Perioperative and oncological outcomes of abdominoperineal resection in the prone position vs the classic lithotomy position: A systematic review with meta-analysis.

BACKGROUND AND OBJECTIVES: This study is a systematic review with meta-analysis designed to compare the perioperative and oncological outcomes of the abdominoperineal resection (APR) carried out in the prone jack-knife position (P-APR) vs the classic lithotomy position (C-APR). METHODS: We conducted an electronic search through PubMed utilizing the PRISMA guidelines. We included all randomized and nonrandomized studies which allowed for comparative analysis between the two groups. Research that focused on and analyzed the extralevator abdominal excision were excluded. Pooled variables and number of events were analyzed using the random-effect model. RESULTS: The final analysis included seven nonrandomized retrospective cohorts encompassing 1663 patients. P-APR was associated with decreased operative time (OT) (DM, -43.8 minutes; P < 0.01) and estimated blood loss (EBL) (DM, 86.9 mL; P < 0.01). There were no observed differences regarding perineal wound infections (PWI) (odds ratio [OR], 0.36; P = 0.18), intraoperative perforation of rectum (IOP) (OR, 0.98; P = 0.97), circumferential resection margin (CRM) positivity (OR, 1.02; P = 0.98) or 5-year LR (OR, 1.00; P = 0.99). CONCLUSION: The prone approach for APR is associated with decreased EBL and OT, although not with any change in the incidence of PWI or IOP. Moreover, surgical positioning per se does not appear to affect the CRM positivity rates or LR rate.

Impact of medical or surgical admission on outcomes of patients with acute cholecystitis.

BACKGROUND: Although acute cholecystitis (AC) is a surgical disease, patients with the condition may be admitted to medical-related services (MS). This may lead to delayed cholecystectomy thereby affecting outcomes and quality of care. METHODS: Between July 2010 and March 2013, 329 patients under 70 years old presented to a community-based tertiary care hospital with AC and underwent same admission cholecystectomy. Outcomes were compared between patients admitted to MS and surgical services (SS). RESULTS: Two hundred fifteen patients (65.3%) were admitted to a MS. Patients under the MS had longer LOS (3.0 days vs. 2.0 days, p < 0.001), waiting time to surgical consultation (7.3 h vs. 5.0 h, p < 0.001) and to cholecystectomy (1.0, 0-2 days vs. 1.0, 0-1 day, p < 0.001), and increased hospital costs ($3685 vs. $4,688, p < 0.001) compared to the SS. Readmission and mortality rates were not significantly different between groups. CONCLUSION: Patients under 70 years old with AC undergoing cholecystectomy admitted to MS had increased LOS, delay to the operation, and hospital costs compared to those admitted to a SS. Admission of patients with AC to a SS needs to be emphasized to reduce costs and improve quality of care.

Optimal Surgical Management for Occult Breast Carcinoma: A Meta-analysis.

BACKGROUND: Occult breast cancer (OBC) represents a rare clinical entity and poses a therapeutic dilemma. Due to limited experience, no optimal treatment approaches have yet been established. METHODS: A meta-analysis was performed using MEDLINE and EMBASE databases to identify all studies investigating the surgical options for OBC: (1) axillary lymph node dissection (ALND) with radiotherapy (XRT); (2) ALND with mastectomy; and (3) ALND alone. Comparative studies including nonoperative management (observation or XRT alone) were excluded. The primary endpoints were locoregional recurrence, distant metastasis, and mortality rates. RESULTS: The literature search yielded 42 publications. Seven studies met the inclusion criteria comprising 241 patients. Among these patients, 94 (39 %) underwent ALND with XRT, 112 (46.5 %) underwent mastectomy, and 35 (14.5 %) underwent ALND alone. Mean follow-up was 61.8 ± 16.2 months (range 5-396 months). Locoregional recurrence (12.7 vs. 9.8 %), distant metastasis (7.2 vs. 12.7 %), and mortality rates (9.5 vs. 17.9 %) were similar between ALND with XRT and mastectomy. ALND with XRT was superior to ALND alone regarding locoregional recurrence (12.7 vs. 34.3 %, p < 0.01) and there was a trend toward improved mortality rates (9.5 vs. 31.4 %, p = 0.09). CONCLUSIONS: There was no difference in survival outcomes between mastectomy and ALND with XRT of patients with OBC. Radiotherapy improves locoregional recurrence and, possibly mortality rates of patients undergoing ALND. Based on this meta-analysis, combined ALND and radiation therapy may appear as the optimal surgical approach in these patients.

