Neuroendocrine neoplasms of the gallbladder: early detection and surgery is key to improved outcome.

PURPOSE: Neuroendocrine neoplasms (NENs) of the gallbladder are very rare. As a result, the classification of pathologic specimens from gallbladder NENs, currently classified as gallbladder neuroendocrine tumors (GB-NETs) and carcinomas (GB-NECs), is inconsistent and makes nomenclature, classification, and management difficult. Our study aims to evaluate the epidemiological trend, tumor biology, and outcomes of GB-NET and GB-NEC over the last 5 decades. METHODS: This is a retrospective analysis of the SEER database from 1973 to 2016. The epidemiological trend was analyzed using the age-adjusted Joinpoint regression analysis. Survival was assessed with Kaplan-Meier analysis and Cox regression was used to assess predictors of poor survival. RESULTS: A total of 482 patients with GB-NEN were identified. Mean age at diagnosis was 65.2 ± 14.3 years. Females outnumbered males (65.6% vs. 34.4%). The Joinpoint nationwide trend analysis showed a 7% increase per year from 1973 to 2016. The mean survival time after diagnosis of GB-NEN was 37.11 ± 55.3 months. The most common pattern of nodal distribution was N0 (50.2%) followed by N1 (30.9%) and N2 (19.2%). Advanced tumor spread (into the liver, regional, and distant metastasis) was seen in 60.3% of patients. Patients who underwent surgery had a significant survival advantage (111.0 ± 8.3 vs. 8.3 ± 1.2 months, p < 0.01). Cox regression analysis showed advanced age (p < 0.01), tumor stage (P < 0.01), tumor extension (p < 0.01), and histopathologic grade (p < 0.01) were associated with higher mortality. CONCLUSION: Gallbladder NENs are a rare histopathological variant of gallbladder cancer that is showing a rising incidence in the USA. In addition to tumor staging, surgical resection significantly impacts patient survival, when patients are able to undergo surgery irrespective of tumor staging. Advanced age, tumor extension, and histopathological grade of the tumor were associated with higher mortality.

Surgery for Complex Abdominal Wall Defects: Update of a Nine-Step Treatment Strategy.

Complex abdominal wall defects (CAWDs) are a new surgical entity that require a dedicated and multidisciplinary approach. The spectra of CAWDs and complex abdominal wall reconstruction (CAWR) are poorly defined, and may include any of these elements: large or multiple recurrent hernia, presence of previously placed mesh (open or laparoscopic), loss of abdominal wall domain due to trauma, infection or tumor resection, hernia in the presence of enterocutaneous or enteroatmospheric fistulae (ECF/EAF), hernia in the presence of infected sinus tract, large debilitating parastomal hernia, hernias in the presence of synthetic erosion into the bowel or causing intestinal obstruction, eroded hernias post open abdomen management with skin graft in the presence of intraabdominal catastrophe or massive trauma, and hernias (umbilical or ventral/incisional) in patients with cirrhosis in the presence of massive ascites. The relevance of abdominal wall reconstruction with reinforcement using synthetic or biological mesh has never been as high as it is now. In particular, the use of biological mesh is rising exponentially due to its inherent properties. We previously described a nine-step approach to the management of difficult abdomen with enterocutaneous fistula. In this paper, we update this strategy based on our recent experience with almost 300 patients at our institution who underwent CAWR. Special attention is paid to the management of contaminated fields and the rationale of using biological mesh.

Does Endovascular Repair for Blunt Traumatic Aortic Injuries Provide Better Outcomes Compared to Its Open Technique? A Systematic Review and Meta-analysis.

INTRODUCTION: Traumatic aortic injuries are devastating events in terms of high mortality and morbidity in most survivors. We aimed to compare the outcomes of endovascular repair (ER) vs. open repair (OR) in the treatment of traumatic aortic injuries. METHODS: PubMed, Embase, and Cochrane Library were systematically searched. Postoperative mortality was the primary endpoint. Secondary endpoints included intensive care unit (ICU) length of stay, hospital length of stay, operating time, paraplegia, stroke, acute renal failure, and reoperation rate. The Mantel-Haenszel method (random-effects model) with odds ratios and 95% confidence intervals (OR (95% CI)), and the inverse variance method with the mean difference (MD (95% CI)), were used to measure the effects of continuous and categorical variables, respectively. RESULTS: A total of 49 studies involving 12,857 patients were included. Postoperative mortality was not significantly different between the two groups (p=0.459). Among secondary outcomes, the paraplegia rate was significantly lower after ER (p=0.032). Other secondary endpoints such as ICU length of stay (p=0.329), hospital length of stay (p=0.192), operating time (p=0.973), stroke rate (p=0.121), ARF rate (p=0.928), and reoperation rate (p=0.643) did not significantly differ between the two groups. CONCLUSION: This meta-analysis found that ER was associated with a reduced paraplegia rate compared to OR for the management of traumatic aortic injury.

