Dindo Grade Research Articles

Postoperative outcomes in patients undergoing elective general surgery after recovery from Covid-19 at a tertiary care centre: A one-year case series.

Background Planned elective surgery had to be postponed for a large number of patients who tested positive for Covid-19 in the preoperative period. We aimed to assess the postoperative outcomes of patients who were operated on for elective indications, following recovery from Covid-19 infection. Methods We did a retrospective study of patients who underwent elective general surgery between 1 April 2020 and 31 March 2021, following recovery from Covid-19. The 30-day postoperative morbidity and mortality were analysed. The data relevant for the study were retrieved from the hospital's electronic medical records. Results Of the 109 patients included, 54.1% were women and the median (range) age was 49 (16-76) years; 53.2% of operations were performed for benign indications and the rest were for malignancies. Eighty-five (78%) patients underwent surgery following recovery from an asymptomatic Covid-19 infection and 23 (21.1%) patients following recovery from mild Covid-19 infection; 73.3% of the operations were performed following a planned delay of 2- 5 weeks from the diagnosis of Covid-19. The 30-day major postoperative morbidity (Clavien-Dindo grade ≥3) was 6.4%, the postoperative pulmonary morbidity was 0.9%, and there was no 30-day mortality. Conclusions Elective general surgical procedures can be done safely in patients who have recovered from asymptomatic and mild Covid-19 infection, following a minimum wait period of 2 weeks.

LAPAROSCOPIC ADRENAL-SPARING SURGERY CASE SERIES: PARTIAL ADRENALECTOMY AND CYST RESECTION.

The aim is to present our case series documenting indications, laparoscopic technique, surgical and endocrinologic outcomes of laparoscopic partial adrenalectomy. In the period from April 2011 until October 2021, we performed 39 procedures. The patients were divided into three groups: unilateral adrenal gland tumor with a normal contralateral gland (group 1), tumor of the solitary adrenal gland (group 2), and adrenal cysts (group 3). There were 20 patients in group 1, 6 patients in group 2, and 13 patients in group 3. The most common histology in group 1 was adenoma (40%), all tumors in group 2 were renal cell carcinoma metastases, and all cysts in group 3 were benign. There were no major complications (Clavien Dindo grade ≥2) in the whole cohort. All patients in groups 1 and 3 had favorable endocrinologic outcomes, and 50% of group 2 patients required lifelong hydrocortisone replacement therapy. The procedure is safe and feasible with favorable outcomes in the hands of a high volume adrenal surgeon.

A Comparative Study of the Efficacy of Thulium Fiber Laser Enucleation and Transurethral Resection for Medium- to Large-Size Prostate

Abstract Purpose: The objective of this study was to evaluate the efficacy and safety of the newer, thulium fiber laser enucleation of the prostate (ThuFLEP) versus the transurethral resection of the prostate (TURP) for medium- to large-volume benign prostatic hyperplasia (BPH). Materials and Methods: We performed a single-center retrospective study between May 2020 and June 2021. Among these, we included patients >50 years of age, with prostate size >80 cc, International Prostate Symptom Score (IPSS) >19, and maximum urine flow rate (Qmax) <15 mL/s. All patients underwent either TURP or ThuFLEP. Preoperative parameters such as IPSS score, quality of life (QoL) score, Qmax, and residual urine were assessed. Results: Of the total of 101 patients, 29 underwent ThuFLEP and 72 TURP. The mean prostate volume was significantly higher in the ThuFLEP group compared to the TURP (P = 0.01). The mean operative time was longer for ThuFLEP compared to TURP (P < 0.0001). No significant difference was noted in the postoperative hematuria (P = 0.29) and mean postoperative hemoglobin (P = 0.37). The QoL scores were significantly improved with ThuFLEP than TURP (P = 0.0006). Compared to a day after catheter removal, the proportion of patients with stress, urge, and total incontinence was significantly reduced at the end of 1 month in the ThuFLEP group (P < 0.00001); however, it was significantly greater than with TURP (P < 0.05). At 3 months, no significant difference was found between IPSS (P = 0.37) and Qmax (P = 0.98) scores between the groups; however, the decrease from baseline was significant for IPSS (P < 0.0001). The Clavien–Dindo Grade I and II complications were 31% and 13.8%, respectively, for ThuFLEP and 8.3% and 1.4% for TURP. There was no significant difference of patients with late complications. Conclusion: ThuFLEP demonstrated efficacy similar to TURP in medium- to larger-size BPH in terms of IPSS and Qmax but had significant improvement in QoL scores. The overall complications with ThuFLEP were higher as compared to TURP.

