Development and internal validation of a clinical prediction model for serious complications after emergency laparotomy.

PURPOSE: Emergency laparotomy (EL) is a common operation with high risk for postoperative complications, thereby requiring accurate risk stratification to manage vulnerable patients optimally. We developed and internally validated a predictive model of serious complications after EL. METHODS: Data for eleven carefully selected candidate predictors of 30-day postoperative complications (Clavien-Dindo grade > = 3) were extracted from the HELAS cohort of EL patients in 11 centres in Greece and Cyprus. Logistic regression with Least Absolute Shrinkage and Selection Operator (LASSO) was applied for model development. Discrimination and calibration measures were estimated and clinical utility was explored with decision curve analysis (DCA). Reproducibility and heterogeneity were examined with Bootstrap-based internal validation and Internal-External Cross-Validation. The American College of Surgeons National Surgical Quality Improvement Program's (ACS-NSQIP) model was applied to the same cohort to establish a benchmark for the new model. RESULTS: From data on 633 eligible patients (175 complication events), the SErious complications After Laparotomy (SEAL) model was developed with 6 predictors (preoperative albumin, blood urea nitrogen, American Society of Anaesthesiology score, sepsis or septic shock, dependent functional status, and ascites). SEAL had good discriminative ability (optimism-corrected c-statistic: 0.80, 95% confidence interval [CI] 0.79-0.81), calibration (optimism-corrected calibration slope: 1.01, 95% CI 0.99-1.03) and overall fit (scaled Brier score: 25.1%, 95% CI 24.1-26.1%). SEAL compared favourably with ACS-NSQIP in all metrics, including DCA across multiple risk thresholds. CONCLUSION: SEAL is a simple and promising model for individualized risk predictions of serious complications after EL. Future external validations should appraise SEAL's transportability across diverse settings.

Artificial Intelligence in Surgical Risk Prediction.

Risk prediction and stratification of short-term and long-term postoperative outcomes are growing in importance and scope of application in everyday clinical practice [...].

Does the Routine Skin-Only Closure in Ruptured Abdominal Aortic Aneurysm Repair Safely Diminish Abdominal Compartment Syndrome? A Hypothesis Generating Retrospective Study.

BACKGROUND: Abdominal compartment syndrome (ACS) often complicates ruptured abdominal aortic aneurysm (rAAA) repair. We report results with routine skin-only abdominal wound closure after rAAA surgical repair. METHODS: This was a single-center retrospective study including consecutive patients undergoing rAAA surgical repair for the duration of 7 years. Skin-only closure was routinely performed, and if possible, secondary abdominal closure was performed during the same admission. Demographic information, preoperative hemodynamic condition, and perioperative information (ACS, mortality, rate of abdominal closure, and postoperative outcomes) were collected. RESULTS: During the study period, 93 rAAAs were recorded. Ten patients were too frail to undergo repair or refused treatment. Eighty-three patients underwent immediate surgical repair. The mean age was 72.4 ± 10.5 years, and the vast majority were male (82:1). Preoperative systolic blood pressure <90 mm Hg was recorded in 31 patients. Intraoperative mortality was recorded in nine cases. Overall in-hospital mortality was 34.9% (29/83). Primary fascial closure was performed in five patients, while skin-only closure was performed in 69. ACS was recorded in two cases in whom skin sutures were removed and negative pressure wound treatment was applied. Secondary fascial closure was feasible in 30 patients during the same admission. Among 37 patients not undergoing fascial closure, 18 died and 19 survived and were discharged with a planned ventral hernia repair. Median length of intensive care unit and hospital stay were 5 (1-24) and 13 (8-35) days, respectively. After a mean follow-up of 21 months, telephone contact was possible with 14/19 patients who left the hospital with an abdominal hernia. Three reported hernia-related complications mandating surgical repair, while in 11, this was well tolerated. CONCLUSION: Routine skin-only closure during rAAA surgical repair results in low rates of ACS at the expense of a high rate of patients being discharged with a planned ventral hernia which, however, seems to be well tolerated by the majority of patients.

