Jejunal Diverticulosis Causing Small Intestinal Volvulus and Closed Loop Obstruction.

BACKGROUND Jejunal diverticulosis are false diverticula of the small bowel that form from outpouching of the mucosa and submucosa. They are pulsion diverticula that are often asymptomatic and can be found incidentally during surgery. In some instances, jejunal diverticula could result in intestinal obstruction. Small intestinal volvulus is an uncommon cause of small bowel obstruction that results in a closed loop obstruction and is an indication for emergent surgical intervention. CASE REPORT We report a case of an 84-year-old man who presented to the Emergency Department with abdominal pain and generalized weakness. A preoperative computerized tomographic scan demonstrated a closed loop small bowel obstruction with mesenteric swirling. The patient was taken for a diagnostic laparoscopy, which revealed extensive proximal jejunal diverticulosis and a volvulus of the involved jejunum. An exploratory laparotomy was warranted for safe detorsion of the small bowel and resection of the diseased segment. The small bowel was successfully detorsed, with resection of the involved jejunum. Intestinal continuity was established by a primary side-to-side anastomosis. CONCLUSIONS Jejunal diverticula have been reported in the literature as a cause of small bowel obstructions, and very few reports exist of concurrent small bowel volvulus. In very rare instances, both of these conditions can coexist. There should be prompt surgical intervention in all cases of closed loop small bowel obstructions to prevent intestinal ischemia, perforation, and sepsis.

Impact of Enhanced Recovery After Surgery (ERAS) Combined with Bariatric Surgery Targeting Opioid Prescriptions (BSTOP) Protocol on Patient Outcomes, Length of Stay and Opioid Prescription After Bariatric Surgery.

BACKGROUND: Evidence shows that 14.2% of opioid-naive patients have long-term opioid dependence after bariatric surgery. Enhanced recovery after surgery (ERAS) protocols are widely used in bariatric surgery, while bariatric surgery targeting opioid prescriptions (BSTOP) protocols were recently introduced. We will investigate the combined impact of ERAS and BSTOP protocols after bariatric surgery. METHODS: We conducted a retrospective review for patients who underwent either a sleeve gastrectomy or Roux-en-Y gastric bypass at a tertiary care center. Pre-intervention and post-intervention data were compared. Primary outcomes were length of stay (LOS), 30-day readmission, 30-day complications, and discharge on opioids. Multivariate Poisson regression with robust standard error was used to analyze LOS. RESULTS: There was no significant difference in 30-day emergency room visits (3.3% vs. 4.0%; p value = 0.631), 30-day readmission (4.4% vs. 5.4%; p value = 0.577) or 30-day complication rate (4.2% vs. 6.4%; p value = 0.199). LOS was significantly lower in the post-intervention group; mean (interquartile range) 2 (1-2) days vs. 1 (1-2) day, p value < 0.001. On multivariate analysis, the post-intervention group had 0.74 (95% confidence interval 0.65-0.85; p value < 0.001) times lower LOS as compared to pre-intervention group. Patients with DM had a significantly longer LOS (relative risk: 1.22; p = 0.018). No other covariates were associated with LOS (p value < 0.05 for all). BSTOP analysis found a significant difference between the two groups. Discharge on opioids decreased from 40.6% pre-intervention to 7.1% post-intervention. CONCLUSION: ERAS and BSTOP protocols reduced length of stay and opioid need at discharge without an increase in complication or readmission rates.

Improved Morbidity, Mortality, and Cost with Minimally Invasive Colon Resection Compared to Open Surgery.

