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Background: The American College of Surgeons National Surgical Quality Improvement Program surgical risk calculator (ACS-NSQIP SRC) has been designed to predict morbidity and mortality and help stratify surgical patients. This study evaluates the performance of the SRC for patients undergoing surgery for colorectal liver metastases (CRLM). Methods: SRC was retrospectively computed for patients undergoing liver or simultaneous colon and liver surgery for colorectal cancer (CRC) in two high tertiary referral centres from 2011 to 2020. C-statistics and Brier score were calculated as a mean of discrimination and calibration respectively, for both group and for every level of surgeon adjustment score (SAS) for liver resections in case of simultaneous liver-colon surgery. An AUC ≥ 0.7 shows acceptable discrimination; a Brier score next to 0 means the prediction tool has good calibration. Results: Four hundred ten patients were included, 153 underwent simultaneous resection, and 257 underwent liver-only resections. For simultaneous surgery, the ACS-NSQIP SRC showed good calibration and discrimination only for cardiac complication (AUC = 0.720, 0.740, and 0.702 for liver resection unadjusted, SAS-2, and SAS-3 respectively; 0.714 for colon resection; and Brier score = 0.04 in every case). For liver-only surgery, it only showed good calibration for cardiac complications (Brier score = 0.03). The SRC underestimated the incidence of overall complications, pneumonia, cardiac complications, and the length of hospital stay. Conclusions: ACS-NSQIP SRC showed good predicting capabilities only for 1 out of 5 evaluated outcomes; therefore, it is not a reliable tool for patients undergoing liver surgery for CRLM, both in the simultaneous and staged resections. [ABSTRACT FROM AUTHOR]

Background : Postoperative ileus is common after gastrointestinal surgery. This network meta-analysis aimed to compare the effectiveness of gum chewing and coffee and caffeine intake on ileus-related outcomes. Methods: A systematic literature review was performed to identify randomized controlled trials (RCTs) comparing noninvasive treatments for ileus after gastrointestinal surgery. The main analyses included random effects network meta-analyses using frequentist methods with simultaneous direct and indirect comparisons of time to first flatus, time to first defecation, and length of stay. Bayesian network meta-analysis using Markov chains was also used. Results: A total of 32 RCTs comparing 4999 patients were included in this network meta-analysis. Time to flatus was reduced by gum chewing (mean difference compared to control (MD): -11 h, 95% confidence interval (95% CI) − 16 to − 5 h, P < 0.001). Time to defecation was reduced by gum chewing and coffee, with MDs of -18 h (95% CI − 23 to − 13 h, P < 0.001) and -13 h (95% CI − 24 to − 1 h, P < 0.001), respectively. Length of stay was reduced by coffee and gum chewing with MDs of − 1.5 days (95% CI: − 2.5 to − 0.6 days, P < 0.001) and − 0.9 days (95% CI: − 1.3 to − 0.4 days, P < 0.001), respectively. Conclusion: Coffee and gum chewing were proven to be effective noninvasive approaches for shortening the postoperative length of hospital stay and time to first defecation, especially in open gastrointestinal surgery; thus these actions should be recommended after gastrointestinal surgery. [ABSTRACT FROM AUTHOR]

Background: In contrast to pancreatic ductal adenocarcinoma (PDAC), the risks of pancreatectomy for mucinous pancreatic cysts (MCs) are balanced against the putative goal of removing potentially malignant tumors. Despite undergoing similar operations, different rates of perioperative complications and morbidity between MC and PDAC patient populations may affect recommendations for resection. We therefore sought to compare the rates of postoperative complications between patients undergoing pancreatectomies for MCs or PDAC. Methods: A prospectively maintained institutional database was used to identify patients who underwent surgical resection for MCs or PDAC from July 2011 to August 2019. Patient demographics, complications, and perioperative data were compared between groups. Results: A total of 103 patients underwent surgical resection for MCs and 428 patients underwent resection for PDAC. Combined major 90-day postoperative complications were similar between MC and PDAC patients undergoing pancreaticoduodenectomy (PD, 32.5% vs. 20.0%, p = 0.068) or distal pancreatectomy (DP, 30.2% vs. 20.5%, p = 0.172). The most frequent complications were postoperative pancreatic fistula (POPF), abscess, and postoperative bleeding. The incidence of 90-day ISGPS Grade B/C POPF was higher in cyst patients undergoing PD (17.5% vs. 4.1%, p = 0.003) but not DP (25.4% vs. 20.5%, p = 0.473). No significant differences in operative time or length of stay between MCs and PDAC cohorts were observed. Conclusions: POPFs occur more frequently and at higher grades in patients undergoing PD for MCs than for PDAC and should inform patient selection. Accordingly, the perioperative management of MC patients undergoing PD should emphasize POPF risk mitigation. [ABSTRACT FROM AUTHOR]

Background: This study investigated the impact and short-term surgical outcomes of two different main energy devices for robotic gastrectomy for gastric cancer. The outcomes of robotic gastrectomy with ultrasonic shears and those of robotic gastrectomy with conventional forceps were compared.Methods: We retrospectively evaluated 171 patients who underwent robotic distal gastrectomy or total gastrectomy for gastric cancer. We classified patients into the ultrasonic shears (US) and Maryland bipolar (MB) forceps groups according to the main energy device used for robotic gastrectomy.Results: We extracted 58 patients from the US group and 58 patients from the MB forceps groups using propensity score matching. The total console time (310 min [interquartile range (IQR), 253-369 min] and 332 min, [IQR, 294-429 min]; p = 0.022) and the console time to gastrectomy (222 min [IQR, 177-266 min] and 247 min [IQR, 208-321 min]; p = 0.004) were significantly shorter in the US group than in the MB forceps group. Less blood loss occurred in the US group than in the MB forceps group (20 mL [IQR, 10-40 mL] and 30 mL [IQR, 16-80 mL]; p = 0.014). The postoperative complication rate and postoperative hospital stay length were similar between groups. A multivariate multiple linear regression analysis demonstrated that the use of an ultrasonically activated device was one an independent factor that reduced the operative time of robotic gastrectomy.Conclusion: Using ultrasonic shears as the main energy device may contribute to better surgical outcomes after robotic gastrectomy for gastric cancer. [ABSTRACT FROM AUTHOR]

Background: Optimal fluid management in pancreaticoduodenectomy patients remains contested. We aimed to examine the association between perioperative fluid administration and postoperative complications. Methods: We studied 168 pancreaticoduodenectomy patients operated in 2015 (n = 93) or 2017 (n = 75) at Helsinki University Hospital. In 2015, patients received intraoperative fluids following a goal-directed approach and, in 2017, according to anesthesiologist's clinical practice (conventional fluid management). We analyzed the differences in perioperative fluid administration between the groups, specifically examining the occurrence of severe complications (Clavien–Dindo ≥ III), pancreatic fistulas, cardiovascular complications, and the length of hospital stay. Results: The goal-directed group received more intraoperative fluids than the conventional fluid management group (12.0 ml/kg/h vs. 8.3 ml/kg/h, p < 0.001). Urine output (770 ml vs. 575 ml, p = 0.004) and intraoperative fluid balance (9.4 ml/kg/h vs. 6.3 ml/kg/h, p < 0.001) were higher in the goal-directed group than in the conventional fluid management group. Severe surgical complications (19.4% vs. 38.7%, p = 0.009) as well as clinically relevant pancreatic fistulas (1.1% vs. 10.7%, p = 0.011) occurred more frequently in patients receiving conventional fluid management. Moreover, the conventional fluid management group experienced longer hospital stays (9.0 vs. 11.5 days, p = 0.02). Lower intraoperative fluid volume accompanying conventional fluid management was associated with a higher risk of severe postoperative complications compared with higher volume in the goal-directed group (odds ratio 2.58 (95% confidence interval 1.04–6.42), p = 0.041). Conclusions: The goal-directed group experienced severe complications less frequently. Our findings indicate that optimizing the intraoperative fluid administration benefits patients, while adopting a too-restrictive approach represents an inferior choice. [ABSTRACT FROM AUTHOR]

Introduction: The selection of the most informative quality of care indicator for laparoscopic liver surgery (LLS) is still debated; among those proposed, textbook outcome (TO) seems to provide a compositive measure of the outcomes of surgery. The aim of this study was to investigate the factors related with the TO in a cohort of patients who underwent LLS.Methods: Patients who underwent LLS from 2014 to 2021 were included. TO for LLS (TOLLS) was defined as: R0 resection, absence of intraoperative incidents, severe complications, reintervention, 30-day readmission and in-hospital mortality. When also considering no prolonged length of hospital stay (LOS), the outcome was called TOLLS+.Results: Four hundred twenty-one patients were included; TOLLS was achieved in 80.5%, TOLLS+ in 60.8% cases. R0 resection was obtained in 90.2% cases, intraoperative incidents occurred in 7.8%, severe complications in 5.0%, reintervention in 0.7%, readmission in 1.4% and in-hospital mortality in 0.2%. 32.5% of patients showed prolonged LOS. After univariate and multivariate analysis, factors influencing TOLLS were age (OR 0.967; p=0.003), concomitant surgery (OR 0.380; p=0.003), operative time (OR 0.996; p=0.008) and blood loss (OR 0.241; p<0.001); factors influencing TOLLS+ were ASA-score (OR 0.533; p=0.008), tumour histology (OR 0.421; p=0.021), concomitant surgery (OR 0.293; p<0.001), operative time (OR 0.997; p=0.016) and blood loss (OR 0.361; p=0.003).Conclusions: TOLLS can be achieved in most patients undergoing LLR, and it seems to be influenced mostly by surgery-related factors; conversely, TOLLS+ is achieved less frequently and seems to be influenced also by patient- and tumour-related factors. [ABSTRACT FROM AUTHOR]

