Incidence Of Postoperative Leakage Research Articles

The Use of Synthetic, Nonabsorbable Graft for Middle Fossa Repair in Patients With Spontaneous Cerebrospinal Fluid Leak: A Pilot, Prospective Study.

To evaluate the efficacy of a nonabsorbable, synthetic graft for the reconstruction of spontaneous middle fossa (sMF) cerebrospinal fluid (CSF) leaks. Six adult patients (age ≥16 yr) who had sMF CSF leaks surgically repaired within an 18-month period at a single university hospital using synthetic, nonbiological, nonabsorbable graft (Neuro-Patch) and a retrospective control group of five patients undergoing multilayer MF repair with autologous grafts. MF repair through a combined transmastoid/MF approach using Neuro-Patch or multilayer autologous grafts. The incidence of postoperative leak within 6 months postoperatively was the main outcome measure; we also recorded the need for lumbar drain, additional hearing loss, length of inpatient stay, body mass index, previous meningitis, preoperative increased intracranial pressure, and age. In the Neuro-Patch group, there was no postoperative CSF leak without the need for lumbar drain. We observed no additional hearing loss; patients were monitored for 2 days without any readmissions. Increased intracranial pressure (four of six), previous episodes of meningitis (two of six) or obesity (five of six) did not affect patient outcomes. Demographic and prognostic factors were the same for the control group. However, one patient needed lumbar drain postoperatively because of residual leak; lumbar drain was used in one more case (two of five cases), whereas three of five patients had to stay for longer than 2 days (5 d). Our pilot study suggests the use of Neuro-Patch via combined transmastoid/MF approach as an effective technique with minimum, if any morbidity; it could be of particular benefit for patients with larger MF dura defects. A larger number of patients are required to strengthen the evidence.

Time from Injury to Initial Operation May Be the Sole Risk Factor for Postoperative Leakage in AAST-OIS 2 and 3 Traumatic Duodenal Injury: A Retrospective Cohort Study.

Background and Objectives: Traumatic duodenal injury is a rare disease with limited evidence. We aimed to evaluate the risk factors for postoperative leakage and outcomes of pyloric exclusion after duodenal grade 2 and 3 injury. Materials and Methods: We reviewed a prospectively collected trauma database for the period January 2004–December 2020. Patients with grade 2 and 3 traumatic duodenal injury were included. To identify the risk factors for postoperative leakage, we used a stepwise multivariable logistic regression model and a least absolute shrinkage and selection operator (LASSO) logistic model. We constructed a receiver operator characteristic (ROC) curve to predict risk factors for postoperative leakage. Results: During the 17-year period, 179,887 trauma patients were admitted to a regional trauma center in Korea. Of these patients, 74 (0.04%) had duodenal injuries. A total of 49 consecutive patients had grade 2 and 3 traumatic duodenal injuries and underwent laparotomy. The incidence of postoperative leakage was 32.6% (16/49). Overall mortality was 18.4% (9/49). A stepwise multivariable logistic regression and LASSO logistic regression model showed that time from injury to initial operation was the sole statistically significant risk factor. The ROC curve at the optimal threshold of 15.77 h showed the following: area under ROC curve, 0.782; sensitivity, 68.8%; specificity, 87.9%; positive predictive value, 73.3%; and negative predictive value, 85.3%. There was no significant difference in outcomes between primary repair alone and pyloric exclusion. Conclusions: Time from injury to initial operation may be the sole significant risk factor for postoperative duodenal leakage. Pyloric exclusion may not be able to prevent postoperative leakage.

Bioabsorbable Glycolide Copolymer is Effective in Reducing Staple Line Bleeding in Sleeve Gastrectomy.

