Platelet to Lymphocyte Ratio as a Predictive Tool for the Perioperative and Postoperative Outcomes in Advanced Stage Ovarian Cancer.

Background: platelet to lymphocyte ratio remains a significant prognostic factor in different malignancies. The aim of the current paper is to study the correlation between the preoperative values of platelet to lymphocyte ratio (PLR) and the postoperative outcomes in ovarian cancer patients. Method: we conducted a retrospective study on 57 patients submitted to cytoreductive surgery between 2014-2020. We determined the optimal cut off value of PLR for predicting survival outcomes by using the Receiver Operating Characteristic curve a value of 350 being obtained. The patients were further classified in two groups according to the PLR value. Results: there were 37 patients with PLR 350 and respectively 20 patients with PLR 350. Patients in the second group were significantly older and presented significantly higher rates of perioperative complications, a significantly higher level of circulating platelets, of CA125 and respectively a significantly lower level of circulating lymphocytes and of preoperative hemoglobin level. Meanwhile, patients in the second group reported a significantly poorer disease free and overall survival. Conclusions: ovarian cancer patients with higher preoperative levels of PLR trend to have a poorer early and long-term postoperative outcome. Therefore, in such cases more aggressive systemic therapies might be needed.

A randomized clinical trial of technical modifications of appendix stump closure during laparoscopic appendectomy for uncomplicated acute appendicitis.

BACKGROUND: Closure of the appendix stump presents the most critical part of laparoscopic appendectomy. The aim of the present study was to compare the medical outcomes and cost analysis of laparoscopic appendectomy with respect to the different methods of stump closure. METHODS: This was a prospective randomized clinical trial conducted in a single institution (University Hospital Ostrava) within a 2-year study period. All included patients were randomized into one of three trial arms (endoloop, hem-o-lok clips or endostapler). RESULTS: In total, 180 patients (60 patients in each arm) were enrolled into the study. The mean length of hospital stay (3.6 ± 1.7 days) was comparable in all study arms. The shortest operative time was noted in the hem-o-lok subgroup of patients (37.9 ± 12.5 min). Superficial surgical site infection was detected in 4.4% of study patients; deep surgical site infection was noted in 1.7% of the patients. The frequency of surgical site infections was comparable in all study arms (p = 0.7173). The mean direct costs of laparoscopic appendectomy were significantly the lowest in the hem-o-lok subgroup of patients. Laparoscopic appendectomy is not a profit-making procedure in our institution (mean profit of made from the study patients was-104.3 ± 579.2 Euro). Closure of the appendix stump by means of endostapler presents the most expensive and the highest loss-incurring technique (p = 0.0072). CONCLUSIONS: The present study indicates that all technical modifications of appendix stump closure are comparable with regards to postoperative complications. The stapler technique is significantly the most expensive. We concluded that hem-o-lok clips have the potential for becoming the preferred method of securing the appendix base during laparoscopic appendectomy. Trial registration NCT03750032 ( http://www.clinicaltrials.gov ).

Laparoscopic Total Extraperitoneal Repair and Open Prolene Hernia System for Inguinal Hernia Repair Have Similar Outcomes: A Retrospective Study.

OBJECTIVE: To compare the results of Laparoscopic total extraperitoneal inguinal hernia repair (LTEPR) and the open prolene hernia system repair (OPHSR), in terms of complications, postoperative pain and quality of life. Background: Inguinal hernia repair is one of the most frequent surgeries made by general surgeons. Although, with the technological development and scientific advances even today it is not possible to define which is the gold standard procedure to hernia repair. Material and Methods: For this observational study, all 577 consecutive patients who underwent hernia repair were included in the study, 293 LTEPR, and 284 OPHSR. The average age for OPHSR was 62.49 years and for LTEPR 55.35 years. The average follow-up of 38.10 months, the mean operative time for OPHSR was 55.58 minutes and for LTEPR was 45.46 minutes, with a hospital stay of 1.1 and 1.08 respectively. Results: Each type of hernia was classified according to Gilbert/Rutcow-Robbins criteria, resulting in the OPHSR, 80.28 % were assigned to class 1 to 3 and only 19.72% in class 4 to 7. In the LTEPR, 52.22% of the patients are classified in degree 1 to 3 and 47.78% were class 4 to 7. In the LTEPR group there was more complications with 9 cases of bleeding controlled at the same time, one tear of the bladder, no other visceral complications; in the OPHSR group, there were fewer complications with significant differences (p= .014). The postoperative complications, principally hematoma, and seroma were the most common complication without statistic differences. The postoperative pain was in the OPHSR group, 77.46% of patients reported suffering from mild or pain-free pain, 21.47% reported moderate pain, and 1.05% reported severe pain, in the LTEPR group 74.4% of patients reported mild pain, 25.25% reported moderate pain and only one patient reported severe pain, without significant differences. In both groups, the patients reported a high index of satisfaction, and in the LTEPR group scare results were better than OPHSR (p .001). CONCLUSION: The outcomes of LTEPR are similar to OPHSR. However, LTEPR has shorter operative time, more intraoperative complications and better scar satisfaction.

