Normal Postoperative Course Research Articles

Eras: is it possible to follow it in a tertiary government hospital set up?

Background: Fast-track surgery (enhanced recovery after surgery) is a set of protocols to reduce surgical trauma and postoperative stress by decreasing pain and complications, improving outcomes and decreasing length of hospital, while expediting recovery following elective procedures without an increase in complications or readmission.Methods: This was a prospective study over 2 years from March 2015 to February 2017 with 6 months follow up. 647 patients undergoing elective general surgery were followed up. Details regarding the age, sex, health status parameters and diagnosis collected. Preoperative evaluation, operative parameters and postoperative complications recorded. Post-operative course in hospital and any deviation of normal post-operative course and its management recorded and analyzed.Results: In government hospital (MKCG Medical College, Berhampur, Odisha), following ERAS protocol completely is impossible. But most protocols in preoperative, intraoperative, postoperative phases were followed, leading to early discharge of patients without any complications in most cases. In my study, drains were given in 157 cases, nasogastric tube in 89 abdominal surgeries. 129 cases were performed under general anaesthesia and 518 cases under spinal/epidural/mid thoracic epidural anaesthesia. 60 underwent overnight fasting. All received carbohydrate loading, antibiotic prophylaxis, thrombo-prophylaxis before surgery. Bowel preparation done in 50 abdominal surgeries.Conclusions: The study provided a strong evidence that ERAS is safe to practice in elective general surgeries. It is associated with decreased incidence of complications, significant reduction in duration of hospitalisation and reduction in overall morbidity and decreased rate of re-admission. Thus, improves patient’s compliance.

Patients with a Normal Pressure Hydrocephalus Shunt Have Fewer Complications than Do Patients with Other Shunts.

Ventriculoperitoneal (VP) shunting is a well-established therapy for hydrocephalus. However, complications are frequent. The incidence of idiopathic normal pressure hydrocephalus (NPH) increases with the aging of the population. We evaluated the functional status of patients and the classification of complications associated with VP shunt procedures in our center. We recorded all VP shunt procedures in our prospective patient registry from January 2013 to December 2015. Functional outcome (Karnofsky Performance Status [KPS] and modified Rankin Scale) and complications were compiled from patient records. Any deviation from the normal postoperative course within 3 months after surgery was considered a complication. Complications were classified with the therapy-oriented Clavien-Dindo grading system. We evaluated potential risk factors with a logistic regression model. From 285 procedures in the reporting period, 90 were excluded, resulting in 195 patients. Among those patients, 174 (90%) were shunt implantations and 21 (11%) were shunt revisions. Forty-four shunts (23%) were implanted for NPH. Median KPS improved over the first year after surgery. Although some type of complication was observed in 114 patients (58%), 60 of those complications (31%) did not require surgical treatment (Clavien-Dindo grade <3). In 50 patients (26%), the complication concerned the shunt itself. A high KPS at admission and NPH as underlying indication significantly reduced the odds ratio for a complication. Although shunt surgery has a high general rate of complications, this rate is significantly lower for patients with NPH. The decision for shunting in patients with NPH should consider the low complication rate specific for the group of patients with NPH.

Validating a therapy-oriented complication grading system in lumbar spine surgery: a prospective population-based study

The aim of the present study was to validate a therapy-oriented complication grading system in a well-defined neurosurgical patient population in which complications may entrain neurological deficits, which are severe but not treated. The prospective patient registry of the Department of Neurosurgery, University of Zurich provides extensive population-based data. In this study we focused on complications after lumbar spine surgeries and rated their severity by Clavien-Dindo grade (CDG). Analyzing 138 consecutive surgeries we noted 44 complications. As to treatment, CDG correlated with the length of hospital stay and treatment cost. As to patient outcome, CDG correlated with performance and outcome (McCormick). The present study demonstrates the correlation between outcome scales and the CDG. While the high correlation of CDG with costs seems self-evident, the present study shows this correlation for the first time. Furthermore, the study validates the CDG for a surgical subspecialty. As a further advantage, CDG registers any deviation from the normal postoperative course and allows comparison between surgical specialties.

