Incidence Of Overall Morbidity Research Articles

The effect of supplementing CLOSTAT 500 (Bacillus subtilis PB6) to yearling steers in a commercial feedyard on health, Salmonella spp. prevalence, feedlot growth performance and carcass characteristics.

British and British × Continental crossbred beef steers, n = 2,100; 313 ± 38 kg of initial body weight (BW) were used to evaluate the effects of Bacillus subtilis PB6 supplementation to yearling steers in a commercial feedyard on health, prevalence of Salmonella spp., growth performance, and carcass characteristics. Steers were blocked by arrival date and assigned randomly to pens within the block; pens were randomly assigned to 1 of 2 dietary treatments within block. Treatments, replicated in 15 pens/treatment with 70 steers/pen, included: 1) control (CON), diets containing no supplemental direct-fed microbials; 2) CLOSTAT (CLO), diets supplemented with 0.5 g/steer/d Bacillus subtilis PB6 (CLOSTAT 500, Kemin Industries, Des Moines, IA) to provide 6.6 × 109 CFU/g of the active ingredient. Supplementing CLO decreased the overall incidence of morbidity (P = 0.03), 10.38% (CLO) vs. 13.43% (CON), decreased the percentage of steers treated once for bovine respiratory disease (BRD; P < 0.01), 9.14% (CLO) vs. 12.76% (CON), and decreased the incidence of BRD retreatment (P = 0.03) compared with CON. Mortality did not differ among treatments (P = 0.23); however, overall deads and removals tended to be less for CLO than CON (53 heads vs. 73 heads respectively, P = 0.06). Prevalence of fecal Salmonella did not differ among treatments, (P ≥ 0.35); overall fecal Salmonella counts tended to be less for CLO (1.59 log (10) CFU/g) than CON (2.04 log (10) CFU/g; P = 0.07). Salmonella concentration in subiliac lymph nodes (n =150/treatment) was not different (P = 0.62) between CON (0.22 log (10) CFU/g) or CLO (0.19 log (10) CFU/g); however, there was a 46% reduction in the overall mean prevalence of lymph node Salmonella (P = 0.46; 15.48% vs. 28.66%) for CLO and CON, respectively. With deads and removals included, final BW was heavier for CLO steers than CON, (654 kg vs. 641 kg, respectively, P = 0.05), and average daily gain (ADG; P = 0.08) and gain efficiency (G:F; P = 0.06) tended to be greater for CLO than CON. With deads and removals excluded, final BW, ADG, and G:F did not differ among treatments (P ≥ 0.30). Carcass traits were not different between treatments (P ≥ 0.15). Supplementing CLO throughout the feeding period in a commercial feedyard improved the health outcomes of yearling steers by decreasing BRD and overall treatment rates, reducing the overall abundance of Salmonella, and resulting in fewer steers removed from the study compared with CON.

Dose-dependent influence of red blood cell transfusion volume on adverse outcomes in cardiac surgery.

Red blood cell (RBC) transfusion is associated with adverse outcomes, but there are few studies on the RBC volume. This study aimed to evaluate the relationship between intraoperative RBC volume and postoperative adverse outcomes for on-pump cardiac surgery. Adult patients undergoing on-pump cardiac surgery from 1 January 2017 to 31 December 2018 were included. Those transfused with more than 6 units of RBC were excluded. The clinical characteristics of four groups with various RBC volume were compared. We analyzed the relationship between RBC volume and adverse outcomes through multivariable logistic regression. 12,143 patients were analyzed, of which 3353 (27.6%) were transfused with 1-6U RBC intraoperatively. The incidence of death, overall morbidity, acute kidney injury and prolonged mechanical ventilation were increased stepwise along with incremental RBC volume. After adjusting for possible confounders, patients transfused with 1-2U were associated with a 1.42-fold risk of death (99% CI, 1.21-2.34, p = 0.01) compared with patients without RBC, patients with 3-4U were associated with a 1.57-fold risk (99% CI, 1.32-2.80, p = 0.005) and patients with 5-6U had a 2.26-fold risk of death (99% CI, 1.65-3.88, p < 0.001). Similarly, the incidence of overall morbidity, acute kidney injury and prolonged mechanical ventilation increased several folds as the RBC numbers increased. There was a significant dose-dependent influence of incremental intraoperative RBC volume on increased risk of adverse outcomes for on-pump cardiac surgery patients. Patient blood management practice should aim to reduce not only transfusion rate but also the volume of blood use.

