High Postoperative Morbidity Rates Research Articles

Clinical outcomes in patients undergoing microlumbar discectomy for lumbar disc herniation

Introduction: Lumbar microdiscectomy has been associated with high rates of success and low postoperative morbidity. We aimed to evaluate the clinical outcome of patients undergoing lumbar microdisectomy for disc herniations. Methodology: The study was performed in the Department of Orthopedics, Lokmanya Hospital Chinchwad and Lokmanya Hospital Nigdi, Pune from August 2002 till May 2004 on all patients scheduled for microlumbar discectomy for lumbar disc herniation. Intra-operatively, type and level of prolapse and operative time was noted. We also noted the length of hospital stay and any complications experienced by the patient. For assessing the patients, instruments like Visual Analog Scale (VAS) for pain at the end of first week and return to normal activity of daily living (ADL) and satisfaction with the result of surgery at the end of six months were used. Results: All surgeries were single level microdiscectomy. Operative time on the average was 85 minutes and 83% of the patients had a stay of less than 5 days in the hospital. Disc sequestration and disc exclusion were the most commonly seen types of prolapse. Pre-operatively five patients had a back pain VAS of more than 4 and four patients had a leg pain VAS of more than 4. On assessing the outcome in patients in terms of returning to activities of daily living and satisfaction with surgery only four and five patients had a score more than two respectively. Conclusions: Proper preoperative planning and correct surgical technique can prevent complications in these cases. Future multicentric studies with larger sample size and longer follow up periods are needed to support our findings.

Perioperative changes in exhaled nitric oxide during oesophagectomy

Introduction: Oesophagectomy is a major surgical procedure, associated with high rates of postoperative cardiopulmonary morbidity, that is in part due to the frequent requirement for periods of intraoperative one-lung ventilation (OLV). The current pilot study aims to investigate variation in exhaled NO levels during oesophagectomy with emphasis on the response to OLV and correlation to physiological variables and clinical outcomes. Methods: Breath-to-breath concentrations of NO were analysed in patients undergoing oesophagectomy at various stages of two-lung ventilation. Furthermore, we also analysed the effects of OLV both in the selectively ventilated and collapsed lungs. Results: Twenty-four patients were recruited to the study (17 male, 60.2 ± 12.8 years). Regarding two-lung ventilation, the baseline levels of NO (2.9 ppb), tended to increase after re-inflation of the collapsed lung (3.5 ppb, P = 0. 888) and decreased at 2 h (2.1 ppb, P = 0.022) and 12 h (2.2 ppb, P = 0.733) postoperatively. Compared to baseline, selective measurements of NO at the end of OLV demonstrated a significant reduction of NO levels in the ventilated lung (1.6 versus 3.1 ppb, P = 0.028), whereas re-inflation of the collapsed lung revealed higher levels of NO (3.4 versus 2.7 ppb, P = 0.657). Exhaled NO correlated significantly with systolic blood pressure and lactate (P < 0.007). Exhaled NO levels tended to be higher at all perioperative time points in patients who developed postoperative respiratory complications (P > 0.05). Conclusion: This study highlights effects of oesophagectomy and OLV on exhaled concentrations of NO. The observed variations may be related to differential ventilation during OLV altering the complex balance between synthesis and consumption of NO as well as local and generalised tissue injury associated with this surgery. Findings should prompt further larger studies to establish the relationship between exhaled NO and lung injury both during and after oesophagectomy and one-lung ventilation.

Perioperative risk

The high-risk surgical patient is a growing challenge to modern health care. This cohort, although comprising only 10-15% of surgical procedures, accounts for approximately 80% of postoperative deaths and suffers a high rate of postoperative morbidity. Developing robust systems to help identify and better manage this patient group should be a priority. Risk stratification has become a valuable clinical tool for shared decision-making and the development of individualized care plans. Methods for stratifying individual risk include assessment tools, measures of functional capacity and plasma biomarker assays. Routine evaluation of perioperative risk is central to the delivery of high quality, appropriate surgical care.

MTE 03.01 Do Extended Resections Improve T4 Lung Cancer Outcomes?