Role of Lactiplantibacillus plantarum UBLP-40, Lactobacillus rhamnosus UBLR-58 and Bifidobacterium longum UBBL-64 in the Wound Healing Process of the Excisional Skin.

The probiotics Lactiplantibacillus plantarum UBLP-40, Lactobacillus rhamnosus UBLR-58 and Bifidobacterium longum UBBL-64 seem to promote wound healing when applied topically. Our aim was to investigate their effect on the mRNA expression of pro-inflammatory, healing and angiogenetic factors during the healing process of a standardized excisional wound model in rats. Rats subjected to six dorsal skin wounds were allocated to Control; L. plantarum; combined formula of L. rhamnosus plus B. longum; L. rhamnosus; and B. longum treatments, applied every two days, along with tissue collection. The pro-inflammatory, wound-healing, and angiogenetic factors of mRNA expression were assessed by qRT-PCR. We found that L. plantarum exerts a strong anti-inflammatory effect in relation to L. rhamnosus-B. longum, given alone or in combination; the combined regime of L. rhamnosus-B. longum, works better, greatly promoting the expression of healing and angiogenic factors than L. plantarum. When separately tested, L. rhamnosus was found to work better than B. longum in promoting the expression of healing factors, while B. longum seems stronger than L. rhamnosus in the expression of angiogenic factors. We, therefore, suggest that an ideal probiotic treatment should definitively contain more than one probiotic strain to speed up all three healing phases.

Prospective multicenter external validation of postoperative mortality prediction tools in patients undergoing emergency laparotomy.

BACKGROUND: Accurate preoperative risk assessment in emergency laparotomy (EL) is valuable for informed decision making and rational use of resources. Available risk prediction tools have not been validated adequately across diverse health care settings. Herein, we report a comparative external validation of four widely cited prognostic models. METHODS: A multicenter cohort was prospectively composed of consecutive patients undergoing EL in 11 Greek hospitals from January 2020 to May 2021 using the National Emergency Laparotomy Audit (NELA) inclusion criteria. Thirty-day mortality risk predictions were calculated using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), NELA, Portsmouth Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (P-POSSUM), and Predictive Optimal Trees in Emergency Surgery Risk tools. Surgeons' assessment of postoperative mortality using predefined cutoffs was recorded, and a surgeon-adjusted ACS-NSQIP prediction was calculated when the original model's prediction was relatively low. Predictive performances were compared using scaled Brier scores, discrimination and calibration measures and plots, and decision curve analysis. Heterogeneity across hospitals was assessed by random-effects meta-analysis. RESULTS: A total of 631 patients were included, and 30-day mortality was 16.3%. The ACS-NSQIP and its surgeon-adjusted version had the highest scaled Brier scores. All models presented high discriminative ability, with concordance statistics ranging from 0.79 for P-POSSUM to 0.85 for NELA. However, except the surgeon-adjusted ACS-NSQIP (Hosmer-Lemeshow test, p = 0.742), all other models were poorly calibrated ( p < 0.001). Decision curve analysis revealed superior clinical utility of the ACS-NSQIP. Following recalibrations, predictive accuracy improved for all models, but ACS-NSQIP retained the lead. Between-hospital heterogeneity was minimum for the ACS-NSQIP model and maximum for P-POSSUM. CONCLUSION: The ACS-NSQIP tool was most accurate for mortality predictions after EL in a broad external validation cohort, demonstrating utility for facilitating preoperative risk management in the Greek health care system. Subjective surgeon assessments of patient prognosis may optimize ACS-NSQIP predictions. LEVEL OF EVIDENCE: Diagnostic Test/Criteria; Level II.

The Hellenic Emergency Laparotomy Study (HELAS): A Prospective Multicentre Study on the Outcomes of Emergency Laparotomy in Greece.

