Postoperative Fistula Formation Research Articles

PRIMARY REPAIR OF PROXIMAL (GRADE IV) HYPOSPADIAS UTILIZING TUNICA VAGINALIS VASCULARISED FLAP

Background: Proximal (grade IV) hypospadias like scrotal and perineal are considered as severe challenging types for surgeons, problematic for the patients and their families, More than three hundreds surgical techniques were used to manage different type of hypospadias . Most of them associated with high incidence of complications. These complications are much more common in the proximal types as in our study. Post-operative fistula formation is expected complications. Utilising the tunica vaginalis as an additional layer during repair may prevent such complications. In this study we evaluated the benefits of using the tunica vaginalis flap as a supportive layer in the primary repair. Most related literatures about this subject used this technique after surgery to manage cases with post-operative fistulas. In the contrary we used this technique during the formal surgery to cover the new urethra to prevent fistula formation not after surgery. Aims of the study: A retrospective study, on fourteen patients with severe hypospadias (Proximal types), to evaluate the role of tunica vaginalis flap in the primary repair of the hypospadias. Patients and Methods: Between January 2016 and January 2024, fourteen children with Grade IV hypospadias were operated on. Only severe cases were treated with this method other simpler and more common cases were treated by different surgeries like Snodgrass technique. The age range was 2 to 16 years. All of them had 2 staged repair the first stage was correcting the chordae by incising the urethral plate excising the fibrous chordae tissues then covering the bare shaft with dorsal flaps. The tunica flap was used in the second stage which was done 6 to 12 months later. Folly's catheter was used for ten to fourteen days after surgery. And the patients were followed for a variable time 3months to 2 years period for the development of complications like fistula formation or stricture. Cosmetic considerations were also noted. Results: All the fourteen patients had proximal types (Grade IV) hypospadias. After surgery all patients had a good cosmetic outcome no fistula formation two had mild distal urethral stricture cured after few urethral dilatation. No post-operative penile torsion was noted. Two patients developed local infection treated conservatively. One patient had partial glanular dehiscence at the distal end which had no clinical significance. One patient complained from on and off penile cutaneous swelling lasted 3 weeks. Conclusions: Using tunica vaginalis vascularised flap to cover the new urethra in severe proximal hypospadias during the second stage seems to be a successful way in preventing fistula formation without increasing the patient's morbidity.

Abstract CT031: A pilot clinical trial of neoadjuvant modified FOLFIRINOX plus nivolumab in borderline resectable pancreas cancer

