Total Postoperative Complications Research Articles

Safety and feasibility of laparoscopic reoperation for treatment of anastomotic leakage after laparoscopic colorectal cancer surgery.

The safety and feasibility of laparoscopic reoperation for anastomotic leakage remain unclear. A total of 3321 patients underwent laparoscopic surgery for primary colorectal cancer at a tertiary referral center from September 2002 to May 2016. Of these, 31 patients who underwent reoperation for treatment of anastomotic leakage were enrolled in this study and divided into two reoperation groups: laparoscopic (n = 15) and open (n = 16). Data regarding patient demographics, operative outcomes, morbidity, length of hospital stay, mortality, and stoma closure after reoperation in the two groups were compared. No significant difference was observed in the primary surgery procedure between the two groups. Estimated blood loss (1 vs 9 mL, P = 0.020), total postoperative complications (26.7% vs 68.8%, P = 0.032), wound infection (0.0% vs 31.2%, P = 0.043), and postoperative hospital stay (18 vs 31 days, P = 0.017) were significantly better in the laparoscopic group than in the open group. Although the rate of stoma closure after reoperation was higher in the laparoscopic group, the difference was not significant (86.7% vs 62.5%, P = 0.220). Laparoscopic reoperation exhibited better short-term outcomes than open reoperation for selected patients with anastomotic leakage.

Transversus abdominis plane block for postoperative analgesia after abdominal surgeries in morbidly obese

Background Pain is a significant problem for many patients after major surgery. The transversus abdominis plane (TAP) block is a new technique that provides analgesia following abdominal surgery. TAP block can be done blindly or by using ultrasound that include posterior and subcostal approach. Aim The primary aim was to study the clinical utility of TAP block as analgesia after lower abdominal surgeries in morbidly obese. The secondary aim was to assess the advantages and disadvantages of the same. Patients and methods A total of 60 patients fulfilling inclusion criteria who were undergoing elective lower abdominal surgeries were divided into two equal groups. Group T (TAP group), which received bilateral ultrasound-guided subcostal TAP block at the end of the surgery before emergence, and group C (control group) that received general anesthesia, with no further narcotic administration. Postoperative mean arterial pressure, heart rate, respiratory rate, visual analog scale, and visual analog scale on cough, PaCO2, time to first request of analgesia, average frequency of analgesia, average total analgesics consumption, average total local anesthetic (bupivacaine) consumption, postoperative complications, and frequency of antiemetic were recorded. Bromage score was assessed at 20 min postoperatively. Results There were significant decrease in mean arterial pressure, heart rate, respiratory rate, visual analog scale, and visual analog scale on cough in group T than group C at 10, 20 min. There wasa high significant decrease in peak expiratory flow rate and significant increase in PaCO2 in group C than group T at 2, 6 h postoperatively. There was a high significant increase in the time to first request of analgesia, and a high significant decrease of both frequency of analgesia and average total consumption of analgesia. A high significant increase was observed in local anesthetic consumption in the first 24 h postoperatively in group T than group C. There were significant differences in nausea, vomiting, and frequency of antiemetic, whereas they did not occur in group T. There were no significant differences in the grade of motor block between two groups at 20 min or any other time. Conclusion TAP block was safe, and easy to perform, and more effective in the early postoperative period with significant reductions in opioid requirement, pain score, and complications, and did not produce motor block.

Clavien System Classification of Complications Developed following Laparoscopic Urological Operations Applied in our Clinic.

Objectives:We analyzed the complications of laparoscopic surgery using Clavien system classification on 396 urological procedures performed at our institution between 2005-2009.Methods:A retrospective analysis was performed, focusing on complications associated with 396 laparoscopic surgeries performed between 2005 and 2009, which included radical and simple nephrectomy (n=188), partial nephrectomy (n=29), pyeloplasty (n=78), sacrocolpopexy (n=16) and radical prostatectomy (n=85). Complication data were tabulated according to the case number, procedure type, patient age, the American Society of Anesthesiologists score (ASA), Clavien classification system and annual complication rate during this study. Statistical analysis was performed with Fisher’s exact and chi-square tests.Results:A total of 75 patients had complications during the study period. Thus, the total postoperative complication rate was 18.9%. When sub-stratified to various surgical procedures, complication rates were: laparoscopic radical and simple nephrectomy (11.1%), laparoscopic partial nephrectomy (37.9%), laparoscopic pyeloplasty (15.3%), laparoscopic sacrocolpopexy (18.7%) and laparoscopic radical prostatectomy (32.9%). When the complications were classified according to Clavien Classification System stage 1, 2, 3, 4, 5, complication rate was observed in 11.6%, 13.8%, 1.2%, 1%, and 0% of patients, respectively. A correlation was not identified between ASA score and complication rate (p=0.02).Conclusion:The data presented here would enable us to compare our complication rates objectively with world literature.

