Partial staple line reinforcement with synthetic buttressing material in laparoscopic sleeve gastrectomy: a propensity score-matched analysis.

PURPOSE: Staple line leakage (SLL) and staple line bleeding (SLB) are the most relevant postoperative complications of sleeve gastrectomy (SG). It is controversial whether and which method of staple line reinforcement (SLR) can best reduce these complications. The primary objective of this study was to investigate whether reinforcement of the most proximal part of the staple line with synthetic buttressing material, a strategy we termed partial SLR (p-SLR), reduces the 30-day incidence of SLL. METHODS: A retrospective search of medical records of all bariatric patients from 2010 to 2019 was performed. Patients who underwent SG with either p-SLR or non-SLR were included. Intraoperative and postoperative outcomes were analyzed before and after propensity score matching (PSM). RESULTS: Data from 431 patients were analyzed (364 in the p-SLR group and 67 in the non-SLR group). No difference in the 30-day incidence of SLL was observed between the two groups. The 30-day incidence of SLB (1.1% vs. 6.0% in the p-SLR and non-SLR groups, respectively) was significantly lower in the p-SLR group. These results were confirmed by PSM analysis. CONCLUSION: Partial staple line reinforcement with synthetic buttressing material does not reduce the 30-day incidence of SLL. Although our analysis showed a significant reduction in the 30-day incidence of SLB in the p-SLR group, this result should be interpreted with caution.

Effects of short or long biliopancreatic limb length after laparoscopic Roux-en-Y gastric bypass surgery for obesity: a propensity score-matched analysis.

PURPOSE: Although recent studies reported superior weight reduction in patients undergoing Roux-en-Y gastric bypass (RYGB) with long biliopancreatic limb (BPL), no recommendation regarding limb lengths exists. This study compares weight loss and resolution of obesity-related comorbidities in patients undergoing RYGB with either long or short BPL. METHODS: A retrospective data search from medical records was performed. A total of 308 patients underwent laparoscopic RYGB with a BPL length of either 100 cm or 50 cm. Data was analyzed before and after propensity score matching. RESULTS: No statistically significant difference in weight reduction between long and short BPL RYGB in terms of percentage of excess weight loss (%EWL) (86.4 ± 24.5 vs. 83.4 ± 21.4, p = 0.285) and percentage of total weight loss (%TWL) (32.4 ± 8.4 vs. 33.0 ± 8.3, p = 0.543) was found 24 months after surgery. Propensity score-matched analysis did not show any statistically significant difference between groups in both %EWL and %TWL. No significant difference between long and short BPL RYGB in the resolution of obesity-related comorbidities was noted 24 months after surgery. CONCLUSION: Weight loss and resolution of obesity-related comorbidities were not significantly different between long and short BPL RYGB 24 months after surgery.

Gallbladder Retrieval From Epigastric Versus Umbilical Port in Laparoscopic Cholecystectomy: A PRISMA-Compliant Meta-Analysis.

Purpose. To date, no evidence supports the retrieval of the gallbladder through a specific trocar site, and this choice is left to surgeons' preference. The aim of this meta-analysis was to investigate the influence of the trocar site used to extract the gallbladder on postoperative outcomes. Methods. According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a literature search of PubMed, Google Scholar, Cochrane Library, and EMBASE databases was performed. Terms used were: ("gallbladder" OR "cholecystectomy") AND "umbilical" AND ("epigastric" OR "subxiphoid"). Randomized trials comparing the gallbladder retrieval from different trocar sites were considered for further analysis. Results. Literature search revealed 145 articles, of which 7 matched inclusion criteria and reported adequate data about postoperative pain, operative time, port-site infections, and hernias. A total of 876 patients were included, and the gallbladder was extracted through epigastric or umbilical trocar site in 441 and in 435 patients, respectively. A statistically significant difference among groups was noted in terms of postoperative pain at 1, 6, 12, and 24 hours in favor of the umbilical trocar site (P < .001). No significant differences were noted in postoperative hernia and infection rate, nor in terms of operative time. Conclusions. This meta-analysis shows a statistically significant reduction in terms of postoperative pain at 1, 6, 12, and 24 hours after surgery when the gallbladder is extracted through the umbilical port. Retrieval time, infections, and hernias rate implicate no contraindication for the choice of a specific trocar site to extract specimens. Despite limitations of this study, the umbilical trocar should be favored as the first choice to retrieve the gallbladder.