Outcomes of Emergency Gastrointestinal Surgery Done on Post-Cardiac Surgery Patients-Analysis From a Tertiary Care Center.

INTRODUCTION: Abdominal complications following cardiac surgery have high mortality rates. This study analyzes the outcomes of patients who have undergone emergency general surgery (EGS) procedures after cardiothoracic surgery (CTS) at the same hospitalization. MATERIALS AND METHODS: This was a retrospective analysis of all patients who underwent emergent abdominal surgery after CTS surgery between 2010-2018. The CTS procedures included coronary artery bypass graft (CABG), valve replacement, cardiac transplant, aortic replacement, ventricular assist device, and pericardial procedures. The records were reviewed to obtain demographics, frequency distribution of EGS procedures, complications, outcomes, and the risk factors of mortality. RESULTS: Of 4826 patients who had CTS, 57 (1.2%) underwent EGS procedures during the period of 2010-2018. This cohort of patients had 113 CTS and 85 EGS procedures during the same hospitalization. The mean age was 62 years, and 49% were elderly (40% were females). CABG with or without valve replacement was the most common surgery (28%). After surgical consultation for "acute abdomen" in the post-CTS phase, the three most common findings on exploratory laparotomy were bowel perforation (23%), massive free fluid leading to abdominal compartment syndrome (19%), and acute cholecystitis (16%). Respiratory failure (46%), acute kidney injury (32%), and multiple organ dysfunction (18%) were the most common hospital-acquired complications. Regarding dispositions, 47% were discharged to an acute rehabilitation center, 10% were discharged to a sub-acute rehabilitation center, and a similar proportion of patients went home (10%). On multivariable logistic regression analysis with backward elimination, age (OR=1.10, 95% CI: 1.02-1.18) and serum proteins (OR=0.99, 95% CI: 0.98-0.998) were independently associated with the odds of mortality after EGS in the immediate CTS phase. CONCLUSIONS: Respiratory failure is the most common complication of EGS immediately after CTS. The older the patient and the lower the serum proteins, the higher the odds of mortality in patients who undergo EGS after ETS.

Safety analysis of a multispecialty surgical volunteerism mission over thirteen years - age alone is not a contradiction.

INTRODUCTION: About five billion people worldwide lack access to safe surgery and multispecialty surgical volunteer missions (SVMs) offer a plausible solution to this problem. This study aimed to evaluate the outcomes of elderly patients operated on over 13 surgical missions between 2006 and 2019 from "Operation Giving Back Bohol" Tagbilaran, Philippines. PATIENTS AND METHODS: This was a retrospective analysis of prospectively collected data on all patients treated during SVM over 13 years (2006-2019). Non-elderly (age 16-64 years) were compared with the elderly (age ≥65 years) for pre-, intra-, and postoperative variables. Multivariable logistic regression was utilized to identify independent predictors of postoperative complications. RESULTS: Of 1184 patients, the majority (1030) were in the non-elderly group and 154 in the elderly. The mean age was 36 ± 13.6 and 68.3 ± 3.8 years in the non-elderly and elderly groups, respectively. Comorbidities, type of surgery, type of anesthesia, operating time, estimated blood loss, estimated blood loss, need for blood transfusion, postoperative complication rates, comprehensive complication index, length of hospital, ICU requirement, and mortality rates stay did not significantly differ between the groups. Multivariable logistic regression found pelvic surgery (OR (95%CI) = 3.7 (1.3-10.8); p = 0.01), hypertension (OR (95%CI) = 8.4 (2.2-32.9); p < 0.01), and intraoperative blood loss (OR (95%CI) = 1.007 (1.005-1.009); p < 0.01) to be independent predictors of postoperative complications. CONCLUSIONS: Elderly patients may be safely undergo general surgery procedures in surgical volunteer missions, and age alone should not preclude them.

