Patients Required Bowel Resection Research Articles

Preoperative Exclusive Enteral Nutrition Is Associated With Reduced Skin and Soft Tissue and Intra-abdominal Infections in Patients With Crohn's Disease Undergoing Intestinal Surgery: Results from a Meta-Analysis.

Malnutrition is an independent risk factor for adverse postoperative outcomes and is common among patients with Crohn's disease (CD). The objective of this meta-analysis was to precisely quantify the association of preoperative exclusive enteral nutrition (EEN) and total parenteral nutrition (TPN) with surgical outcomes in patients undergoing intestinal surgery for CD. PubMed, Embase, and Scopus were queried for comparative studies evaluating the impact of preoperative nutritional support on postoperative outcomes in patients undergoing surgery for CD. Random effects modeling was used to compute pooled estimates of risk difference. Heterogeneity was assessed using I2. Fourteen studies, all nonrandomized cohort studies, met inclusion criteria for studying EEN. After pooling data from 14 studies (874 EEN treated and 1044 control patients), the relative risk of intra-abdominal septic complications was decreased 2.1-fold in patients receiving preoperative EEN (relative risk 0.47, 95% confidence interval [CI], 0.35-0.63, I2 = 0.0%). After pooling data from 9 studies (638 EEN treated and 819 control patients), the risk of skin and soft tissue infection was decreased 1.6-fold (relative risk 0.63; 95% CI, 0.42-0.94, I2 = 42.7%). No significant differences were identified in duration of surgery, length of bowel resected, or operative blood loss. Among the 9 studies investigating TPN, no significant differences were identified in infectious outcomes. Preoperative nutritional optimization with EEN was associated with reduced risk of infectious complications in CD patients undergoing intestinal surgery. Preoperative nutritional support with EEN should be considered for optimizing outcomes in CD patients requiring bowel resection surgery.

ThTP5.7 Laparoscopic Management of Adhesional Small Bowel Obstruction: Is it Feasible?

Abstract Despite advances in laparoscopic surgery, there is limited evidence on its application and outcomes for the management of adhesional small bowel obstruction(aSBO). Literature defines indications for surgery, without addressing the appropriate approach, traditionally involving laparotomy. This study investigated the feasibility of laparoscopic adhesiolysis for aSBO. This retrospective cohort study included electronic data of patients admitted with aSBO, in a large laparoscopic centre over 3 years. Exclusion criteria applied to non-adhesional SBO, large bowel pathology and conservative treatment. Outcomes included the rate and reason for conversion to laparotomy, complications and length of stay (LOS). 85 patients with CT proven aSBO were included, over 3 years. 69(81.2%) of patients were approached laparoscopically and there was a 32%rate of conversion to laparotomy, due to technical difficulty(54.6%), planned “laparoscopy-first”(22.7%) or intraoperative emergency(18.2%).Those managed laparoscopically had 5 days median LOS compared to 9 in the converted subgroup. Operation note review, revealed a standard operative approach using naso-gastric tube, right sided ports, and collapsed small bowel manipulation to identify the adhesion point. Enterotomy rate was 13.0% and 14.5%of patients required bowel resection from an extraction site. Post-operatively, 20.3%of patients suffered prolonged ileus, 5.8%anastomotic leak, 5.8%required re-operation, 8.7%were readmitted with recurrence and there were 10(14.5%) in-hospital deaths. Our study indicated that laparoscopic adhesiolysis could be feasible for selected patients, with a CT proven transition point. Given the observational findings of this single centre study, further research in laparoscopic units is required, including direct comparison with laparotomy, and converted subgroups, aiming to generate standardised guidelines for the laparoscopic management of aSBO.

Single Center Experience of Operative Management in Isolated Mesenteric Artery Dissections

