Clavien-Dindo Grade IIIa Research Articles

Parachute technique for portal vein reconstruction during pancreaticoduodenectomy with portal vein resection in patients with pancreatic head cancer.

The most appropriate venous reconstruction method remains debatable when a long section of portal vein (PV) and/or superior mesenteric vein (SMV) must be resected in patients undergoing a pancreaticoduodenectomy (PD). The aim of the present study was to describe the technical details of the parachute technique, a modified end-to-end anastomotic maneuver that can be used in the above-mentioned circumstances, and to investigate its safety and feasibility. Patients who underwent venous reconstruction using the parachute technique after receiving a PD with PV resection for pancreatic cancer between January 2014 and March 2019 were retrospectively reviewed. For the parachute technique, the posterior wall was sutured in a continuous fashion while the stitches were left untightened. The stitches were then tightened from both sides after the running suture of the posterior wall had been completed, thereby dispersing the tension applied to the stitched venous wall when the venous ends were brought together and solving any problems that would otherwise have been caused by over-tension. The postoperative outcomes and PV patency were then investigated. Fifteen patients were identified. The median length of the resected PV/SMV measured in vivo was 5cm (range, 3-6cm). The splenic vein was resected in all the patients and was reconstructed in 13 patients (87%). The overall postoperative complication rate (≥ Clavien-Dindo grade I) was 60%, while a major complication (≥ Clavien-Dindo grade IIIa) occurred in 1 patient (7%). No postoperative deaths occurred in this series. The PV patency at 1year was 87%. The parachute technique is both safe and feasible and is a simple venous reconstruction procedure suitable for use in cases undergoing PD when the distance between the resected PV and SMV is relatively long.

Stone free rate and clinical complications in patients submitted to retrograde intrarenal surgery (RIRS): Our experience in 571 consecutive cases.

The purpose of this study is to report the stone free rate (SFR) and clinical complications in patients submitted to retrograde intrarenal surgery (RIRS). A total of 571 procedures of upper urinary stones treated using flexible ureteroscopy and holmium laser lithotripsy from January 2014 to February 2020 have been analyzed. Overall SFR was evaluated after 3 months following the procedure by means of a non-contrast computed tomography. Success was considered as stone-free status or ≤ 0.4 cm fragments. The overall SFR was 92.3% in group 1 (stone size: < 1 cm), 88.3% in group 2 (stone size: > 1 ≤ 2 cm), 56.7% in group 3 (stone size: 2-3 cm) and 69.6% in group 4 (multiple stones). Post-operative complications, according to the Clavien- Dindo (CD) classification system, were recorded in 32 (5.6%) procedures. The major complications recorded were: one case of subcapsular hematoma (SRH) associated with pulmonary embolism two days after the procedure (CD Grade IIIa) treated conservatively and one case of hemorrhagic shock 2 hour with multiple renal bleedings requiring urgent nephrectomy (CD Grade IVA). The RIRS is an effective and safe procedure with a high SFR significantly correlated with the stone size; at the same time, RIRS could be characterized by severe clinical complications that require rapid diagnosis and prompt treatment.

Predictive Factors for Acute Urinary Retention After Transperineal Template-Guided Mapping Biopsy

Purpose: We investigated the predictive factors for acute urinary retention (AUR) after transperineal template-guided mapping biopsy (TTMB).Materials and Methods: We retrospectively reviewed the records of 459 patients who had undergone TTMB between May 2017 and July 2020. Overall complications after TTMB were analyzed and categorized according to the Clavien-Dindo classification. Factors that were likely to affect AUR were analyzed using a logistic regression model.Results: Overall complications after TTMB were observed in 95 of the 459 patients (20.7%), of which AUR was the most commonly reported (17.4%, n=80), followed by hematuria (3.1%, n=14). Hematuria in one patient was categorized as Clavien-Dindo grade IIIa. All remaining complications were Clavien-Dindo grade I. In the multivariate regression model, age ≥65 (odds ratio, 2.44; 95% confidence interval [CI], 1.42–4.17; p=0.001), prostate volume ≥30 mL (odds ratio, 3.72; 95% CI, 1.19–11.62; p&lt;0.02), and number of biopsy cores ≥30 (odds ratio, 2.89; 95% CI, 1.29–6.43; p=0.01) were identified as the predictors for AUR after TTMB.Conclusions: AUR is the most common complication after TTMB. Age ≥65 years, prostate volume ≥30 mL, and number of biopsy cores ≥30 were significant predictors of AUR following TTMB.