Pericardial-peritoneal window for malignant pericardial effusion

Background: Malignant pericardial effusion is a pathological accumulation of fluid in the pericardial cavity occurring in patients with different types of cancer. The condition can be life-threatening not only in patients with terminal malignancies but also in those with a more favorable prognosis. The creation of a pericardial-peritoneal window is a surgical procedure connecting the pericardium with the peritoneal cavity and the definitive treatment of pericardial effusion. Methods: Twenty consecutive patients with malignant pleural effusion undergoing pericardial-peritoneal window from 2006 to 2017 were enrolled in the present study. Data were collected on sex, age, preoperative ultrasound and computed tomography findings, histology and pathological stage of the neoplasm, intraoperative findings and additional surgical procedures needed. Further information included total postoperative complications, 30-day mortality rate, pulmonary and cardiac complications, ICU admission and hospital stay, median overall survival (OS). Results: Eleven patients were male and nine were females; median age was 63 years; 14 patients had lung cancer, 3 breast carcinomas, 1 ovarian adenocarcinoma, 1 renal cell carcinoma and 1 malignant mesothelioma. Intraoperative mean volume of the drained pericardial effusion was 500 mL; mean duration of the procedure was 73 minutes; postoperative mean length of stay was four days; five patients had postoperative complications; one patient died within 30 days. OS after 34 months of follow-up was 80.8%. Conclusions: Pericardial-peritoneal window is a safe and effective procedure to resolve malignant pericardial effusion in patients with a favorable short-term prognosis, whereas pericardial drainage should be considered the most appropriate treatment in patients with a less favorable prognosis.

Impact of Patient Subtype and Surgical Variables on Abdominoplasty Outcomes: A 12-Year Massachusetts General Hospital Experience.

The traditional abdominoplasty is one of the most common surgical procedures performed. This study evaluates the impact of different surgical techniques and clinical patient factors on abdominoplasty outcomes. A retrospective review of consecutive patients undergoing abdominoplasty was performed. Seven hundred seventy-nine patients with a mean age of 43.7 years and a body mass index of 27 kg/m underwent abdominoplasty. The majority were women (92.9 percent), and massive weight loss was present in 34.8 percent. Abdominoplasty techniques included traditional (59.4 percent), belt lipectomy (17.9 percent), fleur-de-lis (16.4 percent), umbilical float (9.2 percent), and mini-abdominoplasty (2.8 percent). Half of the study population [n = 384 (49.3 percent)] had concurrent surgical procedures. Total complications (23.0 percent) consisted primarily of wound- and scar-related complications (15.3 percent). Approximately 60 percent of patients received heparin chemoprophylaxis, with overall thromboembolic and hematoma rates less than 1 percent. Univariate analysis revealed that massive weight loss (p = 0.04), fleur-de-lis (p = 0.03) or belt lipectomy (p = 0.05) techniques, and concurrent medial thigh lift (p < 0.001) all significantly increased complications. Previous scars, amount of weight loss, operative time, liposuction, and other concurrent procedures did not affect total complications. Male sex (OR, 1.96; p = 0.04), fleur-de-lis technique (OR, 1.71; p = 0.04), and medial thigh lift (OR, 3.3; p < 0.001) were independent risk factors for total postoperative complications. This study demonstrates that abdominoplasty alone or in combination with liposuction and aesthetic breast surgery can be performed safely, with an acceptable complication profile. Risk, III.

The benefit of immunonutrition in patients undergoing hepatectomy: a systematic review and meta-analysis.

Perioperative immunonutrition in liver resection remains doubtful. A systematic review and meta-analysis was conducted to compare postoperative outcomes between patients undergoing hepatectomy who received perioperative immunonutrition and those who did not.A PubMed, Embase, Cochrane Central Register of Controlled Trials, and Web of Knowledge database search was performed to retrieve all of the randomized controlled trials (RCTs) evaluating the value of perioperative immunonutrition in patients undergoing hepatectomy until the end of September 2016. Data extraction and quality assessment of RCTs were performed in accordance with PRISMA guidelines. The quality of evidence for each postoperative outcome was assessed using the GRADEpro analysis. A random-effects model was used to conduct a meta-analysis with RevMan 5.3.5 software. Eight RCTs including 805 patients (402 with and 403 without immunonutrition) were identified. Immunonutrition, mainly ω-3 fatty acids, significantly reduced the incidence of postoperative total complications (risk ratio [RR] = 0.59; 95% confidence interval [CI], 0.46–0.75; p < 0.0001) and infectious complications (RR = 0.46; 95% CI, 0.32–0.68; p < 0.0001), and shortened the length of hospital stay (standardized mean difference, −0.49; 95% CI, −0.81 to −0.16; p = 0.0004). There was no significant between-group difference in postoperative mortality (RR = 0.46; 95% CI, 0.16–1.31; p = 0.15). Immunonutrition, mainly ω-3 fatty acids, is potentially beneficial in reducing overall and infectious postoperative complications and in shortening the hospital stay for patients undergoing hepatectomy.

