Featured Articles in Oct 2018

Results of Magnetic Sphincter Augmentation for Gastroesophageal Reflux Disease

 

 

Author list: Katrin Schwameis, Milena Nikolic, Delvis G. Morales Castellano, Ariane Steindl, Sarah Macheck, Ivan Kristo, Barbara Zorner, Sebastian F. Schoppmann 

 

Abstract:

Background

Magnetic sphincter augmentation (MSA) is a modern treatment option for gastroesophageal reflux disease (GERD); however, laparoscopic fundoplication remains the gold standard. The aim of the study was to evaluate outcomes of MSA patients at a reflux center.

 

Methods

A retrospective review was performed of all patients that underwent MSA between March 2012 and November 2017. Out of 110 patients, 68 with a follow-up >3 months were included. Postoperative gastrointestinal symptoms, proton pump inhibitor (PPI) intake, GERD-Health-related Quality of Life (GERD-HRQL) and alimentary satisfaction (AS) were assessed. Postoperative esophageal functioning tests were performed in 50% of patients.

 

Results

Sixty-eight patients underwent MSA; hiatal repair was performed in 31 cases. The median OR time was 27 min, and no intraoperative complications occurred. The median follow-up was 13 months (IQR 4.2–45). Endoscopic dilatation was performed in 2 patients (3%) and device removal in another 2 cases. The postoperative GERD-HRQL score was significantly reduced (3 vs. 24; p < 0.001) and the median AS was 8/10. Preoperative experienced heartburn, regurgitations and dysphagia were eliminated in 92, 96 and 100%. Postoperative new-onset difficulties swallowing with solids only were reported to occur occasionally by 16% and rarely by 21% of patients. Satisfaction with heartburn relief was 95%, and the overall outcome was rated excellent/good in 89%. PPI dependency was eliminated in 87%. The median total percentage pH < 4 and number of reflux episodes were significantly reduced. Postoperative pH results were negative or slightly above the norm in 79% and 12%, respectively.

 

Conclusion

Sphincter augmentation results in significantly reduced reflux symptoms, increased GERD-specific Quality of Life and excellent alimentary satisfaction with low perioperative morbidity. This procedure should be considered an excellent alternative to fundoplication in the treatment of GERD.

 

URL: https://rdcu.be/5S14


Gallstone Pancreatitis and Choledocholithiasis: Using Imaging and Laboratory Trends to Predict the Likelihood of Persistent Stones at Cholangiography

 

 

Author list: Nikhil Panda, Yuchiao Chang, Nalin Chokengarmwong, Myriam Martinez, Liyang Yu, Peter J. Fagenholz, Haytham A. Kaafarani, David R. King, Marc A. DeMoya, George C. Velmahos, D. Dante Yeh

 

Abstract:

Background

Patients with gallstone pancreatitis (GP) or choledocholithiasis (CDL) may have common bile duct (CBD) stones that persist until cholangiography. The aim of this study is to evaluate pre-cholangiogram factors that predict persistent CBD stones.

 

Methods

Multiple logistic regression analyses were performed to identify demographic, laboratory, and radiologic predictors of persistent CBD stones and non-therapeutic cholangiography among adults with GP or CDL.

 

Results

In 152 patients from 2010 to 2015, preoperative diagnosis, presence of a CBD stone on US, and age ≥ 60 years were associated with persistent CBD stones. Two risk factors alone had a PPV of 88% and the absence of all risk factors had a NPV of 94%. Age < 60 years and the absence of a CBD stone on US were most predictive of non-therapeutic cholangiography.

 

Conclusion

Age, LFTs, and US help predict persistent CBD stones in patients initially presenting with GP or CDL and help minimize non-therapeutic preoperative cholangiography.

 

URL: https://rdcu.be/5S2o


Acute Pancreatitis After Laparoscopic Transcystic Common Bile Duct Exploration: An Analysis of Predisposing Factors in 447 Patients

 

 

Author list: Matias E. Czerwonko, Juan Pekolj, Pedro Uad, Oscar Mazza, Rodrigo Sanchez-Claria, Guillermo Arbues, Eduardo de Santibanes, Martin de Santibanes, Martin Palavecino

 

Abstract:

Background

In laparoscopic transcystic common bile duct exploration (LTCBDE), the risk of acute pancreatitis (AP) is well recognized. The present study assesses the incidence, risk factors, and clinical impact of AP in patients with choledocholithiasis treated with LTCBDE.

 

Methods

A retrospective database was completed including patients who underwent LTCBDE between 2007 and 2017. Univariate and multivariate analyses were performed by logistic regression.

 

Results

After exclusion criteria, 447 patients were identified. There were 70 patients (15.7%) who showed post-procedure hyperamylasemia, including 20 patients (4.5%) who developed post-LTCBDE AP. Of these, 19 were edematous and one was a necrotizing pancreatitis. Patients with post-LTCBDE AP were statistically more likely to have leukocytosis (p < 0.004) and jaundice (p = 0.019) before surgery and longer operative times (OT, p < 0.001); they were less likely to have incidental intraoperative diagnosis (p = 0.031) or to have biliary colic as the reason for surgery (p = 0.031). In the final multivariate model, leukocytosis (p = 0.013) and OT (p < 0.001) remained significant predictors for AP. Mean postoperative hospital stay (HS) was significantly longer in AP group (p < 0.001).

