Fistula Rate Research Articles

Functional patency rates of arteriovenous fistula of a retrospective cohort study from one of thebiggest centers in Canada.

The main barriers to arterio-venous fistula (AVF) utilization are primary failure, long maturation duration, and low secondary patency rates. In this retrospective cohort study, primary, secondary, functional primary, and functional secondary patency rates were calculated and compared between two age groups (< 75years and > = 75years) and between radiocephalic (RC-) and upper arm (UA-) AVFs, and factors determining the duration of functional secondary patency were evaluated. Between 2016 and 2020,206 predialysis patients whose AVFs had been created previously initiated renal replacement treatment. RC-AVFs comprised 23.3% and were created after favorable analysis of the forearm vasculature. Overall, the primary failure rate was 8.3, and 84.7% started hemodialysis with a functioning AVF. Functional secondary patency rates of primary AVFs were better with RC-AVFs [1,3 and 5year rates of 95.8, 81.9 and 81.9% versus 83.4, 71.8 and 59.2% for UA-AVFs (log rankp: 0.041)]. There was no difference between the two age groups for any of the AVF outcomes assessed. Among patients whose AVF was abandoned, 40.3% had gone on to have a second fistula created. This was significantly less likely in the older group (p < 0.01). (1) UA-AVFs were placed more commonly than RC-AVFs; (2) a selection bias existed whereby RC-AVFs were only created after favorable forearm vasculature was demonstrated or suspected; (3) superior functional secondary patency rates were observed with RC-AV's, perhaps stemming from this selection bias; (4) the elderly were more likely to have only one AVF creation attempt.

First-in-human evaluation of a biological regenerative vascular conduit for hemodialysis access.

The long-term survival and low complication rate of autogenous fistulas for hemodialysis access is often offset by early thrombosis and slow or failed maturation leading to the use of central venous catheters. A regenerative material may have the potential to overcome these limitations. A completely biological acellular vascular conduit was investigated in this first-in-human clinical study. With approval of the ethics board and patients' informed consent, five subjects were enrolled based on predetermined inclusion criteria. Five patients underwent implant of a novel acellular, biological tissue conduit (TRUE AVC™) in the upper arm in a curved configuration between brachial artery and axillary vein. After maturation, standard dialysis was commenced through the new access. Patients were followed up to 26 weeks with ultrasound and physical exam. Serum samples were evaluated for an immune response to the novel allogeneic human tissue implant. This new tissue conduit handled well surgically, with properties similar to that of native human vein. Post procedure conduit flow was excellent in all cases, averaging 1098 ± 388 ml/min at week 4 and remaining stable through 1248 ± 355 ml/min at 26 weeks. Surgical site healing was normal with no edema or erythema by week 4. Six-month primary assisted patency was 80% and secondary patency was 100%. Prescribed dialysis was successfully delivered without infection, and there was no significant change in conduit diameter. Serum testing showed no increase in PRA or IgG specific to the TRUE AVC. One implant required intervention at 5 months with thrombectomy and covered stent procedure. This first-in-human 6-month study with favorable patency and low complication rate establishes the initial safety and feasibility of this novel biological tissue conduit for dialysis access in patients with end-stage kidney disease. Its mechanical durability and lack of immune response establishes TRUE AVC as a potential regenerative material for clinical use.

Visceral Obesity as a Predictor of Postoperative Complications After Pancreaticoduodenectomy.

Obesity is associated with increased morbidity and mortality post surgery. The measurement of visceral obesity can predict postoperative outcomes after pancreaticoduodenectomy. This is a prospective observational study. Visceral obesity was calculated by measuring the fat thickness in the retro-renal area by using a computed tomography scan. Visceral obesity was defined as retro-renal fat thickness (RRFT) of ≥ 2 cm.Patients were divided into two groups: Group-A (RRFT < 2 cm, non-obese) and Group-B (RRFT > 2 cm, obese). Demographic, clinical, and intraoperative variables were correlated with postoperative outcomes. Fifty-six patients were included in the study. Thirty-two patients were included in Group-A, and 24 patients were included in Group-B. The two groups had comparable outcomes. A total of 21 patients in Group-A (65.62%) and 17 patients in Group-B (70.83%) had comorbidities, including diabetes mellitus, hypertension, and coronary disease (p=0.680). American Society of Anesthesiologists (ASA) grading was comparable (p=0.927). BMI was also comparable (p=0.354). Type of pancreaticoduodenectomy, pancreatic texture, pancreatic duct diameter, and technique of pancreaticojejunostomy anastomosis were comparable. The mean operative time was longer in Group-B (362 ± 36.2 min vs. 298 ± 45.2 min) (p=0.001). Intraoperative blood loss was more in Group-B (312 ± 36.8 ml vs. 267 ± 23.7 ml) (p=0.001). The rates of postoperative pancreatic fistula and delayed gastric emptying were comparable (p=0.402 and p=0.134, respectively). The length of hospital stay was longer in patients in Group-B (p=0.004). There was one death in Group-B (obese group). Visceral obesity is a risk factor for postoperative complications after a pancreaticoduodenectomy.