USING THE MODIFIED CLAVIEN GARDING SYSTEM TO CLASSIFY COMPLICATIONS OF BIPOLAR TURP

introduction: TURP is considered gold standard treatment for BPH. TURP was first introduced in 1929 by Maximilian Stern. Complications in TURP are less but not absolute. Modified Clavien Dindo Grading System is well-established classification for post-operative complications. Objective of this study is to assess complications of BIPOLAR TURP by using the modified Clavien grading system. Objective: To assess the evaluation of complications after bipolar transurethral resection of prostate using the Modified Clavien grading system. Materials And Methods: 110 BIPOLAR TURP performed between April 2019 and March 2021 at Meenakshi mission hospital Madurai Tamilnadu India were reviewed retrospectively. All patients with various complications were graded using Modified Clavien grading system in 5 grades. Results: 110 cases were enrolled in our study out of them 21 (19.9%) patients developed complications there was no mortality. Out of 21; 11 (52.4%) grade I, 5 (23.8%) grade II, 2 (9.5%) grade IIIa, 1 ( 4.8%) grade IIIb, 1 (4.8%) in each grade IVa and IVb. Conclusion: Modified Clavien Grading System is an easy and feasible classification system for postoperative complications. In spite of various shortcomings, it is very useful to grade end-urological procedure BIPOLAR TURP short-term complications.

Stone clearance rate and postoperative recovery of mini percutaneous nephrolithotomy: A single-institute study

Introduction: During the last two decades, the evaluation and management of renal and upper ureteric stones have vastly altered. The era of endoscopic surgery replaced open pyelolithotomy or nephrolithotomy which caused significant morbidity. Earlier percutaneous nephrolithotomy (PCNL) replaced open surgery as a safe and effective treatment for renal stones. During this decade, we saw the evolution of endoscopic surgery where Mini PCNL (Mini Perc), Ultra Mini, and Micro Perc have further achieved stone clearance with better outcomes pertaining to reduced morbidity because of reduction in the caliber of tract dilatation, even avoiding a nephrostomy postprocedure in select cases. Aim: The aim of this study summarizes the outcome of 78 cases of patients undergoing Mini Perc. The primary objectives of the study are: 1. Postoperative evaluation of complications associated with Mini Perc by Modified Clavien–Dindo Grading 2. Postoperative pain assessment by visual analog scale 3. Stone clearance rate of the surgical procedure. Settings and Design: The research was carried out in the form of a hospital-based prospective observational study as per the guidelines shared by the Prospective Observational Clinical Studies Good Research Practices Task Force (formed May 16, 2010). Seventy-eight patients who underwent Mini Perc between August 2018 and May 2020 at tertiary care centers and who were vetted against the inclusion criteria were included in the study. Subjects and Methods: This was a hospital-based prospective observational study of 78 consecutive patients who underwent Mini Perc between August 2018 and May 2020 at a tertiary care center and were vetted against the criteria for inclusion and exclusion. A total of 78 patients who met the inclusion criteria were followed up in the study. The management policy for pelvicalyceal calculi at the study center has closely followed those of the American Urological Association (AUA) guidelines for managing renal stones. Results: The mean age of the group was 43.3 years (range: 16–84) with 47 males and 38 females. The mean stone size was 20.11 mm (range 11–8 mm) and the mean operative time was 44.5 min (range: 29–98 min). Double J (DJ) stent was placed in all patients as a prophylaxis to prevent obstruction/postoperative urinary leak. Postoperatively, three patients had bleeding from the operated site, two patients survived sepsis, and one patient each had postoperative fever and pleural injury. Pain assessment done at specified intervals showed a progressive decreasing trend in intensity as evaluated by visual analog scale. The stone clearance rate in our study was 96.15% at the end of 1 month following postoperative period. Conclusion: The study shows that Mini Perc remains the standard of care for the management of renal and upper ureteric stones. The technique beyond doubt is safe, efficient, feasible, and economical in achieving excellent stone clearance rates. The Modified Clavien–Dindo system of grading for perioperative complications is easy to use and reproducible. It can be used as an objective and reliable method for describing the complications of the surgical procedure.

