Lysis Of Adhesions Research Articles

Incidence, associated risk factors, and impact of conversion to laparotomy in elective minimally invasive sigmoidectomy for diverticular disease.

Benefits of minimally invasive surgical approaches to diverticular disease are limited by conversion to open surgery. A comprehensive analysis that includes risk factors for conversion may improve patient outcomes. The US Premier Healthcare Database was used to identify patients undergoing primary elective sigmoidectomy for diverticular disease between 2013 and September 2015. Propensity-score matching was used to compare conversion rates for laparoscopic and robotic-assisted sigmoidectomy. Patient, clinical, hospital, and surgeon characteristics associated with conversion were analyzed using multivariable logistic regression, providing odds ratios for comparative risks. Clinical and economic impacts were assessed comparing surgical outcomes in minimally invasive converted, completed, and open cases. The study population included 13,240 sigmoidectomy patients (8076 laparoscopic, 1301 robotic-assisted, 3863 open). Analysis of propensity-score-matched patients showed higher conversion rates in laparoscopic (13.6%) versus robotic-assisted (8.3%) surgeries (p < 0.001). Greater risk of conversion was associated with patients who were Black compared with Caucasian, were Medicaid-insured versus Commercially insured, had a Charlson Comorbidity Index ≥ 2 versus 0, were obese, had concomitant colon resection, had peritoneal abscess or fistula, or had lysis of adhesions. Significantly lower risk of conversion was associated with robotic-assisted sigmoidectomy (versus laparoscopic, OR 0.58), hand-assisted surgery, higher surgeon volume, and surgeons who were colorectal specialties. Converted cases had longer operating room time, length of stay, and more postoperative complications compared with minimally invasive completed and open cases. Readmission and blood transfusion rates were higher in converted compared with minimally invasive completed cases, and similar to open surgeries. Differences in inflation-adjusted total ($4971), direct ($2760), and overhead ($2212) costs were significantly higher for converted compared with minimally invasive completed cases. Conversion from minimally invasive to open sigmoidectomy for diverticular disease results in additional morbidity and healthcare costs. Consideration of modifiable risk factors for conversion may attenuate adverse associated outcomes.

Arthroscopic Lysis of Adhesions With Manipulation Under Anesthesia Versus Manipulation Alone in the Treatment of Arthrofibrosis After TKA: A Matched Cohort Study.

Arthrofibrosis following total knee arthroplasty (TKA) is a debilitating complication. Treatment options include physical therapy, manipulation under anesthesia (MUA), and arthroscopic lysis of adhesions (ALOA) with or without MUA. The authors studied 70 patients with arthrofibrosis after TKA treated with MUA or ALOA plus MUA. In this matched cohort study, 35 patients were treated with MUA and 35 patients were treated with ALOA plus MUA. Total knee arthroplasty followed by MUA was performed by 2 surgeons and TKA followed by MUA plus ALOA was performed by 1 surgeon at 1 institution. Electronic records were used to collect information and match cohorts based on age, sex, body mass index, diabetes mellitus, perioperative range of motion (ROM), and timing of the procedure for arthrofibrosis. The combination of MUA and ALOA yielded changes in ROM: a 72.7% increase 4 to 12 weeks after index TKA (P=.032), a 50.0% increase 12+ weeks after TKA (P=.032), and a 99.8% increase in patients with a pre-manipulation ROM of 0° to 60° (P=.001). Manipulation under anesthesia yielded a 49.2% increase 4 to 12 weeks after TKA (P=.161), a 27.0% increase 12+ weeks after TKA (P=.161), and a 68.8% increase in patients with pre-manipulation ROM of 0° to 60° (P=.084). Patients treated with ALOA plus MUA had greater increases in ROM (P=.026) and final knee flexion (P=.028) compared with those treated with MUA alone. Arthrofibrosis following TKA is a complication that often requires additional procedures. Traditionally, ALOA is added 3+ months from index TKA, when abundant scar formation has occurred. This study found a benefit to ALOA plus MUA compared with MUA alone, with the largest benefit in patients whose pre-manipulation ROM was 0° to 60°. [Orthopedics. 2019; 42(3):163-167.].

