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The pharyngeal pack is routinely used in many nasopharyngeal surgeries to reduce the spillage of secretions into the trachea and esophagus. Here we report a case of migration of a pharyngeal pack into the stomach of a patient undergoing functional endoscopic sinus surgery and review risks of delayed recognition and the management of this complication. In this case report, we share our experience to reinforce and highlight the importance of proper documentation of pharyngeal pack insertion and removal to prevent easily avoidable morbidity and mortality. It also highlights the importance of an immediate esophago-gastro-duodenoscopy (OGD) to retrieve the migrated pharyngeal pack as soon as its migration to the gastrointestinal tract is suspected.

Simple Summary The aim of this study was to reveal the factors affecting the complexity and difficulties in performing surgery to resect carotid body tumors (CBTs). We analyzed 20 patients with 21 CBTs. We used the “same day surgery” procedure, including preoperative embolization of the feeding arteries in the morning and resection surgery in the afternoon of the same day. Four patients underwent resection of the carotid artery, followed by reconstruction. These four patients were between 18 to 23 years of age at the time of surgery. The mean blood loss and operative time in these patients differed significantly from those in older patients. These results indicated that young age may influence the difficulties faced in CBT surgery, resulting in an increased risk of carotid artery resection. The results obtained from our study could help surgeons safely and effectively perform resection surgery for CBTs. Abstract This study evaluated patient characteristics that affect the complexity and difficulties of performing surgery to resect carotid body tumors (CBTs). We retrospectively reviewed the medical records of 20 patients with 21 CBTs who were enrolled in the study. The median patient age was 46 years and the mean tumor diameter was 37.6 mm. The mean blood loss and operative time were 40.3 mL and 183 min, respectively. Four patients underwent resection of the carotid artery followed by reconstruction. These four patients were between 18 to 23 years of age at the time of surgery. The mean blood loss and operative time in these patients were 166 mL and 394 min, respectively, which differed significantly from those of older patients. Therefore, young age influenced the difficulties faced in surgical resection of CBT, with an increased risk of blood loss and carotid artery resection.

Purpose The present case–control study was conducted to evaluate whether acute normovolemic hemodilution (ANH) can reduce the need for perioperative allogeneic blood transfusion (ABT) and affect the incidence of perioperative complications in free-flap reconstruction of the head and neck. Methods This single-center, retrospective, observational study included the perioperative data of 123 patients who underwent free-flap reconstruction of the head and neck following oncological surgery. Patients were divided into the following two groups according to whether they received ANH: ANH group and non-ANH group. We investigated whether ANH can reduce the need for perioperative ABT using propensity score-adjusted logistic regression analysis. Results Of the 123 patients, 113 patients were assessed; 57 patients were in the ANH group and 56 patients were in the non-ANH group. The rate [ANH group vs. non-ANH group, n (%): 2 (3.5%) vs. 23 (41.1%), p

This study investigates the incidence of post-operative complications and risk factors of sentinel lymph node biopsy (SLNB) in melanoma patients.A retrospective cohort study was conducted at a single cancer institution on 408 consecutive SLNBs.Fifty-five post-operative complications occurred in 39 (9.5%) patients and included: wound infection in 24 (5.9%), seroma and lymphorrhea in 15 (3.7%), wound dehiscence in seven (1.7%), lymphocele in six (1.5%) and others in three (0.7%). Univariate analysis failed to identify possible risk factors (i.e. gender, age, lymph node region, number of excised lymph nodes, Breslow index, pT levels, comorbidities, length of surgery and hospital stay). Metastatic sentinel nodes occurred in four of 135 (3%) patients with thin melanoma (Breslow1 mm) and in 68 of 262 (25.9%) patients with Breslow1 mm.For patients with thin melanoma in whom the incidence of lymph node metastasis is low, the reported post-operative morbidity of almost 10% of SLNB highlights the need for careful patient selection.

ObjectiveThe decision to undertake a major lower limb amputation can be complex. This review evaluates the performance of risk prediction tools in estimating mortality, morbidity, and other outcomes following amputation.MethodsA systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The MEDLINE, Embase, and Cochrane databases were searched to identify studies reporting on risk prediction tools that predict outcomes following amputation. Outcome measures included the accuracy of the risk tool in predicting a range of post-operative complications, including mortality (both short and long term), peri-operative morbidity, need for re-amputation, and ambulation success. A narrative synthesis was performed in accordance with the Guidance on the Conduct of Narrative Synthesis In Systematic Reviews.ResultsThe search identified 518 database records. Twelve observational studies, evaluating 13 risk prediction tools in a total cohort of 61 099 amputations, were included. One study performed external validation of an existing risk prediction tool, while all other studies developed novel tools or modified pre-existing generic calculators. Two studies conducted external validation of the novel/modified tools. Nine tools provided risk estimations for mortality, two tools provided predictions for post-operative morbidity, two for likelihood of ambulation, and one for re-amputation to the same or higher level. Most mortality prediction tools demonstrated acceptable discrimination performance with C statistic values ranging from 0.65 to 0.81. Tools estimating the risk of post-operative complications (0.65 – 0.74) and necessity for re-amputation (0.72) also performed acceptably. The Blatchford Allman Russell tool demonstrated outstanding discrimination for predicting functional mobility outcomes post-amputation (0.94). Overall, most studies were at high risk of bias with poor external validity.ConclusionThis review identified several risk prediction tools that demonstrate acceptable to outstanding discrimination for objectively predicting an array of important post-operative outcomes. However, the methodological quality of some studies was poor, external validation studies are generally lacking, and there are no tools predicting other important outcomes, especially quality of life.

