Surgical Technology International
41st Edition
December 2022 - ISSN:1090-3941
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Direct Peritoneal Resuscitation (DPR) Improves Acute Physiology and Chronic Health Evaluation (APACHE) IV and Acute Physiology Score When Used in Damage Control Laparotomies: Prospective Cohort Study on 37 Patients
Kenji Okumura, MD, Rifat Latifi, MD, Professor of Surgery, Abbas Smiley, MD, MS, PhD, Joon Sub Lee, MD, Ilya Shnaydman, MD, Assistant Professor of Surgery, Bardiya Zangbar, MD, Assistant Professor of Surgery, Matthew Bronstein, MD, Assistant Professor of Surgery, Jorge Con, MD, Associate Professor of Surgery, Kartik Prabhakaran, MD, MHS, FACS, Associate Professor of Surgery, Peter Rhee, MD, MPH, Professor of Surgery, Joshua Klein, DO, Assistant Professor of Surgery, Kiran Shivaraj, MD, Michael D. Klein MD, JD, Associate Professor of Medicine, Daniel M. Miller, MD, Associate Professor of Medicine, Westchester Medical Center, New York, Medical College, Valhalla, New York
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Introduction: Using direct peritoneal resuscitation (DPR) as an adjunct when managing patients undergoing damage control laparotomy (DCL) shows promising results. We report our initial experience in utilizing DPR when managing patients who underwent DCL for emergent surgery at the index operation.
Materials and Methods: We prospectively collected data on 37 patients between August 2020 to October 2021 who underwent DCL with open abdomens after the index operation and utilized DPR. DPR was performed using peritoneal lavage with DIANEAL PD-2-D 2.5% Ca 3.5 mEq/L at a rate of 400ml/hour. Patients’ physiological scores and clinical outcomes were evaluated.
Results: 86% required DCL and DPR due to septic abdomen/bowel ischemia. The median (interquartile range [IQR]) age was 62 years (53–70); 62% were male, and median (IQR) body mass index was 30.0kg/m2 (25.5–38.4). On DPR initiation, median (IQR) APACHE-IV score was 48 (33–64) and median (IQR) Acute Physiology Score (APS) was 31 (18–54). After initiation, median (IQR) APACHE-IV score and median (IQR) APS were 39 (21–62) and 19 (11–56), respectively, and both showed significant improvement in survivors (p<0.05). Median (IQR) DPR duration was four days (2–8) and primary abdominal closure was achieved in 30 patients (81%). There were eight mortalities (21.6%) within 30 days postoperatively, of which seven were within 3–24 days due to uncontrolled sepsis/multiple organ failure. The most frequent complication was surgical-site infection recorded in 12 patients (32%). Twenty-four patients (67%) were discharged home/transferred to a rehab center/nursing home.
Conclusion: DPR application showed significant improvement of APACHE-IV score and APS in patients with peritonitis/septic abdomen.
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Minilaparoscopic CLIPLESS Cholecystectomy: Tips, Tricks and Advanced Maneuvers
Gustavo L. Carvalho, MD, PhD, Associate Professor, University of Pernambuco - Recife, Brazil, Eduardo Moreno Paquentin, MD, ABC Medical Center Santa Fe, Mexico City, Mexico, Roberto Gallardo Diaz, MD, Guatemalan Group in Mini Invasive Surgery and Head Surgeon of Hospital El Pilar, Guatemala City, Guatemala, Prashanth Rao, MD, Global Hospitals & Mamata Hospital, Mumbai, India
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As the world sought the 'Holy Grail' of scarless surgery, minimizing access seemed to be the natural path to follow, and minilaparoscopy (MINI) was considered to be a natural advancement of standard laparoscopy. It aims at minimizing surgical trauma by further reducing the diameter of standard instruments, without compromising range of motion, triangulation or safety. Several different terms have been coined to address this sophisticated reduced-port technique, which is characterized by the use of instruments 3 mm or less in diameter: acuscopic surgery, minilaparoscopy, needlescopic surgery and microlaparoscopy.