Postoperative bleeding from the staple line after sleeve gastrectomy occurs in 2-8% of patients and it is associated with increased length and cost of hospitalization and may demand reoperation to gain hemostasis. Reinforced staplers are used by bariatric surgeons to reduce the incidence of postoperative leak but can have a role in avoiding bleeding. The aim of this study is to analyze the effects of reinforcement on the whole gastric staple line during sleeve gastrectomy on postoperative bleeding. Four hundred forty-eight consecutive patients undergoing sleeve gastrectomy from November 2012 to April 2019 were divided into two groups. In the Top-only group only the top staple shot was realized with reinforced material (GORE® SEAMGUARD®) while in the Bottom-to-Top group, patients received full staple line reinforcement. Statistical analysis focused on postoperative leak and bleeding, and length of stay; a propensity score matching analysis was performed to reduce between-group characteristics imbalance. One hundred forty-five (Top-only) and 303 (Bottom-to-Top) patients were included. Four (2.8%) patients in the Top-only group and none in the Bottom-to-Top group experienced severe bleeding (p = 0.004); the difference was still significant after propensity score matching. Length of stay was significantly shorter for the Bottom-to-Top group before and after propensity score matching (4 vs. 5days, p < 0.001). Staple line buttressing reduces the incidence of severe postoperative bleeding when performed on the whole staple line, and it is associated with a shorter hospitalization.

Impact of intraoperative colonoscopy on anastomotic leakage detection and prevention in colorectal anastomosis for rectal cancer

Introduction and aimThe value of leakage testing during colorectal resections to identify anastomotic leaks or bleeding has not been established. Our aim was to compare the impact of intraoperative colonoscopy (IOC) versus insufflation with a syringe, as leakage testing in lower anterior resection (LAR) for rectal cancer, with respect to the incidence of postoperative leakage (PL). Materials and methodsA retrospective study utilizing a prospective database of 426 patients with rectal cancer that underwent elective LAR, within the time frame of January 2015 and December 2019, was conducted. The anastomotic leak test was chosen by the surgeon. The incidence of postoperative leakage was compared between patients that underwent IOC and those that had the syringe leak test, utilizing the logistic regression analysis. Propensity score matching was included. ResultsThere were no significant differences in the clinical characteristics or morbidity and mortality rates between the two groups. Four patients were excluded, leaving a patient total of 422. Seventy patients with IOC were compared with 352 that had the syringe leak test. The incidence of postoperative leakage was 5.7% in the IOC group and 12.2% in the control group (p = 0.001). After propensity score matching (n = 221), balancing the characteristics between the groups, the incidence of postoperative leakage was 5.7% in the IOC group and 13.9% in the syringe leak test group (p = 0.001). ConclusionIOC was shown to be a safe method for evaluating the integrity of colorectal anastomosis and was associated with a higher percentage of protective stoma use, appearing to reduce the risk for PL.

Short-term outcomes after laparoscopic right hemicolectomy for colon cancer: intracorporeal versus extracorporeal anastomosis.

The aim of this study was to compare the short-term outcomes of laparoscopic right hemicolectomy between intracorporeal (IA) and extracorporeal (EA) anastomosis techniques. A retrospective chart review of 77 consecutive patients who underwent laparoscopic right hemicolectomy from January 2016 to June 2018 was performed. The intracorporeal group included 36 patients and the extracorporeal group 41 patients. Patient demographics and disease-related characteristics were similar. Mean operative time was 152±38.3 minutes in IA vs. 148±34.8 minutes in EA (P=0.664). IA was not associated with less overall postoperative complications and decreased rate of surgical site infections. There was no statistically significant difference in the incidence of postoperative leak, length of stay, mortality in both groups. There was no perioperative difference in median number of lymph node harvested. There was statistically significant difference in the length of larger incision (50 [50-70] mm in IA vs. 80 [70-100] mm in EA; P<0.001), length of the specimen (323±52.7 mm in IA vs. 295±64.7 mm in EA; P<0.05), free tumor margin (113.6±47.4 in IA vs. 75.6±37.4 mm in EA; P<0.001). There was a statistically significant difference in IA in the less postoperative use of analgesics (P<0.032) and return of bowel function (P<0.021). IA seems feasible and safe; it does not significantly affect the length of surgery, and it guarantees maintenance of radical oncological standards. Furthermore, IA significantly improves cosmesis and patient comfort postoperatively, reducing the rates of emesis, which leads to higher rates of early regular diet tolerance. Therefore, laparoscopic right hemicolectomy with intracorporeal anastomosis is associated with improved short-term outcomes.