First description of an acquired internal hernia: a case report

An internal hernia is defined as a protrusion from intestines or other abdominal organs through a congenital or acquired aperture within the peritoneal cavity. Internal hernia are rare, with an incidence of less than 1%. Mostly, they are located paraduodenal (Treitz hernia) and show mortality rates up to 50%. We describe the case of a 26-year-old man presenting with acute bowel obstruction and a history of surgical treatment for a congenital diaphragmatic hernia. Clinical examination and computed tomography (CT) scan were interpreted as intestinal obstruction. Exploratory laparotomy resulting in an appendectomy, small intestine resection, and lysis of adhesions was performed. In situ, an atypical appendix fused to the spleen was detected, forming an aperture within the peritoneal cavity with protrusion and strangulation of the small intestine. The small intestine specimen sent to pathology confirmed necrotic small intestine mucosa. We present the first description of a young man with an internal hernia due to an intraperitoneal aperture formed by his appendix fused to the spleen. Internal hernia are difficult to diagnose but should be included in the differential diagnosis in cases of intestinal obstruction. CT should be performed in cases of suspicion. Surgical intervention shouldn’t be delayed in order to reduce the high morbidity and mortality rates.

The Association of Perioperative Glycemic Control With Adverse Outcomes Within 6 Months After Arthroscopic Rotator Cuff Repair

To determine the association between glycemic control and adverse events after arthroscopic rotator cuff repair (RCR). Patients with a diagnosis of diabetes mellitus who underwent arthroscopic RCR and had a hemoglobin A1c (HbA1c) level determined within 3months before or after surgery were identified in a national database and stratified by HbA1c level. The incidence of postoperative infection within 6months was determined using Current Procedural Terminology and International Classification of Diseases, Ninth Revision codes. A receiver operating characteristic (ROC) curve analysis was performed to determine whether a threshold HbA1c level existed above which the risk of infection, revision rotator cuff surgery, and lysis of adhesions (LOA)-manipulation under anesthesia (MUA) after arthroscopic RCR was significantly increased. This threshold was then tested using a logistic regression analysis. The study included 3,740 patients with an infection rate ranging from a low of 0.29% to a high of 1.14% after RCR. The inflection point of the ROC curve for infection corresponded to an HbA1c level between 7.0 and 8.0mg/dL (P= .035; area under the curve, 0.648; specificity, 61%; sensitivity, 59%). We then used 8.0mg/dL as a threshold to test for adverse outcomes. We found a significant difference in infection rates for patients with levels below versus above the threshold (0.30% vs 0.84%; OR, 2.0; 95% confidence interval, 1.2-3.4; P= .014) but no difference in revision rates (P= .240) or LOA-MUA (P= .650) in patients with levels above versus below the threshold. The risk of infection after RCR in patients with diabetes mellitus increases as the perioperative HbA1c level increases and, although statistically significant, remains low. ROC curve analysis determined that a perioperative HbA1c level above 8.0mg/dL could serve as a threshold level; however, the area under the curve and low sensitivity reflected the poor utility of this test as an independent predictor. This study did not find an association between increased perioperative HbA1c levels and rates of revision rotator cuff surgery or LOA-MUA after RCR. Level III, retrospective cohort study.

