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Patients with Crohn’s disease (CD) are at a considerable risk for intestinal surgery. Approximately 25% of patients with CD will undergo an intestinal resection within 10 years of diagnosis. Postoperative complications after CD surgery have been reported in 20%-47% of the patients. Both general and CD-related risk factors are associated with postoperative complications, and comprise non-modifiable (e.g., age) and potentially modifiable risk factors (e.g., malnutrition). Prehabilitation focuses on the preoperative period with strategies designed to optimize modifiable risk factors concerning the physical and mental condition of the individual patient. The aim of prehabilitation is to enhance postoperative recovery and return to or even improve preoperative functional capacity. Preoperative improvement of nutritional status, physical fitness, cessation of smoking, psychological support, and critical revision of preoperative use of CD medication are important strategies. Studies of the effect on postoperative outcome in CD patients are scarce, and guidelines lack recommendations on tailored management. In this opinion review, we review the current evidence on the impact of screening and management of nutritional status, physical fitness, CD medication and laboratory values on the postoperative course following an intestinal resection in CD patients. In addition, we aim to provide guidance for individualized multimodal prehabilitation in clinical practice concerning these modifiable factors.

Prolonged postoperative mechanical ventilation (PPMV) increases length of stay, hospitalization costs, and postoperative complications. Independent risk factors associated with PPMV are not well-known for children.We identified children (18 years) in the ACS NSQIP-P database who underwent a general surgical abdominal operation. We excluded children with preoperative ventilator dependence and mortality within 48 h of surgery. PPMV was defined as cumulative postoperative mechanical ventilation exceeding 72 h. A multivariable logistic regression model identified independent predictors of PPMV.We identified 108,392 children who underwent a general surgical abdominal operation in the ACS NSQIP-P database from 2012 to 2017. We randomly divided the population into a derivation cohort of 75,874(70%) and a validation cohort of 32,518(30%). In the derivation cohort, we identified PPMV in 1,643(2.2%). In the multivariable model, the strongest independent predictor of PPMV was neonatal age (OR:20.66; 95%CI:16.44-25.97). Other independent risk factors for PPMV were preoperative inotropic support (OR:10.56; 95%CI:7.56-14.77), an operative time longer than 150 min (OR:4.30; 95%CI:3.72-4.52), and an American Society of Anesthesiologists classification3 (OR:12.16; 95%CI:10.75-13.75).Independent preoperative risk factors for PPMV in children undergoing a general surgical operation were neonatal age, preoperative ionotropic support, duration of operation, and ASA classification3.

Estimated blood loss (EBL) is an increasingly important factor used to predict outcomes, such as morbidity and mortality, length of stay, and readmissions, after major abdominal operations. However, blood loss is difficult to estimate, with frequent under- and overestimations, consequences of which can be potentially dangerous for individual patients and confounding for scoring systems relying on EBL. We hypothesized that EBL is often inaccurate and have pro-spectively enrolled consecutive patients undergoing major elective intra-abdominal operations. Actual hemoglobin levels were measured and used to calculate the measured blood loss (MBL), which was compared with the EBL, as estimated both by surgeons (sEBL) and anesthesiologists (aEBL). Of 23 eligible cases at interim analysis, pancreaticoduodenectomy (n = 8) was the most common, followed by colectomy (n = 3), hepatectomy (n = 3) and gastrectomy (n = 2), biliary excision and reconstruction (n = 2), combined gastrectomy + colectomy (n = 1), radical nephrectomy (n = 1), open cholecystectomy (n = 1), pancreatic debridement (n = 1), and exploratory laparotomy (n = 1). aEBL overestimated MBL by 192 mL (143%) on average. The aEBL was significantly greater than the MBL ( P = 0.004), whereas the sEBL was significantly less than the MBL ( P = 0.009). In conclusion, surgeons significantly underestimate and anesthesiologists significantly overestimate EBL. This finding impacts not only immediate patient care but also the interpretation of scoring systems relying on EBL.

