Prospective validation of a surgical complications grading system in a cohort of 2114 patients.

BACKGROUND: We recently reported a grading system for surgical complications. This system proved to have a high sensitivity for recording minor but meaningful complications prolonging hospital stay in patients after colorectal surgery. We aimed to prospectively validate the complication grading system in a general surgery department over 1 year. METHODS: All surgical procedures and related complications were prospectively recorded between January 1st and December 31st, 2009. Surgical complications were graded on a severity scale of 1-5. The system classifies short-term outcome by grade emphasizing intensity of therapy required for treatment of the defined complication. RESULTS: During the study period, 2114 patients underwent surgery. Elective and oncological surgeries were performed in 1606 (76%) and 465 (22%) patients, respectively. There were 422 surgical complications in 304 (14%) patients (Grade 1/2: 203 [67%]; Grade 3/4: 90 [29%]; Grade 5: 11 [4%]). Median length of stay correlated significantly with complication severity: 2.3 d for no complication, 6.2 and 11.8 d for Grades 1/2 and 3/4, respectively (P < 0.001). Older age (OR 2.75, P < 0.001), comorbidities (OR 1.44, P = 0.02), American Society of Anesthesiology score >2 (OR 2.07, P < 0.001), contamination Grade (OR 1.85, P = 0.001), oncological (OR 2.82, P < 0.001), open (OR 1.22, P = 0.03), prolonged >120 min (OR 2.08, P < 0.001), and emergency surgery (OR 1.42, P = 0.02) independently predicted postoperative complications. CONCLUSIONS: This system of grading surgical complications permits standardized reporting of surgical morbidity according to the severity of impact. Prospective validation of this system supports its use in a general surgery setting as a tool for surgical outcome assessment and quality assurance.

Live liver donors' risk thresholds: risking a life to save a life.

BACKGROUND: There is still some controversy regarding the ethical issues involved in live donor liver transplantation (LDLT) and there is uncertainty on the range of perioperative morbidity and mortality risks that donors will consider acceptable. METHODS: This study analysed donors' inclinations towards LDLT using decision analysis techniques based on the probability trade-off (PTO) method. Adult individuals with an emotional or biological relationship with a patient affected by end-stage liver disease were enrolled. Of 122 potential candidates, 100 were included in this study. RESULTS: The vast majority of participants (93%) supported LDLT. The most important factor influencing participants' decisions was their wish to improve the recipient's chance of living a longer life. Participants chose to become donors if the recipient was required to wait longer than a mean ± standard deviation (SD) of 6 ± 5 months for a cadaveric graft, if the mean ± SD probability of survival was at least 46 ± 30% at 1 month and at least 36 ± 29% at 1 year, and if the recipient's life could be prolonged for a mean ± SD of at least 11 ± 22 months. CONCLUSIONS: Potential donors were risk takers and were willing to donate when given the opportunity. They accepted significant risks, especially if they had a close emotional relationship with the recipient.

Biliary stent therapy for dominant strictures in patients affected by primary sclerosing cholangitis.

The diagnosis and the treatment of dominant strictures (DS) in patients with primary sclerosing cholangitis (PSC) is challenging and the scientific literature on the subject is quite limited. Only level II and level III evidence is available to guide physicians managing patients with DS and PSC. For the diagnosis, intraductal endoscopic ultrasound is the most sensitive (64%) and specific (95%) test. However, the majority of cases require a combination of several different diagnostic tests, as there is no single investigation that can rule out malignancy in this group of patients. For the treatment, serial endoscopic or percutaneous dilatations provide 1- and 3-year biliary duct patency in 80 and 60% of patients, respectively. Dilatation and stenting are the most common interventions, although the optimal duration of treatment has still not been clearly defined. Bile duct resection and/or bilioenteric bypass are currently indicated only for patients with preserved liver function. For all other patients, benign DS can be treated with endoscopic dilatation with short-term stenting. This approach is effective and safe and does not increase the risk of malignant transformation or complications for liver transplant candidates. During the last decade, the use of self-expandable metallic stents for benign diseases has become an innovative option. The aim of this article is to review the diagnostic and therapeutic strategies for patients affected by PSC and DS with specific emphasis on the outcomes of patients treated with temporary stents.

