A Scoring System to Determine Patients' Risk of Colectomy Within 1 Year After Hospital Admission for Acute Severe Ulcerative Colitis.

BACKGROUND & AIMS: There is consensus on the criteria used to define acute severe ulcerative colitis (ASUC) and on patient management, but it has been a challenge to identify patients at risk for colectomy based on data collected at hospital admission. We aimed to develop a system to determine patients' risk of colectomy within 1 y of hospital admission for ASUC based on clinical, biomarker, and endoscopy data. METHODS: We performed a retrospective analysis of consecutive patients with ASUC treated with corticosteroids, ciclosporin, or tumor necrosis factor (TNF) antagonists and admitted to 2 hospitals in France from 2002 through 2017. Patients were followed until colectomy or loss of follow up. A total of 270 patients with ASUC were included in the final analysis, with a median follow-up time of 30 months (derivation cohort). Independent risk factors identified by Cox multivariate analysis were used to develop a system to identify patients at risk for colectomy 1 y after ASUC. We developed a scoring system based on these 4 factors (1 point for each item) to identify high-risk (score 3 or 4) vs low-risk (score 0) patients. We validated this system using data from an independent cohort of 185 patients with ASUC treated from 2006 through 2017 at 2 centers in France. RESULTS: In the derivation cohort, the cumulative risk of colectomy was 12.3% (95% CI, 8.6-16.8). Based on multivariate analysis, previous treatment with TNF antagonists or thiopurines (hazard ratio [HR], 3.86; 95% CI, 1.82-8.18), Clostridioides difficile infection (HR, 3.73; 95% CI, 1.11-12.55), serum level of C-reactive protein above 30 mg/L (HR, 3.06; 95% CI, 1.11-8.43), and serum level of albumin below 30 g/L (HR, 2.67; 95% CI, 1.20-5.92) were associated with increased risk of colectomy. In the derivation cohort, the cumulative risks of colectomy within 1 y in patients with scores of 0, 1, 2, 3, or 4 were 0.0%, 9.4% (95% CI, 4.3%-16.7%), 10.6% (95% CI, 5.6%-17.4%), 51.2% (95% CI, 26.6%-71.3%), and 100%. Negative predictive values ranged from 87% (95% CI, 82%-91%) to 92% (95% CI, 88%-95.0%). Findings from the validation cohort were consistent with findings from the derivation cohort. CONCLUSIONS: We developed a scoring system to identify patients at low-risk vs high-risk for colectomy within 1 y of hospitalization for ASUC, based on previous treatment with TNF antagonists or thiopurines, C difficile infection, and serum levels of CRP and albumin. The system was validated in an external cohort.

What to Propose After Failed Adjustable Gastric Banding: One- or Two-step Procedure?

BACKGROUND: Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) can be proposed in case of failed laparoscopic adjustable gastric band (LAGB). The main question is whether the revisional procedure is carried out in one or two stages. OBJECTIVE: Postoperative outcomes between the one-step approach and the two-step approach of conversion of failed LAGB to RYGB or SG were, respectively, compared. METHODS: A systematic review of the literature published until June 2019 was conducted. All studies comparing one-step and two-step approaches after failed LAGB were included. Primary outcomes include both mortality and morbidity at 30 days postoperatively according to Dindo-Clavien classification. Among the studies included, a random effect model was used with Review Manager 5.3 (Cochrane Collaboration, Oxford, UK). RESULTS: A total of 3895 patients had conversion of failed LAGB to RYGB (n = 3214) or SG (n = 681), respectively. The conversion was carried out in one-step (n = 2767) or two-step (n = 1128) approaches. Meta-analysis did not show statistical difference for overall morbidity rate (OR = 1.01, 95%CI = 0.78-1.30, p = 0.96) whether it is for SG (OR = 1.25, 95%CI = 0.73-2.14, p = 0.42) or RYGB (OR = 0.94, 95%CI = 0.71-1.26, p = 0.69) and for major postoperative morbidity (OR = 0.96, 95%CI = 0.59-1.56, p = 0.87) whether it is for SG (OR = 0.66, 95%CI = 0.22-1.97, p = 0.46) or RYGB (OR = 1.05, 95%CI = 0.61-1.81, p = 0.86). Moreover, there was no statistical difference for specific morbidity rate including reoperation, leak, abscess, postoperative bleeding, and late postoperative complications. LIMITATIONS: Given the retrospective nature of the studies, these results should be interpreted with caution. CONCLUSION: This updated meta-analysis suggests that conversion of failed LAGB to RYGB or SG can be safely performed in one-step or two-step approaches.

Hemorrhagic liver cyst rupture: an unusual life-threatening complication of hepatic cyst and literature review.

BACKGROUND & AIMS: Hemorrhagic rupture is an extremely rare complication of hepatic cyst. Its incidence, gravity and treatment modalities are inadequately covered in the literature. Material and methods. Based on a case report concerning a 37 year-old, 13-weeks pregnant woman, presenting with hemorrhagic shock subsequent to hemorrhagic rupture of a hepatic cyst and requiring urgent surgery, a review of the literature was conducted. RESULTS: To date, 11 cases have been described in the literature. This complication is particularly serious with six cases of hemorrhagic shock, three of which led to death. In the majority of cases, urgent surgical treatment is required. CONCLUSIONS: Hepatic cysts are frequent benign tumors of the liver which are most often discovered fortuitously. Hemorrhagic rupture is the rarest associated complication, yet requires to be known for it is both serious and lethal and necessitates urgent surgical intervention.