Isolated mesenteric dissection of vessels is a rare occurrence with management strategies dependent on patient presentation. The study aimed to evaluate a single institution's experience on patient characteristics, treatment modalities, and outcomes on operative vs nonoperative management of mesenteric dissection. Patients from a single institution between January 2017 and November 2022 with diagnosis of superior mesenteric artery (SMA) or celiac artery dissection and its branches were included. Patients with concomitant descending aortic dissection were excluded. Patient demographics, imaging, treatments, and follow-up data was collected and underwent descriptive statistical analysis. All SMA dissections were categorized using the modified Sakamoto classification (types I-VI), with type VI indicating total occlusion of vessel due to dissection. There were 30 patients with diagnosis of isolated mesenteric dissection. Mean age was 61 years, and the majority were male (86%), Asian (60%), and symptomatic (70%). Majority had isolated SMA dissection (n = 19; 63.3%) with the remainder having isolated celiac (n = 9; 30%) or concomitant SMA and celiac dissection (n = 2; 6.7%). Twenty-one patients had involvement of SMA and categorized using the modified Sakamoto Classification (n = 5 type I, n = 0 type II, n = 2 type III, n = 4 type IV, n = 1 type V, n =7 type VI). Nonoperative treatment occurred in 63.3% (n = 19). Operative intervention rate was 33% (n = 10). All patients who underwent an operation were symptomatic with abdominal pain on presentation (P < .01) (Table I). Two patients presented with rupture and five presented with signs of acute mesenteric ischemia necessitating emergent exploration. Two patients required bowel resection for necrosis. Sakamoto classification was also significantly associated with operative intervention (P < .01). Patients presenting with abdominal pain were three times as likely to undergo operative treatment (odds ratio, 3.13; P < .01) (Table II), while patients with a modified Sakamoto classification type V and above were 10 times more likely to undergo an operative intervention (odds ratio, 10.5; P < .02) (Table II). A large majority of operative cases (n = 9; 90%) were diagnosed with involvement of SMA dissection. Unplanned secondary intervention rate was 30% (n = 3). There was 9.5% mortality rate amongst those with SMA vessel involvement (10% overall mortality). Among those patients that followed-up, all were asymptomatic at the time of follow-up (n = 16). Patients with nonoperative interventions had 57% favorable remodeling (n = 4). Symptomatic patient presentation and higher modified Sakamoto classification type (types V and VI) tend to require operative intervention. Although a majority of spontaneous isolated mesenteric dissections may be treated nonoperatively with either medical therapy or observation alone, identifying patient characteristics amongst those that require operative intervention are important considerations for management of this rare disease process.Table IClinical characteristics by operative interventionOverall, n = 30Operative repair, n = 10Nonoperative, n = 20P valueaAge61.00 ± 12.0854.30 ± 13.4164.35 ± 10.11.031Gender.6 Female4 (13)2 (20)2 (10) Male26 (87)8 (80)18 (90)Ethnicity/Race.032 Asian18 (60)5 (50)13 (65) Hispanic5 (17)2 (20)3 (15) Other3 (10)3 (30)0 (0) White4 (13)0 (0)4 (20)Smoking history.7 Yes10 (33)4 (40)6 (30) No20 (67)6 (60)14 (70)Atrial fibrillation.7 Yes7 (23)3 (30)4 (20) No23 (77)7 (70)16 (80)Hypertension.4 Yes10 (33)2 (20)8 (40) No20 (67)8 (80)12 (60)White blood cells.4 >1211 (37)5 (50)6 (30) 4-1219 (63)5 (50)14 (70)Systolic blood pressure groups>.9 High (>140)17 (57)6 (60)11 (55) Normal (100-140)11 (37)3 (30)8 (40) Low (<100)2 (6.7)1 (10)1 (5.0)Modified Sakamoto class (types I-VI).008 Type I5 (24)1 (11)4 (33) Type II0 (0)0 (0)0 (0) Type III2 (9.5)1 (11)1 (8.3) Type IV4 (19)0 (0)4 (33) Type V2 (9.5)0 (0)2 (17) Type VI8 (38)7 (78)1 (8.3)Symptomatic at presentation.011 Yes20 (67)10 (100)10 (50) No10 (33)0 (0)10 (50)Length of stay7.67 ± 8.5614.00 ± 10.424.50 ± 5.35.004Intensive care unit length of stay2.57 ± 4.766.50 ± 6.430.60 ± 1.67<.001Deceased.3 Yes3 (10)2 (20)1 (5) No27 (90)8 (80)19 (95)Values are mean ± SD or number (%).aWilcoxon rank-sum test; Fisher's exact test. Open table in a new tab Table IIOdds ratio analysis of symptomatic presentation and Sakamoto classification with operative interventionOR95% CIP valueSymptomatic at presentation3.131.08-406.55.011Sakamoto class type V-VI10.51.57-105.00.024CI, Confidence interval; OR, odds ratio. Open table in a new tab

Risk of bowel resection in incarcerated inguinal hernia: watch out for ASA score and hernia type.

Incarcerated inguinal hernias can promote bowel ischemia. Emergent bowel resection is associated with increased postoperative morbidity. Risk factors for bowel resection might identify patients who benefit from elective inguinal hernia repair. Sixty-five consecutive patients undergoing emergency inguinal hernia repair between 2012 and 2018 at our institution were entered in a prospective database. Data analysis was approved by the local ethics committee. Patient characteristics, surgery data, and postoperative outcomes were compared between patients with and without bowel resection. Risk factors for bowel resection were assessed with univariate and multivariate analysis. Patients requiring bowel resection were more often female (87%, P = 0.004) and presented in 67% with a femoral hernia. Postoperative complications occurred more often after hernia reduction and bowel resection compared to no resection (67% vs. 36%, P = 0.035). ASA score 3-4 and femoral herniation were independent predictors of bowel resection (P = 0,046 and P = 0,047, respectively). Highly comorbid patients can profit from early elective hernia repair to prevent bowel resection.

