Percutaneous core needle biopsy of neuroblastoma in the pediatric population: what have we learned in the last decade.

INTRODUCTION: Historically, neuroblastoma has been diagnosed by surgical open biopsy (SB). In recent decades, core needle biopsy (CNB) has replaced surgical biopsy due to its safe and adequate method of obtaining tissue diagnosis. AIM: Our study aimed to assess the effectiveness of CNB in obtaining tissue diagnosis for neuroblastoma and evaluate its safety profile in terms of post-operative complications, in comparison to SB. METHODS: A retrospective cohort study, including all patients younger than 18 years who were diagnosed with neuroblastoma from 2012 until 2022 in a single tertiary medical center. Patients' demographics, tumor size and location, pathological results, and clinical outcomes were collected. RESULTS: 79 patients were included in our study: 35 biopsies were obtained using image-guided CNB and 44 using SB. Patients' and tumor characteristics including age, gender, tumor volume, and stage were similar in both groups. The biopsy adequacy rate in the CNB group was 91% and 3 patients in this group underwent repeated biopsy. The safety profile in the CNB group was similar to the SB group. CONCLUSIONS: CNB is a safe method and should be considered the first choice for obtaining tissue diagnosis when feasible due to its high adequacy in terms of tumor histopathological features.

Recurrence rates of pilonidal sinus disease in the pediatric population following trephine surgery.

BACKGROUND: Pilonidal sinus disease (PSD) is a common surgical disease. Multiple surgical methods exist in the literature, without clear consensus regarding which should be the first-line treatment. Minimally invasive methods such as the Gips procedure are gaining popularity in recent years. The aim of our study was to assess recurrence rates following the Gips procedure and to determine whether using the same surgical approach during re-operation is efficient and successful. METHODS: This is a single-center retrospective observational study of pediatric patients that underwent Gips procedure due to PSD between the years 2012-2022. RESULTS: 565 pediatric patients underwent an elective surgery for PSD in the study period. Recurrence rate was 8.1% (n = 46). In all the patients with recurrence, re-operation took place on average 9 months following the first surgery and using the same surgical method. Following the second surgery, only 8 patients (1%) had multiple recurrences. CONCLUSIONS: We found a relatively low recurrence rate in the pediatric population using the Gips method, and nearly 100% success rate following the second operation. Our findings set a new benchmark for pediatric recurrence following PSD operation, with clear recommendation to use the same method of surgery upon further recurrences as well.

Antibiotic Treatment in Complicated Appendicitis: Can It Be Optimized?

BACKGROUND: The management of complicated appendicitis is inconclusive. Guidelines have not been established for the use of personalized antibiotic treatment. OBJECTIVES: To investigate specific risk factors to consider during the initial first-choice antibiotic therapy in children with complicated appendicitis. METHODS: This study included all pediatric patients younger than 18 years of age who underwent a laparoscopic appendectomy during 2012-2022 at a single tertiary medical center. RESULTS: In total, 300 pediatric patients underwent laparoscopic appendectomy due to complicated appendicitis. The patients were treated with ceftriaxone + metronidazole (CM). For 57 (19%) patients, the empirical treatment was changed to tazobactam/piperacillin (TP) due to resistant bacteria or clinical deterioration. The presence of generalized peritonitis during surgery and C-reactive protein (CRP) levels above 20 mg/L at admission were identified as risk factors for changing the antibiotic regimen from CM to TP. CONCLUSIONS: Generalized peritonitis and CRP > 20 gr/L were highly correlated with changing the antibiotic regimen to TP. For such patients, initial treatment with TP may result in clinical improvement and shorter hospitalization.

Negative appendectomy rate in the pediatric population: can we reach near-zero rates? An observational study.