DOZ047.19: Outcomes in the management of long-gap esophageal atresia: is the Foker technique superior?

Abstract Background Long-gap esophageal atresia (LGEA) has traditionally been managed by delayed anastamosis. However, over the last 10 years the Foker technique of esophageal growth elongation has been used. There is limited data evaluating outcomes using both techniques. Aims The aim of this study was to compare the outcomes in LGEA repair using the traditional delayed repair technique versus the Foker technique. Methods A retrospective chart review was done of LGEA patients at Sydney Children's Hospital between 1997 and 2016, comparing the Foker technique with the delayed repair technique. Results There were 9 children repaired using the Foker technique, and 10 by delayed repair. There were 7 patients with Type A, 1 with Type B, and 1 with Type C in the Foker group and in the delayed repair cohort, 5 were Type A, 2 Type B, 2 Type C, and 1 Type D esophageal atresia/tracheoesophageal fistula. There were 4 males in the Foker group and 5 in the non-Foker group. Median time to join was 59 days (15–117 days) for Foker repair and 173 days (16–433 days) for delayed repair. There was no significant difference in the incidence of post-operative leak, incidence of strictures needing dilation, presence of reflux symptoms, presence of reflux esophagitis on endoscopy, proton pump inhibitor use, need for fundoplication, incidence of cyanotic spells, occurrence of recurrent fistula, and symptoms of dysphagia when comparing both groups. Data on time to oral feeds and incidence of malnutrition was incomplete. Details are shown in Table 1. Conclusions Although the time to anastamosis was shorter in the Foker group and the incidence of post-operative leak, strictures needing dilation, need for fundoplication, and dysphagia were lower in the Foker group, the difference was not significant probably secondary to the small sample size. These results require validation in larger cohorts.

A multicenter study of routine versus selective intraoperative leak testing for sleeve gastrectomy

BackgroundStaple line leaks after sleeve gastrectomy are dreaded complications. Many surgeons routinely perform an intraoperative leak test (IOLT) despite little evidence to validate the reliability, clinical benefit, and safety of this procedure. ObjectivesTo determine the efficacy of IOLT and if routine use has any benefit over selective use. SettingEight teaching hospitals, including private, university, and military facilities. MethodsA multicenter, retrospective analysis over a 5-year period. The efficacy of the IOLT for identifying unsuspected staple line defects and for predicting postoperative leaks was evaluated. An anonymous survey was also collected reflecting surgeons’ practices and beliefs regarding IOLT. ResultsFrom January 2010 through December 2014, 4284 patients underwent sleeve gastrectomy. Of these, 37 patients (.9%) developed a postoperative leak, and 2376 patients (55%) received an IOLT. Only 2 patients (0.08%) had a positive finding. Subsequently, 21 patients with a negative IOLT developed a leak. IOLT demonstrated a sensitivity of only 8.7%. There was a nonsignificant trend toward increased leak rates when an IOLT was performed versus when IOLT was not performed. Leak rates were not statistically different between centers that routinely perform IOLT versus those that selectively perform IOLT. ConclusionsRoutine IOLT had very poor sensitivity and was negative in 91% of patients who later developed postoperative leaks. The use of IOLT was not associated with a decrease in the incidence of postoperative leaks, and routine IOLT had no benefit over selective leak testing. IOLT should not be used as a quality indicator or “best practice” for bariatric surgery.