Racism and perinatal health inequities research: where we have been and where we should go

For more than a century, substantial racial and ethnic inequities in perinatal health outcomes have persisted despite technical clinical advances and changes in public health practice that lowered the overall incidence of morbidity. Race is a social construct and not an inherent biologic or genetic reality; therefore, racial differences in health outcomes represent the consequences of structural racism or the inequitable distribution of opportunities for health along racialized lines. Clinicians and scientists in obstetrics and gynecology have a responsibility to work to eliminate health inequities for Black, Brown, and Indigenous birthing people, and fulfilling this responsibility requires actionable evidence from high-quality research. To generate this actionable evidence, the research community must realign paradigms, praxis, and infrastructure with an eye directed toward reproductive justice and antiracism. This special report offers a set of key recommendations as a roadmap to transform perinatal health research to achieve health equity. The recommendations are based on expert opinion and evidence presented at the State of the Science Research Symposium at the 41st Annual Pregnancy Meeting of the Society for Maternal-Fetal Medicine in 2021. Recommendations fall into 3 broad categories-changing research paradigms, reforming research praxis, and transforming research infrastructure-and are grounded in a historic foundation of the advances and shortcomings of clinical, public health, and sociologic scholarship in health equity. Changing the research paradigm requires leveraging a multidisciplinary perspective on structural racism; promoting mechanistic research that identifies the biologic pathways perturbed by structural racism; and utilizing conceptual models that account for racism as a factor in adverse perinatal outcomes. Changing praxis approaches to promote and engage multidisciplinary teams and to develop standardized guidelines for data collection will ensure that paradigm shifts center the historically marginalized voices of Black, Brown, and Indigenous birthing people. Finally, infrastructure changes that embed community-centered approaches are required to make shifts in paradigm and praxis possible. Institutional policies that break down silos and support true community partnership, and also the alignment of institutional, funding, and academic publishing objectives with strategic priorities for perinatal health equity, are paramount. Achieving health equity requires shifting the structures that support the ecosystem of racism that Black, Brown, and Indigenous birthing people must navigate before, during, and after childbearing. These structures extend beyond the healthcare system in which clinicians operate day-to-day, but they cannot be excluded from research endeavors to create the actionable evidence needed to achieve perinatal health equity.

Linear Stapler versus Circular Stapler for Patients Undergoing Anastomosis for Laparoscopic Gastric Surgery: A Meta-Analysis

Background Anastomotic devices, including linear staplers (LSs) and circular staplers (CSs), have been widely used after laparoscopic gastric surgery. However, it is controversial whether linear stapling is superior to circular stapling for anastomosis. Thus, we conducted a meta-analysis to compare the aspects of postoperative complications, particularly anastomotic stricture and anastomotic leakage, on the use of the two techniques to assist clinical decision-making. Methods We conducted a systematic search using Embase, PubMed, and Cochrane Library to evaluate studies that compared LSs and CSs after laparoscopic gastric surgery. Results Pooled analysis suggested that patients who received LSs had fewer postoperative complications (P = 0.019), and anastomotic complications (P < 0.001), stricture (P = 0.001), and bleeding (P = 0.005). The subgroup analyses showed that LSs caused fewer anastomotic complications (P < 0.001), anastomotic strictures (P < 0.001), and postoperative hemorrhage (P = 0.007) in patients with gastric cancer than CS. In addition, LSs caused fewer incidences of overall morbidity (P = 0.042), anastomotic strictures (P = 0.023), postoperative hemorrhage (P < 0.001), wound infection (P < 0.001), and shorter length of hospital stay (P = 0.048) in patients with obesity. Furthermore, the subgroup analyses showed that the use of LS resulted in lower overall morbidity (P = 0.042), anastomotic stricture (P = 0.023), wound infection (P < 0.001), length of hospital stay (P = 0.048), and postoperative hemorrhage (P < 0.001) when applied in gastrojejunostomy, while LSs resulted in fewer anastomotic complications (P < 0.001), anastomotic stricture (P = 0.016) than CS when applied in esophagojejunostomy. Conclusion Compared with CSs, LSs yielded a lower incidence of overall morbidity, anastomotic complications, anastomotic stricture, bleeding, and wound infection, indicating that linear stapling is safer and more efficient than circular stapling when performing anastomosis after laparoscopic gastric surgery.

SRY is a Key Mediator of Sexual Dimorphism in Hepatic Ischemia/Reperfusion Injury.