Objective: Limb graft occlusion (LGO) is a serious complication after endovascular aneurysm repair (EVAR) and while device development enables treatment of increasingly complex aortic anatomy, little is known about how endograft type affects the risk of occlusion. This observational study aimed to explore the incidence of LGO after EVAR for three major endograft systems. Methods: All patients with standard EVAR as the primary intervention for infrarenal abdominal aortic aneurysm (AAA), between January 2012 and December 2018, at five Swedish vascular surgery centres, were included in this multicentre retrospective cohort study. LGO was defined as a total limb occlusion regardless of symptoms, or a treated significant stenosis. A nested case control (NCC) design with incidence density sampling of 1:3 was used for analysis of potential per-operative and morphological risk factors. Conditional logistic regression was used to estimate multivariable odds ratios (OR) with 95% confidence intervals (CI) Results: A total of 924 patients were included. The majority were male (84%), the mean age was 76 years (+/- 7.5 SD), and median AAA diameter was 59 mm (IQR 55, 67). Patients were treated with Zenith Alpha (n = 315, ZISL limbs), Excluder (n = 152, PLC/PXC limbs), and Endurant (n = 457, ETLW/ ETEW limbs). During median follow up of 37 months (IQR 21, 62), 55 occlusions occurred (5.9%); 39 with Zenith Alpha (12.4%), one with Excluder (0.7%), and 15 with Endurant (3.3%). In the NCC analysis, the Zenith Alpha device (OR 5.31, 95% CI 1.97 - 14.3), external iliac artery (EIA) landing (OR 5.91, 95% CI 1.30 - 26.7), and EIA diameter < 10 mm (OR 4.99, 95% CI 1.46 - 16.9) were associated with an increased risk of LGO. Conclusion: Endograft device type is an independent risk factor for LGO after EVAR. Specifically, the Zenith Alpha demonstrated an increased risk of LGO compared with the Endurant and Excluder devices. In addition, a narrow EIA and landing zone in EIA are also risk factors for LGO. Funding Agencies|Swedish Heart-Lung FoundationSwedish Heart-Lung Foundation [20180596]; Swedish Society of Medicine [SLS-174151]; Futurum Jonkoping county; Swedish Research CouncilSwedish Research CouncilEuropean Commission [12660, 20180867, 20180072]

Background/Aim: Older patients are considered to bear a higher perioperative risk. Since idiopathic normal pressure hydrocephalus (NPH) predominantly concerns older patients, identifying risk factors for early shunt failure for preoperative risk/benefit assessment is indispensable for indication and/or consultation of patients for ventriculoperitoneal shunting (VPS).Methods: We performed a retrospective study design, including data acquired from two university hospital neurosurgical institutions between 2012 and 2019. Overall, 211 consecutive patients with clinical/radiological signs for NPH who additionally showed alleviation of symptoms after lumbar cerebrospinal fluid (CSF) drainage, received VPS and were included for further analysis. Frailty was measured using the Clinical Frailty Scale (CFS). Main outcome was early shunt failure or post-operative complications within 30 days after initial VPS surgery.Results: The overall complication rate was 14%. Patient-related complications were observed in 13 patients (6%) and procedure-related complications in 16 patients (8%). Early post-operative complications resulted in a significantly prolonged length of hospital stay 6.9 ± 6.8 vs. 10.8 ± 11.8 days (p = 0.03). Diabetes mellitus with end-organ damage (OR 35.4, 95% CI 6.6 – 189.4, p < 0.0001) as well as preexisting Parkinson's disease were associated with early patient-related post-surgical complications after VPS for NPH.Conclusions: Patients comorbidities but not frailty were associated with early post-operative patient-related complications in patients suffering NPH. While frailty may deter patients from other (neurosurgical) procedures, VPS surgery might contribute to treating NPH in these patients at a tolerable risk.

Background: Angiotensin-converting enzyme inhibitor (ACE-I) and angiotensin-receptor blocker (ARB) users may be associated with increased mortality in patients with post-operative acute kidney injury (AKI), but data are limited. We studied whether users of ACE-I/ARBs with AKI after colorectal cancer surgery (CRC) were associated with increased 1-year mortality after AKI. Methods: This population-based cohort study in Northern Denmark included patients with AKI within 7 days after CRC surgery during 2005-2014. From reimbursed prescriptions, patients were classified as ACE-I/ARB current, former, or non-users. We computed the cumulative 30-day and 1-year mortality after AKI with 95% confidence intervals (95% CI) using the Kaplan-Meier method (1—survival function). Hazard ratios (HRs) comparing mortality in current and former users with non-users were computed by Cox proportional hazards regression analyses, controlling for potential confounders. Results: We identified 10 713 CRC surgery patients. A total of 2000 patients had AKI and were included. Thirty-day mortality was 16.5% (95% CI 13.7-19.8), 16.2% (95% CI 11.3-22.8), and 13.4% (95% CI 11.6-15.4) for current, former, and non-users. Adjusted HR was 1.26 (95% CI 0.96-1.65) and 1.19 (95% CI 0.78-1.82) for current and former users compared with non-users. One-year mortality rates were 26.4% (95% CI 22.9-30.4), 29.8% (95% CI 23.2-37.8), and 24.7% (95% CI 22.4-27.2) in current, former, and non-users. Compared with non-users, the adjusted 1-year HR for death in current and former users were 1.29 (95% CI 0.96-1.73) and 1.11 (95% CI 0.91-1.35). Conclusion: Based on our findings, current users of ACE-I/ARB may possibly have a small increase in mortality rate in the year after post-operative AKI, although the degree of certainty is low.

