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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.

Background South Africa is a middle-income country with major discrepancies in wealth and access to care. There is a significant burden of surgical disease and limited access to quality health care for a large proportion of the population. This article quantifies the burden of abdominal surgery over a 6-month period in KwaZulu-Natal (KZN) province and quantifies the emergency to elective (Ee) ratio for these operations. Methods This study describes the abdominal operations conducted at all regional and tertiary hospitals in the public health sector of KZN province for the period of 1 July to December 31, 2015. Operations performed were tabulated in a spreadsheet and categorized as elective, emergency, and trauma. They were further subdivided by anatomical region and by specific predetermined procedures. Uncertain criteria were clarified using a modified Delphi discussion. The Ee ratio was determined using the recently described technique. Results Between June, 1st and December 31, 2015, of 13,282 operations, there were 4580 (34.5%) elective operations, 7777 (58.6%) emergency operations, and 925 (6.9%) trauma-related operations. A total of 5630 abdominal operations were performed of which 2949 were emergency procedures. There were 660 trauma-related abdominal procedures and 2021 elective procedures. There was a heavy weighting toward emergency surgeries with an Ee ratio of 145 for abdominal surgery. The previous sub-Saharan African ratio was estimated to be 62.6. Conclusions An overview of abdominal surgery in KZN reveals a high ratio of emergency to elective surgery. This suggests that the current primary health care program is failing to detect and treat acute surgical disease timeously.

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

Background Preoperative assessment of geriatric-specific determinants of health may enhance perioperative risk stratification among elderly patients. This study examines effects of geriatric-specific variables on postoperative outcomes in patients undergoing elective major abdominal operations. Methods Patients included in the ACS NSQIP pilot Geriatric Surgery Research File program who underwent elective pancreatic, liver, and colorectal operations between 2014 and 2016 were examined. Multivariable analyses were performed to evaluate associations between patient-specific geriatric variables and risk of death, morbidity, readmission, and discharge destination. Results A total of 4165 patients were included. Patients ≥85 years were more likely to die, experience postoperative morbidity, and be discharged to a facility (all p ≤ 0.039) than younger patients. Preoperatively, patients ≥85 years were more likely to use a mobility aid, have a prior fall, have consent signed by a surrogate, and to live alone at home prior to operation (all p 0.055). Patients 75–84 and ≥85 years were more likely to be discharged to facility (OR 2.33 and 4.75, respectively, both p

Background Nutrition therapy plays a major role in the perioperative management of surgical patients. Understanding energy metabolism and correctly establishing the adequate energy needs is a crucial step to provide optimal nutrition care. The aim of this study was to assess the resting energy expenditure (REE) after major abdominal procedures and its associated factors. Methods This was a prospective observational study conducted at a single center. REEs of patients admitted for gastrointestinal surgical procedures were measured by indirect calorimetry 24 hours prior to the procedure and reassessed at least once within the fifth postoperative day. Substrate oxidation was calculated according to the Frayn equation. Nutrition status was evaluated using subjective global assessment. Results There were no significant changes in the REEs throughout the study period; however, there was a decrease in the respiratory quotient during the postoperative period, as well as a decrease in carbohydrate oxidation and an increase in lipid oxidation. Only 33.3% of the patients presented a postoperative increase in REE > 10%. Those patients presented higher blood-monocyte levels. Conclusion Postoperative REE is not increased in most of the patients. In patients who had increased REE, associated factors included higher levels of monocytes.

PURPOSE Few authors have studied applying the laparoscopic approach in patients with previous upper abdominal operations, but no comparison has been made between laparoscopic and open approaches in patients with previous upper abdominal operations. This article aims to introduce surgical techniques and details in treatment to surgeons specialized in minimally invasive surgery. MATERIALS AND METHODS From January 2010 to January 2018, 460 eligible patients were divided into 3 groups and analyzed retrospectively. Group A: patients with a history of upper abdominal operations who underwent laparoscopy (n=124); group B: patients without a history of upper abdominal operations who underwent laparoscopy (n=140); and group C: patients with a history of upper abdominal operations who underwent an open operation (n=196). Group A was the experimental group; groups B and C served as the control groups. RESULTS No significant difference was found between groups A and B. Significant differences were found between groups A and C in estimated blood loss (258.3±67.2 vs. 424.7±103.7 mL, P

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.