MTE 03.01 Do Extended Resections Improve T4 Lung Cancer Outcomes?

Safety and effectiveness of day-surgery laparoscopic cholecystectomy is still uncertain: meta-analysis of eight randomized controlled trials based on GRADE approach.

Currently, there is no consensus on whether laparoscopic cholecystectomy (LC) performed as day-surgery is safe and effective and can be considered as the standard for the management of symptomatic gallbladder disease. We conducted a meta-analysis of randomized controlled trials (RCTs) to evaluate the safety and effectiveness of this intervention based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. We conducted a systematic search of several databases from their inception to November 10, 2016 for entries on the mortality, morbidity after discharge, readmission, postoperative morbidity, and patient satisfaction at 1week of day-surgery LC. Pooled risk ratio (RR) with 95% confidence intervals (CI) was calculated using the fixed-effects model. Rare outcomes were presented as the Peto odds ratio (Peto OR). Meta-analysis was performed by using the RevMan 5.1 software, and the level of evidence was assessed by using the GRADE guideline and GRADEpro GDT software. Eight RCTs totaling 624 participants were included. The result showed no intergroup difference in short-term mortality. Compared to overnight-stay surgery, day-surgery did not show any clear evidence of reduced morbidity after discharge (Peto OR 0.89; 95% CI 0.39-2.02), lower readmission rate (Peto OR 0.68; 95% CI 0.23-2.05), or higher postoperative morbidity rates (RR 1.28; 95% CI 0.81-2.02). However, the results suggested that day-surgery may improve patient satisfaction at 1week (RR 1.17; 95% CI 1.03-1.33). Evaluation by the GRADE approach revealed that the quality of evidence for each outcome was of low to very low quality due to the risk of bias, imprecision, and inconsistency. Our meta-analysis shows that the safety and effectiveness of day-surgery LC is still uncertain. Additional well-designed and adequately powered RCTs are required before the procedure can be recommended as the standard for clinical practice.

Robotic-assisted radical cystectomy versus open radical cystectomy for management of bladder cancer: review of literature and randomized trials.

Among the many milestones in the last several decades in the management of muscle-invasive bladder cancer and high-risk nonmuscle-invasive bladder cancer including the extension of the standard lymph node dissection and the use of neoadjuvant chemotherapy, minimally invasive techniques have gained traction as an attractive option for radical cystectomy. Open radical cystectomy is plagued with high rates of perioperative and postoperative morbidity and mortality, and as robotic assistance has demonstrated benefits in other arenas of surgery and urology, the evolution of the approach to radical cystectomy has likewise incorporated robotic assistance. We thus sought to critically review the literature comparing open radical cystectomy with robotic-assisted radical cystectomy. Perioperative and oncologic outcomes as well as cost analyses and health-related quality of life were compared between the two approaches, and identified manuscripts were categorized according to level of evidence.

The Association of Frailty With Outcomes and Resource Use After Emergency General Surgery: A Population-Based Cohort Study.

Older patients undergoing emergency general surgery (EGS) experience high rates of postoperative morbidity and mortality. Studies focused primarily on elective surgery indicate that frailty is an important predictor of adverse outcomes in older surgical patients. The population-level effect of frailty on EGS is poorly described. Therefore, our objective was to measure the association of preoperative frailty with outcomes in a population of older patients undergoing EGS. We created a population-based cohort study using linked administrative data in Ontario, Canada, that included community-dwelling individuals aged >65 years having EGS. Our main exposure was preoperative frailty, as defined by the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator. The Adjusted Clinical Groups frailty-defining diagnoses indicator is a binary variable that uses 12 clusters of frailty-defining diagnoses. Our main outcome measures were 1-year all-cause mortality (primary), intensive care unit admission, length of stay, institutional discharge, and costs of care (secondary). Of 77,184 patients, 19,779 (25.6%) were frail. Death within 1 year occurred in 6626 (33.5%) frail patients compared with 11,366 (19.8%) nonfrail patients. After adjustment for sociodemographic and surgical confounders, this resulted in a hazard ratio of 1.29 (95% confidence interval [CI] 1.25-1.33). The risk of death for frail patients varied significantly across the postoperative period and was particularly high immediately after surgery (hazard ratio on postoperative day 1 = 23.1, 95% CI 22.3-24.1). Frailty was adversely associated with all secondary outcomes, including a 5.82-fold increase in the adjusted odds of institutional discharge (95% CI 5.53-6.12). After EGS, frailty is associated with increased rates of mortality, institutional discharge, and resource use. Strategies that might improve perioperative outcomes in frail EGS patients need to be developed and tested.

