Laparotomy Mortality Research Articles

526 Combining Sarcopenia and ASA Status to Inform Emergency Laparotomy Outcomes: Could It Be That Simple?

Abstract Aim Emergency laparotomy mortality prediction tools are usually complex multipoint scoring systems. Our aim was to assess a 2 point system comprising radiological sarcopenia plus simplified ASA (PM;L3/sASA) as a potential predictor of 30-, 90- and 365- day mortality in Emergency Laparotomy patients, and compare this to current widely used tools such as NELA, P-Possum and ACS-NSQIP. Method A retrospective analysis was conducted across four hospitals, identifying 500 patients who underwent emergency laparotomies between 2016-2017 and had contemporaneous abdomino-pelvic CT scans. Radiological sarcopenia was measured using the PM:L3 ratio on a cross-sectional axial CT slice. PM:L3, NELA, ACS-NSQIP, and P-POSSUM, as well as simplified ASA (sASA) were retrospectively calculated and assessed as potential predictors of 30-, 90-, and 365-day mortality. Results ACS-NSQIP, NELA, P-POSSUM and PM:L3/sASA were each statistically significant predictors of 30-day, 90-day and 365-day mortality (p<0.001). Logistic regression models of 30-, 90- and 365-day mortality containing just the two predictors PM:L3 and simplified ASA exhibited AUCs of 0.838, 0.805 and 0.775 respectively, which are comparable with the best currently used predictors ACS-NSQIP and NELA. Conclusions Combining PM:L3 with ASA scores appears to be a significant predictor of 30-, 90-, and 365-day mortality in emergency laparotomy patients in Australia. The results are comparable with some of the best performing widely used risk assessment tools and provide a more time-efficient and accessible method of performing risk assessments in Emergency Laparotomy patients.

1309 A Quality Improvement Project on Small Bowel Obstruction Operative Mortality Rate

Abstract Aim Higher than average emergency laparotomy mortality rates had been identified via the National Emergency Laparotomy Audit (NELA), at a particular hospital. Small bowel obstruction (SBO) is the commonest cause for emergency laparotomy. The aim of this project was to evaluate the management of SBO, and to implement changes to reduce the operative SBO mortality rate. Method NELA was used to assess emergency laparotomy cases between 1st Dec 2018 - 30th Nov 2019; (n = 198), of which there were 24 mortalities. The dataset was filtered for SBO (n = 87), of which there were 12 mortalities. The clinical management of these 12 SBO mortality cases were analysed and compared to the latest ASGBI and NCEPOD recommendations on SBO management. Following this review, a systematic change in the management of SBO was introduced with the aim of reducing time to operation, appropriate candidate selection and avoiding drifting in management. This consisted of producing a SBO management flowchart as well as ensuring allocation of theatre slot within 72 hours for patients suitable for operation. Results Following the intervention, we assessed cases between 1st April 2021 - 31st March 2022 (n = 152), of which there were 13 mortalities. The dataset was filtered for SBO cases (n = 57), of which there were 3 mortalities. Emergency laparotomy mortality rate reduced from 12% to 9%. SBO operative mortality rate reduced from 14% to 5%. Emergency laparotomy deaths relating to SBO reduced from 50% to 23%. Conclusions The intervention resulted in improvement in SBO operative mortality rates as well as overall emergency laparotomy mortality rates.

O051 Combining sarcopenia and asa status to inform emergency laparotomy outcomes: could it be that simple?

Abstract Introduction Emergency laparotomy mortality prediction tools are usually multipoint scoring systems such as NELA, ACS-NSQIP, and P-POSSUM. However, these tools are time consuming and complex to use. Sarcopenia on CT scans is correlated with mortality in emergency laparotomy patients and we explored the combination of this (as measured by PM:L3) with ASA as a simple and efficient tool to predict the outcome of Emergency Laparotomies. Methods A retrospective analysis was conducted across four hospitals, identifying 500 patients who underwent emergency laparotomies between 2016-2017 and had contemporaneous abdomino-pelvic CT scans. Radiological sarcopenia was measured using the PM:L3 ratio on a cross-sectional axial CT slice. PM:L3, NELA, ACS-NSQIP, and P-POSSUM, as well as simplified ASA (sASA) were retrospectively calculated and assessed as potential predictors of 30-, 90-, and 365-day mortality. Results ACS-NSQIP, NELA, P-POSSUM and PM:L3/sASA were each statistically significant predictors of 30-day, 90-day and 365-day mortality (p<0.001). Logistic regression models of 30-, 90- and 365-day mortality containing just the two predictors PM:L3 and simplified ASA exhibited AUCs of 0.838, 0.805 and 0.775 respectively, which are comparable with the best currently used predictors ACS-NSQIP and NELA. Conclusion Combining PM:L3 with ASA scores appears to be a significant predictor of 30-, 90-, and 365-day mortality in emergency laparotomy patients in Australia. The results are comparable with some of the best performing widely used risk assessment tools and provide a more time-efficient and accessible method of performing risk assessments in Emergency Laparotomy patients.

