Single Surgical Unit Research Articles

Morphology of the tubercle of Zuckerkandl and its importance in thyroid surgery.

The tubercle of Zuckerkandl (ZT) is an embryological remnant of the thyroid gland. Its close relationship to the recurrent laryngeal nerve (RLN) makes it an important surgical landmark. Presence and size of the ZT was prospectively assessed during thyroidectomies done at a single surgical unit during 2013. Eighty patients were included in the study. Closest distance and relationship of the ZT to the RLN was measured. Median age was 48 years (range 20-75 years). The ZT was present in 72 (90%) patients at least on one side and 55 (69%) patients on both sides. Grade III tubercles were found in 17 (21.25%) patients. Average distance between RLN and the ZT was 1.2 mm posteriorly or posteromedially. In the majority (79%) RLN was lying at a distance of ≤1 mm. Pressure symptoms were present in 19 (23.75%) patients and it was not related to the presence of grade III tubercles (p = 0.207).

Roux-En-Y Hepaticojejunostomy: An Evaluation Of Its Indications and Results in Benign and Malignant Biliary Tree Disease

Background: Roux-en-Y Hepaticojejunostomy (RYHJ) is the most common form of reconstruction of the biliary pathway. It is a time honoured, durable, less resource intensive and a definitive procedure. Objectives: The aim of this study was to evaluate the indications of Hepaticojejunostomy and to assess the outcome of surgery following change in surgical technique of Hepaticojejunostomy. Methods: All patients who underwent RYHJ from Magh 2067 (January 2011) till Ashad 2071 (July 2014) in a single surgical unit at the Department of Surgery, Kathmandu Medical College Teaching Hospital were included. Demographics of the patient, indications for surgery, type of surgery, hospital stay and duration of drain placement were evaluated. Since, this is a prospective descriptive study, only mean value was calculated for age, hospital stay and duration of drain placement using SPSS Statistics 17.0 for statistical analysis. Results: Twenty patients underwent RYHJ during the study period. Fifteen percent (n=3) were done for malignant diseases. The most common indication was choledocholithiasis (n=8, 40%) followed by choledochal cyst (n=3, 15%) and bile duct injury (n=3, 15%). The morbidity was minimal. The mean duration of drain in situ was four days (range one to 14 days) and the mean hospital stay was six days (range two to 15 days). Prolonged drain placement and hospital stay was noted in two patients with malignant diseases. However, they were non bilious in nature. We encountered no mortality. Conclusion: Roux-en-Y Hepaticojejunostomy (RYHJ) is a common and safe method of biliary reconstruction. The indication of the procedure is varied and wide.DOI: http://dx.doi.org/10.3126/jkmc.v3i3.12247Journal of Kathmandu Medical CollegeVol. 3, No. 3, Issue 9, Jul.-Sep., 2014, page

Gastrointestinal Stromal Tumors: Experience from a Single Surgical Unit

Background : Gastrointestinal stromal tumors (GISTs) are rare tumors, but comprise the most common mesenchymal neoplasms of the gastrointestinal (GI) tract. We report a clinical series of abdominal GIST and discuss the diagnosis and management in Indian patients. Case Series: The data on demographic profile, clinical presentation and management of 12 cases of GIST from a single surgical unit in the last seven years were studied retrospectively. Preoperatively, ultrasonographic and computerized tomographic scans of the abdomen were the main investigations used for evaluation; the others being upper gastrointestinal endoscopy and X-ray of the chest. Histopathological examination and immunohistochemical evaluation were used to confirm the diagnosis. Results: The mean age at presentation was 47.9 years (range 35 – 70 years). Mean duration of

Adrenal tumors: An experience of 10 years in a single surgical unit.