Abstract Background: Combinations of chemotherapy and checkpoint inhibitors have failed to show improvements in pancreas cancer (PC) but all studies reported to date have been in the metastatic setting. Perioperative strategies of PD1 inhibitor combinations have shown promise in many malignancies. The A021501 trial established modified FOLFIRINOX (mFFX) as a reference neoadjuvant regimen for patients (pts) with borderline resectable pancreas cancer (BRPC). Here, we present clinical and pathologic results from a phase 1/2 investigator-initiated study investigating the safety and efficacy of mFFX and Nivolumab in pts with BRPC. Methods: Pts with ECOG PS 0-1 and BRPC confirmed by qualified surgeons were treated with a maximum of 6 cycles of mFFX (oxaliplatin 85 mg/m2, irinotecan 150 mg/m2, leucovorin 400 mg/m2 and infusional 5-fluorouracil 2400 mg/m2 over 46 hours) on days 1 and 15 of a 28-day cycle and Nivolumab (480 mg Iv q 4 weeks). The primary endpoint was safety (including post-operative fistula formation) and pathologic response to neoadjuvant therapy. Secondary endpoints included progression-free survival (PFS), overall response rate (ORR) and overall survival (OS). RNA sequencing was performed on 16 post-treatment resected tumors, 5 patient-matched diagnostic pre-treatment biopsies, and 9 resected tumors from non-trial patients treated with mFFX alone. Results: Overall, 28 pts (median age 68, M: 16, F, 12) were enrolled. 26 (93%) pts completed at least 3 cycles of mFFX and Nivo and 24 (86%) pts underwent surgery (23 R0/1R1). There were no grade 2 post-operative fistulas observed and the rates of grade 3 or higher adverse events was 55% with all being related to mFFX and none attributed to nivolumab. At a median follow-up of 24 months, the median PFS was 34.8 months, and the median OS was 35.1 months. Among pts who underwent pancreatectomy, the 18-month OS rate was 90%. There were 2 pathologic complete responses and 2 near complete responses. Compared to pre-treatment biopsies, RNA sequencing from resected specimens revealed higher CD8 (P=0.018) and Granzyme A (P=0.024) expression. In patients with pathologically node negative disease (n=11), elevated Granzyme A expression was associated with significantly improved PFS (P=0.046). Adenosine-related gene expression increased in 50% (n=8) of post-treatment samples (P<0.022) and correlated with expression of adenosine-generating CD73 (P=0.008). Conclusions: Neoadjuvant mFOLFIRINOX and Nivolumab was associated with favorable rates of R0 resection, PFS and OS relative to historical data in patients with BRPC in this pilot trial. The addition of Nivolumab did not increase rates of G3 AE’s and there were no unexpected safety signals. The addition of Nivolumab to neoadjuvant FOLFIRINOX may benefit some patients by enhancing cytolytic T cell function and decreasing immunosuppressive adenosine. This is the first trial reported with a PD1 inhibitor in neoadjuvant pancreas cancer and a Phase II trial is ongoing. Citation Format: Zev A. Wainberg, Jason Link, David Dawson, Lee Rosen, Stephen Kim, Mark Girgis, Jon King, Joe Hines, Saeed Sadeghi, Olga Olevsky, Deborah J. Wong, Harsimran Multani, Jenna Davis, Lisa Yonemoto, Ann Marie Siney, Christine Kivork, Chi-Hong Tseng, Timothy Donahue. A pilot clinical trial of neoadjuvant modified FOLFIRINOX plus nivolumab in borderline resectable pancreas cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 2 (Late-Breaking, Clinical Trial, and Invited Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(7_Suppl):Abstract nr CT031.

A systematic review and meta-analysis of the use of packing in the management of perianal abscesses.

Perianal abscesses are common presentations and reasons for emergency general surgery admissions. Management involves incision and drainage of the abscess and packing the cavity with internal wound dressings. This meta-analysis aimed to assess in adults if packing an abscess or leaving it unpacked leads to a significant difference in the outcomes of pain on wound dressing, time to healing, rate of fistulation and abscess recurrence. Randomised controlled trials (RCTs) with participants aged 18 years or older that compared packing of perianal abscess cavities with no packing between 2002 and 2022 were searched for in December 2022 on OVID Medline and Embase, the CENTRAL register of trials, PubMed and Google Scholar. Risk of bias was assessed using the Cochrane Risk of Bias tool. Random effects meta-analysis was conducted on the data extracted. Three RCTs involving 490 patients were analysed for the outcomes of abscess recurrence and postoperative fistula formation; the data were not adequate to assess pain on dressing and time to healing. For unpacked versus packed, the pooled relative risk of abscess recurrence was 1.57 (95% confidence interval (CI) 0.764, 3.29, p=0.219) and for fistula formation 0.686 (95% CI 0.430, 1.09, p=0.114). These results suggest there is no significant benefit to packing abscess cavities. Analysis of the outcomes suggests there is no significant difference with regards to rates of abscess recurrence or fistula formation between the packed and unpacked groups; however, appropriately powered RCTs are required in this area to provide more primary evidence to inform best practice and clinical management.

