Patients with ECF can be treated with low morbidity and low recurrence rate in a multidisciplinary setting. We believe that patients with ECF should be referred to specialist units for management.
Peripartum hemodynamic changes can be life-threatening to the parturient with Marfan's syndrome and aortic dilatation. Anesthetic goals for delivery included preparation for possible aortic dissection, and avoidance of increased aortic root shear stress, through careful hemodynamic monitoring, and general anesthesia using remifentanil.
INTRODUCTION AND OBJECTIVES: We previously reported the incidence of urologic-induced Clavien grade III complications of Prophylactic Ureteral Localization Stents (PULSe) is estimated at 2%. Conclusions of this study raised the possibility of mandatory guidewire utilization prior to all PULSe placement, as this was not obligatory in the initial series. As a quality improvement project, we sought to compare a modification of technique, mandatory use of guidewire, prior to PULSe placement to reduce urologic-induced complications in this patient cohort. Moreover, we performed a systematic review of the literature to determine the overall incidence of urologic-induced complications in patients undergoing PULSe placement.METHODS: We performed a retrospective review of all patients who underwent cystoscopy and PULSe placement at the time of General Surgical Procedure over a 12-month period. We compared this patient cohort to our prior cohort from July 2013 to June 2014 with the following variables: age, BMI, ASA score, pre-operative creatinine, post-operative creatinine, pre/post-operative creatinine difference, and Clavien III urologic-induced complications. We then performed a literature review from 1985-2018 using the following search terms: 'prophylactic ureteral stent' and 'localization stent'. Of the 145 studies reviewed, 14 publications met our inclusion criteria of PULSe prior to surgical procedure for the purpose of ureteral localization.RESULTS: In a current institutional series, 132 patients with a mean age and BMI of 55.78 (18-89) and 27.02, respectively, underwent bilateral PULSe placement with mandatory use of guidewire. No Clavien III complications were encountered in the contemporary cohort, compared to the prior incidence of 2% (p<0.001) Moreover, postoperative creatinine and pre/post-procedural creatinine difference also favored the contemporary cohort (p<0.022 and p<0.003, respectively). Review of literature and complication profile can be seen in Table 1. Overall urologic-induced complication rate in the literature is 2.47%.CONCLUSIONS: Mandatory use of guidewire prior to PULSe placement reduced our incidence of urologic-induced Clavien III complications to zero. The literature varies with respect to use of guidewire or fluoroscopy during PULSe placement
Purpose Enterocutaneous fistulae (ECF) present a difficult management problem and can cause significant morbidity. The aim of the study was to assess the outcome of these patients.
Methodology A retrospective chart review of all patients with ECF managed at a tertiary centre between 1996 and 2006. Demographic, management and outcome data was recorded. Factors influencing ECF closure and outcome were assessed with Cox regression analysis.
Results Thirty‐three patients (17 male) were identified with ECF (median age 63, range 27–84). The primary aetiology was Crohn’s (30%), anastomotic leak (24%), iatrogenic (18%), mesh (6%), neoplasia (6%) and other (16%). Definitive surgery was undertaken in 21 (64%) at a median of 6.4 months (0.4–72 range) following presentation. Twenty percent of patients required emergency surgical intervention and 5 patients required preoperative total parenteral nutrition (TPN). Surgical management was formal resection and reanastomosis in all patients, with a mean operative time of 4.75 hours (SD = 1.8). The median hospital stay for the operative group was 19 days (7–85). Four patients required post‐operative TPN. Fistula closure rate was 97% (operative group 21/21, non‐operative group 11/12). Mean follow up was 37.3 months (0.5–217). Six operative patients (19%) developed fistula recurrence. There were 2 deaths at 2 and 5 months (fistula aetiology malignant colonic fistula and radiation enteritis respectively). No factor was predictive of fistula recurrence.
Conclusion Patients with enterocutaneous fistula can be treated with low morbidity and low recurrence rate in a multidisciplinary setting. Patients with ECF should be referred to specialist units for management.
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