Complications in colorectal surgery: risk factors and preventive strategies

Backround: Open or laparoscopic colorectal surgery comprises of many different types of procedures for various diseases. Depending upon the operation and modifiable and non-modifiable risk factors the intra- and postoperative morbidity and mortality rate vary. In general, surgical complications can be divided into intraoperative and postoperative complications and usually occur while the patient is still in the hospital. Methods: A literature search (1980-2009) was carried out, using MEDLINE, PubMed and the Cochrane library. Results: This review provides an overview how to identify and minimize intra- and postoperative complications. The improvement of different treatment strategies and technical inventions in the recent decade has been enormous. This is mainly attributable to the increase in the laparoscopic approach, which is now well accepted for many procedures. Training of the surgeon, hospital volume and learning curves are becoming increasingly more important to maximize patient safety, surgeon expertise and cost effectiveness. In addition, standardization of perioperative care is essential to minimize postoperative complications. Conclusion: This review summarizes the main perioperative complications of colorectal surgery and influencable and non-influencable risk factors which are important to the general surgeon and the relevant specialist as well. In order to minimize or even avoid complications it is crucial to know these risk factors and strategies to prevent, treat or reduce intra- and postoperative complications

Cytokine clearance in serum and peritoneal fluid of patients undergoing damage control surgery with abdominal negative pressure therapy for abdominal sepsis

Objectives: Open abdomen technique with negative pressure therapy (NPT) is widely used in patients with severe abdominal sepsis. The aim of this study was to evaluate cytokine clearance in serumand peritoneal fluidduringNPT. Methods: This prospective pilot study included six patients with severe abdominal sepsis requiring discontinuity resection and NPT for 48 h followed by planned reoperation. Cytokines (IL6, IL8, IL10, TNFalpha, and IL1beta) were measured in the serum and peritoneal fluid during index operation, on postoperative days 0, 1, and 2. Results: Concentrations of cytokines in peritoneal fluid were higher than in serum. IL10 showed a clearance both in serum (to 16.6%, p=0.019) and peritoneal fluid (to 40.9%, p=0.014). IL6 cleared only in serum(to 24.7%, p=0.001) with persistently high levels in peritoneal fluid. IL8 remained high in both serum and peritoneal fluid. TNFalpha and IL1beta were both low in serum with wide range of high peritoneal concentrations. Only TNFalpha in peritoneal fluid showed significant differences between patients with ischemia vs. perforation (p=0.006). Conclusions: The present pilot study suggests that cytokines display distinct patterns of clearance or persistence in the peritoneal fluid and serumover the first 48 h of treatment in severe abdominal sepsis with NPT

A novel approach for treatment of sacrococcygeal pilonidal sinus: less is more

Background: The surgical management of sacrococcygeal pilonidal sinus (PS) is still a matter of discussion. Therapy ranges from complete wide excision with or without closure of the wound to excochleation of the sinus with a brush. In this paper, we introduce a novel limited excision technique. The aim of this study was to assess the morbidity and recurrence rate of this technique. Materials and methods: Limited excision consisted of a selective extirpation of the sinus after tagging the tract with methylene blue. Ninety-three consecutive patients, who underwent surgery between 2001 and 2004, were analyzed. The patients' survey was performed by mail questionnaire and telephone interview inquiring recurrence, time off work, and time to wound healing. Results: Seventy-three percent of the patients were treated in an outpatient setting. With a median follow-up of 2years, the recurrence rate was 5%. The median time off work was 2weeks. The median wound healing time was 5weeks. Conclusion: Limited excision for PS can be done in an outpatient setting with a low recurrence rate and short time off wor

Predictive Factors for Morbidity and Mortality in Patients Undergoing Laparoscopic Paraesophageal Hernia Repair: Age, ASA Score and Operation Type Influence Morbidity

Background: Patients undergoing laparoscopic paraesophageal hernia (PEH) repair risk substantial morbidity. The aim of the present study was to analyze predictive factors for postoperative morbidity and mortality. Methods: A total of 354 laparoscopic PEH repairs were analyzed from the database of the Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTS). Age (<70 and ≥70years) and risk (low: American Society of Anesthesiologists (ASA) scores 1+2; high ASA scores 3+4) groups were defined and multivariate logistic regression was conducted. Results: In patients ≥70years of age postoperative morbidity (24.4% versus 10.1%; p=0.001) and mortality (2.4% versus 0%; p=0.045) were significantly higher than in patients <70years of age. In patients with gastropexy, this significant age difference was again present (38.8% versus 10.5%; p=0.001) whereas in patients with fundoplication no difference between age groups occurred (11.9% versus 10.1%; p=0.65). Mortality did not differ. High-risk patients had a significantly higher morbidity (26.0% versus 11.2%; p=0.001) but not mortality (2.1% versus 0.4%; p=0.18). The multivariate logistic regression identified the following variables as influencing postoperative morbidity: Age ≥70years (Odds Ratio [OR] 1.99 [95% CI 1.06 to 3.74], p=0.033); ASA 3+4 (OR 2.29 [95% Confidence Interval (CI) 1.22 to 4.3]; p=0.010); type of operation (gastropexy) (OR 2.36 [95% CI 1.27 to 4.37]; p=0.006). Conclusions: In patients undergoing laparoscopic paraesophageal hernia repair age, ASA score, and type of operation significantly influence postoperative morbidity and mortality. Morbidity is substantial among elderly patients and those with co-morbidity, questioning the paradigm for surgery in all patients. The indication for surgery must be carefully balanced against the individual patient's co-morbidities, age, and symptoms, and the potentially life threatening complication