MON-331 Pulmonary Carcinoidosis Presenting with Persistent Pneumothorax

Introduction: Lung neuroendocrine (NET) or carcinoid tumors are a rare group of pulmonary neoplasms characterized by insidious clinical behavior. In this report, we present a case of pneumothorax refractory to conservative management with concomitant pulmonary carcinoidosis. We also discuss the diagnostic and management approach followed in such cases. Case: 80 year-old male with history of asthma and Type 2 DM presented to the ER with worsening cough and shortness of breath, and was found to have a left sided spontaneous pneumothorax. Chest tube was inserted. However, due to persistent leak, PleurX catheter was placed, and patient was discharged home afterwards. However, he presented with subcutaneous emphysema on the same day and was subsequently readmitted. Persistent pneumothorax was managed conservatively. PleurX catheter was attached to underwater seal with negative pressure and respiratory status was optimized given evidence of asthma exacerbation. Treatment with Methylprednisolone IV, Montelukast, Tiotropium, Mometasone Furoate/Formoterol inhalers was initiated. However, air leak persisted despite conservative management for 13 days. CT surgery elected to proceed with VATS. Multiple wedge resections were performed along with partial pleurectomy, lysis of adhesions and decortication of left upper lobe. Pathology revealed a sub-pleural 5-mm carcinoid tumor with solid nests of cells along with lung tissue with emphysematous changes, pleural scarring and bullous formation. No nuclear pleomorphism or mitotic figures were noted. Immunoperoxidase stains were positive for TTF-1, synaptophysin, chromogranin and CD56 and negative for CK5/6, calretinin and P-40. Serum Chromogranin A (CgA) was elevated 431 ng/l. Post-op course was uncomplicated and patient was discharged to a rehab facility. Discussion: Lung NETs account for 1-2% of all lung malignancies in adults and 30% of all NETs. Incidence ranges from 0.2-2/100,000 population per year. While some patients may be asymptomatic, others present with obstructive symptoms due to mass effect. Incidence of pneumothorax as a complication of lung neoplasms is rare (0.05-1.4% of all pneumothoraces). Clinical presentation includes carcinoid syndrome, Cushing's syndrome and acromegaly. Diagnosis is confirmed either by bronchoscopic biopsy (for central lesions) or by transthoracic needle biopsy (for peripheral lesions). For patients with localized lung NETs, surgical resection is the treatment of choice. Lung NETs have an excellent prognosis following surgical resection, with 5-year survival rates of 87-100%. Immunohistochemical identification utilizes tissue markers like synaptophysin, neuron-specific enolase, and chromogranin. Serum CgA is usually elevated and is used as a marker to assess disease progression, response to therapy, or recurrence after surgical resection.

Arthroscopic Lysis of Adhesions and Anterior Interval Release With Manipulation Under Anesthesia for Severe Post-traumatic Knee Stiffness: A Simple and Reproducible Step-by-Step Guide

Post-traumatic knee stiffness can present after injuries around the knee and surgery. Management is guided by the type of initial injury, amount of range-of-motion loss, time since injury, and cartilage status. Cases refractory to conservative management may conventionally be treated with manipulation under anesthesia (MUA), arthroscopic lysis of adhesions, or open quadricepsplasty. We describe our arthroscopic technique of lysis of adhesions with anterior interval release and intraoperative MUA, which has been shown to provide sustainable range-of-motion improvement in a subset of patients with severe knee arthrofibrosis. Although technically demanding, this technique benefits from being minimally invasive, allows for direct visualization of intra-articular structures, and allows all-round arthroscopic release of adhesions to improve patellar mobility and decrease the risk of fracture prior to MUA. A rigorous postoperative formal physical therapy protocol and patient compliance are imperative to achieve good outcomes.

Prediction of Discharge Destination Following Major Hepatectomy

BackgroundAnatomic hepatectomies can be associated with complicated post-operative recoveries, often with discharge to post-acute care facilities. This study identifies preoperative and intraoperative factors associated with increased risk for non-home discharge destination after major hepatectomy. MethodsPatients undergoing major hepatectomy were identified in the NSQIP Targeted Hepatectomy Dataset (2014–2016). Multivariable logistic regression was performed. Patients from 2014 to 2015 were used for training cohort with nomogram generation and 2016 for validation cohort. ResultsOverall, 226 of 3750 patients (6.0%) were discharged to rehab, skilled care, or acute care facilities. Preoperative factors associated with non-home discharge on multivariable analysis were outside patient transfers, older age, presence of ascites, ASA physical status 3 or higher, and low preoperative hematocrit (all p < 0.05). Intraoperative factors significantly predictive were concurrent lysis of adhesions, Pringle maneuver, and biliary reconstruction (all p < 0.05). Predictors from testing cohort were validated in validation cohort. Nomograms based on preoperative variables alone and both preoperative and intraoperative variables were generated. ConclusionWe identify several preoperative and intraoperative factors that are associated with increased risk for non-home discharge after major hepatectomy. Preoperative anemia represents a potentially modifiable risk factor. Nomograms for preoperative planning as well as immediately following surgery were generated.