Comment on: Are Parenchyma-Sparing Resections Really Appropriate for Small (

Comment on: Are Parenchyma-Sparing Resections Really Appropriate for Small (<3 cm) Nonfunctional Pancreatic Neuroendocrine Tumors?

Intraoperative Fluorescent Cholangiography Using Indocyanine Green Fluorescence for Identification and Treatment of Bile Leaks After Urgent Laparoscopic Cholecystectomy

Introduction: Laparoscopic cholecystectomy (LC) is one of the most common surgical procedures performed worldwide.1 Postoperative bile leaks caused by bile duct injuries (BDIs) are serious complications after LC, resulting in a prolonged length of hospital stay, increased costs, morbidity, and mortality rates.2 Incidence of BDIs during LC is ~0.4%–1.5%.1 Intraoperative fluorescent cholangiography using indocyanine green fluorescence (ICG-C) is a safe method to observe the biliary tree and may be useful to prevent postoperative bile leaks after LC and hepatic surgery.1,2 However, detection of bile leaks using the ICG-C during LC has limited evidence in international literature.3–8 This video illustrates how to use ICG-C to identify and treat a bile leak after an urgent LC. Materials and Methods: A 54-year-old man with a history of hypertension, diabetes mellitus, cholelithiasis, and hepatic abscesses was admitted with right upper quadrant pain and fever. An urgent CT scan of the abdomen showed acute cholecystitis associated with a large pericholecystic abscess. A percutaneous cholecystostomy (PC) was placed and nonoperative management with intravenous antibiotic was started. On the seventh postprocedural day, the PC was accidentally removed, and a second CT scan of the abdomen showed a reduction of the pericholecystic abscess size, and a subhepatic fluid collection. An urgent LC was performed, and two surgical drains were placed (one subhepatic and one suprahepatic). On the first postoperative day, a low-flow biliary output (250 mL/day) from the subhepatic drainage was associated with a gradual deterioration of the patient's clinical condition. Considering the low flow rate of the biliary fistula, nonoperative management was carried out; on the second post-operative day the patient presented hypotension, oliguria, fever (temperature 38.2°C), and worsening right upper abdominal pain with signs of diffuse peritonitis. The hematologic investigations showed a WBC 17,560/mL, Hb 10.7 g/dL, C-Reactive Protein 17.66 mg/dL, normal liver function tests, and normal bilirubin levels. Owing to signs of septic shock and diffuse signs of peritonitis, an urgent surgical exploration was performed. After the induction of anesthesia, 2.5 mg of Indocyanine Green was intravenously injected. Eight minutes later, the ICG-C demonstrated exactly and in real-time the biliary leak on the liver surface, coming from a subvesical bile duct. Two laparoscopic Roeder's knots were placed to repair the injury. Two surgical drains were placed. Results: The postoperative period was uneventful, with a progressive improvement of the patient's performance status, vital parameters, and laboratory tests. The surgical drains were serosanguinous with low output and both were removed on postoperative day 9. The patient was discharged on day 10 in good clinical condition. Conclusions: One of the most common causes of LC-associated biliary leaks are injuries to the subvesical bile ducts. ICG-C clearly identifies these bile spots on the liver surface during surgery, allowing them to be repaired immediately and prevent biliary fistulas. ICG-C is a safe, easy, repeatable, and noninvasive method to identify bile leaks during surgery. ICG-C may be useful to prevent and treat bile leaks after LC, especially in complicated cholecystitis.5,6 Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. No competing financial interests exist. Running time of video: 8 mins 27 secs

The comparison of manual and mechanical anastomosis after total pharyngolaryngoesophagectomy.