Graham Patch Versus Modified Graham Patch in the Management of Perforated Duodenal Ulcer

Introduction: Peptic ulcer perforation is a serious complication which affects 2-10% of peptic ulcer patients. It presents with an overall mortality of 10% although various authors had reported incidence between 1.3% and 20%. Being a life threatening complication of peptic ulcer disease, it needs special attention with prompt resuscitation and appropriate surgical management if morbidity and mortality are to be contained. Aims and objectives: To compare outcome and complications in Graham patch and Modified Graham patch repair in perforated duodenal ulcer.Material and Methods: A prospective randomized controlled trial was conducted to compare the outcome and complication viz. leakage, obstruction after Graham's patch repair and modified Graham's patch repair undergoing duodenal ulcer perforation in various surgical units of Nepalgunj Medical College Teaching Hospital. Out of these 60 patients; one group (30 cases) underwent Graham's patch repair and another group (30 cases) underwent modified Graham's patch repair. The outcome of procedure was measured in terms of complication like leakage, obstruction and mortality.Results: Duodenal ulcer perforation in group A was more common in male; 58(96.66%) patients were male 2 (3.33%) were female (M:F=29:1). The mean age was 46.80(SD 13.9) years. In Group B it was more common in male; 58(96.66%) patients were male 2(3.33%) were female (M:F=29:1). The mean age was 48.60(SD 14.04) years. Incidence of complication was more common in Group B, no statistically significant difference was found between two groups. The incidence of post operative leakage was 1(3.33%) and in Group B were 2(6.70%). The chi square test was used to compute the p value using SPSS 19. The chi square p value was calculated as 0.554. Hence there was no significant difference between the Group A and Group B. The incidence of burst abdomen was same 2(6.70%) in both the groups.Conclusion: The analysis of results of present study consisting of altogether 60 patients undergoing duodenal ulcer perforation repair showed that Graham's patch repair is as effective as modified Graham's patch repair in terms of morbidity and mortality. Hence there is no statistically significant difference in undergoing either procedure of repair. It is concluded that either procedure can be undertaken depending upon surgeon preference.Journal of Nepalgunj Medical College Vol.13(1) 2015: 28-31

Management of Thoracic Esophageal Perforation

The aim of this study was to characterize an optimal strategy in managing thoracic esophageal perforation, focusing on the differential diagnosis and treatment of patients with contained versus noncontained perforations and on the importance of the time interval between injury and repair and how that affects the outcome of a primary repair. A retrospective study was conducted. A strict definition of contained or noncontained perforation was based on a combination of esophagography, chest CT scan, and endoscopy as well as monitoring systemic symptoms. Management options for our cohort included conservative therapy, primary repair and debridement, esophagectomy, and mesh-covered stents. Patients were stratified into two groups according to the time interval after injury: ≤ 48-h group and >48-h group. Between January 1997 and January 2013, a total of 66 consecutive patients (47 males and 19 females, mean age = 49.1 ± 16.2 years) were treated for thoracic esophageal perforation. Perforation was confirmed by esophagography in 51 patients and by endoscopy in 15 patients. Eighteen patients were assigned to the contained perforation group. All these patients were successfully cured without surgery. The noncontained group included 48 patients; its mortality rate was 7.7 % (3/39) with surgery and 55.6 % (5/9) with stent placement. Compared with the contained group, the noncontained group had a significantly longer length of stay (LOS) (16 ± 3.2 vs. 26.3 ± 18.7 days; p < 0.05) and a higher mortality rate (0 vs. 22.9 %, p < 0.05). In the two time-interval groups, patient characteristics, including age, gender, and comorbidities, etiologic cause, length and location of the perforation, and the incidence of using tissue buttress were similar (p > 0.05). The incidence of postoperative leak was significantly higher in >48-h group (0 in ≤ 48-h group vs. 37.5 % in >48-h group; p < 0.01). In addition, the >48-h group had a significantly longer LOS (18.0 ± 9.1 days in ≤ 48-h group vs. 31.5 ± 18.6 days in >48-h group; p < 0.01). The two deaths occurred in the >48-h group (0 in ≤ 48-h group vs. 12.5 % in >48-h group; p > 0.05) due to postoperative leaks. Contained or noncontained perforation should be rigorously differentiated. Then, for a contained perforation, conservative therapy coupled with repeated imaging is reasonable treatment. For a noncontained perforation, a primary repair can be safely performed within 48 h after injury. After that, a primary repair is still reasonable but is associated with an increased risk of postoperative leaks.

