Featured Articles in Mar 2017

Effect of Pre-operative Anaemia on Post-operative Complications in Low-Resource Settings

 

Author list: Michelle C. White, Lydia Longstaff, Peggy S. Lai

 

Abstract: 

Background

In high-resource settings, even mild anaemia is associated with an increased risk of post-operative complications. Whether this is true in low-resource settings is unclear. We aimed to evaluate the effect of anaemia on surgical outcomes in the Republic of Congo and Madagascar.

 

Method

It is a retrospective chart review of 2064 non-pregnant patients undergoing elective surgery with Mercy Ships. Logistic regression was used to determine the association between pre-operative anaemia and pre-defined surgical complications, adjusted for age, gender, surgical specialty, and country.

 

Results

The average age of patients was 27.2 years; 56.7% were male. Sixty-two percent of patients were not anaemic, and 22.7, 13.9 and 1.4% met sex-related criteria for mild, moderate and severe anaemia, respectively. In adjusted analyses, the severe anaemia group had an 8.58 [3.65, 19.49] higher odds of experiencing any surgical complication (p < 0.001) compared to non-anaemic patients. Analysis of each complication showed a 33.13 [9.57, 110.39] higher odds of unexpected ICU admission (p < 0.001); a 7.29 [1.98, 21.45] higher odds of surgical site infection (p < 0.001); and 7.48 [1.79, 25.78] higher odds of requiring hospital readmission (p < 0.001). Evaluating other anaemia categories, only those with moderate anaemia had a higher risk of requiring ICU admission (odds ratio 2.75 [1.00, 7.04], p = 0.04) compared to those without anaemia.

 

Conclusion

Our results indicate that in low-income settings, severe anaemia is associated with an increased risk of post-operative complications including unexpected ICU admission, surgical site infection and hospital readmission, whereas mild anaemia was not associated with increased post-operative complications.

 

URL: http://rdcu.be/o44g


Mesh Removal and Selective Neurectomy for Persistent Groin Pain Following Lichtenstein Repair

 

Author list: Willem A. R. Zwaans, Christel W. Perquin, Maarten J. A. Loos, Rudi M. H. Roumen, R. M. Scheltinga

 

Abstract: 

Background

Some patients with persistent inguinodynia following a Lichtenstein hernia repair fail all non-surgical treatments. Characteristics of mesh-related pain are not well described whereas a meshectomy is controversial. Aims were to define mesh-related pain symptoms, to investigate long-term effects of a meshectomy and to provide recommendations on meshectomy.

 

Methods

Consecutive patients undergoing open meshectomy with/without selective neurectomy for chronic inguinodynia following Lichtenstein repair were analysed including a follow-up questionnaire. Outcome measures were complications, satisfaction (excellent, good, moderate, poor) and hernia recurrence rate. Recommendations for meshectomy are proposed based on a literature review. 

 

Results

Seventy-four patients (67 males, median age 56 years) underwent mesh removal (exclusively mesh, 26%; combined with tailored neurectomy, 74%) between June 2006 and March 2015 in a single centre. Complications were intraoperatively recognized small bowel injury (n = 1) and testicular atrophy (n = 2). A 64% excellent/good long-term result was attained (median 18 months). Success rates of a meshectomy (63%) or combined with a neurectomy (64%) were similar. Five hernia recurrences occurred during follow-up (7%). A patient with a pure mesh-related groin pain characteristically reports a ‘foreign body feeling’. Pain intensifies during hip flexion (car driving) and is attenuated following hip extension or supine position. Palpation is painful along the inguinal ligament whereas neuropathic characteristics (hyperpathic skin, trigger points) are lacking.

 

Conclusion

Mesh removal either or not combined with tailored neurectomy is beneficial in two of three patients with characteristics of mesh-related inguinodynia following Lichtenstein hernia repair who are refractory to alternative pain treatments.

 

URL: http://rdcu.be/o44N


Preoperative Glycosylated Hemoglobin Levels Predict Anastomotic Leak After Esophagectomy with Cervical Esophagogastric Anastomosis

 

Author list: Akihiko Okamura, Masayuki Watanabe, Yu Imamura, Satoshi Kamiya, Kotaro Yamashita, Takanori Kurogochi, Shinji Mine

 

Abstract: 

Background

Patients with diabetes are considered at increased risk of delayed wound healing and infectious complications, yet the relationship between diabetes and anastomotic leak (AL) remains unclear. Given that glycosylated hemoglobin (HbA1c) is a validated indicator of the long-term glycemic state, we evaluated the relationship between preoperative HbA1c levels and AL after esophagectomy.

