Showing papers in "World Journal of Surgery in 2013"

Guidelines for perioperative care in elective colonic surgery: Enhanced recovery after surgery (ERAS®) society recommendations

Abstract: This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol. A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly. The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

Guidelines for Perioperative Care for Pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society Recommendations

Abstract: Protocols for enhanced recovery provide comprehensive and evidence-based guidelines for best perioperative care. Protocol implementation may reduce complication rates and enhance functional recovery and, as a result of this, also reduce length-of-stay in hospital. There is no comprehensive framework available for pancreaticoduodenectomy. An international working group constructed within the Enhanced Recovery After Surgery (ERAS®) Society constructed a comprehensive and evidence-based framework for best perioperative care for pancreaticoduodenectomy patients. Data were retrieved from standard databases and personal archives. Evidence and recommendations were classified according to the GRADE system and reached through consensus in the group. The quality of evidence was rated “high”, “moderate”, “low” or “very low”. Recommendations were graded as “strong” or “weak”. Comprehensive guidelines are presented. Available evidence is summarised and recommendations given for 27 care items. The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations. The present evidence-based guidelines provide the necessary platform upon which to base a unified protocol for perioperative care for pancreaticoduodenectomy. A unified protocol allows for comparison between centres and across national borders. It facilitates multi-institutional prospective cohort registries and adequately powered randomised trials.

Prognostic nutritional index predicts postoperative outcome in colorectal cancer.

Abstract: The prognostic nutritional index (PNI), which is calculated based on the serum albumin concentration and peripheral blood lymphocyte count, is a useful tool for predicting short-term and long-term postoperative outcome in patients undergoing cancer surgery. However, few studies have investigated PNI in colorectal cancer surgery. We examined the ability of PNI to predict short- and long-term outcomes in patients with colorectal cancer. This retrospective study included 365 patients who underwent resection for colorectal cancer. The prognostic nutritional status was calculated on the basis of admission data as follows: 10 × serum albumin (g/dl) + 0.005 × total lymphocyte count (per mm3). The primary outcomes measured were the impact of PNI on overall survival and postoperative complications. Kaplan–Meier analysis and the log rank test revealed that low PNI was significantly associated with poor survival (P < 0.0001). In multivariate analysis for survival, preoperative low PNI was an independent prognostic factor for poor survival: odds ratio: 2.25, 95 % confidence interval 1.42–3.59). Moreover, low PNI significantly correlated with the incidence of postoperative complications, especially serious ones. Preoperative PNI is a useful predictor of postoperative complications and survival in patients with colorectal cancer.

Current Treatment and Outcome of Esophageal Perforations in Adults: Systematic Review and Meta-Analysis of 75 Studies

Abstract: The current prognosis of esophageal perforation and the efficacy of available treatment methods are not well defined. We performed a systematic review of esophageal perforations published from January 2000 to April 2012 and subjected a proportion of the retrieved data to a meta-analysis. Meta-regression was performed to determine predictors of mortality immediately after esophageal perforation. Analysis of 75 studies resulted in a pooled mortality of 11.9 % [95 % confidence interval (CI) 9.7–14.3: 75 studies with 2,971 patients] with a mean hospital stay of 32.9 days (95 % CI 16.9–48.9: 28 studies with 1,233 patients). Cervical perforations had a pooled mortality of 5.9 %, thoracic perforations 10.9 %, and intraabdominal perforations 13.2 %. Mortality after esophageal perforation secondary to foreign bodies was 2.1 %, iatrogenic perforation 13.2 %, and spontaneous perforation 14.8 %. Treatment started within 24 h after the event resulted in a mortality rate of 7.4 % compared with 20.3 % in patients treated later (risk ratio 2.279, 95 % CI 1.632–3.182). Primary repair was associated with a pooled mortality of 9.5 %, esophagectomy 13.8 %, T-tube or any other tube repair 20.0 %, and stent-grafting 7.3 %. Results of recent studies indicate that mortality after esophageal perforation is high despite any definitive surgical or conservative strategy. Stent-grafting is associated with somewhat lower mortality rates, but studies may be biased by patient selection and limited experience.