The evidence regarding the association of preoperative biologic exposure and postoperative outcomes remains controversial for both antitumor necrosis factor agents and vedolizumab and largely unknown for ustekinumab.The purpose of this study was to determine differences in the rates of 30-day postoperative overall infectious complications and intra-abdominal septic complications among the 3 classes of biologic therapies as compared with no biologic therapy.This was a retrospective review.The study was conducted at an IBD referral center.Adult patients with Crohn's disease who received an antitumor necrosis factor, vedolizumab, ustekinumab, or no biologic therapy within 12 weeks of a major abdominal operation between May 20, 2014, and December 31, 2017, were included.Thirty-day overall postoperative infectious complications and intra-abdominal septic complications were measured.A total of 712 patients with Crohn's disease were included; 272 patients were exposed to an antitumor necrosis factor agents, 127 to vedolizumab, 38 to ustekinumab, and 275 to no biologic therapy within the 12 weeks before an abdominal operation. Patients exposed to a biologic were more likely to be taking a concurrent immunomodulator, but there was no difference in concurrent corticosteroid usage. The particular class of biologic was not independently associated with total overall infectious complications. Vedolizumab was associated with an increased rate of intra-abdominal sepsis on univariate analysis but not on multivariable analysis. Combination immunosuppression was associated with both an increased rate of overall postoperative infectious complications and intra-abdominal sepsis.The study was limited by its retrospective design and single-center data.The overall rate of total infectious complications or intra-abdominal septic complications was not increased based on preoperative exposure to a particular class of biologic. Rates increased with combination immunosuppression of biologic therapy with corticosteroids and previous abdominal resection. See Video Abstract at http://links.lww.com/DCR/B24. BIOLÓGICOS Y COMPLICACIONES POSTOPERATORIAS DE 30 DÍAS DESPUÉS DE LAS OPERACIONES ABDOMINALES PARA LA ENFERMEDAD DE CROHN: ¿EXISTEN DIFERENCIAS EN LOS PERFILES DE SEGURIDAD?:: La evidencia sobre la asociación de la exposición biológica preoperatoria y los resultados postoperatorios sigue siendo controvertida controversial tanto para los agentes del factor de necrosis tumoral (anti-TNF) como para el vedolizumab, y en gran parte desconocida para el ustekinumab.Determinar las diferencias en las tasas de complicaciones infecciosas generales postoperatorias de 30 días y complicaciones sépticas intraabdominales entre las tres clases de terapias biológicas en comparación con ninguna terapia biológica.Revisión retrospectiva.centro de referencia de la enfermedad inflamatoria intestinal.Pacientes adultos con enfermedad de Crohn que recibieron un factor de necrosis antitumoral, vedolizumab, ustekinumab o ningún tratamiento biológico dentro de las 12 semanas de una operación abdominal mayor entre el 5/20/2014 y el 12/31/2017.Complicaciones infecciosas postoperatorias generales de 30 días, complicaciones sépticas intraabdominales.Se incluyeron setecientos doce pacientes con enfermedad de Crohn; 272 pacientes fueron expuestos a un anti-TNF, 127 a vedolizumab, 38 a ustekinumab y 275 a ninguna terapia biológica dentro de las 12 semanas previas a una operación abdominal. Los pacientes expuestos a un producto biológico tenían más probabilidades de tomar un inmunomodulador concurrente, pero no hubo diferencias en el uso simultáneo de corticosteroides. La clase particular de productos biológicos no se asoció de forma independiente con las complicaciones infecciosas totales. Vedolizumab se asoció con una mayor tasa de sepsis intraabdominal en el análisis univariable, pero no en el análisis multivariable. La inmunosupresión combinada se asoció tanto con una mayor tasa de complicaciones infecciosas postoperatorias generales como con sepsis intraabdominal.Diseño retrospectivo, datos de centro único.La tasa general de complicaciones infecciosas totales o complicaciones sépticas intraabdominales no aumentó en función de la exposición preoperatoria a una clase particular de productos biológicos. Las tasas aumentaron con la combinación de inmunosupresión de la terapia biológica con corticosteroides y resección abdominal previa. Vea el Resumen del Video en http://links.lww.com/DCR/B24.

The mini-gastric bypass (MGB) has proven to be a safe, rapid and effective weight-loss procedure. However, as with all abdominal operations, complications may still occur, and should be prevented if possible and treated appropriately. The authors discuss experience with the MGB.

Background: Numerous incisions are described for abdominal operations. However, opinion is divided regarding the correct choice of incision for major upper abdominal surgeries. Material & methods: Experience of 3 surgical centres with the use of modified Makuuchi incision, for major upper abdominal surgeries, from Mar 2014- Dec 2018, was audited. Results: 144 patients [76 Males: 68 Females] with an average age of 48.25 years underwent surgery using modified Makuuchi incision. ’J’ and ‘L’ incisions were used in 96 and 48 patients, respectively. Further extension of the incision was necessary in 2 patients. Adequate exposure and enhanced surgical ergonomics was observed in all cases. Surgical site infection was seen in 19 patients [13.2%]. Incisional hernias was observed in 6 patients [4.2%], on an average follow up of 27.78 months. Conclusions: Modified Makuuchi incision proves efficacious for major upper abdominal surgeries.

Metabolic syndrome is associated with poorer postoperative outcomes after various abdominal operations. However, the impact of metabolic syndrome on outcomes after colorectal cancer surgery remains poorly described.The purpose of this study was to determine the association between metabolic syndrome and short-term postoperative outcomes in patients undergoing elective colorectal cancer surgery.This was a retrospective cohort study.This study used a national multicenter database.Adult patients who underwent elective colectomy for colorectal cancer from 2010 to 2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program database.Thirty-day postoperative mortality and morbidity, unplanned reoperation, unplanned readmission, operative time, and length of stay were measured.A total of 91,566 patients were analyzed; 7603 (8.3%) had metabolic syndrome. On unadjusted analysis, metabolic syndrome was associated with an increased risk of 30-day overall morbidity, pulmonary complications, renal complications, septic complications, cardiac complications, wound complications, blood transfusion, longer length of stay, and unplanned readmissions. On multivariable analysis, metabolic syndrome remained significantly associated with renal complications (OR = 1.44 (95% CI, 1.29-1.60)), superficial surgical site infection (OR = 1.46 (95% CI, 1.32-1.60)), deep surgical site infection (OR = 1.40 (95% CI, 1.15-1.70)), wound dehiscence (OR = 1.47 (95% CI, 1.20-1.80)), and unplanned readmissions (HR = 1.24 (95% CI, 1.15-1.34)). The risks of overall morbidity, cardiac and septic complications, and prolonged length of stay for laparoscopic procedures were significantly associated with diabetes mellitus rather than metabolic syndrome as a composite entity.This study was limited by its retrospective design and inability to analyze outcomes beyond 30 days.Patients with metabolic syndrome undergoing elective surgery for colorectal cancer have an increased risk of 30-day postoperative renal complications, wound complications, and unplanned hospital readmissions. A multidisciplinary approach involving lifestyle modifications and pharmacologic interventions to improve the components of metabolic syndrome should be implemented preoperatively for these patients. See Video Abstract at http://links.lww.com/DCR/A909.

In 1959, we performed 18 operations (appendectomies - 4 laparotomies - 3, gastric resections - 6, other operations - 5) under local anesthesia with V-% novocaine solution according to the method of "creeping infiltrate" according to A.V. Vishnevsky with premedication with drugs phenothiazine series and the introduction of anti-shock fluids during the operation.

