Rate Of Postoperative Fistula Research Articles

30 Does the Use of Antibiotics Prophylaxis Affect the Rate of Postoperative Fistula Rates in Cleft Palate Patients?

Abstract Aim Assess whether post-operative antibiotic prophylaxis affected the incidence of oronasal fistula formation in cleft palate patients. Design and setting: Institutional retrospective study using data from patients undergoing primary palatoplasty. Gold standard Fistula rate of no more than 8-10%. Method In the first cycle, there were two groups (A and B). In group A, the patients had antibiotics on induction and 24 hours after, in group B, the patients had further antibiotics for a week. Our work from the cleft collective showed no evidence of change in fistula rates in relation to the antibiotic regime. Therefore, group A surgeon changed practice had antibiotics only on induction and group B remained the same from the first cycle. Results In cycle 1, we found little evidence to suggest a difference in fistula rate between the use of an antibiotic regimen as binary variables: Grp A(P=0.171) and Grp B (P=0.69). Cycle 2 also demonstrated the following: Grp A (P=0.557) and Grp B(P=0.443). Conclusions The use of antibiotics and differing regimes, postoperatively do not influence the incidence of postoperative fistulae in cleft palate.

46. Does the use of antibiotics prophylaxis affect the rate of postoperative fistula rates in cleft palate patients?

46. Does the use of antibiotics prophylaxis affect the rate of postoperative fistula rates in cleft palate patients?

The risk of clinically-relevant pancreatic fistula after pancreaticoduodenectomy is better predicted by a postoperative trend in drain fluid amylase compared to day 1 values in isolation

BackgroundRecent studies support early drain removal after pancreaticoduodenectomy in patients with a drain fluid amylase on postoperative day 1 (DFA1) level of ≤5,000. The use of DFA1 to guide drain management is increasingly common among pancreatic surgeons; however, the benefit of checking additional drain fluid amylases beyond DFA1 is less known. We sought to determine whether a change in drain fluid amylase (ΔDFA) is a more reliable predictor of clinically relevant postoperative fistula than DFA1 alone. MethodsUsing the American College of Surgeons National Surgical Quality Improvement Plan, pancreaticoduodenectomy patients with intraoperative drain placement, known DFA1, highest recorded drain fluid amylase value on postoperative day 2 to 5 (DFA2nd), day of drain removal, and clinically relevant postoperative fistula status were reviewed. Logistic models compared the predictive performance of DFA1 alone versus DFA1 + ΔDFA. ResultsA total of 2,417 patients with an overall clinically relevant postoperative fistula rate of 12.6% were analyzed. On multivariable regression, clinical predictors for clinically relevant postoperative fistula included body mass index, steroid use, operative time, and gland texture. These variables were used to develop model 1 (DFA1 alone) and model 2 (DFA1 + ΔDFA). Model 2 outperformed model 1 in predicting the risk of clinically relevant postoperative fistula. According to model 2 predictions, the risk of clinically relevant postoperative fistula increased with any rise in drain fluid amylase, regardless of whether the DFA1 was above or below 5,000 U/L. The risk of clinically relevant postoperative fistula significantly decreased with any drop in drain fluid amylase, with an odds reduction of approximately 50% corresponding with a 70% decrease in drain fluid amylase (P < .001). A risk calculator was developed using DFA1 and a secondary DFA value in conjunction with other clinical predictors for clinically relevant postoperative fistula. ConclusionClinically relevant postoperative fistula after pancreaticoduodenectomy is more accurately predicted by DFA1 and ΔDFA versus DFA1 in isolation. We developed a novel risk calculator to provide an individualized approach to drain management after pancreaticoduodenectomy.

Preoperative CT-Based Skeletal Muscle Mass Depletion and Outcomes after Total Laryngectomy.

To assess the role of preoperative CT-based skeletal muscle mass depletion on postoperative clinical outcomes and survival in patients who underwent total laryngectomy for cancer. Patients operated on between January 2011 and March 2020 were retrospectively included. Skeletal muscle area and intra- and inter-muscular fat accumulation were measured at the third lumbar vertebral level on preoperative CT scans. Skeletal muscle mass depletion was defined based on pre-established cut-off values. Their association with postoperative morbidity, length of stay (LOS), costs, and survival was assessed. A total of 84 patients were included, of which 37 (44%) had preoperative skeletal muscle mass depletion. The rate of postoperative fistula (23% vs. 35%, p = 0.348), cutaneous cervical dehiscence (17% vs. 11%, p = 0.629), superficial incisional surgical site infections (SSI) (12% vs. 10%, p = 1.000), and unplanned reoperation (38% vs. 37%, p = 1.000) were comparable between the two patient groups. No difference in median LOS was observed (41 vs. 33 days, p = 0.295), nor in treatment costs (119,976 vs. 109,402 CHF, p = 0.585). The median overall survival was comparable between the two groups (3.43 vs. 4.95 years, p = 0.09). Skeletal muscle mass depletion alone had no significant impact on postoperative clinical outcomes or survival.