The early adoption of MINI was mostly inhibited by the limitations of first-generation instruments, especially with respect to functionality, cost and durability. Furthermore, mini cholecystectomy demanded the use of mini optics, which suffered from poor imaging quality and a short lifetime of the scopes. Newer-generation mini instruments have mitigated these issues through the use of improved effector tips, better insulation, strength and durability, and superior optics. During the early MINI years, surgeons clipped most structures, but sturdy mini clip appliers were either unavailable or did not hold the requisite-size clips. Clipping with MINI required the use of a standard clip applier and the scope had to be changed several times during a procedure, making MINI not only more complicated but also boring and time-consuming. The development and popularization of the clipless technique allowed the surgeon to get free from the expensive and cumbersome minilaparoscopic clip appliers, and replace clips with knots.
The marked improvements in instrumentation and the development of the clipless technique have occurred simultaneously with the development of NOTES, LESS and Robotic surgery, which may have contributed to a greater push towards MINI.
MINI has been proven to offer more than just better cosmesis. Other advantages include better visualization of the surgical field and, with the development of precisely engineered low-friction trocars, which enhance surgical precision during dynamic and delicate tasks (knotting and suturing small structures), less stress and higher efficiency, which makes the procedure easier to perform. Furthermore, transmission of electro cautery through mini instruments has led to less lateral spread of electric current and subsequent less tissue trauma.
For more than 20 years, our team has successfully used minilaparoscopy. Even with the rising popularity of robotic surgery, which still uses 8 mm instruments, minilaparoscopy remains an attractive option that is far from becoming obsolete.
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The Use of Self-Assembling Peptides (PuraStat™) in Functional Endoscopic Sinus Surgery for Haemostasis and Reducing Adhesion Formation. A Case Series of 94 Patients
Yael Friedland, MD, Fiona Stanley Hospital, Perth, Australia, Maurice Bagot d’Arc, MD, BluePharm Consulting, Paris, France, Jennifer HA, MBBS, FRACS, Wexford Medical Center Murdoch, Australia, Claudia Delin, MASc, BluePharm Consulting, Paris, France
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Introduction: Functional endoscopic sinus surgery (FESS) is a treatment option for patients with chronic rhinosinusitis. Bleeding and adhesions are common complications postoperatively.
Objective: To assess the effectiveness of PuraStat™ (3-D Matrix Medical Technology Pty Ltd, Melbourne, Australia) for use in FESS to achieve haemostasis and reduce adhesion formation.
Materials and Methods: A retrospective chart review over four years was performed on 94 patients undergoing FESS by a single surgeon, using PuraStat™ in absence of nasal packing. Results: Twenty-eight patients underwent complete FESS and 66 cases limited FESS most often combined with nasal surgery. Six patients had bleeding postoperatively, of which only four required additional treatment (4.25%). Twenty-three patients (24.47%) required debridement during the follow up, simply performed by suction for 13 or by scissors for 10. No patient required revision surgery for adhesion.
Conclusion: PuraStat™ used for the first time in context of FESS seems to be effective in achieving haemostasis, reducing adhesion formation, and avoiding nasal packing in most patients.
Surgical Technique of Single Anastomosis Duodeno-Ileal Bypass with Sleeve , Gastrectomy (SADI-S)
Jakob Eichelter, MD, Daniel M. Felsenreich, MD, PhD, Christoph Bichler, MD, Lisa Gensthaler, MD, Paula Richwien, MD, Larissa Nixdorf, MD, Julia Jedamzik, MD, Magdalena Mairinger, MD, PhD, Felix B. Langer, MD, Associate Professor, Gerhard Prager, MD, Univ-Prof., Medical University of Vienna, Vienna, Austria Mahir Gachabayov, MD, PhD, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
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Laparoscopic Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-S) is a bariatric/metabolic procedure that has been gaining popularity in recent years. SADI-S strongly affects the secretion of various gut hormones, adipocytokines and incretins. From a mechanistic point of view, the operation combines malabsorption and restriction, and has been shown to have a long-lasting and significant impact on weight loss and remission of comorbidities.
With regard to the technique, first, a Sleeve is created and then the duodenum is tran-sected approximately 3-4cm after the pylorus at the level of the gastroduodenal artery (GDA). Next, 250-300cm of small bowel is measured from the caecum and a hand-sewn duo-deno-ileal anastomosis is performed. The length of the biliopancreatic limb is variable in this procedure. Because of the standardized common limb length in all patients, weight loss is very precise within a low range. Nevertheless, due to the complex hand-sewn anastomosis and the delicacy necessary when handling the duodenum, this procedure should be reserved for experienced bariatric surgeons in specialized centers.