To identify the role and mechanism of a male specific gene, SRY, in I/R-induced hepatic injury. Males are more vulnerable to I/R injury than females. However, the mechanism of these sex-based differences remains poorly defined. Clinicopathologic data of patients who underwent hepatic resection were identified from an international multi-institutional database. Liver specific SRY TG mice were generated, and subjected to I/R insult with their littermate WT controls in vivo. In vitro experiments were performed by treating primary hepatocytes from TG and WT mice with hypoxia/reoxygen-ation stimulation. Clinical data showed that postoperative aminotransferase level, incidence of overall morbidity and liver failure were markedly higher among 1267 male versus 508 female patients who underwent hepatic resection. SRY was dramatically upregulated during hepatic I/R injury. Overexpression of SRY in male TG mice and ectopic expression of SRY in female TG mice exacerbated liver I/R injury compared with WTs as manifested by increased inflammatory reaction, oxidative stress and cell death in vivo and in vitro. Mechanistically, SRY interacts with Glycogen synthase kinase-3β (GSK-3β) and β-catenin, and promotes phosphorylation and degradation of β-catenin, leading to suppression of the downstream FOXOs, and activation of NF-κBand TLR4 signaling. Furthermore, activation of β-catenin almost completely reversed the SRYoverexpression-mediated exacerbation of hepatic I/R damage. SRY is a novel hepatic I/R mediator that promotes hepatic inflammatory reaction, oxidative stress and cell necrosis via inhibiting Wnt/β-catenin signaling, which accounts for the sex-based disparity in hepatic I/R injuries.

Laparoendoscopic rendezvous versus ERCP followed by laparoscopic cholecystectomy in the management of cholecystocholedocholithiasis: a systemic review and meta-analysis.

The ideal management for patients with cholecystocholedocholithiasis is still controversial. Laparoendoscopic rendezvous (LERV), combined with laparoscopy and endoscopy, is a novel and attractive technique. The aim of this research was to compare LERV with traditional two-stage management, preoperative ERCP and laparoscopic cholecystectomy (ERCP + LC), for treating patients with cholecystocholedocholithiasis. Four databases, the Cochrane Library, PubMed, Embase, and Medline, all updated to through September 2019, were searched to identify comparative studies on LERV versus ERCP + LC for treating cholecystocholedocholithiasis. Total operative time, successful common bile duct (CBD) stone clearance, postoperative morbidity, conversion to other procedures, and length of hospital stay were evaluated. Pooled data were measured by odds ratios (ORs) and mean difference (MD) with 95% confidence intervals (CIs). Eight studies with a total of 1061 patients were included in this meta-analysis, including 542 patients who received LERV and 519 patients who received ERCP + LC. There was no significant difference between the two groups regarding successful CBD stone clearance (OR 2.20, P = 0.10), postoperative bleeding (OR 0.67, P = 0.37), postoperative cholangitis (OR 0.66, P = 0.53), postoperative bile leak (OR 0.87, P = 0.81), or conversion to other procedures (OR 0.75, P = 0.62). The total operative time was longer in the LERV group (MD = 44.93, P < 0.00001), while LERV was associated with less postoperative pancreatitis than the two-stage management group (OR 0.26, P = 0.0003). The incidence of overall morbidity was lower in the LERV group than in the two-stage management group (OR 0.41, P < 0.0001), and the LERV group had a shorter hospital stay (MD = -3.52, P < 0.00001). LERV is equivalent to traditional two-stage procedures in terms of CBD stone clearance and conversion, with less pancreatitis, lower overall morbidity, and shorter hospital stay but longer operation time. More clinical trials are needed to determine the best treatment for patients in different conditions.

Association between specific presurgical anthropometric indexes and morbidity in patients undergoing rectal cancer resection.

Baseline body composition has been associated with dismal outcomes in patients undergoing a variety of major abdominal operations. Whether specific anthropometric indexes can predict morbidity after rectal resection has been poorly investigated. The aims of this study were to assess whether there is a relationship between body mass index and the different computed tomography-assessed body composition indexes, and whether the analysis of different body compartments could be predictive of short-term outcomes in patients undergoing curative surgery for rectal cancer. Computed tomography-derived measures of skeletal muscle and adipose tissue areas of patients undergoing surgery for rectal cancer between January 2009 and December 2016 were used to calculate population-specific thresholds of sarcopenia, subcutaneous adiposity, visceral adiposity, visceral obesity, sarcopenic obesity, and myosteatosis. Association between the aforementioned body composition features were related with overall complication, infection, and anastomotic leak. During the study period, 311 patients received surgery and 173 were eligible for an accessible preoperative computed tomography imaging. After surgery, 59 (34.1%) patients experienced a complication, 29 an infection, and 10 an anastomotic failure. The overall morbidity rate was observed more frequently in patients with sarcopenia than in those without sarcopenia (39% versus 17.5%; P=0.002) and infections (41.4% versus 21.5% respectively; P=0.024). The presence of myosteatosis also was associated with a higher incidence of overall morbidity (33.9% versus 20.2% in patients without myoteatosis; P=0.048). Anastomotic failure occurred in 6 of 10 patients with visceral obesity and in 24 of 112 (21.4%) patients without this condition (P=0.007). Some anthropometric indexes are accurate predictors of specific types of morbidity. These findings may allow a more accurate preoperative risk stratification.

