Does the morphology of the umbilicus influence the incidence of surgical site infections in transumbilical single-incision laparoscopic appendectomy?

Background: Transumbilical laparoscopic appendectomy (TULA) may be a feasible alternative to conventional laparoscopic appendectomy. However, a transumbilical incision may increase incisional surgical site infections (SSIs) compared to conventional laparoscopic appendectomy. This study aimed to investigate the relationship between the morphology of the umbilicus and the incidence of SSIs in patients who underwent TULA. Patients and Methods: This retrospective study analysed the medical records of consecutive patients who underwent surgery for acute appendicitis at our institution from June 2016 to October 2020. The patients were assigned to the SSI group (those with an SSI) or the non-SSI group. The morphology of the umbilicus was calculated by measuring its width and depth on preoperative computed tomography images and was compared between the SSI and non-SSI groups. Results: The SSI group included 23 patients, while the non-SSI group included 252 patients. The width of the umbilicus was significantly shorter in the SSI group than in the non-SSI group (29 ± 10 mm vs. 34 ± 9 mm, P = 0.027). The umbilicus was slightly deeper in the SSI group than in the non-SSI group; however, the difference was not significant (16 mm vs. 15 mm, P = 0.384). Conclusions: This was the first study investigating the correlation between the morphology of the umbilicus and SSI development in TULA. SSIs tended to occur more commonly in a narrow and deep umbilicus. An extension of the umbilical incision may help prevent SSI in patients with this umbilical morphology.

Epidemiology, risk factors, and clinical impact of early post-transplant infection in older kidney transplant recipients: the Korean organ transplantation registry study.

BACKGROUND: As in younger recipients, post-transplant infection is a frequent and devastating complication after kidney transplantation (KT) in older recipients. However, few studies have analyzed characteristics of post-transplant infection in older kidney recipients. In this study of a nation-wide cohort of older kidney recipients, we investigated the current epidemiology, risk factors, and clinical impacts of early post-transplant infection, which was defined as infectious complications requiring hospitalization within the first 6 months after KT. METHODS: Three thousand seven hundred thirty-eight kidney recipients registered in the Korean Organ Transplantation Registry between 2014 and 2017 were enrolled. Recipients were divided into two groups, younger (n = 3081) and older (n = 657), with a cutoff age of 60 years. We observed characteristics of early post-transplant infection, and investigated risk factors for the development of infection. We also analyzed the association of early post-transplant infection with clinical outcomes including cardiac events, rejection, graft loss, and all-cause mortality. RESULTS: The incidence of early post-transplant infection was more frequent in older recipients (16.9% in younger group and 22.7% in older group). Bacteria were the most common causative pathogens of early post-transplant infection, and the most frequent site of infection was the urinary tract in both older and younger recipients. Older recipients experienced more mycobacterial infections, co-infections, and multiple site infections compared with younger recipients. In older recipients, female sex (HR 1.398, 95% CI 1.199-1.631), older donor age (HR 1.010, 95% CI 1.004-1.016), longer hospitalization after KT (HR 1.010, 95% CI 1.006-1.014), and experience of acute rejection (HR 2.907, 95% CI 2.471-3.419) were independent risk factors for the development of early post-transplant infection. Experiencing infection significantly increases the incidence of rejection, graft loss, and all-cause mortality. CONCLUSION: Our results illustrate current trends, risk factors, and clinical impacts of early post-transplant infection after KT in older recipients. Considering the poor outcomes associated with early post-transplant infection, careful screening of recipients at high risk for infection and monitoring of recipients who experience infection are advised. In addition, since older recipients exhibit different clinical characteristics than younger recipients, further studies are needed to establish effective strategies for treating older recipients.

Interventional management of central vein occlusion in patients with peripherally inserted central catheter placement.

OBJECTIVE: This study evaluated the incidence of central vein occlusion (CVO) and analyzed the interventional management for CVO during peripherally inserted central catheter (PICC) placement to suggest an adequate management protocol to ensure the success and patency of PICCs. METHODS: We retrospectively reviewed the records of 2568 PICCs to identify CVO in two medical centers between January 2016 and June 2017. Procedural images were reviewed for the following items: date and indication for the PICC; type of catheter; accessed vein and arm; characteristics of CVO on ascending arm venography; PICC placement technique; indwelling period of the PICC; and follow-up records. A guidewire passage trial was performed to the CVO, as follows: a trial with a 0.018-inch single or double guidewire through the pretrimmed PICC lumen; and a trial with a combination of a 0.035-inch guidewire and a curved 5F diagnostic catheter through the PICC introducer sheath. RESULTS: The incidence of CVO was 3.2% (71/2232), and 59 patients were analyzed (23 men; mean age, 69 ± 11 years; median age, 80 years; age range, 31-92 years). Forty-four patients had thrombotic CVO, and 12 patients had acute thrombotic CVO. Thirty-six patients had occlusion of the left innominate vein, and six patients had contiguous involvement of the adjacent central vein. Forty-two patients had obtuse stump morphology of CVO, and 28 patients had grade >III collateral development. The PICC indwelling time was statistically different between the group with successful catheter advancement (n = 36, success group) and the group with failed catheter advancement (n = 18, failure group; P = .007) with ipsilateral trimmed PICCs. Eight patients had a symptomatic catheter associated with upper extremity deep venous thrombosis (UEDVT; <30 days), one in the success group and seven in the failure group. The incidence of catheter-associated UEDVT after primary PICC placement on each arm was statistically different between the success and failure groups (P = .004). CONCLUSIONS: A PICC passage trial for ipsilateral CVO is challenging but frequently successful with a simple guidewire technique, which can preserve catheter patency, decrease contralateral arm access, and prevent the development of new catheter-associated UEDVT.