BACKGROUND: Emergency laparotomy (EL) is accompanied by high post-operative morbidity and mortality which varies significantly between countries and populations. The aim of this study is to report outcomes of emergency laparotomy in Greece and to compare them with the results of the National Emergency Laparotomy Audit (NELA). METHODS: This is a multicentre prospective cohort study undertaken between 01.2019 and 05.2020 including consecutive patients subjected to EL in 11 Greek hospitals. EL was defined according to NELA criteria. Demographics, clinical variables, and post-operative outcomes were prospectively registered in an online database. Multivariable logistic regression analysis was used to identify independent predictors of post-operative mortality. RESULTS: There were 633 patients, 53.9% males, ASA class III/IV 43.6%, older than 65 years 58.6%. The most common operations were small bowel resection (20.5%), peptic ulcer repair (12.0%), adhesiolysis (11.8%) and Hartmann's procedure (11.5%). 30-day post-operative mortality reached 16.3% and serious complications occurred in 10.9%. Factors associated with post-operative mortality were increasing age and ASA class, dependent functional status, ascites, severe sepsis, septic shock, and diabetes. HELAS cohort showed similarities with NELA patients in terms of demographics and preoperative risk. Post-operative utilisation of ICU was significantly lower in the Greek cohort (25.8% vs 56.8%) whereas 30-day post-operative mortality was significantly higher (16.3% vs 8.7%). CONCLUSION: In this study, Greek patients experienced markedly worse mortality after emergency laparotomy compared with their British counterparts. This can be at least partly explained by underutilisation of critical care by surgical patients who are at high risk for death.

Correction: Daskalaki et al. Early Postoperative Parathormone and Calcium as Prognostic Factors for Postoperative Hypocalcemia. J. Clin. Med. 2022, 11, 2389.

In the published article [...].

External Validation of the American College of Surgeons Surgical Risk Calculator in Elderly Patients Undergoing General Surgery Operations.

Preoperative risk stratification in the elderly surgical patient is an essential part of contemporary perioperative care and can be done with the use of the American College of Surgeons Surgical Risk Calculator (ACS-SRC). However, data on the generalizability of the ACS-SRC in the elderly is scarce. In this study, we report an external validation of the ACS-RC in a geriatric cohort. A retrospective analysis of a prospectively maintained database was performed including patients aged > 65 who underwent general surgery procedures during 2012−2017 in a Greek academic centre. The predictive ability of the ACS-SRC for post-operative outcomes was tested with the use of Brier scores, discrimination, and calibration metrics. 471 patients were included in the analysis. 30-day postoperative mortality was 3.2%. Overall, Brier scores were lower than cut-off values for almost all outcomes. Discrimination was good for serious complications (c-statistic: 0.816; 95% CI: 0.762−0.869) and death (c-statistic: 0.824; 95% CI: 0.719−0.929). The Hosmer-Lemeshow test showed good calibration for all outcomes examined. Predicted and observed length of stay (LOS) presented significant differences for emergency and for elective cases. The ACS-SRC demonstrated good predictive performance in our sample and can aid preoperative estimation of multiple outcomes except for the prediction of post-operative LOS.

Advances in Perioperative Nutrition.

In the modern era of prehabilitation, identifying malnourished surgical patients and optimising their nutritional status is crucial [...].

Early Postoperative Parathormone and Calcium as Prognostic Factors for Postoperative Hypocalcemia.

BACKGROUND: Postoperative hypocalcemia is one of the most common complications after total thyroidectomy. Parathormone (PTH) and calcium levels, measured several hours after surgery, have been suggested as valuable markers for detecting patients at risk for post-thyroidectomy hypocalcemia. We aimed to determine if early post-surgery PTH and calcium levels can be used for the early identification of patients at risk for symptomatic hypocalcemia. METHODS: PTH and calcium were measured before surgery and at 10 min and 4 h post-thyroidectomy, in 77 patients. Performance characteristics of PTH and calcium levels and their post/pre-surgery ratios were calculated. RESULTS: Four-hour calcium was a sensitive (93.75%) but not specific (67.61%) indicator of patients at risk for symptomatic hypocalcemia. The 4-h/pre-surgery PTH ratio was the most accurate (90.81%) and the most specific (94.37%) test to identify patients at risk. Serum calcium at 4-h, 4-h/pre-surgery PTH ratio, and PTH at 10 min post-surgery had the higher diagnostic odds ratios (50.86, 32.85, and 29.04, respectively). The 4-h/pre-surgery PTH ratio also had the highest (0.694) Youden's J statistic. CONCLUSIONS: Low serum calcium levels 4 h after thyroidectomy and the 4-h/pre-surgery PTH ratio could be valuable additions to everyday clinical practice in post-thyroidectomy patients.