Sommerlad–Furlow modified palatoplasty: A retrospective study

The purpose of this study was to introduce the surgical process of Sommerlad–Furlow modified (S–F) palatoplasty and compare its surgical and functional outcomes with conventional Sommerlad (S) palatoplasty.Patients with non-syndromic cleft palate who had undergone either S–F palatoplasty or S palatoplasty were retrospectively reviewed. Data on the outcomes of velopharyngeal function and postsurgical palatal fistula incidence were collected for all patients. Data for preselected factors, including gender, age at palatoplasty, and cleft type, were also collected. Chi-square tests were conducted.1254 patients were included. The postsurgical velopharyngeal competence (VPC) rate after S–F palatoplasty was significantly higher than after S palatoplasty (total, 70.5% vs 57.9%, p < 0.0001; age ≤ 1, 87.0% vs 69.2%, p < 0.0001; 1 < age ≤ 2, 78.3% vs 69.3%, p = 0.0479). With regard to different types of cleft palate, the postsurgical VPC rates after S–F palatoplasty were all significantly higher than for S palatoplasty in all patients younger than 2 years of age (complete cleft palate, 78.7% vs 62.4%, p = 0.0016; hard and soft palate cleft, 84.4% vs 74.8%, p = 0.0172; submucosal cleft and soft palate cleft, 96.6% vs 68.4%, p = 0.0114). The postoperative fistula rate after S–F palatoplasty was 4.3%.This modified palatoplasty technique provided adequate cleft palate closure, with satisfactory speech outcomes and low fistula rates, while older age at palatoplasty may affect the postsurgical outcomes. Within the limitations of the study it seems that the Sommerlad–Furlow modified technique is an option for cleft palate repair.

Evaluation of Postoperative Outcomes in Two Cleft Palate Repair Techniques without Relaxing Incisions.

A modified palatoplasty was established by incorporating the designs of both Sommerlad and Furlow techniques in addition to a novel incision on the medial pterygoid plate's surface, named the Sommerlad-Furlow modified technique. Thus, this study aimed to evaluate the clinical and functional outcomes of the Sommerlad-Furlow modified technique against an accepted standard, the Furlow technique. A retrospective review was conducted for 212 consecutive nonsyndromic cleft palate patients who underwent Sommerlad-Furlow ( n = 106) and Furlow ( n = 106) repairs without relaxing incision on the hard palate between 2011 and 2016. The success of surgical procedures was estimated by the rate of postoperative fistula, speech outcomes, and velopharyngeal insufficiency (VPI)-related quality of life. The demographic and surgical data, including sex, age, cleft type, cleft width, and follow-up period were recorded. There was no statistically significant difference between the two treatment groups regarding demographic and surgical data, except the cleft width ( P < 0.001). The incidence of the fistula was 7.5% and 6.6% after the Sommerlad-Furlow and Furlow procedures, respectively. The two groups showed no significant differences in speech outcomes, and adequate velopharyngeal function was found in 84% and 82.1% in Sommerlad-Furlow and Furlow procedures, respectively. Besides, the rate of severe VPI was slightly lower in Sommerlad-Furlow (0.9%) than in Furlow (2.8%) procedures. Moreover, an adequate VPI-related quality of life was found in 80.4% of the Sommerlad-Furlow group and 78.6% of the Furlow group. The Sommerlad-Furlow technique has obtained acceptable postoperative outcomes and could be a choice for cleft palate repair, especially in wider clefts. Therapeutic, III.

Role of tunica vaginalis flap and dartos flap in tubularized incisional plate for primary hypospadias repair: A retrospective monocentric study.