Background Gluteal compartment syndrome is an uncommon condition and can be difficult to diagnose. It has been diagnosed after trauma, vascular injury, infection, surgical positioning, and prolonged immobilization from drug or alcohol intoxication. The diagnosis is based on clinical findings and, in most cases, recognizing these symptoms and making a diagnosis early is critical to a complete recovery. Case presentation A 53-year-old male who underwent left foot surgery had severe pain to his contralateral hip and posterior gluteal compartment radiating to the right lower extremity immediately postoperative. He was positioned supine with a “bump” placed under his right hip to externally rotate his operative leg during the surgery. Due to the patient’s complex past medical history, a presumptive diagnosis of a herniated disc and/or compression of the sciatic nerve was made as a cause for the patient’s pain. This resulted in a misdiagnosis period of 36 h until the patient was diagnosed with unilateral gluteal compartment syndrome. Performing a fasciotomy was decided against due to the increased risk of complications. The patient was treated with administration of IV fluids and closely monitored. On post-op day 6, the patient was discharged. At three months post-op, the patient was walking without a limp and he had no changes in his peripheral neurologic examination compared to his preoperative baseline. Conclusion Gluteal compartment syndrome is a surgical emergency that must be considered postoperatively especially in obese patients with prolonged operation times who experience acute buttock pain. The use of positional bars or “bumps” in the gluteal area should be used with caution and raise awareness of this complication after orthopedic surgeries.

Key Clinical Message Herpes simplex virus hepatitis is a rare but potentially fatal disease without early intervention. Impaired immunity is a major predisposing risk factor but infection in immunocompetent individuals is not unheard of. Diagnosis is complicated by its rarity and nonspecific signs and symptoms on presentation. Identification by liver biopsy is often limited due to concurrent coagulopathy. Early and aggressive treatment is centered on antiviral therapy with acyclovir. We present a case of herpes hepatitis in an immunocompetent woman following abdominal instrumentation.

Background: Single-port laparoscopic cholecystectomy (SPLC) is a new advanced technique in laparoscopic surgery which has many benefits according to previous reports. The purpose of this study was to present personal experiences with SPLC in >800 cases performed by a surgeon to evaluate the safety and feasibility of this procedure. Materials and Methods: A retrospective review of 817 cases of SPLC was conducted. All patients had received elective SPLC by a surgeon in our centre during March 2009–August 2015. Our review suggests patients’ character, peri-operative data and post-operative outcome. Results: Three hundred and ninety-eight men (48.7%) and 419 women (51.3%) with an average age of 48.3 years had received SPLC. Their mean body mass index (BMI) was 23.75 kg/m2. The mean operating time took 46.9 min (19–130). Seventy-nine cases (9.7%) needed additional port during operation. BMI, age and previous abdominal surgical history did not affect conversion to multiport surgery. Bile spillage during operation occurred in 73 cases (8.9%). There were 4 cases of open conversion because of bleeding (2 cases, 0.2%) and common bile duct (CBD) injury (2 cases, 0.2%). Mean duration of hospital stay was 2.36 days. We have experienced 38 cases (4.7%) of post-operative complication: 8 cases (1.0%) of major one and 30 cases (3.7%) of minor one. Major complication occurred in 3 cases (0.4%) of retained CBD stone, 3 cases (0.4%) of cystic duct leakage needed endoscopic retrograde cholangiopancreatography and 2 cases (0.2%) of CBD injury needed reoperation. Most minor complications were wound infections that have healed after conservative treatment. There were no post-operative mortalities. Conclusion: SPLC is a safe and practicable technique. With surgical experience, criteria and area of SPLC can be broadened. SPLC is occupying a greater domain of a laparoscopic cholecystectomy.

Objective: Human amniotic membrane (HAM) used as a wound coverage for more than a century. The aim of this study is to evaluate the efficacy of amniotic membrane on wound healing and reduce post-operative complication. Study design: Randomized clinical trial study. Place and duration of study: Surgery Department, Shahid Faghihi Hospital, Shiraz, in the period of between Sep. 2014 and Nov. 2015. Methodology: 73 patients with anal fistula were divided into two groups. The patients suffered from simple perianal fistula (low type) without any past medical history. Fistulotomy were performed for all of them and in interventional group HAM were applied as biologic dressing. Their wound healing improvement was evaluated post-operative in two groups. Results: From 73 patients participated in the study, 36 patients were in control group and 37 patients were in intervention group. According to the analysis of images taken from the wound, the rate of wound healing was 67.39% in intervention group and 54.51% in control group (p

