Major Abdominal Complications Research Articles

Tomografía computarizada en el posoperatorio de cirugía abdominal mayor

Background: Major abdominal surgeries may present serious postoperative complications that require early diagnosis. Objective: The aim of this study was to determine the usefulness of computed tomography (CT) for the early diagnosis of major abdominal surgery complications. Material and methods: We conducted a retrospective, observational and descriptive study using data obtained from the medical records of patients undergoing major abdominal surgery in a private hospital. Patients were divided into two groups according to the presence or absence of symptoms suggesting a postoperative complication. Patients with symptoms were classified into 3 groups: without CT, with CT with positive findings and with CT without abnormal findings. Results: A total of 154 patients were analyzed; mean age was 61.3 ± 12.5 years and 83 (54%) were male. Of 48 patients (31%) with symptoms suggestive of complications, 6 had very evident symptoms and were re-operated without CT, 7 had positive findings on CT and CT was negative in 14/41. All the patients had findings that supported the decision to re-operate. There were 27 cases (17.5%) with grade 3b complications of the Clavien-Dindo classification and 3 patients (2%) died. Conclusion: Computed tomography was useful to confirm a complication, but not to rule it out. Clinical parameters remain of utmost importance in patients with symptoms and absence of abnormal findings in post-operative CT.

The impact of the 30-day postoperative complications on the quality of life following gastrectomy for gastric carcinoma: A prospective study

BackgroundThe effect of postoperative complications on long-term quality of life (QoL) is controversial in abdominal surgery. This study aimed to investigate the impact of 30-day postoperative complications on long-term QoL after gastrectomy. MethodThis is a longitudinal cohort study that enrolled 908 patients undergoing gastrectomy for gastric cancer between 2016 and 2017. QoL was assessed using the European Organization for Research and Treatment of Cancer (EORTC) generic cancer (QLQ C-30) and gastric module (STO-22) preoperatively and at 1, 6, 12, and 24 months postoperatively. Patients were divided into the morbidity (30-day postoperative complications) and no-morbidity groups, and the postoperative QoL change was compared using a linear mixed model. ResultsThe mean age was 62.5 ± 12.0 years. Subtotal and total gastrectomy was performed in 763 (84.0%) and 145 (16.0%) patients, respectively. There were 189 (20.8%) patients developing postoperative complications. The morbidity group showed worse scores in several functions and symptoms of QoL at the baseline. However, the two groups showed no significant difference in postoperative changes in most functions and symptoms of the QLQ C-30 and STO-22 (Pgroup × time > 0.05). The recovery of global health (Pgroup × time < 0.001) and anxiety (Pgroup × time = 0.008) was slightly better in the morbidity group. The subgroup analysis of patients developing major abdominal complications showed similar results. ConclusionThe morbidity group showed worse QoL in several functions and symptoms at the baseline. However, postoperative complications had little influence on QoL change following gastrectomy for gastric cancer.

Closed-Incision Negative Pressure Therapy Prevents Major Abdominal Donor-Site Complications in Autologous Breast Reconstruction.

Outcomes in autologous breast reconstruction continue to improve with refinements in microsurgical techniques; however, donor-site morbidity remains a concern. Closed-incision negative pressure therapy (ciNPT) has been shown to reduce wound complications. Limited evaluation in abdominal donor sites has shown promising results. We hypothesize that ciNPT will reduce abdominal donor-site complications. A retrospective chart review was performed of patients who underwent abdominally based autologous free tissue transfer for breast reconstruction by 4 microsurgeons at an academic institution from 2015 to 2020. The application of a commercial ciNPT for donor-site management was at the discretion of the operating surgeon. Demographics, operative details, and management of donor-site complications were analyzed. Four hundred thirty-three patients underwent autologous breast reconstruction; 212 abdominal donor sites were managed with ciNPT and 219 with standard dressings. Demographics were statistically similar between groups. Abdominal wound healing complications were noted in 30.2% of ciNPT patients (64/212) and 22.8% of control patients (50/219, P = 0.08); however, overall wound complications were attributed to obesity on multivariable analysis. Closed-incision negative pressure therapy significantly decreased complications requiring reoperation (ciNPT 6.2%, 4/64; control 26.5%, 13/51; P = 0.004). There were no significant differences in surgical site infection rates (P = 0.73) and rates of abdominal scar revisions (ciNPT 11.8%, 25/212; control 9.1%, 20/219; P = 0.37). Use of ciNPT in abdominal donor-site management significantly decreases the incidence of delayed wound healing requiring surgical intervention, with one major wound healing complication prevented for every 6 donor sites managed with ciNPT.