Effect of Enhanced Recovery After Surgery program on pancreaticoduodenectomy: a randomized controlled trial.

This study aims to investigate the noninferiority of Enhanced Recovery After Surgery (ERAS) for pancreaticoduodenectomy (PD). In this single-center trial, we randomly assigned 276 adult patients who underwent open PD into ERAS and conventional groups with 138 patients in each, from 2015 through 2017. The primary endpoint was the incidence of overall morbidity until postoperative 3months. The secondary endpoints were in-hospital or 30-day mortality, postoperative length of stay (LOS), nutritional status and overall hospital costs. Overall morbidity was reported in 64 patients (52.0%, ERAS group) and in 68 patients (54.8%, conventional group) (risk difference [RD] -2.81 percentage points (pp); 90% two-sided confidence interval -13.24 to 7.63). Mortality did not occur in any patients. The two groups did not differ significantly in median postoperative LOS (both 11days; RD -8.46pp), body mass index (22.4±2.75 vs. 22.4±2.65kg/m2 ; RD -3.48pp), Patient-Generated Subjective Global Assessment score over 4 (45 [40.5%] vs. 50 [43.1%] patients; RD -2.56pp), and median overall hospital cost (15.61 vs. 16.04, ×106 KRW; RD -6.08pp). Even in PD, modified ERAS protocol was not inferior to conventional protocol, while reducing treatment burden.

Drain or No Drain Following Pancreaticoduodenectomy: The Unsolved Dilemma.

There is no consensus regarding the routine placement of intra-abdominal drains after pancreaticoduodenectomy. We aim to determine the effects of intraperitoneal drain placement during pancreaticoduodenectomy on 30-day postoperative morbidity and mortality. Patients who underwent pancreaticoduodenectomy for pancreatic tumors were identified from the 2014-2015 American College of Surgeons-National Surgical Quality Improvement Program Database. Univariate and multivariate analyses adjusting for known prognostic variables were performed. A subgroup analysis was performed based on the risk for development of postoperative pancreatic leak determined by the pancreatic duct caliber, parenchymal texture, and body mass index. A total of 6858 patients with pancreatic tumors who underwent pancreaticoduodenectomy were identified in the 2014-2015 American College of Surgeons-National Surgical Quality Improvement Program Database dataset. In all, 87.4% of patients had intraperitoneal drains placed. A 30-day mortality rate was higher in the no-drain group (2.9% vs. 1.7%, P = 0.003). Patients in the drain group had a higher incidence of overall morbidity (49.5% vs. 41.2%, P = 0.0008), delayed gastric emptying (18.1% vs. 13.7%, P = 0.004), pancreatic fistulae (19.4% vs. 9.9%, P ⩽ 0.0001), and prolonged length of hospital stay over 10 days (43.7% vs. 34.9%, P < 0.0001). Subgroup analysis based on risk categories revealed a higher 30-day mortality rate in the no-drain group among patients with high-risk features (3.1% vs. 1.6%, P = 0.02). Delayed gastric emptying and pancreatic fistula development remained significantly higher in the drain group only in the high-risk category. Prolonged length of hospital stay and composite morbidity remained higher in the drain group regardless of the risk category. To our knowledge, this is the largest study to date that aims at clarifying the pros and cons of the intraperitoneal drain placement during pancreaticoduodenectomy for pancreatic tumors. We showed a higher 30-day mortality rate if drain insertion was omitted during pancreaticoduodenectomy in patients with softer pancreatic textures, smaller pancreatic duct caliber, and body mass index over 25. Postoperative 30-day morbidity rate was higher if a drain was inserted regardless of the risk category. Further randomized controlled trials with prospective evaluation of stratification factors for fistula risk are needed to establish a clear recommendation.