Introduction: With widespread adoption of enhanced recovery protocols and a push toward shorter length of stay (LOS) following colon surgery, the extent to which complications have shifted to the post-discharge setting is unknown. The objectives of this study were to (1) characterize changes in LOS and post-discharge complications over time and (2) evaluate risk factors associated with post-discharge complications.Methods: Patients who underwent elective colon resection from 2012 to 2018 were identified from the ACS NSQIP Colectomy-Targeted Dataset. Changes in LOS and the proportion of post-discharge complications were evaluated over time, and predictors of post-discharge complications were assessed using multivariable logistic regression.Results: Of the 98,136 patients who underwent colon resection, median LOS decreased from 5 days in 2012 to 4 days in 2018. Overall, 30-day complication rate was 21.5%, which decreased during the study period (25.8 to 19.1%, p < 0.001). Of the 13 individual complications evaluated, 4 demonstrated a significant increase in the proportion of post-discharge events including overall SSI (55.8 to 63.3%, p = 0.002), superficial SSI (57.3 to 75.7%, p < 0.001), wound disruption (46.0 to 62.1%, p = 0.047), and UTI (41.5 to 62.7%, p < 0.001). Factors associated with the development of any post-discharge complication included female sex, ASA III/IV/V, dependent functional status, and higher BMI. Intraoperative factors included wound class, operation time, and approach.Conclusions: Although LOS and 30-day complications decreased over time, the proportion of events occurring post-discharge increased for several complications. We identified specific factors associated with post-discharge complications which emphasize the importance of a patient monitoring program to early identify and manage post-discharge complications. [ABSTRACT FROM AUTHOR]

Background: Tumor markers are commonly utilized in the diagnostic evaluation, treatment decision making, and surveillance of appendiceal tumors. In this study, we aimed to determine the prognostic significance of elevated preoperative tumor markers in patients with pseudomyxoma peritonei secondary to low-grade appendiceal mucinous neoplasm who underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Methods: Using a multi-institutional database, eligible patients with measured preoperative tumor markers [carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA 19-9), or cancer antigen 125 (CA-125)] were identified. Univariate and multivariate Cox-proportional hazards regression analysis assessed relationships between normal and elevated serum tumor markers with progression-free and overall survival in the context of multiple clinicopathologic variables. Results: zTwo hundred and sixty-four patients met criteria. CEA was the most commonly measured tumor marker (97%). Patients who had any elevated tumor marker had a higher peritoneal carcinomatosis index (PCI) as compared to those with normal range markers. Elevated CEA and CA 19-9 levels were individually associated with longer inpatient length of stay, requirement for intraoperative transfusion, and incomplete cytoreduction. Utilization of neoadjuvant chemotherapy, increased PCI score, elevated CA 19-9 (p = 0.007), and CA-125 levels (p = 0.01) were predictive of decreased progression-free survival on univariate analysis. However, in a multivariate model, only elevated PCI was a statistically significant predictor of progression-free survival. Conclusion: Elevated preoperative tumor markers indicate a higher burden of disease but are not independently associated with survival in this retrospective multi-institutional cohort. Further prospective studies are needed to clarify the utility of these markers in this patient population. [ABSTRACT FROM AUTHOR]

Background and Methods: Gastro- or duodenojejunostomy leaks after pancreatoduodenectomy is rare. This study aims to analyze the incidence, management, and outcome of gastro- or duodenojejunostomy leaks after pancreatoduodenectomy based on a single center experience from 2004 to 2020 with a narrative literature review. Results: Of a total of 1494 pancreatoduodenectomies, eight patients with gastrojejunostomy (n=1) or duodenojejunostomy (n=7) leak were identified from the institutional pancreatic database. All leaks were treated operatively. In two patients dismantling of the duodenojejunostomy, distal gastrectomy, and closure of the pyloric and jejunal side, a percutaneous endoscopic gastrostomy and a feeding jejunostomy ultimately had to be performed after an unsuccessful attempt of gastrojejunostomy and suture of the duodenojejunostomy, respectively. The literature search revealed three more studies specifically addressing this complication after pancreatoduodenectomy (36 patients of a total of 4739 pancreatoduodenectomies). Based on an analysis of the current study and the literature review, the overall incidence of gastro- or duodenojejunostomy leaks after pancreatoduodenectomy was 0.71 % (44/6233 pancreatoduodenectomies). The occurrence of a gastro- or duodenojejunostomy leak was associated with a concomitant postoperative pancreatic fistula in 50 % of the cases, an increased length of hospital stay, and a mortality rate of 15.9 %. Surgical treatment was performed in 84 % of the cases. Conclusion: Gastro- or duodenojejunostomy leak is a rare complication after pancreatoduodenectomy. Prompt diagnosis and early repair is important. In most cases, a surgical intervention is necessary for a good outcome. Under salvage conditions, a bailout strategy may be to temporarily dismantle the gastro- or duodenojejunal anastomosis. [ABSTRACT FROM AUTHOR]

Aim: To systematically review literature and to assess the status of the ERAS protocol in pediatric populations undergoing gastrointestinal surgery. Methods: Literature research was carried out for papers comparing ERAS and traditional protocol in children undergoing gastrointestinal surgery. Data on complications, hospital readmission, length of hospital stay, intraoperative fluid volume, post-operative opioid usage, time to defecation, regular diet, intravenous fluid stop, and costs were collected and analyzed. Analyses were performed using OR and CI 95%. A p value <0.05 was considered significant. Results: A total of 8 papers met the inclusion criteria, with 943 included patients. There was no significant difference in complication occurrence and 30-day readmission. Differently, length of stay, intraoperative fluid volume, post-operative opioid use, time to first defecation, time to regular diet, time to intravenous fluid stop, and costs were significantly lower in the ERAS groups. Conclusions: ERAS protocol is safe and feasible for children undergoing gastrointestinal surgery. Without any significant complications and hospital readmission, it decreases length of stay, ameliorates the recovery of gastrointestinal function, and reduces the needs of perioperative infusion, post-operative opioid administration, and costs. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study is to determine the financial impact of clinical complications and outcomes after minimally invasive Ivor Lewis esophagectomy (MILE) at a safety-net hospital. Methods: This was a single-center retrospective analysis of consecutive patients undergoing MILE from 2013 to 2018. Postoperative complications were classified by Clavien-Dindo grade and associated total and direct recovered costs were assessed. Direct cost and LOS index were defined as the ratio of observed to expected values (>1 denotes above nationwide expectations). Annual outcomes were based on Medicare fiscal years. Results: One hundred twenty-four patients (99 males, mean age 65.7 ± 9.3) were surgically treated for esophageal malignancy (n = 118) and benign disease (n = 6) by MILE between 2014 and 2018. Mean ICU LOS (5.8 ± 6.6 versus 4.3 ± 6.3 days) and LOS index (1.16 versus 0.76) improved from 2014 to 2018. Both direct cost index (1.03 versus 0.99) and indirect costs (43.4% versus 41.4%) decreased over time. However, direct costs recovered (213.6 to 159.0%) and total costs recovered (119.1 to 92.5%) declined during this period. Clinical complications grade was not associated with total costs recovered (p = 0.69). Extent of recovered expenditure was significantly higher from commercial/private payers as compared to government-sponsored payers (p < 0.05). Conclusion: Improvement in clinical outcomes and efficiency of care are not reflected by annual recovered expenditure. Furthermore, clinical complications do not correlate with the ability to recover hospital spending. Financial recovery was primary payer dependent. Enhanced collaboration with hospital administration may be needed in an effort to maximize financial fidelity in the presence of good quality of care after highly complex procedures. [ABSTRACT FROM AUTHOR]

Background: Endoscopic vacuum therapy (EVT) has become a promising option in the management of anastomotic leakage (AL) after esophagectomy. However, EVT is an effortful approach associated with multiple interventions. In this study, we conduct a comparative cost analysis for methods of management of AL.Methods: All patients who experienced AL treated by EVT, stent, or reoperation following Ivor Lewis esophagectomy for esophageal cancer were included. Cases that were managed by more than one modality were excluded. For the remaining cases, in-patient treatment cost was collected for material, personnel, (par)enteral nutrition, intensive care, operating room, and imaging.Results: 42 patients were treated as follows: EVT n = 25, stent n = 13, and reoperation n = 4. The mean duration of therapy as well as length of overall hospital stay was significantly shorter in the stent than the EVT group (30 vs. 44d, p = 0.046; 34 vs. 53d, p = 0.02). The total mean cost for stent was €33.685, and the total cost for EVT was €46.136, resulting in a delta increase of 37% for EVT vs. stent cost. 75% (€34.320, EVT), respectively, 80% (€26.900, stent) of total costs were caused by ICU stay. Mean pure costs for endoscopic management were relatively low and comparable between both groups (EVT: €1.900, stent: €1.100, p = 0.28).Conclusion: Management of AL represents an effortful approach that results in high overall costs. The expenses directly related to EVT and stent therapy were however comparatively low with more than 75% of costs being attributable to the ICU stay. Reduction of ICU care should be a central part of cost reduction strategies. [ABSTRACT FROM AUTHOR]

Background: In patients with severe acute pancreatitis (SAP), infected pancreatic necrosis (IPN) is associated with a worsened outcome. We studied risk factors and consequences of IPN in patients with necrotizing SAP. Methods: The study consisted of a retrospective cohort of 163 consecutive patients treated for necrotizing SAP at a university hospital intensive care unit (ICU) between 2010 and 2018. Results: All patients had experienced at least one persistent organ failure and approximately 60% had multiple organ failure within the first 24 h from admission to the ICU. Forty-seven (28.8%) patients had IPN within 90 days. Independent risk factors for IPN were more extensive anatomical spread of necrotic collections (unilateral paracolic or retromesenteric (OR 5.7, 95% CI 1.5–21.1) and widespread (OR 21.8, 95% CI 6.1–77.8)) compared to local collections around the pancreas, postinterventional pancreatitis (OR 13.5, 95% CI 2.4–76.5), preceding bacteremia (OR 4.8, 95% CI 1.3–17.6), and preceding open abdomen treatment for abdominal compartment syndrome (OR 3.6, 95% CI 1.4–9.3). Patients with IPN had longer ICU and overall hospital lengths of stay, higher risk for necrosectomy, and higher readmission rate to ICU. Conclusions: Wide anatomical spread of necrotic collections, postinterventional etiology, preceding bacteremia, and preceding open abdomen treatment were identified as independent risk factors for IPN. [ABSTRACT FROM AUTHOR]