Effect of obesity and decompressive laparotomy on mortality in acute pancreatitis requiring intensive care unit admission.

BACKGROUND: Controversy still exists on the effect that obesity has on the morbidity and mortality in severe acute pancreatitis (SAP). The primary purpose of this study was to compare the mortality rate of obese versus nonobese patients admitted to the ICU for SAP. Secondary goals were to assess the potential risk factors for abdominal compartment syndrome (ACS) and to investigate the performance of validated scoring systems to predict ACS and in-hospital mortality. METHODS: A retrospective cohort of adults admitted to the ICU for SAP was stratified by their body mass index (BMI) as obese and nonobese. The rates of morbidity, mortality, and ACS were compared by univariate and multivariate regression analyses. Areas under the curve (AUC) were used to evaluate the discriminating performance of severity scores and other selected variables to predict mortality and the risk of ACS. RESULT: Forty-five patients satisfied the inclusion criteria and 24 (53 %) were obese with similar characteristics to nonobese patients. Among all the subjects, 11 (24 %) died and 16 (35 %) developed ACS. In-hospital mortality was significantly lower for obese patients (12.5 vs. 38 %; P = 0.046) even though they seemed to develop ACS more frequently (41 vs. 28 %; P = 0.533). At multivariable analysis, age was the most significant factor associated with in-hospital mortality (odds ratio (OR) = 1.273; 95 % confidence interval (CI) 1.052-1.541; P = 0.013) and APACHE II and Glasgow-Imrie for the development of ACS (OR = 1.143; 95 % CI 1.012-1.292; P = 0.032 and OR = 1.221; 95 % CI 1.000-1.493; P = 0.05) respectively. Good discrimination for in-hospital mortality was observed for patients' age (AUC = 0.846) and number of comorbidities (AUC = 0.801). ACS was not adequately predicted by any of the clinical severity scores (AUC = 0.548-0.661). CONCLUSIONS: Patients' age was the most significant factor associated with mortality in patients affected by SAP. Higher APACHE II and Glasgow-Imrie scores were associated with the development of ACS, but their discrimination performance was unsatisfactory.

Incarcerated hernia in 11-mm nonbladed trocar site following laparoscopic appendectomy.

BACKGROUND: Nonbladed trocars are considered less traumatic to the abdominal wall due to the lack of fascial incision. It has been suggested that closure of the abdominal fascia may be unnecessary when such nonbladed trocars are used. CASE REPORT: We report on 2 patients who were diagnosed with trocar-site hernias 2 days after laparoscopic appendectomy performed using 11-mm nonbladed trocars. CONCLUSION: Although rare, trocar-site hernias after laparoscopic surgery with nonbladed trocars remain a cause of postoperative morbidity and require prompt intervention. Therefore, this report underscores the significance of performing meticulous closure of all trocar sites that are 10mm.

Prospective trial evaluating electrical impedance scanning of thyroid nodules before thyroidectomy: final results.

BACKGROUND: Electrical impedance scanning (EIS) identifies tissue impedance changes associated with malignancy. Methods to distinguish benign from malignant thyroid nodules, particularly in patients with indeterminate cytology are lacking. PURPOSE: To determine the diagnostic accuracy of EIS in the preoperative evaluation of thyroid nodules. PATIENTS AND METHODS: From September 2002 to December 2006, 216 patients underwent thyroid fine needle aspiration (FNA) and EIS prethyroidectomy in this prospective cohort study. EIS, either positive or negative for malignancy, was correlated with final histopathology. A focal bright spot over a thyroid nodule correlating with increased conductivity and/or capacitance >25% baseline sternocleidomastoid muscle impedance defined positive EIS. Study endpoints were EIS accuracy, sensitivity (Sn), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV). This study has been registered in the National Institutes of Health's public trials registry at ClinicalTrials.gov. The registration number is NCT00571077. RESULTS: EIS correctly diagnosed 96 of 110 patients with malignant and 75 of 106 patients with benign dominant thyroid nodules: Sn = 87%, Sp = 71%, PPV = 76%, NPV = 84%: overall EIS accuracy = 79%. Pretest cancer probability of 51% (110 of 216) increased to 76% (96 of 127) post-EIS, and preoperative use of EIS would result in a significant reduction (71%, 75 of 106) in number of operations performed for benign nodules. EIS performance was similar for 109 patients with indeterminate FNA: Sn = 83%, Sp = 67%, PPV = 61%, NPV = 87%, accuracy = 73%. Pretest probability of cancer increased from 39% (42 of 109) to 61% (35 of 57) post-EIS. The use of EIS would result in a significant reduction (67%, 45 of 67) in the number of purely diagnostic thyroidectomy for indeterminate FNA. CONCLUSION: EIS shows promise in differentiating thyroid nodules. Further EIS hardware and software optimization is warranted to improve upon the already favorable negative predictive value in indeterminate thyroid nodules.