INTRODUCTION: Correct diagnosis of acute appendicitis may sometimes be challenging. The Negative appendectomy rate (NAR) has declined in the recent years in Europe and USA, in part due to better diagnostic imaging tools. The aim of this study was to examine the rates of negative appendectomy in our institution, investigate trends in its incidence, and identify possible predicting factors. METHODS: A retrospective cohort study, including all patients younger than 18 years of age who underwent an appendectomy between 2007 and 2021 in a single tertiary medical center. Data regarding patient's demographics, laboratory and imaging results, pathological results and clinical outcome were collected. RESULTS: Between 2007 and 2021, a total of 3937 pediatric patients underwent appendectomy due to a working diagnosis of acute appendicitis. Overall, 143 patients (3.6%) had normal appendix on pathological examination. However, in the last 5 years, the rate of normal appendix was 1.9%, together with an increased rate of pre-operative imaging (from 40% to nearly 100%). CONCLUSION: Low NAR under 2% is an achievable benchmark in the era of accessible pre-operative imaging. In unequivocal cases, a secondary survey that includes repeated physical examination, blood work and imaging is recommended and may result in near-zero rates of NAR.

Umbilical Incarcerated Hernia With Omental Eventration Caused by a Leech Bite in a Pediatric Patient.

Medicinal leech therapy (MLT) is used in various medical disciplines, among which are reconstructive surgery and microsurgery. Medicinal leech therapy is also often adopted by alternative and traditional medicine, aiming to treat various common medical symptoms, such as fever and arthritis. Congenital umbilical hernia is a rather common physical finding in the pediatric population, where every third Caucasian newborn, roughly, is being diagnosed with the condition, and even more so among the African population. Fortunately, most cases resolve spontaneously in the first years of life. Toddlers whose hernia does not close typically require umbilical hernia repair. This article describes the case of a five-year-old girl with an asymptomatic congenital umbilical hernia who was admitted to the ER due to an omental eventration that occurred following the placement of a leech on her umbilicus in her parents' attempt to treat a febrile episode. She subsequently underwent an urgent umbilical exploration and a repair of her umbilical hernia. The main known risks of leeching are bacterial infection, anemia, prolonged bleeding, and, less frequently, pruritus, allergies, marked edema, and cellulitis. This article presents yet another possible complication that, to the best of our knowledge, has not been documented before in the literature. Several old-school therapies transcended over time into medical disciplines. Given that "traditional" practices often take place within households and communities, it is of crucial importance to point out potential complications, both rare and common, that can be caused by those practices in order to reduce the risk of severe, undesired outcomes. Indeed, the growing interface between traditional, alternative therapies and modern, conventional medicine urges better parental guidance and improved education regarding potentially harmful and unauthorized interventions.

Pigtail Catheter versus Large Bore Chest Tube for the Management of Spontaneous Pneumothorax in Children: A Retrospective Study.

INTRODUCTION: Pigtail catheter (PGC) insertion due to spontaneous pneumothorax (SPT) in the pediatric population has increased markedly in the last years. However, only few studies examined its efficacy in terms of length of hospitalization, rate of complications, and especially pain management comparing to large bore catheter (LBC) insertion. We sought to compare analgetic drug consumption, efficacy, and complication rate between PGC and LBC in children with SPT. MATERIALS AND METHODS: This is a single-center retrospective study of pediatric patients that were admitted to the Schneider Children's Medical Center between 2013 and 2021 with a diagnosis of SPT. The following data were collected: type of drainage (PGC or LBC), duration of drainage, length of hospitalization, number of X-rays, complication rate, surgery during hospitalization, readmission due to SPT, and pain management. RESULTS: Seventeen PGC and 23 LBC were inserted in our study. No differences were noted in terms of hospitalization length, tube reposition or replacement, and recurrence of SPT between the groups. Patients with PGC underwent less X-rays comparing to the LBC group (3 X-rays vs. 5, median, p < 0.005). Oral analgesic use in terms of length of therapy was significantly lower in the PGC group than in the LBC group (1 vs. 3+ days, median, p < 0.05). There was no major complication in this cohort. CONCLUSION: PGC is an effective, safe, and less painful alternative compared with a LBC for the drainage of SPT in children.

Recurrence rates following ileo-colic resection in pediatric patients with Crohn's disease.