Hospital-Acquired Conditions in Adult Spinal Deformity Surgery: Predictors for Hospital-Acquired Conditions and Other 30-Day Postoperative Outcomes.

A retrospective study of prospectively collected data. The aim of this study was to identify risk factors in developing hospital-acquired conditions (HACs) and association of HACs with other 30-day complications in the adult spinal deformity (ASD) population. HACs are subject to a nonpayment policy by the Center for Medicare and Medicaid Services and provide an incentive for medical institutions to improve patient safety. HACs in the ASD population may further exacerbate the already high rates of postoperative morbidity and mortality. The 2010 to 2014 ACS-NSQIP database was queried using Current Procedural Terminology (CPT) codes for adults who had fusion for spinal deformity. Patients were divided into two cohorts on the basis of the development of an HAC, as defined as a case of surgical site infection, urinary tract infection, or venous thromboembolism. Univariate and multivariate logistic regression analyses were employed to determine predictors for HACs and association of HACs with other 30-day postoperative outcomes. Five thousand eight hundred nineteen patients met the inclusion criteria for the study of whom 313 (5.4%) had an HAC. Multivariate logistic regression analysis revealed that age 61 to 70 versus ≤50 years [odds ratio (OR) = 1.58, 1.10-2.27, P = 0.013], 71 to 80 versus ≤50 years (OR = 1.94, 1.31-2.87, P = 0.001), and >80 versus ≤50 years (OR = 2.30, 1.21-4.37, P = 0.011), dependent/partially dependent versus independent functional status (OR = 1.74, 1.13-2.68, P = 0.011), combined versus anterior surgical approach (OR = 2.46, 1.43-4.24, P = 0.001), and posterior versus anterior surgical approach (OR = 1.64, 1.19-2.25, P = 0.002), osteotomies (OR = 1.61, 1.22-2.13, P = 0.001), steroid use (OR = 2.19, 1.39-3.45, P = 0.001), obesity (OR = 1.38, 1.09-1.74, P = 0.007), and operation time ≥4 hours (OR = 2.42, 1.82-3.21, P < 0.001) were predictive factors in developing an HAC. Several modifiable and nonmodifiable factors (age, functional status, surgical approach, utilization of osteotomies, steroid use, obesity, and operation time ≥4 hours) were associated with developing an HAC. HACs were also risk factors for other postoperative complications. 3.

Acute and chronic kidney disease in elderly patients with hip fracture: prevalence, risk factors and outcome with development and validation of a risk prediction model for acute kidney injury

BackgroundHip fracture is a common injury in older people with a high rate of postoperative morbidity and mortality. This patient group is also at high risk of acute kidney injury (AKI) and chronic kidney disease (CKD), but little is known of the impact of kidney disease on outcome following hip fracture.MethodsAn observational cohort of consecutive patients with hip fracture in a large UK secondary care hospital. Predictive modelling of outcomes using development and validation datasets. Inclusion: all patients admitted with hip fracture with sufficient serum creatinine measurements to define acute kidney injury. Main outcome measures – development of acute kidney injury during admission; mortality (in hospital, 30-365 day and to follow-up); length of hospital stay.ResultsData were available for 2848 / 2959 consecutive admissions from 2007-2011; 776 (27.2%) male. Acute kidney injury occurs in 24%; development of acute kidney injury is independently associated with male sex (OR 1.48 (1.21 to 1.80), premorbid chronic kidney disease stage 3B or worse (OR 1.52 (1.19 to 1.93)), age (OR 3.4 (2.29 to 5.2) for >85 years) and greater than one major co-morbidities (OR 1.61 (1.34 to 1.93)). Acute kidney injury of any stage is associated with an increased hazard of death, and increased length of stay (Acute kidney injury: 19.1 (IQR 13 to 31) days; no acute kidney injury 15 (11 to 23) days). A simplified predictive model containing Age, CKD stage (3B-5), two or more comorbidities, and male sex had an area under the ROC curve of 0.63 (0.60 to 0.67).ConclusionsAcute kidney injury following hip fracture is common and associated with worse outcome and greater hospital length of stay. With the number of people experiencing hip fracture predicted to rise, recognition of risk factors and optimal perioperative management of acute kidney injury will become even more important.