Surgical outcomes of pancreaticoduodenectomy in young patients: A case series

BackgroundPancreaticoduodenectomy (PD) is a complex procedure for management periampullary neoplasms The aim of our work is to report the surgical outcomes after PD in young adult (YA) (<35 years) and to compare it to a adult patients who underwent PD. MethodsWe retrospectively analyzed the data of all patients who underwent PD in the period from January 1993 to December 2016. The primary outcome was the rate of total postoperative complications. Secondary outcomes included postoperative pathology, exocrine and endocrine function and survival rate. Results58/975 patients (5.9%) were YA and the majority of them were females. The incidence of post-operative complications in the YA was comparable to that in the adult group. Delayed gastric emptying developed significantly in adult group than YA group (0.008). The overall survival was significantly higher in the YA (P = 0.0001). The most common pathology in the YA was adenocarcinoma (41.4%) and solid pseudopapillary tumor (SPT) (29.3%). No significant difference as regards postoperative pancreatic exocrine and endocrine function in both groups. ConclusionPD in YA when performed in tertiary centers with good surgical experience is safe. The most common pathological diagnosis in the YA was adenocarcinoma followed by SPT.

Impact of Total Pars Plana Vitrectomy on Postoperative Complications in Aphakic, Snap-On, Type 1 Boston Keratoprosthesis

To determine the impact of total pars plana vitrectomies (PPVs) with peripheral shaving of the vitreous base on the rates of postoperative complications in patients with aphakic, snap-on type I Boston keratoprostheses (KPros). Retrospective, consecutive case series. A total of 48 eyes in 46 patients with implantation of aphakic, snap-on type 1 Boston KPros performed at a tertiary care facility between January 1, 2007, and December 31, 2013, were included. The cumulative incidences of postoperative complications were compared between patients who underwent total PPVs with shaving of the vitreous base (n= 22) and those who had partial PPVs or anterior vitrectomies (AVs) at the time of KPro implantation (n= 26). Rates of complications between patients who underwent total PPVs and partial PPVs or AVs. The rate of total postoperative complications was lower in the total PPV group (P= 0.018, log-rank test). In particular, eyes that underwent total PPVs had lower rates of retroprosthetic membranes (RPMs) requiring intervention (P= 0.049) and less vision loss due to glaucoma progression (P= 0.046). There was also a trend for fewer corneal melts (P= 0.060) and less sight-threatening complications (P= 0.051) in the total vitrectomy group. There was no difference in the rates of KPro extrusion (P= 0.41), endophthalmitis or vitritis (P= 0.15), retinal detachments (P= 0.76), cystoid macular edema (P= 0.83), or timing of complications between the 2 groups. The mean preoperative and postoperative visual acuities were similar between the 2 groups (P= 0.97). The mean follow-up was 49±22 months. Eyes that underwent total PPVs during implantation of aphakic, snap-on, type I Boston KPros had less postoperative complications than eyes with partial PPVs or AVs during the average 4 years of follow-up.

Anterior Lumbar Interbody Fusion With and Without an "Access Surgeon": A Systematic Review and Meta-analysis.