Laparoscopic totally extraperitoneal repair of strangulated groin hernia

To study the possibility of totally extraperitoneal repair combined with diagnostic laparoscopy in the treatment of strangulated groin hernias (Laparoscopy-Assisted Totally Extraperitoneal Plasty, LATEP). We analyzed the results of laparoscopic totally extraperitoneal hernia repair. The trocar placement technique was modified. There were 38 patients with strangulated groin hernia. The sample included 26 patients with strangulated inguinal hernia, 9 ones with strangulated femoral hernia and 3 patients with recurrent strangulated inguinal hernia. LATEP was attempted in 38 patients and successful in 37 (97.3%) cases. In 1 (2.6%) patient, correction of small bowel strangulation was failed and conversion to open surgery was required. In 29 patients (76.3%), correction of strangulation was performed after laparoscopy-assisted external manipulations and careful traction from abdominal cavity. In 8 (21%) cases, strangulation spontaneously regressed before laparoscopy. Laparoscopy confirmed viability of strangulated organs in 36 patients. One (2.6%) patient required bowel resection due to small intestine wall necrosis. Later, all patients underwent totally extraperitoneal repair. We were able to prevent the contact of hernia sac fluid with the implant in all cases. At the stage of preperitoneal repair, local damage to peritoneum occurred in 9 patients. Nevertheless, sealing was not required since hernia fluid was previously removed from abdominal cavity. There were no signs of implant infection and hernia recurrence within 6-14 months. Totally extraperitoneal repair combined with diagnostic laparoscopy is possible for strangulated groin hernias.

STUDY OF AGE, PERFORMANCE STATUS, PERITONEAL CARCINOMATOSIS INDEX, BOWEL RESECTION AND HISTOPATHOLOGY IN ADVANCED EPIHELIAL OVARIAN CANCER.

Objective –To study the Age, Peritoneal Carcinomatosis Index, Visceral Resection and Histopathology in FIGO stage III epithelial ovarian cancer. Methodology – A retrospective cross-sectional study was conducted at a tertiary hospital in Bangalore, India. All patients diagnosed with FIGO stage III epithelial ovarian cancer who underwent cytoreductive surgery (primary, interval or secondary cytoreductive surgery) between April 2017 to April 2019 were included in the study. Parameters noted were 1) Age at presentation 2) ECOG performance status 3) Peritoneal Carcinomatosis Index (PCI) 4) Visceral resection done 5) Histopathology report. Performance status was calculated according to European Co-operative Oncology Group (ECOG) grade. Histopathology report was grouped into four types. 1) Endometroid type 2) Low grade serous type 3) High grade serous type 4) Mucinous type. Histopathology reported as high-grade serous carcinoma with clear cell changes or high-grade dysplasia were included in high grade serous carcinoma type. Histopathology reported as high-grade serous carcinoma with clear cell changes or high-grade dysplasia were included in high grade serous carcinoma type. Results- A total of 84 patients were included in the study. 45 patients underwent interval, 25 patients underwent primary and 14 patients underwent secondary cytoreductive surgery. Most patients diagnosed with epithelial ovarian cancer was between age 50-70 years (65.46%). Maximum age noted was 82 years and minimum age noted was 36 years in this study. Most of the patients had ECOG performance status 1. 29.76% of patients had ECOG performance status 0, 65.47 % of patients had ECOG performance status 1 and 4.76% of patients had ECOG performance status 2. 45 patients underwent interval, 25 patients underwent primary and 14 patients underwent secondary cytoreductive surgery. Maximum PCI score noted was 36 and minimum PCI score noted was 3. Most of the patients had PCI score between 11-20 (66.66%) who underwent surgery. 26 patients out of 84 patients required bowel resection (30.95%). Most common bowel resection performed was anterior resections / low anterior resections followed by limited right hemicolectomy. 17.85% of patients underwent anterior resection and 5.95% of patients underwent limited right hemicolectomy. Other visceral resection done were limited left hemicolectomy (3.57%), transverse colectomy (1.19%), distal gastrectomy (1.19%), low anterior resection + limited right hemicolectomy (1.19%). None of the patients required diverting stoma. Anastomotic leak was noted in 3 patients (3.57%). Most common histopathology reported was high grade serous (71.44%) followed by low grade serous type (19.04%). Endometroid type and mucinous type was least common (4.76% each). Conclusion – Epithelial ovarian cancer was most common between age group 50-70 years in this study. Most patients had ECOG performance status 1. PCI score between range 11-20 was noted for majority of patients who underwent cytoreductive surgery. Most common bowel resection performed was low anterior resection/ anterior resection followed by limited right hemicolectomy. None of the patients required diverting stoma. Anastomotic leak was noted in 3.57% of patients. Most common histopathology reported was high grade serous (71.44%) followed by low grade serous type (19.04%). Endometroid type and mucinous type were least common (4.76% each)

Acute superior mesenteric venous thrombosis results in high rates of readmission and morbidity

