Intraoperative Deaths Research Articles

In vivo experience with peroral endoscopic myotomy: An essential activity for developing the technique in humans

Introduction and objectivesAchalasia is the most widely studied esophageal motility disorder. No treatment has achieved completely satisfactory results. The laparoscopic Heller esophagomyotomy is currently the most accepted technique. With the advent of minimally invasive surgery, the appearance of peroral endoscopic myotomy (POEM) has promising results. The primary aim of our study was to perform peroral endoscopic esophagomyotomy in animal experimentation models to perfect the technique and later apply it to humans. The secondary aims were to evaluate the intraoperative and postoperative complications and to describe the anatomopathologic findings. Materials and methodsAn experimental study was conducted on 8 live porcine models that were followed for 30 days to identify postoperative complications. Necropsy was then performed to evaluate the histopathologic findings. The international requirements and regulations for animal experimentation were met. ResultsThe technique was carried out in all the models. There was one intraoperative death. Pneumothorax was observed in 50% of the units in experimentation and subcutaneous cervical emphysema in 75%, with no significant clinical repercussions. Histologic muscle layer (myotomy) involvement was above the gastroesophageal junction in 87% of the cases and below it in 25%. ConclusionPeroral endoscopic esophagomyotomy is a feasible, albeit complex, procedure that requires advanced training, and thus should be performed in highly specialized centers. Specific skills in advanced therapeutic endoscopic procedures of this type must continue to be developed through continuing education (ideally in in vivo models), to then be performed on humans.

Critical Importance of Low-Dose Tissue Plasminogen Activator Policy for Treating Intraoperative Pulmonary Thromboembolism During Liver Transplantation

Tissue plasminogen activator (tPA) has been reported to treat intraoperative pulmonary thromboembolism (PTE) during liver transplantation (LT). However, tPA administration is often delayed due to fear of uncontrolled bleeding and storage in a refrigerator outside of operating rooms. Various dosages of tPA were used. We hypothesize that a policy of tPA storage and low dosage use improves patient outcomes. At a transplantation center, a multidisciplinary committee has implemented a tPA policy since April 2014, which includes the following: (1) timely administering of low-dose tPA (0.5-4 mg) for intraoperative PTE; (2) keeping 2 vials of tPA (2 mg/vial) in the operating room at room temperature; and (3) transferring unused tPA vials to the cardiology catheterization laboratory for next-day use. A prospective observational study was conducted to record the incidence and outcome of PTE during LTs. Over the next 19 months, 99 adult deceased donor LTs were performed with 1 (1.0%) intraoperative PTE. A 45-year-old woman with hepatitis C developed PTE within 5 minutes after graft reperfusion. A 2-mg tPA was immediately administered via a central venous line with hemodynamic improvement and clot lysis. Thromboelastography was normalized in 90 minutes. Five LT cases developing intraoperative PTE have been reported to receive "standard" dosages of tPA (20-110 mg) or urokinase (4400 IU/kg), which were administered more than 20 minutes after the diagnosis of PTE. One intraoperative death and one later mortality were noted with intracranial hemorrhages/infarction of 3 cases. The multidisciplinary low-dose tPA policy for PTE was suggested to be effective.

Peri-anaesthetic mortality and nonfatal gastrointestinal complications in pet rabbits: a retrospective study on 210 cases

ObjectiveThe aim of this study was to determine the incidence and the associated risk factors of peri-anaesthetic mortality and gastrointestinal complications in pet rabbits. Study designRetrospective cohort study. AnimalsA total of 185 pet rabbits admitted to the Exotic Referal Service of Beaumont Sainsbury’s Animal Hospital over the period 2009–2016. MethodsThe clinical records of the rabbits were obtained from the database. To evaluate the incidence of peri-anaesthetic mortality, three possible outcomes were considered: alive, dead or euthanized within the 72 hours following the anaesthetic event. Food intake and stool production during the first 72 hours following the anaesthetic event were evaluated to investigate the occurrence of gastrointestinal complications. Thereafter, various hypothesized risk factors, including administration of alpha-2 agonists, body weight, American Society of Anaesthesiologists classification and endotracheal intubation were tested against peri-anaesthetic mortality and gastrointestinal complications, with both univariate and multivariate binary logistic regression. ResultsTwenty-five out of 185 rabbits underwent two anaesthetic events; therefore, data from 210 cases were used. Of these 210 cases, six died during sedation or general anaesthesia and four (one of which euthanized) died during the first 72 postoperative hours, accounting for an actual mortality rate equal to 4.8% (95% confidence interval, 0.025–0.086). Peri-anaesthetic gastrointestinal complications developed in 77 (38%) out of the 204 anaesthetic events whose outcome was not intraoperative death (95% confidence interval, 0.314–0.446). Species-specific risk factors could not be identified for peri-anaesthetic mortality; however, the odds for post-anaesthetic gastrointestinal complications increased significantly with body weight (p = 0.01). Conclusions and clinical relevanceOur findings confirm that rabbits continue to have a higher incidence of peri-anaesthetic mortality than dogs and cats, and highlight a high risk for nonfatal peri-anaesthetic gastrointestinal complications in this species.

