Early Relaparotomy Research Articles

Early relaparotomy in recipients after living donor liver transplantation: causes, risk factors, and consequences.

Despite advancements in surgical methodologies and the extensive perioperative and postoperative care administered to recipients, the prevalence of complications requiring early relaparotomy following living donor liver transplantation (LDLT) remains persistent. This study sought to analyze the determinants influencing relaparotomy occurrences in the initial 30 days following LDLT. Additionally, it was aimed to evaluate the impact of early laparotomy on both graft and patient survival within this distinct patient cohort. The study encompassed recipients (n = 535) aged 18 years and older who underwent primary LDLT at our institution from January 2019 to December 2021. Exclusion criteria involved patients necessitating early retransplantation. Early relaparotomy was specified as surgical intervention within the initial 30 days following LDLT. The study enrolled a total of 535 patients, among whom 85 (15.9%) underwent early relaparotomy. The median age of the patients was 54 (range: 41-60) years, with a predominant male representation (66.2%). Univariate analysis comparing the laparotomy and nonrelaparotomy groups revealed statistically significant differences in the creatinine (p = 0.043) and sodium (p = 0.025) levels, graft side (p < 0.001), etiology (p = 0.005), and blood loss (p = 0.012).In the multivariate analysis, creatinine (p = 0.039; OR = 1.668; 95% CI = 1.027-2.709) and left lobe graft (p < 0.0001; OR = 3.611; 95% CI = 1.960-6.652) emerged as independent risk factors for relaparotomy. The primary causes of early relaparotomy following LDLT include postoperative bleeding, biliary leakage, and vascular complications. Preoperative elevation in creatinine and sodium levels, the presence of Budd-Chiari syndrome, utilization of a left lobe graft, and intraoperative blood loss are identified as risk factors associated with early relaparotomy after LDLT. Patients undergoing early relaparotomy exhibit inferior survival rates compared to those who do not.

Frequency and Risk factors of Reoperation in LDLT Donors

Background: Liver transplantation (LT) is the definitive treatment for end-stage liver disease, acute liver failure, liver tumors, and metabolic diseases. Re-exploration after surgery is associated with poor clinical outcomes and is considered a quality-of-care measure. Objective: To determine the frequency and risk factors of reoperation (early re-laparotomy) after hepatectomy in postoperative LDLT donors. Materials and Methods: A cross-sectional analytical study was conducted at the Pir Abdul Qadir Shah Jeelani Institute of Medical Sciences between December 2023 and May 2024. This study included 672 LDLT donors aged &gt; 18 years old. Data on donor age, sex, blood group, operation time, and re-exploration were collected. The primary endpoints were the frequency and causes of re-exploration, and the secondary endpoints included the association of re-exploration with clinical outcomes. Statistical analyses were performed using SPSS 25.0, with the significance level set at P &lt; 0.05. Blood group analysis revealed that 57.9% of reexplored donors had blood group B+. Results: The frequency of re-exploration was 2.8%. Among those requiring re-exploration, 42.1% were aged 21-28 years. The difference in re-exploration rates between male and female patients was statistically significant (P&lt;0.001). Blood group analysis revealed that 57.9% of the reexplored donors had blood group B+. Bleeding was the primary cause of re-exploration in 73.7% of cases. The majority (57.9%) of re-explorations occurred in patients with operation times between 451-550 minutes. However, the significant sex disparity and high incidence of bleeding as a cause for re-exploration underscores the need for improved postoperative care. Conclusion: This study highlights a relatively low frequency of re-exploration (2.8%) among LDLT donors. However, the significant sex disparity and high incidence of bleeding as a cause for re-exploration underscore the need for improved postoperative care.

Normothermic Liver Machine Perfusion and Successful Transplantation of Split Liver Grafts: From Proof of Concept to Clinical Implementation.