In the tubularized incised plate (TIP) procedure, flap interposition between the skin and neourethra is highly recommended to decrease the postoperative fistula rate. However, there is no consensus regarding the ideal flap for this procedure. This study aimed to report our experiences in the one-stage TIP hypospadias surgery utilizing dartos flap (DF) (penile skin subcutaneous tissue) and tunica vaginalis flap (TVF) (parietal layer of the testis) as a tissue coverage of neourethra. In a retrospective study from Sep 2018 to May 2021, 16 cases of hypospadias with different types, ranging from midpenile to penoscrotal types, were managed with TIP urethroplasty using DF or TVF as a tissue coverage of neourethra were enrolled. The demographic characteristics of the participants, type of hypospadias, outcome, and complications were analyzed and compared. We used TVF and DF as soft tissue coverage in 11 (68.8%) and 5 (31.3%) patients, respectively. The mean age was 56.38 ± 47.83 months. Mid-penile, proximal, and penoscrotal hypospadias were presented in 3 (18.8%), 8 (50.0%), and 5(31.2%) patients, respectively. The total success rate was 14 (87.5%), while 2 (12.5%) patients developed a urethrocutaneous fistula, which required delayed closure later. In comparison between TVF and DF groups: the TVF was applied in all patients with moderate and severe chordee and all patients with penoscrotal hypospadias, and six patients with proximal hypospadias, while only three patients with mild chordee and two patients with proximal hypospadias used the DF and showed statistical significance between groups (p < 0.001 and 0.012) respectively. The success rate was 90.9% vs. 80.0% in TVF and DF groups, respectively, with no statistical significance between groups (p = 1.000). In the primary TIP repair, the TVF is a practical option as a DF for the interposition cover of a neourethra, especially in penoscrotal and proximal hypospadias with severe chordee.

Post-Operative Hypothyroidism Predicts Fistula Development Following Salvage Oropharyngectomy

<h3>Purpose/Objective(s)</h3> Previous work has demonstrated post-operative hypothyroidism adversely affects wound healing in salvage laryngectomy. The purpose of this study is to evaluate the association between wound healing and hypothyroidism in patients undergoing salvage oropharyngectomy. <h3>Materials/Methods</h3> A single-institution retrospective case series was performed. Fifty-three patients who underwent salvage oropharyngectomy for recurrent or second primary oropharyngeal squamous cell carcinoma between 2001 and 2017 after radiation or chemoradiation were included. The principle explanatory variable was post-operative hypothyroidism, defined as thyroid stimulating hormone (TSH) greater than 5.5 mIU/L. The primary endpoints of the study were oropharyngocutaneous fistula development and fistula requiring operation within 30 days. Binary logistical regression multivariate analysis was performed. <h3>Results</h3> Post-operative fistula rate was 35% among hypothyroid patients which was significantly greater when compared to 9.1% among euthyroid patients. Moreover, 20% of patients with hypothyroidism developed a fistula requiring reoperation, while 3% of euthyroid patients developed a fistula requiring re-operative management. In a multivariate analysis, post-operative hypothyroid patients were at a 9.5-fold increased risk of developing a fistula (95% confidence interval [CI] 1.6 – 57.0, p = 0.013). Additionally, post-operative hypothyroid patients were at 13.6-fold increased risk for development of a fistula requiring reoperation (95% CI 1.2 – 160.5, p = 0.038). <h3>Conclusion</h3> Post-operative hypothyroidism in patients undergoing salvage oropharyngectomy is an independent predictor of fistula development and are more likely to require operative management after fistula development. These data support previously published work demonstrating post-operative hypothyroidism as an independent risk factor for fistula development in patients undergoing salvage laryngectomy. This study further supports the role of hypothyroidism management to modulate wound healing and post-operative wound complications.

A randomized controlled trial of stapled versus ultrasonic transection in distal pancreatectomy