Register of Difficult Surgical Situations

Every surgical problem that increases the likelihood of intraoperative and postoperative complications is considered to be a difficult surgical situation. Based on this definition, Korenkov et al. proposed to classify patients according to the following intraoperative difficulty levels (I to IV): (I) ideal situation (easy to operate, no problems), (II) fairly easy/manageable/simple (some minor difficulties may occur), (III) difficult/problematic (difficult to operate; some operative techniques are considerably more difficult than others), and (IV) very difficult (every operative step is difficult/challenging). Kaafrani et al. proposed a severity classification for intraoperative adverse events. Depending on the severity level, classes range from I (injury requiring no repair) to VI (intraoperative death). Clavien and colleagues published a globally established classification system for postoperative complications. In this classification, the severity of postoperative complications ranges from severity grade I (minimal deviation from the normal postoperative course) to severity grade V (death of patient). Based on the proposed classifications and the problems of individual surgical decision-making, we had the idea to create a Register of Difficult Intraoperative Situations (DIS register). The basic principle of such a register is the collection of an individual expert's experiences. The scientific analysis should focus on patients with apparent modifications in treatment due to difficult intraoperative situations. Registration and processing of enrolled cases will be performed anonymously based on an appropriate IT platform. The main goal of this register is to develop an accessible database for practising surgeons. This will provide an opportunity for every surgeon to find out what other surgeons did in similar situations.

An Unexpected Cause of Acute Coronary Syndrome: Iatrogenic Right Coronary Dissection as a Delayed Complication after Valve Replacement Surgery

&lt;p&gt;&lt;strong&gt;Highlights&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;Coronary artery dissection is an unfrequent complication, which in an important number of cases has a iatrogenic cause. Most of them occur after a percutaneous procedure, and usually the right coronary artery is the one affected.&lt;/p&gt;&lt;p&gt;We report the case of a iatrogenic right coronary dissection after valve replacement surgery. The cause was assumed to be the antegrade cannulation of the ostium for cardioplegic perfussion.&lt;/p&gt;&lt;p&gt;What we consider particularly interesting about this case is that it had a delayed clinical manifestation, 9 days after surgery, having a normal immediate post-operative course. The diagnosis was achieved by coronary angiography, and no interventional treatment was performed.&lt;/p&gt;

Red eye after strabismus surgery: community-acquired MRSA periocular infection

A 4-year-old boy with A-pattern alternating exotropia presented to the Duke Eye Center with conjunctival injection and eyelid inflammation 3 weeks following strabismus surgery and a normal postoperative course. Examination in the office demonstrated an elevated, cream-colored lesion of the superotemporal fornix of the left eye. This surgical video demonstrates the incision and drainage of the presumed subconjunctival abscess of the left eye. Cultures from the eye and two cutaneous lesions on the patient’s extremities grew methicillin-resistant Staphylococcus aureus , indicating that a community-acquired MRSA skin infection had likely seeded the distant ophthalmic surgical site.

How to treat post-operative complications: An evidence-based approach.

Post-operative complication can be defined as any deviation from the normal post-operative course. The majority of post-operative complications affects the subgroup of high-risk patients, and they are clearly associated with increased hospital length of stay and mortality. This review deals with the principal complications occurring during the post-operative period. In particular, we describe the preventive and management strategies to face pulmonary, cardiac, renal and neurological complications.

The Experience of Robotic-Assisted Laparoscopic Hysterectomy for Women Treated for Early-Stage Endometrial Cancer: A Qualitative Study.

An increasing number of women are offered robotic-assisted laparoscopic hysterectomy as treatment for early-stage endometrial cancer in the developed world. The aim of this study was to explore how women diagnosed with early-stage endometrial cancer experienced robotic-assisted laparoscopic hysterectomy. Semistructured interviews were carried out with 12 women, and interview data were analyzed by qualitative content analysis. Four overarching themes emerged: "surgery was a piece of cake," "recovering physically after surgery," "going from being off guard to being on guard," and "preparing oneself by seeking information." The women had confidence in the robotic technique and experienced fast recovery after robotic-assisted laparoscopic hysterectomy; however, they had uncertainties and unanswered questions concerning the postoperative course. Shortly after discharge, the women did not consider themselves surviving cancer patients but as cured. The women searched for information from various sources, for example, the Internet and the online patient chart, to prepare for surgery and to come to terms with the diagnosis. Although the women had confidence in the robotic technique and recovered quickly physically, they lacked information about what went on in the operation theatre and about their new anatomy. Patient education about the normal postoperative course in regard to vaginal bleeding, bowel function, and level of physical activity is needed. Individualized information about anatomical changes after surgery is warranted, preferably using anatomical drawings. Potentially, the women could benefit from attending a nursing clinic during the first postoperative months.