Whether prevention strategy for postoperative venous thromboembolism (VTE) should be tailored across racial groups remains unknown.Patients who underwent major abdominal operation in the Nationwide Inpatient Sample (NIS) were examined. Our primary outcome was postoperative VTE, and the secondary outcome was postoperative bleeding. Multivariable logistic regression analyses were performed and validated with the National Surgical Quality Improvement Program (NSQIP) database.781,888 patients from NIS were analyzed. Overall VTE rate was 2.0%. Compared to White patients, Hispanic (OR 0.85, 95% CI 0.78-0.93, p 0.01) and Asian patients (OR 0.49, 95% CI 0.40-0.61, p 0.01) had significantly lower risks for VTE. In contrast, Asian patients had a significantly higher risk of bleeding (OR 1.39, 95% CI 1.24-1.56, p 0.01). Similar trends were observed in NSQIP.The risk-benefit ratio of postoperative VTE prophylaxis for Asian patients is roughly three times higher than that for White patients, suggesting a tailored approach is necessary.

This study aims to test associations between perioperative blood transfusion and postoperative morbidity and mortality after major abdominal operations.The 2014 ACS NSQIP dataset was queried for all patients who underwent one of the ten major abdominal operations. Separate multivariable regression models, were developed to evaluate the independent effects of perioperative blood transfusion on morbidity and mortality.Of 48,854 patients in the study cohort, 4887 (10%) received a blood transfusion. Rates of transfusion ranged from 4% for laparoscopic gastrointestinal resection to 58% for open AAA. After adjusting for significant effects of NSQIP-estimated probabilities, transfusion was independently associated with morbidity and mortality after open AAA repair (OR = 1.99/14.4 respectively, p ≤ 0.010), esophagectomy (OR = 2.80/3.0, p 0.001), pancreatectomy (OR = 1.88/3.01, p 0.001), hepatectomy (OR = 2.82/5.78, p 0.001), colectomy (OR = 2.15/3.17, p 0.001), small bowel resection (OR = 2.81/3.83, p ≤ 0.004), and laparoscopic gastrointestinal operations (OR = 2.73/4.05, p 0.001).Perioperative blood transfusion is independently associated with an increased risk of morbidity and mortality after most major abdominal operations.

Variations of the biliary system present challenges to abdominal operations and can affect postoperative outcomes. Bile leak is an uncommon complication of total gastrectomy. However, any procedure that involves mobilisation of the left lobes of the liver should be executed with additional caution. A thorough assessment including preoperative imaging for aberrant anatomy should be performed, especially aberrant bile ducts in the left triangular ligament. Ligation or suturing of the left triangular ligament should be considered when the aberrant anatomy suggests, to decrease the risk of postoperative bile leak. In addition, the left lateral segment of the liver should be thoroughly inspected on initial completion of the operation.

Background: Intraabdominal adhesions remain a significant cause of morbidity and mortality. Moreover, intraabdominal adhesions can develop in more than 50% of abdominal operations. Aims: We compared the anti-adhesive effects of two different agents on postoperative adhesion formation in a cecal abrasion model. Study Design: Experimental animal study. Methods: Forty Wistar albino type female rats were anesthetized and underwent laparotomy. Study groups comprised Sham, Control, Mitomycin-C, 4% Icodextrin, and Mitomycin-C +4% Icodextrin groups. Macroscopic and histopathological evaluations of adhesions were performed. Results: The frequencies of moderate and severe adhesions were significantly higher in the control group than the other groups. The mitomycin-C and Mitomycin-C +4% Icodextrin groups were associated with significantly lower adhesion scores compared to the control group and 4% Icodextrin group scores (p=0.002 and p=0.008, respectively). The adhesion scores of the Mitomycin-C group were also significantly lower than those of the 4% Icodextrin group (p=0.008). Conclusion: Despite its potential for bone marrow toxicity, Mitomycin-C seems to effectively prevent adhesions. Further studies that prove an acceptable safety profile relating to this promising anti-adhesive agent are required before moving into clinical trials.

Background: Abdominal operations account for a majority of surgical volume in low-income countries, yet population-level prevalence data on surgically treatable abdominal conditions are scarce. Objective: In this study, our objective was to quantify the burden of surgically treatable abdominal conditions in Uganda. Methods: In 2014, we administered a two-stage cluster-randomized Surgeons OverSeas Assessment of Surgical Need survey to 4,248 individuals in 105 randomly selected clusters (representing the national population of Uganda). Findings: Of the 4,248 respondents, 185 reported at least one surgically treatable abdominal condition in their lifetime, giving an estimated lifetime prevalence of 3.7% (95% CI: 3.0 to 4.6%). Of those 185 respondents, 76 reported an untreated condition, giving an untreated prevalence of 1.7% (95% CI: 1.3 to 2.3%). Obstructed labor (52.9%) accounted for most of the 238 abdominal conditions reported and was untreated in only 5.6% of reported conditions. In contrast, 73.3% of reported abdominal masses were untreated. Conclusions: Individuals in Uganda with nonobstetric abdominal surgical conditions are disproportionately undertreated. Major health system investments in obstetric surgical capacity have been beneficial, but our data suggest that further investments should aim at matching overall surgical care capacity with surgical need, rather than focusing on a single operation for obstructed labor.

This case report describes the use of a three-dimensional reconstruction technique to plan the abdominal incision in order to avoid incision-related complications in a 53-year-old female patient who had had a cystic mass in the liver for 16 years and had undergone four previous surgeries. The patient presented with a recurrent cyst. The surgical team used three-dimensional reconstruction to model the liver mass, the area of abdominal wall weakness due to previous surgeries, bowel adhesions, skeletal structure and whole abdominal contour. The models were superimposed upon each other to reveal the relationship between the various features so that the optimum incision point could be selected so as to avoid the area of abdominal wall weakness, bowel adhesions and vital organs. The actual surgical incision was made based on the three-dimensional reconstruction models and the surgeon was able to avoid the area of abdominal wall weakness and bowel adhesions as planned. No incisional hernia and wound infection were observed postoperatively and the incision healed well. The three-dimensional reconstruction technique for preoperative surgical incision planning on patients with a history of multiple abdominal surgeries can minimize incision-related complications and achieve good therapeutic results.