Highlighting uncertainty in clinical risk prediction using a model of emergency laparotomy mortality risk.

Clinical prediction models typically make point estimates of risk. However, values of key variables are often missing during model development or at prediction time, meaning that the point estimates mask significant uncertainty and can lead to over-confident decision making. We present a model of mortality risk in emergency laparotomy which instead presents a distribution of predicted risks, highlighting the uncertainty over the risk of death with an intuitive visualisation. We developed and validated our model using data from 127134 emergency laparotomies from patients in England and Wales during 2013–2019. We captured the uncertainty arising from missing data using multiple imputation, allowing prospective, patient-specific imputation for variables that were frequently missing. Prospective imputation allows early prognostication in patients where these variables are not yet measured, accounting for the additional uncertainty this induces. Our model showed good discrimination and calibration (95% confidence intervals: Brier score 0.071–0.078, C statistic 0.859–0.873, calibration error 0.031–0.059) on unseen data from 37 hospitals, consistently improving upon the current gold-standard model. The dispersion of the predicted risks varied significantly between patients and increased where prospective imputation occurred. We present a case study that illustrates the potential impact of uncertainty quantification on clinical decision making. Our model improves mortality risk prediction in emergency laparotomy and has the potential to inform decision-makers and assist discussions with patients and their families. Our analysis code was robustly developed and is publicly available for easy replication of our study and adaptation to predicting other outcomes.

SP9.1.2 Sarcopenia and myosteatosis predict thirty-day emergency laparotomy mortality [The FrOGS study

Abstract Aims Sarcopenia (low muscle mass - SM) and myosteatosis (low muscle quality - SM-RA) are associated with poor outcomes after elective cancer surgery. Body composition parameters have not been explored in emergency surgery and may offer additive value to risk prediction scores. This multicentre study assessed the association of body composition and survival after emergency laparotomy. Methods A retrospective longitudinal cohort of 674 patients, across 10 hospitals in southern England were recruited (NCT03534765). All patients underwent emergency laparotomy, fulfilling NELA criteria, between August 2016 and November 2017. Pre-operative CTs were blindly analysed using L3 slices, assessing SM and SM-RA. Regression analysis was used to assess associations of body composition and 30-day mortality. Results Six hundred and ten patients were included [283(46%) men, median(IQR) age 71 years (57-79)]. P-POSSUM and NELA predicted mortality was 7% and 4.5% respectively, with a length of stay of 15 days (9-24), 30-day mortality of 7.8% and 1-year mortality of 18.9%. Significant univariate associations between 30-day mortality and age (OR1.04 (1.02-1.07);p=0.001), Charlson score (OR 6.84 (1.64-28.55);p=0.008), P-POSSUM (OR 1.03 (1.02-1.05);p<0.001, NELA mortality (OR 1.06 (1.04-1.08);p<0.001), SM (OR 0.98 (0.97-0.99);p=0.003 and SM-RA (OR 0.93 (0.9-0.96);p<0.001. Significant multivariate associations between 30-day mortality and NELA (OR 1.05 (1.03-1.07); p < 0.001, P-POSSUM (OR 1.03 (1.01-1.04); p < 0.001, SM-RA (OR 0.94 (0.9-0.97); p < 0.001. Conclusions Sarcopenia and myosteatosis are associated with increased mortality in patients undergoing emergency surgery. Body composition should be considered as an objective adjunct to traditional risk assessments, further informing the shared-decision making process around emergency surgery.

