Laparoscopic Versus Open Re-operations Within 30 Days After Lower Gastrointestinal Tract Surgery: a Retrospective Comparative Study.

BACKGROUND: Re-operations within 30 days after lower gastrointestinal tract surgery are associated to high morbidity and mortality. Laparoscopic approach has been reported as feasible and safe in selected patients, but comparative data to laparotomy are scarce. The aim of this study was to review our experience in laparoscopic re-operations and compare it to laparotomy. METHODS: From January 2012 to December 2016, patients undergoing a re-operation within one month after lower gastrointestinal tract surgery were included and divided into laparoscopy and laparotomy groups. The primary endpoint was successful re-operation, defined as recovery without any of the following: conversion to laparotomy, need of further invasive treatments or death. Secondary outcomes were the length of hospital stay and 30-day morbidity and mortality. Demographic, clinical and surgical characteristics were collected and analyzed. RESULTS: Out of 114 patients who underwent a re-operation, 71 met the inclusion criteria. Thirty (42%) patients underwent laparoscopy and 41 (58%) laparotomy. Thirty (42%) patients were male and median age was 72.0 years-old. The initial operation was elective in 24 (34%) patients, and 50% of the initial operations were colorectal resections in both groups. Multivariate analyses showed that type of approach did not affect the re-operation success rate. Laparotomy was an independent predictor of prolonged hospital stay (OR 3.582, 95%CI 1.191-10.776, p = 0.023) and mortality (OR 13.123, 95%CI 1.301-131.579, p = 0.029). CONCLUSIONS: Re-operations within 30 days after lower gastrointestinal tract surgery may be safe in selected patients, as effective as laparotomy, and associated with shorter hospital stay and lower mortality rates.

Traumatic perforated duodenal diverticulum after a fight, a case report.

INTRODUCTION: Fewer than 200 cases of Perforated Duodenal Diverticulum ("PDD") have been reported in the literature. The percentage of caused by trauma is generally very low and similar to rates recorded for duodenal injuries caused by trauma in the absence of diverticula (3 %-5 %). As a rare cause of abdominal pain after trauma, perforated duodenal diverticula are seldom diagnosed preoperatively. Despite preoperative CT scan demonstrating duodenal perforation, a diverticular origin is often only identified intraoperatively. PRESENTATION OF CASE: A 36-year-old man was admitted to the emergency department with severe upper abdominal pain that began after blunt trauma by a kick to his upper abdomen during a fight. A duodenal injury was identified by CT. Exploratory laparotomy then revealed a retroperitoneal perforation of a diverticulum located at the second segment of the duodenum. DISCUSSION: A review of the literature found few cases reporting perforated duodenal diverticulum secondary to trauma. Most cases identified the diverticulum at intraoperative exploration, with most approaches being through open surgery. CONCLUSION: Perforation of a duodenal diverticulum secondary to trauma is an extremely rare event, which is why it is often overlooked in the differential diagnosis of acute abdomen. As the presenting signs are often suggestive of duodenal perforation without a clear notion of duodenal diverticula at CT scan, a surgical approach and exploration is most frequently described. In our experience, the management of traumatic PDD aligns with the literature favoring the open surgical approach.

Early peristomal complications: detailed analysis, classification and predictive risk factors.

INTRODUCTION: Peristomal complications are frequently neglected by surgeons. Our aim was to assess peristomal complications occurring within 30 days after surgery and identify predictive risk factors. METHODS: All patients who underwent stoma creation from January 2014 to June 2016 in our institution were included unless patients who died, had their stoma reversed or were lost to follow-up. Peristomal complications were retrospectively analysed using a photography database, a validated scale for peristomal skin lesions and the Clavien-Dindo score. Peristomal complications were categorized as absent, mild or relevant. Univariate and multivariate analysis were performed to identify risk factors for a) incidence of and b) persistence of relevant peristomal complications at 30 postoperative days. RESULTS: 111 patients were included, 16 (14%) patients had mild and 65 (59%) patients had relevant complications. The most common event was mucocutaneous separation in 57 (51%) patients. Complications were still present at 30 days in 36 (32%) patients. Double-barrel (vs end stoma) was an independent risk factor for significant morbidity (OR=2.394 (95%CI=1.082-5.293), p=0.030). Persistence of relevant complications at 30 days was more likely associated to urgent surgery (OR=4.239 (95%CI=1.105-16.257), p=0.035) and to ASA score III/IV (OR=5.963 (95%CI=1.447-24.569), p=0.013). Male sex (OR=0.246 (95%CI=0.069-0.874), p=0.030) and age over 70 years (OR=0.121 (95%CI=0.029-0.515), p=0.004) appeared to be protective. CONCLUSIONS: Early peristomal complications are common, usually mild. They are most likely to persist beyond 30 days in patients operated as emergencies and with an ASA score of III-IV. KEY WORDS: Complications, Complications, Stoma, Mucocutaneous separation.