Surgical Residents' Proficiency and Turnover May Affect the Overall Efficiency in an Emergency Department.

BACKGROUND: Within Emergency Department (ED), problem responsiveness and organizational capacity are extremely important for providing acute care. The "July effect" has been described as the period when junior doctors start new turnovers, possibly reflecting on hospital and ED efficiency. The objective of this study was to investigate the impact of residents' turnover on ED efficiency at a Swiss teaching hospital. METHODS: We retrospectively evaluated patients presenting with surgical needs to ED from June 2014 to January 2019. Data regarding gender, age, length of stay (LOS), resident doctors and level of urgency were collected and analyzed. RESULTS: We identified 27,767 surgical admissions treated by 92 residents. The LOS analysis within residents' period in the ED showed a progressive reduction over time, with 80% of proficiency achieved after 98 patients. The mean LOS was 257.3 and 237.6 min during and after the learning curve (p < 0.0001), although no difference was noted in triage level 1 patients (p = 0.813). By replacing 40-70% of residents (January and July), the LOS raised from 243.1 to 259.7 min (absolute difference 16.6 min, p < 0.001), but if only 10-20% of residents newly started, no difference was detected (p = 0.071). CONCLUSIONS: Our study demonstrates that surgical residents' turnover within the ED could affect the overall efficiency. The training period for new resident physicians was a caseload of 98 patients, respectively, 3 weeks of work. The impact of trainees' turnover was only relevant if more than 40% of the resident team is replaced at one time and only less urgent cases were affected.

Is the cortical thickness index a valid parameter to assess bone mineral density in geriatric patients with hip fractures?

INTRODUCTION: Reduced bone quality is a common problem during surgical fixation of geriatric hip fractures. The cortical thickness index (CTI) was proposed to assess the bone mineral density (BMD) of the proximal femur on the basis of plain X-rays. The purpose of this study was to evaluate the inter- and intraobserver reliability of the CTI and to investigate correlation between CTI and BMD in geriatric patients. METHODS: 60 patients (20 pertrochanteric fractures, 20 femoral neck fractures, 20 without fractures) were included. All patients had ap and lateral hip X-rays and measurement of BMD by Dual Energy X-ray Absorptiometry at different areas of the hip. The ap and lateral CTI was measured twice by four blinded observers and correlation between mean CTI and BMD was calculated. RESULTS: Mean ap CTI was 0.52 and mean lateral CTI was 0.45. Inter- and intraobserver reliability was good for ap CTI (ICC 0.71; 0.79) and lateral CTI (ICC 0.65; 0.69). A significant correlation between CTI and overall BMD was found in patients without fractures (r = 0.74; r = 0.67). No significant correlation between CTI and overall BMD was found in patients with proximal femoral fractures. CONCLUSION: The CTI has sufficient reliability for the use in daily practice. It showed significant correlation with BMD in patients without hip fractures. In patients with proximal femoral fractures, no correlation between CTI and BMD was found. We do not recommend the CTI as parameter to assess the BMD of the proximal femur in geriatric patients with hip fractures.

Effect of three-dimensional computed tomography reconstructions on reliability.