ObjectiveSuperior mesenteric venous thrombosis (MVT) is a poorly understood clinical entity, and as such, outcomes are poorly described. This study aimed to identify predictors of bowel ischemia after MVT and to compare outcomes for patients treated medically (group 1) with those for patients treated with bowel resection (group 2). MethodsThis was a retrospective, single-institution study capturing all patients diagnosed with symptomatic acute MVT on computed tomography imaging from 2008 to 2018. Demographics, comorbidities, imaging, laboratory values, and treatment were included. Predictors of bowel resection were analyzed by univariate and multivariate statistics. Outcomes including mortality, readmissions for abdominal pain, and chronic mesenteric venous congestion were compared using χ2 test. ResultsThere were 121 patients included in the study; 98 patients were treated medically (group 1), 19 patients were treated with bowel resection (group 2), and 4 patients were treated with endovascular recanalization (group 3). Group 1 and group 2 were compared directly. Patients requiring bowel resection tended to have higher body mass index (P = .051) and a hypercoagulable disorder (P = .003). Patients who required bowel resection were more likely to present with lactic acidosis (P < .001) and leukocytosis (P < .001) with bowel wall thickening on scan (P < .001). On multivariable analysis, a genetic thrombophilia was a strong predictor of bowel ischemia (odds ratio, 3.81; 95% confidence interval, 1.12-12.37). One-year mortality and readmission rates did not differ between groups. However, readmission rates for abdominal pain were high for both groups (group 1, 44.90%; group 2, 57.89%; P = .317), and a significant proportion of patients exhibited chronic mesenteric venous congestion on repeated scan (group 1, 42.86%; group 2, 47.37%; P = .104). ConclusionsA genetic hypercoagulable disorder is a predictor of bowel ischemia due to MVT. Regardless of treatment, outcomes after MVT are morbid, with high rates of readmission for abdominal pain. An alternative approach to treat these patients is needed, given the poor outcomes with current strategies.

Parenteral Nutrition Instead of Early Reoperation in the Management of Early Postoperative Small Bowel Obstruction

BackgroundIn majority of patients, early postoperative small bowel obstruction (EPSBO) resolves with nasogastric decompression and bowel rest alone, while in some patients, symptoms persist without urgent indications for surgery. The purpose of this study was the evaluation of home parenteral nutrition (HPN) instead of elective surgery as an initial approach to persistent EPSBO. MethodsPatients developing EPSBO prescribed HPN without reoperation within 6 weeks after index intestinal surgery were identified from an institutional HPN registry and retrospectively compared with patients undergoing reoperation for EPSBO within the same time period. ResultsThirty-four patients for the HPN group and 27 patients in elective reoperative (REOP) group met the inclusion criteria. In the HPN group, mean interval between surgery and PN initiation was 11 days. HPN duration ranged from 17 to 244 days with a median of 60 days. Thirty-one patients (91%) successfully recovered bowel function and resumed enteral nutrition without reoperation, while 3 patients required reoperation > 6 weeks after index surgery due to HPN failure. In the REOP group, mean interval between index surgery and reoperation was 17 days. At reoperation, 12 patients required bowel resection, 5 having incidental enterotomies, and 3 required new stoma creation. Postoperatively, 2 patients developed enterocutaneous fistulas, 1 experienced an anastomotic leak, and another had fascial dehiscence. ConclusionHPN is a safe alternative to elective surgery in clinically stable patients with persistent EPSBO. This approach avoids hazardous reoperation during the recovery phase when adhesions are at their worst.

Enteric duplication in children.

Enteric duplication is a congenital anomaly with varied clinical presentation that requires surgical resection for definitive treatment. This had been approached with laparotomy for resection, but has changed with minimally invasive technique. The purpose of our study was to determine the demographics, natural history, operative interventions, and outcomes of pediatric enteric duplication cysts in a contemporary cohort. With IRB approval, we performed a retrospective chart review of all patients less than 18years old treated for enteric duplication between January 2006 and August 2016. Demographics, patient presentation, operative technique, intraoperative findings, hospital course, and follow-up were evaluated. Descriptive statistical analysis was performed; all medians were reported with interquartile range (IQR). Thirty-five patients underwent surgery for enteric duplication, with a median age at surgery of 7months (2.5-54). Median weight was 7.2kg (6-20). Most common patient presentations included prenatal diagnosis 37% (n = 13). Thirty-four patients (97%) had their cyst approached via minimally invasive technique (thoracoscopy or laparoscopy) with only three (8%) requiring conversion to an open operation. Median operative time was 85min (54-133) with 27 (77%) patients requiring bowel resection. Median length of bowel resected was 4.5cm (3-7). Most common site of duplication was ileocecal (n = 15, 42%). Postoperative median hospital length of stay was 3days (2-5) and median number of days to regular diet was 3 (1-4). No patients required re-operation during their hospital stay. Median follow-up was 25days (20-38). In our series, most enteric duplication cysts were diagnosed prenatally. These can be managed via minimally invasive technique with minimal short-term complications, even in neonates and infants.

The value of CT findings for prognostic prediction of spontaneous superior mesenteric artery dissection.