 

Method

We assessed 300 consecutive patients who underwent esophagectomy reconstructed with cervical esophagogastric anastomosis between 2011 and 2015. HbA1c levels were measured within 90 days before esophagectomy. We performed comparison between the patients with and without diabetes. In addition, the predictive factors for AL, as well as the relationship between HbA1c levels and AL, were investigated.

 

Results

Among the 300 patients, 35 had diabetes. The overall prevalence of AL was 11.7%, and patients with diabetes had a higher prevalence of AL than those without (p = 0.045). In univariate analysis, we identified diabetes, HbA1c level, and hand-sewn anastomosis as risk factors for AL significantly (p = 0.033, 0.009, and 0.011, respectively), but we also found previous smoking history, chronic hepatic disease, and supracarinal tumor location also showed tendencies to be risk factors (p = 0.057, 0.055, and 0.064, respectively). Multivariate logistic regression analysis indicated that chronic hepatic disease (p = 0.048), increased HbA1c level (p = 0.011), and hand-sewn anastomosis (p = 0.021) were independent risk factors for AL.

 

Conclusion

Preoperative HbA1c level was significantly associated with the development of AL after cervical esophagogastric anastomosis. We recommend preoperative HbA1c screening for all patients scheduled to undergo esophagectomy.

 

URL: http://rdcu.be/o44S


Enhanced Recovery Program in High-Risk Patients Undergoing Colorectal Surgery: Results from the PeriOperative Italian Society Registry

 

Author list: Marco Braga, Nicolo Pecorelli, Marco Scatizzi, Felice Borghi, Giancarlo Missana, Danilo Radrizzani

 

Abstract: 

Background

Enhanced recovery after surgery (ERAS) pathways represent the optimal approach for patients undergoing colorectal surgery. Elderly or low physical status patients have been often excluded from ERAS pathways because considered at high risk. The aim of this study is to assess the adherence to ERAS protocol and its impact on short-term postoperative outcome in patients with different surgical risk undergoing elective colorectal resection.

 

Method

Prospectively collected data entered in an electronic Italian registry specifically designed for ERAS were reviewed. Patients were divided into four groups according to age (70-year-old cutoff) and preoperative physical status as measured by the ASA grade (I–II vs. III–IV). Adherence to 18 ERAS elements and postoperative outcomes were compared between groups. Regression analysis was used to identify independent factors associated with improved outcomes.

 

Results

Eleven Italian hospitals reported data on 706 patients undergoing elective colorectal surgery within an ERAS protocol. Patients with low physical status had reduced adherence to preoperative carbohydrate loading, epidural analgesia, PONV prophylaxis, and early urinary catheter removal. No difference was found between groups for adherence to other perioperative elements. Major complications occurred in 37 (5.2 %) patients without significant differences among groups (p = 0.384). Median (IQR) time to readiness for discharge (TRD) was 4 (3–6) days, length of hospital stay (LOS) was 6 (4–7) days, and both were significantly shorter by only 1 day in the groups of younger patients (p < 0.001). At multivariate analysis, laparoscopy increased adherence to ERAS items and reduced TRD, LOS, and morbidity. A high ASA grade was significantly associated with lower adherence, whereas older age significantly prolonged TRD and LOS.

 

Conclusions

ERAS pathway can be safely applied in elderly and low physical status patients yielding slight differences in postoperative morbidity and time to recover. Laparoscopy was independently associated with increased adherence to ERAS protocol and improved short-term postoperative outcome.

 

URL: http://rdcu.be/o44Y


Cost Effectiveness of a Fast-Track Protocol for Urgent Laparoscopic Cholecystectomies and Appendectomies

 

Author list: Colleen M. Trevino, Karina M. Katchko, Amy L. Verhaalen, Marie L. Bruce, Travis P. Webb

 

Abstract: 

Background

Fast-track protocols (FTPs) are used to decrease length of stay (LOS) and hospital costs for elective outpatient procedures. Few institutions have implemented FTP for urgent procedures such as laparoscopic cholecystectomy (LC) and laparoscopic appendectomy (LA).

