Postoperative Abdominal Abscess Research Articles

Neoadjuvant Chemotherapy in Patients With T4b or Obstructive Colon Cancer: A Single Center Retrospective Cohort Study.

The efficacy of neoadjuvant chemotherapy (NAC) for colon cancer remains unestablished. This study aimed to investigate the outcomes of NAC in patients with locally advanced T4b or obstructive T4a colon cancers (LACC). Data of patients with LACC who underwent colon surgery between 2010 and 2022 after NAC at our institution were retrospectively reviewed. Patient characteristics, surgical outcomes, tumor features, and prognosis were analyzed. Among 800 patients with LACC who underwent radical resection, 11 received NAC because of cT4b or cT4a with mechanical obstruction. NAC, administered as a doublet regimen, had a median duration of three months, without grade ≥3 adverse events. R0 resection was achieved in all patients and downstaging was observed in eight patients. One patient developed a postoperative abdominal abscess, and adjuvant chemotherapy was administered to eight patients. Four patients experienced recurrence: liver metastasis in two, and local recurrence in two. Among these, three patients underwent resection of recurrent tumors. Median follow-up was 30 months. NAC is feasible for T4b or obstructive T4a colon cancer and may be a treatment option for LACC. Further large-scale studies are required to confirm the efficacy of NAC in these patients.

P214 Effects of rectal stump proctitis on short-term postoperative complications after proctectomy and ileal pouch-anal anastomosis for Ulcerative Colitis

Abstract Background Inflammation of the rectal stump (proctitis) after subtotal colectomy with ileostomy for ulcerative colitis (UC) is common. Proctitis may affect the postoperative outcomes of ileal pouch-anal anastomosis (IPAA). This study aims to explore associations between rectal stump proctitis and short-term postoperative complications (POCs) after proctectomy and IPAA for UC. Methods This retrospective single-centre study included patients who underwent proctectomy, IPAA and protective ileostomy for UC from 2000-2023. Data were retrieved from our prospectively-maintained database. Exclusion criteria were dysplasia or cancer (103 pts), missing pathology results (50 pts), undetermined colitis or Crohn’s Disease features at proctectomy (18 pts). All patients underwent three-staged IPAA and were divided into four groups according to the rectal stump proctitis status at pathology: remission, mild, moderate, and severe proctitis. A stepwise binary logistic regression analysis was performed for each short-term outcome. Models included variables with a different distribution according to the outcome (p-value ≤0.1). Results We included 785 patients who underwent proctectomy and IPAA. At pathology, remission was achieved by 162 (20.6%) patients, while proctitis of the rectal stump was mild in 211 (26.9%), moderate in 246 (31.3%), and severe in 166 (21.1%) patients, respectively. Table 1 details population characteristics and outcomes according to the proctitis status. Patients with moderate and severe proctitis received more preoperative biologics and ongoing systemic steroids at surgery. While they underwent previous abdominal surgery less frequently, the laparoscopy rate was lower with a longer postoperative length of stay. At multivariate (Table 2), Medical POCs were independently associated with ongoing antibiotics (OR 2.29 [1.01-5.20] p=0.047) and ASA score≥3 (OR 1.93 [1.11-3.35] p=0.019). Surgical POCs were independently associated with ongoing systemic steroids (OR 2.09 [1.19-3.68] p=0.011, while ongoing antibiotics (OR 0.2 [0.04-0.86] p=0.031) and laparoscopy (OR 0.53 [0.28-1.00] p=0.049) were protective. Intra-abdominal septic complications (IASCs) and abdominal/pelvic abscesses were independently associated with the proctitis status (OR 1.1 [1.06-2] p=0.018 and OR 1.56 [1.08-2.25] p=0.017, respectively). Conclusion Rectal stump proctitis was independently associated with postoperative abdominal and pelvic abscesses and IASCs after proctectomy and IPAA for UC. The association between proctitis and IPAA’s long-term outcomes and pouch failure need to be further explored.

Impact of robotic and open surgery on patient wound complications in gastric cancer surgery: A meta-analysis.