Spontaneous superior mesenteric artery (SMA) dissection is rare cause of acute abdomen. Time-dependent change of SMA dissection has not been established. To determine Sakamoto classification (SC) type of acute and chronic SMA dissection (aSMAD and cSMAD) to predict the treatment methods and outcome. From April 2003 to March 2017, unenhanced and contrast-enhanced CT were used to diagnose acute symptomatic or chronic asymptomatic SMA dissection in 25 consecutive patients without aortic dissection. Correlations between SCs and treatment methods and outcomes were investigated. All 13 patients with aSMAD initially received conservative treatment. Initial SCs in aSMAD were type I = 1, type III = 9, and type IV = 3. Three of nine initial type III and two of three initial type IV changed to type I at follow-up. One of nine type III changed to type II at follow-up. Ohers did not change. One with initial type III required vascular repair, so the final SC was not available. Three patients required bowel resection. In cSMAD of 12 patients, the initial/final SC were type I and IV in ten and two patients, respectively, without change during follow-up. cSMAD was significantly older than aSMAD. The initial length of dissection of aSMAD was longer than in the cSMAD group. In aSMAD, the final length of dissection was significantly shorter than in the initial computed tomography scan. Initial SC differed significantly between aSMAD and cSMAD. Initial SC types in aSMAD were type III and IV mainly, and changed during the observation period. In cSMAD, SC types were I and IV without change.

Ten-year review of isolated spontaneous mesenteric arterial dissections

ObjectiveIsolated spontaneous dissection of the superior mesenteric artery (SMA) and celiac artery (CA) remains a rare condition; however, it has been increasingly noted incidentally on diagnostic imaging. The purpose of this study was to examine the natural history and outcomes of patients presenting with isolated spontaneous mesenteric artery dissection (SMAD). We hypothesized that most SMADs can be treated nonoperatively. MethodsThis was a single-center retrospective review of patients presenting with the diagnosis of SMAD between 2006 and 2016. Data analysis included demographics, clinical data, radiologic review, treatment, and outcomes. ResultsA total of 77 patients were found to have CA dissection, SMA dissection, or both in the absence of aortic dissection diagnosed on computed tomography or magnetic resonance imaging. The average age was 56 years (range, 26-86 years), 80% were male, and 10 patients (13%) had underlying connective tissue disorders. The majority, 64%, presented with symptoms including abdominal pain, back pain, and chest pain; the remaining 36% were asymptomatic. Combined SMA and CA dissection was found in 14 (18%) patients; 33 (43%) presented with isolated CA dissection, and 30 (39%) presented with isolated SMA dissection. Only four patients required intervention. Mesenteric bypass was performed in two patients, and SMA endarterectomy with patch angioplasty was performed in one patient for signs of bowel ischemia. No patient required bowel resection. The two bypasses were anastomosed to a branch of the SMA, and complete lumen restoration was seen on long-term imaging follow-up. One patient underwent stent grafting of the CA and hepatic artery for aneurysmal degeneration 1 month after diagnosis. The remaining 73 patients were managed nonoperatively; 40 (52%) were treated with a short course of anticoagulation, 23 (30%) were treated with antiplatelet therapy, and 10 (13%) were treated with observation alone. No other late interventions or recurrences were noted during a mean follow-up of 21 months. ConclusionsWhereas isolated SMAD poses a risk of visceral ischemia, most patients presenting with this diagnosis can be treated nonoperatively with a short course of antiplatelet or anticoagulant therapy. Only a small number of patients require surgical revascularization for bowel ischemia.

Outcomes following repair of incarcerated and strangulated ventral hernias with or without synthetic mesh

BackgroundThe use of synthetic mesh for ventral hernia repair under contaminated conditions is a controversial issue due to the considerable risk of surgical site infection (SSI). This study aimed to review the outcomes of repair of incarcerated and strangulated ventral hernias with or without synthetic mesh in compliance with established clinical guidelines regarding the incidence of SSI and hernia recurrence.MethodsThe records of patients with complicated ventral hernias who were treated with or without synthetic mesh repair were reviewed. Variables collected included the characteristics of patients and of ventral hernias, type of repair, and incidence of SSI and recurrence.ResultsOne hundred twenty-two patients (56 males) of a mean age of 56 years were included. Fifty-two (42.6%) and 70 (57.4%) patients presented with incarcerated and strangulated ventral hernias, respectively. Sixty-six (54%) patients were treated with on-lay mesh repair, and 56 (46%) were managed with suture repair. Twenty-one patients required bowel resection. SSI was detected in eight (6.5%) patients. There was no significant difference between both groups regarding the incidence of SSI (7.5% for mesh group vs 5.3% for suture group). Recurrence occurred in seven patients. Median follow-up period was 24 months. The suture repair group had a significantly higher incidence of recurrence than the mesh group. Diabetes mellitus, previous recurrence, and intestinal resection were significant predictors for SSI.ConclusionFollowing established guidelines, synthetic mesh repair of incarcerated and strangulated ventral hernias attained lower recurrence rate, comparable incidence of SSI, and higher rate of seroma formation than suture repair.Trial registrationResearch Registry, researchregistry1891

Stapled versus hand-sewn: A prospective emergency surgery study. An American Association for the Surgery of Trauma multi-institutional study.

