Postoperative Surveillance Of Patients Research Articles

Tubular adenoma at the hepatico-jejunal anastomosis in familial adenomatous polyposis (FAP) following pancreaticoduodenectomy: challenges in adenoma surveillance and management.

Upper gastrointestinal tumors, including ampullary adenomas, occur frequently in patients with familial adenomatous polyposis (FAP). Guidelines recommend upper gastrointestinal endoscopy in FAP for surveillance of gastric and duodenal adenomas. However, adenomas can rarely arise from biliary epithelium in patients with FAP. Here, we describe a case of tubular adenoma at the hepatico-jejunal anastomosis with intraductal extension in a patient with FAP and previous pancreaticoduodenectomy. This report illustrates a unique case and emphasizes the need for data on postoperative surveillance in patients with FAP, particularly following pancreaticoduodenectomy.

Assessing abdominal aortic aneurysm growth using radiomic features of perivascular adipose tissue after endovascular repair

ObjectivesThe study aimed to investigate the relationship between the radiomic features of perivascular adipose tissue (PVAT) and abdominal aortic aneurysm (AAA) growth after endovascular aneurysm repair (EVAR).MethodsPatients with sub-renal AAA who underwent regular follow-up after EVAR between March 2014 and March 2024 were retrospectively collected. Two radiologists segmented aneurysms and PVAT. Patients were categorised into growing and non-growing groups based on volumetric changes observed in two follow-up computed tomography examinations. One hundred seven radiomic features were automatically extracted from the PVAT region. Univariable and multivariable logistic regression was performed to analyse radiomic features and clinical characteristics. Furthermore, the performance of the integrated clinico-radiological model was compared with models using only radiomic features or clinical characteristics separately.ResultsA total of 79 patients (68 ± 9 years, 89% men) were enroled in this study, 19 of whom had a growing aneurysm. Compared to the non-growing group, PVAT of growing AAA showed a higher surface area to volume ratio (non-growing vs growing, 0.63 vs 0.70, p = 0.04), and a trend of low dependence and high dispersion manifested by texture features (p < 0.05). The area under the curve of the integrated clinico-radiological model was 0.78 (95% confidence intervals 0.65–0.91), with a specificity of 87%. The integrated model outperformed models using only radiomic or clinical features separately (0.78 vs 0.69 vs 0.69).ConclusionsHigher surface area to volume ratio and more heterogeneous texture presentation of PVAT were associated with aneurysm dilation after EVAR. Radiomic features of PVAT have the potential to predict AAA progression.Clinical relevance statementRadiomic features of PVAT are associated with AAA progression and can be an independent risk factor for aneurysm dilatation to assist clinicians in postoperative patient surveillance and management.Key PointsAfter EVAR for AAA, patients require monitoring for progression.PVAT surrounding growing AAA after EVAR exhibits a more heterogeneous texture.Integrating PVAT-related features and clinical features results in better predictive performance.Graphical

Liver-First Resection in Patients With Synchronous Colorectal Liver Metastases Is Associated with Inferior Recurrence-Free Survival: Reconsidering the Importance of the Primary Cancer.

Synchronous colorectal liver metastases may be managed with primary-first, simultaneous, or liver-first resection. Relative oncologic outcomes based upon treatment sequencing are understudied. This study aimed to assess oncologic survival outcomes in patients with synchronous colorectal liver metastases managed with each of the three treatment strategies, with respect to early or delayed removal of the primary tumor. Retrospective analysis of prospectively maintained database, with 1:1 propensity-matching of relevant clinicopathologic variables comparing liver-first to primary-first/simultaneous approaches. Single-institution, tertiary cancer center. Patients undergoing curative-intent hepatectomy for synchronous colorectal liver metastases from 2003-2019. Overall and recurrence-free survival. Of 151 patients, 23% (n = 35) had liver-first and 77% (n = 116; primary-first = 93 and simultaneous = 23) had primary-first/simultaneous approaches. Median follow-up was 45 months. Recurrence-free survival was worse for liver-first versus primary-first/simultaneous groups (median 12 versus 16 months, p = 0.02), driven by three-year extrahepatic recurrence-free survival of 19%, 58%, and 50% for liver-first, primary-first, and simultaneous groups, respectively. Three-year overall survival was not significantly different at 86%, 79%, and 86%, respectively. Oncologic outcomes did not significantly differ between primary-first and simultaneous groups (all p > 0.4). Matching yielded 34 clinicopathologically similar patients per group (liver-first = 34, primary-first = 28/simultaneous = 6). The liver-first approach was associated with shorter recurrence-free survival (median 12 versus 23 months, p = 0.004), driven by extrahepatic recurrence-free survival (3-year: 20% versus 55%, p = 0.04). Overall survival was not significantly different at 3-years (79% versus 80%, p = 0.95) or 5-years (59% versus 59%, p > 0.99). This study has a retrospective design and limited sample size. A liver-first approach is associated with worse recurrence free-survival compared to primary-first or simultaneous resection, driven by extrahepatic recurrence. Prospective study of whether oncologic risk is associated with leaving the primary in situ is needed. Multidisciplinary treatment sequencing and enhanced postoperative surveillance for patients receiving liver-first resection is recommended. See Video Abstract.

