The role of perioperative endoscopic retrograde cholangiopancreatography and biliary drainage in large liver hydatid cysts.

BACKGROUND: The best surgical technique for large liver hydatid cysts (LHCs) has not yet been agreed on. Objectives. The objective of this study was to examine the role of perioperative endoscopic retrograde cholangiopancreatography (ERCP) and biliary drainage in patients with large LHCs. MetHODS: A 20-year retrospective study of patients with LHCs treated surgically at the University Clinical Center of Kosovo (UCCK). We divided patients into 2 groups based on treatment period: 1981-1990 (Group I) and 2001-2010 (Group II). Demographic characteristics (sex, age), the surgical procedure performed, complications rate, and outcomes were compared. RESULTS: Of the 340 patients in our study, 218 (64.1%) were female with median age of 37 years (range, 17 to 81 years). 71% of patients underwent endocystectomy with partial pericystectomy and omentoplication, 8% total pericystectomy, 18% endocystectomy with capitonnage, and 3% external drainage. In Group I, 10 patients underwent bile duct exploration and T-tube placement; in Group II, 39 patients underwent bile duct exploration and T-tube placement. In addition, 9 patients in Group II underwent perioperative ERCP with papillotomy. The complication rate was 14.32% versus 6.37%, respectively (P = 0.001). CONCLUSION: Perioperative ERCP and biliary drainage significantly decreased the complication rate and improved outcomes in patients with large LHCs.

Enterocutaneous fistulas and a hostile abdomen: reoperative surgical approaches.

Damage-control surgery and open-abdomen is an acceptable­and often lifesaving­approach to the treatment of patients with severe trauma, abdominal compartment syndrome, necrotizing soft tissue catastrophes, and other abdominal disasters, when closing the abdomen is not possible, ill advised, or will have serious sequelae. However, common consequences of open-abdomen management include large abdominal wall defects, enterocutaneous fistulas (ECFs), and enteroatmospheric fistulas (EAFs). Furthermore, in such patients, a frozen and hostile abdomen (alone or combined with ECFs) is not uncommon. Adding biologic mesh to our surgical armamentarium has revolutionized hernia surgery.

Recurrence of infection and hernia following partial versus complete removal of infected hernia mesh: a systematic review and cohort meta-analysis.

BACKGROUND: The aim of this systematic review and meta-analysis was to determine whether complete removal of infected hernia mesh (CMR) provides better results as compared to partial removal (PMR). METHODS: PubMed, EMBASE, Cochrane Library, and MEDLINE via Ovid were systematically searched for records published from 1980 to 2018 by three independent researchers (GM, GS, and GG). Quality assessment, data extraction and analysis were performed according to the Cochrane Handbook for Systematic Reviews of Interventions. Mantel-Haenszel method with odds ratio and 95% confidence interval (OR (95% CI)) as the measure of effect size of dichotomous primary and secondary endpoints was utilized. Random-effects model was used for meta-analysis. RESULTS: Five observational studies totaling 421 patients were included in the meta-analysis. Rates of infection recurrence were 58.5% (62/106) in PMR and 25.5% (62/315) in CMR. The difference was statistically significant [OR (95% CI) 4.15 (2.30, 7.47); p < 0.001]. Rates of hernia recurrence were 9.7% (8/82) in PMR vs. 40.2% (41/102) in CMR. This difference was not statistically significant [OR (95% CI) 0.25 (0.04, 1.62); p = 0.15]. Low risk of publication bias was found using funnel plots and Egger's test. CONCLUSIONS: This meta-analysis found significantly increased rates of infection recurrence in patients undergoing partial removal of infected hernia mesh as compared to complete removal. Complete removal of infected hernia mesh may be associated with increased rates of hernia recurrence. Further longitudinal observational studies are needed to confirm these findings.

Complex abdominal wall hernia repair with biologic mesh in elderly: a propensity matched analysis.

BACKGROUND: Complex abdominal wall reconstruction (CAWR) has become a common surgical procedure both in non-elderly and elderly patients. OBJECTIVE: The aim of this study is to analyze the outcomes of the elderly compared to nonelderly undergoing CAWR using propensity score matching. METHODS: All patients who underwent CAWR using porcine-derived, non-crosslinked acellular dermal matrix (ADM) (Strattice™) between January 2014 and July 2017 were studied retrospectively. Propensity matched analysis was performed for risk adjustment in multivariable analysis and for one-to-one matching. The outcomes were analyzed for differences in postoperative complications, reoperations, mortality, hospital length of stay and adverse discharge disposition. RESULTS: One hundred-thirty-six patients were identified during the study period. Non-elderly (aged 18-64 years) constituted 70% (n = 95) and elderly (aged ≥ 65 years) comprised 30% of the overall patient population (n = 41). Seventy-three (56.7%) were females. After adjustment through the propensity score, which included 35 pairs, the surgical site infection (p = 1.000), wound necrosis (p = 1.000), the need for mechanical ventilation (p = 0.259), mortality (p = 0.083), reoperation rate (p = 0.141), hospital length of stay (p = 0.206), and discharge disposition (p = 0.795) were similar. CONCLUSION: Elderly patients undergoing CAWR with biological mesh have comparable outcomes with non-elderly patients when using propensity matching score.