Laparoscopic Sleeve Gastrectomy with Tri-Staple™ Reinforcement for Severe Obesity

Background: Obesity is a chronic disease that affects over 500 million adults globally. Bariatric surgery is the only evidence-based treatment to achieve sustainable weight loss. Laparoscopic Sleeve Gastrectomy (LSG) is a restrictive procedure with important physiologic changes. Staple line dehiscence and hemorrhage represent two of the major complications associated with this procedure. Respectively, surgeons have attempted numerous modalities to avert these issues by using various stapling products, buttresses and hemostatic adjuncts. The purpose of this study is to analyze the utility of a Tri-staple non-buttressed stapler on the incidence of postoperative leakage and hemorrhage post LSG. Methods: A retrospective review of medical records was performed for 97 consecutive patients that underwent LSG with the Tri-Staple™ between July 2011 and October 2012. Results: The mean age of patients was 44.4 ± 9.2 years, with mean preoperative BMI of 48.5±10.6kg/m2. Preoperative comorbidities included Type 2 diabetes (34%), hypertension (42%), dyslipidemia (28%), and obstructive sleep apnea (43%). The mean operative time was 80.0 ± 22.0min. There were no intraoperative leaks identified. There were no documented postoperative leaks or bleeds after a median follow up of 12 months. At 12 months following surgery, BMI had significantly decreased to 33.9 ± 6.6 kg/m2 (p<0.05), corresponding to a EWL% of 54.8% ± 24.2%. HbA1c was significantly reduced after 1 year (6.7 ± 1.2 vs 5.6 ± 0.7, P<0.05). Conclusion: The Tri-Staple™ configuration used in LSG seems to mitigate staple line failures. Furthermore, weight loss and co morbidity reduction was determined to be acceptable and equivalent to LSG using other staplers

Omental Reinforcement for Intraoperative Leak Repairs during Laparoscopic Roux-en-Y Gastric Bypass

Leaks from the gastrojejunostomy after laparoscopic Roux-en-Y gastric bypass (LRYGB) have the potential for significant morbidity and mortality. When intraoperative leaks are discovered, we choose to perform omental reinforcement around the gastrojejunostomy and pouch after suture repair of the leaks. This study examined the hypothesis that omental reinforcement would be useful after intraoperative leaks during LRYGB. Omental reinforcement was performed on gastrojejunostomies, in which leaks were seen, created using a circular stapler during LRYGB. Data were reviewed retrospectively on these patients. There were a total of 387 patients with 32 (8.26%) patients who had a staple line dehiscence or evidence of gastric pouch or gastrojejunostomy leak intraoperatively. Leaks/dehiscences were repaired with sutures and then reinforced with omentum. None of these patient developed anastomotic leak postoperatively. Of the other 365 patients, there were four (1.1%) leaks from the gastrojejunostomy and/or gastric pouch. Omental reinforcement may be useful in decreasing the incidence of postoperative leaks when an intraoperative leak is encountered during LRYGB. However, omental reinforcement does not completely prevent a postoperative leak. Consideration of reinforcement with omentum may be given for patients in whom an intraoperative leak is noted.

