Unraveling factors associated with textbook outcome after cholecystectomy in patients with uncomplicated cholecystolithiasis: A posthoc analysis of individual data of 1,124 patients.

BACKGROUND: A textbook outcome for the management of uncomplicated cholecystolithiasis is the targeted clinical scenario and is characterized by no recurrent biliary colic, absence of surgical and biliary complications, and absence or relief of abdominal pain. The aim of this study was to assess the incidence of textbook outcomes after cholecystectomy and identify associated baseline factors. METHODS: Patients from 2 Dutch multicenter prospective trials between 2014 and 2019 (SECURE and SUCCESS trial) were included. The primary outcome was the proportion of patients with textbook outcomes after cholecystectomy at 6-month follow-up. Regression analysis was used to identify which factors before surgery were associated with textbook outcomes. RESULTS: A total of 1,124 patients underwent cholecystectomy. A textbook outcome at 6-month follow-up was reached in 67.9% of patients. Persistent abdominal pain was the main reason for the failure to achieve textbook outcome. Patients who did achieve textbook outcomes more often reported severe pain attacks (89.4% vs 81.7%, P < .001) and/or biliary colic (78.6% vs 68.4%, P < .001) at baseline compared with patients without textbook outcomes. The presence of biliary colic at baseline (odds ratio = 1.56, 95% confidence interval: 1.16-2.09, P = .003) and nausea/vomiting at baseline (odds ratio = 1.33, 95% confidence interval: 1.01-1.74, P = .039) were associated with textbook outcome. The use of non-opioid analgesics (odds ratio = 0.76, 95% confidence interval: 0.58-0.99, P = .043) and pain frequency ≥1/month (odds ratio = 0.56, 95% confidence interval: 0.43-0.73, P < .001) were negatively associated with textbook outcome. CONCLUSION: Textbook outcome is achieved in two-thirds of patients who undergo cholecystectomy for uncomplicated cholecystolithiasis. Intensity and frequency of pain, presence of biliary colic, and nausea/vomiting at baseline are independently associated with achieving textbook outcomes. A more stringent selection of patients may optimize the textbook outcome rate in patients with uncomplicated cholecystolithiasis.

Ultrasonographic findings of fluid accumulation and hyperechogenic spots suggestive of surgical site infection following laparotomy for colic in horses.

BACKGROUND: The aim of this study was to compare ultrasonographic findings of the ventral midline incision after exploratory laparotomy for colic in horses with and without surgical site infection (SSI). METHODS: Ultrasonographic examination of the surgical wound was performed on postoperative day 5 (D5) and day 10 (D10) to assess the presence of fluid accumulation, suture sinus formation, hyperechogenic spots and fistulous path. Clinical evaluation of the wound was used to classify horses with and without SSI. The accuracy, sensitivity, specificity and positive and negative predictive values of the ultrasonographic findings were then calculated. Multivariable logistic regression analyses were performed with SSI as a dependent variable and age, sex, breed and ultrasonographic findings as independent variables after univariate and collinearity analyses. RESULTS: Twenty-nine of the 84 horses examined had an SSI. Detection of fluid accumulation and hyperechogenic spots increased the odds for SSI at D5 (odds ratio [OR]: 4.99, 95% confidence interval [CI]: 1.53-16.33, p = 0.008; OR: 10.78, 95% CI: 1.75-26.59, p = 0.01, respectively) and D10 (OR: 11.51, 95% CI: 2.39-55.47, p = 0.002; OR: 12.34, 95% CI: 3.45-44.15, p < 0.001, respectively). LIMITATION: Ultrasonographic images were taken only on the longitudinal section. CONCLUSION: Ultrasonographic examination is helpful in evaluating the surgical incision after laparotomy, with the detection of fluid accumulation and hyperechogenic spots surrounding the sutures being strongly related to SSI.

Measuring tissue oxygen saturation in the orad intestinal segment during equine colic surgery may aid in predicting the occurrence of postoperative ileus.