Native Valve Infective Endocarditis - the Postoperative Results and Role of the Endocarditis Team. A Single Center Experience.

Background: Infective endocarditis (IE) may present with quite different aspects. Consequently, it's management involves a collaborative approach between several specialties. We analyzed the timing of surgery and the role of the "Endocarditis Team" in patients with IE. Methods: The medical records of patients operated for IE in our center during an 18-year period were retrospectively analyzed for the demographic data, causative agent, imagistic features of the affected valve and systemic lesion extension and postoperative results. Results: Patients age ranged between 7 and 84 years, and in many cases (55.88%) the etiology remained unidentified. The early postoperative complications were not significantly higher in patients operated in emergency compared to those with elective surgery. The overall early postoperative mortality rate was 14.05%, significantly lower in the elective surgery cases (p = 0.001). The long-term follow-up for patients operated between 2008 and 2017 showed a late postoperative death rate of 17.8% (34 patients). Conclusions: Emergency surgery for patients with native valve IE provides in most cases a good chance for a cure, despite the relatively high frequency of postoperative complications and rate of postoperative death. The advances in pre- and post-operative management of IE patients, as well as in surgical techniques and prosthetic valves seem to further improve the outcome.

What are the Specifics of Biliary Surgery in Cirrhotic Patients?

This work's objective was to review the literature on biliary surgery in order to best define the surgical indications and the specifics of their management. A review of the literature from 1995 to August 2015 was conducted in Pubmed and Google Scholar.

The Value of C Reactive Protein and the Leukocytes in the Peritoneal Fluid in the Predicting Postoperative Digestive Fistulas.

Anastomotic fistulas in digestive surgery are a severe complication of the patient. The identification of paraclinical laboratory investigations which would allow an early diagnosis of fistulas would lead to the optimization of patient's management. We have performed a retrospective study on 100 cancer patients, with digestive tract surgeries, between May 2016 and December 2017, in the First Clinic of General surgery and Surgical Oncology from the Bucharest Oncology Institute. The postoperative follow-up included: the testing of the C reactive protein (CRP ), and also the monitoring of the number of leukocytes (Ld) from the abdominal cavity, with probes taken from the drainage tube, all in association with the number of leukocytes in the blood (Ls) in all patients (with or without digestive fistula). By calculating the values of these tests and comparing them always with the clinical evolution of the patients, and sometimes with other tests as well, one would confirm an early diagnosis of fistula. The data obtained have shown that in patients with digestive fistulae there is a rapid growth and maintaining of increased values of serum PCR and of the leukocytes from the peritoneal cavity, values to which we associated also an increase in blood leukocytes. The modifications appear with approx. two days before the appearance of clinical signs or their confirmation through imagery (ultrasound, computed tomography). The regular and standardized follow-up in days 1, 3 and 5 postoperatively of the PCR value in blood, of the number of leukocytes in the abdominal cavity and of the serum leucocytosis, increasing the value of these parameters, could allow the early identification of the patients with a risk of fistula and the rapid selection of those which need supplementary investigations and/or surgical intervention.

Elderly Patients with Colorectal Cancer - A Predisposed Category for Postoperative Complications.

