High Postoperative Morbidity Rates Research Articles

Clinicopathologic characteristics and surgical outcomes of elderly patients with thyroid cancer.

Age is one of the important prognostic factors in thyroid cancer, and old age is generally related to higher rate of post-operative morbidity and mortality. The study analyzed the characteristics of thyroid cancer in elderly patients compared with those in younger patients. Patients who underwent surgery between 1992 and 2011 were enrolled. The patients were divided into those ≥70 years of age (older group) and <70 years of age (younger group). Data including clinicopathological features and post-operative complications was analyzed. Molecular markers including Galectin-3, Cyclooxygenase-2, bcl-2, Cyclin D1, Epidermal growth factor receptor and BRAF mutation were reviewed. Survival analyses including recurrence-free survival and overall survival were examined. Of 1867 patients, 98 were age-classified in older group and the remaining 1769 were in younger group. Older group displayed larger tumor size, and increased extrathyroidal extension, vascular invasion and neural invasion than younger group, and all were statistically significant. Molecular marker analyses revealed no significant differences between the groups. Post-operative complication rates were not significantly different between the older and younger groups in both univariate and multivariate analyses. Elderly patients showed poor recurrence-free survival and overall survival than younger patients in univariate analyses. However, age ≥70 years was not associated with poor recurrence-free survival after adjustment of confounding factors. Molecular features of elderly patients may be similar with younger patients. Even though aggravated clinicopathological features of thyroid carcinoma are more prevalent in elderly patients, thyroid surgery in elderly patients can be performed with favorable surgical and oncological outcomes.

Pre-operative nutrition support in patients waiting for digestive surgery at Hospital Mateu Orfila (Maó-Menorca)

Malnutrition is associated with high postoperative morbidity and mortality rates. This pilot study evaluated the effectiveness of a peri-operative nutritional support programme for patients who were about to undergo major gastrointestinal surgery. A high-calorie/high-protein enteral formula was administered peri-operatively to the group of patients at nutritional risk/with malnutrition (NR/MN). In order to assess the effectiveness of the preoperative nutritional intervention, the results were compared to a retrospective control group. Statistically-significant differences were found between the two NR/MN groups in incidence of vomiting; wound infection; hyperglycaemia; death in hospital; length of hospital stay; time in ICU; and administration of TPN. Postoperative progress was found to be better in the group of NR/MN patients supplemented preoperatively with an enteral nutrition formula.

Outcomes of surgical revascularization for lower extremity arterial thromboembolism in patients with advanced malignancy

The objective of this study was to describe the outcomes of surgical revascularization for lower extremity arterial thromboembolism in patients with advanced malignancy. The 2005-2011 American College of Surgeons National Surgical Quality Improvement Program database was used for this study. Preoperative characteristics and postoperative outcomes of patients with known advanced malignancy who underwent surgical revascularization for lower extremity arterial thromboembolic disease were assessed and compared with those of patients without known advanced malignancy. Parsimonious multivariate logistic regression analysis was used to determine the independent association between advanced malignancy and 30-day postoperative mortality and morbidity after adjustment for demographic characteristics, acute and chronic comorbid disease burden, history of peripheral arterial disease, functional and nutritional status, acuity of presentation, and procedure type. The study included 136 patients with advanced malignancy who underwent surgical revascularization for lower extremity arterial thromboembolism for analysis (65% thromboembolectomy, 26% thromboendarterectomy, and 22% bypass grafting). The 30-day mortality and morbidity rates in these patients were 30.2% and 38.2%, respectively. Compared with patients without advanced malignancy, patients with advanced malignancy had a significantly greater risk of postoperative death (adjusted odds ratio, 5.92; 95% confidence interval, 3.69-9.52; P< .001) but not morbidity (adjusted odds ratio, 1.28; 95% confidence interval, 0.87-1.87; P= .21). Our study is the largest to date to describe the outcomes of patients with advanced malignancy who undergo surgical revascularization for arterial thromboembolism of the lower extremities. Such patients suffer high rates of early postoperative mortality and morbidity, especially when emergency operation is required. Early involvement of palliative care specialists is warranted in these patients to ensure that the decision to pursue surgical revascularization is aligned with their goals of care.

Staphylococcus aureus and repeat bacteremia in febrile patients as early signs of sternal wound infection after cardiac surgery.

