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Hysteroscopy is essential in gynaecological practice, providing a useful tool for the diagnosis and management of intrauterine pathology. Proper visualisation of the uterine cavity during hysteroscopy requires a distension medium. Fluid is preferred for this purpose as it allows for continuous irrigation and therefore clear visualisation. The complications of fluid overload may be catastrophic and a thorough understanding of the principles of patient and procedural safety are essential. These include an appreciation of fluid selection and management, as well as the early detection and treatment of complications. In this review we explore the pertinent principles of operative hysteroscopy and fluid management. [ABSTRACT FROM AUTHOR]

Background: This is a retrospective single-center analysis investigating the results of a percutaneous lysis-assisted balloon (LAB) thrombectomy procedure for the treatment of thrombosed arteriovenous dialysis grafts (AVGs).Materials and Methods: Within 5 years (January 2012-December 2016), 291 declotting procedures were performed for the treatment of thrombosed dialysis arteriovenous fistulas or grafts. Data were available for 129 patients (75 men, 58.1%) with an AVG, undergoing 241 procedures [1.87 procedures/patient (1-10)]. Procedure includes initial lysis with 5 mg recombinant tissue plasminogen activator followed by thrombectomy with a high-pressure balloon for thrombus maceration using "facing sheaths" technique. 61 patients had ≥ 2 declotting procedures. In 80 cases (80/241; 33.2%), a stent graft (SG) was used for treatment of persistent stenosis. Main primary outcome measures were clinical success and postintervention assisted primary patency (PAPP). Secondary outcome measures included procedural complications and investigation of independent factors that could influence circuit survival.Results: Median PAPP was 434 days according to Kaplan-Meier survival analysis. Clinical success was 96.26%. In six cases (6/241, 2.49%) declotting failed and a catheter was placed. There were 16 minor (16/241, 6.64%) and no major complications. There was no significant difference in circuit survival regardless of SG use (No SG 406 days vs. SG 349 days; p = 0.24). There was a significant difference in favor of the second declotting compared to the first in 61 patients (first: 162 days vs. second: 447 days; p < 0.0001).Conclusion: LAB thrombectomy resulted in high-circuit survival rates with increased technical success and minimum complications without the use of thrombectomy devices. [ABSTRACT FROM AUTHOR]

Percutaneous osteosynthesis and cementoplasty (POC), a minimally invasive technique, is used for pain palliation and prevention of pathological fractures in cancer patients that are noncandidates for surgical stabilization. POC is a relatively new technique, and very few complications have been described thus far. In this case study, we report on a tumorous dissemination along the screw trajectory after POC was used for the prevention of an impending pathological fracture on a trochanteric metastasis. [ABSTRACT FROM AUTHOR]

Postoperative pulmonary complications are a major determinant of outcome for patients and consume huge resources within hospital, particularly in critical care. Prediction and anticipation of postoperative pulmonary complications are vital for patient selection and, in some cases, for informed patient consent. Being able to assess the likelihood of postoperative pulmonary complications also allows research into methods to reduce them by allowing allocation of patients to the appropriate arms of research trials. Some patients have pre-operative characteristics or belong to patient groups such as those with chronic obstructive pulmonary disease or obstructive sleep apnoea, where techniques and evidence-based guidance to avoid or reduce complications are becoming established. Intra-operative ventilation and the use of lung-protective ventilation may be helpful during major surgery, but studies looking at reduced tidal volumes, recruitment and levels of positive end-expiratory pressure, have this far only led to a degree of consensus in terms of tidal volume, although parameters that predispose to postoperative pulmonary complications are becoming clearer. Optimal postoperative care in terms of analgesia, positioning, physiotherapy and mobilisation is another developing area. Techniques such as continuous positive airways pressure, non-invasive ventilation and high-flow nasal humidified oxygen appear to show some benefit, but the exact roles, pressures and timings of each are currently being explored. Much remains to be researched and developed into evidence-based practice. [ABSTRACT FROM AUTHOR]

Cardiac complications are common after non-cardiac surgery. Peri-operative myocardial infarction occurs in 3% of patients undergoing major surgery. Recently, however, our understanding of the epidemiology of these cardiac events has broadened to include myocardial injury after non-cardiac surgery, diagnosed by an asymptomatic troponin rise, which also carries a poor prognosis. We review the causation of myocardial injury after non-cardiac surgery, with potential for prevention and treatment, based on currently available international guidelines and landmark studies. Postoperative arrhythmias are also a frequent cause of morbidity, with atrial fibrillation and QT-prolongation having specific relevance to the peri-operative period. Postoperative systolic heart failure is rare outside of myocardial infarction or cardiac surgery, but the impact of pre-operative diastolic dysfunction and its ability to cause postoperative heart failure is increasingly recognised. The latest evidence regarding diastolic dysfunction and the impact on non-cardiac surgery are examined to help guide fluid management for the non-cardiac anaesthetist. [ABSTRACT FROM AUTHOR]

Spinal cord injury arising during anaesthetic practice is a rare event, but one that carries a significant burden in terms of morbidity and mortality. In this article, we will review the pathophysiology of spinal cord injury. We will then discuss injuries relating to patient position, spinal cord hypoperfusion and neuraxial techniques. The most serious causes of spinal cord injury - vertebral canal haematoma, spinal epidural abscess, meningitis and adhesive arachnoiditis - will be discussed in turn. For each condition, we draw attention to practical, evidence-based measures clinicians can undertake to reduce their incidence, or mitigate their severity. Finally, we will discuss transient neurological symptoms. Some cases of spinal cord injury during anaesthesia can be ascribed to anaesthesia itself, arising as a direct consequence of its conduct. The injury to a spinal nerve root by inaccurate and/or incautious needling during spinal anaesthesia is an obvious example. But in many cases, spinal cord injury during anaesthesia is not caused by, related to, or even associated with, the conduct of the anaesthetic. Surgical factors, whether direct (e.g. spinal nerve root damage due to incorrect pedicle screw placement) or indirect (e.g. cord ischaemia following aortic surgery) are responsible for a significant proportion of spinal cord injuries that occur concurrently with the delivery of regional or general anaesthesia. [ABSTRACT FROM AUTHOR]

Peri-operative acute kidney injury is common, accounting for 30-40% of all in-hospital cases of acute kidney injury. It is associated with clinically significant morbidity and mortality even with what was hitherto regarded as relatively trivial increases in serum creatinine, and carries over a 12-fold relative risk of death following major abdominal surgery. Comorbid conditions such as diabetes, hypertension, liver disease and particularly pre-existing chronic kidney disease, as well as the type and urgency of surgery, are major risk factors for the development of postoperative acute kidney injury. As yet, there are no specific treatment options for the injured kidney, although there are several modifiable risk factors of which the anaesthetist should be aware. As well as the avoidance of potential nephrotoxins and appropriate volume balance, optimal anaesthetic management should aim to reduce the risk of postoperative renal complications. This may include careful ventilatory management and blood pressure control, as well as appropriate analgesic strategies. The choice of anaesthetic agent may also influence renal outcomes. Rather than concentrate on the classical management of acute kidney injury, this review focuses on the potential development of acute kidney injury peri-operatively, and the means by which this may be ameliorated. [ABSTRACT FROM AUTHOR]

The present study aimed to identify potential genes associated with prostate cancer (PCa) recurrence following radical prostatectomy (RP) in order to improve the prediction of the prognosis of patients with PCa. The GSE25136 micro-array dataset, including 39 recurrent and 40 non-recurrent PCa samples, was downloaded from the Gene Expression Omnibus database. Differentially-expressed genes (DEGs) were identified using limma packages, and the pheatmap package was used to present the DEGs screened using a hierarchical cluster analysis. Furthermore, gene ontology functional enrichment analysis was used to predict the potential functions of the DEGs. Subsequently, Kyoto Encyclopedia of Genes and Genomes pathway enrichment analyses were performed to analyze pathway enrichment of DEGs in the regulatory network. Lastly, a protein-protein interaction (PPI) network of the DEGs was constructed using Cytoscape software to understand the interactions between these DEGs. A total of 708 DEGs were identified in the recurrent and non-recurrent PCa samples. Functional annotation revealed that these DEGs were primarily involved in cell adhesion, negative regulation of growth, and the cyclic adenosine monophosphate and mitogen-activated protein kinase (MAPK) signaling pathways. Furthermore, five key genes, including cluster of differentiation 22, insulin-like growth factor-1, inhibin β A subunit, MAPK kinase 5 and receptor tyrosine kinase like orphan receptor 1, were identified through PPI network analysis. The results of the present study have provided novel ideas for predicting the prognosis of patients with PCa following RP. [ABSTRACT FROM AUTHOR]