The effect of Enhanced Recovery After Surgery program on pancreaticoduodenectomy: a randomized, controlled trial

Introduction: This study aims to investigate the noninferiority of Enhanced Recovery After Surgery (ERAS) for pancreaticoduodenectomy (PD). There is a lack of evidence whether ERAS is effective perioperative management plan on PD, one of the most complex abdominal surgeries. Method: In this single-center trial, we randomly assigned 276 adult patients who underwent open pancreaticoduodenectomy into ERAS and conventional groups with 138 patients in each, from 2015 through 2017. In ERAS group, the modified ERAS Guidelines were applied. The primary endpoint was the incidence of overall morbidity until postoperative 3 months, with noninferiority margin of 15.0 percentage points (pp). The secondary endpoints were in-hospital or 30-day mortality, postoperative length of stay, nutritional status and overall hospital costs. Result: Overall morbidity was reported in 64 patients (52.0%, ERAS group) and in 68 patients (54.8%, conventional group) (risk difference (RD), -2.81 pp; 90% two-sided confidence interval, -13.24 to 7.63). Mortality did not occur in any patients. The two groups did not differ significantly in terms of median postoperative length of stay (both 11 days; RD, -8.46 pp), body mass index (22.4 ± 2.75 vs. 22.4 ± 2.65 kg/m2; RD, -3.48 pp), Patient-Generated Subjective Global Assessment score over 4 (45 (40.5%) vs. 50 (43.1%) patients; RD, -2.56 pp), and median overall hospital cost (15.61 versus 16.04, x 106 KRW; RD, -6.08 pp). Conclusion: Even in pancreaticoduodenectomy, modified ERAS protocol was not inferior to conventional protocol regarding the postoperative morbidity, mortality, postoperative length of stay and hospital cost, while reducing treatment burden.

Tuberculum Sellae Meningiomas: Nuances in Treatment

Tuberculum sellae meningiomas (TSMs) represent special surgical challenge for neurosurgeons. In this review, we summarize the most common clinical manifestations, diagnostic images, surgical approaches and prognostic factors for outcome at single tertiary care teaching hospitals. Material and Methods: Prospective study was done between January 2010 and January 2017 (Minimum 24-month follow-up). Imaging and clinical data of 31 consecutive patients with TSMs were collected and analyzed. There were no exclusion criteria. Result: The majority of patients were >40 years old (22 patients; 71%). There was a female preponderance 74%: 23 cases (M/F ratio was 1:3). The most common clinical presentation was visual impairment (24; 77%). The mean tumor size was 3.3 cm. Thirty-one patients underwent surgical excision by different approaches. The overall visual improvement was 29% (9 of 31 patients) however visual deterioration occurred in 6.4% (2 of 31 patients). Favorable prognosis was found in patients with short preoperative visual affection (less than 6 months). This finding was statistically significant (P ≤ 0.05). Also, visual outcome had significant correlations with edema surrounded tumor: arterial encasement by the tumor and brain-tumor interface. Two patients died 3 weeks postoperatively from brain stem infarction (overall incidence of mortality 6%) while the overall incidence of morbidity was 19% (6 of 31 patients). Conclusion: The most common symptom of Tuberculum sellae meningioma is visual affection. The favorable prognosis was found in patients with short preoperative visual affection (less than 6 months). Also; visual prognosis had significant correlations with peritumoral edema, arterial encasement by the tumor, and brain-tumor interface.

External versus internal pancreatic duct stenting in duct-to-mucosa pancreaicojejunostomy after pancreaticoduodenectomy: a prospective randomized study

Background: A pancreatic duct stent is often placed across the pancreaticojejunostomy after pancreaticoduodenectomy to decrease the incidence rate of postoperative pancreatic fistula. However, there are few reports in the literatures compared between external and internal pancreatic duct stents. Methods: We conducted a prospective randomized study with 30 patients who underwent pancreaticoduodenectomy and we compared the effects of using external stent versus internal stent in pancreaticojejunostomy on postoperative course, particularly on incidence of postoperative pancreatic fistula. Results: The incidence rate of pancreatic fistula according to the International Study Group on Pancreatic Fistula criteria was significantly higher in external stent group (external, 26.7%; vs internal, 13.3%). In subgroup analysis of patients with soft pancreas, we found similar rates of pancreatic fistula in the two studied groups. The incidence of overall morbidity was similar between both groups while mortality was higher in external stent group. The mean postoperative hospital stay was not significantly different between the two studied groups. Conclusions: Both external stent and internal pancreatic duct stents were safely used for pancreaticojejunostomy. Internal stent had less incidence of postoperative pancreatic fistula and simplifies postoperative management and it might be a better option than external stent in pancreaticojejunostomy after pancreaticoduodenectomy.