BACKGROUND: Ileo-colic resection (ICR) is an important therapeutic option for Crohn's disease (CD) patients. There are limited updated data of clinical and endoscopic post-operative recurrence (POR) in pediatric patients with CD for the long run. We aimed to determine recurrence rates following ICR over an extended period of time and asses its risk factors. METHODS: This is a single-center retrospective review of 35 patients with CD between the ages of 6 and 17.9 years who required ICR between 2003 and 2021 at Schneider Children Medical Center of Israel. Medical charts were reviewed at different time-points post-ICR. RESULTS: Clinical recurrence following ICR was demonstrated in only 11.4% and 28.6% (n = 4, n = 10) in the first two and five years-much lower rates than what was reported so far. We found no specific risk factor that correlated with clinical recurrence, although patients that were treated with early prophylaxis of anti-TNF medications following ICR tend to have less recurrence. CONCLUSIONS: We found lower POR following ICR, especially in the first years after surgery-which can be attributed to close surveillance and early medical treatment. Such surveillance seems to improve recurrence rates in the first years following ICR.

Is fundoplication mandatory in children with neurological impairment undergoing gastrostomy?

AIM: Percutaneous endoscopic gastrostomy (PEG) and surgical gastrostomy (SG) are common procedures in children with neurological impairment (NI) with swallowing difficulties. Pulmonary aspirations are a major concern and performing concomitant or delayed fundoplication is still controversial, especially among these patients. The aim of our study was to review our experience with fundoplication performed concomitantly with gastrostomy or later and to evaluate patient outcomes. METHODS: This is a retrospective, cohort study including all paediatric patients who underwent SG or PEG with or without Nissen fundoplication at Schneider Children's Medical Center of Israel between the years 2007 and 2018. Patients' clinical and surgical data were recorded and analysed. RESULTS: Between 2007 and 2018, 345 patients underwent SG or PEG. Of these, 89 patients underwent fundoplication. Of the patients who underwent PEG/SG, 158 (45.8%) were neurologically impaired. Most of the patients who underwent fundoplication (n = 69, 77.5%) were NI patients (P = 0.0001). NI patients with refractory seizures showed almost no improvement in terms of relief of gastro-oesophageal reflux disease symptoms following fundoplication (P = 0.0001) compared to NI patients without refractory seizures. CONCLUSION: Our findings suggest that in NI patients a concomitant fundoplication is not mandatory and is not efficacious in preventing gastro-oesophageal reflux disease in patients with refractory seizures.

Low psoas muscle area is associated with postoperative complications in Crohn's disease.

BACKGROUND AND AIMS: Crohn's disease (CD) is associated with increased postoperative morbidity. Sarcopenia correlates with increased morbidity and mortality in various medical conditions. We assessed correlations of the lean body mass marker and psoas muscle area (PMA), with postoperative outcomes in CD patients undergoing gastrointestinal surgery. METHODS: We included patients with CD who underwent gastrointestinal surgery between June 2009 and October 2018 and had CT/MRI scans within 8 weeks preoperatively. PMA was measured bilaterally on perioperative imaging. RESULTS: Of 121 patients, the mean age was 35.98 ± 15.07 years; 51.2% were male. The mean BMI was 21.56 ± 4 kg/m2. The mean PMA was 95.12 ± 263.2cm2. Patients with postoperative complications (N = 31, 26%) had significantly lower PMA compared with patients with a normal postoperative recovery (8.5 ± 2.26 cm2 vs. 9.85 ± 2.68 cm2, P = 0.02). A similar finding was noted comparing patients with anastomotic leaks to those without anastomotic leaks (7.48 ± 0.1 cm2 vs. 9.6 ± 2.51 cm2, P = 0.04). PMA correlated with the maximum degree of complications per patient, according to the Clavien-Dindo classification (Spearman's coefficient = -0.26, P = 0.004). Patients with major postoperative complications (Clavien-Dindo ≥ 3) had lower mean PMA (8.12 ± 2.75 cm2 vs. 9.71 ± 2.57 cm2, P = 0.03). Associations were similar when stratifying by gender and operation urgency. On multivariate analysis, PMA (HR = 0.72/cm2, P = 0.02), operation urgency (HR = 3.84, P < 0.01), and higher white blood cell count (HR = 1.14, P = 0.02) were independent predictive factors for postoperative complications. CONCLUSION: PMA is an easily measured radiographic parameter associated with postoperative complications in patients with CD undergoing bowel resection.

Cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy in patients with peritoneal carcinomatosis from colorectal cancer: The prognostic impact of baseline neutrophil-lymphocyte, platelet-lymphocyte and lymphocyte-monocyte ratios.

PURPOSE: In this retrospective analysis we sought to determine if the preoperative neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR) and lymphocyte-monocyte ratio (LMR) were predictive of both operability and survival in those patients presenting with peritoneal carcinomatosis (PC) from colorectal cancer (CRC) who underwent cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). METHODS: Analysis included all patients admitted between 2009 and 2017 with PC from CRC who were treated with curative intent by CRS-Mitomycin C-HIPEC. Patients were assessed pre- and intra-operatively by the PC index (PCI) and by a completeness of cytoreduction (CC) score with calculation of Kaplan-Meier survival curves and multivariate analysis of prognostic factors. Discrimination was made for NLR >3.5, PLR >168.8 and LMR >4.4. RESULTS: We identified 98 CRC patients undergoing 105 CRS-HIPEC procedures. There were no associations detected between NLR/PLR/LMR and the rates of incomplete or abandoned CRS cases. Overall survival (OS) after CRS-HIPEC was worse with high versus low NLR (19.9 mths vs. 45.7 mths, respectively; P = 0.009) and also with low versus high LMR (27.1 mths vs. 53.2 mths, respectively; P = 0.01). On multivariate analysis, a low LMR (P = 0.008), the preoperative CT PCI value (P = 0.004), poor tumor differentiation (P = 0.023) and the preoperative CEA level (P < 0.001) were all independent variables associated with a worse OS after surgery. CONCLUSIONS: The baseline LMR value may have potential value as a selection tool for CRS-HIPEC in patients with CRC-related PC.

Comparison between laparoscopic and open Hartmann's reversal: results of a decade-long multicenter retrospective study.

BACKGROUND: Hartmann's reversal is a challenging surgical procedure with significant postoperative morbidity rates. Various surgical methods have been suggested to lower the risk of postoperative complications. In this study, we aimed to compare the postoperative results between open and laparoscopic techniques for Hartmann's reversal. METHODS: A retrospective study of all patients who underwent Hartmann's reversal in five centers in central Israel between January 2004 and June 2015 was conducted. Medical charts were reviewed, analyzing preoperative and operative parameters and short-term postoperative outcomes. RESULTS: 260 patients were included in the study. 76 patients were operated laparoscopically with a conversion rate of 26.3% (20 patients). No differences were found between patients operated laparoscopically and those operated in an open technique regarding gender (p = 0.785), age (61.34 vs. 62.64, p = 0.521), body mass index (26.6 vs. 26.2, p = 0.948), Charlson index score (1.79 vs. 1.95, p = 0.667), and cause for Hartmann's procedure (neoplastic vs. non-neoplastic, p = 0.644). No differences were seen in average time from the Hartmann's procedure to reversal (204.89 vs. 213.60 days, p = 0.688) and in overall complication rate (46.4 vs. 46.5%, p = 1). The Clavien-Dindo score for distinguishing between minor (0-2 score, p = 1) and major complications (3-5 score, p = 0.675) failed to demonstrate an advantage to laparoscopy, as well as to average length of stay (10.91 days in the laparoscopic group vs. 11.72 days in the open group, p = 0.529). An analysis based on the intention-to-treat with laparoscopy, including converted cases in the laparoscopic group, showed similar results, including overall complication rate (48.6 vs. 45.6%, p = 0.68) and Clavien-Dindo score in both minor (p = 0.24) and major complications (p = 0.44). Length of stay (10.92 vs. 11.81 days, p = 0.45) was also similar between the two groups. CONCLUSION: In this series, a laparoscopic approach to Hartmann's reversal did not offer any short-term advantage when compared to an open surgical approach.