Superior vena cava resection and reconstruction in mediastinal tumors and benign diseases.

This study aims to evaluate our results of resection and reconstruction of the superior vena cava invaded by mediastinal tumors and benign diseases. Seventeen patients (8 males, 9 females; mean age 46±17 years; range 9 to 74 years) undergoing superior vena cava resection and reconstruction due to mediastinal pathologies between September 2006 and September 2016 were retrospectively reviewed. Patients who had angioplasty with primary suturing or partial resection with stapler were excluded. Mortality and morbidity rates were analyzed based on the demographic, and intra- and postoperative measures. Majority of patients (94%) had mediastinal tumors. Twelve patients (71%) had thymic epithelial tumors. Tubular graft interposition was performed using ringed polytetrafluoroethylene prosthesis in nine patients (53%), while patch plasty using autologous pericardium, polytetrafluoroethylene or Dacron grafts was performed in eight patients (47%). Eleven patients (65%) necessitated concomitant resections of neighboring structures. Mean length of hospital stay was 11±6 days. There was no intraoperative death. Mortality occurred in three patients (18%). Five patients (29%) developed complications. Mortality occurred commonly in elderly patients (p<0.0001). Postoperative complications were more common in patients with concomitant resections (p=0.05). Neither acute nor chronic thrombosis developed in any patients. Median survival in patients with malignant diseases was 57 months, with a oneyear and three-year probability of survival of 83% and 74%, respectively. Replacement of superior vena cava should be included in the therapeutic algorithm of selected patients with mediastinal tumors and benign diseases. Mortality rates may be higher in older patients, while the need for concomitant resections may increase morbidity rates.

Surgical Fires in Otolaryngology: A Systematic and Narrative Review.

Objective To bring attention to the epidemiology, prevention, management, and consequences of surgical fires in otolaryngology by reviewing the literature. Data Sources PubMed, EMBASE, Web of Science, and Scopus. Review Methods Comprehensive search terms were developed, and searches were performed from data source inception through August 2016. A total of 4506 articles were identified; 2351 duplicates were removed; and 2155 titles and abstracts were independently reviewed. Reference review was also performed. Eligible manuscripts described surgical fires involving patients undergoing otolaryngologic procedures. Results Seventy-two articles describing 87 otolaryngologic surgical fire cases were identified. These occurred during oral cavity or oropharyngeal procedures (11%), endoscopic laryngotracheal procedures (25%), tracheostomies (36%), "other" general anesthesia procedures (3%), and monitored anesthesia care or local procedures (24%). Oxidizing agents consisted of oxygen alone (n = 63 of 81, 78%), oxygen and nitric oxide (n = 17 of 81, 21%), and room air (n = 1 of 81, 1%). The fractional inspired oxygen delivered was >30% in 97% of surgical fires in non-nitrous oxide general anesthesia cases (n = 35 of 36). Laser-safe tubes were used in only 12% of endoscopic laryngotracheal cases with endotracheal tube descriptions (n = 2 of 17). Eighty-six percent of patients experienced acute complications (n = 76 of 87), including 1 intraoperative death, and 22% of patients (n = 17 of 77) experienced long-term complications. Conclusion Surgical fires in otolaryngology persist despite aggressive multi-institutional efforts to curb their incidence. Guideline recommendations to minimize the concentration of delivered oxygen and use laser-safe tubes when indicated were not observed in many cases. Improved institutional fire safety practices are needed nationally and internationally.