The aim of the present study was to summarize the management of upper urinary tract calculi in crossed fused renal ectopia (CFRE). Two patients were retrospectively studied in Xiangya Hospital (Changsha, China) and all relevant literature published in English between 1996 and 2016 was reviewed. All patients, including those reported in the literature, were characterized by age, sex, manifestation, therapy history, ectopic side, stone location, surgery and outcome. The patients had a mean age of 42.3±18.5 years, a male: Female ratio of 5:4 and the ratio of renal ectopic side was 9:8 (left:right). All patients suffered from different degrees of pain on the affected side, with or without hematuria. Up to 89% of patients presented with renal stones. These patients received treatments including conservative management in 2, extracorporeal shock wave lithotripsy (ESWL) in 2, percutaneous nephrolithotomy (PCNL) in 11, laparoscope nephrolithotomy in 1 and retrograde intrarenal surgery (RIRS) in 3. Complete stone clearance was achieved in 14 patients (73.7%). In addition, 3 patients had a history of failed ESWL. No obvious intraoperative or postoperative complications occurred. The results suggested that, for the treatment of CFRE with upper urinary tract calculi, conservative treatment and ESWL are insufficient. PCNL is a safe and effective treatment for renal calculus, and laparoscopic nephrolithotomy is an alternative choice for treating large or staghorn renal stones. RIRS may become the first line of treatment for renal stones (≤3.5 cm) due to its multiple merits, including higher stone-free rates, minimal invasion and fewer complications. [ABSTRACT FROM AUTHOR]

Background Reports of isolated tricuspid valve replacement (iTVR) are relatively rare. The present study aimed to evaluate independent risk factors of perioperative morbidity and mortality after iTVR. Materials and methods We retrospectively reviewed 118 consecutive patients (42 males; mean age, 49.1 ± 12.9 y) who underwent iTVR from May 2003 to April 2016 in our center. The multivariate logistic regression model was used to analyze the independent risk factors associated with perioperative morbidity and mortality following iTVR. Results One hundred one patients (85.6%) were classified as New York Heart Association functional class III or IV preoperatively. The overall perioperative mortality was 11.8% (14/118), and a significant difference was observed between the nonreoperative group and the reoperative group (6.7% versus 18.3%, P = 0.047). The multivariate logistic regression analyses identified that preoperative New York Heart Association functional class IV (OR [odds ratio] = 15.43, 95% CI [confidence interval] = 3.46-68.83, P = 0.000) and ascites (OR = 4.88, 95% CI = 1.24-19.27, P = 0.024) were independent risk factors of perioperative deaths. The previous cardiac surgery (OR = 3.28, 95% CI = 1.41-7.62, P = 0.006) was independently associated with perioperative major adverse events. Conclusions The present study revealed that iTVR has relatively high mortality and morbidity rates. Timely surgery may be recommended for this high-risk cohort of patients before the development of severe heart and end-organ failure. [ABSTRACT FROM AUTHOR]

Major burn is considered the most severe type of injury, with high mortality risk and poor quality of life prognosis for survivors. Appropriate burn wound management may require multiple treatment modalities, with specifi c sequencing particular to each patient, addressing every injured area depending on burn surface and depth, patient's general status and also available infrastructure and burn center resources. Early excision of burn eschar and grafting with autologous split-thickness skin grafts remains the universal standard of surgical burn care in acute phase. Ongoing research is conducted for developing new skin substitutes that meet the ethical, safety effi ciency and economical criteria in order to obtain adequate wound coverage when autologous skin grafts are not available. Each severe burned patient represents a complex case, requiring long-term multiple-stage and interdisciplinary treatment, adequate rehabilitation and follow-up program to obtain optimal functional results and socio-professional reinsertion. [ABSTRACT FROM AUTHOR]

Background: Endoscopic biliary stenting is a common procedure in routine gastroenterology practice. Plastic stents are the most common type of stents used and are indicated mainly for short-term biliary drainage. Prolonged indwelling plastic stents can result in disastrous complications.Methods: We conducted a retrospective analysis of patients who presented with complications of forgotten biliary stents in a tertiary care hospital during January 2010 to October 2016. All patients were managed either by endoscopic or surgical means. Details of these patients were obtained from departmental patient database, endoscopy records, and surgical register.Results: A total of 21 cases of retained biliary stents were managed in the study period and their outcome was analyzed. The median age was 47 years (range 17-70 years) and 17 (80.9%) patients were female. Primary indication of biliary stenting was stone disease in 76.2% (n = 16), while benign biliary stricture accounted for 19% of cases (n = 4). Mean duration at presentation to hospital after ERCP stenting was 3.53 years (range 1-14 years), with cholangitis being the most common presentation (66.67%). Definitive endoscopic treatment for forgotten stent and its associated complication was possible only in five patients (23.8%); in remaining 16 (76.2%) cases, surgical exploration was required. Despite life-threatening complications and major surgical interventions, no mortality was recorded.Conclusions: Instances of forgotten biliary stents presenting with serious complications are not uncommon in Indian setup. Patients either ignore advice for timely stent removal or are unaware of the presence of endoprosthesis or need for removal. Adequate patient counseling, information, and proper documentation are essential to avoid this condition. [ABSTRACT FROM AUTHOR]

Background: Endoscopic vacuum-assisted closure (EVAC) therapy is increasingly being used as a new promising method for repairing upper gastrointestinal defects of different etiologies with high success rates. EVAC therapy consists of placing a sponge either within the lumen or within an abscess cavity connected with a nasogastric (NG) tube to a negative pressure system, thus decreasing bacterial contamination and edema and promoting granulation tissue proliferation, thereby gradually decreasing the cavity size until complete closure. Herein, we describe a modified technique for EVAC therapy in which the NG tube is passed into the esophagus through an existing intrapleural drain tract using a rendezvous technique. The small residual fistula was amendable to fibrin glue embolization. This allows easier sponge placement and exchange compared to traditional EVAC technique, and allows oral intake during treatment. We also review the literature regarding other endoscopic treatment options for esophageal anastomotic leaks and perforations.Methods: The PubMed database was searched using the terms "esophagus," "esophageal," "leak," "fistula," "endoluminal vacuum-assisted closure (VAC)," "endoscopic VAC," "stent," "sealant," "glue," and "over-the-scope clip (OTSC)." Reference lists of identified articles were searched for further articles, and the "similar articles" function was used on all included articles.Results: Complete closure of the nonhealing fistula was achieved after 8 days of EVAC treatment and fibrin glue embolization.Conclusions: Modified EVAC technique as described is feasible and safe. To the best of our knowledge, this is the first description of this technique. The technique allows easier sponge placement and exchange compared to traditional EVAC technique, and allows oral intake during treatment. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study is to investigate the efficacy and safety of needling-revision augmented with a high dose of mitomycin C (MMC) in failing or failed blebs after trabeculectomy in Indian eyes.Methods: Prospective, noncomparative, interventional study. All patients (>18 years) who had raised intraocular pressure (IOP) following trabeculectomy (>6 weeks and <2 years), who had a flat bleb, bleb encapsulation, and/or required antiglaucoma medication (AGM) for IOP control were eligible for inclusion. MMC was injected subconjunctivally at least ½ hour before the needling procedure was carried out at the slit lamp in the outpatient's clinic.Results: Thirty-nine eyes of 38 patients were included. The median follow-up was 20 months and time interval between trabeculectomy and needle revision was 113 days. Initially, in all cases, aqueous flow was re-established with a raised bleb; 7 eyes required repeat needling. IOP decreased from median 24 mmHg (Q1 21, Q3 27, interquartile range [IQR] 6, range 18-35) preneedling to median 14 mmHg (Q1 10, Q3 16, IQR 6, range 6-18) postneedling at last follow-up (P < 0.0001, 95% confidence interval [CI]: 8.2-13.0). The use of AGM reduced from median 1 (Q1 0, Q3 3, IQR 3, range 0-4) preneedling to median 0 postneedling (P < 0.0001, 95% CI: 1-2). Complete success was seen in 28 eyes (71.8%, 95% CI: 71.1%-96.4%); another 5 eyes (12.8%) were controlled with AGM (qualified success) with overall success of 84.6%. Most complications were transient in nature with resolution within 1 week. One patient developed hypotony, and another developed a late bleb leak.Conclusion: Needling revision augmented with high-dose MMC, at the slit lamp, effectively rescues failing or failed filtration, and appears to be safe. [ABSTRACT FROM AUTHOR]