This meta-analysis is intended to evaluate the effect of both robotic and open-cut operations on postoperative complications of stomach carcinoma. From the earliest date until June 2023, a full and systemic search has been carried out on four main databases with keywords extracted from 'Robot', 'Gastr' and 'Opene'. The ROBINS-I instrument has been applied to evaluate the risk of bias in nonrandomized controlled trials. In these 11 trials, a total of 16 095 patients had received surgical treatment for stomach cancer and all 11 trials were nonrandomized, controlled trials. Abdominal abscesses were reported in 5 trials, wound infections in 8 trials, haemorrhage in 7 trials, wound dehiscence in 2 trials and total postoperative complications in 4 trials. Meta-analyses revealed no statistically significantly different rates of postoperative abdominal abscesses among patients who had received robotic operations than in those who had received open surgical procedures (OR, 0.91; 95% CI, 0.25, 3.36; p = 0.89). The incidence of bleeding after surgery was not significantly different from that in both groups (OR, 1.37; 95% CI, 0.69, 2.75; p = 0.37). Similarly, there was no significant difference between the two groups (OR, 0.78; 95% CI, 0.52, 1.18; p = 0.24). No significant difference was found between the two groups (OR, 1. 28; 95% CI, 0.75, 2.21; p = 0.36). No significant difference was found between the two groups of patients who had received the robotic operation and those who had received the surgery after the operation (OR, 1.14; 95% CI, 0.78, 1.66; p = 0.49). Generally speaking, this meta-analysis suggests that the use of robotics does not result in a reduction in certain postsurgical complications, including wound infections and abdominal abscesses. Thus, the use of a microinvasive robot for stomach carcinoma operation might not be better than that performed on the surgical site after the operation. This is a valuable guide for the surgeon to select the operative method.

CT-Guided Transhepatic Catheter Drainage of Deep Postoperative Collections: Initial Experience

Abstract Purpose This article assesses the safety and utility of transhepatic drainage of deep seated postoperative intra-abdominal collections under computed tomography (CT) guidance in a short series. Methods This retrospective study included five patients (mean age: 45.8 years; 3 males, 2 females) who underwent CT-guided transhepatic drainage of postoperative abdominal abscess in our department between April 2019 and December 2020. The clinical and surgical details and the details of the transhepatic drainage procedure were evaluated along with success rates and complications. Results The surgical procedures were Whipple's pancreaticoduodenectomy in four patients and gastrectomy in one patient. Four out of five abscesses were drained through the right lobe of liver, while one was through the left lobe with a technical success rate of 100%. The mean total time for catheter drainage procedure including patient positioning and preparation was 29.2 minutes. None of the patients had procedure-related complications. Mean duration of catheter drainage was 12 days. All patients had complete resolution of symptoms after drainage and the clinical success rate was 100%. Conclusion Transhepatic approach is safe and effective for the drainage of inaccessible postoperative abdominal collections or abscesses where a standard percutaneous approach is not possible.

Preoperative body mass index and amylase level predict postoperative pancreatic fistula independently

Postoperative pancreatic fistula (POPF) is one of the difficult complications after distal pancreatectomy (DP), resulting increased postoperative morbidity and mortality. It is still a hotspot to prevent the occurrence of POPF in recent researches. Our study aimed to investigate the risk factors of pancreatic fistula in patients following DP. We retrospectively analyzed 206 patients with DP in Tongji Hospital, China, from January 2014 to March 2019. Univariate and multivariate logistic regressions were performed to assess the risk factors of POPF. A total of 206 eligible patients were enrolled into this study, including 123 females and 83 males. The overall morbidity was 30.1%. Postoperative complications included postoperative biliary fistula (0.5%), delayed gastric emptying (1%), grade B pancreatic fistula (4.9%), grade C pancreatic fistula (1.9%), postoperative abdominal abscess (2.4%), wound infection (3.4%), percutaneous drainage (18.4%) and reoperation (0.5%). The first hospitalization time was 24 days. There were 21 patients re-hospitalized within 30 days and 8 patients within 90 days. No postoperative death was observed.Univariate analysis indicated that the occurrence of POPF was related to preoperative BMI > 25 kg/m2 (p = 0.034), serum pancreatic amylase > 53 U/L (p = 0.049), splenic preservation (p = 0.069) and splenic vessel preservation (p = 0.036). Multivariate analysis showed that preoperative BMI > 25 kg/m2 (OR = 2.637, p < 0.05) and serum pancreatic amylase > 53 U/L (OR = 2.658, p < 0.05) were independent risk factors of clinical related-postoperative pancreatic fistula. Preoperative BMI > 25 kg/m2 and serum amylase > 53 U/L are independent risk factors of POPF. It is necessary to monitor BMI and amylase level preoperatively in patients undergoing DP.