A novel tool to evaluate bias in literature on use of biologic mesh in abdominal wall hernia repair.

PURPOSE: Biologic meshes are being increasingly used for abdominal hernia repair in high-risk patients or patients with a previous history of wound infection, due to their infection-resistant properties. Several studies have been carried out to assess whether biologic mesh is superior to synthetic mesh, as well as to establish guidelines for their use. Unfortunately, most of these studies were not rigorously designed and were vulnerable to different types of bias. The systematic reviews that have been published so far on this topic contain the same biases and limitations of the primary articles that are analyzed. The lack of a literature review on the bias on the use of biological mesh prompted us to conduct the literature search, assessment and plan this article. METHODS: We performed a literature search in PubMed, Embase and Cochrane databases of systematic reviews on biologic mesh for ventral hernia repair. The literature review was conducted using the Population, Intervention, Comparisons, Outcomes and Design approach. We identified 40 studies that matched the stringent criteria we had set. We then created a 13-point instrument to assess for bias and applied it on the primary studies that we intended to analyze. RESULTS: Most primary studies are case series or case reports of patients undergoing abdominal hernia repair with biologic mesh, without any comparison group, and the inclusion of cases was only specified to be consecutive in 6 out of 40 cases. In terms of assessing outcomes, in none of the 40 articles were the outcome assessors blinded to the intervention or exposure status of participants. CONCLUSION: The instrument that we created could allow to assess the risk of bias in different kind of studies. Our assessment of the studies based on the criteria that we had set up in the instrument clearly identified that further research needs to be done due to the lack of unbiased studies regarding the use of biologic meshes for abdominal hernia repair.

Telemedicine and telepresence for trauma and emergency care management.

The use of telemedicine is long-standing, but only in recent years has it been applied to the specialities of trauma, emergency care, and surgery. Despite being relatively new, the concept of teletrauma, telepresence, and telesurgery is evolving and is being integrated into modern care of trauma and surgical patients. This paper will address the current applications of telemedicine and telepresence to trauma and emergency care as the new frontiers of telemedicine application. The University Medical Center and the Arizona Telemedicine Program (ATP) in Tucson, Arizona have two functional teletrauma and emergency telemedicine programs and one ad-hoc program, the mobile telemedicine program. The Southern Arizona Telemedicine and Telepresence (SATT) program is an inter-hospital telemedicine program, while the Tucson ER-link is a link between prehospital and emergency room system, and both are built upon a successful existing award winning ATP and the technical infrastructure of the city of Tucson. These two programs represent examples of integrated and collaborative community approaches to solving the lack of trauma and emergency care issue in the region. These networks will not only be used by trauma, but also by all other medical disciplines, and as such have become an example of innovation and dedication to trauma care. The first case of trauma managed over the telemedicine trauma program or "teletrauma" was that of an 18-month-old girl who was the only survival of a car crash with three fatalities. The success of this case and the pilot project of SATT that ensued led to the development of a regional teletrauma program serving close to 1.5 million people. The telepresence of the trauma surgeon, through teletrauma, has infused confidence among local doctors and communities and is being used to identify knowledge gaps of rural health care providers and the needs for instituting new outreach educational programs.

Massive localized lipolymphedema pseudotumor in a morbidly obese patient.

We describe a 31 year old man with a massive localized tumor-like lipolymphedema, a puzzling entity that afflicts the morbidly obese. The 281 kg man presented with a growing ulcerated bleeding mass located on his proximal medial thigh and suspicious for sarcoma. After en bloc resection of the 28.2 kg edematous mass, no evidence of neoplasm was found, only prominent lymphatic vessel dilation and edema with large quantities of unremarkable adipose and connective tissue. The lesion conformed to the diagnostic criteria for massive localized lipolymphedema (MLL) pseudotumor.

2016 WSES guidelines on acute calculous cholecystitis.

Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of "high risk" patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.

Erratum to: 2016 WSES guidelines on acute calculous cholecystitis.

[This corrects the article DOI: 10.1186/s13017-016-0082-5.].

Nutritional support in liver failure.