Intra-operative acute hypersensitivity reactions require a decision to be made regarding whether to proceed with or abandon the planned surgical procedure once the patient has stabilised. Using retrospective case controls, we examined all cases (223) of proven acute hypersensitivity reactions from 2005 to 2014 in Western Australia, in which the syndrome was recognised by the treating clinician before or during surgery, to determine whether recovery outcomes were adversely affected by proceeding with the planned procedure. Surgery proceeded in 104 patients (47%) and was abandoned in 119 (53%). The severity of acute hypersensitivity reactions was Société Française d'Anesthésie et de Réanimation grade 1 or 2 in 56 patients (25%), grade 3 in 128 (56%) and grade 4 in 39 (17%). Abandoning surgery was more common in patients with increasing severity of hypersensitivity. The rate of major hypersensitivity-related complications for all patients was zero for grade 1 and 2 reactions, 4.7% for grade 3 and 12.8% for grade 4. There were no deaths. Patients in whom surgery was completed were not observed to have a higher frequency of major hypersensitivity-related complications when compared with cases of similar severity in whom surgery was abandoned. For patients admitted to the intensive care unit, proceeding with surgery was not associated with an increased duration of mechanical ventilation of the lungs. Our results suggest that, once initial resuscitation has been achieved and if resuscitative efforts can be re-instituted if required, continuing with planned surgery in grade 1, 2 and 3 immediate hypersensitivity was not associated with poorer outcomes. After grade 3 reactions, there was a significant incidence of complications attributable to acute hypersensitivity regardless of whether surgery proceeded or was abandoned. Surgery was frequently abandoned in grade 4 immediate hypersensitivity and was associated with a high rate of complications. [ABSTRACT FROM AUTHOR]

Background: Postoperative recurrence (POR) of Crohn's disease (CD) is common. Guidelines on POR management have recently been issued, but clinical practice may vary.Aims: To examine the current clinical practice of POR management in the USA METHODS: A web-based survey was sent to all members of the American Gastroenterological Association and the American College of Gastroenterology. The survey consisted of multiple-choice questions with clinical scenarios to assess how participants manage POR.Results: A total of 189 responses were received from practices in 34 states. 44% of participants were from academic settings. The median number of CD patients seen each month was 20-30 patients per participant. The majority of participants considered smoking, prior intestinal surgery, penetrating disease, perianal fistula, early disease onset, and long extent of disease as high-risk factors for POR. To diagnose and grade endoscopic recurrence, 57% of participants used an endoscopic scoring system; 86% defined clinical recurrence using a combination of symptoms and endoscopic findings; and 79% of participants routinely performed colonoscopy after surgery. In high-risk patients, 65% offered medical prophylaxis-most often biologics and/or immunomodulators-immediately after surgery, while 34% offered medical prophylaxis regardless of the patient's risk of POR. 64% of participants never stopped medical prophylaxis once initiated.Conclusions: Most gastroenterologists routinely perform colonoscopy to guide POR management. The majority of these providers continue medical prophylaxis indefinitely regardless of subsequent endoscopic findings. Further research is needed to determine the risks and benefits of continuing versus deescalating therapy in patients with potentially surgically induced remission. [ABSTRACT FROM AUTHOR]

Liver transplantation is a cure to many devastating acute and end-stage liver diseases. In the immediate postoperative period, patients are prone to graft, end-organ, and immunosuppressive complications. This article reviews the causes, diagnosis, and treatment of acute postoperative liver transplant complications. [ABSTRACT FROM AUTHOR]

This overview provides insight into changes in clinical practice and the implications for nursing staff and clinicians who are involved in the management of patients undergoing primary total hip arthroplasty. The review highlights commonly used surgical approaches, their advantages, their associated risks and how to manage complications if they occur. [ABSTRACT FROM AUTHOR]

Background: There are conflicting data on the results of irrigation and debridement with component retention in patients with acute periprosthetic hip infections. The goals of this study were to examine contemporary results of irrigation and debridement with component retention for acute infection after primary hip arthroplasty and to identify host, organism, antibiotic, or implant factors that predict success or failure.Methods: Ninety hips (57 total hip arthroplasties and 33 hemiarthroplasties) were diagnosed with acute periprosthetic hip infection (using strict criteria) and were treated with irrigation and debridement and component retention between 2000 and 2012. The mean follow-up was 6 years. Patients were stratified on the basis of McPherson criteria. Hips were managed with irrigation and debridement and retention of well-fixed implants with modular head and liner exchange (70%) or irrigation and debridement alone (30%). Seventy-seven percent of patients were treated with chronic antibiotic suppression. Failure was defined as failure to eradicate infection, characterized by a wound fistula, drainage, intolerable pain, or infection recurrence caused by the same organism strain; subsequent removal of any component for infection; unplanned second wound debridement for ongoing deep infection; and/or occurrence of periprosthetic joint infection-related mortality.Results: Treatment failure occurred in 17% (15 of 90 hips), with component removal secondary to recurrent infection in 10% (9 of 90 hips). Treatment failure occurred in 15% (10 of 66 hips) after early postoperative infection and 21% (5 of 24 hips) after acute hematogenous infection (p = 0.7). Patients with McPherson host grade A had a treatment failure rate of 8%, compared with 16% (p = 0.04) in host grade B and 44% in host grade C (p = 0.006). Most treatment failures (12 of 15 failures) occurred within the initial 6 weeks of treatment; failures subsequent to 6 weeks occurred in 3% of those treated with chronic antibiotic suppression compared with 11% of those who were not treated with suppression (hazard ratio, 4.0; p = 0.3).Conclusions: The success rate was higher in this contemporary series than in many previous series. Systemic host grade A was predictive of treatment success.Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Although occlusion of the coronary arteries during transcatheter aortic valve replacement is rare, the mortality is high. In this review, we discuss the prevention and management of this complication. Occlusion of coronary ostia is a very rare, but serious, complication of transcatheter aortic valve replacement (TAVR). Although reported as only occurring in <1% of TAVR cases, it carries a high risk of fatality, with some series reporting a mortality rate as high as 40%. We present the management of an occluded left coronary artery after a self-expanding TAVR, and review the incidence, prevention, and management of this complication. [ABSTRACT FROM AUTHOR]