Surgical site infections (SSIs) represent a significant source of preventable patient morbidity and hospital expense. Our objective was to assess the role of postoperative incisional alcohol cleansing in decreasing the rates of SSI as compared with standard care (control). Patients undergoing clean-contaminated abdominal operations at a single center were included. Prospectively collected data on control patients were compared with patients treated with daily postoperative alcohol-based surgical site cleansing (70% isopropyl alcohol) for the primary outcome of an SSI within the first 30 postoperative days. A total of 93 patients were included, 56 managed with standard care and 37 managed with the addition of daily alcohol cleansing. A significantly lower rate of SSI in the group managed with daily alcohol cleansing was observed (13% vs 32%, P = 0.04). This study suggests a role for adding daily incisional alcohol cleansing to further reduce the rate of SSIs.

kirk120220.f1 For generations of trainee surgeons, buying a copy of Jerry Kirk’s Basic Surgical Techniques or General Surgical Operations was a rite of passage. Kirk was a professor of surgery at the Royal Free Hospital in London, and, as a colleague said, “surgical education was his being.” He was a shrewd and generous mentor, believing it a privilege to pass on his skills and encourage trainees, whether in person or through his prose. A very precise surgeon with high standards, he had learnt from greats such as Ian Aird and Norman Tanner, but was unhappy with the shortcomings of operative textbooks that he said did not tackle the hazards and difficulties of surgical procedures. He started writing practical “how-to” titles for trainee surgeons, beginning with A Manual of Abdominal Operations , which was published in 1967. His bestselling Basic Surgical Techniques followed in 1973 and General Surgical Operations in 1978. Kirk wrote and edited texts into his 90s. He was a hard worker, always at his computer, …

Incisional hernia is one of the most frequent complications of abdominal surgery [1–3] with a reported prevalence from 0.5% to 13.9% for abdominal operations but may be as high as 41% after aortic ...

Background Laparoscopic surgery is progressing rapidly is becoming the normal route for many abdominal operations, even for major complex surgery. The integrated laparoscopic theatre is a state-of-the-art system in which the laparoscopic equipment and multiple flat-screen monitors are permanently installed to be operational on demand inside the theatre. These expensive systems are being widely adopted, however very little research has been published regarding which features of these systems are desired by the surgeons who use them. The study objective was to assess the strength of preference for key attributes of integrated laparoscopic theatres and to compare these preferences between Gynaecologists and General surgeons. Methods This was an electronically distributed discrete choice experiment survey of British practicing Laparoscopic Gynaecologists and General Surgeons (Through The British Society of Gynaecology Endoscopy and The Association of Laparoscopic Surgeons of Great Britain and Ireland). An electronic survey was designed and pre-tested. This was then sent to practicing British Laparoscopic Gynaecologists and General-Surgeons. There were structured questions regarding the seven key attributes of integrated laparoscopic theatres in the standard form for a discrete choice experiment. Results Questionnaires from 167 respondents were analysed. One hundred three were gynaecologists and 64 were general-surgeons. Adjustable screens for height and position was the most favoured attribute and it is 4.7 times more desirable than the next most desirable attribute, which was a wire free floor. The least desirable features were piped CO2, ceiling-mounted-screens and external-transmission-of-images. Conclusion Both groups favour adjustable screens for position and height above all the other features. These findings are in contrast with previous research, which showed that when asked to rank the attributes in order, gynaecologists chose ceiling mounted screens first and adjustable screens fourth. When asked to “trade off” attributes in the discrete choice experiment the adjustability of the screens became much more important than how the screens were mounted. With new wireless technology the benefits of a fully integrated theatre could be delivered with floor mounted systems at a considerably reduced cost. This information is important to manufacturers and purchasers of these systems in order to design cost effective ergonomic theatres that are fit for purpose. Electronic supplementary material The online version of this article (10.1186/s12905-018-0576-2) contains supplementary material, which is available to authorized users.

Background The effect of alcohol exposure on patients undergoing a laparotomy for trauma is unknown. The purpose of this study was to compare outcomes of morbidity and mortality between alcohol positive and alcohol negative trauma patients who required emergent laparotomies using the National Trauma Data Bank (NTDB). Methods A retrospective database analysis was performed using 28,354 NTDB incident trauma cases, from 2007 through 2012, who had been tested for alcohol and who required abdominal operations (using ICD-9-CM procedure codes) within 24 h of presentation. Variables used: age, gender, admission year, alcohol presence, ISS, GCS, injury type & mechanism, discharge status, hospital LOS, ICU stay, ventilator use, and hospital complications. Results In adjusted analyses, there were no statistically significant differences between the alcohol positive and alcohol negative cohorts when evaluating in-hospital mortality (OR, 0.93; 95% CI: 0.84–1.03), likelihood of earlier hospital discharge (HR, 1.02; 95% CI: 0.99–1.05), and the all-inclusive category of in-hospital complications (OR, 1.04; 95% CI: 0.97–1.12). Conclusions After adjusting for age, gender, admission year, ISS, GCS, and injury mechanism, there were no major differences between the alcohol positive and alcohol negative cohorts when it came to in-hospital mortality, likelihood of earlier hospital discharge, and most of the in-hospital complications measured among adult trauma patients requiring emergency laparotomies.

The problem of retained surgical bodies (RSB) after surgery is an issue for surgeons, hospitals and the entire medical team. They have potentially harmful consequences for the patient as they can be life threatening and usually, a further operation is necessary. The incidence of RSB is between 0.3 to 1.0 per 1,000 abdominal operations, and they occur due to a lack of organisation and communication between surgical staff during the process. Typically, the RSB are surgical sponges and instruments located in the abdomen, retroperitoneum and pelvis.