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

Background Gastrografin (GG)-based nonoperative approach is both diagnostic and therapeutic for partial small bowel obstruction (SBO). Absence of X-ray evidence of GG in the colon after 8 h is predictive of the need for operation, and a recent trial used 48 h to prompt operation. We hypothesize that a significant number of patients receiving the GG challenge require >48 h before an effect is seen. Methods A post hoc analysis of an Eastern Association for the Surgery of Trauma multi-institutional SBO database was performed including only those receiving GG challenge. Successful nonoperative management (NOM) was defined as passage of flatus or nasogastric tube (NGT) removal. NOM was considered a failure if operative intervention was required. Multiple logistic regression was performed to identify predictors of delayed (>48 h) GG challenge effect and expressed as odds ratios with 95% confidence intervals. Results Of 286 patients receiving GG, 208 patients (73%) were successfully managed nonoperatively. A total of 60 (29%) NOM patients had NGT decompression for >48 h (n = 54) or required >48 h to pass flatus (n = 34), with some requiring both (n = 28). Prior abdominal operations and SBO admission were protective of delayed GG effect (0.411 [0.169-1.00], P Conclusions A significant proportion of patients at 48 h (29%) “failed” the GG challenge as they had yet to pass flatus or still required NGT but were nonetheless successfully managed nonoperatively. Extending the GG challenge beyond 48 h may help avoid unnecessary operations. Level of evidence Level II.

Background After the Institute of Medicine (IOM) report To Err Is Human highlighted the impact of medical errors, the Agency for Healthcare Research and Quality (AHRQ) developed Patient-Safety Indicators (PSI) to improve quality by identifying potential inpatient safety problems. PSI-15 was created to study accidental punctures and lacerations (APL), but PSI-15 may underestimate APLs in populations of patients. This study compares PSI-15 with a more inclusive approach using a novel composite of secondary diagnostic and procedural codes. Methods We used Nationwide Inpatient Sample (NIS) data (2000–2012) from AHRQ's Healthcare Cost and Utilization Project (H-CUP). We analyzed PSI-15-positive and -negative cholecystectomies. Cross tabulations identified codes that were significantly more frequent among PSI-15-positive cases; these secondary diagnostic and procedural codes were selected as candidate members of a composite marker (CM) of APL. We chose cholecystectomy patients for study because this is one of the most common general operations, and the large size of NIS allows for meaningful analysis of infrequent occurrences such as APL rates. Results CM identified 1.13 times more APLs than did PSI-15. Patients with CM-detected APLs were significantly older and had worse mortality, comorbidities, lengths of stay, and charges than those detected with PSI-15. Further comparison of these two approaches revealed that time-series analysis for both APL markers revealed parallel trends, with inflections in 2007, and lowest APL rates in July. Conclusions Although CM may yield more false positives, it appears more inclusive, identifying more clinically significant APLs, than PSI-15. Both measures presented similar trends over time, arguing against inflation in PSI-15 reporting. While arguably less specific, CM may increase sensitivity for detecting APL events during cholecystectomies. These results may inform the interpretation of other large population studies of APLs following abdominal operations.

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.

There is still uncertainty regarding the use of prophylactic drainage in abdominal surgical procedures. This meta-review aimed to summarize systematic reviews and meta-analyses evaluating abdominal drain placement in patients undergoing abdominal procedures, with a focus on surgical site infection and death from infections.Systematic reviews and meta-analyses identified in MEDLINE, EMBASE, CINHAL, Cochrane Central Register of Controlled Trials, World Health Organization Regional Medical Databases, and African Index Medicus were reviewed.Fifteen systematic reviews and meta-analyses concerning prophylactic abdominal drainage in abdominal operations were included in this analysis. The median score of methodologic quality was eight (6-10). The majority of meta-analyses found no benefits of prophylactic drainage in reducing surgical site infection, but no significant differences were identified. Three studies demonstrated a significant difference in favor of no drainage, with two regarding cholecystectomy and one on appendectomy (p 0.05). The quality of evidence provided by each review was mainly low and very low.Most reviews fail to detect an increased incidence of surgical site infection in the setting of drainage placement but also fail to attribute any specific benefits to the presence of a drain in abdominal procedures.