Continuous monitoring after laparoscopic Roux-En-Y gastric bypass: a pathway to ambulatory care surgery - a pilot study.

Same-day discharge (SDD) after Laparoscopic Roux-En-Y Gastric Bypass (LRYGB) faces resistance due to possible undetected postoperative complications. These present with changes in vital signs, which continuous remote monitoring devices can detect. This study compared continuous vital signs monitoring using the Isansys Patient Status Engine™ with standard nursing vital signs measurements to assess the device's reliability in postoperative surveillance of patients undergoing LRYGB. We conducted a pilot study including patients who underwent LRYGB. During their hospital stay, patients were continuously monitored using the Isansys Patient Status Engine™ with Lifetouch™, Lifetemp™, and Nonin Pulse Oximeter™ sensors. The heart rate (HR), body temperature, and oxygen saturation (SpO2) collected by the device were compared with standard nursing assessments. Thirteen patients with a mean body mass index of 41.5 ± 4.4 kg/m2 were included. No major complications occurred. The median HR assessed by standard and continuous monitoring did not significantly differ (75.5 [69-88] vs. 77 [66-91] bpm, p = 0.995), nor did the mean values of SpO2 (94.7 ± 2.0 vs. 93.7 ± 1.8%, p = 0,057). A significant difference was observed in median body temperature between the nursing staff and the monitoring device (36.3 [36.1-36.7] vs. 36.1 [34.5-36.6] degrees Celsius, p = 0.012), with a tendency for lower temperature measurements by the device. In conclusion, this is the first study on continuous postoperative surveillance using the Isansys Patient Status Engine™ monitoring device for LRYGB patients. Our results introduce a novel tool for more efficient surgery. Prospective randomized experimental studies are warranted to evaluate this method's efficacy and safety.

Clinical implications of pediatric biliary intraepithelial neoplasia diagnosed from a choledochal cyst specimen

BackgroundBiliary intraepithelial neoplasia (BilIN), a noninvasive precursor of cholangiocarcinoma, can manifest malignant transformation. Since cholangiocarcinoma (CCA) may progress due to chronic inflammation in the bile ducts and gallbladder, choledochal cysts are considered a precursor to CCA. However, BilIN has rarely been reported in children, to date.MethodsWe reviewed medical records of patients (< 18 years of age, n = 329) who underwent choledochal cyst excision at Asan Medical Center from 2008 to 2022. BilIN was diagnosed in 15 patients. Subsequent analyses were performed of the demographics, surgical procedures, clinical course, and outcomes in these patients. Subgroup analysis and multivariate logistic regression test were performed to identify factors influencing BilIN occurrence.ResultsThe mean age of the patients included in our study was 40.1 ± 47.6 months. In 15 patients, BilIN of various grades was diagnosed. Todani type I was prevalent in 80% of the patients. The median age at surgery was 17 months. During a mean follow-up of 63.3 ± 94.0 months, no adverse events such as stone formation in the remnant intrapancreatic common bile duct and intrahepatic duct or cholangiocarcinoma were observed, indicating a favorable outcome until now.ConclusionsThe potential progression of choledochal cysts to BilIN in children was demonstrated. These results could underscore the importance of early and comprehensive excision of choledochal cysts, including resection margins for associated lesions and more thorough postoperative surveillance in patients with or at risk of BilIN.