We report the case of a 36-year old man who underwent elective posterior lumbar spinal fusion after presenting with bilateral leg pain with associated back pain. He had undergone a L5/S1 discectomy in 2001, which provided good symptomatic relief. On this admission, he underwent elective L4-S1 posterolateral fusion and bilateral L4/5 and L5/S1 decompression. Intra-operatively a pedicle screw had to be re-inserted after fluoroscopy confirmed a lateral breech. The patient had no major postoperative complications until the sixth day when the patient re-presented with acute leg pain and weakness. Following a local multidisciplinary meeting (MDT) an MRI showed a large haematoma at the right psoas muscle. CT angiogram confirmed a bleeding lumbar segmental vessel at the site of the previous misplaced screw and an emergency fluoroscopic guided embolisation of the vessel was performed. The patient recovered well post operatively and was discharged back to the community 12 days later. Haemorrhage, as in this case a psoas haematoma should be considered as one of the differentials in patients with recurrent post-operative radiculopathy following posterior lumbar spine fusion. This should be suspected particularly if there has been a misplacement of one or more screws as this can cause injury to blood vessels and be fatal for the patient., Highlights • Recognition of post-operative complication in minimally invasive spine surgery. • Importance of urgency in investigating in post-operative spine patients. • Misplacement of a screw in spine surgery can have serious and potentially fatal outcomes in patients.

Background: There exists a high risk of post-operative complications with primary and revision total ankle replacement surgery. Delayed wound healing of the anterior incision is common. The reason for this is multi-factorial and, to date, most of the research has focused on predisposing factors involving the patients themselves. Only recently have researchers begun to look at the post-operative dressing as a possible consideration when trying to prevent incision wound healing complications. Currently, no standard post-operative dressing for primary or revision total ankle replacement exists. However, the principles of post-operative edema reduction to improve healing, as advocated by Sir Robert Jones and demonstrated in his compressive dressing, have been known for decades. We have been using a modified Sir Robert Jones compressive dressing for both primary and revision total ankle replacements. Recently, we have added an aperture pad made of cotton cast padding over the anterior incision in order to protect the area from pressure necrosis. Methods: This is a comparison study of the post-operative wound complications involving 35 patients that received the original dressing and 33 patients that received the addition of the aperture pad. Results: With no significant difference in the patient populations, the results demonstrate a 3-fold decrease in the number of anterior incision wound healing complications with the use of the aperture pad. Conclusion: This dressing represents a simple, reproducible, easy to apply and inexpensive way to prevent post-operative edema and anterior incision wound healing complications.

Background The aim of this study is to evaluate factors (clinical, pathological and perioperative) associated with the risk of hospital readmission after radical prostatectomy (RP) over the long term in a single tertiary referral center where both open RP (ORP) and robot assisted RP (RARP) are performed. Methods From January 2013 to December 2018 patients older than 18 years, who provided signed consent and underwent open or robot assisted radical prostatectomy were enrolled and retrospectively evaluated. Patients who underwent any previous prostate cancer (PCA) treatments were excluded. Specifically, skilled and experienced surgeons performed the two surgical approaches. Patients were followed for complications and hospital readmission (RAD) for a period of six months. The association of factors with the risk of readmission was assessed by Cox's multivariate proportional hazards. Results A total of 1062 patients underwent RP. RARP was performed in 891 cases and ORP in 171 subjects. Extended pelvic lymph node dissection (ePLND) was performed in 651 patients. Hospital readmission occurred in 53 cases (5%). Based on the final multivariate model, independent factors associated with the risk of hospital readmission were seminal vesicle invasion (HR=2.093; 95% CI: 1.177-3.722), ORP (HR=4.393; 95% CI: 2.516-7.672) and ePLND (HR=4.418; 95% CI: 1.544-12.639). Conclusions ORP, ePLND and seminal vesicle invasion are independent predictors of the risk of hospital readmission over the long term at a large single tertiary referral center. When surgery is chosen as a primary treatment of PCA, patients should be informed of the risk of hospital readmission and related risk factors. Assessing seminal vesicle invasion by preoperative clinical staging identifies locally advanced disease, which is associated with an increased risk of hospital readmission.

Complications after tooth extraction may occur because of several factors correlated to the patient&rsquo, s medical history, surgical site or type of intervention. The aim of this retrospective cohort study was to evaluate type and frequency of complications after exodontic surgery, its correlation with antibiotic administration and between patient&rsquo, s related systemic factors. From June 2015 until February 2016 1701 exodontic interventions, for a total of 2322 extracted teeth, were carried out at the Unit of Oral Surgery in Trieste. Descriptive statistic, and backward multiple logistic regressions were performed to identify the variables associated with the presence of post-operative alveolitis or any other post-operative complication. The presence of coagulopathy and smoking habit were related to high risk of post-operative alveolitis (OR = 5.51, p = 0.035 and OR = 2.5, p = 0.029, respectively). Tooth fracture was found to be correlated with higher probability of post-operative alveolitis (p = 0.001) and concomitant chemotherapy put at a higher risk post-operative complications, including alveolitis (OR = 29.5, p = 0.018). According to the present results, antibiotic consumption did not seem to reduce the incidence of post-operative infective complications (alveolitis). A careful analysis of medical history, the adequate surgical technique, and the correct instructions in post-surgical behavior, prevent the insurgence of intra and post-operative complications.