Clinical evaluation of fast track protocol versus standard care in patients undergoing elective colorectal surgeries

Background: Colo rectal surgeries are on the rise given colorectal carcinoma being the third most common cancer globally affecting more than 1 million people every year. Apart from carcinoma colo rectal surgeries are performed for severe inflammatory bowel diseases, strictures, diverticular diseases etc. The traditional approach to colo rectal surgery has been associated with high morbidity subjecting the patient to unnecessary preparations and prolonged hospital stay. Fast-track surgery consists of a protocol of evidence-based techniques to reduce surgical trauma and postoperative stress by minimizing pain, reducing complications, improving outcomes, and decreasing length of hospital stay while expediting recovery following elective procedures. Fast track protocols for colorectal surgery patients were developed to reduce physiological stress and postoperative organ dysfunction through optimization of perioperative care and recovery. Methods: A total of 40 patients who are undergoing any elective colo-rectal surgeries will be included in the prospective study. Details regarding the age, sex and diagnosis were collected. Operative parameters and post-operative complications were recorded. Post-operative course in hospital and any deviation of normal post-operative course and its management is recorded and analyzed. Results: The overall complication rates were significantly higher in the control group as compared to the Fast track group (p<0.05). The duration of stay was found to be significantly shorter in the study group (mean 8.8 days Vs 11.7 days). Conclusions: This evaluation provides strong evidence that the fast track approach is safe in colo-rectal surgeries and is not associated with increased incidence of complications. It results in significantly reduced duration of hospitalisation and reduction in overall cardio-pulmonary morbidity and complications.

Surgical Treatment of Enormous Recurrent Dermatofibrosarcoma Protuberans.

A patient with enormous recurrent dermatofibrosarcoma protuberans underwent modified three-dimensional histology surgery. Frozen-section examination was used to identify the margins. The patient had a normal postoperative course.

Assessment of complications according to the Clavien-Dindo classification after distal pancreatectomy.

The absence of a definition and a widely accepted ranking system to classify surgical complications has hampered proper interpretation of the surgical outcome. Sixty-one patients undergoing distal pancreatectomy. The complications were classified according to the Clavien-Dindo classification; each grade was evaluated regarding the length of the postoperative stay and was compared to the most important complications. Thirty (49.2%) patients had no complications; out of the thirty-one (50.8%) patients with complications, 9 (14.5%) had grade I, 15 (24.6%) had grade II, 6 (9.8%) had grade III, and 1 (1.6%) had grade IV. There were no postoperative deaths (grade V). A progressive increase in the length of hospitalization from patients with no complications to those having grade IV (P < 0.001) was noted. Postoperative pancreatic fistula and postpancreatectomy hemorrhage rates did not significantly increase from Clavien-Dindo grade I to grade IV (P = 0.118 and P = 0.226, respectively). The severity of a postpancreatectomy hemorrhage, instead, was positively related to the grade of the Clavien-Dindo classification (P = 0.049) while postoperative pancreatic fistula resulted near the significant value (P = 0.058). The Clavien-Dindo classification is a simple way of reporting all complications following distal pancreatectomy. It allows us to distinguish a normal postoperative course from any deviation and the severity of complications and it may be useful for comparing postoperative morbidity between different pancreatic centers.

Revision of Carpal Tunnel Release due to Palmaris Longus Profundus.

Purpose. The palmaris longus profundus has been documented throughout the literature as a cause of carpal tunnel syndrome. We present a case of palmaris profundus tendon removal during the revision of carpal tunnel release. Method. During a carpal tunnel release in a 66-year-old woman, palmaris profundus tendon was found inside the tunnel under the transverse carpal ligament, just above the median nerve, but it was left intact. The patient complained of pain in the hand at night and weakness of her hand one month after surgery. We decided on a revision of the carpal tunnel release. The palmaris profundus tendon was found and was removed. Results. The patient had a normal postoperative course. Two months later she returned to her normal activities and was asymptomatic. Conclusions. When a palmaris profundus muscle is located in carpal tunnel, we recommend its excision during carpal tunnel release. This excision will eliminate the possibility of recurrent compression over the median nerve.