BackgroundThe pancreatic transection method during distal pancreatectomy is thought to influence postoperative fistula rates. Yet, the optimal technique for minimizing fistula occurrence is still unclear. The present randomized controlled trial compared stapled versus ultrasonic transection in elective distal pancreatectomy.MethodsPatients undergoing distal pancreatectomy from July 2018 to July 2020 at two high-volume institutions were considered for inclusion. Exclusion criteria were contiguous organ resection and a parenchymal thickness > 17 mm on intraoperative ultrasound. Eligible patients were randomized in a 1:1 ratio to stapled transection (Endo GIA Reinforced Reload with Tri-Staple Technology®) or ultrasonic transection (Harmonic Focus® + or Harmonic Ace® + shears). The primary endpoint was postoperative pancreatic fistula. Secondary endpoints included overall complications, abdominal collections, and length of hospital stay.ResultsOverall, 72 patients were randomized in the stapled transection arm and 73 patients in the ultrasonic transection arm. Postoperative pancreatic fistula occurred in 23 patients (16%), with a comparable incidence between groups (12% in stapled transection versus 19% in ultrasonic dissection arm, p = 0.191). Overall complications did not differ substantially (35% in stapled transection versus 44% in ultrasonic transection arm, p = 0.170). There was an increased incidence of abdominal collections in the ultrasonic dissection group (32% versus 14%, p = 0.009), yet the need for percutaneous drain did not differ between randomization arms (p = 0.169). The median length of stay was 8 days in both groups (p = 0.880). Intraoperative blood transfusion was the only factor independently associated with postoperative pancreatic fistula on logistic regression analysis (OR 4.8, 95% CI 1.2–20.0, p = 0.032).ConclusionThe present randomized controlled trial of stapled versus ultrasonic transection in elective distal pancreatectomy demonstrated no significant difference in postoperative pancreatic fistula rates and no substantial clinical impact on other secondary endpoints.

Surgical Team Trips to Vietnam: Implementation of a Dedicated Cleft Palate Perioperative Program Improves Fistula Rates.

ReSurge International is a nongovernmental organization that organizes surgical team trips to low- and middle-income countries. Cleft palate repair is commonly performed on these trips. A comprehensive cleft care program was implemented to help reduce postoperative palatal fistula rates. A retrospective review of all patients undergoing cleft palate repair surgery with ReSurge International in Vietnam from 2013 through 2019 was performed. The cleft care program was implemented in 2018. This intervention involved preoperative education of patients and close postoperative monitoring. Critically, this program also provided closer access to providers. Subsequent follow-up was performed by a ReSurge physician. Parent-reported outcomes were assessed preoperatively and postoperatively using 5-point Likert-like survey questions. Two hundred three patients underwent cleft palate repair. The patients were older and of higher Veau classification than is usually seen in the United States. The palatal fistula rate in the preintervention group was 37.5% and 14.3% in the intervention group (P = 0.014). Patients without fistulas demonstrated improvements on parent-reported outcomes compared with those with fistulas, with food less likely to go up their nose (P < 0.001), less difficulty eating (P < 0.001), and more understandable speech (P = 0.015). Implementation of a comprehensive cleft palate program reduced postoperative fistula rates by more than 50%. Improvements in parent-reported outcomes were observed after surgery among patients without fistulas. The blueprint for improved outcomes in these more complex patients includes enhanced perioperative patient counseling, close follow-up, and maintenance of communication with patients.

Administration of Single-Dose Antibiotic Does Not Decrease Oronasal Fistula Rates After Primary Palatoplasty.

Oronasal fistula (ONF) is a known complication after primary palatoplasty (PP). Studies investigating the effect of perioperative antibiotics on fistula rates after PP are limited by inadequate sample size or reliance on self-reporting through national databases. In this study, the authors evaluated the association between single-dose perioperative antibiotics and postoperative fistula rates after PP at a single institution. A retrospective study. Children younger than 2 years who underwent PP from April 2009 to September 2019 were included. Patients were divided into 2 categories: Group 1 received a single intraoperative dose of IV antibiotic, while group 2 did not. Outcome measures included ONF formation, length of stay (LOS), and 30-day readmission rates. Multivariable firth logistic regression, quantile regression, and χ2 tests were performed. Of the 424 patients, 215 and 209 patients were in groups 1 and 2, respectively. The overall ONF rate was 1.9% among all patients. Patients in group 1 experienced an ONF rate of 3.3%, while patients in group 2 had an ONF rate of 0.5%. After correcting for confounding variables, the difference in ONF rates was not statistically different (P = .68). Median LOS was 35.7 hours and 35.5 hours (P = .17), while the rate of readmission within 30 days was 4.7% and 2.4% for group 1 and 2, respectively (P = .96). Administration of a single-dose perioperative antibiotic did not decrease fistula formation after PP, nor did it affect the patient's LOS or 30-day readmission rate.