A Single Tertiary Center 10-Year Experience in the Surgical Management of Gastrointestinal Bezoars.

BACKGROUND: Gastrointestinal (GI) bezoars are the most common foreign bodies causing obstruction in the GI tract. They are frequently seen following upper GI tract surgery and surgical intervention is required often. The aim of this study is to describe the surgical management of GI bezoars. MATERIALS AND METHODS: A retrospective cohort study, including all patients diagnosed with bezoars between May 2008 and May 2017, was conducted. Patient charts were reviewed, and demographics, clinical, surgical, and postoperative data were collected and analyzed. RESULTS: Forty-five patients were included, with a mean age of 62.04 years (Range 18-91). Thirty patients underwent previous surgery (66.6%), most commonly surgical interventions for peptic ulcer disease (22 patients, 73.3%). Obstruction was most common in the ileum (27 patients, 60%). Thirty-nine patients (86.7%) required surgical intervention. Laparoscopy was attempted in 20 patients (51.2%), but conversion to open procedure was required in 11 patients (55%). Postoperative complication rate was 41%. No preoperative factors were found to be correlated with postoperative complications. Postoperative complications were associated with a longer length of stay (P = .006) and a higher readmission rate (P = .04). Patients treated with laparoscopy tended to have a lower BMI (P = .04), less previous surgeries (P = .04), and a bezoar located more proximally (P = .03), however, laparoscopy showed no benefit in complications rate, readmissions, and length of stay. CONCLUSIONS: GI bezoars require surgical intervention at high rates. Postoperative complications are common. Completion of an upper GI endoscopy is important and should be performed at an early stage of management.

Hospital readmission rates and risk factors for readmission following cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal surface malignancies.

BACKGROUND: Cytoreductive surgery and Hyperthermic intra-peritoneal chemotherapy (CRS/HIPEC) for peritoneal surface malignancies is associated with high morbidity. The increased numbers of patients undergoing CRS/HIPEC in recent years mandates risk analysis and quality assurance. However, only scarce data exist regarding causative parameters for readmission. The aim of this study was to assess readmission rates and risk factors associated with readmission. METHODS: A retrospective-cohort study including patients from two high-volume centers who underwent CRS/HIPEC surgery between the years 2007-2016 was performed. Patients' demographics, peri-operative data and readmission rates were recorded. RESULTS: 223 patients were included in the study. The 7 and 30-day readmission rates were 3.5% (n = 8) and 11% (n = 25), respectively. Late readmission rates (up to 90 days) were 11% (n = 25). The most common causes of readmission were surgical related infections (35%), small bowel obstruction (17.5%) and dehydration (14%). Post-operative complications were associated with higher readmission rates (p = 0.0001). PCI score was not associated with higher rates of readmission. CONCLUSION: Readmissions following CRS/HIPEC occur mainly due to infectious complications and dehydrations. Patients following CRS/HIPEC should be discharged after careful investigation to a community based continuing care with access for IV fluid replacement or antibiotics administration when required.

Preoperative Nutritional Optimization for Crohn's Disease Patients Can Improve Surgical Outcome.

BACKGROUND: Preoperative preparation of patients with Crohn's disease is challenging and there are no specific guidelines regarding nutritional support. The aim of this study was to assess whether preoperative nutritional support influenced the postoperative outcome. METHODS: A retrospective, cohort study including all Crohn's disease patients who underwent abdominal surgery between 2008 and 2014 was conducted. Patients' characteristics and clinical and surgical data were recorded and analyzed. RESULTS: Eighty-seven patients were included in the study. Thirty-seven patients (42.5%) received preoperative nutritional support (mean albumin level 3.14 vs. 3.5 mg/dL in the non-optimized group; p < 0.02) to optimize their nutritional status prior to surgery. Preoperative albumin level, after adequate nutritional preparation, was similar between the 2 groups. The 2 groups differ neither in demographic and surgical data, overall post-op complication (p = 0.85), Clavien-Dindo score (p = 0.42), and length of stay (p = 0.1). Readmission rate was higher in the non-optimized group (p = 0.047). CONCLUSION: Nutritional support can minimize postoperative complications in patients with low albumin levels. Nutritional status should be optimized in order to avoid hazardous complications.