Normothermic liver machine perfusion (NLMP) is advancing the field of liver transplantation (LT). Beyond improved preservation and organ assessment, NLMP helps to increase organ utilization. We herein address the feasibility and merit of NLMP in split liver transplantation (SLT) to postpone the transplantation of the second split graft to the following day. We analyzed the perfusion characteristics and outcomes of all consecutive adult recipients who underwent SLT following NLMP from February 1, 2018, to June 30, 2023. The primary endpoint was 90-d graft and patient survival. Secondary endpoints were posttransplant complications and 90-d morbidity. Three right and 3 extended right SLT following NLMP have been performed. NLMP was uneventful in all cases. Perfusion characteristics differed according to graft volume. Mean perfusion time was 17:00 h (±05:13) and bile production ranged between 8 and 21 mL/h. All split grafts fulfilled predefined center viability criteria during NLMP and were transplanted on the following day. The 90-d graft and patient survival rate was 100%. Three patients (50%) required an early relaparotomy, and 2 patients (33.3%) developed biliary complications. The 90-d morbidity as recorded by the comprehensive complication index was 62.7 (±24.7). NLMP of split liver grafts is technically feasible and safe. Through prolongation of preservation time, NLMP allows to safely postpone transplantation of the second split liver graft to the next day.

Surgical Closure of Equine Abdomen, Prevention, and Management of Incisional Complications.

Although rarely fatal, complications of ventral midline laparotomy incision in equine patients increase hospitalization cost and duration and may jeopardize return to athletic function. Therefore, many techniques have been developed to reduce their occurrence and expedite their resolution when they occur. Our technique of celiotomy incision closure includes the use of tension sutures (vertical U mattress) of polyglactin 910 on the linea alba, which is then apposed by polyglactin 910 interrupted sutures or a simple continuous pattern suture with a stop midway before routine closure of the superficial layers. The celiotomy incision is protected by an elastic bandage during the immediate postoperative period. This technique has been associated with favorable results: 5.3% confirmed incisional infections after a single celiotomy and 26.7% after repeat celiotomy. The overall incisional complication (serous/sanguineous discharge, hematoma, infection, hernia formation, and complete wound breakdown) occurrence was 9.5% and 33.3% after single and repeat laparotomy, respectively. In cases considered more susceptible to infection (early relaparotomy or laparotomy incisions longer than 30 cm), negative pressure therapy was found easy to apply on closed incisions. No detrimental effects were observed. However, the potential prophylactic benefit of this therapy needs to be confirmed in a larger group. In infected laparotomy wounds requiring drainage, the use of negative pressure therapy seemed to have a positive effect on the formation of granulation tissue. However, there was no control group to allow statistical confirmation. Finally, one case of complete breakdown of the laparotomy incision was managed by stainless steel retention sutures, the application of negative pressure therapy, and a hernia belt. At re-evaluation 15 months post-surgery, several small hernias were detected, but the horse had returned to his previous level of sports performance and had not shown any episode of colic.

Impact of Back-to-Base Normothermic Machine Perfusion on Complications and Costs: A Multicenter, Real-World Risk-Matched Analysis.

Assess cost and complication outcomes after liver transplantation (LT) using normothermic machine perfusion (NMP). End-ischemic NMP is often used to aid logistics, yet its impact on outcomes after LT remains unclear, as does its true impact on costs associated with transplantation. Deceased donor liver recipients at 2 centers (January 1, 2019, to June 30, 2023) were included. Retransplants, splits, and combined grafts were excluded. End-ischemic NMP (OrganOx-Metra) was implemented in October 2022 for extended-criteria donation after brain death (DBDs), all donations after circulatory deaths (DCDs), and logistics. NMP cases were matched 1:2 with static cold storage controls (SCS) using the Balance-of-Risk [donation after brain death (DBD)-grafts] and UK-DCD Score (DCD-grafts). Overall, 803 transplantations were included, 174 (21.7%) receiving NMP. Matching was achieved between 118 NMP-DBDs with 236 SCS; and 37 NMP-DCD with 74 corresponding SCS. For both graft types, median inpatient comprehensive complications index values were comparable between groups. DCD-NMP grafts experienced reduced cumulative 90-day comprehensive complications index (27.6 vs 41.9, P =0.028). NMP also reduced the need for early relaparotomy and renal replacement therapy, with subsequently less frequent major complications (Clavien-Dindo ≥IVa). This effect was more pronounced in DCD transplants. NMP had no protective effect on early biliary complications. Organ acquisition/preservation costs were higher with NMP, yet NMP-treated grafts had lower 90-day pretransplant costs in the context of shorter waiting list times. Overall costs were comparable for both cohorts. This is the first risk-adjusted outcome and cost analysis comparing NMP and SCS. In addition to logistical benefits, NMP was associated with a reduction in relaparotomy and bleeding in DBD grafts, and overall complications and post-LT renal replacement for DCDs. While organ acquisition/preservation was more costly with NMP, overall 90-day health care costs-per-transplantation were comparable.