 

Conclusion

The risk of AP is moderate and should be considered in patients with preoperative leukocytosis and jaundice and exposed to longer OT. AP has a strong impact on postoperative HS.

 

URL: https://rdcu.be/5S3b


Perforated Diverticulitis with Generalized Peritonitis: Low Stoma Rate Using a “Damage Control Strategy”

 

 

Author list: Maximillian Sohn, I. Iesalnieks, A. Agha, P. Steiner, A. Hochrein, J. Pratschke, P. Ritschl, F. Aigner

 

Abstract:

Background

Optimal surgical management of perforated diverticulitis of the sigmoid colon has yet to be clearly defined. The purpose of this study was to evaluate efficacy of a “Damage Control Strategy” (DCS).

 

Methods

Patients with perforated diverticulitis of the sigmoid colon complicated by generalized peritonitis (Hinchey III and IV) surgically treated according to a damage control strategy between May 2011 and February 2017 were enrolled in the present multicenter retrospective cohort study. Data were collected at three surgical centers. DCS comprises a two-stage concept: [1] limited resection of the perforated colon segment with oral and aboral blind closure during the emergency procedure and [2] definitive reconstruction at scheduled second laparotomy (anastomosis ∓ loop ileostomy or a Hartmann’s procedure) after 24–48 h.

 

Results

Fifty-eight patients were included into the analysis [W:M 28:30, median age 70.1 years (30–92)]. Eleven patients (19%) initially presented with fecal peritonitis (Hinchey IV) and 47 patients with purulent peritonitis (Hinchey III). An anastomosis could be created during the second procedure in 48 patients (83%), 14 of those received an additional loop ileostomy. In the remaining ten patients (n = 17%), an end colostomy was created at second laparotomy. A fecal diversion was performed in five patients to treat anastomotic complications. Thus, altogether, 29 patients (50%) had stoma at the end of the hospital stay. The postoperative mortality was 9% (n = 5), and median postoperative hospital stay was 18.5 days (3–66). At the end of the follow-up, 44 of 53 surviving patients were stoma free (83%).

 

Conclusions

The use of the Damage Control strategy leads to a comparatively low stoma rate in patients suffering from perforated diverticulitis with generalized peritonitis.

 

URL: https://rdcu.be/5S3v


Patient Frailty Should Be Used to Individualize Treatment Decisions in Primary Hyperparathyroidism

 

 

Author list: Carolyn D. Seib, Kathryn Chomsky-Higgins, Jessica E. Gosnell, Wen. T. Shen, Insoo Suh, Quan-Yang Duh, Emily Finlayson

 

Abstract:

Background

Primary hyperparathyroidism (PHPT) is a common endocrine disorder that predominantly affects patients >60 and is increasing in prevalence. Identifying risk factors for poor outcomes after parathyroidectomy in older adults will help tailor operative decision making. The impact of frailty on surgical outcomes in parathyroidectomy has not been established.

 

Methods

We performed a retrospective review of patients ≥40 years who underwent parathyroidectomy in the 2005–2010 ACS NSQIP. Frailty was assessed using the modified frailty index (mFI). Multivariable regression was used to determine the association of frailty with 30-day complications, length of stay (LOS), and reoperation.

 

Results

We identified 13,123 patients ≥40 who underwent parathyroidectomy for PHPT. The majority of patients were not frail, with 80% with a low NSQIP mFI score (0–1 frailty traits), 19% with an intermediate mFI score (2–3), and 0.9% with a high mFI score (≥4). Overall 30-day complications were rare, occurring in 141 (1.1%) patients. Increasing frailty was associated with an increased risk of complications with adjusted odds ratios (ORs) of 1.76 (95% CI 1.20–2.59; p = 0.004) for intermediate and 8.43 (95% CI 4.33–16.41; p < 0.001) for high mFI score. Patient age was independently associated with an increased risk of complications only when ≥75, as was African-American race. Anesthesia with local, monitored anesthesia care, or regional block was the only factor associated with decreased odds of complications. A high NSQIP mFI was also associated with a significant 4.77-day adjusted increase in LOS (95% CI 4.28–5.25; p < 0.001) and increased odds of reoperation (OR 4.20, 95% CI 1.64–10.74; p = 0.003).

 

Conclusion

Patient frailty is associated with increased complications, reoperation and prolonged LOS in patients undergoing parathyroidectomy for PHPT. The risks of surgical management should be weighed against potential benefits in frail patients with PHPT to individualize treatment decisions in this vulnerable population.

 

URL: https://rdcu.be/5S3P


Early Closure of Defunctioning Loop Ileostomy: Is It Beneficial for the Patient? A Meta-analysis

 

 

Author list: Benjamin Menahem, Jean Lubrano, Antoine Vallois, Arnaud Alves

 

Abstract:

Background

To perform a meta-analysis to answer the question, whether early closure (EC) of defunctioning loop ileostomy may be beneficial for patient as compared with late closure (LC) without exceeding the risk of surgical-related morbidity.