Background: Despite the fact that aspirin is of benefit to patients following coronary artery bypass grafting (CABG), continuation or administration of preoperative aspirin before CABG or any cardiac surgical procedure remains controversial. Therefore, we performed a systematic review and meta-analysis to assess the influence of preoperative aspirin administration on patients undergoing cardiac surgery.Materials and Methods: Medline database was searched using OVID SP interface. Similar searches were performed separately in EMBASE, PubMed, and Cochrane Central Registry of Controlled Trials.Results: Twelve randomized controlled trials and 28 observational studies met our inclusion criteria and were included in the meta-analysis. The use of preoperative aspirin in patients undergoing CABG at any dose is associated with reduced early mortality as well as a reduced incidence of postoperative acute kidney injury (AKI). Low-dose aspirin (≤160 mg/d) is associated with a decreased incidence of perioperative myocardial infarction (MI). Administration of preoperative aspirin at any dose in patients undergoing cardiac surgery increases postoperative bleeding. Despite this effect of preoperative aspirin, it did not increase the rates of surgical re-exploration due to excessive postoperative bleeding nor did it increase the rates of packed red blood cell transfusions (PRBC) when preoperative low-dose aspirin (≤160 mg/d) was administered.Conclusions: Preoperative aspirin increases the risk for postoperative bleeding. However, this did not result in an increased need for chest re-exploration and did not increase the rates of PRBC transfusion when preoperative low-dose (≤160 mg/d) aspirin was administered. Aspirin at any dose is associated with decreased mortality and AKI and low-dose aspirin (≤160 mg/d) decreases the incidence of perioperative MI. [ABSTRACT FROM AUTHOR]

Background: Hemorrhage is one of the serious adverse events of endoscopic sphincterotomy (EST). However, the risk factors for delayed hemorrhage after EST have not been clarified. The aim of this study was to examine the risk factors for delayed hemorrhage after EST.Methods: Consecutive patients who underwent EST between January 2011 and December 2015 were analyzed retrospectively. The incidence, treatment outcomes, and risk factors for delayed hemorrhage were evaluated. Delayed hemorrhage was defined as symptomatic hemorrhage occurring 24 h after an endoscopic procedure.Results: After analyzing 1113 patients who underwent EST, delayed hemorrhage was seen to occur in 30 (2.7%) patients. The median period before presentation of delayed hemorrhage was 2 days (range 1-6) after EST, and its severity was mild in four, moderate in 20, and severe in six patients. All patients with delayed hemorrhage received successful endoscopic hemostasis. Univariate analysis showed that delayed hemorrhage occurred more frequently in patients with hemodialysis (p = 0.013), heparin replacement of antithrombotic agents (p = 0.012), or early hemorrhage occurring just after EST (p < 0.001). Among these, hemodialysis (OR 6.44, 95% CI 1.67-24.8; p = 0.007), heparin replacement (OR 3.76, 95% CI 1.42-9.98; p = 0.008), and early hemorrhage (OR 4.35, 95% CI 1.90-9.96; p < 0.001) proved to be independent risk factors for delayed hemorrhage on multivariate analysis.Conclusions: The incidence of delayed hemorrhage after EST was 2.7%. Hemodialysis, heparin replacement, and early hemorrhage were the risk factors for delayed hemorrhage. [ABSTRACT FROM AUTHOR]

Introduction: We present our experience with a novel three-layer two-step posterior reconstruction (PR) technique using peritoneum during robot-assisted radical prostatectomy (RARP) to improve recovery of postoperative urinary continence. Methods: Forty-eight patients with localized prostate cancer were enrolled in this study and were divided randomly into two groups, which were treated by the standard PR technique (standard PR group; n = 24) or the three-layer PR technique using peritoneum (three-layer PR group; n = 24) during RARP. We prospectively analyzed the continence rate by the 1-hour pad test. All patients underwent urethrocystography at 6 days postoperatively to evaluate position of vesicourethral junction. Pelvic MRI was also performed at 6 months postoperatively for anatomical evaluation. Results: Four weeks after RARP, the urinary continence rate was significantly higher in the three-layer PR group (57%) than in the standard PR group (26%, p = 0.036). Urethrocystography demonstrated that the postoperative craniocaudal distance from the symphysis pubis to the level of the vesicourethral junction was significantly shorter in the three-layer PR group than in the standard PR group ( p < 0.01), suggesting that there was less tension on the vesicourethral anastomosis after three-layer PR. MRI confirmed that three-layer PR provided firmer reinforcement of the structures, supporting the posterior aspect of the urethral sphincter complex. Conclusions: This prospective comparative study might suggest that three-layer two-step PR using peritoneum during RARP is a simple and feasible method seeming to improve early recovery of postoperative continence compared with standard two-step PR, although larger multicenter randomized controlled trials will be needed. [ABSTRACT FROM AUTHOR]

Background: Postoperative nausea and vomiting (PONV) is one of the most common complications in the patients undergoing strabismus surgery. The aim of current study was comparing supplemental 80% and 40% oxygen on reducing postoperative nausea and vomiting in the pediatrics undergoing strabismus surgery. Materials and Methods: In this clinical trial study, 100 pediatric patients scheduled for strabismus surgery under general anesthesia were allocated randomly into two parallel supplemental 80% and 40% oxygen groups during surgery. PONV in patients was compared until 24hrs after operation. Results: In the first 6hrs postoperatively, PONV in the supplemental 40% and 80% oxygen groups were 48.8% and 30.6% respectively, also were 20.8% and 12.2% in the 6 to 24hrs postoperatively. Therefore, there were no significant differences between both groups in regarding of PONV in 6hrs and 6 to 24hrs postoperatively (p values were 0.18 and 0.25, respectively). Conclusion: According to our results, there is no any difference between 40% and 80% oxygen postoperatively in the pediatrics undergoing strabismus surgery. [ABSTRACT FROM AUTHOR]

Background: The Affordable Care Act of 2010 advanced the economic model of bundled payments for total joint arthroplasty (TJA), in which hospitals will be financially responsible for readmissions, typically at 90 days after surgery. However, little is known about the financial burden of readmissions and what patient, clinical, and hospital factors drive readmission costs.Questions/purposes: (1) What is the incidence, payer mix, and demographics of THA and TKA readmissions in the United States? (2) What patient, clinical, and hospital factors are associated with the cost of 30- and 90-day readmissions after primary THA and TKA? (3) Are there any differences in the economic burden of THA and TKA readmissions between payers? (4) What types of THA and TKA readmissions are most costly to the US hospital system?Methods: The recently developed Nationwide Readmissions Database from the Healthcare Cost and Utilization Project (2006 hospitals from 21 states) was used to identify 719,394 primary TJAs and 62,493 90-day readmissions in the first 9 months of 2013 based on International Classification of Diseases, 9th Revision, Clinical Modification codes. We classified the reasons for readmissions as either procedure- or medical-related. Cost-to-charge ratios supplied with the Nationwide Readmissions Database were used to compute the individual per-patient cost of 90-day readmissions as a continuous variable in separate general linear models for THA and TKA. Payer, patient, clinical, and hospital factors were treated as covariates. We estimated the national burden of readmissions by payer and by the reason for readmission.Results: The national rates of 30- and 90-day readmissions after THA were 4% (95% confidence interval [CI], 4.2%-4.5%) and 8% (95% CI, 7.5%-8.1%), respectively. The national rates of 30- and 90-day readmissions after primary TKA were 4% (95% CI, 3.8%-4.0%) and 7% (95% CI, 6.8%-7.2%), respectively. The five most important variables responsible for the cost of 90-day THA readmissions (in rank order, based on the Type III F-statistic, p < 0.001) were length of stay (LOS), all patient-refined diagnosis-related group (APR DRG) severity, type of readmission (that is, medical- versus procedure-related), hospital ownership, and age. Likewise, the five most important variables responsible for the cost of 90-day TKA readmissions were LOS, APR DRG severity, gender, hospital procedure volume, and hospital ownership. After adjusting for covariates, mean 90-day readmission costs reimbursed by private insurance were, on average, USD 1324 and USD 1372 greater than Medicare (p < 0.001) for THA and TKA, respectively. In the 90 days after TJA, two-thirds of the total annual readmission costs were covered by Medicare. In 90 days after THA, more readmissions were still associated with procedure-related complications, including infections, dislocations, and periprosthetic fractures, which in aggregate account for 59% (95% CI, 59.1%-59.6%) of the total readmission costs to the US healthcare system. For TKA, 49% of the total readmission cost (95% CI, 48.8%-49.6%) in 90 days for the United States was associated with procedure issues, most notably including infections.Conclusions: Hospital readmissions up to 90 days after TJA represent a massive economic burden on the US healthcare system. Approximately half of the total annual economic burden for readmissions in the United States is medical and unrelated to the joint replacement procedure and half is related to procedural complications.Clinical Relevance: This national study underscores LOS during readmission as a primary cost driver, suggesting that hospitals and doctors further optimize, to the extent possible, the clinical pathways for the hospitalization of readmitted patients. Because patients readmitted as a result of infection, dislocation, and periprosthetic fractures are the most costly types of readmissions, efforts to reduce the LOS for these types of readmissions will have the greatest impact on their economic burden. Additional clinical research is needed to determine the extent to which, if any, the LOS during readmissions can be reduced without sacrificing quality or access of care. [ABSTRACT FROM AUTHOR]