Acute appendicitis is one of the main indications for urgent surgery representing a high-volume procedure worldwide. The current spending review in Italy (and not only in this country) affects the health service and warrants care regarding the use of different surgical devices. The aim of our study is to perform a cost evaluation, comparing the use of endoloops and staplers in complicated acute appendicitis (phlegmonous and gangrenous), taking into consideration the cost of the device in relation to the management of any associated postoperative complications. We retrospectively evaluated 996 laparoscopic appendectomies of adult patients performed in the Emergency General Surgery-St. Orsola University Hospital in Bologna (Italy). Surgical procedures together with the related choice of using endoloops or staplers were performed by attending surgeons or resident surgeons supervised by a tutor. A systematic review was performed to compare our outcomes with those reported in the literature. In our experience, the routine use of endoloop leads to a real estimated saving of 375€ for each performed laparoscopic appendectomy, even considering post-operative complications. Comparing endoloop and stapler groups, the total number of complications is significantly lower in the endoloop group. Our systematic review confirmed these findings even if the superiority of one technique has not been proved yet. Our analysis shows that the routine use of endoloop is safe in most patients affected by acute appendicitis, even when complicated, and it is a cost-effective device even when taking into consideration extra costs for potential post-operative complications.

ObjectivesThe purpose of this study was to investigate the effects of smoking on prognosis after elective surgeries. Incidence of 30-day postoperative complications was compared between propensity score-matched ‘ever-smoker’ and ‘never-smoker’ cohorts. Thirty-day mortality and medical costs during the hospital stay were also compared.Design and settingA large-scale retrospective study using deidentified administrative claims data obtained from 372 acute care hospitals across Japan using the Diagnosis Procedure Combination system (ie, a flat-fee payment system).ParticipantsInpatients who were hospitalised to undergo elective surgery.Primary and secondary outcome measuresThe primary endpoint of this study was incidence of 30-day postoperative complications. Secondary endpoints were 30-day mortality and total medical costs during hospitalisation. Comparison between ever-smokers and never-smokers was conducted using matched cohorts created by 1:1 propensity score matching.ResultsUsing 561 598 eligible patients, matched ever-smoker and never-smoker cohorts (n=1 55 593 each) were created. Ever-smokers were defined as patients with Brinkman Index ≥1. The percentage of patients who were male was 76.7%, and mean ages for ever-smokers and never-smokers were 65.1±13.8 years old and 66.4±15.3 years old, respectively. The Brinkman Index of the ever-smoker cohort was 677.6±553.4. Smoking was significantly associated with higher risk of 30-day postoperative complications compared with not smoking (OR 1.15, 95% CI 1.13 to 1.17, pConclusionsOur results suggest that smoking could be associated with risk of poor postoperative outcomes. In particular, a history of smoking may increase the risk of 30-day postoperative complications as well as that of 30-day mortality. The results suggest that smoking might have a harmful effect on postoperative outcomes irrespective of types of surgery.

In 6.2% of gynaecologic malignancies, vascular involvement is reported. Cytoreductive surgery presents in those cases a higher rate of major complications. Arterial-enteric fistula is a very rare post-surgical complication with serious repercussions on the patient's life due to intestinal haemorrhage and the overlapping sepsis. This is the first case report about iliac-colonic fistula formation in recurrent ovarian cancer with lymph-node metastasis after laparoscopic secondary cytoreductive surgery in a 75-year-old woman and its successful surgical management. A literature review about arterial-enteric fistula formation in gynaecologic cancer treatment, specifically ovarian cancer, is also reported, hypothesising the risk factors of this severe postoperative complication and possible surgical solutions.

Introduction Stoma closure surgery (SCS; restoring intestinal continuity) in children is associated with high post-surgical complication rates with no established preventive strategies. Although many of these complications can be directly or indirectly attributable to bowel obstruction, no anatomical obstructive pathology is found in the majority. Intestinal dysmotility in children with no prior surgery is a well-known entity, which can lead to clinical features similar to anatomical obstruction. It is not known if a similar pathology could be the reason for SCS complications as well. Method & Results We retrospectively reviewed five consecutive cases in our institution between 2016 and 2018, where scintigraphy was utilized to assess bowel motility prior to SCS. The radiotracer is administered via stoma or per anum, admixed with barium for anatomical assessment. Three children had failed prior attempts at SCS (underlying disease: spontaneous neonatal perforation, necrotizing enterocolitis, colonic atresia). A fourth patient, with gastroschisis, had ongoing obstruction despite multiple stricture resections. In all these patients, a dysmotile section of bowel was identified on scintigraphy in the distal small or large bowel and was resected. Three had excellent post-surgical follow up with no complications; one patient died in the immediate postoperative period likely from unrelated cause. A fifth child had a normal bowel motility study prior to SCS and had an uneventful follow up. Conclusions Areas of segmental dysmotility in the distal gut may be the primary cause of post-SCS complications. Using a novel approach of assessing bowel motility using scintigraphy, such areas can be identified pre-operatively and resected, leading to reduced post-SCS complications. We recommend further investigation and validation in a larger prospective study.

Background Treatment for tracheoesophageal fistula (TEF), a life-threatening complication after esophagectomy, is challenging. Case presentation A 75-year-old man with thoracic esophageal cancer underwent subtotal esophagectomy and gastric tube reconstruction through the post-mediastinal root after neoadjuvant chemotherapy. Owing to postoperative anastomotic leakage, an abscess formed at the anastomotic region. Sustained inflammation from the abscess caused refractory TEF between the esophagogastric anastomotic site and membrane of the trachea, and several conservative therapies for TEF failed. Hence, the patient underwent surgery including division of the fistula, direct suturing of the leakage sites, and reinforcement with the flap of the thymus pedicle. As a result, the abscess and TEF disappeared after surgery and the patient was immediately administered an oral diet and discharged home 103 days after initial surgery. Conclusions Although pedicle flaps for the reinforcement of TEF are usually obtained from muscle or pericardium, these flaps need enough lengths to overcome moving distance. We are the first in the existing literature to have successfully treated TEF with surgical repair using a thymus flap located close to TEF. The thymus pedicle might be another candidate for the reinforcement flap in TEF.

