Reducing Cesarean Delivery Surgical Site Complications

Cesarean delivery (CD) wound complications disrupt the time a mother spends with her newborn. Surgical site infections (SSI) may result in unplanned office visits, emergency room visits, and hospital readmissions. Despite increasing attention to preoperative preparation, the CD SSI rate remains high. Local practices must be evaluated, and new methods to reduce CD SSI must be used.

Complications in cardiac surgery: An analysis of factors contributing to sternal dehiscence in patients who underwent surgery between 2010 and 2014 and a comparison with the 1990-2009 cohort

BACKGROUND

Sternal dehiscence is a serious postoperative complication of cardiac surgery observed in 0.2-5% of procedures performed by median sternotomy.

OBJECTIVES

Assessment of factors, including the method of sternum closure, which may affect the incidence of this complication.

MATERIAL AND METHODS

A total of 5,152 consecutive patients undergoing surgery with median sternotomy access in the Cardiac Surgery Department of the Pomeranian Medical University between 2010 and 2014 were included in the study. The analysis centered on cases of sternal dehiscence, which occurred in 45 patients (0.9%).

RESULTS

Factors such as age (p < 0.05), body mass (p < 0.005) and coronary artery bypass surgery (CABG) (p < 0.005) were found to be significant risk factors. Diabetes and chronic obstructive pulmonary disease (COPD) also had an impact on an increased risk of sternal dehiscence (p < 0.006 and p < 0.015). However, the differences were only significant in the whole study group. Apart from CABG, the type of operation did not affect the incidence of dehiscence. Logistic regression analysis found independent risk factors for the development of sternal dehiscence: body mass index (BMI) (odds ratio (OR): 2.1; p < 0.019), diabetes (OR: 2.4; p < 0.004), COPD (OR: 2.7; p < 0.016), and redo procedure (OR: 3.0; p < 0.014). There were no significant differences in postoperative mortality between these groups - 6.7% in the group with sternal dehiscence and 3.9% in the group without dehiscence.

CONCLUSIONS

Introducing a more durable sternum stabilization method with 8+ loops helped to improve conditions for bone union and reduced the risk of dehiscence. Therefore, we suggest that centers which still use 6-loop sternal closure should consider shifting to a stronger technique.

Prophylactic, Synthetic Intraperitoneal Mesh Versus No Mesh Implantation in Patients with Fascial Dehiscence

BACKGROUND

Primary closure of post-operative facial dehiscence (FD) is associated with a high incidence of recurrence, revisional surgery, and incisional hernia. This retrospective study compares outcomes of implantation of non-absorbable intra-abdominal meshes with primary closure of FD. The outcomes of different mesh materials were assessed in subgroup analysis.

METHODS

A total of 119 consecutive patients with FD were operated (70 mesh group and 49 no mesh group) between 2001 and 2015. Primary outcome parameter was hernia-free survival. Secondary outcome parameters include re-operations of the abdominal wall, intestinal fistula, surgical site infections (SSI), and mortality. Kaplan-Meier analysis for hernia-free survival, adjusted Poisson regression analysis for re-operations and adjusted regression analysis for chronic SSI was performed.

RESULTS

Hernia-free survival was significantly higher in the mesh group compared to the no mesh group (P = 0.005). Fewer re-operations were necessary in the mesh group compared to the no mesh group (adjusted incidence risk ratio 0.44, 95% confidence interval [CI] 0.20-0.93, P = 0.032). No difference in SSI, intestinal fistula, and mortality was observed between groups. Chronic SSI was observed in 7 (10%) patients in the mesh group (n = 3 [6.7%] with polypropylene mesh and 4 [28.6%] with polyester mesh). The risk for chronic SSI was significantly higher if a polyester mesh was used when compared to a polypropylene mesh (adjusted odds ratio 8.69, 95% CI 1.30-58.05, P = 0.026).

CONCLUSION

Implantation of a polypropylene but not polyester-based mesh in patients with FD decreases incisional hernia with a low rate of mesh-related morbidity.

Poststernotomy wound management by debridement and pedicle flaps reconstruction

BACKGROUND

Sternal wound infection and sternal dehiscence are very serious, sometimes life-threatening complications of cardiac surgery, which require immediate attention. The mortality rate can reach 50%. During the past 30 years,various flaps for coverage of sternal wounds have been described.

OBJECTIVE

The authors objective was to evaluate their 7-year experience with flaps used for coverage of poststernotomy wounds, with an emphasis on flap selection and post repair complications.

RESULTS

The records of 15 patients were reviewed. The most common coverage techniques were pectoralis major flap (n=5)and rectus abdominis flap (n=4). Four patients had both of these flaps. One patient had a latissimus dorsi flap, and another one had an omental flap. Eight of the 15 patients experienced a local complication; these included seroma(n=2), hematoma (n = 1), infection requiring debridement and antibiotics (n = 2), partial flap necrosis (n = 2) and abdominal hernia (n=1). The perioperative mortality rate was 13.3% (n = 2), and all deaths were attributable to multiple organ deficiency due to sepsis.

CONCLUSIONS

Early debridement and coverage of the remained defects with flaps are the two main principles in the management of poststernotomy infected wounds, especially insituations where rapid wound healing and recovery are extremely important. Individual approach to each patient and proper selection of the method of reconstruction significantly reduces the postoperative morbidity and mortality rate.

Post-operative peritonitis due to anastomotic dehiscence after colonic resection. Multicentric experience, retrospective analysis of risk factors and review of the literature

INTRODUCTION

Intraperitoneal sepsis due to anastomotic leakage significantly affects the outcomes of intestinal surgery. The aim of this retrospective review is to examine retrospectively general and local factors involved in anastomotic leakage and their prognostic value.

MATERIALS AND METHODS

Between April 1998 and April 2008, 367 patients underwent elective (217=59%) or emergency (150=41%) primary colonic resection for benignan (77=21%) or malignant (290=79%) disease in our department. We performed the following operations; 124 right colon resections with immediate anastomoses (primary resection), 65 (52.4%) of which were emergency and 59 (47.6%) elective procedures; 171 left colon resections, 73 (42.7%) of which were emergency and 98 (57.3%) elective procedures, and 72 primary rectal resections, 12 (16.7%) of which were emergency and 60 (83.3%) elective procedures. The considered variables were stapled or manual anastomoses, protective stomas and medical comorbidities.

RESULTS

The perioperative mortality rate was 6.6% for emergency and 3.6% for elective procedures. The leak rate was 8.7% (32/367), 13.3% for emergency and 5.5% for elective procedures. Fistula was observed in 7/124 (5.6%) ileocolic, 13/171 (7.6%) colo-colic and 12/72 (16.6%) colo-rectal anastomoses, 8 of which were fashioned during emergency surgery. Twenty-one patients with anastomotic dehiscence were treated conservatively (3 underwent reoperation), while 11, with severe dehiscence, in all cases in the left colon, underwent an emergency Hartmann's procedure, with a perioperative mortality rate of 35.7%.

CONCLUSIONS

In our experience, the site of colonic anastomosis represents the risk factor most strictly related to the anastomotic leak rate, while other technical factors seem weakly associated with leakage. A significantly high percentage of patients (65.6%) with anastomotic fistulas have medical comorbidities.

The bridge stent technique for salvage of pancreaticojejunal anastomotic dehiscence

OBJECTIVES

Although infrequent, Grade C postoperative pancreatic fistulae (POPF) following pancreaticoduodenectomy (PD) are morbid and potentially lethal. Traditional management of a disrupted pancreaticojejunostomy (PJ) anastomosis consists of either wide external drainage or completion pancreatectomy. The aim of this study is to describe an alternative management approach to PJ dehiscence after PD.