Telescopic Invagination Transpancreatic End-to-end Pancreatojejunostomy

Background: Postoperative pancreatic fistula is the main cause of operative morbidity andmortality in patients who undergo pancreatoduodenectomy. Various pancreatoenteric anastomosis techniques have been reported to minimize the postoperative fistula rate. No consensus exists regarding the most effective form of pancreaticojejunostomy. In this presentation the telescopic invagination transpancreatic end-to-end pancreatojejunostomy is described. Method: Especially in soft pancreas we are using the telescopic invagination method. We are using two double-armed PDS mattress sutures going through two layers of jejunum making an intestinal cuff, after that through the pancreas, another two layers of jejunum and the same on the way back. After suturing the invagination is created. Another two PDS sutures on the edges of anastomosis are usually sufficient. Results: There were 81 pancreatoduodectomies in 3 years provided in our surgery, 10 of these were operated with described telescopic method (one surgeon). In this group the rate of pancreatic fistula is 10%, in other group (different methods and surgeons) the pancreatic fistula rate is 21%. Conclusion: Telescopic invagination transpancreatic end-to-end pancreatojejunostomy seems to be good technique. Further studies with more patients are needed.

Cleft Palate Repair by Otolaryngologist-Head and Neck Surgeons: Risk Factors for Postoperative Fistula.

To assess the incidence of palatal fistula after primary repair of the cleft palate among two cohorts of Otolaryngologist-Head and Neck Surgeons and to identify patient and surgeon characteristics that may predict fistula development. Retrospective case series with chart review. Children who underwent primary repair of cleft palate at one of two multidisciplinary cleft centers over a 10 year period were identified. Charts were reviewed for the presence of palatal fistula; chi square test and multivariate logistic regression analysis were performed to determine variables associated with fistula formation. From 2007 to 2017, 477 patients underwent primary repair of cleft palate by one of 6 Otolaryngologist-Head and Neck Surgeons. Twenty-four children had incomplete charts, allowing 453 patients to be included in the final analysis. The pooled mean incidence of palatal fistula was 6.6% (P = .525) and varied significantly by cleft type. Logistic regression analysis controlling for multiple variables, showed that Veau IV classification had the highest risk of fistula (OR = 10.582; P = .004). Repair by a specific surgeon was not a significant risk factor for fistula development (P > .07 for each surgeon). Among six Otolaryngologist-Head and Neck Surgeons with fellowship training in cleft palate repair postoperative fistula rates were consistent and compared favorably to standards in the Cleft and Craniofacial surgery literature established by other surgical specialties. Consistent with larger database studies involving multiple surgical specialties, Veau IV classification was the strongest predictor of palatal fistula development, even after adjusting for multiple variables, including differing levels of experience. 4 Laryngoscope, 131:1281-1285, 2021.

Reconstructive Options During Nonfunctional Laryngectomy.

ObjectiveA paucity of data exists regarding surgical outcomes for patients undergoing total laryngectomy for a dysfunctional larynx. Herein, we present the largest study evaluating the method of closure on postoperative fistula rate and swallowing ability.MethodWe performed a retrospective review of patients undergoing total laryngectomy for a dysfunctional larynx after primary radiation or chemoradiation therapy for laryngeal carcinoma from 1998 to 2020. Demographic information, operative details, length of hospitalization, fistula formation, method of fistula treatment, and need for enteral feeding 6 months after surgery were analyzed.ResultsA total of 268 patients were included. Flaps were performed in 140 (52.2%) patients, including radial forearm free flaps (RFFF), pectoralis flaps, and supraclavicular flaps. Sixty‐four (23.9%) patients developed postoperative fistulas. There was no significant difference in the fistula rate between flap and primary closure methods (P = .06). However, among patients who had a flap, RFFF had a significantly lower fistula rate (P = .02). Significantly more patients who had initial closure with a pectoralis flap required an additional flap for fistula repair than those who underwent RFFF or primary closure (P < .05). Last, whereas 87 patients (32.5%) required an enteral feeding tube 6 months after surgery, significantly fewer patients who underwent RFFF were feeding tube‐dependent (P = < .0001).ConclusionHerein, we present the largest study of outcomes after total laryngectomy for dysfunctional larynx. Postoperative fistula rates are high, 23%; however, the majority of patients, 67%, will not require long‐term enteral support. The RFFF is an excellent option demonstrating the lowest rates of postoperative fistula and enteral feeding tube dependence.Level of Evidence4 Laryngoscope, 131:E1510–E1513, 2021

Clinical study of transverse island fasciocutaneous fascia flap for treatment of meatus and navicular fossa stricture

