Surgery News
Major haemorrhagic complications of acute pancreatitis
Haemorrhage is a rare, potentially fatal complication in acute pancreatitis (AP). The aim was to investigate the incidence, management and outcome related to this complication.
Fourteen (1·0 per cent) of 1356 patients diagnosed with AP developed major haemorrhage. Angiography established the diagnosis in four of six patients. Embolization was successful in one patient. Surgery was performed in two patients. Sentinel bleeding occurred in three of four patients with major postoperative bleeding. The overall mortality rate was 36 per cent (5 of 14 patients). Haemorrhage presenting after more than 7 days was associated with a higher mortality rate of 80 per cent (4 of 5 patients). A fatal outcome was at least three times more likely in patients with severe AP and haemorrhagic complications than in those with severe AP but no bleeding.Concluding major haemorrhagic complications of AP are rare, but clinically important. Major postoperative bleeding is often preceded by sentinel bleeding. Intra-abdominal haemorrhage presenting more than 1 week after disease onset is a highly fatal complication.
The value of pre-operative magnetic resonance cholangiopancreatography (MRCP) in management of patients with gall stones
This article analyzed the influence of pre-operative MRCP on the management of patients with gall stones through a prospective randomized study was carried on 250 patients who underwent laparoscopic cholecystectomy within 3 years. It found that MRCP is diagnostically useful in management of patients with gall stones prior to laparoscopic cholecystectomy and its routine use can reduce the incidence of post-operative complications.
Randomized comparison of Limberg flap versus modified primary closure for the treatment of pilonidal disease
The best surgical technique for sacrococcygeal pilonidal disease is still controversial. The aim of this randomized prospective trial was to compare both the results of Limberg flap procedure and primary closure.
Success of surgery was achieved in 84.62% of Limberg flap patients versus 77.69% of primary closure for which the surgical time for primary closure was shorter, also having a higher wound infection was more frequent in the primary closure group (P = .0254), but experienced less postoperative pain (P < .0001). Recurrence was observed in 3.84% versus 0% in the primary closure versus Limberg flap group. These results do not show a clear benefit for surgical management by Limberg flap or primary closure. Limberg flap showed less convalescence and wound infection; our technique of tension-free primary closure was a day case procedure, less painful, and shorter than Limberg flap.
Peripherally Inserted Central Catheters May Lower the Incidence of Catheter-Related Blood Stream Infections in Patients in Surgical Intensive Care Units
Long-term central venous catheterization is associated with a higher rate of catheter-related blood stream infections (CR-BSI). It is unclear whether there is a difference in the CR-BSI rate associated with central venous catheters (CVCs) and peripherally inserted central catheters (PICCs) in long-stay patients in surgical intensive care units (SICUs). This article hypothesized that PICC use reduces the rate of CR-BSI compared with use of antiseptic CVCs in these patients. In this non-randomized study, PICC was associated with fewer CR-BSIs in long-stay SICU patients, although CVCs were in place longer than PICC lines. The only predictor of CVC infection was the duration the line was in place. These results suggest that minimizing the duration of central venous access and substituting PICC for CVC may reduce the incidence of CR-BSI in long-stay SICU patients.
Computed tomographic colonography in the diagnosis of colorectal cancer
This study aimed to determine the sensitivity of computed tomographic colonography (CTC) in diagnosing colorectal cancer and to explore the reasons why these cancers are missed on CTC. Patients who underwent CTC in the 56-month period from 1 January 2004 to 1 September 2008, and all cases of colorectal cancer recorded in the National Cancer Registry database from 1 January 2004 to 1 December 2008, were identified. Overall the sensitivity of 95 per cent for CTC in the diagnosis of colorectal cancer compares favourably with that of double-contrast barium enema (92 per cent) and colonoscopy (94 per cent).