BackgroundSternal wound infection is a devastating complication of cardiothoracic surgery that carries high postoperative morbidity and mortality rates. We explored whether our current program of extensive bacteriological examination including repeat blood cultures may contribute to the early diagnosis of sternal wound infection.MethodsWe retrospectively analyzed 112 patients who were subjected to our bacteriological examination protocol including within 90 days after cardiothoracic surgery. Univariate and multivariate analyses were made in order to identify risk factors for sternal infection.ResultsThe median patient age was 75 years, and 65 patients were male. In 35 cases (31.2%) the blood cultures showed the presence of bacterial infection with the following frequencies: Staphylococcus aureus, 18 cases; Coagulase-negative Staphylococcus, 7 cases; other organisms, 10 cases. Eleven patients presented repeat bacteremia on at least 2 different occasions. Twenty patients (17.8%) presented sternal wound infections. There was no difference in operative mortality between the patients with and without sternal wound infection. Univariate and multivariate analyses demonstrated that bilateral mammary artery use (OR, 13.68, 95% CI, 1.09-167.36, p = 0.043), positive blood culture for Staphylococcus aureus (OR, 19.51, 95% CI, 4.46-104.33, p < 0.0001), repeat bacteremia (OR, 17.98, 95% CI, 2.51-161.77, p = 0.004) were risk factors that were associated for sternal wound infection.ConclusionRepeat blood cultures in febrile patients appear to be useful for the early detection of Staphylococcus aureus and repeat bacteremia, and these were associated with sternal wound infection. Bilateral internal mammary artery use was another risk factor of sternal wound infection in febrile patients. These factors may identify patients suitable for expeditious radiological examination and aggressive treatments.

Interposition of the omentum and/or the peritoneum in the emergency repair of large ventral hernias with polypropylene mesh

BackgroundVentral and incisional hernias are common surgical problems and their repairs are among the common surgeries done by a general surgeon. Repair of a large ventral hernia is still associated with high postoperative morbidity and recurrence rates. No single approach to ventral hernia repair will be the best choice for all patients. Large ventral hernias are often better approached with open surgery but may still be problematic when the defect is too wide for primary fascial closure to be achieved, as this leaves mesh exposed, bridging the gap. Techniques for incisional hernia repair have evolved over many years, and the use of mesh has reduced recurrence rates dramatically. The use of polypropylene mesh is reported to be associated with long-term complications such as severe adhesions and enterocutaneous fistula, which occur more commonly if the mesh is applied intraperitoneally with direct contact of the serosal surface of the intestine. Composite meshes containing expanded polytetrafluoroethylene (ePTFE) have been used recently; their major drawbacks lie in their high cost, inferior handling characteristics, and poor incorporation into the tissues. Although several studies have clearly demonstrated the safety and efficacy of prosthetic mesh repair in the emergency management of the incarcerated and/or strangulated inguinal and ventral hernias, however, surgeons remained reluctant to use prosthetics in such settings. PurposeThe aim of this work was to evaluate the effectiveness and safety of placing the omentum and/or the peritoneum of the hernia sac as a protective layer over the viscera in the emergency repair of large ventral hernias using on-lay polypropylene mesh whenever complete tension-free closure of the abdominal wall was impossible. Patients and methodsThis study was carried out on all patients with large ventral hernia presented to the Gastrointestinal Surgery Unit, Main Alexandria University Hospital in an emergency situation during the period from October 2005 till October 2012. All patients were treated by placing the omentum and/or the peritoneum of the hernia sac between the viscera and the mesh whenever complete tension-free closure of the abdominal wall was impossible. Some patients necessitated removal of previous meshes and resection-anastomosis of the non-viable bowel prior to mesh repair. Those who underwent complete closure of the abdominal wall without tension prior to mesh repair were excluded from the study as there was no need for interposition of the omentum and/or peritoneum. All patients' data, surgical procedures, complications and follow-up were collected, reviewed and analyzed. After approval of local ethics committees of both the General Surgery Department and the Alexandria Faculty of Medicine, all patients included in the study were informed well about the operative procedure and use of prosthetic mesh and an informed written consent was obtained from every patient before carrying the procedure. ResultsBetween October 2005 and October 2012; 105 patients (13 males and 92 females) with incarcerated and/or strangulated large ventral hernias were operated upon in the Gastrointestinal Surgery Unit, Main Alexandria University Hospital using an onlay polypropylene mesh. Their age ranged from 37 to 83 years with a mean of 59.3 + 11.7 years. The hernia was para-umbilical in 5 patients (4.8%), incisional in 22 patients (21%) and recurrent in 78 patients (74.3%). The recurrent hernias were recurrent para-umbilical hernias in 56 patients and recurrent incisional hernias in 22 patients. Resection anastomosis of non-viable, devitalized or injured small intestine during removal of adherent previous meshes was performed in 19 patients (18%). Hospital stay ranged from 2 to 13 days with a mean of 3.57 + 1.6 days. There was one perioperative mortality. Complications were encountered in 28 patients (26.7%) and included wound infection with delayed wound healing in 6 patients, seroma formation in 12 patients, chest infection in 8 patients and deep vein thrombosis in 2 patients. Follow-up duration ranged from 13 to 80 months with a mean of 46.8 + 20.3 months. ConclusionPlacing the omentum and/or the peritoneum of the hernia sac as a protective layer over the viscera in repair of incarcerated and/or strangulated large ventral hernia using on-lay polypropylene mesh is cost-effective and safe even with resection anastomosis of small intestine.