Inguinal hernia repair using a synthetic long-term resorbable mesh: results from a 3-year prospective safety and performance study.

PurposeConventional meshes for hernia repair and abdominal wall reinforcement are usually made from polypropylene, polyester or other synthetic plastic materials known to promote foreign body reactions and a state of chronic inflammation that may lead to long-term complications. A novel approach is to use long-term resorbable implants like TIGR® Matrix Surgical Mesh. Preclinical studies have shown that this mesh maintains mechanical integrity beyond the point in time where newly formed tissue is capable of carrying the abdominal loads.MethodsThis was a first-in-man, prospective, pilot study performed during 2009, at two sites in Sweden. Forty patients with primary inguinal hernias were enrolled for Lichtenstein repair using TIGR® Matrix Surgical Mesh. The primary endpoint was safety as assessed by monitoring the incidence of adverse events and serious adverse events (SAEs) both related and unrelated to the mesh. The secondary endpoint was pain or discomfort. Visual Analogue Scale (VAS) 0–10 and Inguinal Pain Questionnaire were used for scoring pain and discomfort. Included patients have been followed for 36 months using ultrasound in combination with clinical examination.ResultsAll patients followed a normal early postoperative course. After 12 months no SAEs were reported. None of the patients with an isolated lateral inguinal hernia (LIH) had developed a recurrence but 4 (44 %) with medial and 4 (33 %) with combined hernias had recurred at 36-month follow-up. After 3-year follow-up none of the patients with LIH reported pain in the VAS-form and none of those patients could feel the sensation of a mesh in their groin. In the total study population 5 (16 %) patients experienced chronic pain in the form of mild sporadic pain and 3 (9.7 %) patients could feel the sensation of a mesh in their groin.ConclusionThe use of a synthetic long-term resorbable mesh (TIGR® Matrix Surgical Mesh) in Lichtenstein repair was found to be safe, without recurrences, and promising regarding pain/discomfort at 3-year follow-up in patients with LIH. However, patients with medial and combined inguinal hernias had high recurrence rates.

Early Rise in C-Reactive Protein Is a Marker for Infective Complications in Laparoscopic Colorectal Surgery

Infective complications are the most significant cause of morbidity associated with elective colorectal surgery. It can sometimes be difficult to differentiate complications from the normal postoperative course. C-reactive protein (CRP) is an acute phase reactant which has been reported to be predictive of postoperative infective complications. Between July 2010 and June 2012, 169 patients underwent elective laparoscopic colorectal surgery. Daily postoperative CRP was measured until discharge and infective complications were observed. A total of 169 patients underwent laparoscopic colorectal surgery. Twenty-one (12.4%) had infective complications, 6 (3.6%) had anastomotic leaks. There was a significant difference in CRP levels between those with infective complications and those without infective complications on postoperative days 3 and 5 (day 3 postop, P=0.0001; day 5 postop, P=0.0001). Of those with infective complications, there was a significant difference between CRP levels when comparing preoperative levels with those on day 3 and day 5 (preoperative vs. day 3, P=0.0001; preoperative vs. day 5, P=0.0003). A raised CRP is a predictor of infective complication from day 3 (odds ratio 1.012, P<0.001) where as white cell count is not an accurate predictor. A CRP cutoff of 148 on day 3 provided the highest sensitivity and specificity of predicting infective complications, 86% and 77%, respectively. CRP is effective as an early predictor of infective complications after laparoscopic colorectal surgery and may be a useful adjunct in conjunction with an enhanced recovery program in reducing morbidity. A CRP of >148 mg/mL on postoperative day 3 or a persistently elevated CRP should heighten clinical suspicion of an infective complication.