This article provides an overview of the standard surgical technique at the Department of Visceral Surgery at the Medical University of Vienna, as well as information about patient selection and pre- and postoperative care.
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Feasibility and Accuracy of a Novel Hands-Free Robotic System for Percutaneous Needle Insertion and Steering
Agnieszka Witkowska, MD, Sebastian Flacke, MD, PhD, Professor, Lahey Hospital and Medical Center,, Tufts University Medical School, Burlington, MA, US, Shiran Levy, MD, Jacob Sosna, MD, Professor, Isaac Leichter, PhD, S. Nahum Goldberg, MD, Professor , Hadassah Hebrew University Medical Center, Jerusalem, Israel, Ido Roth, MS, Moran Shochat, MS, Danielle Bradbury, MIS, RRA, RT(R), ARRT, XACT Robotics, Caesarea, Israel
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Purpose: To assess the performance and accuracy of CT-guided needle insertion for clinical biopsies using a novel, hands-free robotic system that balances accuracy with the duration of the procedure and radiation dose.
Materials and methods: A prospective, multi-center study was conducted on 60 clinically indicated biopsies of abdominal lesions at two centers (Center 1, n=26; Center 2, n=34). CT datasets were obtained for planning and controlled placement of 17g and 18g needles using a patient-mounted, CT-guided robotic system with 5 degrees of freedom. Planning included target selection, skin entry point, and predetermined checkpoints where additional imaging was performed to permit stepwise correction of the needle trajectory. Success rate, needle tip-to-target distance, number of checkpoints used, number of trajectory corrections, procedure duration, and effective radiation dose were recorded and compared between centers.
Results: In 55 of 60 procedures (91.7%), the robot positioned the trocar needle successfully on target. In the remaining 5 patients, the procedure was manually performed by the operator due to technical failure (n=3) or patient-related factors (n=2).
The average lesion size was 2.8 ± 1.7cm with a lesion depth from the skin of 8.7 ± 2.6cm, and there was no difference between centers. The overall accuracy (needle tip-to-target distance) was 1.71 ± 1.49 (range 0.05-7.20mm), with an accuracy of 2.06 ± 1.45 mm at Center 1 and 1.45 ± 1.52 mm at Center 2 (p=0.1358).
Center 1 used significantly more checkpoints (4.96 ± 1.08) and performed target adjustments in 20 of 24 (83%) cases compared to Center 2 (2.77 ± 0.6 checkpoints and target adjustments in 13 of 31 cases, 42%) (p=0.0024). Accordingly, the steering duration from skin entry to the target varied between Centers 1 and 2; 13.1min ± 4.25min vs. 5.7min ± 2.7min, respectively (p<0.001). The average DLP for the entire procedure was 1147 ± 820 mGycm, with a slightly lower average at Center 2 (1031 ± 724 mGycm) compared to Center 1 (1297 ± 925 mGycm) (p=0.236).
Conclusion: Accurate needle-targeting within an error of 2mm can be achieved in patients using a CT-guided robotic system. The variation in the number of checkpoints did not affect system accuracy but was related to shorter steering times and may contribute to a lower radiation dose.
Accurate needle insertion using a hands-free CT-guided robotic system may facilitate difficult needle placement and enhance the performance of less-experienced interventionalists.
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Predictors of In-Hospital Mortality in Non-Elderly Adult Patients Emergently Admitted with Rhabdomyolysis: A 10-Year Analysis of 27,688 Patients from the National Inpatient Sample
Joon Sub Lee, MD, Abbas Smiley, MD, PhD, Assistant Professor, New York Medical College Valhalla, New York, Rifat Latifi, MD, FACS, FICS, Minister of Health, Adjunct Professor of Surgery, Republic of Kosova, University of Arizona, Tucson, Arizona
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Introduction: Rhabdomyolysis is a condition where muscle damage leads to the leakage of intracellular contents such as myoglobin and creatine kinase. These leak into systemic circulation and can cause detrimental effects. Due to the detrimental effect of rhabdomyolysis on patient mortality and potential complications, identifying factors that affect patient mortality in those with rhabdomyolysis could provide valuable insight in early management strategies and potentially benefit patient outcomes.
