30-Day Outcomes After Intraoperative Leak Testing for Bariatric Surgery Patients.
ABSTRACT: BACKGROUND:Intraoperative testing of anastomoses and staples lines is commonly performed to minimize the risk of postoperative leaks in bariatric surgery, but its impact is unclear. The aim of this study was to determine the association between leak testing and 30-d postoperative leak, bleed, reoperation, and readmission rates for patients undergoing laparoscopic sleeve gastrectomy (LSG) or Roux-en-Y gastric bypass (RYGB). METHODS:This is a retrospective observational study utilizing 2015-2016 data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. Postoperative outcomes were compared using ?2 test. Multivariable logistic regression was used to identify factors associated with 30-d outcomes. RESULTS:We included 237,081 patients. Leak testing was performed on 73.0% and 92.1% of LSG and RYGB patients, respectively. LSG was associated with lower rates of leak, bleed, reoperation, and readmission than RYGB. On multivariable analysis, intraoperative leak testing was associated with increased rates of postoperative leak for LSG and RYGB (OR 1.48 and 1.90, respectively) and lower rates of bleed for LSG (OR 0.76). There were no significant associations between leak testing and rates of reoperation or readmission. CONCLUSIONS:Use of intraoperative leak testing was not associated with improved outcomes for either LSG or RYGB. A prospective trial investigating leak testing is warranted to better elucidate its impact.
Project description:BACKGROUND: Hepatic resection for malignancies or symptomatic benign liver lesions remains the standard of treatment. Historically, the principal cause of mortality during liver resection was intraoperative bleeding. Advances in surgical and anesthetic techniques, along with application of new technologies, have decreased blood loss and dramatically improved the outcomes for major liver surgery. METHODS: The purpose of this prospective study was to determine the utility of a saline-cooled radiofrequency coagulation device (TissueLink Medical, Inc.) for hepatic resection. Intraoperative bleeding, blood transfusion, postoperative bile leak, and other complications were noted. RESULTS: The results are described for 170 patients undergoing hepatic resection over a three-year period. There were no intraoperative or postoperative deaths. Six patients in the series received blood transfusions for a transfusion rate of 3.5%. Four patients experienced a transient postoperative bile leak. Three of the four closed spontaneously prior to discharge home, and the fourth closed promptly after ERCP. There were no episodes of postoperative hemorrhage, hepatic failure, liver abscess, or reoperation. CONCLUSIONS: The saline-cooled radiofrequency coagulation device is very effective in achieving intraoperative hemostasis and facilitates liver parenchymal transection during hepatic resection.
Project description:BACKGROUND:Gastric fistulas, bleeding, and strictures are commonly reported after laparoscopic sleeve gastrectomy (LSG), that increase morbidity and hospital stay and may put the patient's life at risk. We report our prospective evaluation of application of synthetic sealant, a modified cyanoacrylate (Glubran®2), on suture rime, associated with omentopexy, to identify results on LSG-related complications. METHODS:Patients were enrolled for LSG by two Bariatric Centers, with high-level activity volume. Intraoperative recorded parameters were: operative time, estimated intraoperative bleeding, conversion rate. We prospectively evaluated the presence of early complications after LSG during the follow up period. Overall complications were analyzed. Perioperative data and weight loss were also evaluated. A control group was identified for the study. RESULTS:Group A (treated with omentopexy with Glubran®2) included 96 cases. Control group included 90 consecutive patients. There were no differences among group in terms of age, sex and Body Mass Index (BMI). No patient was lost to follow-up for both groups. Overall complication rate was significantly reduced in Group A. Mean operative time and estimated bleeding did not differ from control group. We observed three postoperative leaks in Group B, while no case in Group A (not statistical significancy). We did not observe any mortality, neither reoperation. Weight loss of the cohort was similar among groups. In our series, no leaks occurred applying omentopexy with Glubran®2. CONCLUSION:Our experience of omentopexy with a modified cyanoacrylate sealant may lead to a standardized and reproducible approach that can be safeguard for long LSG-suture rime. TRIAL REGISTRATION:Retrospective registration on clinicaltrials.gov PRS, with TRN NCT03833232 (14/02/2019).