Magnitude of early relaparotomy and its outcome among patients who underwent laparotomy in a tertiary hospital in Eastern Ethiopia: a cross- sectional study

IntroductionSeveral studies conducted worldwide revealed the magnitude of early relaparotomy and its outcome among patients undergoing laparotomy. However, there was very little evidence on the magnitude of early relaparotomy and its outcome among patients who underwent laparotomy in Ethiopia, especially in the study area.Objectivethis study aimed to the assess magnitude of early relaparotomy and its outcome among patients who underwent laparotomy in a Tertiary Hospital in Eastern Ethiopia.MethodsA retrospective cross-sectional study was conducted. All patients who underwent laparotomy during the data retrieval period were included. Data were collected using a data abstraction checklist from patients’ medical records. The collected data were entered, cleaned, and analyzed by using SPSS version 23. Descriptives statistics were generated where by continuous variables were summarized into means and standard deviation and categorical variables were summarized as the frequency with proportions.ResultThe magnitude of relaparotomy was 6.8%. Among 82 patients included in the final analysis, 53 (64.6%) were males and the mean (± SD) age of patients was 33.32 ± 16.63 years. The major indications for relaparotomy were intra-abdominal collection (26.8%) and anastomotic leak (24.4%). Among 82 patients who underwent relaparotomy, 52(63.4%) were developed post relaparotomy complications, and 30(36.6%) patients died.ConclusionThe magnitude of early relaparotomy was 6.8%. The magnitude of in-hospital mortality was high in comparison to earlier study findings from developing countries. About three fourth of patients who underwent relaparotomy were developed postoperative complications.

Does dialysis modality or duration influence outcomes in simultaneous pancreas-kidney transplant recipients? Single center experience and review of the literature.

The influence of dialysis modality and duration on outcomes following simultaneous pancreas-kidney transplantation (SPKT) remains uncertain. We performed a single-center retrospective review in 255 SPKT recipients according to dialysis modality (55 preemptive/no dialysis-ND, 70 peritoneal dialysis-PD, 130 hemodialysis-HD) and duration (55 none, 137<2 years, 41 2-4 years, 22>4 years). Mean follow-up was 9.4 years (median 9.2 years). Early (3-month) relaparotomy rate (20% ND vs. 36% PD/HD, p=.03) was lower in ND patients. There were no differences in early graft loss, patient survival, overall or death-censored kidney or pancreas graft survival rates (GSR) at 1 or 10 years follow-up. When analyzing dialysis duration, there were no differences in rates of pancreas thrombosis or early pancreas graft loss. Kidney delayed graft function (DGF) was lower in the ND/short dialysis groups combined (1.0%), compared to the intermediate/long dialysis groups combined (9.5%, p=.003). Early relaparotomy rates were higher with longer duration of dialysis (p=.045 between ND and >4 years of dialysis). Patient survival in the long dialysis group was 50% compared to 69.5% in the other three groups combined (p=.09). However, both overall and death-censored kidney and pancreas GSR were comparable. Preemptively transplanted patients had a lower incidence of kidney DGF and relaparotomy whereas patient survival was slightly lower with longer dialysis vintage prior to SPKT. Dialysis modality and duration did not influence either overall or death-censored pancreas or kidney GSR in patients with short waiting times, low KDPI donor organs, and dialysis duration up to 4 years.