Data from the trauma patient population suggests handsewn (HS) anastomoses are superior to stapled (ST). A recent retrospective study in emergency general surgery (EGS) patients had similar findings. The aim of the current study was to evaluate HS and ST anastomoses in EGS patients undergoing urgent/emergent operations. The study was sponsored by the American Association for the Surgery of Trauma Multi-Institutional Studies Committee. Patients undergoing urgent/emergent bowel resection for EGS pathology were prospectively enrolled from July 22, 2013 to December 31, 2015. Patients were grouped by HS/ST anastomoses, and variables were collected. The primary outcome was anastomotic failure. Similar to other studies, anastomotic failure was evaluated at the anastomosis level. Multivariable logistic regression was performed controlling for age and risk factors for anastomotic failure. Fifteen institutions enrolled a total of 595 patients with 649 anastomoses (253 HS and 396 ST). Mean age was 61 years, 51% were men, 7% overall mortality. Age and sex were the same between groups. The overall anastomotic failure rate was 12.5%. The HS group had higher lactate, lower albumin, and were more likely to be on vasopressors. Hospital and intensive care unit days, as well as mortality, were greater in the HS group. Anastomotic failure rates and operative time were equivalent for HS and ST. On multivariate regression, the presence of contamination at initial resection (odds ratio, 1.965; 95% confidence interval, 1.183-3.264) and the patient being managed with open abdomen (odds ratio, 2.529; 95% confidence interval, 1.492-4.286) were independently associated with anastomotic failure, while the type of anastomosis was not. EGS patients requiring bowel resection and anastomosis are at high risk for anastomotic failure. The current study illustrates an apparent bias among acute care surgeons to perform HS techniques in higher-risk patients. Despite the individualized application of technique for differing patient populations, the risk of anastomotic failure was equivalent when comparing HS and ST anastomoses. Therapeutic study, level II.

Prosthetic Mesh Repair for Incarcerated Inguinal Hernia.

Incarcerated inguinal hernia is a commonly encountered urgent surgical condition, and tension-free repair is a well-established method for the treatment of non-complicated cases. However, due to the risk of prosthetic material-related infections, the use of mesh in the repair of strangulated or incarcerated hernia has often been subject to debate. Recent studies have demonstrated that biomaterials represent suitable materials for performing urgent hernia repair. Certain studies recommend mesh repair only for cases where no bowel resection is required; other studies, however, recommend mesh repair for patients requiring bowel resection as well. The aim of this study was to compare the outcomes of different surgical techniques performed for strangulated hernia, and to evaluate the effect of mesh use on postoperative complications. Retrospective cross-sectional study. This retrospective study was performed with 151 patients who had been admitted to our hospital's emergency department to undergo surgery for a diagnosis of incarcerated inguinal hernia. The patients were divided into two groups based on the applied surgical technique. Group 1 consisted of 112 patients treated with mesh-based repair techniques, while Group 2 consisted of 39 patients treated with tissue repair techniques. Patients in Group 1 were further divided into two sub-groups: one consisting of patients undergoing bowel resection (Group 3), and the other consisting of patients not undergoing bowel resection (Group 4). In Group 1, it was observed that eight (7.14%) of the patients had wound infections, while two (1.78%) had hematomas, four (3.57%) had seromas, and one (0.89%) had relapse. In Group 2, one (2.56%) of the patients had a wound infection, while three (7.69%) had hematomas, one (2.56%) had seroma, and none had relapses. There were no statistically significant differences between the two groups with respect to wound infection, seroma, hematoma, or relapse (p>0.05). In Group 3, it was observed that one (6.7%) of the patients had wound infections, while one (6.7%) had a hematoma, one patient (6.7%) had seroma, and none had relapses. In Group 4, seven (7.2%) of the patients had wound infections, while one (1%) had a hematoma, three (3%) had seromas, and one (1%) had a relapse. There were no significant differences between the two groups with respect to wound infection, seroma, hematoma, or relapse (p>0.05). In urgent groin hernia repair surgeries, polypropylene mesh can be safely used even in the patients undergoing bowel resection.

Survival Impact of Secondary Cytoreductive Surgery for Recurrent Ovarian Cancer in an Asian Population.

