Surgery-related Mortality Research Articles

Total Oesophagogastric Dissociation in Neurologically Impaired Children: 18 Years' Experience and Long-term Follow-up.

Total oesophagogastric dissociation (TOGD) is an alternative antireflux surgery for neurologically impaired children because of a 16% to 38% fundoplication failure rate. This study evaluates TOGD's feasibility and its long-term efficacy both as a Primary and as a "Rescue" procedure after failed fundoplication. Thirty patients (18 boys) who underwent TOGD between 2000 and 2018 in 2 Italian Centres were retrospectively reviewed. Twenty-three were Primary procedures and 7 were "Rescue" ones. Inclusion criteria were severe neurodisability, intractable gastroesophageal reflux, and dysphagia. Preoperatively, all children had regurgitation, vomiting or retching, and 93% had unsafe swallowing and aspiration, with recurrent chest infections/aspiration pneumonia. Median relative weight was 77% (48%--118%). All patients were taking antireflux medication before surgery. Median age at TOGD was 6.48 years (0.69--22.18). Median follow-up was 3.5 years (0.6-17.7). No recurrence of gastroesophageal reflux (GER) and vomiting was recorded. The number of chest infections and length of hospital stay showed a significative decrease (P value <0.0001 for both), whereas median relative weight reached 101% (P value 0.002). Parents'/caregivers' perception of outcome showed a significative improvement. Six patients (20%) experienced early complications and 3 required surgical intervention. Three late complications (10%) also required surgery. There was no surgery-related mortality. TOGD is an effective procedure with an acceptably low complication rate for children with severe neurological impairment and is followed by a major improvement in general health and quality of life for children and families. There was no substantial difference in outcome between Primary and "Rescue" procedures.

Safety of the paramedian supracerebellar-transtentorial approach for selective amygdalohippocampectomy.

The goal of this study was to assess the reproducibility and safety of the recently introduced paramedian supracerebellar-transtentorial (PST) approach for selective amygdalohippocampectomy (SA). The authors performed a retrospective analysis of prospectively collected data originating from their surgical register of patients undergoing SA via a PST approach for lesional medial temporal lobe epilepsy. All patients received thorough pre- and postoperative clinical (neurological, neuropsychological, psychiatric) and instrumental (ictal and long-term EEG, invasive EEG if needed, MRI) workup. Surgery-induced complications were assessed at discharge and at every follow-up thereafter and were classified according to Clavien-Dindo grade (CDG). Epilepsy outcome was defined according to Engel classification. Data were reported according to common descriptive statistical methods. Between May 2015 and May 2018, 17 patients underwent SA via a PST approach at the authors' institution (hippocampal sclerosis in 13 cases, WHO grade II glioma in 2 cases, and reactive gliosis in 2 cases). The median postoperative follow-up was 7 months (mean 9 months, range 3-19 months). There was no surgery-related mortality and no complication (CDG ≥ 2) in the whole series. Transitory CDG 1 surgical complications occurred in 4 patients and had resolved in all of them by the first postoperative follow-up. One patient showed a deterioration of neuropsychological performance with new slight mnestic deficits. No patient experienced a clinically relevant postoperative visual field defect. No morbidity due to semisitting position was recorded. At last follow-up 13/17 (76.4%) patients were in Engel class I (9/17 [52.9%] were in class IA). The PST approach is a reproducible and safe surgical route for SA. The achievable complication rate is in line with the best results in the literature. Visual function outcome particularly benefits from this highly selective, neocortex-sparing approach. A larger patient sample and longer follow-up will show in the future if the seizure control rate and neuropsychological outcome also compare better than those achieved with current common surgical techniques.