Systematic review and meta-analysis of enhanced recovery after pancreatic surgery with particular emphasis on pancreaticoduodenectomies.

Abstract: In the past decade, Enhanced Recovery after Surgery (ERAS) protocols have been implemented in several fields of surgery. With these protocols, a faster recovery and shorter hospital stay can be accomplished without an increase in morbidity or mortality. The purpose of this study was to review systematically the evidence for implementation of an ERAS protocol in pancreatic resections, with particular emphasis on pancreaticoduodenectomies (PDs). A systematic search was performed in Medline, Embase, Pubmed, CINAHL, and the Cochrane library for papers describing an ERAS program in adult patients undergoing elective pancreatic surgery published between January 1966 and December 2012. The primary outcome measure was postoperative length of stay. Secondary outcome measures were time to recovery of normal function, overall postoperative complication rates, readmissions, and mortality. Subsequently, a meta-analysis of outcome measures focusing on PD was conducted. This systematic review and meta-analysis was performed according to the PRISMA statement. The literature search produced 248 potentially relevant papers. Of these, eight papers met the predefined inclusion criteria: five case-control studies, two retrospective studies, and one prospective study, describing a total of 1,558 patients. Only three of the studies reported data on discharge criteria and assessed time to recovery and return to normal function. Implementation of an ERAS protocol led in four of five comparative studies to a significant decrease in length of stay (reduction of 2–6 days in different studies). Meta-analysis of four studies focusing on PDs showed that there was a significant difference in complication rates in favor of the ERAS group (absolute risk difference 8.2 %, 95 % confidence interval (CI) 2.0–14.4, p = 0.008). Introduction of an ERAS protocol did not result in an increase in mortality or readmissions. Delayed gastric emptying and incidence of pancreatic fistula did not differ significantly between groups. All studies reporting on hospital costs showed a decrease after implementation of ERAS. This systematic review suggests that using an ERAS protocol in pancreatic resections may help to shorten hospital length of stay without compromising morbidity and mortality. This seemed to apply to distal pancreatectomy, total pancreatectomy, and PD. Meta-analysis was performed for those studies focusing on PD and showed that there were no differences in readmission or mortality. Morbidity rates were significantly lower for patients managed according ERAS principles.

Trauma-related preventable deaths in Berlin 2010: need to change prehospital management strategies and trauma management education.

Abstract: Fatal trauma is one of the leading causes of death in Western industrialized countries. The aim of the present study was to determine the preventability of traumatic deaths, analyze the medical measures related to preventable deaths, detect management failures, and reveal specific injury patterns in order to avoid traumatic deaths in Berlin. In this prospective observational study all autopsied, direct trauma fatalities in Berlin in 2010 were included with systematic data acquisition, including police files, medical records, death certificates, and autopsy records. An interdisciplinary expert board judged the preventability of traumatic death according to the classification of non-preventable (NP), potentially preventable (PP), and definitively preventable (DP) fatalities. Of the fatalities recorded, 84.9 % (n = 224) were classified as NP, 9.8 % (n = 26) as PP, and 5.3 % (n = 14) as DP. The incidence of severe traumatic brain injury (sTBI) was significantly lower in PP/DP than in NP, and the incidence of fatal exsanguinations was significantly higher. Most PP and NP deaths occurred in the prehospital setting. Notably, no PP or DP was recorded for fatalities treated by a HEMS crew. Causes of DP deaths consisted of tension pneumothorax, unrecognized trauma, exsanguinations, asphyxia, and occult bleeding with a false negative computed tomography scan. The trauma mortality in Berlin, compared to worldwide published data, is low. Nevertheless, 15.2 % (n = 40) of traumatic deaths were classified as preventable. Compulsory training in trauma management might further reduce trauma-related mortality. The main focus should remain on prevention programs, as the majority of the fatalities occurred as a result of non-survivable injuries.