Complications of modern pancreaticoduodenectomy: A systematic review and meta-analysis.

BACKGROUND: In the past decades, the perioperative management of patients undergoing pancreaticoduodenectomy (PD) has undergone major changes worldwide. This review aimed to systematically determine the burden of complications of PD performed in the last 10 years. DATA SOURCES: A systematic review was conducted in PubMed for randomized controlled trials and observational studies reporting postoperative complications in at least 100 PDs from January 2010 to April 2020. Risk of bias was assessed using the Cochrane RoB2 tool for randomized studies and the methodological index for non-randomized studies (MINORS). Pooled complication rates were estimated using random-effects meta-analysis. Heterogeneity was investigated by subgroup analysis and meta-regression. RESULTS: A total of 20 randomized and 49 observational studies reporting 63 229 PDs were reviewed. Mean MINORS score showed a high risk of bias in non-randomized studies, while one quarter of the randomized studies were assessed to have high risk of bias. Pooled incidences of 30-day mortality, overall complications and serious complications were 1.7% (95% CI: 0.9%-2.9%; I2 = 95.4%), 54.7% (95% CI: 46.4%-62.8%; I2 = 99.4%) and 25.5% (95% CI: 21.8%-29.4%; I2= 92.9%), respectively. Clinically-relevant postoperative pancreatic fistula risk was 14.3% (95% CI: 12.4%-16.3%; I2 = 92.0%) and mean length of stay was 14.8 days (95% CI: 13.6-16.1; I2 = 99.3%). Meta-regression partially attributed the observed heterogeneity to the country of origin of the study, the study design and the American Society of Anesthesiologists class. CONCLUSIONS: Pooled complication rates estimated in this study may be used to counsel patients scheduled to undergo a PD and to set benchmarks against which centers can audit their practice. However, cautious interpretation is necessary due to substantial heterogeneity.

Prolonged complete atrioventricular block due to neostigmine and amiodarone interaction in an amyloidosis patient with left main dissection and postoperative intestinal pseudo-obstruction.

Cardiac amyloidosis has been strongly associated with postoperative intractable circulatory failure, and intestinal amyloidosis could lead to intestinal pseudo-obstruction. The latter can be treated with neostigmine, which is notorious for its brief bradyarrhythmic complications. The amyloidosis patient presented herein, suffered an iatrogenic left main dissection, failure of bailout stenting and finally underwent urgent surgery. Meticulous fluid and drug management was key to keeping this patient stable. Postoperative atrial fibrillation was treated with amiodarone. The postoperative course was complicated with intestinal pseudo-obstruction, which was ultimately resolved with neostigmine. This short-lived cholinesterase inhibitor interacted with amiodarone and caused a previously undocumented prolonged complete atrioventricular block that resolved 48 hours after both drugs' discontinuation. The neostigmine amiodarone interaction warrants clinical vigilance and is speculated to be due to their partially shared second messenger pathway involving cyclic adenosine monophosphate. Patients with cardiac amyloidosis could maintain hemodynamic stability perioperatively.

A Comparison of the Malnutrition Universal Screening Tool (MUST) and the Mini Nutritional Assessment-Short Form (MNA-SF) Tool for Older Patients Undergoing General Surgery.

The optimal malnutrition screening tool in geriatric surgery has yet to be determined. Herein, we compare two main tools in older patients undergoing general surgery operations. Older patients (>65 years old) who underwent general surgery operations between 2012 and 2017 in a tertiary centre were included. The Malnutrition Universal Screening Tool (MUST) and the Mini Nutritional Assessment Short Form (MNA-SF) were used for nutritional risk assessment. Preoperative variables as well as postoperative outcomes were recorded prospectively. Agreement between tools was determined with the weighted kappa (κ) statistic. Multiple regression analysis was used to assess the association of the screening tools with postoperative outcomes. A total of 302 patients (median age 74 years, range: 65-92) were included. A similar number of patients were classified as medium/high risk for malnutrition with the MNA-SF and MUST (26% vs. 36%, p = 0.126). Agreement between the two tools was moderate (weighted κ: 0.474; 95%CI: 0.381-0.568). In the multivariate analysis, MNA-SF was associated significantly with postoperative mortality (p = 0.038) and with postoperative length of stay (p = 0.001). MUST was associated with postoperative length of stay (p = 0.048). The MNA-SF seems to be more consistently associated with postoperative outcomes in elderly patients undergoing general surgery compared with the MUST tool.