Cost-effectiveness of surveillance intervals after curative resection of colorectal cancer.

Major guidelines consistently recommend 5years of postoperative surveillance for patients with colorectal cancer. However, they differ in their recommendations for examination intervals and whether they should vary according to disease stage. Furthermore, there are no reports on the cost-effectiveness of the different surveillance schedules. The objective of this study is to identify the most cost-effective surveillance intervals after curative resection of colorectal cancer. A total of 3701 patients who underwent curative surgery for colorectal cancer at the National Cancer Center Hospital were included. A cost-effectiveness analysis was conducted for the five surveillance strategies with reference to the guidelines. Expected medical costs and quality-adjusted life years after colorectal cancer resection were calculated using a state-transition model by Monte Carlo simulation. The incremental cost-effectiveness ratio per quality-adjusted life years gained was calculated for each strategy, with a maximum acceptable value of 43 500-52 200 USD (5-6 million JPY). Stages I, II and III included 1316, 1082 and 1303 patients, respectively, with 45, 140 and 338 relapsed cases. For patients with stage I disease, strategy 4 (incremental cost-effectiveness ratio $26 555/quality-adjusted life year) was considered to be the most cost-effective, while strategies 3 ($83 071/quality-adjusted life year) and 2 ($289 642/quality-adjusted life year) exceeded the threshold value. In stages II and III, the incremental cost-effectiveness ratio for strategy 3 was the most cost-effective option, with an incremental cost-effectiveness ratio of $18 358-22 230/quality-adjusted life year. In stage I, the cost-effectiveness of intensive surveillance is very poor and strategy 4 is the most cost-effective. Strategy 3 is the most cost-effective in stages II and III.

Impact of periodic neck ultrasonography on locoregional disease control in surveillance after total thyroidectomy for patients with low- and intermediate-risk papillary thyroid carcinoma: a propensity score-matched study.

This study aimed to evaluate the impact of periodic neck ultrasonography (US) on postoperative surveillance for locoregional disease control of patients with low- and intermediate-risk papillary thyroid carcinoma (PTC) who underwent total thyroidectomy. This retrospective cohort study included patients with PTC who underwent total thyroidectomy and central neck dissection at our institution between January, 2000 and December, 2016. The patients were divided into two groups: the physical examination (PE) group (follow-up by PE without periodic US) and the US group (follow-up by PE with periodic US). Serum thyroglobulin levels were measured periodically in both groups. Propensity score matching was used to rigorously balance the significant variables and assess the 10-year postoperative outcomes between the groups. Of the 189 patients, 150 were included after matching (75 in each group). There were no significant differences between the two groups in terms of background characteristics. The median follow-up period was 127.9 months. There was no significant difference in locoregional relapse-free survival between the PE and US groups (97.0 vs. 98.7%, p = 0.541). The overall survival was 96.7% and 98.7% in the PE and US groups, respectively, with no significant difference (p = 0.364). This study demonstrated that the addition of periodic US to PE for postoperative surveillance of patients with low- and intermediate-risk PTC who underwent total thyroidectomy did not significantly affect locoregional control.

Leveraging Edge Computing ML Model Implementation and IoT Paradigm towards Reliable Postoperative Rehabilitation Monitoring

In this work, an IoT system with edge computing capability is proposed, facilitating the postoperative surveillance of patients who have undergone knee surgery. The main objective is to reliably identify whether a set of orthopedic rehabilitation exercises is executed correctly, which is critical since it is often necessary to supervise patients during the rehabilitation period so as to avoid injuries or long recovery periods. The proposed system leverages the Internet of Things (IoT) paradigm in combination with deep learning and edge computing to classify the extension–flexion movement of one’s knee via embedded machine learning (ML) classification algorithms. The contribution of the proposed work is multilayered, as this paper proposes a system tackling the challenges at the embedded system level, algorithmic level, and user-friendliness level considering a performance evaluation, including the metrics at the power consumption level, delay level, and throughput requirement level, as well as its accuracy and reliability. Furthermore, as an outcome of this work, a dataset of labeled knee movements is freely available to the research community with no limitations. It also provides real-time movement detection with an accuracy reaching 100%, which is achieved with an ML model trained to fit a low-cost off-the-shelf Bluetooth Low Energy platform. The proposed edge computing approach allows predictions to be performed on device rather than solely relying on a Cloud service. This yields critical benefits in terms of wireless bandwidth and power conservation, drastically enhancing device autonomy while delivering reduced event detection latency. In particular, the “on device” implementation is able to yield a drastic 99.9% wireless data transfer reduction, a critical 39% prediction delay reduction, and a valuable 17% increase in the event prediction rate considering a reference period of 60 s. Finally, enhanced privacy comprises another significant benefit from the implemented edge computing ML model, as sensitive data can be processed on site and only events or predictions are shared with medical personnel.