 

Methods

Medline and the Cochrane Trials Register were searched for trials published up to November 2016 comparing EC (defined as ≤14 days from the index operation in which the ileostomy was performed) versus LC for stoma closure after rectal surgery. Meta-analysis was performed using Review Manager 5.0. Inclusion criteria

 

Results

Six studies were included and analyzed, yielding 570 patients (252 in EC group and 318 in LC). Meta-analysis showed no significant difference in the overall morbidity rate between the EC and LC groups (OR 0.63; 95% CI, 0.22–1.78; P = 0.38). Despite a significant higher wound infection rate of stoma site (OR 3.83; 95% CI 2.14–6.86; P < 0.00001), meta-analysis showed no significant difference in the anastomotic leakage rate between the EC and LC groups (OR 0.63; 95% CI 0.22–1.78; P = 0.38). Moreover, both stoma-related complications (OR 0.46; 95% CI 0.24–0.86; P = 0.02) and small bowel obstruction rates (OR 0.11; 95% CI 0.06–0.20; P < 0.00001) were significantly lower in the EC group than in the LC group, respectively.

 

Conclusions

This meta-analysis suggests that EC of a defunctioning loop ileostomy is effective and safe in careful selected patients without increasing overall postoperative complications. This promising strategy should be proposed in patients in order to reduce stoma-related complications.

 

URL: https://rdcu.be/5S38


Association Between Circular Stapler Diameter and Stricture Rates Following Gastrointestinal Anastomosis: Systematic Review and Meta-analysis

 

 

Author list: W. Allen, C. I. Wells, M. Greenslade, I. P. Bissett, G. O’Grady

 

Abstract:

Background

Stricture is a common complication of gastrointestinal (GI) anastomoses, associated with impaired quality of life, risk of malnutrition, and further interventions. This systematic review and meta-analysis aimed to determine the association between circular stapler diameter and anastomotic stricture rates throughout the GI tract.

 

Methods

A systematic literature search of EMBASE, MEDLINE and Cochrane Library was performed. The primary outcome was the rate of radiologically or endoscopically confirmed anastomotic stricture. Pooled odds ratios (OR) were calculated using random-effects models to determine the effect of circular stapler diameter on stricture rates in different regions of the GI tract.

 

Results

Twenty-one studies were identified: seven oesophageal, twelve gastric, and three lower GI. Smaller stapler sizes were strongly associated with higher anastomotic stricture rates throughout the GI tract. The oesophageal anastomosis studies showed; 21 versus 25 mm circular stapler: OR 4.39 ([95% CI 2.12, 9.07]; P < 0.0001); 25 versus 28/29 mm circular stapler: OR 1.71 ([95% CI 1.15, 2.53]; P < 0.008). Gastric studies showed; 21 versus 25 mm circular stapler: OR 3.12 ([95% CI 2.23, 4.36]; P < 0.00001); 25 versus 28/29 mm circular stapler: OR 7.67 ([95% CI 1.86, 31.57]; P < 0.005). Few lower GI studies were identified, though a similar trend was found: 25 versus 28/29 mm circular stapler: pooled OR 2.61 ([95% CI 0.82, 8.29]; P = 0.100).

 

Conclusions

The use of larger circular stapler sizes is strongly associated with reduced risk of anastomotic stricture in the upper GI tract, though data from lower GI joins are limited.

 

URL: https://rdcu.be/5S4w


Intravenous Local Anaesthetic Compared with Intraperitoneal Local Anaesthetic in Abdominal Surgery: A Systematic Review

 

 

Author list: Wiremu S. MacFater, Weisi Xia, Ahmed Barazanchi, Bruce Su’a, Darren Svirskis, Andrew G. Hill

 

Abstract:

Background

Modern perioperative care strategies aim to optimise perioperative care by reducing the body’s stress response to surgery. A major facet of optimising an abdominal surgery analgesia programme is using a multimodal opioid sparing approach. Local anaesthetics have shown promise and there has been considerable research into the most effective route for their administration. This review aims to determine if there is a difference in analgesic efficacy between intraperitoneal local anaesthetic (IPLA) and intravenous local anaesthetic (IVLA).

 

Methods

In concordance with the PRISMA statement, a literature search was conducted to identify randomised control trials that compared IVLA with IPLA in abdominal surgery. The primary outcomes of interest were opioid analgesia requirements and pain score assessed by visual analogue score. Data were extracted and entered into pre-designed electronic spreadsheets.

 

Results

This review has identified six papers that compared intravenous lignocaine to intraperitoneal lignocaine. This review showed significantly lower morphine consumption at 4 and 24 h in the intraperitoneal group. There was no significant difference in pain scores.

 

Conclusions

From the analysis of these studies, intraperitoneal local anaesthetic had an analgesic benefit over intravenous lignocaine with regard to decreased opioid consumption for abdominal surgery. Further research investigating IVL combined with intraperitoneal local anaesthetic is warranted.

 

URL: https://rdcu.be/5S4U


 

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