Total pharyngolaryngoesophagectomy (TPLE) is considered as a curative treatment for hypopharynx cancer and cervical esophageal carcinomas (HPCECs). Traditional pharyngo-gastric anastomosis is usually performed manually, and postoperative complications are common. The aim of this study was to introduce a new technique for mechanical anastomosis and to evaluate perioperative outcomes and prognosis. From May 1995 to Nov 2021, a series of 75 consecutive patients who received TPLE for a pathological diagnosis of HPCECs at Sun Yat-sen Memorial Hospital were evaluated. Mechanical anastomosis was performed in 28 cases and manual anastomosis was performed in 47 cases. The data from these patients were retrospectively analyzed. The mean age was 57.6 years, and 20% of the patients were female. The rate of anastomotic fistula and wound infection in the mechanical group were significantly lower than that in the manual group. The operation time, intraoperative blood loss and postoperative hospital stays were significantly higher in the manual group than that in the mechanical group. The R0 resection rate and the tumor characteristics were not significantly different between groups. There was no significant difference in overall survival and disease-free survival between the two groups. The mechanical anastomosis technology adopted by this study was shown to be a safer and more effective procedure with similar survival comparable to that of manual anastomosis for the HPCECs patients.

Conservative surgery versus colorectal resection for endometriosis with rectal involvement: a systematic review and meta-analysis of surgical and long-term outcomes.

The optimal surgical approach for removal of colorectal endometrial deposits is unclear. Shaving and discoid excision of colorectal deposits allow organ preservation but risk recurrence with associated functional issues and re-operation. Formal resection risks potential higher complications but may be associated with lower recurrence rates. This meta-analysis compares peri-operative and long-term outcomes between conservative surgery (shaving and disc excision) versus formal colorectal resection. The study was registered with PROSPERO. A systematic search was performed on PubMed and EMBASE databases. All comparative studies examining surgical outcomes in patients that underwent conservative surgery versus colorectal resection for rectal endometrial deposits were included. The two main groups (conservative versus resection) were compared in three main blocks of variables including group comparability, operative outcomes and long-term outcomes. Seventeen studies including 2861 patients were analysed with patients subdivided by procedure: colorectal resection (n = 1389), shaving (n = 703) and discoid excision (n = 742). When formal colorectal resection was compared to conservative surgery there was lower risk of recurrence (p = 0.002), comparable functional outcomes (minor LARS, p = 0.30, major LARS, p = 0.54), similar rates of postoperative leaks (p = 0.22), pelvic abscesses (p = 0.18) and rectovaginal fistula (p = 0.92). On subgroup analysis, shaving had the highest recurrence rate (p = 0.0007), however a lower rate of stoma formation (p < 0.00001) and rectal stenosis (p = 0.01). Discoid excision and formal resection were comparable. Colorectal resection has a significantly lower recurrence rate compared to shaving. There is no difference in complications or functional outcomes between discoid excision and formal resection and both have similar recurrence rates.

P162 Earlier (luminal) surgery is associated to reduced postoperative morbidity in ileocaecal Crohn’s disease: results from SURGICROHN – LATAM study

Abstract Background Early surgical resection is an emerging concept for patients with ileocaecal Crohn’s disease (CD). The aim of this study was to compare postoperative outcomes after ileocaecal resections between patients with luminal and complicated CD. Methods A retrospective analysis of patients operated for ileocaecal CD during an 8-year period in ten tertiary referral academic centres from Latin America was performed. Patients were allocated into 2 groups: those operated for early (luminal) disease (Early Crohn’s Disease -ECD-) and for complications of CD (Complicated Crohn’s disease -CCD-). A comparative analysis was performed regarding short-term outcomes of surgery, considering overall postoperative complications as main outcome. Results 337 patients were included in the analysis, 60 (17.80%) in the ECD group. Smoking and exposure to perioperative biologic drugs were more prevalent in CCD group. CCD patients had increased requirement of urgent surgery (26.71 vs. 15%, p=0.056), longer operative time (164.25 vs. 90.53 minutes, p&amp;lt; 0.01), lower rates of primary anastomosis (90.23 vs. 100%, p=0.012), increased rate of overall postoperative complications (33.21 vs. 16.67%, p=0.013), more reoperations (13.36 vs. 3.33%, p=0.026), and higher rates of major anastomotic fistulas and hospital stay. On multivariable analysis, smoking (p= 0.001,95%CI: 2.59-32.11), operative time (p=0.022,95%CI:1-1.02), associated procedures (p=0.036,95%CI:1.09-15.72) and intraoperative complications (p=0.021,95%CI:1.45-92.31) were independently related to presenting postoperative complications. Conclusion Early (luminal) ileocaecal resections were associated to lower rates of overall postoperative complications. Proper timing for surgery, avoiding delays in surgical indication can impact postoperative outcomes.