A systematic review and meta-analysis. The aim of this study was to investigate the outcomes of anterior lumber interbody fusion (ALIF) with and without an "access surgeon." Anterior approaches for spine operations have become increasingly popular but may often involve unfamiliar anatomy and territory for spine surgeons, potentially placing the patient at risk to a greater proportion of approach-related complications. Thus, many spine surgeons require or prefer the assistance of an "access surgeon" to perform the exposure. However, there has been much debate about the necessity of an "access surgeon." A systematic search of six databases from inception to April 2016 was performed by two independent reviewers. Meta-analysis was used to pool overall rates, and compare the outcomes of ALIF with an access surgeon and without. A total of 58 (8028 patients) studies were included in this meta-analysis. The overall intraoperative complications were similar with and without an "access surgeon." The overall pooled rate of arterial injuries [no access 0.44% vs. access 1.16%, odds ratio (OR) 2.67, P < 0.001], retrograde ejaculation (0.41% vs. 0.96%, OR 2.34, P = 0.005), and ileus (1.93% vs. 2.26%, OR 2.45, P < 0.001) was higher with an "access surgeon." However, the overall pooled rates of peritoneal injury (0.44% vs. 0.16%, OR 0.36, P = 0.034) and neurological injury (0.99% vs. 0.11%, OR 0.11, P < 0.001) were lower with an "access surgeon." Total postoperative complications (5.95% vs. 4.08%, OR 0.67, P < 0.001) were lower with an "access surgeon" along with prosthesis complications (1.59% vs. 0.89%, OR 0.56, P < 0.001) and reoperation rates (2.28% vs. 1.31%, OR 0.57, P < 0.001). Compared with no access surgeon, the use of an access surgeon was associated with similar intraoperative complication rates, higher arterial injuries, retrograde ejaculation, ileus, and lower prosthesis complications, reoperation rates, and postoperative complications. In cases wherein exposure may be difficult, support from an "access surgeon" should be available. 1.

Laparoscopic Colectomy Versus Open Colectomy for Treatment of Transverse Colon Cancer: A Systematic Review and Meta-Analysis.

The surgical management of transverse colon cancer (TCC) is still not standardized. The aim of this meta-analysis was to evaluate the effect of laparoscopic colectomy (LC) for treatment of TCC in terms of short-term and long-term outcomes compared with open colectomy. A systematic literature search with no limits was performed in PubMed and Embase. The last search was performed on September 15, 2016. The short-term outcomes included intraoperative outcomes, postoperative outcomes, and oncological surgical quality. The long-term outcomes included overall survival (OS) and disease-free survival (DFS). Thirteen articles and one conference abstract published between 2010 and 2016 with a total of 1728 patients were enrolled in this meta-analysis. LC was associated with significant less estimated blood loss, fewer total postoperative complications, and shorter time to first flatus, time to liquid diet, length of hospital stay, and length of postoperative hospital stay. However, longer operative time was needed in LC. There was no statistically significant difference between the groups concerning the intraoperative complications, mortality, ileus, anastomotic leakage, bleeding, wound infection, abdominal infection, lymph nodes harvested, proximal resection margin, distal resection margin, OS, or DFS. Our meta-analysis suggests that LC is a safe and feasible technique for TCC associated with less estimated blood loss, fewer total postoperative complications, quicker recovery of intestinal function, shorter length of hospital stay, and equivalent long-term outcomes. Furthermore, a large-scaled, prospective randomized controlled study is warranted to verify those results.

Clinical application of modified peroral endoscopic myotomy to treatment of achalasia(with video)

Objective To compare the difference between modified peroral endoscopic myotomy(Liu-POEM) and conventional POEM for achalasia. Methods Thirty achalasia patients treated with Liu-POEM and 30 with conventional POEM were enrolled. A retrospective study was performed to compare the conventional POEM and Liu-POEM procedures by evaluating total operation time, postoperative complications and symptoms(Eckardt score). Results The average total operation time of Liu-POEM was 27.13 ±11.42 min and the average myotomy time was 13.20±5.09 min. There was no pneumomediastinum, subcutaneous emphysema or fever. The average total operation time of conventional POEM was 51.22±25.63 min. The average myotomy time was 11.18±7.61 min. There were three cases(10%) of subcutaneous emphysema but recovered after two days without any special treatment. One patient who underwent conventional POEM had fever(the highest temperature was 37.6℃)and his temperature subsided to normal after physical cooling in one day. Postoperative Eckardt scores of patients were all less than 3. After postoperative follow-up of 3 to 12 months, no complications occurred in any patient. Conclusion Liu-POEM is a modified approach to treat achalasia, advantageous over conventional POEM in more simplified operation procedure, shorter operation time and less invasiveness. Key words: Esophageal achalasia; Modified peroral endoscopic myotomy; Comparative study

Comparative evaluation of early laparoscopic cholecystectomy for mild gallstone pancreatitis vs acute cholecystitis