Vascular Reconstruction Is Not Warranted in Most Civilian Traumatic Shank Vascular Injuries.

BACKGROUND: Operative management of traumatic shank vascular injuries (SVI) evolved significantly in the past few decades, thereby leading to a dramatic decrease in amputation rates. However, there is still controversy regarding the minimum number of patent shank arteries sufficient for limb salvage. METHODS: Between January 2006 and September 2011, 191 adult trauma patients presented to an urban level I trauma center in Miami, Florida, with traumatic lower extremity vascular injuries. Variables collected included age, gender, mechanism of injury, and clinical status at presentation. Surgical data included vessel injury, technical aspects of repair, associated complications, and outcomes. RESULTS: A total of 48 (25.1%) patients were identified comprising 66 traumatic shank arterial injuries. Mean age was 38.2 ± 13.4 years, and the majority of patients were men (40 patients, 83.3%) presenting with blunt injuries (35 patients, 72.9%). Ligation was performed in 38 injured arteries (57.6%) and no vascular intervention was required in 20% of the patients. Vascular reconstruction was performed in only 6 patients (9.1%): 4 (6.1%) with concurrent popliteal trauma, 1 (1.5%) isolated anterior tibial, and 1 (1.5%) 3-vessel injury. Autogenous venous interposition conduit and polytetrafluoroethylene grafting were performed in 5 (7.6%) and 1 (1.5%) patient, respectively. All amputations (8 patients, 16.7%) occurred in blunt trauma patients presenting with unsalvageable limbs. The overall mortality rate in this series was 2.1%. CONCLUSIONS: Civilian shank arterial injuries are associated with acceptable rates of limb loss. Patients with a single-vessel patent inflow did not require vascular reconstruction in this series. Arterial reconstruction may no longer be determinant for successful management of isolated and double arterial SVI, whereas it is yet essential in the presence of 3-vessel or concurrent above-the-knee vascular injuries. Further investigation including larger number of patients is still warranted to define the role of conservative management in these complex injuries.

Repair of an acute blunt popliteal artery trauma via endovascular approach.

Popliteal vascular trauma remains a challenging entity and carries the greatest risk of limb loss among the lower extremity vascular injuries. Operative management of patients presenting with traumatic popliteal vascular injuries continues to evolve. We present a case of successful endovascular repair with stent grafting of an acute blunt popliteal artery injury. Endovascular repair of traumatic popliteal vascular injuries appears as an attractive alternative to surgical repair in a very selective group of patients. Further investigation is still needed to define the safety and feasibility of endovascular approach in the management of traumatic popliteal vascular injuries.

The role of MR cholangiopancreatography in preoperative assessment for repair of major iatrogenic biliary injury: 10-year experience.

BACKGROUND/AIMS: Major iatrogenic biliary injury is a potentially life-threatening complication after laparoscopic cholecystectomy. Early diagnosis is essential to improve outcomes, however, to date, there is no consensus regarding the best imaging approach for preoperative assessment of these injuries. METHODOLOGY: From March 2002 to February 2012, 40 patients with postoperative major biliary injury underwent biliary reconstruction at our Institution. Mean age was 51.7 ± 18.1 years (19-86) with 30 (75%) females. Magnetic resonance cholangiopancreatography (MRCP) were compared with different diagnostic modalities and definitive intraoperative findings. RESULTS: Of 40 patients, 10 (25%) had Bismuth type I, 10 (25%) Bismuth type II, 6 (15%) Bismuth type III injury, 10 (25%) Bismuth type IV and, 4 (10%) Bismuth type V. MRCP has similar accuracy to define injury site, but is superior in delineating proximal ductal anatomy that was often not visualized with endoscopic retrograde cholangiopancreatography (ERCP). CONCLUSION: MRCP is a reliable, accurate and readily available diagnostic tool to assess complex biliary injuries. It provides adequate visualization of the proximal and distal biliary trees and may be considered as first-line test in the management of major iatrogenic biliary injuries. Revision of current guidelines for diagnostic approach of this condition is warranted.