Early relaparotomy following pediatric living-donor liver transplantation: experience in an Indonesian national referral hospital

BackgroundLiving donor liver transplantation (LDLT) remains the only curative treatment for children with end-stage liver disease; however, complications of the procedure are associated with indications for early relaparotomy. Several risk...

Influence of donor and recipient sex on outcomes following simultaneous pancreas-kidney transplantation in the new millennium: Single-center experience and review of the literature.

The influence of sex on outcomes following simultaneous pancreas-kidney transplantation (SPKT) in the modern era is uncertain. We retrospectively studied 255 patients undergoing SPKT from 11/2001 to 8/2020. Cases were stratified according to donor (D) sex, recipient (R) sex, 4 D/R sex categories, and D/R sex-matched versus mismatched. D-male was associated with slightly higher patient (p=.08) and kidney (p=.002) but not pancreas (p=.23) graft survival rates (GSR) compared to D-female. There were no differences in recipient outcomes other than slightly higher pancreas thrombosis (8% R-female vs. 4.2% R-male, p=.28) and early relaparotomy rates in female recipients (38% R-female vs. 29% R-male, p=.14). When analyzing the 4 D/R sex categories, the two D-male groups had higher kidney GSRs compared to the two D-female groups (p=.01) whereas early relaparotomy and pancreas thrombosis rates were numerically higher in the D-female/R-female group compared to the other three groups. Finally, there were no significant differences in outcomes between sex-matched and sex-mismatched groups although overall survival outcomes were lower with female donors irrespective of recipient sex. The influence of D/R sex following SPKT is subject to multiple confounding issues but survival rates appear to be higher in D-male/R-male and lower in D-female/R-male categories.

Improved surgical outcomes following simultaneous pancreas-kidney transplantation in the contemporary era.

Complications leading to early technical failure have been the Achilles' heel of simultaneous pancreas-kidney transplantation (SPKT). The study purpose was to analyze longitudinally our experience with early surgical complications following SPKT with an emphasis on changes in practice that improved outcomes in the most recent era. Single center retrospective review of all SPKTs from 11/1/01 to 8/12/20 with enteric drainage. Early relaparotomy was defined as occurring within 3 months of SPKT. Patients were stratified into two sequential eras: Era 1 (E1): 11/1/01-5/30/13; Era 2 (E2) 6/1/13-8/12/20 based on changes in practice that occurred pursuant to donor age and pancreas cold ischemia time (CIT). 255 consecutive SPKTs were analyzed (E1, n=165; E2, n=90). E1 patients received organs from older donors (mean E1 27.3vs. E2 23.1 years) with longer pancreas cold CITs) (mean E1 16.1vs. E2 13.3h, both p<.05). E1 patients had a higher early relaparotomy rate (E1 43.0%vs. E2 14.4%) and were more likely to require allograft pancreatectomy (E1 9.1%vs. E2 2.2%, both p<.05). E2 patients underwent systemic venous drainage more frequently (E1 8%vs. E2 29%) but pancreas venous drainage did not influence either relaparotomy or allograft pancreatectomy rates. The most common indications for early relaparotomy in E1 were allograft thrombosis (11.5%) and peri-pancreatic phlegmon/abscess (8.5%) whereas in E2 were thrombosis, pancreatitis/infection, and bowel obstruction (each 3%). Maximizing donor quality (younger donors) and minimizing pancreas CIT are paramount for reducing early surgical complications following SPKT.

O026 Post-operative mortality following planned versus on-demand relaparotomy for secondary bacterial peritonitis: a literature review