Laparoscopic cholecystectomy (LC) during index admission for acute cholecystitis (AC) is now an established procedure, but timing for LC in gallstone-induced acute biliary pancreatitis (ABP) is still controversial. Interval cholecystectomy is justified in cases of severe pancreatitis, however, in patients with mild disease, which constitute the majority (80%) of the cases, patients can safely be operated during the index admission. The profile of patients with mild gallstone pancreatitis and AC appears to be similar, since both are complications of gallstone disease. The LC in both situations is equally challenging, due to risk of inflammation and adhesions. However, both conditions are likely to benefit from early LC, in terms of rapid recovery and shortened hospital stay. But no author has compared the outcome of LC in these two similar clinical entities in the past. Hence the present study compares the outcome of LC in case of mild ABP versus AC. This prospective study was conducted on 77 patients undergoing LC for AC with or without pancreatitis, during index admission. Cases were divided into two groups of mild ABP (n=25) and AC (n=52). Both groups were compared with respect to the clinical presentation, timing of cholecystectomy, operative findings, duration of surgery, difficulty in dissection, intra-operative or postoperative complications, duration of hospital stay and outcome at time of discharge. The majority of patients in both groups underwent successful LC. Both groups were comparable, with respect to demographic profile, mean duration of surgery, gallbladder adhesions (32% vs 29%), thickened edematous gallbladder (76% vs 71%), difficult dissection (32% vs 29%) and need of conversion to open procedure (16% vs 17%). Both groups were also comparable, with respect to intra-operative complications (8% vs 10%). Post operative recovery was prolonged in case of ABP, in comparison to AC, but was not significant statistically (p >0.05). Total post-operative complications were significantly more in ABP group (p <0.01). Post operative stay (mean days 2.76 vs 2.34), as well as total hospital stay (mean days 7.24 vs 5.15) was significantly prolonged in cases with ABP (p <0.05). LC can be safely performed during index admission in patients with mild ABP as can be done in cases of AC.

An Elevated HbA1c Level Is Associated With Short-Term Adverse Outcomes in Patients With Gastrointestinal Cancer and Type 2 Diabetes Mellitus.

BackgroundAlthough an elevated hemoglobin A1c (HbAc1) level is an independent predictor of worse survival in patients with both digestive cancer and diabetes mellitus, its relationship to short-term prognosis in these patients has not been addressed. This study assessed this relationship in gastrointestinal cancer (GIC) patients with type 2 diabetes mellitus (T2DM).MethodsA retrospective review of patients with GIC with or without T2DM from 2004 to 2014 was performed. Patients with T2DM were grouped according to HbA1c level, either normal (mean < 7.0%) or elevated (mean ≥ 7.0%). Age- and sex-matched GIC patients without T2DM served as controls.ResultsOne hundred and eighteen patients aged 33 - 81 years with T2DM met the study eligibility criteria; 51 were in the normal HbA1c group, and 67 were in the elevated HbA1c group. The 91 patients in the non-T2DM group were randomly selected and matched to the T2DM group in terms of admittance date, age, and sex. There was a trend toward a higher 180-day mortality rate in the T2DM group compared with the non-T2DM group (15.3% vs. 7.7%, P = 0.095) and in the elevated HbA1c group compared with the normal HbA1c group (19.4% vs. 9.8%, P = 0.151); however, the differences were not significant. The duration of the hospital stay was longer in patients with T2DM than in those without T2DM (13.2 vs. 8.9 days, P < 0.05) and in patients with elevated versus normal HbA1c levels (14.5 vs. 11.4 days, P < 0.05). Diabetic GIC patients with elevated HbA1c levels had significantly more total postoperative complications than those with normal HbA1c levels (25.4% vs. 9.8%, P < 0.05). In multivariate regression analyses, short-term adverse outcomes were strongly associated with elevated HbA1c levels (odds ratio (OR): 5.276; 95% confidence level (CI): 1.73 - 16.095; P < 0.05) and no strict antidiabetic treatment (OR: 7.65; 95% CI: 2.49 - 23.54; P < 0.001).ConclusionAn elevated level of HbA1c significantly correlated with and was an independent predictor of short-term adverse outcomes in GIC patients with T2DM.

P1.08-044 Comparison of Peri-Operative Outcomes after Robotic-Assisted Video-Thoracoscopic Lobectomies versus Segmentectomies