Objective Endoscopic vascular anastomosis of abdominal aortic aneurysms is rarely performed and requires standardization. Here, we examined the impact of the surgeon's experience of abdominal aortic aneurysm surgery on the learning curve for robot-assisted endoscopic vascular anastomosis. Methods Three vascular surgeons with more than 10 years’ experience (group A), three vascular surgeons with less than 10 years’ experience (group B), and three medical students with no experience (group C) of performing vascular surgery used the da Vinci surgical system to anastomose 8-mm–diameter vascular prostheses in an end-to-end manner with continuous 5–0 Prolene sutures. The procedure was performed five times by each participant. Outcomes were anastomosis time, number of actions, visual score, and pressure test. Snapping of the prolene thread was recorded as a procedural failure. Results Procedural failure occurred only in group C (3/15 trials, 20%; P < 0.0001). Learning curves were apparent in all three groups for anastomosis time and in groups A and C for the number of actions. Between trials 1 and 5, learning curves were apparent in all three groups for anastomosis time and in groups A and C for the number of actions but were not apparent for leakage or visual score in any group. Visual score and leakage were not significantly different among the three groups in each trial ( P = 0.10 and P = 0.45, respectively). Conclusions By using the da Vinci surgical system, experienced vascular surgeons and surgically naive students showed marked improvements in vascular anastomosis techniques with a short period of training.

Vedolizumab was recently approved by the Food and Drug Administration for the treatment of moderate to severe ulcerative colitis [UC] and Crohn's disease [CD]. No study to date has examined the rate of postoperative infectious complications among patients who received vedolizumab in the perioperative period. We sought to determine the 30-day postoperative infectious complication rate among inflammatory bowel disease [IBD] patients who received vedolizumab within 12 weeks of an abdominal operation as compared to patients who received tumour necrosis factor α [TNFα] inhibitors or no biological therapy.A retrospective chart review between May 1, 2014 and December 31, 2015 of adult IBD patients who underwent an abdominal operation was performed. The study cohort comprised patients who received vedolizumab within 12 weeks of their abdominal operation and the control cohorts were patients who received TNFα inhibitors or no biological therapy.In total, 94 patients received vedolizumab within 12 weeks of an abdominal operation. Fifty experienced postoperative complications [53%], 35 of which were surgical site infections [SSIs] [36%]. The vedolizumab group experienced significantly higher rates of any postoperative infection [53% vs 33% anti-TNF and 28% non-biologics; p0.001] and SSI [37% vs 10% and 13%; p0.001]. On univariate and multivariate analysis, exposure to vedolizumab remained a significant predictor of postoperative SSI [p0.001].Thirty-seven per cent of IBD patients who received vedolizumab within 30 days of a major abdominal operation experienced a 30-day postoperative SSI, significantly higher than patients receiving TNFα inhibitors or no biological therapy. Vedolizumab within 12 weeks of surgery remained the only predictor of 30-day postoperative SSI on multivariate analysis.

Inadvertent gastrointestinal tract injuries (IGITI) during abdominal operations increase postoperative morbidity. Common mechanisms for this type of injury are not well-defined. The risk factors associated with an increase in missed IGITI during elective abdominal surgery and a possible strategy that may contribute to early diagnosis were not previously evaluated. Between 1998 and 2006, all the patients who underwent a subsequent laparotomy within 30 days of an index operation were identified. Patients reoperated for missed IGITI, defined as perforation at sites other than previous anastomosis or bowel repair, were collected. Data pertaining to patients, disease, and primary operations’ characteristics, as well as reoperation findings and outcomes were studied. Methods of diagnosis of perforation for each particular patient were assessed. Thirty-two patients (15 females, 17 males) underwent a second operation for gastrointestinal tract leak within 30 days of an index surgery due to missed IGITI. The mean age was 59.5 ± 18.2 years (range 21–87). The average time between the first and second operation was 5.3 ± 3.5 days (range 1–13). Adhesions (27 patients), previous operations (20 patients), and laparoscopic approach (13 patients) were the most commonly documented factors that may result in missed IGITI. Diagnosis of gastrointestinal leak due to missed IGITI was made clinically in 12 patients. Twenty patients underwent contrast study before reoperation. Careful selection of patients and type of surgery in addition to awareness of this rare complication may decrease the frequency of missed IGITI, lead to earlier diagnosis, and possibly improve outcomes.

The actual incidence of gossypiboma is difficult to determine possibly due to reluctance to report occurrence arising from fear of legal repercussion, but retained surgical sponge is reported to occur one in every 3000-5000 abdominal operations and is most frequently discovered in abdomen. Here, we report a case of 69-year-old male patient who suffered from severe irritative voiding symptoms with abdominal wall fistula at the incision site due to accidently left surgical sponge in bladder following suprapubic cystolithotomy surgery for bladder stone at some other hospital.

Background Patients with previous history of abdominal operations are sometimes excluded from consideration for peritoneal dialysis because of concerns for increased risk of complications during the implantation procedure and inadequate dialysis due to reduced peritoneal surface area. Employing a laparoscopic approach, we compared the outcome of peritoneal dialysis catheters in 2 groups of patients with and without intra-abdominal adhesions. Methods All data in this report were recorded prospectively. Revision-free and overall survival of catheters, the incidence of mechanical and infectious complication, and surgical revision rates were compared between the 2 groups. Results In 217 successful catheter implantations, there was a history of previous abdominal surgery in 42.9% of procedures; only 26.9% of them had intraperitoneal adhesions; 2.8% of patients without history of previous abdominal surgery had intraperitoneal adhesions. There were no significant differences between the 2 groups for 1- and 2-year revision-free and overall catheter survival, mechanical dysfunction, infectious complications, or surgical revision rates. Conclusion History of previous abdominal surgery should not be used to judge the eligibility of patients for peritoneal dialysis. Laparoscopic placement is the best way to ensure optimal catheter outcomes equivalent to patients without previous abdominal surgery.