Dual versus Triple Antibiotics Regimen in Children with Perforated Acute Appendicitis.

INTRODUCTION: Acute appendicitis is the most common emergency condition in pediatric surgery. Historically, a triple-antibiotic therapy consisted of ampicillin, gentamicin, and clindamycin has been used postoperatively for perforated appendicitis. According to recently published trials, dual therapy consists of ceftriaxone and metronidazole only, offers a more efficient and cost-effective antibiotic management compared with triple therapy. Based on these results, our department applied dual antibiotic therapy for children with perforated appendicitis that underwent appendectomy from 2009 and forth. AIM: The aim of our study was to compare postoperative outcomes between patients treated with triple therapy (ampicillin, gentamicin, and metronidazole) (group A) versus dual therapy (ceftriaxone and metronidazole) (group B). METHODS: Clinical and laboratory data were retrospectively collected by review of the medical records for all children who underwent appendectomy for the perforated appendix at the Schneider Children's Medical Center of Israel, a tertiary pediatric care center between 2007 and 2011. Children with perforated appendicitis received antibiotic therapy in accordance with the hospital's guidelines that were valid at the time the surgery took place. In the first period (years 2007-2009) (group A) a triad of ampicillin, gentamicin, and metronidazole and the second period (2009-2011) (group B) dual therapy consists of ceftriaxone and metronidazole. The two groups were compared for outcome and complications, such as wound infections, changing of antibiotic therapy, and length of stay. RESULTS: During the study period 1,203 patients underwent an appendectomy. Of these, 175 patients were diagnosed with perforated appendix and were treated with postoperative antibiotic's regimen. Group A and group B consisted of 89 and 86 patients, respectively. The two groups were not different significantly in terms of demographic data, length of stay, or readmission rates. However, more rates of wound infection and changing of antibiotic therapy were seen in group B, although not statistically significant (p = 0.064). CONCLUSION: Dual antibiotic therapy for perforated appendicitis is a cost-effective and efficient mode of therapy compared with triple-antibiotic's regimen. However, prospective studies are required to determine whether this policy is associated with higher rates of wound infections and change in antibiotic therapy.

Considerations for Hartmann's reversal and Hartmann's reversal outcomes-a multicenter study.

PURPOSE: Hartmann's procedure is commonly practiced in emergent cases with the restoration of bowel continuity planned at a second stage. This study assessed the rate of restorations following Hartmann's procedure and evaluated factors affecting decision-making. METHODS: Data on patient demographics, comorbidities, causes for Hartmann's procedure, reversal rate, and complications were collected in a multicenter retrospective cohort study of patients who underwent Hartmann's procedure in five medical centers. RESULTS: Six hundred forty patients underwent Hartmann's procedure for diverticular disease (36.1%), obstructing malignancy (31.8%), benign obstruction (5%), and other reasons (23.1%). Overall, 260 (40.6%) patients underwent subsequent restoration of bowel continuity. One hundred twenty-one (46.5%) patients had post-reversal complications, with an average Clavien-Dindo score of 1.4 and a mortality rate of 0.77%. Decision to avoid reversal was mostly related to comorbidities (49.7%) and metastatic disease (21.6%). Factors associated with the decision to restore bowel continuity included male gender (P = 0.02), patient age (62.3 years in Hartmann's reversal patients vs 73.5 years in non-reversal patients; P < 0.0001), number of comorbidities (1.1 vs 1.58; P < 0.001), average Charlson score (1.93 vs 3.44; P < 0.001), and a neoplastic etiology (P < 0.0001). A sub-analysis excluding all patients who died in the 30 days following Hartmann's procedure showed similar factors associated with ostomy closure. CONCLUSION: Many patients do not have restoration of bowel continuity after undergoing Hartmann's procedure. Hartmann's reversal is associated with a significant postoperative morbidity. Surgeons and patients should be aware of the possibility that the colostomy might become permanent.