METHODS

A bridge stent technique is employed in the setting of a disrupted PJ anastomosis. Upon re-exploration, a 5-Fr or 8-Fr silastic feeding tube stent is placed across a gap between the jejunal enterotomy and the pancreatic duct, and secured with an absorbable suture at both ends. Depending upon the degree of local inflammation, this may be externalized by coursing the stent downstream through the pancreaticobiliary drainage limb in a Witzel fashion.

RESULTS

Over 8 years and 357 PDs with duct-to-mucosa PJ reconstruction, seven ISGPF (International Study Group on Pancreatic Fistula) Grade C fistulae occurred (2%). Two patients ultimately died secondary to POPF (neither anastomosis was dehisced). The described technique was used in the other five patients, all of whom had evidence of a dehisced PJ anastomosis. All originally had at least two or three recognized risk factors for POPF development (high-risk pathology, soft gland, duct diameter ≤ 3 mm, estimated blood loss ≥ 1000 ml). All patients survived this complication and were discharged from hospital. There have been no longterm external fistulae, nor any recognized PJ strictures or remnant atrophy (median follow-up: 10.7 months).

CONCLUSIONS

In the context of a dehisced pancreaticojejunal anastomosis, the bridge stent technique is a safe and effective method of management that contributes to diminished mortality and helps to salvage pancreatic function.

Impact of anastomotic leakage on long-term survival after total gastrectomy for carcinoma of the stomach

BACKGROUND

Recent studies suggest that anastomotic leak may adversely affect long-term survival in patients undergoing surgery for gastrointestinal malignancies. Data relating to total gastrectomy for gastric cancer are scarce.

METHODS

An electronic database of all patients with resectable gastric cancer treated between January 1999 and December 2004 at seven university surgical centres cooperating in the Polish Gastric Cancer Study Group was reviewed.

RESULTS

Anastomotic leakage was diagnosed in 41 (5.9 per cent) of 690 patients who underwent total gastrectomy. The prevalence of surgical and general complications, and mortality rates were significantly higher in patients diagnosed with anastomotic leakage. The only two independent risk factors for leakage were Eastern Cooperative Oncology Group performance status of 2 or 3 (odds ratio 5.09, 95 per cent confidence interval (c.i.) 2.29 to 11.32) and splenectomy (odds ratio 2.58, 95 per cent c.i. 1.08 to 6.13). Two Cox proportional hazards models including all the patients and excluding in-hospital deaths identified anastomotic leakage as an independent predictor of survival with hazard ratios of 3.47 (95 per cent c.i. 1.82 to 6.64) and 3.14 (1.51-6.53) respectively.

CONCLUSION

The occurrence of anastomotic leakage was a major independent prognostic factor for long-term survival.

[Isoperistaltic endoluminal drainage (IED) in the surgical treatment of upper digestive tract dehiscence]

Dehiscence of upper gastrointestinal sutures still remains a severe clinical problem and often requires complex surgical repair. Despite its multifactorial aetiopathogenesis, endoluminal pressure seems to play an important role in the onset and maintenance of this complication. The efficacy of isoperistaltic endoluminal drainage (IED) in the operative treatment or prevention of upper gastrointestinal surgical dehiscence was assessed in a retrospective study. The IED procedure is obtained by means of a two-way nasogastric tube inserted in the proximal jejunum through the abdominal and advanced to the site of the leak in order to achieve low endovisceral pressure, normal intestinal free flow downstream of the lesion and monitoring of the healing process. Over the past decade 31 patients (mean age 62 years; 52.9% male) with postoperative dehiscences of the thoraco-abdominal oesophagus, stomach or duodenum underwent reintervention. During the surgical repair an IED was inserted in 17, while no IED was inserted in 14 (NOIED): the two groups were well matched for age, gender, primary pathology, site and type of leak. The overall operative mortality (30 days) was 16% (12.5% IED vs. 20% NOIED), and morbidity was 45% (37.5% IED vs. 53.3% NOIED). The rate of leak relapse was significantly different: 6% IED vs. 20% NOIED. In the last 5 years the IED procedure has also been used preventively with promising outcomes in another 16 other high-risk upper gastrointestinal suture patients. The results of this retrospective study appear to support the use of the IED procedure to minimize the risk of failure of the suture/anastomosis in upper gastrointestinal surgery. Other studies are needed to validate the efficacy of this supplementation of surgical treatment.

[Postoperative complete abdominal dehiscence: risk factors and clinical correlations]

The purpose of this study is to review our clinical experience with abdominal wound dehiscence in the Surgical Department of City Hospital Timisoara.

PATIENTS AND METHODS

19.116 abdominal procedures were performed between January 1992 - March 2009 in our Department and 29 complete dehiscences were identified (0,15%). Significant risk factors in our analysis were intraabdominal infection, wound infection, emergency surgery, malignancies, digestive fistulae, hiperabdominal pressure, sex and age over 65 years. Less significant factors were the abdominal type of incision, the method of wound closure and heart or respiratory diseases.

CONCLUSIONS

postoperative complete dehiscence is a constant presence in a surgical department; despite its low frequency, wound dehiscence is associate with a hight mortality and morbidity rate, and increase the costs and hospitalisation periode. Risk factors evaluation and their associations represente an important role in the therapeutic management of the surgical patient.

[Laparoscopic Roux-en-Y gastric bypass surgery for morbid obesity. Experience at the Nacional de Ciencias Médicas y Nutrición Salvador Zubirán]

INTRODUCTION

Morbid obesity is a serious health problem associated to a significant reduction in life expectancy.

OBJECTIVE

To evaluate the anthropometric and metabolic changes observed in obese patients, 3, 6 and 12 months after laparoscopic Roux-en-Y gastric bypass surgery and the complications associated with the procedure.

MATERIAL AND METHODS

Retrospective study that included 128 consecutive obese patients submitted for bariatric surgery at the INCMNSZ (2004-2006).

RESULTS

Their mean age was 38 +/- 10 years, 83% were women with a BMI of 48 +/- 6 Kg/m2. 65% were hypertensives, 55% had hypertriglyceridemia and 34% diabetes. A year after surgery all patients had at least reduced 20% their body weight and the percentage of excess body weight loss was 73%. The prevalence of hypertension, hypertrigliceridemia and diabetes was reduced to 24%, 17% and 12%, respectively (p < 0.001). Four patients died (3%), all of them had a leak of the anastomosis and intra-abdominal abscess. One died because pulmonary embolism, another with a myocardial infarction (after surgical reinterventions) and the other two with sepsis.

CONCLUSIONS

Laparoscopic Roux-en-Y gastric bypass surgery in morbid obese patients favors significant reductions in body weight and associated co morbidities. This surgery is not free of complications and mortality, reason why it must be done only by surgical and interdisciplinary groups with experience in these procedures.

[Esophago-digestive anastomosis dehiscence]

This paper aim is to discuss the main etiopathogenic aspects responsible for eso-digestive anastomotic leakage, as well as prophylactic and therapeutic measures of this postoperative complication. There were studied 173 consecutive eso-digestive anastomosis: 103 anastomosis performed for malignancy and 70 anastomosis for benign conditions. Surgical operations followed by an eso-digestive anastomosis were: esophageal reconstruction for benign esophageal caustic strictures (n=67); total gastrectomy (n=55); total esophagectomy (n=13); total esophagectomy plus total gastrectomy (one case); eso-gastrectomies (n=34); upper gastric pole resection (n=2); distal esophageal resection (n=1). Eso-digestive anastomosis topography were cervical (n=81), intrathoracic (n=37) and abdominal (n=57). There were 30 eso-gastrostomies, 81 eso-jejunostomies, and 62 eso-colostomies. There were recorded 24 eso-digestive anastomotic dehiscences (13.8%): 14 in the cervical region (17.2% out of 81 cervical anastomosis); 5 intrathoracic leakages (14.2% out of 35 anastomosis); 5 intraabdominal anastomotic dehiscences (8.7% out of 57 intraabdominal anastomosis). Four patients died as an anastomotic leakage consequence: two patients died after cervical eso-gastrostomy dehiscences, one patient died after an intrathoracic eso-jejunostomy leakage, and one patient died after intraabdominal eso-gastrostomy leakage. In conclusion, we analyze postoperative results, emphasizing the role of discovering and removal of predisposing factors which may lead to an eso-digestive anastomotic leakage.