Object Ventriculoperitoneal shunts (VPSs) are commonly placed into the peritoneal cavity via a small laparotomy or blindly by using a split trocar. Larger patients require larger incisions, and placement is made more difficult by previous abdominal operations and obesity. For general surgeons, laparoscopy has become the first-choice approach for abdominal procedures, using 1 or several very small incisions. The authors discuss their pediatric series of patients in whom laparoscopy was used to place distal shunt catheters. Methods The authors reviewed the medical records accrued over a 9-year period, noting VPS operations performed using laparoscopy. Complications, morbidity, and alterations of planned management were noted. Results One hundred thirty-seven VPS operations in 126 patients were identified, 92 performed by the senior author (M.H.H.) alone and 45 conducted with the assistance of a general surgeon. A second port was placed for lysis of adhesions or retrieval of old catheters in 7 cases. There were no immediate complications. The infection rate was 6.6%, comparable with the institutional norm (6.3%) over an 8-year period. There were 3 early failures due to abdominal malabsorption without infection. Five catheters later broke at the level where they were introduced into the abdomen due to shearing by the abdominal trocar. Conclusions Laparoscopic placement of distal VPS catheters is relatively safe and allows insertion via inconspicuous incisions. It can allow for inspection or lysis of adhesions and removal of foreign bodies, help determine if and where the abdomen can absorb shunt fluid, and make VPS surgery in the obese patient easier.

An 404 Patienten, die sich in einem Krankenhaus der Regelversorgung gastrointestinalen Karzinomresektionen oder groseren Eingriffen in der Bauchhohle, zum Teil mit kompliziertem Verlauf, unterziehen musten, wurden zur perioperativen hochkalorischen parenteralen Ernahrung 500 Cava-Katheter in die V. subclavia eingelegt. Der Grosteil der Katheter lag zwischen 6 und 20 Tagen. Die langste Liegedauer betrug 44 Tage. Die Katheterinsertion gelang in 97,8 %. Fehllagen der Katheterspitze traten in 4,4 % auf, wobei in 2,8 % eine Korrektur unter dem Bildwandler moglich war. 92,2 % der Katheter blieben komplikationslos. In 1,4 % kam es zum Pneumothorax, in 0,4 % zur zentralen Thrombose. Eine Kathetersepsis trat in 6,2 % auf. Peri-operative high-calorie nutrition was administered, through a total of 500 catheters introduced into the superior vena cava via the subclavian vein, to 404 patients admitted to hospital for gastro-intestinal cancer resection or other major abdominal operations, some of them taking a complicated course. Most of the catheters remained in situ for 6-20 days; the longest period was 44 days. Catheter insertion was successful in 97.8 %. Faulty position of the catheter occurred in 4.4 %; in 2.8 % it was rectified under fluoroscopic control. In 92.2 % there were no complications ascribable to the catheter. A pneumothorax resulted in 1.4 % of patients, central thrombosis in 0.4 %. Catheterrelated sepsis was noted in 6.2 %.

Background Postoperative bowel obstruction (PBO) plagues patients of all ages after intraabdominal surgery. We examined the incidence, risk factors, and the need for operative intervention of PBO. Methods We reviewed all children who underwent a laparotomy or laparoscopy. Parameters included age, diagnosis, type and number of procedures, complications, time interval to PBO, treatment of PBO, morbidity, and mortality. Results From 2001 to 2005, 2187 abdominal operations were performed. Overall, 61 patients (2.8%) developed a PBO; 43 (70.5%) required reoperation. Postoperative bowel obstruction was more common in patients younger than 1 year (28/601, 4.7%) compared with older children (33/1586, 2.1%; P = .01, β = .80). In infants, PBO was not influenced by initial diagnosis ( P = .26) or whether the initial operation was clean/clean-contaminated or contaminated/dirty ( P = .12). In children older than 1 year, nonoperative treatment was more likely to be successful if PBO occurred within 12 weeks of initial operation (12/16 vs 3/14; P = .01). In contrast, all but one infant (16/17) with early PBO required reoperation. Conclusion The incidence of PBO is significantly higher in newborns and infants than in older children (who have rates comparable to those reported in adults). Infants are significantly more likely to require operative intervention, particularly if PBO occurs early after the initial operation.

Emergency services have an increasingly high profile: they are the acute contact zone between the NHS and the population it serves. Furthermore, emergencies represent an increasingly high percentage of all surgical admissions and account for almost half of all abdominal operations. Despite these well-recognised statistics, no actual policy directive other than the Department of Health (DoH) and The Royal College of Surgeons of England guidelines has been issued to deal with the problems inherent in the delivery of emergency general surgical services.