A systematic review of transarterial embolization versus emergency surgery in treatment of major nonvariceal upper gastrointestinal bleeding.

BackgroundEmergency surgery or transarterial embolization (TAE) are options for the treatment of recurrent or refractory nonvariceal upper gastrointestinal bleeding. Surgery has the disadvantage of high rates of postoperative morbidity and mortality. Embolization has become more available and has the advantage of avoiding laparotomy in this often unfit and elderly population.ObjectiveTo carry out a systematic review and meta-analysis of all studies that have directly compared TAE with emergency surgery in the treatment of major upper gastrointestinal bleeding that has failed therapeutic upper gastrointestinal endoscopy.MethodsA literature search of Ovid MEDLINE, Embase, and Google Scholar was performed. The primary outcomes were all-cause mortality and rates of rebleeding. The secondary outcomes were length of stay and postoperative complications.ResultsA total of nine studies with 711 patients (347 who had embolization and 364 who had surgery) were analyzed. Patients in the TAE group were more likely to have ischemic heart disease (odds ratio [OR] =1.99; 95% confidence interval [CI]: 1.33, 2.98; P=0.0008; I2=67% [random effects model]) and be coagulopathic (pooled OR =2.23; 95% CI: 1.29, 3.87; P=0.004; I2=33% [fixed effects model]). Compared with TAE, surgery was associated with a lower risk of rebleeding (OR =0.41; 95% CI: 0.22, 0.77; P<0.0001; I2=55% [random effects]). There was no difference in mortality (OR =0.70; 95% CI: 0.48, 1.02; P=0.06; I2=44% [fixed effects]) between TAE and surgery.ConclusionWhen compared with surgery, TAE had a significant increased risk of rebleeding rates after TAE; however, there were no differences in mortality rates. These findings are subject to multiple sources of bias due to poor quality studies. These findings support the need for a well-designed clinical trial to ascertain which technique is superior.

Management of hypoglossal schwannomas: single institutional experience of 14 cases.

Background Hypoglossal schwannomas are rare intracranial neoplasms. Microsurgical resection with the goal of cure is the aim of management but is associated with a high rate of postoperative morbidity. Objective The objective of the study was to outline the clinical presentation, radiologic characteristics, surgical techniques, postoperative morbidity, and long-term follow-up results for hypoglossal schwannomas. Methods Patients treated for hypoglossal schwannoma at the Department of Neurosurgery of a tertiary-level referral institution from January 2001 until December 2010 were analyzed retrospectively using hospital records. Results There were 14 patients who were treated in the study period. Tongue atrophy and swallowing difficulties were the most common presenting symptoms. Surgery done in 12 patients using a variety of approaches (retromastoid retrosigmoid suboccipital in 9, midline suboccipital in 2, and far lateral in 1). Five patients having small residual tumors received gamma knife (GK) subsequently. two patients received primary GK stereotactic radiosurgery. Three patients had permanent morbidity in the form of cranial nerve paresis. Immediate postoperative complications like cerebrospinal fluid leak and pneumonia were present in three patients. Conclusion Complete microsurgical resection is often associated with a high rate of morbidity. Subtotal and near-total resection followed by stereotactic radiosurgery or observation now offers an alternative approach.