Mid-term Outcomes of Endovascular Repair of Ruptured Thoraco-abdominal Aortic Aneurysms with Off the Shelf Branched Stent Grafts

ObjectiveTo assess the mid-term outcomes and feasibility of branched endovascular repair (b-EVAR) of ruptured thoracoabdominal aortic aneurysms (rTAAAs). MethodsAll patients undergoing b-EVAR of rTAAAs between 2011 and 2016 were included. Pre-, intra and postoperative imaging was reviewed to assess technical success, outcomes, and feasibility of b-EVAR in the emergent setting. ResultsEleven emergency b-EVAR of rTAAAs (10 aneurysms and 1 chronic dissection) were performed using off-the-shelf (OTS) branched stentgrafts. Only 18% of patients complied to the anatomical instruction-for-use of the OTS device; a small aortic lumen and occluded target vessels were the main violations. Median operative time was 430 (IQR 395-629) minutes. Technical failure was 36% including one intraoperative death, one target vessel catheterization failure, one type Ia and one type III endoleak. Thirty-day mortality was 27%. Only early re-intervention was for the type Ia endoleak. Spinal cord ischemia occurred in 4 patients (30%), of which 2 recovered completely. Median clinical follow-up were 15 (IQR 7-39) months respectively. The median clinical follow-up index (FUI) was 0.65 (0.32–0.95). Overall survival was 75 ± 21.7% at 18 months. Four branch occlusions occurred; one renal stent occlusion led to permanent hemodialysis. Branch patency was 87.5 ± 8.3% and 72.2 ± 12% at 1 and 2 years, respectively. One stentgraft migrated but no late major endoleak occurred. ConclusionEmergency b-EVAR of rTAAA with OTS device is feasible despite a low anatomical suitability. With proper adjunctive procedures, it can be offered to most hemodynamically stable patients. These time-consuming complex procedures are not suitable for unstable patients. Often the procedure is done as life-saving in the emergency setting and reinterventions may be needed later. Consequently, the success rates are lower than in the elective setting. These results need to be confirmed by larger studies and longer follow-up.

Occult aortic fistulation affects late outcome of ruptured descending thoracic aortic aneurysms after emergency thoracic endovascular aortic repair in patients with initial hematemesis/hemoptysis

Background: Although thoracic endovascular aneurysm repair (TEVAR) has been widely used as the first choice of emergency surgical procedure for ruptured descending thoracic aortic aneurysms (rDTAAs), the risk factors of adverse outcome have less been investigated. Purpose: To investigate the outcomes of patients undergoing TEVAR for rDTAA and to identified risk factors of worse prognoses. Materials and Methods: The surgical outcome of TEVAR for rDTAA in National Cheng Kung University Hospital was retrospectively analyzed. From February 2008 to December 2016, 27 patients were included, after excluding patients with traumatic aortic injury, infected aneurysm, esophageal malignancy-related aortoesophageal fistula or those in association with aortic dissection. Results: There were 5 (18.5%) 30-day mortalities, including 3 (11.1%) intraoperative deaths. Seven additional patients died during follow-up and the estimated survival rate at 1 year and 3 years was 61.3 ± 9.7% and 50.5 ± 10.6%, respectively. Among these patients with late mortality, five patients presented with hematemesis or hemoptysis preoperatively. Aortoesophageal fistula was confirmed in three patients by esophagogastroduodenoscopy presenting with hematemesis. These patients underwent subsequent open debridement along with esophagectomy after TEVAR and remained alive during follow-up. On the other hand, those with possible occult aortic fistulations that were not detected by endoscopic examinations and not surgically managed had worse late outcomes (P = 0.058). Conclusions: For patients with rDTAA having hematemesis or hemoptysis as part of the initial presentations, careful survey for possible aorta-related fistulation is important. Although definite diagnosis of fistulation might be difficult, surgical exploration for hematoma evacuation, adequate debridement, and repair of intraoperative identified fistulation should be advocated.