P300 Colectomy and health-related quality life in children with ulcerative colitis

Abstract Background Restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) is the recommended elective surgery for children with ulcerative colitis (UC). The aim of the present study was to evaluate health outcomes of children with UC and undergone restorative proctocolectomy with IPAA and to compare preoperative and postoperative health-related quality of life (HRQoL). Methods We reviewed the hospital records of all paediatric patients who had undergone surgery for UC between January 2009 and December 2016 in the Units of Paediatric Surgery and Gastroenterology of the University Hospitals of Messina and Genoa. Surgical treatment was represented by restorative proctocolectomy and laparoscopic IPAA. Patients and parents were interviewed by telephone before and after surgery, and responded to the modified IMPACT III questionnaire about health outcomes and HRQoL. The final version was made up of 15 closed questions of functional outcomes and HRQoL. All of the issues were grouped into 5 domains, such as gastrointestinal functional aspects (7 questions), school functioning (2 questions), social functioning (3 questions), emotional functioning (3 questions). The questionnaire was scored on a five-point scale with higher scores indicating a better HRQoL. The total score ranged from 35 (worst HRQoL) to 175 (best HRQoL). Results Data were obtained in 30 patients (16 males), who underwent surgery after a median post-diagnosis period of 3 years (range 1–4.5), at a median age of 12 (range 3–16). The most common indication for colectomy was acute severe colitis (63%, n = 19). Table 1 shows all the functioning total scores before and after IPAA. HRQoL scores showed a statistically significant improvement after IPAA. This difference was observed in all dimensions of HRQoL (symptoms, school attendance, social activities, and emotional functioning). Overall, nearly all were completely satisfied with the outcome of colectomy. No operation-related mortality was reported. By the end of the follow-up, one patient developed pouchitis 1 month after colectomy, and responded well to antibiotic therapy. Conclusion Our data confirmed that HRQoL is low in children with UC referred for possible operation, and showed that surgical treatment may positively affect the overall HRQoL.

How do perioperative beta-blockers compare with placebo/standard care for preventing surgery-related mortality and morbidity in adults undergoing non-cardiac surgery?

How do perioperative beta-blockers compare with placebo/standard care for preventing surgery-related mortality and morbidity in adults undergoing non-cardiac surgery?

Subtotal cholecystectomy: early and long-term outcomes.

In difficult gallbladders, partial or subtotal cholecystectomy (SC) has been described as a reasonable procedure with safe outcomes. Our aim was to look at our data on SC with respect to safety, morbidity and long-term outcome. A retrospective analysis was performed for 3560 patients undergoing cholecystectomy from January 2010 to June 2016. For patients who underwent SC, demographics, intra-operative and follow-up details were analysed. A total of 168 SC patients were included. 102 (60.7%) were male while 66 (39.3%) were female. The median age was 63years (31-87). These patients were on follow-up for a median of 29months (1.7-80). 153 were attempted laparoscopically and there were 25 (16.3%) patients which had open conversion. The rest of the 15 patients had open SC. Mean operative time 150min (70-315) and average blood loss was 170 ml (50-1500). Median length of stay for these patients was 4days (1-68). There were no common bile duct (CBD) injuries. We had 12 (7.1%) post-operative collections, 4 (2.4%) wound infections, 1 (0.6%) bile leak and 7 (4.2%) retained stones. Post-operative endoscopic retrograde cholangiopancreatography (ERCP) was performed on 4 (2.4%) patients with successful retrieval of CBD stones. One patient has spontaneous passage of CBD stone. The rest of the two patients with very small retained stones in remnant gallbladder were successfully managed conservatively. There was no 30-day or operation-related mortality. No patient required a second operation. SC is safe and feasible when encountering a difficult gallbladder.

Surgery for ulcerative colitis in geriatric patients is safe with similar risk to younger patients.