Accuracy of physical examination versus Doppler ultrasonography for determining maturity in postoperative arteriovenous fistula formation

Differentiating between arteriovenous fistula (AVF) maturation and failure can help determine which AVF will undergo successful canulation and which ones will require immediate rescue. A prospective observational study was conducted at Vajira Hospital in Bangkok, Thailand, between October 2020-November 2022. A single vascular surgeon performed a physical examination on patients with chronic kidney disease undergoing AVF placement, and a radiologist conducted Doppler ultrasonography during the second and sixth postoperative weeks. Dialysis nurses determined AVF maturity by performing cannulation. The study compared the accuracy of physical examination and Doppler ultrasonography. A model was developed to predict the success of AVF use. Out Of the 125 recruited patients, 81% demonstrate unassisted maturation of their AVF. The male sex and brachiocephalic type are associated with AVF maturation. The physical examination findings of palpable thrill and the absence of a strong pulse at the 6th week show an area under the receiver operating curve (AUC) value of 0.79. Similarly, arterial end-diastolic velocity on ultrasonography at the 6th week also demonstrates a comparable predictive value with an AUC of 0.82 (p=0.697). Meanwhile, the model that combined end-diastolic velocity and venous volume flow yields the best results for predicting AVF maturation, with an AUC of 0.92. These models provide more accurate predictions compared to physical examination alone (AUC: 0.92 vs. 0.79; p<0.01). Although a prudent physician predicts AVF maturation through a thorough physical examination, Doppler ultrasonography is preferred in anticipating the success of postoperative AVF placement.

Preoperative pancreatic radiologic characteristics predict pancreatic-specific complications before pancreaticoduodenectomy: the pancreatic acinar radiologic score

BackgroundHigh acinar pancreatic contents are associated with a higher rate of postpancreatectomy acute pancreatitis and pancreatic fistula formation (POPF). Predicting acinar contents preoperatively might identify those at high risk of developing postoperative complications. MethodsA multivariable analysis was performed to identify radiological factors associated with high pancreatic acinar content at histology in patients undergoing pancreaticoduodenectomy. Clinical and radiological variables identified were used to build a composite score predicting low, moderate, and high acinar pancreatic contents. ResultsPancreatic density, wirsung caliber, and pancreatic thickness on preoperative CT-scan predicted acinar contents. These three variables predicted low, moderate, and high acinar content in 94 (26%), 122 (33.6%), and 147 (40.5%) patients, respectively. Patients with high radiological acinar scores compared with patients with intermediate-low risk scores were more frequently male (73.4% vs. 54.1%; p = 0.0003), obese (14% vs. 6%; p = 0.01), and had a statistically significant higher rate of pancreatic-specific complications (23.8% vs. 8.33%; p = 0.01), POPF (12.9% vs. 4.63%; p = 0.005) and pancreaticogastrostomy bleeding (10.8% vs. 4.17%; p = 0.01). ConclusionA simple radiological score combining pancreatic thickness, density, and wirsung caliber at CT scan preoperatively predicts patients with pancreatic parenchyma that are at higher risk of postoperative pancreatic-specific complications.

Early Predictors of Fistula Formation Following Head and Neck Reconstruction.

Salivary fistula formation is a common and serious complication following head and neck reconstruction. Because it can cause delayed wound healing and infection and carotid artery rupture in severe cases, hence, early detection and treatment are crucial. This study was designed to identify early predictors of postoperative fistula formation. We conducted a retrospective analysis of patients who underwent head and neck reconstruction between 2015 and 2022. Body temperature, serum white blood cell (WBC) count, and serum C-reactive protein (CRP) levels were assessed until postoperative day (POD) 14 and compared between patients with and without fistula. In this study, 200 patients were included. No significant differences in body temperature and WBC count were observed between the two groups during the entire study period. CRP levels after POD2 were higher in the fistula group than in the without fistula group. From the receiver operating characteristic curves comparing the two groups, the best cutoff level for CRP was 6.27 mg/dL from POD7 to POD8, with 77.1% sensitivity, 69.8% specificity, and 90.1% negative predictive value. CRP is a valuable predictor of fistula formation following head and neck reconstruction. The course of CRP levels in patients with fistulas remains consistently elevated compared to patients without fistulas, and it is particularly useful for the exclusion diagnosis of fistula.

