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Our objective was to examine the associations between early discharge and readmission after major abdominal operations.Advances in patient care resulted in earlier patient discharge after complex abdominal operations. Whether early discharge is associated with patient readmissions remains controversial.Patients who had colorectal, liver, and pancreas operations abstracted in 2011-2017 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data Files were included. Patient readmission was stratified by 6 operative groups. Patients who were discharged before median discharge date within each operative group were categorized as an early discharge. Analyses tested associations between early discharge and likelihood of 30-day postoperative unplanned readmission.A total of 364,609 patients with major abdominal operations were included. Individual patient groups and corresponding median day of discharge were: laparoscopic colectomy (n = 152,575; median = 4), open colectomy (n =137,462; median = 7), laparoscopic proctectomy (n = 12,238; median = 5), open proctectomy (n = 24,925; median = 6), major hepatectomy (n = 9,805; median = 6), pancreatoduodenectomy (n = 27,604; median = 8). Early discharge was not associated with an increase in proportion of readmissions in any operative group. Early discharge was associated with a decrease in average proportion of patient readmissions compared to patients discharged on median date in each of the operative groups: laparoscopic colectomy 6% versus 8%, open colectomy 11% versus 14%, laparoscopic proctectomy 13% versus 16%, open proctectomy 13% vs 17%, major hepatectomy 8% versus 12%, pancreatoduodenectomy 16% versus 20% (all P ≤ 0.02). Serious morbidity composite was significantly lower in patients who were discharged early than those who were not in each operative group (all P0.001).Early discharge in selected patients after major abdominal operations is associated with lower, and not higher, rate of 30-day unplanned readmission.

The aim of this study was to examine the outcomes of elective and emergent abdominal operations performed in end-stage heart failure patients supported with ventricular assist devices (VADs).With the growing volume of end-stage heart failure patients receiving VADs, an increasing number of these patients require surgery for noncardiac pathology. There is a paucity of studies on the safety of abdominal operations in this population.We performed a retrospective chart review across 3 hospitals of patients with VADs who underwent abdominal surgeries between 2003 and 2015. We used Chi-square, Fisher exact, and Mann-Whitney U tests for comparison of elective and emergent cases.Fifty-seven patients underwent 63 operations, of which 23 operations were elective, 24 were emergent, and 16 were emergently performed in the same admission as VAD placement and analyzed separately. Patients undergoing elective versus emergent procedures had similar comorbidities (Charlson score 2.9 vs 3.0). 43% versus 32% of patients had VADs as a destination therapy. Although perioperative anticoagulation approach was variable, holding warfarin and starting heparin/enoxaparin/bivalirudin bridge was most common (65% vs 54%). Although 2-fold higher in the emergent group (50 vs 100 mL, P = 0.06), median estimated blood loss was low. Postoperative bleeding requiring transfusion was not very common (13% vs 8%), whereas rate of ischemic cerebrovascular accident (4% each) and venous thromboembolism was low (0% vs 13%, P = 0.23). Thirty-day mortality rate was 4% versus 17%, P = 0.19.VAD patients have an acceptable risk profile for abdominal surgery.

A randomized controlled trial was undertaken to investigate the effect of prophylactic negative pressure dressings on postoperative surgical site infection (SSI) rates in closed laparotomy wounds.Laparotomy wounds are associated with high rates of SSI. The effect of prophylactic negative pressure dressing of closed incisional wounds on SSI rate is unknown.A randomized, controlled, open-label trial was conducted (clinicaltrials.gov registration number NCT02780453). Fifty patients undergoing open abdominal surgery were included, with 25 patients randomized to the negative pressure dressing group and 25 to the standard dressing group. The primary endpoint was SSI incidence at 30 days postoperatively. Secondary endpoints included SSI incidence at 4 days, length of stay, cosmetic outcome, and patient satisfaction. Statistical analysis was performed on a per-protocol basis using SPSS version 23.0.The incidence of SSI at 30 days postoperatively was significantly reduced in the treatment group compared with the control group [8.3% vs 32.0%, P = 0.043 (1-sided), P = 0.074 (2-sided)]. There was no difference in SSIs at 4 days postoperatively [4.1% vs 8.0%, P = 0.516 (1-sided), P = 1.0 (2-sided)]. Analysis of predictors of wound infection identified standard wound dressings as the only significant predictor of SSI development. Length of stay was significantly reduced in the negative pressure dressing group [6.1 vs 14.7 days, P = 0.019 (2-sided)]. Cosmetic outcome and patient satisfaction did not show any difference between the 2 groups.Prophylactic use of negative pressure dressings for closed laparotomy wounds significantly reduces the incidence of SSI at 30 days postoperatively.