A prior study indicated that postoperative mortality and complications were higher in geriatrics with inflammatory bowel disease (IBD). We sought to assess the rates of surgical complications and mortality in patients aged ≥65 years after colectomy for ulcerative colitis (UC). This is a single center retrospective study at a tertiary care center. We reviewed all hospital discharges with ICD-9 code 556.X between January 2002 and January 2014. Patients were included if they underwent a colectomy for UC. All records were manually reviewed for demographics, complications and mortality within 90 days postoperatively. A total of 259 patients underwent surgery for UC during the study period and 34 patients were ≥65 years old (range 65-82) at the time of their surgery. There was no difference in overall length of stay (10.5 days vs. 9.6 days; P = 0.645) or complication rates (44% vs. 47%; P = 0.854) in the ≥65 cohort compared with the under 65 cohort. Mortality was higher in the geriatric cohort but this included only two deaths within 90 days, one of which was unrelated to the surgery, compared with one death related to surgery within 90 days in the younger cohort. Readmissions occurred in 24% of both cohorts within 90 days. Geriatric patients undergoing surgery for UC are not at increased risk of surgery-related morbidity or mortality compared with a younger cohort.

Inter-implant fractures: an unmet medical need-a preventive approach proposal.

Inter-implant fractures are associated with reduced quality of life and increased 1-year mortality. For that reason, we propose, instead of treating, a novel, preventative surgical approach that involves splinting the inter-implant femoral shaft interval. In patients with a previous femoral implant in whom a second surgery for new material implantation was necessary (including knee or hip arthroplasty, plate or femoral nailing), an overlapping technique using the minimally invasive plate osteosynthesis technique was performed during the second surgery. Nine patients were included, all females with median (range) age of 78 (55-88)years. No surgery-related complications or mortality occurred. Two patients suffered fractures from a casual fall postoperatively with no implant failure or hospital admission required. In conclusion, instead of treating such fractures after they occur, we propose an effective, safe and reproducible preventative surgical approach, not previously reported, which involves internal femoral splinting, a plate and the minimally invasive plate osteosynthesis technique.

Bariatric surgery, compared to medical treatment, reduces morbidity at all ages but does not reduce mortality in patients aged < 43years, especially if diabetes mellitus is present: a post hoc analysis of two retrospective cohort studies.

Bariatric surgery (BS) reduces long-term mortality in comparison with medical treatment of obesity. Some studies indicate that this effect is significant for patients above mean age in different cohorts, but not for younger patients. These findings raise the question whether morbid obese patients should undergo BS as soon as possible, or whether patients might undergo surgery later in their life. We performed a post hoc analysis of two studies; we evaluated surgery-related long-term mortality in: (1) the whole cohort [857 surgery patients (163 diabetes) vs. 2086 controls (512 diabetes)]; (2) patients above mean age [> 43 years, 427 surgery patients (133 diabetes) vs. 1054 controls (392 diabetes)]; (3) patients below mean age [≤ 43 years, 432 surgery patients (30 diabetes) vs. 1032 controls (120 diabetes]. Then, we analyzed age-related long-term mortality in the whole cohort, as well as in surgery patients and in controls. Finally, we analyzed incident diseases (diabetes, cardiovascular disease, and cancer) as a function of surgery versus no-surgery and of mean age. Surgery patients, compared with controls receiving standard medical/dietary treatment, had reduced mortality in the whole cohort (HR = 0.45, 95% CI 0.33-0.62, p = 0.001) and in the study group aged > 43 years (HR = 0.39, 95% CI 0.28-0.56, p = 0.001), but not in the study group aged ≤ 43 years (HR = 0.87, 95% CI 0.42-1.80, p = 0.711). Reduced mortality was observed in non-diabetic and diabetic patients aged > 43 years (HR = 0.37, 95% CI 0.23-0.62, p = 0.001 and HR = 0.45, 95% CI 0.27-0.74, p = 0.002, respectively) who underwent bariatric surgery. In contrast, in patients aged ≤ 43 years, no significant protective effect of bariatric surgery appeared in non-diabetic patients (HR = 0.64, 95% CI 0.24-1.71, p = 0.371), and mortality increased, almost significantly, in diabetic patients aged < 43 years (HR = 2.87, 95% CI 0.96-8.56, p = 0.058), and even more in diabetic patients aged 33-43years; HR = 4.99, 95% CI 1.18-21.09, p = 0.029). As expected, age-related mortality was increased in the whole cohort (HR = 7.23, 95% CI 5.14-10.17, p = 0.001), in non-diabetic and diabetic controls (HR = 8.55, 95% CI 5.77-12.68, p = 0.001, and HR = 3.76, 95% CI 1.97-7.18, p = 0.001, respectively). The effect of aging was slightly reduced in surgery patients (HR = 3.76, 95% CI 1.87-7.58, p = 0.001), while it was not significant in diabetic surgery patients (HR = 0.70, 95% CI 0.26-1.90, p = 0.88), further emphasizing that diabetes per se has a strong negative effect on survival, also with concomitant bariatric surgery. In a supplementary analysis, HRs did not change when surgery and control parents were matched for the presence of diabetes. Incident diseases (cardiovascular, diabetes, and cancer) were less frequent in surgery than in control patients, irrespective of age. Bariatric surgery reduces long-term mortality in comparison with medical treatment when performed in patients aged > 43 years, but not in younger patients, where it is neutral or could even increase mortality; reduction in morbidity occurs at any age.

