The incidence of fungal infections in pancreas transplant recipients in the absence of systemic antifungal prophylaxis.

BACKGROUND: There is a lack of high-level evidence identifying meaningful outcomes and the place in therapy for systemic perioperative antifungal prophylaxis (ppx) in pancreas transplant recipients. As our program does not routinely utilize systemic perioperative antifungal ppx in pancreas transplant recipients, we assessed the incidence of post-transplant infectious complications. METHODS: This was a single-center, retrospective cohort study of consecutive adult pancreas transplant recipients between 01/2016 and 04/2018 to describe the incidence of fungal infections. Patients with a history of previous simultaneous pancreas-kidney (SPK) transplant, HIV, or unexplained use of antifungal ppx after transplantation were excluded. The primary outcome was the incidence of fungal infections within 3 months after transplantation. RESULTS: After screening 60 patients, 56 met inclusion criteria. Within 3 months post-transplantation, two (3.6%) patients had a positive fungal culture requiring systemic antifungal treatment. The sources for infection in both cases were intra-abdominal fluid cultures, positive for Candida albicans. Both patients were treated with fluconazole. Allograft-related outcomes included a 6-month pancreas graft survival of 91.1% and pancreas transplant rejection incidence of 10.7%. CONCLUSION: In this single-center experience, pancreas transplant recipients not receiving systemic antifungal ppx had similar infectious and graft-related outcomes to what is reported in literature.

A comparison of outcomes between open, laparoscopic and robotic pancreaticoduodenectomy.

BACKGROUND: The advantages and comparison of minimally invasive techniques for pancreaticoduodenectomies have not been fully explored using large national multicenter data. STUDY DESIGN: A retrospective review of NSQIP targeted data from 2014 to 2015 was performed. Demographics and outcomes were compared between open (OPD), laparoscopic (LPD) and robotic pancreaticoduodenectomies (RPD). RESULTS: Of 6827 pancreaticoduodenectomies, 6336 (92.8%) were OPD, 280 (4.1%) were LPD, and 211 (3.1%) were RPD. Compared to OPD, LPD required more post-operative drainage procedures (18.4% vs 13.2%, p = 0.013), had less SSI (3.2% vs 9%, p = 0.001), and had fewer discharges to a new facility (8.1% vs 13%, p = 0.018). Compared to OPD, RPD had less perioperative transfusions (14.2% vs 20.5%, p = 0.026) and more readmissions (23.2% vs 16.7%, p = 0.013). After controlling for differences, LPD was independently associated with decreased 30-day morbidity compared to OPD (OR 0.75, 95% CI 0.56-0.99). There was no difference in 30-day mortality. CONCLUSIONS: This is the first study to compare the outcomes of laparoscopic and robotic pancreaticoduodenectomies to open using the NSQIP database. After controlling for differences between groups, LPD is independently associated with less morbidity. In experienced hands, it appears safe and valuable to pursue refinement of minimally invasive techniques for pancreaticoduodenectomies.

Obesity May Not be Protective in Abdominal Stab Wounds.

CONTEXT: Current protocols for the management of abdominal stab wounds were established based on retrospective data from prior decades. Few have investigated whether higher body mass index (BMI) affects outcomes after these injuries. AIM: The aim was to determine the effects of obesity on outcomes in abdominal stab wound patients. SETTING AND DESIGN: This was a retrospective cohort study at a Level I university-associated trauma center in the United States. MATERIALS AND METHODS: We reviewed medical records of 100 adult patients admitted to our trauma center with abdominal stab wounds. Demographics, types of internal organ injury, gastrointestinal (GI) resection and repair, mortality, length of hospital stay (LOS), units of blood transfused within 24 h of admission, need and indications for exploratory laparotomy, surgical site infections (SSI), and need for re-operation were compared between obese and nonobese patients. STATISTICAL ANALYSIS: Categorical and continuous outcome variables were compared between the two groups using Chi-squared and independent-samples t-tests, respectively. BMI was evaluated as a predictor of outcomes using univariate and multivariate logistic regression. RESULTS: Records of 100 adult abdominal stab wound patients were reviewed. Twenty-five patients were obese. The obese group was older (38.76 vs. 31.23, P = 0.018). Rates of therapeutic laparotomy were similar between obese and nonobese patients (20 [80.00%] vs. 64 [85.33%]). Obesity was associated with longer LOS (9.6 vs. 6.5, P = 0.026). In the multivariate analysis, increasing BMI was an independent predictor of need for GI resection (odds ratio: 1.10 [1.02-1.18], P = 0.018). One patient from the obese group died. CONCLUSIONS: Obese patients with abdominal stab wounds have longer LOS than nonobese patients. Increasing BMI was an independent predictor of need for GI resection.