Most of the adrenal masses are discovered incidentally by imaging techniques for reasons unrelated to adrenal diseases. Treatment is based on various factors such as, nature of adrenal mass, age of presentation, size of tumor, and the functional status of tumor. We report a series of 14 consecutive cases of adrenal tumors treated in a single surgical unit in our hospital. The aim of this study was to evaluate the clinical profile and outcome of treatment of adrenal tumors treated in a surgical unit. It is a retrospective study data of 14 cases of adrenal tumors treated in a single surgical unit in University Hospital over 10 years have been analyzed. Various parameters such as gender, age, size of tumor, functional status, histopathology, type of management, and outcome have been reviewed. A total of 14 patients with adrenal masses were seen over a 10 year period (1997-2006). All were referred cases, either from endocrinology or medicine wards. There were seven female and seven male patients. Mean age of patients was 48.6 years (range 14-60 years). Mean size of tumor was 8.0 cm (5.9 cm for benign tumors and 9.7 cm for malignant tumors). There were six cases of adrenal carcinoma, four cases of adrenal myelolipoma, two cases of pheochromocytoma, and one each case of adrenal hyperplasia and histoplasmosis. There were only two functional tumors. All, except two malignant cases were treated operatively. A total of 5 year survival was 100% in benign cases and 27% in malignant tumors. Adrenal tumors need to be assessed for their functional status and malignant potential prior to treatment. Surgical excision is usually curative for benign lesion. Among malignant tumors the benefits of surgery depend on local extent and metastatic status of tumors.

Risk Factors for Anastomotic Leakage: A Retrospective Cohort Study in a Single Gastric Surgical Unit

PurposeAlthough several studies report risk factors for anastomotic leakage after gastrectomy for gastric cancer, they have yielded conflicting results. The present retrospective cohort study was performed to identify risk factors that are consistently associated with anastomotic leakage after gastrectomy for stomach cancer.Materials and MethodsAll consecutive patients who underwent gastrectomy at a single gastric surgical unit between May 2003 and December 2012 were identified retrospectively. The associations between anastomotic leakage and 23 variables related to patient history, diagnosis, and surgery were assessed and analyzed with logistic regression.ResultsIn total, 3,827 patients were included. The rate of anastomotic leakage was 1.88% (72/3,827). Multiple regression analysis showed that male sex (P=0.001), preoperative/intraoperative transfusion (P<0.001), presence of cardiovascular disease (P=0.023), and tumor location (P<0.001) were predictive of anastomotic leakage. Patients with and without leakage did not differ significantly in terms of their 5-year survival: 97.6 vs. 109.5 months (P=0.076).ConclusionsMale sex, cardiovascular disease, perioperative transfusion, and tumor location in the upper third of the stomach were associated with an increased risk of anastomotic leakage. Although several studies have reported that an anastomotic complication has a negative impact on long-term survival, this association was not observed in the present study.

Weight-for-age standard score - distribution and effect on in-hospital mortality: A retrospective analysis in pediatric cardiac surgery.

Objective:To study the distribution of weight for age standard score (Z score) in pediatric cardiac surgery and its effect on in-hospital mortality.Introduction:WHO recommends Standard Score (Z score) to quantify and describe anthropometric data. The distribution of weight for age Z score and its effect on mortality in congenital heart surgery has not been studied.Methods:All patients of younger than 5 years who underwent cardiac surgery from July 2007 to June 2013, under single surgical unit at our institute were enrolled. Z score for weight for age was calculated. Patients were classified according to Z score and mortality across the classes was compared. Discrimination and calibration of the for Z score model was assessed. Improvement in predictability of mortality after addition of Z score to Aristotle Comprehensive Complexity (ACC) score was analyzed.Results:The median Z score was -3.2 (Interquartile range -4.24 to -1.91] with weight (mean±SD) of 8.4 ± 3.38 kg. Overall mortality was 11.5%. 71% and 52.59% of patients had Z score < -2 and < -3 respectively. Lower Z score classes were associated with progressively increasing mortality. Z score as continuous variable was associated with O.R. of 0.622 (95% CI- 0.527 to 0.733, P < 0.0001) for in-hospital mortality and remained significant predictor even after adjusting for age, gender, bypass duration and ACC score. Addition of Z score to ACC score improved its predictability for in-hosptial mortality (δC - 0.0661 [95% CI - 0.017 to 0.0595, P = 0.0169], IDI- 3.83% [95% CI - 0.017 to 0.0595, P = 0.00042]).Conclusion:Z scores were lower in our cohort and were associated with in-hospital mortality. Addition of Z score to ACC score significantly improves predictive ability for in-hospital mortality.

