The successful use of simple tube duodenostomy in large duodenal perforations from varied etiologies

INTRODUCTION: Tube decompression of the duodenum is an old but underutilized technique known to decrease morbidity and mortality in patients with difficult to manage duodenal injuries. Broad arrays of techniques have been described in the literature and are reviewed, but most are complex procedures not appropriate for the management of an unstable patient. PRESENTATION OF CASE: In this paper we describe the technique of tube duodenostomy and the successful application in three cases of large defects (> 3 cm) which two of these cases had failed previous repair attempts. The defects were caused by very different etiologies, including blunt trauma, peptic ulcer disease and erosion from cancer. All were finally managed by application of tube duodenostomy with success. DISCUSSION: Patients with "difficult to manage duodenum" usually present with hemodynamic instability with hostile abdomen. Complex procedures in an unstable patient are associated with adverse outcomes. In patients with significant comorbidities and instability the damage control principle of trauma surgery is gaining popularity. Tube duodenostomy technique described in this paper fits in well with that principle. CONCLUSION: Application of tube duodenostomy instead of a complex procedure in an unstable patient provides an opportunity to stabilize the patient, converting an impending catastrophe to a future scheduled surgery. (C) 2012 Surgical Associates Ltd. Published by Elsevier Ltd

Diaphragmatic Hernia With Incarcerated Spleen as a Complication After Lateral Anterior Column Realignment

BACKGROUND: The creation of sagittal balance of the spine is critical in the treatment adult spinal deformity. Anterior column release (ACR) has gained traction as a minimally invasive alternative to pedicle subtraction osteotomy. By releasing the anterior longitudinal ligament, the anterior column can be lengthened and physiologic lordosis restored. Risks such as transient psoas weakness and thigh numbness have been well documented in the literature; however, diaphragmatic hernia has never been reported. OBJECTIVE: To highlight the difficulties encountered in diagnosing, managing, and treating iatrogenic diaphragmatic hernia in the setting of ACR and stress the relevant retropleural, retroperitoneal, and diaphragmatic structures during the surgical approach. METHODS: In this technical note, we discuss the relevant anatomy in a direct lateral approach to the thoracolumbar junction and the management of an iatrogenic diaphragmatic hernia, which occurred in a patient who underwent a L1 ACR. RESULTS: Three months after surgery, our patient was assessed in clinic and endorsed significant improvements in her pain and mobility. Her 3-month postoperative scoliosis x-rays demonstrated a significant improvement in her sagittal alignment, and she experienced no further negative sequelae from the iatrogenic hernia. CONCLUSION: Iatrogenic diaphragmatic hernia with an intrathoracic spleen after direct lateral ACR is a risk spine surgeons should be aware of and address promptly

Preoperative Prognosticators of Safe Laparoscopic Hepatocellular Carcinoma Resection in Advanced Cirrhosis: a Propensity Score Matching Population-Based Analysis of 1799 Western Patients

The safety and oncologic outcomes of patients with advanced cirrhosis undergoing laparoscopic liver resection (LLR) compared to open resection (OLR) for hepatocellular carcinoma (HCC) remain unclear. Patients with HCC resection during 2010-2014 were identified from the National Cancer Database. Patients with severe fibrosis; single lesions; M0; and known grade, margin status, tumor size, length of hospital stay, 30- and 90-day mortality, 30-day readmission, surgical approach, and complete follow-up were included. A 1:1 propensity score matching analysis of LLR:OLR was performed. Prognostic effect of LLR was assessed by multivariable Cox proportional hazards model. A total of 1799 hepatectomy patients (minor (n = 491, 27.3%); major (n = 1308, 72.7%)) were included. Of 193 (10.7%) LLR patients, 190 were eligible for matching. The LLR vs OLR did not differ for patient characteristics, resection margin status, and 30-day (p = 0.141), 90-day mortality (p = 0.121), or 30-day readmission (p = 0.784). Median hospital stay was shorter for LLR (6 vs 8 days, p = 0.001). Median overall survival (OS) was similar for LLR vs OLR (44.2 and 39.5 months, respectively, p = 0.064). Predictors of worse OS were older age (hazard ratio (HR) 1.04, p = 0.034), > 2 comorbidities (HR 1.29, p = 0.012), grade 3-4 disease (HR 1.81, p = 0.025), N1 disease (HR 1.04, p = 0.048), and R1 margins (HR 1.34, p = 0.002). After adjustment for confounders, LLR vs OLR was not a significant risk factor for OS (HR 1.14, 95% CI 0.76-1.71, p = 0.522). While LLR in advanced cirrhosis for patients with HCC proved safe, optimal patient selection based on the preoperatively available factors comorbidities, age, degree of underlying liver disease, and high-quality oncologic surgery will determine long-term survival

Selection criteria for minimally invasive resection of intrahepatic cholangiocarcinoma-a word of caution: a propensity score matched analysis using the national cancer database