Routine Ultrasound and Limited Computed Tomography for the Diagnosis of Acute Appendicitis
Acute appendicitis continues to be a challenging diagnosis. Preoperative radiological imaging using ultrasound (US) or computed tomography (CT) has gained popularity as it may offer a more accurate diagnosis than classic clinical evaluation. The optimal implementation of these diagnostic modalities has yet to be established. The aim of the present study was to investigate a diagnostic pathway that uses routine US, limited CT, and clinical re-evaluation for patients with acute appendicitis. Positive and negative predictive values for the clinical diagnosis of appendicitis were 63 and 98%, respectively; for US 94 and 97%, respectively; and for CT 100 and 100%, respectively. The negative appendicitis rate was 3.3%, the perforation rate was 23.5%, and the missed perforated appendicitis rate was 3.4%. This study showed a diagnostic pathway using routine US, limited CT, and clinical re-evaluation for patients with acute abdominal pain can provide excellent results for the diagnosis and treatment of appendicitis.
Postoperative Calcium Requirements in 6,000 Patients Undergoing Outpatient Parathyroidectomy: Easily Avoiding Symptomatic Hypocalcemia
This study sought to determine the amount and duration of supplemental oral calcium for patients with varying clinical presentations discharged immediately after surgery for primary hyperparathyroidism. Overall there were seven parameters found to have a substantial impact on the amount of calcium required to prevent symptomatic hypocalcemia: preoperative serum calcium >12 mg/dL, >13 mg/dL, and >13.5 mg/dL, bone density T score less than −3, morbid obesity, removal of >1 parathyroid, and manipulation/biopsy of all remaining glands (all p < 0.05). Each independent variable increased the daily calcium required by 315 mg/day. Using our scaled protocol, <8% of patients showed symptoms of hypocalcemia, nearly all of whom were successfully self-treated with additional oral calcium. Only 6 patients (0.1%) required a visit to the emergency room for IV calcium, all occurring on postoperative day 3 or later.
Role of Prophylactic Antibiotics in Laparoscopic Cholecystectomy and Risk Factors for Surgical Site Infection
The aim of this clinical trial was to determine whether prophylactic antibiotics could prevent surgical site infection (SSI) after laparoscopic cholecystectomy and to identify any risk factors for infection. The study included 100 patients undergoing laparoscopic cholecystectomy. They were randomized to receive either a single dose of ceftriaxone or physiologic saline as placebo. It was shown that a single dose of prophylactic antibiotic failed to decrease the likelihood of SSI after laparoscopic cholecystectomy.
Tranexamic Acid Reduces Mortality in Trauma Patients
Tranexamic acid may be an effective option for reducing bleeding and mortality among trauma patients, without increasing the risk of serious complications such as myocardial infarction, stroke, or pulmonary embolism, according to a study published online June 15 in The Lancet.
Diagnosis of Necrotizing Soft Tissue Infections by Computed Tomography
In contrast to previous beliefs, an article in this weeks Archives of Surgery hypothesized that computed tomography (CT) scanning is sensitive and specific for the diagnosis of necrotizing soft tissue infections (NSTIs). Patients who were clinically suspected of having NSTIs from January 1, 2003, through April 30, 2009, and who underwent imaging with a 16- or 64-section helical CT scanner were studied. Of 67 patients with study inclusion criteria, 58 underwent surgical exploration, and NSTI was confirmed in 25 (43%). The remaining 42 patients had either nonnecrotizing infections during surgical exploration (n = 33) or were treated nonoperatively with successful resolution of the symptoms (n = 9). The sensitivity of CT to identify NSTI was 100%, specificity was 81%, positive predictive value was 76%, and negative predictive value was 100% concluding that a negative CT result reliably excludes the diagnosis of NSTI while a positive CT result correctly identifies the disease with a high likelihood.
Splenectomy leads to a persistent hypercoagulable state after trauma
It was hypothesized that splenectomy following trauma results in hypercoagulability. A prospective, nonrandomized, single-center study was performed to evaluate coagulation parameters in trauma patients with splenic injury. Overall it was found that fibrinogen was elevated, tissue plasminogen activator, plasminogen activator inhibitor–1, and activated partial thromboplastin time were higher in splenectomy patients and baseline thromboelastography showed faster fibrin cross-linking and enhanced fibrinolysis following splenectomy. The study also found that deep venous thrombosis developed in 7% of splenectomy patients and no control patients.
