Dual-surgeon approach in complex abdominal surgery: Should it be standard practice?

IntroductionMore and more often complex abdominal surgeries are performed in the elderly. Together with the ageing population these patients are at risk for incisional hernias. We aimed on assessing outcomes following incisional hernia surgery in patients 80 years and older.Material and methodsUsing the Herniamed-Registry, a prospective multi-institutional database, data on patients undergoing surgery for incisional hernias were retrospectively assessed. 46,040 patients were included and divided by age. Intraoperative-, general-, and postoperative complications as well as 1-year follow-up outcomes were assessed and compared between patients 80 years and older vs younger than 80 years.ResultsIntra- (2.3% vs 1.5%; p < 0.001) and postoperative (8.6% vs 7.2%; p = 0.001) complications, general complications (5.5% vs 3.0%; p < 0.001), as well as reoperations (3.8% vs 3.0%; p = 0.007) were more likely to occur in elderly patients. By contrast, recurrences (3.6% vs 4.5%; p = 0.007), pain at rest (7.3% vs 10.1%; p < 0.001) and on exertion (11.3% vs 18.3%; p < 0.001), as well as pain requiring treatment (5.4% vs 7.7%; p < 0.001) was less likely in the group of patients aged ≥ 80 years.ConclusionIncisional hernia repair in patients 80 years and older is associated with a slightly higher complication risk but is quite acceptable and also have improved pain scores. The recurrence difference is also clinically unimportant.

Background: Complex abdominal surgeries, necessitated by severe conditions like cancer, trauma, and inflammatory diseases, require advanced expertise and precise, multifaceted techniques to restore function and appearance. This review systematically assesses the outcomes of combined reconstructive techniques, such as mesh reinforcement, component separation, flap reconstruction, and laparoscopic-assisted repairs, in achieving optimal functional and aesthetic results. Methodology: RCTs, cohort studies, and case series on reconstructive techniques in complex abdominal surgeries for adults were included. A comprehensive search in PubMed, Cochrane Library, and Embase used primary and secondary keywords along with MESH terms. Studies on pediatric patients, non-English publications, and those lacking outcome data were excluded. Results: Autologous tissue grafting and abdominoplasty demonstrated the highest success rates at 100%, with flap reconstruction and composite tissue allotransplantation also showing strong results at 92% and 95%, respectively. Laparoscopic-assisted repairs shows lower success rate at 77% and mesh reinforcement and Botox-assisted repairs shows 70-80% of success outcomes. General satisfaction rates for abdominal aesthetics in these surgeries range from 75% to 95%, reflecting varied patient satisfaction with aesthetic outcomes. Conclusion: Reconstructive techniques success rate for complex abdominal surgeries vary. Autologous grafting and abdominoplasty achieved high rates and other methods showed promising results but varied efficiency.

Australian scientists lobby for antimicrobial oversight body

In 2002, Ochsner laparoscopic surgeons and nephrologists began placing peritoneal dialysis (PD) catheters via a laparoscopic-assisted method. We compared laparoscopically placed PD catheters (LAPD) with catheters most recently placed without laparoscopic aid (STPD). The method for this study is a retrospective chart review. Demographics of both groups were similar. Nine of 20 (45%) in the STPD group and 16 of 23 (70%) in the LAPD group had had previous abdominal surgery. Three of 20 (15%) of STPD had complications, including one small bowel injury. Four of 23 (17.4%) of the LAPD had complications. One of 20 (5%) in the STPD group and 3 of 23 (13%) in the LAPD group had dialysate leaks. In the STPD group, 8 of 20 (40%) had catheter problems that led to removal in 7 (35%). In the LAPD group, 6 of 23 (26%) had catheter malfunction: 3 were salvaged with a laparoscopic procedure; 3 (13%) were removed for malfunction. 1) LAPD allows proper PD placement after complex abdominal surgery; 2) Although dialysate leak complications are increased, bowel perforation risk is less; 3) Because of proper placement, PD catheter malfunction rate is less with LAPD; 4) Although no results obtained statistical significance, we found LAPD superior to STPD and have converted to this technique.