Abstract Introduction Post-operative peritonitis is a life-threatening complication of surgical care, whereby early relaparotomy is paramount in diagnosing and controlling the infective source. Currently, there are no clear guidelines on surgical strategies for re-laparotomy. This study aimed to evaluate the current evidence on the mortality rates and length of hospital admission associated with planned (PR) versus on-demand re-laparotomy (ODR) in patients with secondary peritonitis. Methods Literature review was conducted using Ovid MEDLINE and PubMed to identify English-language papers directly comparing ODR and PR in adults over 18 years. Case reports, reviews and papers including individuals with peritonitis post-pancreatitis or abdominothoracic surgery were excluded. Eight of the 154 studies identified met inclusion criteria following abstract screening. Results No significant difference was found between post-operative mortality in PR and ODR for patients with secondary peritonitis (mean mortality rates 30.0% and 31.7% respectively). ODR was shown to have better overall outcomes in avoiding unnecessary surgeries, reducing infection-related complications and length of ITU admissions. ODR is favoured provided there is no operation delay. However, in patients with extensive peritonitis and high APACHE-II scores, PR is preferred to effectively control infection source. Conclusion Literature analysis shows there is still much debate regarding whether PR or ODR is favoured for post-operative peritonitis. Further randomised control-trials across multiple international centres are required to improve the evidence base for future surgical practice. Take-home message Mortality and complication rates are comparable following planned and on-demand re-laparotomy in patients with post-operative peritonitis. Further international research is required to construct evidence-based guidelines for re-laparotomy and improve our future care for critically unwell surgical patients.

Liver transplantation of partial grafts after ex situ splitting during hypothermic oxygenated perfusion-The HOPE-Split pilot study.

Partial liver grafts from ex situ splitting are considered marginal due to prolonged static cold storage. The use of ex situ hypothermic oxygenated perfusion (HOPE) may offer a strategy to improve preservation of ex situ split grafts. In this single-center pilot study, we prospectively performed ex situ liver splitting during HOPE (HOPE-Split) for adult and pediatric partial grafts over a 1-year period (November 1, 2020 to December 1, 2021). The primary safety endpoint was based on the number of liver graft-related adverse events (LGRAEs) per recipient, including primary nonfunction, biliary complications, hepatic vascular complications, and early relaparotomies and was compared with consecutive single-center standard ex situ split transplantations (Static-Split) performed from 2018 to 2020. Secondary endpoints included preservation characteristics and early outcomes. Sixteen consecutive HOPE-Split liver transplantations (8 HOPE-Split procedures) were included and compared with 24 Static-Splits. All HOPE-Split grafts were successfully transplanted, and no graft loss nor recipient death was encountered during the median follow-up of 7.5 months (interquartile range, 5.5-12.5). Mean LGRAE per recipient was similar in both groups (0.31 ± 0.60 vs. 0.46 ± 0.83; p=0.78) and split duration was not significantly increased for HOPE-Split (216 vs. 180 min; p=0.45). HOPE-Split grafts underwent perfusion for a median of 125 min, which significantly shortened static cold storage (472 vs. 544 min; p=0.001), whereas it prolonged total ex vivo preservation (595 vs. 544 min; p=0.007) and reduced neutrophil infiltration on reperfusion biopsies (p=0.04) compared with Static-Split. This clinical pilot study presents first feasibility and safety data for transplantation of partial liver grafts undergoing ex situ split during HOPE and suggests improved preservation compared with static ex situ splitting. These preliminary results will allow to set up large-scale trials on the use of machine perfusion in pediatric and split-liver transplantation.

P.130: Achilles Heel No Longer: Marked Decline in Early Relaparotomy and Allograft Pancreatectomy Rates Following Simultaneous Kidney-Pancreas Transplantation in the Contemporary Era