Is complete mesocolic excision oncologically superior to conventional surgery for colon cancer? A retrospective comparative study.

Background:During the last decade, many efforts have been made in order to improve the oncologic outcomes following colonic resection. Complete mesocolic excision (CME) has proved to provide high rates of disease-free and overall survival rates in patients undergoing resection for colonic malignancies. The aim of our study was to further investigate the role of CME in colonic surgery through comparison with a series of conventional resections.Methods:All data regarding resections for colonic cancer since 2006 were obtained prospectively from two surgical departments. Retrieved data from 290 patients were analyzed and compared between those who underwent CME and those who had conventional surgery.Results:The CME group presented a higher rate of postoperative morbidity and readmissions. Histopathological features were in favor of CME surgery compared with the conventional group, in terms of both resected bowel length (33 vs. 20 cm) and lymph node harvest (27 vs. 18). Although CME was associated with better disease-free and overall survival times, only tumor differentiation, adjuvant chemotherapy and age had a statistically significant affect on those outcome values (P<0.05).Conclusion:CME improves histopathologic features, but without presenting oncologic superiority. Larger prospective studies following adequate surgical training are needed to prove the technique’s advantages in oncologic outcomes.

Laparoscopic gastric bypass versus laparoscopic sleeve gastrectomy: A retrospective multicenter comparison between early and long-term post-operative outcomes

BackgroundLaparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are the most commonly performed procedures for morbid obesity. MethodsWe performed a retrospective review of patients undergoing LRYGB or LSG between August 2000 and November 2014. ResultsData from 581 (280 LSG and 301 LRYGB) were gathered. Operating time (77.6 vs 250.5 min; p < 0.001), post-operative complication rate (3.9% vs 11.6%; p < 0.001), overall occlusions (p = 0.004), need for re-intervention (p < 0.001), hospital stay (5.7 vs 9.2 days; p < 0.001) and mean 1-year EWL (49% vs 61%; p = 0.001) resulted statistically significant lower in LSGs compared with LRYGBs.Not statistically significant differences were found about leakage, bleeding requiring transfusion, infections, short-term mortality and mean 2- and 3-years EWL. Upon univariate analysis, basal weight, basal BMI, age and gender were not associated with the rate of re-intervention and with the combination of re-intervention or death. ConclusionsLRYGB resulted associated with higher post-operative morbidity rate and increased 1-year EWL than LSG. Prospective studies are needed to assess the impact of these two surgical procedures on the long-term weigh loss.

Preoperative 6-minute walk distance accurately predicts postoperative complications after operations for hepato-pancreato-biliary cancer

Operation for hepato-pancreato-biliary cancer is among the most invasive open abdominal operations, with a high postoperative morbidity and mortality rate. The purpose of the present study is to investigate whether a preoperative 6-minute walk distance can predict major postoperative complications after operation for hepato-pancreato-biliary diseases. A total of 81 participants who underwent pancreaticoduodenectomy, major hepatectomy with extrahepatic bile duct resection, or hepatopancreatoduodenectomy were included. The 6-minute walk distance was performed within 1week before operation. Patients were categorized into 2 groups based on surgical complications: Clavien-Dindo grade <3 and Clavien-Dindo grade ≥3. Clinical differences between the 2 groups were analyzed. Multivariate logistic regression analysis was performed to identify risk factors for postoperative complications that were categorized as Clavien-Dindo grade ≥3. The multiple logistic regression model revealed a significant correlation between major postoperative complications and preoperative low 6-minute walk distance, low body mass index, and major blood loss. In patients with 6-minute walk distance <400m (1,312 feet), the Clavien-Dindo grade was considerably greater than patients with ≥400m. The 6-minute walk distance is useful in identifying patients with a greater chance of developing major postoperative complications after surgery for hepato-pancreato-biliary cancer.