The implications of sarcopenia in the treatment and prognosis of pancreatic cancer

Sarcopenia is the subclinical loss of skeletal muscle and strength and has been extensively studied in both cancer and surgical patients. Patients with sarcopenia are particularly vulnerable to major physiological stressors including surgery and surgical complications. Sarcopenia has thus gained significant recognition as an important prognostic factor for both complications and survival in cancer patients. The aim of this review was to evaluate the current literature on the effect of sarcopenia on the treatment and prognosis of pancreatic cancer. The prevalence of sarcopenia in pancreatic cancer patients range between 20 and 65% due to the heterogeneous groups of patients, difference in disease stage, and the different methods of measuring sarcopenia. Sarcopenia would be more accurately assessed by utilizing both imaging and clinical data, such as frailty. Although malnutrition could be responsible for the attenuated healing process of pancreatic anastomosis the relationship between sarcopenia and outcome following pancreaticoduodenectomy is debated. Most studies showed a higher risk of postoperative pancreatic fistula formation in patients with concurrent sarcopenia and high fat mass (sarcopenic obesity). Sarcopenia seems generally to be associated with lower survival. The assessment of sarcopenia can therefore lead to changes in management strategy, patient selection, and improved informed consent prior to surgical resection of pancreatic cancer. An improved prediction of clinically relevant pancreatic fistula formation after pancreatic surgery using preoperative computed tomography scan, including a fistula risk score using sarcopenic obesity and subcutaneous fat area will be useful. Although treatment for sarcopenia still remains an area of research a protocol to improve nutrition and fitness preoperatively may improve sarcopenia and surgical outcome.

Dual-crosslinking immunostimulatory hydrogel synchronously suppresses pancreatic fistula and pancreatic cancer relapse post-resection

In pancreatic cancer (PC), surgical resection remains the sole curative option, albeit patients undergoing resection are susceptible to postoperative pancreatic fistula (PF) formation and tumor recurrence. An unmet need exists for a unified strategy capable of concomitantly averting PF and tumor relapse to mitigate morbidity in PC patients after surgery. Herein, an original dual crosslinked biological sealant hydrogel (methacrylate-hyaluronic acid-dopamine (MA-HA-DA) and sulfhydryl-hyaluronic acid-dopamine (SH-HA-DA)) was engineered as a drug depot and loaded with polydopamine-cloaked cytokine interleukin-15 and platelets conjugated with anti-TIGIT. In vitro analyses validated favorable tissue adhesion, cytocompatibility, and stability of the hydrogels. In a PF rodent model, the hydrogel effectively adhered to the pancreatic stump, sealing the severed pancreatic end and impeding post-operative elevations in amylase and lipase. In PC murine models, hydrogels potently stimulated CD8+ T and NK cells to deter residual tumor re-growth and distant metastasis. This innovative hydrogel strategy establishes a new framework for concomitant prevention of PF and PC recurrence.

A Comparison of a Small-Stitch Closure With a Standard Closure in Midline Laparotomy Incisions: A Prospective Comparative Study.

Introduction Midline incision provides a rapid and thorough approach to the abdominal cavity and, therefore, is widely employed in both emergency and elective procedures. However, midline laparotomy is associated with many post-operative complications likewound dehiscence, incisional hernia, fistula formation, and surgical site infection (SSI). The purpose of the study is to comparethe complications that occurred post-operativelyin associationwith thelong and smallbite suture techniques for midline laparotomy incisions. Methodology A prospective comparative study was carried out among 90 cases of midline laparotomies for 18 months (January 2021 to June 2022). The participants were categorizedinto two groups: (1) Group A, which included 45 patients, underwent small-suture abdominal fascia closure, and (2) Group B, which consisted of the remaining45 patients, underwent large-suture abdominal midline wound closure. Patients were followed up in the hospital till the day of discharge and in the outpatient department (visit 1, within one month of surgery) for pain, wound dehiscence, and surgical site infection. Patients were called for visit 2 (six months post-surgery) and incisional hernia rates were assessed. Results On the numerical pain rating scale, the mean score was higher in Group B, that is, 4.1 than in Group A, which was 3.5. Wound dehiscence and incisional hernia rates were higher among Group B cases. The majority of SSIs were noted in Group B with statistically significant results. Conclusion Despite the lack of randomization,the results demonstrated in this study support the use of small bite sutures in comparison to long bite sutures for laparotomy closure.