Background: A higher rate of postoperative morbidity and mortality in patients with portal hypertension from cirrhosis is well recognized; however, the rate of postoperative morbidity and mortality among patients with portal hypertension from non-cirrhotic portal vein thrombosis (NCPVT) is largely unknown. Method: All adults undergoing abdominal and pelvic surgery were identified from the National Inpatient Sample database from 2002 to 2015. Patients were then categorized into three groups: non-cirrhotic non-portal vein thrombosis (NCNPVT), NCPVT, and cirrhotic portal vein thrombosis (CPVT). Inpatient mortality, type of disposition, transfusions, length of stay, postoperative complications, and total charges were compared. Logistic regression and ordinary least squares regression analyses were performed for factors associated with inpatient mortality, transfusions, surgery-related complications, and log length of stay. Results: Patients with NCPVT had significantly higher inpatient mortality rates, surgery-related complications, and longer length of stays compared with patients with NCNPVT (2.64% vs. 0.34%, 10.26% vs. 3.26%, 8 vs. 2 days) but less than patients with CPVT (2.64% vs. 6.31%, 10.26% vs. 17.48%, 8 vs. 11 days). In multiple logistic regression analyses, NCPVT groups remained associated with increased inpatient mortality rate, transfusions, and postoperative complications with odds ratios of 3.71 (1.88, 7.32), 3.43 (2.54, 4.62), and 3.08 (2.16, 4.39), respectively. NCPVT was also associated with 2.4 times increased length of stay. Discussion: Patients with NCPVT had significantly higher risks of postoperative morbidity and mortality than patients with NCNPVT but less than patients with CPVT. Future studies with detail regarding the characteristics of PVTs are needed to confirm the findings in this study. [ABSTRACT FROM AUTHOR]

Background and Purpose: Previous abdominal surgery can be a risk factor for perioperative complications in patients undergoing laparoscopic procedures. Today, distal pancreatectomy is increasingly performed laparoscopically. This study investigates the consequences of prior upper abdominal surgery (PUAS) for laparoscopic distal pancreatectomy (LDP). Methods: Patients who had undergone LDP from April 1997 to January 2020 were included. Based on the history and type of PUAS, these were categorized into three groups: minimally invasive (I), open (II), and no PUAS (III). To reduce possible confounding factors, the groups were matched in 1:2:4 fashion based on age, sex, body mass index (BMI) and American Society of Anesthesiology grade. Results: After matching, 30, 60, and 120 patients were included in the minimally invasive, open and no PUAS groups, respectively. No statistically significant differences were found in terms of intraoperative outcomes. Postoperative morbidity, mortality and length of hospital stay were similar. Open PUAS was associated with higher Comprehensive Complication Index (33.7 vs 20.9 vs 26.2, p = 0.03) and greater proportion of patients with ≥ 2 complications (16.7 vs 0 vs 6.7%, p = 0.02) compared with minimally invasive and no PUAS. Male sex, overweight (BMI 25–29.9 kg/m2), diagnosis of neuroendocrine neoplasia, and open PUAS were risk factors for severe morbidity in the univariable analysis. Only open PUAS was statistically significant in the multivariable model. Conclusions: PUAS does not impair the feasibility and safety of LDP as its perioperative outcomes are largely comparable to those in patients without PUAS. However, open PUAS increases the burden and severity of postoperative complications. [ABSTRACT FROM AUTHOR]

Background: Postoperative ileus (POI) remains a common complication following bowel resection. Selective opioid antagonists have been increasingly studied as prophylactic pharmaceutical aids to reduce rates of POI. The aim of this study was to evaluate the impact of selective opioid antagonists on return of bowel function following bowel resection.Methods: MEDLINE, Embase, and CENTRAL were systematically searched. Articles were included if they compared the incidence of POI and/or length of stay (LOS) in patients receiving and not receiving selective opioid antagonists following elective bowel resection. A pairwise meta-analyses using inverse variance random effects was performed.Results: From 636 citations, 30 studies with 45,051 patients receiving selective opioid antagonists (51.3% female, mean age: 60.9) and 55,071 patients not receiving selective opioid antagonists (51.2% female, mean age: 61.1) were included. Patients receiving selective opioid antagonists had a significantly lower rate of POI (10.1% vs. 13.8%, RR 0.68, 95%CI 0.63-0.75, p < 0.01). Selective opioid antagonists also significantly reduced LOS (MD - 1.08, 95%CI - 1.47 to - 0.69, p < 0.01), readmission (RR 0.94, 95%CI 0.89-0.99, p = 0.03), and 30-day morbidity (RR 0.85, 95%CI 0.79-0.90, p < 0.01). Improvements in LOS, readmission rate, and morbidity were not significant when analysis was limited to laparoscopic surgery. There was no significant difference in inpatient healthcare costs (SMD - 0.33, 95%CI - 0.71-0.04, p = 0.08).Conclusions: Rate of POI decreases with the use of selective opioid antagonists in patients undergoing bowel resection. Selective opioid antagonists also improve LOS, rates of readmission, and 30-day morbidity for patients undergoing open bowel resection. Addition of these medications to enhance recovery after surgery protocols should be considered. [ABSTRACT FROM AUTHOR]

Background: Although previous studies have suggested that drain management is highly variable, data on drain placement and timing of drain removal among patients undergoing hepatic resection remain scarce. The objective of the current study was to define the utilization of drain placement among patients undergoing major hepatic resection. Methods: The ACS NSQIP-targeted hepatectomy database was used to identify patients who underwent major hepatectomy between 2014 and 2017. Association between day of drain removal, timing of discharge, and drain fluid bilirubin on postoperative day (POD) 3 (DFB-3) was assessed. Propensity score matching (PSM) was used to compare outcomes of patients with a drain removed before and after POD 3. Results: Among 5330 patients, most patients had an abdominal drain placed at the time of hepatic resection (n = 3075, 57.7%). Of 2495 patients with data on timing of drain removal, only 380 patients (15.2%) had their drain removed by POD 3. Almost 1 in 6 patients (n = 441, 17.7%) were discharged home with the drain in place. DFB-3 values correlated poorly with POD of drain removal (R2 = 0.0049). After PSM, early drain removal (≤ POD 3) was associated with lower rates of grade B or C bile leakage (2.1% vs. 7.1%, p = 0.008) and prolonged length of hospital stay (6.0% vs. 12.7%, p = 0.009) compared with delayed drain removal (> POD 3). Conclusions: Roughly 3 in 5 patients had a drain placed at the time of major hepatectomy and only 1 in 7 patients had the drain removed early. This study demonstrated the potential benefits of early drain removal in an effort to improve the quality of care following major hepatectomy. [ABSTRACT FROM AUTHOR]

Background: Bilio-enteric diversion is the current surgical standard in patients after deceased donor liver transplantation (DDLT) with a biliary anastomotic stricture failing interventional treatment and requiring surgical repair. In contrast to this routine, the aim of this study was to show the feasibility and safety of a duct-to-duct biliary reconstruction. Patients: Between 2012 and 2019, we performed a total of 308 DDLT in 292 adult patients. The overall biliary complication rate was 20.5%. Patients with non-anastomotic or combined strictures were excluded from this analysis. Out of 273 patients after a primary duct-to-duct reconstruction, 20 (7.3%) developed late isolated AS. Seven of these patients failed interventional biliary treatment and required a surgical repair. Results: Duct-to-duct reconstruction was feasible and successful in all patients. Liver function tests fully normalized and no patient required any form of biliary intervention after surgery. One patient with intraoperative cholangiosepsis was ICU bound for 5 days, and another patient with a subhepatic abscess required percutaneous drainage. There was no perioperative death. The median length of hospital stay was 8 (5–17) days. The median time of follow-up after relaparotomy was 1593 (434–2495) days. Conclusion: Duct-to-duct reconstruction is a feasible and safe option in selected patients requiring surgical repair for isolated AS after DDLT. This approach preserves the biliary anatomy and avoids the potential side effects of a bilio-enteric diversion. [ABSTRACT FROM AUTHOR]

Purpose: To compare laparoscopic non-CME colectomy with laparoscopic CME colectomy in two hospitals with similar experience in laparoscopic colorectal surgery. Methods: Data was collected retrospectively from Päijät-Häme Central Hospital (PHCH, NCME group) and Central Finland Central Hospital (CFCH, CME group) records. Elective laparoscopic resections performed during 2007–2016 for UICC stage I–III adenocarcinoma were included to assess differences in short-term outcome and survival. Results: There were 340 patients in the NCME group and 325 patients in the CME group. CME delivered longer specimens (p < 0.001), wider resection margins (p < 0.001), and more lymph nodes (p < 0.001) but did not result in better 5-year overall or cancer-specific survival (NCME 77.9% vs CME 72.9%, p = 0.528, NCME 93.2% vs CME 88.9%, p = 0.132, respectively). Thirty-day morbidity, mortality, and length of hospital stay were similar between the groups. Conversion to open surgery was associated with decreased survival. Discussion: Complete mesocolic excision (CME) is reported to improve survival. Most previous studies have compared open CME with open non-CME (NCME) or open CME with laparoscopic CME. NCME populations have been historical or heterogeneous, potentially causing bias in the interpretation of results. Studies comparing laparoscopic CME with laparoscopic NCME are few and involve only small numbers of patients. In this study, diligently performed laparoscopic non-CME D2 resection delivered disease-free survival results comparable with laparoscopic CME but was not safer. [ABSTRACT FROM AUTHOR]