Studying major amputations in a developing country using Amit Jain's typing and scoring system for diabetic foot complications - time for standardization of diabetic foot practice

Background:Aim of current study was to analyse major amputation occurring in patients with diabetic foot complication through the new principle and practice of diabetic foot.Methods:A 5 year retrospective study was done in a single surgical unit in department of surgery of St John’s medical college, Bangalore, India.Results:26 patients were included in this study. 76.9% of the patients who underwent major amputation had type 1 diabetic foot complications. Infected ulcers were the most common cause for major amputation. Most patients who underwent major amputation had a score ranging from 16-20. 11.54% of the patients who underwent major amputation had osteomyelitis with type 3C diabetic foot osteomyelitis being most common.Conclusions:This unique study for the first time utilizes the new Amit Jain’s principle and practice of diabetic foot to study major amputation in diabetic foot. Majority of the patients who undergo major amputation in India has type 1 diabetic foot complication. Most of the patients undergoing major amputation belongs to the high risk category for major amputation.

Safety and Efficacy of Colonoscopy in Patients 85 Years and Older: Retrospective Review

Introduction: To determine the safety and complication rate of colonoscopy in the population over 85 years and older in a single center outpatient ambulatory surgical unit. Methods: We under took a retrospective review of 410 patients ages 85 years and older from 2006 through 2012 in a single center outpatient ambulatory surgical center. We reviewed the charts of these patients to find indication for colonoscopy, comorbidities, whether sedation was given, the quality of the bowel preparation, whether cecal intubation or ileal visualization was accomplished, and any complications. Results: We reviewed 410 patients charts aged 85 years and older between 2006 and 2012. Mean age was 87.3 years, of which 228 (52.5%) of the patients were males. The leading indications for colonoscopy were: screening in 100 (38.2%), history of a polyp or cancer in 90 (34.4%), and history of bleeding and anemia in 38 (14.5%) patients. Heart disease was seen in 172(42.0%), lung disease in 52 (12.7%), and renal disease in 40 (9.8%) patients. One hundred eighty-nine (46.1%) patients did not receive any form of sedation during colonoscopy. Excellent to good quality bowel preparation was documented in 146 (59.6%), fair to adequate in 82 (39.6%) and poor in 2 (0.8%) patients. Polyps were detected in 122 patients with 87 (21.2%) having pre-cancerous polyps (tubular, tubulovillous, or villous) and 7 (1.7%) having colon cancer. Cecal intubation or ileal visualization was accomplished in all of the patients. Bleeding after the procedure was seen in 7 (1.7%) patients, but in no case was hospitalization or further intervention required. There were no perforations, cardiovascular complications, or pulmonary complications observed. Sixty-five patients were deceased at the time of chart review. We were able to find the cause of death only in 3 of these patients, which were unrelated to the procedure. Conclusion: The United States Preventive Services Task Force (USPSTF) recommends against colon cancer screening in the elderly population due to concerns over procedure-related complications. Over 70% of the population in this review underwent colonoscopy because there was a history of polyps or cancer or for screening. The complication rate in this review was negligible. With the increasing life span of people and reduced complications from colonoscopy, healthy elderly patients can consider colonoscopy for various indications. Further prospective study is needed to determine whether screening colonoscopies in the elderly can prolong life.

Selective histology of cholecystectomy specimens—is it justified?

BackgroundGallbladder cancer (GBC) is rare but the most common malignancy of biliary tract with a dismal prognosis. The early diagnosis and surgical treatment of GBC offers the only chance of long-term survival. Despite advances in radiological imaging, early diagnosis of GBC is still rarely achieved without histopathology. In our hospital, routine histologic examination of all resected gallbladder specimens has been standard practice. This study seeks to define whether selective histologic examination for gallbladder specimens based on preoperative imaging or intraoperative findings is justified. Materials and methodsFrom September 2008–September 2013, all histopathology reports of gallbladder specimens after elective cholecystectomy were retrospectively analyzed in a single surgical unit. Preoperative imaging, intraoperative findings, and histology notes were analyzed in all cases. ResultsOut of 14,369 (60% female and 40% male) patients undergoing cholecystectomy, GBC was found in only 46 cases (0.32%). More than one fifth (10/46) of GBC patients presented with acute cholecutitis (AC). All 10 AC patients coexisted with GBC harbored “significantly inflamed’ gallbladders, and about 83.49% AC patients were judged with “significant inflammation.” Carcinoma in situ and early GBC (T1a, T1b) accounted for 61% of all cases. Only two patients with Tis and T1a respectively did not show suspicious lesion on preoperative and intraoperative findings, but for the remaining cases (44/46), GBC was suspected either by preoperative imaging and/or intraoperative findings. ConclusionsAlmost all cases of invasive GBC will show macroscopic abnormalities following examination by a simple procedure—a full dissection, inspection, and palpation of the gallbladder. Any patient with early GBCs “missed” on macroscopic examination can still receive the appropriate treatment by the cholecystectomy alone. The gallbladder should be sent for histology only if macroscopic examination raises suspicion. This selective policy is more cost-effective, and does not appear to compromise patients outcome.