Purpose: Technical complications requiring early relaparotomy (relap) and allograft pancreatectomy (AP) have long been the Achilles heel of simultaneous kidney-pancreas transplantation (SKPT). Methods: Single center retrospective review of all SKPTs from 11/1/01 – 8/12/20 managed with T-cell depleting antibody, tacrolimus, MMF, steroids, and enteric exocrine drainage. Early relap was defined as occurring within 3 months of SKPT. Patients (pts) were stratified into 2 sequential eras: Era 1 (E1): 11/1/01 – 5/30/13; Era 2 (E2) 6/1/13 – 8/12/20. Results: During the period of study, 255 SKPTs were performed (E1, n=165; E2, n=90) with an overall mean follow-up of 8.1±5 years. Recipient age and donor and recipient ethnicity, gender, and BMI were comparable between eras. E1 pts received organs from older donors (E1 27 vs. E2 23 years, P<0.001) with longer pancreas graft cold ischemic times (CIT) (E1 16 vs. E2 13 hours, P=0.04). E2 pts received more imported organs (E1 16% vs. E2 27%, P=0.04). E1 pts had a higher early relap rate (E1 43% vs. E2 14%, P<0.001) and were more likely to require AP (E1 10.3% vs E2 2.2%, P=0.019). E2 pts underwent systemic venous drainage more frequently (E1 8% vs. E2 29%, P<0.001). The most common indications for early relap in E1 were pancreas thrombosis (12%), abscess/infection (12%), bleeding (4%), and leak (4%) whereas in E2 were for abscess/infection (3%), small bowel obstruction (3%), and thrombosis (2%), P=0.001. Pancreas venous drainage technique did not affect either early relap or AP rates. Mean transplant volume was 14/year for E1 and 13/year for E2; mean transplant volume in the past 3 years of E2 was 18/year. Conclusions: Maximizing donor quality (younger donors) and minimizing CIT are paramount for reducing complications requiring either early relap or AP and for optimizing long-term pancreas graft survival following SKPT.

P.133: Systemic Venous Versus Portal Venous Drainage in Simultaneous Pancreas-Kidney Transplantation: A Matched-pair Analysis

Purpose: Portal venous drainage of pancreatic transplant appears more physiologic compared to systemic venous drainage. However, present data does not support the superiority of one technique over the other. The study purpose was to evaluate outcomes in vascularized pancreas transplantation (PTx) with enteric exocrine drainage based on technique of venous delivery. Methods: We retrospectively analyzed 231 simultaneous pancreas-kidney transplants (SPKTs) performed at our center between 7/2003 – 7/2019 and identified 27 that were performed with systemic venous (iliac vein) and enteric exocrine (systemic-enteric [S-E]) drainage. These 27 patients were compared to 27 case controls with portal venous and enteric exocrine drainage matched for recipient age, gender, race, and date of transplant. Results: The 2 groups were well-matched.Indications for S-E drainage were central obesity/thickened mesentery (10), unfavorable vascular anatomy (11), or surgeon preference (6). The S-E drainage group was characterized byslightly more patients ≥ 80 kg (44% S-E versus 26% P-E), with C-peptide positive diabetes (30% S-E versus 18% P-E), and with diabetes onset at >20 years of age (41% S-E versus 26% P-E, all p=NS), suggesting a Type 2 diabetes phenotype. Although the incidence of early pancreas thrombosis (3.7% S-E versus 0% P-E), early relaparotomy (30% S-E versus 22% P-E), and mean initial length of hospital stay (11 days S-E versus 8 days P-E) were numerically higher in S-E versus P-E SPKTs, none of these differences were significant. With a mean follow-up of 5 years in both groups, respective one and 3-year patient survival (100% and 96% S-E vs 100% and 100% P-E), kidney graft survival (100% and 96% S-E vs 100% and 89% P-E), and pancreas graft survival (96% and 96% S-E vs 100% and 100% P-E) rates were comparable. Conclusions: The method of venous delivery of insulin following PTx does not appear to influence medium-term outcomes in SPKT with enteric exocrine drainage. K. Gurung2, R. Stratta2, A. Farney2, G. Orlando2, C. Jay2, A. Reeves-Daniel3, A. Mena-Gutierrez3, N. Sakhovskaya3, W. Doares4, S. Kaczmorski4, M. Magid4, J. Rogers2 .

Analysis of early relaparotomy in recipients of adult living donor liver transplantation

Background: While early relaparotomy following living donor liver transplantation (LDLT) is an important event and its outcomes are still unclear, the aim of this retrospective study is to investigate the causes and outcomes of early relaparotomy in recipients of adult living donor liver transplantations. Materials and methods: Between April 2015 and April 2020 at Medipol University Medical Faculty Hospital Organ Transplantation Department, Istanbul, Turkey, 15 patients (9.3%) who underwent early relaparotomy were studied retrospectively. Results: Eight patients (53.3%) had a history of upper abdominal surgery in the early laparotomy group. The most common cause of early relaparotomy had postoperative bleeding in 9 patients (60%). The overall survival rate was 66.7%. Mortality was higher in the group over 60 years old and with a history of upper abdominal surgery. Conclusions: The history of upper abdominal surgery appears to be a risk factor for early relaparotomy. Also, previous upper abdominal surgery group and elderly patients group present with more mortality. We should be very careful in these groups.