Prospective Study Examining Clinical Outcomes Associated with a Negative Pressure Wound Therapy System and Barker’s Vacuum Packing Technique

Abstract: Background The open abdomen has become a common procedure in the management of complex abdominal problems and has improved patient survival. The method of temporary abdominal closure (TAC) may play a role in patient outcome.

Robotic-assisted colorectal surgery in the United States: a nationwide analysis of trends and outcomes.

Abstract: While robotic-assisted colorectal surgery (RACS) is becoming increasingly popular, data comparing its outcomes to other established techniques remain limited to small case series. Moreover, there are no large studies evaluating the trends of RACS at the national level. The Nationwide Inpatient Sample 2009–2010 was retrospectively reviewed for robotic-assisted and laparoscopic colorectal procedures performed for cancer, benign polyps, and diverticular disease. Trends in different settings, indications, and demographics were analyzed. Multivariate regression analysis was used to compare selected outcomes between RACS and conventional laparoscopic surgery (CLS). An estimated 128,288 colorectal procedures were performed through minimally invasive techniques over the study period, and RACS was used in 2.78 % of cases. From 2009 to 2010, the use of robotics increased in all hospital settings but was still more common in large, urban, and teaching hospitals. Rectal cancer was the most common indication for RACS, with a tendency toward its selective use in male patients. On multivariate analysis, robotic surgery was associated with higher hospital charges in colonic ($11,601.39; 95 % CI 6,921.82–16,280.97) and rectal cases ($12,964.90; 95 % CI 6,534.79–19,395.01), and higher rates of postoperative bleeding in colonic cases (OR = 2.15; 95 % CI 1.27– 3.65). RACS was similar to CLS with respect to length of hospital stay, morbidity, anastomotic leak, and ileus. Conversion to open surgery was significantly lower in robotic colonic and rectal procedures (0.41; 95 % CI 0.25–0.67) and (0.10; 95 % CI 0.06–0.16), respectively. The use of RACS is still limited in the United States. However, its use increased over the study period despite higher associated charges and no real advantages over laparoscopy in terms of outcome. The one advantage is lower conversion rates.

Incidence and localization of ectopic parathyroid adenomas in previously unexplored patients.

Abstract: Background Parathyroidectomy has a success rate of >95 % for cure of primary hyperparathyroidism. In about 6–16 % of cases, one or more hyperfunctioning parathyroid gland(s) are found in an ectopic location. Accurate preoperative imaging can aid in detecting these ectopically located glands and allow a focused surgical approach with an even higher success rate. The objective of this study was to assess the utility of ultrasonography (US) and technetium-99m-sestamibi (MIBI) scans in locating ectopic parathyroid glands in previously unexplored patients who presented with primary hyperparathyroidism.

Pancreatic anastomotic leakage after pancreaticoduodenectomy. Risk factors, clinical predictors, and management (single center experience).

Abstract: Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) remains a challenge even at high-volume centers. This study was designed to analyze perioperative risk factors for POPF after PD and evaluate the factors that predict the extent and severity of leak. Demographic data, preoperative, intraoperative, and postoperative variables were collected. A total of 471 consecutive patients underwent PD in our center. Fifty-seven patients (12.1 %) developed a POPF of any type; 21 patients (4.5 %) had a fistula type A, 22 patients (4.7 %) had a fistula type B, and the remaining 14 patients (3 %) had a POPF type C. Cirrhotic liver (P = 0.05), BMI > 25 kg/m2 (P = 0.0001), soft pancreas (P = 0.04), pancreatic duct diameter 4,000 IU/L, WBC, pancreatic duct diameter 4,000 IU/L on POD 1 and 5, WBC, pancreatic duct diameter, pancreatic texture may be predictors of POPF B, C.