Background: Dedicated stents for treatment of cervical anastomotic leakage are currently unavailable. In this study, we aimed to assess the feasibility and efficacy of using custom-designed stents for treatment of cervical anastomotic leakage after esophagectomy.Methods: The stents were designed according to the location and size of the leakage and the residual esophageal length as determined by esophagography in each case. It had a cup-shaped upper end and a globular lower end and a total height of 60-85 mm. The diameter of the upper cup-shaped part was 24-26 mm and the length 20-25 mm. The cup part and the stent main body were connected at a right angle. Data from cervical anastomotic leakage patients treated with these stents were retrospectively analyzed.Results: Data from a total of 27 patients with cervical anastomotic leakage were retrospectively analyzed. The custom-designed esophageal covered stents were placed successfully at the first attempt in 24 cases (88.9%). The total operative time was 5-15 min. The stents were removed 7 days to 3 months after leakage healing. Follow-up showed no leakage recurrence; three patients had anastomosis scar strictures. Fifteen patients died (median survival 13.4 months) and nine survived.Conclusion: Placement of the novel esophageal covered stent is a minimally invasive, efficacious treatment option for the patients with cervical anastomotic leakage after esophagectomy. [ABSTRACT FROM AUTHOR]

Conventionally, patients suffered from recurrent common bile duct (CBD) stone after cholecystectomy are suggested to be treated with endoscopic retrograde cholangiopancreaticography. This study was designed to explore the feasibility of laparoscopic common bile duct exploration (LCBDE) as a salvage procedure for recurrent CBD calculi after cholecystectomy. A retrospective review was conducted of data from 65 patients who underwent LCBDE for recurrent CBD calculi after cholecystectomy from January 2011 to July 2015. LCBDE was successfully carried out in 61 cases, with a successful rate of 93.8 per cent. Three cases required open conversion because of serious abdominal adhesion, and one case for intraoperative bleeding. Postoperative bile leakage occurred in two cases, and bile peritonitis developed in one case; all these three patients with complications were fully cured by conservative treatment. A postoperative retained CBD stone was found in one patient, which was extracted with endoscopic sphincterotomy. Furthermore, it was found that the mean operative time and length of postoperative hospital stay were much shorter in primary closure group (n = 49) than in T-tube drainage group (n = 12), and the hospital expense was also lower in primary closure group. We suggest that LCBDE could be a novel approach as a salvage procedure for the recurrent CBD stone after cholecystectomy, and we prefer to intraoperative primary closure of CBD if possible. [ABSTRACT FROM AUTHOR]

Purpose: Flexion in a stiff total knee arthroplasty (TKA) can be improved by manipulation under anaesthesia (MUA). Although this intervention usually results in an improvement in range of motion, the expected result is not always achieved. The purpose of this study is to determine which factors affect range of motion after manipulation in patients with a stiff total knee.Methods: After exclusion (n = 22), the data of 158 patients (138 knees) with a stiff knee after TKA who received a manipulation under anaesthesia between 2004 and 2014 were retrospectively analysed. Pre-, peri- and post-operative variables were identified and examined for their influence on flexion after the manipulation using Kruskal-Wallis and Mann-Whitney U tests and Spearman correlations.Results: After MUA, a mean improvement in flexion of 30.3° was observed at the final follow-up. Preoperative TKA flexion, design of TKA and interval between TKA procedure and MUA were positive associated with an increase in flexion after MUA. MUA performed 12 weeks or more after TKA procedure deteriorated the outcome.Conclusions: Three factors, pre-TKA flexion type of prosthesis and interval between TKA procedure and manipulation under anaesthesia, were found to have impact on flexion after TKA and MUA were identified. Results are expected to be inferior in patients with low flexion before TKA procedure or with a long interval (>12 weeks) between the TKA procedure and the manipulation under anaesthesia.Level Of Evidence: IV. [ABSTRACT FROM AUTHOR]

Background: Leaks after laparoscopic sleeve gastrectomy (LSG) are serious complications of this procedure. The objective of the present study was to evaluate the costs of leaks after LSG.Setting: Private hospital, France.Methods: A retrospective analysis was conducted on a prospective cohort of 2012 cases of LSG between September 2005 and December 2014. Data were collected on all diagnostic and therapeutic measures necessary to manage leaks, ward, and intensive care unit (ICU) length of stay. Additional outpatient care was also analyzed.Results: Twenty cases (0.99%) of gastric leak were recorded. Fifteen patients had available data for cost analysis. Of these, 13 patients were women (86.7%) with a mean age of 41.4 years (range 22-61) and mean BMI of 43.2 kg/m2 (range 34.8-57.1). The leaks occurred after 7.4 days (±2.3) postoperatively. Only one gastric leak was recorded for the last 800 cases in which absorbable staple line reinforcement was used. Mean intra-hospital cost was 34398 € (range 7543-91,632 €). Prolonged hospitalization in ICU accounted for the majority of hospital costs (58.9%). Mean additional outpatient costs for leaks were 41,284 € (range 14,148-75,684€).Conclusions: Leaks after LSG are an expensive complication. It is therefore important to take all necessary measures to reduce their incidence. Our data should be considered when analyzing the cost effectiveness of staple line reinforcement usage. [ABSTRACT FROM AUTHOR]

Aims Topical tranexamic acid (TXA) is used in patients undergoing total knee arthroplasty to reduce perioperative blood loss. However, the optimal dosing regimen remains undetermined. The aim of the present study was to quantitatively evaluate the effect of topical TXA on the reduction of postoperative drainage, and identify the dosing regimen factors affecting the efficacy of topical TXA. Methods Model-based meta-analysis was used to evaluate the efficacy of topical TXA and the dosing regimen factors influencing clinical efficacy. Data from a systemic literature search was identified and used to build a time-effect model for placebo and TXA in treating perioperative blood loss. Results Fourteen studies containing 16 TXA-control groups of drainage volume data were included for MBMA modelling. The model described the postoperative drainage-time profiles adequately. According to the model estimation, TXA can finally reduce the postoperative drainage by about 41.7%, and 10.9 h was needed to reach 50% of the maximal drainage volume. Covariate analysis indicated that both dose and contact time alone did not correlate well with clinical efficacy. However, when considered together, they can dramatically improve fitting of the data. Simulation showed that increasing dose or contact time extensively would produce a plateau-like effect: 2-3 g TXA with contact time of 1-2 h would yield >60% reduction in the drainage volume. Conclusions Dose and contact time together determined the efficacy of TXA. Extensively large dose or long contact time seems unnecessary. These findings may further guide the clinical practice on the topical TXA regimen optimization. [ABSTRACT FROM AUTHOR]