The Right Axillary Incision: A Potential New Standard of Care for Selected Congenital Heart Surgery

Although the median sternotomy has been the traditional approach for congenital heart surgery, young patients and their families often find the midline scar to be cosmetically unappealing. At our center, a right transverse axillary incision has become the standard approach for many congenital cardiac lesions because of its safety, versatility, and unsurpassed aesthetic result. We present our experience with the axillary approach for a diverse array of congenital defects. A retrospective review of patients receiving a right transverse axillary incision for congenital cardiac surgery between 2005 and 2016 was conducted. The right transverse axillary incision was performed in 358 patients for 24 unique procedures. Median age was 5 years (range 1 month-60 years) and 225 patients (63%) were female. Median weight was 17 kg (range 4-124 kg), with 19 patients (5%) weighing less than 6 kg. The most common lesions were atrial septal defects (n = 244, 68%) and ventricular septal defects (n = 72, 20%). As experience with this approach increased, other repairs included subvalvular aortic membrane resection (n = 10, 3%), tetralogy of Fallot repair (n = 7, 2%), ventricular assist device placement (n = 3, 1%), and mitral valve repair (n = 2, 1%). There were no intraoperative deaths or conversions to sternotomy. In-hospital complications included mortality (n = 1, 0.3%), reoperations for bleeding (n = 5, 1%), pneumothorax or pleural effusion (n = 6, 2%), and permanent pacemaker (n = 4, 1%). The right axillary incision allows a safe and effective repair for a broad range of congenital heart defects and is a potential new standard of care for many patients.

Cardiac arrest and cardiopulmonary resuscitation in the operating room

The occurrence of cardiac arrest during anesthesia and surgery is nowadays associated with many challenges imposed by 21st century medicine. On the one hand, good education of healthcare practitioners, sophisticated anesthetic techniques and equipment, along with safer anesthetics and improved surgical techniques have significantly reduced the risk of cardiac arrest during the perioperative period. Still, the introduction of new, invasive diagnostic and therapeutic procedures in the aging patients and those with comorbidities carries along new risk and challenges. Epidemiological data indicate that intraoperative cardiac arrest is an extremely rare event. Due to variety of moral and ethical prejudices, intraoperative cardiac arrest is frequently presented as if it has happened in the immediate postoperative period, following surgery and anesthesia. The preventive measures, the etiology and diagnosis of cardiac arrest, as well as the specificities regarding organization and performance of cardiopulmonary resuscitation in the operating room, result in a better prognosis compared to other hospital departments. The article also describes the specifics of cardiopulmonary resuscitation in the catheterization laboratory, while a separate section is dedicated to cardiopulmonary resuscitation following systemic toxicity of local anesthetics. Since intraoperative cardiac arrest and death represent very rare complications, European Resuscitation Council has only recently published Guidelines for Resuscitation for performing cardiopulmonary resuscitation in the operating room ? in 2015.

Complications and Their Prevention in Experimental Renal Transplantation in Rats.

Experimental rat models of renal transplant have played a pivotal role in renal transplant research. Both intraoperative and postoperative complications during donor nephrectomy and implantation in the recipient can be associated with significant morbidity and mortality. The aim of this paper is to discuss the incidence, pathophysiology, and prevention of complications that occurred in the process of establishment of a rat model of chronic allograft injury at our institution. The complications observed while performing 67 consecutive donor nephrectomies and 61 renal transplants were recorded prospectively, and appropriate measures were taken to prevent these complications in the subsequent transplant procedures. Donor-related complications included failure of the kidney to clear of blood by the kidney perfusion solution and intraoperative deaths. The recipient-related complications included intraoperative hemorrhage, inadequately perfused kidneys with dusky appearance, congested and paralyzed hind limbs, urine leak, necrosis of the kidneys, renal and bladder calculi formation, and death during and after kidney transplant. Complications during donor nephrectomy and renal transplant can lead to significant loss of kidneys and animals. Proper recognition can allow appropriate measures to be taken to prevent these complications, thus achieving high-quality transplants and prolonged graft and animal survival.