Replacement of infected aortic prosthetic graft with aortic homograft after heart transplantation: 13-year follow-up.

Acute ascending aortic dissection (AAAD) is a rare complication after orthotopic heart transplantation. We report a patient with AAAD after heart transplantation in whom repair was complicated by infection of the ascending aortic prosthetic graft. This was successfully managed by re-do replacement with two cryopreserved aortic homografts. Despite extensive calcification in the wall, the homografts show no aneurysm or dilation after 10 years.

Robotic removal of eroded vaginal mesh into the bladder.

Vaginal mesh erosion into the bladder after midurethral sling procedure or cystocele repair is uncommon, with only a few cases having been reported in the literature. The ideal surgical management is still controversial. Current options for removal of eroded mesh include: endoscopic, transvaginal or abdominal (either open or laparoscopic) approaches. We, herein, present the first case of robotic removal of a large eroded vaginal mesh into the bladder and discuss potential benefits and limitations of the technique.

Biliary-colonic fistula caused by cholecystectomy bile duct injury.

Biliary-colonic fistula is a rare complication after laparoscopic cholecystectomy. We present a case of post-cholecystectomy iatrogenic biliary injury that resulted in a fistula between the common hepatic duct and large bowel. Magnetic resonance cholangiopancreatography provided good visualization of injury even with concurrent normal level of alkaline phosphatase. Radiologic findings and surgical management of this condition are discussed in detail.

Unexpected persistent left superior vena cava and absent right superior vena cava in situs solitus patient.

We, herein, report a patient with persistent left superior vena cava with enlarged coronary sinus and absent right superior vena cava. This anomaly, diagnosed intraoperatively during the third open-heart surgery in the course of transesophageal echocardiography examination, was not mentioned during the patient's previous two cardiac operations. Challenges in intraoperative management and implications for subsequent treatments are discussed.

Beating heart valve surgery in patients with low left ventricular ejection fraction.

BACKGROUND: Patients with very low left ventricular ejection fraction (LVEF) are at high risk for valve surgery. We herein present our experience with beating heart valve surgery in such patients. METHODS: From May 2000 to October 2006, 346 consecutive patients underwent beating heart valve surgery. Of these, 50 patients had LVEF <30%: 7 had LVEF 21 to 29%, 34 had LVEF <20%, and 9 had LVEF <10%. Mean age was 57.44 +/- 12.45 years (range 28 to 85 years). There were 40 males (80%) and 10 females (20%). RESULTS: Isolated mitral valve (MV) and aortic valve replacements were performed in 11 (22%) and 10 (20%) of patients, respectively. Fourteen (28%) patients underwent combined coronary artery bypass grafting and valve replacements. MV repairs were performed; 13 (26%) patients and 2 (4%) patients had combined MV replacements and tricuspid repairs. Mean hospital stay was 15.37 +/- 13.12 days (range 3 to 55 days). Overall early mortality (<30 days) was 6% (three patients) and one patient (2%) died late (>30 days). CONCLUSIONS: Beating heart valve surgery in patients with poor LVEF yields results similar to conventional surgery using cardioplegia. Additional studies are needed to fully evaluate the potential benefits of this method of myocardial perfusion for this high-risk group of patients.

Pulmonary embolectomy: recommendation for early surgical intervention.

BACKGROUND: Acute pulmonary embolism (PE) is a life-threatening disease which often results in death if not diagnosed early and treated aggressively. Despite all efforts at improving outcomes, there is no consensus on the management of acute severe PE. METHODS: From May 2000 to June 2009, 16 consecutive patients underwent surgical pulmonary embolectomy at our institution. Mean age was 45 +/- 17 years (range, 14 to 76) with nine (56%) males and seven (43%) females. Preoperatively, all cases were classified as massive PE; seven (43%) patients were in hemodynamic collapse and emergently underwent operation while receiving cardiopulmonary resuscitation. RESULTS: There were nine (56%) urgent/emergent and seven (44%) salvage patients undergoing surgical pulmonary embolectomy. Of nine nonsalvage patients, seven (77%) patients presented with moderate to severe right ventricular (RV) dilation/dysfunction. Mean cardiopulmonary bypass time was 43 +/- 41 minutes (range, 9 to 161). Mean follow-up duration was 48 +/- 38 months (range: 0.3 to 109), with seven in-hospital deaths (43%): mortality was 11% (1/9) in emergent operations and 85% (6/7) in salvage operations. CONCLUSIONS: Surgical pulmonary embolectomy should be considered early in the management of hemodynamically stable patients with PE who show evidence of RV dilation and/or failure, as it is associated with satisfactory outcomes. Conversely, pulmonary embolectomy has dismal results under salvage conditions. Revision of current guidelines for the surgical management of this condition may be warranted.