Application of ex vivo liver resection and autotransplantation in treating Budd-Chiari syndrome secondary to end-stage hepatic alveolar echinococcosis: A case series.

Background:Secondary Budd-Chiari syndrome (BCS) occurs due to a blockage in the liver caused by invasion or compression by a large lesion. Conventional treatments for BCS do not solve practical problems, wherease liver transplantation has been only applied as a last-resort therapy and as the only opportunity for a radical cure. We explored the feasibility of applying ex vivo liver resection and autotransplantation (ELRA) for the new indications of treating patients with end-stage hepatic alveolar echinococcosis (HAE). Our center has firstly proposed the idea and successfully treated the 49 patients with HAE. This article for the first time reports the application of ELRA in treating patients with BCS secondary to HAE.Methods:According to the degree of lesion invasion and surgical options, 11 patients were divided into 4 types. These 11 patients had large lesions that invaded the second and third hilum of the caudate lobe and involved the confluence of the hepatic vein and the inferior vena cava, suprahepatic vena cava, or at least 2 hepatic veins and led to secondary BCS. The aim of the present work was to report 11 patients with life-threatening diseases who underwent ELRA (ex vivo liver resection and autotransplantation) for secondary BCS, to propose a classification system for secondary BCS, and to suggest that secondary BCS is an indication for ELRA.Results:Eleven patients successfully underwent ELRA without intraoperative mortality. The median autograft weight was 690 g (440–950 g); operative time was 12.5 hours (9.4–16.5 hours); Postoperative hospital stay was 15 days (7–21 days). Clavien-Dindo grade IIIa or higher postoperative complications occurred in only 5 patients.Conclusions:This article for the first time reports the application of ELRA in treating patients with BCS secondary to HAE, not only provides new ideas for alternative treatments of secondary BCS, but also provides a classification system for secondary BCS. This article describes the technical process of outflow tract reconstruction and the experience for expanding the indications for ELRA. Our study demonstrated that ELRA is well feasible for treatment of BCS secondary to advanced HAE.

The left graft may be the “right” graft: A comparative study of using the right versus left graft in adult-to-adult living donor liver transplantation

Adult-to-adult living donor liver transplantation (LDLT) has been a dominant type of liver transplantation, especially in Asian countries where deceased donors are extremely scarce. Several centers have been attempted to use left liver graft because it could reduce the postoperative risk to the donor. This study retrospectively compared clinical outcomes between right and left liver grafts in adult-to-adult LDLT. All consecutive 116 patients who underwent adult-to-adult LDLT between 2010 and 2020 were enrolled in this study. The study cohort comprised of 94 patients in the right liver (RL) group and 22 in the left liver (LL) group. When both hemiliver grafts meet the selection criteria, LL graft was preferred. Prospectively collected clinicopathologic characteristics, perioperative outcomes, and survival were evaluated. In terms of donor variables, median actual graft-to-recipient weight ratio was higher in the RL group than in the LL group (1.01 [0.66-1.66] vs. 0.85 [0.63-1.50], p = 0.030). Total bilirubin level and prothrombin time on postoperative day 5 were worse in the RL group, but it did not reach statistical significance. In terms of recipient variables, hepatic venous pressure gradient after reperfusion was comparable between the groups. The 90-day complication (above Clavien-Dindo grade IIIA) and 1-year graft survival rates were not different between the RL and LL groups (35.9% vs. 56.2%, p = 0.123; 91.3% vs. 93.8%, p = 0.744; respectively). This study demonstrated comparable donor and recipient outcomes between the RL and LL groups. In an effort to minimize potential donor risk, LL graft is worth considering when both grafts meet the selection criteria.

Efficacy of one-surgeon basketing technique for stone extraction during flexible ureteroscopy for urolithiasis