Purse-string suture after ligating by endoloop for closing of the appendiceal stump is an alternative for endostapler in selected cases: A propensity score-matched study.

The closure of the appendiceal stump is a crucial part of a laparoscopic appendectomy, and an endoloop or endostapler is generally used. The endoloop can be more cost effective than the endostapler. However, reports have shown that the endoloop has a higher postoperative abdominal abscess rate than the endostapler in complicated appendicitis. At our institution, we perform a purse-string suture after ligating by endoloop to reduce postoperative abdominal abscess risk. This study aimed to clarify whether this method could reduce the incidence of postoperative abdominal abscess compared with the endostapler. Patients with acute appendicitis were classified into the purse-string suture group (n=149) and the endostapler group (n=82). Postoperative outcomes were compared after propensity score matching (n=47). No significant difference was found between the two groups in terms of the patient characteristics and postoperative complications, including abdominal abscess. However, the purse-string suture group had more drain placement and a shorter hospital stay than the endostapler group (P=.04 and P=.02, respectively). In patients with complicated appendicitis, there was less drain placement and a shorter hospital stay in the purse-string suture group than in the endostapler group (P < .01 and P < .01, respectively). This might have reflected the difficulty of the operation. All postoperative abdominal abscesses occurred in complicated appendicitis cases. Endoloop with additional purse-string suture had a lower incidence of abscess than previous reports of using endoloop alone. Moreover, the postoperative abdominal abscess rate is similar between the two closure methods.

COMPARISON OF TREATMENT OF INTRAABDOMINAL POST-OPERATIVE ABSCESSES WITH THE LAPAROTOMIC AND MINI-INVASIVE INVASIVE ACCESS

Summary. The aim of the work was to compare the results of surgical treatment of patients for postoperative abdominal abscesses using different tactics.&#x0D; Materials and methods. The study included data from 63 patients with postoperative abdominal abscesses. Laparotomy access and use of percutaneous puncture / drainage were compared. Kaplan-Meier survival analysis was used to compare hospitalization duration.&#x0D; Results. Laparotomic access was performed according to classical methods. After the application of general anesthesia and treatment of the surgical field was performed opening the anterior abdominal wall. The abscess was opened and the contents were aspirated, after treatment of the cavity site with aqueous solutions of antiseptics, the wound was closed and the drainage system was established. Further stages of treatment of intra-abdominal abscess after routine surgery were: aspiration of abscess in the postoperative period through established drainage; diagnostic control of abscess resolution; effective antimicrobial and detoxification therapy. Percutaneous puncture / abscess drainage was performed under ultrasound control using special puncture needles of size F8 - F12. The needle or drainage stlet-catheter was inserted into the abscess cavity, followed by aspiration of the abscess contents and leaving the drainage system. Kaplan-Maier has reduced hospitalizations in patients who have used mini-invasive technologies.&#x0D; Conclusions. Treatment of postoperative abdominal abscesses involves a surgical approach. Patients with postoperative abscesses who underwent laparotomy access were likely to have an increased total hospitalization duration of 5 days compared with the use of mini-invasive technologies.

APPENDICULAR PERITONITIS IN CHILDREN: AN EFFICIENT SURGICAL APPROACH AND INTENSIVE CARE

Introduction. Currently, there is no any unified approach to the treatment of complicated forms of acute appendicitis in children. The purpose of our study is to evaluate the effectiveness of the local Protocol for diagnostics and treatment of appendicular peritonitis (AP) in children. Material and methods. 149 children with AP, aged 2 - 17 (11 ± 3.5 ), were included into the study. All of them were treated at the Clinical and Research Institute Emergency Pediatric Surgery and Trauma (CRIEPST) in 2015-2018. In the gender structure, boys (104; 69.8%) prevailed over girls (45; 30.2%). The following parameters were evaluated: AP structure, surgical tactics, postoperative course (incidence of postoperative intestinal failure syndrome (IFS), postoperative complications, length of hospital stay). A tactics for surgical treatment and volume of intensive care in the postoperative period were defined depending on AP severity and according to the local Protocol. Laparoscopic appendectomy was performed in 145 (97.3%) patients. There were no intraoperative complications and conversions in the studied group. In case of periappendiular abscess (PA) 3 (2.7%), patients had puncture and abscess drainage under ultrasound control. Results. While analyzing the AP structure by forms , the following picture was shown: free and abscessed forms were approximately equal - 72 (48.3%) and 77 (51.7%), respectively (p &gt; 0.05). Diffuse peritonitis - 31.5%; generalized - 16.8%; combined - 17.4%; periappendicular abscess (PA) stage 1-14.8%; PA 2-16.8%; PA 3-2.7%. Postoperative complications - 4 (2.7%): postoperative abdominal abscesses - 3 (2.0%); early adhesive intestinal obstruction - 1 (0.7%). In postoperative abscesses, puncture and drainage were performed under ultrasound control; in early adhesive intestinal obstruction - laparoscopic adhesiolysis. All the children recovered. Length of intensive care was 2.9 ± 1.8 days; hospitalization - 12.0 ± 5.2 days. Conclusion. The local Protocol developed by the researchers helps to define a surgical tactics and volume of intensive care in the postoperative period. Laparoscopic surgery, in the vast majority of cases, is an optimal and effective technique for AP surgical treatment in children. Contraindications to laparoscopic surgery are PA 3 and total abscessing peritonitis.