Safety and feasibility of enhanced recovery after surgery in the patients underwent distal pancreatectomy for pancreatic cancer.

This study assessed whether our enhanced recovery after surgery (ERAS) program for distal pancreatectomy (DP) is safe and feasible. The subjects were patients who underwent consecutive DP between 2012 and 2014 at the Department of Gastrointestinal Surgery, Kanagawa Cancer Center. They received perioperative care according to ERAS program. All data were retrieved retrospectively. Outcome measures included postoperative mortality, morbidity, hospitalization, and 30-day readmission rate. Our ERAS program included 12 elements (4 preoperative elements, 3 intraoperative elements, and 5 postoperative elements). A total of 44 patients were studied. The overall incidence of morbidity was 29.5%, the incidence of mortality was 0%, and the incidence of readmission was 0%. Four preoperative elements and 3 intraoperative elements seemed feasible. Among the 5 postoperative elements, 4 elements seemed feasible, accounting 90%< performance rate however the early removal of catheters and drain seemed not feasible. The median postoperative hospital stay was 14 days (range: 8-39 days). The median postoperative hospital stay was 13 days (range: 8-27 days) in patients without postoperative complications while the median postoperative hospital stay was 26 days (range: 14-39 days) in patients with postoperative complications. This study results suggested that our ERAS program is safe and feasible in patients who undergo DP. However, achieving compliance on the postoperative element, especially the removal of catcher and drain, was more challenging.

Surgical Site Infection Is Associated with Tumor Recurrence in Patients with Extrahepatic Biliary Malignancies

BackgroundSurgical site infections (SSI) are one of the most common complications after hepato-pancreato-biliary surgery. Infectious complications may lead to an associated immune-modulatory effect that inhibits the body’s response to cancer surveillance. We sought to define the impact of SSI on long-term prognosis of patients undergoing surgical resection of extrahepatic biliary malignancies (EHBM). MethodsPatients undergoing surgery for EHBM between 2000 and 2014 were identified using a large, multi-center, national cohort dataset. Recurrence free survival (RFS) was calculated and a multivariable Cox proportional hazards model was utilized to identify potential risk factors for RFS including SSI. ResultsSeven hundred twenty-eight patients included in the analytic cohort; 236 (32.4%) patients had perihilar cholangiocarcinoma, 241 (33.1%) gallbladder cancer, and 251 (34.5%) distal cholangiocarcinoma. A major resection, liver resection, was performed in 205 (28.3%) patients, while 110 (15.2%) patients had a pancreaticoduodenectomy. The overall incidence of morbidity was 55.8%; among the 397 patients who experienced a complication, 161 patients specifically had an SSI. The SSI occurred as an infection of the surgical site (n = 70, 9.6%) or formation of an abscess in the operative bed (n = 91, 12.5%). SSI was associated with long-term survival as patients who experienced an SSI had a median RFS of 19.5 months compared with 30.5 months for those patients who did not have an SSI (HR 1.40, 95% CI 1.08–1.80; p = 0.01). Among 279 patients who had EHBM that had no associated lymph node metastases, well-to-moderate tumor differentiation, as well as an R0 resection margin, SSI remained associated with worse RFS (HR 1.84, 95% CI 1.03–3.29; p = 0.038), as well as overall survival (HR 1.87, 95% CI 1.18–2.97; p = 0.008). ConclusionSSI was a relatively common occurrence following surgery for EHBM as 1 in 10 patients experienced an SSI. In addition to standard tumor-specific factors, the occurrence of postoperative SSI was adversely associated with long-term survival.

An Institutional Experience of Introducing an Enhanced Recovery After Surgery (ERAS) Program for Pancreaticoduodenectomy

This study assessed whether our enhanced recovery after surgery (ERAS) program for pancreaticoduodenectomy (PD) is safe and feasible. The subjects included 109 consecutive patients who underwent PD between 2012 and 2014 at the Department of Gastrointestinal Surgery, Kanagawa Cancer Center. They received perioperative care according to the ERAS program. All data were retrieved retrospectively. Outcome measures included postoperative mortality, morbidity, hospitalization, and 30-day readmission rate. Our ERAS program included 12 elements (4 preoperative, 3 intraoperative, and 5 postoperative elements). Of the 109 patients studied, the overall incidence of morbidity was 51.4%, the incidence of mortality was 1.8%, and the incidence of readmission was 1.8%. The median postoperative hospital stay (23 days) was significantly shorter than the pre-ERAS value (29 days). Though 4 preoperative and 2 intraoperative elements were feasible, only 1 among 5 postoperative elements was applicable. Our ERAS program for PD has succeeded in shortening the postoperative hospital stay without increasing the risk of morbidity or mortality. The cutoff values of postoperative ERAS elements, however, were not feasible and should be reconsidered.