ABSTRACT Objective: To evaluate the safety and efficacy of using one-surgeon basketing technique by a solo surgeon for stone extraction during flexible ureteroscopy (f-URS) for urolithiasis. Patients and methods: This retrospective study enrolled patients with urinary calculus who underwent f-URS at two institutions in Japan between September 2014 and March 2020. A total of 100 patients were operated by one experienced surgeon using the one-surgeon basketing technique. With this approach, the f-URS apparatus was manipulated with the non-dominant hand and the basket catheter was manipulated with the dominant hand. We retrospectively examined the perioperative results, complications, and stone-free rate [with ‘stone free’ defined as ≤2 mm with kidney–ureter–bladder (KUB) at 1 month after f-URS] to estimate the safety and efficacy for comparison with the results of conventional retrieval basketing technique. Results: Among our study population, the median stone size was 14 mm and median operative time was 74 min. A stone-free status was achieved in 91 patients (91%). The median stone fragmentation time was 15 min and stone retrieval time was 30 min. All included patients were treated using the one-surgeon basketing technique. Complications related to stone retrieval were identified in two patients (2%); the degree of ureteral injury was classified as Clavien–Dindo Grade IIIa. Conclusion: The one-surgeon basketing technique is safe and effective for the extraction of stone fragments during f-URS for urolithiasis. This technique does not require assistance for basketing; therefore, f-URS with active retrieval basketing can be completed by a solo surgeon. Abbreviations: BMI: body mass index; KUB: kidney–ureter–bladder; SFR: stone-free rate; UAS: ureteral access sheath; f-URS: flexible ureteroscopy

Propensity matched analysis of short term oncological and perioperative outcomes following robotic and thoracolaparoscopic esophagectomy for carcinoma esophagus- the first Indian experience.

Thoracolaparoscopic esophagectomy (TLE) for carcinoma esophagus has better short-term outcomes compared to open esophagectomy. The precise role of robot-assisted laparoscopic esophagectomy (RALE) is still evolving. Single center retrospective analysis of TLE and RALE performed for carcinoma esophagus between January 2015 and September 2018. Propensity score matching was done between the groups for age, gender, BMI, ASA grade, tumor location, neoadjuvant therapy, the extent of surgical resection (Ivor Lewis or McKeown’s), histopathological type (squamous cell carcinoma or adenocarcinoma), clinical T and N stages. The primary outcome parameter was lymph node yield. Secondary outcome parameters were resection margin status, duration of surgery, blood loss, conversion to open procedure, length of hospital stay, length of ICU stay, complications, 90-day mortality and cost. There were 90 patients in TLE and 25 patients in RALE group. After propensity matching, there were 22 patients in each group. The lymph node yield was similar in both the groups (23.95 ± 8.23 vs 22.73 ± 11.63; p = 0.688). There were no conversions or positive resection margins in either group. RALE was associated with longer operating duration (513.18 ± 91.23 min vs 444.77 ± 64.91 min; p = 0.006) and higher cost ($5271.75 ± 456.46 vs $4243.01 ± 474.64; p < 0.001) than TLE. Both were comparable in terms of blood loss (138.86 ± 31.20 ml vs 133.18 ± 34.80 ml; p = 0.572), Clavien-Dindo grade IIIa and above complications (13.64% vs 9.09%; p = 0.634), hospital stay (12.18 ± 6.35 days vs 12.73 ± 7.83 days; p = 0.801), ICU stay (4.91 ± 5.22 days vs 4.77 ± 4.81 days; p = 0.929) and mortality (0 vs 4.55%; p = 0.235). RALE is comparable to TLE in terms of short-term oncological and perioperative outcomes except for longer operating duration when performed for carcinoma esophagus. RALE is costlier than TLE.

Features of the complications for intracorporeal Billroth-I and Roux-en-Y reconstruction after laparoscopic distal gastrectomy for gastric cancer.

Recently, the Roux-en-Y procedure (R-Y) and delta-shaped Billroth-I anastomosis (DB-I) have become prevalent as intracorporeal gastroenteric anastomosis methods after laparoscopic distal gastrectomy (LDG) for gastric cancer. However, the differences in postoperative outcomes between the two methods have not been clarified. Hence, this retrospective study aimed to reveal the features of the complications of the R-Y versus DB-I after LDG. The study cohort comprised patients with gastric cancer who underwent DB-I or R-Y after LDG from January 2013 to May 2016. Patient characteristics and surgical and postoperative variables were analyzed. To compensate for intergroup differences in baseline characteristics, estimated propensity scores were used to perform one-on-one matching between the groups. A total of 564 patients were included, and propensity score matching created a matched cohort of 149 pairs in the DB-I and R-Y groups. The incidence of short-term complications such as gastrointestinal fistula classified as Clavien-Dindo grade IIIa or above was significantly greater in the DB-I group than the R-Y group (14.1% versus 4.7%, p=0.004). In contrast, the R-Y was associated with long-term complications such as internal hernia and tended to result in a slightly higher readmission rate in the R-Y group compared with the DB-I group (2.7% versus 6.0%, p=0.128). DB-I after LDG was associated with a significantly higher rate of short-term complications compared with the R-Y, whereas characteristic long-term complications tended to be observed after the R-Y. These differences should be considered during the selection of the reconstruction method and postoperative management of LDG.