Background: Previous studies have documented increased complications following pancreaticoduodenectomy in patients who undergo preoperative biliary stenting (PBS). However, in the modern era, the vast majority of patients with jaundice are stented. We hypothesized that there is no difference in short-term postoperative outcomes between PBS and no PBS in patient with obstructive jaundice undergoing pancreaticoduodenectomy. Methods: We performed an analysis using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) participant use file (2014–2017). Patients who received neoadjuvant chemotherapy and required stenting were excluded from the analysis. A propensity-matched analysis was performed to select obstructive jaundice patients who underwent PBS and those who did not with similar characteristics prior to pancreaticoduodenectomy. Short-term postoperative outcome measures included superficial surgical site infection (S-SSI), deep surgical site infection (D-SSI), hospital length of stay (LOS), postoperative pancreatic fistula (POF), hospital readmission, minor morbidity (Clavien-Dindo I–II), major morbidity (Clavien-Dindo III, IV, V), and 30-day mortality. Results: A total of 5851 patients with obstructive jaundice underwent pancreaticoduodenectomy without neoadjuvant chemotherapy. 81.6% underwent PBS. Based on the propensity-matched analysis, 927 patients who received PBS and 927 patients who did not were selected for comparing the outcomes between the two groups. There was no significant difference in outcome measures between the two groups with respect to S-SSI (OR 1.30 , 95% CI = 0.94–1.80, p = 0.12), D-SSI (OR 1.07, 95% CI = 0.81–1.41, p = 0.62), POF (OR 1.11, 95% CI = 0.87–1.42, p = 0.40), hospital readmission (OR 0.99, 95% CI = 0.77–1.27, p = 0.94), minor morbidity (OR 0.91, 95% CI = 0.76–1.11, p = 0.36), major morbidity (OR 0.84, 95% CI = 0.67–1.06, p = 0.14), and 30-day mortality (OR 1.05, 95% CI = 0.57–1.95, p = 0.87). Patients who underwent PBS were more likely to have shorter LOS (RR 0.87, 95% CI = 0.81–0.93, p < 0.0001). Conclusion: Contrary to previously reported studies, there was no increased risk of short-term postoperative outcomes after pancreaticoduodenectomy between PBS and N-PBS in a propensity-matched analysis. Preoperative biliary stenting is safe and does not need to be avoided before surgical intervention in patients who present with obstructive jaundice. [ABSTRACT FROM AUTHOR]

Aim and Background: The aim of this study was to compare the efficacy and safety between endoscopic full-thickness resection (EFR) and laparoscopic or surgical resection methods for gastric gastrointestinal stromal tumor (GIST) in size of 5.0 cm or less. Gastric GISTs are common, and resection is the most effective treatment.Method: We retrospectively reviewed 216 resections of gastric GISTs in size of up to 5.0 cm at our center from 2009 to 2017.Eligible resection cases were divided into EFR (n = 85), laparoscopic(n = 64), and surgical (n = 67) groups. The clinical records, patient demographic, symptoms, perioperative data, pathological findings, and long-term follow-up outcomes were collected and compared statistically.Results: No tumor rupture or recurrence occurred in the three groups. The prevalence of complications was significantly lower in EFR (5.9%) than both laparoscopic (7.8%) and surgical group (16.4%) (P < 0.01). In EFR group, the R0 resection rate (95.3%) was significantly lower than in the laparoscopic group and surgical group (100%) (P < 0.001). The hospital cost (OR = 62.79, CI: 12.954-304.363, P < 0.0001) were significantly lower in the EFR than in the laparoscopic group. The hospital cost (OR = 39.032, CI: 8.045-189.371, P < 0.0001) and post-operative diet time (OR = 2.779, CI: 1.225-6.304, P < 0.05) were also significantly lower in the EFR than in the surgical group.Conclusion: EFR was a feasible treatment for gastric GISTs of size of ≤ 5.0 cm with an acceptable complete resection rate. In addition, EFR had significantly fewer postoperative complications, shorter length of hospital stay, and lower cost. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the clinical value of CT angiography (CTA), CT colonography (CTC), and image fusion in the preoperative evaluation of laparoscopic complete mesocolic excision (CME) for right colon cancer.Methods: In this randomized prospective study, 80 patients undergoing laparoscopic CME for right colon cancer were randomly divided into two groups: image fusion [the original images were reconstructed using CTA and CTC, then fused into three-dimensional images of the blood vessels and intestines (n = 40)] and control (without CTA and CTC reconstruction before surgery). All patients underwent plain and enhanced abdominal CT before surgery.Results: In the image fusion group, the gastrocolic trunk of Henle was present in 33 cases, and its branches originated from the colon vein, right gastroepiploic vein, and superior anterior pancreaticoduodenal vein. Among these patients, 5 exhibited the right gastroepiploic vein and superior anterior pancreaticoduodenal vein; 21 exhibited a gastrointestinal trunk consisting of 2 or 3 branches of the right gastroepiploic vein, right colon vein, and middle colon vein; and 7 exhibited 3 or 4 gastro-pancreatic and colon trunks consisting of the right colon vein, middle colon vein, right gastroepiploic vein, and superior anterior pancreaticoduodenal vein. The correspondence with the anatomy actually observed during surgery was 100%. Compared with the conventional CT group, the duration of the operation in the image fusion group was shorter, with reduced intraoperative bleeding, and more lymph node dissection. There were no significant differences in the incidence of complications and length of hospital stay between the two groups (p > 0.05).Conclusions: For laparoscopic CME for right colon cancer, CTA, CTC, and image fusion were effective preoperative evaluation methods, which avoided some unseen dangers in the operation process and led to better therapeutic outcomes. [ABSTRACT FROM AUTHOR]

Background: Although the Clavien-Dindo classification is well established in many fields of surgery, a conclusive severity grading system for liver surgery-specific complications has not yet been standardized. Post-hepatectomy liver Failure, Ascites, Bile leakage, Infection, and Bleeding were found to be the five most important components in an international survey. A score system with FABIB as the acronym was proposed by the authors to increase the feasibility of routine use.Methods: The definition and grading of three components ("liver failure," "bile leakage," and "bleeding") were adopted from the International Study Group for Liver Surgery. The definition and grading for "ascites" as well as "infection" were proposed by the authors. The postoperative complications were documented prospectively. The data from 2012 to 2016 were reviewed and the correlations to other clinical parameters were analyzed retrospectively.Results: Five hundred one consecutive liver resections were assessed. Two hundred twenty-four (44.7%) patients had at least one postoperative complication of the FABIB system. The FABIB score was found to correlate with the operation complexity (major vs minor liver resection, with or without biliodigestive anastomosis), underlying liver disease (normal liver parenchyma vs fibrosis vs cirrhotic liver), 90-day mortality (statistically significantly different within three predefined categories), and the length of hospital stay (the mean value increases proportionately to FABIB score).Conclusion: Using the FABIB reporting system, the five main complications after liver surgery can be documented in a standardized manner. Its clinical relevance might increase the feasibility and comparability of studies or trials in liver surgery. [ABSTRACT FROM AUTHOR]

Background: Cardiopulmonary exercise testing (CPX) can objectively measure fitness and oxygen uptake at anaerobic threshold. The relationship between fitness and postoperative outcomes after upper gastro-intestinal surgery is unclear. The aim of the present review is to assess the prognostic ability of CPX in predicting postoperative outcome associated with oesophagogastric surgery. Methods: Relevant studies were identified through a systematic search of EMBASE, Medline, CINAHL, Cochrane Library, and Web of Science to July 2019. The eligibility criteria for studies included prognostic studies of upper gastro-intestinal surgery among adult populations using a preoperative CPX and measurement of postoperative outcome (mortality or morbidity or length of stay). Risk of bias was assessed using the QUIPS Quality in Prognostic Studies validated tool. Results: Thirteen papers with a total of 1735 participants were included in data extraction. A total of 7 studies examined the association between CPX variables and postoperative mortality. Patients undergoing gastro-intestinal surgery with lower anaerobic threshold values were found to have an increased risk of postoperative mortality. Similarly, a lower rate of oxygen consumption was found to be associated with higher mortality. There was conflicting evidence regarding the association between CPX variables and postoperative morbidity. The evidence did not demonstrate any association between preoperative CPX variables and hospital length of stay. Conclusion: Studies report an association between CPX variables and postoperative mortality; however, there is conflicting evidence regarding the association between CPX variables and postoperative morbidity. [ABSTRACT FROM AUTHOR]

Background: Chewing gum as a form of sham feeding is an inexpensive and well-tolerated means of promoting gastrointestinal motility following major abdominal surgery. Although recognised by the Enhanced Recovery After Surgery (ERAS) Society as one of the multimodal approaches to expedite recovery after surgery, strong evidence to support its use in routine postoperative practice is lacking.Methodology: A comprehensive literature review of all randomised controlled trials (RCTs) was performed in the Medline and Embase databases between 2000 and 2019. Studies were selected to compare the use of chewing gum versus standard care in the management of postoperative ileus (POI) in adults undergoing colorectal surgery. The primary outcome assessed was the incidence of POI. Secondary outcomes included time to passage of flatus, time to defecation, total length of hospital stay and mortality.Results: Sixteen RCTs were included in the systematic review, of which ten (970 patients) were included in the meta-analysis. The incidence of POI was significantly reduced in patients utilising chewing gum compared to those having standard care (RR 0.55, 95% CI 0.39, 0.79, p = 0.0009). These patients also had a significant reduction in time to passage of flatus (WMD - 0.31, 95% CI - 0.36, - 0.26, p < 0.00001) and time to defecation (WMD - 0.47, 95% CI - 0.60, - 0.34, p < 0.00001), without significant differences in the total length of hospital stay or mortality.Conclusion: The use of chewing gum after colorectal surgery is a safe and effective intervention in reducing the incidence of POI and merits routine use alongside other ERAS pathways in the postoperative setting. [ABSTRACT FROM AUTHOR]