Does laparoscopic appendectomy confer advantages over open appendectomy for pediatric complicated appendicitis? A single institute experience

Introduction: Laparoscopic appendectomy (LA) for complicated appendicitis appears to be controversial due to the difficulty in dissection and clearing off the peritoneal contamination, prolonged operating times, higher incidence of post-operative abdominal abscess, and wound infections. Objectives: The objective of the study was to compare laparoscopic and open appendectomy (OA) and evaluate the outcome of LA in children with complicated appendicitis. Materials and Methods: A retrospective analysis of 182 patients’ records with complicated appendicitis was done. Data collected included demographics, operative time, resumption of oral intake, and infectious complications such as wound infection and intra-abdominal abscess, need for redo surgery, length of hospitalization, and duration of antibiotic use. Patients were followed up for 6 months in the post-operative period to assess delayed complications. Results: LA was performed in 102 patients and 80 patients underwent an OA. The two groups did not differ significantly in mean age, duration of antibiotic use, resumption of oral intake, and length of the hospital stay. The duration of surgery was significantly longer for LA (p&lt;0.0001). However, the wound infection was significantly more common in the OA group than the laparoscopy group (p=0.0058). None of the patients in the LA group developed delayed complications. A total of four patients in the open group had to undergo surgery for late-onset complications. Conclusion: LA for complicated appendicitis is more advantageous than OA as there is reduced surgical site infection. However, the operative time is prolonged with an increased incidence of immediate post-operative intestinal obstruction. Nevertheless, it avoids the late complications of OA.

Gastroduodenal artery pseudoaneurysm hemorrhage 1 year after laparoscopic distal gastrectomy: a case report

BackgroundPostoperative bleeding originating from pseudoaneurysms after radical gastrectomy is not common, but it can be fatal. In particular, delayed bleeding that occurs after the seventh postoperative day is rare.Case presentationA 54-year-old man underwent laparoscopic distal gastrectomy, D2 lymph node dissection, and Roux en-Y reconstruction for duodenal neuroendocrine tumors. Drainage was performed for a postoperative pancreatic fistula and abdominal abscess. On the 28th postoperative day, he passed a large amount of bloody stool; therefore, emergency esophagogastroduodenoscopy (EGD) and angiography were performed. However, neither examination demonstrated any bleeding foci or pseudoaneurysm. He was conservatively observed and discharged on the 50th postoperative day. Approximately 1 year after the surgery, he passed a bloody stool and experienced hemorrhagic shock. An EGD revealed exposed blood vessels at the duodenal blind end. His condition was diagnosed as a pseudoaneurysm arising from gastroduodenal artery, which ruptured into the duodenum, based on abdominal contrast-enhanced computed tomography findings. Emergency angiography was performed, and the pseudoaneurysm and artery were successfully embolized.ConclusionsThis case illustrates that there is a possibility of delayed bleeding even 1 year after gastrectomy. Such cases may be serious and require immediate and careful management.

Bevacizumab-associated intestinal perforation and perioperative complications in patients receiving bevacizumab.