8:36 AM; Abstract No. 235 - Percutaneous stabilization of metastatic disease in the acetabulum

Patients with periacetabular bone destruction and impending or pathologic fractures from metastatic cancer have limited treatment options. Complex acetabular reconstruction can improve mobility, but has a high rate of complications and post-operative morbidity, and can delay chemotherapy and radiation.1 Through the collaboration of orthopedic oncologists and interventional radiologists, we have developed an alternative, minimally invasive approach to stabilize the pelvis.

8:45 AM; Abstract No. 236; FEATURED ABSTRACT - Interactive near real-time high resolution imaging for open MR guided interventions using zoom MRI at 1.0 Tesla - initial experience

Purpose: Patients with periacetabular bone destruction and impending or pathologic fractures from metastatic cancer have limited treatment options. Complex acetabular reconstruction can improve mobility, but has a high rate of complications and post-operative morbidity, and can delay chemotherapy and radiation. Through the collaboration of orthopedic oncologists and interventional radiologists, we have developed an alternative, minimally invasive approach to stabilize the pelvis. Materials and Methods: Ten patients underwent percutaneous screw fixation and polymethyl methacrylate augmentation for impending or non-displaced pathologic fractures of the acetabulum due to metastatic disease between 11/2011-5/2013. Ablation was performed when appropriate. Medical records were reviewed for hospital course, ability to receive chemotherapy and radiation, pain, and functional scores before and after surgery based on the Musculoskeletal Tumor Society (MSTS) scoring system. Results: Ten patients with a median age of 57.5 made up our cohort. We had a 100% technical success rate and no major complications. Seven patients received conscious sedation, and 3 general anesthesia. Postoperatively, 9 patients were weightbearing as tolerated, and 1 patient was toe-touch weight bearing. Five patients were discharged within 24 hours of surgery, with a mean hospital stay of 4 days. Nine patients could immediately receive chemotherapy and radiation. The mean preoperative and postoperative MSTS scores were 0.3 vs. 2.7 for pain (5 is normal), and 7.1 vs. 15.2 for the total functional score (30 is normal). Pain and mobility improved for all patients. Conclusion: Percutaneous acetabular stabilization improves the pain, mobility, and quality of life in patients with painful metastatic disease and limited life expectancy. It carries a low risk of complications and allows for earlier chemotherapy and radiation. Therefore, patients with painful impending or pathologic pelvic fractures should be considered for minimally invasive stabilization through our multidisciplinary approach.

Preoperative oral supplementation support in patients with esophageal cancer.

Surgeries for cancer of the esophagus are still associated with a high rate of postoperative morbidity. There are few reports of perioperative nutritional support for patients undergoing esophageal cancer surgery, and there is insufficient evidence to recommend routine use of immunonutrition in these patients. The aim of this study was to determine whether preoperative immunonutrition positively influences key clinical outcomes such as postoperative infectious complications, mortality, length of hospital stay, and short-term survival in this population. We undertook a retrospective investigation of the effects of preoperative nutritional support on the postoperative course of esophageal cancer surgery at the Department of Gastroenterological Surgery, International University of Health and Welfare Mita Hospital, Tokyo, Japan. Fifty-five patients who underwent esophagectomy for esophageal cancer were included in this study. Of the 55 patients, 26 patients consumed a liquid dietary supplement (IMPACT group) before surgery and 29 patients did not (STANDARD group). Before surgery, the IMPACT group consumed 750 ml (3 packs)/day of Impact for 5 consecutive days. The analysis was based on postoperative complications, hospital mortality, length of hospital stay, and short-term survival. Significantly fewer patients developed postoperative infections in the IMPACT group compared with the STANDARD group (p=.007): 4 of 21 patients in the IMPACT group and 10 of 29 patients in the STANDARD group. Either an infectious complication or another complication developed in 8 patients in the IMPACT group and 13 patients in the STANDARD group, with the result that 6 patients in the STANDARD group died of postoperative complications (p=.001). The duration of hospitalization was 34 days in the IMPACT group and 48 days in the STANDARD group; hence, hospitalization was significantly shorter in patients treated with Impact (p=.008). The mean 6-month survival rates for the IMPACT group and the STANDARD group were 92% (24/26) and 72% (21/29), respectively (p=.028). Simple preoperative supplementation significantly improved outcome. Administration of the supplemental diet before esophageal surgery appeared to be an effective strategy in reducing infectious complications, mortality, and hospitalization, and improving short-term survival.