Venous Thromboembolism in Geriatric Trauma Patients-Risk Factors and Associated Outcomes.

BACKGROUND: Venous thromboembolism (VTE) places elderly trauma patients at a high risk of morbidity. The purpose of this study was to determine the outcomes related to VTE in geriatric trauma patients, as well as to identify risk factors for the development of VTE in this population. We also assessed the impact of the type and timing of VTE prophylaxis, and the type of injuries, on development of VTE in geriatric trauma population. METHODS: We performed a 2-year retrospective review from American College of Surgeons-Trauma Quality Improvement Project (ACS-TQIP) databank from 2014 to 2016. A total of 354,272 patients aged 65 y or older who developed VTE after trauma were included in the study. RESULTS: Overall, 354,272 elderly trauma patients with complete records were identified from the year 2014 to 2016, and of this, 4290 (1.1%) patients developed in-hospital VTE. Male gender was more predominant in the VTE group (P < 0.001). Both the ICU length of stay and hospital length of stay (P < 0.001) were higher in the VTE group. Spine injury (P = 0.002), lower extremity injury (P < 0.001), age category 75-84 y (P < 0.001), age ≥85 y (P < 0.001), frailty (P < 0.001), severe traumatic brain injury (TBI) (GCS3-8) (P < 0.001), ventilator days (P < 0.001), and transfusion of plasma products in first 24 h of admission (P < 0.001) were independent predictors of developing VTE after trauma in the elderly. Higher injury severity score, TBI, and transfusion of packed red blood cells within 24 h were associated with longer time to initiate VTE prophylaxis. Time to initiate chemical deep vein thrombosis prophylaxis was significantly longer in those patients that developed VTE (3.73 ± 4.82 d), when compared with those patients without VTE ((1.81 ± 2.53 d) (P < 0.001). CONCLUSIONS: Our study demonstrates that ICU and hospital length of stay were higher in VTE group. Frailty, severe TBI, spine injury, lower extremity injury, longer duration of mechanical ventilation, and transfusion of plasma products in the first 24 h of hospital admission were independent predictors of developing VTE after trauma in elderly. Type and timing of VTE prophylaxis were not significant independent predictors of developing VTE after trauma, while higher injury severity score, TBI, and transfusion of packed red blood cells within 24 h were associated with longer time to initiate VTE prophylaxis. Future multi-institutional prospective studies are warranted to gather more evidence on this topic.

Falling Again? Falls in Geriatric Adults-Risk Factors and Outcomes Associated With Recidivism.

BACKGROUND: The elderly population is at increased risk of fall-related readmissions (FRRs). This study is aimed to identify the factors predictive of repeat falls and to analyze the associated outcomes. METHODS: We studied the Nationwide Readmission Database for the year 2010 and identified the patients (≥65 years) who were admitted after falls, and from that subset, further analyzed patients with ≥1 FRRs. Descriptive statistics were used to analyze continuous and categorical variables. Multivariable logistic regression was used to identify predictors of readmission in geriatric patients after controlling for covariates. RESULTS: A total of 358,581 initial fall-related admissions in geriatric adults were identified, and of these, 21,713 experienced ≥1 FRRs (6.06% risk of repeat fall-related admission). Females outnumbered males, and female gender was identified as an independent predictor of FRR (OR 1.10 95% CI 1.07-1.14 P = 0.000). The other independent predictors significantly associated with FRR were age (OR 1.007, 95% CI 1.005-1.009), depression (OR 1.25, 95% CI 1.21-1.30), drug abuse (OR 1.37, 95% CI 1.15-1.63), liver disease (OR 1.25, 95% CI 1.15-1.43, P < 0.001), psychosis (OR 1.16, 95% CI 1.09-1.23), valvular heart disease (OR 1.07, 95% CI 1.02-1.12), chronic pulmonary disease (OR 1.10, 95% CI 1.06-1.13), and number of chronic conditions (OR 1.022, 95% CI 1.016-1.29). Patients admitted emergently or urgently had higher odds of FRR (OR 1.44, 95% CI 1.36-1.52). Hospital demographic was a significant predictor of FRR, as hospitals with bed number >500 was associated with lower odds (OR 0.95, 95% CI 0.92-0.98, P < 0.001). Geriatric patients admitted at nonteaching hospitals and hospitals in large metro areas (population > 1 million) had higher odds of FRR (OR 1.10, 95% CI 1.03 - 1.16) and (OR 1.10, 95% C1 1.07-1.14), respectively. With respect to discharge disposition, patients in the FRR group were less likely to go home (5.9% versus 21.0%) or with home health care (12.6% versus 18.5%), but more likely to be discharged to skilled nursing or intermediate-care facilities (64.1% versus 54.9%) and short-term hospitals (2.8% versus 1.4%). The mortality rate was higher in the FRR group but was not statistically significant (OR 1.06, 95% CI 0.99-1.14). CONCLUSIONS: Given the high burden of fall-related injuries and FRRs to patients and the health care system, it is essential to identify those who are at risk. This study provides a comprehensive list of high-risk predictors as well as the impact on patient outcomes, and hence a chance to intervene for patients with FRRs.