O12 Artificial intelligence-based risk prediction for death after emergency laparotomy using multi slice contrast enhanced computerised tomography

Abstract Introduction Emergency laparotomy has a considerable mortality risk, with more than one in ten patients not surviving to discharge. Preoperative risk prediction using clinical tools is well established, however implemented variably. Preoperative CT is undertaken almost universally and contains granular data beyond diagnostics, including body composition, disease severity and other abstract features with the potential to enhance risk prediction. In this study we established the value of features extracted in an automated fashion from pre-operative CT in predicting 90-day post-surgery mortality. Method Anonymised CTs were collated from patients undergoing emergency laparotomy at ten hospitals in Southern England (2016–2017). For each case, axial portal venous abdominal/pelvic series were analysed using a pre-trained neural network, with each image converted into a matrix of numerical features. An elastic-net regression model to predict 90-day mortality was trained using these features and evaluated by bootstrapping with 1000 resampled datasets. Result A total of 136,709 images from 274 cases were available for analysis with a mean of 503 per case. Mortality within 90 days occurred in 34 cases (12.4%) with an average NELA mortality prediction of 8.5%. On internal (bootstrap) validation, the elastic net model derived from CT yielded excellent performance (AUC 0.903 95%CI 0.897–0.909), significantly in excess of the NELA risk calculator (AUC 0.809 95%CI 0.736–0.875), with a broader prediction range (0.01%-89.71%). Conclusion Artificial intelligence techniques applied to routinely performed cross-sectional imaging predicts emergency laparotomy mortality with greater accuracy than clinical data alone. Integration of these automated tools may be possible in the future. Take-home Message Automated analysis of CT can accurately predict risk of mortality after emergency laparotomy.

New Zealand and Australia emergency laparotomy mortality rates compare favourably to international outcomes: a systematic review.

Almost 20 000 people undergo an emergency laparotomy each year in New Zealand and Australia. Common indications include small and large bowel obstruction, and intestinal perforation. Considered a high-risk procedure, emergency laparotomy is associated with significantly high morbidity and mortality. The aim of this review was to identify and compare 30-day, 90-day and 1-year mortality rates following emergency laparotomy in New Zealand and Australia. A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Electronic searches were performed in Medline, Embase, PubMed and Scopus in April 2020. Thirty-three papers met the inclusion criteria. Studies ranged in size from 58 to 75 280 patients. Weighted mean 30-day mortality was 8.40% (8.39-8.41). Mortality rates increased with longer postoperative follow up with 90-day weighted mortality rate of 14.14% (14.13-14.15) and the weighted mortality rate at 1 year of 24.60% (24.56-24.66). There was significant variability in mortality rates between countries. There is a wide variability of 30-day, 90-day and 1-year mortality rates internationally. Lowering postoperative mortality rates following emergency laparotomy through quality improvement initiatives could result in up to 120 lives in New Zealand and over 250 lives in Australia being saved each year. The continued work of the Australian and New Zealand Emergency Laparotomy Audit - Quality Improvement is crucial to improving emergency laparotomy mortality rates further in New Zealand and Australia.

Journal-related Activities and Other Special Activities at the 2020 American Society of Anesthesiologists Meeting.

Journal-related Activities and Other Special Activities at the 2020 American Society of Anesthesiologists Meeting.

Abstract 4355: Different strategies for peritoneal lavage cytology testing in the staging of gastric cancer: A cost-effectiveness analysis