Screening for abdominal aortic aneurysms shows cost effectiveness
An article in this months British Journal of Surgery sought to estimate long-term mortality benefits and cost-effectiveness of screening for abdominal aortic aneurysm (AAA) in men aged 64-73 years. 6306 men were invited for abdominal ultrasonography at a regional hospital. Mortality and AAA-related interventions were recorded in national databases. The relative risk reduction of the screening programme in AAA-related mortality was 66 per cent (hazard ratio 0·34, 95 per cent confidence interval (c.i.) 0·20 to 0·57). The corresponding risk reduction in all-cause mortality was 2 per cent showing that there was a mortality benefit of screening for AAA in men aged 64-73 years that it was maintained in the longer term and screening was cost effective.
Failure to Perform Cholecystectomy for Acute Cholecystitis in Elderly Patients Is Associated with Increased Morbidity, Mortality, and Cost
Cholecystectomy during initial hospitalization is the current recommended therapy for acute cholecystitis. The rate of cholecystectomy and subsequent health care trajectory in elderly patients with acute cholecystitis has not been evaluated. An article in this months American College of Surgeons used 5% national Medicare sample claims data from 1996 to 2005 to identify a cohort of patients aged 66 years and older, requiring urgent or emergent admission for acute cholecystitis. The results of the study demonstrated that 25% of cholecystectomies on Medicare beneficiaries were not performed on initial hospitalization, leading to readmissions in 38% of surviving patients. For patients requiring readmission, the percentage of open procedures was increased, and the additional Medicare payment was $7,000 per re-admission. Cholecystectomy for acute cholecystitis in elderly patients should be performed during initial hospitalization to prevent recurrent episodes of cholecystitis, multiple readmissions, higher readmission rates, and increased costs.
Comparison of Laparoscopic and Open Repair With Mesh for the Treatment of Ventral Incisional Hernia
Laparoscopic repair of ventral incisional hernias has not been proved to be safer than open mesh repair. An article in this weeks Archives of Surgery published a prospective randomized trial that looked at one hundred sixty-two patients with ventral incisional hernias. Of the 162 randomized patients, 146 underwent surgery (73 open and 73 laparoscopic repairs). Surgical site infection through 8 weeks was less common in the laparoscopic group (5.6% vs 23.3%; AOR, 0.2; 95% CI, 0.1-0.6). The mean worst pain score in the laparoscopic group was 15.2 mm lower on a visual analog scale at 52 weeks (95% CI, 1.0-29.3; P = .04). Time to resume work activities was shorter for the laparoscopic group than for the open repair group (median, 23.0 days vs 28.5 days), with an adjusted hazard ratio of 0.54 (95% CI, 0.28-1.04; P = .06). Overall recurrence at 2 years was 12.5% in the laparoscopic group and 8.2% in the open repair group (AOR, 1.6; 95% CI, 0.5-4.7; adjusted P = .44).
Bacteremia Increases the Risk of Death among Patients
with Soft-Tissue Infections
Soft-tissue infections traditionally have been viewed as carrying a lower risk of death than other
types of infection such as pneumonia, blood stream, and intra-abdominal. The influence of secondary bacteremia on the outcomes of patients with soft-tissue infections is not well described.
This articel sought to describe the risk factors for bacteremia among patients admitted to an urban medical center with
soft-tissue infections and the influence of bacteremia on outcomes through a retrospective cohort study of 717 patients with culture-positive non-necrotizing soft-tissue infections
admitted between April 1, 2005, and December 31, 2007.
The results showed that bBacteremia was present in 52% of the patients. Increasing age, previous hospitalization, decubitus or
lower-extremity ulcers, device-related soft-tissue infection, and polymicrobial infection were independent predictors
of bacteremia. Intensive care unit admission, lower-extremity ulcer , and bacteremia were independent predictors of in-hospital death. When patients with device-related soft-tissue infections
were excluded, the rate of secondary bacteremia was 37.6%, and it remained an independent predictor
of in-hospital death.