Background and Objectives: Despite the growth of minimally invasive surgery (MIS) in many specialties, open colon surgery is still routinely performed. The purpose of this study was to compare outcomes and costs between open colon and minimally invasive colon resections. Methods: We analyzed outcomes between January 1, 2016 and December31, 2018 using the Vizient® clinical database. Demographics, hospital length of stay, readmissions, complications, mortality, and costs were compared between patients undergoing elective open and minimally invasive colon resections. For bivariate analysis, Wilcoxon rank-sum test was used for continuous variables and χ2 test was used for categorical variables. Multiple Logistic and Quintile regression were used for multivariable analyses. Results: A total of 88,405 elective colon resections (open: 56,599; minimally invasive: 31,806) were reviewed. A significantly larger proportion of patients undergoing minimally invasive surgery were obese (body mass index > 30) compared to those undergoing open surgery (71.4% vs. 59.6%; p < 0.0001). As compared to minimally invasive colectomy, open colectomy patients had: a longer median length of stay [median (range): 7 (4-13) days vs. 4 (3 - 6) days, p < 0.0001], higher 30-day readmission rate [n = 8557 (15.1%) vs. 2815 (8.9%), p < 0.0001], higher mortality [n = 2590 (4.4%) vs. 107 (0.34%), p < 0.0001], and a higher total direct cost [median (range): $13,582 (9041-23,094) vs. $9013 (6748 - 12,649), p < 0.0001]. Multivariable models confirmed these findings. Conclusion: Minimally invasive colon surgery has clear benefits in terms of length of stay, readmission rate, mortality and cost, and the routine use of open colon resection should be revaluated.

Gastric Banding with Previous Roux-en-Y Gastric Bypass (Band over Pouch): Not Worth the Weight.

Background and Objectives: Revisional bariatric surgery continues to increase. Laparoscopic adjustable gastric banding (LAGB) after previous Roux-en-Y gastric bypass (RYGB), known colloquially as "band-overpouch" has become an option despite a dearth of critically analyzed long-term data. Methods: Our prospectively maintained database was retrospectively reviewed for patients who underwent band-overpouch at our Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Center of Excellence in a 18-year period ending October 31, 2021. We evaluated: demographics, comorbidities, operative procedures, and outcomes (30-day and > 30-day). Results: During the study period, of 4,614 bariatric procedures performed, 42 were band-overpouch with 39 (93%) being women. Overall, mean age was 49.8 years (range 26-75), a mean weight 251 pounds (range 141-447), and mean body mass index 42.4 (range 26-62). Comorbidities included: hypertension (n = 31; 74%), diabetes (n = 27; 64%), obstructive sleep apnea (n = 26; 62%), gastroesophageal reflux disease (n = 26; 62%), and osteoarthritis (n = 25; 60%). All procedures were performed laparoscopically with no conversions to open. Mean length of stay was 1.2 days (range 1-3). Mean follow-up time was 4.2 years (range 0.5-11). Mean excess weight loss was 14.9%, 24.3%, and 28.2% at 6 months, 1 year and ≥ 3 years, respectively. There was one 30-day trocar-site hematoma requiring transfusion. Long-term events included: 1-year (1 endoscopy for retained food; 1 internal hernia), 3-year (1 LAGB erosion; 1 LAGB explant), 4-year (1 anastomotic ulcer), 6-year (1 LAGB explant and Roux-en-Y revision), and 8-year (1 LAGB erosion). One 5-year mortality occurred (2.4%), in association with hospitalization for chronic illness and malnutrition. Band erosions were successfully treated surgically without replacement. Conclusion: Band-overpouch is associated with moderate excess weight loss and has good short-term safety outcomes.

Diagnostic accuracy of computed tomography in differentiating peritoneal tuberculosis from peritoneal carcinomatosis.

INTRODUCTION: Peritoneal tuberculosis is difficult to diagnose as it may mimic peritoneal carcinomatosis, which has similar symptomatology. We sought to determine the diagnostic accuracy of computed tomography in differentiating peritoneal tuberculosis versus peritoneal carcinomatosis. MATERIALS AND METHODS: The associations of radiological findings in 124 patients with peritoneal carcinomatosis (n = 55) or tuberculosis (n = 69) were determined using Chi-square test. Sensitivity, specificity, positive and negative predictive value, and total diagnostic accuracy of CT imaging, with histopathology as gold standard, was determined. Subgroup analyses to determine these parameters by age (>40 years and ≤40 years) and gender (male and female) were performed. RESULTS: Mean age of study population was 44.1 ± 13.2 years with 61 males (49.2%) and 63 females (50.8%). The most common radiological abnormality in both peritoneal carcinomatosis (90.9%) and peritoneal tuberculosis (89.9%) was omental smudging, followed by presence of extraperitoneal mass (81.8%) in carcinomatosis and presence of micro-nodules in tuberculosis (88.4%). The findings significantly different in both the carcinomatosis and tuberculosis groups were high-density ascites, splenic calcification, splenomegaly, lymph node calcifications, micro-nodules, and macro-nodules. The diagnostic accuracy of CT in differentiating peritoneal tuberculosis from peritoneal carcinomatosis was 83.8%; sensitivity and specificity for peritoneal tuberculosis were 88.4% and 78.2%, respectively. CONCLUSION: The diagnostic accuracy of CT in differentiating peritoneal tuberculosis from peritoneal carcinomatosis revealed an overall diagnostic accuracy of 83.8%. Subgroup analysis revealed that CT may be a more specific diagnostic tool to predict peritoneal tuberculosis in female patients and in those over 40 years old.