Climbing a long hill: pelvic floor surgery and the need for geriatric urogynecology

The topic of geriatric urogynecology is receiving much attention lately as a public health priority because of the global increase in female life expectancy and the significant risk of associated pelvic floor dysfunctions. Statistics from the USA project that in 2050, 25 % of the population will be >60 years and that those >85 will increase from a population of 1.9 % in 2010 to 4.3 % in 2050 [1]. The urogynecological community should thus expect to face a worldwide and progressively growing demand from patients seeking care for pelvic floor dysfunctions. One study predicted >50 % increased demand for urogynecological services over the next 40 years [2]. The changing female demographics is accompanied by a considerable interest in the contemporary literature to standardize the indications, techniques, and outcomes of surgical treatment of pelvic floor dysfunctions. Only a few reports appreciate that increasing age of our female population is an intrinsic biological variable interfering with the standardization process [3]. Women aged >80 years undergoing urogynecological surgery have a 13.6 higher risk of postoperative death than their younger counterparts. In the majority of cases, the cause of death is not directly related to the procedure [4]. Despite the obvious need for operative intervention among these elderly women and the strong evidence for the inherent morbidity and mortality of this treatment option, there is scarce urogynecological data on the risks and specific perioperative management in this patient group. Ageing influences lower urinary tract symptoms (LUTS), pelvic floor function, and perioperative and postoperative courses. The higher postoperative morbidity rate is also an important factor that is often overlooked in most surgical studies. Main concerns when treating elderly women are:

Surgical and radiation therapy management of recurrent anal melanoma.

Melanoma of the anorectal mucosa is a rare but highly aggressive tumor. Its presenting symptoms are frequently confused with hemorrhoids, thereby causing a delay in diagnosis. Anorectal melanoma carries with it a very poor prognosis. There is a paucity of data investigating management options for anorectal melanoma, and even fewer data reporting recurrent or refractory cases. This case documents a 41-year-old female with a long history of hemorrhoids presenting with anorectal discharge. She was incidentally found have anorectal melanoma following surgical resection. Systemic diagnostic work-up demonstrated PET-avid lymphadenopathy in her right groin. She underwent right groin dissection. However, seven months later she recurred in her right groin and a new recurrent mass was found in her pelvis. She underwent a second groin dissection and resection of the pelvic recurrence. This was followed by a course of hypofractionated radiation therapy then systemic immunotherapy. Surgery has been the mainstay of treatment. However, the extent of surgery has been the topic of investigation. Historically, radical resections have been performed but they result in high rates of post-operative morbidity. Newer studies have compared radical resection with wide local excisions and found comparable outcomes. Anorectal melanoma is frequently a systemic disease. The ideal systemic therapy regimen has not yet been determined but numerous studies show a benefit to multi-agent treatments. Radiation therapy is typically given in the post-operative or palliative setting. Anorectal mucosal melanoma is a very rare but aggressive disease with a poor prognosis. The overall treatment goal should strive to optimize quality of life and tumor control while minimizing treatment-related morbidities.

Clinical feasibility and nutritional effects of early oral feeding after pancreaticoduodenectomy