BACKGROUND: This study evaluated the impact of three-dimensional (3D) volume-rendering computed tomography (CT) reconstructions on the inter- and intraobserver reliability of six commonly used classification systems in the assessment of calcaneal fractures. METHODS: Four independent observers with different levels of clinical training evaluated 64 fractures according to the classifications of the Orthopaedic Trauma Association (OTA), Essex-Lopresti, Sanders, Crosby, Zwipp, and Regazzoni, using two-dimensional (2D) CT scans with multiplanar reconstructions and 3D volume-rendering reconstructions. RESULTS: Interobserver reliability was moderate for the OTA, Essex-Lopresti, Sanders, Crosby, and Regazzoni classifications with 2D CT scans and 3D CT reconstructions. The Zwipp classification was poor with 2D CT scans and improved to moderate with 3D reconstructions. Intraobserver reliability with 2D CT scans was good for the Essex-Lopresti classification and moderate for the OTA, Sanders, Crosby, Zwipp, and Regazzoni classifications. After the addition of 3D reconstructions, all classifications showed moderate intraobserver reliability. CONCLUSION: According to the findings of this study, the additional use of 3D reconstructions is of minor value when used in conjunction with the classifications of the OTA, Sanders, Crosby, Regazzoni, and Essex-Lopresti. If calcaneal fractures are assessed with the Zwipp classification, 3D reconstructions could be used to achieve comparable reproducibility compared to other classifications. CLINICAL RELEVANCE: 3D reconstructions may have other benefits not evaluated in the presented study and may give useful information not captured by current classification systems.

[Can Uncomplicated Adult Appendicitis Also Be Treated Conservatively?] / Kann die unkomplizierte Appendizitis des Erwachsenen auch konservativ behandelt werden?

Can Uncomplicated Adult Appendicitis Also Be Treated Conservatively? Abstract. For more than a century, appendectomy has been the first-line treatment for acute appendicitis. Despite modern imaging, it is not an easy disease to diagnose and is one of the most common emergency procedures worldwide. Conservative therapy for uncomplicated adult appendicitis is increasingly becoming the focus of discussion. Due to current data, a recommendation for conservative therapy of uncomplicated adult appendicitis can not be given. For the time being it should be reserved for a selected patient group.

Jejunal Diverticulosis Probably Leading to Pylephlebitis of the Superior Mesenteric Vein.

Thrombophlebitis of the portal vein (pylephlebitis) is a rare but serious condition with a high mortality rate of 11-50%. A 56-year-old male patient presented with a two-day history of postprandial, colic-like epigastric pain, nausea, fever, chills, and diarrhea. Clinical workup showed peritonism, leukocytosis, and elevated C-reactive protein (CRP). A computed tomography (CT) scan revealed a long-segment, partial thrombosis of the superior mesenteric vein as well as gas in the portal venous system. Additionally, extensive jejunal diverticulosis was present. Pylephlebitis mostly results from intestinal infections, e.g., appendicitis or diverticulitis. We assumed that the patient had suffered from a self-limiting episode of jejunal diverticulitis leading to septic thrombosis. Initially, antibiotic therapy and anticoagulation with heparin were administered. The patient deteriorated, and due to increasing abdominal defense, fever, and hypotension, a diagnostic laparoscopy was performed. Bowel ischemia could be ruled out, and after changing antibiotic therapy, the patient's condition improved. He was discharged without any further complications and without complaints on day 13. An underlying coagulopathy like myeloproliferative neoplasm or antiphospholipid syndrome could be ruled out.

Faecopneumothorax Caused by Perforated Diaphragmatic Hernia.

Incarcerated diaphragmatic hernias with intrathoracic perforation of the colon is a very rare but serious surgical emergency. A 78-year-old male patient presented to our emergency department with severe abdominal pain. A computer tomography (CT) scan revealed herniation of the left transverse colon and spleen into the thorax with colon perforation and fecal contents in the thoracic cavity. An emergent laparotomy confirmed the radiological diagnosis and showed a 6 cm dehiscence of the left diaphragm with strangulation of the left transverse colon as well as the spleen. A left-sided hemicolectomy with terminal transversostomy and splenectomy were performed. The diaphragm was closed with interrupted nonabsorbable sutures. We abstained from reinforcement of the suture line with a mesh because of the feculent contamination of the abdominal cavity. After extensive thoracoscopic lavage and insertion of two chest tubes, the patient was transferred to the intensive care unit. Diaphragmatic hernia even after a mild chest trauma can cause fatal complications. Diagnosis and treatment can be challenging and an interdisciplinary approach is recommended. Due to the associated comorbidity and long-lasting sequelae, we believe the awareness of this rare pathology as a differential diagnosis is important; both as an abdominal and thoracic emergency.