Impact of Drain Placement and Duration on Outcomes After Pancreaticoduodenectomy: A National Surgical Quality Improvement Program Analysis.

BACKGROUND: The decisions to routinely place a drain after pancreaticoduodenectomy and how long to leave the drain remain controversial due to conflicting evidence and significant variations in clinical practice. This study aims to address those questions by using a large national database and a rigorous analytical model. METHODS: The American College of Surgeons National Surgical Quality Improvement Program 2015-2016 Pancreatectomy Participant Use Data Files were used to identify patients who had undergone pancreaticoduodenectomy (n = 7583). Univariable and multivariable binomial regression analyses were performed to control for potential confounders and various preoperative risk factors. Cox regression with drain as a time-dependent covariate, conditional on having a drain placed, was used to examine the association between the drain remaining in place and morbidities. RESULTS: Of 7583 patients, drains were placed in 6666 (87.9%). Drain placement decreased the risk of developing serious morbidity (relative risk [RR] 0.73, 95% confidence interval [CI] 0.65-0.82), overall morbidity (RR 0.79, 95% CI 0.72-0.87), and organ space surgical site infection (RR 0.72, 95% CI 0.61-0.85). Drain placement did not change the risk of developing a clinically relevant postoperative pancreatic fistula (RR 0.96, 95% CI 0.78-1.19). However, for those with drains placed, length of drainage was independently associated with serious morbidity (hazard ratio [HR] 3.06, 95% CI 2.65-3.53), overall morbidity (HR 2.48, 95% CI 2.20-2.80), and organ space surgical site infection (HR 1.47, 95% CI 1.23-1.74). CONCLUSIONS: Routine drain placement following pancreaticoduodenectomy may decrease postoperative complications, including serious morbidity, overall morbidity, and organ space surgical site infections; however, length of drainage was associated with increased risk of the previously-named complications. These results support the routine placement and early removal of intraoperative surgical drains in pancreaticoduodenectomy.

Maximizing the Use of Scoring Systems in the Prediction of Outcomes in Acute Pancreatitis.

BACKGROUND/AIMS: No single classification system has so far effectively predicted the severity for Acute Pancreatitis (AP). This study compares the effectiveness of classification systems: Original Atlanta (OAC), Revised Atlanta (RAC), Determinant based classification (DBC), PANC 3, Harmless AP Score (HAPS), Japanese Severity Score (JSS), Symptoms Nutrition Necrosis Antibiotics and Pain (SNNAP), and Beside Index of Severity for AP (BISAP) in predicting outcomes in AP. METHODS: Scores for BISAP, Panc 3, HAPS, SNNAP, OAC, RAC, and DBC were calculated for 221 adult patients hospitalized for AP. Receiver Operating Characteristic curve analysis and Akaike Information Criteria were used to compare the effectiveness of predicting need for surgery, intensive care unit (ICU) admission, readmission within 30 days, and length of hospital stay. RESULTS: Both the RAC and the DBC strongly predict the length of hospital stay (p < 0.0001 for both) and ICU admission (p < 0.0001 for both). Additionally, both BISAP and PANC 3 showed weak predictive capacity at identifying length of stay and ICU admission. CONCLUSIONS: We suggest that BISAP and PANC3 be obtained within the initial 24 h of hospitalization to offer an early prediction of length of stay and ICU admission. Subsequently, RAC and DBC can offer further information later in the course of the disease.

A comparison of portal venous versus systemic venous drainage in pancreas transplantation.