Although sarcopenia has been identified as a predictor of poor, postoperative, clinical outcomes, the financial impact of sarcopenia remains undetermined. We sought to evaluate the relationship between sarcopenia and hospital finances among a cohort of patients undergoing a hepato-pancreatico-biliary or colorectal resection.Clinical, financial, and morphometric data were collected for 1,169 patients undergoing operative resection between January 2011 and December 2013 at the Johns Hopkins Hospital. Multivariable regression analysis was performed to assess the relationship between sarcopenia and total hospital costs.Using sex-specific cutoffs for total psoas volume, 293 patients were categorized as sarcopenic. The presence of sarcopenia was associated with a $14,322 increase in the total hospital cost (median covariate-adjusted cost, sarcopenia versus no sarcopenia: $38,804 vs $24,482, P .001). Patients who presented with sarcopenia demonstrated a higher total hospital cost within the subgroup of patients who developed a postoperative complication (sarcopenia versus no sarcopenia: $65,856 vs $59,609) and among those patients who did not develop a postoperative complication (sarcopenia versus no sarcopenia: $26,282 vs $23,763, both P .001). Similarly, total hospital costs were higher among patients presenting with sarcopenia regardless of the length of stay for index admission (observed:expected, length of stay 1: sarcopenia versus no sarcopenia: $25,038 vs $22,827; observed:expected, length of stay 1: sarcopenia versus no sarcopenia: $43,283 vs $38,679, both P .001).As measured by sarcopenia, patient frailty is inversely related to total hospital costs. Sarcopenia represents a novel tool for forecasting patient outcomes and operative costs and can be used to inform quality improvement and cost containment strategies.

Wound classification helps predict wound-related complications and is useful in stratifying surgical site infection reporting. We sought to evaluate misclassification among commonly performed surgeries that are at least clean-contaminated.The National Surgical Quality Improvement Program database was queried from 2005 to 2016 by Current Procedural Terminology codes identifying common surgeries that are, by definition, not clean: colectomy, cholecystectomy, hysterectomy, and appendectomy. Univariate analysis and multivariate logistic regression were performed.Of the 1,208,544 operative cases reviewed, 22,925 (1.90%) were misclassified as clean. Hysterectomy was the most commonly misclassified operation (3.11%), and colectomy the least (0.82%). Misclassification was higher in laparoscopic cases (1.92% versus 1.82%; P 0.01). Misclassification increased from 2005 to 2016 (0.22% versus 3.11%; P 0.01). Misclassified patients were younger (46.7 versus 47.7 y; P 0.01); had lower rates of hypertension, chronic obstructive pulmonary disease, smoking history, and steroid use (P 0.01); and had shorter length of stay (2.2 versus 3.2 d; P 0.01), lower 30-d readmission rates (3.7% versus 5.0%; P 0.01), and less surgical site infections (1.7% versus 3.4%; P 0.01). Open hysterectomy was the most significant positive predictor for misclassification (odds ratio 3.34; P 0.01). Open appendectomy was the most significant negative predictor (odds ratio 0.20; P 0.01).There is an increasing trend of misclassifying wounds as clean. Misclassified patients have better outcomes, and misclassification may be affected by patient characteristics, operative approach, and type of procedure rather than reflecting the true infectious burden. Further research is warranted.

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.

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 ...

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. 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. 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. 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.

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.

Objective The aim of the present study was to evaluate the safety and efficacy of a “Cravat’’ technique for the management of uterine prolapse in patients who want to preserve uterus, involving suspension of the uterus from the sacral promontory by using polypropylene mesh. Materials and Methods A prospective observational study between January 2011 and September 2013 was conducted. Prior to surgery, prolapse assessment was undertaken with Baden-Walker halfway system to grade the degree of prolapse at all sites. Patients with severe uterine prolapse (stage II-IV) who want to preserve uterus, were operated with Cravat technique. All patients were evaluated at 2 weeks and 6 weeks after surgery and followed for 6 months. Outcomes were evaluated objectively by vaginal examination using Baden-Walker halfway classification, and subjectively classifying patients as ‘very satisfied’, ‘satisfied’ and ‘not satisfied’ at the 6th month postoperatively. Results Sacral uteropexy was successfully performed by laparoscopy in 32/33 patients (one needed to be converted to laparotomy). Nine patients also had a concurrent procedure as colporaphy anterior, colporaphy posterior or transobturator tape. Postoperative recovery has been uneventful with subjective and objective cure rates were 96.9% and 93.9%, respectively at six month. One recurrence of total prolapse needed to be reoperated and two patients with sacrouteropexy still remained at stage 2 prolapse. There have been no cases of graft exposure, rejection or infection with a median follow-up of 23.9 months. Conclusions Laparoscopic sacral uteropexy with “Cravat technique” was found to be safe and simple procedure.

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

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.