 

Results

There were significant reductions in LOS between all study groups compared: between PRE (n = 256) and POST (n = 472) cohorts by half a day (2.0 vs. 1.5 days, p < 0.02); between FT and NFT (0.68 vs. 1.82 days, p < 0.01); and FT-C and FT-F (0.49 vs. 1.05 days, p < 0.01). Total hospital charges were significantly reduced in FT compared with NFT ($22,347 vs. $30,868, p < 0.01) with an average savings of $8521. Total hospital charges were decreased in the FT-C compared with FT-F cohorts ($21,971 vs. $22,939, p = 0.3) with an average savings of $968. Readmissions, complications, and satisfaction were similar for all comparison groups.

 

Conclusions

FTPs for urgent appendectomies and cholecystectomies can significantly reduce hospital costs by reducing LOS without compromising patient outcomes.

 

URL: http://rdcu.be/o45b


Diagnostic Accuracy of Abdominal Ultrasound for Diagnosis of Acute Appendicitis: Systematic Review and Meta-analysis

 

Author list: Vanja Giljaca, Tin Nadarevic, Goran Poropat, Vesna Stefanac Nadarevic, Davor Stimac

 

Abstract: 

Background

To determine the diagnostic accuracy of abdominal ultrasound (US) for the diagnosis of acute appendicitis (AA), in terms of sensitivity, specificity and post-test probabilities for positive and negative result.

 

Methods

A systematic search of MEDLINE, Embase, The Cochrane library and Science Citation Index Expanded from January 1994 to October 2014 was performed. Two authors independently evaluated studies for inclusion, extracted data and performed analyses. The reference standard for evaluation of final diagnosis was pathohistological report on tissue obtained at appendectomy. Summary sensitivity, specificity and post-test probability of AA after positive and negative result of US with corresponding 95% confidence intervals (CI) were calculated.

 

Results

Out of 3306 references identified through electronic searches, 17 reports met the inclusion criteria, with 2841 included participants. The summary sensitivity and specificity of US for diagnosis of AA were 69% (95% CI 59–78%) and 81% (95% CI 73–88%), respectively. At the median pretest probability of AA of 76.4%, the post-test probability for a positive and negative result of US was 92% (95% CI 88–95%) and 55% (95% CI 46–63%), respectively.

 

Conclusion

Abdominal ultrasound does not seem to have a role in the diagnostic pathway for diagnosis of AA in suspected patients. The summary sensitivity and specificity of US do not exceed that of physical examination. Patients that require additional diagnostic workup should be referred to more sensitive and specific diagnostic procedures, such as computed tomography.

 

URL: http://rdcu.be/o45q


Plate Fixation Versus Intramedullary Nailing for Both-Bone Forearm Fractures: A Meta-analysis of Randomized Controlled Trials and Cohort Studies

 

Author list: Liang Zhao, Baojun Wang, Xiadong Bai, Zhenyu Liu, Hua Gao, Yadong Li

 

Abstract: 

Background

The aim of this study was to compare the radiographic and functional outcomes of operative intervention in patients with both-bone forearm fractures treated by open reduction and internal fixation (ORIF) with plates or intramedullary (IM) nailing.

 

Methods

Studies published in PubMed, EMBASE, Web of Science, SinoMed (Chinese BioMedical Literature Service System, China), and CNKI (China National Knowledge Infrastructure, China) were systematically searched. The main outcomes included time to union, union rate, operation time, magnitude and location of radial bow, loss of forearm rotation, and complication rates. Results were expressed with weighted mean difference or risk ratio with 95 % confidence intervals. Pooled estimates were calculated using a fixed-effects or random-effects model according to the heterogeneity among studies.

 

Results

A total of 13 studies met the inclusion criteria and were included in this meta-analysis. Compared with ORIF, IM nailing significantly reduced the operation time and complication rate. However, no significant differences were observed between the two surgical techniques in several outcomes, including time to union, union rate, radial bow magnitude, and loss of forearm rotation. Except in complications, these findings were consistent across the subgroup analysis of children and adult patients.

 

Conclusions

IM nailing is associated with shorter operation time and lower complication rate compared with ORIF. It is an effective and safe treatment option for children and adults with both forearm fractures. However, considering the limitations in this study, large-scale, high-quality randomized controlled trials are needed to indentify these findings.

 

URL: http://rdcu.be/o45x


 

BACK