BACKGROUND: The decision to utilize portal or systemic venous drainage in pancreas transplantation is surgeon- and center-dependent. Information regarding the superior method is based on single-center reports and animal models. METHODS: UNOS data on adults receiving pancreas and kidney-pancreas transplants from 1987 to 2016 were analyzed (n = 29 078). The groups analyzed were: systemic venous pancreas graft drainage (SVD, n = 24 512) or portal venous pancreas graft drainage (PVD, n = 4566). A Cox proportional hazard model compared patient and allograft survival between groups. RESULTS: No statistically significant differences were observed for patient and allograft survival at 1, 3, 5, 10, or 15 years post-transplant at each time interval and cumulatively (patient - HR:1.041; 95% CI:0.989-1.095; allograft - HR:0.951; 95% CI:0.881-1.027). PVD reduced the risk of death by 22.0% (P = 0.017) compared to SVD for patients undergoing pancreas after kidney transplant (PAK); no statistically significant difference was found for patients undergoing other types of transplants. CONCLUSION: There is no significant clinical difference in patient or allograft survival between PVD and SVD in pancreas transplantation for the majority of patients. For the subgroup of PAK, PVD was associated with decreased mortality. For individual surgeons, center and patient scenarios should dictate which technique is performed.

Predictors of 30-day readmission following pancreatic surgery: A retrospective review.

BACKGROUND: Pancreatectomies have been identified as procedures with an increased risk of readmission. In surgical patients, readmissions within 30 days of discharge are usually procedure-related. We sought to determine predictors of 30-day readmission following pancreatic resections in a large healthcare system. METHODS: We retrospectively collected information from the records of 383 patients who underwent pancreatic resections from 2004-2013. To find the predictors of readmission in the 30 days after discharge, we performed a univariate screen of possible variables using the Fisher's exact test for categorical variables and the Mann-Whitney U test for continuous variables. Multivariate analysis was used to determine the independent factors. RESULTS: Fifty-eight (15.1%) patients were readmitted within 30 days of discharge. Of the patients readmitted, the most common diagnoses at readmission were sepsis (17.2%), and dehydration (8.6%). Multivariate logistic regression found that the development of intra-abdominal fluid collections (OR = 5.32, P < 0.0001), new thromboembolic events (OR = 4.08, P = 0.016), and pre-operative BMI (OR = 1.06, P = 0.040) were independent risk factors of readmission within 30 days of discharge. CONCLUSION: Our data demonstrate that factors predictive of 30-day readmission are a combination of patient characteristics and the development of post-operative complications. Targeted interventions may be used to reduce the risk of readmission.

Bladder Versus Enteric Drainage of Exocrine Secretions in Pancreas Transplantation: A Retrospective Analysis of the United Network for Organ Sharing Database.

OBJECTIVES: The method for drainage of exocrine secretions in pancreas transplantation remains a matter of debate. Different methods have evolved over time. Most data on these methods are from single-center studies with small sample sizes. Larger studies have yielded conflicting results. METHODS: Data from the United Network for Organ Sharing database on all adult subjects who received pancreas and kidney-pancreas transplants between 1996 and 2012 were analyzed (n = 19,934). Subjects were divided into 3 groups: enteric drainage with Roux-en-Y (n = 4308), enteric drainage without Roux-en-Y (n = 11,145), and bladder drainage (n = 4481). Primary end points were patient and graft survival at 1, 3, 5, 10, and 15 years. RESULTS: There was a patient and graft survival advantage with enteric drainage without Roux-en-Y reconstruction compared with the other methods. This was consistent at 1, 3, 5, 10, and 15 years. CONCLUSIONS: Our study demonstrated increased graft and patient survival when comparing enteric drainage of the transplanted pancreas without Roux-en-Y reconstruction to enteric drainage with Roux-en-Y and bladder drainage at 1, 3, 5, 10, and 15 years. Based on this study, we recommend enteric drainage without Roux-en-Y reconstruction as the method of choice in pancreas transplantation.

Outcomes following operative vs. non-operative management of blunt traumatic pancreatic injuries: a retrospective multi-institutional study.