Prognostic Value of Preoperative Molecular Testing and Implications for Initial Surgical Management in Thyroid Nodules Harboring Suspected (Bethesda V) or Known (Bethesda VI) Papillary Thyroid Cancer

Molecular testing is commonly used in the diagnosis of thyroid nodules with indeterminate cytology. The role of molecular testing in prognosticating oncologic outcomes in thyroid nodules with suspicious or malignant cytology is unclear. To determine whether molecular profiling of Bethesda V (suspicious for thyroid cancer) and VI (thyroid cancer) nodules is associated with improved prognostication and whether it may inform initial treatment. This retrospective cohort study included consecutive patients with Bethesda V or VI nodules who underwent surgery, with histopathology showing differentiated thyroid cancer, between May 1, 2016, and July 31, 2019 in the University of California, Los Angeles health system. Data were analyzed between April 2, 2021, and January 18, 2023. Masked ThyroSeq, version 3 molecular analysis after completion of initial treatment and acquisition of follow-up data. Structural disease persistence or recurrence, distant metastasis, and recurrence-free survival were assessed using ThyroSeq Cancer Risk Classifier (CRC) molecular risk groups (low, RAS-like; intermediate, BRAF-like; high, combination of BRAF/RAS plus TERT or other high-risk alterations) using Cox proportional hazards regression models. In 105 patients with papillary thyroid cancer (median [IQR] follow-up, 3.8 [3.0-4.7] years), ThyroSeq identified genomic alterations in 100 (95%) samples (6 [6%] low risk, 88 [88%] intermediate risk, and 6 [6%] high risk; median [IQR] age, 44 [34-56] years; 68 [68%] female and 32 [32%] male). No patients with low-risk or negative results experienced recurrence. Of the 88 patients with intermediate risk, 6 (7%) experienced local recurrence, with 1 of them also developing distant metastasis. The 6 patients with high risk (all with BRAF V600E plus TERT mutation) underwent total thyroidectomy followed by radioactive iodine (RAI) ablation. Four patients with high risk (67%) experienced local recurrence, with 3 of them also developing distant metastasis. Thus, patients with high-risk alterations were more likely to experience persistence or recurrence and distant metastasis than patients with intermediate risk. In a multivariable analysis incorporating patient age, sex, cancer size, ThyroSeq molecular risk group, extrathyroidal extension, lymph node positivity, American Thyroid Association risk, and RAI ablation, only cancer size (hazard ratio, 1.36; 95% CI, 1.02-1.80) and ThyroSeq CRC molecular risk group (high vs intermediate and low: hazard ratio, 6.22; 95% CI, 1.04-37.36) were associated with structural recurrence. Among the 6% of patients with high-risk ThyroSeq CRC alterations in this cohort study, the majority experienced recurrence or distant metastasis despite initial treatment with total thyroidectomy and RAI ablation. In contrast, patients with low- and intermediate-risk alterations had a low recurrence rate. Preoperative knowledge of molecular alteration status at diagnosis may allow for deescalation of initial surgery and refining of the intensity of postoperative surveillance in patients presenting with Bethesda V and VI thyroid nodules.

Surgical Sealant with Integrated Shape-Morphing Dual Modality Ultrasound and Computed Tomography Sensors for Gastric Leak Detection.