Bilateral Laparoscopic Postchemotherapy Retroperitoneal Lymph-Node Dissection in Nonseminomatous Germ Cell Tumors–a Comparison to Template Dissection

Retroperitoneal lymph node dissection (RPLND) is performed in patients with advanced nonseminomatous (NSGCT) germ cell tumors and residual retroperitoneal mass post-chemotherapy. The extent of node dissection remains unclear. Ipsilateral template dissection is a compromise between morbidity and oncological efficacy. Here, we compare ipsilateral with primary bilateral laparoscopic (L)-RPLND after chemotherapy in terms of morbidity and oncological safety. Nineteen laparoscopic ipsilateral L-RPLNDs (Group A) after platinum-based chemotherapy in patients with clinical stage IIA-III NSGCT were performed, while 20 patients underwent primary bilateral L-RPLND (Group B). We included patients with residuals localized in the retroperitoneum >1 cm and a tumor marker negativity after chemotherapy. The patients in group B had nerve sparing based on their respective tumor volume. All L-RPLND was successfully finished without conversion. Mean operative time in group A was 221 minutes and 270 minutes in group B (p=0.12). There were no deviations from the normal postoperative course in 36 cases. There was one Grade II complication (bleomycin-induced pneumonitis) in group A and 1 grade III complication (chylous ascites) in group B. The mean hospitalization time in both groups was 5 days (p=0.1). With regard to the overall rate of disease recurrence, no significant difference was found between both groups (HR=1.84; 95% CI 0.17-39.92; p=0.6109). Postchemotherapy L-RPLND remains technically challenging. However, the morbidity of primary bilateral post-chemotherapy L-RPLND is similar to that of template dissection. Additional oncological safety is provided, which is particularly relevant in patients with more extensive retroperitoneal tumor volume.

Is Pyloric Gland Metaplasia in Ileal Pouch Biopsies a Marker for Crohn’s Disease?

Approximately 5-10 % of ulcerative colitis (UC) patients who undergo ileal pouch-anal anastomosis (IPAA) will develop postoperative complications such as refractory pouchitis or a change in diagnosis to Crohn's disease (CD). Serological markers and histologic aspects of the pouch such as pyloric gland metaplasia (PGM) have been associated with a risk for these complications. Twenty-eight IPAA patients with either CD of the pouch or chronic pouchitis (cases) and 36 IPAA controls who experienced a normal postoperative course were originally consented. Of these 64 subjects, 22 cases and 17 controls had histopathologic and serologic data available and were subsequently enrolled. Demographic and clinical data were entered into a database, blood analyzed for serological markers (Prometheus Labs, San Diego, CA) and biopsies of the pouch and the afferent limb reviewed by two GI pathologists. Of the cases, 55 % (12/22) had evidence of PGM in their pouch and/or small bowel biopsies, as compared to 12 % (2/17) of the controls (p = 0.006). Of 13 subjects with CD, 77 % (10/13) were found to have PGM versus subjects with chronic pouchitis in which 22 % (2/9) were found to have PGM (p = 0.03). There was a trend of ASCA positivity (both IgG and IgA, p = 0.20) and of higher ASCA titer levels (p = 0.07) with postoperative complications. This study suggests that the presence of ileal pouch PGM is associated with postoperative complications and favors a diagnosis of CD over UC with chronic pouchitis.

Atypical Hemorrhagic Presentation of a Fourth Ventricle Subependymoma: Case Report

To present a case of a fourth ventricle subependymoma (SE) with a spontaneous acute subarachnoid intra-cisternal bleeding. A 33-year-old man was admitted with 5 days history of oppressive occipital headache and neck pain without additional neurological focus. Unenhanced computed tomography (CT) scan demonstrated an isointense mass located in the fourth ventricle with a spontaneously hyperdense acute extratumoral hemorrhage in the cisterna magna. Contrast-enhanced magnetic resonance imaging (MRI) revealed a well-delimitated non-enhanced tumor, hypointense on T1-weighted and hyperintense on T2-weighted images, involving the floor of the fourth ventricle and extending caudally into the cervical spinal canal via foramen magnum. Intraoperative, a large blood clot was removed and a macroscopically hypovascularlesion was completely excised from the right lateral recess and the floor of the fourth ventricle. Intra and postoperative immuno-histopathological examination revealed a SE. The patient has a normal postoperative course and was discharged in the fifth postoperative day. A 10-month postoperative MRI study confirmed a complete tumor resection. Symptomatic SEs should be surgically treated emphasizing the urgency in the presence of hemorrhage. The interest of this case is to demonstrate that infratentorial SEs although extremely rare, might present with acute subarachnoid bleeding.