Anastomotic leakage as a risk factor for the long-term outcome after curative resection of colon cancer

AIMS

Long-term outcome for curative colon cancer surgery may be impaired by anastomotic leakage, but most studies regard colon and rectal cancer patients as one group. The aim of this study was to determine whether anastomotic leakage following potentially curative resection for colon cancer is a risk factor for postoperative mortality and for long-term survival.

PATIENTS AND METHODS

Medical records of a cohort of 440 consecutive patients undergoing 445 curative resections for explicit colon cancer with primary anastomosis above the peritoneal reflection were reviewed. Therefore patients with rectal cancer were not included. Diagnosis of leakage was made by clinical features or abdominal CT-scans.

RESULTS

The study population consisted of 266 men and the mean age was 68.6 years. Median follow-up time was 66.5 months. Anastomotic leakage occurred in 12 patients. Four of these died within 30 days after surgery compared to 15 of the remaining 428 patients without leakage (p<0.001). The 5-year overall survival rate was 25% in patients with anastomotic leakage compared to 61.2% in those without leakage (p<0.001). Excluding 30-day mortality, respective values were 33.3 and 63.7% (p=0.02).

CONCLUSION

Although anastomotic failure after colon cancer surgery is rare, it is a very severe complication that not only impairs the perioperative morbidity and mortality but also significantly influences the long-term outcome negatively.

[Diagnosis and treatment of the bile diverting anastomosis sutures insufficiency]

The results of complex diagnosis and treatment of 64 patients, in whom bilediverting anastomoses sutures insufficiency (BDASI) had occurred, were analyzed. It was established, that dynamical ultrasonographic investigation and laparoscopy constitute the principal methods of BDASI early diagnosis. In 25 patients conservative methods of treatment were used effectively, in 34--relaparotomy was performed and in 5--videolaparoscopic interventions. Eighteen patients died.

Risk factors and oncologic impact of anastomotic leakage after rectal cancer surgery

PURPOSE

The impact of anastomotic leakage on the long-term oncologic outcome is not clear. This retrospective study evaluated risk factors and oncologic impacts of anastomotic leakage after rectal cancer surgery.

METHODS

Data were analyzed from 1,391 patients who underwent sphincter preservation for rectal cancer between January 1997 and August 2003. Operations were classified as anterior resection (n = 164), low anterior resection (n = 898), or ultralow anterior resection (n = 329).

RESULTS

The anastomotic leakage rate was 2.5 percent. Multivariate analysis identified male (hazard ratio, 3.03), old age (hazard ratio, 2.42), and lower anastomosis level (hazard ratio, 2.68) as risk factors for leakage. The local recurrence rates were 9.6 and 2.2 percent for the leakage and nonleakage groups, respectively but were not significant (P = 0.14). The overall five-year survival rates were 55.1 and 74.1 percent in the leakage and nonleakage groups, respectively (P < 0.05), and the cancer-specific survival rates were 63 and 78.3 percent in the leakage and nonleakage groups, respectively (P = 0.05). However, in subgroup analysis, significant differences were identified only in Stage III patients.

CONCLUSIONS

Age, sex, and ultralow anterior resection were found to be risk factors for anastomotic leakage after rectal cancer surgery. In addition, leakage was associated with poor survival.

216 cases of pancreaticoduodenectomy: risk factors for postoperative complications

BACKGROUND/AIMS

Surgical resection remains the best treatment for patients with periampullary tumors. Many series have been reported with low or zero mortality, however, high incidence of complications is the rule. This study aims to present the results of pancreaticoduodenectomy and factors predisposing to postoperative complications, especially pancreatic leak, at our center.

METHODOLOGY

Between January 2000 and December 2006, 216 periampullary tumors were treated by Whipple pancreaticoduodenectomy. Pancreaticogastrostomy was done in 183 patients and pancreaticojejunostomy in 33 patients. Hospital mortality and surgical complications were recorded with special emphasis on pancreatic leak. All specimens were histologically examined for the presence and origin of malignant tissue.

RESULTS

The mean age was 58 years and male to female ratio was 2:1. The commonest symptom was jaundice (97.7%) followed by abdominal pain (74%). Operative mortality in 7 patients (3.2%). 71 (33%) patients developed 1 or more complications, pancreatic leak occurred in 23 (10.6%) patients, abdominal collection in 23 patients (10.6%) and delayed gastric emptying in 19 (8.8%) patients. Factors that influenced the development of postoperative complications included type of pancreaticoenteric anastomosis, pancreatic texture and intraoperative blood transfusion of 4 or more blood units. Pancreatic leak was commoner with PJ (p=0.001), soft pancreatic texture (p=0.008), intraoperative blood transfusion of 4 or more units (p<0.0001). Periampullary adenocarcinoma was found in 204 (94.4%) patients, chronic pancreatitis in 9 (4.2%) patients, 2 patients with solid and papillary neoplasm, and 1 patient with NHL (Non-Hodgkin's Lymphoma).

CONCLUSIONS

Surgery is the only hope for patients with periampullary tumors. Postoperative complications after pancreaticoduodenectomy depend largely on surgical technique and can be reduced reasonably with the adoption of pancreaticogastrostomy, which is safer and easier to learn than pancreaticojejunostomy.

Impact of anastomotic leakage on oncological outcome after rectal cancer resection

BACKGROUND

: Anastomotic leakage has a major impact on morbidity and mortality in rectal cancer surgery. Its relevance to oncological outcome is controversial. This observational study investigated the influence of anastomotic leakage on oncological outcome.

METHODS

: Data for 1741 patients undergoing curative resection of rectal cancer (located less than 12 cm from the anal verge) with normal healing were compared with those for 303 patients who experienced anastomotic leakage. Morbidity, mortality and long-term oncological outcomes were analysed.

RESULTS

: Median follow-up was 40 months. Patients with anastomotic leakage had a higher postoperative mortality rate than those with no leakage (4.3 versus 1.2 per cent; P < 0.001). Patients with leakage necessitating surgical treatment had a higher 5-year local recurrence rate (17.5 versus 10.1 per cent; P = 0.006) and a lower 5-year disease-free survival rate (70.9 versus 75.4 per cent; P = 0.020) than those without leakage. Patients with anastomotic leakage not requiring surgical intervention did not have a worse oncological outcome.

CONCLUSION

: A negative prognostic impact of anastomotic leakage on local recurrence and disease-free survival was found only for patients with leakage needing surgical revision.

Die Wertigkeit der Spülbehandlung bei der Peritonitis

The treatment of severe diffuse peritonitis is still associated with a mortality of up to 50 %. Particularly the postoperative peritonitis shows high mortality rates due to septic organ failures. The aim of surgical treatment is the definitive source control followed by removal of fibrin and abdominal lavage of contaminants and infectious fluids. Dependent on the severity of the peritoneal reaction, further treatment consists of primary abdominal closure and relaparotomy on demand, programmed lavage or laparostomy respectively. Septic complications have to be treated by intensive care medicine.

Pancreatic fistula after pancreaticoduodenectomy: the impact of a standardized technique of pancreaticojejunostomy

BACKGROUND

The leading cause for morbidity and mortality after pancreaticoduodenectomy is a pancreatic anastomotic leak and fistula. The two most commonly performed anastomoses after pancreaticoduodenectomy are pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ). The role of standardization on outcomes after pancreaticoduodenectomy has not been sufficiently addressed.