Using percutaneous transhepatic cholangioscopic lithotripsy for intrahepatic calculus in hostile abdomen

Prehabilitation worth it? A theoretical algorithmic for the cost-effectiveness of a multimodal prehabilitation program for complex abdominal surgery

Background: Probiotics are protective against Clostridioides difficile infection and antibiotic-associated diarrhea, and they may decrease risk of infections following complex abdominal surgeries. Infectious risks associated with probiotic use are not well described in the literature. We describe probiotic use among patients with bloodstream infections (BSIs) due to organisms typically found in probiotics. Methods: Patients with positive blood cultures with Lactobacillus spp, Saccharomyces spp, and Bifidobacterium spp at our large academic hospital from October 2016 through October 2019 were identified using Theradoc, a clinical surveillance tool. Clinical data and orders for probiotics, including probiotic capsules, probiotic yogurt, and kefir, were extracted from the electronic medical record. Cases were considered distinct if the cultures were collected 7 or more days apart. True infections were defined as positive cultures which were treated with antimicrobials and had provider documentation outlining clinical relevance of culture data. Results: Among 26 distinct episodes of BSI, 16 (62%) were considered true infections. The remaining 10 cases were interpreted as contaminants or of unclear significance. Of the 16 cases representing true infection in 14 patients, 6 (38%) had received probiotics in the hospital in the preceding month. Among these patients, 5 had Lactobacillus bacteremia and had received Lactobacillus capsules, probiotic yogurt, and/or kefir. One patient had Saccharomyces fungemia following receipt of probiotic yogurt and kefir. All 6 patients with BSI possibly related to probiotic use had an antecedent gastrointestinal procedure or surgery within a month of the BSI, and 2 had intra-abdominal abscesses from which the same organism was cultured. Of the 16 true BSIs, 9 occurred in immunocompromised hosts, but antecedent probiotic use was confirmed in only 1 of these cases. Two episodes caused by different organisms occurred within the same month; all other episodes were &gt;60 days apart. Conclusions: In our retrospective review of BSIs with organisms typically found in probiotics over a 3-year period at a large academic hospital, more than one-third of those with clinically relevant BSIs had antecedent probiotic use within the hospital. All patients with infections possibly related to probiotic use had recent gastrointestinal procedures or surgery, raising concern for probiotic use following interventions that increase the risk for gastrointestinal tract leakage or translocation. Further research is necessary to assess the risk of bloodstream infection in postoperative patients treated with probiotics.Funding: NoneDisclosures: None

Aim Complex patients have been shown to have favourable outcomes when managed under the care of the multi-disciplinary teams (MDT) 1,2. In 2019 we published our experience of a single centre complex AWH MDT and advocated its use 3 in line with EHS and a collaborative group from AWRE 2020 4,5. Expansion Further development has led to the set-up of a regional, tertiary, complex, abdominal wall reconstruction MDT service. This has facilitated identification of patients who will ultimately benefit from management of the regional AWH MDT surgical teams undertaking the most complex of abdominal wall procedures together. Since 2021 our regional MDT discussed 87 cases including tertiary referrals from within and out with the immediate geographical area. 71 abdominal wall hernias including 15 recurrent, 6 with concurrent parastomal hernias, 9 parastomal hernias and one perineal hernia. Progression The development of virtual conferencing services has allowed the MDT improved access for healthcare professionals. With resources for benign cases becoming increasing restricted, having an MDT approved management plan for patients streamlines services and allows costs to be rationalised. Scheduling joint operations between different hospitals facilitates pooling of expertise for difficult cases. We are developing an online registry for involved abdominal wall units to allow data sharing, service evaluation and improve accountability. Conclusion Appreciation of complex abdominal wall surgery as a stand-alone sub-specialty is increasing and there is a consensus among hernia surgeons that these patients should be managed by the MDT in specialist centres by specialist surgeons enhancing learning, proficiency, and accountability.