Personality traits and virtual reality performance

Background: Surgeons' personalities have been described as different from those of the general population, but this was based on small descriptive studies limited by the choice of evaluation instrument. Furthermore, although the importance of the human factor in team performance has been recognized, the effect of personality traits on technical performance is unknown. This study aimed to compare surgical residents' personality traits with those of the general population and to evaluate whether an association exists between their personality traits and technical performance using a virtual reality (VR) laparoscopy simulator. Methods: In this study, 95 participants (54 residents with basic, 29 with intermediate laparoscopic experience, and 12 students) underwent personality assessment using the NEO-Five Factor Inventory and performed five VR tasks of the Lap Mentor™ basic tasks module. The residents' personality traits were compared with those of the general population, and the association between VR performance and personality traits was investigated. Results: Surgical residents showed personality traits different from those of the general population, demonstrating lower neuroticism, higher extraversion and conscientiousness, and male residents showed greater openness. In the multivariable analysis, adjusted for gender and surgical experience, none of the personality traits was found to be an independent predictor of technical performance. Conclusions: Surgical residents present distinct personality traits that differ from those of the general population. These traits were not found to be associated with technical performance in a virtual environment. The traits may, however, play an important role in team performance, which in turn is highly relevant for optimal surgical performanc

Impact of clinical pathways in surgery

Background: One strategy to reduce the consumption of resources associated to specific procedures is to utilize clinical pathways, in which surgical care is standardized and preset by determination of perioperative in-hospital processes. The aim of this prospective study was to establish the impact of clinical pathways on costs, complication rates, and nursing activities. Method: Data was prospectively collected for 171 consecutive patients undergoing laparoscopic cholecystectomy (n = 50), open herniorrhaphy (n = 56), and laparoscopic Roux-en-Y gastric bypass (n = 65). Results: Clinical pathways reduced the postoperative hospital stay by 28% from a mean of 6.1 to 4.4days (p < 0.001), while the 30-day readmission rate remained unchanged (0.5% vs. 0.45%). Total mean costs per case were reduced by 25% from € 6,390 to € 4,800 (p < 0.001). Costs for diagnostic tests were reduced by 33% (p < 0.001). Nursing hours decreased, reducing nursing costs by 24% from € 1,810 to € 1,374 (p < 0.001). A trend was noted for lower postoperative complication rates in the clinical pathway group (7% vs. 14%, p = 0.07). Conclusions: This study demonstrates clinically and economically relevant benefits for the utilization of clinical pathways with a reduction in use of all resource types, without any negative impact on the rate of complications or re-hospitalizatio

Emergency Left Colon Resection for Acute Perforation. Primary Anastomosis or Hartmann's Procedure? A Case-matched Control Study

Background: The optimal treatment remains controversial for acute left-sided colon perforation. Therefore, the effectiveness and safety of primary anastomosis versus Hartmann's operation (HP) was compared in a case-matched control study. Methods: Thirty consecutive patients with primary anastomosis and protective ileostomy (PAS) were matched to 30 HP patients, controlling for age, gender, American Society of Anesthesiologists (ASA) score, body mass index (BMI), and peritonitis severity (Hinchey). In a second analysis, PAS patients with purulent peritonitis (Hinchey 3) were matched to patients with primary anastomosis without ileostomy (PA). Results: Hospital mortality was similar between HP (17%) and PAS (10%). Complication frequency and severity (requiring re-intervention or admission to the Intensive Care Unit [ICU]) were comparable for the first operation (60% versus 56% and 30% versus 32%). The stoma reversal rate was higher in PAS than in HP (96% versus 60%, p=0.001), with significantly fewer complications (23% versus 66%, p=0.02), and lower severity (7% versus 33%, p=0.02). Additional analysis of PAS versus PA showed similar morbidity (52% versus 41%, p=0.45) and complication severity (18% versus 24%, p=0.51), whereas overall operation time and hospital stay were significantly shorter in PA (169 versus 320 min, p=0.003, 17 versus 28 days, p<0.001). Conclusions: Primary anastomosis and protective ileostomy is a superior treatment to HP in acute left-sided colon perforation. In the absence of feculent peritonitis an ileostomy appears unnecessar

Gas emission during laparoscopic colorectal surgery using a bipolar vessel sealing device: A pilot study on four patients

ABSTRACT: BACKGROUND: Dissection during laparoscopic surgery produces smoke containing potentially toxic substances. The aim of the present study was to analyze smoke samples produced during laparoscopic colon surgery using a bipolar vessel sealing device (LigaSuretrade mark). METHODS: Four consecutive patients undergoing left-sided colectomy were enrolled in this pilot study. Smoke was produced by the use of LigaSuretrade mark. Samples (5,5l) were evacuated from the pneumoperitoneum in a closed system into a reservoir. Analysis was performed with CO2-laser-based photoacoustic spectroscopy and confirmed by a Fourier-transform infrared spectrum. The detected spectra were compared to the available spectra of known toxins. RESULTS: Samples from four laparoscopic sigmoid resections were analyzed. No relevant differences were noted regarding patient and operation characteristics. The gas samples were stable over time proven by congruent control measurements as late as 24 h after sampling. The absorption spectra differed considerably between the patients. One broad absorption line at 100 ppm indicating H2O and several unknown molecules were detected. With a sensitivity of alpha min ca 10-5 cm-1 no known toxic substances like phenol or indole were identified. CONCLUSION: The use of a vessel sealing device during laparoscopic surgery does not produce known toxic substances in relevant quantity. Further studies are needed to identify unknown molecules and to analyze gas emission under various conditions