Feasibility of thoracoscopic U-clip esophageal anastomosis: an alternative for esophageal atresia reconstruction

Background The authors propose that U-Clips can significantly decrease the technical difficulty of performing thoracoscopic esophageal reconstruction, thus, reducing operating time, the incidence of postoperative leak, and stricture rate. Methods After obtaining Institutional Animal Care and Use Committee approval, 3 4-kg female piglets underwent complete thoracoscopic esophageal transections. The esophagus was reconstructed thoracoscopically using S50 and S60 U-Clips over an 8F transanastomotic tube. Esophagrams were performed on postoperative day (POD) 7, 21, 44, and 77. Results Mean operating time was 57 minutes (45 to 75 min). Two of 3 piglets had no evidence of leak on POD 7 esophagrams. One animal had a small leak that resolved spontaneously on antibiotics. All 3 piglets tolerated a formula diet orally by POD 8. Over a 77-day survival period all 3 piglets had steady weight gain on an oral diet. Conclusions U-Clips are a feasible alternative to sutures for esophageal reconstruction in thoracoscopic surgery. Further study is warranted to investigate the full potential of U-Clips in minimally invasive pediatric surgery.

Use of Tisseel Fibrin Sealant in Neurosurgical Procedures: Incidence of Cerebrospinal Fluid Leaks and Cost-Benefit Analysis in a Retrospective Study

OBJECTIVE To determine the clinical efficacy and cost effectiveness of using the fibrin sealant (FS) Tisseel (Baxter Healthcare Corp., Deerfield, IL) for patients undergoing anterior cranial base, infratemporal, and retromastoid surgical procedures. METHODS A retrospective review was performed, comparing two matched populations of patients who underwent surgical procedures using anterior cranial, infratemporal, or retromastoid approaches to intracranial pathological lesions. The incidences of cerebrospinal fluid (CSF) leaks in matched groups treated with the FS Tisseel or treated without FS were compared. The costs of Tisseel use were examined in comparison with the costs of postoperative management of CSF leaks and/or tension pneumocranium with spinal drainage and occasionally surgical reexploration, when lumbar drainage failed. RESULTS Patients who received the FS Tisseel exhibited no detectable postoperative CSF leaks or tension pneumocranium. Patients who did not receive Tisseel demonstrated 4 to 16% incidences of postoperative leaks, depending on the surgical approach used. The costs of treating those leaks far exceeded the costs of using Tisseel, even if it were used indiscriminately for all patients. CONCLUSION This retrospective review indicates that the FS Tisseel reduces the incidence of postoperative CSF leaks and tension pneumocranium while reducing overall management costs. Further prospective study is needed to determine which patients can benefit most from FS use.

Use of Tisseel Fibrin Sealant in Neurosurgical Procedures: Incidence of Cerebrospinal Fluid Leaks and Cost-Benefit Analysis in a Retrospective Study

To determine the clinical efficacy and cost effectiveness of using the fibrin sealant (FS) Tisseel (Baxter Healthcare Corp., Deerfield, IL) for patients undergoing anterior cranial base, infratemporal, and retromastoid surgical procedures. A retrospective review was performed, comparing two matched populations of patients who underwent surgical procedures using anterior cranial, infratemporal, or retromastoid approaches to intracranial pathological lesions. The incidences of cerebrospinal fluid (CSF) leaks in matched groups treated with the FS Tisseel or treated without FS were compared. The costs of Tisseel use were examined in comparison with the costs of postoperative management of CSF leaks and/or tension pneumocranium with spinal drainage and occasionally surgical reexploration, when lumbar drainage failed. Patients who received the FS Tisseel exhibited no detectable postoperative CSF leaks or tension pneumocranium. Patients who did not receive Tisseel demonstrated 4 to 16% incidences of postoperative leaks, depending on the surgical approach used. The costs of treating those leaks far exceeded the costs of using Tisseel, even if it were used indiscriminately for all patients. This retrospective review indicates that the FS Tisseel reduces the incidence of postoperative CSF leaks and tension pneumocranium while reducing overall management costs. Further prospective study is needed to determine which patients can benefit most from FS use.