Introduction: The value of routine ICU admission after elective surgery has been debated due to the lack of robust evidence supporting its benefit, as well as the increased incurred costs. We sought to analyze outcomes of patients undergoing hepatectomy who were routinely admitted to the intensive care unit (ICU) compared with surgical ward admission.Methods: Patients were identified in the Truven Health Analytics MarketScan Commercial Claims and Encounters Database from 2010 to 2016. Routine postoperative ICU admission was defined as ICU admission for ≤ 24 h on postoperative day 0. Potential association between routine ICU admission with extended length-of-stay (LOS), failure-to-rescue, and total inpatient costs was analyzed.Results: In total 7970 patients underwent hepatectomy; 37.7% (n = 3001) had routine ICU admission and 62.3% (n = 4969) surgical ward admission. Among the 3001 patients who had routine ICU admission, 1137 (37.9%) had a major and 1864 (62.1%) had a minor hepatectomy. Routine ICU admission was not associated with lower failure-to-rescue (routine ICU 4.9% vs. ward 1.8%; p < 0.001). Patients routinely admitted to the ICU had longer median LOS (routine ICU 7 days, IQR 5-15 days vs. ward 5 days, IQR 4-7 days; p < 0.001). Median payments were higher for routine ICU admission than for surgical ward admission ($50,501, IQR $34,270-$80,459 vs. $39,774, IQR $28,555-$58,270, respectively).Conclusion: Routine ICU admission was associated with longer LOS and higher hospital payments, yet did not translate into lower failure-to-rescue among patients undergoing hepatectomy. [ABSTRACT FROM AUTHOR]

Background: Multimodal analgesia protocols are becoming a common part of enhanced recovery pathways after colorectal surgery. However, few protocols include a robust intraoperative component in addition to pre-operative and post-operative analgesics.Method: A prospective cohort study was performed in an urban teaching hospital in patients undergoing minimally invasive colorectal surgery before and after implementation of a multimodal analgesia protocol consisting of pre-operative (gabapentin, acetaminophen, celecoxib), intraoperative (lidocaine and magnesium infusions, ketorolac, transversus abdominis plane block), and post-operative (gabapentin, acetaminophen, celecoxib) opioid-sparing elements. The main outcome measure was use of morphine equivalents in the first 24-h post-operative period.Results: The study cohort (n = 71) included 41 patients before and 30 patients after implementation of a multimodal analgesia protocol. Mean age of the entire study cohort was 47 ± 19.7 years and 46% were male. Patients undergoing surgery post-multimodal analgesia vs. pre-multimodal analgesia had significantly lower use of IV morphine equivalents in first 24-h post-operative period (5.8 ± 6.4 mg vs. 22.8 ± 21.3 mg; p = 0.005) and first 48-h post-operative period (7.6 ± 9.4 mg vs. 42 ± 52.9 mg; p = 0.0008). This reduction in IV morphine equivalent use post-multimodal analgesia was coupled with improved pain scores in the post-operative period. Post-operative hospital length of stay, post-operative ileus, and overall complications were not significantly different between groups.Conclusions: Multimodal analgesia incorporating pre-operative, intraoperative, and post-operative opioid-sparing agents is an effective method for reducing perioperative opioid utilization and pain after minimally invasive colorectal surgery. [ABSTRACT FROM AUTHOR]

Background and Aim: Sarcopenia defined as degenerative loss of skeletal muscle mass associated with aging, represents an objective parameter to measure frailty and to estimate patient's physiologic reserves. It is a robust predictor of post-operative complications in transplantation and major oncologic surgeries. There is no data regarding the prevalence of sarcopenia in chronic pancreatitis or its impact on the outcome of patients undergoing TPIAT for CP. We sought to estimate the prevalence of sarcopenia, its impact on post-operative morbidity and prediction of islet yield and metabolic outcomes in patients undergoing TPIAT. Methods: Adult patients undergoing TPIAT between 2008 and 2018 were identified from our prospectively maintained database and were included if they had CT within 6 months before TPIAT. Skeletal muscle index (SMI) was evaluated by pre-operative CT at the level of L3 vertebra. Sarcopenia was defined as SMI < 52.4 in males and < 38.5 in females. Post-operative morbidity occurring within 90 days after TPIAT was graded as per the validated Clavien-Dindo score. Major post-surgical morbidity was defined as Clavien-Dindo score of IIIa or more. The yield of islets was quantified as islet equivalents (IEQ) and IEQ/kg recipient body weight was calculated. Results: One hundred and thirty-eight patients underwent TPIAT, with 46 (one-third) being classified as having pre-operative sarcopenia based on CT. No significant differences were observed in the incidence of any major surgical complications, length of hospital stay (median (range in days) 111–8 vs. 122–9; p = 0.6) and 30-day readmission rate (7 (15.2%) vs, 2 (2.2%); p = 0.5) between sarcopenic and non-sarcopenic patients. More patients with sarcopenia needed to be discharged to residential rehabilitation facility compared with non-sarcopenic patients (7 (15.2%) vs. 2 (2.2%), p = 0.007). Sarcopenia (OR 7.4 (95% CI 1.32–41.24); p = 0.023) and presence of calcification (OR 5.5 (95% CI 0.94–32.19); p = 0.05) were independent predictors of low islet yield (< 2500 IEQ/kg) on multivariate analysis. Conclusion: Sarcopenia is frequent in CP patients undergoing TPIAT, but not readily recognized by standard anthropometric measurement. Sarcopenia was associated with increased chance of discharge to a residential rehabilitation facility and with a poor islet yield during TPIAT. It is therefore critical to optimize nutrition prior to TPIAT surgery in CP patients. [ABSTRACT FROM AUTHOR]

Background: Emergency laparotomy for small bowel pathologies comprises a significant number of all emergency surgeries. Application of evidence-based adapted enhanced recovery after surgery (ERAS) protocol can potentially improve the perioperative outcome in these procedures.Aims: To determine the feasibility, safety, and efficacy of adapted ERAS pathway in emergency small bowel surgery.Methodology: This was a single-center, prospective, open-labeled, superiority, randomized controlled trial. Patients suspected to have small bowel pathology by the emergency surgical team were randomized preoperatively into standard care and adapted ERAS group. Patients with American Society of Anesthesiologist class ≥ 3, polytrauma patients with associated other intra-abdominal organ injuries, duodenal ulcer perforations, patients presenting with refractory shock, and pregnant patients were excluded. Primary outcome parameter was the length of hospitalization (LOH). Morbidity and other functional recovery parameters were also assessed.Results: Thirty-five patients were included in the adapted ERAS and standard care group. The laboratory and demographic variables were comparable. Patients in the ERAS group had significantly earlier recovery (days) in terms of first fluid diet (1.48 ± 0.18, p < 0.001), solid diet (2.11 ± 0.17, p < 0.001), time to first flatus (1.25 ± 0.24, p < 0.001), and first stool (1.8 ± 0.27, p < 0.001). Postoperative nausea, vomiting (RR 0.69, p = 0.19), pulmonary complications (RR 0.38, p = 0.16), superficial (RR 0.79, p = 0.33), and deep surgical site infections (RR 0.65, p = 0.39) were similar. Compared with the standard care group, ERAS group had significantly shorter LOH (8 ± 0.38 vs. 10.83 ± 0.42; Mean difference, 2.83 ± 0.56; p < 0.001).Conclusion: Adapted ERAS pathways are feasible, safe, and significantly reduces the LOH in select patients undergoing emergency small bowel surgery. [ABSTRACT FROM AUTHOR]

Purpose: Postoperative length of stay (PLOS) and readmission rate are pancreatoduodenectomy (PD) outcome measures, which are reported individually but may be interrelated. The purpose of this study was to evaluate how well a composite length of stay measure (CLOS) that included PLOS and readmission length of stay describes outcomes. To do so, we evaluated how well CLOS correlated to postoperative complications absolutely and compared to PLOS.Methods: A total of 668 PDs performed between 2011 and 2018 were evaluated. CLOS was calculated from PLOS and readmission length of stay. Complication severity was judged by the Modified Accordion Grading System (MAGS). Multinomial logistical regression models (MLRM) were used to investigate the relationship between either PLOS or CLOS and complications. Multilevel and pairwise area under curves (AUC) using SAS macro %MultAUC were provided for both models.Results: A total of 432 of 668 patients (65%) developed complications. One hundred seventy-seven patients (27%) were readmitted. Mean PLOS was 10.2 days (7.1 SD) and mean CLOS was 12.3 days (10.1 SD). PLOS and CLOS both were correlated linearly to MAGS grade. Spearman correlation coefficient for CLOS vs. MAGS of 0.68 was higher than that of 0.49 for PLOS vs. MAGS. Multilevel AUC from MLRM using PLOS was 0.66, but multilevel AUC from MLRM using CLOS was 0.71.Discussion: CLOS provides an accurate estimate of hospital day utilization per patient for PD, reflecting not only the basal hospital recovery time for PD but the added time needed because of readmissions due to complications. It is tightly correlated to number and severity of postoperative complications. [ABSTRACT FROM AUTHOR]

Purpose: To identify discrepancies between intraoperative and histological evaluations of the appendix in acute appendicitis and to evaluate the effect on surgical outcome.Methods: Data was used from our previous multicentre, prospective, cohort study of patients with suspected acute appendicitis. Appendices were scored during intraoperative and histological evaluation as uncomplicated or complicated appendicitis. Primary outcome was percentage of concordance between intraoperative and histological evaluation. Secondary outcomes were (infectious) postoperative complications, length of hospital stay, hospital re-admission and re-intervention rate, all within 30 days of surgery.Results: A total of 1850 patients were included. In 65.7% (1215/1850) of the appendices, the intraoperative evaluation was uncomplicated and in 34.3% (635/1850), complicated appendicitis. Patients with uncomplicated appendicitis had a postoperative course with significantly less postoperative complications (7.2% vs 24.3%), a shorter length of hospital stay (2 vs 5 days) and a lower re-admission (4.2% vs 9.6%) and re-intervention rate (1.1% vs 4.3%) than intraoperative complicated appendicitis (p < 0.001). In 93.5% (1136/1215) of the intraoperative uncomplicated patients and in 46.6% (296/635) of the intraoperative complicated patients, there was an agreement with pathology (Kappa 0.45). In 23.9% (81/339) of patients with intraoperative complicated and histological uncomplicated appendicitis, a postoperative complication was observed, which was similar to the postoperative complication rate of complicated appendicitis both on intraoperative and histological evaluation (24.7% (73/296)).Conclusions: There is a moderate agreement between a surgeon and pathologist in diagnosing patients with complicated appendicitis. However, the intraoperative diagnosis of complicated appendicitis was significantly associated with postoperative complications. Routine histological evaluation should be preserved for excluding malignancies in suspect appendices. [ABSTRACT FROM AUTHOR]