Project description:OBJECTIVE:Robotic surgery (RS) has been increasingly used for the resection of rectal cancer, and its advantages over laparoscopic surgery (LS) have been demonstrated. However, few studies focused on the severity of postoperative complications. This study aimed to compared the postoperative complications within 30 days after RS over LS according to the Clavien-Dindo (C-D) classification. METHODS:A literature research of PubMed, Embase, Cochrane Library and Web of Science were systematically performed. The studies comparing the complications of RS and LS for rectal cancer based on the C-D classification were enrolled. Primary outcomes were C-D grade III, IV, V, III-V (severe complications). RESULTS:Seventeen studies (3193 patients) were included in the final analysis: 1554 underwent RS and 1639 underwent LS. The RS group was associated with significantly lower rates of severe complications (OR = 0.69, 95% CI 0.53-0.90, P = 0.005), C-D grade IV (OR = 0.69, 95% CI 0.53-0.90, P = 0.005), and anastomotic leak (OR = 0.66, 95% CI 0.48-0.91, P = 0.01). There was no significant difference in C-D grade III, C-D grade I, II, I-II (minor complications), overall complications, bleeding, wound complications, postoperative ileus, urinary retention, readmission, reoperation between two groups. CONCLUSIONS:Robotic surgery is safe for rectal cancer and may be an effective alternative to laparoscopic surgery, with lower rates of severe complications, C-D grade IV, and anastomotic leak. Further large randomized controlled trials are necessary to confirm this conclusion.
Project description:Transection of gastric tissue during laparoscopic sleeve gastrectomy (LSG) can be challenging. Reinforcing the staple line may decrease the incidence of issues requiring intervention.The objective of this study was to compare the number of intraoperative surgical interventions for a surgical stapler and reload system with Gripping Surface Technology (GST) to standard reloads in patients who underwent LSG. Patients who underwent elective LSG were enrolled. The study was conducted in two stages. For Stage 1, procedures were performed using a powered stapler and standard reloads. For Stage 2, a reload system with GST was used. The primary endpoint was surgical interventions for bleeding and/or staple line issues during transection of the greater curvature of the stomach. Propensity score matching was applied to create two groups similar in baseline characteristics and risk factors.A total of 111 subjects were enrolled across four centers. Propensity-matched procedures were completed with the standard (n?=?38) or GST reloads (n?=?38). The mean number of interventions in the standard group was 1.9 (1.29) versus 1.1 (1.45) in the GST group. Nonparametric comparisons were statistically significant, indicating a reduction in the distribution of interventions for GST subjects (P?=?.0036 for matched pair data). Tissue slippage during transection was low for both groups. Intraoperative leak testing was negative in all procedures, and no procedures were converted to open.Use of the GST stapling system reduces the need for staple line interventions in LSG. Both stapling systems had an acceptable safety profile.
Project description:Purpose:Prolonged air leak (PAL) is a challenging complication in thoracic surgery. The aim of this study was to analyze the incidence, risk factors, and outcomes of PAL. Methods:We retrospectively analyzed 319 patients treated in a single center submitted to lobectomy, bilobectomy, segmentectomy, and wedge resections from January 2012 until August 2015. PAL was defined as air leak lasting more than 7 days after surgery. Results:The incidence of PAL was 14.7%. Bronchial obstruction (p?<?0.05), low body mass index (BMI, p?<?0.05), and hypoproteinemia (p?<?0.001) were identified as independent preoperative risk factors of PAL. Intraoperative risk factors were lob- (p?<?0.01) and bilobectomies (p?<?0.05), pleural adhesions (p <?0.001), and length of stapler line (p?<?0.001). Among the postoperative risk factors, we identified the use of active drainage (p?<?0.01), the presence of subcutaneous emphysema (p?<?0.001), massive air leak on the first postoperative day (POD 1, p?<?0.001), and an incomplete re-expansion of the lung (p?<?0.001). PAL was not associated with more complications in the postoperative period. One patient required reoperation due to a massive air leak. Twenty-six patients were discharged with a Heimlich valve with no complications and no need for re-admission. Conclusions:Bronchial obstruction, low BMI, hypoproteinemia, lob- and bilobectomies, pleural adhesions, length of stapler line, use of active drainage, the presence of subcutaneous emphysema, massive air leak on POD 1, and incomplete re-expansion of the lung were identified as independent risk factors of PAL. It had no influence on outcomes.