Непосредственные результаты робот-ассистированных оперативных вмешательств при раке желудка

Background: stomach cancer is the 5th most common cancer worldwide and the 3rd leading cause of cancer death. In recent years, minimally invasive (including robot-assisted) techniques have been actively implemented in surgery for urological, gynecological, and gastrointestinal cancers. Aim: to summarize the experience with robot-assisted surgical interventions for gastric cancer and to demonstrate direct surgical outcomes. Patients and Methods: in 2018–2022, 111 patients (60 men and 51 women) with gastric cancer underwent robot-assisted surgery. The mean age was 64.6±5.5 years (33–78). The mean body mass index (BMI) was 27.9±2.8 kg/m2, 39.2% of patients had obesity (BMI>30 kg/m2). The tumor was located in the gastric cardia in 19 patients (17.1%), upper third of the stomach in 9 patients (8.1%), middle third of the stomach in 4 patients (3.6%), lower third of the stomach in 21 patients (18, 9%), and gastric antrum in 58 patients (52.3%). Distal subtotal gastric resection was performed in middle-third and lower-third gastric carcinomas. Gastrectomy was performed in the upper-third and gastric cardiac carcinoma. Two surgical systems, Da Vinci® Si and Da Vinci® Xi, were used for surgical interventions. Results: 79 distal subtotal gastric resections and 32 gastrectomies were performed. The median duration of distal subtotal gastric resection and gastrectomy was 210.5 min [178.8; 249.5] and 285.0 min [275.5; 303.0], respectively. The median intraoperative blood loss was 65.0 ml [10.0; 170.0], and the median number of removed lymph nodes was 29.0 [18.0; 43.0]. Histological examination revealed clear resection margins (R0) in all patients. The conversion of surgical access was required in 2 patients (1.8%). Death was reported in 1 patient (0.9%). Clavien–Dindo grade III–IV postoperative complications were detected in 7 patients (6.3%). The median in-hospital stay was 7.0 days [7.0; 10.0] after distal subtotal gastric resection and 9.0 days [9.0; 12.0] after gastrectomy. Conclusion: our findings support the global experience with robot-assisted surgical interventions for gastric cancer with minimal intra- and postoperative complications, which generally occur in elderly patients with severe comorbidities, obesity, and locally advanced cancer at baseline. KEYWORDS: robotic surgery, gastric cancer, oncology, gastric resection, gastrectomy. FOR CITATION: Kovalenko S.A., Gladyshev D.V., Moiseev M.E., Vetoshkin V.A., Svitich V.Yu., Gnedash S.S. Immediate outcomes of robot- assisted surgical interventions for gastric cancer. Russian Medical Inquiry. 2023;7(6):353–358 (in Russ.). DOI: 10.32364/2587-6821- 2023-7-6-3.

The safety and efficacy of laparoscopic microwave ablation-assisted partial nephrectomy: a new avenue for the treatment of cystic renal tumors

Purpose Clinically, the management of cystic renal masses is tricky. The study aims to evaluate the safety and efficacy of laparoscopic microwave ablation-assisted partial nephrectomy (LMAPN) for cystic renal tumors. Methods and materials Between November 2017 and January 2022, LMAPN was performed on 43 patients (29 men and 14 women; age range: 22–80 years; median age 54 years) with Bosniak category III (n = 15) or IV (n = 28) cystic renal tumors (size range: 1.2–5.0 cm; mean size 2.8 cm). The median follow-up period was 26 months (range: 7–56 months). Baseline and perioperative data, pathological features, renal function, postoperative complications and oncologic outcomes were collected and evaluated. Results Forty-three cystic renal tumors were successfully managed by LMAPN. The mean operating time was 79 min (range: 40–130 min). The mean time of renal pedicle clamping was 19 min (range: 12–25 min). Mean intraoperative blood loss was 28.4 mL (range: 10–80 mL). The mean postoperative hospitalization duration was 4 days (range: 2–6 days). Negative surgical margins were diagnosed in all cases. During the follow-up, no patient appeared with distant metastasis, wound or peritoneal cavity implantation. No major but minor complications of Clavien–Dindo grade I were encountered after the operation. The 1-, 3- and 4-year overall survival rate was 100%, 96.6% and 88.5%, respectively. Conclusion This is the first study focusing on LMAPN for cystic renal tumors, demonstrating its favorable feasibility, safety and disease control. Long-term follow-up is necessary to draw conclusions on the preference and advantages of the new therapeutic approach.

