Early Postoperative Vital Signs Predict Subsequent 90-Day Mortality After Pancreaticoduodenectomy.

BACKGROUND: While complication rates after pancreaticoduodenectomy (PD) have improved in recent decades, surgical-related death remains a possibility. Postoperative vital signs offer an untapped opportunity to identify predictors of 90-day mortality. METHODS: We performed a retrospective chart review interrogating postoperative day (POD 0-7) vital sign measurements from patients undergoing a PD at Thomas Jefferson University Hospital, Philadelphia, PA (2009-2014). Five specific vital signs were examined as predictors of mortality: temperature, heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure. Statistical analyses and logic algorithms were employed to rank vital sign parameters, with cut-points, to identify those associated with the highest risk of mortality and the most clinical relevance. RESULTS: In our cohort, 11/750 patients (1.5%) died within 30 days of surgery, and 21/750 patients (2.8%) died within 90 days of surgery. Vital sign perturbations associated with the highest risk of mortality included mean SBP < 95 mmHg on POD 7 (odds ratio 51.46) and the mean temperature < 96.9℉ on POD 3 (odds ratio 22.63) with specificities exceeding 99%. The most clinically relevant predictor (i.e., a higher sensitivity) was DBP < 60.5 mmHg on POD 7 (odds ratio 12.45, sensitivity of 75%). These predictors remained statistically significant in a multivariable model. CONCLUSIONS: Vital signs can be more effectively utilized to predict 90-day mortality after pancreaticoduodenectomy. Values beyond an informative threshold can potentially identify patients for more intensive monitoring with a goal of rescuing patients and preventing death.

Early laparoscopic-assisted surgery is associated with decreased post-operative inflammation and intestinal strictures in infants with necrotizing enterocolitis.

INTRODUCTION: In 2015, a protocol including early laparoscopy-assisted surgery in the treatment of necrotizing enterocolitis (NEC) was implemented at our institution. Carbon dioxide insufflation during laparoscopy may have an anti-inflammatory effect. We aimed to compare post-operative outcome after early laparoscopy-assisted surgery and classical laparotomy for NEC. MATERIAL AND METHODS: Charts of premature infants undergoing surgery for NEC (2012-2021) were reviewed. Cases operated by early laparoscopy-assisted surgery (2015-2021) were compared to infants operated for NEC between 2012 and 2015 (laparotomy-NEC). Outcomes were post-operative CRP, need for reintervention, mortality, and the occurrence of post-NEC intestinal strictures. CRP was measured on the day of surgery (POD-0), 2 days (POD-2), and 7 days after surgery (POD-7). Data were compared using contingency tables for categorical variables and Student t-test or Mann-Whitney test for continuous variables. RESULTS: Infants with NEC operated by early laparoscopy (n = 48) and laparotomy (n = 29) were similar in terms of perforation (60% vs 58%, p = 0.99) and POD-0 CRP (139 vs 124 mg/L, p = 0.94). Delay between first signs of NEC and surgery was shorter in the laparoscopy group (3 vs 6 days, p = 0.004). Early laparoscopy was associated with a lower CRP on POD-2 (108 vs 170, p = 0.005) and POD-7 (37 vs 68, p = 0.002), as well as a lower rate of post-operative intestinal stricture (34% vs 61%, p = 0.04). CONCLUSIONS: In addition to being safe and feasible in premature infants, early laparoscopic-assisted surgery was associated with decreased NEC-related post-operative inflammation and strictures. A prospective, randomized study is needed in order to evaluate short and long-term effects of laparoscopy in infants with NEC. LEVEL OF EVIDENCE: Level III.

Mowat Wilson syndrome and Hirschsprung disease: a retrospective study on functional outcomes.

AIM OF THE STUDY: Mowat Wilson syndrome (MWS) is a complex genetic disorder due to mutation or deletion of the ZEB2 gene (ZFHX1B), including multiple clinical features. Hirschsprung disease is associated with this syndrome with a prevalence between 43 and 57%. The aim of this study was to demonstrate the severe outcomes and the high complication rates in children with MWS, focusing on their complicated follow-up. METHODS: A retrospective comparative study was conducted on patients referred to Robert-Debré Children's Hospital for MWS from 2003 to 2018. Multidisciplinary follow-up was carried out by surgeons, geneticists, gastroenterologists, and neurologists. Data regarding patient characteristics, surgical management, postoperative complications, and functional outcomes were collected. RESULTS: Over this period of 15 years, 23 patients were diagnosed with MWS. Hirschsprung disease was associated with 10 of them (43%). Of these cases, two patients had recto-sigmoïd aganglionosis (20%), three had aganglionic segment extension to the left colic angle (30%), two to the right colic angle (20%), and three to the whole colon (30%). The median follow-up was 8.5 years (2 months-15 years). All patients had seizures and intellectual disability. Six children (60%) presented with cardiac defects. At the last follow-up, three patients still had a stoma diversion and 7 (70%) were fed orally. One patient died during the first months. Eight (80%) of these children required a second surgery due to complications. At the last follow-up, three patients reported episodes of abdominal bloating (42%), one recurrent treated constipation (14.3%), and one soiling (14.3%). Genetic analysis identified three patients with heterozygous deletions, three with codon mutations, and three with frameshift mutations. CONCLUSIONS: MWS associated with Hirschsprung disease has a high rate of immediate surgical complications but some patients may achieve bowel function comparable with non-syndromic HD patients. A multidisciplinary follow-up is required for these patients. LEVEL OF EVIDENCE: Retrospective observational single cohort study, Level 3.