Utility of the laparoscopic approach to surgical treatment of acute appendicitis in a single surgical unit.

IntroductionAcute appendicitis (AA) is one of the most common reasons for emergency surgery within the abdominal cavity in Poland.AimTo compare outcomes of surgical treatment of AA using both classical (OA) and laparoscopic methods (LA).Material and methodsRetrospective analysis of 299 patients (157 men and 142 women) operated on in 2008–2011 due to AA. The following comparisons between LA and OA were done: mean operative time, mean hospital stay after surgery, conversion rate, proportion of LA to OA in successive years.ResultsLaparoscopic appendectomy was performed in 170 (56.9%) patients (74 men and 96 women), whereas OA was done in 89 (29.8%) patients (44 men and 45 women). In 13.4% of patients (24 men and 16 women) conversion from LA to OA was done. Mean operating time was 53.4 ±16.1 min (range: 25–100 min) for LA, and 55.4 ±20.2 min (range: 20–140 min) for OA; p = 0.64. Mean hospital stay after LA was 4.0 ±1.2 days (range: 2–9 days), while it was 6.0 ±4.2 days (range: 2–28 days) after OA; p < 0.001. Laparoscopic appendectomy was 24.1% of all appendectomies performed in the year 2008, 54.1% in the year 2009, and in consecutive years 71.7% in 2010 and 65.6% in 2011.ConclusionsLaparoscopic appendectomy method did not require longer surgery times and entailed shorter hospital stays as compared with OA. In our opinion, LA should be the preferred approach in surgical treatment of AA in adults.

Impact of Technical Sources of Variation on the Hand Microbiome Dynamics of Healthcare Workers

We assessed the dynamics of hand microbial community structure of 34 healthcare workers from a single surgical intensive care unit over a short (3 week) time period, whilst taking into account the technical sources of variability introduced by specimen collection, DNA extraction, and sequencing. Sample collection took place at 3 different time points. Only the sampling collection method appeared to have a significant impact on the observed hand microbial community structure among the healthcare workers. Analysis of samples collected using glove-juice showed a slightly more similar microbial composition within individual hand samples over time than between the hands of different individuals over time. This was not true for samples collected using a swab, where samples from a single individual were no more similar to each other over time than those among other individuals over time, suggesting they were essentially independent. DNA extraction techniques (lysozyme only versus enzyme cocktail) and sequencing (replicate set 1 versus 2) using Ion Torrent Personal Genome Machine, were not influential to the microbial community structures. Glove-juice sample collection may likely be the method of choice in hand hygiene studies in the healthcare setting.

Predicting mortality after congenital heart surgeries: evaluation of the Aristotle and Risk Adjustement in Congenital Heart Surgery-1 risk prediction scoring systems: a retrospective single center analysis of 1150 patients.

To validate Aristotle basic complexity and Aristotle comprehensive complexity (ABC and ACC) and risk adjustment in congenital heart surgery-1 (RACHS-1) prediction models for in hospital mortality after surgery for congenital heart disease in a single surgical unit. Patients younger than 18 years, who had undergone surgery for congenital heart diseases from July 2007 to July 2013 were enrolled. Scoring for ABC and ACC scoring and assigning to RACHS-1 categories were done retrospectively from retrieved case files. Discriminative power of scoring systems was assessed with area under curve (AUC) of receiver operating curves (ROC). Calibration (test for goodness of fit of the model) was measured with Hosmer-Lemeshow modification of χ2 test. Net reclassification improvement (NRI) and integrated discrimination improvement (IDI) were applied to assess reclassification. A total of 1150 cases were assessed with an all-cause in-hospital mortality rate of 7.91%. When modeled for multivariate regression analysis, the ABC (χ2 = 8.24, P = 0.08), ACC (χ2 = 4.17 , P = 0.57) and RACHS-1 (χ2 = 2.13 , P = 0.14) scores showed good overall performance. The AUC was 0.677 with 95% confidence interval (CI) of 0.61-0.73 for ABC score, 0.704 (95% CI: 0.64-0.76) for ACC score and for RACHS-1 it was 0.607 (95%CI: 0.55-0.66). ACC had an improved predictability in comparison to RACHS-1 and ABC on analysis with NRI and IDI. ACC predicted mortality better than ABC and RCAHS-1 models. A national database will help in developing predictive models unique to our populations, till then, ACC scoring model can be used to analyze individual performances and compare with other institutes.