Backgrounds/AimsPancreaticoduodenctomy (PD) is associated with high rates of postoperative morbidity and mortality. Although many studies have shown that early postoperative enteral nutrition improves postoperative outcomes, limited clinical information is available on postoperative early oral feeding (EOF) after PD. The aim of this study was to evaluate the clinical feasibility, safety, and nutritional effects of EOF after PD.MethodsClinical outcomes were investigated in 131 patients who underwent PD between 2003 and 2013, including 81 whose oral feeding was commenced within 48 hours (EOF group) and 50 whose oral feeding was commenced after resumption of bowel movements (traditional oral feeding [TOF] group). Postoperative complications, energy intake, and length of stay (LOS) were reviewed.ResultsDemographic factors were similar in the two groups. The EOF group had a significantly shorter LOS (25.9±8.5 days vs. 32.3±16.3 days; p=0.01) than the TOF group. The rates of anastomotic leak (1.2% vs. 16%, p=0.00) and reoperation (3.7% vs. 20%, p=0.01) were significantly lower in the EOF group. In the clinically acute phase from postoperative day 1 to day 5, the mean daily calorie intake (847.0 kcal vs. 745.6 kcal; p=0.04) and mean daily protein intake (42.2 g vs. 31.9 g; p=0.00) in the EOF group were significantly higher than that in the TOF group.ConclusionsPostoperative EOF is a clinically safe, feasible, and effective method of nutritional support after PD.

Invited Commentary

Aspergillosis is a ubiquitous infection caused by the Aspergillus species. Pulmonary aspergilloma is the most frequently diagnosed aspergillosis and there has been an increase in the number of cases, especially in developing countries. The most important symptom of pulmonary aspergillosis is hemoptysis, which is why surgical treatment has sometimes been selected as the treatment for pulmonary aspergilloma. Because the surgical treatment for pulmonary aspergilloma is associated with high postoperative morbidity and mortality rates, the procedures used for the surgical treatment of pulmonary aspergilloma remain challenging. The authors demonstrate that video-assisted thoracic surgery (VATS) has evolved in the last decade and is now a new choice for the surgical treatments of pulmonary aspergilloma. Dr Q-K Chen and colleagues [1Chen Q.-K. Chen C. Chen X.-F. Jiang G.-N. Video-assisted thoracic surgery for pulmonary aspergilloma: a safe and effective procedure.Ann Thorac Surg. 2014; 97: 218-223Scopus (27) Google Scholar] retrospectively reported the results of 76 patients with pulmonary aspergilloma who underwent an attempted VATS lobectomy and compared them to 76 patients selected by propensity score matching from 310 patients with thoracotomy. They showed that the VATS group had a shorter hospital stay and fewer complications compared with those in the thoracotomy group, indicating that the VATS can be an alternative to open procedures that could be used for the management of pulmonary simple aspergilloma (SPA) and localized complex aspergilloma (CPA) without infiltration of the hilum. In this study, the authors selected the candidates for VATS based on the following: young patients with aesthetic demands; no severe parenchymal and pleural scarring, and no calcified lymph nodes near pulmonary arteries and veins based on computed tomographic (CT) scans; and CT scan image findings showing SPA or localized CPA. This indicates not only good indications for VATS but a bias toward the patients who would undergo VATS. To rule out any bias that may be associated with this study, further studies should be prospectively performed. Pulmonary aspergilloma lesions that require a pneumonectomy still remain a major challenge for VATS. Although the authors note that aspergilloma lesions with infiltration of the hilum require a pneumonectomy, no explanation was made with regard to the conditions of 3 patients for pneumonectomy. In addition, in a case that underwent a simple pneumonectomy, which is sometimes not a sufficient surgical modality to cure aspergilloma, extrapleural pneumonectomy is necessary. We wonder if a patient with extrapleural pneumonectomy was included in the patients with pneumonectomy and if the authors could explain the propriety to use the propensity score which made a control group. In conclusion, the most important point of the present study is that VATS is safe and effective for the treatment of pulmonary aspergilloma in selected patients, and the VATS procedure may therefore be a useful surgical modality for the treatment of patients with pulmonary aspergilloma who meet the above-mentioned criteria. Video-Assisted Thoracic Surgery for Pulmonary Aspergilloma: A Safe and Effective ProcedureThe Annals of Thoracic SurgeryVol. 97Issue 1PreviewA variety of complications occur in patients with pulmonary aspergilloma. The safety and feasibility of a thoracoscopic approach to therapeutic lung resection for pulmonary aspergilloma have not been well evaluated. Full-Text PDF

Sun's procedure of total arch replacement using a tetrafurcated graft with stented elephant trunk implantation: analysis of early outcome in 398 patients with acute type A aortic dissection.

