Aortic stenosis and noncardiac surgery: risks and postoperative outcomes

Pislaru SV, et al. Aortic stenosis and noncardiac surgery: managing the risk. Curr Probl Cardiol. 2015 Nov;40(11):483-503.

Full-text for Emory users. 

“In summary, the mortality risk at contemporary noncardiac surgery has followed the general trend of decreasing surgical mortality rate, and is currently at 1.5%-4% for elective procedures, significantly lower than those in the early reports (Fig 1). Presence of severe AS does not result in increased mortality rates, but rather in excess cardiovascular morbidity (most notably myocardial infarction [13] or new or worsening heart failure [14]). Symptomatic patients have worse outcomes.” (pg. 488) Continue reading

The impact of abdominal incisional closure techniques on rates of fascial dehiscence

Tolstrup MB, Watt SK, Gögenur I. Reduced Rate of Dehiscence After Implementation of a Standardized Fascial Closure Technique in Patients Undergoing Emergency Laparotomy. Ann Surg. 2017 Apr;265(4):821-826.

Full-text for Emory users.

RESULTS: We included 494 patients from 2014 to 2015 and 1079 patients from our historical cohort for comparison. All patients had a midline laparotomy in an emergency setting. The rate of dehiscence was reduced from 6.6% to 3.8%, P = 0.03 comparing year 2009 to 2013 with 2014 to 2015. Factors associated with dehiscence were male gender [hazard ratio (HR) 2.8, 95% confidence interval (95% CI) (1.8-4.4), P < 0.001], performance status ≥3 [HR 2.1, 95% CI (1.2-3.7), P = 0.006], cirrhosis [HR 3.8, 95% CI (1.5-9.5), P = 0.004], and retention sutures [HR 2.8, 95% CI (1.6-4.9), P < 0.000]. The 30-day mortality rate was 18.4% in the standardized group vs 22.4% in 2009 to 2013, P = 0.057 and 90-day mortality 24.2% vs 30.4%, P = 0.008.

CONCLUSION: The standardized procedure of closing the midline laparotomy by using a “small steps” technique of continuous suturing with a slowly absorbable (polydioxanone) suture material reduces the rate of fascial dehiscence.

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Surgeon’s choice: TEP or TAPP for recurrent inguinal hernia repair?

One discussion involved the comparison of outcomes for TEP and TAPP for hernia repair.

Reference: Kockerling F, et al. TEP or TAPP for recurrent inguinal hernia repair-registered-based comparison of the outcome. Surgical Endoscopy. 2017 Oct;31(10):3872-3882. doi: 10.1007/s00464-017-5416-1

Summary: To date, no randomized trials have been conducted to compare the TEP vs TAPP outcome for recurrent inguinal hernia repair. Between September 1, 2009 and August 31, 2013 data were entered into the Herniamed Registry on a total of 2246 patients with recurrent inguinal hernia repair following previous open primary operation in either TAPP (n = 1,464) or TEP technique (n = 782).

  • TAPP group: recurrent repair was performed for n=974/1,464 (66.5%) patients after suture and n=490/1,464 (33.5%) after mesh repair.
  • TEP group: recurrent repair was performed for n=554/782 (70.8%) patients following previous suture repair and for n=228/782 (29.2%) after mesh repair.

No significant differences were found between the recurrent operations in TEP vs TAPP technique with regard to the intraoperative complications, complication-related reoperations, re-recurrence rates, rates of pain at rest, pain on exertion, or chronic pain requiring treatment. Unfavorable results were identified only with regard to the higher seroma rates associated with TAPP; these responded to conservative treatment.

In summary, both TEP and TAPP can be recommended as effective techniques for treatment of recurrent inguinal hernia following previous open primary operation. The decision to use one or the other technique should be based solely on the surgeon’s expertise. The registry study presented here thus confirms the recommendations in the guidelines on laparo-endoscopic treatment of recurrent inguinal hernia following previous open primary operation.


What is the effect of abdominal insufflation on deep vein flow?

One discussion this week involved the effect of abdominal insufflation on deep vein flow.

Reference: Yang C, Zhu L. Coagulation and deep vein flow changes following laparascopic total extraperitoneal inguinal hernia repair: a single-center, prospective cohort study. Surgical Endoscopy. 2019 Feb 11. doi: 10.1007/s00464-019-06700-6.

Summary: The authors observed morphologic change of the iliac vein during TEP procedure. The iliac vein was almost completely collapsed, which not only impaired venous return from the lower extremities but also caused vein distention. The acute distention caused vessel wall damage due to mechanical disruption of the endothelial lining. Vessel wall damage is one of Virchow’s triad in the pathogenesis of thrombosis.

In this study, activated coagulation and impaired deep venous flow implied that the TEP procedure had a certain degree of potential risk for DVT during the early postoperative period.

An algorithm for preoperative cardiac risk assessment

One discussion last week involved cardiac arrest in the setting of hernia repair. The reference below was highlighted in the chief resident’s presentation.

Reference: Rafiq A, Skylar E, Bella JN. Cardiac evaluation and monitoring of patients undergoing noncardiac surgeryHealth Services Insight. 2017 Feb 20; 9: 1178632916686074. doi: 10.1177/1178632916686074.