Postoperative anastomotic leaks are the most feared complications after gastric surgery. For diagnostics clinicians mostly rely on clinical symptoms such as fever and tachycardia, often developing as a result of an already fully developed, i.e., symptomatic, surgical leak. A gastric fluid responsive, dual modality, electronic-free, leak sensor system integrable into surgical adhesive suture support materials is introduced. Leak sensors contain high atomic number carbonates embedded in a polyacrylamide matrix, that upon exposure to gastric fluid convert into gaseous carbon dioxide (CO2 ). CO2 bubbles remain entrapped in the hydrogel matrix, leading to a distinctly increased echogenic contrast detectable by a low-cost and portable ultrasound transducer, while the dissolution of the carbonate species and the resulting diffusion of the cation produces a markedly reduced contrast in computed tomography imaging. The sensing elements can be patterned into a variety of characteristic shapes and can be combined with nonreactive tantalum oxide reference elements, allowing the design of shape-morphing sensing elements visible to the naked eye as well as artificial intelligence-assisted automated detection. In summary, shape-morphing dual modality sensors for the early and robust detection of postoperative complications at deep tissue sites, opening new routes for postoperative patient surveillance using existing hospital infrastructure is reported.

Is a less-intensive follow-up for colon cancer in early stages reasonable?

PurposePatients with colon cancer are usually included in an intensive 5-year surveillance protocol after curative resection, independent of the tumor stage, though early stages have a considerably lower risk of recurrence. The aim of this study was to analyze the adherence to an intensive follow-up and the risk of recurrence in patients with colon cancer in UICC stages I and II.MethodsIn this retrospective study, we assessed patients who underwent resection for colon cancer in UICC stages I and II between 2007 and 2016. Data were collected on demographics, tumor stages, therapy, surveillance, recurrent disease, and oncological outcome.ResultsOf the 232 included patients, 43.5% (n = 101) reached the 5-year follow-up disease-free. Seven (7.5%) patients in stage UICC I and sixteen (11.5%) in UICC II had a recurrence, with the highest risk in patients with pT4 (26.3%). A metachronous colon cancer was detected in four patients (1.7%). The therapy of recurrence was intended to be curative in 57.1% (n = 4) of UICC stage I and in 43.8% (n = 7) of UICC stage II, but only in one of seven patients over 80 years. 44.8% (n = 104) of the patients were lost to follow-up.ConclusionA postoperative surveillance in patients with colon cancer is important and recommended as a recurrent disease can be treated successfully in many patients. However, we suggest that a less intensive surveillance protocol is reasonable for patients with colon cancer in early tumor stages, especially in UICC stage I, as the risk of recurrent disease is low. With elderly and/or frail patients in a reduced general condition, who will not endure further specific therapy in case of a recurrence, the performance of the surveillance should be discussed: we recommend a significant reduction or even renunciation.

Hydrocephalus surveillance following CSF diversion: a modified Delphi study.

Long-term follow-up is often recommended for patients with hydrocephalus, but the frequency of clinical follow-up, timing and modality of imaging, and duration of surveillance have not been clearly defined. Here, the authors used the modified Delphi method to identify areas of consensus regarding the modality, frequency, and duration of hydrocephalus surveillance following surgical treatment. Pediatric neurosurgeons serving as institutional liaisons to the Hydrocephalus Clinical Research Network (HCRN), or its implementation/quality improvement arm (HCRNq), were invited to participate in this modified Delphi study. Thirty-seven consensus statements were generated and distributed via an anonymous electronic survey, with responses structured as a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree). A subsequent, virtual meeting offered the opportunity for open discussion and modification of the statements in an effort to reach consensus (defined as ≥ 80% agreement or disagreement). Nineteen pediatric neurosurgeons participated in the first round, after which 15 statements reached consensus. During the second round, 14 participants met virtually for review and discussion. Some statements were modified and 2 statements were combined, resulting in a total of 36 statements. At the conclusion of the session, consensus was achieved for 17 statements regarding the following: 1) the role of standardization; 2) preferred imaging modalities; 3) postoperative follow-up after shunt surgery (subdivided into immediate postoperative imaging, delayed postoperative imaging, routine clinical surveillance, and routine radiological surveillance); and 4) postoperative follow-up after an endoscopic third ventriculostomy. Consensus could not be achieved for 19 statements. Using the modified Delphi method, 17 consensus statements were developed with respect to both clinical and radiological follow-up after a shunt or endoscopic third ventriculostomy. The frequency, modality, and duration of surveillance were addressed, highlighting areas in which no clear data exist to guide clinical practice. Although further studies are needed to evaluate the clinical utility and cost-effectiveness of hydrocephalus surveillance, the current study provides a framework to guide future efforts to develop standardized clinical protocols for the postoperative surveillance of patients with hydrocephalus. Ultimately, the standardization of hydrocephalus surveillance has the potential to improve patient care as well as optimize the use of healthcare resources.