The Non-Muscle-Splitting Mini-Incision Donor Nephrectomy Remains a Feasible Technique in the Laparoscopic Era of Living Kidney Donation

Laparoscopic donor nephrectomy (LDN) is the current gold standard in kidney donation. Mini-incision open donor nephrectomy (MINI) techniques have been used extensively but have become less popular. The aim of the present study was to compare the results and safety of a non-muscle-splitting MINI technique with the current gold standard of LDN. A single center retrospective cohort study of all living donor nephrectomies between 2011 and 2019 was used for the study. The primary outcome of this study was short term (<30 days) with Clavien–Dindo grade complications. Secondary outcomes included multivariable regression analysis of perioperative data. No differences in complication rates were observed between MINI and LDN and also after correction for known confounders. As expected, the operative time and first warm ischemia were significantly shorter in the MINI group and less blood loss was observed in the LDN group. Complications and conversion rate (LDN to open) among the LDN patients were in line with recent published meta-analyses. This study confirms the perioperative safety of living kidney donation in modern practice. Complication rates of both MINI and LDN procedures are limited and not different between procedures. In specific circumstances, the MINI procedure can still be considered a safe and feasible alternative for living kidney donation.

Resection of supratentorial brain metastases with intraoperative radiotherapy. Is it safe? Analysis and experiences of a single center cohort.

Intraoperative Radiotherapy (ioRT) is an emerging treatment option in oncologic surgery for various diseases including intraaxial brain lesions to improve surgical outcome and accelerate the adjuvant oncologic therapy. Despite its use in glioma surgery, the application and data regarding ioRT in the treatment of brain metastases (BMs) is sparse. Here were report the largest series of supratentorial BMs treated with resection and ioRT according to functional outcome and adverse events. We performed a retrospective chart review analysis of patients undergoing surgery for BMs following an interdisciplinary tumor board decision in every case with ioRT at our institution. Patient properties, functional status (Karnofsky Performance Score/KPS) before and after surgery as well as oncologic (disease, recursive partitioning analysis, lesion size) and operative parameters were analyzed until hospital discharge. Adverse events (AE) were recorded until 30 days after surgery and rated according to the Clavien Dindo Grading (CDG) scale. 70 patients (40 female) with various oncologic diseases were identified and analyzed. Six underwent prior RT. Mean age was 66 ± 11 years. Preoperative median KPS was 80% with a mean BM volume of 3.2 ± 1.2 cm3. Nine patients (13%) experienced in total 14 AEs, including 2 cases (3%) of postoperative death (CDG5) and 2 with new postoperative epilepsy necessitating additional pharmacotreatment (CDG2). Five patients suffered from new neurologic deficit (CDG1) not needing further surgical or medical treatment. After surgery, the neurological status in 7 patients (10%) deteriorated while it improved in 21 cases (30%). Patients experiencing AEs had longer hospitalization and poorer postoperative KPS mdn. 90 vs. 80%. There was no statistically significant deterioration of the functional status during the immediate postoperative course in the whole patient cohort. Surgery for supratentorial BMs with ioRT seems safe and feasible. Further studies on the benefit regarding oncologic outcome need to be performed.

Surgical Outcome After Pancreatoduodenectomy for Duodenal Adenocarcinoma Compared with Other Periampullary Cancers: A Nationwide Audit Study

BackgroundSurgical outcome after pancreatoduodenectomy for duodenal adenocarcinoma could differ from pancreatoduodenectomy for other cancers, but large multicenter series are lacking. This study aimed to determine surgical outcome in patients after pancreatoduodenectomy for duodenal adenocarcinoma, compared with other periampullary cancers, in a nationwide multicenter cohort.MethodsAfter pancreatoduodenectomy for cancer between 2014 and 2019, consecutive patients were included from the nationwide, mandatory Dutch Pancreatic Cancer Audit. Patients were stratified by diagnosis. Baseline, treatment characteristics, and postoperative outcome were compared between groups. The association between diagnosis and major complications (Clavien–Dindo grade III or higher) was assessed via multivariable regression analysis.ResultsOverall, 3113 patients, after pancreatoduodenectomy for cancer, were included in this study: 264 (8.5%) patients with duodenal adenocarcinomas and 2849 (91.5%) with other cancers. After pancreatoduodenectomy for duodenal adenocarcinoma, patients had higher rates of major complications (42.8% vs. 28.6%; p < 0.001), postoperative pancreatic fistula (International Study Group of Pancreatic Surgery [ISGPS] grade B/C; 23.1% vs. 13.4%; p < 0.001), complication-related intensive care admission (14.3% vs. 10.3%; p = 0.046), re-interventions (39.8% vs. 26.6%; p < 0.001), in-hospital mortality (5.7% vs. 3.1%; p = 0.025), and longer hospital stay (15 days vs. 11 days; p < 0.001) compared with pancreatoduodenectomy for other cancers. In multivariable analysis, duodenal adenocarcinoma was independently associated with major complications (odds ratio 1.14, 95% confidence interval 1.03–1.27; p = 0.011).ConclusionPancreatoduodenectomy for duodenal adenocarcinoma is associated with higher rates of major complications, pancreatic fistula, re-interventions, and in-hospital mortality compared with patients undergoing pancreatoduodenectomy for other cancers. These findings should be considered in patient counseling and postoperative management.

