Article of interest: Assessment of morbidity and mortality after esophagectomy using a modified frailty index

Hodari A, et al. Assessment of morbidity and mortality after esophagectomy using a modified frailty index. Ann Thorac Surg. 2013 Oct;96(4):1240-1245.

Full-text for Emory users.

Results: A total of 2,095 patients were included in the analysis. Higher frailty scores were associated with a statistically significant increase in morbidity and mortality. A frailty score of 0, 1, 2, 3, 4, and 5 had associated morbidity rates of 17.9% (142 of 795 patients), 25.1% (178 of 710 patients), 31.4% (126 of 401 patients), 34.4% (48 of 140 patients), 44.4% (16 of 36 patients), and 61.5% (8 of 13 patients), respectively. A frailty score of 0, 1, 2, 3, 4, and 5 had associated mortality rates of 1.8% (14 of 795 patients), 3.8% (27 of 710 patients), 4% (16 of 401 patients), 7.1% (10 of 140 patients), 8.3% (3 of 36 patients), and 23.1% (3 of 13 patients), respectively. When using multivariate logistic regression for mortality comparing age, functional status, prealbumin, emergency surgery, wound class, American Society of Anesthesiologists score, and sex, only age and frailty were statistically significant. The odds ratio was 31.84 for frailty (p = 0.015) and 1.05 (p = 0.001) for age.

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Management of Nonvariceal Upper Gastrointestinal Bleeding

Barkun AN, Almadi M, Kuipers EJ, et al. Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group. Ann Intern Med. 2019 Dec 3;171(11):805-822.

Full-text for Emory users.


Preendoscopic management: The group suggests using a Glasgow Blatchford score of 1 or less to identify patients at very low risk for rebleeding, who may not require hospitalization. In patients without cardiovascular disease, the suggested hemoglobin threshold for blood transfusion is less than 80 g/L, with a higher threshold for those with cardiovascular disease.

Endoscopic management: The group suggests that patients with acute UGIB undergo endoscopy within 24 hours of presentation. Thermocoagulation and sclerosant injection are recommended, and clips are suggested, for endoscopic therapy in patients with high-risk stigmata. Use of TC-325 (hemostatic powder) was suggested as temporizing therapy, but not as sole treatment, in patients with actively bleeding ulcers.

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Management of Esophageal Perforation

Lindenmann J, Matzi V, Neuboeck N, et al. Management of esophageal perforation in 120 consecutive patients: clinical impact of a structured treatment algorithm. J Gastrointest Surg. 2013 Jun;17(6):1036-43.

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Click to enlarge.

Results: Iatrogenic perforation was the most frequent cause of esophageal perforation (58.3 %); Boerhaave’s syndrome was detected in 15 cases (6.8 %). Surgery was performed in 66 patients (55 %), 17 (14 %) patients received conservative treatment and 37 (31 %) patients underwent endoscopic stenting after tumorous perforation. Statistically significant impact on mean survival had Boerhaave’s syndrome (p = 0.005), initial sepsis (p = 0.002), pleural effusion/empyema (p = 0.001), mediastinitis (p = 0.003), peritonitis (p = 0.001), and redo-surgery (p = 0.000). Overall mortality rate was 11.7 %, in the esophagectomy group 17 % and in the patients with Boerhaave’s syndrome 33.3 %.

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Dor versus Toupet fundoplication after laparoscopic Heller myotomy

Torres-Villalobos G, et al. Dor Vs Toupet Fundoplication After Laparoscopic Heller Myotomy: Long-Term Randomized Controlled Trial Evaluated by High-Resolution Manometry. J Gastrointest Surg. 2018 Jan;22(1):13-22.

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Surgical data table

Results: Seventy-three patients were randomized, 38 underwent Dor and 35 Toupet. Baseline characteristics were similar between groups. Postoperative HRM showed that the integrated relaxation pressure (IRP) and basal lower esophageal sphincter (LES) pressure were similar at 6 and 24 months. The number of patients with abnormal acid exposure was significantly lower for Dor (6.9%) than that of Toupet (34.0%) at 6 months, but it was not different at 12 or 24 months. No differences were found in postoperative symptom scores at 1, 6, or 24 months.

Conclusion: There were no differences in symptom scores or HRM between fundoplications in the long term. A higher percentage of abnormal 24-h pH test were found for the Toupet group, with no difference in the long term.