Predictors of 30- and 90-Day Readmissions After Complex Abdominal Wall Reconstruction With Biological Mesh: A Longitudinal Study of 232 Patients.

BACKGROUND: Hospital readmissions are recognized as indicators of poor healthcare services which further increase patient morbidity. The aim of this study is to analyze predicting factors for the 30-day and 90-day readmissions after a complex abdominal wall reconstruction (CAWR). METHODS: A pooled analysis of the prospective study and retrospective database patients undergoing CAWR with acellular porcine dermis from 2012 to 2019 was carried out. Independent t test for continuous variables and Chi-square and Fischer's exact tests for categorical variables were used. A multivariable logistic regression model and linear regression analysis were used to analyze the independent predictors of 30-day and 90-day readmissions. RESULTS: A total of 232 patients underwent CAWR, and the readmission rate (RR) was 16.8% (n = 40). The 30-day and 90-day RR was 11.3% (n = 23) and 13.3% (n = 33), respectively. There were no statistical differences in age, frailty, and gender distribution between the two groups. There was no difference in ASA score, type of component separation, ventral hernia working group class, size of the biological mesh, placement of mesh, and intestinal resection rate. The Clavien-Dindo complications and mean comprehensive complication index (CCI) were higher in the readmission group as compared to no readmission group (p < 0.01). Readmitted patients had higher surgical site infections (p < 0.01) and wound necrosis (p = 0.01). Higher CCI, past or concomitant pelvic surgery, and the presence of enterocutaneous fistula were independent predictors of earlier days to readmission. CONCLUSION: Surgical site occurrences were associated with 30-day and 90-day readmissions after CAWR, while the presence of ascites and dialysis was associated with 90-day readmissions.

Fragmentation of Care After Geriatric Trauma: A Nationwide Analysis of outcomes and Predictors.

The health care system for the elderly is fragmented, that is worsened when readmission occurs to different hospitals. There is limited investigation into the impact of fragmentation on geriatric trauma patient outcomes. The aim of this study was to compare the outcomes following readmissions after geriatric trauma. The Nationwide Readmissions Database (2016-2017) was queried for elderly trauma patients (aged ≥65 years) readmitted due to any cause. Patients were divided into 2 groups according to readmission: index vs non-index hospital. Outcomes were 30 and 180-day complications, mortality, and the number of subsequent readmissions. Multivariable logistic regression was performed to analyze the independent predictors of fragmentation of care. A total of 36,176 trauma patients were readmitted, of which 3856 elderly patients (aged ≥65 years) were readmitted: index hospital (3420; 89%) vs non-index hospital (436; 11%). Following 1:2 propensity matching, elderly with non-index hospital readmission had higher rates of death and MI within 180 days (P = .01 and .02, respectively). They had statistically higher 30 and 180-day pneumonia (P < .01), CHF (P < .01), arrhythmias (P < .01), MI (P < .01), sepsis (P < .01), and UTI (P < .01). On multivariable binary logistic regression analysis, pneumonia (OR 1.70, P = .03), congestive heart failure (CHF) (OR 1.80, P = .03), female gender (OR .72, P = .04), and severe Head and Neck trauma (AIS≥3) (OR 1.50, P < .01) on index admission were independent predictors of fragmentation of care. While the increase in time to readmission (OR 1.01, P < .01) was also associated independently with non-index hospital admission. Fragmented care after geriatric trauma could be associated with higher mortality and complications.

Non-operative management of cirrhotic patients with acute calculous cholecystitis: How effective is it?