Complications after transesophageal echocardiogram in pediatric patients with gastrostomy tube and/or Nissen fundoplication.

Transesophageal echocardiography (TEE) is frequently used in children with and without congenital heart disease when transthoracic echocardiography is inadequate for visualizing cardiac structures. Recent guidelines state relative contraindications of TEE include post-gastrostomy tube (GT) or Nissen fundoplication surgery. No data exist documenting the incidence of complications in this population after a TEE. Aim of this study was to document the incidence of abdominal complications after TEE in pediatric patients who previously had a GT or Nissen fundoplication. Single institution retrospective study was performed evaluating patients from 2013 through 2020. Patients were included if they had previously undergone a GT or Nissen procedure and subsequently underwent a TEE procedure. Baseline demographics were obtained. Major (esophageal/gastric perforation, oropharyngeal dysphagia, GT displacement, and Nissen breakdown) and minor (abdominal pain, feeding intolerance, and GT leakage) complications were recorded. Total of 34 patients underwent 48 TEE procedures. Age was 6.2±6.6 years (median 3.0 years, .4 - 23.0 years) and weight was 18.5±14.8 kgs (median 12.4 kgs, 4.2 - 57.5kg) at time of TEE. Twenty-nine patients had congenital heart disease. Five patients had a Nissen fundoplication, 14 patients had a GT, and 15 patients had both procedures prior to the TEE. No patient had a major abdominal complication after the TEE. One patient had abdominal pain (2.1%), one patient had feeding intolerance and leakage around the GT site (2.1%), and two patients had leakage around the GT site (4.2%) after the TEE. Patients that experienced complications were significantly younger (1.7±1.1 years vs. 6.6±6.7 years, P<.01) and weighed less (8.7±3.5kg vs. 20.1±15.5kg, P<.01) than those that had no complications. All minor complications resolved with minimal interventions required. In this study, major abdominal complications did not occur after a TEE procedure in pediatric patients that had previous abdominal surgeries. The incidence of minor complications was relatively low and was easily remedied in this patient population. Though a relative contraindication by guidelines, TEE imaging, including transgastric views, can be performed relatively safely in pediatric patients with prior abdominal surgeries if needed.

Perioperative fluid management-Goal Directed Therapy (GDT)

Perioperative goal-directed hemodynamic therapy is a protocolized treatment strategy aimed at optimization of global cardiovascular dynamics, including oxygen delivery to tissues and organ perfusion pressure. This is achieved by titrating fluids, vasopressors, and inotropes to predefined physiological target values of hemodynamic variables. Its scope is to reduce complications (acute kidney disease, pulmonary oedema, respiratory distress syndrome, wound infections), decrease major abdominal and systemic postoperative complications, length of stay and postoperative morbidity and mortality mainly in high-risk patients undergoing major surgery. Identifying patients in whom perioperative goal-directed hemodynamic therapy can actually improve postoperative outcomes is crucial. This is a review focusing on all the aspects of GDFT compared to standard fluid therapy during surgery.

Damage control laparotomy in trauma: a pilot randomized controlled trial. The DCL trial

BackgroundAlthough widely used in treating severe abdominal trauma, damage control laparotomy (DCL) has not been assessed in any randomized controlled trial. We conducted a pilot trial among patients for whom...