Overall this study showed that the occurrence of bacteremia in soft-tissue infections is associated with a greater risk of death. Health
care providers should be aware of the risk factors for bacteremia in patients with soft-tissue infections in order to
provide more appropriate initial antimicrobial therapy and to ascertain its presence as a prognostic indicator.
Endovascular versus Open Repair of Abdominal Aortic Aneurysm
Few data are available on the long-term outcome of endovascular repair of abdominal aortic aneurysm as compared with open repair. An article in this weeks New England Journal of Medicine randomly assigned 1252 patients with large abdominal aortic aneurysms (5.5 cm in diameter) to undergo either endovascular or open repair; 626 patients were assigned to each group. Patients were followed for rates of death, graft-related complications, reinterventions, and resource use until the end of 2009. Logistic regression and Cox regression were used to compare outcomes in the two groups. The 30-day operative mortality was 1.8% in the endovascular-repair group and 4.3% in the open-repair group (adjusted odds ratio for endovascular repair as compared with open repair but by the end of follow-up, there was no significant difference between the two groups in the rate of death from any cause.
Percent Body Fat and Prediction of Surgical Site Infection
Obesity is a risk factor for surgical site infection (SSI) after elective surgery. Body mass index (BMI) is commonly used to define obesity (BMI ≥30 kg/m2), but percent body fat (%BF) (obesity is >25%BF [men]; >31%BF [women]) might better predict SSI risk because BMI might not reflect body composition and an article in this month's Journal of American College of Surgeons evaluated this. Overall Obesity, defined by %BF, is associated with a 5-fold increased SSI risk. This risk increases as %BF increases. %BF is a more sensitive and precise measurement of SSI risk than BMI. Additional studies are required to better understand this relationship.
Chlorhexidine Whole-Body Bathing Decreases Hospital-Acquired Infections Among Trauma Patients
To demonstrate whether daily bathing with cloths impregnated with 2% chlorhexidine gluconate will decrease colonization of resistant bacteria and reduce the rates of health care–associated infections in critically injured patients an article in the Archives of Surgery performed a Retrospective analysis and found Patients receiving chlorhexidine baths were significantly less likely to acquire a catheter-related bloodstream infection than comparators (2.1 vs 8.4 infections per 1000 catheter-days, P = .01). The rate of colonization with MRSA (23.3 vs 69.3 per 1000 patient-days, P < .001) and Acinetobacter (1.0 vs 4.6 per 1000 patient-days, P = .36) was significantly lower in the chlorhexidine group than in the comparison group.
Endoscopic versus open component separation in complex abdominal wall reconstruction
Open component separation has a high wound complication rate. Newer endoscopic approaches are described with no comparative trials. A study out of the American Journal of Surgery completed retrospective review (2005–2009) of patients undergoing open or endoscopic component separation was performed. It concluded that Open and endoscopic components separation have similar rates of recurrence. The endoscopic group had shorter lengths of stay and less major wound complications. The endoscopic approach may be the ideal technique for complex abdominal wall reconstruction.
Insurance Coverage Is Associated with Mortality after Gunshot Trauma
An article in this months American College of Surgeons hypothesized that insurance coverage is also associated with mortality after gunshot trauma and found that Despite similar injury severity, uninsured trauma patients were more likely to die after gunshot injury than insured patients. The in-hospital mortality rate was significantly higher for uninsured patients than for insured patients (9% vs 6%, p = 0.02). After controlling for age, gender, race, and injury severity by logistic regression analysis, the odds ratio for death of uninsured patients was 2.2 (95% CI 1.1 to 4.5).