AIM

The goal is to study the impact of a standardized technique of pancreatic anastomosis (PJ) after pancreaticoduodenectomy in a tertiary referral cancer teaching hospital.

MATERIALS AND METHODS

A single-institution database was analyzed over 15 years. The entire data were subdivided into two periods, viz., period A (1992 to 2001), when PG (dunking) was predominantly used, and period B (2003-2007), when a standardized technique of PJ (duct to mucosa) was employed.

RESULTS

There were 144 pancreaticoduodenectomies performed during period A with a pancreatic fistula rate of 16%. During period B, 123 pancreaticoduodenectomies were performed with a pancreatic fistula rate of 3.2% (p < 0.0005).

CONCLUSIONS

It appears that a standardized approach to the pancreatic anastomosis and a consistent practice of a single technique can help to reduce the incidence of complications after pancreaticoduodenectomy.

Anastomotic leakage is associated with poor long-term outcome in patients after curative colorectal resection for malignancy

The impact of anastomotic leakage on long-term outcomes after curative surgery for colorectal cancer has not been well documented. This study aimed to investigate the effect of anastomotic leakage on survival and tumor recurrence in patients who underwent curative resection for colorectal cancer. Prospectively collected data of the 1,580 patients (904 men) of a median age of 70 years (range: 24-94), who underwent potentially curative resection for colorectal cancer between 1996 and 2004, were reviewed. Cancer-specific survival and disease recurrence were analyzed using Kaplan Meier method, and variables were compared with log rank test. Cox regression model was used in multivariate analysis. The cancer was situated in the colon and the rectum in 933 and 647 patients, respectively. Anastomotic leakage occurred in 60 patients (clinical leakage: n = 48; radiological leak: n = 12). The leakage rate was significantly higher in patients with surgery for rectal cancer (6.3 vs 2.0%, p < 0.001). The 5-year cancer-specific survivals were 56.9% in those with leakage and 75.9% in those without leakage (p = 0.012). The 5-year systemic recurrence rates were 48.4 and 22.6% in patients with and without anastomotic leak, respectively (p = 0.001), whereas the 5-year local recurrence rates were 12.9 and 5.7%, respectively (p = 0.009). Anastomotic leakage remained an independent factor associated with a worse cancer-specific survival (p = 0.043, hazard ratio: 1.63, 95% CI: 1.02-2.60) and a higher systemic recurrence rate (hazard ratio: 1.94, 95% CI: 1.23-3.06, p = 0.004) on multivariate analysis. In rectal cancer, anastomotic leakage was an independent factor for a higher local recurrence rate (hazard ratio: 2.55, 95% CI: 1.07-6.06, p = 0.034). In conclusion, anastomotic leakage is associated with a poor survival and a higher tumor recurrence rate after curative resection of colorectal cancer. Efforts should be undertaken to avoid this complication to improve the long-term outcome.

[Tracheobronchial ruptures: classification and management]

BACKGROUND

Tracheobronchial ruptures are rare surgical emergencies with significant mortality. We present management and outcome of such ruptures treated at the University of Leipzig in Germany and propose a novel therapeutic algorithm-a new classification system for stratifying treatment of patients with tracheobronchial ruptures.

METHODS

We retrospectively studied 24 patients 19 to 88 years old who were treated in our institution for tracheobronchial injury.

RESULTS

Eighty-seven percent of the injuries were caused iatrogenically. Fifty-four percent were type I injuries (isolated tracheal lesions), 38% type II (involvement of carina or main stem bronchi), and 8% type III (distal lesions of lobar or segmental bronchi). Seventy-five percent of the patients were operated via right-sided dorsolateral thoracotomy. In four (22%), insufficiency of the tracheal closure occurred, with mediastinitis possibly being a significant risk factor for this event (P<0.001). In surgically treated patients, rupture-related and overall mortality were 5.5% and 28%, respectively, whereas in medically treated patients, mortality was 33%.

CONCLUSION

The proposed classification of tracheobronchial injuries enables stratifying the treatment of patients with tracheobronchial ruptures. Type I lesions can be surgically closed either by a right-sided thoracotomy or transcervical-transtracheal approach. In contrast, surgical management of type II and III injuries always requires thoracotomy.

Offene Kolonchirurgie

Open resection of the colon is one of the most frequent abdominal operations, which clearly indicates the great importance of colon carcinomas. The surgical aim is resection of the affected intestinal region and the according lymph drainage region. In this respect, the techniques employed are strictly standardized: right hemicolectomy for right colon carcinoma, transverse resection for right colon carcinoma, left hemicolectomy for descendent colon carcinoma, and sigmoid resection for sigmoid carcinoma. In case of benign underlying disease, the operational method depends largely on the extent to which the intestine is affected and can include anything from simple colotomy and polyp removal to colectomy for toxic megacolon. Elective colon surgery is usually primary, but in emergencies a protective stoma might be necessary. Standardized indication and operational techniques enable low perioperative mortality and complication rates that make open colon resection usually un-problematic even in very old patients.

Intrathoracic leaks following esophagectomy are no longer associated with increased mortality

OBJECTIVES

Assess outcomes following intrathoracic leaks after esophagectomy from 1970 to 2004 to evaluate the impact of evolving surgical and perioperative techniques on leak-associated mortality (LAM).

SUMMARY BACKGROUND DATA

An intrathoracic leak following esophagectomy has historically been considered a catastrophic event, with mortality as high as 71%. Concerns about this complication often affect choice of surgical approach for esophagectomy.

METHODS

A retrospective review of all esophagectomies for cancer from 1970 to 2004 (n = 1223) was performed. Outcomes following intrathoracic anastomoses (n = 621) were analyzed by era: historical 1970-1986 (n = 145) and modern 1987-2004 (n = 476).

RESULTS

There was no difference in the frequency of leak between the time intervals (4.8% versus 6.3%, P = 0.5). Despite a significant increase in the use of preoperative chemoradiation (1% versus 42%, P < 0.001) in the historical versus modern era, the overall mortality decreased from 11% to 2.5% (P < 0.001). The LAM was markedly reduced from 43% to 3.3% (P = 0.016). Factors associated with LAM included failure to use enteral nutrition (HR 13.22, CI 1.8-96.8) and era in which the surgery was performed (HR 18.3, 1.9-180). Other differences included an increased proportion of successful reoperations for leak control (11/30 versus 0/7, P = 0.08) and use of reinforcing muscle flaps (7/11). In the modern era, perioperative mortality is not significantly different for patients with or without intrathoracic leaks (3.3% versus 2.5%, P = 0.55), nor is long-term survival (P = 0.16).

CONCLUSIONS

Modern surgical management of intrathoracic leaks results in no increased mortality and has no impact on long-term survival. Clinical decisions regarding the use of intrathoracic anastomoses should not be affected by concerns of increased mortality from leak.

Impact of anastomotic leakage on long-term survival of patients undergoing curative resection for colorectal cancer

Background

The impact of anastomotic leakage on immediate postoperative mortality in patients undergoing potentially curative resection for colorectal cancer is well recognized. Its impact on long-term survival is less clear. The aim of the present study was to evaluate the relationship between anastomotic leakage and long-term survival in patients undergoing potentially curative resection for colorectal cancer.

Methods

A total of 2235 patients who underwent potentially curative resection for colorectal cancer between 1991 and 1994 in Scotland were included in the study. Five-year survival rates and adjusted hazard ratios were calculated.