Safety and feasibility of enhanced recovery after surgery in the patients underwent pancreaticoduodenectomy for hepatobiliary and pancreatic malignancy.

338 Background: Pancreaticoduodenectomy (PD) remains the mainstay of surgical treatment for hepatobiliary and pancreatic malignancy and offers the only chance of long term survival. However, the morbidity and mortality after PD has been reported to be high. Therefore, it is important to determine the most appropriate perioperative care. This study assessed whether enhanced recovery after surgery (ERAS) program is safe and feasible in patients who underwent pancreaticoduodenectomy Methods: The subjects were patients who underwent consecutive PD between 2012 and 2014 at the Department of Gastrointestinal Surgery, Kanagawa Cancer Center. They received perioperative care according to ERAS program. All data were retrieved retrospectively. Outcome measures included postoperative mortality, morbidity, hospitalization and 30-day readmission rate. Key ERAS program targets were: nasogastric tube (NGT) removal [postoperative day (POD) 1]; resumption of oral fluids (POD 2); urinary catheter removal (POD 3); tolerating diet (POD 5); drain removal (POD 7). Results: A total of 109 patients were studied. The overall incidence of morbidity was 51.4%, the incidence of mortality was 1.8%, and the incidence of readmission was 1.8%. The median postoperative hospital stay was 23 days. The proportions of patients achieving key targets were: 93.6% for NGT removal; 94.5% for resumption of oral fluids; 31.2% for urinary catheter removal; 79.8% for tolerating diet; 80.7% for meeting mobility targets, and 37.6% for drain removal. Conclusions: ERAS program is safe and feasible in patients who undergo PD. However, achieving compliance on some targets, especially the removal of catcher and drain, were more challenging.

Impact of ICDS services in urban and rural area beneficiaries children of Ghaziabad, Uttar Pradesh, India: a comparative evaluation study

Background: The rich experience of ICDS has brought about a welcome transition from welfare orientation to a new challenging perspective of social change. It aims at enhancing survival and development of children from the vulnerable sections of the society. Being the world's largest outreach program targeting infants and children below 6 years of age, expectant and nursing mothers. Methods: A longitudinal and comperative study of morbidity (Prevalence and Incidence) among children bellow 6 years of age was conducted in two adjoining areas ,conducted in adjoining area of Rural health training centre and urban health training centre of both area ,covered by ICDS Centre of a concern medical college of Ghaziabad Uttar Pradesh.Impact was assessed ( nutritional status and incidence of illness) in children of both the area. Results: The overall incidence of morbidity was significantly higher in rural ICDS covered area (7.97episode per child per year) than in urban ICDS area (5.43 episodes per child per year) . On initial survey, overall prevalence of morbidity was significantly higher in rural ICDS area(54.14%) than urban area ICDS.(45.85%). Conclusions: There are program gaps in coverage of supplementary nutrition in rural ICDS area children, its regular supply to the beneficiaries, in pre-school activities coverage, recording of immunization, and regular health check-up of beneficiaries and referral of sick children.

The short- and long-term outcomes of radical antegrade modular pancreatosplenectomy for adenocarcinoma of the body and tail of the pancreas.

BackgroundRadical antegrade modular pancreatosplenectomy (RAMPS) is a relatively new modification of the standard distal pancreatosplenectomy. In this method, dissection proceeds from right-to-left to achieve negative posterior resection margins. However, short-term and long-term outcomes of RAMPS for pancreatic cancer have not yet been clarified. The aim of this study is to evaluate short-term and long-term outcomes in the patients who have undergone RAMPS.MethodsConsecutive 49 patients were selected from the retrospective database of the Kanagawa Cancer Center from 2000 to 2014. Data from the operative notes, pathology reports, postoperative data, and outpatient data (recurrence and survival) were entered into the database.ResultsAll patients were undergone anterior RAMPS. The median operation time was 278 min (range from 140 to 625 mins). The median blood loss in operation was 850 ml (range from 60 to 2790 ml). The overall incidence of morbidity was 51.4 % and the incidence of mortality was 0 %. Forty-one patients (83.7 %) had negative resection margins. The mean number of lymph nodes harvested was 15 and 27 patients had lymph node metastasis. After the median follow-up period was 41.1 months, 1-year and 3-year overall survival rates were 84.1 and 38.6 %, respectively. Median overall survival was 22.6 months.ConclusionsThe present study results suggested that RAMPS procedure might be safe and feasible without an increase in morbidity and morbidity and have survival benefit compared with standard DP.