Project description:(1) Background: Oncological gastrectomy requires complex multidisciplinary management. Clinical pathways (CPs) can potentially facilitate this task, but evidence related to their use in managing oncological gastrectomy is limited. This study evaluated the effect of a CP for oncological gastrectomy on process and outcome quality. (2) Methods: Consecutive patients undergoing oncological gastrectomy before (n = 64) or after (n = 62) the introduction of a CP were evaluated. Assessed parameters included catheter and drain management, postoperative mobilization, resumption of diet and length of stay. Morbidity, mortality, reoperation and readmission rates were used as indicators of outcome quality. (3) Results: Enteral nutrition was initiated significantly earlier after CP implementation (5.0 vs. 7.0 days, p < 0.0001). Readmission was more frequent before CP implementation (7.8% vs. 0.0%, p = 0.05). Incentive spirometer usage increased following CP implementation (100% vs. 90.6%, p = 0.11). Mortality, morbidity and reoperation rates remained unchanged. (4) Conclusions: After implementation of an oncological gastrectomy CP, process quality improved, while indicators of outcome quality such as mortality and reoperation rates remained unchanged. CPs are a promising tool to standardize perioperative care for oncological gastrectomy.
Project description:Objective Transclival endoscopic endonasal approaches to the skull base are novel with few published cases. We report our institution's experience with this technique and discuss outcomes according to the clival region involved. Design Retrospective case series. Setting Tertiary care academic medical center Participants All patients who underwent endoscopic endonasal transclival approaches for skull base lesions from 2008 to 2012. Main Outcome Measures Pathologies encountered, mean intraoperative time, intraoperative complications, gross total resection, intraoperative cerebrospinal fluid (CSF) leak, postoperative CSF leak, postoperative complications, and postoperative clinical course. Results A total of 49 patients underwent 55 endoscopic endonasal transclival approaches. Pathology included 43 benign and 12 malignant lesions. Mean follow-up was 15.4 months. Mean operative time was 167.9 minutes, with one patient experiencing an intraoperative internal carotid artery injury. Of the 15 cases with intraoperative cerebrospinal fluid (CSF) leaks, 1 developed postoperative CSF leak (6.7%). There were six other postoperative complications: four systemic complications, one case of meningitis, and one retropharyngeal abscess. Gross total resection was achieved for all malignancies approached with curative intent. Conclusions This study provides evidence that endoscopic endonasal transclival approaches are a safe and effective strategy for the surgical management of a variety of benign and malignant lesions. Level of Evidence 4.
Project description:INTRODUCTION:Anastomotic leakage (AL) remains one of the most threatening complications in colorectal surgery with the incidence of up to 20%. The aim of the study is to evaluate the safety and feasibility of novel - trimodal intraoperative colorectal anastomosis testing technique. METHODS AND ANALYSIS:This multi-center prospective cohort pilot study will include patients undergoing colorectal anastomosis formation below 15?cm from the anal verge. Trimodal anastomosis testing will include testing for blood supply by ICG fluorescence trans-abdominally and trans-anally, testing of mechanical integrity of anastomosis by air-leak and methylene blue leak tests and testing for tension. The primary outcome of the study will be AL rate at day 60. The secondary outcomes will include: the frequency of changed location of bowel resection; ileostomy rate; the rate of intraoperative AL; time, taken to perform trimodal anastomosis testing; postoperative morbidity and mortality; quality of life. DISCUSSION:Trimodal testing of colorectal anastomosis may be a novel and comprehensive way to investigate colorectal anastomosis and to reveal insufficient blood supply and integrity defects intraoperatively. Thus, prevention of these two most common causes of AL may lead to decreased rate of leakage. STUDY REGISTRATION:Clinicaltrials.gov (https://clinicaltrials.gov/): NCT03958500, May, 2019.