Trentino Hernia Team Technique Plus Endoscopic Transversus Abdominis Release for Large Ventral Incisional Hernias: Description of the First Case

Trentino Hernia Team Technique Plus Endoscopic Transversus Abdominis Release for Large Ventral Incisional Hernias: Description of the First Case

The Improved Mediastinal Drainage Strategy for the Enhanced Recovery System After Esophagectomy

The improved drainage strategy was the transperitoneal placement of a single mediastinal drainage tube after esophagectomy. This study aimed to explore its effect on the incidence of postoperative complications, pain scores, and hospital stay. Data from 108 patients who underwent minimally invasive esophagectomy were retrospectively analyzed. Patients were divided into 2 groups: those in group A were treated with transthoracic placement of mediastinal drain and those in group B were treated with transperitoneal placement. The incidence of postoperative complications, pain scores, and postoperative hospital stay were compared. The maximum pain scores in group B were significantly lower than those in group A from the first to the fourth postoperative days (PODs): POD1, 3.9 ± 0.7 vs 2.3 ± 0.7; POD2, 3.5 ± 0.8 vs 2.1 ± 0.7; POD3, 3.3 ± 0.8 vs 1.7 ± 0.8; and POD4, 3.1 ± 0.7 vs 1.7 ± 0.8 (all P<.001). Compared with group A, there were fewer postoperative analgesic drug users in group B (44.6% vs 17.9%; P= .005), fewer cases of pleural effusion (10.7% vs 0%; P= .045), and fewer cases of closed thoracic drainage due to pleural effusion or pneumothorax (14.3% vs 0%; P= .014). There were no significant differences in the incidence of anastomotic leakage, mediastinitis, major pulmonary complications, major abdominal complications, surgical site infection, and total postoperative complications, without statistical differences in postoperative hospital stay and 30-d mortality (all P > .05). The transperitoneal placement of a single mediastinal drain can reduce postoperative pain and the incidence of pleural effusion, without increasing the incidence of other major postoperative complications and postoperative hospital stay.

Readmission With Major Abdominal Complications After Penetrating Abdominal Trauma

BackgroundDespite improvements in operative techniques, major abdominal complications (MACs) continue to occur after penetrating abdominal trauma (PAT). This study aimed to evaluate the burden of MAC after PAT. MethodsThe (2012-2015) National Readmission Database was queried for all adult (age ≥18 y) trauma patients with penetrating injuries who underwent exploratory laparotomy and were readmitted within 6 mo of index hospitalization discharge. Patients were stratified by firearm injuries (FIs) and stab injuries (SIs). Primary outcomes were rates of MAC: intra-abdominal abscesses (IAAs), superficial surgical site infection (SSI), and fascial dehiscence within 6 mo after discharge. Secondary outcomes were both nonabdominal complications and mortality, postdischarge, and 6-mo readmission. Regression analysis was performed. ResultsA total of 4473 patients (FI, 2326; SI, 2147) were included in the study; the mean age was 32 ± 14 y, the Injury Severity Score was 19 (15-25), and 23% underwent damage control laparotomy (DCL). The rate of MAC within 6 mo was 22% (IAA 19%, SSI 7%, and fascial dehiscence 4%). Patients with FIs had a higher rate of IAA (27% versus 10%; P < 0.01), SSI (11% versus 3%; P < 0.01), fascial dehiscence (5% versus 3%; P = 0.03), nonabdominal complications (54% versus 24%; P < 0.01), and postdischarge mortality (8% versus 6%; P < 0.01) compared with patients with SIs . On regression analysis, DCL (P < 0.01), large bowel perforation (P < 0.01), biliary-pancreatic injury (P < 0.01), hepatic injury (P < 0.01), and blood transfusion (P = 0.02) were predictors of MAC. ConclusionsMAC developed in one in five patients after PAT. FIs have a higher potential for hollow viscus injury and peritoneal contamination, and are more predictive of MAC and nonabdominal complications, especially after DCL. Level of EvidenceLevel III Prognostic.

Incidence of infection in non-tunnelled thoracic epidural catheters after major abdominal surgery.