Extramammary Paget disease of the perianal region: the potential role of imiquimod in achieving disease control

Extramammary Paget disease (EMPD) is a rare perineal neoplasia associated with a high rate of local recurrence. Surgical excision is the standard treatment; however, this has high rates of post-operative morbidity in combination with potentially mutilating results. Previous literature has demonstrated good response with imiquimod 5% cream in patients with vulval EMPD, yet its effectiveness in primary perianal disease is unknown.We describe the case of a 40-year-old woman presenting with EMPD of the perianal region, providing detailed histological and pictoral evidence of its response to topical imiquimod 5% cream over a 16-week period, which initially resulted in remission prior to metastatic lymph node recurrence. This case demonstrates the potential for topical imiquimod cream to avoid major surgery and its associated complications in patients presenting with EMPD of the perianal region. We discuss the current evidence for treating this rare condition with medical therapy, how this case adds to current literature and possible future directions.

The Risk Factors for Refractory Fistula after Esophagectomy with Gastric Tube Reconstruction in Patients with Esophageal Cancer

Background/Aims: Anastomotic leakage (AL) after esophagectomy is associated with high rates of postoperative morbidity and mortality. In cases with leakage, a refractory fistula (RF) is sometimes recognized after esophagectomy. The aim of this study was to evaluate the risk factors for RF after esophagectomy with gastric tube reconstruction. Methods: This study enrolled 244 consecutive esophageal cancer patients who had undergone esophagectomy with gastric tube reconstruction. RF was defined as a noncurative anastomotic site-cutaneous fistula that had been present for more than 2 months. We evaluated the risk factors for RF. Results: AL occurred in 30 patients (12.3%). There was one mortality case (0.4%) due to mediastinitis caused by AL in the present series. A multivariate analysis revealed that the subcutaneous route was an independent risk factor for AL (OR 4.42, 95% CI 1.42-13.8, p = 0.01), and that the subcutaneous route was an independent risk factor for RF (OR 13.30, 95% CI 2.50-71.30, p = 0.0024). Conclusion: The results of this retrospective study suggest that subcutaneous route was associated with an increased risk of RF after esophagectomy with gastric tube reconstruction. The preoperative identification of risk factors may contribute to the prevention of postoperative AL and RF.

Postoperative Interleukin-6 Level and Early Detection of Complications After Elective Major Abdominal Surgery.

To assess the association of systemic inflammation and outcome after major abdominal surgery. Major abdominal surgery carries a high postoperative morbidity and mortality rate. Studies suggest that inflammation is associated with unfavorable outcome. Levels of C-reactive protein (CRP), interleukin-6 (IL-6), and tumor necrosis factor-α and the systemic inflammatory response syndrome (SIRS) were assessed in 137 patients undergoing major abdominal surgery. Blood samples were drawn on days 0, 1, 3, and 7, and SIRS was scored during 48 hours after surgery. Primary outcome was a composite of mortality, pneumonia, sepsis, anastomotic dehiscence, wound infection, noncardiac respiratory failure, atrial fibrillation, congestive heart failure, myocardial infarction, and reoperation within 30 days of surgery. An IL-6 level more than 432 pg/mL on day 1 was associated with an increased risk of complications (adjusted odds ratio: 3.3; 95% confidence interval [CI]: 1.3-8.5) and a longer median length of hospital stay (7 vs 12 days, P < 0.001). As a single test, an IL-6 cut-off level of 432 pg/mL on day 1 yielded a specificity of 70% and a sensitivity of 64% for the prediction of complications (area under the curve: 0.67; 95% CI: 0.56-0.77). Levels of CRP started to discriminate from day 3 onward with a specificity of 87% and a sensitivity of 58% for a cut-off level of 203 mg/L (AUC: 0.73; 95% CI: 0.63-0.83). A high IL-6 level on day 1 is associated with postoperative complications. Levels of IL-6 help distinguish between patients at low and high risk for complications before changes in levels of CRP.