Background: A reduced-port approach including single-site surgery has been used for distal pancreatectomy. However, triangulation is difficult in reduced-port laparoscopic distal pancreatectomy, and instrument crowding, and collision may occur, so this approach has not been widely used. Recently, an innovative technique for distal pancreatectomy using a robotic single-site surgical system was introduced. Herein, we evaluate the safety and feasibility of this technique.Methods: Twenty-seven patients with a pancreatic tail mass underwent robotic single-site plus one-port distal pancreatectomy at six centers. We collected clinicopathologic data and evaluated the short-term perioperative outcomes of robotic single-site plus one-port distal pancreatectomy.Results: We evaluated 26 patients who underwent robotic single-site plus one-port distal pancreatectomy excluding one patient who needed more ports because of fatty abdomen. The mean age and body mass index were 47.3 years (range 21-74) and 22.6 kg/m2 (range 15.8-28.8), respectively. The most common pathologic diagnosis was solid papillary neoplasm followed by a neuroendocrine tumor. The mean operating time was 201 min. The mean length of hospital stay after surgery was 7 days (range 4-10). The rate of spleen preservation was 34.6% (9/26). Six patients had postoperative pancreatic fistula (POPF) grade A, and no patients had POPF grade B or C. Only one patient had class II morbidity.Conclusion: Robotic single-site plus one-port distal pancreatectomy is safe and feasible in terms of short-term outcomes. This technique could be performed in select cases to expand the surgical boundaries of the robotic single-site platform. Further studies are needed with more cases to investigate long-term outcomes. [ABSTRACT FROM AUTHOR]

Background: The optimal timing for early laparoscopic cholecystectomy (ELC) in patients with acute calculous cholecystitis (ACC) is still controversial. The aim of this study was to assess the outcomes of ELC in patients with delayed presentation.Methods: Retrospective analysis of 381 patients who underwent ELC for ACC between January 2010 and September 2018. Included patients were classified into two groups according to the timing of surgery from the onset of symptoms: group 1 (G1) within the first 7 days and group 2 (G2) beyond 7 days.Results: There were no significant differences regarding conversion rate (G1 8.6% vs. G2 11.8%; p = 0.527), operative time (G1 100 min [75-120] vs. G2 120 min [71-150]; p = 0.060), bile duct injuries (G1 0.3% vs. G2 0%; p = 1), major postoperative complications (G1 11% vs. G2 5.9%; p = 0.557), reoperation rates (G1 1.4% vs. G2 0%; p = 1), length of stay (G1 4 days [3-7] vs. G2 5 days [3-7]; p = 0.539), readmissions (G1 3.7% vs. G2 5.9%; p = 0.633) and costs (G1 6035 € [3693-8330] vs. G2 7243 € [4921-11,336]; p = 0.395).Conclusion: ELC may be considered for patients with ACC who can tolerate surgery with more than 1 week of symptom duration. [ABSTRACT FROM AUTHOR]

Introduction: Laparoscopic paraesophageal hernia (PEH) is associated with a low morbidity and mortality but an objective hernia recurrence rate in excess of 50% at 5 years. Biologic mesh has not been shown to reduce hernia recurrence rates. Recently, a new bioresorbable mesh made with poly-4-hydroxybutyrate with a Sepra-Technology coating on one side (Phasix-ST mesh) has become available. The aim of this study was to evaluate the feasibility, safety, and short-term efficacy of Phasix-ST mesh for reinforcement of the primary crural closure in patients undergoing elective, laparoscopic PEH repair.Methods: A prospective database was initiated and maintained for all patients undergoing PEH repair with the use of Phasix-ST mesh. We retrospectively reviewed the records of consecutive patients who had an elective, first-time laparoscopic PEH repair with Phasix-ST mesh and who completed their 1-year objective follow-up study. Patients having a reoperation, non-laparoscopic repair, or who failed to comply with the objective follow-up were excluded.Results: To achieve the desired 50 patients with 1-year objective follow-up, we reviewed the records of 90 consecutive PEH patients. In the final cohort of 50 patients, there were 32 females (64%) and 18 males. The median age of the patients at surgery was 67 years (range 44-84). The operation was PEH repair with fundoplication alone in 29 patients (58%) and PEH repair with Collis gastroplasty and fundoplication in 21 patients (42%). Phasix-ST mesh was used for crural reinforcement in all patients, and there were no intraoperative issues with the mesh or any difficulty placing or fixating the mesh at the hiatus. A diaphragm relaxing incision was performed in 2 patients (4%). The mean length of hospital stay was 2.8 days, and there was no major morbidity or mortality. On the 1-year objective follow-up study (median 12 months) a recurrent hernia was found in 4 patients (8%). No patient that had a Collis gastroplasty or a relaxing incision had a recurrent hernia. No patient had a reoperation. No patient had a mesh infection or mesh erosion.Conclusions: Phasix-ST mesh reinforcement of the crural closure during laparoscopic primary, elective PEH repair was associated with no adverse mesh-related events such as infection or erosion. Phasix-ST crural reinforcement in combination with tension-reduction techniques when necessary resulted in a very low (8%) objective hernia recurrence rate at a median follow-up of 1 year. These results demonstrate the safety of Phasix-ST mesh for use at the hiatus for crural reinforcement. This safety, along with the encouraging short-term efficacy for reducing hernia recurrence, should encourage further studies using the combination of resorbable biosynthetic mesh crural reinforcement and tension-reducing techniques during repair of paraesophageal hernias. [ABSTRACT FROM AUTHOR]

Objective: To compare the efficacy of omentoplasty with non-omentoplasty in the prevention of postoperative anastomotic leakage, and to investigate the safety of omentoplasty.Methods: Literature searches were performed of the Medline, EMBASE, and Cochrane Library databases. Studies that compared the efficacy of omentoplasty and non-omentoplasty after esophagectomy were selected. A meta-analysis was performed on anastomotic leakage, anastomotic stenosis, hospital mortality, and length of hospital stay. Results were reported as odds ratio (OR), weighted mean difference (WMD), or relative risk (RR), with 95% confidence intervals.Results: Six studies involving a total of 1608 patients met inclusion criteria. Compared with the non-omentoplasty group, the incidence of anastomotic leakage in the omentoplasty group (OR, 0.37; 95% CI, 0.23-0.60; P < 0.0001) was significantly reduced and the length of hospital stay (WMD, 2.13; 95% CI, 3.57-0.69; P = 0.004) was significantly shortened. However, there was no significant difference in the incidence of anastomotic strictures (OR, 0.82; 95% CI, 0.37-1.80; P = 0.61) or in-hospital mortality (OR, 0.61; 95% CI, 0.25-1.51; P = 0.29).Conclusions: Omentoplasty after esophagectomy is a safe and effective method to prevent anastomotic leakage. [ABSTRACT FROM AUTHOR]

Background: Potential advantages of laparoscopic sigmoidectomy for perforated diverticulitis are still under consideration. This study is designed to determine if emergent laparoscopic sigmoidectomy for perforated diverticulitis is associated with outcomes comparable to the traditional open approach.Methods: The American College of Surgeons-National-Surgical-Quality-Improvement-Program (ACS-NSQIP) database was queried for laparoscopic and open emergent sigmoidectomy cases for perforated diverticulitis from 2012 through 2017. Using propensity score weights, 30-day outcomes between laparoscopic and open approaches were compared in two ways: one with converted cases as a separate group and another with converted cases combined with the laparoscopic-completed group (intention-to-treat).Results: A total of 3756 cases met inclusion criteria-282 laparoscopic-completed, 175 laparoscopic-converted-to-open, and 3299 open. The laparoscopic-completed approach had significantly better outcomes than open and laparoscopic-converted cases. When combining laparoscopic-completed and laparoscopic-converted cases (intention-to-treat), the laparoscopic approach still had significantly fewer complications per patient, less unplanned intubation (p = 0.01), and acute renal failure (p = 0.005) than the open group. Laparoscopic groups had longer operating times and shorter hospital length of stay than the open group. Subgroup analysis comparing laparoscopic and open Hartmann's procedure and primary anastomosis with and without diverting stoma also showed favorable outcomes for the laparoscopic group.Conclusions: Laparoscopic emergent sigmoid resection for perforated diverticulitis is associated with favorable outcomes compared to the open approach. Hartmann's procedure is still common and conversion rate is high. Training efforts that increase adoption of minimally invasive surgery and decrease conversion rates are justified. Randomized trials comparing laparoscopic and open approaches may allow further critical assessment of these findings. [ABSTRACT FROM AUTHOR]

Background: Enhanced recovery after surgery (ERAS) is a multimodal perioperative care pathway designed to achieve early recovery by preserving preoperative organ function and minimizing the stress response following surgery. Few studies have assessed the association between ERAS and postoperative cardiac complications. The goal of this study is to evaluate the impact of ERAS on postoperative cardiac complications.Materials and Methods: A retrospective review of a prospectively maintained database of colorectal patients who underwent surgery at a tertiary colorectal cancer referral center was carried out. Preoperative, intraoperative, and postoperative factors including demographics, comorbidities, medications, and fluid administration were recorded. The primary outcome was postoperative cardiac arrhythmia, and secondary outcomes included other postoperative complications.Results: A total of 800 patients who underwent elective colorectal surgery were identified. Four hundred seventeen patients (52%) were in the control group and 383 patients (48%) were in the ERAS group. Patients in both groups were similar with regard to demographics and clinical characteristics. There were significantly higher rates of cardiac arrhythmia in the control group (5.3%) compared with the ERAS group (1.8%), p = 0.009. Multivariable analysis revealed that ERAS was an independent predictor of decreased postoperative cardiac arrhythmia (OR 0.30, 95%CI 0.17-0.55, p < 0.001) while older age was an independent predictor of increased postoperative cardiac arrhythmia (OR 1.08, 95%CI 1.02-1.13, p = 0.008). Patients receiving lower amounts of intravenous fluids had significantly decreased postoperative cardiac arrhythmia (OR = 0.25, 95%CI 0.09-0.67, p = 0.006).Conclusions: ERAS and goal-directed fluid therapy are associated with significant reductions in postoperative cardiac arrhythmias. [ABSTRACT FROM AUTHOR]