Lobectomy is the standard procedure for early stage lung cancer. The role of sub-lobar resection is currently under investigation. Published comparisons between VATS, R-VATS, and open lobectomy vs. segmentectomy have been reported. The goal of our study was to compare peri-operative outcomes after R-VATS lobectomy vs segmentectomy. Comparison between these two procedures using robotic instruments has not been published. We retrospectively analyzed prospectively collected data from 253 consecutive patients who underwent lobectomy (N=208) and segmentectomy (N=45) via R-VATS performed by one surgeon. Unpaired Student’s t-test and Chi-square test were used to determine statistical significance (p≤ 0.05) of intra- and post-operative outcomes between these 2 groups. View Large Image Figure ViewerDownload Hi-res image Download (PPT) No significant difference was found on intra-operative complications (18/208 vs. 4/43; p=0.70). However, the mean duration of R-VATS segmentectomy was longer than lobectomy(258min vs. 207.5min: p<0.01). Total post-operative complications didn't differ between the groups(24/43 vs. 84/208; p=0.071). Individual complications reviewed included cardiovascular, wound infections, and respiratory adverse outcomes. Only pneumothorax after chest tube removal (p=0.032) and effusion/empyema(p=0.011) requiring intervention were significant. R-VATS segmentectomy on average take longer and has more postoperative complications which can be explained by patients' underlying pulmonary disease. R-VATS segmentectomy may be considered as an alternative procedure to R-VATS lobectomy in order to conserve lung function.

腹腔镜胆总管探查一期缝合术2326例报告

目的：总结运用腹腔镜胆总管探查一期缝合术的治疗经验。方法：回顾性分析1992年6月至2017年6月，成都市第二人民医院运用腹腔镜胆总管探查一期缝合术对2326例病人进行治疗的经验及效果。结果：一期缝合的2326例病人中有2148例(92.3%)腹腔镜手术获成功，中转开腹获成功15例(0.6%)。术后胆汁漏94例(4.0%)，术后残石29例(1.2%)，1例胰腺癌术后15 d死亡(0.1%)，术后有其他并发症39例(1.7%)，总并发症发生率为7.0% (163/2326)。结论：从本研究对本医院有限病例进行初步研究发现，只要选择合适的病例，腹腔镜胆总管探查一期缝合术是可行、有效和安全的。 Objective: To summarize the experience on laparoscopic choledochotomy with primary suture. Methods: From June 1992 to June 2017 in the Second People,s Hospital of Chengdu, 2326 patients were received the primary closure of duct incision in laparoscopic common bile duct exploration. Results: It had obtained successful in 2148 (92.3%) out of 2326 patients, fifteen cases (0.6%) were shifted to open common bile duct exploration. Bile leakage occurred in 94 cases (4.0%). Residual stones were in 29 cases (1.2%). One patient (0.1%) of pancreatic carcinoma died in post-operation 15 days. Thirty-nine cases (1.7%) were other complications. Total postoperative complication formation rate is 7.0% (163/2326). Conclusion: From preliminary results of limited cases in this study in our hospital, if patients are suitable, laparoscopic choledochotomy with primary closure was a feasible, safe and effective method.

同期三镜、扩张导管、气囊鼻胆管治疗肝左外叶及胆总管结石26例

目的：探讨同期三镜(腹腔镜、胆管镜、十二指肠镜)、扩张导管(逐级扩张导管、球囊导管)、气囊鼻胆管(LCDND)治疗肝左外叶及胆总管结石的应用体会。方法：回顾性分析成都市第二人民医院2011年3月至2017年9月期间，符合入选标准的26例患者的临床资料。结果：腹腔镜下切除肝左外叶和探查胆总管胆管镜取石26例，切除胆囊15例。逐级导管扩张左肝管和乳头并留置气囊鼻胆管65.5% (17/26)，逐级导管扩张左肝管和推挤左肝管结石出总管切口并留置气囊鼻胆管11.5% (3/26)，逐级导管联合球囊导管扩张左肝管并留置气囊鼻胆管3.8% (1/26)，逐级导管扩张左肝管和乳头、十二指肠镜行乳头小切开或微切开并留置气囊鼻胆管11.5% (3/26)，逐级导管扩张左肝管后因肝内胆管残石并腹腔镜下留置T管7.7% (2/26)。鼻胆管引流术后无残石，胆汁漏2例(7.7%)，轻症胰腺炎1例(3.8%)。无肠穿孔、胆管穿孔、大出血、重症胰腺炎等并发症，无围手术期再次手术和死亡患者。术后总并发症发生率为11.5% (3/26)。结论：从本研究对本医院有限病例进行初步研究发现，只要病例选择合适，LCDND治疗肝左外叶及胆总管结石是可行、有效和安全的。 Objective: To explore the surgical technique and clinical effect of laparoscopy, choledochoscopy, duodenoscopy, dilatable catheter and balloon nasobiliary drainage (LCDND) of the corresponding period for the treatment of the left lateral lobe hepatic duct and common bile duct stones during the course of therapeutic laparoscopy. Methods: The clinical data of 26 cases of the left lateral lobe hepatic duct and common bile duct stones undergoing LCDND were analyzed retrospectively from March 2011 to September 2017 in the Second People’s Hospital of Chengdu. Results: It was in 26 cases removed the left hepatic lateral lobe and exploration of common bile duct and in 15 cases removed the gallbladder by laparoscopy. Through the duct incision with choledochoscopy to remove gallstones, step by step dilatable catheter expanded left hepatic duct and duodenal papilla and indwelling balloon nasobiliary was in 65.5% (17/26); push the stones into the common hepatic duct in 11.5% (3/26); step by step dilatable catheter combining balloon catheter expanded left hepatic duct and duodenal papilla and indwelling balloon nasobiliary was in and 3.8% (1/26); step by step dilatable catheter expanded left hepatic duct and duodenal papilla and duodenoscopic papillary sphincterotomy of micro incision or small incision, and indwelling balloon nasobiliary was in 11.5% (3/26); via choledochoscopic examination indwelling T shape tube drainage due to residual stone of the intrahepatic bile duct in 7.7% (2/26). Residual stone was not occurred after the nasobiliary drainage. Bile leakage was cured in two cases (7.7%). One patient (3.8%) was a slight pancreatitis. No cases had perforation of intestine and bile duct, bleeding, severe pancreatitis. No perioperative reoperation and death. Total postoperative complication formation rate was in 11.5% (3/26). Conclusion: From preliminary results of limited cases in this study in our hospital, if patients are suitable, LCDND for treatment of the left lateral lobe hepatic duct stones and common bile duct stones, it is safe and effective.