Clinical Outcomes of Endovascular Aneurysm Repair with the Kilt Technique for Abdominal Aortic Aneurysms with Hostile Aneurysm Neck Anatomy: A Korean Multicenter Retrospective Study.

PURPOSE: We aimed to evaluate the clinical efficacy and short-term clinical outcomes of Kilt technique-based endovascular aneurysm repair (EVAR) with Seal® stent-grafts for abdominal aortic aneurysms (AAAs) with hostile neck anatomy (angle > 60°). MATERIALS AND METHODS: We retrospectively evaluated the pre-EVAR and follow-up computed tomography angiography findings of 24 patients (mean age 71 ± 11 years; age range 32-87 years; mean follow-up 50 ± 12 months) with hostile neck AAAs treated between 2010 and 2015. Serial change in aneurysmal neck angle was calculated using a standardized protocol. Relationships between clinical variables and outcomes were evaluated using univariate and multivariate Cox analyses and mixed-model regression. In addition, the Kaplan-Meier method was used to assess the cumulative rates of survival, endoleak, and reintervention. RESULTS: The primary technical success rate (success within 24 h after EVAR) was 100% (24/24). The survival rate was 96 ± 8% at 1 month, 6 months, 1 year, and 3 years, and 87 ± 18% at 5 years. Endoleaks occurred in three patients. Four reinterventions were performed in three patients; no surgical revisions were required. Causes of post-EVAR mortality included intracerebral hemorrhage at 14 days and rhabdomyolysis at 32 months. The most remarkable change after Kilt-based EVAR was an acute decrease in the neck angle, which was observed between the pre-EVAR and first follow-up visits (at 1 month) (P = 0.001). CONCLUSION: Kilt-based EVAR with Seal® stent-grafts for AAAs with a severely angulated neck (angle > 60°) provided high technical success, low mortality, and low complication rates during short-term follow-up.

The blind pushing technique for peripherally inserted central catheter placement through brachial vein puncture.

OBJECTIVE: The objective of this study was to conduct a prospective clinical trial evaluating the technical feasibility and short-term clinical outcome of the blind pushing technique for placement of pretrimmed peripherally inserted central catheters (PICCs) through brachial vein access. METHODS: Patients requiring PICC placement at any of the three participating institutions were prospectively enrolled between January and December 2016. The review boards of all participating institutions approved this study, and informed consent was obtained from all patients. PICC placement was performed using the blind pushing technique and primary brachial vein access. The following data were collected from unified case report forms: access vein, obstacles during PICC advancement, procedure time, and postprocedural complications. RESULTS: During the 12-month study period, 1380 PICCs were placed in 1043 patients. Of these, 1092 PICCs placed in 837 patients were enrolled, with 834 PICCs (76%) and 258 PICCs (34%) placed through brachial vein and nonbrachial vein access, respectively. In both arms, obstacles were most commonly noted in the subclavian veins (n = 220) and axillary veins (n = 94). Successful puncture of the access vein was achieved at first try in 1028 PICCs (94%). The technical success rate was 99%, with 1055 PICCs (97%) placed within 120 seconds of procedure time and 1088 PICCs (99%) having the tip located at the ideal position. Follow-up Doppler ultrasound detected catheter-associated upper extremity deep venous thrombosis (UEDVT) for 18 PICCs in 16 patients and late symptomatic UEDVT for 16 PICCs in 16 patients (3.1%). Catheter-associated UEDVT was noted for 28 PICCs (82%) and 6 PICCs (18%) placed through brachial vein and nonbrachial vein access, respectively. The incidence of obstacles and the procedure time (<120 seconds) differed significantly between brachial vein and nonbrachial vein access (P = .001). There was no statistically significant difference between brachial vein and nonbrachial vein access in the incidence of UEDVT (odds ratio, 0.68; 95% confidence interval, 0.59-3.52; P = .22). CONCLUSIONS: The placement of pretrimmed PICCs by the blind pushing technique and primary brachial vein access is technically feasible and may represent an alternative to the conventional PICC placement technique, having low incidences of UEDVT and other complications, with no significant difference in outcomes between brachial vein and nonbrachial vein access.