Thoracic epidural analgesia is beneficial after major abdominal surgery, though side-effects and complications are rare but potentially devastating. The incidence of catheter-related infection is approximately 5.5%. Several guidelines have been recommended to prevent complications during thoracic epidural catheterization. Tunnelling is often recommended to reduce the incidence of infections and dislocations. A retrospective, single-centre analysis of our acute pain service database was performed between 2010 and 2018. The hygiene measures of the German Society of Anaesthesiology have been incorporated in our standard operating protocol since 2009. The procedure remained constant, but the skin disinfectant was changed from propan-2-ol to propan-2-ol with octenidine in 2014. Tunnelling of catheters was not performed. We analysed the incidence of catheter-related infections (primary endpoint) and effect of the used disinfectant (secondary endpoint). A total of 2755 patients underwent elective major abdominal surgery with thoracic epidural catheterization. Sixteen patients (0.6%) showed symptoms of mild catheter-related infection. Moderate or severe infections were not observed in any patient. The type of disinfectant did not show any significant effect on the incidence of infection. The incidence of catheter-related infections was low, and only mild signs of infection were observed. Non-tunnelling could be an alternative to tunnelling, especially if hygiene protocols are followed, and the duration of catheter use is short. A comprehensive database and regular examinations by trained staff are essential for early detection of abnormalities and immediate removal of the catheter, if required.

Readmission with Major Abdominal Complications after Penetrating Abdominal Trauma

Readmission with Major Abdominal Complications after Penetrating Abdominal Trauma

Surgical Outcomes after Abdominoperineal Resection with Sacrectomy and Soft Tissue Reconstruction: Lessons Learned.

Abdominoperineal resection (APR), which involves resection of the rectum, anal canal, and perianal skin, results in a large dead space in the pelvis, devascularized tissues, and high bacterial loads. This predisposes to wound complications, especially in the setting of neoadjuvant chemoradiotherapy. Additional sacral resection further compounds these effects. We aimed to assess perineal wound outcomes and complications in patients who underwent flap reconstruction for APR with sacrectomy (APRS) at our institution. We reviewed the charts of all patients who underwent flap reconstruction for APRS over a 20-year period (1999-2018). Medical comorbidities, details of the surgical procedure, and major and minor wound complications were recorded and analyzed. Forty-six patients underwent flap reconstruction following APRS-28 (60%) for colorectal cancer, 8 (17%) for sacral chordoma, and 10 diagnosed with other malignant histologies. Rectus abdominis myocutaneous (RAM) flap reconstruction was used in 42 patients (91%). The median time to the first major perineal complication was 111 days (interquartile range: 22-660 days). Half of our cohort (n = 23) experienced a major perineal complication. No significant differences were found in major or minor perineal or abdominal wall complications between RAM flap and other flaps. APR with high sacrectomy was performed in 27 patients (59%) and was associated with significantly increased full-thickness dehiscence in the perineal region when compared with APR with low sacrectomy, 33 versus 0%, respectively (p = 0.0076). Complete flap loss occurred in one patient. The RAM flap was the workhorse flap for pelvic reconstruction following APRS in our cohort. Wound complications are common following APRS. High sacrectomy is associated with higher incidence of complications compared with low sacrectomy. Optimal surgical planning and patient counseling is fundamental to improve current surgical outcomes.

Effect of damage control laparotomy on major abdominal complications and lengths of stay: A propensity score matching and Bayesian analysis.

In patients for whom surgical equipoise exists for damage control laparotomy (DCL) and definitive laparotomy (DEF), the effect of DCL and its associated resource utilization are unknown. We hypothesized that DEF would be associated with fewer abdominal complications and less resource utilization. In 2016, six US Level I trauma centers performed a yearlong, prospective, quality improvement project with the primary aim to safely decrease the use of DCL. From this cohort of patients undergoing emergent trauma laparotomy, those who underwent DCL but were judged by majority faculty vote at each center to have been candidates for potential DEF (pDEF) were prospectively identified. These pDEF patients were matched 1:1 using propensity scoring to the DEF patients. The primary outcome was the incidence of major abdominal complications (MAC). Deaths within 5 days were excluded. Outcomes were assessed using both Bayesian generalized linear modeling and negative binomial regression. Eight hundred seventy-two total patients were enrolled, 639 (73%) DEF and 209 (24%) DCL. Of the 209 DCLs, 44 survived 5 days and were judged to be patients who could have safely been closed at the primary laparotomy. Thirty-nine pDEF patients were matched to 39 DEF patients. There were no differences in demographics, mechanism of injury, Injury Severity Score, prehospital/emergency department/operating room vital signs, laboratory values, resuscitation, or procedures performed during laparotomy. There was no difference in MAC between the two groups (31% DEF vs. 21% pDEF, relative risk 0.99, 95% credible interval 0.60-1.54, posterior probability 56%). Definitive laparotomy was associated with a 72%, 77%, and 72% posterior probability of more hospital-free, intensive care unit-free, and ventilator-free days, respectively. In patients for whom surgeons have equipoise for DCL versus definitive surgery, definitive abdominal closure was associated with a similar probability of MAC, but a high probability of fewer hospital-free, intensive care unit-free, and ventilator-free days. Therapeutic/care management, level III.