P491 Efficacy and safety of upadacitinib for the treatment of fistulas and fissures in patients with Crohn’s disease

Abstract Background Intestinal and perianal fistulas and fissures are associated with significant morbidity and decreased quality of life in patients with Crohn’s disease (CD). We evaluated rates of fistula and fissure improvements with upadacitinib (UPA), an oral selective Janus kinase inhibitor, in patients with CD who had fistulas or fissures at baseline in phase 3 induction and maintenance trials. Methods In the U-EXCEL (NCT03345849) and U-EXCEED (NCT03345836) phase 3 induction trials, patients with moderate-to-severe CD were randomized to UPA 45 mg once daily (QD) or placebo (PBO) for 12 weeks. Patients who achieved clinical response after 12 weeks of induction were eligible for U-ENDURE (NCT03345823) and rerandomized to UPA 30 mg QD, UPA 15 mg QD, or PBO for an additional 52 weeks of maintenance treatment. Fistula activity was assessed by presence of external openings and draining upon gentle compression. Presence of perianal fissures was also assessed. The proportion of patients with external closure of fistula openings, complete resolution of draining, and ≥ 50% reduction in draining was recorded at weeks 12 and 52. Endpoints were analyzed using non-responder imputation. Results Of 1021 enrolled patients, 143 patients had fistulas (124 [86.7%] perianal; 19 [13.3%] enterocutaneous) and 54 patients had perianal fissures at baseline. The proportion of patients who achieved external closure of fistula openings was higher with UPA vs PBO at week 12 (Fig 1A) and at week 52 (Fig 2A). The proportion of patients who achieved complete resolution of draining and ≥ 50% reduction in draining was higher with UPA vs PBO at week 12 (Fig 1B and 1C) and at week 52 (Fig 2B and 2C). A higher proportion of patients achieved complete resolution of fissures with UPA vs PBO at week 12 (Fig 1D) and at week 52 (Fig 2D). At weeks 12 and 52, a higher proportion of patients with fistulas treated with UPA vs PBO achieved clinical remission and endoscopic response (Fig 1E and 2E). Rates of adverse events (AEs), serious AEs, or AEs leading to study drug discontinuation were similar in UPA groups compared with PBO during the induction and maintenance periods. Rates of abscess formation were 1.8% with UPA 45 mg and 6.8% with PBO at week 12, and 3.0% with UPA 30 mg, 6.4% with UPA 15 mg, and 2.5% with PBO at week 52. Conclusion Among patients with CD complicated with fistulas and/or fissures at baseline, UPA treatment led to higher rates of external closure of fistula openings, resolution of draining, and healing of fissures, along with clinical remission and improvements in luminal disease compared with PBO. No new safety concerns were identified.

Evaluation of late cleft palate repair by a modified technique without relaxing incisions

ObjectiveTo evaluate the postoperative outcomes together with analyzing the associated influencing factors following a late cleft palate repair by the Sommerlad-Furlow modified technique (S-F). Materials and methodsIn a retrospective cohort, 320 consecutive patients with cleft palate, who received S-F technique between 2011 and 2017, were reviewed. The patients were divided into three age groups, less than one year (143), one to two years (113), and greater than 2 years (64). The postoperative outcomes included wound healing (complete/fistula) and velopharyngeal function (VPF). ResultsThe overall cleft width was 10 ± 3.07 mm. The overall rates of complete wound healing and proper velopharyngeal function were 96.6% and 81.56%, respectively. No significant difference was found between the age groups regarding wound healing, with an overall fistula rate of 3.4%. The VPF was significantly varied among the age groups (P<0.001). In context, the rates of velopharyngeal insufficiency (VPI) were 9.8%, 14.2%, and 45.4% among patients repaired at ˂1, 1–2, and >2 years old, respectively. The cleft type was the most potential factor associated with fistula. The age at repair was identified as the most implicating factor for VPI. ConclusionsThe S-F technique had achieved low fistula rate and satisfactory speech outcome, especially in early repair group and even in the wide cleft palate. The older age at repair and severe cleft type had a major impact on the postoperative outcomes.