Objective: The goal of this study was to identify independent predictors of in-hospital mortality in non-elderly adult patients who underwent emergency admission due to rhabdomyolysis.
Materials and Methods: A retrospective cohort study was done by analyzing 27,688 non-elderly adult patients (18–64 years) with rhabdomyolysis who underwent emergency admission using the National Inpatient Sample (NIS) during 2005–2014. Factors such as demographic information, clinical course, and comorbidities were collected to identify predictors of in-hospital mortality. Chi square and student’s t-tests were utilized to evaluate various group differences on categorical and continuous variables. Backward logistic regression analyses were performed to examine factors that could affect patient mortality.
Results: A total number of 27,688 non-elderly adult patients (age 18–64 years) were included, of which, 20,137 patients were male (72.8%) with a mean (SD) age of 40.60 (13.34) years, and 7,551 patients were female (27.3%) with a mean (SD) age of 45.63 (13.20) years. Multivariable backward logistic regression analysis was performed to evaluate the associations between mortality and different variables in our patient sample. Out of different factors, respiratory diseases, cardiac disease, and genitourinary system disease demonstrated the most significant association with mortality, shown by odds ratios of 3.67, 3.59, and 3.08, respectively. Additionally, patient age, history of surgical procedure, bacterial infection (other than tuberculosis), and cerebrovascular diseases were also positively associated with mortality. Their respective odds ratios were 1.03, 2.14, 2.13, and 2.66.
Conclusion: Each additional year in age leads to 3% increased odds of mortality in non-elderly adult patients who are emergently admitted with rhabdomyolysis.
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RefluxStop™ Therapy – a New Minimally Invasive Technology in Anti-reflux Surgery
Dietmar Stephan, MD, Saitama University International Medical Center, Japan, Yves Borbely, MD, University Clinic for Visceral Surgery and Medicine, Inselspital Bern, Switzerland, Sebastian Friedrich Schoppmann, MD, PhD, Professor, University Clinic for Surgery, Vienna, Austria
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The symptoms of gastroesophageal reflux disease (GERD) are very common, but cannot be reliably controlled with medication, as more than 40% of patients suffer troublesome symptoms more than twice a week even when taking maximum doses of proton pump inhibitors (PPI).
Until recently, the only surgical option was anti-reflux surgery, usually performed as a hiatal hernia repair and some form of fundoplication. While this is still the gold standard, some centers note high recurrence rates and/or high rates of side effects such as dysphagia, bloating, and post-prandial discomfort.
This paper describes a new surgical procedure that controls reflux symptoms through hiatal hernia repair in combination with the implantation of a silicone cube. The cube is implanted near the left side of the esophagus above the lower esophageal sphincter (LES).
The details of the procedure, the indications for this new approach, the initial results, and the rate of side effects compared to Nissen fundoplication are described. Implantation of the CE-certified RefluxStop™ (Implantica, Zug, Switzerland) has been used for 3 years and the initial studies show encouraging success rates. In addition, side effects are significantly reduced. These results must be evaluated in further studies.
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Longer Hospital Length of Stay and Emergency Surgical Intervention are Associated with Lower Rates of Mortality In Elderly Patients with Ruptured Abdominal Aortic Aneurysm: An Analysis of 7,214 Patients
Antonio Lobao, BS, Abbas Smiley, MD, PhD, Assistant Professor, New York Medical College, School of Medicine and Westchester Medical Center, Valhalla, New York, Rifat Latifi, MD, FACS, FICS, FKCS, Minister of Health, Republic of Kosova, Adjunct Professor of Surgery, University of Arizona, Tucson, Arizona
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Introduction: We aimed to determine predictors for in-hospital mortality for elderly patients with ruptured abdominal aortic aneurysms (AAA) undergoing emergency admission.
Materials and Methods: This was a retrospective cohort study utilizing the National Inpatient Sample (NIS) Database, 2005–2014, on elderly patients with ruptured AAA undergoing emergency admission. ICD-9 code 441.3 was used to identify patients with ruptured AAA. Male versus female sex, survived versus deceased patients, and operated versus not-operated ones were compared for various patient characteristics. A multivariable logistic regression with backward elimination and a generalized additive model (GAM) were implemented to evaluate the associations between potential risk factors and mortality.