Salvage esophagectomy for initially unresectable locally advanced T4 esophageal squamous cell carcinoma.

Definitive chemoradiotherapy (dCRT) for esophageal squamous cell carcinoma (ESCC) is a potentially curative treatment modality, even for patients with unresectable T4 tumors. For patients who fail dCRT, salvage esophagectomy is known to be a high-risk procedure. However, the efficacy and safety of salvage surgery for these patients remain unclear. A total of 35 patients who underwent salvage esophagectomy after dCRT for initially unresectable locally advanced T4 ESCC were assessed, and both outcomes and prognostic factors after surgery were investigated. Among the study population, R0 resection was achieved in 19 patients (54.3%). Postoperatively, 8 patients (22.9%) experienced Clavien-Dindo grade IIIb or higher complications, and 3 patients (8.6%) registered surgery-related mortality. Overall survival rates were 45.7%, 28.6%, and 5.7% at 1, 2, and 5years, respectively. In Cox regression analysis, residual or relapsed tumor limited to T2 or less was an independent prognostic factor for better survival (P = 0.010). On the other hand, postoperative pneumonia and incomplete resection were negative prognostic factors (P < 0.001 and P = 0.019, respectively). Nodal involvement and extent of lymph node dissection did not impact patient survival. Although salvage esophagectomy for initially unresectable T4 ESCC is considered a high-risk surgery with poor prognosis, long-term survival may be achieved in patients with ≤ T2 residual tumors. In addition, R0 resection and postoperative pneumonia prevention are crucial to improve patient survival.

Impact of certification status of the institute and surgeon on short-term outcomes after surgery for thoracic esophageal cancer: evaluation using data on 16,752 patients from the National Clinical Database in Japan

BackgroundIn 2009, the Japan Esophageal Society (JES) established a system for certification of qualified surgeons as “Board Certified Esophageal Surgeons” (BCESs) or institutes as “Authorized Institutes for Board Certified Esophageal Surgeons” (AIBCESs). We examined the short-term outcomes after esophagectomy, taking into consideration the certifications statuses of the institutes and surgeons.MethodsThis study investigated patients who underwent esophagectomy for thoracic esophageal cancer and who were registered in the Japanese National Clinical Database (NCD) between 2015 and 2017. Using hierarchical multivariable logistic regression analysis adjusted for patient-level risk factors, we determined whether the institute’s or surgeon’s certification status had greater influence on surgery-related mortality or postoperative complications.ResultsEnrolled were 16,752 patients operated on at 854 institutes by 1879 surgeons. There were significant differences in the backgrounds and incidences of postoperative complications and surgery-related mortality rates between the 11,162 patients treated at AIBCESs and the 5590 treated at Non–AIBCESs (surgery-related mortality rates: 1.6% vs 2.8%). There were also differences between the 6854 patients operated on by a BCES and the 9898 treated by a Non-BCES (1.7% vs 2.2%). Hierarchical logistic regression analysis revealed that surgery-related mortality was significantly lower among patients treated at AIBCESs. The institute’s certification had greater influence on short-term surgical outcomes than the operating surgeon’s certification.ConclusionsThe certification system for surgeons and institutes established by the JES appears to be appropriate, as indicated by the improved surgery-related mortality rate. It also appears that the JES certification system contributes to a more appropriate medical delivery system for thoracic esophageal cancer in Japan.