Laparoscopic Radical Prostatectomy Demonstrates Less Morbidity Than Open Radical Prostatectomy: An Analysis of the American College of Surgeons-National Surgical Quality Improvement Program Database with a Focus on Surgical Trainee Involvement

Complication rates of open radical prostatectomies (ORPs) and laparoscopic radical prostatectomies (LRPs) performed by highly experienced surgeons in centers of excellence are well known. Using a standardized, national, risk-adjusted surgical database, we compared 30-day outcomes following ORP and LRP and analyzed how trainee involvement influenced outcomes. The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) is a risk-adjusted data collection analyzing preoperative risk factors, demographics, and 30-day postoperative outcomes. From 2005 to 2011, we identified 10,669 total prostatectomies. Of these, 2278 were ORP and 8391 were LRP. Data on trainee involvement were available on 63% of cases. Comparison of all 10,669 prostatectomies showed a decreased incidence of overall morbidity, serious morbidity, surgical site infections, mortality, wound disruption, urinary tract infection, bleeding, and sepsis or septic shock (p<0.05) for LRP compared with ORP. Trainee involvement was associated with a higher incidence of bleeding, overall and serious morbidity (p<0.001). This difference is isolated to postgraduate year (PGY) 6-10 trainees performing ORP (p<0.001). Overall and serious morbidity was equivalent between PGY groups 1-10 versus attending without trainee performing LRP and PGY groups 1-5 versus attending without trainee performing ORP. Operative times were shorter for ORP versus LRP by an average of 38 minutes (p<0.05), and in cases involving trainees, operative times decreased with trainee experience for both procedures. The length of stay was shorter for LRP compared with ORP (3.2 vs. 1.8 days, p<0.001). The large sample size, standardized data definitions, and quality control measures of the ACS-NSQIP database allow for in-depth analysis of subtle, but significant differences in outcomes between groups. Trainee involvement in LRP appears safe to patients. However, the increased morbidity in ORP involving trainees may be mitigated by awareness, simulation laboratories, and standardized competency assessment.

A Multi-Institutional Perspective of Complication Rates for Elective Nonreconstructive Breast Surgery: An Analysis of NSQIP Data From 2006 to 2010

As elective nonreconstructive breast surgery increases in popularity, there is greater demand for accurate multi-institutional data on minor and major postoperative complications. The authors utilized a multi-institutional database to compare 30-day morbidities and reoperation rates among the different types of elective nonreconstructive breast surgery. Patients in the National Surgical Quality Improvement Program (NSQIP) participant use file who underwent elective nonreconstructive breast surgery between 2006 and 2010 were identified. Twenty defined morbidities were compared among mastopexy, reduction mammaplasty, and augmentation mammaplasty patients using analysis of variance and χ(2) tests for continuous variables and categorical variables, respectively. Logistic regression modeling was employed to identify preoperative risk factors for complications. Of the 3612 patients identified, 380 underwent mastopexy, 2507 underwent reduction mammaplasty, and 725 underwent augmentation mammaplasty. Complication rates were low in all cohorts, and patients undergoing augmentation mammaplasty had the lowest overall complication rate compared with mastopexy and reduction mammaplasty (1.24%, 2.37%, and 4.47%). Patients undergoing reduction mammaplasty had a modestly elevated incidence of overall morbidity, superficial surgical site infections, and wound disruptions (P < .05). Moreover, 30-day reoperation rates for mastopexy, reduction mammaplasty, and augmentation mammaplasty were low (1.58%, 2.07%, and 0.97%), as were the rates of life-threatening complications (0%, 0.16%, and 0%). One death was observed for all 3612 procedures (0.03%). Elective breast surgery is a safe procedure with an extremely low incidence of life-threatening complications and mortality. Comprehensive data collated from the NSQIP initiative add to the literature, and the findings of this multi-institutional study may help further guide patient education and expectations on potentially deleterious outcomes.