In terms of economic impact, the occurrence of an anastomotic leakage has a large negative influence on medical resource utilization, so that, despite the complication-related increase of DRG-reimbursement, every complicated case represents a financial burden for the hospital.
HighlightsUrachal remnant anomalies are uncommon in adulthood.Surgical removal of urachal remnants is indicated to prevent recurrent infection.Urachal carcinoma is a rare but aggressive cancer.Laparoscopic approach represents the safest approach to remove urachal remnant.
BackgroundThe elevated serum and peritoneal cytokine concentrations responsible for the systemic response syndrome (SIRS) and multiorgan failure in patients with severe acute pancreatitis lead to high morbidity and mortality rates. Prompted by reports underlining the importance of reducing circulating inflammatory mediators in severe acute pancreatitis, we designed this study to evaluate the efficiency of laparotomy followed by continuous perioperative peritoneal lavage combined with postoperative continuous venovenous diahemofiltration (CVVDH) in managing critically ill patients refractory to intensive care therapy. As the major clinical outcome variables we measured morbidity, mortality and changes in the Acute Physiology and Chronic Health Evaluation (APACHE II) score and cytokine concentrations in serum and peritoneal lavage fluid over time.MethodsFrom a consecutive group of 23 patients hospitalized for acute pancreatitis, we studied 6 patients all with Apache II scores ≥19, who underwent emergency surgery for acute complications (5 for an abdominal compartment syndrome and 1 for septic shock) followed by continuous perioperative peritoneal lavage and postoperative CVVDH. CVVDH was started within 12 hours after surgery and maintained for at least 72 hours, until the multiorgan dysfunction syndrome improved. Samples were collected from serum, peritoneal lavage fluid and CVVDH dialysate for cytokine assay. Apache II scores were measured daily and their association with cytokine levels was assessed.ResultsAll six patients tolerated CVVDH well, and the procedure lasted a mean 6 days (range, 3-12). Five patients survived and one died of Acinetobacter infection after surgery (mortality rate 16.6%). The mean APACHE II score was ≥ 19 (range 19-22) before laparotomy and decreased significantly during peritoneal lavage and postoperative CVVDH (P = 0.013 by matched-pairs Students t-test). The decrease in cytokine concentrations in serum and lavage fluid was associated with the decrease in APACHE II scores and high interleukin 6 (IL-6) and tumor necrosis factor (TNF) concentrations in the hemofiltrate.ConclusionIn critically ill patients with abdominal compartment syndrome, septic shock or high APACHE II scores related to severe acute pancreatitis, combining emergency laparotomy with continuous perioperative peritoneal lavage followed by postoperative CVVHD effectively reduces the local and systemic cytokines responsible for multiorgan dysfunction syndrome thus improving patients' outcome.
To assess the impact of three-dimensional (3D) vision use on operative time (OT) in laparoscopic Roux-en-Y gastric bypass (LRYGB) with hand-sewn anastomoses. Methods: We analyzed a prospectively collected database of patients who underwent LRYGB. We included all patients operated on with either 2D or 3D vision. Demographics and clinical characteristics, operative time, hospital stay and 30-day postoperative complications were collected for all patients and analyzed. Results: During the study time, out of 143 patients who underwent LRYGB for morbid obesity, 111 were considered eligible. Seventy-eight patients were operated with 2D vision and 33 patients with 3D vision. Demographics and clinical characteristics were not different among groups. Mean OT was 203±51 and 167±32 minutes in the 2D and 3D groups respectively (p<0.001). Multivariate analyses showed that increasing age and BMI were independently related to prolonged OT, while 3D vision (OR 6.675, 95% CI 2.380-24.752, p<0.001) was strongly associated with shorter OT. Conclusions: The use of 3D vision in LRYGB significantly reduced the OT, though intra-and postoperative complication rates and the length of hospital stay were not affected. Despite its limitations, our study supports the value of 3D vision laparoscopy in bariatric surgery.
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