Background: Failure of laparotomy closure develops after up to 20% of abdominal operations. Suture tension has an influence on the quality of tissue regeneration. No sensors are available to register suture tension dynamics in vivo. Methods: In a series of animal experiments, the effect of suture tension on the ultrastructure of the healing incision was examined. Surgeons’ ability to suture with target tension was tested. An implantable sensor and data logger were developed and tested experimentally in sutures closing midline laparotomies in pigs both under normal and elevated intra-abdominal pressure. Results: High suture tension has a negative influence on the regeneration of laparotomy incisions. Running sutures for laparotomy closure lose 45% of their initial tension over periods of 23 h. Intermittent elevation of intra-abdominal pressure to 30 mm Hg leads to a near total loss of suture tension after 23 h. Conclusion: Surgeons are not able to control and reproduce suture tension. Suture tension dynamics can be measured in vivo by the sensor developed. Further research is needed to define a tissue-specific suture tension optimum to reduce the incidence of complications after laparotomy. Techniques for laparotomy closure need to be modified.

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.

Sonography is a comparatively cheap, convenient, and noninvasive testing on diagnosing fatty liver disease and with satisfied sensitivity and specificity. The sonographic diagnosis of fatty liver is usually made by radiologists who have few opportunities to observe the macroscopic changes on fatty liver. Having observed some obvious macroscopic changes of simple fatty liver in abdominal operations, we wanted to know how many morphological changes of the simple fatty liver there were in the end and what is the corresponding relationship between sonographic diagnosis and morphologic changes of the fatty liver. So, we designed this study for these destinations by using the intuitive and minimally invasive advantages of laparoscopy.For this study, we chose patients with benign cholecystic disease and simple fatty liver diagnosed by sonography. In the laparoscopic operations, the surface and periphery of the liver were observed and videotaped simultaneously. Liver biopsies were performed during the operations, and the specimen was analyzed by experienced pathologists postoperatively. The videos, histologic results, and the sonographic examinations on fatty liver were compared and tried to find some potential correlation among them.In this study, we found some common macroscopic changes of the fatty liver under laparoscopy, such as hepatomegaly, the dullness of the liver edge, the fatty infiltration of the liver surface, the texture of the liver changing from softness to tenacity, and the blood vessels of the liver surface becoming more fuzzy. According to the histologic results, the characteristics of different gradings of fatty liver under laparoscopy could be confimed. The statistical analysis revealed a higher consistency between sonographic diagnosis and laparoscopic macroscopic changes of the fatty liver.There are some typical features of the simple fatty liver under laparoscopy. These characteristics correspond to the sonographic diagnosis on the fatty liver. There is a high consistency between sonographic diagnosis and laparoscopic findings on the fatty liver. According to the macroscopic changes of the liver under laparoscopy, the extent of simple fatty liver could be evaluated under laparoscopy.

Venous thrombolism (VTE) is a significant cause of morbidity for surgical patients. Comparative risk across major procedures is unknown.Retrospective analysis of the Nationwide Inpatient Sample (2001-2005) was conducted. Eight surgeries were identified: bariatric surgery, colorectal surgery, esophagectomy, gastrectomy, hepatectomy, nephrectomy, pancreatectomy, splenectomy. Age18, patients with multiple major surgeries, and those admitted for treatment of VTE were excluded. Primary outcome was occurrence of VTE. Independent variables included age, gender, race, Charlson score, hospital teaching status, elective procedures, cancer/metastasis, trauma, and year.Patients, 375,748, were identified, 5,773 (1.54%) with VTE. Overall death rate was 3.97%, but 13.34% after VTE. Unadjusted rate (0.35%) and adjusted risk for VTE were lowest among bariatric patients. On multivariate analysis, highest risk for VTE was splenectomy (odds ratio 2.69, 95% CI 2.03-3.56). Odds ratio of in-hospital mortality following VTE was 1.84 (1.65-2.05), associated with excess stay of 10.88days and $9,612 excess charges, translating into $55 million/year nationwide.Highest risk for VTE was associated with splenectomy, lowest risk with bariatric surgery. Since bariatric patients are known to have greater risk for this complication, these findings may reflect better awareness/prophylaxis. Further studies are necessary to quantify effect of best-practice guidelines on prevention of this costly complication.

OBJECTIVE To compare occlusive hydrocolloid dressing (OHD; Karayahesive) and gauze dressing (GD) with regard to the cost and incidence of wound infection after abdominal surgery. METHODS A total of 134 patients who underwent incisions were randomized to have their wounds dressed with either OHD or GD. OHD was left on until the sutures were removed, and GD was changed everyday postoperatively. The cost calculations represent the number of dressings required for each treatment group as determined by the frequency of required dressing changes and cost per dressing. RESULTS There were no differences between the groups regarding the need for dressings to be changed or the incidence of infection. OHD was less expensive and complicated than GD, which needed to be changed everyday ( p CONCLUSION The results suggest that OHD is less expensive to use than GD, and the risk of wound infection is not increased compared to GD.