Impact of atherosclerosis on the postoperative complications of colorectal surgery in older patients with colorectal cancer

BackgroundAtherosclerosis is associated with various comorbidities; nonetheless, its effect on the postoperative complications of colorectal surgery in older patients with colorectal cancer (CRC) remains unclear. This study aimed to evaluate the impact of atherosclerosis on the postoperative complications of colorectal surgery in older adults with CRC.MethodsPatients aged ≥ 65 years who underwent surgery for CRC between April 2017 and October 2020 were enrolled. To evaluate atherosclerosis, we prospectively calculated the cardio-ankle vascular index (CAVI) measured by the blood pressure/pulse wave test and abdominal aortic calcification (AAC) score from computed tomography. Risk factors for Clavien–Dindo grade ≥ III postoperative complications were evaluated by univariate and logistic regression analyses.ResultsOverall, 124 patients were included. The mean CAVI value and AAC score were 9.5 ± 1.8 and 7.0 ± 8.0, respectively. Clavien–Dindo grade ≥ III postoperative complications were observed in 14 patients (11.3%). CAVI (odds ratio, 1.522 [95% confidence interval, 1.073–2.160], p = 0.019), AAC score (1.083 [1.009–1.163], p = 0.026); and operative time (1.007 [1.003–1.012], p = 0.001) were identified as risk factors for postoperative complications. Based on the optimal cut-off values of CAVI and AAC score, the probability of postoperative complications was 27.8% in patients with abnormal values for both parameters, which was 17.4 times higher than the 1.6% probability of postoperative complications in patients with normal values.ConclusionsAtherosclerosis, particularly that assessed using CAVI and AAC score, could be a significant predictor of postoperative complications of colorectal surgery in older adults with CRC.

Comparison of Clinical Outcomes between Robot-Assisted Partial Nephrectomy and Cryoablation in Elderly Patients with Renal Cancer

Advances in imaging technologies have increased the opportunities for treating small-diameter renal cell carcinomas (RCCs) in the elderly. This retrospective study based on real-world clinical practice compared perioperative complications, preoperative and postoperative renal function, recurrence-free survival, and overall survival in elderly patients with RCC who had undergone robot-assisted partial nephrectomy (RAPN) or percutaneous cryoablation (PCA). A total of 99 patients (aged ≥70 years), including 50 and 49 patients in the RAPN and PCA groups, respectively, were analyzed. In the entire cohort, Clavien-Dindo grade ≥3 complications occurred in only one patient who had undergone RAPN. Renal function was significantly lower in the postoperative period than in the preoperative period in both the RAPN and PCA groups. The recurrence-free survival and overall survival rates were worse in the PCA group than in the RAPN group, albeit not significantly. RAPN was considered a safe and effective method for treating RCCs in elderly patients. Moreover, although the recurrence rate was slightly higher in the PCA group than in the RAPN group, PCA was deemed to be a safe alternative, especially for treating patients in whom general anesthesia poses a high risk.

Long-term quality of life after surgical Essure removal for device-attributed symptoms

ObjectiveTo analyze quality of life(QoL) and symptom resolution after surgical removal of Essure devices. MethodsSingle-center cohort study which included patients with Essure removal between February 2017 and March 2018. Surgery was performed in 65 patients by laparoscopy (Salpingectomy only or Hysterectomy). Questionnaires were used to assess QoL(SF-36), emotional disorders(HAD) and symptoms preoperatively, at 3 months and 4 years postoperatively. Results4(6,1%) and 16(24,6%) patients were lost of follow-up at three months and 4 years postoperatively respectively. Four(6,1%) intraoperative surgical complications occurred. During the three-months postoperative period, 3(4,6%) complications occurred: five Clavien Dindo Grade 1 complications (umbilical hematoma) and one Grade 2 complication (hyperthermia and digestive disorder requiring antibiotic therapy). Preoperative QoL scores were lower than those of general population. Scores were significantly improved at 3 months and 4 years postoperatively. At 4 years postoperatively, 17/49(34,7%) had a complete regression of symptoms, 21/49(42,8%) partial resolution and 11/49(22,4%) no improvement. 27/49(55,1%) patients made the connection between symptoms and ESSURE device after media coverage. 22/49(44,89 %) were influenced by media coverage in their decision of surgery. There was a higher percentage of patients with anxiety disorder before Essure removal than 4 years after [22/44 (50 %) versus 11/44 (25 %); p = 0.0045]. ConclusionEssure removal has a restorative role in terms of QoL in short and long-term. Patients should be informed about possibility of no improvement after surgery and surgical morbidity. Larger prospective cohort is needed to make a well-considered decision about risks of surgery compared with expected benefits.

