Fissurectomy combined with botulinum toxin A:a review of short- and long-term efficacy of this treatment strategy for chronic anal fissure; a consecutive proposal of a treatment algorithm for chronic anal fissure

Background Several studies have investigated the short- and long-term efficacy of fissurectomy combined with botulinum toxin A injection for patients with chronic anal fissure. Objective To evaluate the short- and long-term efficacy of the combined treatment strategy of fissurectomy with botulinum toxin A for chronic anal fissure and to discuss recurrence rates in the light of current theory on the aetiology of anal fissure. Materials and methods This is a narrative review. We conducted an article search using PubMed and calculated the means of the reported efficacy ranges. Results Fissurectomy combined with botulinum toxin A injections freed at least 78% of the patients from symptoms and yielded a fissure healing rate of up to 86%. Within 12 months after treatment a 3% recurrence rate was reported. On average, the long-term recurrence rate was 22%. One study reported a 50% recurrence rate 22 months after treatment. Conclusion The efficacy of fissurectomy combined with botulinum toxin A injection for chronic anal fissure is high. The short-term recurrence rate is low, while long-term recurrence is relatively high. Extended follow-up indicates that recurrence of chronic anal fissure is possibly caused by anal basal pressure building up steadily once again. If so, the cause of renewed increase of pressure should be addressed. Based on the literature and on our clinical experience, we assume that the underlying cause of increasing anal basal pressure is that patients use their pelvic floor muscles inadequately and this in turn leads to chronic anal fissure

Post-operative Day 1 Serum Transaminase Levels in Relation to Morbidity After Liver Resection

Background Post-operative serum transaminases have been proposed as possible early predictors of morbidity after liver resection. This study aimed to verify the clinical value of post-operative serum transaminases. Methods Clinical data from 2001 to 2016 in a single non-academic referral HPB center were collected from a prospectively held database. Post-operative day 1 serum aspartate transaminase (AST) and alanine transaminase (ALT) were tested for their relationship with post-operative major morbidity, defined by a Clavien-Dindo score 3 or higher, and mortality. Results For this analysis, 371 patients were included, including 149 (40%) undergoing major liver resections. In total, 17% of the patients developed major morbidity. Stepwise logistic regression demonstrated that AST, and not ALT, is an independent predictor for major morbidity (p = 0.017). The probability of major morbidity significantly increased with increasing AST values. A threshold value of 242 U/L was found to be predictive for one or more major complications. Conclusions In this study, post-operative serum AST on day 1 was a predictive factor for major morbidity after liver resection. For patients with low AST value, early discharge could be considered. However, because of the substantial inter-individual variability of AST values, more studies are needed to translate these results into clinical practice

A Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis analysis to evaluate the quality of reporting of postoperative pancreatic fistula prediction models after pancreatoduodenectomy:A systematic review

BACKGROUND: Postoperative pancreatic fistula is a frequent and potentially lethal complication after pancreatoduodenectomy. Several models have been developed to predict postoperative pancreatic fistula risk. This study was performed to evaluate the quality of reporting of postoperative pancreatic fistula prediction models after pancreatoduodenectomy using the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) checklist that provides guidelines on reporting prediction models to enhance transparency and to help in the decision-making regarding the implementation of the appropriate risk models into clinical practice.METHODS: Studies that described prediction models to predict postoperative pancreatic fistula after pancreatoduodenectomy were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The TRIPOD checklist was used to evaluate the adherence rate. The area under the curve and other performance measures were extracted if reported. A quadrant matrix chart is created to plot the area under the curve against TRIPOD adherence rate to find models with a combination of above-average TRIPOD adherence and area under the curve.RESULTS: In total, 52 predictive models were included (23 development, 15 external validation, 4 incremental value, and 10 development and external validation). No risk model achieved 100% adherence to the TRIPOD. The mean adherence rate was 65%. Most authors failed to report on missing data and actions to blind assessment of predictors. Thirteen models had an above-average performance for TRIPOD checklist adherence and area under the curve.CONCLUSION: Although the average TRIPOD adherence rate for postoperative pancreatic fistula models after pancreatoduodenectomy was 65%, higher compared to other published models, it does not meet TRIPOD standards for transparency. This study identified 13 models that performed above average in TRIPOD adherence and area under the curve, which could be the appropriate models to be used in clinical practice.</p