Role of Laparoscopy in Penetrating Abdominal Trauma: A Systematic Review

Abstract: Debate remains regarding the optimum role of laparoscopy in the setting of trauma although it can offer advantages over traditional exploratory laparotomy. Laparoscopy can be a screening, diagnostic or therapeutic tool in trauma. The purpose of this review is to evaluate the role of laparoscopy in penetrating abdominal trauma The PUBMED database was searched with the keywords “Laparoscopy AND Trauma”. Additional citation searching and searching of the grey literature was conducted. Relevant studies were chosen on the basis of the defined inclusion and exclusion criteria and quality was assessed where appropriate using the Downs and Black checklist In total, 51 studies were included in the analysis of which only 13 were prospective. In most studies, laparoscopy was used as a screening, diagnostic or therapeutic tool. In total, 2569 patients underwent diagnostic laparoscopy (DL) for penetrating abdominal trauma (PAT), 1129 (43.95 %) were positive for injury. 13.8 % of those with injury had a therapeutic laparoscopy. In total 33.8 % were converted to laparotomy, 16 % of which were non-therapeutic and 11.5 % of them were negative. 1497 patients were spared a non-therapeutic laparotomy. Overall, 72 patients suffered complications, there were 3 mortalities and 83 missed injuries. Sensitivity ranged from 66.7–100 %, specificity from 33.3–100 % and accuracy from 50–100 %. 23 of the 50 studies reported sensitivity, specificity and accuracy of 100 %, including the four most recent studies. In general the quality of the reported studies was poor. When used for cohort studies, the mean Downs and Black checklist score was 13.25 out of a possible total of 28. In summary, laparoscopy in PAT may have an important role in a selected subgroup of patients, with surgeon expertise also an important factor. Laparoscopy has screening, diagnostic and therapeutic roles, particularly where diaphragm injury is suspected. It is extremely sensitive in determining need for laparotomy but detects hollow visceral injuries less reliably. It has potential as a therapeutic tool in centres with appropriate expertise. The development of specific guidelines or protocols may increase the value of laparoscopy in trauma but this would require more evidence of a higher quality.

Multifocality, But Not Bilaterality, Is a Predictor of Disease Recurrence/Persistence of Papillary Thyroid Carcinoma

Abstract: Background Although papillary thyroid carcinoma (PTC) often presents as multifocal or bilateral tumors, but whether multifocality or bilaterality is associated with disease recurrence/persistence is controversial We evaluated the association between multifocality and bilaterality of PTC and disease recurrence/persistence We also analyzed the location and number of tumors in multifocal PTC

Structured synchronous implementation of an enhanced recovery program in elective colonic surgery in 33 hospitals in The Netherlands.

Abstract: Background It has been clearly shown that after elective colorectal surgery patients benefit from multimodal perioperative care programs. The Dutch Institute for Health Care Improvement started a breakthrough project to implement a multimodal perioperative care program of enhanced recovery after surgery (ERAS). This pre/post noncontrolled study evaluated the success of large-scale implementation of the ERAS program for elective colonic surgery using the breakthrough series.

Surgical Outcomes of Gastrectomy for Elderly Patients with Gastric Cancer

Abstract: This study was designed to determine the surgical outcomes of gastric cancer in elderly patients. This information can help establish appropriate treatment for these patients. A total of 1,193 patients with gastric cancer who underwent gastrectomy between 1995 and 2010 were enrolled in this retrospective study. The clinicopathologic features of 104 elderly patients (aged ≥80 years) were compared with those of 1,089 nonelderly patients. (1) Tumors located in the lower-third of the stomach, differentiated cancer, and surgery with limited lymph node dissection were more common in elderly patients. However, there was no difference in the proportion of laparoscopic gastrectomy between elderly and nonelderly patients. (2) Although surgical complication rates were similar in the two groups, the operative mortality rate was higher in elderly patients (1.9 %) than in nonelderly patients (0.7 %). (3) Elderly patients had a significantly poorer overall survival rate, whereas the disease-specific survival rates of the two groups were similar. Limited lymph node dissection did not influence the disease-specific survival rate of elderly patients. (4) The median life expectancy of elderly gastric cancer survivors was 9.8 years in patients aged 80–84 years and 6.0 years in those ≥85 years. The patients with limited lymph node dissection had slightly better prognosis. The treatment results in elderly patients were comparable to those in nonelderly patients. These findings suggest that R0 resection with at least limited lymph node dissection according to Japanese guidelines should be considered, even for elderly patients.