Efficacy and Complications of the Re-Adjustable Male Sling System for Stress Urinary Incontinence after Radical Prostatectomy.

The aim of this study was to investigate the outcomes of re-adjustable male slings in pa-tients with postoperative stress urinary incontinence (SUI) following radical prostatectomy (RP). We retrospectively analyzed 18 patients with SUI following RP for prostate cancer, who were treated with re-adjustable male slings from January 2016 to December 2021. The clinical outcomes were evaluated based on daily pad usage and urodynamic studies, both preoperatively and post-operatively. The degree of SUI was categorized as either mild, moderate, or severe. Success was defined as no more pad use or significantly decreased pad use. Complications were classified ac-cording to the Clavien-Dindo system. The mean age of patients was 70.4 ± 5.9 years, and 61.1% of cases were diagnosed as locally advanced prostate cancer. Mild, moderate, and severe SUI were reported as 33.3%, 50.0%, and 16.7%, respectively. The average daily pad use after RP was 3.3 pads and there was a significant reduction in the number of daily pads used after the re-adjustable male sling procedure (3.3 vs. 1.3; p = 0.002). Overall, the operation was considered successful in 11 pa-tients (61.1%), 1 case showed improvement (5.6%), and it was considered unsuccessful in 6 patients (33.3%). Impressively, in the severe incontinence subgroup (three patients), one (33.3%) had im-provement and one (33.3%) had success. Transient perineal discomfort after the operation was the most common complaint. However, two patients had severe complications with bowel injury during sling implantation (Clavien-Dindo grade III). The re-adjustable male sling system was an efficient surgical treatment option for post-RP SUI, even in a locally advanced disease dominant population. One should pay attention to the complication of bowel perforation during surgery.

Outcomes and risks in palliative pancreatic surgery: an analysis of the German StuDoQ|Pancreas registry

BackgroundNon-resectability is common in patients with pancreatic ductal adenocarcinoma (PDAC) due to local invasion or distant metastases. Then, biliary or gastroenteric bypasses or both are often established despite associated morbidity and mortality. The current study explores outcomes after palliative bypass surgery in patients with non-resectable PDAC.MethodsFrom the prospectively maintained German StuDoQ|Pancreas registry, all patients with histopathologically confirmed PDAC who underwent non-resective pancreatic surgery between 2013 and 2018 were retrospectively identified, and the influence of the surgical procedure on morbidity and mortality was analyzed.ResultsOf 389 included patients, 127 (32.6%) underwent explorative surgery only, and a biliary, gastroenteric or double bypass was established in 92 (23.7%), 65 (16.7%) and 105 (27.0%). After exploration only, patients had a significantly shorter stay in the intensive care unit (mean 0.5 days [SD 1.7] vs. 1.9 [3.6], 2.0 [2.8] or 2.1 [2.8]; P < 0.0001) and in the hospital (median 7 days [IQR 4–11] vs. 12 [10–18], 12 [8–19] or 12 [9–17]; P < 0.0001), and complications occurred less frequently (22/127 [17.3%] vs. 37/92 [40.2%], 29/65 [44.6%] or 48/105 [45.7%]; P < 0.0001). In multivariable logistic regression, biliary stents were associated with less major (Clavien–Dindo grade ≥ IIIa) complications (OR 0.49 [95% CI 0.25–0.96], P = 0.037), whereas—compared to exploration only—biliary, gastroenteric, and double bypass were associated with more major complications (OR 3.58 [1.48–8.64], P = 0.005; 3.50 [1.39–8.81], P = 0.008; 4.96 [2.15–11.43], P < 0.001).ConclusionsIn patients with non-resectable PDAC, biliary, gastroenteric or double bypass surgery is associated with relevant morbidity and mortality. Although surgical palliation is indicated if interventional alternatives are inapplicable, or life expectancy is high, less invasive options should be considered.