Abstract Background & Aims: The positive peritoneal cytology (PCY) indicates metastasis disease in patients with gastric cancer (GC); thus, the cytology testing is directly related to subsequent treatments, patients' prognoses, and medical costs. However, the cost-effectiveness of PCY testing remains unclear. We aim to evaluate the cost-effectiveness of PCY testing by comparing two active testing strategies of a guideline-recommended intraoperative laparoscopic peritoneal lavage (ILPL) and a newly proposed preoperative percutaneous peritoneal lavage (PPPL), and a third strategy of exploratory laparotomy with no cytology testing (ELNC) among GC patients. Methods: We developed a decision-analytic Markov model to compare the cost-effectiveness of the above three strategies for a hypothetical cohort of GC patients with curative intent after initial imaging, from the perspective of Chinese society. Quality-adjusted life-years (QALYs), transition probabilities and costs were modeled using data mainly from published literature. We performed base case analysis and measured incremental cost-effectiveness ratios (ICERs) for various strategies, which were compared to a willingness-to-pay (WTP) threshold that was set to a three-fold of Chinese gross domestic product (GDP) per capita, $29,313/QALY gained. Furthermore, we conducted both one-way and probabilistic sensitivity analyses to investigate the model's robustness. Results: In the base case analysis, we found that ELNC was dominated (i.e., more expensive and less effective) by PPPL and ILPL. ILPL was the most cost-effective method, with an ICER of US $16,673/QALY compared to PPPL. One-way sensitivity analyses demonstrated that the exploratory laparotomy mortality following ILPL and the peritoneal cytology prevalence were the only two influential parameters within their plausible range when assessing the cost-effectiveness of PPPL and ILPL. In the probabilistic sensitivity analyses, the probability of ILPL being cost-effective was 71.3% at the WTP threshold of $29,313/QALY; however, PPPL was more likely to be cost-effective when the willing-to-pay (WTP) threshold was below $17,020/QALY gained. Conclusion: Cytology testing for GC staging through either ILPL or PPPL dominated ELNC in patients with curative intent. Moreover, ILPL was the most cost-effective modality at the current WTP threshold, while PPPL could potentially be cost-effective in lower-income areas. Citation Format: Qifei He, Jinyi Zhu, Anqiang Wang, Xia Li, Zhaode Bu, Jiafu Ji. Different strategies for peritoneal lavage cytology testing in the staging of gastric cancer: A cost-effectiveness analysis [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 4355.

Outcomes of Emergency Laparotomy (EL) Care Protocol at Tertiary Care Center from Low-Middle-Income Country (LMIC).

Emergency laparotomy mortality ranges between 10 and 20% in best of Western healthcare systems and is currently a major focus for quality improvement programs. In contrast, emergency surgery scenario in LMIC is largely undefined, often neglected and complex (large burden of diseases but only limited capacity for adequate treatment). We evaluated the efficacy of 'EL care protocol' aimed at cost-effective optimal utilization of best available local expertise and infrastructure. One hundred and two consecutive adult patients (≥16years) who underwent EL from December 2012-December 2015 at a private tertiary hospital were retrospectively analyzed. The patients who underwent emergency laparoscopic procedures were excluded from the analysis. The EL care protocol included. (1) Admission to surgical intensive care unit for pre- and postoperative optimization. (2) Preferred radiologic investigation: abdominal computed tomography (CT) scan. (3) Surgery and critical care by senior surgical gastroenterologists and internists/anesthesiologists, respectively. Outcome measures were procedure-related complications (Clavien-Dindo classification), readmissions and costs. Of the 102 patients, there were 62 males and 40 females with median age of 60 (range 16-93) years. There were no complications in 22 (21.6%) patients, while Clavien-Dindo complications grade I or II occurred in 48 (47%) patients. Grade V Clavien-Dindo complications and the 30-day mortality were similar of 19 (18.6%). The readmission rate was 8 (7.8%). The expected mortality for the study group by P-POSSUM score was 31.2 (30.6%). The ratio (O/E) of observed to expected mortality was 0.61. The all inclusive median cost of treatment was INR 379,255 ($5590). LMIC centers should develop their own center-specific EL care protocols to improve outcomes of EL.

Why Would a Hospital be an Outlier For Emergency Laparotomy Mortality? A Retrospective Audit of All Deaths Within 30 Days of Emergency Laparotomy

Why Would a Hospital be an Outlier For Emergency Laparotomy Mortality? A Retrospective Audit of All Deaths Within 30 Days of Emergency Laparotomy