Evaluation of Postoperative Outcomes in Two Cleft Palate Repair Techniques without Relaxing Incisions.

A modified palatoplasty was established by incorporating the designs of both Sommerlad and Furlow techniques in addition to a novel incision on the medial pterygoid plate's surface, named the Sommerlad-Furlow modified technique. Thus, this study aimed to evaluate the clinical and functional outcomes of the Sommerlad-Furlow modified technique against an accepted standard, the Furlow technique. A retrospective review was conducted for 212 consecutive nonsyndromic cleft palate patients who underwent Sommerlad-Furlow ( n = 106) and Furlow ( n = 106) repairs without relaxing incision on the hard palate between 2011 and 2016. The success of surgical procedures was estimated by the rate of postoperative fistula, speech outcomes, and velopharyngeal insufficiency (VPI)-related quality of life. The demographic and surgical data, including sex, age, cleft type, cleft width, and follow-up period were recorded. There was no statistically significant difference between the two treatment groups regarding demographic and surgical data, except the cleft width ( P < 0.001). The incidence of the fistula was 7.5% and 6.6% after the Sommerlad-Furlow and Furlow procedures, respectively. The two groups showed no significant differences in speech outcomes, and adequate velopharyngeal function was found in 84% and 82.1% in Sommerlad-Furlow and Furlow procedures, respectively. Besides, the rate of severe VPI was slightly lower in Sommerlad-Furlow (0.9%) than in Furlow (2.8%) procedures. Moreover, an adequate VPI-related quality of life was found in 80.4% of the Sommerlad-Furlow group and 78.6% of the Furlow group. The Sommerlad-Furlow technique has obtained acceptable postoperative outcomes and could be a choice for cleft palate repair, especially in wider clefts. Therapeutic, III.

Comparation between the Bricker ileal conduit vs double-barrelled wet colostomy after pelvic exenteration for gynaecological malignancies

BackgroundAfter exhausting other therapeutic options, pelvic exenteration is performed in patients who suffer from relapsed gynaecologic tumours, with most of them requiring some sort of urinary diversion. Material and methodsThe main objective of this study was to assess the short- and medium/long-term urinary complications associated with the Bricker ileal conduit versus double-barrelled wet colostomy after performing a pelvic exenteration for gynaecologic malignancies. ResultsA total of 61 pelvic exenterations were identified between November 2010 and April 2022; 29 Bricker ileal conduits and 20 double-barrelled wet colostomies were included in the urinary diversion analysis. Regarding the specific short-term urinary complications, no differences were found in the rate of urinary leakage (3 vs 0 %; p = 1), urostomy complications (7 vs 0 %; p = 0.51), acute renal failure (10 vs 20 %; p = 0.24) or urinary infection (0 vs 5 %; p = 0.41). Up to 69 % of patients with Bricker ileal conduits and 65 % of double-barrelled wet colostomies (p = 0.76) presented specific medium/long-term urinary complications. No differences in the rates of pyelonephritis (59 vs 53 %; p = 0.71), urinary fistula (0 vs 12 %; p = 0.13), ureteral stricture (10 vs 6 %; p = 1), conduit failure and reconstruction (7 vs 0 %; p = 0.53), renal failure (38 vs 29 %; p = 0.56) or electrolyte disorders (24 vs 18 %; p = 0.72) were found. ConclusionsThere are no significant differences in the rate of complications between double-barrelled wet colostomy and the Bricker ileal conduit. The long-term complications related to urinary diversion remained high regardless of the type of technique. In this context, the double-barrelled wet colostomy presents advantages such as the single stoma placement and the simplicity of the technique.

Association between chronic steroids and outcomes in hepatobiliary and pancreatic surgery