Background While minimally invasive liver resection (MILR) vs. open approach (OLR) has been shown to be safe, the perioperative and oncologic safety for intrahepatic cholangiocarcinoma (ICC) specifically, necessitating often complex hepatectomy and extended lymphadenectomy, remains ill-defined. Methods The National Cancer Database was queried for patients with ICC undergoing liver resection from 2010 to 2016. After 1:1 Propensity Score Matching (PSM), Kruskal-Wallis and chi(2) tests were applied to compare short-term outcomes. Kaplan-Meier survival analyses and Cox multivariable regression were performed. Results 988 patients met inclusion criteria: 140 (14.2%) MILR and 848 (85.8%) OLR resulting in 115 patients MILR and OLR after 1:1 PSM with c-index of 0.733. MILR had lower unplanned 30-day readmission [OR 0.075, P = 0.014] and positive margin rates [OR 0.361, P = 0.011] and shorter hospital length of stay (LOS) [OR 0.941, P = 0.026], but worse lymph node yield [1.52 vs 2.07, P = 0.001]. No difference was found for 30/90-day mortality. Moreover, multivariate analysis revealed that MILR was associated with poorer overall survival compared to OLR [HR 2.454, P = 0.001]. Subgroup analysis revealed that survival differences from approach were dependent on major hepatectomy, tumor size > 4 cm, or negative margins. Conclusion MILR vs. OLR is associated with worse lymphadenectomy and survival in patients with ICC greater than 4 cm requiring major hepatectomy. Hence, MILR major hepatectomy for ICC should only be approached selectively and if surgeons are able to perform an appropriate lymphadenectomy

Is minimally invasive surgery for large gastric GIST actually safe? A comparative analysis of short- and long-term outcomes

Introduction While minimally invasive surgery (MIS) is frequently utilized to remove small gastric gastrointestinal stromal tumors (GIST), MIS surgery for tumors >= 5 cm is currently not endorsed by national guidelines as standard of care due to concerns of safety and inferior oncologic outcomes. Hence this study investigates the perioperative and long-term outcomes of MIS for T3 gastric GIST measuring 5-10 cm. Methods The National Cancer Database (NCDB) 2017 was queried for gastric GIST measuring 5-10 cm or T3 category. Inclusion criteria were known: stage, size, comorbidities, grade, lymphovascular invasion, type of surgery, approach, conversion info, margin status, mitotic rate, neoadjuvant and adjuvant treatment, hospital stay, readmission, 30- and 90-day mortality, complete follow-up, type of institution, and hospital gastric surgery case volume. Binary logistic regression, linear regression models, and Kaplan-Meier survival analysis were used. Results In 3765 patients, mean tumor size was 67.3 mm; 26.3% MIS; and 73.8% open. Median hospital stay was shorter for MIS (4.77 vs 7.04 days, p < 0.001). There was no significant difference in incidence of R1 margins [2.9% MIS vs. 3.1% open (p = 0.143)], unplanned readmission [2.9% MIS and 4.1% open (OR 0.474 p = 0.025)], 30-day mortality [0.5% MIS vs 1.2% open (OR 0.325, p = 0.031)], and 90-day mortality [0.9% MIS vs 2.1% open (OR 0.478 p = 0.036)]. Cox regression models for OS showed no difference in survival (p = 0.137, HR 0.808). Conclusion This analysis provides substantial evidence that MIS for gastric GIST >= 5-10 cm may not only offer improved postoperative morbidity but also oncologic safety. Moreover, as both approaches lead to similar long-term survival, national guidelines may need to incorporate this new information

High Ligation of the Inferior Mesenteric Artery in Left-Sided Colon and Rectal Cancer Resection: Rates of Success and Outcomes

BACKGROUNDHigh ligation of the inferior mesenteric artery, defined as ligation before the takeoff of the left colic artery, is often described as the gold standard in low left-sided colon and rectal cancer surgery. The aim of this study is to quantify the rate of ligation at the described level at a single academic center. Additionally, we examined the relationship between level of ligation and cancer-related outcomes. METHODSThis retrospective cohort study included patients ages 18 and over with low left-sided colon, rectal, and anal cancers undergoing surgical resection. Radiographic evidence of high ligation was defined as ligation of the inferior mesenteric artery before the takeoff of the left colic artery. Patients with and without radiographic evidence of high ligation on CT were compared. Secondary outcomes include lymph node yield and positivity, need for adjuvant therapy, and time from surgery to adjuvant therapy. RESULTS169 patients (54% male) were included in the study. 61.5% of operative reports described high ligation of the IMA. There was radiographic evidence of high ligation in 55.6% of total patients and in 70.2% of patients where high ligation was intended. There was no significant difference in surgeon experience, surgical procedure, or surgical approach. There was no difference in lymph node yield, time to adjuvant chemotherapy, or recurrence rates. CONCLUSIONThis study demonstrates good technical success rate of high ligation of the inferior mesenteric artery but shows no difference in short-term patient-measured outcomes between high and low ligation (or successful and unsuccessful high ligation)