Preventing Delayed Gastric Emptying After Whipple's Procedure-Isolated Roux Loop Reconstruction With Pancreaticogastrostomy.

Although delayed gastric emptying (DGE) after Whipple's pancreaticoduodenectomy is not life-threatening and can be treated conservatively, it results in discomfort and significant prolongation of the hospital stay and adds on to the hospital costs. To overcome this problem, we started using the isolated loop technique of reconstruction along with pancreaticogastrostomy and we present our series using this technique. All consecutive patients undergoing Whipple's pancreaticoduodenectomy in a single surgical unit from January 2009 until December 2012 were included. In the absence of hepatic and peritoneal metastasis, resection (Whipple's procedure) with curative intent was done using isolated loop technique with pancreaticogastrostomy. Delayed gastric emptying was assessed clinically and on oral gastrograffin study. Bile reflux was also assessed on clinical parameters and evidence of beefy friable gastric mucosa on upper GI endoscopy and presence of reflux on hepatobiliary scintigraphy. A total of 52 patients were operated using this technique from January 2009 to October 2012. The mean operative time was 260.8 ± 50.3, and the mean operative blood loss was 1,068.0 ± 606.1ml. Mean gastric emptying time 106.0 ± 6.1min (89-258min). Three out of the 52(5.7%) patients had persistent vomiting in the post-operative period requiring reinsertion of NG tube. A HIDA scan done on POD7 for all patients did not show any evidence of bile reflux in any of the patients. Pancreatogastrostomy with isolated loop in pancreaticoduodenal resection markedly reduces the post-operative incidence of alkaline reflux gastritis and DGE.

Factors Affecting Short-Term and Long-Term Outcomes After Bilioenteric Reconstruction for Post-cholecystectomy Bile Duct Injury: Experience at a Tertiary Care Centre.

Bile duct injury following cholecystectomy is an iatrogenic catastrophe associated with significant perioperative morbidity, reduced long-term survival and quality of life. There has been little literature on the long-term outcomes after surgical reconstruction and factors affecting it. The aim of this study was to study factors affecting long-term outcomes following surgical repair of iatrogenic bile duct injury being referred to a tertiary care centre. Between January 2005 to December 2011, 138 patients with bile duct injury were treated in a single surgical unit in a tertiary care referral hospital. Preoperative details were recorded. After initial resuscitation, any intra-abdominal collection was drained and an imaging of biliary anatomy was done. Once the general condition of the patient improved, patients were taken up for a side-to-side extended left duct hepaticojejunostomy. The post-operative outcomes were recorded and a hepatobiliary iminodiacetic acid scan and liver function tests were done, and then the patients were followed up at regular intervals. Clinical outcome was evaluated according to clinical grades described by Terblanche and Worthley (Surgery 108:828-834, 1990). The variables were compared using chi-square, unpaired Student's t test and Fisher's exact test. A two-tailed p value of <0.05 was considered significant. One hundred thirty-eight patients, 106 (76.8%) females and 32 (23.2%) males with an age range of 20-63years (median 40.8 ± SD) with bile duct injury following open or laparoscopic cholecystectomy, were operated during this period. Majority of the patients [83 (60.1%)] had a delayed presentation of more than 3months. Based on imaging, Strasburg type E1 was seen in 17 (12.5%), type E2 in 30 (21.7%), type E3 in 85 (61.5%) and type E4 in 6 (4.3%). On multivariate analysis, only level of injury, longer duration of referral and associated vascular injury were independently associated with an overall poor long-term outcome. This study demonstrates level of injury at or above the confluence; associated vascular injury and delay in referral were associated with poorer outcomes in long-term follow-up; however, almost all patients had excellent outcome in long-term follow-up.