Patient-related Risk Factors for Postoperative Stiffness Requiring Surgical Intervention After Arthroscopic Rotator Cuff Repair.

Risk factors for stiffness after arthroscopic rotator cuff repair (RCR) have been limited to studies with small patient numbers. The objective is to determine patient-related risk factors for stiffness after RCR. The PearlDiver database was queried from 2007 to 2015 for patients undergoing isolated arthroscopic RCR. A multivariate binomial logistic regression analysis assessed for risk factors requiring a postoperative manipulation under anesthesia (MUA) or lysis of adhesions (LOA) within 9 months after RCR. Two hundred thirty-two of 19,229 patients (1.2%) underwent a LOA and/or MUA within 9 months after arthroscopic RCR. Significant risk factors identified were age less than 50 years (odds ratio [OR], 1.9; P < 0.0001), female gender (OR, 2.0; P < 0.0001), diabetes mellitus (DM) type I (OR, 2.7; P < 0.0001), hypothyroidism (OR, 1.3; P = 0.020), and systemic lupus erythematosus (OR, 2.1; P = 0.004). However, tobacco use was associated with a 0.5 risk of developing stiffness (P < 0.0001). Systemic lupus erythematosus, hypothyroidism, and DMI (but not DMII) in addition to young age and female gender were risk factors for LOA/MUA after arthroscopic RCR.

Preoperative Pneumoperitoneum: Low-Risk Surgical Adjunct to the Surgical Management of Dense Abdominal Adhesions

Surgical lysis of intra-abdominal adhesions is associated with a high rate of complications. This brief report presents 24 patients with dense intra-abdominal adhesions who underwent preoperative progressive pneumoperitoneum (PPP) prior to surgical lysis of adhesions. PPP was successfully performed in 23 patients, with few adverse events, resulting in subjectively improved ease of intraoperative tissue dissection. One patient withdrew due to intractable pain during insufflation. The results suggest that PPP is a low-risk technique with the potential to improve access to intra-abdominal structures in patients for whom conventional surgical therapy is predicted to carry a high rate of complications.

The perceptions of gynecologic oncology fellows on readiness for subspecialty training following OB/GYNRESIDENCY

A recent survey of fellowship program directors (PD) within gynecologic oncology (GO) noted concerns regarding the abilities of incoming fellows. The objective of this study was to evaluate the perceptions of current and former fellows in gynecologic oncology of their readiness for fellowship training. A previously used survey was modified and distributed in 2016 to current and former fellows in GO. The survey explored domains of independent practice, psychomotor ability, clinical evaluation and scholarship. A standard Likert scale was employed and domains/responses were tailored to the subspecialty. A total of 150 current and recently former fellows responded to the survey, for a response rate of 38.7%. Nearly 70% of respondents reported being able to independently perform a hysterectomy when starting fellowship, and nearly 50% felt they could perform lysis of adhesions either without assistance. Although nearly 95% reported having had the opportunity to develop a plan of action for patients on labor and delivery, only 40.7% felt able to independently manage postoperative complications without assistance. Common themes that emerged in the open-ended responses pertained to self-perception of inadequate surgical skills and knowledge specific to gynecologic oncology. Although the majority of current and former fellows in gynecologic oncology report feeling prepared for fellowship, themes noted in the open-ended responses suggest a lack of confidence in surgical skills and clinical knowledge.

Laparoscopic surgery: Any role in patients with unexplained infertility and failed in vitro fertilization cycles?