INTRODUCTION: Nonoperative management (NOM) of acute calculous cholecystitis (ACC) in patients with cirrhosis was proposed. We examined the outcomes of cirrhotic patients with ACC treated with cholecystectomy compared to NOM. METHODS: We analyzed the 2017-Nationwide Readmissions Database including cirrhotic patients with ACC. Patients were stratified: cholecystectomy, percutaneous cholecystostomy (PCT), and antibiotics only. PRIMARY OUTCOMES: complications, failure of NOM. SECONDARY OUTCOMES: mortality, length of stay (LOS), and charges. RESULTS: 3454 patients were identified. 1832 underwent cholecystectomy, 360 PCT, and 1262 were treated with antibiotics. PCT patients had higher mortality 16.9% vs. the antibiotics group 10.9% vs. cholecystectomy group 4.2%. PCT patients had longer LOS, but lower charges compared to the operative group. Failure of NOM was 28.2%. On regression, PCT was associated with mortality. CONCLUSION: ACC remains a morbid disease in cirrhosis patients. One in three failed NOM, had longer LOS, and higher mortality. Further studies are warranted to identify predictors of NOM failure. LEVEL OF EVIDENCE: Level III, prognostic.

Pelvic fractures in severely injured elderly: a double-adjustment propensity score matched analysis from a level I trauma center.

PURPOSE: Pelvic trauma has increased risk of mortality in the elderly. Our study aimed to analyze the impact of the additional burden of pelvic fractures in severely injured elderly. METHODS: This is a retrospective analysis of a prospectively maintained trauma registry from 2012 to 2018 at an American College of Surgeons (ACS) verified Level I Trauma Center. Trauma patients aged ≥ 65 years with ISS ≥ 16 and AIS severity score ≥ 3 in at least two body regions were divided in two groups: group I, consisted of elderly polytrauma patients without pelvic fractures, and group II elderly who had concomitant pelvic fractures. We used a double-adjustment method using propensity score matching (PSM) with subsequent covariate adjustment to minimize the effect of confounding factors, and give unbiased estimation of the impact of pelvic fractures. Balance assessment was conducted by computing absolute standardized mean differences (ASMDs) and ASMD < 0.10 reflects good balance between groups. RESULTS: Of 12,774 patients admitted during this time, 411 (3.2%) elderly with a mean age of 77.75 ± 8.32 years met the inclusion criteria. Of this cohort, only 92 patients (22.4%) had pelvic fractures. Females outnumbered males (55 vs. 45%). Comparing characteristics of group I and group II using ASMDs, pelvic trauma patients were more likely to have higher systolic blood pressure (SBP), head injuries, lower extremity injuries, anticoagulant therapy, and cirrhosis. Fewer variables differed significantly after matching. We observed few instances of worse outcomes associated with pelvic trauma using PSM with and without covariate adjustment. Crude PSM without covariate adjustment, showed a significantly higher rate of deep vein thrombosis (DVT) for pelvic trauma (p < 0.001). Crude PSM also showed a significantly higher rate of ventilator-associated pneumonia (VAP) in group II (p = 0.006). PSM with covariate adjustment did not confirm differences on these outcomes. PSM both without and with covariate adjustment found lower ventilator days and ICU length of stay among patients with pelvic trauma. No significant differences were seen on 12 outcomes: death, acute kidney injury (AKI), acute respiratory distress syndrome (ARDS), cardiac arrest with cardiopulmonary resuscitation (CPR), myocardial infarction (MI), pulmonary embolism (PE), unplanned intubation, unplanned admission to intensive care unit (ICU), catheter-associated urinary tract infection (CAUTI), and hospital length of stay. CONCLUSIONS: At a Level I Trauma Center the additional burden of pelvic fractures in seriously injured elderly did not translate into higher mortality. PSM without covariate adjustment suggests worse rates among pelvic trauma patients for DVT and VAP but covariate adjustment removed statistical significance for both outcomes. Pelvic trauma patients had shorter time on ventilator and in the ICU. Whether similar analytic methods applied to patients from larger data sources would produce similar findings remains to be seen.

Robotic duodenal (D3) resection with Roux-en-Y duodenojejunostomy reconstruction for large GIST tumor: Step by step with video.