International audience; INTRODUCTION AND HYPOTHESIS:The use of mesh in pelvic organ prolapse (POP) surgery has become a widespread treatment option, but carries a risk of specific complications. The objective was to report the rate and type of reoperation for mesh-related complications after pelvic organ prolapse surgery in an urogynecological referral center over a period of 8 years.METHODS:A retrospective study was carried out including all patients operated for a mesh complication after prolapse surgery between September 2006 and September 2014 in the urogynecology unit in Nîmes hospital.RESULTS:Sixty-nine mesh complications were recorded among the 67 patients included. Surgical treatment of mesh-related complications accounted for 7% of all pelvic surgeries performed in our center. Thirty-two patients (47.8%) were referred from other centers and 35 patients (52.2%) were initially operated in our unit. The global rate of reintervention for mesh-related complications after prolapse repair performed in our unit was 2.8%. Of 69 mesh complications, 48 patients (71.6%) had transvaginal mesh (TVM) and 19 patients (28.4%) sacrocolpopexy (SCP). The indication for surgery was a symptomatic or large vaginal erosion (47.8%), symptomatic mesh contraction (20.3%), and infection (11.6%). The most frequent primary symptom was pelvic/perineal pain or dyspareunia (33.3% of cases). The mean time between initial mesh surgery and the reoperation for a complication was 33.4 months (95% CI, 24.5 to 42.2). Eleven patients (15.9%) required several interventions. In total, 77.9% of patients experienced complete recovery of symptoms after surgical management.CONCLUSION:In a referral center the global rate of reinterventions for mesh-related complications after POP repair is 2.8%. The surgical treatment of mesh complications appears to be a safe and effective procedure with cure of the symptoms in most cases.

Background: Individuals with Down syndrome have an increased risk for congenital cataracts, but descriptions of surgical, medical and developmental outcomes are sparse. Materials and Methods: Retrospective review of medical charts of patients with Down syndrome with visits to Cincinnati Children’s Hospital from 1988 to 2013 was performed. A case series of five patients with Down syndrome and cataracts is presented. A total of 47 patients with Down syndrome without cataracts were used as a developmental control. Developmental quotients were compared using an independent-sample, unequal variance t-test. Results: Post-operative cataract complication rates ranged from 20% to 60%. Visual outcomes were varied; significant associations between complication rate and visual outcome were not found. Developmental quotients did not show an association with number of complications, but were lower for children with Down syndrome with cataracts requiring surgery compared to children with Down syndrome without cataracts. Conclusion: In children with Down syndrome and congenital cataract, surgical intervention has risk for post-operative complications. Further investigation is needed to determine if there is an association between surgical complications and visual or developmental outcomes.

Background There is a lack of high-level evidence on the surgical management of cleft palate. An appreciation of the differences in the complication rates between different surgical techniques and timing of repair is essential in optimizing cleft palate management. Method A comprehensive electronic database search will be conducted on the complication rates associated with cleft palate repair using MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials. Two independent reviewers with expertise in cleft pathology will screen all appropriate titles, abstracts, and full-text publications prior to deciding whether each meet the predetermined inclusion criteria. The study findings will be tabulated and summarized. The primary outcomes will be the rate of palatal fistula, the incidence and severity of velopharyngeal insufficiency, and the rate of maxillary hypoplasia with different techniques and also the timing of the repair. A meta-analysis will be conducted using a random effects model. Discussion The evidence behind the optimal surgical approach to cleft palate repair is minimal, with no gold standard technique identified to date for a certain type of cleft palate. It is essential to appreciate how the complication rates differ between each surgical technique and each time point of repair, in order to optimize the management of these patients. A more critical evaluation of the outcomes of different cleft palate repair methods may also provide insight into more effective surgical approaches for different types of cleft palates. Electronic supplementary material The online version of this article (doi:10.1186/s13643-017-0438-2) contains supplementary material, which is available to authorized users.

Background: Utero-cutaneous fistula (UCF) is an extremely rare entity and only a few case reports have been published. Most UCFs develop secondary to postpartum or postoperative complications. Case Report: A 42 year-old woman began to complain from bleeding and malodorous discharge through her abdominal incision scar. The fistula tract with a thickness of 8 mm was observed between the uterus and wound using magnetic resonance imaging (MRI). The risks and benefits of conservative treatment have been discussed; the patient demanded definitive treatment, so hysterectomy and excision of the fistulous tract was performed. Histopathology of the fistulous tract showed endometrial epithelization of the tract lined by granulation. Conclusion: There are many causes of such an extremely rare entity. Patients should be counseled for medical or surgical treatment considering their age, accompanied uterine pathologies such as fibroids and fertility expectations.