Introduction: Colorectal cancer (CRC) is among the leading causes of cancer-related deaths around the world. Elderly patients are often considered as a high-risk category of patients, predisposed for postoperative complications. Materials and methods: 138 patients aged over 75 years and diagnosed with colorectal cancer were retrospectively reviewed. Patients were divided in two groups, as follows: Study Group including patients who developed postoperative complications, and Control Group including patients without problems in the postoperative period. There were compared clinical, preoperative, surgical, postoperative and oncological data. The aim of study was to determine possible risk factors for short-term postoperative complications and analyze of the influence of postoperative complications on survival. Results: Risk factors as male gender, obesity, heart failure, diabetes type II, severe anemia, low total protein level, ASA III-IV classification, emergency surgery, prolonged surgical intervention, increased intraoperative blood loss, prolonged hospital stay, distal localization of tumors, TNM stages III-IV, surgery for digestive cancer and non-cancerous major abdominal surgery in the medical history were identified. Conclusion: The surgical treatment of colorectal cancer in the aging population still remains a challenge, these category of patients should benefit of special attention in order to ensure a chance to minimize or avoid these complications.

Can some early revision total hip arthroplasties be avoided?

AIMS: Studying the indications for revision total hip arthroplasty (THA) may enable surgeons to change their practice during the initial procedure, thereby reducing the need for revision surgery. The aim of this study was to identify and describe the potentially avoidable indications for revision THA within five years of the initial procedure. PATIENTS AND METHODS: A retrospective review of 117 patients (73 women, 44 men; mean age 61.5 years (27 to 88)) who met the inclusion criteria was conducted. Three adult reconstruction surgeons independently reviewed the radiographs and medical records, and they classified the revision THAs into two categories: potentially avoidable and unavoidable. Baseline demographics, perioperative details, and quality outcomes up to the last follow-up were recorded. RESULTS: A total of 60 revision THAs (51.3%) were deemed potentially avoidable and 57 (48.7%) were deemed unavoidable. The following were identified as avoidable factors: suboptimal positioning of the acetabular component (29; 48%), intraoperative fracture or a fracture missed on an intraoperative radiograph (20; 33%), early (less than two weeks) aseptic loosening (seven; 11.7%), and symptomatic leg length discrepancy of > 1 cm (four; 6.7%). CONCLUSION: A surprisingly large proportion of acute revision THAs are potentially avoidable. Surgeons must carefully evaluate the indications for revision THAs in their practice and identify new methods to address these issues. Cite this article: Bone Joint J 2019;101-B(6 Supple B):97-103.

D2 Lymphadenectomy for Gastric Adenocarcinoma: Long-term Results and the Impact of Surgeon Experience on the Survival Rates.

Background: Surgery is the main component of the multimodality treatment of gastric cancer (GC). The present study aims to comparatively assess the early and long-term outcomes after D1 and D2 lymph node dissection. Furthermore, the impact of surgeon case-load on the long-term survival after D2 gastrectomies is also explored. Methods: A number of 773 patients with curative-intent surgery for GC adenocarcinoma (1997 - 2010: 325 patients with D1 lymphadenectomy, 448 patients with D2 lymphadenectomy) were included. Results: No statistically significant differences of overall morbidity rates were observed between the D1 and D2 groups of patients (16.3%for D1 group vs. 18.8% for D2 group, p = 0.39). However, statistically significant higher rates of post operative pancreatic fistulae rates were observed in the D2 group of patients (3.2% for D1 group vs. 7.9% for D2 group, p 0.001). Interestingly, statistically significant higher rates of mortality were observed for the D1 group of patients (8.9% for D1 group vs. 2.9% for D2 group, p 0.001). The 5-year survival rate was statistically significant higher in the D2 group of patients (median overall survival time of 18 months for D1 group vs. 60 months for D2 group, p 0.001). A statistically significant correlation (p=0.005, r=0.571) was observed between the overall survival time and the number of D2 lymphadenectomies performed by each surgeon. Conclusions: D2 lymph node dissection is associated with statistically significant improved longterm survivals at the expense of higher postoperative pancreatic fistulae rates, compared to D1 surgery. However, no increased mortality rates were observed in the D2 group of patients. D2 radical gastrectomies should be performed in high-volume centers by high case-load surgeons.