Liver disease secondary to intestinal failure.

IFALD is a common and potentially life-threatening condition for patients with SBS requiring long-term PN. There exists the potential for decreasing its incidence by optimizing the composition and the rate of infusion of parenteral solutions, by advocating a multidisciplinary approach, and by early referral for intestinal-liver transplantation to ensure long-term survival of patients with SBS.

Pathophysiology, epidemiology, classification and treatment options for polycystic liver diseases.

Polycystic liver diseases (PLD) represent a group of genetic disorders in which cysts occur in the liver (autosomal dominant polycystic liver disease) or in combination with cysts in the kidneys (autosomal dominant polycystic kidney disease). Regardless of the genetic mutations, the natural history of these disorders is alike. The natural history of PLD is characterized by a continuous increase in the volume and the number of cysts. Both genders are affected; however, women have a higher prevalence. Most patients with PLD are asymptomatic and can be managed conservatively. Severe symptoms can affect 20% of patients who develop massive hepatomegaly with compression of the surrounding organs. Rrarely, patients with PLD suffer from acute complications caused by the torsion of hepatic cysts, intraluminal cystic hemorrhage and infections. The most common methods for the diagnosis of PLD are cross sectional imaging studies. Abdominal ultrasound and computerized tomography are the two most frequently used investigations. Magnetic resonance imaging is more sensitive and specific, and it is a valuable test for patients with intravenous contrast allergies or renal dysfunction. Different treatment modalities are available to physicians caring for these patients. Medical treatment has been ineffective. Percutaneous sclerotherapy, trans-arterial embolization, cyst fenestration, hepatic resection and liver transplantation are indicated to specific groups of patients and have to be tailored according to the extent of disease. This review outlines the current knowledge of the pathophysiology, clinical course, diagnosis and treatment strategies of PLD.

A rare grade III symptomatic Tsunoda class III left lobe hepatolithiasis in a North American woman.

A 44-year-old Caucasian woman without any identified predisposing factors, presented to her local emergency room with multiple episodes of recurrent ascending cholangitis. She underwent a laparoscopic cholecystectomy several years prior to her admission to the hospital for parenteral antibiotic therapy and she had no personal or family history of hypercholesterolaemia. Transferred to a tertiary hospital for surgical therapy, she underwent a left hepatic resection for a chronically infected left lobe hepatolithiasis (HL) conditioning atrophy of the parenchyma due to obstruction of the biliary tree by multiple large cholesterol stones. HL is a very rare condition in Western countries and its aetiology and predisposing factors are still unclear. We present her symptomatology, diagnostic and therapeutic management and discuss the epidemiology and risk factors of HL, that is, a common condition in South East Asia while exceptional in Caucasian patients who have not travelled in high-prevalence regions.

Benign inflammatory pseudotumour mimicking extrahepatic bile duct cholangiocarcinoma in an adult man presenting with painless obstructive jaundice.