A meta-analysis of totally percutaneous access versus open femoral exposure for endovascular aortic aneurysm repair

Objective: This study was aim to compare the efficacy and safety of percutaneous access and open femoral exposure for endovascular aortic aneurysm repair. Methods: Eligible studies were searched from PubMed, Embase, and Corchrane databases published in English from January 1999 to December 2015. Data extracted from each study were synthesized into overall odds ratios (OR) for technical success rates and complications. The outcomes on technical success rates and complications of both totally percutaneous access and open femoral exposure group were compared. Results: After a systematic review of English language articles, ten studies including 1 504 patients were eligible for the Meta-analysis. The technical success rates of the percutaneous endovascular aortic aneurysm repair (PEVAR) group was 95.1%, close to that of femoral exposure (FE) group (97.5%). The difference did not show significantly (OR=0.57, 95% CI: 0.31-1.04, P>0.05). However, the incidence of total postoperative complications in PEVAR group was 8%, significantly lower than that in FE group (15.9%) (OR=0.52, 95% CI: 0.37-0.42, P<0.01). Conclusion: PEVAR is associated with a similar technical success rate and lower complication incidence rate comparing with FE. Therefore, it could be as a preferred approach of endovascular aortic aneurysm repair.

Impact of different sarcopenia stages on the postoperative outcomes after radical gastrectomy for gastric cancer

The association between sarcopenia and postoperative outcomes has been well reported. However, the impact of different sarcopenia stages on postoperative outcomes has never been investigated. We conducted a large, prospective study of patients who underwent radical gastrectomy for gastric cancer from August 2014 to December 2015. Sarcopenia was staged as "presarcopenia," "sarcopenia," and "severe sarcopenia" according to the definition of the European Working Group on Sarcopenia in Older People. Univariate and multivariate analyses evaluating the risk factors for total, surgical, and medical complications were performed. A total of 470 patients were included, in which 20.6%, 10%, and 6.8% of the patients were identified as having "presarcopenia," "sarcopenia," and "severe sarcopenia," respectively. Postoperative complications, duration of hospital stays, and costs increased with advancing sarcopenia stages. Severe sarcopenia, visceral fat area to total abdominal muscle area ratio, American Society of Anesthesiologists grade III, and tumor located at the cardia were independent risk factors for total complications. Visceral fat area to total abdominal muscle area ratio and tumor located at the cardia were independent risk factors for operative complications. Presarcopenia, sarcopenia, and severe sarcopenia were all identified as independent risk factors for medical complications, as well as age ≥75years and Charlson Comorbidity Index. Patients had worse postoperative outcomes after gastric cancer operation with advancing sarcopenia stages. Severe sarcopenia, but not presarcopenia or sarcopenia, was an independent risk factor for total postoperative complications. The 3 sarcopenia stages independently influence medical but not surgical complications. Recognizing sarcopenia stages is important for preoperative risk stratification.