Phase II study of systemic chemotherapy with S-1 plus oxaliplatin followed by surgery in patients with cT3-T4a and/or node-positive advanced adenocarcinoma of the esophagogastric junction: Primary endpoint results of the ESOX trial.

214 Background: Perioperative chemotherapy has been suggested to be beneficial in patients with advanced gastric cancer. Based on the German FLOT-4 study, the FLOT regimen is considered as the new standard perioperative chemotherapy regimen for resectable gastric cancer in Europe. However, most clinical trials have included few or no cases of esophagogastric junction (EGJ) cancer, because of the difference in surgical procedures. The benefit of neoadjuvant chemotherapy in patients with advanced adenocarcinoma of the EGJ thus remains controversial in Japan. Methods: We conducted a phase II study in 13 Japanese institutions. Eligible patients had histopathologically confirmed adenocarcinoma of the EGJ (Siewert type I or II with invasion of the esophagus ≥30 mm) with clinical T3/4a and/or node-positive on imaging findings, who required thoracic surgery to achieve R0 resection. Patients received three cycles of S-1 (80 mg/m2) twice a day on days 1–14 and oxaliplatin (130 mg/m2) (SOX) on day 1 of a 21-day cycle before surgery. The primary endpoint was R0 resection rate and the secondary endpoints were overall response rate, pathological complete response (pCR) rate, 2-year and 3-year disease-free survival, overall survival, and toxicity. The planned sample size was 50 patients based on an expected R0 resection rate of 85% and the threshold was 70%, with a one-sided alpha of 0.1 and power of 80%. Results: Fifty patients were enrolled in this study between June 2016 and April 2020. Totals of 21/29 and 7/4/22/8/8/1 had Siewert type I/II and clinical stage IIA/IIB/IIIA/IIIB/IIIC/IV disease, respectively. The completion rates for preoperative chemotherapy and surgery were 92% and 88%, respectively. Neoadjuvant therapy resulted in downstaging in 46% of patients (95% confidence interval (CI) 31.8%-60.7%). The pCR rate was 18% (95% CI 8.6%-31.4%) and the R0 resection rate was 82.0% (95% CI 68.6%-91.4%, 80% CI 73.1%-88.9%). Adverse events ≥ grade 3 during chemotherapy included thrombocytopenia (10%), neutropenia (8%), anemia (4%), anorexia (4%), nausea(2%), hypocalcemia(2%), hyponatremia(2%) and diarrhea (2%). Surgical morbidity was acceptable (Clavien-Dindo Grade IIIa surgical complications included anastomotic leakage (6.3%), pleural effusion (4.2%), thromboembolism (2.1%), and anastomotic infection (2.1%)). Conclusions: Neoadjuvant SOX met the primary endpoint of R0 resection rate 82% ( &gt; 70%), with acceptable adverse effects and no impression on surgeries, suggesting that neoadjuvant SOX might be a new treatment strategy for patients with EGJ adenocarcinoma in Japan. Clinical trial information: 000020815.

Jaundice as a clinical presentation in liver hydatidosis increases the risk of postoperative biliary fistula

Echinococcosis, also known as hydatidosis, is a zoonosis that is endemic in many countries worldwide. Liver hydatid cysts have a wide variety of clinical manifestations, among which obstructive jaundice is one of the rarer forms. The aims of the study were to analyze the preoperative management of these patients and to record the kind of surgical treatment performed and the short- and long-term postoperative results. A retrospective two-center observational study of patients operated upon for liver hydatidosis with initial symptoms of obstructive jaundice. Preoperative characteristics, surgical data, and postoperative complications, including biliary fistula, were recorded. Of 353 patients operated upon for liver hydatidosis, 44 were included in the study. Thirty-five patients (79.6%) were defined as CE2 or CE3 in the World Health Organization (WHO) classification. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) was performed in 25 patients (56.8%) and identified intrabiliary communication in 29. Radical surgery was carried out in 29 of the total sample (65.9%). Severe postoperative complications (Clavien-Dindo grade IIIA or higher) were recorded in 25% of patients. The factors associated with greater postoperative morbidity were age above 65 (HR 8.76 [95% CI 0.78-97.85]), cyst location (HR 4.77 [95% CI 0.93-24.42]), multiple cysts (HR 14.58 [95% CI 1.42-149.96]), and cyst size greater than 5 cm (HR 6.88 [95% CI 0.95-50]). The presentation as obstructive jaundice causes greater postoperative morbidity. The main postoperative complication in these cases, despite radical surgery, is biliary fistula. In our series, routine preoperative ERCP did not show any benefit.