Paradigm change in the management of patients with acute type A aortic dissection who had prior cardiac surgery.

BACKGROUND: Acute type A aortic dissection (ATAAD) is a life-threatening disease entity. Untreated, it usually results in death due to rupture of the proximal aorta into the pericardial cavity, leading to cardiac tamponade. Should patients who have had prior cardiac surgery presenting with ATAAD be treated emergently with surgery, or should they be managed medically? We herein present preliminary evidence that suggests that medical treatment, at least initially, is the best option for these patients. Surgery is indicated in the follow-up, depending on increased size of the dissection or aorta, or to prevent or treat complications. PATIENTS AND METHODS: From January 2004 to November 2009, ten consecutive male patients with prior cardiac surgery were admitted to hospital with the diagnosis of ATAAD. Mean age was 61.90 +/- 14.68 years (range, 36 to 79 years), with nine (90%) males and one (10%) female. All were treated medically as the definitive form of management. RESULTS: Mean follow-up duration was 14.62 +/- 11.12 months (range, 1 to 31 months). Overall mortality during follow-up was 20% (two patients). Eight patients (80%) are alive and well. CONCLUSIONS: This initial experience with a small, consecutive series of patients, suggests that medical treatment is an option in the initial management of patients with ATAAD who had prior cardiac surgery. It appears that emergency surgery is seldom needed. A larger series of patients and longer follow-up period are needed prior to recommending this treatment approach for such patients.

Effects of donor age on patient survival in liver transplantation: short-and long-term analysis.

BACKGROUND/AIMS: This study aim was to investigate an association between donor age and lower recipient survival in liver transplantation. METHODOLOGY: A total of 178 consecutive patients underwent liver transplantation between 1999 and 2007. Among these patients, 172 liver transplants (donor age: 32.04 +/- 16.66) and 167 recipients were included in the analysis. Mean recipient age was 39.16 +/- 21.61 years (range: 6 mo-71 years) and 90 (53.89%) were males. RESULTS: Among 172 transplants, 32.9% recipients died during follow-up. Mean follow-up time was 34.37 +/- 20.50 mo. A lower mean recipient survival prevailed from donors older than 50 years (p = .01) at 7-year patient survival. At 6-month and 1-year recipient survival, cut-offs were 50 and 55 years, respectively (p < .05). A significant difference was observed in graft survival from donors older than 30 years (p = .02) and at 6-month and 1-year, cutoffs were 35 and 50 years, respectively (p < .05). CONCLUSIONS: Although the utilization of donors with increased age in liver transplantation offers a new option to increase the number of liver transplants it presents lower survivals. Other factors related to graft loss such as MELD score > 15 and longer CIT (cold ischemia time) should be avoided to reduce the risk of using elderly donor grafts.

Efficacy, feasibility, and pitfalls of transseptal approach in beating-heart mitral valve surgery.

BACKGROUND: Mitral valve surgery can be performed through the trans-atrial or the trans-septal approach. Although the trans-atrial is the preferred method, the trans-septal approach has also been used recently and has a particular value in beating-heart mitral valve surgery. Herein we report our experience with beating-heart mitral valve surgery via trans-septal approach, and discuss its advantages and pitfalls. METHODS: Between 2000 and 2007, 214 patients underwent mitral valve procedures using the beating-heart surgical approach. RESULTS: One hundred and forty-three patients (66.8%) had mitral valve replacement, 68 patients (31.7%) mitral valve repair, and 82 patients (38.3%) concomitant valve procedures. Coronary artery bypass grafting was simultaneously performed in 30 (14%) patients. Thirty-day mortality was 7.4%, reoperation for bleeding 7%, stroke 0.4%, and myocardial infarction 0.4%, and failed mitral valve repair 0.9%. CONCLUSION: Our experience suggests that beating-heart mitral valve surgery is facilitated by using the trans-septal approach.