Primary Repair of Traumatic Complete Pancreatic Rupture.

Isolated pancreatic injury with transection of the pancreatic duct is generally treated with pancreatic resection, but the optimal management is not based on high-level evidence. Herein, we report a case of primary repair of complete rupture of the pancreas and pancreatic duct after a blunt abdominal trauma and a review of the literature. A 33-year-old patient had an isolated pancreatic injury after blunt abdominal trauma. At laparotomy, an even transection was found with minimal necrosis and tissue loss and an end-to-end anastomosis of the duct and the parenchyma with omental patch was performed. Patient's postoperative course was complicated by a 6 cm pseudocyst and a low output pancreatic fistula which did not require any intervention and were self-limited. In the literature, 17 cases with primary repair of similar grade IV pancreatic injuries have been reported. Postoperative complications included mostly fistulas and pseudocysts.

Factors Associated with Malnutrition and Its Impact on Postoperative Outcomes in Older Patients.

Malnutrition is associated with dismal treatment outcomes in older patients but its impact in geriatric surgery has not been studied extensively. Herein, we report the prevalence of malnutrition risk, its risk factors and its association with postoperative outcomes in older patients undergoing operations of general surgery. This is a retrospective analysis of a prospectively maintained database including patients older than 65 years who were to undergo general surgery operations between 2012 and 2017. The Malnutrition Universal Screening Tool (MUST) was used for nutritional risk. Demographics, socioeconomic data, site and magnitude of the operation, various measures of comorbidity and functional dependence as well as postoperative complications based on Clavien-Dindo classification and length of stay were recorded. There were 501 patients. A total of 28.6% of them were at intermediate malnutrition risk (MUST = 1) and 14.6% were at high malnutrition risk (MUST ≥ 2). Variables independently associated with malnutrition risk (MUST ≥ 1) were smoking (Odds Ratio, OR:1.6, p = 0.041), upper gastrointestinal (GI) tract surgery (OR:20.4, p < 0.001), hepatobiliary-pancreatic surgery (OR:3.7, p = 0.001), lower GI surgery (OR:5.2, p < 0.001) and American Society of Anesthesiologists (ASA) class III/IV (OR:2.8, p = 0.001). In the multiple regression analysis adjusted for several confounding variables, the MUST score was significantly associated with postoperative death (OR:9.1, p = 0.047 for MUST = 1 and OR:11.9, p = 0.035 for MUST score ≥ 2) and postoperative hospital stay (adjusted incidence rate ratio, 1.3, p = 0.041 for MUST = 1 and 1.7, p < 0.001 for MUST ≥ 2). Malnutrition risk was highly prevalent in this sample, particularly in patients with operations of the gastrointestinal tract, in patients with poor physical status and it was associated with postoperative mortality and length of stay.

A Prospective Study of Intraarterial Infusion Chemotherapy in Advanced Wild-Type BRAF Melanoma Patients.