Treatment of iron deficiency in patients scheduled for pancreatic surgery:implications for daily prehabilitation practice in pancreatic surgery

BACKGROUND: Preoperative anemia is a frequent complication in pancreatic surgical patients, and it adversely affects morbidity, mortality, and postoperative red blood cell (RBC) transfusion rates. Iron deficiency (ID) is often the underlying cause of anemia and constitutes a modifiable risk factor.METHODS: Single-center, longitudinal prospective cohort study conducted between May 2019 and August 2022 at the University Medical Center Groningen in the Netherlands. Patients scheduled for pancreatic surgery were referred to the outpatient prehabilitation clinic for preoperative optimization of patient-related risk factors. Patients were screened for anemia (&lt; 12.0 g/dL in women and &lt; 13.0 g/dL in men) and ID (either absolute [ferritin &lt; 30 µg/L] or functional [ferritin ≥ 30 µg/L + transferrin saturation &lt; 20% + C-reactive protein &gt; 5 mg/L]). Intravenous iron supplementation (IVIS) (1,000 mg ferric carboxymaltose) was administered to patients with ID at the discretion of the consulting internist. Pre- and postoperative hemoglobin (Hb) levels were assessed, and perioperative outcomes were compared between patients receiving IVIS (IVIS-group) or standard care (SC-group).RESULTS: From 164 screened patients, preoperative anemia was observed in 55 (33.5%) patients, and in 23 (41.8%) of these patients, ID was the underlying cause. In 21 patients, ID was present without concomitant anemia. Preoperative IVIS was administered to 25 patients, out of 44 patients with ID. Initial differences in mean Hb levels (g/dL) between the IVIS-group and SC-group at the outpatient clinic and one day prior to surgery (10.8 versus 13.2, p &lt; 0.001, and 11.8 versus 13.4, p &lt; 0.001, respectively) did not exist at discharge (10.6 versus 11.1, p = 0.13). Preoperative IVIS led to a significant increase in mean Hb levels (from 10.8 to 11.8, p = 0.03). Fewer SSI were observed in the IVIS-group (4% versus 25.9% in the SC-group, p = 0.02), which remained significant in multivariable regression analysis (OR 7.01 (1.68 - 49.75), p = 0.02).CONCLUSION: ID is prevalent in patients scheduled for pancreatic surgery and is amendable to preoperative correction. Preoperative IVIS increased Hb levels effectively and reduced postoperative SSI. Screening and correction of ID is an important element of preoperative care and should be a standard item in daily prehabilitation practice.</p

Personalisation of breast cancer follow-up: a time-dependent prognostic nomogram for the estimation of annual risk of locoregional recurrence in early breast cancer patients

The objective of this study was to develop and validate a time-dependent logistic regression model for prediction of locoregional recurrence (LRR) of breast cancer and a web-based nomogram for clinical decision support. Women first diagnosed with early breast cancer between 2003 and 2006 in all Dutch hospitals were selected from the Netherlands Cancer Registry (n = 37,230). In the first 5 years following primary breast cancer treatment, 950 (2.6 %) patients developed a LRR as first event. Risk factors were determined using logistic regression and the risks were calculated per year, conditional on not being diagnosed with recurrence in the previous year. Discrimination and calibration were assessed. Bootstrapping was used for internal validation. Data on primary tumours diagnosed between 2007 and 2008 in 43 Dutch hospitals were used for external validation of the performance of the nomogram (n = 12,308). The final model included the variables grade, size, multifocality, and nodal involvement of the primary tumour, and whether patients were treated with radio-, chemo- or hormone therapy. The index cohort showed an area under the ROC curve of 0.84, 0.77, 0.70, 0.73 and 0.62, respectively, per subsequent year after primary treatment. Model predictions were well calibrated. Estimates in the validation cohort did not differ significantly from the index cohort. The results were incorporated in a web-based nomogram (http://​www.​utwente.​nl/​mira/​influence). This validated nomogram can be used as an instrument to identify patients with a low or high risk of LRR who might benefit from a less or more intensive follow-up after breast cancer and to aid clinical decision making for personalised follow-up

The effect of sarcopenic obesity and muscle quality on complications after DIEP-flap breast reconstruction