The aim of this study was to evaluate the role of secondary cytoreductive surgery in Asian patients with recurrent ovarian cancer and to assess prognostic variables on overall post-recurrence survival time. We conducted a retrospective review of patients with recurrent ovarian cancer who underwent secondary cytoreduction at the Gynaecological Cancer Center at the KK Women's and Children's Hospital, Singapore, between 1999 and 2009. Eligible patients included those who had been firstly treated by primary cytoreductive surgery and followed by adjuvant chemotherapy and had a period of clinical remission of at least six months and subsequently underwent secondary cytoreductive surgery for recurrence. Univariate analysis was performed to evaluate various variables influencing the overall survival. Twenty-five patients met our eligibility criteria. The median age was 52 years (range=31-78 years). The median time from completion of primary treatment to recurrence was 25.1 months (range=6.4-83.4). Secondary cytoreduction was optimal in 20 of 25 patients (80%). The median follow-up duration was 38.9 months (range=17.8-72.4) and median overall survival time was 33.1 months (95% confidence interval, 15.3-undefined.). Ten (40.0%) patients required bowel resection, but no end colostomy was performed. One (4.0%) patient had wedge resection of the liver, one (4.0%) had a distal pancreatectomy, one (4.0%) had a unilateral nephrectomy, and one (4.0%) had adrenalectomy. There were no operative deaths. The overall survival of patients who responded to secondary cytoreductive surgery and adjuvant chemotherapy was significantly longer than those patients who did not respond to the treatment. Of those patients who responded to the surgical management, patients with clear cell carcinoma fared well compared to those with the endometrioid, mucinous adenocarcinoma, and papillary serous type (p<0.001). Complete secondary cytoreductive surgery appeared to have some relationship to overall survival but was not statistically significant. In carefully selected patients with recurrent ovarian cancer, optimal cytoreductive surgery is possible and in a subgroup of patients who respond to surgery and chemotherapy survival is significantly longer.

Management of Spontaneous Isolated Visceral Artery Dissection

Spontaneous isolated dissection of the celiac artery (CA) or the superior mesenteric artery (SMA) is rare but increasingly recognized because of widespread use of advanced abdominal imaging technology. Indications for specific therapeutic options and long-term outcomes are not well defined. This study analyzed clinical features, management strategies, and outcomes for patients with spontaneous visceral artery dissections. Medical records of all patients diagnosed with CA or SMA dissections at 2 institutions (Scripps Green Hospital and San Diego Kaiser Medical Center) between January 2005 and January 2014 were retrospectively reviewed. Patient demographics included age, symptoms, associated comorbidities, and type of intervention. Anatomic features including length of dissection and entry point were measured. Efficacy of the various treatments was compared on the basis of symptom resolution and clinical course. Over an 8-year period, 23 patients with a diagnosis of visceral artery dissection were identified. Eighteen (78%) patients were men. Most patients (78%) were symptomatic on initial presentation with abdominal or back pain. Treatment included observation in 4, anticoagulation in 13, and endovascular stenting in 6 patients. The mean follow-up was 23.8 months. No patient required bowel resection. Twenty of twenty-three patients reported resolution of symptoms at follow-up. In this series, all patients with isolated visceral artery dissection had favorable outcomes, with no significant morbidity or mortality. Conservative management with anticoagulation is recommended as the first-line therapy. When conservative management fails, endovascular therapy is the treatment of choice.

Childhood intussusceptions at a tertiary care hospital in northwestern Tanzania: a diagnostic and therapeutic challenge in resource-limited setting

BackgroundIntussusception remains a common cause of bowel obstruction in children and results in significant morbidity and mortality if not promptly treated. There is a paucity of prospective studies regarding childhood intussusception in Tanzania and particularly the study area. This study describes the pattern, clinical presentations and management outcomes of childhood intussusception in our setting and highlights the challenging problems in the management of this disease.MethodsThis was a prospective descriptive study of patients aged < 10 years operated for intussusception at Bugando Medical Centre. Ethical approval to conduct the study was obtained from relevant authorities. Data was analyzed using SPSS version 17.0.ResultsA total of 56 patients were studied. The male to female ratio was 3.3: 1. The median age was 6 months. Three-quarter of patients were < 1 year. Etiology was mainly idiopathic in 91.1% of cases. The classic triad of bloody stool, vomiting and abdominal distention/abdominal pain was found in 24 (42.5%) patients. The diagnosis of intussusception was mainly clinically in 71.4% of cases. All patients were treated surgically. Ileo-colic was the most frequent type of intussusception (67.9%). Twenty-six (46.4%) patients required bowel resection. The rate of bowel resection was significantly associated with late presentation > 24 hour (p = 0.001). Complication rate was 32.1% and surgical site infection (37.5%) was the most frequent complication. The median length of hospital stay was 7 days. Patients who had bowel resection and those who developed complications stayed longer in the hospital and this was statistically significant (p < 0.001). Mortality rate was 14.3%. Age < 1 year, delayed presentation, associated peritonitis, bowel resection and surgical site infection were the main predictors of mortality (p < 0.001). The follow up of patients was generally poorConclusionIntussusception in our setting is characterized by late presentation, lack of specialized facilities and trained personnel for nonsurgical reduction. Therefore, surgery remains the main stay of treatment in our centre. A high index of suspicion and proper evaluation of patients is essential for an early diagnosis and timely definitive treatment, in order to decrease the morbidity and mortality associated with this disease.