Development of the "OS-SEV90 Score" to Predict Severe Postoperative Complications at 90 Days Following Bariatric Surgery.

BACKGROUND: Bariatric surgery may be associated with severe postoperative complications (SPC). Factors associated with the risk of SPC have not been fully investigated. OBJECTIVES: This study aimed to identify preoperative risk factors of SPC within 90 days and to develop a risk prediction model based on these factors. METHODS: We conducted a retrospective single-center cohort study based on a prospectively maintained database of obese patients undergoing laparoscopic bariatric surgery from October 2005 to May 2019. All SPC occurring up to the 90th postoperative day were recorded according to the Dindo-Clavien classification. Associations between potential risk factors and SPC were analyzed using a logistic regression model, and the risk prediction ("OS-SEV90 score") was computed. Based on the OS-SEV90 score, the patients were grouped into 3 categories of risk: low, intermediate, and high. RESULTS: Among 1963 consecutive patients, no patient died and 82 (4.2%) experienced SPC within 90 days. History of gastric or esophageal surgery (adjusted odds ratio (aOR) 3.040, 95% confidence interval; CI 1.78-5.20, p< 0.0001), past of thromboembolic event aOR 2.26, 95%; CI 1.12-4.55, p = 0.0225), and surgery performed by a junior surgeon (aOR 1.99, 95%; CI 1.26-3.13, p = 0.003) were all independently associated with risk for SPC, adjusting for ASA physical status system (ASA) score ≥ 3, severe OSA, psychiatric disease, asthma, a history of abdominal surgery, alcohol, cardiac disease, and dyslipidemia. "the OS-SEV90 score" based on these factors was constructed to classify patients into 3 risk groups: low (≤2), intermediate (3-4), and high (≥5). According to "the OS-SEV90 score," SPC increased significantly from 2.9% in the low-risk group, 7.7% in the intermediate-risk group, and 23.3% in the high-risk group. CONCLUSIONS: A predictive model of SPC within 90 days "the OS-SEV90 score" has been developed using 9 baseline risk factors. The use of the OS-SEV90 score may help the multidisciplinary team to identify the specific risk of each patient and inform them about and optimize the comorbidities before the surgery. Further studies are warranted to validate this score in a new independent cohort before using it in clinical practice.

Does the Implementation of Enhanced Recovery After Surgery (ERAS) Guidelines Improve Outcomes of Bariatric Surgery? A Propensity Score Analysis in 464 Patients.

BACKGROUND: The aim of this study was to investigate whether the implementation of enhanced recovery after surgery (ERAS) guidelines according to Thorell and co. in our tertiary referral bariatric center might improve post-operative outcomes. METHODS: ERAS program was introduced in our center since January 1, 2017. Retrospective review of a prospectively collected database identified patients who underwent laparoscopic primary and revisional bariatric surgeries from October 2005 to January 2018. Patients exposed to ERAS program ("ERAS group") were matched in a 1:1 ratio with patients exposed to conventional care (control group) using a propensity score based on age, gender, preoperative body mass index (BMI), diabetes mellitus, and the type of procedures. The primary outcome was total hospital length of stay (LOS) and the secondary outcomes included the post-operative complications and readmission rates. RESULTS: During the study period, 464 patients were included, 232 in each group. Implementation of the ERAS protocol was significantly associated with a reduction of LOS (2.47 ± 1.7 vs 5.39 ± 1.9 days, p < 0.00001). One-third of patients was discharged (77/232, 33%) on the first postoperative day (POD) and more than three quarter of patients on POD 2 (182/232, 77%). At the opposite, no patients of the control group were discharged on POD 2. Overall 30-day and 90-day morbidity and readmission rates were the same in both groups. There was no death in each group. CONCLUSIONS: This large case-matched study using a propensity score analysis suggests that implementation of ERAS program significantly reduced length of hospital stay without significant increases on overall morbidity, and readmission rates.

Acute gastric volvulus: an unreported long-term complication of pericardial drainage.

We report the case of a girl who had tetralogy of fallot (TOF) repaired at birth without any associated diaphragmatic hernia. At the age of 2½ years, she experienced an upper gastrointestinal occlusion. At laparoscopy an organoaxial gastric volvulus was observed related to a peritoneal adhesion secondary to pericardial drainage that had been performed at the time of the TOF repair. After reduction of the volvulus, a phrenofundopexy was done. Postoperatively, the child has remained asymptomatic with a follow-up of 24 months. There are few cases of pericardial drainage complications documented in the literature but none in the pediatric population. Based on this observation, we advise that during pericardial drainage tube placement, the peritoneal cavity be carefully avoided to prevent formation of intra-peritoneal adhesions and the risk of gastric volvulus.