Background: Screening high-risk individuals (HRI) can detect potentially curable pancreatic ductal adenocarcinoma (PDAC) and its precursors. We describe the outcomes of high-risk individuals (HRI) after pancreatic resection of screen-detected neoplasms.Methods: Asymptomatic HRI enrolled in the prospective Cancer of the Pancreas Screening (CAPS) studies from 1998 to 2014 based on family history or germline mutations undergoing surveillance for at least 6 months were included. Pathologic diagnoses, hospital length of stay, incidence of diabetes mellitus, operative morbidity, need for repeat operation, and disease-specific mortality were determined.Results: Among 354 HRI, 48 (13.6%) had 57 operations (distal pancreatectomy (31), Whipple (20), and total pancreatectomy (6)) for suspected pancreatic neoplasms presenting as a solid mass (22), cystic lesion(s) (25), or duct stricture (1). The median length of stay was 7 days (IQR 5-11). Nine of the 42 HRI underwent completion pancreatectomy for a new lesion after a median of 3.8 years (IQR 2.5-7.6). Postoperative complications developed in 17 HRI (35%); there were no perioperative deaths. New-onset diabetes mellitus after partial resection developed in 20% of HRI. Fourteen PDACs were diagnosed, 11 were screen-detected, 10 were resectable, and 9 had an R0 resection. Metachronous PDAC developed in remnant pancreata of 2 HRI. PDAC-related mortality was 4/10 (40%), with 90% 1-year survival and 60% 5-year survival, respectively.Conclusions: Screening HRI can detect PDAC with a high resectability rate. Surgical treatment is associated with a relatively short length of stay and low readmission rate, acceptable morbidity, zero 90-day mortality, and significant long-term survival.Clinical Trial Registration Number: NCT2000089. [ABSTRACT FROM AUTHOR]

Background: Enhanced recovery after surgery (ERAS) protocols are evidence-based, multimodal and patient-centred approach to optimize patient care and experience during their perioperative pathway. It has been shown to be effective in reducing length of hospital stay and improving clinical outcomes. However, evidence on its effective in liver surgery remains weak. The aim of this review is to investigate clinical benefits, cost-effectiveness and compliance to ERAS protocols in liver surgery.Methods: A systematic literature search was conducted using CINAHL Plus, EMBASE, MEDLINE, PubMed and Cochrane for randomized control trials (RCTs) and cohort studies published between 2008 and 2019, comparing effect of ERAS protocols and standard care on hospital cost, LOS, complications, readmission, mortality and compliance.Results: The search resulted in 6 RCTs and 21 cohort studies of 3739 patients (1777 in ERAS and 1962 in standard care group). LOS was reduced by 2.22 days in ERAS group (MD = -2.22; CI, -2.77 to -1.68; p < 0.00001) compared to the standard care group. Fewer patients in ERAS group experienced complications (RR, 0.71; 95% CI, 0.65-0.77; p = < 0.00001). Hospital cost was significantly lower in the ERAS group (SMD = -0.98; CI, -1.37 to - 0.58; p < 0.0001).Conclusion: Our review concluded that the introduction of ERAS protocols is safe and feasible in hepatectomies, without increasing mortality and readmission rates, whilst reducing LOS and risk of complications, and with a significant hospital cost savings. Laparoscopic approach may be necessary to reduce complication rates in liver surgery. However, further studies are needed to investigate overall compliance to ERAS protocols and its impact on clinical outcomes. [ABSTRACT FROM AUTHOR]

Background: Nationally, Medicaid enrollees with emergency surgical conditions experience worse outcomes overall when compared with privately insured patients. The goal of this study is to investigate disparities in the treatment of cholecystitis based on insurance type and to identify contributing factors.Methods: Adults with cholecystitis at a safety-net hospital in Central Massachusetts from 2017-2018 were included. Sociodemographic and clinical characteristics were compared based on Medicaid enrollment status (Medicare excluded). Univariate and multivariate analyses were used to compare the frequency of surgery, time to surgery (TTS), length of stay (LOS), and readmission rates between groups.Results: The sample (n = 203) included 69 Medicaid enrollees (34%), with a mean age of 44.4 years. Medicaid enrollees were younger (p = 0.0006), had lower levels of formal education (high school diploma attainment, p < 0.0001), were more likely to be unmarried (p < 0.0001), Non-White (p = 0.0012), and require an interpreter (p < 0.0001). Patients in both groups experienced similar rates of laparoscopic cholecystectomy, TTS, and LOS; however, Medicaid enrollees experienced more readmissions within 30 days of discharge (30.4% vs 17.9%, p < 0.001).Conclusion: Despite anticipated population differences, the treatment of acute cholecystitis was similar between Medicaid and Non-Medicaid enrollees, with the exception of readmission. Further research is needed to identify patient, provider, and/or population factors driving this disparity. [ABSTRACT FROM AUTHOR]

Background: Bundled payments are increasingly becoming common in surgery, yet little is known regarding their potential impact on reimbursements for patients presenting with acute appendicitis. This study examines the financial impact of bundled payments for acute appendicitis.Methods: This was a retrospective review of all open or laparoscopic appendectomies between July 2014 and June 2017. Patients that were not candidates for surgery were not included in this review.Results: Of the total 741 patients, 42.1% were diagnosed with complicated acute appendicitis. The median length of stay was 1 day (range, 0 to 21 days). The median hospital cost was $4183 (range, $2075 to $71,023). The 90-day readmission rate was 3.2%, with a mean cost of $5025 per readmission (range, $1595 to $10,795). Length of stay, hospital costs, and 90-day readmissions were significantly higher for complicated versus uncomplicated acute appendicitis. In our current fee-for-service model, hospital reimbursements resulted in margins of - 4.0% to 24.6% depending on the severity of disease. If we assume that bundled payments do not reimburse for readmissions, we estimate that our hospital would incur losses of - 5.7% for patients with acute appendicitis with localized peritonitis and - 20.2% for patients with acute appendicitis with generalized peritonitis.Conclusions: As bundled payments become more common, hospitals may incur significant losses for acute appendicitis under a model that does not reflect the heterogeneous nature of patients requiring appendectomies. These losses can range up to - 20.2% for complicated cases. Improving clinical outcomes by reducing readmissions may mitigate some of these anticipated losses. [ABSTRACT FROM AUTHOR]

Background: Ulcerative colitis (UC) is primarily medically managed. Colectomy is required in patients with refractory disease or severe complications. Older studies have reported 20-year colectomy rates of over 50%, but recent studies showed decreased rates to 15%. Temporal trends in the use of colectomy in UC over the past decade (when the use of biologics has become widespread) are lacking.Methods: Case-control study using the National Inpatient Sample database for years of 2007, 2010, 2013, and 2016 was performed. The primary outcome was determining the temporal trends in the use of colectomy in hospitalized patients with UC. Secondary outcomes were determining the total number of admissions for patients with UC and associated trend in inflation-adjusted hospital costs, charge, and length of hospital stay (LOS). Multivariate regression analyses were used to adjust for other co-variables.Results: 443,043 patients with UC were identified, of which 19,208 underwent colectomy in the study period. The mean patient age was 52 years, and 47% were female. Five percent of hospitalized patients with UC underwent colectomy in 2007, while 2.7% of patients with UC had colectomy in 2016, representing a 46% decrease in colectomies in hospitalized patients in the study period. Patients with UC displayed adjusted odds of colectomy of 0.51 (p < 0.01), adjusted additional mean hospital costs decrease by - $2898 (p < 0.01), hospital charges increase by $26,554 (p < 0.01), LOS decrease by - 2.2 days (p < 0.01) in 2016 compared to 2007.Conclusion: The odds of colectomy in UC patients decreased significantly over the past decade, likely secondary to improved medical care. [ABSTRACT FROM AUTHOR]

Background: Adhesive small bowel obstruction (ASBO) is a common post-operative cause of hospitalisation. Water-soluble contrast media (WSCM) has become a popular non-surgical approach to treatment. However, previous reviews have concluded with conflicting results. This meta-analysis of randomised controlled trials (RCTs) re-evaluated the therapeutic value of WSCM in the management of ASBO.Methods: A comprehensive search of PubMed, Embase, and Cochrane databases was undertaken to identify RCTs from January 2000 to November 2018. The primary outcomes of length of stay and secondary outcomes of time to resolution, need for surgery, and mortality were extracted from the included studies. Quantitative pooling of the data was based on the random effects model.Results: Eight hundred and seventy-nine patients from the nine studies were included in the analysis. The administration of oral WSCM reduced the length of hospital stay (weighted mean difference - 0.15 days, P < 0.0001). However, WSCM does not reduce the need for surgery (relative risk 0.84, P < 0.009) and makes no difference to mortality rate (RR 0.99, P < 1.000). The definition of time to resolution of ASBO differed between the studies, ranging from time to passing flatus, to cessation of abdominal pain, and time to initiating oral intake. The significant differences in definition precluded meaningful quantitative pooling of this outcome.Conclusions: This meta-analysis evaluating the therapeutic value of WSCM has shown that it does not reduce the need for operative management in ASBO or impact mortality rates. It shortens hospital stay by 0.15 days (3.6 h) which is not clinically significant. [ABSTRACT FROM AUTHOR]