Therapeutic role of water-soluble contrast agent in adhesive small bowel obstruction
A meta-analysis out of the British Journal of Surgery assessed the diagnostic and therapeutic role of water-soluble contrast agent (WSCA) in adhesive small bowel obstruction (SBO). The appearance of contrast in the colon within 4-24 h after administration had a sensitivity of 96 per cent and specificity of 98 per cent in predicting resolution of SBO. It concluded that water-soluble contrast was effective in predicting the need for surgery in patients with adhesive SBO. In addition, it reduced the need for operation and shortened hospital stay.
Risk Factors for Treatment Failure in Patients Receiving Vancomycin for Hospital-Acquired Methicillin-Resistant Staphylococcus aureus Pneumonia
The rate of vancomycin failure in patients with hospital-acquired pneumonia (HAP) caused by methicillin-resistant Staphylococcus aureus (MRSA) has exceeded 40% in several studies. This observation was attributed initially to the lack of weight-based dosing and targeting of lower trough concentrations. However, a subsequent study demonstrated no additional benefit in patients who achieved trough vancomycin concentrations >15mg/L compared with patients with concentrations between 5 and 15mg/L. A study out of Surgical Infections sought to identify contributors to vancomycin failure in patients with MRSA HAP and found data suggest that patients who have recent exposure to vancomycin are at high risk for vancomycin failure and may benefit from an appropriate alternative when a diagnosis of MRSA HAP is made.
Benefits shown with early versus delayed laparoscopic cholecystectomy for acute cholecystitis
In many countries laparoscopic cholecystectomy for acute cholecystitis is mainly performed after the acute episode has settled because of the anticipated increased risk of morbidity and higher conversion rate from laparoscopic to open cholecystectomy.A systematic review was performed with meta-analysis of randomized clinical trials of early laparoscopic cholecystectomy (ELC; performed within 1 week of onset of symptoms) versus delayed laparoscopic cholecystectomy (performed at least 6 weeks after symptoms settled) for acute cholecystitis. Five trials with 451 patients were included. There was no significant difference between the two groups in terms of bile duct injury or conversion to open cholecystectomy. The total hospital stay was shorter by 4 days for ELC.
Study suggests use of anitbiotic lavage in peritonitis increases survival
Morbidity and mortality associated with bacterial peritonitis remain a challenge for contemporary surgery. Despite great surgical improvements, death rates have not improved. A secondary debate concerns the volume and nature of peritoneal lavage or washout - what volume, what carrier and what, if any, antibiotic or antiseptic? In an experimental peritonitis setting a mortality rate of 48·9 per cent was found for saline lavage compared with 16·4 per cent for antibiotic lavage.
Chlorhexidine–Alcohol versus Povidone–Iodine for Surgical-Site Antisepsis
A new study from the New England Journal of Medicine hypothesized that preoperative skin cleansing with chlorhexidine–alcohol is more protective against infection than is povidone–iodine. The primary outcome was any surgical-site infection within 30 days after surgery. Secondary outcomes included individual types of surgical-site infections. The overall rate of surgical-site infection was significantly lower in the chlorhexidine–alcohol group than in the povidone–iodine group. Chlorhexidine–alcohol was significantly more protective than povidone–iodine against both superficial incisional infections and deep incisional infections.
Predicting Death in Necrotizing Soft Tissue Infections: A Clinical Score
Necrotizing soft tissue infections (NSTIs) are associated with a high mortality rate; however, there is no uniform way to categorize the severity of this disease early in its course. The goal of this study was to develop a clinical score based on data available at the time of initial assessment to aid in stratifying patients according to their risk of death.
Six admission parameters independently predicted death: Age>50 years, heart rate>110 beats/min, temperature <36°C, white blood cell count>40,000/mcL, serum creatinine concentration>1.5mg/dL, and hematocrit>50%. The accuracy of this model was 86.8%; the area under the receiver-operating characteristic curve was 0.81, and the Hosmer-Lemeshow statistic was 11.8.