BACKGROUND: Duodenal gastrointestinal stromal tumors (GISTs) are uncommon, making up only 3-5% of all GISTs. [1,2] Historically, the treatment of choice for duodenal GIST tumors was pancreaticoduodenectomy. [3]Currently, newer surgical intervention methods including local resection via laparotomy, endoscopic resection, and robotic resection are feasible. When doing a local resection, the defect can be closed either primarily or via a Roux-en-Y duodenojejunostomy. [3] Case presentation: Our patient is a 64-year- old female who presented initially with shortness of breath and was found to have a pulmonary embolism. She then developed upper GI bleeding from anticoagulation and was found to have an ulcerated GIST tumor in the anti-mesenteric border of the third portion of the duodenum (D3). Initial surgery was postponed due to high pulmonary artery pressure from the pulmonary embolism. The patient underwent argon beam coagulation of the bleeding mass to control the bleeding, followed by localized radiotherapy plus Gleevec. Unfortunately, the tumor grew in size during follow-up. The patient was then taken to the OR for a robot-assisted partial duodenal resection (D3) with Roux-en-Y duodenojejunostomy to reconstruct the large defect. She did well post operatively and her final pathology showed a GIST tumor, c-kit and DOG1 positive, 3.5 cm in size, with negative margins. CONCLUSION: Robotic duodenal resection is a new technique currently being used to resect duodenal GIST tumors. Our video demonstrates the feasibility of D3 partial resection with Roux-en-Y duodenojejunostomy. Duodenal GIST tumor robotic resection offers both decreased morbidity and adequate oncologic outcomes.

The Role of Nutritional Access in Malnourished Elderly Undergoing Major Surgery for Acute Abdomen: A Propensity Score-Matched Analysis.

BACKGROUND: About 50% of the elderly undergoing emergency abdominal surgery are malnourished. The role of timely surgical nutritional access in this group of patients is unknown. METHODS: We analyzed the National Inpatient Sample database from 2009 through the first three-quarters of 2015 of patients aged ≥65 years who were malnourished and underwent major abdominal surgery for the acute abdomen within the first 2 days of hospital admission. RESULTS: Of 3 246 721 patients analyzed, 4311 patients met inclusion criteria. Of these, only 507 (11.8%) patients had surgical nutritional access (gastrostomy or jejunostomy) (group I), while 3804 patients (88.2%) did not (group II). In the propensity score-matched population, there were 482 patients in each group. The patients in group I had lower odds of mortality and postoperative gastrointestinal complications (paralytic ileus, anastomotic dehiscence, and intestinal fistulae) (P-value <.01, respectively). DISCUSSION: Elderly who receive surgical nutritional access have lower rates of gastrointestinal complications and mortality.

Gallbladder cancer: Historical treatment and new management options.

Gallbladder cancer is a rare, aggressive malignancy that has a poor overall prognosis. Effective treatment consists of early detection and surgical treatment. With the wide spread treatment of gallbladder disease with minimally invasive techniques, the rate of incidental gallbladder cancer has seen an equitable rise along with stage migration towards earlier disease. Although the treatment remains mostly surgical, newer modalities such as regional therapy as well as directed therapy based on molecular medicine has led to improved outcomes in patients with advanced disease. We aim to summarize the management of gallbladder cancer along with the newer developments in this formidable disease process.

Simultaneous Robot Assisted Colon and Liver Resection for Metastatic Colon Cancer.

INTRODUCTION: Simultaneous robot assisted colon and liver resections are being performed more frequently at present due to the expanded adoption of the robotic platform for surgical management of metastatic colon cancer. However, this approach has not been studied in detail with only case series available in the literature. The aim of this systematic review was to evaluate the current body of evidence on the feasibility of performing simultaneous robotic colon and liver resections. METHODS: A systematic review was performed through PubMed to identify relevant articles describing simultaneous colon and liver resections for metastatic colon cancer. RESULTS: A total of 28 patients underwent simultaneous resections robotically with an average operative time of 420.3 minutes and average blood loss of 275.6 ml. Postoperative stay was 8.6 days on average with all cases achieving negative surgical margins. CONCLUSIONS: Robotic simultaneous resection of colorectal cancer with liver metastases is technically feasible and seems oncologically equivalent to open or laparoscopic surgery. Further studies are urgently needed to assess benefits of robotic surgery in the patient population.

Robotic pancreaticoduodenectomy provides better histopathological outcomes as compared to its open counterpart: a meta-analysis.