Early Outcomes of the t-Branch Off-the-Shelf Multibranched Stent-Graft in Urgent Thoracoabdominal Aortic Aneurysm Repair

Purpose: To assess the short-term outcomes of the multibranched off-the-shelf t-Branch stent-graft for urgent thoracoabdominal aortic aneurysm (TAAA) repair and to evaluate the impact on outcomes of the learning curve and adherence to the instruction for use (IFU). Methods: Between 2014 and 2017, 42 patients (mean age 73.3±7 years; 26 men) underwent urgent TAAA treatment using the t-Branch stent-graft [18 in the early (2014–2015) period and 24 in the late (2016–2017) period]. Nearly half the patients were symptomatic (n=18) and 12 had contained rupture. Aneurysm diameter >80 mm was present in 12 (mean diameter 77.7±13.2 mm). Nineteen patients did not meet the IFU for the t-Branch due to target vessel anatomy. The primary endpoints were spinal cord ischemia (SCI), renal function impairment, and 30-day mortality. Target vessel patency and endoleak incidence were assessed at 30 days. Multivariate analyses examined associations between perioperative variables and outcomes; the results are presented as the odds ratio (OR) and 95% confidence interval (CI). Results: The technical success rate was 93% (39/42). Successful catheterization was achieved in 150/155 target vessels (97%). The postoperative SCI rate was 21% (5 paraplegia/4 transient paraparesis) and was correlated with age (OR 1.26, 95% CI 1.01 to 1.56, p=0.04). The renal function impairment rate was 23% (10/42; 2 temporary, 2 permanent dialysis) and was correlated with early experience (OR 7.74, 95% CI 1.3 to 43.9, p=0.019). The 30-day mortality was 14% (no intraoperative deaths); no factor was associated with mortality. During the first month, the incidences of type I, II, and III endoleaks were 0%, 43%, and 0%, respectively; branch patency was 99% (150/151). Procedure time decreased in the later experience (479±333 vs 407±25 minutes, p=0.09), though it was increased in cases outside the IFU (497±135 vs 389±118 minutes, p=0.009), along with fluoroscopy time (121±48 vs 92±33 minutes, p=0.036). Conclusion: Endovascular repair of urgent TAAA using the t-Branch is a feasible treatment option with acceptable 30-day mortality and morbidity in terms of SCI and renal function impairment. Adherence to the IFU prolonged procedure time but had no effect on outcomes. Increased experience of such cases over time may improve outcomes.

Posterolateral thoracic decompression with anterior column cage reconstruction versus decompression alone for spinal metastases with cord compression: analysis of perioperative complications and outcomes.

The optimal surgical strategy for patients with spinal metastases remains unknown. The aim of this study was to determine if performing an anterior column reconstruction to a posterolateral approach adds to perioperative complications. A retrospective review of all adult patients with spinal metastases who had a posterolateral approach for resection between January 2000 and December 2008. Perioperative complications and functional outcomes were determined. A total of 23 patients met the study criteria. Eleven patients underwent a costotransversectomy (CT) approach with anterior column reconstruction while 12 patients had a transpedicular (TP) approach without anterior column reconstruction. The mean age was 55.9 and 59.3 years in the CT and TP groups, respectively. There was no intraoperative death in either group. One death attributed to sepsis occurred in the TP group. A total of 5 (45.5%) complications occurred in the CT group and 7 (58.3%) in the TP group (P=0.68). An improvement in American Spinal Injury Association (ASIA) impairment scale grades was observed in 3 (27.3%) patients in the CT group and 1 (8.3%) in TP group. ASIA grades remained the same in 8 (72.7%) patients in CT and 10 (83.3%) patients in TP groups. No patient worsened in the CT group whereas 1 (8.3%) patient in TP group worsened. The median survival was 12.2 months in the CT group and 19.0 months in the TP group (P=0.37). The addition of anterior column reconstruction does not appear to be associated with more operative or perioperative complications when compared to decompression alone. Anterior column reconstruction should not be aborted in fear of increasing perioperative complications.

Subxiphoid uniportal video-assisted thoracoscopic surgery for synchronous bilateral lung resection

ABSTRACTObjectives: With advancements in medical imaging and current emphasis on regular physical examinations, multiple pulmonary lesions increasingly are being detected, including bilateral pulmonary lesions. Video-assisted thoracic surgery is an important method for treating such lesions. Most of video-assisted thoracic surgeries for bilateral pulmonary lesions were two separate operations. Herein, we report a novel technique of synchronous subxiphoid uniportal video-assisted thoracic surgery for bilateral pulmonary lesions.Methods: Synchronous bilateral lung resection procedures were performed through a single incision (~4 cm, subxiphoid).Results: This technique was used successfully in 11 patients with bilateral pulmonary lesions. There were no intraoperative deaths or mortality recorded at 30 days.Conclusions: Our results show that the subxiphoid uniportal thoracoscopic procedure is a safe and feasible surgical procedure for synchronous bilateral lung resection with less surgical trauma, postoperative pain and better cosmetic results in qualifying patients. Further analysis is ongoing, involving a larger number of subjects.