Introduction: The natural history and potential morbidity of gutter endoleaks are unclear. We present our experience with intraoperative gutter endoleaks and strategies to determine which of these require intervention. Methods: This is a retrospective review of all patients treated with parallel stent grafts from January 2010 to September 2015. We reviewed all operative records and intraoperative angiograms as well as all postoperative imaging and secondary interventions. All gutter leaks were classified as low- flow/nonsac-enhancing gutter endoleaks or high-flow/sac-enhancing gutter endoleaks. Adjunctive interventions to manage the gutter leaks were noted, as were all subsequent interventions for gutter leak and endoleak management. Results: Seventy-eight patients had 144 parallel stents placed over a 5-year period with an average of 1.8 stents per patient. Twenty-eight patients (36%) had gutter endoleaks diagnosed intraoperatively. Seventeen patients had adjunctive procedures to reduce gutter leaks prior to leaving the operating room (OR). Patients selected for treatment had gutters filling early during completion angiography and/or contrast enhancement of the aneurysm sac. Twenty-two patients (28%) left the OR with low-flow/delayed/nonsac-enhancing gutter endoleaks. At 30 days, a total of 6 persistent gutter endoleaks were diagnosed on computed tomographic angiography. This gives a 73% rate of resolution for low-flow/nonaneurysm sac-enhancing endoleaks. There were 2 de novo endoleaks not detected at the index procedure diagnosed at 6-month follow-up. Of the 8 total postoperative endoleaks, 5 required additional intervention with a 100% success rate. Multivariate analysis revealed that the only significant predictor of having a postoperative endoleak is leaving the OR with an endoleak. Conclusions: Intraoperative treatment of gutter endoleaks has an acceptable rate of resolution. It does have a high rate of converting high-flow endoleaks to low-flow endoleaks. Low-flow/nonsac-enhancing gutter endoleaks have a high rate of spontaneous resolution. Intraoperative gutter endoleaks are not predictive of future aneurysm sac growth. [ABSTRACT FROM AUTHOR]

Background and Study Aims: Laparoscopic sleeve gastrectomy (LSG) is gaining popularity in treating morbid obesity. Prior studies showed a 3.5% risk of gastric sleeve stenosis (GSS). There is no consensus on how to treat these patients, and the role of endoscopic therapy has been addressed in only a few studies. We aim to assess the efficacy and safety of endoscopic stenting in the management of GSS following LSG.Patients and Methods: Retrospective data were reviewed from July 2009 to November 2013. Patients were referred for endoscopic therapy for symptoms or imaging findings suggestive of gastric leak or narrowing following LSG. Endoscopic therapy included the use of fully covered self-expanding esophageal metal stents (FCSEMS) in addition to over-the-scope clip system (OTSC) when necessary.Results: All 27 patients were females with mean age of 40 years; six patients were excluded from the study. Major symptom was nausea and vomiting in 57% of the patients. Five of 21 patients had concomitant leaks. All 21 patients underwent FCSEMS placement, and four out of five patients (80%) with concomitant leak had OTSC. The success rate in both groups for resolution of stricture and leak was 100%, and no surgical intervention was required. There were no immediate or delayed complications of endoscopic therapy. Median follow-up of 6 months was available for 20/21 patients. Among patients with gastric leak, 80% had resolution of their symptoms compared with 93% of patients with GSS.Conclusions: Endoscopic therapy for LSG-related GSS or leaks with FCSEMS is highly effective and safe. [ABSTRACT FROM AUTHOR]

Cleft lip with or without cleft palate is the most common congenital malformation of the head and the third-most common birth defect. Surgical repair of the lip is the only treatment and is usually performed during the first year of life. Hypertrophic scar (HTS) formation is a frequent postoperative complication that impairs soft tissue form, function, or movement. Multiple lip revision operations are often required throughout childhood, attempting to optimize aesthetics and function. The mechanisms guiding HTS formation are multifactorial and complex. HTS is the result of dysregulated wound healing, where excessive collagen and extracellular matrix proteins are deposited within the wound area, resulting in persistent inflammation and resultant fibrosis. Many studies support the contribution of dysregulated, exaggerated inflammation in scar formation. Fibrosis and scarring result from chronic inflammation that interrupts tissue remodeling in normal wound healing. Failure of active resolution of inflammation pathways has been implicated. The management of HTS has been challenging for clinicians, since current therapies are minimally effective. Emerging evidence that specialized proresolving mediators of inflammation accelerate wound healing by preventing chronic inflammation and allowing natural uninterrupted tissue remodeling suggests new therapeutic opportunities in the prevention and management of HTS. [ABSTRACT FROM AUTHOR]

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Purpose: The aim of this study is to assess the safety, effectiveness and long-term outcome of endovascular management of arterial haemorrhage after radical prostatectomy (RP).Materials and Methods: Ten patients who received endovascular treatment for refractory bleeding after RP between January 2008 and December 2016 were retrospectively identified. Contrast-enhanced computed tomography (CT) was performed and followed by catheter-directed treatment by means of transarterial embolization (TAE) or stent graft placement. Follow-up included analysis of bleeding recurrence, embolization-related adverse events and tumour recurrence.Results: Contrast-enhanced CT and catheter-directed angiography showed pelvic contrast extravasation in nine patients. Nine patients were successfully treated with TAE of the internal pudendal, superior and/or inferior vesical or (the anterior division or main branch of) the internal iliac arteries using microparticles in two patients, coils in two patients, a combination of microparticles and coils in three patients, glue in one patient and Gelfoam in one patient. The remaining patient was treated with stent graft placement in the external iliac artery, which was most likely injured during robot-assisted lymphadenectomy. One patient developed a puncture site pseudoaneurysm. No other complications related to the endovascular procedures occurred, in particular no pelvic ischaemic complications were identified. Mean follow-up period was 45 months (range 22-80).Conclusions: The endovascular management of arterial haemorrhage after RP is safe and effective, without post-embolization ischaemic events. [ABSTRACT FROM AUTHOR]

Purpose-Osteomyelitis is a bone infection that appears as a complication after a fracture or orthopedic surgery. Ciprofloxacin is a broad spectrum antibiotic that can be used in local drug delivery systems for the treatment of bone related infections due to its bactericidal activity against both Gram-negative and Gram-positive bacteria. The purpose of the present study was to include ciprofloxacin in poly (lactic-co-glycolic acid) (PLGA) microspheres. Material and methods-Microspheres were prepared by both water/oil/water (w/o/w) solvent evaporation method and solid/oil/water (s/o/w) dispersion solvent evaporation method. The obtained microspheres were characterized by Fourier Transform Infrared Spectroscopy. High performance liquid chromatography method was deployed to determine the encapsulation ratio. Results-The solvent evaporation method chosen for this experiment resulted in microspheres with good entrapment efficiency. Furthermore the microspheres obtained by the s/o/w method displayed better entrapment efficiency. Conclusion-The particles obtained through the s/o/w technique should be further investigated in order to develop a local drug delivery system. [ABSTRACT FROM AUTHOR]

Postoperative adhesions remain one of the more challenging issues in surgical practice. Although peritoneal adhesions occur after every abdominal operation, the density, time interval to develop symptoms, and clinical presentation are highly variable with no predictable patterns. Numerous studies have investigated the pathophysiology of postoperative adhesions both in vitro and in vivo. Factors such as type and location of adhesions, as well as timing and recurrence of adhesive obstruction remain unpredictable and poorly understood. Although the majority of postoperative adhesions are clinically silent, the consequences of adhesion formation can represent a lifelong problem including chronic abdominal pain, recurrent intestinal obstruction requiring multiple hospitalizations, and infertility. Moreover, adhesive disease can become a chronic medical condition with significant morbidity and no effective therapy. Despite recent advances in surgical techniques, there is no reliable strategy to manage postoperative adhesions. We herein review the pathophysiology and clinical significance of postoperative adhesions while highlighting current techniques of prevention and treatment. [ABSTRACT FROM AUTHOR]

Background The short- and long-term surgical results in patients with esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) have been described in depth from a physician's perspective. Contrarily, the perception and coping strategies of affected patients and their parents have rarely been reported. The aim of this study was to generate data on this matter. Patients and Methods A total of 154 patients who had operative reconstruction for EA between 1971 and 2012 were evaluated for demographic data, surgical technique, affection of daily life, and coping strategies. Results Gastroesophageal reflux (GER) symptoms were reported in 59% of cases with 33% requiring fundoplication. Regular bougienages of anastomotic strictures were necessary in 68% with 36% requiring repeated dilatations in the first postoperative year. Enteral nutrition via a nasogastric tube was performed in 66% after surgery. In 40%, the tube was needed until their sixth week of life. In 25%, nutritional support was necessary more than 1 year out of surgery. Quality of life in general was felt to be impaired according to the patients' parents in 50%. Regarding medical advice about long-term morbidities, more than 50% of the parents felt insufficiently advised. There were no statistical differences between the EA/TEF subtypes regarding GER symptoms, frequency of esophageal dilatations, eating behaviors, or support of the parents in feeding management. Conclusion Our observations indicate that a high percentage of EA/TEF patients and families require more intensive aftercare and support during the first year following primary reconstruction than previously thought. We observed a higher need for adequate parental information on long-term complications of their children compared with current practice. [ABSTRACT FROM AUTHOR]