Volume change in the rectus abdominis muscle after deep inferior epigastric perforator flap harvest

Deep inferior epigastric perforator (DIEP) flap is associated with less donor site morbidity than transverse rectus abdominis myocutaneous flap. However, abdominal muscle atrophy and donor site complications caused by denervation during pedicle dissection cannot be avoided. This retrospective study investigated the change in the rectus abdominis muscle volume after DIEP flap harvest. Of 395 patients who underwent unilateral DIEP flap breast reconstruction between August 2007 and July 2017, 25 patients with >2-year postoperative abdominal computed tomography data were evaluated. Preoperative and postoperative images of the abdominal muscle after pedicle dissection and the nonoperated side were compared. The volume of the muscles from the lower margin to the umbilicus was determined by using OsiriX image analysis application. The muscle volumes on the side of pedicle dissection decreased from 72.63 ± 23.29 cm3 preoperation to 53.09 ± 16.93 cm3 postoperation (p < 0.001). The corresponding volumes on the side without dissection were 73.29 ± 19.25 cm3 and 60.89 ± 18.79 cm3 (p < 0.001). The percentage of postoperative retained volume relative to the preoperative retained volume was 75.65% ± 19.18% on the pedicle dissection side and 84.65% ± 19.00% on the contralateral side. The 9% difference was not statistically significant (p = 0.10). No major abdominal complications were observed. Despite nerve injury during DIEP flap surgery, the volume loss of the involved and contralateral muscles did not differ. More than 75% of the abdominal muscle volume was retained. Muscle integrity was well maintained without any postoperative complications.

The effect of damage control laparotomy on major abdominal complications: A matched analysis

IntroductionDamage control laparotomy (DCL) for trauma is thought to be associated with increased abdominal complications. The purpose of this study is to determine the effect of DCL on abdominal complications by comparing two groups of trauma patients: DCL patients who were prospectively adjudicated to potentially being closed at the primary laparotomy (potential DEF or pDEF) and those who underwent definitive laparotomy (DEF). MethodsThe pDEF group was matched to DEF patients according to mechanism of injury, abdominal injury severity, operating room transfusions, and performance of a colon resection. The primary outcome was major abdominal complications (MAC), a composite variable. ResultsNo statistically significant difference in the primary outcome, major abdominal complications, were seen (pDEF 19% versus DEF 56%, p = 0.066). The pDEF group was more likely to have a fascial dehiscence (38% versus 0%, p = 0.018), and to be re-opened after fascial closure (38% versus 0%, p = 0.018). ConclusionDamage control laparotomy was associated with clinically but not statistically significant increase in rates of MAC. Increased numbers of patients to analyze in this fashion is needed.

Damage control laparotomy trial: design, rationale and implementation of a randomized controlled trial

BackgroundDamage control laparotomy (DCL) is an abbreviated operation intended to prevent the development of hypothermia, acidosis, and coagulopathy in seriously injured patients. The indications for DCL have since been broadened...

A Randomized Trial of Goal Directed vs Standard Fluid Therapy in Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy

The use of adequate fluid therapy during cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) remains controversial. The aim of the study was to assess whether the use of fluid therapy protocol combined with goal-directed therapy (GDT) is associated with a significant change in morbidity, length of hospital stay, and mortality compared to standard fluid therapy. Patients American Society of Anesthesiologists (ASA) II–III undergoing CRS and HIPEC were randomized into two groups. The GDT group (N = 38) received fluid therapy according to a protocol guided by monitored hemodynamic parameters. The control group (N = 42) received standard fluid therapy. We evaluated incidence of major complications, total length of hospital stay, total amount of fluids administered, and mortality rate. The incidence of major abdominal complications was 10.5 % in GDT group and 38.1 % in the control group (P = 0.005). The median duration of hospitalization was 19 days in GDT group and 29 days in the control group (P < 0.0001). The mortality rate was zero in GDT group vs 9.5 % in the control group (P = 0.12). GDT group received a significantly (P < 0.0001) lower amount of fluid (5812 ± 1244 ml) than the control group (8269 ± 1452 ml), with a significantly (P < 0.0001) lower volume of crystalloids (3884 ± 1003 vs 68,528 ± 1413 ml). In CRS and HIPEC, the use of a GDT improves outcome in terms of incidence of major abdominal and systemic postoperative complications and length of hospital stay, compared to standard fluid therapy protocol.