BackgroundChronic steroid use has been associated with increased postoperative complication; however, the association between chronic steroids and hepatobiliary and pancreatic surgery through all aspects of disease etiologies and types of surgery performed remains an area of active research. Therefore, this study analyzed the association of chronic steroids use with outcomes after hepatobiliary and pancreatic surgery. MethodsThe National Surgical Quality Improvement Program Participant Use Data Files for hepatobiliary and pancreatic surgeries performed between 2015 and 2019 were analyzed for chronic steroid use and postoperative adverse events. ResultsA total of 54,382 patients underwent hepatobiliary or pancreatic surgery during the study period, of which 1672 (3.1%) were on chronic steroids. In patients undergoing pancreatic surgery, steroid use was associated with higher rates of pneumonia (odds ratio [OR] 1.3, 95% confidence interval [95% CI] 1.2–2.2), unplanned intubation (OR 1.2, 95% CI 1.1–2.3), readmission (OR 1.4, 95% CI 1.3–2.4), intraoperative or postoperative transfusions (OR 1.5, 95% CI 1.2–2.3), being more likely to remain on a ventilator for greater than 48 h (OR 1.4, 95% CI 1.2–1.9), and greater mortality (OR 1.2, 95% CI 1.1–3.1) when compared to those, not on chronic steroids. In patients undergoing hepatobiliary surgery, chronic steroid use was associated with higher rates of sepsis (OR 1.3, 95% CI 1.2–2.9), unplanned intubation (OR 1.4, 95% CI 1.2–2.7), intraoperative or postoperative transfusions (OR 1.5, 95% CI 1.3–2.3), and readmission (OR 1.2, 95% CI 1.0–1.9). There was no difference in pancreatic fistula rates or post-hepatectomy liver failure rates after pancreatic and hepatobiliary resections, respectively. ConclusionChronic steroids use was associated with higher rates of poor outcomes both perioperatively and postoperatively in pancreatic and hepatobiliary surgery. These results will allow clinicians to be better equipped to counsel patients on surgery's increased risks and establish various perioperative protocols for chronic steroid users.

Retrospective Analysis of the Effect of Hand-sewn and Stapler Closure of Pancreatic Stump After Distal Pancreatectomy on the Development of Postoperative Pancreatic Fistula

Aim: Hand-sewn (HS) and stapled closure (ST) of pancreatic stump following distal pancreatectomy are two frequently used techniques. Rates of postoperative pancreatic fistula (POPF) might be associated with stump closure techniques. This study was carried out to determine rates of POPF after distal pancreatectomy and evaluate impact of two closure methods on development of POPF. &#x0D; Material and Methods: All patients who underwent elective open or laparoscopic distal pancreatectomy for malignant and benign pancreatic pathologies between 2011 and 2021 were retrospectively evaluated. Patients were grouped as Groups HS and ST. POPF was diagnosed and graded according to International Study Group of Pancreatic Fistula guidelines. Rates of biochemical leak and grades of POPF were primary outcome. &#x0D; Results: There were 44 patients (28 in Group HS and 16 in Group ST) with a mean age of 51.8±15.1 years. Groups were similar in demographic and clinical characteristics (p&gt;0.05). There were 15 patients (53.6%) with a biochemical leak in Group HS. In Group ST, six patients (37.5%) developed biochemical leaks. There was no significant in difference between groups in terms of biochemical leak (p=0.305). No patient in Group ST developed a pancreatic fistula. There was only one case with Grade B POPF in Group HS. We did not detect a significant difference in terms of POPF between groups (p=0.999). &#x0D; Conclusion: Both techniques had no significant impact on biochemical leak and POPF rates in patients who underwent distal pancreatectomy. Both pancreatic stump closure approaches are equally safe and can be used with similar clinical efficacy.

Association of Head and Neck Anatomic Zones with Microvascular Reconstruction Outcomes.

Background: Head and neck free flap survival relies on adequate tissue perfusion from the external carotid artery (ECA), and vessel length is inversely proportional to blood flow rate. Objective: Investigate whether distance from the ECA (as a proxy for pedicle vessel length) predicts flap survival or complications. Methods: Retrospective review of free flaps performed at three academic centers from 9/2006 to 8/2021. Flaps were categorized by distance from the ECA: orbit and above (zone 1), maxilla to parotid (zone 2), and mandible and below (zone 3). Secondary analysis assessed flap outcomes stratified by average historical pedicle length. Results: A total of 2,369 flaps were identified in zones 1 (n = 109), 2 (n = 1878), and 3 (n = 382). Rates of flap failure (4.9%) and perioperative complications (36.3%) did not differ by zone or pedicle length. Zone 3 flaps, most commonly located in the larynx and hypopharynx, had significantly higher rates of fistula and infection. Conversely, 30-day readmission rates were significantly lower in patients with zone 2 flaps (p < 0.001). Rates of all other complications did not differ significantly between zones. Conclusions: Proximity to mucosal anatomic sites was a more powerful predictor of free flap viability than pedicle length or ECA proximity.

Morbidity and survival after laparoscopic versus open pancreatoduodenectomy: propensity score matched comparison.