Inflammatory markers sampled by microdialysis catheters distinguish rejection from ischemia in liver grafts

Rejection and ischemia are serious complications after liver transplantation. Early detection is mandatory, but specific markers are largely missing, particularly for rejection. The objective of this study was to explore the ability of microdialysis catheters inserted in liver grafts to detect and discriminate rejection and ischemia through postoperative measurements of inflammatory mediators. Microdialysis catheters with a 100-kDa pore size were inserted into 73 transplants after reperfusion. After the study's completion, complement activation product 5a (C5a), C-X-C motif chemokine 8 (CXCL8), CXCL10, interleukin-1 (IL-1) receptor antagonist, IL-6, IL-10, and macrophage inflammatory protein 1β were analyzed en bloc in all grafts with biopsy-confirmed rejection (n = 12), in grafts with vascular occlusion/ischemia (n = 4), and in reference grafts with a normal postoperative course of circulating transaminase and bilirubin levels (n = 17). The inflammatory mediators were elevated immediately after graft reperfusion and decreased toward low, stable values during the first 24 hours in nonischemic grafts. In grafts suffering from rejection, CXCL10 increased significantly (P = 0.008 versus the reference group and P = 0.002 versus the ischemia group) 2 to 5 days before increases in circulating alanine aminotransferase and bilirubin levels. The area under the receiver operating characteristic curve was 0.81. Grafts with ischemia displayed increased levels of C5a (P = 0.002 versus the reference group and P = 0.008 versus the rejection group). The area under the curve was 0.99. IL-6 and CXCL8 increased with both ischemia and rejection. In conclusion, CXCL10 and C5a were found to be selective markers for rejection and ischemia, respectively.

Inadvertent insertion of a nasogastric tube into the brain: case report and review of the literature

The inadvertent insertion of a nasogastric tube (NGT) into the brain of a trauma patient with skull base fractures is reported. A 52-year-old male with head trauma was referred following a car accident with an NGT in situ. Serosanguineous fluid was withdrawn from the NGT, which was considered to be an indication of gastrointestinal bleeding, and cold saline lavage was performed. Skull X-rays revealed intracranial position and coiling of the NGT and pneumocranium. The NGT was immediately removed manually. The patient finally went through neurosurgical operation because of an extradural hematoma, with normal postoperative course and outcome.

Parapharyngeal space hemangiopericytoma treated with surgery and postoperative radiation- a case report

Hemangiopericytoma (HPC) is a rare tumor of uncertain malignant potential arising from mesenchymal cells with pericytic differentiation. It accounts for 3-5% of soft tissue sarcomas and 1% of vascular tumors. It usually presents in 5th to 6th decade of life. Most common sites are limbs, pelvis and head and neck. About 20% of all hemangiopericytomas are seen in head and neck, mostly in adults. Usually it presents in orbit, nasal cavity, oral cavity, jaw, parotid gland, parapharyngeal space, masticator space and jugular foramen. Long term follow up is important because of imprecise nature of the histological criteria for prediction of biologic behavior.We report herein a case of HPC in 66-year-old man, who presented in our department with headache, nasal obstruction and dysphagia. A neck computer tomography scan and magnetic resonance imaging showed a large left parapharyngeal mass bulging into nasopharynx and oropharynx with extension to pharyngeal mucosal surface and causing narrowing of airways and total obstruction of left posterior nostril. Angiography showed a highly vascular neoplasm. Initially he was managed as a case of schwannoma and embolization was done but with no response. An attempt to do complete surgical resection was made, but due to its critical position, it was not possible. During surgery, highly vascularised tumor was found. The histopathologic examination revealed a vascular tumor consistent with hemangiopericytoma G-II. The patient had normal postoperative course of healing and was given adjuvant radiation. He is on regular follow up without signs of recurrence or metastases.In summary, parapharyngeal space is a rare site of presentation for hemangiopericytoma which is highly vascular tumor, requiring extensive work up including magnetic resonance imaging, computed tomography scan and angiography. Complete surgical excision should be attempted. Postoperative radiation is indicated in cases of incomplete resection.