Pulmonary embolism: specific risk factor after pancreas resection?

Pulmonary embolism (PE) after major abdominal surgery is a serious and potentially lethal complication. The purpose of the present study was to identify risk factors for postoperative PE after pancreas resection. Our prospective database for pancreatic surgery was retrospectively analyzed for patients treated between January 2006 and August 2012 in a tertiary care Swiss hospital. Risk factors for PE were identified in univariate and multivariate analyses that included preoperative, intraoperative, and postoperative variables. Among 251 patients, 187 underwent pancreato-duodenectomy (PD), 62 underwent distal pancreatectomy, and 2 underwent other types of pancreas resections. PE was diagnosed in 13 patients (7.0%) after PD and none after other procedures. Compared with the non-PE group, the PE group had higher body mass indices (≥25 kg/m, P = 0.04), longer median operation times (P = 0.009), higher rates of severe abdominal complications (P < 0.001), longer median intensive care unit stays (P = 0.003), and longer hospital stays (P = 0.01). Multivariate analyses identified the following independent predictors for PE: a history of thromboembolic events (odds ratio [OR], 22.3), prolonged operation time (OR, 5.76), and major abdominal complications (OR, 10.8). Prolonged operation times and major postoperative abdominal complications were strong risk factors for PE after PD, in both univariate and multivariate analyses.

Using Propensity Score Analysis to Compare Major Complications between DIEP and Free Muscle-Sparing TRAM Flap Breast Reconstructions

Previous studies comparing muscle-sparing transverse rectus abdominis myocutaneous (TRAM) versus deep inferior epigastric artery perforator (DIEP) free flaps have not considered procedure selection bias. Propensity score analysis provides a statistical approach to consider preoperative factors in flap selection, and was used to compare major complications (breast and abdominal) between these microsurgical breast reconstruction (free muscle-sparing TRAM versus DIEP). This study evaluated major breast and abdominal complications in 292 consecutive patients (428 free abdominal flaps). Propensity scores were calculated for patient differences affecting flap selection (DIEP versus free muscle-sparing TRAM). Multivariate logistic models using selected covariates separately analyzed breast and abdominal complications between flap methods. There were 83 major complications (28 percent): breast, 20 percent; abdomen, 8 percent. Using propensity scores, the adjusted odds of abdominal complications were significantly higher in free muscle-sparing TRAM than in DIEP flaps (OR, 2.73; 95 percent CI, 1.01 to 7.07). With prior chemotherapy, body mass index significantly increased abdominal complications (OR, 1.16; 95 percent CI, 1.01 to 1.34). Using propensity scores, there was no significant association between reconstruction method and breast complications; diabetics had significantly increased breast complications (OR, 4.19; 95 percent CI, 1.14 to 15.98). Previous abdominal operations (OR, 1.77; 95 percent CI, 0.96 to 3.30) and immediate reconstruction (OR, 1.86; 95 percent CI, 0.94 to 3.71) approached significance. Propensity score analysis indicated significantly higher abdominal complications in free muscle-sparing TRAM compared with DIEP flaps. This study highlights the importance of separately evaluating recipient breast and donor abdominal complications and use of propensity scores to minimize procedure selection bias. Therapeutic, III.

Death After Elective Major Abdominal Resection's Intraoperative Data and Major Complications in the First 5 Postoperative Days Provide Little Additional Prediction Capability Over Preoperative Data Alone

Death After Elective Major Abdominal Resection's Intraoperative Data and Major Complications in the First 5 Postoperative Days Provide Little Additional Prediction Capability Over Preoperative Data Alone