The aim of this meta-analysis was to evaluate whether robotic pancreaticoduodenectomy (PD) may provide better clinical and pathologic outcomes compared to its open counterpart. The Pubmed, EMBASE, and Cochrane Library were systematically searched. Overall postoperative morbidity and resection margin involvement rate were the primary endpoints. Secondary endpoints included operating time, estimated blood loss (EBL), incisional surgical site infection (SSI) rate, length of hospital stay (LOS), and number of lymph nodes harvested. Twenty-four studies totaling 12,579 patients (2,175 robotic PD and 10,404 open PD were included. Overall postoperative mortality did not significantly differ [OR (95%CI) = 0.86 (0.74, 1.01); p = 0.06]. Resection margin involvement rate was significantly lower in robotic PD [15.6% vs. 19.9%; OR (95%CI) = 0.64 (0.41, 1.00); p = 0.05; NNT = 23]. Operating time was significantly longer in robotic PD [MD (95%CI) = 75.17 (48.05, 102.28); p < 0.00001]. EBL was significantly decreased in robotic PD [MD (95%CI) = - 191.35 (- 238.12, - 144.59); p < 0.00001]. Number of lymph nodes harvested was significantly higher in robotic PD [MD (95%CI) = 2.88 (1.12, 4.65); p = 0.001]. This meta-analysis found that robotic PD provides better histopathological outcomes as compared to open PD at the cost of longer operating time. Furthermore, robotic PD did not have any detrimental impact on clinical outcomes, with lower wound infection rates.

Early versus delayed complex abdominal wall reconstruction with biologic mesh following damage-control surgery.

BACKGROUND: Damage-control surgery for trauma and intra-abdominal catastrophe is associated with a high rate of morbidities and postoperative complications. This study aimed to compare the outcomes of patients undergoing early complex abdominal wall reconstruction (e-CAWR) in acute settings versus those undergoing delayed complex abdominal wall reconstruction (d-CAWR). METHOD: This study was a pooled analysis derived from the retrospective and prospective database between the years 2013 and 2019. The outcomes were compared for differences in demographics, presentation, intraoperative variables, Ventral Hernia Working Grade (VHWG), US Centers for Disease Control and Prevention wound class, American Society of Anesthesiologists (ASA) scores, postoperative complications, hospital length of stay, and readmission rates. We performed Student's t test, χ2 test, and Fisher's exact test to compare variables of interest. Multivariable linear regression model was built to evaluate the association of hospital length of stay and all other variables including the timing of complex abdominal wall reconstruction (CAWR). A p value of <0.05 was considered significant. RESULTS: Of the 236 patients who underwent CAWR with biological mesh, 79 (33.5%) had e-CAWR. There were 45 males (57%) and 34 females (43%) in the e-CAWR group. The ASA scores of IV and V, and VHWG grades III and IV were significantly more frequent in the e-CAWR group compared with the d-CAWR one. Postoperatively, the incidence of surgical site occurrence, Clavien-Dindo complications, comprehensive complication index, unplanned reoperations, and mortality were similar between the two groups. Backward linear regression model showed that the timing of CAWR (ß = -11.29, p < 0.0001), ASA (ß = 3.98, p = 0.006), VHWG classification (ß = 3.62, p = 0.015), drug abuse (ß = 13.47, p = 0.009), and two comorbidities of cirrhosis (ß = 12.34, p = 0.001) and malignancy (ß = 7.91, p = 0.008) were the significant predictors of the hospital length of stay left in the model. CONCLUSION: Early CAWR led to shorter hospital length of stay compared with d-CAWR in multivariable regression model. LEVEL OF EVIDENCE: Therapeutic, level IV.

Does computed tomography scan add any diagnostic value to the evaluation of stab wounds of the anterior abdominal wall? A systematic review and meta-analysis.