Project description:BACKGROUND:There is significant morbidity after diverting ileostomy closure, so identifying predictors of complications could be of great benefit. The aim of our study was to evaluate the incidence and risk factors for postoperative morbidity after elective ileostomy closure. METHODS:The ACS-NSQIP dataset was evaluated for elective ileostomy closures from 1/1/2015 to 12/31/2016. Demographic characteristics, operative, and postoperative outcomes were evaluated. The primary outcome was 30-day major morbidity (Clavien class III and greater). Secondary outcomes were rates and predictors of major morbidity, superficial site infection (SSI), reoperation, and readmission from multivariate logistic regression modeling. RESULTS:We retrospectively evaluated 1885 patients. The median operative time was 65 (IQR 50-90) minutes and median length of stay was 3 (IQR 2-5) days. Major morbidity was recorded in 6.7%, including mortality (1.0%), deep/organ space SSI (2.6%), dehiscence (0.8%), reintubation (0.5%), sepsis (1.7%), septic shock (0.8%), and reoperation (3.7%). Readmission was recorded in 9.7% and 6.2% had SSI. Multivariate logistic regression showed male sex (OR 1.584; 95% CI 1.068-2.347; p?=?0.022) and longer operative time (OR 1.004; 95% CI 1.001-1.007; p?=?0.009) were among those variables associated with increased odds of major morbidity. Dyspnea (OR 2.431; 95% CI 1.139-5.094; p?=?0.021) and longer operative time (OR 1.003; 95% CI 1.001-1.007; p?=?0.034) were among the independent risk factors for SSI. Male sex (OR 2.246; 95% CI 1.297-3.892; p?=?0.004, chronic obstructive pulmonary disease (OR 2.959; 95% CI 1.153-7.591; p?=?0.024), and longer operative time (OR 1.005; 95% CI 1.001-1.009; p?=?0.011) were associated with increased odds of reoperation. Chronic obstructive pulmonary disease (OR 2.578; 95% CI 1.338-4.968; p?=?0.005), wound infection (OR 2.680; 95% CI 1.043-6.890; p?=?0.041), and inflammatory bowel disease (OR 2.565; 95% CI 1.203-5.463; p?=?0.015) were associated with increased odds of readmission. CONCLUSIONS:Elective stoma closure has significant risk of morbidity. Patients with longer operative times were at increased risk for major morbidity, overall SSI, and reoperation. From the analysis, factors specifically associated with major morbidity, overall infectious complications, readmissions, and reoperations were identified. This information can be used to prospectively prepare for these high-risk patients, potentially improving postoperative outcomes.
Project description:BACKGROUND: The reoperation rate remains high after liver transplantation and the impact of reoperation on graft and recipient outcome is unclear. The aim of our study is to evaluate the impact of early reoperation following living-donor liver transplantation (LDLT) on graft and recipient survival. METHODS: Recipients that underwent LDLT (n?=?111) at the University of Tokyo Hospital between January 2007 and December 2012 were divided into two groups, a reoperation group (n?=?27) and a non-reoperation group (n?=?84), and case-control study was conducted. RESULTS: Early reoperation was performed in 27 recipients (24.3%). Mean time [standard deviation] from LDLT to reoperation was 10 [9.4] days. Female sex, Child-Pugh class C, Non-HCV etiology, fulminant hepatitis, and the amount of intraoperative fresh frozen plasma administered were identified as possibly predictive variables, among which females and the amount of FFP were identified as independent risk factors for early reoperation by multivariable analysis. The 3-, and 6- month graft survival rates were 88.9% (95%confidential intervals [CI], 70.7-96.4), and 85.2% (95%CI, 66.5-94.3), respectively, in the reoperation group (n?=?27), and 95.2% (95%CI, 88.0-98.2), and 92.9% (95%CI, 85.0-96.8), respectively, in the non-reoperation group (n?=?84) (the log-rank test, p?=?0.31). The 12- and 36- month overall survival rates were 96.3% (95%CI, 77.9-99.5), and 88.3% (95%CI, 69.3-96.2), respectively, in the reoperation group, and 89.3% (95%CI, 80.7-94.3) and 88.0% (95%CI, 79.2-93.4), respectively, in the non-reoperation group (the log-rank test, p?=?0.59). CONCLUSIONS: Observed graft survival for the recipients who underwent reoperation was lower compared to those who did not undergo reoperation, though the result was not significantly different. Recipient overall survival with reoperation was comparable to that without reoperation. The present findings enhance the importance of vigilant surveillance for postoperative complication and surgical rescue at an early postoperative stage in the LDLT setting.