Fondaparinux appears to offer protection against VTE in high-risk trauma patients
Journal of the American College of Surgeons
Venous thromboembolic events (VTE) remain a major cause of morbidity and mortality after trauma. Fondaparinux, a synthetic, nonheparin drug, has shown promise in reducing VTE in orthopaedic patients, but has not previously been studied in trauma patients. The goal of this study was to determine the safety and efficacy of fondaparinux when incorporated into our VTE prevention protocol.Overall incidence of DVT among the 87 enrolled patients was 4.6%. DVT developed in only 1 of 80 patients who received fondaparinux (1.2%).
Insulin Resistance Heralds Positive Cultures after Severe Injury
Surgical Infections
Insulin resistance and hyperglycemia are common in acutely injured patients, and associated with poor outcomes. In the era of tight glucose control, measures of insulin responsiveness (IR) may provide a better indicator of patient status than does the serum glucose concentration. It was hypothesized that measures of IR during tight glycemic control protocols are associated with infection and may be more predictive than the serum glucose concentration. During the six-month study period, 356 patients were placed on the tight glycemic control protocol. Of these, 101 patients had 192 positive cultures. Patients with positive cultures required significantly more hourly insulin than those without a positive culture . A greater insulin requirement suggesting resistance may be used as a marker of a higher risk of nosocomial infection.
Pulmonary Embolism May Not Result from Deep Venous Thrombosis in Trauma
Archives of Surgery Abstract
The rationale for the study is the fact that, as documented by several other investigators, many patients with PE have no DVT. This study showed that among 247 trauma patients undergoing CTPA/CTV, PE was diagnosed in 46 (19%) and DVT in 18 (7%). Few patients with PE have DVT of the pelvic or proximal lower extremity veins. Pulmonary embolism may not originate from these veins, as commonly believed, but instead may occur de novo in the lungs. These findings have implications for thromboprophylaxis and, particularly, the value of vena cava filters.
Positive Serum Ethanol Level Decreases Mortality in Moderate to Severe Traumatic Brain Injury
Archives of Surgery
A Retrospective database review was conducted A total of 38 019 patients with severe traumatic brain injuries were evaluated. Thirty-eight percent tested positive for ethanol. Ethanol-positive patients were younger, had a lower Injury Severity Score, and a lower Glasgow Coma Scale score compared with their ethanol-negative counterparts. After logistic regression analysis, ethanol was associated with reduced mortality and higher complications.
Randomized clinical trial of folate supplementation in patients with peripheral arterial disease
British Journal of Surgery
The aim was to determine whether folate supplementation improved arterial function in patients with peripheral arterial disease (PAD). Individuals with PAD were randomly assigned to receive 400 µg folic acid (45 patients) or 5-methyltetrahydrofolate (5-MTHF) (48) daily, or placebo (40) for 16 weeks. Primary endpoints were changes in plasma total homocysteine (tHcy), ankle : brachial pressure index (ABPI) and pulse wave velocity (PWV). Folate administration reduced plasma homocysteine, and slightly improved ABPI and bk-PWV.
Hospital variation in transfusion and infection after cardiac surgery
Transfusion practices in hospitalised patients are being re-evaluated, in part due to studies indicating adverse effects in patients receiving large quantities of stored blood. Concomitant with this re-examination have been reports showing variability in the use of specific blood components. This investigation was designed to assess hospital variation in blood use and outcomes in cardiac surgery patients.
Intravenous lidocaine decrease postsurgical ileus and shorten hospital stay in elective bowel surgery
The American Journal of Surgery
This study examined whether systemic infusion of lidocaine, a local anesthetic with anti-inflammatory properties, can decrease surgical pain, length of postsurgical ileus, and hospital stay. The return of bowel movement after surgery was considered significant (lidocaine 88.3 ± 6.08 hours vs placebo group 116 ± 10.1 hours; P = .0286). The lidocaine group was discharged by mean day 3.76 ± .24 versus placebo at mean day 4.93 ± .42; P = .0277
Diagnostic value of hyperbilirubinemia as a predictive factor for appendiceal perforation in acute appendicitis
The American Journal of Surgery Abstract
Patients with hyperbilirubinemia and clinical symptoms of appendicitis should be identified as having a higher probability of appendiceal perforation than those with normal bilirubin levels.