Role of laparoscopy in the diagnosis and management of abdominal tuberculosis

Background: Each year tuberculosis (TB) results in the death of 1.5 million people globally .The complexity of TB is clearly evident by noting that this disease primarily involved the lung now involves all organs and systems. Abdominal TB is one such complex presentation. The use of laparoscopy in the diagnostic work-up of suspected abdominal tuberculosis is underutilized in developing countries. Methods: The study of Role of laparoscopy in the diagnosis and management of abdominal tuberculosis was conducted in patients with clinically suspected abdominal tuberculosis but histologically or microbiologically unconfirmed tuberculosis at any other site. Patients satisfying inclusion criteria are subjected to diagnostic laparoscopy, biopsy of specimen from peritoneum , omentum, tissues, mesenteric lymph nodes for histopathological examination, AFB staining and cartridge based nucleic acid amplification test (CBNAAT) of peritoneal aspirates for confirmation of abdominal tuberculosis. Results: Total 38 cases were included in this study with a clinical and radiological diagnosis of suspected abdominal tuberculosis. All patients underwent diagnostic laparoscopy. Conclusions: Diagnostic laparoscopy avoids the morbidity and mortality of laparotomy in chronically ill patients, reduces the rate of misdiagnosis of other abdominal conditions and unnecessary long-term therapy. Diagnostic laparoscopy and tissue sampling is a viable and reliable strategy in patients with suspected abdominal tuberculosis.

PTU-251 Emergency laparotomy survival factors in a unique 100%- consultant operator series

Introduction There is increasing interest in assessing outcomes from emergency laparotomy in the UK, and implementing care bundles to improve them. This follows on from work from the National Emergency Laparotomy Network suggesting that laparotomy mortality rates are at a level that would be ‘unthinkable’ from elective surgery (average 14.9% mortality). It noted variability in presence of consultant surgeons and anaesthetists at the surgery and related this to possible variations in mortality. In the knowledge that consultant presence at laparotomy is extremely high at our busy District General Hospital, research was carried out into the factors influencing the survival of the emergency laparotomy patients. Method A prospective database was created of 144 consecutive laparotomy patients, using local hospital and NELA data. The following factors were ascertained: grade of surgeon and anaesthetist, deprivation score, day of week of surgery, time of day of surgery, ASA grade, postoperative P-POSSUM predicted mortality (combining operative severity score and preoperative physiology), length of stay, 30-day mortality. Survival was ascertained using Kaplan-Meier analysis, with univariate analysis by log-rank test and then multivariate analysis performed using Cox Proportional Hazards Analysis. Results 100% of patients were operated on by consultant surgeons and 95% had a consultant anaesthetist presence. The 30-day mortality rate seen overall was 17.4%. It was notable that the mean P-POSSUM score for the patients was 17.2%. 50% were aged over 65. Of note even on univariate analysis, time of day of operation and weekday versus weekend were not significant predictors of mortality. On multivariate analysis, P-POSSUM score, ASA grade and age remained independent predictors of emergency laparotomy mortality. Conclusion Even in a series of patients operated on exclusively by consultants, mortality is close to the national average. It is likely that strong influences on this are the severity of patient physiology and severity of operation, seen in the striking similarity of mean P-POSSUM and observed mortality in these patients, and its independence on multivariate analysis. As expected, age is also an independent factor. Further work will be carried out to see if any remediable factors could be contributing. Disclosure of interest None Declared.

PTU-252 Higher emergency laparotomy mortality rates in over 65s with higher p-possum scores

<h3>Introduction</h3> Various factors are associated with increased laparotomy mortality rates, the study of which could help with the difficult decision of which patients should not have laparotomy as they are unlikely to survive. P-POSSUM in some studies has been shown to predict laparotomy survival and we were keen to assess if this persists in different age groups. <h3>Method</h3> A prospective database had been created of 144 consecutive laparotomy patients in a busy district general hospital, using locally tabulated and National Laparotomy Database data, to allow calculation of 30-day mortality, and analysis of various patient factors. A previous multivariate analysis, performed using Cox Proportional Hazards Analysis, had suggested that age and postoperative P-POSSUM were independent predictors of mortality. For this study, mortality rates were calculated for patients over 65, and over 80, and separately within each category for those whose P-POSSUM scores were under and equal to or over the mean values, with the differences being assessed with chi-squared analysis. <h3>Results</h3> Mean age of the patients was 63.3 (13–92). Overall mean P-POSSUM score was 17.2%. 50% of the patients were over 65 and 25% over 80. In the patients who were over 65, mortality was 29%. In those over-65s who had a P-POSSUM score equal to or over the mean, mortality was 44.8% and in those under the mean it was 17% (p = 0.014). In patients over 80, mortality was 36%. In octogenarians who had a P-POSSUM score equal to or over the mean, mortality was 40% and in those under, 33.3% and this was not a significant difference (p = 0.734). <h3>Conclusion</h3> In the over-65s POSSUM scoring signficiantly divides this population into higher and lower mortality, which could be used to direct operative decisions. In the over 80s this difference cannot be shown, potentially due to being over 80 itself being such a strong predictor of laparotomy mortality. <h3>Disclosure of interest</h3> None Declared.