OBJECTIVE: To assess the histological injury and intestinal microperfusion measured by laser Doppler flowmetry and spectrophotometry (LDFS) of the small intestine orad to a strangulation during colic surgery. ANIMALS: Horses with naturally occurring small intestinal strangulations undergoing colic surgery were included. METHODS: In this prospective clinical trial, intestinal tissue oxygen saturation (tSO2) and tissue blood flow (tBF) were measured by LDFS orad to the strangulation following release of the strangulation (n = 18). The number of horses with postoperative reflux (POR) and the cases that survived until discharge were compared between groups using Fisher's exact test (P < .05). Intestinal biopsies were taken in cases that underwent intestinal resection or intraoperative euthanasia (n = 28). Measurements were compared between injured and noninjured segments with a Mann-Whitney U or t test. RESULTS: The tSO2 and tBF of the orad intestine were lower than previously reported in healthy horses. Horses with low tSO2 of < 35% were significantly more likely to suffer from POR (6/6 cases) compared to cases with tSO2 > 69% (1/6). The number of horses that survived were not statistically different between these groups (2/6 and 6/6). All horses with mucosal injury developed POR (6/6), which was significantly more likely compared to horses without mucosal injury (3/13). No significant difference in tSO2 or tBF could be found between the segments with and without histological injury. CLINICAL RELEVANCE: The results suggest that measuring tSO2 in the orad segment during colic surgery may aid in predicting postoperative issues.

Ponies, miniatures, and younger equids are at higher risk of fecalith obstruction compared to a general colic population.

OBJECTIVE: To determine breed, age, and sex predispositions for fecalith obstruction and to evaluate short-term survival and prognostic factors following surgical treatment of fecalith intestinal obstruction in equids. ANIMALS: 151 equids. METHODS: Medical records of equids undergoing surgery for fecalith obstruction from 2000 to 2020 were reviewed. Signalment, history, presenting clinicopathological data, surgical findings, complications, and short-term survival were recorded and compared between survivors and nonsurvivors. Signalment of the fecalith population was compared to a contemporaneous colic population. Clinical factors were assessed for association with outcome. RESULTS: 64 females, 53 castrated males, and 31 intact males were included. Three equids presented twice. Miniature horses, ponies, and miniature donkeys/mules represented 48% (71/148) of fecalith population and full-sized breeds represented 52% (77/148). Miniature horses and ponies were overrepresented and equids ≤ 1 year of age were overrepresented in the fecalith population compared to the colic population. One hundred thirty-nine equids (92%) survived to discharge, 6% (9/148) were euthanized intraoperatively, and 2% (3/148) were euthanized during hospitalization. Nonsurvivors showed more severe colic signs on admission, tachycardia on admission, and hyperlipemia. Equids with postoperative colic (P = .01) and complications (P = .002) were less likely to survive. CLINICAL RELEVANCE: Miniature horses and ponies were overrepresented compared to the colic population; however, full-sized breeds were also affected. Surgical treatment had an excellent short-term prognosis. Severe colic signs, tachycardia, hyperlipemia, postoperative colic, and surgical complications negatively affected short-term survival.

A cross-sectional study of colic and rate of return to racing in Thoroughbreds at Seoul Racecourse in Korea between 2010 and 2020.

BACKGROUND: The incidence of colic and the outcomes of colic surgery have not been surveyed in racetracks in Korea. OBJECTIVES: This study examined the incidence, mortality, and case fatality of colic and investigated the effects of age and sex after an exploratory celiotomy on the long-term survival rate (return to racing), subsequent racing performance, and career longevity. METHODS: The incidence, mortality, and case fatalities of colic were examined over an 11-year period. The records of 40 horses that had undergone a celiotomy, after participating in at least one race and 75 race-matched control horses were analyzed. The racing performance and career length of the horses that returned to racing post-surgery were compared with a control group. RESULTS: The annual incidence, fatality rate of colic, and annual mortality rate at Seoul Racecourse were 6.5, 2.8 per 100 horse-years, and 0.2 deaths cases per 100 horse-years, respectively. Of the 40 horses that underwent colic surgery, 26 (65%) returned to racing. The likelihood of returning to racing decreased with increasing age of the horses, and geldings had a lower probability of returning. While the performance in the five preoperative races between the two groups was not significantly different, a significant decrease in racing performance was observed after the surgery date (p < 0.01). Horses that underwent colic surgery did not show a significant decrease in career length. CONCLUSIONS: Surgical treatment for colic at the age of three and four years had a negative impact on the racing performance. On the other hand, there was no significant difference in career longevity between the two groups.