BACKGROUND: Traumatic pancreatic injuries are rare, and guidelines specifying management are controversial and difficult to apply in the acute clinical setting. Due to sparse data on these injuries, we carried out a retrospective review to determine outcomes following surgical or non-surgical management of traumatic pancreatic injuries. We hypothesize a higher morbidity and mortality rate in patients treated surgically when compared to patients treated non-surgically. METHODS: We performed a retrospective review of data from four trauma centers in New York from 1990-2014, comparing patients who had blunt traumatic pancreatic injuries who were managed operatively to those managed non-operatively. We compared continuous variables using the Mann-Whitney U test and categorical variables using the chi-square and Fisher's exact tests. Univariate analysis was performed to determine the possible confounding factors associated with mortality in both treatment groups. RESULTS: Twenty nine patients were managed operatively and 32 non-operatively. There was a significant difference between the operative and non-operative groups in median age (37.0 vs. 16.2 years, P = 0.016), grade of pancreatic injury (grade I; 30.8 vs. 85.2%, P value for all comparisons <0.0001), median injury severity score (ISS) (16.0 vs. 4.0, P = 0.002), blood transfusion (55.2 vs. 15.6%, P = 0.0012), other abdominal injuries (79.3 vs. 38.7%, P = 0.0014), pelvic fractures (17.2 vs. 0.00%, P = 0.020), intensive care unit (ICU) admission (86.2 vs. 50.0%, P = 0.003), median length of stay (LOS) (16.0 vs. 4.0 days, P <0.0001), and mortality (27.6 vs. 3.1%, P = 0.010). CONCLUSIONS: Patients with traumatic pancreatic injuries treated operatively were more severely injured and suffered greater complications than those treated non-operatively. The greater morbidity and mortality associated with these patients warrants further study to determine optimal triage strategies and which subset of patients is likely to benefit from surgery.

Glycated Hemoglobin, Plasma Glucose, and Erythrocyte Aging.

BACKGROUND: The relationship between HbA1c and blood glucose averages has been characterized many times, yet, a unifying, mechanistic description is still lacking. METHODS: We calculated the level of HbA1c from plasma glucose averages based solely on the in vivo rate of hemoglobin glycation, and the different turnover rates for erythrocytes of different ages. These calculations were then compared to the measured change of HbA1c due to changes in mean blood glucose (MBG), to complex models in the literature, and our own experiments. RESULTS: Analysis of data on erythrocyte ageing patterns revealed that 2 separate RBC turnover mechanisms seem to be present. We calculated the mean red blood cell (RBC) life span within individuals to lie between 60 and 95 days. Comparison of expected HbA1c levels to data taken from continuous glucose monitors and finger-stick MBG yielded good agreement (r = .87, P < .0001). Experiments on the change with time of HbA1c induced by a change of MBG were in excellent agreement with our calculations (r = .98, P < .0001). CONCLUSIONS: RBC turnover seems to be dominated by a constant rate of cell loss, and a mechanism that targets cells of a specific age. Average RBC life span is 80 ± 10.9 days. Of HbA1c change toward treatment goal value, 50% is reached in about 30 days. Many factors contribute to the ratio of glycated hemoglobin, yet we can make accurate estimations considering only the in vivo glycation constant, MBG, and the age distribution of erythrocytes.

Recipient Criteria Predictive of Graft Failure in Kidney Transplantation.

Several classifications systems have been developed to predict outcomes of kidney transplantation based on donor variables. This study aims to identify kidney transplant recipient variables that would predict graft outcome irrespective of donor characteristics. All U.S. kidney transplant recipients between October 25,1999 and January 1, 2007 were reviewed. Cox proportional hazards regression was used to model time until graft failure. Death-censored and nondeath-censored graft survival models were generated for recipients of live and deceased donor organs. Recipient age, gender, body mass index (BMI), presence of cardiac risk factors, peripheral vascular disease, pulmonary disease, diabetes, cerebrovascular disease, history of malignancy, hepatitis B core antibody, hepatitis C infection, dialysis status, panel-reactive antibodies (PRA), geographic region, educational level, and prior kidney transplant were evaluated in all kidney transplant recipients. Among the 88,284 adult transplant recipients the following groups had increased risk of graft failure: younger and older recipients, increasing PRA (hazard ratio [HR],1.03-1.06], increasing BMI (HR, 1.04-1.62), previous kidney transplant (HR, 1.17-1.26), dialysis at the time of transplantation (HR, 1.39-1.51), hepatitis C infection (HR, 1.41-1.63), and educational level (HR, 1.05-1.42). Predictive criteria based on recipient characteristics could guide organ allocation, risk stratification, and patient expectations in planning kidney transplantation.