Introduction: The aim of this study was to evaluate whether sarcopenic obesity and muscle quality as expressed by skeletal muscle radiodensity (SMD) are associated to postoperative complications in women undergoing DIEP-flap breast reconstruction (BR). Methods: All patients who underwent DIEP-flap BR at our tertiary center between 2010 and 2018 were asked to sign informed consent for the use of their electronic medical records and images. By outlining anatomical skeletal muscle contours on the preoperative abdominal CT-scan at lumbar level L3, SMD and skeletal muscle indices (SMI) were measured by two observers independently. Using logistic regression analyses, the association between sarcopenic obesity (BMI >25 & SMI <39), low SMD (<40HU), and Clavien-Dindo (CD) grade ≥ II complications was evaluated. In this way odds ratios (OR) and adjusted odds ratios (ORadjusted) were provided. Results: Out of the 103 patients included in this study, 36% had CD grade ≥ II complications within 30 days of surgery. Twenty patients (19%) suffered from sarcopenic obesity of whom eleven patients (55%) had CD grade ≥ II complications (OR = 2.7, p = 0.05). In a multivariate analysis, sarcopenic obesity was not significantly related to a higher complication rate (ORadjusted = 2.2, p = 0.14) but women with SMD below average and those with prior radiotherapy had a higher risk for grade ≥ II complications (ORadjusted = 2.9, p = 0.02 and ORadjusted = 2.7, p = 0.02 respectively). Conclusion: Below average SMD (<40HU) was found to be associated with the development of postoperative CD grade ≥ II complications in women undergoing DIEP-flap BR. Future research should evaluate whether improving SMD reduces the complication incidence in this patient group

The Effect of Unenhanced MRI on the Surgeons' Decision-Making Process in Females with Suspected Appendicitis

This prospective study evaluated the impact of the results of unenhanced magnetic resonance imaging (MRI) on the surgeon's diagnosis of acute appendicitis in potentially fertile females. 112 female patients, aged 12-55, with suspected appendicitis underwent MRI of the abdomen. At three defined intervals; admission and clinical re-evaluation before and after revealing the MRI results, the surgeon recorded the attendance of each patient in operative treatment, observation or discharge. Appendicitis was confirmed or declined by pathology or by telephone follow-up in case of non-intervention. Appendicitis was confirmed in 29 of 112 patients. At admission the surgeon's disposition had a sensitivity of 97 % and specificity of 29 %. After knowing the MRI results, sensitivity was 97 % and specificity 64 %. The sensitivity and specificity of MRI alone were 89 and 100 %, with a negative and positive predictive value of 96 and 100 %, respectively. We believe that MRI should perhaps be standard in all female patients during their reproductive years with suspected appendicitis. It avoids an operation in 32 % of cases and allows earlier planning for patients with an equivocal clinical picture. Trial number: OND1292733 (Narcis.nl)

Preoperative physical performance as predictor of postoperative outcomes in patients aged 65 and older scheduled for major abdominal cancer surgery:A systematic review

Background: Abdominal cancer surgery is associated with considerable morbidity in older patients. Assessment of preoperative physical status is therefore essential. The aim of this review was to describe and compare the objective physical tests that are currently used in abdominal cancer surgery in the older patient population with regard to postoperative outcomes. Methods: Medline, Embase, CINAHL and Web of Science were searched until 31 December 2020. Non-interventional cohort studies were eligible if they included patients ≥65 years undergoing abdominal cancer surgery, reported results on objective preoperative physical assessment such as Cardiopulmonary Exercise Testing (CPET), field walk tests or muscle strength, and on postoperative outcomes. Results: 23 publications were included (10 CPET, 13 non-CPET including Timed Up & Go, grip strength, 6-minute walking test (6MWT) and incremental shuttle walk test (ISWT)). Meta-analysis was precluded due to heterogeneity between study cohorts, different cut-off points, and inconsistent reporting of outcomes. In CPET studies, ventilatory anaerobic threshold and minute ventilation/carbon dioxide production gradient were associated with adverse outcomes. ISWT and 6MWT predicted outcomes in two studies. Tests addressing muscle strength and function were of limited value. No study compared different physical tests. Discussion: CPET has the ability to predict adverse postoperative outcomes, but it is time-consuming and requires expert assessment. ISWT or 6MWT might be a feasible alternative to estimate aerobic capacity. Muscle strength and function tests currently have limited value in risk prediction. Future research should compare the predictive value of different physical instruments with regard to postoperative outcomes in older surgical patients