Elevated liver function tests (eLFTs) are a major cause of unplanned readmissions (UR) after orthotopic liver transplantation. Diagnostic workup for eLFTs requires multiple invasive and noninvasive procedures, often done in the inpatient setting to expedite diagnosis, yet consequently resulting in increased costs. In this study, we evaluated eLFT readmissions at a single institution with respect to resource utilization. From 3/2013 to 12/2015, 388 patients underwent orthotopic liver transplantation, resulting in 463 UR totaling 5833 bed days; 87 (18.8%) UR and 929 (15.9%) bed days were for eLFTs. During eLFT-UR all patients underwent repeat laboratory testing, 75 (86.2%) liver ultrasound, 66 (75.8%) liver biopsy, and 17 (19.5%) endoscopic retrograde cholangiopancreatography. Discharge diagnoses were acute cellular rejection (40.2%), transaminitis not otherwise specified (17.2%), biliary complications (16.1%), recurrent hepatitis (11.5%), vascular complications (5.8%), viral hepatitis (5.8%), and steatohepatitis (3.5%). The greatest bed-day utilization was secondary to acute cellular rejection (60.8%) and biliary complications (13.7%). More than 35 per cent of eLFT-UR were due to transaminitis not otherwise specified, steatohepatitis, recurrent or viral hepatitis, none of which necessitate inpatient treatment. In addition, >25 per cent of eLFT-UR bed days were attributed to diagnostic workup. Identifying patients who can undergo expedited outpatient workup and require only outpatient management will result in significantly decreased readmissions, bed days, and hospital costs. [ABSTRACT FROM AUTHOR]

Studies suggest that early contact (EC) after hospital discharge may help reduce hospital readmissions among medical patients. The objective of this study is to determine if EC after hospital discharge in patients undergoing a pancreaticoduodenectomy (PD) can reduce readmission. We performed a retrospective study of 35 patients who underwent PD over 18 months. Early, focused contact after hospital discharge was either a telephone call by a registered nurse or a clinic visit with a provider within four days of discharge. Hospital readmission rates were analyzed between the EC and no-early contact (NC) cohorts. Nineteen patients received EC after hospital discharge and 16 were in the NC group. Fourteen patients (40%) were readmitted, with postoperative pancreatic fistula and delayed gastric emptying as the most common indications for readmission (71.4%). Overall readmission rates were not significantly different between the EC and NC groups (31.6 vs 50.0%, respectively, P = 0.27). EC after hospital discharge in patients undergoing PD does not prevent readmission. This is likely due to the high incidence of postoperative pancreatic fistula or delayed gastric emptying that clinically manifests after hospital discharge and EC and requires readmission for management. [ABSTRACT FROM AUTHOR]

Pathological steal is an uncommon but devastating complication after the creation of arteriovenous access for hemodialysis. In this study, we sought to assess predictors of clinically significant steal syndrome and to further evaluate the outcome of differing surgical treatment approaches. A retrospective analysis was performed of 282 consecutive patients undergoing hemodialysis access at a single center from November 2014 to April 2016. Adequate follow-up to assess for the development of steal was obtained in 237 patients. One hundred and fifty-seven (66%) patients were male, 152 (64%) Hispanic, and 164 (69%) had diabetes. Forty-three (18%) had prior access procedures. Autologous fistula was created in 218 patients (92%). Pathologic steal occurred in 15 patients (6.7%). On univariate analysis, significant predictors of steal included female sex [P = 0.03, odds ratio (OR) = 3.3, CI [1.1-9]), no systemic heparin at operation (P = 0.02, OR = 5.0, CI [1.4-10]), use of angiotensin-converting enzyme inhibitor (P = 0.003, OR = 5.6, CI [1.7-18.6]), and increased vein size (3.1 vs 4.1 mm P = 0.01). Twelve patients had steal managed with an intervention, but only one patient received distal revascularization. Furthermore, we identify key predictors of clinically significant steal syndrome while demonstrating that distal revascularization and/or fistula ligation are rarely indicated treatment modalities. [ABSTRACT FROM AUTHOR]

The open abdomen technique and temporary abdominal closure after damage control surgery is fast becoming the standard of care for managing intra-abdominal bleeding and infectious or ischemic processes in critically ill patients. Expansion of this technique has evolved from damage control surgery in severely injured trauma patients to use in patients with abdominal compartment syndrome due to acute pancreatitis and other disorders. Subsequent therapies after use of the open abdomen technique and temporary abdominal closure are resuscitation in the intensive care unit and planned reoperation to manage the underlying cause of bleeding, infection, or ischemia. Determining the need for this potentially lifesaving intervention and managing the wound after the open abdomen has been created are all within the realm of critical care nurses. Case studies illustrate the implementation of the open abdomen technique and patient management strategies. [ABSTRACT FROM AUTHOR]

Postoperative ileus is a common and often life-threatening gastrointestinal complication with few management methods available for patients. Integrating acupressure into perioperative care promises to bring benefits into preventing postoperative ileus. This systematic review and meta-analysis aims to evaluate the efficacy of acupressure in identifying the signs and symptoms of postoperative ileus among patients undergoing abdominal surgery. The MEDLINE, EMBASE, Web of Science, CINAHL, China Journal Net and Wanfang databases were searched for high-quality RCTs using keywords such as acupressure, postoperative ileus, abdominal surgery, etc. A total of six studies () were included in this review and meta-analysis. The quality of the literature was found to be uniformly moderate by the Effective Public Health Practice Project (EPHPP) assessment tool. The results of meta-analyses revealed that acupressure could significantly reduce risks for postoperative nausea (OR 0.52, 95% CI 0.39-0.70, ) and vomiting (OR 0.54, 95% CI 0.39-0.75, ) compared with the control group, without significant heterogeneity among studies. Meta-analysis of the need for antiemetic drugs suggested that the OR was 0.39 (95% CI 0.20-0.78, ) with significant heterogeneity among studies. Our results suggested that acupressure might be effective in reducing the incidence of postoperative nausea and vomiting and the need for antiemetic drugs among patients undergoing abdominal surgery. Considering the substantial risk of bias in the articles included, future high-quality RCTs with a rigorous methodology are desirable to provide solid evidence. Furthermore, other signs and symptoms of postoperative ileus should be explored in future. [ABSTRACT FROM AUTHOR]

Background: Pancreatic leaks occur as a complication of upper gastrointestinal surgery, acute pancreatitis, or abdominal trauma. Pancreatic fistulas and leaks are primarily managed conservatively. Overall, conservative measures are successful in more than half of cases. Whenever conservative treatment is not efficient, surgery is usually considered the treatment of choice. Nowadays however, endoscopic treatment is being increasingly considered and employed in many cases, as a surgery sparing intervention.Aim: To introduce a classification of pancreatic fistulas according to the location of the leak and ductal anatomy and finally propose the best suited endoscopic method to treat the leak according to current literature.Methods: We performed an extensive review of the literature on pancreatic fistulae and leaks.Results: In this paper, we review the various types of leaks and propose a novel endoscopic classification of pancreatic fistulas in order to standardize and improve endoscopic treatment.Conclusions: A proper and precise diagnosis should be made before embarking on endoscopic treatment for pancreatic leaks in order to obtain prime therapeutic results. A multidisciplinary team of interventional endoscopists, pancreatic surgeons, and interventional radiologists is best suited to care for these patients. [ABSTRACT FROM AUTHOR]

Aortic root replacement with a biological conduit results in excellent hemodynamics but has limited durability. We report a series of six patients who underwent successful Perceval-S surgical aortic valve implantation following surgical deterioration of a biological valve composite conduit and discuss the technical details and the importance of appropriate valve sizing for this procedure. [ABSTRACT FROM AUTHOR]