The Effect of Presurgical Nasoalveolar Molding on Oronasal Fistula Following Primary Palatoplasty

Objective: Presurgical nasoalveolar molding (PNAM) is widely used in cleft care protocol. This study investigated the correlation between PNAM and oronasal fistula after primary palatoplasty. Methods: A case-controlled study of 80 unilateral and bilateral complete cleft palate patients who underwent cleft palate repair were enrolled. Patients were divided into 2 groups: (1) no PNAM use and (2) PNAM use. The incidence of oronasal fistula and postoperative complications were compared between groups. Results: Forty patients in each group demonstrated the same baseline characteristics. The PNAM group showed a significantly lower postoperative oronasal fistula rate (15% versus 50%, P=0.003). Palatal cleft width wider than 12.5 mm increases the odds ratio of fistula formation by 1.19-fold (P=0.037), and the PNAM protected against postoperative palatal fistula formation (odds ratio 0.20, P=0.003). Conclusion: Presurgical nasoalveolar molding can reduce postoperative oronasal fistula in wide-gap Veau type III and IV cleft palate.

Clinical presentation, diagnosis and surgical treatment of intrabiliary ruptured hydatid disease of the liver

Background: Intrabiliary rupture (IBR) of liver hydatid cyst is common and serious and fatal complication. The incidence of (IBR) varies from 1% to 25%. The treatment of IBR is still controversial among surgfons. We aimed to show clinical presentations, diagnosis treatment and outcome of IBR in liver hydatid cysts by reviewing our cases. Method: In a retrospective study we collected data of records of all patients who were operated on for hydatid disease of the liver operated between 2016 and 2021 at Razi teaching and privat Arya Hospital were review. 322 patients who had been operated for hydatid cyst of the liver were detected. Approval for this study was obtained from our Institutional Review Board. Results: Intrabiliary ruptured hydatid cysts of the liver was determined in 14 of the patients was in frank IBR and 32 patient with occult IBR was determined in 322 patients was operated for hydatid cysts of the liver. The average age of patients was 28 to 64 years (range 21 - 68 years). . The most frequent symptoms were right upper quadrant,epigastric pain, dyspepsia, jaundice,fever,wight loss and pruritus Conclusions: Intrabiliary ruptured hydatid cysts of the liver is the most common complication. With appropriate evaluation and intervention, this will lead to decresed postoperative bile leakage and fistula formation, a major cause of morbidity and mortality.Every effort should be made to detect and prevent these complications,ERCPand MRCPcan hellpfor diagnosis and treatmen or IBR .Laparatomy, choledochal exploration should be performed during operation. For decompress intrabiliary pressure T-tube drainage may be preferred in the management of intrabiliary ruptured hydatid cysts because of deresed morbidity, the ability to, easier monitoring of the biliary drainage.

The Implications of Sarcopenia in the Treatment and Prognosis of Pancreatic Cancer