Clinical Utility of Bioelectrical Impedance Analysis Parameters for Evaluating Patients with Lower Limb Lymphedema after Lymphovenous Anastomosis.

In lymphedema, lymphatic fluid accumulates in the interstitial space, and localized swelling appears. Lymphovenous anastomosis (LVA) is the most widely used surgery to rebuild a damaged lymphatic system; however, assessing outcome of LVA involves performing volume measurements, which provides limited information on body composition changes. Therefore, we analyzed the bioelectrical impedance analysis (BIA) parameters that can reflect the status of lymphedema patients who underwent LVA. We retrospectively reviewed records of 42 patients with unilateral lower extremity lymphedema who had LVA. We measured the perioperative BIA parameters such as extracellular water (ECW) ratio and volume as defined by the percentage of excess volume (PEV). We evaluated the relationship between the amount of change in PEV and in BIA parameters before and after surgery. We confirmed the correlation between ΔPEV and BIA parameters using Spearman's correlation. Most patients included had secondary lymphedema due to cancer. Average age was 51.76 years and average body mass index was 23.27. PEV and all BIA parameters after surgery showed a significant difference (p < 0.01) compared with preoperative measurements. The ECW ratio aff/unaff showed the strongest correlation with PEV with a correlation coefficient of 0.473 (p < 0.01). Our findings suggest that BIA parameters, especially ECW ratio aff/unaff could reflect the status of patients with lower limb lymphedema after LVA. Appropriate use of BIA parameters may be useful in the postoperative surveillance of patients.

Perioperative Management of Patients With Myasthenia Gravis Undergoing Robotic-Assisted Thymectomy—A Retrospective Analysis and Clinical Evaluation

Postoperative myasthenic crisis with respiratory failure is a potentially lethal complication, warranting careful perioperative planning and extended postoperative surveillance of patients. Data on the incidence of postoperative respiratory failure and optimal management of patients after robotic-assisted thymectomy are limited. The objective of this study was to evaluate the incidence of respiratory complications and the need for intensive care unit (ICU) capacities after robotic-assisted thymectomy in patients with myasthenia gravis. Retrospective cohort study. Single University hospital in Vienna, Austria, from January 2014 to December 2019. The authors included adult patients who underwent robotic-assisted thymectomy due to myasthenia gravis. Of 72 patients, 4 patients (5.6%) developed postoperative respiratory failure, needing noninvasive ventilation/intubation. Respiratory failure occurred within the first hours after extubation when patients still were under surveillance in the recovery room or in the ICU. One patient (1.4%) suffered from worsened myasthenic symptoms several days after surgery, and was treated with plasmapheresis. Sixty-five patients (90.3%) were extubated in the operating room, 35 of these (48.6%) were transferred to the ICU, and 30 patients (41.7%) primarily were transferred to the recovery room. Fourteen patients (19.4%) were transferred to the surgical ward after extended observation in the recovery room. Furthermore, after implementation of a standardized perioperative algorithm in 2020, a reduction of ICU admissions was achieved. After careful patient selection, planning, and postoperative patient evaluation, robotic-assisted thymectomy can be performed safely without postoperative surveillance in an ICU.

Colonoscopy surveillance of colorectal cancer post-surgery in Sanglah General Hospital, Bali, Indonesia: a descriptive study