Results

Fourteen (16 per cent) of the 86 patients with an anastomotic leak died within 30 days of surgery compared with 83 (3·9 per cent) of 2149 without a leak. The 5-year cancer-specific survival rate, including postoperative deaths, was 42 per cent in patients with an anastomotic leak compared with 66·9 per cent in those with no leak (P &lt; 0·001). Excluding postoperative deaths, respective values were 50 and 68·0 per cent (P &lt; 0·001). The adjusted relative hazard ratios, for patients with an anastomotic leak compared with those without a leak, and excluding 30-day mortality, were 1·61 (95 per cent confidence interval (c.i.) 1·19 to 2·16; P = 0·002) for overall survival and 1·99 (95 per cent c.i. 1·42 to 2·79; P &lt; 0·001) for cancer-specific survival.

Conclusion

Development of an anastomotic leak is associated with worse long-term survival after potentially curative resection for colorectal cancer.

Short-term deployment of self-expanding metallic stents facilitates healing of bronchial dehiscence

Bronchial dehiscence after lung transplantation is difficult to treat and associated with high mortality. We describe our experience using self-expanding metallic stents to treat post-lung transplant bronchial dehiscence. From January 1995 to June 2004, 189 single and 118 double lung transplants were performed in our institution, totaling 425 at-risk bronchial anastomoses. Seven (1.6%) incidents of life-threatening bronchial dehiscence were treated with self-expanding metallic stents. The interval between transplant and diagnosis of dehiscence was 29.1 +/- 18.5 days. All patients presented with respiratory distress, and three required mechanical ventilation. Self-expanding metallic stent placement resulted in complete bronchial healing. All three patients with respiratory failure requiring mechanical ventilation were successfully weaned after stent placement. In two later cases, the stents were electively removed after adequate healing of the dehiscence. Complications included stent migration (one patient) and in-stent stenosis (three patients). Two of these patients required repeat stent insertion after removal, due to bronchomalacia. In patients with life-threatening bronchial dehiscence, self-expanding metallic stents offer prospects for a successful outcome. Self-expanding metallic stents are known to be associated with significant granulation tissue formation, and this property provides a platform for healing of dehiscence and, in time, peribronchial soft tissue grows in to cover the defect, allowing stent removal.

Anastomotic leakage post-esophagogastrectomy for esophageal carcinoma: retrospective analysis of predictive factors, management and influence on longterm survival in a high volume centre

OBJECTIVE

Anastomotic leak post-gastro-esophagectomy for esophageal carcinoma remains an important issue in immediate as well as late morbidity and mortality. Several predictive factors such as patient and technical variables have been suggested with inconsistent findings. Our aim was to compare these factors and the results of treatment of anastomotic dehiscence on short and longterm survival in our center to published data.

METHODS

A retrospective study of 276 consecutive patients post-Ivor-Lewis gastro-esophagogastrectomy for esophageal carcinoma between 1992 and 1999. Explanatory variables taken into account for predicting anastomotic leak included preoperative weight loss, neoadjuvant therapy, inkwelling of the anastomosis, gastric drainage procedure and involvement of longitudinal resection margins. Incidence variation over time was compared. 5-year survival was assessed using the Kaplan-Meier method.

RESULTS

The anastomotic leak rate was 5.1% with only minor variation over time. The 30-day mortality with anastomotic leak was 35.7% compared to 4.2% for patients without leak (P<0.05). None of the suggested explanatory variables analyzed reached statistical significance at a 5% level. On multiple logistic regression there was a trend towards gastric outlet drainage procedure which might decrease the relative risk by 61% (P=0.099). After excluding the 30-day mortality the 5-year survival with anastomotic leak was not different to those without.

CONCLUSIONS

None of the factors reported in the literature reached statistical significance in our series. High institutional and high surgeon volume seem to outweigh any other contributing factor. Aggressive management for substantial leaks is advocated by the authors as long term palliation does not seem to be affected once the leak has been successfully treated.

Anastomotic leakage is predictive of diminished survival after potentially curative resection for colorectal cancer

OBJECTIVE

The aim of this study was to determine whether anastomotic leakage has an independent association with overall survival and cancer-specific survival.

SUMMARY BACKGROUND DATA

There are many known prognostic indicators following surgery for colorectal cancer (CRC). However, the impact of anastomotic leakage has not been adequately assessed.

METHODS

Consecutive patients undergoing resection between 1971 and 1999 were recorded prospectively in the Concord Hospital CRC database. Total anastomotic leakage was defined as any leak, whether local, general, or radiologically diagnosed. Patients were followed until death or to December 31, 2002. The association between anastomotic leakage and both overall survival and cancer-specific survival was examined by proportional hazards regression with adjustment for other patient and tumor characteristics influencing survival. Confidence intervals (CI) were set at the 95% level.

RESULTS

From an initial 2980 patients, 1722 remained after exclusions. The total leak rate was 5.1% (CI 4.1-6.2%). In patients with a leak, the 5-year overall survival rate was 44.3% (CI 33.5-54.6%) compared to 64.0% (CI 61.5-66.3%) in those without leak. In proportional hazards regression-after adjustment for age, gender, urgent resection, site, size, stage, grade, venous invasion, apical node metastasis and serosal surface involvement-anastomotic leakage had an independent negative association with overall survival (hazard ratio [HR] 1.6, CI 1.2-2.0) and cancer-specific survival (HR 1.8, CI 1.2-2.6).

CONCLUSION

Apart from its immediate clinical consequences, anastomotic leakage also has an independent negative association with survival.

Prospective study of routine contrast radiology after total gastrectomy

BACKGROUND

The practice of routine contrast radiology before recommencing oral nutrition after total gastrectomy is not evidence based. The aim of this prospective study was to evaluate the clinical role and timing of this investigation.

METHODS

Seventy-six consecutive patients underwent total gastrectomy with a stapled oesophagojejunal anastomosis. A contrast swallow using non-ionic contrast and barium was performed routinely 5 and 9 days after surgery. The surgeon was blinded to the result of the first of these examinations. Patients with clinical evidence of a leak underwent contrast radiology and upper gastrointestinal videoendoscopy.

RESULTS

Eight patients (11 per cent) developed a clinical leak from the oesophagojejunal anastomosis, seven before the first scheduled contrast swallow. Contrast radiology identified a leak in four of six patients. Endoscopy detected a leak in both patients with a false-negative swallow and in two patients who were not fit to undergo contrast radiology. Routine contrast radiology identified a subclinical leak in a further five patients (7 per cent), none of whom developed clinical signs. Four of seven in-hospital deaths were associated with an anastomotic leak.

CONCLUSION

There is no role for routine contrast swallow after total gastrectomy with a stapled oesophagojejunal anastomosis, but patients with clinical suspicion of leakage should undergo urgent contrast radiology, plus endoscopy if the contrast examination is normal.

Randomized clinical trial of morbidity after D1 and D3 surgery for gastric cancer

BACKGROUND

A randomized comparison of D1 (level 1 lymphadenectomy) and D3 (levels 1, 2 and 3 lymphadenectomy) dissection was performed to evaluate morbidity and effects on survival from gastric cancer.

METHODS

A total of 221 patients were studied after resection for gastric cancer, 110 after D1 surgery and 111 after D3 surgery.

RESULTS

The morbidity rate was higher after D3 than after D1 resection (17.1 (95 per cent confidence interval (c.i.) 10.1 to 24.1) versus 7.3 (95 per cent c.i. 2.4 to 12.2) per cent respectively; P = 0.012). The difference was largely related to abdominal abscess (8.1 per cent after D3 versus none after D1 resection; P = 0.003). The D3 group had an anastomotic leak rate of 4.5 per cent whereas there was no leakage in the D1 group (P = 0.060). All anastomotic leaks were minor and were managed non-operatively with nutritional support. Patients who had D3 resection had longer operating times, greater blood loss and postoperative drain outputs, and more patients needed blood transfusion. There was no death in either group. The hospital stay was longer after D3 than D1 surgery (mean(s.d.) 19.6(13.9) (range 10-98) versus 15.0(4.0) (range 10-30) days; P = 0.001).