Eighty-six cases of total pancreatectomy for pancreatic neoplasms

Background: Although frequency of total pancreatectomy (TP) indicated for pancreatic neoplasm has increased, surgical outcome and nutrition was still unclear. Objective: To clarify the outcome of TP. Methods: Patients with pancreatic neoplasms who underwent between 1990 and 2018 were analyzed. Surgical variables and outcome were compared between subjects who underwent simple TP [group A], TP followed by pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) according to intraoperative pathological diagnosis of pancreatic margin [B], TP followed by past PD or DP for another disease [C]. Results: A total 86 patients, 64 [36-80] year-old 44 males and 42 females, underwent TP. Operative time and blood loss were 520 [155-1070] minutes and 1095 [85-8155] ml, respectively. Mortality rate [n=2(2%)] and morbidity rate [>=Clavien-Dindo grade IIIa; n=4(5%)] were acceptable. Sixty-one cases were indicated for ductal adenocarcinoma (PDAC), 7 for neuroendocrine tumor, 7 for metastatic tumor from renal cell carcinoma, 11 for others. Although overall survival of patients with PDAC in group A (n=25), B (n=30), C (n=5) were statistically comparable respectively, the survival (3-5 years survival/ median survival time) of group A (29-29%/15.5 months) tended to be worse than that of group B and C (53-29%/ 46.9 months and 60-30%/ 56.6 months). PDAC patients with CA19-9 level less than 500 U/ml (56-41%/ 48.6 months) survived statistically more than those with CA19-9 level more than 500 U/ml (18-0%/ 16.4 months, P=0.011). Conclusions: Because of recent advance of surgical technique and management of TP, TP for wide-spread non PDAC or less advanced PDAC provides acceptable prognosis.

Accurate prediction of severe postoperative complications after pancreatic surgery: POSSUM vs E-PASS.

Few reports have evaluated the differences in the predictive accuracy between the physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) and estimation of physiologic ability and surgical stress (E-PASS) in pancreatic surgery. Thus, we evaluated the accuracy and similarity of POSSUM and E-PASS for the prediction of severe postoperative complications (PCs) after pancreatic surgery. We enrolled 343 consecutive patients who underwent pancreatic surgery in our department between April 2006 and September 2017.The difference in predictive values of POSSUM and E-PASS for the occurrence of PCs≥Clavien-Dindo grade IIIa (PCs-CD≥IIIa) was nonparametrically compared. The predictive accuracy and similarity of each tool was examined using the receiver operating characteristic (ROC) curve and linear regression analyses. Forty-five patients developed PCs-CD≥IIIa. E-PASS had a significantly higher predictive value for estimating PCs-CD≥IIIa occurrence (P=.002) than did POSSUM. The area under the curve value in ROC analysis was significantly higher in E-PASS than in POSSUM (0.643 vs 0.543, P=.014), with a weak positive correlation in the predictive value between E-PASS and POSSUM (R2 =.333, P<.001). Estimation of physiologic ability and surgical stress was useful for predicting severe PCs after pancreatic surgery and had a higher accuracy than POSSUM.

Safety and Efficacy of Laparoscopic Liver Resection for Colorectal Liver Metastasis With Obesity.

Laparoscopic liver resection (LLR) in obese patients has been reported to be particularly challenging owing to technical difficulties and various comorbidities. The safety and efficacy outcomes in 314 patients who underwent laparoscopic or open nonanatomical liver resection for colorectal liver metastases (CRLM) were analyzed retrospectively with respect to the patients' body mass index (BMI) and visceral fat area (VFA). Two hundred and four patients underwent LLR, and 110 patients underwent open liver resection (OLR). The rate of conversion from LLR to OLR was 4.4%, with no significant difference between the BMI and VFA groups (P = .647 and .136, respectively). In addition, there were no significant differences in terms of operative time and estimated blood loss in LLR (P = .226 and .368; .772 and .489, respectively). The incidence of Clavien-Dindo grade IIIa or higher complications was not significantly different between the BMI and VFA groups of LLR (P = .877 and .726, respectively). In obese patients, the operative time and estimated blood loss were significantly shorter and lower, respectively, in LLR than in OLR (P = .003 and < .001; < .001 and < .001, respectively). There was a significant difference in the incidence of postoperative complications, organ/space surgical site infections, and postoperative bile leakage between the LLR and OLR groups (P = .017, < .001, and < .001, respectively). LLR for obese patients with CRLM can be performed safely using various surgical devices with no major difference in outcomes compared to those in nonobese patients. Moreover, LLR has better safety outcomes than OLR in obese patients.