Sarcopenia is the subclinical loss of skeletal muscle and strength and has been extensively studied in both cancer and surgical patients. Patients with sarcopenia are particularly vulnerable to major physiological stressors including surgery and surgical complications. Sarcopenia has thus gained significant recognition as an important prognostic factor for both complications and survival in cancer patients. The aim of this review was to evaluate the current literature on the effect of sarcopenia on the treatment and prognosis of pancreatic cancer. The prevalence of sarcopenia in pancreatic cancer patients range between 20% to 65% due to the heterogeneous groups of patients, difference in disease stage, and the different methods of measuring sarcopenia. Sarcopenia would be more accurately assessed by utilizing both imaging and clinical data, such as frailty. Although malnutrition could be responsible for the attenuated healing process of pancreatic anastomosis the relationship between sarcopenia and outcome following pancreaticoduodenectomy is debated. Most studies showed a higher risk of Postoperative Pancreatic Fistula (POPF) formation in patients with concurrent sarcopenia and high fat mass (sarcopenic obesity). Sarcopenia seems generally to be associated with lower survival. The assessment of sarcopenia can therefore lead to changes in management strategy, patient selection, and improved informed consent prior to surgical resection of pancreatic cancer. An improved prediction of clinically relevant pancreatic fistula formation after pancreatic surgery using preoperative Computed Tomography (CT) scan, including a fistula risk score using sarcopenic obesity and subcutaneous fat area will be useful. Although treatment for sarcopenia still remains an area of research a protocol to improve nutrition and fitness preoperatively may improve sarcopenia and surgical outcome.

Interposition grafting of collagen-gelatin sponge impregnated with basic fibroblast growth factor in primary palatoplasty

IntroductionAn oronasal fistula is a challenging post-operative complication of palatoplasty due to impaired velopharyngeal function or its high recurrence rate. Muscle repositioning, a key procedure in palatoplasty, causes dead space at the junction between the hard and soft palates. Consequently, thin oral and nasal mucosae are prone to break down and form fistulas. In this study, we used basic fibroblast growth factor-impregnated collagen gelatin sponge (bFGF-CGS) in primary palatoplasty to reduce fistula formation. MethodsThis retrospective study assessed the complications and efficacy of bFGF-CGS to reduce fistula formation. Patients who underwent primary palatoplasty with bFGF-CGS were included. The same number of patients who underwent primary palatoplasty without bFGF-CGS was included as a control group. The outcomes included post-operative oronasal fistula formation, delayed healing, bleeding, and infection. ResultsBoth groups included 44 patients. Except for age at palatoplasty, there were no statistically significant demographic differences between the two groups; however, the rates of fistula formation in the study and control group were 2.3% and 13.6%, respectively. There were no infections among the patients. ConclusionsThe grafting of bFGF-CGS in primary palatoplasty was safe and probably effective in reducing post-operative oronasal fistula formation.

Classification of left-side hepatolithiasis for laparoscopic middle hepatic vein-guided anatomical hemihepatectomy combined with transhepatic duct lithotomy.

Laparoscopic middle hepatic vein-guided anatomical hemihepatectomy combined with transhepatic duct lithotomy (MATL) is an approach that can substantially improve stone clearance rates while reducing the rate of postoperative biliary fistula formation, residual stone rates, and rates of recurrence. In this study, we classified left-side hepatolithiasis cases into four subtypes based upon the diseased stone-containing bile duct, the middle hepatic vein, and the right hepatic duct. We then investigated the risk associated with different subtypes and evaluated the safety and efficacy of the MATL procedure. In total, 372 patients who underwent left hemihepatectomy for left intrahepatic bile duct stones were enrolled. Based on the distribution of the stones, the cases could be divided into four types. The risk of surgical treatment was compared for the four types and the safety, short-term efficacy, and long-term efficacy of the MATL procedure in the four types of left intrahepatic bile duct stones were studied. Type II was found to be the most likely to cause intraoperative bleeding while type III was likely to cause biliary tract damage and type IV was associated with the highest stone recurrence rate. The MATL procedure did not increase the risk of surgery and was found to reduce the rate of bile leakage, residual stones, and stone recurrence. Left-side hepatolithiasis-associated risk classification is feasible and may represent a viable means of improving the safety and feasibility of the MATL procedure.

Single-arm phase II trial to evaluate the safety of laparoscopic/robotic total gastrectomy with spleen-preserving splenic hilar dissection for locally advanced proximal gastric cancer that invades the greater curvature: JCOG1809.