Background: Primary wound closure following laparotomy for peritonitis is generally believed to be associated with wound complications and long hospital stay. Open wound management has long been the most common practice after laparotomy for peritonitis. Primary closure (PC), however, has recently been advocated to reduce cost and morbidity. This study determined the incidence and severity of wound complications and their impact on hospital stay and overall outcome when PC of abdominal wounds is done following laparotomy for peritonitis. Patients and Methods: A prospective review of patients who had PC of abdominal wounds following laparotomy for peritonitis over a 6-year period. Results: Fifty-six children were analysed (35 boys and 21 girls), aged 11 months to 13 years (median: 8 years). The indication for laparotomy was typhoid intestinal perforation 47 (83.9%), perforated appendicitis 4 (7.1%), complicated cholecystitis 3 (5.3%) and penetrating abdominal injury with bowel perforation and intestinal obstruction with bowel perforation, 1 (1.8%) each, respectively. Postoperatively, 34 patients had wound complications. Nine patients (16.1%) had superficial wound infection alone, 12 (21.4%) had superficial wound infection with partial wound dehiscence, 6 (10.7%) had deep wound infection, 7 (12.5%) had deep wound infection with complete wound dehiscence, whereas 22 (39.3%) had no wound complication. Overall, wound complications in 13 (23.2%) patients were considered to be severe, but none resulted in mortality. Hospital stay in patients who developed wound complications was 8–37 days (median: 25 days) and 6–22 days (median: 10 days) in patients who had no wound complications (P = 0.02). Conclusion: The rate of wound complications following PC of dirty abdominal wounds remain but PC is safe and gives good healing outcomes.

Fractures of the acromion and scapula are known to occur after reverse shoulder arthroplasty. We present a case of a fracture at the base of the acromion 5 months after arthroplasty treated successfully with dual plating of the acromion. Eighteen months after fracture fixation, the patient had 160 degrees of active forward flexion, a QuickDASH of 29.5, a Constant score of 69 and she was satisfied with the result. A concomitant review of the literature produced, in addition to our patient, 56 cases. These were used to produce a classification system, based on bony and functional anatomy as follows. Tip fractures are of the most lateral or anterior portion of the acromion, those of the body of the acromion are medial to the tip but lateral to the beginning of the scapular base. Fractures at the scapular base are termed fractures of the base of the acromion and those more medial to that, fractures of the scapular spine. The functional results of these case series demonstrated poorer functional outcomes for more medial fractures. As future research in this domain increases, clarity on the nomenclature of these fractures will allow for prognostication and treatment based on fracture location as well as comparison between studies.

Aim: The purpose of this study was to analyze the nature of the disease, the surgical procedures, complications, and survival of preterm infants with necrotizing enterocolitis (NEC) from two tertiary care referral neonatal intensive units in central India.Materials and Methods: A prospective study of a cohort of 110 preterm neonates with gestational age less than 36 weeks and weight less than 1600 g infants diagnosed to have NEC were followed for 90 days. All the neonates were born between January 2015 and December 2017 and treated at two neonatal intensive care units. Infants with sepsis, congenital gastrointestinal anomalies, major cardiac problems, and intraventricular hemorrhage were excluded.Results: Mean gestational age in this cohort was 32.40 ± 3.87 weeks, and the mean age of NEC onset was 13.04 ± 3.54 postnatal days. There were 39 neonates with Stage 1, 45 with Stage 2, and 26 with stage 3 NEC. Pneumoperitoneum, positive paracentesis and progressive clinical deterioration were the indications for laparotomy. The most common complications were sepsis 97/110 (88.18%). Post-operative complications occurred in 22 (84.61%) infants, wound infection in 19 (73.07%), intestinal stricture in 9 (34.61%), wound dehiscence in 7 (26.92%), stoma stenosis in 3 (11.53%), ileostomy prolapse in 2 (7.69%), and burst abdomen in 1 (3.84 %). The overall 90-day survival rate was 87.27% (96/110), and the post-operative survival rate was 46.15% (12/26). The age of gestation, weight, and extent of the disease were the main risk factor for mortality.Conclusion: The short-term outcomes for Stage 3 NEC were associated with high morbidity and mortality. The outlook for infants with Stage 1 and 2 NEC was favorable.

No abstract available. Article truncated at 150 words. A 39 year-old woman was referred to our hospital for evaluation of persistent broncho-pleural fistula after severe necrotizing streptococcal pneumonia. She had undergone a segmentectomy for the necrosis resulting in the broncho-pleural fistula. Her overall medical condition and malnutrition precluded another major surgery such as a muscle flap for the persistent air leak. Endobronchial valve placement was attempted to minimize the gradient and leak across the parenchymal defect to promote healing. A sequential balloon occlusion technique was used to localize the leak to the right upper lobe, which was the site of the previous surgery. The sub-segments were measured and three endobronchial valves (Spiration®, Olympus Respiratory, USA) (1). Valves of 5 mm, 6 mm and 7 mm – were placed in the three sub-segments of the right upper lobe (Figure 1) with a flexible bronchoscope. Near elimination of the air leak was seen post procedure. Figure 2 shows post procedure chest ...