Aim Sarcopenia is defined as the skeletal muscle mass loss and is considered as a prognostic factor in oncological surgical patients, liver transplant and trauma surgery. It can be reversed with exercise and diet. Nonetheless there is a lack of evidence of its impact on complex abdominal wall surgery. The aim is to evaluate the impact of sarcopenia in postoperative complications after complex incisional hernia repair. Material and Methods Retrospective study of patients undergoing surgery for complex incisional hernias &amp;gt;10cm (W3 of European Hernia Society classification) between 2014–2021. Sarcopenia was stablished as the skeletal muscle index (SMI), measured at L3 transversal section of a preoperative CT-scan. Previously defined literature-based SMI cutoff values were used: men &amp;lt;52,4cm2/m2, women &amp;lt;38,5cm2/m2. Results We included 105 patients, of which 29 (27,6%) were sarcopenic. The mean follow-up was 24,11 (19,28) months. The mean age and body mass index was 65,34 (10,98) and 31,85 (5,55), respectively. Sarcopenia was significantly associated with a higher risk of death [OR 11,21 (IC95% 2,76–45,52); p=0,001]. We observed a difference in need of intensive care unit (ICU) stay [OR 2,24 (IC95% 0,88–5,69); p=0,089] and cardiac complications [OR 2,96 (IC95% 0,79–11,11); p=0,108], not reaching statistical significance. Differences in surgical site occurrence or infection were not observed. After analysing by possible cofounding factors (age, comorbidities, ICU stay), sarcopenia remains associated with a higher risk of death [OR 9,08 (IC95% 2,08–39,59); p=0,003]. Conclusions Given the results of our study sarcopenia might increase the risk of death, independent of age, comorbidities and ICU stay.

There are an increasing number of elderly patients who were earlier considered to be at high risk now having the advantage of receiving complex abdominal surgery due to marked improvements in healthcare. This population is at an inherent risk of “difficult abdominal wall” after emergency surgical procedures. This chapter will address the important concept of complex abdominal wall reconstruction (CAWR) in the elderly in the acute phase. We will highlight some basic definitions of the CAWR surgery followed by techniques and principles of performing safe CAWR in the acute phase.

BACKGROUNDPancreaticoduodenectomy (PD) is a complex surgical procedure with a high morbidity rate. The serious complications are major risk factors for poor long-term surgical outcome. Studies have reported an association between early postoperative prognostic nutritional index (PNI) and prediction of severe complications after abdominal surgery. However, there have been no studies on the use of early postoperative PNI for predicting serious complications following PD.AIMTo analyze the risk factors and early postoperative PNI for predicting severe complications following PD.METHODSWe retrospectively analyzed 238 patients who underwent PD at our hospital between January 2007 and December 2017. The postoperative complications were classified according to the Dindo-Clavien classification. Grade III-V postoperative complications were classified as serious. The risk factors for serious complications were analyzed by univariate analysis and multivariate logistic regression analysis.RESULTSOverall complications were detected in 157 of 238 patients (65.9%) who underwent PD. The grade III-V complication rate was 26.47% (63/238 patients). The mortality rate was 3.7% (9/238 patients). Multivariate logistic regression analysis revealed that preoperative serum albumin [odds ratio (OR): 0.883, 95% confidence interval (CI): 0.80-0.96; P < 0.01] and PNI on postoperative day 3 < 40.5 (OR: 2.77, 95%CI: 1.21-6.38, P < 0.05) were independent factors associated with grade III-V postoperative complications.CONCLUSIONPerioperative albumin is an important factor associated with serious complications following PD. Low early postoperative PNI (< 40.5) is a predictor for serious complications.

ESRA19-0716 Pain rebound in day surgery: how can we avoid it?

Hypothesis tests

Perioperative Medicine

Pain control and early ambulation are two important postoperative goals. Strategies that decrease morphine use while increasing ambulation have the potential to decrease postoperative complications. In this study the authors sought to determine the effect of an abdominopelvic binder on postoperative morphine use, pain, and ambulation in the first day after surgery. The authors randomly assigned 75 patients undergoing abdominal gynecologic surgery to either binder or not after surgery. Demographic data and surgical characteristics were collected. Outcome variables included morphine use, pain score, time to ambulation, and number of ambulations. A group at high risk for decreased mobility was identified and the binder increased the number of ambulatory events by 300%, 260%, and 240% in patients with vertical incisions, age over 50 years, and complex surgeries, respectively. Morphine use and pain scores were not significantly different. The binder increased ambulations in the subset of patients at the highest risk for postoperative complications: elderly, cancer patients, and vertical incisions. Routine use of the binder may benefit particularly high-risk gynecologic surgical patients.