Irreversible electroporation of hepatocellular carcinoma: patient selection and perspectives.

Irreversible electroporation (IRE) is a novel form of tissue ablation that uses high-current electrical pulses to induce pore formation of the cell lipid bilayer, leading to cell death. The safety of IRE for ablation of hepatocellular carcinoma (HCC) has been established. Outcome data for ablation of HCC by IRE are limited, but early results are encouraging and suggest equivalency to the outcomes obtained for thermal ablation for appropriately selected, small (<3 cm) tumors. Long-term oncologic efficacy and histopathologic response data have not been published, and therefore, application of IRE for the treatment of HCC should still be viewed with caution.

Preoperative Myocardial Injury as a Predictor of Mortality in Emergency General Surgery: An Analysis Using the American College of Surgeons NSQIP Database.

BACKGROUND: Recent studies have linked postoperative serum troponin elevation to mortality in a range of different clinical scenarios. To date, there has been no investigation into the significance of preoperative troponin elevation in emergency general surgery (EGS) patients. We define this as preoperative myocardial injury (PMI). We hypothesize that PMI seen in EGS patients may predict postoperative morbidity and mortality. STUDY DESIGN: Using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database, we performed a retrospective review of all EGS cases between 2008 and 2014. Patients with preoperative troponin I drawn were compared. RESULTS: There were 464 EGS patients who had troponin I measurements preoperatively. Eighty-two (18%) had preoperative troponin elevations. Patients with PMI were more likely to have the following preoperative physiologic derangements: acute renal failure (18% vs 4%; p = 0.002) and septic shock (40% vs 13%; p < 0.001). Patient comorbidities associated with PMI included congestive heart failure (13% vs 3%; p = 0.007), dialysis dependence (16% vs 3%; p = 0.002), and American Society of Anesthesiologists (ASA) class ≥ 4 (52% vs 29%; p < 0.001). Compared with controls, patients with PMI had higher rates of postoperative events (77% vs 52%; p < 0.001) and mortality (34% vs 13%; p = 0.009). Univariate analysis showed that patients with PMI had an increased risk of postoperative events (odds ratio [OR] 3.02; 95% CI 1.74 to 5.25) and mortality (OR 3.53; 95% CI 1.66 to 7.47). Multivariate analysis revealed preoperative troponin I elevation was an independent predictor of mortality (OR 3.03; 95% CI 1.19 to 7.72, p = 0.020). CONCLUSIONS: Emergency general surgery patients with PMI are at increased risk for postoperative events and death. Preoperative myocardial injury is an independent predictor of mortality and has prognostic utility that can prepare surgical teams for adverse events so that they can be recognized, evaluated, and treated earlier.

Current state of art management for vascular complications after liver transplantation.

Vascular complications by compromising the blood flow to the allograft can have significant and sometimes life-threating consequences for the patient. High level of suspicion and aggressive utilization of diagnostic modalities can lead to early diagnosis and salvage of the allograft. This review will summarize the current trends in the management of vascular complications after liver transplantation. Current trends show an increase in the utilization of endovascular interventions initially to address vascular complications after liver transplantation. Operative repair still has its major role, especially if endovascular procedures fail.