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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.

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.

Objective To evaluate the efficacy of dexmedetomidine as an opioid-sparing agent in infants following open thoracic or abdominal operations. Methods Retrospective review of postoperative neonates who received IV acetaminophen with or without dexmedetomidine. The primary outcome was opioid dosage within the first ten postoperative days. Secondary outcomes included times to extubation, full feedings and discharge. Results 112 infants met inclusion criteria. Those managed with dexmedetomidine received 1.8-4.3 times more opioid on postoperative days 1-3, had longer times to extubation and trended towards longer lengths of hospital stay than infants who were not. Opioid was dosed >0.2 ME/kg on only 23% of days when the acetaminophen dose was >40 mg/kg/day and 10% of days when the acetaminophen dose was >45 mg/kg. Conclusion Dexmedetomidine may not be opioid sparing after major operations in neonates and its use delays recovery. IV acetaminophen dosed at 40 mg/kg/day or greater may yield the most substantial opioid-sparing effect.

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.

Surgery is constantly evolving along the history. Surgery has seen an impressive evolution due to advances in anesthesia, basic research, means of exploration, immunology, genetics, pharmacology and especially in artificial intelligence. Surgery has evolved from open surgery to minimally invasive surgery, then to robotic surgery and in future to digital surgery. The five pillars of digital surgery are: (1) robotics, (2) advanced instrumentation, (3) enhanced visualization, (4) connectivity, and (5) data analytics and machine learning. Surgical education has evolved from Halsted's model (one see, one do, one teach) to special training programs such as the Rasmussen model in 3 stages: skill based behavior, ruled based behavior, knowledge based behavior. Digital technologies are changing surgical education. New terms appear such as: Massive open online courses, Flipped classrooms, Digital badges, Virtual anatomy, Medical holograms. Artificial intelligence can improve surgical education. It can bring transparency to the operating room and accelerate surgical education. Digital Mentoring provides the next generation of the digital platform with the transfer of surgical knowledge from an expert to a practitioner and allows surgeons to evolve to achieve the best results. In addition, all members of the operative team can benefit from training using augmented virtual reality. Establishing an infrastructure that allows the perfect integration of robotics, artificial intelligence, advanced instrumentation, advanced training methods, educational programs will allow the rapid development of innovation and surgical progress. In this way, digital surgery will provide globally advanced surgical care in continuous improvement. The classical methods still remain valid in the training of young surgeons. The most important aspect remains the training in the operating room. The new methods do not exclude the classic training that gave good results, but they complement and make general surgery more attractive for the new generation. In the desire to reform surgical education we have actually lost the purpose of training - the surgical patient, which is real, not virtual. The most important aspect that must be transmitted to young surgeons is the humanism of our profession, which for the time being cannot take the digital form.

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.

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

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.

Background: There is no conclusive data on postoperative recommendations after abdominal and hernia surgery, and there is significant variation in the literature on that question. Thus, this study evaluates the status quo of recommendations of postoperative activity restriction after abdominal surgery.Materials and Methods: A national (German) and international survey of general surgeons on postoperative recommendations after abdominal and hernia surgery was pooled and analyzed.Results: A total of 74.6% recommended postoperative reduced activity for 2 weeks or less after laparoscopy. For midline laparotomy, 48.8% considered a reduced activity of 4 weeks or less to be sufficient. A majority from the national survey recommended more than 4 weeks instead (60.2%), whereas only 31.5% from the international survey did so (p = 0.000). In the pooled analysis, 258 of 450 (57.3%) rated 4 weeks or less suitable. However, the recommendations differed significantly between the surveys (4 weeks or less: a national survey, 47.1% vs. international survey, 64.6%; p = 0.000).Conclusion: There was substantial variation in the given recommendations. However, we found no evidence against immediate mobilization, reduced physical activity, and lifting for up to 2 weeks after laparoscopic surgery and for up to 4 weeks after open abdominal surgery and open incisional/ventral hernia repair in uncomplicated and standard cases. There might be individual and socioeconomic benefits to allow patients to return to their whole personal level of activity and work without putting them at risk of complications. Due to lack of evidence, both retrospective and prospective, controlled studies are in need to develop reliable recommendations.