Fistulae can result from diverticulitis-associated abscesses perforating into surrounding structures. Diverticular ureterocolic fistulae are rare, with only nine previous cases reported.1 They are usually related to previous operations and affect the left ureter due to its proximity to the sigmoid colon.2 In the absence of a non-functioning infected kidney, it is recommended to resect the diseased colon with no manipulation of the urinary system (eg, nephroureterectomy).2 Our case is the first to report a spontaneous right ureterocolic fistula secondary to diverticular disease in a patient with no previous abdominal operations. A 68-year-old man presented with …

It was with great interest that we read the manuscript entitled ‘Postoperative Outcomes in Vedolizumab-treated Patients Undergoing Abdominal Operations for Inflammatory Bowel Diseases’, recently published in this journal, by Lightner et al .1 In this retrospective study, 94 patients with previous exposure to vedolizumab [VEDO] within 12 weeks before abdominal operations were compared with two control groups, [preoperative infliximab [IFX] and conventional therapy] to check differences in postoperative complications. Patients with previous VEDO had more overall complications and surgical site infections [SSIs] than patients with previous IFX or no biologics [ p < 0.001]. In multivariate …

Among the surgical procedures with abdominal approach (Burch colposuspension, Marshall-Marchetti-Krantz operation, Richardson paravaginal repair) used to correct genuine stress incontinence (GSI), the Burch colposuspension is both easy to perform and very effective. The purpose of the operation is to reposition the cervicourethral complex in a fixed retropubic space. Since anterior replacement of the vaginal axis may cause iatrogenic enterocele or increase a posterior cystocele or a previous rectocele, other complementary operations (Douglas obliteration, anterior or posterior vaginal repair) are necessary. The authors report that in 256 patients with type I and II genuine stress incontinence, the recovery rate after Burch colposuspension associated with gynecological procedures has been 81.25% in a 1 to 5-year follow-up.

PURPOSE: The study contained herein used the database of the American Board of Colon and Rectal Surgery to demonstrate trends in colorectal practice from 1989 to 1996 and to compare the one-year technical experience of a colorectal resident with the five-year totals of a general surgery resident. METHODS: Complete case lists from applicants for the American Board of Colon and Rectal Surgery's qualifying examination have been entered into a database. Similar data have been compiled from the Residency Review Committee for Surgery. RESULTS: From 1989 through 1996, 446,082 procedures have been listed by 417 colorectal residents, an average of 1,060 cases per resident. When contrasted with the operative experience of a general surgery resident, the colorectal resident performs substantially more anorectal operations, more endoscopic procedures, and more index abdominal operations in one year than the average general surgery resident performs in five years. CONCLUSIONS: When added to the required general surgery experience, one year of training in colorectal surgery trains a true subspecialist with unique expertise in the treatment of disorders of the colon, rectum, and anus.

Background Recent literature suggests that obesity is protective in critically illness. This study addresses the effect of BMI on outcomes after emergency abdominal surgery (EAS). Methods Retrospective, ACS-NSQIP analysis. All patients that underwent EAS were included. The study population was divided into five groups based on BMI; regression models were used to evaluate the role of obesity in morbidity and mortality. Results 101,078 patients underwent EAS; morbidity and mortality were 19.5% and 4.5%, respectively. Adjusted mortality was higher in underweight patients (AOR 1.92), but significantly lower in all obesity groups (AOR's 0.73, 0.66, 0.70, 0.70 respectively). Underweight and class III obesity was associated with increased complications (AOR 1.47 and 1.30), while mild obesity was protective (AOR 0.92). Conclusions Underweight patients undergoing EAS have increased morbidity and mortality. Although class III obesity is associated with increased morbidity, overweight and class I obesity were protective. All grades of obesity may be protective against mortality after EAS relative to normal weight patients.

Summary Experience with absorbable gauze during the past ten months has shown that it was frequently useful in controlling bleeding during abdominal gynecologic operations. It should in no sense replace the careful control of hemor rhage by clamp and ligature. However, when bleeding was difficult to control by such methods, either because of its oozing character or because the source of hemorrhage was not readily accessible, absorbable gauze was found to have a, definite place as a hemostatic agent. Its application to the area of bleeding followed by momentary digital pressure was successful in most instances. When, in a few cases, hemorrhage recurred following the removal of digital pressure, satisfactory results were attained by superimposing ordinary packing. The latter material was removed in twenty-four hours with evidence of a minimal amount of bleeding in the interim, and no recurrence of bleeding following its removal. The early complete removal of plain packing without fear of provoking fresh hemorrhage was a great advantage. No reaction could be traced to the leaving of varying amounts of oxidized gauze within the abdominal or pelvic cavities. A few unusual applications of it during abdominal operations have been mentioned. Undoubtedly others will occur as experience in the application of this material grows. Absorbable gauze also proved to be of value during vaginal procedures. As has been pointed out, it sometimes proved to be ineffective when applied to the oozing incision of completed plastic operations. Its inability to control such bleeding cannot be regarded as a failure, but as a faulty application. The gauze must be placed in direct contact with the bleeding vessels under temporaxy or permanent pressure to cause hemostasis. On the other hand, absorbable gauze was used effectively during the course of a plastic operation to check oozing not readily controlled by ligature. It was effective in controlling hemorrhage from biopsy wounds and from the crater of a carcinomatous cervix. The most valuable application of this material noted in this series of cases was in a group exhibiting violent secondary hemorrhage some days after a, plastic operation, a cervical amputation, or a complete hysterectomy. Absorbable gauze placed against the source of hemorrhage and held in position with plain packing promptly controlled such hemorrhage. Formerly plain packing usually proved ineffective Trader such circumstances, necessitating ligation of bleeding vessels and resuture of the disrupted area under conditions of difficult exposure. The use of absorbable gauze in such cases appeared to offer great advantages.

In the present study it has been found that 10 percent of the 2968 college students questioned have had an appendectomy at some previous time. People of this age have few abdominal operations other than those for appendicitis. These students are largely from the middle class of the population. Perhaps 20 percent of the population in the United States have an appendectomy during life for appendicitis and an equal number do not have the appendectomy even though so diagnosed.