BACKGROUND: The aim of this systematic review and meta-analysis was to evaluate whether computed tomography (CT) scan adds any diagnostic value in the evaluation of stab wounds of the anterior abdominal wall as compared with serial clinical examination (SCE). METHODS: PubMed, EMBASE, Cochrane Library, and MEDLINE via Ovid were systematically searched for records published from 1980 to 2018 by two independent researchers (M.G., R.L.). Quality assessment, data extraction, and analysis were performed according to the Cochrane Handbook for Systematic Reviews of Interventions. Mantel-Haenszel method with odds ratio (OR) and 95% confidence interval (95% CI) as the measure of effect size was used for meta-analysis. RESULTS: Three studies (1 randomized controlled trial and 2 observational studies) totaling 319 patients were included in the meta-analysis. Overall laparotomy rate was 12.8% (22 of 172 patients) in SCE versus 19% (28 of 147 patients) in CT. This difference was not significant (OR [95% CI], 0.63 [0.34-1.16]; p = 0.14). Negative laparotomy rate was 3.5% (6 of 172 patients) in SCE versus 5.4% (8 of 147 patients) in CT. The difference was not significant (OR [95% CI], 0.61 [0.20-1.83]; p = 0.37). CONCLUSION: This meta-analysis compared SCE with CT scan in patients presenting with stab wounds of the anterior abdominal wall and provided level II evidence showing no additional benefit in CT scan. Further observational and experimental clinical studies are needed to confirm the findings of this meta-analysis. LEVEL OF EVIDENCE: Systematic review and meta-analysis, level II.

Perioperative complications of complex abdominal wall reconstruction with biologic mesh: A pooled retrospective cohort analysis of 220 patients from two academic centers.

BACKGROUND: Perioperative outcomes in patients who undergo complex abdominal wall reconstruction (CAWR) may be associated with severe complications, mainly when these procedures are done urgently or emergently. This study aims to identify perioperative predictors of outcomes after CAWR with biologic mesh (BM). MATERIALS AND METHODS: In a retrospective study, perioperative complications (length of hospital stay, ventilator support, surgical site infection, need for wound VAC, reoperation, total complications, and mortality), were analyzed in all patients who underwent open CAWR with BM over six years in two academic centers. Furthermore, we examined the effect of cardiac disease, BMI, diabetes, COPD, case mixed index, hernia size, wound classification, mesh technique, the setting of surgery, on perioperative complications. Multivariable linear and logistic regression analyses were performed. RESULTS: There were 220 patients: 134 patients from center A and 86 patients from center W Mean age was 54.9 ± 14.8 years, 47.7% were females, 33.8% of the patients had BMI ≥30 kg/m2 and median hospital length of stay was 7 days. Center W patients had increased need for mechanical ventilation (10.5% vs. 3%, p = 0.02) and higher need for wound VAC (19.8% vs. 6.7%, p = 0.003). On multivariable linear regression, independent patient predictors of increased hospital length of stay (HLO) were: urgent/emergent surgery (ß 6.93, 95% CI 1.65-12.22, p = 0.01), cardiac disease (ß 7.84, 95% CI 1.23-14.46, p = 0.02) and epigastric defect (ß 13.68, 95% CI 0.29-27.06, p = 0.045). Addition-ally, urgent/emergent setting (OR 3.06, 95% CI 1.69-5.55, p < 0.001) and cardiac disease (OR 2.15, 95% CI 1.03-4.50, p = 0.042) were independently associated with increased odds for perioperative complications. CONCLUSIONS: Perioperative complications of patients undergoing CAWR are considerable and depend on defect complexities, the setting of surgery, comorbidities, wound classification, procedural factors, and case-mix index. Prospective studies on perioperative complications are needed.

Medullary Thyroid Cancer in Patients Older than 45-Epidemiologic Trends and Predictors of Survival.

Sporadic medullary thyroid cancer (MTC) can occur anytime in life although they tend to present at a later age (≥45 years old) when the tumors are more easily discernible or become symptomatic. We aimed to identify the factors affecting the survival in patients ≥45 years of age diagnosed with MTC. We analyzed the Surveillance, Epidemiology, and End Results (SEER) registry from 1973-2016 focusing on patients ≥45 years of age with MTC as an isolated primary. A total of 2533 patients aged ≥45 years with MTC were identified. There has been a statistically significant increase of 1.19% per year in the incidence of MTC for this group of patients. The disease was more common in females and the Caucasian population. Most patients had localized disease on presentation (47.6%). Increasing age and advanced stage of presentation were associated with worse survival with HR 1.05 (p < 0.001) and HR 3.68 (p < 0.001), respectively. Female sex and surgical resection were associated with improved survival with HR 0.74 (p < 0.001) and 0.36 (p < 0.001), respectively. In conclusion, the incidence of MTC in patients ≥45 years of age is increasing. Patients should be offered surgical resection at an early stage to improve their outcomes.