Efficacy of laparoscopic ureteroureterostomy with intraoperative retrograde ureteroscopy-assisted technique for ureteral strictures secondary to Holmium laser lithotripsy

Objective To investigate the safety and efficacy of laparoscopic ureteroureterostomy with intraoperative retrograde ureteroscopy-assisted technique in the treatment of ureteral strictures secondary to Holmium laser lithotripsy. Methods The clinical data of 26 cases of ureteral strictures secondary to Holmium laser lithotripsy performed by laparoscopic ureteroureterostomy from December 2013 to January 2016 in our hospital were analyzed retrospectively. The patients included 15 men and 11 women, with an average age of 39.5 years (range 24-71 years). The ureteral strictures secondary to holmium laser lithotripsy were found on average follow-up of 5.2 months (range 1-22 months). There were 12 cases of mild hydronephrosis before surgery, moderate hydronephrosis in 11 cases, severe hydronephrosis in 3 cases. Preoperative serum creatinine was 102.0 μmol/L on average ( range 53.3-201.4 μmol/L), and ureteral stenosis length was 15.0 mm on average (range 8.0-26.0 mm) .The upper ureteral strictures in 6 cases, the middle strictures in 13 cases, and the lower strictures in 7 cases. Results All the operations were completed successfully without conversion to open and no intraoperative death .The average operation time was 121.4 min(range 90-155 min); the estimated blood loss was 92.3 ml(range 30-200 ml); the mean recovery time of gastrointestinal function after operation was 1.4 d(range 0.5-2.5 d); the mean hospital stay was 6.2 d(range 4-9 d)with indwelling double J; the Foley catheter was removed 14.5 d(range 12-16 d)postoperatively; the mean time of double J withdrawal was 76.3 d(range 61-86 d ). Postoperative fever occurred in two patients and were successfully treated by re-indwelling catheter and antibiotic administration. Urine leakage occurred in 1 patient postoperatively and was successfully treated by conservative management 5 days later. After a period of 11 to 22 months of follow-up, no patient had ureteric re-stenosis. Conclusions Laparoscopic ureteroureterostomy with intraoperative retrograde ureteroscopy-assisted technique could accurately locate and cure the ureteral strictures. It might be safe and effective with short operation time, less injury and quick recovery. Key words: Laparoscope; Ureteroscope; Holmium laser lithotripsy; Ureteral strictures

Clinical study on microwave ablation combined with concurrent chemotherapy in treatment of locally advanced pancreatic cancer

Objective To investigate the clinical efficacy and safety of microwave ablation combined with concurrent chemotherapy in treatment of locally advanced pancreatic cancer. Methods Thirty-one patients with locally advanced pancreatic cancer with between August 2013 and April 2016 were divided into two groups according to the different treatments: 15 patients in the control group were treated with gemcitabine monotherapy; 16 patients in the combination group were treated with the same regimen as control group 1-2 weeks after the microwave ablation. The efficacy and side effects of the two groups were compared by chi-square test. Results The effective rates in the combination group and control group were 25.0% (4/16) and 13.3% (2/15), the difference between the two groups was not significant (χ 2= 1.034, P= 0.247); the local control rates were 68.8% (11/16) and 26.7% (4/15), the difference between the two groups was statistically significant (χ 2= 6.579, P= 0.012). The pain relief rates in the combination group and control group were 87.5% (14/16) and 26.7% (4/15) (χ 2= 8.146, P= 0.004). The 3-, 6-, 9-and 12-month survival rates in the combination group and control group were 100.0% vs. 100.0% (P= 1.000), 68.8% vs. 40.0% (P= 0.097), 56.3% vs. 20.0% (P= 0.033), 50.0% vs. 13.3% (P= 0.021). In the combination group, 9 cases (56.3%) occurred postablation syndrome, the serum amylase of 7 cases (43.8%) increased 1d after ablation, 1 case (6.3%) occurred pancreatic fistula. The intraoperative and perioperative death did not occur. The main complications of the two groups were myelosuppression, gastrointestinal reactions and so on. Conclusions Microwave ablation combined with concurrent chemotherapy has a synergistic effect in treatment of locally advanced pancreatic cancer. In disease control rate, pain relief rate and survival of patients, microwave ablation combined with concurrent chemotherapy is better than chemotherapy alone, but the adverse reactions are similar. Key words: Pancreatic neoplasms; Microwave ablation; Drug therapy; Safety

Short-term and mid-term survival in bronchial sleeve resection by robotic system versus thoracotomy for centrally located lung cancer.