Acute type A aortic dissection (AAAD) remains one of the most lethal conditions requiring surgical repair, and is associated with a high rate of postoperative mortality and morbidity. Despite the satisfactory clinical outcomes achieved with the frozen elephant trunk technique so far, controversies still exist regarding the use of this aggressive approach in patients with AAAD. In this study, we seek to analyze the early outcomes of the Sun's procedure, which is an approach integrating total arch replacement using a 4-branched graft with implantation of a special stented graft in the descending aorta, and identify the risk factors for postoperative mortality and morbidity of the Sun's procedure in patients with AAAD. Clinical data of 398 consecutive AAAD patients undergoing the Sun's procedure were analyzed. The associations between 20 preoperative and intraoperative variables and early mortality were assessed by univariate and multivariate analysis. Early mortality occurred in 31 patients (7.8%, 31/398), with leading causes including multi-organ failure in 16 patients (51.6%), permanent neurologic deficit in 6 (19.4%), and low cardiac output syndrome in 4 (12.9%). Permanent neurologic deficit and spinal cord injury occurred, each in 10 patients (2.5%, 10/398). Five significant risk factors for early mortality were identified with multivariate analysis: preexisting cerebrovascular disease [relative risk (RR) 14.76; P<0.001], acute heart failure (RR 18.18; P=0.001), spinal cord malperfusion (RR 60.13; P<0.002), visceral malperfusion (RR 30.25; P<0.001) and cardiopulmonary bypass time >190 minutes (RR 3.62; P=0.007). The Sun's procedure has generated a relatively lower mortality rate in 398 patients with AAAD. Patients with preexisting cerebrovascular disease, acute heart failure, spinal cord malperfusion, visceral malperfusion and long cardiopulmonary bypass time are at a higher risk of early mortality.

Effects of biliary drainage on the intestinal barrier function in obstructive jaundice.

Despite advances in preoperative evaluation and postoperative care, intervention, especially surgery, for relief of obstructive jaundice still carries high morbidity and mortality rates. In obstructive jaundice, intestinal barrier dysfunction has been postulated to be a key factor contributing to high postoperative morbidity and mortality rates. Since surgery in patients with jaundice is thought to increase the risk of postoperative complications, preoperative biliary drainage (PBD) was introduced to improve the postoperative outcome. To date, whether biliary drainage should be routinely performed in patients with jaundice undergoing a pancreatoduodenectomy remains controversial, and the effect of biliary drainage on the intestinal barrier function in obstructive jaundice remains unknown. Biliary drainage is almost exclusively associated with beneficial results, such as improved intestinal barrier function in experimental models. However, clinical data in this field are limited, indirect and remain controversial. Most importantly, routine PBD will result in a highly procedure-related complication rate and an increase in operative infectious complications. PBD should not be performed routinely, unless further improved PBD techniques would become available in clinical studies. Future studies should focus on PBD techniques, and then on the effects of biliary drainage on intestinal mucosa in obstructive jaundice in clinical.

Non‐transplantation surgical approach for chronic intestinal pseudo‐obstruction: analysis of 63 adult consecutive cases

Chronic intestinal pseudo-obstruction (CIPO) is a recurrent disorder caused by intestinal dysmotility. Although, CIPO is not a surgically remediable condition, surgery is a common issue in CIPO patients. The aim of this study was to assess postoperative morbidity and mortality of patients operated on for CIPO and risk of re-operation. Adult patients that have undergone surgery for CIPO since 1980 were included in this retrospective study using a prospective database. Postoperative morbidity, according to Clavien-Dindo classification and CIPO-related re-operation rates were evaluated with univariate and multivariate analysis. Sixty-three patients (33 women, median age 37 [range: 15-79] years) were included. Median follow-up was 6 (0.2-28) years. Overall postoperative mortality rate was 7.9%. Overall morbidity rate was 58.2% (Clavien-Dindo ≥3 in 20.7%) leading to re-operation in 17% of cases. In multivariate analysis, major postoperative morbidity (Clavien-Dindo ≥3) was significantly increased when there was an intraoperative bowel injury (HR=15.7 [2.4-102], P=0.004), idiopathic CIPO (HR=4.2 [1.5-12], P=0.007) and emergency procedure (HR=3 [1.3-6.8]. After the first surgery, probabilities of CIPO-related re-operation were 44%, 60%, and 66% at 1, 3, and 5years respectively. In multivariate analysis, CIPO-related reoperation for CIPO was significantly increased when there was a major postoperative morbidity (HR=2.1 [1.1-4.4], P=0.040) and intraoperative bowel injury (HR=33.1 [2-553], P=0.015) after the first procedure. The surgical management of CIPO patients was associated with high postoperative morbidity and mortality rates and frequent re-operation. Attempts should be made to avoid surgery when possible and optimize nutritional status.