Retroperitoneoscopic Living-Donor Nephrectomy and Laparoscopic Kidney Transplantation

To evaluate the feasibility, safety, and outcome of laparoscopic kidney transplantation (LKT) after retroperitoneoscopic living-donor nephrectomy. Between February 2010 and January 2012, a total of 217 renal transplantations were performed from living donors by a single surgical unit. All living-donor nephrectomies were performed by retroperitoneoscopic approach. Recipient surgery was performed either laparoscopically (n=72) or by conventional open approach (n=145). In the LKT group, a 5 to 6 cm Pfannenstiel incision was placed and the kidney was dropped into abdomen. Renal vessels were anastomosed by freehand suturing technique. Calcineurin inhibitor-based immunosuppressants were given. The mean operative time was 223.8 and 175.7 min (P=0.07) and the rewarming time was 60.3 and 30.3 min (P=0.03) in the LKT and open kidney transplantation (OKT) groups, respectively. The estimated glomerular filtration rate value on days 7 and 30 was significantly less in the LKT group, but no difference was found at 3, 6, 12, and 18 months. The mean wound length was 5.5 and 17.8 cm (P=0.0001) and the analgesic requirement was 1.4 and 3.2 mg morphine equivalent in first 24 hr (P=0.005) in the LKT and OKT groups, respectively. In the LKT group, four cases required conversion to open surgery due to vascular complications and one for urinary leak. Kaplan-Meier curve shows 86.5% and 94.6% (P=0.086) and patient survival is 94.1% and 94.7% (P=0.745) at 22.3 months of follow-up. LKT after living-donor nephrectomy is feasible, but it has steep learning curve. Graft fixation with peritoneal fold is necessary to avoid torsion and related graft loss. Pain after LKT is significantly less compared with conventional OKT.

Retroperitoneoscopic Living Donor Nephectomy and Laparoscopic Kidney Transplantation: Experience of First 72 Cases

Introduction: Laparoscopic surgery is having advantages of less pain, early ambulation, better cosmesis and better convalescence in compare to open surgery. Kidney transplantation is conventionally performed by open approach. We herewith present our experience of laparoscopic kidney transplantation following live donor nephrectomy and compare the data with open conventional kidney transplantation. Methods: Between February 2010 and January 2012 total 217 renal transplantations were performed from living donor by single surgical unit. All living donor nephrectomy were performed by retroperitoneoscopic approach. Recipient surgery was performed either laparoscopically (group 1, n= 72) or by conventional open approach (group 2, n=145). Laparoscopic recipient surgery was performed under general anesthesia with endotracheal intubation. Four or five ports were placed and external iliac vessels were mobilized. A 5 cm Pfannenstiel incision was placed and kidney was dropped into abdomen. Renal vessels were anastomosed in end to side fashion by free hand suturing technique using 5/0 polypropylene suture. Ureteroneocystostomy was performed by modified Lich-Gregoir method using 4/0 polyglactin suture. No stent was used in any case. Kidney was retroperitonealized in all but 6 cases. CNI based immunosuppressants were given in all patients. All recipients were followed by color doppler ultrasound at day 1,7 and thenafter as and when required in follow up. Results: Data analysis was performed by SPSS software version 12. Recipients in group 1 were having significant longer operative time and rewarming time than in group 2 (p< 0.03). No significant difference was found in blood loss and delayed graft function. Mean wound length was 5.5 cm± 0.8 cm in group 1 while 17.8 cm ± 4.6 cm in group 2. Serum Creatinine value on day 7 and 30 was significantly more in group 1 (p=0.01) but no difference was found at one year. In group 1, four cases require conversion to open surgery due to vascular complications. One case of urinary leak required open exploration on 9th post operative day for ureteral reimplantation in group 1. No vascular or urinary complications were seen in group 2. Perigraft collection was seen in 9 cases in group 2 while none in group 1. Visual Analogue Score for pain was significantly less in group 1 (p< 0.05). Kaplan Meier curve shows one year graft survival 87.7% and 96.5% p=0.02, and patient survival was 98% and 96.8% in group 1 and 2 respectively. Conclusion: Laparoscopic kidney transplantation following living donor nephrectomy is feasible. It has steep initial learning curve. Retroperitonealization of renal allograft is necessary to avoid torsion and related graft loss. Pain is significantly less in compare to open kidney transplantation surgery.