P4697Complications and mortality related to non-cardiac surgery in adult congenital heart disease: Results of a nationwide study including 20,450 cases

Abstract Background Adults with congenital heart disease (ACHD) represent a growing patient population with high morbidity and increasing health resource utilization. In addition to acute and chronic cardiac complications, these patients require numerous non-cardiac surgical procedures during their life-time. Limited data on the morbidity and mortality risk related to non-cardiac surgical procedures exist in contemporary CHD patients. The aim of this study was to analyse the frequency and outcome of non-cardiac surgical procedures in contemporary ACHD patients based on all hospital admissions in Germany between 2011 and 2016. Methods Based on the German diagnosis related groups data of patients treated between 2011 and 2016 we identified all ACHD patients treated surgically as inpatients for non-cardiac problems. The dataset contains information on patient demographics, primary and secondary diagnoses, interventional or surgical procedures, duration of stay and outcome including mortality. The primary endpoint of the study was surgery related mortality as well as major adverse events (defined as death or myocardial infarction, stroke, pulmonary embolism, sepsis or resuscitation). Results Overall, 48,872 ACHD cases were hospitalized during the study period. Of these, 20,450 (41.8%) were hospitalized for non-cardiac surgical procedures. The median age at surgery was 50.0 years and 62.9% of patients were male. The overall mortality rate following non-cardiac operations was 2.8% (95% CI 2.6–3.0%). The highest mortality rates were observed for procedure codes involving pharynx, larynx or trachea (27.2%; 95% CI: 22.3–32.1%) and lung surgery (15.4%; 95% CI: 13.3–17.8%). Abdominal surgery (9.2%; 95% CI: 7.7–10.9) and neurosurgical procedures (7.8%; 95% CI: 5.4–10.9) also had relative high mortality rates. The major adverse event rate overall was 12.7% (95% CI 11.7–12.7%). The highest major adverse event rates were observed for surgery of the airways (43.2%; 95% CI: 40.2%-46.4%). Conclusions Non-cardiac surgical procedures are common in ACHD patients and are associated with considerable mortality and morbidity in this cohort. Especially, surgical procedures involving the airways or neurosurgery emerged as risky procedures. However, even for routine abdominal or orthopaedic surgery considerable mortality and morbidity was observed. Overall, our data support careful pre-operative patient evaluation and concentration of surgical procedures at centres with extensive surgical and anaesthetic experience with ACHD patients.

Cochrane Corner: Perioperative beta-blockers for preventing surgery-related mortality and morbidity