Transplant Radical Nephrectomy and Transplant Radical Nephroureterectomy for Renal Cancer: Postoperative and Survival Outcomes.

BackgroundThe treatment of complex tumors in non-functioning renal transplants requiring surgical extirpation is challenging. Here, we report the largest series of patients who underwent transplant radical nephrectomy for renal cell carcinoma (RCC) and transplant radical nephroureterectomy for urothelial cell carcinoma (UCC) in their transplanted kidneys.Material/MethodsFrom 2004 to 2018, 10 patients underwent transplant radical nephrectomy (7 patients) and nephroureterectomy (3 patients). Retrospective analyses, in terms of complications, oncological recurrence, and survival, of peri-operative and long-term outcomes, were performed.ResultsOut of the 10 patients, 7 had RCC and 3 had UCC. No intraoperative mortality occurred. Three patients presented with Clavien-Dindo grade IIIa or greater within 30 days of surgery. Two patients died within 60 days of surgery, both due to vascular events: one due to myocardial infarction and one due to stroke. Two other patients died: one after 2.9 years, due to myocardial infarction, and the other after 6 years, due to unknown reasons. At the 7-year follow-up, there was a 60% overall survival rate. For all patients, average survival post-nephrectomy was approximately 4.5 years, including the 6 living patients and 4 deceased patients. Importantly, there was no observed cancer recurrence.ConclusionsThis study reports outcomes of the largest series of transplant radical nephrectomy and nephroureterectomy for malignancies of renal allografts. In the optimized setting, extirpative surgeries appear safe, with favorable long-term oncological and survival outcomes.

Pancreatic resections in patients who refuse blood transfusions. The application of a perioperative protocol for a true bloodless surgery

BackgroundThe refusal of blood transfusions compels surgeons to face ethical and clinical issues. A single-institution experience with a dedicated perioperative blood management protocol was reviewed to assess feasibility and short-term outcomes of true bloodless pancreatic surgery. MethodsThe institutional database was reviewed to identify patients who refused transfusion and were scheduled for elective pancreatic surgery from 2010 through 2018. A protocol to optimize the hemoglobin values by administration of drugs stimulating erythropoiesis was systematically used. ResultsPerioperative outcomes of 32 Jehovah’s Witnesses patients were included. Median age was 67 years (range, 31–77). Nineteen (59.4%) patients were treated with preoperative erythropoietin. Twenty-four (75%) patients underwent pylorus-preserving pancreaticoduodenectomy, 4 (12.5%) distal pancreatectomy (DP) with splenectomy, 3 (9.4%) spleen-preserving DP, and 1 (3.1%) total pancreatectomy. Median estimated blood loss and surgical duration were 400 mL (range, 100–1000) and 470 min (range, 290–595), respectively. Median preoperative hemoglobin was 13.9 g/dL (range, 11.7–15.8) while median postoperative nadir hemoglobin was 10.5 g/dL (range, 7.1–14.1). The most common histological diagnosis (n = 15, 46.9%) was pancreatic ductal adenocarcinoma. Clavien-Dindo grade I-II complications occurred in fourteen (43.8%) patients while one (3.1%) patient had a Clavien-Dindo grade IIIa complication wich was an abdominal collection that required percutaneous drainage. Six (18.8%) patients presented biochemical leak or postoperative pancreatic fistula grade B. Median hospital stay was 16 days (range, 8–54) with no patient requiring transfusion or re-operation and no 90-day mortality. ConclusionsA multidisciplinary approach and specific perioperative management allowed performing pancreatic resections in patients who refused transfusion with good short-term outcomes.