Causes, diagnosis, and treatment of postoperative obstructive jaundice

AIM: This study aimed to analyze the causes, diagnosis, and clinical treatment of postoperative obstructive jaundice (POOJ) in routine surgical practice.&#x0D; MATERIALS AND METHODS: Twenty-four patients with POOJ that developed in the organs of the hepatobiliary system after surgical interventions were included in this study. The patients were subjected to the following procedures to diagnose the causes of POOJ and choose the treatment methods: general clinical examination, biochemical blood tests, dynamic postoperative ultrasound examination of the abdominal organs, video laparoscopy, computed tomography, magnetic resonance imaging, fistulocholangiography, endoscopic retrograde cholagiopancreatography, and percutaneous transhepatic cholangiostomy.&#x0D; RESULTS: POOJ occurred in 18 cases after they had different variants of surgical interventions on the biliary tract after traditional (n = 6) and video laparoscopic cholecystectomy (n = 12). POOJ also developed in 6 cases after they underwent surgery on the liver: atypical (n = 2) and anatomical (n = 2) resection of the liver. This condition manifested after the opening and draining of liver abscesses under US control (n = 2). POOJ was treated with different methods to alleviate the developed complications. After surgical interventions on the liver and biliary tract in 6 cases, relaparotomy, sequestrectomy with sanation, drainage of the abdominal cavity (n = 4), and right-sided hemihepatectomy (n = 2) were performed. In 6 other cases, on days 34 of the development of POOJ after laparoscopic operation (n = 2), relaparotomy was performed, clips and ligature were removed from the choledoch with the formation of Roux-en-Y hepaticojejunostomy. Minimally invasive methods of POOJ correction were applied to 12 cases. Of the 12 cases, 5, 2, and 1 were subjected to endoscopic papillosphincterotomy with lithoextraction, endoscopic papillosphincterotomy with lithoextraction coupled with nasobiliary drainage, and relaparoscopy and redrainage of the common bile duct, respectively. In 4 cases, percutaneous transhepatic cholangiostomy was performed at the first stage. At the second stage, after POOJ resolution, the following procedures were implemented: redrainage of the common bile duct (n = 2) and dilatation of the orifice of the right hepatic duct with reconstruction of hepaticojejunostomy on the hidden transhepatic drainage.&#x0D; CONCLUSION: POOJ is still encountered in clinical practice in a sufficient number of cases. Treatment results largely depend on the time of diagnosis and the choice of optimal surgical strategies. The main causes of POOJ are tactical and technical diagnostic and treatment errors. POOJ is diagnosed on the basis of the data of modern radiation and laboratory and instrumental examination methods. Surgical tactics for POOJ are individually active and dependent on the severity, time, and causes of development. They also depend on the general condition of patients. Along with minimally invasive interventions for POOJ, early relaparotomy is less dangerous than passive expectation tactics.

Splenic Tumor in a Patient After Liver Transplantation

Question: A 38-year-old man who underwent a liver transplant due to primary sclerosing cholangitis 9 years ago and a colectomy for descending colon cancer and ulcerative colitis 3 years ago was admitted for a regular checkup. Of note, his liver transplant procedure was complicated by splenic artery steal syndrome immediately after surgery, for which an early relaparotomy with splenic artery ligation was performed with normalization of flow in the hepatic artery and liver function tests. His immunosuppressive regimen consisted of tacrolimus and azathioprine once daily.