Some surgeons perform the operation very skillfully and aseptically, but care little about the further fate of their patients, who often die from various accidents after the operating period. Indicating and preventing these accidents dr. Hickman dedicates his article. After gastrointestinal surgery, it is necessary to tightly bandage the abdomen, starting from the lower ribs, and the legs to the knees, the abdominal muscles must be made motionless, but the movements of the legs affect the latter, therefore, for the first 3-4 days, the legs must also be bandaged.

BACKGROUND: Surgical site infection is the most important and preventable cause of infections in surgical patients. It determines the morbidity and mortality in post -operative patients. Determination of modifiable factors can aid in modifying the course of post-operative period. The focus of this study is on the factors and organisms predisposing patient to surgical site infections. MATERIAL AND METHODS: A total of 140 cases undergoing emergency non traumatic abdominal operations were included and the variable factors were determined .RESULTS: Most of the patients (89.29 %) were in between 10-49 years. Rate of SSI was highest 26.47 % (9 among 34) in the 40 - 49 years age group. The rate of SSI was as high as 15 among 46 (32.61 %) dirty cases. Most of the infections (91.66 %) were started between 4th and 8th post operative days (POD) and it was highest 8 (33.33 %) on 5th POD. CONCLUSION: Multiple host, environment and infective organism related factors determine the outcome of surgery.

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.

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

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.

Background/Purpose: Prolonged postoperative mechanical ventilation (PPMV) can lead to poor outcomes including pneumonia, ventilator-associated lung injury, prolonged hospital length of stay, increased postoperative mortality, and overall increased cost of surgical care. Our objective was to identify independent risk factors for PPMV in pediatric general surgery patients undergoing abdominal operations. Method: Utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) …

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.

Although laparoscopic cholecystectomy is the gold standard treatment for benign gallbladder disease, a number of conditions have been repetitively shown to be associated with an increased risk of conversion to the open approach. These include several disease-related and patient-related factors such as advanced age, severe acute cholecystitis, a history of multiple abdominal operations, and comorbidities. Although preoperative identification is crucial for proper patient selection and treatment algorithm, the verdict to convert is primarily deemed on the intraoperative surgeon decision as a safe “bailout” technique. This chapter aims to review the conditions that have been shown to consistently increase the risk of conversion, as well as highlight the importance of conversion as wise approach in the difficult cholecystectomy case where the risks of continuing with the laparoscopic cholecystectomy clearly outweigh the morbidity that comes with conversion to open.

Objective: To determine the frequency of deep venous thrombosis after abdominal surgery. Study Design: Cross Sectional Study. Settings: Department of Surgery, Bolan Medical Complex, Quetta Pakistan. Duration: Six-months started from 14-06-2014 to 13-12-2014. Methodology: All patients with age 40 years to 70 years of either gender presented with ASA status I or II underwent major abdominal operations lasting more than 30 minutes were enrolled. Patients were followed for 7th postoperative day and final outcome that is DVT was assessed. Results: Patients mean age was 58.40 ±9.59 years. Female preponderance was found to be higher, i.e. 47 (53.40%). Mean BMI of the patients was 25.3 ±5.4Kg/m2. There were 58 (65.9%) patients with HTN, 34 (38.60%) smokers and 42 (47.70%) diabetic patients. There were 14 (15.90%) DVT cases were reported. Conclusion: The frequency of deep venous thrombosis was found in 14 (15.90) patients after abdominal surgery.

The aim of this chapter is to challenge and encourage anesthesiologists and surgeons to consider adding existing or newer regional anesthesia techniques to their repertoire to minimize postoperative pain following abdominal operations. Use of regional anesthesia techniques is an important and increasingly widely used component of multimodal analgesia. Effective blocks result in reduced use of systemic oral and intravenous analgesics, especially opioids, and allow earlier return to normal function.