The most important manifestations of advanced liver disease are malnutrition, encephalopathy, and hepatorenal syndrome. Appropriate and optimal nutritional and metabolic support with specially formulated solutions enriched in branched-chain amino acids, together with other advanced treatments such as plasmapheresis, hemofiltration, and continuous arteriovenous hemodialysis, can correct the most important metabolic and clinical aberrations and temporarily improve the quality of life. However, the ultimately poor prognosis of patients with severe liver failure has not been altered significantly to date by the provision of nonspecific or specifically tailored nutrient regimens. The prognosis appears to depend on the arrest, correction, or reversal of the primary pathophysiologic process.

Nutritional management of acute and chronic pancreatitis.

Acute pancreatitis often results in a catabolic state characterized by profound hemodynamic, metabolic, cardiovascular, pulmonary, hematologic, and renal aberrations. Parenteral nutrition and metabolic support are essential if morbidity and mortality are to be minimized. In chronic pancreatitis, nutritional management ranges from fundamental dietary manipulation with or without administration of appropriate digestive enzymes to enteral supplementation with modular chemically defined diets to total parenteral nutrition, depending on the stage, severity, and manifestations of the disease. In prescribing nutrient substrates in both acute and chronic pancreatitis, consideration must be given to their effects on pancreatic enzyme secretion if optimal results are to be achieved.

Nutritional management of inflammatory bowel disease.

The etiology and specific treatment of Crohn's disease and ulcerative colitis are unknown, and the treatment strategy for patients with inflammatory bowel disease is essentially symptomatic and supportive. The malnutrition that frequently accompanies inflammatory bowel disease is a manifestation of intestinal failure and should be vigorously corrected with total parenteral nutrition, elemental diets, or both. Evidence exists for the value of total parenteral nutrition and elemental diets as primary therapy for inflammatory bowel disease in selected patients. Judicious nutritional therapy remains a cornerstone in the adjunctive management of these patients.

Management of the short-bowel syndrome.

The patient with short-bowel syndrome after massive small-intestinal resection represents one of the greatest clinical challenges a general surgeon must face. Maintaining optimal nutritional and metabolic support until maximum bowel adaptation can occur is the top priority of therapy. Currently, no operative procedure for adjunctive management of the short-bowel syndrome is sufficiently safe and effective to recommend its routine use. Long-term parenteral nutrition remains the cornerstone of successful management.

Arrest and reversal of atherosclerosis with parenteral nutrition.

In a large subset of patients with atherosclerotic cardiovascular disease, all medical and surgical treatment alternatives have been exhausted or have proved to be ineffective. Intravenous infusion of specially formulated amino acid solutions, developed in the animal laboratory, has been efficacious in arresting and reversing atherosclerosis in humans for the first time. It is anticipated that the principles derived from these precise parenteral studies will eventually permit development of oral and enteral dietary formulations effective for the systemic control and management of atherosclerosis.

Epidemiology, causes and prevention of car rollover crashes with ejection.

Rollover crashes (ROCs) are responsible for almost a third of all highway vehicle occupant fatalities. Although ROCs are common and serious mechanism of injury, ROCs are under-reported. To analyze the causes, mechanism, impact and prevention of ROCs, we reviewed the literature between 1984 and 2013. By utilizing the search engines PubMed, MEDLINE and EMBASE by using key words "ROCs" "Ejection" and "vehicle" the initial search yielded 241 abstracts, of which 58 articles were relevant. Most of the articles were either retrospective or experimental studies funded by automobile companies. All vehicles are susceptible to rollovers to certain extents. Despite continuing innovation in vehicles' safety, human factor is pivotal in prevention of ROCs. Distracted driving, speeding and drinking escalate the chances of rollover crashes. Wearing a seatbelt greatly improves the chances of surviving a ROC.

Nutrition therapy for critically ill and injured patients.

BACKGROUND: Nutrition support has undergone significant advances in recent decades, revolutionizing the care of critically ill and injured patients. However, providing adequate and optimal nutrition therapy for such patients is very challenging: it requires careful attention and an understanding of the biology of the individual patient's disease or injury process, including insight into the consequent changes in nutrients needed. OBJECTIVE: The objective of this article is to review the current principles and practices of providing nutrition therapy for critically ill and injured patients. METHODS: Review of the literature and evidence-based guidelines. RESULTS: The evidence demonstrates the need to understand the biology of nutrition therapy for critically ill and injured patients, tailored to their individual disease or injury, age, and comorbidities. CONCLUSION: Nutrition therapy for critically ill and injured patients has become an important part of their overall care. No longer should we consider nutrition for critically ill and injured patients just as "support" but, rather, as "therapy", because it is, indeed, a key therapeutic modality.