Utility of Tokyo guidelines and intraoperative safety steps in improving the outcome of laparoscopic cholecystectomy in complex acute calculus cholecystitis: a prospective study

Laparoscopic cholecystectomy (LC) in complicated acute calculus cholecystitis (ACC) poses multiple challenges. This prospective, observational study assessed the utility and safety of a set protocol and intraoperative steps in LC for complex ACC. All cases of ACC from 2008 to 2018 were graded asper Tokyo guidelines; moderate and severe ACC were termed as 'complex ACC (CACC).' Patients were subjected to upfront LC or percutaneous drainage (PCD) followed by LC. Seven intraoperative safety steps were used to achieve critical view of safety (CVS). Use of safety steps, duration of surgery, and length of hospital stay were compared between moderate and severe ACC; complications were classified using Clavien-Dindo classification. We analyzed 145 patients with moderate (74.5%) and severe (25.5%) ACC. There were significantly more male (p = 0.0059) and older (p = 0.0006) patients with severe ACC. Upfront LC was performed in 81.4%; PCD required in 6.9%. Timing of LC from symptom onset was < 1week (53.1%), 2-5weeks (28.3%), and ≥ 6weeks (18.6%). CVS was achieved in 97.2%, subtotal cholecystectomy performed in 2.8%, conversion rate was 1.4%, major postoperative complications (Clavien-Dindo Grade IIIa and IIIb) were seen in 4.1%, no bile duct injury, and mortality was 0.7%. The outcomes were similar irrespective of timing of intervention. The study concludes that preoperative assessment by Tokyo guidelines, algorithmic plan of treatment and use of intraoperative safety steps results in favorable outcome of LC in ACC.

Treatment of Advanced Pancreatic Body and Tail Cancer by En Bloc Distal Pancreatectomy with Transverse Mesocolon Resection Using a Mesenteric Approach.

Pancreatic body and tail cancer easily invades retroperitoneal tissue, including the transverse mesocolon. It is difficult to ensure a dissected peripancreatic margin with standard distal pancreatectomy for advanced pancreatic body and tail cancer. Thus, we developed a novel surgical procedure to ensure dissection of the peripancreatic margin. This involved performing dissection deeper than the fusion fascia of Toldt and further extensive en bloc resection of the root of the transverse mesocolon. We performed distal pancreatectomy with transverse mesocolon resection (DP-TCR) using a mesenteric approach and achieved good outcomes. There are two main considerations for surgical procedures using a mesenteric approach: 1) dissection deeper than the fusion fascia of Toldt (securing the vertical margin) and 2) modular resection of the pancreatic body and tail, with the root of the transverse mesocolon and adjacent organs in a horizontal direction (ensuring the caudal margin). From 2017 to 2019, we performed DP-TCR using a mesenteric approach for six patients with advanced pancreatic body and tail cancer. Histopathological radical surgery was possible in all patients who underwent DP-TCR. No Clavien-Dindo grade IIIa or worse perioperative complications were observed in any patient. We believe that DP-TCR is useful as a radical surgery for advanced pancreatic body and tail cancer with extrapancreatic invasion.

One-surgeon basketing technique for stone extraction during flexible ureteroscopy for urolithiasis: A comparison between novice and expert surgeons.

To determine the safety and efficacy of the one-surgeon basketing technique for stone extraction during flexible ureteroscopy when carried out by novice surgeons under instructor guidance. We retrospectively compared perioperative results, complications and the "stone-free" rate (defined as ≤2mm fragments on kidney-ureter-bladder imaging 1month after flexible ureteroscopy) between experienced (groupA, n=50) and novice (groupB, n=50) surgeons using the one-surgeon basketing technique. Baseline patients' characteristics were similar between the two groups. There were no significant differences between groupsA and B in operative time (mean 76min vs 85min, P=0.46), stone-free rate (98% vs 92%, P=0.36), postoperative fever events (4% vs 4%, P=1.00) and postoperative hospital stay (24h vs 24h, P=1.00). Clavien-Dindo gradeIIIa complications (ureter injury) were only observed in two cases (4%) in groupB. The one-surgeon basketing technique for the extraction of stone fragments during flexible ureteroscopy might be safely and effectively carried out by surgeons with no prior experience under proper guidance.