Effect of Preoperative Exercise on Cardiorespiratory Function and Recovery After Surgery: a Systematic Review

Abstract: Background This systematic review aims to investigate the extent to which preoperative conditioning (PREHAB) improves physiologic function and whether it correlates with improved recovery after major surgery.

Outcomes after emergency versus elective ventral hernia repair: a prospective nationwide study.

Abstract: Early surgical results after emergency repairs for the most frequent ventral hernias (epigastric, umbilical, and incisional) are not well described. Thus, the aim of present study was to investigate early results and risk factors for poor 30-day outcome after emergency versus elective repair for ventral hernias. All patients undergoing epigastric, umbilical, or incisional hernia repair registered in the Danish Hernia Database during the period 1 January 2007 to 31 December 2010 were included in the prospective study. Follow-up was obtained through administrative data from the Danish National Patient Register. In total, 10,041 elective and 935 emergency repairs were included. The risk for 30-day mortality, reoperation, and readmission was significantly higher (by a factor 2–15) after emergency repairs than after elective repairs (p ≤ 0.003). In addition, there were significantly more patients with concomitant bowel resection after emergency repairs than after elective repairs (p 2–7 cm, and repair for a primary hernia (vs recurrent hernia) (all p < 0.05). Independent risk factors for emergency incisional hernia repair were female gender, increasing age, and hernia defects ≤7 cm (all p < 0.05). Emergency umbilical/epigastric or incisional hernia repair was beset with up to 15-fold higher mortality, reoperation, and readmission rates than elective repair. Older age, female gender, and umbilical hernia defects between 2 and 7 cm or incisional hernia defects up to 7 cm were important risk factors for emergency repair.

Preoperative Prediction of Central Lymph Node Metastasis in Thyroid Papillary Microcarcinoma Using Clinicopathologic and Sonographic Features

Abstract: The purpose of the present study was to evaluate the clinicopathologic factors and ultrasound (US) features predictive of central lymph node metastasis (LNM) in patients diagnosed with papillary thyroid microcarcinoma (PTMC). From March 2008 to August 2008, the clinicopathologic features and preoperative US features of 483 patients who were diagnosed with conventional PTMC were included. Medical records, US features, and pathology reports of all patients were retrospectively reviewed. Univariate and multivariate analysis was performed to identify clinicopathological prognostic factors associated with central LNM. Odds ratios (OR) with relative 95 % confidence intervals (95 % CI) were calculated to determine the relevance of all potential predictors of central LNM. Among the 483 patients with PTMC, 139 (28.8 %) patients had central LNM. The OR of significant independent factors were 2.055 (95 % CI, 1.137–3.716), 2.075 (95 % CI, 1.27–3.39), 1.71 (95 % CI, 1.073–2.724), and 15.897 (95 % CI, 4.173–60.569), respectively, for bilaterality, larger tumor size (>5 mm), extracapsular invasion, and lateral LNM. No significant association was seen among the US features of PTMC with central LNM. Central lymph node metastasis in patients with PTMC was significantly associated with various clinicopathological factors, including larger tumor size (>5 mm), bilaterality, extracapsular invasion, and lateral LNM. When these features are detected on preoperative US, selective central compartment dissection may be helpful in patients diagnosed with PTMC.

Laparoscopy-assisted distal gastrectomy versus open distal gastrectomy. A prospective randomized single-blind study