Natural orifice translumenal endoscopic surgery (NOTES) involves the intentional puncture of one of the viscera (e.g., stomach, rectum, vagina, urinary bladder) with an endoscope to access the abdominal cavity and perform an intraabdominal operation. Early laboratory work focused on feasibility studies, including such accomplishments as pure transgastric splenectomy and gastrojejunostomy. Contemporary laboratory work is investigating the infectious and immunologic implications of NOTES and honing the tools and techniques required for complex abdominal operations. Today NOTES has entered the clinical arena in a few cases: the first clinical series of transgastric peritoneoscopy has recently been published; multiple groups are accumulating patients in studies of NOTES cholecystectomy, either via the transgastric or transvaginal route; and a series of transgastric appendectomies has been well publicized, yet it remains unpublished. Although clinical NOTES is gaining momentum, the field should remain in check while rigorous laboratory work is performed and cogent clinical trials are undertaken. The zeal for NOTES should not take precedence over the welfare of the patient.

Pancreatic redo procedures belong to the most difficult abdominal operations because of altered anatomy, significant adhesions, and the potential of recurrent disease. We report on our experience with 15 redo procedures among a series of 350 consecutive pancreatic operations.From January 1, 2004 to May 31, 2006 a total of 350 patients underwent pancreatic surgery in our department. There were 15 patients identified who had pancreatic redo surgery for benign (14) or malignant (1) disease. Perioperative parameters and outcome of 15 patients undergoing redo surgery after pancreatic resections were evaluated.Operative procedures included revision and redo of the pancreaticojejunostomy after resection of the pancreatic margin (6), completion pancreatectomy (3), conversion from duodenum-preserving pancreatic head resection to pylorus-preserving pancreaticoduodenectomy (3), classic pancreaticoduodenectomy after nonresective pancreatic surgery (1), redo of left-sided pancreatectomy (1), and classic pancreaticoduodenectomy after left-sided pancreatectomy (1). Histology revealed chronic pancreatitis in 14 and a mucinous adenocarcinoma of the pancreas in 1 patient. Median operative time was 335 min (235-615 min) and median intraoperative blood loss was 600 ml (300-2,800 ml). Median postoperative ICU stay was 20 h (4-113 h) and median postoperative hospital stay was 15 days (7-30 days). There was no perioperative mortality and morbidity was 33%.Pancreatic redo surgery can be performed with low morbidity and mortality. Redo surgery has a defined spectrum of indications, but to achieve good results surgery may be performed at high-volume centers.

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.

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 …

Background: The aim of the present study was to evaluate the effect of gallstone disease (GD) and laparoscopic cholecystectomy on gastric electrical activity of slow waves, which was recorded via transcutaneous electrogastrography (EGG). Methods: Twenty-one consecutive patients (M/F: 12/9, 52.7 ± 15 years old) with GD and no previous history of abdominal operations or known disease affecting gastrointestinal motility were studied. The EGG was performed for 30 min prior to and 90 min after a standard meal, during a 4–6 month period prior to and after laparoscopic cholecystectomy. The percentile proportion of the three spectra of gastric slow waves frequency was studied, defined as follows: bradygastria, 1–2.1 cycles per min (c.p.m.); normogastria, 2.2–3.9 c.p.m.; and tachygastria, 4–9 c.p.m. The findings were compared to those of nine healthy subjects (M/F: 5/4, 49.5 ± 14.8 years old). Results: No statistically significant difference was found in percentile distribution of bradygastria, normogastria and tachygastria, pre- or post-prandially, neither before or after laparoscopic cholecystectomy, nor between patients and controls. Conclusions: Patients with GD do not exhibit differences in gastric electrical activity of slow waves in comparison to normal subjects and laparoscopic cholecystectomy does not alter gastric electrical activity. These findings suggest that cholelithiasis does not seem to cause dyspeptic symptoms due to gastric dysrythmias.