Intracorporeal Versus Extracorporeal Colo-colic Anastomosis in Minimally-invasive Left Colectomy: a Systematic Review and Meta-analysis.

PURPOSE: The primary aim was to investigate the operative outcomes of intracorporeal (IA) and extracorporeal (EA) anastomosis in left-sided minimally-invasive colectomy. METHODS: A comprehensive literature search was conducted for studies comparing operative outcomes and follow-up data of IA versus EA in minimally-invasive left colectomy. Studies that investigated recto-sigmoid resections using transanal circular staplers were excluded. Data from eligible studies were extracted, qualitatively assessed, and included in a meta-analysis. Odds ratios (ORs) and mean differences with 95 per cent confidence intervals were calculated. RESULTS: Eight studies with a total of 750 patients were included (IA n = 335 versus EA n = 415). IA was associated with significantly lower overall morbidity (OR 0.40, 95% CI 0.26-0.61, p < 0.0001) and less frequent surgical site infection (SSI) (OR 0.27, 95% CI 0.12-0.61, p = 0.002) as primary outcomes compared to EA. Of the secondary outcomes, length of incision (SMD -2.51, 95% CI -4.21 to -0.81, p = 0.004), time to first oral diet intake (SMD -0.49, 95% CI -0.76 to -0.22, p = 0. 0004) and time to first bowel movement (SMD -0.40, 95% CI -0.71 to -0.09, p = 0.01) were significantly in favor of IA, while operative time was significantly shorter in the EA group (SMD 0.36, 95% CI 0.14-0.59, p = 0.001). CONCLUSIONS: IA proves to be a safe and feasible option as it demonstrates benefits in terms of lower overall morbidity, fewer rates of SSI, smaller incision length, and faster postoperative gastrointestinal recovery despite a longer operative time compared to EA.

Persistent and new-onset symptoms after cholecystectomy in patients with uncomplicated symptomatic cholecystolithiasis: A post hoc analysis of 2 prospective clinical trials.

BACKGROUND: Laparoscopic cholecystectomy is the gold standard for treating biliary colic in patients with gallstones, but post-cholecystectomy abdominal pain is commonly reported. This study investigates which symptoms are likely to persist and which may develop after a cholecystectomy. METHODS: Patients from 2 previous prospective trials who underwent laparoscopic cholecystectomy for symptomatic cholecystolithiasis were included. Patients completed questionnaires on pain and gastrointestinal symptoms before surgery and at 6 months follow-up. The prevalence of persistent and new-onset abdominal symptoms was evaluated. RESULTS: A total of 820 patients received cholecystectomy and were included, 75.4% female (n = 616/820) mean age 49.4 years (standard deviation 13.7). At baseline, 74.1% (n = 608/820) of patients met all criteria for biliary colic. Cholecystectomy successfully resolved biliary colic in 94.8% (n = 327/345) of patients, but 36.5% (n = 299/820) of patients reported persistent abdominal pain after 6 months of follow-up. The prevalence of most abdominal symptoms reduced significantly. Symptoms such as flatulence (17.8%, n = 146/820) or restricted eating (14.5%, n = 119/820) persisted most often. New-onset symptoms were frequent bowel movements (9.6%, n = 79/820), bowel urgency (8.5%, n = 70/820), and new-onset diarrhea (8.4%, 69/820). CONCLUSION: Postcholecystectomy symptoms are mainly flatulence, frequent bowel movements, and restricted eating. Newly reported symptoms are mainly frequent bowel movements, bowel urgency, and diarrhea. The present findings give clinical guidance in informing, managing, and treating patients with symptoms after cholecystectomy.

Assessment and comparison of microcirculation and macrocirculation in horses undergoing emergency exploratory celiotomy versus elective surgical procedures.