CONCLUSION

Extended lymphadenectomy for gastric cancer is associated with more complications than limited lymphadectomy but this does not lead to significant mortality.

[Technique of pancreatic anastomosis]

Postoperative morbidity after pancreatic resection is primarily due to leakage of the pancreatic anastomosis. The duct-to-mucosa pancreatico-jejunostomy either as an end-to-end or end-to-side anastomosis is the preferred technique in our hands. The use of a temporarily catheter to drain the main pancreatic duct is optimal. The pancreatic leakage rate depends in many series on the consistence of the pancreatic parenchyma, the diameter of the major pancreatic duct and the local perfusion. A meticulous, standardized technique, the possibility to adapt the technique in case of unexpected findings and the operative routine of the surgeon are of paramount importance for achieving a low leakage rate. In so called "high volume" centers the pancreatic fistula rate today is in the range of 3 to 13% and the mortality of pancreatic head resection varies between 0.5 and 3%.

Experience with over 3,000 open and laparoscopic bariatric procedures: multivariate analysis of factors related to leak and resultant mortality

BACKGROUND

Intestinal leak is a potentially lethal complication of Roux en-Y gastric bypass (GBP). Identification of patients at high risk for leak may reduce complication rates of surgeons early in the procedure learning curve.

METHODS

A total of 3073 patients who underwent GBP were analyzed using univariate and multivariate logistic regression analyses of the following preoperative factors: hypertension (HTN), diabetes mellitus (DM), sleep apnea (SA), age, gender, weight, body mass index (BMI), and surgery type. Multivariate logistic regression analysis was performed for each procedure type.

RESULTS

There were 48 (1.5%) deaths. Independent risk factors for death included leak, weight, procedure type, and HTN. A total of 102 (3.2%) leaks were found. Independent factors for leak included age, male gender, SA, and procedure type.

CONCLUSION

The data suggests that older, heavier male patients with multiple comorbid conditions are at increased risk for leak and mortality. Surgeons early in their learning curve should avoid these high-risk patients to reduce complications.

Management of postoperative hemorrhage after pancreatoduodenectomy

BACKGROUND/AIMS

Hemorrhage after pancreatoduodenectomy is a severe, life-threatening complication. This study was conducted to determine the guidelines appropriate for the prevention and management of hemorrhagic complications.

METHODOLOGY

We reviewed the medical records of 456 patients who had undergone pancreatoduodenectomy at our hospital between 1991 and 2000.

RESULTS

Significant postoperative bleeding occurred in 21 patients (4.6%). Early bleeding (within the 5th postoperative day) caused by improper intraoperative hemostasis occurred in 5 of these cases; 3 of whom were saved by prompt operation and one by conservative management. The other 16 cases consisted of late bleeding (after the 5th postoperative day), of which 12 patients (75%) experienced pancreatic leaks and 8 pseudoaneurysms of major arteries. "Sentinel bleeding" was evident in 8 cases. Angiographic embolization was performed in 8 cases, 7 of which were successful. Reoperation was tried in 7 cases with complete hemostasis being achieved in 2. As a result, 15 of 21 patients obtained complete hemostasis and the mortality rate from hemorrhage was 28.6% (6/21).

CONCLUSIONS

Rapid decision-making is mandatory when bleeding stigmata such as pseudoaneurysm on CT and sentinel bleeding are noted. Prompt operation for early bleeding and angiographic embolization for late bleeding are recommended. In order to prevent hemorrhage after pancreatoduodenectomy, meticulously performed hemostasis and the avoidance of pancreatic anastomotic leaks are essential.

Long-term outcome of anastomosis leakage after curative resection for mid and low rectal cancer

BACKGROUND/AIMS

The aim of this study was to evaluate the relationship of the disease recurrence and prognosis of rectal cancer with anastomosis leakage after curative low anterior resection.

METHODOLOGY

The records of 566 patients with primary rectal adenocarcinoma in the Veterans General Hospital-Taipei, Taiwan between 1991 and 1997 were reviewed. Patients who did not have anastomosis (abdominoperineal resection 72, Hartmann's operation 15), did not have curative resection (62) or expired within 30 days after operation (11) were excluded from the study. Another 34 patients were excluded because they did not visit our clinic or could not be reached by telephone or questionnaire after operation. 372 patients who received restorative curative resection with a colorectal anastomosis were analyzed. The product-limit method (Kaplan-Meier) and Cox proportional hazard model were used to analyze survival rate and tumor recurrence.

RESULTS

Twenty-five out of the 406 patients had anastomosis leakage after the operation. The 5-year disease-free, local recurrence-free survival of the leakage group (32.5%, 58.7%) was significantly lower than that of the non-leakage group (71%, 88.3%). The multivariate analysis showed TNM staging (p = 0.0001) and histological differentiation (p = 0.0002) were associated with overall tumor recurrence. The factors affected local tumor recurrence were TNM staging (p = 0.006) and anastomosis leakage (p = 0.014).

CONCLUSIONS

These results suggested that anastomotic leakage after curative rectal surgery is associated with the local tumor recurrence-free survival rate even after adjusting for stage.

Implications of anastomotic leakage after total gastrectomy for gastric carcinoma

BACKGROUND/OBJECTIVES

Oesophagojejunal anastomotic leakage is a serious complication following total gastrectomy, and is reported to be decreasing in frequency. This study was an audit of the radiological and clinical frequency of such leakage and its consequences.

METHODS

A retrospective (1983-2000) cohort study was undertaken in a tertiary institution where 175 patients had undergone a total gastrectomy for gastric carcinoma with oesophagojejunal reconstruction using a stapling device and a 50 cm J-loop. Anastomotic leakage was sought 3-9 days postoperatively using a Gastrograffin (diatrizoate meglumine) swallow.

RESULTS

Leakage was demonstrated in 7 patients (4%), being subclinical in 2, minor in 4, and fatal in 1. There was no correlation between leakage and patient factors (age, medical risk, haemoglobin, albumin), surgical factors (surgical seniority, approach, reconstruction, splenectomy, lymph node dissection) or tumour factors (stage, nodes examined, and margin positivity). However, intraoperative difficulties or mishaps were recorded in most cases of leakage. Subclinical leakage was marked by an uneventful postoperative course, and low-volume enterocutaneous fistulas were self-limiting. One patient developed a subphrenic abscess that required drainage. One patient suffered an intrathoracic leak which proved fatal.

CONCLUSIONS

Anastomotic leakage was an infrequent complication of total gastrectomy when using a stapling device and a 50 cm J-loop. It was related to intraoperative surgical difficulty and mishap rather than conventional patient and tumour factors. It was subclinical or self-limiting, if occurring in the abdomen, but fatal if in the chest.

Experimental study using PTFE (Goretex) patches for replacement of the oesophageal wall

BACKGROUND

The purpose of this study was to evaluate tolerance and integration of expanded polytetrafluoroethylene patches used to replace loss of a fragment of the complete oesophageal wall in rats of the Wistar strain.

METHODS

The experiment was performed on 10 Wistar rats. Those surviving the experiment were killed 7-28 days after surgery.

RESULTS

None of these animals showed signs of peritonitis. The patch was not visible macroscopically. After examination under the microscope, we observed that the material had undergone phagocytosis by macrophages, and there was scar tissue covering the epithelium.

CONCLUSION

It is possible to successfully suture a polytetrafluoroethylene patch to the oesophageal wall in Wistar rats as a prosthetic replacement of a wall fragment.

Risk factors influencing the outcome after surgical treatment of complicated deep sternal wound complications

BACKGROUND

Median sternotomy is the most frequently used incision for cardiac procedures but carries a substantial risk for deep sternal wound infections and/or sternal dehiscence. In contrast to previous studies that examined risk factors for sternal infections this study evaluates factors that lead to poor outcome after surgical revision of the non healing sternum.