Background: The postoperative surveillance of patients treated for colorectal cancer is intended to prolong survival by diagnosing recurrent and metachronous cancers at a curable stage as well as preventing metachronous cancer by detection and removal of precancerous polyps. This study evaluates the surveillance colonoscopy and its association with sociodemographic and clinical findings in a descriptive study.Methods: This is a cross sectional study of colorectal cancer patients who underwent surveillance colonoscopy as follow up after tumor resection from January 2020 to September 2021 in Sanglah General Hospital. Clinical data were gathered from medical records and databases by a qualified reviewer. Data were analyzed descriptively using SPSS version 20 for Windows.Results: The majority of patients who underwent surveillance colonoscopy were male (82.40%), tumor location at rectum (58.8%), stage IV (29.40%), underwent low anterior resection surgery (35.30%) and received Folfox (35.30%) or Capeox (35.30%) adjuvant chemotherapy. There was 2 (11.80%) residual mass found in this study. There was no significant difference between subjects who underwent surveillance colonoscopy with residual mass and without residual mass in all variables assessed (p&gt;0.05).Conclusion: Colonoscopy surveillance plays an important role in early detection for any recurrence or pre-cancer lesion and metachronous cancer in a patient with colorectal malignancies in Sanglah General Hospital, Bali, Indonesia.

Suture granuloma with hydronephrosis caused by ileostomy closure after rectal cancer surgery: a case report

BackgroundSuture granuloma with hydronephrosis after abdominal surgery is extremely rare. We herein report a successfully treated case of suture granuloma with hydronephrosis caused by ileostomy closure after rectal cancer surgery.Case presentationA 63-year-old male underwent laparoscopic low anterior resection with covering ileostomy. Two months after primary operation, ileostomy closure was performed with two layered hand-sewn suture (Albert–Lembert method) using absorbable suture. In that operation, marginal blood vessels in the mesentery were ligated with silk suture. The patient had remained in remission with no evidence of tumor recurrence, however, 2 years and 5 months after primary surgery, a contrast-enhanced computed tomography (CT) scan showed a mass-forming lesion on the right external iliac artery (43 × 26 mm) and hydronephrosis. Positron emission tomography/computed tomography (PET/CT) showed a mass-forming lesion without high accumulation, which obstructed the right ureter. Recurrence could not be ruled out due to the rapid appearance of tumor and hydronephrosis in the short-term period. Thus, the patient underwent laparotomy. The tumor located in the mesentery near the anastomosis of ileostomy closure and it was strongly adherent to the retroperitoneum, which obstructed the right ureter. The adhesion between the tumor and ureter was carefully dissected and tumor resection with partial small bowel resection was then performed with preservation of the ureter using ureteral stents. Pathological examination of the tumor revealed fibrous proliferation of foreign body granuloma. In the resected tumor, sutures with foreign giant cells were found. Therefore, we diagnosed the tumor as silk suture granuloma, which was caused by the silk suture used to ligate blood vessels of the mesentery at the ileostomy closure. The patient remained well with no evidence of tumor recurrence as 5 years after the primary operation of rectal cancer.ConclusionsSuture granuloma is a rare surgery-related complication in the postoperative surveillance of patients with colorectal cancer. If suture granuloma mimicking local recurrence is a differential diagnosis, it would be important to consider to avoid unnecessary extended resection.

Perioperative Implication of Sodium-glucose Cotransporter-2 Inhibitor in a Patient Following Major Surgery.

ABSTRACTSodium-glucose cotransporter-2 inhibitors (SGLT2i) are the second line of therapy in diabetes mellitus type 2. They are frequently coprescribed with other noninsulin glucose-lowering medications. Diabetic ketoacidosis (DKA) with lower-than-anticipated glucose levels is an important SGLT2i-related adverse effect in postoperative patients. This case highlights the need for increased postoperative surveillance of patients on this group of medications. Ketonuria was managed with short-acting insulin infusion with dextrose-containing intravenous fluid, as a part of the ongoing intensive care treatment to which the patient responded well. Awareness of DKA with lower-than-anticipated glucose levels is an important clinical challenge, an entity that can be confused in the setting of major and complex surgeries. The frequency of this arcane and underreported diagnosis in the perioperative setting is unknown.How to cite this article: Vadi S, Lad V, Kapoor D. Perioperative Implication of Sodium-glucose Cotransporter-2 Inhibitor in a Patient Following Major Surgery. Indian J Crit Care Med 2021;25(8):958–959.

Nomograms for Predicting Recurrent Herniation in PETD with Preoperative Radiological Factors.