But: Comparer les effets des pansements occlusifs (Comfeel) et des pansements classiques (Mepore) sur la cicatrisation des incisions cutanees apres chirurgie abdominale. Type d'etude : Prospective randomisee. Provenance: Laboratoire et hopital universitaires, Danemark. Patients: Soixante treize patients ayant eu une chirurgie abdominale propre par une incision de plus de 5 cm de long entre Aout 1993 et Aout 1995 dont le pansement a ete fait apres tirage au sort soit avec du Comfeel soit avec du Mepore. Methodes : Le Comfeel a ete laisse en place jusqu'a l'ablation des fils, et le Mepore a ete retire a J2 postoperatoire. Principaux criteres de jugement: La survenu d'infections, d'accolements, d'ecoulements et l'aspect esthetiqua 3 mois plus tard. Resultats : Le choix entre Comfeel et Mepore a ete fait fait par tirage au sort. Vingt neuf patients n'ont pas ete analyses (20 ont eu du Mepore et 9 du Comfeel) 26 et 17 patients ayant ete respectivement retenus pour l'analyse des resultats. Il y a eu un abces de paroi dans le groupe Comfeel et 5 dans le groupe Mepore (p = 0,2). Il n'y avait pas de difference entre les deux groupes en ce qui concerne la necessite de changer le pansement, l'incidence des ecoulements, ou l'incidence de decollement du pansement de la peau. Le Comfeel adherait bien a la peau et restait plus ou moins transparent jusqu'au moment de l'ablation des fils. Chez 23 patients (64%) le pansement est reste completement transparent, et chez aucun des patients il est devenu totalement opaque. Du point de vue esthetique il n'y avait pas de difference a trois mois. Nous avons eu l'impression que les patients qui avaient du Comfeel etaient plus confortables et accomplissaient leurs activitees quotidiennes plus facilement. Conclusions: Les pansements occlusifs tiennent bien en place et restent transparents, et ils n'augmentent pas le risque d'infection. Ils pourraient meme etre plus confortables. Ils representent une alternative raisonnable aux pansements traditionels.

But: Evaluer les effets des lavements preoperatoires sur la reprise du transit apres une intervention digestive n'interessant pas le colon. Type d'etude : Essai prospectif, randomise. Provenance: Centre universitaire et ses hopitaux dependants, Suisse. Patients: Cent seize patients (âges de plus de 16 ans) programmes pour une intervention de chirurgie digestive n'interessant pas le colon. Methodes: Apres randomisation, les patients ont eu un lavement d'un litre d'eau et de glycerine le jour precedent leur intervention (n = 53) ou aucune preparation intestinale preoperatoire (n=53 ). Principaux criteres de jugement: La reprise du transit apres l'intervention, evaluee par l'auscultation abdominale et le moment des premieres selles. Tous les patients ont ete suivis quotidiennement pendant 10 jours ou jusqu'a leur sortie par le meme examinateur. Resultats: Un consentement eclaire a ete donne par 110 patients, 6 ont refuse de participer a l'etude, et 4 ont du etre exclus apres randomisation, faisant ainsi porter l'analyse sur 106 cas. La reapparition des bruits intestinaux et le moment de la premiere selle ont ete significativement plus precoces chez les patients qui n'avaient pas eu de lavement preoperatoire (p=0,02 et p=0,01 respectivement). Aucun sous groupe de patients n'a beneficie des lavements. Conclusions: Les lavements preoperatoires retardent plutot qu'ils n'ameliorent la reprise du transit apres chirurgie. Selon nous, cette habitude devrait etre abandonnee.

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

PURPOSE OF REVIEW The scope of this article is to provide an updated review examining the role of early feeding in the postoperative period. RECENT FINDINGS Guidelines for postoperative care after abdominal surgery have historically outlined the dogma of 'nil by mouth' until bowel movement returns, but they are currently questioned. This change in mindset, especially after colorectal surgery, was initiated with fast-track or enhanced recovery after surgery programs, which particularly led to an opioid-sparing strategy. Many randomized trials and meta-analyses suggested an absence of benefit in keeping patients 'nil by mouth'. Conversely, in elective abdominal surgery, improvement in comfort without increased morbidity is now demonstrated with a liberal strategy, and a recent meta-analysis even demonstrated a decrease in mortality. Early caloric hydration and chewing gum are the most acceptable actions with a high level of proof. After emergency surgery, few data are available but a similar strategy should probably be chosen with no obvious benefit from maintenance of fasting. SUMMARY Early oral intake is possible after elective abdominal surgery and should be moderate and progressive to be well tolerated. Any sign of nausea may mean intestinal or gastric disturbance and is a caution not to pursue this policy. The strategy in emergency abdominal surgery still requires adequately powered, randomized controlled trials.

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

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 …