METHODS

Between 1985 and 1999, 193 adults (mean age 64 +/- 9 years, m/f = 3/1) necessitated sternal revisions (incidence 1.93%). Pre-, intra- and post-operative risk factors were evaluated for their influence on the outcome after sternal revision.

RESULTS

65 of the 193 patients had a complicated course: ten (5.2%) died due to sepsis/multi organ failure (n = 6) or cardiac causes (n = 4). 32 patients (16.6%) needed several revisions, 17 (9%) were discharged with sternal instability, 5 (3%) with chronic fistula and one with persistent osteomyelitis. Univariate and multivariate analysis identified cardiopulmonary resuscitation (odds ratio (OR) = 11.188, p = 0.010), corticoid treatment (OR = 7.043, p = 0.0055), diabetes (OR = 4.130, p = 0.0128), smoking history (OR = 2.996, p = 0.0041), renal insufficiency (hazard ratio (HR) = 1.884), old age (OR = 1.108, p = 0.0266), high body mass (HR = 1.06), ECC time (p = 0.023), cross clamp time (p = 0.028), systemic hypothermia (p = 0.016), non-use of IMA (p = 0.042) or prolonged ventilation as risk factors for mortality or poor outcome. No correlation between sternal closure technique, mediastinal irrigation or antibiotic therapy and outcome after mediastinal revision could be found.

CONCLUSIONS

To avoid disappointing results after sternal revision one should aim to preoperatively identify high-risk patients and aggressively address risk factors. This rather than modifications of the surgical and medical approach might improve the outcome of patients with mediastinal complications.

A modified bronchial anastomosis technique for lung transplantation

BACKGROUND

Low rates of major complications have been reported for the intussuscepting bronchial anastomotic technique but stenosis, malacia, and granulation tissue at the anastomosis may cause clinically important morbidity. We hypothesized that a modification of the telescoping technique that improves bronchial wall apposition might be associated with improved bronchial healing and clinical outcomes.

METHODS

The telescoping horizontal mattress "U-stitch" suture technique was modified to incorporate figure-of-eight sutures placed in the cartilaginous wall between each of three intussuscepting U stitches. Serial videotape records of 152 individual anastomoses (99 modified, 53 telescoped) in 118 consecutive operative survivors were retrospectively reviewed by examiners blinded with respect to technique used. Stenosis, airway instability, mucosa quality, and devascularized luminal tissue were graded at 4 to 14 days (initial), 4 to 12 weeks (early), and 6 to 12 months (late) after transplantation.

RESULTS

The incidence of anastomotic stenosis was significantly lower using the modified technique at the initial (p = 0.025) and late (p = 0.015) observations. In the initial phase airway instability (p = 0.015) and devascularization grades (p = 0.001) were also significant lower in the modified group. There were no significant differences in mucosal condition between techniques. The modified telescoping technique was associated with significant survival advantage (mean 17.7%; p = 0.029) by multivariate analysis. The incidence of major airway complications (dehiscences and stenoses required stents) tended to be lower (3% versus 6%) in the modified group.

CONCLUSIONS

The modified telescoping bronchial anastomosis technique is associated with improved early and late bronchial healing and higher 5-year survival without increased major airway complications.

Risk factors influencing the outcome after surgical treatment of complicated deep sternal wound complications

BACKGROUND

Median sternotomy is the most frequently used incision for cardiac procedures but carries a substantial risk for deep sternal wound infections and/or sternal dehiscence. In contrast to previous studies that examined risk factors for sternal infections this study evaluates factors that lead to poor outcome after surgical revision of the non healing sternum.

METHODS

Between 1985 and 1999, 193 adults (mean age 64 +/- 9 years, m/f = 3/1) necessitated sternal revisions (incidence 1.93%). Pre-, intra- and post-operative risk factors were evaluated for their influence on the outcome after sternal revision.

RESULTS

65 of the 193 patients had a complicated course: ten (5.2%) died due to sepsis/multi organ failure (n = 6) or cardiac causes (n = 4). 32 patients (16.6%) needed several revisions, 17 (9%) were discharged with sternal instability, 5 (3%) with chronic fistula and one with persistent osteomyelitis. Univariate and multivariate analysis identified cardiopulmonary resuscitation (odds ratio (OR) = 11.188, p = 0.010), corticoid treatment (OR = 7.043, p = 0.0055), diabetes (OR = 4.130, p = 0.0128), smoking history (OR = 2.996, p = 0.0041), renal insufficiency (hazard ratio (HR) = 1.884), old age (OR = 1.108, p = 0.0266), high body mass (HR = 1.06), ECC time (p = 0.023), cross clamp time (p = 0.028), systemic hypothermia (p = 0.016), non-use of IMA (p = 0.042) or prolonged ventilation as risk factors for mortality or poor outcome. No correlation between sternal closure technique, mediastinal irrigation or antibiotic therapy and outcome after mediastinal revision could be found.

CONCLUSIONS

To avoid disappointing results after sternal revision one should aim to preoperatively identify high-risk patients and aggressively address risk factors. This rather than modifications of the surgical and medical approach might improve the outcome of patients with mediastinal complications.

Morbidity and mortality associated with pancreatogastrostomy and pancreatojejunostomy following partial pancreatoduodenectomy

BACKGROUND

The pancreatic anastomosis is still the Achilles heel in partial pancreatoduodenectomy (PPD).

METHODS

This study describes retrospectively a series of 441 patients who underwent standard or extended PPD and reconstruction by either pancreatogastrostomy or pancreatojejunostomy over a period of 13 years (1988-2000).

RESULTS

Reconstruction of the pancreatic remnant was achieved by pancreatogastrostomy in 250 patients (56.7 per cent) and by pancreatojejunostomy in 191 patients (43.3 per cent). The leakage rate of the pancreatic anastomosis was 2.8 per cent after pancreatogastrostomy versus 12.6 per cent after pancreatojejunostomy (P < 0.001), whereas other surgical complications (bile leakage, haemorrhage, pancreatitis) were identical in the two groups. The leakage rate after standard PPD with or without vascular reconstruction was 2.0 per cent (four of 205 patients) after pancreatogastrostomy and 11.5 per cent (18 of 156) after pancreatojejunostomy (P < 0.001); following extended PPD it was 6.7 per cent (three of 45) after pancreatogastrostomy and 17.1 per cent (six of 35) after pancreatojejunostomy. The mortality rate due to leakage was 1.6 per cent (four of 250 patients) after pancreatogastrostomy versus 5.2 per cent (ten of 191) after pancreatojejunostomy (P = 0.037).

CONCLUSION

Pancreatogastrostomy is a safe and reliable method of reconstruction after PPD that may be associated with a lower leakage and mortality rate than pancreatojejunostomy.

Risk factors influencing pancreatic leakage and the mortality after pancreaticoduodenectomy in a medium-volume hospital

BACKGROUND/AIMS

This study was designed to evaluate risk factors influencing pancreatic leakage and pancreatic leakage-related mortality in a medium-volume hospital.

METHODOLOGY

We retrospectively reviewed the clinical records of 107 patients who underwent pancreaticoduodenectomy at the Kobe University Hospital. Fourteen predictive factors for pancreatic leakage and the pancreatic leakage-related mortality were evaluated using univariate and multivariate logistic regression models.

RESULTS

In univariate analysis, the degree of pancreatic fibrosis, type of resection (PD/PPPD), anastomosis techniques (invagination or duct-to-mucosa anastomosis), anastomosis sites (jejunum/stomach), and the presence of congestion in anastomosis sites significantly influenced pancreatic leakage, and the degree of pancreatic fibrosis influenced pancreatic leakage-related mortality. Multivariate logistic regression analysis revealed that congestion in anastomosis sites was the strongest parameter for pancreatic leakage. Univariate analysis of the patients with normal/mild fibrosing pancreas revealed that pancreatic leakage was influenced by type of resection, anastomosis techniques, anastomosis sites, congestion in anastomosis sites and the management of pancreas parenchyma.