Abstract: Laparoscopy-assisted distal gastrectomy (LADG) is generally considered superior to open distal gastrectomy (ODG) with regard to postoperative quality-of-life. Differences in postoperative pain may exist due to recent pain control techniques including epidural anesthesia. There is little evidence for this difference. In this article we report the results of our randomized single-blind study in LADG versus ODG. The aim of the present study was to evaluate differences in postoperative physical activity between LADG and ODG. Forty patients with early gastric cancer (stage IA and IB) were registered in this randomized study. For strict evaluation, patients were not told about the type of operation until postoperative day 7. Postoperative physical activity was evaluated objectively by Active Tracer, which records the cumulative acceleration over a 24 h period to investigate differences in postoperative recovery. Questionnaire and visual analog scale score related to postoperative pain were also investigated. Significant differences were observed with a more favorable outcome noted in the LADG group with respect to intraoperative blood loss (P < 0.001), total amount of pain rescue (P < 0.001), wound size (P < 0.001), postoperative hospital stay (P < 0.001), and inflammatory parameters (C-reactive protein, SaO2, and duration of febrile period) (P < 0.001). Cumulative physical recovery to 70 % of the preoperative level was significantly shorter (by 3 days, P < 0.001) in the LADG group. Comparison of LADG and ODG for patients with early gastric cancer showed favorable outcome and earlier recovery of physical activity in the LADG group.

Risk Factors of Hypoparathyroidism Following Total Thyroidectomy for Thyroid Cancer

Abstract: Background The risk factors responsible for hypoparathyroidism after total thyroidectomy have not been completely defined. The present study evaluated one surgeon’s personal experience of postoperative hypoparathyroidism after total thyroidectomy for thyroid cancer and predisposing risk factors of postoperative hypoparathyroidism.

Influence of Prophylactic Neck Dissection on Rate of Retreatment for Papillary Thyroid Carcinoma

Abstract: Prophylactic neck dissection (PND) for papillary thyroid cancer is controversial. The objective of this study was to analyze the influence of PND on the rate of retreatment. In this retrospective case-control study, papillary thyroid carcinomas >10 mm without ultrasonographic evidence of nodal disease (cN0) were treated with total thyroidectomy (TT) or TT with bilateral central compartment PND. All received postoperative radioactive iodine (131I) and were followed for at least 1 year. We compared the rate of retreatment (surgery or 131I). Altogether, 246 patients (mean age 46 years, 78 % women) underwent TT (n = 91) or TT + PND (n = 155). The groups were similar in age, sex, tumor size, and follow-up (median 6.3 years) (p > 0.05). Overall, 11 (12 %) of the patients in the TT group underwent reoperation in the central compartment for recurrence versus 3 (2 %) in the TT + PND group (p < 0.001). There were 1.18 administrations of 131I for the TT group versus 1.08 for the TT + PND group (p = 0.08). The average cumulative dose of 131I was 3.9 ± 1.8 GBq for the TT group and 3.8 ± 1.3 GBq for the TT + PND group (p = 0.52). Actuarial (Kaplan-Meier) 5-year retreatment rates were 14.7 % in the TT group and 6.5 % in the TT + PND group (p = 0.01, log-rank). The rate of permanent recurrent nerve paralysis was 2 % for the TT group and 1 % for the TT + PND group (p = 0.98). The rates of permanent hypoparathyroidism were 7 versus 3 %, respectively (p = 0.12). Five-year retreatment rates were lower in patients treated with PND, with no added permanent morbidity.

Lower Reoperation Rate for Recurrence after Mesh versus Sutured Elective Repair in Small Umbilical and Epigastric Hernias. A Nationwide Register Study

Abstract: Background Repair for a small (≤2 cm) umbilical and epigastric hernia is a minor surgical procedure. The most common surgical repair techniques are a sutured repair or a repair with mesh reinforcement. However, the optimal repair technique with regard to risk of reoperation for recurrence is not well documented. The aim of the present study was in a nationwide setup to investigate the reoperation rate for recurrence after small open umbilical and epigastric hernia repairs using either sutured or mesh repair.

Risk factors for infection after 46,113 intramedullary nail operations in low- and middle-income countries.

Abstract: Background The fields of surgery and trauma care have largely been neglected in the global health discussion. As a result the idea that surgery is not safe or cost effective in resource-limited settings has gone unchallenged. The SIGN Online Surgical Database (SOSD) is now one of the largest databases on trauma surgery in low- and middle-income countries (LMIC). We wished to examine infection rates and risk factors for infection after IM nail operations in LMIC using this data.