AimThe purposes of this study are to present cases of emergency surgery in which gastrointestinal perforation occurred during bevacizumab administration, consider the indications for emergency surgery, and examine the safety of scheduled surgery after a washout period for bevacizumab.Methods(a) We retrospectively investigated seven patients who underwent emergency surgery for bevacizumab‐associated intestinal perforation. (b) We investigated 104 patients with advanced colorectal cancer treated with neoadjuvant therapy who underwent surgery from 2008 to 2018, retrospectively.Results(a) In the seven patients undergoing emergency surgery for gastrointestinal perforation, the median bevacizumab administration and washout periods were 16 weeks and 24 days, respectively. A stoma was created in all patients except in those who were not candidates. Two patients developed postoperative abdominal abscesses, and two patients died from perioperative sepsis and gastrointestinal bleeding, respectively; both of these patients had poor performance status. (b) In patients receiving bevacizumab (n = 45) and patients treated with bevacizumab‐free regimens as neoadjuvant therapy (n = 59), 31 and 52 patients received chemoradiotherapy, respectively. We found no correlation with postoperative complications with or without bevacizumab.ConclusionThe surgical indications should be considered carefully in patients with gastrointestinal perforation secondary to bevacizumab administration. Meanwhile, after appropriate cessation time, scheduled surgery following bevacizumab administration is feasible.

Surgical starting time in the morning versus the afternoon: propensity score matched analysis of operative outcomes following laparoscopic colectomy for colorectal cancer.

The number of colorectal cancer cases is increasing, and so the number of laparoscopic colectomy procedures being performed is also increasing, leading to an increased workload for surgeons. However, operating for prolonged time periods may cause surgeons to lose their concentration and develop fatigue. We hypothesized that there is a time-of-day variation in outcome for patients with colorectal cancer who undergo laparoscopic colectomy. The present study aimed to compare the operative outcome between laparoscopic colectomy for colorectal cancer performed in the morning versus the afternoon. This was a single-center, retrospective study. All 1961 consecutive patients who underwent laparoscopic surgery for colorectal cancer between 2007 and 2017 were included; 1006 of these patients underwent morning surgery, while 955 underwent afternoon surgery. These patients were analyzed using propensity score matching, giving 791 patients in each group. The short- and long-term outcomes in both groups were compared. Before propensity score matching, the morning group had a larger mean tumor size than the afternoon group (30cm vs 35cm; P = 0.0035). After matching, the two groups did not significantly differ in any patient characteristics. Compared with the afternoon group, the morning group had a significantly lesser incidence of intra-operative organ injury (0.25% vs 1.13%; P = 0.027), and a significantly greater incidence of post-operative abdominal abscess (2.03% vs 0.75% P = 0.028). The incidences of other complications and morbidities were similar in both groups. The median operative time in the morning group (201min) was significantly longer than that in the afternoon group (193min; P = 0.0124). The two groups did not differ in 5-year overall survival rates and 5-year disease-free rates within any disease stage. Surgical start times are correlated with surgical outcomes. Our data will help to ensure the safest possible surgeries.