Background: Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) represents a new surgical technique for the resection of advanced hepatic malignancies with predicted insufficient future liver remnant. In some patients, ALPPS can be associated with an increased risk of poor outcomes. Minimally invasive surgery (MIS) has been proposed in combination with ALPPS with the intent to minimize this risk. We systematically evaluated the outcomes of MIS-ALPPS cases to compare the relative outcomes of open ALPPS versus MIS-ALPPS.Methods: A systematic review was done in accordance with the PRISMA guidelines. Search terms utilized included the following: ("ALPPS"[Title/Abstract] OR "associating liver partition and portal vein ligation for staged hepatectomy"[Title/Abstract] OR "in situ split"[Title/Abstract]) AND ("minimally invasive"[Title/Abstract] OR "laparoscopic"[Title/Abstract] OR "robotic"[Title/Abstract]).Results: Fifteen articles were identified, with a total of 27 patients reported. Colorectal metastatic disease was the most commonly observed indication for MIS-ALPPS (66.7%), followed by hepatocellular carcinoma (25.9%). Time passed from the first to the second stage ranged 7-30 days. MIS-ALPPS patients did not experience procedure failures between the first and second stages. Only four (15.4%) subjects had a grade IIIb complication. No perioperative mortality after the first or second stage was reported. Compared with open ALPPS, MIS-ALPPS demonstrated better results. Hospital stay duration ranged 8-33 days with a follow-up ranging 1-20 months.Conclusions: MIS-ALPPS appears to be safe, with potentially lower morbidities and mortalities relative to open patients. The present results should be considered with caution. A limited number of articles exist on this topic. Furthermore, selection biases exist when comparing open versus MIS-ALPPS data. Registry studies are needed to better define the outcomes of patients undergoing MIS-ALPPS. [ABSTRACT FROM AUTHOR]

Background: Emergent laparoscopic transcystic common bile duct exploration (LTCBDE) has been reported to be on the increase in some institutions, reflecting the growing confidence with the technique. However, no study has focused on the outcomes of LTCBDE in the non-elective setting. The aim of this study is to investigate whether LTCBDE can be performed effectively and safely in the emergency.Methods: This is a retrospective study of 500 consecutive patients with choledocholithiasis subjected for LTCBDE at the Hospital Italiano de Buenos Aires from January 2009 to January 2018. Procedures were classified according to the setting as emergent or elective. Demographic data and perioperative parameters were compared between groups.Results: Throughout the period comprised, 500 patients were admitted for choledocholithiasis and gallstones. A single-step treatment combining LTCBDE and laparoscopic cholecystectomy was attempted: 211 (42.2%) were performed electively and the 289 (57.8%) as an emergency. There was no significant difference in the success rate of LTCBDE (93.9% versus 93.8%, p = 0.975) for the two groups. The operative time was slightly longer in the emergency group (122 ± 63 versus 106 ± 53 min, p = 0.002). Postoperative recovery was slower in the emergency group, as reflected by a higher rate of prolonged postoperative stay (21.1% vs 5.7%, p < .001). The rates of postoperative complications were similar between groups (2.8% vs 5.9%, p = 0.109).Conclusion: Emergent LTCBDE can be performed with equivalent efficacy and morbidity when compared to an elective procedure. Patients undergoing emergent procedures have longer procedures and hospital stays. [ABSTRACT FROM AUTHOR]

Background: Gastric per oral endoscopic myotomy (G-POEM) is a recently developed incisionless procedure to address gastroparesis. It has been previously described to treat medical and postsurgical gastroparesis. The present study is a case series of patients undergoing G-POEM for a variety of indications, both elective and urgent.Methods: IRB approval was obtained for retrospective review of a prospectively collected database including patients who underwent G-POEM during a 1.5-year period. Using an upper endoscope, a mucosotomy is made 2 cm proximal to the pylorus on the anterior surface of the stomach. A submucosal tunnel is made to the pylorus muscle, which is completed incised. When possible, Endoflip® was used to evaluate pyloric distensibility before and after the myotomy. Patient demographic factors, additional procedures, and other follow-up were collected by chart review. Elective cases were offered repeat gastric emptying study at 6 months.Results: There were 17 patients available for review. The procedure was technically completed in all cases. There was one gastric perforation recognized on postoperative day two that was addressed with laparoscopy and omental patch. Median length of stay was zero days, and 13/17 (76%) of patients experienced symptomatic relief. Pyloric distensibility significantly decreased intraoperatively from 5.6 (± 1.7) to 10.8 (± 5.0) cm2/mmHg (p = 0.002).Conclusion: This limited case series demonstrates G-POEM to be a versatile procedure able to address gastroparesis in a variety of settings. Success rates are congruent with previously published reports, and one serious complication was able to be addressed laparoscopically. Endoflip® was able to verify a successful myotomy intraoperatively. This procedure is an attractive alternative to less effective non-invasive treatments and a more invasive laparoscopic pyloroplasty. [ABSTRACT FROM AUTHOR]

Background: Urgent abdominal operations commonly occurred in low-volume hospitals with high failure-to-rescue rates. Recent studies have demonstrated a survival benefit associated with readmission to the original hospital after operation, presumably due to improved continuity of care. It is unclear if this survival benefit persists in low-volume hospitals. We seek to evaluate differences in mortality between readmission to the original hospital and a higher-volume hospital after urgent abdominal operations.Methods: A retrospective cohort study using the National Readmissions Database from 2010 to 2014 was performed. Propensity score-weighted multilevel regression analysis was used to examine the association between readmission destination and mortality after accounting for hospital volume.Results: A total of 71,551 adult patients who experienced 30-day readmission following urgent abdominal operations were identified, among whom 10,368 (14.5%) were readmitted to a different hospital. Patients with higher baseline comorbidity scores, lower income, less comprehensive insurance coverage, systemic complications, prolonged length of stay, or non-home disposition were more likely to experience readmission to a different hospital. Following stratification by readmission hospital volume and propensity score weighting to adjust for baseline mortality risk differences, readmission to a different hospital is still associated with higher mortality rates than the original hospital.Conclusions: The adverse outcomes associated with case fragmentation are present even after adjusting for readmission hospital volume. Patients who received urgent abdominal operations at low-volume hospitals should return to the original hospital for concern of care fragmentation. [ABSTRACT FROM AUTHOR]

Background: Passage of flatus after abdominal surgery signals resolution of physiological postoperative ileus (POI) and often, particularly after complex open surgeries, serves as the trigger to initiate oral feeding. To date, there is no objective tool that can predict time to flatus allowing for timely feeding and optimizing recovery. In an open, prospective study, we examine the use of a noninvasive wireless patch system that measures electrical activity from gastrointestinal smooth muscles in predicting time to first flatus.Methods: Eighteen patients who underwent open abdominal surgery at El Camino Hospital, Mountain View, CA, were consented and studied. Immediately following surgery, wireless patches were placed on the patients' anterior abdomen. Colonic frequency peaks in the spectra were identified in select time intervals and the area under the curve of each peak times its duration was summed to calculate cumulative myoelectrical activity.Results: Patients with early flatus had stronger early colonic activity than patients with late flatus. At 36 h post-surgery, a linear fit of time to flatus vs cumulative colonic myoelectrical activity predicted first flatus as much as 5 days (± 22 h) before occurrence.Conclusions: In this open, prospective pilot study, noninvasive measurement of colon activity after open abdominal surgery was feasible and predictive of time to first flatus. Interventions such as feeding can potentially be optimized based on this prediction, potentially improving outcomes, decreasing length of stay, and lowering costs. [ABSTRACT FROM AUTHOR]

Background: Minimally invasive resection for upper gastrointestinal tumors has been associated with favorable results. However, the role of laparoscopic surgery (LS) in the multimodal treatment of patients with advanced adenocarcinoma of the stomach or gastroesophageal junction needs further investigation.Methods: Clinicopathological data of patients who underwent gastrectomy between 2005 and 2017 were assessed. Outcomes of patients undergoing LS were compared with those of patients treated with a conventional open resection (OR) using a 1:1 propensity score matching analysis.Results: Curative resection for adenocarcinoma of the stomach or gastroesophageal junction was performed in 417 patients during the study period. Beginning in June 2014, the majority of patients underwent LS (n = 72) and they were matched with 72 patients who were treated with an OR. The majority of patients treated with LS (89%) had advanced cancer (UICC stages II and III) and 82% of them received neoadjuvant chemotherapy. LS was significantly associated with a higher number of harvested lymph nodes (26 (9-62) vs. 21 (4-46), P = .007), a lower 90-day major complication rate (13 vs. 26%, P = .035), and a lower length of hospital stay (14 vs. 16 days, P = .001). After a median follow-up time of 32 months, 1-year overall survival rate was higher after LS than after OR (93 vs. 74%, P = .126); however, results did not reach statistical significance.Conclusion: LS for adenocarcinoma of the stomach or gastroesophageal junction is feasible and significantly reduces major postoperative morbidity resulting in a reduced length of hospital stay. Therefore, LS should be preferably considered for the curative treatment of patients with these malignancies. [ABSTRACT FROM AUTHOR]

Background: Extended lymph node dissection (ELND) remains an important component of curative intent resection of mid-stage gastric cancer (GC). Benefits include enhanced staging accuracy, extending regional disease control, and optimizing potential curability. ELND during gastrectomy remains underutilized in US centers due to a low prevalence of GC operations.Methods: The traditional en bloc ELND was modified into a two-step technique to facilitate greater ease of dissection with better exposure. After completion of the gastrectomy component, retrogastric nodes are dissected in a separate, contiguous specimen. Resulting data were compared to outcomes after en bloc resection.Results: Of 179 consecutive patients undergoing gastrectomy, 129 underwent an ELND (73%). There were 97 men and 32 women, with a median age of 64 years (range 24-98). The median total LN count was 25 (3-86). The two-step dissection yielded an average of 18.3 (± 8.5 S.D.) perigastric and 12.1 (± 5.8) retrogastric nodes. Two-step LND was associated with lower estimated blood loss (265 vs. 448 ml, p = 0.0005), lower transfusion requirements (6 vs. 28%, p = 0.007), greater mean total LN counts (30 vs. 26, p = 0.03), and a greater rate of obtaining at least 15 or 20 LNs (91 vs. 77% and 83 vs. 65%, p = 0.05). Major morbidity (overall 16%), length of stay, and survival outcomes were not different.Conclusions: The two-step LND technique as described was found to be associated with favorable operative and postoperative outcome parameters and an excellent LN yield. It can be recommended for standard ELND indications in the absence of macroscopically abnormal LNs. [ABSTRACT FROM AUTHOR]