Resection of At-Risk Mesenteric Lymph Nodes Is Associated with Improved Survival in Patients with Small Bowel Neuroendocrine Tumors

Abstract: Background Neuroendocrine tumors of the small intestine commonly metastasize to regional lymph nodes (LNs). Single-institution reports suggest that removal of LNs improves outcome, but comprehensive data are lacking. We hypothesized that the extent of lymphadenectomy reported in a large administrative database would be associated with overall survival for jejunal and ileal neuroendocrine tumors.

Initial Experiences of an Enhanced Recovery Protocol in Esophageal Surgery

Abstract: A recent development in gastrointestinal surgery is the implementation of enhanced recovery after surgery (ERAS) programs. Evidence regarding the benefit of these programs in patients undergoing esophageal surgery is scarce. We investigated the feasibility and possible benefit of a perioperative ERAS program in patients undergoing esophagectomy for malignant disease. The ERAS program was initiated in 2009. Patients who underwent esophagectomy and were treated according to the ERAS program were included. Items of ERAS included preoperative nutrition, early extubation, early removal of nasogastric tube, and early mobilization. Primary outcome parameters were hospital stay and the incidence of postoperative complications. Outcome parameters in the ERAS cohort were compared to a cohort of patients who underwent surgical resection in the year prior to the implementation of the ERAS protocol. A feasibility analysis was performed among a sample of ERAS patients to determine the number of achieved items per patient. Between 2008 and August 2010, 181 patients in our department underwent esophagectomy. Of these, 103 patients were included in the ERAS program (ERAS+ group) and were compared to 78 patients who had undergone an esophagectomy in 2008 (ERAS– group). Overall hospital stay was 14 days versus 15 days (ERAS+ and ERAS–, respectively; p = 0.013). There were no significant differences in the incidence of postoperative complications in either group. The percentage of achieved items varied between 42 and 93 % per item. The implementation of an ERAS program in esophageal surgery was feasible and resulted in a small but significant reduction in overall hospital stay, whereas overall morbidity was not affected.

Use of a Transanal Drainage Tube for Prevention of Anastomotic Leakage and Bleeding after Anterior Resection for Rectal Cancer

Abstract: The aim of the present study was to investigate the usefulness of the transanal drainage tube for prevention of anastomotic leakage and bleeding after anterior resection for rectal cancer. Between January 2007 and May 2011 a nonrandomized prospective study of patients undergoing anterior resection for rectal cancer was done. The patients were divided into the transanal drainage tube (TDT) and non-transanal drainage tube (NTDT) groups according to whether the transanal drainage tube was used in the operation. Clinical characteristics and postoperative complications were compared between the TDT and NTDT groups. The study included 81 patients in the TDT group and 77 patients in the NTDT group. In the TDT group, anastomotic leakage occurred in 2 patients and no anastomotic bleeding occurred. In the NTDT group, anastomotic leakage occurred in 7 patients and anastomotic bleeding occurred in 2 patients. The TDT group had significantly fewer anastomotic complications compared with the NTDT group (2.5 vs 11.7 %; P = 0.029). Furthermore, the TDT group showed an obvious reduction in the rate of anastomotic leakage and anastomotic bleeding compared with the NTDT group (2.5 vs 7.8 % and 0.0 vs 2.6 %), but because the number of cases is relatively small, the difference did not reach statistical significance (P = 0.160 and P = 0.236). The use of a transanal drainage tube in anterior resection for rectal cancer may be a simple, safe, and effective means of preventing or reducing the occurrence of anastomotic leakage and bleeding. A larger-scale single or multi-center prospective randomized study or a meta-analysis including similar studies is necessary for further elucidation of this issue.

Trans-cutaneous Closure of Central Defects (TCCD) in laparoscopic ventral hernia repairs (LVHR).

Abstract: Background Laparoscopic ventral hernia repair (LVHR) has been reported to have lower recurrence rates, fewer surgical site infections, and shorter hospital stays compared to open repair. Despite improved surgical outcomes with standard LVHR (sLVHR), seroma formation, eventration (or bulging of mesh or tissue), and hernia recurrence remain common complications. Our objective was to evaluate outcomes with trans-cutaneous closure of central defects in LVHR compared to sLVHR.