Patients who undergo several in-vitro fertilization (IVF) treatment cycles and fail to conceive present a frustrating problem to the clinician. When 1 cycle of IVF treatment fails, should we offer the couples to choose additional cycle of IVF instead of evaluation of the potential peritoneal factor? In cases of otherwise unexplained infertility, the investigation cannot be considered to be complete until laparoscopy has been performed. The aim of the study is to investigate the fertility outcome of laparoscopic treatment in infertile women with repeated IVF failures.This is a retrospective case-control study conducted in a tertiary care, academic teaching hospital from January 2012 to December 2015. Patients recruited in this study were classified into 2 groups. Study group (n = 45) were offered laparoscopy for evaluation of infertility, control group (n = 45) elected to proceed to IVF without laparoscopy. Diagnostic laparoscopy and subsequent excision of suspected endometriotic lesions, lysis of adhesion and treatment of tubal pathology were performed when indicated.Forty-four (97.8%) patients in study had pelvic pathologies and the treatment was performed at the same time. Twenty-four patients in study group conceived including 16 patients conceived spontaneously and 14 patients conceived with additional IVF following laparoscopy management. There was a significant difference in the ongoing pregnancy rates between patients conceived through IVF in study group and control group (41.9% vs 19.6%, P < .05).Laparoscopy in women with normal hysterosalpingography but recurrent IVF failures can detect unrecognized pelvic pathologies. Laparoscopy evaluation prior to additional cycle of IVF seems to improve the subsequent pregnancy rate.

Gastric cancer in a post pancreaticoduodenectomy patient with ATM mutation – interesting case

Background: 50 y old female with past history of ampullary cancer diagnosed 10 years prior. Patient underwent a pancreaticoduodenectomy and pathology was consistent with a poorly differentiated T4 lesion which was node negative and margin negative with lymphovascular and perineural invasion. Patient underwent adjuvant chemotherapy followed by chemo-radiation. She was found to have ATM mutation on genetic panel analysis. She was lost to follow up after completing surveillance for 5 years. She presented with anemia several years later and underwent an endoscopy which revealed an ulcerated mass in the stomach just proximal to the gastrojejunal anastomosis. Methods: She underwent endoscopic ultrasound which revealed a T2 lesion and no significant regional lymphadenopathy. Patient underwent staging scans including a PET-CT which did not demonstrate metastatic disease. She underwent oncologic surveillance with mammography and pap smear and gynecologic examination. She was started on perioperative regimen of FLOT (5-FU/leucovorin/oxaliplatin/docetaxel) and was taken to the operating room after restaging scans. Results: She underwent an exploratory laparotomy, extensive lysis of adhesions, subtotal gastrectomy and roux-en-y reconstruction of the biliopancreatic limb and the alimentary limb as well as completion celiac, hepatic and splenic lymphadenectomy with feeding jejunostomy tube placement. Patient was discharged home with an uneventful postoperative recovery. Conclusion: Final pathology demonstrated poorly differentiated diffuse type gastric adenocarcinoma with submucosal invasion( T1N0) with negative margins . Patient to complete perioperative chemotherapy with FLOT and then proceed with surveillance.

Laparoscopic-assisted ERCP

Background: Conventional ERCP has become the gold standard for visualization and extraction of common bile duct stones. Gastric bypass patients pose a unique challenge, especially in a community setting in which double-balloon ERCP is not readily available. Several modalities are available for this patient population, including: PTC, double balloon ERCP, and open/laparoscopic surgery. Our patient―a 71 year old female with history of cholecystectomy and multiple bariatric surgeries, including gastric bypass―was admitted and treated for cholangitis. IV antibiotics per sepsis protocol were initiated and definitive treatment was done by laparoscopic-assisted ERCP. Methods: The procedure was done under general endotracheal anesthesia. Five trocar technique was performed using 12 mm supraumbilical Hasson trocar for camera, 5 mm RUQ, RLQ and LLQ trocars for instruments, and 15 mm RUQ trocar for endoscope. Extensive lysis of adhesions were taken down with combined blunt and sharp dissection using harmonic scalpel and endoshears. The gastric remnant was identified and entered between two stay sutures using harmonic scalpel. Esophagogastroduodenoscope was inserted through 15mm RUQ port and gastrotomy. ERCP was then successfully performed by the gastroenterologist with extraction of two large stones and subsequent visualization of clear biliary tract on fluoroscopy. Gastrostomy was subsequently closed by endo-GIA 65 mm blue load and over-sewn with 3-0 silk sutures. Results: Operative time was approximately 180 minutes including intraoperative ERCP. Blood loss was estimated at 10cc. Successful entry into the gastric remnant and subsequent cannulation of Ampulla of Vater with extraction of 2 large common bile duct stones was achieved71-year-old and subsequent visualization of clear biliary tract on fluoroscopy was seen. The patient tolerated surgery well with normalization of abnormal labs by postoperative day 2 with subsequent discharge home in stable and improved condition. Conclusion: Laparoscopic-assisted ERCP may be a viable treatment modality for patients with history of multiple bariatric surgeries presenting with cholangitis, especially in a community setting where double-balloon ERCP is limited.