Congenital diaphragmatic hernia in adults: a decade of experience from a single tertiary center

Introduction Congenital diaphragmatic hernias (CDHs) in adults remain rare, with limited data on them available. However, CDHs can cause respiratory and gastrointestinal symptoms in adults, even resulting in the strangulation of the bowel when incarcerated. Here, we aimed to analyze surgical outcomes among adult patients. The primary outcome of interest was the complication rate, reoperations and 90-day mortality after laparoscopic and open hernia repair. Methods We identified all adult patients diagnosed with a Morgagni or Bochdalek hernia treated operatively between 2010 and 2019 in a single tertiary care hospital. Data on patient demographics, surgical characteristics, mortality and morbidity were collected. Results In total, we identified 37 patients (67.6% female; average age, 57 years). Overall, 78.4% patients underwent minimally invasive operations, while 35.1% underwent emergency operations. A Clavien–Dindo grade II–V complication was experienced by 18.9% of patients. No deaths occurred within 90 days of surgery, and we detected no recurrences in short-term or long-term follow-up. A minimally invasive technique correlated with a shorter hospital stay of 3.6 days versus 6.8 days in the open surgery group (p = .007, t = 3.3, 95% confidence interval = 1.04−5.21). Conclusion Our findings indicate that the laparoscopic repair of a congenital diaphragmatic hernia is safe and effective, offering short hospital stay and a low amount of complications.

Is There a Role for Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy in Peritoneal Carcinomatosis Due to Uterine Cancer?

Uterine canceris one of the most common pelvic tumors in females. Advanced stage uterine cancer only represents 15% of newly diagnosed cases; however, they are related with poor prognosis. Our aim was to analyze the benefits of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in peritoneal carcinomatosis due to uterine cancer. At the Istanbul Umraniye Training and Research Hospital, Surgical Oncology Clinic, morbidity, overall survival and survival without progression were analyzed over the 5-year follow up. Twenty-two cases who had undergone cytoreductive surgery and hyperthermic intraperitoneal chemotherapy due to uterine-peritoneal carcinomatosis were included in this study. Cases were followed up in terms of postoperative morbidity-mortality, disease-free survival and overall survival. The cut off value for the peritoneal carcinomatosis index score was set at 15. Intraperitoneal chemotherapy consisting of cisplatin and doxorubicin was applied to all patients for 60 min after the suturation of the abdomen. Median age of the patients was 64.6 (43-72). Average PCI score was 12.8 (3-15). CC score was 0 in 16 (72.7%) cases, 1 in 3 cases and 2 in 3 cases. Of these patients, 12 of them were previously operated upon. Median stay at the hospital was 13.1 days. No major complications due to chemotherapy were reported. A Clavien-Dindo Grade 3 complication was observed in seven (31.8%) patients. Mortality was not observed in patients during their stay at the hospital. The 5-year disease-free survival and overall survival rates were 36.8 (36%) months and 45.3 (57%) months, respectively. We think that due to longer disease-free survival and overall survival, cytoreductive surgery and hyperthermic intraperitoneal chemotherapy should be preferred in peritoneal carcinomatosis due to uterine cancer patients having low peritoneal carcinomatosis index scores and manageable complication rates. However, prospective randomizedtrials with a high number of cases are needed for this subject.

Enteral versus parental nutrition after pancreaticoduodenectomy under enhanced recovery after surgery protocol: study protocol for a multicenter, open-label randomized controlled trial (ENE-PAN trial)

BackgroundInfectious complications are the main causes of morbidity after pancreaticoduodenectomy (PD). Early enteral nutrition (EN) is a reasonable form of nutritional support that aims to mitigate the occurrence and severity of infectious complications by maintaining gut immunity. However, it remains unclear whether EN is beneficial for patients who underwent PD and are under enhanced recovery after surgery (ERAS) protocol.MethodsA multicenter (six hospitals), open-label, randomized controlled trial will be started in July 2022. A total of 320 patients undergoing open PD will be randomly assigned to an EN group or a peripheral parental nutrition (PPN) group in a 1:1 ratio. The stratification factors will be the hospital, age (≥ 70 or not), and preoperative diagnosis (pancreatic cancer or not). In the EN group, enteral nutrition will start on postoperative day (POD) 1 at 200–300 ml/day via the percutaneous tube placed operatively. The volume of the diet will be increased to 400–600 ml/day on POD 2 and depend on the surgeon’s decision from POD 3. In the PPN group, PPN will be delivered after surgery. In both groups, oral feeding will start on POD 3. Each treatment will be finished when patients’ oral food intake reaches 60% of the nutritional requirement (25–30 kcal/day). The primary endpoint will be the occurrence of postoperative infectious complications within 90 days of surgery. The secondary endpoints will be all complications, including major ones such as Clavien–Dindo grade 3 or more and clinically relevant postoperative pancreatic fistula. Data will be analyzed per the intention to treat.DiscussionThis will be the first, large, and well-designed RCT that aims to determine whether EN is beneficial for patients who underwent PD under the ERAS protocol. According to the results of this study, either EN or PPN would be adopted as the standard nutritional support for patients undergoing PD.Trial registrationjRCT1030210691. Registered on March 23, 2022.