Declining institutional memory of open abdominal aortic aneurysm repair

ObjectiveSince its introduction, endovascular aneurysm repair (EVAR) has become a mainstay in the treatment of abdominal aortic aneurysms (AAAs), resulting in the decline of open aneurysm repairs. The objective of this study was to determine whether reduced open aneurysm repair frequency has led to a reduction in perioperative efficiency and increase in postsurgical complications. MethodsA retrospective cohort study compared perioperative data and complications of 49 consecutive juxtarenal AAA (<1-cm neck) open repairs performed between 2014 and 2017 and 53 consecutive juxtarenal AAA controls (2005-2007) at The Ottawa Hospital. There was no change in surgical personnel during this 10-year comparison. ResultsThe Ottawa Hospital experienced a 61% decline in the number of open AAA repairs between the two time periods examined; 541 open AAA repairs and 86 EVARs were performed between 2005 and 2007, whereas 358 open AAA repairs and 385 EVARs were performed between 2014 and 2017. Age of participants significantly decreased in the 2014 to 2017 group (P = .01), as did the number of women undergoing open juxtarenal AAA repair (P = .05). Total operating room time and anesthesia time were longer in the 2014-2017 group (P = .02; P = .01), whereas surgical times remained consistent (P = .13). Suprarenal clamp time and blood loss during the procedure were decreased in the 2014-2017 group (P < .01; P < .01). Intensive care unit stay and overall hospital stay were not significantly different between groups (P = .77; P = .87); however, there were large standard deviations observed for the 2014-2017 group. As well, 18.4% of patients in the 2014-2017 group experienced postsurgical complications of Clavien-Dindo grade IIIa or higher compared with 11.3% of patients in the historical control group (P = .07). Mortality also trended toward an increase in the 2014-2017 group (P = .43). ConclusionsThe reduced rate of open repair performance at The Ottawa Hospital reflects the global trend toward EVAR. Anesthesia and operating room times increased during the period examined, reflecting a possible loss of expertise in the last decade. Complications also increased during this time for anatomically similar patients. Taken together, these findings may reflect a decreased institutional familiarity with open aneurysm repair and postsurgical care.

This Month in Pediatric Urology

You have accessJournal of UrologyThis Month in Pediatric Urology1 May 2020This Month in Pediatric Urology Julian Wan Julian WanJulian Wan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000784AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail The pediatric articles published in this issue of The Journal represent 2 ends of the pathological spectrum. Peycelon et al focus on the beginning in their report on in utero maternal hormone levels that may predict the risk for hypospadias.1 Aksenov and Granberg evaluate the potential complications of minimally invasive surgery to treat common conditions such as ureteropelvic junction narrowing and vesicoureteral reflux.2 Linking the articles is the acquisition, collection and analysis of large pools of data. The collection, storage, examination and commerce of personal data including medical information has expanded in the last few decades and is likely to continue to grow as greater segments of the population become associated with electronic medical record systems. Despite the many real concerns about privacy and exploitation, there are legitimate scientific applications of these larger data collections. By sampling blood collected as part of general screening, specific disease relationships can be identified and complications may emerge when gathering reports of procedures. Association of Maternal Human Chorionic Gonadotropin and Hypospadias Using a large national registry, Peycelon et al (page 1017) from France examined the association between first trimester maternal serum free beta-human chorionic gonadotropin (HCG) levels and subsequent finding of hypospadias in the newborn. It has been established that tubularization of the urethra occurs early and is usually complete by 16 to 18 weeks of gestation. This process is affected by testosterone activity which, in turn, is affected by the release of HCG from maternal placental syncytiotrophoblasts. The authors suspect that the relationship may depend more on total HCG rather than just the beta subunit. Using a large metropolitan Paris database of maternal blood samples taken as part of routine prenatal screening, they found that proximal hypospadias, but not distal hypospadias or hypospadias overall, was associated with significantly higher levels of beta-HCG. The study was controlled for age and excluded pregnancies that were initiated by artificial reproductive technologies (a known risk for hypospadias), chromosomal anomalies, twins, fetal death and terminations. However, the authors acknowledged the limitations inherent with this type of analysis, most of which relate to potential bias from underreporting of less severe forms and the small number of proximal hypospadias cases (13 of 194 hypospadias cases). Complications of Minimally Invasive Surgery in Children To assess complications in patients treated with minimally invasive surgery, Aksenov et al (page 1010) from North Carolina and Minnesota conducted a review of the existing literature.2 While the Clavien-Dindo (CD) system of classification has been widely used, it was used in only a third of the articles in their review, whereas for the remaining articles complications were adjudicated by the authors and assigned a CD grade. In particular, the authors focused on complications resulting in subsequent surgical, radiological and endoscopic interventions (CD grade IIIa without general anesthesia, CD grade IIIb with general anesthesia). They also noted conversion rates related to open surgery. A significantly lower rate of grade III complications was reported for nephrectomy than for pyeloplasty and ureteral reimplantation. Complex reconstructions, as one would expect intuitively, resulted in the highest grade III complication rate at 12%. Likewise, the complication rate was highest for conversion to open surgery, followed by partial nephrectomy, nephrectomy and ureteral reimplantation. The lowest complication rate occurred after pyeloplasty (1%) which may reflect longer experience with this procedure. The clear separation of open conversion and the need for a complication related subsequent procedure is of practical use when discussing possible risks with families, patients and referring physicians.