More PubMed results on Dor vs.Toupet fundoplication after Heller myotomy.

Article of interest: Endoscopic or Surgical Myotomy in Patients with Idiopathic Achalasia

One discussion this week included a question about the patient outcomes of those undergoing the POEM procedure.

Werner YB, Hakanson B, Martinek J, et al. Endoscopic or Surgical Myotomy in Patients with Idiopathic Achalasia. N Engl J Med. 2019;381(23):2219–2229.

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Results: A total of 221 patients were randomly assigned to undergo either POEM (112 patients) or LHM plus Dor’s fundoplication (109 patients). Clinical success at the 2-year follow-up was observed in 83.0% of patients in the POEM group and 81.7% of patients in the LHM group (difference, 1.4 percentage points; 95% confidence interval [CI], −8.7 to 11.4; P=0.007 for noninferiority). Serious adverse events occurred in 2.7% of patients in the POEM group and 7.3% of patients in the LHM group. Improvement in esophageal function from baseline to 24 months, as assessed by measurement of the integrated relaxation pressure of the lower esophageal sphincter, did not differ significantly between the treatment groups (difference, −0.75 mm Hg; 95% CI, −2.26 to 0.76), nor did improvement in the score on the Gastrointestinal Quality of Life Index (difference, 0.14 points; 95% CI, −4.01 to 4.28). At 3 months, 57% of patients in the POEM group and 20% of patients in the LHM group had reflux esophagitis, as assessed by endoscopy; at 24 months, the corresponding percentages were 44% and 29%.

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Upper GI bleeding: CTA prior to flouroscopic angiography?

A discussion this week included a diagnostic CTA prior to flourscopic angiography.

Reference: Wells ML, et al. CT for evaluation of acute gastrointestinal bleeding. RadioGraphics. 2018 Jul-Aug;38(4):1089-1107. doi:10.1148/rg.2018170138

Summary: “Teaching point: CT angiography is gaining popularity for use in emergent evaluations of acute GI bleeding. It has potential for use in the first-line evaluation of acute LGIB and the evaluation of UGIB after failed or nondiagnostic endoscopy.”

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Barbed sutures: a manufacturer’s indications for use, and a study of use in anastamotic closures

One discussion this week involved the appropriate use of V-LOC sutures.

References: Davis J. Global Value Dossier for V-LOC Wound Closure Device: Technology and Surgical Applications (version 2.0). 2018 Apr 20. Germany: Coreva-Scientific

Tsukata T, et al. Use of barbed sutures in laparoscopic gastrointestinal single-layer sutures. JSLS. 2016 Jul-Sep;20(3): pii: e2016.00023. doi: 10.4293/JSLS.2016.00023.

Summary: When contemplating the best use for a technology, it helps to ask the creator, or in this case, the manufacturer. In section 2.4 (p.12) of their Global Value Dossier for V-LOC Wound Closure Device, Medtronic describes the indications for use as follows:

“Always refer to the package insert for indications and instructions for use of V-LocTM wound closure devices appropriate for your jurisdiction. Absorbable (V-LocTM 90 and 180), and nonabsorbable (V-LocTM PBT), devices are indicated for use in soft tissue approximation wherever the use of standard, non-barbed absorbable or non-absorbable sutures is appropriate, respectively. The product is contraindicated for patients with allergies to its components and should not be secured by tying surgical knots, or used with interrupted suturing patterns, or for ligating vessels or luminal structures. The technology has not been established for use in fascial closures (abdominal wall, thoracic, extremity fascial closures), gastrointestinal anastomoses, cardiovascular anastomoses, neurological, ophthalmic, orthopedic or microsurgery applications.”

(Davis, 2018).

In a 2016 study out of Japan, Tsukada, Kaji, Kinoshita, and Shimizu analyzed the results of 40 laparoscopic anastomoses that involved V-LOC sutures.

METHODS: Between August 2012 and March 2014, 15-cm-long barbed sutures (V-Loc 180; Covidien, Mansfield, MA, USA) were used for laparoscopic intestinal anastomoses, including intestinal hole closure for esophagojejunal and gastrojejunal anastomoses after mechanical anastomoses and gastric wall closure after partial resection.