CAUSES OF EARLY RELAPAROTOMIES IN SURGERY

Summary. Introduction. Despite the introduction of modern methods of diagnosis, tactics, and treatment of diseases of the abdominal organs, the risk of developing early postoperative complications remains high.&#x0D; The aim of this study is to clarify the causes of early postoperative complications and indications for their surgical treatment.&#x0D; Materials and methods. 3947 case histories of patients operated on for urgent indications were analyzed. In 73 cases, relaparotomies were performed in the early postoperative period (1.85 %).&#x0D; Results and discussion. The main nosologic unit, during the surgical treatment of which relaparotomies were performed, was acute appendicitis. Then there was a perforated pyloroduodenal ulcer and a strangulated hernia of various localization. The main indications for relaparotomy were progressive peritonitis, early adhesive intestinal obstruction, intra-abdominal abscesses, and infiltrates. In two cases, no pathology was detected during relaparotomy – there was an over diagnosis of postoperative peritonitis and anastomotic suture failure.&#x0D; Conclusion. 1. The main cause for relaparotomies in urgent surgery is the progression of preoperative peritonitis. 2. The second important cause is early postoperative adhesive intestinal obstruction. 3. Errors in intraoperative diagnostics, tactics, and techniques are the third leading cause of early relaparotomies.

Early re-laparotomy for patients with high-grade liver injury after damage-control surgery and perihepatic packing.

PurposeThe likelihood of re-bleeding after damage-control surgery (DCS) and perihepatic packing for high-grade liver injuries is a major concern. Thus, although early re-laparotomy tends to be recommended, we conducted this study to evaluate the feasibility of performing definite laparotomy within ≤ 48 h in this clinical population.MethodsThe subjects of this retrospective study were 65 patients (n = 24, ≤ 48-h group; n = 41, > 48-h group) who underwent DCS and perihepatic packing. The primary outcome was the rate of repacking for bleeding during re-laparotomy and the secondary outcomes were mortality and length of stay in the intensive care unit (ICU).ResultsThe ≤ 48-h group had a higher rate of angioembolization and transfusion of red blood cells (RBCs), fresh frozen plasma, and platelets, but the rates of repacking and mortality were not significantly different between the groups. However, the incidence of pneumonia and ventilation support requirement were significantly lower in the ≤ 48-h group than in the > 48-h group.ConclusionThe re-laparotomy performed within ≤ 48 h after DCS and perihepatic packing is feasible for patients with high grade liver injury, using angioembolization and aggressive transfusion, as required. Early re-laparotomy reduces the need for prolonged ventilator support and the incidence of ventilator-associated pneumonia.

Surgical Complications Requiring an Early Relaparotomy in HIV-Infected Liver Transplant Recipients: Risk Factors and Impact on Survival

AimWe aimed to analyze the risk factors for early surgical complications requiring relaparotomy and the related impact on overall survival (OS) in HIV-infected patients submitted to liver transplantation. MethodsWe performed a retrospective study on a nationwide multicenter cohort of 157 HIV-infected patients submitted to liver transplantation in 6 Italian transplant units between 2004 to 2014. ResultsThe median preoperative model for end-stage liver disease score was 18 (interquartile range 12-26.5). An early relaparotomy was performed in 24.8% of patients, and the underlying clinical causes were biliary leak (8.2%), bleeding (8.2%), intestinal perforation (4.5%), and suspected vascular complications (3.8%). The OS at 1, 3, and 5 years was 74.3%, 68.0%, and 60.0%, respectively, and an early relaparotomy was not a prognostic factor itself, but an increasing number of relaparotomies was associated with decreased survival (hazard ratio = 1.40, 95% confidence interval [CI] 1.07-1.81, P = .01). In the multivariate analysis, preoperative refractory ascites (odds ratio 3.32, 95% CI 1.18-6.47, P = .02) and Roux-en-Y choledochojejunostomy reconstruction (odds ratio 12.712, 95% CI 2.47-65.38, P ≤ .01) were identified as significant risk factors for early relaparotomy. ConclusionsIn HIV-infected liver transplant recipients, an increasing number of early relaparotomies due to surgical complications did negatively affect the OS. Preoperative refractory ascites reflecting a severe portal hypertension and a difficult biliary tract reconstruction requiring a Roux-en-Y choledochojejunostomy were associated with an increased risk of early relaparotomy.