Gentamicin submucosal lavage during peroral endoscopic myotomy (POEM): a retrospective analysis

Gentamycin irrigation significantly reduces 28-day surgical site infection after emergency neurosurgery

OBJECTIVE

This study aims to evaluate the effectiveness of gentamycin irrigation in preventing postoperative surgical site infection (SSI) in emergency neurosurgical procedures.

METHODS

A total of 518 consecutive emergency neurosurgeries, including craniotomies, endoscopic and burr hole procedures were reviewed retrospectively. Patients received either only normal saline (NS) irrigation or NS irrigation with gentamycin added (80 mg/L) during the whole process of surgery. SSIs including wound infection and intracranial infection were the primary outcome. SSI was considered while purulence was observed during wound dressing and confirmed with bacterial culture of wound exudation. In addition, positive result of bacterial growth culture of cerebrospinal fluid was also considered as infection. Infection rates were calculated 28 days after surgery. Statistical analysis was performed using t test or Chi-squared test where appropriate.

RESULTS

This study included 444 patients. Gentamycin was used in 179 (40.3%) patients. Only 2 (1.1%) of 179 patients receiving gentamycin irrigation had an infection. However, among the other 265 patients receiving only NS irrigation, the infection rate was 8.3%. With the addition of gentamycin, the infection rate was decreased by 86.7% (P = 0.001). The two infected patients in gentamycin group were compromised postoperatively: one patient had removed his own extraventricular drainage tube accidentally due to restlessness, and the other had severely contaminated his wound with vomitus during the intracranial drainage tube removal process. If these two patients were excluded from analysis, the effective infection rate using gentamycin irrigation is 0%.

CONCLUSION

The gentamycin plus NS irrigation during emergency neurosurgical procedures can lead to a significantly lower rate of postoperative infection than when NS is used alone.

Impact of antibiotic prophylaxis and conditioning modalities in per-oral endoscopic myotomy for esophageal motor disorders

BACKGROUND AND AIMS

No recommendation regarding antibiotic prophylaxis and preparation modalities are available for patients with esophageal motor disorders who benefit from Per-Oral Endoscopic Myotomy (POEM). The aim of our study was to evaluate their impact on the POEM's safety.

PATIENTS AND METHODS

This study was a comparative and multicentric retrospective analysis of a database prospectively collected. Patients over 18 years old with esophageal motor disorders confirmed by prior manometry, who underwent POEM were included. The primary endpoint was the occurrence of adverse events, as classified by Cotton, based on whether or not antibiotic prophylaxis was administered.

RESULTS

A total of 226 patients (median age 52.9 ± 19.12 years [18-105], 116 women [51.3%]) were included. The indication for POEM was mainly type 2 achalasia (n = 135, 60.3%). Antibiotic prophylaxis was administered to 170 patients (75.2%) during 3.93 ± 3.46 days [1-21]. The overall adverse events rate was 9.3% (n = 21). Antibiotic prophylaxis was associated with the occurrence of adverse events (p = .003), but had no impact on their severity (p = .238). Antibiotic prophylaxis didn't influence the effectiveness of POEM (1 [0-4] vs 1 [0-9], p = .231). The use of a liquid diet in the 48 h prior to the procedure was significantly associated with a lower adverse events rate (3.1% vs 6.19%, p = .0002).

CONCLUSION

The antibiotic prophylaxis during POEM does not prevent adverse events, had no impact on their severity and the efficacy of the procedure. A liquid diet before the procedure should be systematically proposed.

Peroral Endoscopic Myotomy for Achalasia

BACKGROUND

Peroral endoscopic myotomy (POEM) utilizes the principles of natural orifice transluminal surgery to create an operative tunnel within the submucosal space, perform an endoluminal esophagogastromyotomy, and ultimately mitigate the progressive symptoms of achalasia. POEM is an innovative minimally invasive technique increasing in popularity and clinical significance as an effective treatment for achalasia and other disorders of spastic esophageal motility.

METHODS

A comprehensive literature review was performed regarding the procedure, outcomes, and technical advancements in POEM.

RESULTS

A growing number of studies world-wide have shown that POEM is a safe and effective for all types of achalasia, sigmoid and non-sigmoid type.

CONCLUSIONS

POEM continues to gain traction as a highly effective therapeutic modality for achalasia. As natural orifice transluminal surgery advances, further research is necessary to optimize utilization of endoluminal functional imaging, to tailor endoscopic technique, and to address the adverse effect of post-operative reflux and esophagitis.

Clinical Outcomes, Trends in Weight, and Weight Loss Strategies in Patients With Obesity After Durable Ventricular Assist Device Implantation

PURPOSE OF REVIEW

To discuss clinical outcomes, changes in weight, and weight loss strategies of patients with obesity post left ventricular assist device (LVAD) implantation.

RECENT FINDINGS

Despite increased complications in patients with obesity after LVAD implantation, survival is comparable to patients without obesity. A minority of patients with obesity lose significant weight and become eligible for heart transplantation after LVAD implantation. In fact, a great majority of such patients gain weight post-implantation. Obesity by itself should not be considered prohibitive for LVAD therapy but, rather, should be incorporated into the overall risk assessment for LVAD implantation. Concerted strategies should be developed to promote sustainable weight loss in patients with obesity and LVAD to improve quality of life, eligibility, and outcomes after heart transplantation. Investigation of the long-term impact of weight loss on patients with obesity with LVAD is warranted.

Adverse events during and after per-oral endoscopic myotomy: prevention, diagnosis, and management

Per-oral endoscopic myotomy (POEM) has surfaced as an effective endoscopic treatment modality for achalasia cardia (AC). Promising results in short- and mid-term follow-up studies have increased the use of POEM for the management of AC. POEM can be safely performed in an endoscopy suit, and major adverse events (AEs) are uncommon. AEs encountered during POEM or during the perioperative period principally include insufflation-related AEs, mucosal injuries, bleeding, pain, and aspiration pneumonia. Most insufflation-related AEs do not require an active intervention and therefore should not be considered as AEs in the true sense. When management of AEs is required, most intraoperative AEs can be managed at the same time without untoward consequences. Occurrences of AEs lessen after completion of the learning curve. However, experience alone does not ensure "zero" incidence of AEs, and early recognition remains essential. Postoperative AEs, like leaks, delayed bleeding, and delayed mucosal perforations, may pose special challenges for diagnosis and management. There is no standardized classification system for grading the severity of AEs associated with POEM, resulting in wide variation in their reported occurrences. Uniform reporting of AEs is not only crucial to comprehensively analyze the safety of POEM but also for comparison with other established treatment modalities like Heller's myotomy. GERD is an important long-term AE after POEM. Unlike the perioperative AEs, little is known regarding the intraoperative or patient-related factors that influence the occurrence of post-POEM GERD. Large prospective studies with long-term follow-up are required to determine the procedural factors associated with GERD after POEM.