782 A Novel Method for Monitoring Risk-Adjusted Complications in Pediatric Cardiac Surgery

BackgroundAs overall mortality rates have fallen in pediatric cardiac surgery, complication monitoring is becoming an increasingly important metric of patient outcome. Currently, there is no tool available to monitor severity-adjusted complications in congenital cardiac surgery.MethodsComplications associated with pediatric cardiac surgical procedures were prospectively collected on consecutive index procedures in a single pediatric cardiac surgical unit Oct 1,2009-Sept 31, 2011. Complications were accounted for by frequency and severity and then stratified by surgical complexity (using RACHS), giving an average morbidity burden per RACHS category. “Expected” morbidity burden for each RACHS category was derived from year 1 (2009-10) data. Observed minus expected (O:E) plots were then generated for the complications from year 2 (2010-11) data. Separate O:E plots were also created for five complication classes. These plots were then monitored for increases in frequency and/or severity of complications based on apriori limits.Results80 of 181 procedures (44%) were associated with complications. The frequency and severity of complications increased with surgical complexity. The O:E plot of all complications was flagged twice for increases in severity-adjusted complications. Using the class-specific O:E plots to dissect what the origin of the alarms were, the flags were found to originate from increased rates of infectious and cardiac/operative complications.ConclusionLe Alexander Endowment Award BackgroundAs overall mortality rates have fallen in pediatric cardiac surgery, complication monitoring is becoming an increasingly important metric of patient outcome. Currently, there is no tool available to monitor severity-adjusted complications in congenital cardiac surgery. As overall mortality rates have fallen in pediatric cardiac surgery, complication monitoring is becoming an increasingly important metric of patient outcome. Currently, there is no tool available to monitor severity-adjusted complications in congenital cardiac surgery. MethodsComplications associated with pediatric cardiac surgical procedures were prospectively collected on consecutive index procedures in a single pediatric cardiac surgical unit Oct 1,2009-Sept 31, 2011. Complications were accounted for by frequency and severity and then stratified by surgical complexity (using RACHS), giving an average morbidity burden per RACHS category. “Expected” morbidity burden for each RACHS category was derived from year 1 (2009-10) data. Observed minus expected (O:E) plots were then generated for the complications from year 2 (2010-11) data. Separate O:E plots were also created for five complication classes. These plots were then monitored for increases in frequency and/or severity of complications based on apriori limits. Complications associated with pediatric cardiac surgical procedures were prospectively collected on consecutive index procedures in a single pediatric cardiac surgical unit Oct 1,2009-Sept 31, 2011. Complications were accounted for by frequency and severity and then stratified by surgical complexity (using RACHS), giving an average morbidity burden per RACHS category. “Expected” morbidity burden for each RACHS category was derived from year 1 (2009-10) data. Observed minus expected (O:E) plots were then generated for the complications from year 2 (2010-11) data. Separate O:E plots were also created for five complication classes. These plots were then monitored for increases in frequency and/or severity of complications based on apriori limits. Results80 of 181 procedures (44%) were associated with complications. The frequency and severity of complications increased with surgical complexity. The O:E plot of all complications was flagged twice for increases in severity-adjusted complications. Using the class-specific O:E plots to dissect what the origin of the alarms were, the flags were found to originate from increased rates of infectious and cardiac/operative complications. 80 of 181 procedures (44%) were associated with complications. The frequency and severity of complications increased with surgical complexity. The O:E plot of all complications was flagged twice for increases in severity-adjusted complications. Using the class-specific O:E plots to dissect what the origin of the alarms were, the flags were found to originate from increased rates of infectious and cardiac/operative complications. ConclusionLe Alexander Endowment Award Le Alexander Endowment Award