OBJECTIVE: To assess oral buccal microcirculation by hand-held videomicroscopy in horses during colic surgery, comparing microcirculation values with macrocirculatory parameters and with those of healthy elective surgical horses. STUDY DESIGN: Clinical prospective study. ANIMALS: Client-owned horses (nine in the colic group; 11 in the elective group). METHODS: In the colic group, buccal mucosal side stream dark-field microscopy (DFM) videos, cardiac output (CO), mean arterial pressure (MAP), and lactate were obtained at three timepoints under general anesthesia (30, 90, and 150 min after induction). Video analysis was used to determine total vessel density, proportion of perfused vessels, perfused vessel density, and heterogeneity index. Dark-field microscopy videos, MAP, and lactate were obtained at a single timepoint under general anesthesia (45 min after induction) in the elective group. RESULTS: There were no differences in microcirculatory parameters between colic and elective horses, nor was there a difference across timepoints in the colic group. There was a weak negative correlation between microvascular parameters and CO (rho = -0.23). CONCLUSION: The colic group did not have decreased microcirculation in comparison with the healthy elective group. Dark-field microscopy did not correlate well with macrocirculatory parameters in the colic group. IMPACT: Dark-field microscopy may not be a sensitive enough indicator to detect differences in microcirculation between colic and elective groups. The lack of difference in microcirculation may be due to sample size, probe location, or variation in disease severity.

Role of Laparoscopy in Diagnosis and Management of Equine Colic.

Laparoscopy can be valuable in the diagnosis and treatment of specific types of colic in horses. Most commonly, it is used for horses with chronic recurrent colic for further diagnosis, such as by taking biopsies or to perform treatment. Laparoscopy is also often used for prevention of colic, for example, by closing the nephrosplenic space or epiploic foramen. There are fewer indications for laparoscopy in acute colic, though in some cases the technique can be useful for diagnosis, after which the procedure is converted to a hand-assisted laparoscopy. However, manipulation of the intestine is limited compared with an open laparotomy.

Colic Surgery: Recent Updates.

The following article provides an overview of the last 5 years of research and innovation within the field of equine colic surgery, focusing on new techniques, new or recently described lesions, prevention of lesion recurrence or postoperative complications, and updates in prognoses. Early surgical intervention is an important factor in horse survival.

Abdominal Sonographic Evaluation: In the Field, at the Hospital, and After Surgery.

Abdominal sonography is currently a routine procedure in the evaluation of colic in the horse. This imaging technique is used in both the assessment of the horse presented in the emergency setting with acute colic and the assessment of the horse presented for chronic or recurrent colic in the nonemergency setting. Sonography for colic evaluation is used by specialists in different disciplines and by general practitioners in the ambulatory and hospital settings. In this review, we will focus on indications and clinical interpretation of findings as well as recent developments in abdominal sonography.

Critical Care of the Colic Patient: Monitoring, Fluid Therapy, and More.

A successful outcome to management of the critical colic patient is highly dependent on how the patient is monitored and treated, particularly, in the perioperative period. In this article, we will provide an update on monitoring techniques, advances in fluid therapy, nutrition management and pharmacotherapeutic agents, inclusive of pain monitoring and management, prokinetics, and management of systemic inflammatory response syndrome and the hypercoagulable state.

Early Identification of Intestinal Strangulation: Why It Is Important and How to Make an Early Diagnosis.

Horses with colic caused by intestinal strangulation can have an excellent outcome with early surgical correction of the obstruction. The expense associated with surgery is typically less with early lesion correction. The challenge is making an early diagnosis of intestinal strangulation. Although for some horses with a strangulating obstruction, the need for surgery is made based on severe colic signs or lack of response to analgesia, in other horses, it is less obvious. Signalment, history, and meticulous physical examination, combined with some targeted diagnostic procedures can help with early diagnosis of intestinal strangulation. Improving the outcome of these horses requires diligence and a team-based approach from the owner or caregiver, primary care veterinarian, and specialists.

Basic Postoperative Care of the Equine Colic Patient.