Purely Off-Clamp Partial Nephrectomy: Robotic Approach Better than Open Using a Pentafecta Outcome with Propensity Score Matching.

Partial nephrectomy (PN) is the gold standard treatment for localized renal masses. Robot-assisted PN (RAPN) has overcome laparoscopy's technical limitations, greatly expanding the indications of minimally invasive PN, which is dominated by renal artery clamping in almost all published series. We compared off-clamp RAPN (OFFC-RAPN) with the open approach (OFFC-OPN) using propensity score (PS) matching. A favourable pentafecta outcome was defined as a combination of no positive surgical margins (PSM), no complications of Clavien-Dindo (CD) grade ≥ 3, post-operative eGFR loss &lt;10%, length of hospital stay (LOS) ≤ 5 days and estimated blood loss (EBL) &lt; 200 mL. A total of 340 consecutive patients were included. The PS-matched cohort included 142 patients: 71 matched pairs well-balanced for all covariates. The OFFC-RAPN group showed significantly shorter operative time (149.8 vs. 173.9 min, p = 0.003), lower EBL (182.1 vs. 329.3 mL, p = 0.001), and shorter LOS (5.8 vs. 6.9 days, p = 0.02), with a higher proportion of patients with LOS ≤ 5 days (57.7% vs. 23.9%, p &lt; 0.001). No significant differences were found for PSM rate (2.8% vs. 8.4%, p = 0.27), CD &gt; 2 complication rate (4.2% vs. 2.8%, p = 1.00) and mean ± SD eGFR change (-0.06 ± 0.3 vs. -0.8 ± 0.3, p = 0.5). Pentafecta was achieved in 56.3% and 21.1% in the OFFC-RAPN and OFFC-OPN series, respectively (p &lt; 0.0001). On multivariable analysis, surgical approach and BMI proved to be independent predictors of achieving pentafecta. After adjusting for potential treatment selection bias, OFFC-RAPN outperformed OFFC-OPN for important peri-operative outcomes, without compromising oncological and functional safety.

Outcomes of Robot-Assisted Laparoscopic Pyeloplasty Based on Degree of Obstruction on Preoperative Tc-99 MAG-3 Renal Scintigraphy.

Objective: Management of symptomatic ureteropelvic junction (UPJ) obstruction with hydronephrosis and discordant Tc-99 mercaptoacetyltriglycine (MAG-3) renal scintigraphy is challenging. In this study we describe long-term outcomes of patients who underwent robot-assisted laparoscopic pyeloplasty for the correction of symptomatic UPJ obstruction with discordant preoperative Tc-99m MAG-3 renal scintigraphy. Methods: Patients undergoing robot-assisted laparoscopic pyeloplasty for symptomatic UPJ obstruction at a single academic center from 2009 to 2021 were retrospectively reviewed. Patients were categorized into three groups with varying degrees of obstruction based on preoperative MAG-3 imaging: Group 1: no obstruction (Lasix T1/2 clearance <10 minutes), Group 2: equivocal obstruction (Lasix T1/2 clearance 10-20 minutes), and Group 3: obstruction (Lasix T1/2 clearance >20 minutes. Pyeloplasty success was defined as resolution of symptoms and improvement/stable computed tomography (CT) imaging or MAG-3 scintigraphy. Failure was defined as persistence of symptoms with either obstruction on functional imaging, worsening hydronephrosis, or subsequent intervention. Results: A total of 125 cases were identified, with a median patient age of 35 years. Dismembered pyeloplasty technique was performed in 98.4% of cases. Median preoperative split renal function on MAG-3 scintigraphy was the only statistically significant (p = 0.003) difference in preoperative characteristics between the three groups. There were 15 postoperative complications, with a rate of Clavien-Dindo grade 3 or higher complications of 4.8%. Overall pyeloplasty success was 92.8%, with success rates of 100% (15/15) and 97% (32/33) in the no obstruction and equivocal obstruction groups, respectively. Median time to pyeloplasty failure was 20.4 months. Conclusion: Robot-assisted laparoscopic pyeloplasty is a safe and effective surgical intervention for correcting UPJ obstruction. Patients with symptoms of UPJ obstruction and discordant functional imaging studies demonstrate similar or improved success rates after pyeloplasty compared with patients with documented high-grade obstruction. Based on these findings preoperative renal scan may not be reliable in appropriate selection of candidacy for pyeloplasty.