Author Archives: John

Arterial pseudoaneurysm is a rare but potentially fatal complication after pancreaticoduodenectomy (PD). Evaluating the incidence and predictors associated with pseudoaneurysm formation and patient death caused by its rupture.

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“Post pancreatectomy hemorrhage (PPH) is a rare but fatal complication with reported mortality rates of 16%-50%. It is associated with significant morbidity and mortality, especially when repeat laparotomy is required to control bleeding. Among the causes of PPH, intraabdominal pseudoaneurysm is directly associated with prolonged hospital stay and death due to sudden hemorrhage. An aneurysm is a localized dilatation of the artery and can either be true aneurysm (involves all the 3 arterial layers) or pseudoaneurysm (lack a complete arterial wall or surrounded by soft tissue). An arterial leak is an extravasation or a persistent blood flow following arterial anastomosis or arterial repair into the aneurysm sac. The cause of post-PD pseudoaneurysms is described to be multifactorial. However, it is well known that pancreatic fistula is mostly associated with the development of pseudoaneurysm. Other factors predisposed for its development include iatrogenic trauma of vessel walls during lymphadenectomy, biliary fistula, mechanical irritations by
drainage tubes, and intra-abdominal infections that destroy the vessel wall.”

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Surgical management of ostomy complications

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“Most stomal complications are managed non-operatively, through a multidisciplinary and multi-specialist approach. MISSTO in 2021 published the guidelines for the nursing management of stoma-related morbidity. In this context, a key role is played by nurses specialized in stoma care. Sometimes, the conservative approach is not effective to solve the complication, and surgical treatment becomes necessary. The aim of this mapping review is to get a comprehensive overview on the incidence, the risk factors, and the management (conservative and surgical) of the main surgical complications of ostomies,
identifying research gaps and collecting evidence for future research directions.”

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Perioperative Management of Patients Taking Direct Oral Anticoagulants

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“Direct oral anticoagulants (DOACs), including apixaban, rivaroxaban, edoxaban, and dabigatran, are widely used anticoagulants. Approximately 4 million patients in the
US are currently being treated with DOAC therapy. DOACs are indicated for stroke prevention in patients with atrial fibrillation and for the prevention and treatment of venous thromboembolism. For these conditions, DOACs have advantages compared with war-
farin that include a lower risk of bleeding, fixed dosing that does not require coagulation test monitoring, and fewer potential drug-drug interactions.
Knowing how to advise patients who are taking a DOAC and need a surgical procedure (a surgical operation typically with general/spinal anesthetic) or nonsurgical procedure (a nonsurgical intervention, such as a biopsy or colonoscopy, that typically does not require general/spinal anesthetic) is important because approximately 20% of DOAC-treated patients undergo an elective or urgent procedure annually. Moreover, DOAC use is
increasing, especially among older patients for whom a surgical or nonsurgical procedure is most commonly performed.Perioperative DOAC management requires careful decisions about preoperative interruption and postoperative DOAC resumption to minimize the risks of thromboembolism and bleeding. Surgical-site bleeding increases the likelihood of reoperation and delays resumption of anticoagulant therapy, which increases the risk for
thromboembolism,”

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Outcomes of colostomy takedown following Hartmann’s procedure

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“Reversal of the end colostomy following a Hartmann’s procedure (HP) remains a frequently performed operation, undertaken by colorectal and general surgeons. While Henri Hartmann initially described the procedure in 1921 as a treatment for rectosigmoid cancer, it is now most commonly employed in cases of Hinchey 3 and 4 diverticulitis, where performance of a primary anastomosis is considered unsafe. Trauma, colorectal malignancy, inflammatory bowel disease and ischaemic colitis are other common reasons for performing HP in the USA. Ideally, Hartmann’s reversal (HR) is performed once the patient has recovered from the initial illness in order to re-establish intestinal continuity and avoid a permanent stoma. Historically this procedure has had low rates of success and a high morbidity, leading
to the presence of a permanent stoma in a substantial percentage of patients.

“This paper analyses a large institutional series of reversal of Hartmann’s procedure and provides a new perspective on the outcomes in specialized referral centres. Restoration
of bowel continuity following Hartmann’s procedure is a major surgical undertaking and in previously published literature has been associated with a low probability of success. Although it is associated with significant morbidity we describe a high success rate for restoration of intestinal continuity, at times in patients who have been denied surgery at other locations.”

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Stapled Versus Hand-Sewn Anastomoses in Emergency Intestinal Surgery

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“Since Ravitch and Steichen introduced a modified form of the Soviet-developed stapling instruments in the 1960s, various types of staplers and stapling techniques have been adopted worldwide. There are two main types of stapled intestinal anastomoses: anatomical end-to-end anastomoses, performed with circular staplers, and functional side-to-side anastomoses, performed with linear staplers. According to several studies, stapled anastomoses have rendered hand-sewn anastomoses obsolete. It is known that less time is required for stapled intestinal anastomosis than for conventional hand-sewn anastomosis, and that the rate of anastomostic-related complications after stapling is acceptably low. However, some articles have pointed out that stapled anastomoses are unfavorable in certain situations. To our knowledge there are no papers in the literature comparing stapled and manual anastomosis in emergency traumatic or nontraumatic intestinal surgery. Thus, we conducted a prospective randomized study to compare emergency intestinal surgical
stapling with manual suturing.”

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Implementation of an SSI care bundle for patients undergoing emergency laparotomy (EL)

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“EL is a procedure performed for a heterogenous group of patients for a diverse range of pathologies, such as intestinal obstruction, perforation and peritonitis. Patients are often
frail with limited physiological reserve. The in-hospital mortality rate is 9.3%, increasing to 15.3% in patients aged >65 years, compared with 1—2% for elective procedures. EL
carries a higher risk of postoperative complications, and SSI is more likely after dirty procedures where the surgical site is already contaminated.
Use of a care bundle has been shown to reduce the SSI rate by 40—50% in patients undergoing elective colorectal surgery and 7.6% in patients undergoing EL. There is
no consensus on what constitutes a care bundle for SSI, except inclusion of three or more interventions.”

Consort diagram. LOS, length of stay; SSI, surgical site infection.
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Counterclockwise Rotation of Roux-En-Y Limb Significantly Reduces Internal Herniation in Laparoscopic Roux-En-Y Gastric Bypass

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“The impact of rotation of the Roux limb after initial staple division, and creation of the jejunojejunal anastomosis and its relation to the biliopancreatic limb on the development of internal herniation has not been adequately addressed. It is probable, due to the wide range of reported incidences, that there are details to the construction of the limb that play a vital role in the propensity for development of internal hernias. The objective of current study was to investigate whether direction of rotation of the Roux limb to create the jejunojejunostomy has any influence on rates of internal herniation. We hypothesized that counterclockwise rotation of Roux limb with the jejunojejunostomy performed on the left side of the axis of the mesentery with biliopancreatic limb remaining on the left side of the axis, is associated with better orientation and decreased incidence of internal herniation.”

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