Su1366 PERCUTANEOUS VERSUS ENDOSCOPIC ULTRASOUND (EUS)-GUIDED DRAINAGE OF UPPER ABDOMINAL ABSCESSES

Percutaneous drainage (PCD) is the first-line treatment of intraabdominal abscesses. EUS-guided drainage (EUS-D) has also been employed in postoperative abdominal and liver abscesses. There are potential advantages of EUS-D over PCD, however the evidence to supportEUS-D is scant. To compare feasibility, safety, and clinical outcomes of EUS-D versus PCD of upper abdominal abscesses. Single center retrospective cohort study of all consecutive patients undergoing PCD or EUS-D of upper abdominal abscesses between January 2012-June 2017. Patients presenting at least one abdominal abscess proximal to the Treitz ligament were included. Abscess was defined by the presence of fever, pain and consistent imaging. Pancreatic fluid collections and liver transplant patients were excluded. Primary endpoints: technical success, clinical success and adverse event rates. Secondary endpoints: time to resolution, number of interventions and relapse rates. Technical success: ability to access and drain the abscess by placement of a drainage catheter/stent, with purulent effluent. Clinical success: complete resolution of clinical symptoms with disappearance or greater than 50% decrease in abscess size on imaging. To compare primary and secondary endpoints Pearson Chi-squared test or Fisher exact test were applied as warranted. 80 patients met inclusion criteria, 18 patients underwent EUS-D and 62 PCD. Baseline demographics and clinical characteristics are shown in Table 1. There were no statistically significant differences in age, sex, immunosuppressive therapy, number of lesions and etiology. Size was larger in the PCD group (80 vs 65.5 mm, p=0.04) and location around the gallbladder was more frequent in the PCD group (24.2% vs 11.1%, p=0.003). The transgastric route was chosen in 14 (77.8%) EUS-D. Covered metal stents were placed in 16 (89.9%) subjects (9 lumen apposing metal stents and 7 tubular self-expandable metal stents). Double pig-tail plastic stents were placed in 6 (33.3%) patients. Through-the-stent lavage/debridement was performed in 5 (27.8%). A naso-cavitary drainage catheter was placed in one patient for continuous irrigation. Procedure outcomes are shown in Table 2. There were no significant differences in primary or secondary endpoints. In the EUS-D group there were mild or moderate adverse events in four cases (22.2%): three patients presented gastrointestinal bleeding requiring conservative management and one presented a perforation which was closed during the procedure. In the PCD group, there were complications in 13 patients (21%), 7 of them severe. EUS-D presents a similar efficacy compared to PCD, with a non-significant reduction in the number of relapses. EUS-D affords large-diameter stents and through-the-stent intervention. These promising results warrant formal comparison in randomized trials.Tabled 1Table 1: Baseline characteristics of patientsEndoscopic drainage (n=18)Percutaneous drainage (n=62)PMale sex, n (%)12 (66.7%)45 (72.6%)0.63Age, mean (SD)66 (16.5)66.9 (15)0.83Immunosupressive therapy, n (%)1 (5.6%)1 (1.6%)0.40Size (mm), median (IQR)65.5 (51-80)80 (60-97.5)0.04Encapsulated, n (%)11 (61.1%)27 (43.6%)0.28Multiple lesions, n (%)2 (11.1%)17 (27.4%)0.21Location--0.003-Right hepatic lobe, n (%)5 (27.8%)22 (35.5%)-Left hepatic lobe, n (%)4 (22.2%)5 (8.1%)-Perivesicular, n (%)2 (11.1%)15 (24.2%)-Perigastric, n (%)6 (33.3%)6 (9.7%)-Subphrenic, n (%)014 (22.6%)-Left pararenal, n (%)1 (5.6%)0Etiology,--0.10-Biliary, n (%)9 (50%)12 (19.4%)-Postsurgical, n (%)6 (33.3%)31 (50%)-Other, n (%)1 (5.6%)9 (14.5%)-Unknown, n (%)2 (11.1%)10 (16.1%)Previous bile duct manipulation,--0,03-None, n (%)9 (50%)23 (37.1%)-ERCP, n (%)6 (33.3%)8 (12.9%)-Surgical, n (%)1 (5.6%)22 (35.5%)-Multiple, n (%)2 (11.1%)9 (14.5%) Open table in a new tab Tabled 1Table 2: ResultsEndoscopic drainage (n=18)Percutaneous drainage (n=62)PTechnical success, n (%)16 (88.9%)60 (96.8%)0.22Clinical success, n (%)16 (88.9%)51 (82.3%)0.50Time until clinical success (days), median (IQR)17.5 (5.5-25.5)17 (7-27)0.71Time until drainage removal (days), median (IQR)92 (31.5-124)10 (6-21)<0.001Number of procedures, median (IQR)1 (1-1)1 (1-1)0.23Relapse, n (%)010 (16.1%)0.11Time from procedure until relapse (days), median (IQR)37.5 (17-66)Adverse events,--0.91-Mild, n (%)4 (22.2%)6 (9.8%)-Severe, n (%)07 (11.2%) Open table in a new tab

Study of laparoscopic cholecystectomy in rural hospital

Background: Laparoscopic cholecystectomy is the preferred mode of treatment for gall stone diseases. This study is the audit of 125 laparoscopic cholecystectomy done in our institute between year 2013 to year 2014. In laparoscopic cholecystectomy common bile duct injuries were more common than open surgery. Objective of this study is to find out intra and postoperative complications in laparoscopic cholecystectomy and to find the reasons for conversion to open cholecystectomy. Methods: This is the retrospective study of standard four port laparoscopic cholecystectomy done during year 2013 to year 2014 in our institute. The result and complications of laparoscopic surgery were documented in audit form for each laparoscopic cholecystectomy and at the end the results are analyzed. Results: There were no common bile duct injury in our study of 125 cases and we had 5.6% conversion to open cholecystectomy due to various reasons discussed in the paper. There were no cases of postoperative abdominal abscess, port site hernia, common bile duct stricture or mortality in our study. One patient with cystic duct leak was managed successfully with post-operative endoscopic spincterotomy and stenting of common bile duct. Conclusions: Laparoscopic cholecystectomy as treatment of choice is associated with high success rate at our institute with added benefits of minimal invasive surgery. Our results are comparable to international standards. Critical view of safety is an essential prerequisite for prevention of bile duct injuries.