Randomized controlled trials have yielded conflicting results regarding the impact of beta-blockers on perioperative cardiovascular morbidity and mortality. This Cochrane systematic review assessed the impact of this intervention on mortality and cardiovascular events. Eighty-eight randomized controlled trials with 19 161 participants were included (53 trials on cardiac surgery and 35 trials on non-cardiac surgery). In cardiac surgery perioperative beta-blockers had a protective effect against supraventricular and ventricular arrhythmias but had no significant effect on mortality or on the occurrence of acute myocardial infarction (AMI), stroke, heart failure, hypotension or bradycardia. In non-cardiac surgery, beta-blockers had a protective effect against AMI and arrhythmias, but this was counterbalanced by an increased risk of death and stroke. In conclusion, perioperative use of beta-blockers appears overall to be beneficial in cardiac surgery. However, in non-cardiac surgery the substantial reduction in rhythm disturbances and AMI appears to be offset by an increase in mortality and stroke, and so the systematic use of beta-blockers in this setting is not recommended. Os resultados de ensaios clínicos aleatorizados relativos à utilização de betabloqueantes no período perioperatório de cirurgia cardíaca e não cardíaca têm sido controversos. Esta revisão sistemática da Cochrane avaliou o impacto dessa intervenção na mortalidade e eventos cardiovasculares peri-operatórios. Foram incluídos 88 ensaios clínicos aleatorizados com um total de 19 161 participantes (53 ensaios com cirurgia cardíaca e 35 com cirurgia não cardíaca). A utilização perioperatória de betabloqueantes na cirurgia cardíaca reduziu significativamente a ocorrência de disritmias supraventriculares e ventriculares, sem impacto significativo na mortalidade, bem como no risco de enfarte agudo do miocárdio (EAM), acidente vascular cerebral (AVC), insuficiência cardíaca, hipotensão e bradicardia. Por outro lado, na cirurgia não cardíaca, apesar de existir uma redução no risco de EAM e nos eventos arrítmicos supraventriculares, esse efeito foi contrabalançado pelo aumento do risco de morte e AVC. Em conclusão, a utilização de betabloqueantes no período perioperatório de cirurgia cardíaca parece ser benéfica. Por outro lado, na cirurgia não cardíaca apesar da redução significativa de EAM e disritmias, há um aumento da mortalidade e de AVC, pelo que a utilização sistemática de betabloqueantes em doentes submetidos a cirurgia não cardíaca não está recomendada.

Cochrane Corner: Perioperative beta-blockers for preventing surgery-related mortality and morbidity

Randomized controlled trials have yielded conflicting results regarding the impact of beta-blockers on perioperative cardiovascular morbidity and mortality. This Cochrane systematic review assessed the impact of this intervention on mortality and cardiovascular events.Eighty-eight randomized controlled trials with 19 161 participants were included (53 trials on cardiac surgery and 35 trials on non-cardiac surgery).In cardiac surgery perioperative beta-blockers had a protective effect against supraventricular and ventricular arrhythmias but had no significant effect on mortality or on the occurrence of acute myocardial infarction (AMI), stroke, heart failure, hypotension or bradycardia. In non-cardiac surgery, beta-blockers had a protective effect against AMI and arrhythmias, but this was counterbalanced by an increased risk of death and stroke.In conclusion, perioperative use of beta-blockers appears overall to be beneficial in cardiac surgery. However, in non-cardiac surgery the substantial reduction in rhythm disturbances and AMI appears to be offset by an increase in mortality and stroke, and so the systematic use of beta-blockers in this setting is not recommended.

Perioperative beta-blockers for preventing surgery-related mortality and morbidity in adults undergoing non-cardiac surgery.

Perioperative beta-blockers for preventing surgery-related mortality and morbidity in adults undergoing non-cardiac surgery.

Perioperative beta-blockers for preventing surgery-related mortality and morbidity in adults undergoing cardiac surgery.

Perioperative beta-blockers for preventing surgery-related mortality and morbidity in adults undergoing cardiac surgery.

Management of isolated para-aortic lymph node recurrence of colorectal cancer

Isolated para-aortic lymph node recurrence (PALNR) after curative surgery for colorectal cancer (CRC) is rare and its optimal management is not defined clearly. This review investigates the best outcomes among published studies on the management of PALNR in the field of CRC. We searched the PubMed database for studies reporting on the management of isolated PALNR in CRC, published in English or Japanese from January, 2000 to December, 2018. Studies including patients with other metastases were excluded. A total of 24 retrospective studies including 227 patients with PALNR were evaluated. The 3-year overall survival (OS) ranged from 60 to 100%, with a median OS of 34-80months for patients who underwent PALNR dissection, and 14-42months for patients who received non-surgical treatment. No surgery-related mortality was reported and the incidence of surgical, mainly low-grade, complications ranged from 33 to 52%. The predictors of improved survival outcome included R0 resection margins. Dissection for PALNR from CRC is considered a feasible treatment option that may yield a better prognosis than non-surgical treatment alone. Preoperative chemotherapy or CRT should be considered for their potential benefits, including a reduction in cancer volume and improved R0 resection rates.