Objective To investigate the clinical effect of transverse island fasciocutaneous penile flap in the treatment of meatus and navicular fossa stricture. Methods Fifteen patients with urethral reconstruction with transverse island fasciocutaneous penile flap from October 2014 to December 2018 were enrolled. Six patients had a history of urethroscopic surgery, three had a history of lichensclerosus, three had a history of urethral dilation, and three had no obvious causes. All patients underwent transverse incision under the coronal sulcus, and after fully dissecting the urethra, the urethra was opened longitudinally ventrally. After measuring the actual length of stenosis, the irradiance fascia flap with the corresponding length of the incision was reconstructed. The patients were reviewed at 1 and 3 months after operation, and any complications such as recurrence or urinary fistula were recorded. The urine flow rate was tested 3 months after surgery. Results All 15 patients in this group underwent a successfully operation. The actual measurement of urethral stricture length was 0.5-4.0 cm during operation, with the average of 2.82 cm. Three months after the operation, the urine flow rate ranged from 13.5 ml/s to 23.7 ml/s, with an average of 18.5 ml/s. The overall successful rate was 93.3%(14/15). The rate of post-operative fistula was 20.0%(3/15). Two cases complained of needle-like fistula at the incision. One case healed after 3 months, and the other gave up further treatment. One patient developed urethral stricture and urethral skin spasm again 1 month later and was surgically repaired again. Conclusions The initial experience of pedicled island fascia flap for the treatment of urethral stenosis and scaphoid stenosis is safe, feasible and effective for the treatment of urethral stricture. Key words: Uethral stricture; Navicular fossa; Pedical flap; Urethral reconstruction

Pancreatogastrostomy as reconstructive technique after pancreatoduodenectomy

Background: Recent series and metanalisis showed pancreatogastrostomy after pancreatoduodenctomy as an alternative to reconstruction with pancreatojejunostomy in order to reduce the rate of postoperative fistula after head pancreatic resection. Nevertheless a higher incidence of postoperative hemorrhage has been described. Methods: We present the video corresponding to the operative procedure in a male patient, 69 years old, who presented icteric at our institutions in relation with the existence of a neoplasm in the distal biliary tree. Results: The main purpose is to expose technical aspects of pancreatogastrostomy who is performed through transgastric approach in a double row of suture. Piloric preservation is standard in our team in these tumours. Two of our patients with this reconstruction need for surgical reintervention due to intragastric hemorrhage , in one case due to pancreatitis of the pancretic stump and in the other secondary to active bleeding in the pancreas. Conclusion: Pancreatogastrostomy is an atractive technique of reconstruction after pancreatoduodenectomy specially, in our opinion, in cases of soft pancreas and/or small diameter of the Wirsung duct in order a reduce the incidence of postoperative fistula. But we must keep in mind a higher risk of postoperative hemorraghe related to the ubication of the pancreatic stump in the gastric lumen.

Single-Stage Primary Cleft Lip and Palate Repair: A Review of the Literature.

Single-stage cleft lip and palate repair is a debated surgical approach. While some studies have described favorable outcomes, concerns include the effect on craniomaxillofacial growth and increased risk of complications. To this date, there has not been a comprehensive appraisal of available data following combined cleft lip and palate repair. An extensive literature review was performed to identify all relevant articles. The level of evidence of these articles was graded according to the Oxford Centre for Evidence-Based Medicine Levels of Evidence Scale. A total of 22 relevant articles were identified, all of which were retrospective in nature. Patient age at the time of surgery ranged from 1 month to 10 years, the longest duration of follow-up was 18 years, and the largest study included 106 patients. Review of the literature shows that overall surgical outcomes following combined cleft lip and palate repair are encouraging. An increased rate of postoperative fistulas with associated speech abnormalities in some studies is noteworthy. Importantly, there is no evidence to suggest an impact on craniomaxillofacial growth, and psychosocial outcomes and parental satisfaction seem to be improved with single-stage surgery as compared with the staged approach. Our review shows overall favorable outcomes associated with combined cleft lip and palate repair. The limited follow-up time or nature of evaluated outcomes in some studies may underrepresent the true rate of adverse events, and highlights the need for additional long-term studies with standardized follow-up. To our knowledge, our review is the first to evaluate existing data regarding outcomes following combined cleft lip and palate repair.