Getting the Job Done: Analysis of the Impact and Effectiveness of the SmileTrain Program in Alleviating the Global Burden of Cleft Disease

Abstract: The study measured the success of SmileTrain, the largest cleft charity globally, in alleviating the global burden of disease (GBD). It was done by estimating averted disability-adjusted life years (DALYs) and delayed averted DALYs because of the global backlog in cleft procedures. Anonymized data for all procedures in the SmileTrain global database were analyzed by age, sex, country, region, and surgery type. DALYs averted were calculated using life expectancy tables and established and estimated disability weights. The cost-effectiveness analysis used mean SmileTrain procedural disbursement figures. Sensitivity analysis was performed using various cleft incidence rates, life expectancy tables, and disability weights. During 2003–2010 a total of 536,846 operations were performed on 364,467 patients—86 % in Southeast Asia and the western Pacific region. Procedure numbers increased yearly. Mean age at primary surgery—6.2 years (9.8 years in Africa)—remained fairly constant over time in each region. Globally, 2.1–4.7 million DALYs were averted through the operations at a total estimated cost of US$196 M. Mean DALYs per patient were 3.8–9.0, and mean cost per DALY was $72–$134. Total delayed GBD due to advanced age at surgery was 191,000–457,000 DALYs. Despite an unparalleled number of surgeries performed and yearly increase by one charity, the unmet and delayed averted cleft GBD remains significant in all regions. Large geographic disparities reflect varied challenges regarding access to surgery. Cleft surgeries are cost-effective interventions to reduce the global burden of disease (GBD). Future challenges include increased collaboration among cleft care providers and a focus on remote global areas by building infrastructure and local training.

Surgery and anesthesia capacity-building in resource-poor settings: description of an ongoing academic partnership in Uganda.

Abstract: Background Surgery and perioperative care have been neglected in the arena of global health despite evidence of cost-effectiveness and the growing, substantial burden of surgical conditions. Various approaches to address the surgical disease crisis have been reported. This article describes the strategy of Global Partners in Anesthesia and Surgery (GPAS), an academically based, capacity-building collaboration between North American and Ugandan teaching institutions.

Perioperative Fluid Restriction in Major Abdominal Surgery: Systematic Review and Meta-analysis of Randomized, Clinical Trials

Abstract: Fluid management is a fundamental component of surgical care. Recently, there has been considerable interest in perioperative fluid restriction as a method of facilitating recovery following elective major surgery. A number of randomized trials have addressed the issue in various surgical specialities, and a recent meta-analysis proposed uniform definitions regarding fluid amount as well as examining fluid restriction in patients undergoing colonic resection. Medline, Embase, trial registries, conference proceedings, and article reference lists were searched to identify randomized, controlled trials of perioperative fluid restriction versus “standard” perioperative fluid management, as per definitions formulated previously. All of the studies involved patients undergoing colonic resection. The primary outcome measure was postoperative morbidity. Secondary endpoints included mortality, renal failure, time to first flatus, and length of hospital stay. A random effects model was applied. Seven randomized, controlled trials with a total of 856 patients investigating standard versus restrictive fluid regimes, as denoted by the definitions, were included. Perioperative fluid restriction had no effect on the risk of postoperative complications (OR 0.49 (95 % confidence interval (CI) 0.2–1.18; P = 0.101). There was no detectable effect on death and fluid restriction did not reduce hospital stay (Pooled weighted mean difference −0.25; 95 % CI 0.72–0.21; P = 0.29). Perioperative fluid restriction does not significantly reduce the risk of complications following major abdominal surgery. Furthermore, it does not appear to reduce length of hospital stay.

Characterizing the Global Burden of Surgical Disease: A Method to Estimate Inguinal Hernia Epidemiology in Ghana

Abstract: Background Surgical conditions represent an immense yet underrecognized source of disease burden globally. Characterizing the burden of surgical disease has been defined as a priority research agenda in global surgery. Little is known about the epidemiology of inguinal hernia, a common easily treatable surgical condition, in resource-poor settings.