Single Incision Laparoscopic Transabdominal Preperitoneal Repair for Strangulated Groin Hernia

Introduction: Single incision laparoscopic surgery (SILS) has become more popular for various surgical procedures including hernia surgery. Initial results of SILS in elective hernia repair were comparable to those of conventional laparoscopic approaches. However the use of SILS in emergency case has not been widely reported. This study aimed to evaluate the feasibility of the use of single incision laparoscopic transabdominal preperitoneal (TAPP) repair for patients presenting with strangulated groin hernia. Method: Emergency single incision laparoscopic TAPP repair were performed in our unit from June 2011 onwards for selected patients. Retrospectively data including the patient demographics, operative time, type of hernia, hospital stay, complications and recurrence rate were collected and analyzed. Result: There were a total of five patients in this series from June 2011 to June 2012. The median age was 62 years old with a male to female ratio of 4:1. Four patients had unilateral hernia (one femoral and three inguinal hernias) and one had bilateral hernia (unilaterally strangulated femoral hernia and bilaterally reducible indirect inguinal hernia). The median operative time was 75 minutes for patients with unilateral repair. None of the patients required bowel resection. The conversion rate to either conventional laparoscopic or open repair was zero. The median hospital stay was 2 days. No major complication or recurrence was detected. Conclusion: This series showed that single port laparoscopic TAPP repair for strangulated groin hernia is a feasible option with no major complication reported.

Peri-operative outcomes of patients with stage IV endometriosis undergoing robotic-assisted laparoscopic surgery.

We analyzed peri-operative outcomes of 80 patients who underwent robotic-assisted laparoscopic surgery and were diagnosed with stage IV endometriosis (revised American Society for Reproductive Medicine) between January 2007 and December 2010 at a tertiary gynecologic oncology referral center with a fellowship training program. Eligible women had a combination of one or more factors: pelvic mass, sub-acute or chronic pelvic pain, dysmenorrhea, dyspareunia, elevated serum CA-125, diagnosed with stage IV endometriosis at surgery with robotic-assisted gynecologic procedures using the da Vinci(®) Surgical System. The mean age was 43.7±7.0years, body mass index 27.5±7.4kg/m(2), and 23 (28.9%) patients had prior endometriosis surgery. Presenting symptoms included: chronic pelvic pain (48.8%), dysmenorrhea (40.3%), and dyspareunia (33.8%). Sixty-nine (86%) patients had pelvic masses (43 unilateral and 26 bilateral). Thirty-seven (46.3%) had elevated CA-125 levels (mean 97.9±71.6 U/ml). Forty-eight (60%) underwent robotic-assisted laparoscopic hysterectomy (RALH)/bilateral salpingo-oophorectomy (BSO), 9 (11.3%) RALH/unilateral salpingo-oophorectomy (USO), 5 (6.3%) modified radical hysterectomy, and 10 (13%) USO or BSO only. Four (5%) had ovarian cystectomies with excision of endometriotic implants. Three (3.8%) underwent appendectomy and no patient required bowel resection. Four (5%) patients required conversion to laparotomy during the first 15 cases of this series [dense adhesions (3) and ureteral injury (1)]. Mean operative time was 115±46min, blood loss 88±67ml, and length of stay 1.0±0.4days. There were four (5%) complications (ureteral injury, cuff abscess, cuff hematoma, re-admission for nausea and vomiting secondary to narcotics) and no transfusions. One (1.3%) patient underwent a second surgery for pain (dyspareunia). Robotic-assisted surgery for stage IV endometriosis resulted in excellent pain relief, with few laparotomy conversions or complications during a robotic learning-curve experience.

Systematic review of gastrointestinal injury caused by magnetic foreign body ingestions in children and adolescence

To study the diagnosis and treatment of gastrointestinal injury caused by magnetic foreign body ingestions in children. A literature search was performed to identify all the studies related to gastrointestinal tract injury caused by ingesting magnetic foreign body using databases including Google, Medline, ISI Web of Knowledge, Ovid, Wanfang data, VIP, CNKI, degree dissertation, meeting abstracts, and request for document delivery. Language was limited to English, Chinese, Japanese, and Korean. Parameters studies were age at diagnosis, gender, country, regional distribution, number of magnetic foreign bodies, source of magnetic foreign bodies, clinical features, diagnosis, and method for foreign body removal. A total of 98 cases of magnet ingestion were identified from 17 countries and regions. There were 94 patients under the age of 18, with most children younger than 5 years old(62.2%,61/98). The age at peak incidence was 3 years old (16.3%, 16/98). Magnetic foreign bodies ingested included toys(74.5%), medical apparatus(8.2%), accessories(4.1%), and others(6.2%). The number of bodies ranged from 2 to 100. Eleven (11.2%) patients were complicated with allotriophagia or autism. Delay diagnosis and treatment existed in all the patients to varying extents, of whom one died from severe infection. Exploratory laparotomy showed a wide range of bowel damage from the esophagus to the colon, including perforation and intestinal fistula. Intestinal damage was the most common injury (51.0%), followed by intestine-colon fistula (15.3%). All the patients required bowel resection with anastomosis or fistula repair except for 2 children who were managed by endoscopic removal of the foreign bodies. Ingesting more than one magnet will lead to severe gastrointestinal injury. Early diagnosis and surgical intervention are important. More precautious measures should be taken for children aged younger than 5 years old.