A Long Gastrojejunostomy Is Associated With Decreased Incidence and Severity of Delayed Gastric Emptying After Pancreaticoduodenectomy

Delayed gastric emptying (DGE) after pancreaticoduodenectomy (PD) is associated with increased hospital length of stay (LOS) and health care costs. We hypothesized that a long gastrojejunostomy for PD (LGPD) is associated with decreased incidence of DGE. Data were reviewed from patients who underwent standard PD (SPD), pylorus-preserving PD (PPPD), or LGPD with a 9-cm-long anastomosis between August 2000 and July 2010. Primary outcomes included presence and grade of DGE and LOS. The International Study Group of Pancreatic Surgery definition was used to define DGE. A total of 194 PDs (28 SPDs, 82 PPPDs, and 84 LGPDs) were performed. The rates of DGE were 46.4%, 37.8%, and 16.7%, respectively (P = 0.001). The LGPD was associated with fewer grades B/C DGE (2.4%) compared to SPD (10.7%) and PPPD (17.5%). Rates of postoperative abdominal fluid collection and abscess were similar among the groups. Patients with DGE had significantly longer LOS (14.0 vs 7.0 days, P < 0.001). This is the first study evaluating the effect of a long gastrojejunostomy on the incidence of DGE after PD. The LGPD is associated with significantly decreased DGE compared to SPD and PPPD and warrants further exploration as a means to improve outcome for patients who undergo PD.

腹腔鏡補助下幽門側胃切除後の腹腔内膿瘍に対して内視鏡的経残胃ドレナージが有効であった1例

腹腔鏡補助下幽門側胃切除後の腹腔内膿瘍に対して内視鏡的経残胃ドレナージが有効であった1例

Laparoscopic Appendectomy in Complicated Appendicitis of Children

I read with great interest your article, which describes the value of laparoscopy in management of complicated appendicitis (1). You should be congratulated for the excellent results and for providing the best standards of care to your patients. I have an experience of about 1000 appendicectomies; half of that number was done by laparoscopic approach in the UK and overseas. The conversion rate was 0.4%. I believe laparoscopic approach should be the gold standard for managing complicated appendicitis with systemic signs of sepsis, for the following reasons: 1) Laparoscopy will provide diagnostic and therapeutic options. It will provide an excellent view and access to the whole peritoneal cavity including liver and splenic areas, paracolics, pelvic and interloop spaces. 2) Using laparoscopy, surgeons can levage the whole peritoneal cavity with copious saline under direct vision until the returning fluid is clear, thus it’s better than open approach when the surgeon is limited by access through grid iron incision. 3) Recovery, post-operative pain, cosmesis and wound complications are far better than open approach. 4) Induction of pneumoperitoneum may be challenging in complicated appendicitis. I had no major difficulties using Veress needle. Hasson’s technique is equally safe and can be used by surgeons who have no experience or not familiar with Veress needle technique. 5) In the UK, about 26% of our peadiatric patients are overweight. Lapraoscopic approach will add the benefits of easy access and again avoids wound complications. My approach in complicated appendicitis is: 1) Any child with complicated appendicitis, history of right iliac fossa pain and show signs of sepsis should undergo an urgent laparoscopy. An urgent laparoscopy rather than laparotomy can be repeated if the patient shows signs of deterioration after initial laparoscopy. 2) If on clinical examination there is a mass and controlled sepsis (no systemic signs): I will start antibiotics and arrange an abdominal scan. If the scan showed collection then this will be drained radiologically under Ultrasound guidance. If the child and family are not happy for radiological drainage under local anesthetics, laparoscopic drainage +/appendicectomy (if seen) is performed. This has worked for me very well without problem. You have cited Horwits et al. and Krisher et al. studies that represent an early laparoscopic experience to manage appendicitis, both studies published in 1997 and 2001 and they are out of date! Both had worse outcomes compared to Yagmurlu A et al. and Esposito C et al. studies, which were published in 2006 and 2007. You have mentioned appendicitis together with peritonitis is mostly managed with open surgery with a midline or large transverse incision and wound would be open for many days as a rule (2). This study is published in 1995, which mean it was reported patients outcome and experience before laparoscopic era. The incidence of complications especially the postoperative abdominal abscess is negligible. Our study of 200 cases (including 7.5% of perforated appendicitis) in 2008 (3) reported no single case of abdominal abscess.