Early fixation versus conservative therapy of multiple, simple rib fractures (FixCon): protocol for a multicenter randomized controlled trial

BackgroundMultiple rib fractures are common injuries in both the young and elderly. Rib fractures account for 10% of all trauma admissions and are seen in up to 39% of patients after thoracic trauma. With morbidity and mortality rates increasing with the number of rib fractures as well as poor quality of life at long-term follow-up, multiple rib fractures pose a serious health hazard. Operative fixation of flail chest is beneficial over nonoperative treatment regarding, among others, pneumonia and both intensive care unit (ICU) and hospital length of stay. With no high-quality evidence on the effects of multiple simple rib fracture treatment, the optimal treatment modality remains unknown. This study sets out to investigate outcome of operative fixation versus nonoperative treatment of multiple simple rib fractures.MethodsThe proposed study is a multicenter randomized controlled trial. Patients will be eligible if they have three or more multiple simple rib fractures of which at least one is dislocated over one shaft width or with unbearable pain (visual analog scale (VAS) or numeric rating scale (NRS) > 6). Patients in the intervention group will be treated with open reduction and internal fixation. Pre- and postoperative care equals treatment in the control group. The control group will receive nonoperative treatment, consisting of pain management, bronchodilator inhalers, oxygen support or mechanical ventilation if needed, and pulmonary physical therapy. The primary outcome measure will be occurrence of pneumonia within 30 days after trauma. Secondary outcome measures are the need and duration of mechanical ventilation, thoracic pain and analgesics use, (recovery of) pulmonary function, hospital and ICU length of stay, thoracic injury-related and surgery-related complications and mortality, secondary interventions, quality of life, and cost-effectiveness comprising health care consumption and productivity loss. Follow-up visits will be standardized and daily during hospital admission, at 14 days and 1, 3, 6, and 12 months.DiscussionWith favorable results in flail chest patients, operative treatment may also be beneficial in patients with multiple simple rib fractures. The FixCon trial will be the first study to compare clinical, functional, and economic outcome between operative fixation and nonoperative treatment for multiple simple rib fractures.Trial registrationwww.trialregister.nl, NTR7248. Registered May 31, 2018.

Surveillance for pancreatic cancer in high‐risk individuals

BackgroundSurveillance of individuals at high risk of pancreatic ductal adenocarcinoma (PDAC) and its precursors might lead to better outcomes. The aim of this study was to determine the prevalence and outcomes of PDAC and high‐risk neoplastic precursor lesions among such patients participating in surveillance programmes.MethodsA multicentre study was conducted through the International CAncer of the Pancreas Screening (CAPS) Consortium Registry to identify high‐risk individuals who had undergone pancreatic resection or progressed to advanced PDAC while under surveillance. High‐risk neoplastic precursor lesions were defined as: pancreatic intraepithelial neoplasia (PanIN) 3, intraductal papillary mucinous neoplasia (IPMN) with high‐grade dysplasia, and pancreatic neuroendocrine tumours at least 2 cm in diameter.ResultsOf 76 high‐risk individuals identified in 11 surveillance programmes, 71 had undergone surgery and five had been diagnosed with inoperable PDAC. Of the 71 patients who underwent resection, 32 (45 per cent) had PDAC or a high‐risk precursor (19 PDAC, 4 main‐duct IPMN, 4 branch‐duct IPMN, 5 PanIN‐3); the other 39 patients had lesions thought to be associated with a lower risk of neoplastic progression. Age at least 65 years, female sex, carriage of a gene mutation and location of a lesion in the head/uncinate region were associated with high‐risk precursor lesions or PDAC. The survival of high‐risk individuals with low‐risk neoplastic lesions did not differ from that in those with high‐risk precursor lesions. Survival was worse among patients with PDAC. There was no surgery‐related mortality.ConclusionA high proportion of high‐risk individuals who had surgical resection for screening‐ or surveillance‐detected pancreatic lesions had a high‐risk neoplastic precursor lesion or PDAC at the time of surgery. Survival was better in high‐risk individuals who had either low‐ or high‐risk neoplastic precursor lesions compared with that in patients who developed PDAC.