The aim of the present study was to assess the clinical relevance of the pre-operative granulocyte/lymphocyte (G/L) ratio as a predictive marker of post-operative complications in patients with colorectal cancer. In total, 85 patients (59 males and 26 females; mean age, 68.9 years) underwent surgery for colorectal cancer at the Department of Surgery, Ibraki Medical Center, Tokyo Medical University (Ami, Japan), and were divided into post-operative complication and non-complication groups. Clinical data, including age, gender, body mass index, tumor localization, tumor pathological type, cancer staging, surgery time, volume of surgical bleeding, pre-operative G/L ratio and further pre-operative laboratory data, including levels of albumin and C-reactive protein, Glasgow Prognostic Score, white blood cell count and levels of hemoglobin, creatine kinase, lactate dehydrogenase, carcinoembryonic antigen and carbohydrate antigen 19-9 were analyzed between these groups. The total post-operative complication rate was 18.8%. On univariate analysis, the amount of surgical bleeding and the pre-operative G/L ratio were significantly higher in the complication group than in the non-complication group (299.8±361.7 vs. 155.6±268.6 ml, P

Background/Aims. Our policy for the surgical treatment of hepatocellular carcinoma (HCC) has been to minimize the extent of liver resection using a microwave tissue coagulator (MTC) and to not perform Pringle's maneuver for the prevention of ischemic injury to the liver routinely. We verify the safety of liver resection using MTC in HCC patients with poor liver functional reserve, and clarify the long-term outcome of HCC patients who underwent curative resection using MTC. Methodology. One hundred sixty-eight patients who underwent curative resection using MTC between 1992 and 2001 were divided into two groups according each patient's score in the Indocyanin Green Retension 15 Test (ICG-R15 test). The high (ICG-R15 values>20) and low ICG-R15 groups (ICG-R15 values

AIM To assess whether the surgical apgar score (SAS) is a prognostic tool capable of identifying patients at risk of major complications following lower extremity amputations surgery. METHODS This was a single-center, retrospective observational cohort study conducted between January 2013 and April 2015. All patients who had either a primary transtibial amputation (TTA) or transfemoral amputation (TFA) conducted at our institution during the study period were assessed for inclusion. All TTA patients underwent a standardized one-stage operative procedure (ad modum Persson amputation) performed approximately 10 cm below the knee joint. All TTA procedures were performed with sagittal flaps. TFA procedures were performed in one stage with amputation approximately 10 cm above the knee joint, performed with anterior/posterior flaps. Trained residents or senior consultants performed the surgical procedures. The SAS is based on intraoperative heart rate, blood pressure and blood loss. Intraoperative parameters of interest were collected by revising electronic health records. The first author of this study calculated the SAS. Data regarding major complications were not revealed to the author until after the calculation of SAS. The SAS results were arranged into four groups (SAS 0-4, SAS 5-6, SAS 7-8 and SAS 9-10). The cohort was then divided into two groups representing low-risk (SAS ≥ 7) and high-risk patients (SAS < 7) using a previously established threshold. The outcome of interest was the occurrence of major complications and death within 30-d of surgery. RESULTS A logistic regression model with SAS 9-10 as a reference showed a significant linear association between lower SAS and more postoperative complications [all patients: OR = 2.00 (1.33-3.03), P = 0.001]. This effect was pronounced for TFA [OR = 2.61 (1.52-4.47), P < 0.001]. A significant increase was observed for the high-risk group compared to the low-risk group for all patients [OR = 2.80 (1.40-5.61), P = 0.004] and for the TFA sub-group [OR = 3.82 (1.5-9.42), P = 0.004]. The AUC from the models were estimated as follows: All patients = [0.648 (0.562-0.733), P = 0.001], for TFA patients = [0.710 (0.606-0.813), P < 0.001] and for TTA patients = [0.472 (0.383-0.672), P = 0.528]. This indicates moderate discriminatory power of the SAS in predicting postoperative complications among TFA patients. CONCLUSION SAS provides information regarding the potential development of complications following TFA. The SAS is especially useful when patients are divided into high- and low-risk groups.

ObjectivesDespite the burden of venous thromboembolism (VTE) among surgical patients on health systems in Australia, data on VTE incidence and its variation within Australia are lacking. We aim to explore VTE and subsequent mortality rates, trends and variations across Australian acute public hospitals.SettingA large retrospective cohort study using all elective surgical patients in 82 acute public hospitals during 2002–2009 in New South Wales, Australia.ParticipantsPatients underwent elective surgery within 2 days of admission, aged between 18 and 90 years, and who were not transferred to another acute care facility; 4 362 624 patients were included.Outcome measuresVTE incidents were identified by secondary diagnostic codes. Poisson mixed models were used to derive adjusted incidence rates and rate ratios (IRR).Results2/1000 patients developed postoperative VTE. VTE increased by 30% (IRR=1.30, CI 1.19 to 1.42) over the study period. Differences in the VTE rates, trends between hospital peer groups and between hospitals with the highest and those with the lowest rates were significant (between-hospital variation). Smaller hospitals, accommodated in two peer groups, had the lowest overall VTE rates (IRR=0.56:0.33 to 0.95; IRR=0.37:0.23 to 0.61) and exhibited a greater increase (64% and 237% vs 19%) overtime and greater between-hospital variations compared to larger hospitals (IRR=8.64:6.23 to 11.98; IRR=8.92:5.49 to 14.49 vs IRR=3.70:3.32 to 4.12). Mortality among patients with postoperative VTE was 8% and remained stable overtime. No differences in post-VTE death rates and trends were seen between hospital groups; however, larger hospitals exhibited less between-hospital variations (IRR=1.78:1.30 to 2.44) compared to small hospitals (IRR>23). Hospitals performed differently in prevention versus treatment of postoperative VTE.ConclusionsVTE incidence is increasing and there is large variation between-hospital and within-hospital peer groups suggesting a varied compliance with VTE preventative strategies and the potential for targeted interventions and quality improvement opportunities.