The aim of this study was to compare the short-term and mid-term results of patients with centrally located lung cancer who underwent bronchial sleeve resection by robotic system or thoracotomy. From September 2014 to September 2015, 103 patients, including 17 robotic and 86 open cases, were included in our study. All the clinicopathological data, operative details and follow-up information were investigated. There were no intraoperative deaths. The mean console time was 113.59 min. The operative time for robotic surgery (155.06 ± 44.75 min), even in our initial cases, was comparable to that for thoracotomy (150.30 ± 47.84 min, P = 0.71). The 30-day mortality rate in the robotic and thoracotomy groups was 1 (6%) patient and 2 (2%) patients, respectively, with no significant difference (P = 0.43). A total of 4 (24%) patients in the robotic group and 22 (26%) patients in the thoracotomy group experienced postoperative complications (P = 0.86). In multivariable analysis, tumour size and postoperative radiotherapy were significant predictors of relapse-free survival, whereas only the intensive care unit stay was a significant predictor of overall survival. There was no significant difference in relapse-free survival (log-rank P = 0.16) and overall survival (log-rank P = 0.59) between the 2 groups. Robotic surgery for bronchial sleeve resection is safe and feasible and has similar oncological outcomes compared with open procedures. But long-term survival still needs to be investigated.

Incidence and Management of Umbilical Artery Flow Abnormalities during Open Fetal Surgery

Introduction: Umbilical artery (UA) Doppler ultrasound is used to assess uteroplacental insufficiency. Absent or reversed end diastolic flow (AREDF) in the UA is associated with increased perinatal mortality in fetuses with intrauterine growth restriction. We describe the incidence of UA Doppler abnormalities during open fetal surgery. Methods: We conducted a retrospective review of patients undergoing open in utero myelomeningocele (MMC) repair between 2008 and 2015. Intermittent UA Dopplers were performed during key portions of all cases. Our primary outcome was the rate of any AREDF. Secondary outcomes included analysis of absent versus reversed end diastolic flow (EDF), vasopressor use, and volatile anesthetic and clinical outcomes. Results: Thirty-four of 47 fetuses developed UA Doppler abnormalities intraoperatively. Nineteen had absent EDF and 15 had reversed EDF. No AREDF was present before induction, and all AREDF resolved by postoperative day 1. Ten of 19 (52.6%) patients who received sevoflurane had reversed EDF, versus 5/28 (17.9%) for desflurane, odds ratio (95% CI) 5.11 (1.36-19.16), p = 0.02. One intraoperative fetal death occurred in the AREDF group. Discussion: AREDF is a common phenomenon during open MMC repair. Anesthetic agent choice may influence this risk. Future studies of UA flow during fetal surgery are needed to further evaluate the impact of intraoperative AREDF on fetal well-being.

Concurrent hydrocelectomy during inguinal herniorrhaphy is a risk factor for complications and reoperation: data from rural Haiti.

Series of conventional inguinal herniorrhaphy from low and middle income countries (LMICs) suggest elevated rates of morbidity, mortality, and recurrence, although the reasons remain incompletely understood. We sought to identify risk factors for adverse outcomes from inguinal herniorrhaphy performed in a resource-limited LMIC setting. We performed mesh-free modified Bassini inguinal herniorrhaphies on 141 consecutive patients with 156 inguinal hernias over 10 months in rural Haiti. We prospectively followed these patients for complications. No intraoperative or perioperative deaths occurred. Follow-up was poor, with 20 patients (14%) returning after discharge. 14 complications were identified in 11 patients, yielding an identified complication rate per herniorrhaphy of 9%. Five complications required reoperation, for an overall reoperative complication rate per herniorrhaphy of 3%. Reoperative complications included one postoperative hemorrhage, one persistent painful cord mass, and three infected hematomas or seromas. On univariate analysis, trends towards complication and need for reoperation were noted with concurrent repair of an ipsilateral hydrocele (OR 4.5, p=0.300, for complication; OR 9.0, p=0.115, for reoperative complication). In rural Haiti, we found that adding ipsilateral hydrocele repair to inguinal herniorrhaphy may elevate the risk of both complications and need for reoperation. This previously unreported association is of high relevance to surgical practice across tropical LMICs, where concurrent inguinal hernia and hydrocele is common.