Results: A total of 7,214 patients aged 65 and older with ruptured AAA were included. About 31% of total sample, 26% of survived, and 36% of deceased were female. Mortality rate was higher in older patients, females, and those who were not operated on (40.6%) versus those that were (74.5%). Age, sex, healthcare insurance, severity of illness subclass, hospital length of stay, total charges, and several comorbidities had significant association with mortality in univariable models. Multivariable logistic regression with backward elimination confirmed age (odds ratio[OR]=1.04; 95% confidence interval [CI]=1.03–1.05; p<0.001), sex (OR=1.23; 95%CI=1.07–1.41; p=0.004), hospital length of stay (OR=0.87; 95%CI=0.86–0.88; p<0.001), bacterial infection (OR=3.79; 95%CI=3.07–4.68; p<0.001), cardiac disease (OR=1.97; 95%CI=1.71–2.28; p<0.001), liver disease (OR=2.90; 95%CI=2.22–3.77; p<0.001), fluid and electrolyte disorders (OR=1.34; 95%CI=1.18–1.52; p<0.001), and coagulopathy (OR=1.96; 95%CI=1.04–1.37; p=0.01) to be the independent predictors of mortality. Age showed a linear association with mortality; whereas, hospital length of stay had a significant L-shaped association. Elderly patients emergently admitted for ruptured AAA had the lowest risk of mortality with hospital stays greater than seven days (EDF=13.91, p<0.0001).
Conclusion: Longer hospital length of stay (>7 days) of emergently admitted elderly patients with ruptured abdominal aortic aneurysm was associated with better outcomes and lower risk of mortality. Surgical intervention was also associated with much lower rate of mortality, while increasing age was associated with higher rate of mortality. In elderly patients admitted for ruptured abdominal aortic aneurysm, every one year older than 65, increased the odds of mortality by 4% and female sex increased the odds of mortality by 23%.
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Surgical Technique for Weight Regain after Roux-en-Y Gastric Bypass: Pouch-resizing and the MiniMIZER® Gastric Ring
Larissa Nixdorf, MD, Daniel M Felsenreich, MD, PhD, Christoph Bichler, MD, Julia Jedamzik, MD1, Jakob Eichelter, MD, Lisa Gensthaler, MD, Magdalena Mairinger, MD, PhD, Paula Richwien, MD, Felix B Langer, MD, Gerhard Prager, MD, Professor, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria, Mahir Gachabayov, PhD, Section of Colorectal Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
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Laparoscopic Roux-en-Y Gastric Bypass (RYGB) is a commonly used method in bariatric surgery that leads to sufficient long-term weight loss and consequently to improvement or resolution of obesity-associated diseases. The nadir weight is commonly reached between six months and two years after surgery. Despite this initially good weight loss, weight regain is observed in up to 20% of the patients. Besides intensive dietological evaluation, bariatric re-operation can be an option in these cases. Before the surgical reintervention, an intensive evaluation of the esophagus, pouch, anastomosis, and adjacent small bowel using upper GI-endoscopy and radiological examinations (X-ray and/or 3D-CT volumetry) is mandatory. In patients with a dilated pouch, pouch-resizing with a MiniMIZER® Gastric Ring (Bariatric Solutions GmbH, Stein am Rhein, Switzerland) could be an option to reestablish restriction in the long term. Currently, there is no gold standard for the choice of the weight regain procedure or for the technique used in the procedure itself.
This article focuses on the standardized procedure of pouch resizing with implantation of a MiniMIZER® Gastric Ring for the surgical therapy of weight regain due to pouch dilatation and/or dilatation of the gastrojejunostomy and the adjacent small bowel (usually approximately the first 20cm), resulting in a huge neo-stomach after RYGB, as performed at the Medical University of Vienna. Further, indications for revisional surgery for weight regain, mandatory examinations, and recommended conservative therapy options prior to surgery will be described. Next, the fast-track concept and its advantages are explained. Lastly, the surgical procedure, including positioning of the patient, placement of trocars, the intraoperative process, and special advice, is presented. Exact planning of the procedure and postoperative follow-up are indispensable for a further long-term success after weight regain surgery.
In conclusion, pouch-resizing and implantation of the MiniMIZER® Gastric Ring represent a practical and effective solution in patients with dilated pouch/anastomosis/adjacent small bowel with weight regain after RYGB, if conservative therapy, including dietitian counseling and new drugs (e.g., Semaglutide), has failed.
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