TPS479 Background: The standard treatment for locally advanced proximal gastric cancer invading the greater curvature is “open total gastrectomy combined with splenectomy” (OTG+S) aiming for whole clearance of the splenic hilar lymph nodes. However, its pertinent postoperative severe complication (e.g. pancreatic fistula) is problematic. An objective of this study is to evaluate the safety of “laparoscopic or robotic total gastrectomy with spleen-preserving splenic hilar dissection” (LRSHD) as a new treatment option which has a potential to reduce surgical morbidity, subsequently to replace the current standard treatment, OTG+S. Methods: This is a multicenter single-arm phase II trial. The main eligibility criteria are as follows; clinical T2-4a resectable locally advanced proximal gastric adenocarcinoma that invades the greater curvature; without obvious lymph node metastasis at the splenic hilum nor direct invasion to the spleen/splenogastric ligament. Protocol treatment is laparoscopic or robotic total gastrectomy with splenic hilar lymph node dissection (D2 + No.10 lymphadenectomy according to the Japanese guidelines) in which the spleen is preserved with skeletonizing the splenic vessels. Quality control of surgery is assured by surgeon’s qualification and central peer review of intraoperative photo at the splenic hilum after dissection. The primary endpoint is the proportion of postoperative pancreatic fistula and/or intra-abdominal abscess formation with Clavien-Dindo Grade III or higher (within 30 days after surgery). Secondary endpoints are intraoperative blood loss, operation time, mortality, overall postoperative complication, number of yield splenic hilar nodes, number of metastatic splenic hilar nodes, conversion to splenectomy, conversion to laparotomy, relapse-free survival, and overall survival. Sample size was set as 85 patients to obtain 80% power considering that 15% of patients are judged as unresectable intraoperatively, with the hypothesis that the primary endpoint would have an expected value of 7% and a threshold value of 16% in one-sided alpha of 0.1. Planned accrual period is 5 years. The accrual began in August 2019. As of August 2022, 53 of the planned 85 patients (62.4%) have been enrolled. When the safety of LRSHD is proved by this study, a non-inferiority phase III trial will be consequently launched. Clinical trial registry number: UMIN000037580. Clinical trial information: UMIN000037580 .

Association of postoperative opioid use with pancreatic fistula rates after distal pancreatectomy

Background: The rate of clinically relevant postoperative pancreatic fistula (CR-POPF) after distal pancreatectomy ranges from 15-35% in the literature. Many risk factors have been reported with no consensus on their predictive value. Prior studies have observed an association between increased postoperative opioid use and fistula formation, secondary to increased sphincter of Oddi tone that leads to impaired emptying and increased pancreatic duct pressure. Our group has implemented perioperative care pathways, with each iteration increasingly using non-opioid medication bundles and reducing administered opioids. The aim of this study was to determine the association between perioperative variables, including early postoperative opioid use, and CR-POPF.

Obesity Is Associated With Increased Risk for Adverse Postoperative Outcomes After Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma

IntroductionConflicting reports exist about the effect obesity has on adverse postoperative surgical outcomes after distal pancreatectomy (DP). The aim of this study is to explore the role of obesity in terms of morbidity and pancreas-specific complications following DP for pancreatic ductal adenocarcinoma (PDAC). MethodsAll patients who underwent DP at a single institution over 10 y were analyzed (2009-2020). Patients were categorized as nonobese (body mass index [BMI] < 30 kg/m2) and obese (BMI ≥ 30 kg/m2). Independent predictors of adverse postoperative outcomes were calculated using multivariate logistic regression models. Overall survival was assessed using Kaplan–Meier survival analysis. ResultsOf the 178 patients included, 58 (32.5%) were obese. Clinically relevant postoperative pancreatic fistula (CR-POPF) formation rate was significantly higher in the obese group (20.6% versus 7.5%, P value = 0.011). We did not identify any significant difference between obese and nonobese patients in median overall survival (30.2 mon versus 28.9 mon, P value = 0.811). On multivariate binary logistic regression analysis, BMI ≥ 30 was an independent predictor of morbidity (any complication) and CR-POPF formation after DP for PDAC. ConclusionsObesity is associated with a significantly increased risk for CR-POPF in patients undergoing DP for PDAC. Obesity should be considered as a variable in fistula risk calculators for DP.