The effect of pre-operative optimization on post-operative outcome in Crohn's disease resections.

BACKGROUND: The timing of surgical intervention in Crohn's disease (CD) may depend on pre-operative optimization (PO) which includes different interventions to decrease the risk for unfavourable post-operative outcome. The objective of this study was to investigate the effect of multi-model PO on the post-operative outcome in CD. METHOD: This is a multicentre retrospective cohort study. The primary outcome was 30-day post-operative complications. Secondary outcomes were intra-abdominal septic complications, surgical site infection (SSI), re-operation, length of post-operative stay in a hospital and re-admission. PO included nutritional support, discontinuation of medications, pre-operative antibiotic course and thrombosis prophylaxis. RESULTS: Two hundred and thirty-seven CD elective bowel resections were included. Mean age was 39.9 years SD 14.25, 144 (60.8 %) were female and 129 (54.4 %) had one or more types of medical treatment pre-operatively. Seventy-seven patients (32.5 %) optimized by at least nutritional support or change in pre-operative medications. PO patients were more likely to have penetrating disease phenotype (p = 0.034), lower albumin (p = 0.015) and haemoglobin (p = 0.021) compared to the non-optimized. Multivariate analyses showed that treatment with anti-TNF alpha agents OR 2.058 CI [1.043-4.4.064] and low haemoglobin OR 0.741 CI [0.572-0.0.961] increased the risk of overall post-operative complications. Co-morbidity increased the risk of SSI OR 2.567 CI [1.182-5.576] while low haemoglobin was a risk factor for re-admission OR 0.613 CI [0.405-0.926]. Low pre-operative albumin correlated with longer stay in hospital. CONCLUSIONS: PO did not change post-operative outcome most likely due to selection bias. Anti-TNF alpha agents, low haemoglobin, low albumin and co-morbidity were associated with unfavourable outcome.

Teaching Laparoscopic Adrenalectomy to Surgical Residents.

INTRODUCTION: Laparoscopic adrenalectomy is the surgical treatment for various adrenal diseases. The procedure is a common surgical practice for urologists and general surgeons and requires fundamental laparoscopic skills, nowadays common in the surgical education of residents in these practices. The aim of this study is to assess whether laparoscopic adrenalectomy differs in outcome between certified and trained surgeons and surgical residents and whether the learning curve changes the endpoint of the surgery. MATERIALS AND METHODS: A cohort retrospective study, including all adult patients who underwent laparoscopic adrenalectomy between June 2008 and June 2014, was conducted. Patients' demographic, clinical, and surgical data were recorded and analyzed. RESULTS: Fifty-three patients were included in the database (21 men, 32 women) with a mean age of 54 years (range 17-77). The cause for surgery was most commonly a benign adrenal tumor (27 patients, 50.9%) followed by large nonfunctioning adrenal tumors (16 patients, 30.1%), and adrenal cancer (8 patients, 15%). Eighteen patients (33.9%) were operated by residents (4-6 years into the residency) and 35 patients by a certified senior surgeon (66.1%). Left-sided adrenalectomy was preferred to right-sided adrenalectomy for resident tutoring (P = .03). Overall, intraoperative complications were seen in 6 patients (11.3%) and postoperative complications were seen in 9 patients (16.9%). There were no differences in operation time (P = .36), intraoperative complications (P = .76), postoperative complications (P = .96), and length of stay (P = .34) between the patients operated by senior residents and certified surgeons. CONCLUSION: Laparoscopic adrenalectomy is a complex surgical procedure that should be a part of the surgical training of surgery residents, as it is safe in guided hands.