Laparoscopic Appendectomy in Complicated Appendicitis of Children

Background: Laparoscopy is not an accepted procedure for complicated appendicitis in children for most pediatric surgeons. This procedure is associated with a higher incidence of postoperative abdominal abscess reported in some studies. Objectives: In this study, we investigated the security, efficacy and complications of laparoscopy in children with complicated appendicitis in Mofid Children's Hospital. Patients and Methods: From April 2010 to January 2013, we performed laparoscopic appendectomy (LA) in all cases of non-complicated and complicated appendicitis (including perforated appendicitis and localized or generalized peritonitis based on the operation findings and pathological reports). Primary outcomes were incidence of complications, intra-abdominal abscess and wound infection. Secondary outcomes were length of operation, length of hospital stay, resumption of diet, incidence of bowel obstruction, duration of antibiotic use and readmission. Laparoscopy appendectomy was performed with two working ports. Results: LA was performed in 123 children aged 2 to 14 years (mean of eight years) over a 3-year period, of whom only 34 cases had complicated appendicitis (either localized or generalized peritonitis). There was one conversion to open appendectomy (OA) in a patient with appendicular abscess with a mass, which excluded from our analysis. There were 6 patients with generalized peritonitis and 26 patients with localized abscess, and two patients with appendicular mass. The Average duration of symptoms was four days (ranged 3-6 days). The mean length of operation was 52 minutes (ranged 40-80 minutes). The average length of hospital stay was 4.4 days (ranged 4-7 days). They were able to restart oral intake from 16 to 48 hours postoperatively. Two patients (5%) had postoperative complications; one patient with intra-abdominal abscess who underwent reoperation and the second patient with umbilical wound infection was resolved with antibiotherapy. The average follow-up was 14 months (ranged from 4-36 months). Conclusions: We recommend laparoscopic approach for all children presenting complicated appendicitis as the initial procedure of choice.

English

BACKGROUND: Since 1990 laparoscopic cholecystectomy is the gold standard treatment for symptomatic gall stones disease. The aim of this study was to evaluate the results of three port laparoscopic cholecystectomy in symptomatic patients with gall stones in terms of conversion rate, length of hospital stay, post operative complications, morbidity and mortality. METHODOLOGY: The retrospective study was carried out in Department of Surgery at Chirayu Medical College and Hospital, Bhopal. All the patients who underwent laparoscopic cholecystectomy in the department of surgery from (May2011- April 2013) were reviewed from department records. Patients with co morbidities, altered Liver function test and obstructive jaundice were excluded from the study. Demographics with patient details, conversion to open, complications of anaesthesia and surgery were reviewed from clinical notes, and department register. Data was analysed using SPSS-18 and results were compared with international studies. RESULTS: Out of 200 patients174 were females (87%) and 26(13%) males. The mean age of patients was 40.47±12yrs, the youngest patient was10 yrs old and oldest patient was 80 yr old. Mean operative time was 50min±11.16 min. The conversion rate in our series was 6(3.0%) cases; Port site wound infection was seen in 6 (3%) patients. There was no bile duct injury, major haemorrhage or bowel injury necessitating opening surgery. On follow up no patient had post operative abdominal abscess, port site hernia or post operative bile duct stricture, there was no mortality in our study. CONCLUSION: Laparoscopic cholecystectomy with three ports is effective & safe modality to treat gall stones. Good training careful case selection, initial learning curve, meticulous technique, well trained team and high standard equipments are of paramount importance to ensure good results.

NASPGHAN Clinical Report on the Evaluation and Treatment of Pediatric Patients With Internal Penetrating Crohn Disease

Natural History of Pediatric Crohn Disease T he natural history of pediatric Crohn disease (CD) remains unpredictable, although some trends are observed that differentiate children from adults. Pediatric CD often presents with more severe disease and more frequent need for immunosuppressive therapy (1). Growth failure, present in 15% to 20% of patients, is a unique characteristic of pediatric CD not seen in adult-onset CD (2). Colonic disease distribution is common in patients younger than 10 years (1). The need for surgical intervention also varies, with 1 study reporting the actuarial risk of having undergone an extensive intestinal resection being 48.6% 5% in a childhood-onset group versus 14.6% 2% in the adult-onset group (P< 0.001) (1). More recently, long-term follow-up of patients enrolled in pediatric registries shows a cumulative surgical rate of 14% to 17% at 5 years and 28% at 10 years (3,4).