Effectiveness and feasibility of robotic gastric neurostimulator placement in patients with refractory gastroparesis.

Gastric neurostimulation (GNS) with Enterra® therapy device (Medtronic, Minneapolis, MN) appears as the last resort for patients with refractory gastroparesis. Currently, the device has Humanitarian Use status by Food and Drug Administration, thereby requiring further investigation. We aim to describe its feasibility and clinical outcomes using robotic technique. From June 2014 to September 2016, 15 consecutive patients underwent robotic insertion of Enterra® device. Patient demographics, comorbidities, and clinical outcomes including mortality, length of stay, readmission rates, reoperation and complications were retrospectively collected. Patients were also assessed based on a validated 14-point questionnaire regarding satisfaction with the operation, quality of life and symptomatic relief. Mean age was 41.6 years ± 13.8 and there were 11 females (73.3%). No mortality was reported. The annual hospital admissions were reduced after GNS (2.5 ± 4.1 vs. 3.6 ± 4.4, p = 0.004). The frequency of bloating (p = 0.029) and severity of emesis (p = 0.038), early satiety (p = 0.042) and bloating (p = 0.031) were reduced after GNS. The severity and frequency total scores were also improved after GNS (12.6 ± 1.4 vs. 18.1 ± 2.7, p = 0.008 and 12.9 ± 2.2 vs. 16.1 ± 1.1, p = 0.016, respectively). This is the first report describing the clinical experience with robotic insertion of GNS device. This approach is safe and feasible and seems to have similar long-term outcomes as laparoscopic technique. Potential advantages to robotic technique include enhanced dexterity and suturing of the device within gastric wall. Further experience with large prospective studies and randomized clinical trials may be warranted.

Assessing surgical residents' imaging interpretation skills.

PURPOSE: During general surgery (GS) training, residents are expected to accurately interpret radiologic images. Objective evidence evaluating residents' ability to provide accurate interpretation of imaging studies is currently lacking. METHODS: A 30-item web-based test was developed using images from different radiologic modalities. Residents from 6 ACGME accredited GS programs participated. Residents from 1 radiology program served as a control group. RESULTS: 74 GS residents (GSR) enrolled in the online test. The mean score for GSR was 75% (±9) and 83% (±6) for RR (p = 0.006). Residents correctly answered 63% x-rays, 74%, CT(head), 84% CT(body), 69% ultrasound, and 88% tube/line localization questions. Senior residents were more proficient than junior residents at interpreting CT (body) and ultrasound images. CONCLUSION: GS residents were able to accurately interpret 75% of basic radiology images. In an effort to improve patient care, programs should consider integrating radiological education during surgical training.

Outcomes of Laparoscopic Hiatal Hernia Repair in Nine Bariatric Patients with Prior Sleeve Gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) may exacerbate gastroesophageal reflux disease (GERD) in patients with a hiatal hernia (HH). Surgical repair may be needed, however prior LSG precludes standard HH repair with fundoplication. METHODS: We retrospectively reviewed our experience with bariatric patients with prior LSG undergoing laparoscopic HH repair from August 2010 to July 2016. Patient demographics and outcomes including mortality, length of stay (LOS), readmission rates, reoperation, and complications were described. A validated 13-point questionnaire was used to determine symptomatic relief, weight loss, and overall satisfaction. RESULTS: A total of nine consecutive patients with prior LSG underwent HH repair and were included in the analysis. Repair was performed using Bio-A Gore® mesh (W.L Gore Inc., Newark, DE) in six (66.7%) cases and posterior cruroplasty in three (33.3%) patients. Heartburn was significantly decreased at 1 year (1.4 ± 0.9 vs. 2.6 ± 0.9, p = 0.031), and 78% of patients reported some degree of symptomatic relief after HH repair. CONCLUSIONS: Laparoscopic HH repair offers a safe and feasible approach in the management of persistent GERD after LSG in well-selected bariatric patients. Larger prospective studies are warranted to investigate the effectiveness of HH repair in this population as 22% of our patients did not demonstrate postoperative symptomatic improvement.