Pancreaticoduodenectomy for adenocarcinoma of the pancreatic head is justified in elderly patients: A Retrospective Cohort Study

BackgroundThe increasing elderly population is an inevitable trend worldwide in developed countries. Therefore, we aimed to assess the experience of a tertiary pancreatic center with a very homogenous population comprising only patients diagnosed with PDAC of the pancreatic head in patients older than 75 years of age compared to their younger counterparts regarding the benefit in life expectancy and tumor biological aggressiveness. Methods300 patients underwent partial pancreaticoduodenectomy (PD) or pylorus preserving pancreaticoduodenectomy (PPPD) for PDAC of the pancreatic head between 2002 and 2012 and were evaluated with regard to their co-morbidities, clinicopathological and perioperative variables, postoperative morbidity, mortality and long term survival. Therefore, two groups according to the age at the procedure (A: <75 years, n = 241, B: ≥75 years, n = 59) were designed. ResultsThere were no differences between groups with regard to gender, performed procedure (PPPD or PD), operation time, blood loss, tumor invasiveness and grade of tumor differentiation, R-status, lymph node ratio, 30-day mortality, length of stay and adjuvant chemotherapy. Extended resections including total pancreatectomy were slightly more often performed in younger patients (p = 0.071) and trended toward a higher rate of surgical complications in patients <75 years of age (p = 0.183). A higher rate of preoperative co-morbidities in elderly patients (group B), was associated with more postoperative non-surgical complications (p = 0.002) in this group of patients. However, the median overall survival (19.2 vs. 18.4 months) did not differ significantly between groups. ConclusionsMajor pancreatic surgery for ductal adenocarcinoma of the pancreatic head is justified in elderly patients. With careful patients' selection and prudent perioperative management, elderly patients will have a similar long term outcome despite the higher rate of postoperative morbidity based on non-surgical complications.

Hyperlactatemia in patients undergoing adult cardiac surgery under cardiopulmonary bypass: Causative factors and its effect on surgical outcome.

Objectives of the Study:To identify the factors causing high lactate levels in patients undergoing cardiac surgery under cardiopulmonary bypass (CPB) and to assess the association between high blood lactate levels and postoperative morbidity and mortality.Methods:A retrospective observational study including 370 patients who underwent cardiac surgeries under cardiopulmonary bypass. The patients were divided into 2 groups based on serum lactate levels; those with serum lactate levels greater than or equal to 4 mmol/L considered as hyperlactatemia and those with serum lactate levels less than 4 mmol/L. Blood lactate samples were collected intraoperatively and postoperatively in the ICU. Preoperative and intraoperative risk factors for hyperlactatemia were identified using the highest intraoperative value of lactate. The postoperative morbidity and mortality associated with hyperlactatemia was studied using the overall (intraoperative and postoperative values) peak lactate levels. Preoperative clinical data, perioperative events and postoperative morbidity and mortality were recorded.Results:Intraoperative peak blood lactate levels of 4.0 mmol/L or more were present in 158 patients (42.7%). Females had higher peak intra operative lactate levels (P = 0.011). There was significant correlation between CPB time (Pearson correlation coefficient r = 0.024; P = 0.003) and aortic cross clamp time (r = 0.02, P = 0.007) with peak intraoperative blood lactate levels. Patients with hyperlactatemia had significantly higher rate of postoperative morbidity like atrial fibrillation (19.9% vs. 5.3%; P = 0.004), prolonged requirement of inotropes (34% vs. 11.8%; P = 0.001), longer stay in the ICU (P = 0.013) and hospital (P = 0.001).Conclusions:Hyperlactatemia had significant association with post-operative morbidity. Detection of hyperlactatemia in the perioperative period should be considered as an indicator of inadequate tissue oxygen delivery and must be aggressively corrected.

The Influence of Patient-related Constutional and Environmental Factors on Early Results of a Combined Modality Therapy of Esophageal Cancer.