Postoperative Investigations Resulting in Cost Reduction in Oncological Patients Undergoing Major Abdominal and Pelvic Surgery.

AIM: Rising costs in health care are of progressively growing interest and a major factor affecting hospitalization costs is represented by postoperative complications. Complications of Major Abdominal Surgery (MAS) are associated with increased morbidity and mortality. This study estimates the costs of postoperative care associated with complications. Material and Methods: We performed a retrospective study on 254 patients admitted to the 1st General and Oncological Surgery Clinic of the Bucharest Oncology Institute who were submitted to MAS. The total hospitalization, complications and treatment costs were analysed. Results: For a patient undergoing MAS, the average costs for surgery without complications are 5,791.3 RON and reach an average of 20,806 RON after major complications. CONCLUSION: The results provide insight into the costs of hospitalization for oncology patients submitted to surgical interventions. Complications occur in 20.86% of patients undergoing MAS and account for 50% of total care costs. Establishing and implementing a protocol aimed at early diagnosis and treatment of specific complications could lead to a decrease in morbidity and mortality, as well as of the costs of hospitalization.

Failure to Rescue, Rescue Surgery and Centralization of Postoperative Complications: A Challenge for General and Acute Care Surgeons.

PURPOSE OF REVIEW: To explore the current literature on the failure to rescue and rescue surgery concepts, to identify the key items for decreasing the failure to rescue rate and improve outcome, to verify if there is a rationale for centralization of patients suffering postoperative complications. RECENT FINDINGS: There is a growing awareness about the need to assess and measure the failure to rescue rate, on institutional, regional and national basis. Many factors affect failure to rescue, and all should be individually analyzed and considered. Rescue surgery is one of these factors. Rescue surgery assumes an acute care surgery background. SUMMARY: Measurement of failure to rescue rate should become a standard for quality improvement programs. Implementation of all clinical and organizational items involved is the key for better outcomes. Preparedness for rescue surgery is a main pillar in this process. Centralization of management, audit, and communication are important as much as patient centralization.

Extension of Hepatic Resection Ameliorates Survival in Patients with Type IIIa or IIIb Klatskin Tumors Despite Surgical Complications.

Background: Major hepatectomies for hilar cholangiocarcinoma (HC) are associated with high rates of morbidity and mortality. We aimed to evaluate how and if surgical complications related to extended hepatectomies for HC type III and IV according to Bismuth-Corlette classification influence patients long-term survival. Methods: The files of all patients with major hepatectomy for HC and postoperative complications were retrospectively reviewed. Only patients with a complete postoperative follow up have be taken into account for the study. Postoperative morbidity and mortality, length of hospital stay (LOS) as well as overall survival (OS) and disease free survival (DFS) were recorded. Results: Five patients have been found to respond to all inclusion criteria. Three of them required re-operation with one in hospital death. Two patients are still alive and two other died because of the tumor recurrence with a DFS of 36 and 49 months respectively. The actuarial mean OS for the group was 30 months and the actuarial DFS was 26 months. Conclusions: In patients with HC, extensive resections bring a clearly benefit in terms of survival, even though there is an increase in postoperative morbidity and mortality. However, postoperative complications, if managed susccesfully do not interfere with the long-term survival.

Fatal pyoderma gangrenosum with pathergy after coronary artery bypass grafting.

Surgeons and others who perform invasive procedures should be aware of the possibility of pyoderma gangrenosum and the risk of pathergy in patients who have a history of unexplained skin ulcers or poor wound-healing. We report the case of a 70-year-old man in whom diffuse erythema over the anterior chest wall and marked leukocytosis developed after coronary artery bypass grafting. This prompted débridement and opening of the sternotomy wound. The cause of the erythema was pyoderma gangrenosum that expressed the pathergy phenomenon. The pyoderma gangrenosum subsequently involved the saphenous vein harvest site, a chest-tube site, and a previously healed abdominal scar. The patient died when an exposed saphenous vein graft was perforated. To our knowledge, this is the 9th reported case of pathergy due to pyoderma gangrenosum after coronary artery bypass grafting and the first with a fatal outcome.