A prospective audit of the use of diagnostic laparoscopy to establish the diagnosis of abdominal tuberculosis

The incidence of abdominal tuberculosis is much higher in an HIV-positive cohort. The use of laparoscopy in the diagnostic work-up of suspected abdominal tuberculosis is underutilized and its use and efficacy in the context of HIV co-infection has never been examined. A prospective clinical audit of the use of diagnostic laparoscopy was conducted in patients with clinically suspected abdominal tuberculosis but histologically or microbiologically unconfirmed tuberculosis at any site. From January 2008 to June 2010, 81 patients underwent diagnostic laparoscopy; 34 were male and 47 were female, with a mean age of 33years, and 77% were HIV-positive. Fifty-five patients (68%) had positive histology or culture for tuberculosis. In 15 patients (19%), histology revealed non-specific inflammation, no pathology was found in one patient, and no specimen was taken from one patient. Eighty percent of peritoneal deposits and 77% of lymph nodes were positive for tuberculosis, whereas 35% of ascitic fluid cultures were positive. In nine patients (11%) an alternative diagnosis was found; nine patients (11%) had conversion to laparotomy. There was no procedure-related death. Nine patients (11%) died during the 2-month follow-up period. Diagnostic laparoscopy avoids the morbidity and mortality of laparotomy in chronically ill patients, and reduces the rate of misdiagnosis of other abdominal conditions and unnecessary long-term therapy. Diagnostic laparoscopy and tissue sampling is a viable and reliable strategy in patients with suspected abdominal tuberculosis.

Mortality and Management of Surgical Necrotizing Enterocolitis in Very Low Birth Weight Neonates: A Prospective Cohort Study

Necrotizing enterocolitis (NEC) is a leading cause of death in very low birth weight (VLBW) neonates. The overall mortality of NEC is well documented. However, those requiring surgery appear to have increased mortality compared with those managed medically. The objective of this study was to establish national birth-weight-based benchmarks for the mortality of surgical NEC and describe the use and mortality of laparotomy vs peritoneal drainage. There were 655 US centers that prospectively evaluated 188,703 VLBW neonates (401 to 1,500 g) between 2006 and 2010. Survival was defined as living in-hospital at 1-year or hospital discharge. There were 17,159 (9%) patients who had NEC, with mortality of 28%; 8,224 patients did not receive operations (medical NEC, mortality 21%) and 8,935 were operated on (mortality 35%). On multivariable regression, lower birth weight, laparotomy, and peritoneal drainage were independent predictors of mortality (p < 0.0001). In surgical NEC, a plateau mortality of around 30% persisted despite birth weights >750 g; medical NEC mortality fell consistently with increasing birth weight. For example, in neonates weighing 1,251 to 1,500 g, mortality was 27% in surgical vs 6% in medical NEC (odds ratio [OR] 6.10, 95% CI 4.58 to 8.12). Of those treated surgically, 6,131 (69%) underwent laparotomy only (mortality 31%), 1,283 received peritoneal drainage and a laparotomy (mortality 34%), and 1,521 had peritoneal drainage alone (mortality 50%). Fifty-two percent of VLBW neonates with NEC underwent surgery, which was accompanied by a substantial increase in mortality. Regardless of birth weight, surgical NEC showed a plateau in mortality at approximately 30%. Laparotomy was the more frequent method of treatment (69%) and of those managed by drainage, 46% also had a laparotomy. The laparotomy alone and drainage with laparotomy groups had similar mortalities, while the drainage alone treatment cohort was associated with the highest mortality.