To assess the utility of advanced tests performed before surgery on patients who needed emergent abdominal operations, and to assess the outcomes of these patients relative to their diagnoses.Patients with a potential abdominal catastrophe may have various presentations, contributing to the difficulty of the decision about whether an operation is indicated. Advanced tests can be valuable, but the use of these adjuncts should be appropriate to the clinical status of the patient so that treatment is not delayed. The role of these tools in the evaluation of the patient who may need an emergent abdominal operation is less well defined.Data were reviewed on adult patients undergoing emergent abdominal operations. Entrance criteria included patients who had an emergent abdominal operation, defined as one performed for presumed gastrointestinal perforation, infarction, or hemorrhage within 6 hours of admission or surgical consultation. Advanced tests were those that were time-consuming or invasive or required scheduling with other departments so that the risk/benefit ratio of these tests could be questioned. A useful test was one that provided information that contributed to a change in the patient's management.During a 5-year period, 300 consecutive adult patients (158 perforations, 66 hemorrhage, 53 ischemia/infarction, and 23 "other") underwent emergent nontrauma celiotomies. Overall, the death rate was 20%. Advanced preoperative tests were performed in 135 (45%) of the 300 patients, and 40 of these patients had delayed treatments. Preoperative localization of bleeding sites was accomplished in 77% of patients with upper gastrointestinal bleeding and 86% of patients with lower gastrointestinal bleeding.Most patients in need of emergent abdominal operations should not undergo advanced tests. The primary role of advanced tests in these patients is in the localization of a bleeding site. With the exception of patients who present with hemorrhage, advanced tests frequently cause a delay in treatment.

To compare a new technique of radical hemorrhoidectomy using an electrothermal device originally devised to seal vessels in abdominal operations, with the conventional open Milligan-Morgan procedure performed with diathermy.Hemorrhoidectomy is one of the most commonly performed anorectal operations. Two well-established methods, the "open" Milligan-Morgan excision and the "closed" Ferguson technique, both carry risks of postoperative bleeding, urinary retention, and late anal stenosis. The convalescence is similarly long and difficult after both operations. The quest for an improved technique of radical excision of hemorrhoids is justified.In this case-control study, two groups of patients were alternatively allocated into study and control groups. In the study group (n = 40), an electrothermal system was used. The tissue fusion produced by this device consists of melting of collagen and elastin. This technique essentially achieves a sutureless closed hemorrhoidectomy. The operative time, postoperative complications, and time off work were compared with the group undergoing conventional Milligan-Morgan hemorrhoidectomy (control group, n = 40).The operative time and time off work were significantly shorter in the study group. There were also fewer postoperative complications in this group.The "tissue-welding" properties of this device and the shape of the electrode handpiece may be successfully applied to the performance of an operation most appropriately described as a "modified sutureless closed hemorrhoidectomy." This pilot study shows that this new technique is simple and safe, significantly shortens the operation, and is followed by a significantly easier and shorter recovery.

Biliary tract operations were performed in conjunction with another intra-abdominal operation in 253 patients. Of this group, 137 patients had unplanned or "incidental" biliary procedures, with a morbidity rate of 15% and a mortality rate of 7%. Three of the 20 nonfatal complications were related to the biliary tract surgery. A planned biliary tract operation concomitant with another intra-abdominal procedure was performed in 65 patients, with a morbidity rate of 20% and mortality rate of 2%. None of these postoperative complications or deaths were attributed to the biliary tract operation. A planned biliary tract procedure plus another incidental and unplanned operation were performed in 51 patients, with a morbidity rate of 11.8% and no deaths. The complications were not specific to the biliary tract operation. The data suggest that it is feasible to perform concomitant cholecystectomy for cholecystostomy for calculous biliary tract disease in patients operated on for nonbiliary diseases. It is also reasonable to perform definitive surgery for most gastrointestinal diseases discovered incidental to a planned cholecystectomy. These recommendations are valid only if the condition of the patient permits the additional operative stress and the exposure is adequate to perform a safe procedure on the gallbladder. Concomitant operations that require choledochotomy are not recommended, except under unusual circumstances.

A NNULAR PANCREAS is a rare anatomic anomaly which, according to Ravitch and Woods,23 is probably the only true congenital abnormality of the gastrointestinal tract that often does not become apparent until adult life. It may be entirely asymptomatic only to be discovered as an incidental finding at necropsy. The incidence of the condition is difficult to assess. McNaught 21 found 39 cases in the literature before 1933. More recently, however, cases have been reported with increasing frequency, and the cumulative literature now records approximately 250 examples, of which more than 70% have been reported since 1952. That the condition is rare is supported by the review of Ravitch and Woods 3 in which only three instances of annular pancreas were found in 20,000 autopsies at Johns Hopkins Hospital. Marchese 18 did not find any in 28,000 autopsies, and Vasconcelos and Sadek 28 found only one in a review of 22,243 abdominal operations. Between the years 1947 and 1971, 14 patients have been seen and treated at the Lahey Clinic Foundation, five of whom were documented previously.25'30 These 14 patients form the basis for review of annular pancreas presented here.