Technical challenges and a perceived higher risk of complications hinder a wide adoption of minimally invasive pancreatoduodenectomy. We aim to further define the place of minimally invasive pancreatoduodenectomy by comparison with the traditional open approach. A comparison of the surgical outcomes and survival after laparoscopic (LPD) versus open pancreatoduodenectomy (OPD) was retrospectively performed from a prospectively kept database. To reduce the effect of bias and confounding, baseline characteristics of both groups were matched using propensity score matching (NCT05110573; Nov 8, 2021; retrospectively registered). From a total of 67 LPD and 105 OPD patients, propensity score matching resulted in two balanced groups of 38 patients. In both groups, 87% of surgeries were performed for cancer. In the LPD group, conversion rate was 22.4%. Mean operative time was significantly longer after LPD versus OPD (320.1 ± 53.8 vs. 277.7 ± 63.8min; p = .008). Hospital stay was significantly shorter after LPD versus OPD (median 13.5 vs. 17.0days; p = .039). No significant differences were observed in blood loss, total complication rate (73.7% vs. 86.8%; p = .249), major complication rate (26.5% vs. 10.5%; p = .137), postoperative pancreatic fistula rate (13.2% vs. 7.9%; p = .711), 90-day mortality rate (5.3% vs. 0%; p = .493), R0 resection rate (85.4% vs. 85.8%), or number of lymph nodes (median 10.0 vs. 8.5; p = .273). In cancer patients, no significant differences were observed in overall survival (median 27.1 vs. 23.9months; p = .693), disease-free survival, or recurrence rate. LPD provided acceptable short-term and oncological outcomes. Compared to OPD, we noted a higher major complication rate, without compromising surgical safety or oncological outcomes.

Central hepatectomy versus major hepatectomy for patients with centrally located hepatocellular carcinoma: a systematic review and meta-analysis

Background and aimFor those with a centrally located HCC, the two types of liver sectionectomy that can be performed are extended hepatectomy (EH) and central hepatectomy (CH). This meta-analysis aimed to compare the short- and long-term outcomes between patients treated with CH and patients treated with EH for those with centrally located HCC.MethodWe searched PubMed, Scopus, Web of Science, and Cochrane library for eligible studies from inception to 1 April 2022 and a systematic review and meta-analysis were done to compare the outcomes between the two groups.Resultswe included 9 studies with a total of 1674 patients in this study. The pooled results in this meta-analysis showed equal long-term overall survival, Disease-free survival, recurrence and mortality between the two groups (5-year OS, RR = 1.14, 95% CI = 0.96–1.35, P = 0.12; I2 = 56%), (5-year DFS, RR = 0.81, 95% CI = 0.61–1.08, P = 0.15; I2 = 60%), (Recurrence, RR = 1.04, 95% CI = 0.94–1.15, P = 0.45; I2 = 27%), and (Mortality, RR = 0.55, 95% CI = 0.26–1.15, P = 0.11; I2 = 0%). In addition to that, no significant difference could be detected in the overall incidence of complications between the two groups (Complications, RR = 0.94, 95% CI = 0.76–1.16, P = 0.57; I2 = 0%). However, CH is associated with a remarkable increase in the rate of biliary fistula (Biliary fistula, RR = 1.90, 95% CI = 1.07–3.40, P = 0.03; I2 = 0%). And Liver cell failure was higher in the case of EH (LCF, RR = 0.47, 95% CI = 0.30–0.76, P = 0.002; I2 = 0%). Regarding the operative details, CH is associated with longer operative time (Time of the operation, Mean difference = 0.82, 95% CI = 0.36, 1.27, P = 0.0004; I2 = 57%).ConclusionNo significant difference in the short and long-term survival and recurrence between CH and MH for CL-HCC. However, CH is associated with greater future remnant liver volume that decreases the incidence of LCF and provides more opportunities for a repeat hepatectomy after tumour recurrence.