Cryoablation versus Partial Nephrectomy for Clinical T1b Renal Tumors: A Matched Group Comparative Analysis

BackgroundThe traditional treatment for a cT1b renal tumor has been radical nephrectomy. However, recent guidelines have shifted towards partial nephrectomy (PN) in selected patients with cT1b renal tumors. Furthermore, practitioners have extended the role of cryoablation (CA) to treat cT1b tumors in selected patients. ObjectiveTo evaluate the efficacy of CA compared to PN for cT1b renal tumors. Design, setting, and participantsWe performed a retrospective review of patients who underwent either renal CA (laparoscopic or percutaneous) or PN (robot-assisted) for a cT1b renal mass (>4cm and ≤7cm) between November 1999 and August 2014. To reduce the inherent biases of a retrospective study, CA and PN groups were matched on the basis of key variables: tumor size, Charlson comorbidity index (CCI), age, body mass index (BMI), American Society of Anesthesiologists (ASA) score, preoperative serum creatinine, preoperative estimated glomerular filtration rate (eGFR), gender, and solitary kidney. The matching algorithm was 1:1 genetic matching with no replacement. Outcome measurements and statistical analysisSurvival analysis was performed only for patients diagnosed with renal cell carcinoma according to histopathologic evaluation of a tumor biopsy or resected tumor specimen. Recurrence-free, overall, and cancer-specific survival were analyzed using Kaplan-Meier survival curves. Survival outcomes were compared between groups using the log-rank test. Results and limitationsA total of 31 patients were treated using CA and 161 using PN during the study period. After matching, there was no significant difference between the PN and CA groups for tumor size (4.6 vs 4.3cm; p=0.076), CCI (6 vs 6; p=0.3), RENAL score (9 vs 8; p=0.1), age (68 vs 68 yr; p=0.9), BMI (30 vs 31kg/m2; p=0.2), ASA score (3 vs 3; p=0.3), preoperative creatinine (1.2 vs 1.4mg/dl; p=0.2), preoperative eGFR (63 vs 53ml/min/1.73 m2; p=0.2), and proportion of patients with a solitary kidney (19% vs 32%; p=0.4). The total postoperative complication rate was higher for PN than for CA (42% vs 23%; p=0.10). There was no significant difference in percentage eGFR preservation between PN and CA (89% vs 93%; p=0.5). The rate of local recurrence was significantly higher for CA than for PN (p=0.019). There was no significant difference in cancer-specific mortality (p=0.5) or overall mortality (p=0.15) between the CA and PN groups. ConclusionsPatients treated with CA for cT1b renal tumors had a significantly higher rate of local cancer recurrence at 1 yr compared to those treated with PN. Until further studies are performed to clearly define the role of CA in cT1b renal tumors, CA should be reserved for patients with imperative indications for nephron-sparing surgery who cannot be subjected to the risks of more invasive PN. Patient summaryWe evaluated the efficacy of renal cryoablation compared to partial nephrectomy for clinical T1b renal tumors. The cryoablation and partial nephrectomy groups were matched to provide a better comparison. We concluded that renal cryoablation had a higher rate of local cancer recurrence.

Outcomes of pancreaticoduodenectomy in elderly patients

Although the mortality and morbidity of pancreaticoduodenectomy (PD) have improved significantly over the past years, the concerns for elderly patients undergoing PD are still present. Furthermore, the frequency of PD is increasing because of the increasing proportion of elderly patients and the increasing incidence of periampullary tumors. This study aimed to analyze the outcomes of PD in elderly patients. We studied all patients who had undergone PD in our center between January 1995 and February 2015. The patients were divided into three groups based on age: group I (patients aged <60 years), group II (those aged 60 to 69 years) and group III (those aged ≥70 years). The primary outcome was the rate of total postoperative complications. Secondary endpoint included total operative time, hospital mortality, length of postoperative hospital stay, delayed gastric emptying, re-exploration, and survival rate. A total of 828 patients who had undergone PD for resection of periampullary tumor were included in this study. There were 579 (69.9%) patients in group I, 201 (24.3%) in group II, and 48 (5.8%) in group III. The overall incidence of complications was higher in elderly patients (25.9% in group I, 36.8% in group II, and 37.5% in group III; P=0.006). There were more patients complicated with delayed gastric emptying in group II compared with the other two groups. There was no significant difference in the incidence of postoperative pancreatic fistula, biliary leakage, pancreatitis, pulmonary complications and hospital mortality. PD can be performed safely in selected elderly patients. Advanced age alone should not be a contraindication for PD. The outcome of elderly patients who have undergone PD is similar to that of younger patients, and the increased rate of complications is due to the presence of associated comorbidities.