Inflammatory pseudotumours (IPTs) of the biliary tract are extremely rare and heterogeneous by aetiology and clinical presentation. They might cause biliary obstruction and mimic cholangiocarcinomas and their final diagnosis is usually achieved only after surgical excision. The most characteristic feature of IPT is the presence of chronic inflammatory cell infiltrates with variable degree of proliferating fibrous tissue. IPTs have the potential for recurrence even after resection and if untreated they can grow causing a variety of symptoms due to compression of the surrounding structures and organs. Despite the significant improvement of modern imaging techniques, preoperative distinction between IPTs of the biliary system and malignancies is extremely difficult. Histological diagnosis poses a clinical challenge because sampling is often suboptimal. Although rare, IPTs should be in the differential diagnosis of patients who present with painless jaundice and no other clinical symptoms or signs characteristics of cholangiocarcinomas.

Liver abscess caused by toothpick and treated by laparoscopic left hepatic resection: case report and literature review.

Hepatic abscesses caused by ingested foreign bodies have been reported in the medical literature but represent very uncommon events. Extra-luminal migration of sawing needles and pins is the most common cause of perforation of the gastrointestinal tract associated with liver infections. Other non-metallic sharp objects such as animal bones and toothpicks have been described but are less frequent. The authors present a case of a 45-year-old woman who suffered from sepsis and a liver abscess because of the migration of a toothpick that lodged in the left hepatic lobe. Review of the literature on the pathogenesis and clinical management of liver abscesses caused by ingested foreign is presented.

Application of a novel severity grading system for surgical complications after colorectal resection.

BACKGROUND: Uniform and accurate reporting of surgical complications is the basis for quality control. We developed a computerized system for reporting and grading surgical complications in colorectal surgery. This study was conducted to evaluate this computerized reporting system. STUDY DESIGN: A retrospective chart review was conducted of all surgical complications in patients who underwent resection of the colon or rectum at our institution between the years 1999 and 2004 (n = 408). All complications were recorded using the computerized reporting system and compared with complications reported in the literature. RESULTS: Elective operations were performed in 75.7% of patients, and 24.3% required emergency operations. Of the 408 patients in the study, 239 (58.6%) had an uneventful recovery without complications. At least 1 complication was recorded in 169 (41.4%) patients. Grades 1 and 2 complications were recorded in 83 (20.3%) and 105 (25.7%) patients, respectively, requiring observation or medical treatment only, and 59 patients (14.5%) had grades 3 to 5 complications. The three leading complications were surgical site infection, intraabdominal abscess, and hemorrhage requiring blood transfusion. The grades 3 to 5 complication rate was within the range described in the literature, and the rate of grades 1 and 2 complications was substantially higher. These grades 1 and 2 complications were associated with a substantially longer hospital stay. CONCLUSIONS: This novel complication reporting system was found feasible and proved to have a higher sensitivity for recording minor but meaningful complications that tend to prolong hospital stay.

Expression of P53, P27 and KI-67 in colorectal cancer patients of various ethnic origins: clinical and tissue microarray based analysis.

BACKGROUND: This study was conducted to determine survival according to the expression of molecular markers in colorectal cancer (CRC) patients of various ethnic origins. METHODS: Resection of primary tumor was conducted on 171 patients with CRC. Corresponding archived paraffin-embedded blocks were retrieved and tissue microarray (TMA) constructed. Immunohistochemical staining of the TMA for p53, p27 and Ki-67 was quantified by two independent pathologists. Survival was analyzed using the Kaplan-Meier product limit method. RESULTS: With a median follow-up of 65 months, 56 patients (32.7%) died of disease. AJCC stage correlated with disease-free (DFS, P < 0.0001) and overall survival (OS, P < 0.0001). IHC staining was positive for Ki-67 in 77.4%, p53 in 55.8% and p27 in 54.2% of patients. Primary tumor marker expression did not correlate with DFS or OS. The 5-year DFS for Ashkenazi Jews was 75%, significantly higher than Sephardic Jews (SJ) 64% and Palestinian Arabs (PA) 38%, P = 0.001. CONCLUSIONS: Ethnicity among Ashkenazi and SJ and PA appears to have a significant impact on disease outcome in patients with CRC patients, while primary tumor expression of p53, p27 and Ki-67 was unrelated to disease outcome.