The 3 time periods around colic surgery (preoperative, operative, and postoperative) are all critical to successful outcomes. Although much focus is often paid to the first 2 time periods, the importance of sound clinical judgment and rational decision-making in the postoperative period cannot be overstated. This article will outline the basic principles of monitoring, fluid therapy, antimicrobial therapy, analgesia, nutrition, and other therapeutics routinely used in patients following colic surgery. Discussions of the economics of colic surgery and expectations for normal return to function will also be included.

Does colonization with MRSA, ESBL - producing Enterobacteriaceae, and/or Acinetobacter baumannii - increase the risk for postoperative surgical site infection?

OBJECTIVE: Evaluation of the role of indicator pathogens in equine surgical site infection (SSI) and other infection-promoting factors. STUDY DESIGN: Cross-sectional study. ANIMALS: Horses presenting with an open injury or surgical colic during 1.5 years. METHODS: A nasal swab and a faecal sample were collected from every patient upon admission. Furthermore, a wound swab was collected from wounds of injured horses. Details on the wounds and procedures were documented. Laparotomy incisions and injuries were monitored for signs suggesting infection. RESULTS: In total, 156 horses presented because of a surgical colic (n = 48) or open injuries (n = 108). Thirteen surgical colic patients and three injured horses did not survive beyond 24 h, and four injured horses were discharged from the clinic at the day of admission. SSIs occurred in 31 (30.7%) injured horses and 11 (31.4%) horses after laparotomy. Regarding injuries, general anaesthesia increased the risk of developing a WI compared to sedation. Indicator pathogens were cultured from 29/42 SSI. In total, 10/11 infected laparotomy incisions and 19/31 injuries with SSI tested positive for multidrug-resistant pathogens (MDRPs) . Indicator pathogens were not detected at admission in any of the horses that developed incisional SSIs after laparotomy but were detected in two of the injured horses that developed SSIs. CONCLUSION: MDRPs were identified in almost 70% of the SSI. Less than 5% of the affected animals were colonized with the same pathogen before admission, indicating that colonization with MDR pathogens is only one of the crucial factors for the development of SSI. CLINICAL SIGNIFICANCE: Colonization with MDRP seems not to predispose horses to MDR SSIs.

Postoperative sinusitis and pneumonia following exploratory celiotomy for treatment of colic in horses.

Sinusitis and pneumonia following exploratory celiotomy in horses were studied, evaluating associations between these 2 respiratory complications and selected pre-, peri-, and post-operative variables. The incidence of sinusitis was 2.5% (8/318) and pneumonia 3.5% (11/318). These respiratory complications were associated with peri-operative reflux, longer antimicrobial treatment, and longer hospitalization.

Sinusite et pneumonie postopératoires suite á une coeliotomie exploratoire pour le traitement des coliques chez le cheval. La sinusite et la pneumonie consécutives á une coeliotomie exploratoire chez le cheval ont été étudiées, afin d'évaluer les associations entre ces deux complications respiratoires et certaines variables pré-, péri- et postopératoires. L'incidence des sinusites était de 2,5 % (8/318) et des pneumonies de 3,5 % (11/318). Ces complications respiratoires étaient associées á un reflux périopératoire, á un traitement antimicrobien plus long et á une hospitalisation plus longue.(Traduit par Dr Serge Messier).

How to Do It: Laparoscopic Total Abdominal Colectomy with Complete Mesocolic Excision (CME) for Transverse Colon Cancer in Ulcerative Colitis.

BACKGROUND: Ulcerative colitis (UC) is a chronic mucosal inflammatory bowel disease of the colon and rectum. After 10 years of having the disease, there is a significant risk of dysplasia or cancer in the affected colon and rectum, and because of the often aggressive biology of these tumors, frequent endoscopic surveillance is warranted. Over a third of patients with UC will ultimately require an operation, and although for specific cases alternative operations can be pursued, most patients prefer an ileal pouch-anal anastomosis (IPAA) with J-pouch construction. CASE: A staged IPAA removes the affected colon and rectum treating UC and also restores intestinal continuity. However, the standard colectomy for UC includes low ligations of the main colonic vascular pedicle branches (ileocolic, right colic, middle colic and inferior mesenteric) that does not address a proper oncologic operation. A high ligation of the named vessels as well as a proper resection of the affected colon with its mesentery and lymph node package are needed to treat colon cancer. Analogous to a total mesorectal exicision for rectal cancer, a more radical procedure to remove the tumor and lymph node packet for colon cancer is described as a complete mesocolic exision (CME) in efforts to increase disease free survival. DISCUSSION: We demonstrate a laparoscopic subtotal colectomy for UC, with an oncologic complete mesocolic excision for a left transverse colon carcinoma in the setting of chronic mucosal inflammation secondary to chronic UC as the first procedure in a 3-staged IPAA. In the video, it is also demonstrated how the lymph node dissection is extended towards the greater gastric curvature and comprising omentum and gastrocolic ligament. There were no postoperative complications in the 44-year old male patient.

