High impact complications after Whipple procedure

Mirrielees JA, et al. Pancreatic Fistula and Delayed Gastric Emptying Are the Highest-Impact Complications After Whipple. J Surg Res. 2020 Jun;250:80-87.

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Results: About 10,922 patients undergoing pancreaticoduodenectomy were included for analysis. The most common postoperative complications were DGE (17.3%), POPF (10.1%), incisional SSI (10.0%), and organ/space SSI (6.2%). POPF and DGE were the only complications that demonstrated sizable effects for all clinical and resource utilization outcomes studied. Other complications had sizable effects for only a few of the outcomes or had small effects for all the outcomes.

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Retained Gastric Antrum Syndrome

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Dumon K, Dempsey DT. (2019). Postgastrectomy Syndromes. Shackelford’s Surgery of the Alimentary Tract, 8th ed.: 719-734.

“Hypergastrinemia after distal gastrectomy can be caused by gastrinoma or retained antrum. In the latter there is residual antral tissue left in continuity with the duodenal stump after gastric resection with Billroth II anastomosis. The G cells in this retained antral tissue are not exposed to luminal acid, resulting in continuous secretion of gastrin and intense stimulation of acid production by parietal cells in the proximal gastric remnant. The exposure of the unbuffered jejunum to this high acid level at the Billroth II GJ results in marginal ulcer (see Fig. 62.12B ).

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Comparison of different reconstruction methods following distal gastrectomy

Nishizaki D, Ganeko R, Hoshino N, et al. Roux-en-Y versus Billroth-I reconstruction after distal gastrectomy for gastric cancer. Cochrane Database Syst Rev. 2021 Sep 15;9(9): CD012998.

Matsumoto K, Tanaka S, Toyonaga T, et al. Clinical Impact of Different Reconstruction Methods on Remnant Gastric Cancer at the Anastomotic Site after Distal Gastrectomy. Clin Endosc. 2021 Aug 13. Epub ahead of print.

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Management of the difficult duodenal stump.

Burch JM, Cox CL, Feliciano DV, Richardson RJ, Martin RR. Management of the difficult duodenal stump. Am J Surg. 1991 Dec;162(6):522-6.

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Abstract: Leakage from the duodenal stump has been the most feared complication of the Billroth II reconstruction following gastric resection. The purpose of our study was to evaluate four methods of duodenal stump closure in 200 patients. One hundred and forty-seven (74%) patients had duodenal ulcers; 28 (14%) had gastric ulcers; and 25 (13%) had a variety of other inflammatory conditions. The most common indication for operation was acute hemorrhage (51%), followed by perforation (24%), intractability (15%), and obstruction (10%). Conventional duodenal closures were performed in 160 (80%) patients, Nissen’s closure in 25 (13%), Bancroft’s closure in 6 (3%), and tube duodenostomy in 9 (5%). Duodenal leaks occurred in four (2.5%) patients with conventional closures and in three (33%) patients with tube duodenostomies. No leaks occurred in patients with Nissen’s or Bancroft’s closures. The hospital mortality rate for the series was 9.5%; however, no patient who developed a duodenal leak died. We conclude that Nissen’s and Bancroft’s closures were safe and effective, but that tube duodenostomy did not reliably prevent uncontrolled leakage.

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Article of interest: The C-reactive protein-to-prealbumin ratio predicts fistula closure

Harriman S, Rodych N, Hayes P, Moser MA. The C-reactive protein-to-prealbumin ratio predicts fistula closure. Am J Surg. 2011 Aug;202(2):175-8.

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Background: The purpose of this study was to evaluate the predictability of fistula closure using the ratio of C-reactive protein to prealbumin (C:P ratio).

Methods: A database of 89 patients with gastrointestinal fistulas (1994-2009) was created based on the records of our Nutrition Support Services Team. All patients had weekly blood work including C-reactive protein level, prealbumin level, and albumin level. Forty-three fistulas were managed without surgery for 6 weeks or more; of these, 29 closed.

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Abdominal surgery in neutropenic patients

Jolissaint JS, et al. Timing and Outcomes of Abdominal Surgery in Neutropenic Patients. J Gastrointest Surg. 2019 Apr;23(4):643-650.

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Results: Amongst 237 patients, mortality was 11.8% (28/237) and morbidity 54.5% (130/237). Absolute neutrophil count < 500 cells/μL (50% vs. 20.6%, P < 0.01) and perforated viscus (35.7% vs. 14.8%, P = 0.01) were associated with mortality. Perforated viscus (25.4% vs. 7.5%) was also associated with morbidity. Urgent operations were associated with higher morbidity (63.6% vs 34.7%, P < 0.001) and mortality (16.4% vs 1.4%, P = 0.002) when compared to elective operations. Transfer from an outside hospital (22.3% vs. 11.2%, P = 0.02) and longer median time from admission to operation (2 days (IQR 0-6) vs. 1 day (IQR 0-3), P < 0.01) were associated with morbidity. An ANC threshold of 350 provided the best discrimination for mortality.

Conclusions: Elective surgery in the appropriately chosen neutropenic patient is relatively safe. For patients with obvious surgical pathology, we advocate for earlier operation and a lower threshold for surgical consultation in an effort expedite the diagnosis and necessary treatment.

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Anti-fungal therapy in the treatment of perforated peptic ulcers: what’s the evidence?

Huston JM, et al. Role of Empiric Anti-Fungal Therapy in the Treatment of Perforated Peptic Ulcer Disease: Review of the Evidence and Future Directions. Surg Infect (Larchmt). 2019 Dec;20(8):593-600.

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Results: There are no randomized clinical trials comparing outcomes specifically for patients with PPU treated with or without empiric anti-fungal therapy. We identified one randomized multi-center trial evaluating outcomes for patients with intra-abdominal perforations, including PPU, that were treated with or without empiric anti-fungal therapy. We identified one single-center prospective series and three additional retrospective studies comparing outcomes for patients with PPU treated with or without empiric anti-fungal therapy. 

Conclusion: The current evidence reviewed here does not demonstrate efficacy of anti-fungal agents in improving outcomes in patients with PPU. As such, we caution against the routine use of empiric anti-fungal agents in these patients. Further studies should help identify specific subpopulations of patients who might derive benefit from anti-fungal therapy and help define appropriate treatment regimens and durations that minimize the risk of resistance, adverse events, and cost.

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