drain amylase on POD3 were determined as 41 mm and 1026 IU/L, respectively. The sensitivity and specificity of FC diameters > 41 mm were 76.9% and 75.0%, respectively, while those of drain amylase levels > 1026 IU on POD3 were 73.1% and 75.8%, respectively.

 

Conclusions

While treating some FCs after DP was necessary for the management of POPF, others did not require any intervention since most of them spontaneously disappeared. FC size and drain amylase levels on POD3 were found to be significantly associated with POPF and could potentially help to determine appropriate treatment.

 

 


Years of Life Lost for Older Patients After Colorectal Cancer Diagnosis

 

Author list 

Federico Mazzotti, Alessandro Cucchetti, Yvette H. M. Claassen, Amanda C. R. K. Bos, Esther Bastiaannet, Giorgio Ercolani, Jan Willem T. Dekker

 

Abstract

Background

An aging population combined with an increased colorectal cancer (CRC) incidence in the older population will increase its prevalence in the elderly, questioning how many years of life are lost (YLLs) in these patients.

 

Patients and methods

Data from 32,568 Dutch CRC patients ≥ 80 years were used to estimate the number of YLLs after diagnosis, using a reference age-, sex- and year-of-onset-matched cohort derived from national life tables. YLLs were additionally adjusted by comorbidities. Number needed to treat (NNT) was used as measure of surgical effect size.

 

Results

Surgery was applied in 74.9% of patients leading to 1.3 YLLs, being superior in 86.1% of cases with respect to alternative therapies (YLLs 4.8 years) and resulting in a number of two patients needed to operate to achieve one positive outcome. YLLs and NNTs depended on CRC stage, patient’ age and comorbidities. For Stage I–II patients in the best clinical conditions (80–85 years without comorbidities), YLLs increased up to 4.1 years after surgery and up to 8.8 years without surgery (NNT 3). For Stage III patients, the NNT of surgery varied between 2 when they were in the best clinical conditions and 4 when they were older with high comorbidities. In Stage IV patients, the NNT ranged between 6 and 31.

 

Conclusions

YLLs represents a novel approach to evaluate CRC prognosis. Stage I–III surgical patients can have a life expectancy similar to that of general population, being the NNT of surgery reasonably small compared with alternatives. Personalized comorbidity data are needed to confirm present findings.

 

URL https://rdcu.be/bKr2u

 


Perioperative Mortality Rates as a Health Metric for Acute Abdominal Surgery in Low- and Middle-Income Countries: A Systematic Review and Future Recommendations

 

Author list 

Marie-Rachelle Felizaire, Tiffany Paradis, Andrew Beckett, Paola Fata, Jeremy Grushka, Walter Johnson, Kosar Khwaja, John G. Meara, Gabriel Ndayisaba, Ipshita Prakash, Tarek Razek, Tongmeesee Somprasong, Evan Wong, Prem Yohannan, Dan L. Deckelbaum

 

Abstract

Background

Approximately 5 billion people do not have access to safe, timely, and affordable surgical and anesthesia care, with this number disproportionately affecting those from low–middle-income countries (LMICs). Perioperative mortality rates (POMRs) have been identified by the World Health Organization as a potential health metric to monitor quality of surgical care provided. The purpose of this systematic review was to evaluate published reports of POMR and suggest recommendations for its appropriate use as a health metric.

 

Methods

The protocol was registered a priori with PROSPERO. A peer-reviewed search strategy was developed adhering with the PRISMA guidelines. Relevant articles were identified through Medline, Embase, CENTRAL, CDSR, LILACS, PubMed, BIOSIS, Global Health, Africa-Wide Information, Scopus, and Web of Science databases. Two independent reviewers performed a primary screening analysis based on titles and abstracts, followed by a full-text screen. Studies describing POMRs of adult emergency abdominal surgeries in LMICs were included.

 

Results

A total of 7787 articles were screened of which 7466 were excluded based on title and abstract. Three hundred and twenty-one articles entered full-text screen of which 70 articles met the inclusion criteria. Variables including timing of POMR reporting, intraoperative mortality, length of hospital stay, complication rates, and disease severity score were collected. Complication rates were reported in 83% of studies and postoperative stay in 46% of studies. 40% of papers did not report the specific timing of POMR collection. 7% of papers reported on intraoperative death. Additionally, 46% of papers used a POMR timing specific to the duration of their study. Vital signs were discussed in 24% of articles, with disease severity score only mentioned in 20% of studies.

 

Conclusion

POMR is an important health metric for quantifications of quality of care of surgical systems. Further validation and standardization are necessary to effectively use this health metric.

 

URL https://rdcu.be/bKr2K

 


Laparoscopic Transcystic Versus Transductal Common Bile Duct Exploration: A Systematic Review and Meta-analysis

 

Author list 

Shahin Hajibandeh, Shahab Hajibandeh, Diwakar Ryali Sarma, Sankar Balakrishnan, Mokhtar Eltair, Rajnish Mankotia, Misra Budhoo, Yogesh Kumar

 

Abstract

Objective

To evaluate comparative outcomes of laparoscopic transcystic (TC) and transductal (TD) common bile duct (CBD) exploration.

 

Methods

We systematically searched MEDLINE, EMBASE, CINAHL, CENTRAL, the World Health Organization International Clinical Trials Registry, ClinicalTrials.gov, ISRCTN Register, and bibliographic reference lists. CBD clearance rate, perioperative complications, and biliary complications were defined as the primary outcome parameters. Procedure time, length of hospital stay, conversion to open procedure were the secondary outcomes. Combined overall effect sizes were calculated using random-effects models.

 

Results

We identified 30 studies reporting a total of 4073 patients comparing outcomes of laparoscopic TC (n = 2176) and TD (N = 1897) CBD exploration. The TC approach was associated with significantly lower overall complications (RD: −0.07, P = 0.001), biliary complications (RD: −0.05, P = 0.0003), and blood loss (MD: −16.20, P = 0.02) compared to TD approach. Moreover, the TC approach significantly reduced the length of hospital stay (MD: −2.62, P < 0.00001) and procedure time (MD: −12.73, P = 0.005). However, there was no significant difference in rate of CBD clearance (RD: 0.00, P = 0.77) and conversion to open procedure (RD: 0.00, P = 0.86) between two groups.

 

Conclusions

Laparoscopic TC CBD exploration is safe and reduces overall morbidity and biliary complications compared to the TD approach. Moreover, it is associated with significantly shorter length of hospital stay and procedure time. High-quality randomised trials may provide stronger evidence with respect to impact of the cystic duct/CBD diameter, number or size of CBD stones, or cystic duct anatomy on the comparative outcomes of TC and TD approaches.

 

URL https://rdcu.be/bKr2V

 


 

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