OUCHI, K., TAKEDA, K. and MATSUNO, S. Efficacy of Patient-Controlled Analgesia for Management of Pain after Abdominal Operations. Tohoku J. Exp. Med., 1991, 165 (3), 193-199-In order to control pain during the early postoperative period, patient-controlled analgesia (PCA) with buprenorphine as an analgesic drug was applied in 23 patients undergoing abdominal operations. With this “on demand” system, the patient was allowed to self-administer narcotic analgesic medication using a programmable infusion pump. Overdose could be minimized with a mandatory lock-out interval between allowable injections. Average total requirement of buprenorphine was 0.355mg at 48hr after operation. Nineteen of the 23 (82.6%) patients characterized their pain control as “excellent” or “good”. In these patients there existed high correlation between the total number of patient attempts and the number of successful injections. The PCA system was thought to provide improved pain relief at smaller total drug dosages. In addition, earlier and greater spontaneous physical activity was maintained with PCA therapy. The potential for overdose could be minimized, and thereby PCA appears to be an efficacious and safe method of providing for postoperative pain relief.

A total of 1084 surgical procedures was performed during the first 10 years of independence in the small Pacific island nation of Tuvalu. Visiting surgical teams performed 29% of these. Obstetrical and gynaecological operations, eye and abdominal operations counted for more than half of the total number of operations; of the individual operations, cataract extraction, tubal ligation and appendicectomy were the most common. After local anaesthesia, epidural, spinal or ketamine anaesthesia, respectively, were performed more often than general anaesthesia. During the 10-year period, only 12 patients were sent overseas for surgical treatment. Of the estimated 110 patients needing surgical treatment in Tuvalu each year, the great majority can be managed with present facilities. Regular visits by an eye and a plastic surgery team are useful, and a small number of selected patients need surgical treatment overseas. The adequate treatment of surgical emergencies from outer islands in an island community with great distances and poor communications remains the biggest challenge for surgical services in the future.

Forty consecutive patients with an extraabdominal primary tumor, later treated surgically for intraabdominal problems, were investigated. The most common causes of abdominal operations were intestinal obstruction (N = 17), intraabdominal tumor mass (N = 8), and intraabdominal hemorrhage (N = 5). The overall postoperative mortality was 25%, morbidity 48%, median survival 3 months, and cumulative 5 year survival 3%. The mortality after emergency procedures, 67%, was significantly higher (P less than 0.01) than after elective operations, 18%. Conditions requiring enterostomy (N = 14) were associated with a mortality of 36%, whereas the figures in resected (N = 13) and bypassed (N = 7) patients were 14% and 17%, respectively. Wound infection (N = 5) and pulmonary infection (N = 5) were the most common complications, and pulmonary infection was fatal in three of the five cases. Of the patients, 22 (55%) were discharged from hospital to their home; ten (25%) of them had postoperatively a 3 month relief of cancer symptoms and four (10%) a 6 month relief. Nine patients (25%) have survived for over 1 year and one (3%) for over 5 years. It is concluded that abdominal procedures seldom prevent further cancer growth within these patients and that symptoms are relieved only in one in every four patients. According to strict criteria, these operations are useful and can add to patient comfort.

Background/Purpose The distribution of surgical care of very low birth weight (VLBW) neonates among centers with varying specialized care remains unknown. This study quantifies operations performed on VLBW neonates nationally with respect to center type. Methods VLBW neonates born 2009–2012 were assessed using a prospectively collected multi-center database encompassing 80% of all VLBW neonates in the United States. Surgical centers were categorized based on availability of pediatric surgery (PS) and anesthesia (PA). Results 48,711 major procedures (29,512 abdominal operations) were performed on 24,318 neonates. Of all patients, 20,892 (85.9%) underwent surgery at centers with PS and PA available on site. 1663 (6.8%) patients were treated at centers with neither specialty on site. Neonates requiring complex operations were more likely to receive surgery at centers with both PS and PA on staff than those requiring non-complex operations (95.6% vs 93.6%). Conclusion This study confirms that most operations on VLBW neonates in the U.S. are performed at centers with pediatric surgeons and anesthesiologists on staff. Further research is necessary, however, to elucidate why a significant minority of this challenging population continues to be managed at centers without pediatric specialists.

Iatrogenic injury to the iliac vein or inferior vena cava (IVC), which may occur during abdominal operations or posterior orthopedic procedures, can have devastating consequences. Operative management is challenging and may be associated with significant morbidity. The authors report herein 3 cases of iatrogenic pelvic vein injuries that were managed with different treatment approaches. Both traditional open surgical therapy and endovascular techniques are described.

Objective To obtain detailed information about the degree of surgical trainee supervision and delegation of procedures in a subspecialised department. Design Operative procedures and their logical components were recorded in a database constructed in Microsoft Access. Information about operating surgeon and assistants and their grade was registered prospectively over 12 months. Subjects and methods A total of 1250 intermediate or major procedures were performed by eight consultants, one staff specialist, four senior registrars, three specialist registrars, and five registrars. Main measure Number of components performed by surgeons in each grade and the degree of supervision and delegation. Results Eight hundred and eighty five of the operations were elective, while 365 were done as emergency procedures. Emergency procedures were far more often done by surgeons in training than by a staff surgeon, while the opposite was true for elective operations. Out of 323 elective operations done by surgeons in training, 189 were done under supervision (58.5%), while 119 out of 276 emergency operations done by surgeons in training were supervised (43.1%; p=0.0002). One hundred and twenty eight of 638 (20%) open abdominal operations were done by the most junior surgeons, and yet they closed 36% of all abdominal wounds. Although the most junior surgeons only served as operating surgeons in 39 of 334 bowel operations (12%), they constructed 24% of all stomas, and 20% of all anastomoses. Registrars and specialist registrars never constructed stomas or anastomoses without supervision. Conclusion Detailed information about individual and general training and supervision was achieved by a simple registration. Significant additional information was obtained about the extent of delegation of components compared with standard registration of operative procedures.

Surplus skin from plastic surgery patients was sold to a British defence agency for chemical warfare research without patients' knowledge, an NHS hospital trust admitted last week. Salisbury Health Care Trust apologised for selling skin from breast and abdominal operations to the Defence Evaluation and Research Agency at nearby Porton Down, without fully explaining what it would be used for. The trust …