Modifiable Risk Factors for Early Mortality in Low-Risk Penn Class Aa Acute Type A Aortic Dissection Patients – A Descriptive Study

Acute Type A aortic dissection (ATAAD) without end-organ or generalized ischemia is Penn class Aa and considered low-risk. Nevertheless, surgical mortality can be considerable in this subgroup and may be related to modifiable factors. The objective of this study was to analyze 30-day mortality among ATAAD Penn class Aa patients with special reference to modifiable perioperative factors. Among all patients operated for ATAAD from 1990 to 2010, all Penn class Aa patients dying within 30 days were included in a retrospective descriptive study. Pre- and intraoperative variables related to 30-day mortality were retrieved from medical records and analyzed according to avoidable or modifiable errors such as initial misdiagnosis, preoperative delay, adverse events, and forced and unforced additional procedures. Overall 30-day mortality was 13% (31/235). Intraoperative death occurred in 32% (10/31) of patients. Among patients not dying intraoperatively, stroke was the most common complication (48%) and cause of death overall, followed by reoperation for bleeding (33%), respiratory failure (24%), and renal failure (14%). Preoperative errors were detected in 48% of patients; one-third had initial misdiagnosis and/or diagnostic delay ≥ 24 hours. Intraoperative error(s) was noted in 74% of patients, mainly involving adverse event(s), forced additional procedures, and assisted bleeding control, with each affecting approximately 45% of patients. Modifiable errors in pre- and intraoperative management are not uncommon among Penn class Aa patients and may contribute to 30-day mortality. Efforts should be made to mitigate the effects of modifiable factors to reduce early mortality in low-risk ATAAD.

Surgical and medical approach to patients requiring total small bowel resection: Managing the “no gut syndrome”

Total resection of the jejunum and ileum, a rarely performed procedure, is indicated after mesenteric vascular events, trauma, or resection of abdominal neoplasms. We describe our recent experience with the operative and medical management of patients with "no gut syndrome." We retrospectively reviewed 341 adult patients who were referred to our center between January 2013 and December2016. Thirteen patients with a mean age of 42.5years (range 17 to 66years) underwent near total enterectomy. Indications for small bowel resection were vascular event (n=5), intraabdominal fibroid/desmoid (n=4), and trauma (n=4). Foregut secretions were managed with duodenocolostomy (n=5), tube decompression (n=5), and end duodenostomy (n=2). Duodenal stump was stapled off in 4 cases. One patient underwent a spleen-preserving duodenopancreatectomy combined with total enterectomy. Biliary secretions were managed with choledochocolostomy. All patients were discharged on full total parenteral nutrition infused over a 10- to 16-hour period. Average total parenteral nutrition volume and caloric requirement were 2,800mL/day (range 2,000 to 4,000) and 1,774Kcal/day (range 1,443 to 2,290), respectively. Patients who underwent duodenocolonic anastomosis received smaller TPN volume (33.8 vs 49.8mL/kg). Ten patients (77%) required supplemental intravenous fluid. There were no intraoperative or perioperative deaths. One patient was lost to follow-up 2months after operation. After a 20-month median follow-up (range 4 to 48months), 9 patients are still alive (75%). All patients with duodenocolostomy remain alive (median follow-up 36.4months). Three patients underwent uneventful isolated small bowel transplantation, and another 4 are being evaluated or are already listed for visceral transplantation. In summary, resection of the entire small bowel is feasible and can be a lifesaving procedure for a select group of patients. Long-term survival can be achieved in specialized centers. In addition, reestablishment of gastrointestinal tract continuity after total enterectomy appears to be the best option for postoperative fluid and electrolyte management.