Index Admission Cholecystectomy for Biliary Colic Precludes the Risk of Readmissions with Biliary Complications and should be Standard Treatment.

BACKGROUND: Emergency biliary colic admissions can be managed with an index or elective laparoscopic cholecystectomy (LC). Opting to perform an elective LC may have significant repercussions such as the risk of readmissions before operation with further attacks or with biliary complications (e.g. cholecystitis, pancreatitis, choledocholithiasis). The risk of readmission and biliary complications in patients admitted with biliary colic but scheduled for elective surgery has never been investigated. The secondary aim was to compare rates of peri-operative morbidity between the index admission, elective and readmission LC cohorts. METHOD: All patients admitted with a diagnosis of biliary colic over a 5-year period and proceeding to LC were included in the study (n = 441). The risk of being readmitted and suffering further morbidity whilst awaiting elective LC was investigated. Peri-operative morbidity was compared between the index admission, elective and readmitted LC groups using univariate and multivariate analysis. RESULTS: Following a biliary colic admission, the risk of readmission whilst awaiting elective LC is significant (2 months-25%; 10 months-48%). In this group, the risks of subsequent biliary complications (18.0%) and the requirement for ERCP (6.5%) were significant. Patients who are readmitted before LC, suffer a more complicated peri-operative course (longer total length of stay, higher post-operative complications, imaging and readmission). DISCUSSION: Index admission LC for biliary colic avoids the significant risk of readmission and biliary complications before surgery and should be the gold standard. Readmitted patients are likely to have higher rates of peri-operative adverse outcomes. Patients should be counselled about these risks.

A multicenter retrospective case-cohort study on the prevalence of incisional morbidities in late pregnant mares following exploratory celiotomy (2014-2019): 579 cases.

OBJECTIVE: To report the prevalence and risk factors for incisional morbidities in late pregnant and nonpregnant/early pregnant control mares following colic surgery. DESIGN: Multicenter, retrospective, cohort study from January 2014 to December 2019. SETTING: Two university teaching hospitals and 1 private referral center. ANIMALS: Five hundred and seventy-nine fillies and mares ≥2 years old that underwent celiotomy. Pregnant mares (n = 54) were >240 days in gestation from the last known breeding date and were compared to control females (n = 525) undergoing colic surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Morbidity rates were not different between mare groups with 56% of pregnant mares and 51% of control mares reporting at least 1 morbidity. Incisional swelling was the most common reported complication in both groups. Incisional swelling was associated with shorter hospital stays (odds ratio [OR], 0.18; P < 0.01), and drainage was associated with a longer hospital stay (OR, 1.27; P ≤ 0.01) and with use of an abdominal bandage (OR, 4.4; P < 0.01). Herniation was associated with hypercapnia under anesthesia (OR, 1.1; P = 0.048), previous abdominal surgery (OR, 8.3; P = 0.003), and with use of an abdominal bandage (OR, 56; P = 0.006). Body wall dehiscence was associated with longer hospital stay (OR, 1.2; P < 0.01). Nonsurvival was higher in pregnant mares (13%) compared to control mares (5%; P = 0.02). CONCLUSIONS: The prevalence of incisional morbidities did not differ between pregnant and control mares undergoing colic surgery. Several factors were associated with incisional morbidities, including the duration of surgery and anesthesia, anesthetic variables, abdominal bandage use, previous ventral abdominal incision, and longer duration of hospitalization.