Real-Time Complication Monitoring in Pediatric Cardiac Surgery

As overall mortality rates have fallen in pediatric cardiac surgical procedures, complication monitoring is becoming an increasingly important metric of patient outcome. Currently there is no standardized method available to monitor severity-adjusted complications in congenital cardiac surgical procedures. Complications associated with pediatric cardiac surgical procedures were prospectively collected from consecutive cases in a single pediatric cardiac surgical unit from October 1, 2009 to September 31, 2011. Complications were accounted for by frequency and severity and then stratified by surgical complexity, using the Risk Adjustment for Congenital Heart Surgery (RACHS) method, giving an average morbidity burden per RACHS category. "Expected" morbidity burden for each RACHS category was derived from year 1 (2009-2010) data. Observed minus expected (O:E) plots were then generated for the entire series of complications from year 2 (2010-2011) data. Separate O:E plots were also created for 5 complication classes and monitored for increases. There were 181 index surgical procedures performed in 178 patients. Two hundred and seventeen complications occurred in 80 procedures. The frequency and severity of complications increased with surgical complexity. The overall O:E plot was flagged twice for unanticipated increases in severity-adjusted complications. When the class-specific O:E plots were monitored for increases, the overall flags were found to originate from increased rates of infections and cardiac/operative complications. The O:E plot provides a simple and effective system to monitor complication rates over time based on severity-adjusted complication data. Grouping complications into classes allows us to identify specific subsets of complications that can be focused on to improve patient outcomes.

Surgical management of benign strictures of the oesophagus: 18 years of experience

Introduction: Benign strictures of the oesophagus are not uncommon. The majority are due to ingestion of corrosives. Different forms of therapy have been recommended. Repeated stricture dilatation has been advocated; when this fails surgical replacement of the oesophagus may be required. There is little information regarding oesophageal dilatation in Sri Lanka. Aim: To retrospectively analyze an 18 year series of patients with benign strictures of the oesophagus treated in a single surgical unit to determine the safety and long term effectiveness of oesophageal replacement by a variety of techniques. Methods: 110 Patients with benign strictures of the oesophagus were treated in a single surgical unit at the Sri Jayawardenapura General Hospital, Nugegoda, Sri Lanka from 1994 to 2011. Clinical, pathological and operative data were reviewed from medical records and interviews with patients and relatives. Results: The male: female ratio was 1.14. Caustic soda ingestion was the commonest cause. Ninety two patients had undergone dilatation prior to presentation without improvement of dysphagia, while 65 had other procedures performed. Transhiatal resection of the oesophagus was the preferred method. Gastric transposition was performed in 67 while the colon was used as the conduit in the others. Recurrence of dysphagia was seen in 8 (7.6%) while the operative mortality rate was 5.4% Conclusion: Surgical treatment of benign strictures of the oesophagus by oesophageal replacement with the stomach or colon is a good option in patients with strictures that do not respond to dilatation and can be carried out with low mortality and morbidity. Repeated attempts at dilatation are unwarranted in such patients. DOI: http://dx.doi.org/10.4038/sljs.v30i1.4502 The Sri Lanka Journal of Surgery 2012; 30(1):18-25

Clinical utility of the preoperative Glasgow prognostic score in patients undergoing potentially curative resection for colorectal cancer.

3611 Background: There is now good evidence that, in addition to TNM stage, the pre-operative combination of the standardised measurements of C-reactive protein and albumin, the Glasgow Prognostic Score (mGPS) provides valuable prognostic information. The aim of the present study was to examine the clinical application of the pre-operative mGPS in a large mature cohort of patients undergoing potentially curative resection for colorectal cancer. Methods: From a prospectively maintained database, consecutive patients (n= 797) with histologically proven colorectal cancer who were considered to have undergone potentially curative resection between January 1997 and December 2010 in a single surgical unit at the Royal Infirmary, Glasgow were included in the study. Results: Patients with an elevated mGPS were more likely to be older (p&lt;0.001), female (p&lt;0.05), have colonic tumours (&lt;0.001), present as an emergency (p&lt;0.001), had higher TNM stage (p&lt;0.05) and more likely to die of their disease (p&lt;0.01). The median follow-up was 66 months and using 3 year cancer-specific mortality as an endpoint, the area under the receiver operator curve was 0.652 (95% CI, 0.591–0.714; p&lt;0.001) for the mGPS and 0.668 (95% CI, 0.610–0.727; p&lt;0.001) for TNM stage. The cancer-specific survival, at 3 years, varied between 86% and 64% according to the mGPS and between 88% and 72% according to TNM stage. The cancer-specific survival, at 3 years, in patients with a mGPS 0 was 91% and 81% for TNM stage II and III respectively. The cancer-specific survival, at 3 years, in patients with a mGPS 1 was 89% and 66% for TNM stage II and III respectively. The cancer-specific survival, at 3 years, in patients with a mGPS 2 was 77% and 43% for TNM stage II and III respectively. Conclusions: The results of the present study show the clinical utility of the pre-operative mGPS in predicting cancer specific survival of potentially curative surgery for colorectal cancer.