32: Incidence and risk factors of early post-operative small bowel obstruction in patients undergoing hysterectomy for benign indications

The objective of this study was to evaluate the incidence of and risk factors for early small bowel obstruction (SBO), occurring within the first month of surgery, after benign hysterectomy. This was a retrospective cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program database from 2014 to 2016. Current Procedural Terminology codes were used to identify patients undergoing hysterectomy for benign indications with or without concomitant colpopexy, lysis of adhesions (LOA), adnexectomy, or appendectomy. Patient demographics, clinical and surgical factors were obtained. Patients were then stratified into those with and without and SBO. Differences between groups were evaluated using Chi-squared and Fisher’s exact tests for categorical variables, and the Student’s t-test for continuous variables. Multivariable logistic regression was used to identify significant independent predictors of SBO. There were 286 (0.06%) occurrences of SBO out of 47,937 hysterectomies. Patients experiencing SBO were more likely to undergo abdominal hysterectomy (72.0% vs 21.2%, p<0.001), LOA (5.2% vs 2.1%, p<0.001), appendectomy (1.7% vs 0.5%, p=0.02), and cystotomy repair (1.0% vs 0.3%, p= 0.002). After logistic regression, mode of hysterectomy was not a significant predictor of SBO, while contaminated and infected wounds (aOR=5.93, 95% CI: 2.71-12.96) and perioperative transfusion (aOR=5.21, 95% CI: 3.66-7.29) were the most significant risk factors. Additional risk factors for early SBO included non-white race (aOR= 1.83, 95% CI: 1.34-2.48), older age (aOR=1.03, 95% CI: 1.02-1.05), prior abdominal or pelvic surgery (aOR=1.45, 95% CI: 1.26-2.60), operating times exceeding 170 minutes (aOR=1.90, 95% CI: 1.39-2.59), uterine weight greater than 250 grams (aOR=1.54, 95% CI: 1.11-2.14), lysis of adhesions (aOR=2.12, 95% CI: 1.24-3.66), and concurrent appendectomy (aOR=2.98, 95% CI: 1.20-7.41). Early small bowel obstruction is a rare complication of benign hysterectomy and is unrelated to route of hysterectomy after adjusting for confounders. Multiple risk factors related to abdomino-pelvic adhesive disease were associated with a higher risk of bowel obstruction.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Intraoperative Consultations to Acute Care Surgery at a Level I Trauma Center

Intraoperative consultations are an important component of acute care surgery (ACS). The nature of these consultations is incompletely characterized by the existing literature. The study objective was to define the characteristics of intraoperative consults managed by a mature ACS program at a Level I trauma center. All intraoperative consultations requested from the ACS service at LAC+USC Medical Center (January 2011-July 2016) were identified. Demographics, date/time of consultation, referring service, procedure data, and outcomes were abstracted. Sixty-four intraoperative consultations were identified. Patients had a mean age of 45 (range 21-64) and 84 per cent (n = 54) were female. Gynecology was the most frequent consulting service (n = 42, 66%), followed by urology (n = 12, 19%). Surgical intervention was required in 61 per cent (n = 39) and verbal advice with clinical follow-up was required in 39 per cent (n = 25). The most common procedures were repair of an injury (n = 19, 49%), usually to the small bowel or colon; resection of an incidental finding (n = 13, 33%), typically the appendix or a Meckel's diverticulum; and lysis of adhesions (n = 7, 18%). In conclusion, intraoperative consultation is provided by ACS to a wide range of consultants, especially gynecology and urology. These consults are most frequently requested for concern for iatrogenic injury. Both surgical and verbal interventions are used.