Natural History and Surgical Management of Colonic Perforations in Vascular Ehlers-Danlos Syndrome: A Retrospective Review.

Vascular Ehlers-Danlos syndrome is a rare and severe genetic condition leading to spontaneous, potentially life-threatening arterial and digestive complications. Colonic ruptures are a common feature of the disease, but clear recommendations on their management are lacking. This study aimed to identify surgery-related morbidity and 30-day postoperative mortality after colonic perforation. This was a retrospective review. A large cohort of patients with vascular Ehlers-Danlos syndrome was followed in a tertiary referral center. Between 2000 and 2016, the French National Reference Centre for Rare Vascular Diseases (HEGP, AP-HP, Paris, France) followed 148 patients with molecularly proven vascular Ehlers-Danlos syndrome. The primary outcomes measured were surgery-related morbidity and 30-day postoperative mortality. Of 133 patients with molecularly proven vascular Ehlers-Danlos syndrome, 30 (22%) had a history of colonic perforation and 15 (50%) were males. These subjects were diagnosed with vascular Ehlers-Danlos syndrome at a younger age than patients with a history of GI events without colonic perforation (p = 0.0007). There were 46 colonic perforations, median 1.0 event per patient (interquartile range, 1.0-2.0). Reperforations occurred in 14 (47%) patients, mostly males. Surgical management consisted of Hartmann procedures or subtotal abdominal colectomies, with a nonnegligible rate of reperforation following partial colonic resection (11 patients, 41%). The main limitations of this work are its retrospective design and that the diagnosis of vascular Ehlers-Danlos syndrome was made after colonic perforations in a majority of patients. Colonic perforations seem more severe in males, with a high rate of reperforation after Hartmann procedure. Subtotal colectomy may reduce digestive morbidity, particularly in male patients. Additional studies are required to identify other predictors of reperforation. See Video Abstract at http://links.lww.com/DCR/A937.

A new treatment strategy for end-stage hepatic alveolar echinococcosis: IVC resection without reconstruction

Patients with hepatic alveolar echinococcosis (HAE) infringing on the inferior vena cava (IVC) have a poor prognosis when radical resection cannot be performed because curative resection is limited by IVC reconstruction. There is little information concerning combined resection of the liver and the IVC. This study explored a novel treatment method for HAE infringing on the IVC and evaluated the safety and feasibility of combined resection of the liver and the IVC. A total of 13 patients were treated with liver resection combined with IVC resection for end-stage HAE between January 2016 and July 2018 at the Affiliated Hospital of Qinghai University. The demographic, clinical, and follow-up data were collected and analysed. The 13 patients underwent resection of the IVC without reconstruction. Of these, 3 exhibited oedema of both lower limbs and the scrotum (23.1%), 2 exhibited pneumothorax (15.4%), 1 exhibited bile leakage (7.7%), 1 exhibited bacteraemia (7.7%), and 1 developed abdominal haemorrhage that was stopped with conservative treatment (7.7%). There was 1 case of operation-related mortality because of upper gastrointestinal haemorrhage (7.7%), and no patients developed recurrence or had residual lesions. Liver resection combined with IVC resection is effective and feasible for patients with HAE infringing on the IVC.