Is pancreaticoduodenectomy justified for octogenarians even in the low-volume center? Single community-based center opinion

Introduction: Establishment of the Japanese Society of Hepato-Biliary-Pancreatic Surgery board certification system has decreased mortality subsequent to pancreaticoduodenectomy (PD) in Japan. However, not all patients, especially octogenarians, live in proximity to board-certified centers. The aim of this study is to evaluate clinical outcomes of PD in octogenarians from a community-based low-volume center. Method: Between 2006 and 2017, a total of 54 PD were performed. We analyzed clinicopathological data and short-term outcomes in octogenarians (Group O: n = 15) compared with patients <80 years (Group Y: n = 39). Results: In our center, the proportion of octogenarians who underwent PD reached 27.8%. There were no statistical differences between two groups in preoperative morbidity; however, preoperative median prognostic nutritional index (PNI) in Group O was 37.7 (26.3–51.9) and significantly lower than Group Y (p = 0.0036). There were no significant differences in operative time and blood transfusion between two groups. In terms of postoperative complications, Clavien-Dindo IIIa≧ was 26.7% in Group O and 12.8% in Group Y, which was not significantly different (p = 0.415). The rate of postoperative fistula, delayed gastric empting, and severe infection were almost same between two groups. The median length of hospital stay were 25 days in Group O and 17 days in Group Y, which was not significantly different (p=0.067). The rate of hospital mortality was 0% in Group O and 2.6% in Group Y. Conclusions: Fortunately, our outcomes of PD were equivalent of high-volume centers; however, if there is a system that board-certified surgeons relocate to low-volume centers, further developments may be expected.

Unraveling Pancreatic Segmentation.

Limited pancreatic resections are increasingly performed, but the rate of postoperative fistula is higher than after classical resections. Pancreatic segmentation, anatomically and radiologically identifiable, may theoretically help the surgeon removing selected anatomical portions with their own segmental pancreatic duct and thus might decrease the postoperative fistula rate. We aimed at systematically and comprehensively reviewing the previously proposed pancreatic segmentations and discuss their relevance and limitations. PubMed database was searched for articles investigating pancreatic segmentation, including human or animal anatomy, and cadaveric or surgical studies. Overall, 47/99 articles were selected and grouped into 4 main hypotheses of pancreatic segmentation methodology: anatomic, vascular, embryologic and lymphatic. The head, body and tail segments are gross description without distinct borders. The arterial territories defined vascular segments and isolate an isthmic paucivascular area. The embryological theory relied on the fusion plans of the embryological buds. The lymphatic drainage pathways defined the lymphatic segmentation. These theories had differences, but converged toward separating the head and body/tail parts, and the anterior from posterior and inferior parts of the pancreatic head. The rate of postoperative fistula was not decreased when surgical resection was performed following any of these segmentation theories; hence, none of them appeared relevant enough to guide pancreatic transections. Current pancreatic segmentation theories do not enable defining anatomical-surgical pancreatic segments. Other approaches should be explored, in particular focusing on pancreatic ducts, through pancreatic ducts reconstructions and embryologic 3D modelization.

Mathieu technique with incision of the urethral plate versus standard tubularised incised-plate urethroplasty in primary repair of distal hypospadias: A prospective randomised study

ObjectiveTo compare outcomes of the Mathieu incised-plate (Mathieu-IP) technique vs the standard tubularised incised-plate (TIP) technique for primary management of distal hypospadias. Patients and methodsBetween April 2012 and August 2015, 66 patients (aged 15–60months) with primary distal hypospadias were randomly allocated to two groups. Group 1 included 34 patients who underwent Mathieu-IP repair and Group 2 included 32 patients managed using the TIP technique for primary management of distal hypospadias. Postoperatively, all patients were examined weekly up to 1month and then at 3 and 6months. Perioperative data, complications and outcomes of both procedures were statistically analysed and compared. ResultsThere were no statistically significant differences in patient demographics between the groups at baseline. There was no statistically significant difference in the mean (SD) operative time between Groups 1 and 2, at 95 (7.6) and 91.2 (8.1) min, respectively. There was no statistically significant difference in the shape of the urine stream at micturition or the neomeatus between the groups postoperatively. The rate of postoperative fistula was significantly higher in Group 2 (TIP) compared to Group 1 (Mathieu-IP), at 18.7% vs 2.9% (P=0.004). There was no postoperative meatal stenosis in Group 1, which did occur in five patients (15.6%) in Group 2 (P=0.002). ConclusionThe Mathieu-IP technique appeared to be better than the standard TIP technique with regard to postoperative fistula formation and meatal stenosis, and with acceptable cosmesis.