Background and study aims Colonoscopic polypectomy reduces colorectal cancer incidence, but is associated with complications including post-polypectomy bleeding (PPB). PPB ranges in severity from minor to life-threatening, making interpretation and comparison difficult. No previous studies have examined PPB rate according to a standardized severity grading system. We aimed to determine the PPB rate stratified by severity grading, explore factors that contribute to PPB severity grading, and describe PPB management. Methods Data relating to PPB were prospectively collected from all colonoscopies performed in one region of the English NHS Bowel Cancer Screening Programme (BCSP) from 06/12/2010 to 15/07/2014. PPB was defined and stratified into major, intermediate, and minor according to BCSP standardized definitions based on the American Society for Gastrointestinal Endoscopy adverse events lexicon. Results A total of 15 285 colonoscopies (23 766 polypectomies) were analyzed. The PPB rate per colonoscopy was 0.44 % (95 % confidence interval [CI] 0.34 - 0.54) and the rate per polypectomy was 0.29 % (95 %CI 0.20 - 0.38); 2.9 % of PPBs were major and 42.6 % were intermediate. Repeat endoscopy occurred in 27.9 % and was the most common reason for bleeding being categorized as of intermediate severity, although therapy was applied in only 36.8 % of these cases. A therapeutic intervention was significantly more common in patients with PPB who had either a hemoglobin drop ≥ 2 g/dL and/or a blood transfusion (P = 0.04, relative risk 3.47, 95 %CI 1.05 - 11.52). Conclusions This study specifically examined colonoscopic PPB rate, stratified using standardized criteria. The rates of PPB were low, with the majority of PPB being of minor severity. Current stratification of PPB severity combines measures of bleed severity with interventions. Using only hemoglobin drop ≥ 2 g/dL and/or blood transfusion as markers of PPB severity may simplify stratification, and allow a better assessment of the necessity and impact of an intervention. [ABSTRACT FROM AUTHOR]

Background: Bleeding and gastric fistula are the most common postoperative complications after laparoscopic sleeve gastrectomy (LSG). The long stapler line represents the most frequent source of bleeding, which ranges between 0 and 20%. The aim of this retrospective study was to analyze the 4-year experience of a high-volume center with respect to the prevention and management of perioperative LSG bleeding.Methods: The prospectively maintained database from June 2012 to June 2016 was reviewed. Outcomes, especially perioperative bleeding (until patient discharge), its management, and follow-ups, were analyzed.Results: Out of 870 LSG (603 females, 267 males), 31 cases (3.5%) of postoperative complications were registered: bleeding was the most frequent complication (1.9%). Hemoperitoneum was managed laparoscopically in 9/17 patients (52.9%) with only one conversion to laparotomy (11.1%). Conservative treatment successfully controlled bleeding in 8/17 patients (47.1%). However, four patients (50%) developed an infected hematoma; two of them were treated conservatively with a CT-guided drainage, and the other two were complicated by late gastric leak treated laparoscopically. No mortalities occurred in the investigated cases.Conclusions: In a high-volume center, the expected incidence of bleeding after LSG is 1.7% even after the adoption of all preventive strategies. The intraoperative protocol for detecting silent bleeding was effective, and no cases of bleeding were observed since its application. Our findings showed that the conservative management of postoperative bleeding should be considered as a high-risk condition for late leakage. [ABSTRACT FROM AUTHOR]

Introduction: Laparoscopic sleeve gastrectomy (LSG) is becoming an increasingly popular form of bariatric surgery, accounting for more than 50% of these procedures performed in the USA. Given this popularity, more is being understood about the complications associated with LSG, which, though uncommon, include the formation of strictures and stenosis. The purpose of this study is to establish a safe and effective protocol for the treatment of stenosis post-LSG using endoscopic balloon dilatation.Materials and Methods: This is a prospective review of 26 patients who had undergone LSG in Kuwait, followed by sleeve gastrectomy stenosis (SGS) and were then referred to Amiri Hospital for endoscopic balloon dilatation from October 2008 up to June 2016.Results: A total of 26 patients (four males; 22 females) presented with symptoms of stenosis post-LSG during the study period. The mean age of the patients was 34.6 ± 10.8 years. The mean body mass index at the time of surgery was 43 ± 1.6 kg/m2. The median interval from the initial LSG surgery was 95 days. Nine patients had an early presentation (≤3 months from surgery), while 17 presented late (>3 months). The patients were followed for a mean duration of 156 ± 20 days from the last endoscopic balloon dilatation. A total of 23 (88.5%) patients had complete resolution of their symptoms. Adverse events were observed in one patients, who was removed from the study.Conclusions: Gastric stenosis is a rare but potentially serious complication of LSG. Serial dilatation of SGS employing endoscopic balloons is a safe method of treatment, with high efficacy rates. This new method may offer a less invasive alternative to surgical revision. However, if endoscopic treatment fails, surgery is necessary. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the outcome of patients with an established indication for oral anticoagulation (OAC) undergoing coronary stent implantation (PCI-S) and stratified by the baseline risk of bleeding.Material and Methods: The database of the prospective, multicentre, observational WAR-STENT registry (ClinicalTrials.gov identifier NCT00722319) was analyzed and patients with atrial fibrillation and CHA2DS2-VASc score ≥2, mechanical heart valve, prior cardiac embolism, intra-cardiac thrombus and recent venous thromboembolism who were treated with either triple (warfarin, aspirin and clopidogrel) or dual (warfarin and clopidogrel) or dual antiplatelet (aspirin and clopidogrel) therapy, identified. Patients were then sorted into two groups at non-low and low risk of bleeding, as defined by an ATRIA score >3 and ≤3 respectively, and compared regarding major adverse cardiac and vascular events (MACVE) and bleeding.Results: At 12-month follow up, MACVE were comparable in the two groups, whereas total, major and minor bleeding, as well as combined MACVE and total bleeding, were significantly more frequent in the non-low bleeding risk group. Upon Cox univariate and multivariable analysis, non-low bleeding risk category confirmed as an independent predictor of major bleeding. The choice of antithrombotic therapy however, appeared not to be influenced by the bleeding risk category at baseline.Conclusions: In patients with an established indication for OAC undergoing PCI-S, non-low bleeding risk category is the most potent independent predictor of major bleeding. Stratification of the bleeding risk at baseline should therefore be regarded as an indispensable process to be carried out before selection of the antithrombotic therapy. [ABSTRACT FROM AUTHOR]

Postoperative junctional ectopic tachycardia (JET) is a frequent complication after pediatric cardiac surgery. Current recommendations on how and when to treat JET are inconsistent. We evaluated the management strategies of postoperative JET in German-speaking countries. We sent an online survey to 30 centers of pediatric cardiology that perform surgery for congenital heart defects in Germany (24), Austria (4), and Switzerland (2). The survey asked 18 questions about how and in what treatment sequence postoperative JET was managed. All 30 centers completed the survey (100% return rate). There was general agreement that the management of JET is based on administration of antiarrhythmic drugs, body surface cooling, and temporary pacing. Many centers presented treatment algorithms based on published literature, all centers named amiodarone as the first drug of choice. Significant disagreement was found concerning the timing and sequential order of additional therapeutic measures and particularly about the dosing of amiodarone and the role of R-wave synchronized atrial pacing.Conclusion: This survey reveals that from center to center, the treatment of postoperative JET may vary substantially. Future work should focus on those treatment modalities where a high rate of variation is found. Such studies may be of value to achieve commonly adopted treatment recommendations. What is known: • Treatment of postoperative junctional ectopic tachycardia is predominantly based on administration of antiarrhythmic drugs, therapeutic cooling, and temporary pacing. • Amiodarone is the antiarrhythmic drug of choice in this context. What is new: • Dosing and duration of administration of amiodarone differ relevantly from center to center. • The sequential order of drug administration, therapeutic cooling, and pacing is not consistent. [ABSTRACT FROM AUTHOR]