CONCLUSIONS

In a medium-volume hospital, reconstruction after pancreaticoduodenectomy should be performed with careful attention to pancreas and anastomosis sites. In the patients with normal/mild fibrosing pancreas, duct-to-mucosa anastomosis without suturing the pancreas parenchyma may be a useful technique for reconstruction.

[Anastomotic insufficiencies of the esophagus--early surgical endoscopy and endoscopic therapy]

Therapeutic value of flexible endoscopy regarding treatment of esophagoenteric anastomotic leakage was retrospectively analyzed in 56 patients (female n = 13, male n = 43, age 60 years, 1/1992-4/2000). Endoscopic treatment was performed in 44 patients (self-expanding metal stent n = 38, fibrin glue n = 16, feeding tube/decompression tube n = 20, endoscopic percutaneous jejunostomy n = 8), interventional radiological technique in 4 patients and surgical treatment in 11 patients. All patients with open surgical reintervention developed reinsufficiency of the anastomosis. Successful endoscopic therapy was achieved in 75% with a mortality of 21.4%. Endoscopic treatment of esophageal anastomotic insufficiency is an effective alternative to conventional re-thoracotomy. The appropriate endoscopic intervention needs to be decided individually depending on diagnosis and location.

Interventional bronchoscopy for the management of airway complications following lung transplantation

STUDY OBJECTIVES

To assess the efficacy and complications of different interventional bronchoscopic techniques used to treat airway complications after lung transplantation.

DESIGN

Retrospective study.

SETTING

Heart-lung transplant unit of a university hospital.

PATIENTS

From November 1986 to January 2000, interventional bronchoscopy was performed in 41 of 312 lung transplant recipients (13.1%) for tracheobronchial stenosis, bronchomalacia, granuloma formation, and dehiscence.

INTERVENTIONS

Dilatation, stent placement, laser or forceps excision.

MEASUREMENTS AND RESULTS

Mean (+/- SE) improvement in FEV(1) in 26 patients undergoing dilatation for a stenotic or a combined lesion was 93 +/- 334 mL or 8 +/- 21%. In seven of these patients not proceeding to stent placement, mean improvement in FEV(1) was 361 +/- 179 mL or 21 +/- 9%. Patients needing stent placement after dilatation had a mean change in FEV(1) after dilatation of - 5 +/- 325 mL or 3 +/- 23%, and an improvement of 625 +/- 480 mL or 52 +/- 43% after stent insertion. Mean improvement in FEV(1) for patients treated with stent insertion for bronchomalacia was 673 +/- 30 mL or 81 +/- 24%. Complications of airway stents were migration (27%), mucous plugging (27%), granuloma formation (36%), stent fracture (3%), and formation of a false passage (6%). Mortality associated with interventional bronchoscopy was 2.4% (1 of 41 patients). For patients with airway complications successfully undergoing interventional bronchoscopy, the overall 1-year, 3-year, and 5-year survival rates were 79%, 45%, and 32%, respectively, vs 87%, 69%, and 56% for those without airway complications (p < 0.05).

CONCLUSION

Only a small number of patients with airway stenosis after lung transplantation will respond to bronchial dilatation alone. Patients with airway complications after lung transplantation have a higher mortality than patients without airway complications.

Early enteral feeding versus "nil by mouth" after gastrointestinal surgery: systematic review and meta-analysis of controlled trials

OBJECTIVE

To determine whether a period of starvation (nil by mouth) after gastrointestinal surgery is beneficial in terms of specific outcomes.

DESIGN

Systematic review and meta-analysis of randomised controlled trials comparing any type of enteral feeding started within 24 hours after surgery with nil by mouth management in elective gastrointestinal surgery. Three electronic databases (PubMed, Embase, and the Cochrane controlled trials register) were searched, reference lists checked, and letters requesting details of unpublished trials and data sent to pharmaceutical companies and authors of previous trials.

MAIN OUTCOME MEASURES

Anastomotic dehiscence, infection of any type, wound infection, pneumonia, intra-abdominal abscess, length of hospital stay, and mortality.

RESULTS

Eleven studies with 837 patients met the inclusion criteria. In six studies patients in the intervention group were fed directly into the small bowel and in five studies patients were fed orally. Early feeding reduced the risk of any type of infection (relative risk 0.72, 95% confidence interval 0.54 to 0.98, P=0.036) and the mean length of stay in hospital (number of days reduced by 0.84, 0.36 to 1.33, P=0.001). Risk reductions were also seen for anastomotic dehiscence (0.53, 0.26 to 1.08, P=0.080), wound infection, pneumonia, intra-abdominal abscess, and mortality, but these failed to reach significance (P>0.10). The risk of vomiting was increased among patients fed early (1.27, 1.01 to 1.61, P=0.046).

CONCLUSIONS

There seems to be no clear advantage to keeping patients nil by mouth after elective gastrointestinal resection. Early feeding may be of benefit. An adequately powered trial is required to confirm or refute the benefits seen in small trials.

[Staged resection in rectal carcinoma]

INTRODUCTION

The objectives of surgical treatment of rectal cancer are radical tumor excision, low morbidity and adequate functional outcome. The technique of total mesorectal excision (TME) has reduced the rate of local recurrences and led to an increase of ultra-low colorectal and coloanal anastomoses, which have a higher risk for anastomotic leakage.

METHODS

Advantages, disadvantages and consequences of staged resection for rectal cancer are discussed on the basis of international literature and our own results.

RESULTS

There are few stringent criteria for the use of diverting stomas. The decision for staged resection is often influenced by the personal experience of the surgeon.

CONCLUSIONS

The occurrence of anastomotic leaks cannot be prevented by diverting ostomies, but the usually irreversible consequences regarding survival and functional outcome can be minimized.

[Spontaneous perforation of the large intestine. Resection with primary anastomosis or staged (Hartmann) procedure?]

Whereas primary resection to remove the septic focus stands undisputed in the therapy of spontaneous perforation of the colon, there is still no consensus as to whether to perform a primary anastomosis or a staged procedure (Hartmann). Prospective randomized studies comparing both concepts are lacking. Obviously these two competing therapies fit different groups of patients whose diseases differ concerning etiology, localisation and severity. Analysis of the literature of the past few years defined some criteria that help to decide when to omit primary anastomosis: MPI > 20, APACHE II score > 15, preoperative organ insufficiency, Hinchey grade III or IV and ASA score IV. In these cases a discontinuity resection is recommended. Primary resection with anastomosis and Hartmann procedure are not competing operations but situation-dependent therapeutic concepts in spontaneous colonic perforation.

Complete dehiscence of the abdominal wound and incriminating factors

OBJECTIVE

To find out the causes of abdominal wound dehiscence.

DESIGN

Retrospective study.

SETTING

University hospital, Greece.

SUBJECTS

Abdominal wound dehiscence occurred in 89 cases out of 19,206 major abdominal operations including 4671 emergencies during the past 15 years (0.5%).

INTERVENTIONS

In the study group 14 local and systemic risk factors were analysed and compared with those in a control group of 89 patients who had similar procedures without dehiscence.

MAIN OUTCOME MEASURES

Statistical analysis using the chi square test.

RESULTS

Significant factors (p < 0.05) included age over 65 years, emergency operation, cancer, haemodynamic instability, intra-abdominal sepsis, wound infection, hypoalbuminaemia, ascites, obesity, and steroids. Risk factors that were not significant included sex, anaemia, diabetes mellitus and pulmonary disease. Overall morbidity and mortality were 30% and 16%, respectively. The mortality and the possibility of dehiscence seem to correlate directly with the number of risk factors.

CONCLUSION

Patients with these risk factors require more attention and special care to minimise the risk of its occurrence.