Our Experience with Tension-Free Urethral Reconstruction with Urethral Plate Dorsal Slit Technique

Background Hypospadias is among the most common urogenital anomaly which is usually corrected by various surgical techniques. The global burden of hypospadias is shared among adult and pediatric urologists and plastic surgeons as well. Potential complications of the repair include meatal stenosis, urethrocutaneous fistula, urethral stricture, and urethral diverticulum. Fistula rates in large hypospadias series have been reported to range from 2% to 14% in Snodgrass repairs. Objective Our aim of this study is to identify the effectiveness of the dorsal urethral plate slit technique for tension-free hypospadias repair. Material and Methods A retrospective review was performed. A total of 53 patients presented to the plastic surgery outpatient department of Liaquat National Hospital within 2 years from January 2019 – December 2020 with congenital hypospadias, out of these 14 patients were included in the study who met the inclusion criteria. None of the patients had any prior hypospadias correction. The surgical technique involved the dorsal slit technique for tension-free repair. The patients were followed post-operatively for a total duration of 2 years to assess for any post-operative complications. Result The mean age of patients was 11 years, with the most common preoperative complaints of abnormal urinary stream. In all operated cases we observed a 7.1% rate of fistula formation. None of the subject patients developed meatal stenosis and only 1 patient developed a fistula during the study period. All other patients reported a good urinary stream and had an acceptable cosmesis postoperatively. Conclusions The urethral plate dorsal slit technique for tension-free hypospadias repair has a good outcome with relatively fewer complications and a high success rate. This modification along with careful preoperative planning during patient selection plays a key role in the outcome of the repairs.

Autologous platelet-rich-plasma injection and platelet-rich fibrin glue interposition for treatment of anal fistula resistant to surgery.

The current study purposed to evaluate the autologous platelet-rich plasma (PRP), and platelet-rich fibrin glue (PRFG) effect on the treatment of complex, and recalcitrant anal fistula (AF) which was not cured by several surgeries. AF has remained one of difficult challenges for centuries. Surgery is the common treatment method for it, but the risk of fecal incontinence and recurrence is still a distressing complication for patients and surgeons. New procedures were published in the scientific literature, each with advantages and disadvantages. According to reports, an effective therapy option is the autologous fibrin glue that is rich in platelets. Autologous PRP and PRFG were prepared from 10 patients' own blood. The surgeon curetted the tract of anal fistula for the deepithelialisation till hemorrhage occurred; PRP was injected around the fistula into the tissue, and PRFG was interpositioned in the tract. Age, number of previous surgeries, complications, number of PRP and PRFG administrations, and duration of halting the discharge were among the information gathered. Patients were followed up between 10 months to 84 months after treatment. No complications were observed during and after the injection. During the period of follow-up, AF leakage was stopped for 6 patients, but not for 4 patients. Since autologous PRP injection, and PRFG interposition is a safe, effective, and minimally invasive procedure for resistant AF to surgeries; it can be used, along with surgery to increase the healing rate of complex anal fistula.

Minimally invasive enucleation versus open enucleation for benign or low-grade malignant pancreatic neoplasms: Effects on clinical outcomes and quality of life.

The efficacy and safety of minimally invasive pancreatic enucleation (PE) have rarely been investigated. This study aimed to compare the perioperative and long-term outcomes of minimally invasive enucleation (MIEn) with those of open enucleation (OEn) for benign/low-grade malignant pancreatic neoplasms. Data collected from patients who underwent PE between January 2011 and June 2020 at our centre were analysed. Forty-two patients who underwent MIEn (10 - robot-assisted and 32 - laparoscopic) and 47 who underwent OEn were included in this study. Compared with the OEn group, the MIEn group showed shorter operation time (147.6 ± 71.3 min vs. 183.1 ± 64.3 min), shorter post-operative hospital stay (11.5 ± 3.9 days vs. 13.4 ± 4.2 days), shorter off-bed activity time (2.9 ± 0.9 days vs. 3.7 ± 1.0 days) and lower estimated blood loss (EBL) (118.5 ± 59.2 mL vs. 153.1 ± 85.0 mL). Overall complication rate (47.6% vs. 55.3%), overall post-operative pancreatic fistula (POPF) rate (40.5% vs. 44.7%) and Grade B + C POPF rate (11.9% vs. 19.1%) were similar in both the groups. For neoplasms located in the proximal pancreas, MIEn showed more favourable perioperative outcomes than OEn. Unlike MIEn for superficial neoplasms, MIEn for neoplasms deeply embedded in the pancreas resulted in a longer operative time and tended to increase EBL and the incidence of complications and POPF. During the follow-up period, no significant differences were observed between these two groups in terms of pancreatic function or quality of life. Compared to OEn, MIEn is effective and safe for patients with benign or low-grade malignant pancreatic neoplasms. However, MIEn for embedded pancreatic neoplasms is recommended only in experienced centres because of the high rates of complications and POPF.