BACKGROUND: Treatment strategies for advanced cutaneous melanoma (CM) patients, resistant or not treatable with novel target and immunotherapeutic drugs, remain a significant challenge, particularly for patients with unresectable stage IIIC/D disease localized to inferior limbs and pelvis, for whom specific outcomes are rarely considered. MATERIALS AND METHODS: This is a prospective study of multidisciplinary treatments, including locoregional melphalan chemotherapy, in 62 BRAF wild-type CM patients with locoregional metastases in the inferior limbs and pelvis, including inguinal regions. Patients were either in progression following or ineligible for, or not treatable with novel immunotherapy. For exclusively inferior limb-localised disease, patients received locoregional melphalan chemotherapy performed by hyperthermic isolated limb perfusion (n = 19) or isolated limb infusion (n = 19), and for synchronous lesions localised to inferior limbs and pelvis, received hypoxic pelvic and limb perfusion (n = 24). Additional multidisciplinary therapy included local, locoregional and systemic treatments and the primary endpoint was tumour response. RESULTS: The objective response rate following first cycle of locoregional chemotherapy was 37.1% at 3 mo and median progression-free survival was 4-mo, with 12.9% procedure-related complications, 30.6% low-grade haematological toxicity and 11.3% severe limb toxic tissue reactions. Multivariate logistic regression showed that the odds of response were significantly higher for patients ≤ 75 y of age and for patients with locoregional metastases exclusively located in the inferior limbs. CONCLUSION: In this subgroup of CM patients with BRAF wild-type status, locoregional metastases localized to inferior limbs and pelvis, in progression following or ineligible for immunotherapy, melphalan locoregional chemotherapy demonstrated a safe and effective profile. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT01920516; date of trial registration: August 6, 2013.

Challenging the Contraindications of Minimally Invasive Inguinal Lymph Node Dissection: Report of 2 Cases.

BACKGROUND: Endoscopic inguinal dissection is an emerging procedure utilizing minimally invasive technology to perform inguinal dissections aiming to avoid skin complications. Despite numerous reports there seems to be no consensus on inclusion and exclusion criteria, raising the question of when and when not to choose the minimally invasive technique. We compare the inclusion and exclusion criteria in published literature, and present our experience with 2 challenging cases; 1 with skin infiltration and the other with a previous lymphadenectomy scar. MATERIALS AND METHODS: We present 2 cases where this procedure was performed, despite limited nodal skin infiltration in the first case, and presence of a fresh scar of a previous biopsy and recent history of chemotherapy treatment in the second case. RESULTS: Despite skin infiltration by inguinal nodes, endoscopic inguinal dissection was performed and the attached skin was excised and delivered with the lymph nodes through the incision in the first case. Presence of a fresh scar and history of chemotherapy did not affect the outcomes in the second case, albeit fibrosis and adhesions. CONCLUSIONS: Skin infiltration, previous lymphadenectomy, and previous groin therapy might not represent absolute contraindications in selected cases and in the hands of experienced surgeons.

A feasibility study of circulating melanoma cells in the perioperative context of hyperthermic isolated limb perfusion (HILP) in 20 patients.

INTRODUCTION: Hyperthermic Ιsolated Limb Perfusion using melphalan and TNFα (TM-HILP) is a regional chemotherapy method for advanced melanoma. PURPOSE: To explore the feasibility of the study of Circulating Melanoma Cells (CMCs) in the context of acute physiological changes induced by TM-HILP and their association with oncological outcomes. METHODS: The study included 20 patients undergoing TM-HILP for unresectable in-transit melanoma of the limbs, stage III(B/C/D). CMCs in the peripheral blood were analyzed at 5-time points from the preoperative day until day 7 from surgery using the following biomarkers: MITF, Tyrosinase mRNA, Melan-A and S100b, through quantitative RT-PCR. RESULTS: No CMCs according to Tyrosinase and Melan-A biomarkers were found in any sample. Friedman test showed significant alterations perioperatively for MITF (p < .001) and S100b (p = .001). Pairwise tests showed a significant increase of MITF levels on postoperative day 7 compared with postoperative day 1, intraoperative and preoperative levels (p < .05). Pairwise tests for S100b showed a significant difference between intraoperative sample and postoperative day 7 (p < .0001). Patients who experienced a complete response to TM-HILP (n = 12) had higher mean levels of MITF and the difference was significant at the time point immediately after the operation (0.29 ± 0.27 vs. 0.06 ± 0.06, p = .014) and on postoperative day 1 (1.48 ± 2.24 vs. 0.41 ± 0.65, p = .046). There was no association of MITF or S100b levels with 4-year disease specific survival. CONCLUSION: TM-HILP is associated with increased levels of CMCs, but there was no association of this increase with survival. Patients with complete response to HILP demonstrate higher values of MITF shortly after the operation.