PurposeTo investigate the preoperative radiological risk factors for recurrent lumbar disc herniation (rLDH) within 1 year after percutaneous endoscopic transforaminal discectomy (PETD).Patients and MethodsA retrospective case–control study was conducted. Between January 2013 and November 2019, a total of 1210 patients with single-level L4/5 LDH who underwent PETD were enrolled in the present study. In total, 62 rLDH patients were diagnosed and collected based on the clinical and radiological manifestations, and 224 non-rLDH controls were selected from the remaining 1148 patients. Preoperative radiological parameters were collected and measured. An age threshold to distinguish patients into subgroups was established using the Youden index. The relationships between the risk factors and rLDH were evaluated by univariate and multivariate analyses in two subgroups. Predictive models were established based on logistic analysis. The area under the curve (AUC) of receiver operating characteristic (ROC) curves, calibration plots, and decision curve analysis (DCA) were used to assess the predictive models.ResultsIn the present study, logistic analysis identified six significant predictors associated with rLDH in the young group: superior endplate concave angle (ECA), sacral slope, Modic changes, sagittal range of motion (sROM), extension intervertebral angle (IVA), and lumbar lordosis. Four significant predictors were identified in the elderly group: disc height index (DHI), retrolisthesis (posterior spondylolisthesis), sROM, and extension IVA. Validation of both models demonstrated excellent model discrimination (AUC= 0.940 and 0.946, respectively). DCA also showed excellent clinical utility and benefits.ConclusionThe nomograms that we constructed could accurately predict individual patient recurrence risk. Individualized measures should be taken for patients of different ages with the above risk factors, and tailored postoperative surveillance of patients who underwent PETD can be planned.

The combination of conventional ultrasound and shear-wave elastography in evaluating the segmental heterogeneity of liver fibrosis in biliary atresia patients after Kasai portoenterostomy.

To retrospectively assess the value of the combination of conventional ultrasound and shear-wave elastography (SWE) in evaluating the segmental heterogeneity of liver fibrosis in biliary atresia (BA) patients after Kasai portoenterostomy. A total of 35 BA patients with liver segmental deformation were enrolled. The segmental deformation was assessed by conventional ultrasound followed with SWE examinations for evaluating the liver stiffness. Liver biopsy was performed in 11 patients in the region of SWE measurement and liver fibrosis was assessed using the Metavir classification. Aminotransferase to platelet ratio index (APRI) was calculated for comparison. The correlations between serum biochemical tests with SWE values were evaluated. Spearman's rank coefficient test was performed to evaluate the correlation between variables. The SWE values of the biopsy segments had significant positive correlations with liver fibrosis severity (r = 0.828, p = 0.001), which was better than APRI (r = 0.366, p = 0.242). The levels of bilirubin and transaminase showed significant correlations with the SWE values at hypertrophic segments in all patients (r from 0.336 to 0.576, all p < 0.05). Awareness of the segmental heterogeneity of liver fibrosis evaluated by conventional ultrasound and SWE may assist in selecting an appropriate biopsy location and predicting postoperative surveillance for patients with BA.

Proposal of a Multivariable Prediction Model for Graded Morbidity after Liver Resection for Colorectal Metastases.

Prognostic models to predict individual early postoperative morbidity after liver resection for colorectal liver metastases (CLM) are not available but could enable optimized preoperative patient selection and postoperative surveillance for patients at greater risk of complications. The aim of this study was to establish a prognostic model for the prediction of morbidity after liver resection graded according to Dindo. N = 679 cases of primary liver resection for CLM were retrospectively analyzed using univariable and multivariable ordinal regression analyses. Receiver operating characteristics curve (ROC) analysis was utilised to assess the sensitivity and specificity of predictions and their potential usefulness as prognostic models. Internal validation of the score was performed using data derived from 129 patients. The final multivariable regression model revealed lower preoperative levels, a greater number of units of intraoperatively transfused packed red blood cells (pRBCs), longer duration of surgery, and larger metastases to independently influence postoperatively graded morbidity. ROC curve analysis demonstrated that the multivariable regression model is able to predict each individual grade of postoperative morbidity with high sensitivity and specificity. The areas under the receiver operating curves (AUROC) for all of these predictions of individual grades of morbidity were > 0.700, indicating potential usefulness as a predictive model. Moreover, a consistent concordance in Grades I, II, IV, and V according to the classification proposed by Dindo et al. was observed in the internal validation. This study proposes a prognostic model for the prediction of each grade of postoperative morbidity after liver resection for CLM with high sensitivity and specificity using pre- and intraoperatively available variables.