Summary: Cardiovascular complications in the perioperative period are one of the most common events leading to increased morbidity and mortality. Although such events are very small in number, they are associated with a high mortality rate making it essential for physicians to understand the importance of perioperative cardiovascular risk assessment and evaluation. Its involves a detailed process of history taking, patient’s medical profile, medications being used, functional status of the patient, and knowledge about the surgical procedure and its inherent risks.

That being said, this review by Rafiq et al (2017) aims to provide a concise but comprehensive analysis on all such aspects of perioperative cardiovascular risk assessment for noncardiac surgeries and provide a basic methodology toward such assessment and decision making.

The ideal approach toward perioperative cardiac risk assessment requires a multidisciplinary team or a dedicated perioperative team of physicians. This leads expert physicians in this field to be involved in patient care with improved communications among primary physicians, anesthesiologist, surgeons, the patient, family members of the patient, cardiologist, and all other ancillary departments of health care involved.

Figure 1: Algorithm for perioperative cardiac risk assessment prior to noncardiac surgery (p.2)

algorithm cardiac

The authors state that it is important to stress the fact that a majority of these recommendations are based, to a large extent, on observational studies and clinical experience. There are only few RCTs that address this matter. It is prudent that more randomized trials are needed to improve on current recommendations, hence leading to further improvement in patient care and management in the perioperative period.

Hepaticojejunostomy vs end-to-end biliary reconstructions in treatment of bile duct injury

One discussion this week included treatments for bile duct injury.

Reference: Jablonska B, et al. Hepaticojejunostomy vs end-to-end biliary reconstructions in the treatment of iatrogenic bile duct injuries. Journal of Gastrointestinal Surgery. 2009 Jun;13(6):1084-1093. doi:10.1007/s11605-009-0841-7.

Summary: Iatrogenic bile duct injuries (IBDI) most frequently develop during cholecystectomy. An increase in patients with IBDI has been associated with the widespread use of laparoscopic cholecystectomy (p.1084).

Jablonska et al (2009) clarify that the Roux-Y hepaticojejunostomy (HJ) is the most frequently recommended type of reconstruction. End-to-end ductal anastomosis (EE) is used very seldom in the surgical treatment of IBDI but is performed during hepatic transplantation with good results.

In this study by Jablonska et al (2009), 94 patients underwent reconstructive surgery for IBDI (49, Roux-Y HJ, and 45, EE) between January 1990 and March 2005. The major findings include:

  • Early complications occurred more after HJ (24.5%) than after EE (6.7%).
  • Wound infection was most frequent early complication: 16.3% of HJ group, 2.2% of EE group.
  • HJ group saw 2% early postoperative mortality rate, and 8% early reoperations rate. EE group saw no mortality, no early reoperations.
  • Excellent/good long-term results were observed in 78.94% of HJ group, and 77.42% of EE group.
  • Recurrent stricture was observed in 2 HJ patients (5.3%) and 3 EE patients (9.6%).
  • Quality of life in both groups was comparable.

“This study emphasizes that it is possible to achieve very good long-term results and high quality of life using both HJ and the EE” (p.1092).

Sugarbaker vs Keyhole repair in parastomal hernias

One discussion this week involved the Sugarbaker repair vs Keyhole repair.

Reference: DeAsis FJ et al. Current state of laparoscopic parastomal hernia repair: a meta-analysis. World Journal of Gastroenterology. 2015 Jul 28;21(28):8670-8677. doi: 10.3748/wjg.v21.i28.8670

Summary:  The primary differences between keyhole repair and Sugarbaker repair are the orientation of the bowel and the presence of a slit in the mesh. In the modified Sugarbaker approach, the bowel is exteriorized through the side of the mesh, whereas in the Keyhole approach the bowel is inserted through a 2 to 3 cm slit in the center of mesh. Both methods apply the mesh intraperitoneally (DeAsis et al, 2015, p.8673).

DeAsis et al (2015) performed a systematic review of PubMed and Medline. The primary outcome analyzed was recurrence of parastomal hernia. Secondary outcomes were mesh infection, surgical site infection, obstruction requiring reoperation, death, and other complications.

In an analysis of 15 articles involving 469 patients, the recurrence rate was 10.2% (95%CI: 3.9-19.0) for the modified laparoscopic Sugarbaker approach, and 27.9% (95%CI: 12.3-46.9) for the keyhole approach. There were no intraoperative mortalities reported and six mortalities during the postoperative course.

The review concluded that the non-slit mesh modified Sugarbaker approach and the slit mesh Keyhole approach are currently the most reported options for laparoscopic repair. When choosing between the two, a modified Sugarbaker technique appears to be a superior method given the low recurrence rates compared to the keyhole technique if an ePTFE mesh is used (p.8676).

Types of abdominal wall mesh for hernia repair: a brief review

One discussion this week included abdominal wall mesh.

Reference: Cevasco M, Itani KMF. Ventral hernia repair with synthetic, composite, and biologic mesh: characteristics, indications, and infection profile. Surgical Infections. 2012 Aug;13(4):209-215. doi:10.1089/sur.2012.123.

Summary: Cevasco and Itani (2012) provide a succinct overview of available mesh materials, as well as their characteristics and special situations.

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Calculation of essential metabolites in Total Parenteral Nutrition: the basics

One discussion this week involved how to perform basic TPN metabolite calculations.

Reference: Madsen H and Frankel EH. The hitchhiker’s guide to parenteral nutrition management for adult patients. Practical Gastroenterology. 2006 July. Retrieved from

Summary: This was discussed as a possible question on boards. Below are three tables, taken directly from the article referenced.