RESULTS: 38 patients underwent 40 laparoscopic anastomoses

( 26 esophagojejunostomies; 7 gastrojejunostomies; 7 simple closure of gastric defect)

  • No cases required conversion to open surgery.
  • Two cases exhibited positive air leak test results during surgery (1 case of esophagojejunostomy and 1 case of simple closure of gastric defect)
  • Two cases of intestinal obstruction were noted; of those, one patient with postoperative intestinal paresis (grade II) was managed conservatively, and the other underwent repeat laparoscopic surgery (grade IIIb) for internal herniation unrelated to V-Loc use.
  • No postoperative complications at the anastomosis site and no surgery-related deaths were noted.

CONCLUSION: Single-layer entire-thickness running suturing with the V-Loc 180 barbed suture after stapled side-to-side intestinal anastomosis was found to be safe and feasible in the reported cases.

Risk factors for aspiration in community-acquired pneumonia

One discussion this week involved the risk factors for aspiration in community-acquired pneumonia (CAP).

References: Komiya K, et al. Prognostic implications of aspiration pneumonia in patients with community acquired pneumonia: A systematic review with meta analysis. Scientific Reports. 2016 Dec7;6:38097. doi: 10.1038/srep38097

Taylor JK et al. Risk factors for aspiration in community-acquired pneumonia: analysis of a hospitalized UK cohort. American Journal of Medicine. 2013 Nov;126(11):995-1001. doi:10.1016/j.amjmed.2013.07.012.

Summary: Aspiration pneumonia can be defined as pneumonia in patients who have aspiration risk. Komiya et al (2016) list the following as risk factors for aspiration:

  • impaired consciousness
  • chronic neurological disease
  • weakness
  • swallowing difficulties
  • esophageal dysfunction or mechanical obstruction
  • aspiration witnessed during eating or vomiting
  • sedation

Overt aspiration is generally not witnessed, and aspiration alone cannot fully explain the development of pneumonia. Most healthy subjects passively aspirate oropharyngeal secretions during night, but their cough reflex, mucociliary clearance, and immune system usually prevents the development of pneumonia (Komiya et al, 2016).

In their observational study of 1348 patients with CAP, Taylor et al (2013), while also listing the factors above, noted these additional risk factors:

  • older (above 60-84, median of 74 years)
  • comorbidities of chronic liver disease, congestive heart failure, and stroke

Komiya et al’s (2016) systematic review findings suggest that aspiration risk is associated with greater in-hospital and 30-day mortality in subjects with CAP except, perhaps, in the ICU setting. Although there are insufficient data to perform a meta-analysis on long-term mortality, recurrent pneumonia, and hospital readmission, the few reported studies suggest that aspiration pneumonia is also associated with these outcomes.


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).

Symptomatic hyperthyroidism following parathyroidectomy

A discussion in January included postoperative hyperthyroidism following parathyroidectomy.

Reference: Patel SG, et al. Hyperthyroidism after parathyroid surgery: A prospective analysis of potential contributing factors. (unpublished)


In a prospective study of 101 patients between 2014 and 2015, Patel et al examined surgical extent, anatomic findings, thyroid manipulation, anesthetic medication, and outcomes in order to identify potential intraoperative contributing factors for hyperthyroidism after parathyroidectomy.

Unilateral exploration was found to be significantly less often associated with postoperative hyperthyroidism than bilateral exploration. Additionally, incidence was lower with intraoperative ephedrine and four-fold higher with bilateral exploration. The authors recommend that “postoperative TSH screening for those who require bilateral exploration and/or symptoms of hyperthyroidism should be strongly considered.”

It is stated that this prospective study is the first “to evaluate the type and extent of thyroid manipulation during parathyroid exploration as a cause of hyperthyroidism.”

Due to the fact that the data/manuscript is currently unpublished, minimal information is shared here. We will post a notification when it is published. Our deepest thanks to Dr. Patel for his generosity in sharing this information.

Additional reading: Madill EM, Cooray SD, Bach LA. Palpation thyroiditis following subtotal parathyroidectomy for hyperparathyroidism. Endocrinology, Diabetes & Metabolism Case Reports. 2016 July; pii: 16-0049. doi: 10.1530/EDM-16-0049

Mai VQ et al. Palpation thyroiditis causing new-onset atrial fibrillation. Thyroid. 2008;18(5):571-573. doi:10.1089/thy.2007.0246

Stang MT, et al. Hyperthyroidism after parathyroid exploration. Surgery. 2005 Dec;138(6):1058-1064.