Spiliotis-Farfarelos Maneuver for the Management of Small Bowel Obstruction and Frozen Pelvis in Patients With Peritoneal Metastasis.

The management of the advanced peritoneal disease is demanding especially in cases of extensive bowel infiltration and the obstruction of the gastrointestinal tract in different sites. Patients with bowel obstruction due to peritoneal carcinomatosis have an overall survival that ranges from three to eight months to four to five weeks based on the operability or not of the disease, respectively. The decision to operate should carefully consider the balance between the probability of symptomatic relief and the risk of severe perioperative complications and survival after surgery. The extent of the disease and postoperative malnutrition could further complicate patients' postoperative course. We aim to present an operative maneuver of bowel preparation and fixation in cases of extensive infiltration of the small bowel by peritoneal carcinomatosis (PC) in order to eliminate the risk of postoperative fistula formation or anastomotic leakage.

Neck Dissection Timing in Transoral Robotic or Laser Microsurgery in Oropharyngeal Cancer: A Systematic Review.

ObjectiveThis review assesses the effect on intra- and postoperative patient outcomes of the timing of neck dissection in relation to transoral surgery. Outcome measures include postoperative bleeding, intra- and postoperative fistula formation, and disease-specific and overall survival.Data SourcesA search was conducted across the MEDLINE, Embase, US National Library of Medicine, and Cochrane databases with search terms in July 2021.Review MethodsArticles that conformed with specified inclusion criteria were included. Included articles were scanned for bias with the ROBINS-I tool.ResultsNineteen articles were selected for qualitative analysis, including 546 patients who had neck dissection in conjunction with transoral robotic surgery/transoral laser microsurgery (TORS/TLM). Seventy-one (18%) patients had neck dissection prior to TORS/TLM, 39 (10%) had neck dissection performed after TORS/TLM, and 281 (72%) had concurrent procedures. In patients with neck dissection before TORS/TLM, 3% experienced major postoperative bleeding, and fistula rates were 0%. In the cohort with neck dissection after TORS/TLM, 3% experienced minor postoperative hemorrhage, and 8% had intraoperative fistulae. In the concurrent cohort of patients, 1% had major postoperative bleeds and 0.3% had minor bleeds, while 4% developed intraoperative fistulas and 0.3% developed postoperative fistulas.ConclusionCurrent evidence indicated that there appears to be no correlation between timing of neck dissection and complications. This systematic review found insufficient data to comment on whether the timing of neck dissection in relation to TORS/TLM affects the outcomes of patients.

Comparative study between snodgrass urethroplasty and modified snodgrass urethroplasty for distal penile hypospadias in terms of post-operative urethrocutaneous fistula formation

Background: Hypospadias is a congenital defect involving the male urethra characterized by the absence of urethral meatus at its normal position. This anomaly is usually associated with the ventrally deficient but dorsally hooded skin. In some cases, the penis is ventrally curved. Surgery is the option for this defect. So many procedures have been developed but none is free from the development of urethrocutaneous fistula. Now-a-days, the popular Snodgrass procedure is widely practiced but still fistula occurs. Many factors are thought to be responsible for it. The most important one is defective ventral penile skin which is deficient of vascular and collagen tissues. To minimize these deficient factors, a dorsal vascular preputial flap is transferred ventrally (modified) to reduce fistula formation further. A comparative study was disigned to determine the role of dorsal vascular flap.Methods: The prospective observational study was conducted in the department of pediatric surgery, Bangabandhu Sheikh Mujib medical university, Dhaka, Bangladesh since February 2017 to May 2021.Results: A total of 40 patients with distal penile hypospadias were included in this study. They were divided into Group A and group B, 20 for each. Snodgrass procedure was for Group A and the modified Snodgrass procedure was done for group B. The outcome of both the groups was determined in terms of fistula formation. Seven patients in group-A and one patient in group B developed fistula. The results were analyzed and were found statistically significant.Conclusions: Modified Snodgrass urethroplasty has a better outcome.