Systematic review of central pancreatectomy and meta-analysis of centralversusdistal pancreatectomy

Central pancreatectomy (CP) is a parenchyma-sparing surgical procedure that enables the removal of benign and/or low-grade malignant lesions from the neck and proximal body of the pancreas. The aim of this review was to evaluate the short- and long-term surgical results of CP from all published studies, and the results of comparative studies of CP versus distal pancreatectomy (DP). Eligible studies published between 1988 and 2010 were reviewed systematically. Comparisons between CP and DP were pooled and analysed by meta-analytical techniques using random- or fixed-effects models, as appropriate. Ninety-four studies, involving 963 patients undergoing CP, were identified. Postoperative morbidity and pancreatic fistula rates were 45·3 and 40·9 per cent respectively. Endocrine and exocrine pancreatic insufficiency was reported in 5·0 and 9·9 per cent of patients. The overall mortality rate was 0·8 per cent. Compared with DP, CP had a higher postoperative morbidity rate and a higher incidence of pancreatic fistula, but a lower risk of endocrine insufficiency (relative risk (RR) 0·22, 95 per cent confidence interval 0·14 to 0·35; P < 0·001). The risk of exocrine failure was also lower after CP, although this was not significant (RR 0·59, 0·32 to 1·07; P = 0·082). CP is a safe procedure with good long-term functional reserve. In situations where DP represents an alternative, CP is associated with a slightly higher risk of early complications.

Interposition of the hernia sac as a protective layer in repair of giant incisional hernia with polypropylene mesh

Repair of giant incisional hernia is still associated with high postoperative morbidity and recurrence rates. We evaluated the effectiveness of placing the hernia sac between the viscera and the polypropylene mesh in the repair. The subjects of this study were patients with an incisional hernia at least 15 cm in diameter, diagnosed between June 2004 and October 2010 and treated with on-lay polypropylene mesh at least 25 cm in length. We operated using a simplified method of placing the hernia sac between the viscera and the mesh, and fixing the mesh with interrupted trans-fascial U sutures. We evaluated the patient demographics and postoperative complications retrospectively. A total of 25 patients (mean age 57.1 ± 10 years) were included. The mean length of hospital stay was 1.8 ± 1.2 days. Seroma developed in four patients (16 %), but only two with cystic seroma required excision of the cyst wall with preservation of the mesh. Twenty-two patients (88 %) were followed up for a mean period of 42.6 ± 23 months. There was no incidence of chronic pain, hospitalization for intestinal obstruction, or enterocutaneous fistulization. There was only one recurrence (4.55 %). The hernia sac can be interposed in all patients undergoing giant incisional hernia repair if direct contact between the polypropylene mesh and intestine is unavoidable.

Management of post-hepatectomy complications

Hepatic resection had an impressive growth over time. It has been widely performed for the treatment of various liver diseases, such as malignant tumors, benign tumors, calculi in the intrahepatic ducts, hydatid disease, and abscesses. Management of hepatic resection is challenging. Despite technical advances and high experience of liver resection of specialized centers, it is still burdened by relatively high rates of postoperative morbidity and mortality. Especially, complex resections are being increasingly performed in high risk and older patient population. Operation on the liver is especially challenging because of its unique anatomic architecture and because of its vital functions. Common post-hepatectomy complications include venous catheter-related infection, pleural effusion, incisional infection, pulmonary atelectasis or infection, ascites, subphrenic infection, urinary tract infection, intraperitoneal hemorrhage, gastrointestinal tract bleeding, biliary tract hemorrhage, coagulation disorders, bile leakage, and liver failure. These problems are closely related to surgical manipulations, anesthesia, preoperative evaluation and preparation, and postoperative observation and management. The safety profile of hepatectomy probably can be improved if the surgeons and medical staff involved have comprehensive knowledge of the expected complications and expertise in their management. This review article focuses on the major postoperative issues after hepatic resection and presents the current management.