Steroid maintenance is associated with an increased risk of infections but has no effect on patient and graft survival in pancreas transplantation: A retrospective review of the UNOS database.

INTRODUCTION: The appropriateness of steroid maintenance in pancreas transplantation is unproven. The current literature is insufficient due to small numbers, short follow-up and sparse data. METHODS: Data from the UNOS database on adults ≥18 years old, who received pancreas and kidney-pancreas transplants between January 1996 and March 2014 were analyzed (n = 27,077). Two groups were evaluated: (a) Steroids Induction only (n = 4391) and (b) Steroid maintenance (n = 22,686). One-, 3-, 5-, 10-, and 15-year unadjusted patient and graft survival rates were compared. A Cox proportional hazards model was used to determine what patient factors were associated with these outcomes. RESULTS: There were differences in patient survival at 1 and 3 years and in graft survival at 3 and 5 years. There was a higher rate of infectious complications in the maintenance group, but after controlling for several recipient factors, whether a patient received steroid maintenance or not, was not significantly associated with the risk of death or graft failure. CONCLUSION: The use of maintenance steroids is significantly associated with an increased risk of infectious complications, but no difference in patient death or graft failure after controlling for multiple recipient factors. There is also no benefit with the use of steroid maintenance after pancreas transplantation.

Pancreatic retransplantation is associated with poor allograft survival: an update of the United Network for Organ Sharing database.

UNLABELLED: The aim of the study was to assess outcomes of pancreas retransplantation versus primary pancreas transplantation. METHODS: Data from the United Network for Organ Sharing database on all adult (age, ≥18 years) subjects who received pancreas and kidney-pancreas transplants between 1996 and 2012 were analyzed (n = 20,854). The subjects were analyzed in the following 2 groups: retransplant (n = 1149) and primary transplant (n = 19,705). RESULTS: Kaplan-Meier analysis demonstrated significantly different patient survival (P < 0.0001) and death-censored graft survival (P < 0.0001) between the primary transplant versus retransplant subjects. Allograft survival was significantly poorer in the retransplantation group. Patient survival was greater in the retransplant group. CONCLUSIONS: The results of our study differ from previous studies, which showed similar allograft survival in primary and secondary pancreas transplants. Further studies may elucidate specific patients who will benefit from retransplantation. At the present time, it would appear that pancreas retransplantation is associated with poor graft survival and that retransplantation should not be considered for all patients with primary pancreatic allograft failure.

A retrospective chart review of drug treatment patterns and clinical outcomes among patients with metastatic or recurrent soft tissue sarcoma refractory to one or more prior chemotherapy treatments.

BACKGROUND: Limited clinical data on real-world practice patterns are available for patients with metastatic/relapsed soft tissue sarcomas (STS). The primary objective of this study was to evaluate treatment patterns in patients with metastatic/relapsed STS following failure of prior chemotherapy by examining data collected from 2000 to 2011 from a major tertiary academic cancer center in the United States. METHODS: Medical records, including community-based referral records, from a tertiary cancer center for adult patients with metastatic/relapsed STS with confirmed disease progression who commenced second-line treatment between January 1, 2000 and February 4, 2011, and with at least 3 months of follow-up data following second-line treatment initiation, were retrospectively reviewed. Overall survival, time to progression, and clinician-reported tumor response were collected. RESULTS: A total of 99 patients (leiomyosarcoma, n = 48; synovial cell sarcoma, n = 7; liposarcoma, n = 5; or other histological subtypes, n = 39) received an average of four lines of treatment (maximum of 10). No consistent or dominant regimens were used in each treatment line beyond the second line. Median second-line treatment duration was 4.1 months (95% confidence interval, 3.0-5.0). Overall, 72 of 99 patients (73%) discontinued second-line treatment due to progressive disease. Median progression-free survival from initiation of second-line treatment varied across regimens from 2.0 to 6.6 months (overall median, 5.4 months). CONCLUSIONS: Wide variations in treatment were evident, with no single standard of care for patients with metastatic/relapsed STS. Most patients discontinued second-line treatment due to progressive disease, often receiving additional systemic therapy with other drugs. These data suggest a high unmet need for more efficacious treatment options and improved data collection to guide practice among patients with relapsed/refractory STS.