Dangerous abdominal operations such as liver resection could not reasonably advance unless capabilities developed to recognize and address the physiological changes resulting from surgical trauma and loss of blood. This would translate to a better control of the anesthetized patient, more sophisticated monitoring measures, and the ability to quickly resuscitate if blood loss threatened hemodynamic stability.

Iatrogenic splenic injury is a well-recognized and potentially serious complication during different abdominal operations. However, the highest percentage of all iatrogenic splenic injuries is related to colorectal surgery. The most common mechanism is excessive traction on the ligaments attached to the spleen. A less frequent mechanism of injury is a direct mechanical injury of the spleen capsule or parenchyma caused by a surgical instrument. Although the risk factors of splenic injury are a given conditions, splenic injury is a technical error and the surgeon must take all possible measures to avoid it. We will review our strategy and some tips and tricks to avoid splenic injury during colorectal surgery. In addition, we will propose a step-by-step approach to the management of splenic injury during colorectal surgery.

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.

Current management of simple ventral hernia involves the use of a prosthetic mesh to reconstruct the abdominal wall with a low recurrence rate. Complex abdominal wall defects, however, pose a challenge to the surgeon to restore the structural anatomy and to provide coverage and good functional outcome using solely a mesh. Such large and complex abdominal wall defects often result from trauma, multiple abdominal operations, infections, resection of tumours and obesity. Despite advances in surgical technology, such hernias/defects could be too large or even impossible to repair with a mesh alone. This chapter will focus on contemporary component separation technique (CST) to treat complex ventral hernias and how to avoid pitfalls associated with this procedure.

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

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

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.

Peutz-Jeghers syndrome is a relatively rare autosomal-dominant inheritance type disease characterized by multiple hamartomas in the gastrointestinal tract. Treatment of such patients is traditionally surgical, but nowadays, due to the introduction of new methods of intraluminal endoscopy, it is often possible to avoid open abdominal operations, diagnose and remove the hamartomatous polyps in a minimally invasive way. The aim of this article is to demonstrate the diagnostic and surgical capabilities of modern intraluminal endoscopy for the treatment of patients with multiple hereditary gastrointestinal polyposis as shown on our own clinical observations. The technique of deep single balloon enteroscopy in conjunction with standard routine endoscopic manipulations allows to perform a total examination of the whole gastrointestinal tract and, if necessary, to remove almost all epithelial neoplasia, which certainly has a positive impact on the quality of the patient’s life.

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.

Introduction The impact of ustekinumab on adverse postoperative outcomes in Crohn’s disease (CD) remains largely unknown. We determined the difference in 90-day postoperative complication rates among CD patients exposed to ustekinumab within 12 weeks prior to an abdominal operation as compared to patients not exposed to biologic therapy. Methods A retrospective chart review of all adults with CD who underwent an abdominal operation between October 1, 2017 and December 31, 2018 at a single tertiary medical center was performed. Data collection included patient demographics, concurrent immunosuppression, serum laboratory values, operative values, and 90-day outcomes including superficial surgical site infection (sSSI), intra-abdominal sepsis, overall infectious complications, readmission, and reoperation rates. The primary outcome was the 90-day rate of intra-abdominal sepsis. Results Fifty-seven CD patients received ustekinumab and 277 received no biologic therapy in the 12 weeks prior to major abdominal surgery. Ustekinumab-exposed patients were younger, less likely to have diabetes mellitus or active tobacco exposure, were more often obese, and more often taking a concurrent immunomodulator. Ustekinumab remained an independent predictor of intra-abdominal sepsis on multivariable logistic regression. Immunomodulator exposure was associated with significantly increased rates of sSSI and overall complication rates. Conclusions Ustekinumab is associated with increased rates of 90-day postoperative intra-abdominal sepsis following a major abdominal operation for CD.