Minimally Invasive Approach to Surgical Removal of a Retained Broken Needle

A 46-year-old woman presented to our clinic with a history of pelvic pain that started after a total laparoscopic hysterectomy at an outside facility 1 year prior. During the closure of the vaginal cuff with an Endo Stitch (Covidien, Minneapolis, MN), it was noted that a portion of the needle was retained. This could not be located at the time of her surgery. She then underwent a reoperation 6 months later. This consisted of lysis of adhesions and a search for the missing needle with a radical upper vaginectomy and cystoscopy.

Risk Factors for Manipulation Under Anesthesia and/or Lysis of Adhesions Following Anterior Cruciate Ligament Reconstruction

The primary goal of this study was to investigate if government sponsored healthcare patients are more likely to undergo manipulation under anesthesia (MUA) and/ or lysis of adhesion (LOA) to address arthrofibrosis following anterior cruciate ligament reconstruction (ACLR). The secondary goal was to report on other associated factors that may influence the risk of undergoing MUA/LOA.

Incidence and risk factors of early postoperative small bowel obstruction in patients undergoing hysterectomy for benign indications

Small bowel obstruction (SBO) is a major cause of postoperative mortality and morbidity following abdominal and pelvic surgery, with 225,000-345,000 annual admissions. SBO may be classified based on onset from day of surgery. Early SBO occurs within the first 30 days following surgery, whereas late SBO occurs after the initial 30-day postoperative window. The majority of either type of bowel obstruction is believed to be secondary to intra-abdominal adhesions. Early SBO warrants special attention because of the difficulty in distinguishing between mechanical and nonmechanical obstruction during this period. Whereas conservative management often leads to resolution of nonmechanical obstruction and some partial SBO, surgical management is associated with a higher rate of complications compared to surgery for late SBO because of the presence of hypervascular adhesions in the early postoperative period. The current literature regarding SBO, and early SBO in particular, following hysterectomy is limited. Given that approximately 400,000 hysterectomies are performed annually, understanding the risk factors associated with SBO following these types of surgeries is imperative for improving patient outcomes. The objective of this study was to evaluate the incidence of and risk factors for early small bowel obstruction (SBO) after hysterectomy for benign indications. This was a retrospective cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2014 to 2016. Current Procedural Terminology codes were used to identify patients undergoing hysterectomy for benign indications with or without concomitant colpopexy, lysis of adhesions (LOA), adnexectomy, or appendectomy. Data on patient demographics and clinical and surgical factors were obtained. Patients were then stratified into those with and those without SBO. Pairwise comparison was performed using the Wilcoxon rank-sum test and Fisher exact tests. Multivariable logistic regression was used to identify significant independent predictors of SBO. Of 47,937 hysterectomies, SBO occurred in 286 patients, at a rate of 5.9 per 1000 hysterectomies. Comparing patients with and without SBO, those with an obstruction were older (49 vs 46 years, P<.001) and were more likely to smoke (21.0% vs 15.8%, P= .02), to have a history of prior abdominal surgery (73.4% vs 65.4%, P= .005), and to have medical comorbidities such as hypertension and dyspnea. Patients experiencing SBO were also more likely to undergo abdominal hysterectomy (72.0% vs 21.2%, P < .001), adhesiolysis (5.2% vs 2.1%, P < .001), appendectomy (1.7% vs 0.5%, P= .02), and cystotomy repair (1.0% vs 0.3%, P= .002). After logistic regression, route of hysterectomy was not a significant risk factor for SBO, whereas wound class ≥3 (adjusted odds ratio [aOR], 5.96; 95% confidence interval [CI], 2.71-12.99) and perioperative transfusion (aOR, 5.01; 95% CI, 3.54-7.13) were the most significant risk factors. Additional risk factors for early SBO included nonwhite race (aOR, 1.84; 95% CI, 1.33-2.48), increasing age (aOR, 1.04; 95% CI, 1.02-1.05), prior abdominal or pelvic surgery (aOR, 1.49; 95% CI, 1.17-2.03), operating times >170 minutes (aOR, 1.90; 95% CI, 1.37-2.58), uterine weight >250 g (aOR, 1.54; 95% CI, 1.11-2.14), lysis of adhesions (aOR, 2.10; 95% CI, 1.23-3.66), and concurrent appendectomy (aOR, 2.64; 95% CI, 1.06-6.65). Early SBO is a rare complication of benign hysterectomy. Although route of hysterectomy was not found to be a significant risk factor for early SBO, variables typically associated with abdominal hysterectomy compared to minimally invasive hysterectomy, including higher wound class, larger uteri, and perioperative transfusion (a marker of intraoperative blood loss), were strongly correlated with subsequent development of early obstruction.