We retrospectively analyzed prospectively collected data of 84 patients with esophageal cancer randomly assigned to a combined modality treatment. We evaluated the relationship between early outcome of neoadjuvant therapy (overall toxic events, serious toxic events, treatment-related mortality, clinical and pathological response to the treatment) or surgical treatment (postoperative morbidity, mortality and curative resections - R0) and constitutional (age, gender, height, body mass index, Karnofski Performance Status - KPS, blood type) or environmental (inhabitation, smoking duration and intensity, frequency and amount of alcohol consumption and occupational exposure) patient-related factors. Significantly more neoadjuvant therapy related deaths were found in patients with KPS 70-80 (p=0.0016). Interestingly, significantly more toxic events (p=0.0034) after neoadjuvant therapy and a higher postoperative morbidity rate (p=0.0293) were observed in nonsmokers. Similarly, significantly more toxic events (p=0.0029) after neoadjuvant therapy and a higher postoperative mortality rate (p=0.0405) were found in light drinkers. Smoking and consumption of excessive amount of alcohol may attenuate toxic effect of neoadiuvant and surgical therapy in patients treated due to esophageal cancer. The information regarding the mentioned above addictions should not result in giving up an attempt to provide a curative treatment.

Improvement of digestive complaints in women with severe colorectal endometriosis benefiting from continuous amenorrhoea triggered by triptorelin. A prospective pilot study

ObjectiveTo assess the impact of therapeutic amenorrhoea triggered by triptorelin in the digestive complaints of women with deep endometriosis infiltrating the rectum. DesignProspective series of consecutive patients with deep endometriosis of the rectum enrolled over a period of 17 consecutive months. SettingUniversity tertiary referral center. PatientsSeventy patients. InterventionsMedical therapy (triptorelin 11.25 mg and add-back therapy using estradiol) administered for 3.4±1.8months before surgery. Main outcome measuresGastrointestinal standardised questionnaires before beginning medical treatment and the day before surgery. ResultsThe most frequent digestive complaints at baseline were: defecation pain in 77.1% of patients, bloating in 60%, diarrhoea in 54.3% and constipation in 50%. The largest diameter of the rectal area infiltrated by the disease was <1cm in 12.2% of women, 1 to 2.9 cm in 34.3% and ≥3cm in 51.4%. Multiple colorectal nodules were found in 32.9%. Medical treatment led to disappearance of cyclic defecation pain in 78.6%, dyschesia in 58.3%, diarrhoea in 58.3% and bloating in 50%. Relieving digestive complaints was not significantly related to either length of triptorelin administration or size of rectal infiltration by deep endometriosis. ConclusionTherapeutic amenorrhoea averaging 3 months allowed complete improvement of various cyclic digestive complaints in more than half of patients. In selected patients, continuous therapeutic amenorrhoea could compensate for the lack of complete resection of deep infiltrating endometriosis of the rectum, when this latter is likely to result in a high rate of postoperative morbidity.

Major liver resection as definitive treatment in post-cholecystectomy common bile duct injuries.

Common bile duct injuries (CBDI) are serious complications of cholecystectomies which are often associated with vascular involvement, meaning that their management represents a major challenge to the physician. We present our experience in major hepatectomy due to CBDI, highlighting indications, postoperative complications, and long-term outcomes. From August 1993 to September 2013, 287 patients with CBDI were treated in our centre. In 15 patients of this group (5 %), a major hepatectomy was performed. Eleven patients presented E4 and four presented E5 injuries of Strasberg classification. Seven patients presented vascular involvement. In 12 patients, prior treatment attempts, either biliodigestive anastomosis, endoscopic or percutaneous drainage, was performed without success. The median time delay between lesional surgery and hepatectomy was 24 months. Right hepatectomy was performed in 10 patients and left hepatectomy in 5. Postoperative morbidity was 60 %. The incidence of serious complications (≥ grade IIIa of DC classification) was 40 %. There was no mortality in our study. The mean follow-up was 43.5 months and the overall survival was 100 %. Three patients had a single episode of ascendant cholangitis who were successfully treated with medical treatment. All other patients were asymptomatic during follow-up. No patients required further surgical procedures. In our series, major hepatectomy due to CBDI was a successful treatment with high rates of postoperative morbidity and excellent long-term outcomes which require a multidisciplinary approach in referral centres of HPB surgery.