Author Archives: John

The evaluation of risk factors in fascia dehiscence after abdominal surgeries

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“Fascial dehiscence (FD), a serious complication of open surgical procedures, is regarded as a significant concern after abdominal surgeries. Its prevalence is reported to be 0.4–1.2% in elective laparotomies and up to 12% in emergency laparotomies. The mortality rate associated with it exceeds 21%. FD leads to an increase in hospitalization costs, prolonged hospital stays, a higher likelihood of re-operation, and an increase in subsequent
medical visits.
FD is described as the separation of sutured edges of the abdominal fascia following surgery. Four main mechanisms lead to FD, suture breakage, knot failure, suture loosening, or fascial disruption due to a hematoma. The latter is considered the most common. FD can be subclinical, and detectable only through radiology.”

able 1.

Frequency of studied variables in patients with and without fascia dehiscence.

The group without fascia dehiscence (control group), n (%)Group with fascia dehiscence (case group), n (%)
Variables(n=40)(n=20)P
Age
 40–6519 (47.5)14 (70)0.09
 65–8021 (52.2)6 (30)
Sex
 Male22 (55)11 (55)1
 Female18 (45)9 (45)
CRP>10 at the beginning of hospitalization8 (20)3 (15)0.6
Hb <10 (anemia)9 (22.5)3 (15)0.4
Pr<61 (2.5)2 (10)0.2
Smoking
 Type of surgery
  Elective22 (55)8 (40)0.2
  Emergency18 (45)12 (60)
History of abdominal surgery8 (20)5 (25)0.6
History of cancer20 (50)8 (40)0.4
Chemotherapy, immunodeficiency and corten use10 (25)8 (40)0.2
Pack cell injection before surgery10 (25)2 (10)0.1
Death6 (15)14 (70)<0.001
Surgery more than 3 h4 (10)4 (20)0.2
Bleeding more than 200 ml1 (2.5)2 (10)0.2
history of diabetes5 (12.5)2 (10)0.7
Chronic lung disease1 (2.5)1 (5)0.6
Stoma10 (25)7 (35)0.4
Drain installation16 (40)14 (70)0.02
Anastomosis30 (75)12 (60)0.2
Using stapler7 (17.5)6 (30)0.2
Preoperative preparation
 Yes22 (55)7 (35)0.14
 No18 (45)13 (65)
Alb
 3>2 (5)13 (65)<0.001
 3<38 (95)7 (35)
Type of surgery
 Small intestine10 (25)5 (25)1
 Colon and rectom30 (75)15 (75)

Alb, albumin; CRP, C-reactive protein; Hb, hemoglobin; Pr, platelet count.

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Novel approach to surgical repair of enterovaginal fistula in the irradiated pelvis

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“Gynecologic malignancies are often treated with surgical resection and pelvic irradiation. The small bowel is most important in determining the dose of pelvic radiation because of its sensitivity to the effects of radiation. Enterovaginal fistulas in an irradiated field are rare and very challenging problems, often with devastating clinical and personal consequences. We investigated the use of the rectus abdominis muscle flap for the definitive treatment of recurrent enterovaginal fistula in the irradiated field. The rectus abdominis muscle has
ideal features for this use, including a long vascular pedicle, good bulk, low flap-related complication rates, and excellent graft survival.”

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Clinical algorithms for the prevention of variceal bleeding and rebleeding in patients with liver cirrhosis

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“Variceal bleeding is a severe, and often deadly, complication of portal hypertension. Screening for varices, effective bleeding prophylaxis and standardized management of bleeding is critical to improve clinical outcomes. While carvedilol seems to be the treatment of choice for primary prophylaxis in compensated cirrhosis, the use of hepatic venous pressure gradient measurements and safety of non-selective betablockers in advanced cirrhosis with refractory ascites is controversial. The pre-emptive use of transjugular intrahepatic portosystemic shunt within 72 h after variceal bleeding prevents rebleeding and mortality in Child C10-C13 patients.”

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A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy

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“Despite advancements in operative technique and improvements in postoperative outcomes, pancreatic fistula is widely considered to be the most common and
troublesome complication after pancreatic resection. It represents the factor most often linked with postoperative mortality, certain complications such as delayed gastric emptying, longer hospital stays, readmissions, and increased costs. Furthermore, it frequently delays
timely delivery of adjuvant therapies, and reduces overall patient survival. Placement of pancreatic duct stents, the use of somatostatin analogs or adhesive sealants, or modifications in reconstruction technique have done little to change the incidence or alter the impact of postoperative pancreatic fistulas (POPF).”

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Development of Diabetes after Pancreaticoduodenectomy

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“The association with new-onset impaired glucose tolerance (or pre-diabetes) and diabetes has been observed since the inception of and subsequent popularization of pancreaticoduodenectomy (PD) the gold-standard surgical treatment for resectable pancreatic head pathologies. Standardization of surgical techniques, advancements in peri-operative care, and improved understanding of inflicting pathologies have led to drastic reductions in mortality and morbidity across all indications. Despite these advancements, the relationship between diabetes development and parenchymal resection, pathology, and
comorbid states remains understudied.”

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Advantages of routine intraoperative cholangiography in a teaching hospital

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“The role of routine IOC during cholecystectomy has been controversial. Opponents to routine IOC assert that this procedure increases operating times and exposes caregivers and patients to radiation. In addition, there is the possibility of detection of indolent CBD stones with consequently unnecessary removal. On the other hand, advocates in favor
of routine IOC state that intraoperative visualization of the bile duct anatomy may decrease either the rate of complications such as CBD injury, or hospital readmissions for subsequent removal of retained CBD stones. Despite lacking strong evidence for not performing IOC vs. routine IOC vs. selective IOC, fitting in one of these three groups can depend on training, technical experience, and surgical habit. If a surgeon never performs IOC in their daily practice, they are not eager to change their habits, even though literature may suggest otherwise.”

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Acute Kidney Injury within an Enhanced Recovery after Surgery (ERAS) Program for Colorectal Surgery

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“Acute kidney injury (AKI) is a common complication following major abdominal surgery and is associated with increased length of hospital stay, the progression of chronic kidney disease (CKD), and increased long-term mortality. The rate of AKI amongst patients within different enhanced recovery programs (ERP) is reported to be between 3 and 23%. Patient-related risk factors for AKI include age, comorbidities such as hypertension and diabetes, a history of CKD, and use of angiotensin-converting enzyme inhibitors. Procedure-related factors that may impact on the prevalence of AKI include open surgery, the requirement for blood products, the use of intraoperative vasopressors, and a restrictive perioperative fluid regimen. The original guidelines published by the Enhanced Recovery After Surgery (ERAS) Society for colorectal surgery (CRS) as well as their recent update (2018 guidelines) promote a number of measures which aim to maintain near euvolaemia such as preoperative carbohydrate loading, avoidance of bowel preparation, minimisation of fasting times, minimally invasive surgery, and early resumption of oral fluid therapy.”

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