Ghost Ileostomy with or without abdominal parietal split

BackgroundIn patients who undergo low anterior rectal resection, the fashioning of a covering stoma (CS) is still controversial. In fact, a covering stoma (ileostomy or colostomy) is worsened by major complications related to the procedure, longer recovery time, necessity of a re-intervention under general anesthesia for stoma closure and poorer quality of life. The advantage of Ghost Ileostomy (GI) is that an ileostomy can be performed only when there is clinical evidence of anastomotic leakage, without performing further interventions with related complications when anastomotic leak is absent and therefore the procedure is not necessary. Moreover, in case of anastomotic dehiscence and necessity of delayed stoma opening, mortality and morbidity in patients with GI are comparable with the ones that occur in patients which had a classic covering stoma. On the other hand, is simple to think about the possible economic saving: avoiding an admission for performing the closure of the ileostomy, with all the costs connected (OR, hospitalization, post-operative period, treatment of possible complications) represents a huge saving for the hospital management and also raise the quality of life of the patients.MethodsIn this study we prospectively analyzed 20 patients who underwent anterior extra-peritoneal rectum resection for rectal carcinoma with TME and fashioning of GI realized with or without abdominal parietal split.ResultsIn the group of patients that received a GI without split laparotomy mortality was absent and in one case an anastomotic leak occurred. In the group of patients in which GI with split laparotomy was fashioned, one death occurred and there were one case of infection and one respiratory complication. Clinical follow-up was 12 months.ConclusionsThe use of different techniques for fashioning a GI do not present significant differences when they are performed by expert surgeons, but further evidence is needed with more randomized trials, in order to have more data supporting the clinical observation.

The decision between single- and combined-modality therapy in Hodgkin's disease

Using the technique of decision analysis to evaluate data on single-modality and combined-modality therapy in Hodgkin's disease, we have been able to determine which treatment gives the best chance for prolonged disease-free survival in given settings. Both the potential of combined-modality therapy for inducing secondary hematologic malignancies and the rate of salvage with MOPP following relapse after radiotherapy have been studied to observe the effect of different rates of these variables on the therapeutic decision. An analysis of patients with known pathologic stage endorsed the continued use of extended-mantle radiotherapy for Stages IA and IIA disease; under most of the conditions analyzed, combined-modality therapy appeared the best option for Stage IIIA disease. The results for Stages IB and IIB disease showed neither combined-modality therapy nor total nodal irradiation to have a conclusive advantage. We also analyzed management decisions for patients who had not had pathologic staging. For this, probabilities of each pathologic stage were derived from a large patient data base and were incorporated into the decision analysis. The results of this analysis indicated that, despite the mortality of laparotomy, treatment designated according to pathologic stage was more effective than immediate combined-modality therapy for most types of patients. For certain patients in whom the clinical features could be used to predict a high probability of advanced disease, the most effective management was immediate MOPP chemotherapy without staging laparotomy.

The decision to perform staging laparotomy in symptomatic Hodgin's disease.

This study defines patients with symptomatic Hodgkin's disease for whom risks of staging laparotomy (LAP) outweigh benefits conferred by accurate knowledge of stage. From a database of more than 900 pathologically-staged patients, probabilities of pathological stage are calculated for combinations of basic findings and lymphangiogram results. Decision-making thresholds are defined at which results of treatment after LAP, taking operative mortality into account, are equivalent to immediate treatment appropriate to clinical stage. These thresholds are substantially altered by varying LAP mortality estimates, by assigning a false negative rate to LAP, and by considering uncertainty in treatment results. Fifty-four combinations of findings are described for which immediate therapy with MOPP is justified; total nodal irradiation (TNI) is never indicated in B patients without prior LAP staging. Analysing 94 B patients who had LAP showed an appreciable number might have been spared this, particularly when uncertainty in treatment results is considered. With 0.03 (=3%) uncertainty in treatment, and 1% LAP mortality, LAP was not indicated in one in seven patients; nearly one third of patients should have immediate treatment with 3% LAP mortality. Threshold analysis can define those patients for whom risks of LAP outweigh benefits.

Decision analysis to evaluate lymphangiography in the management of patients with Hodgkin's disease.

We used decision analysis to explore the role of lymphangiography for staging Hodgkin's disease. Factors included were status of the patient before the test, accuracy and mortality of lymphangiography, mortality of laparotomy and effectiveness of selected treatment. We analyzed hypothetical cases with varying probabilities being in Stages I+II, III and IV to determine the population in which indication for laparotomy would depend upon results of lymphangiography. Calculations made for asymptomatic patients revealed that the diagnostic usefulness of lymphangiography is restricted to patients either with a relatively low probability of Stage IV or with a very high probability of Stage IV disease. This population is further restricted as false-positive and false-negative results of lymphangiography increase.