Optimal Interval of Time from Operative Hysteroscopy to Embryo Transfer in an In Vitro Fertilization Cycle

Study ObjectiveData are limited regarding optimal timing between operative hysteroscopy and embryo transfer (ET). This study aimed to assess whether the time interval from operative hysteroscopy to ET affects implantation and clinical pregnancy rates. DesignRetrospective cohort study (Canadian Task Force classification II-2). SettingPrivate academic center. PatientsAll patients who had operative hysteroscopy followed by a day 5 ET from 2012 to 2017. InterventionInterval of time from operative hysteroscopy to ET. Measurements and Main ResultsThe interval of time from hysteroscopy to ET was calculated, and linear regression analyses were performed to assess the impact on clinical outcome. A subanalysis of patients who underwent subsequent single, euploid, frozen ET(s) was performed. A total of 318 patients were included. Indications for hysteroscopy included polypectomy (n = 205), myomectomy (n = 36), lysis of adhesions (n = 46), septum resection (n = 19), and retained products of conception (n = 12). The mean interval of time from hysteroscopy to ET was 138.4 ± 162.7 days (range, 20–1390). There was no significant difference in mean interval of time between procedure and subsequent ET when comparing patients who achieved and did not achieve implantation. Patients stratified by interval of time from operative hysteroscopy to ET had similar clinical outcomes. The time interval from hysteroscopy had no impact on odds of implantation (odds ratio [OR], 1.001; 95% confidence interval [CI], .999–1.002; p = .49), ongoing pregnancy (OR, 1.001; 95% CI, .999–1.002; p = .42), or early pregnancy loss (OR, .997; 95% CI, .994–1.000; p = .07) (adjusted for oocyte age, recipient age, endometrial thickness, use of preimplantation genetic testing, use of donor egg, fresh vs frozen ET, ET count). Similar results were observed in the subanalysis restricted to euploid single frozen ETs from autologous cycles. ConclusionThe time interval from operative hysteroscopy to subsequent ET does not impact the likelihood of successful clinical outcome. Patients who have undergone operative hysteroscopy do not need to delay fertility treatment.

Thoracoscopic decortication for stage III empyema; a minimal invasive approach in a delayed presentation disease

BackgroundStage III empyema still a problem that thoracic surgeons should deal with. We try to reduce the postoperative pain and hospital stay for those patients with using a minimal invasive approach in every case. MethodsProspective study of all cases assigned for one surgeon with diagnosis of turbid and/or hemorrhagic pleural effusion that showed loculations with thick peal or failed simple chest tube drainage admitted to our thoracic surgery service. An informed consent was taken of a trial for thoracoscopic procedure (VATS) with the possibility of open surgery in case that thoracoscopy fail to proceed. Operative technique was to completely remove the fibrous peel at the surface of the lung without parietal decortication. ResultsForty-seven patients who met the inclusion criteria were assigned for the study, 38 males and 9 females. Mean age was 45.32 (17-82 years). Twenty-eight cases need only drainage and debridement with lysis of fine adhesions without the need for visceral decortication. The remaining 19 cases were subjected to VATS decortication. Of the 19 cases of decortication, 2 cases (10.52%) need conversion to open thoracotomy and one case converted from uniportal to 2 ports approach. All cases of decorication were discharged with mean drainage days of 5.42 (2-30 days). Mean operative time for decortication cases was 116.68 min (86-140 min). ConclusionsStage III empyema is no longer an absolute contraindication for VATS with the fact that not all cases with a preoperative diagnosis of stage III empyema might need decortication. Moreover, VATS decortication is feasible with a reasonable operative time, short hospital stay and no mortality compared to historical control.