Physical activity decreases in patients on the liver transplant waiting list and influences postoperative outcome-a prospective cohort study

Background

Physical deconditioning affects patients suffering from end-stage liver disease (ESLD). Liver transplantation (LT) is the only curative option for ESLD. Growing evidence suggests that pre-habilitation is beneficial in reducing post-surgical morbidity and mortality. We investigated physical activity (PA) in patients awaiting LT in a country with long waiting times.

Methods

Prospective, single center, longitudinal study in Bern, Switzerland between June 2019 and February 2020 (halted due to SARS-CoV-2 pandemic), with follow-up data up to six months post-transplant. Patients were instructed to use a wrist tracker (FitBit) to monitor PA, which was assessed using mixed-effects generalized linear models. The study was approved by the local ethics committee (BASEC ID 2019-00606).

Results

Thirty-five patients were included [71% male, median 59 years, body mass index (BMI) 28 kg/m2, lab Model End-Stage Liver Disease (MELD) 11], 17 (49%) pre-frail and 5 (14%) frail according to the Liver Frailty Index (LFI). Twenty-eight patients underwent transplantation with 0 ninety-day mortality and 15 (53.6%) composite adverse clinical outcome. Median daily steps were 4,661 [interquartile range (IQR), 1,685-8,609] and weekly moderate PA (MPA) was 41 min (IQR, 0-127 min). Longitudinal analysis showed that female patients and patients on nutritional support had an increase in MPA between weeks 20 and 40. A significant decrease was seen in MPA after week 40, whilst no significant association was seen with age, Child-Pugh Score, LFI or quality of life at time of inclusion. MPA was significantly associated with the occurrence of the composite clinical endpoint after week 30 of waiting time (odds ratio 0.882, P=0.026). World Health Organization (WHO)-recommended MPA was significantly associated with less adverse composite clinical outcomes (P<0.001).

Conclusions

In patients listed for LT, MPA decreased over time, showing a significant association with adverse outcome, specifically after week 30 on the waiting list. Our data support the implementation of routine pre-habilitation in patients awaiting LT.

Current standards of surgical management of gastric cancer: an appraisal

PURPOSE

Gastric cancer (GC) is the fifth most common malignancy worldwide and portends a grim prognosis due to a lack of appreciable improvement in 5-year survival. We aimed to analyze the available literature and summarize the current standards of surgical care for curative and palliative intent treatment of GC.

METHODS

We conducted a systematic search on the PubMed database for studies on the management of GC.

RESULTS

Endoscopic resection is an acceptable treatment option for T1a tumors. The role of optimal resection margin for GC remains unclear. D2 lymph node dissection remains the standard of care with splenectomy needed selectively for splenic hilum involvement. A distal pancreatic resection should be avoided. The advantage of bursectomy and omentectomy in GC surgery is not clear. Multi-visceral resection may be considered for locally advanced GC in carefully selected patients. Minimally invasive approaches are non-inferior to open surgery. Surgery should be abandoned prior even in metastatic GC within the frame of multimodal therapy approach.

CONCLUSION

Various trials have conclusively shown improved patient outcomes when well-established surgical standards are followed.

Performance of quick sequential organ failure assessment and modified age disease adjusted qadSOFA for the prediction of outcomes in emergency general surgery patients

BACKGROUND

Sepsis is a highly prevalent condition and is associated with a reported in-hospital mortality rate up to 40% in patients with abdominal sepsis requiring emergency general surgery (EGS). The quick sequential organ failure assessment score (qSOFA) has not been studied for EGS patients.

METHODS

Retrospective cohort study in adult patients undergoing abdominal EGS at a university tertiary care center from 2016 to 2018. The primary outcome was mortality. The effect of clinical variables on outcomes was assessed in univariable and multivariable logistic regression analyses. Based on these results, the qSOFA score was modified. The performance of scores was assessed using receiver operating characteristics.

RESULTS

Five hundred seventy-eight patients undergoing abdominal EGS were included. In-hospital mortality was 4.8% (28/578). Independent predictors for mortality were mesenteric ischemia (odds ratio [OR] 15.9; 95% confidence interval [CI] 5.2-48.6; p < 0.001), gastrointestinal tract perforation (OR 4.9; 95% CI 1.7-14.0; p = 0.003), 65 years or older (OR 4.1; 95% CI 1.5-11.4; p = 0.008), and increasing qSOFA (OR 1.8; 95% CI 1.2-2.8; p = 0.007). The modified qSOFA (qadSOFA) was developed. The area under the receiver operating characteristic curve of the qSOFA and qadSOFA for mortality was 0.715 and 0.859, respectively. Optimal cutoff value was identified as qadSOFA ≥ 3 (Youden Index 64.1%).

CONCLUSION

This is the first study investigating the qSOFA as a predictor for clinical outcomes in EGS. Compared with the qSOFA, the new qadSOFA revealed an excellent predictive power for clinical outcomes. Further validation of qadSOFA is warranted.

LEVEL OF EVIDENCE

Diagnostic test/criteria; Level II.

Vasoconstrictor nasal spray causing life-threatening complications after bariatric surgery: A case report

Introduction and importance

Bariatric surgery is an evolving surgical field with increasing cases per year, as obesity is prevalent, especially in developed countries. Complication diagnosis and management can be challenging. Marginal ulcers and anastomosis perforation are rare, but their incidence is likely underestimated.

Case presentation

To the best of our knowledge, we present the first case with a two and a half years history of recurrent ischemia, marginal ulcers, and recurrent perforation after laparoscopic omega loop gastric bypass, most likely due to an abuse of an over-the-counter (OTC) sympathomimetic nasal spray. The complications (Clavien-Dindo classification IIIb) caused the necessity of recurrent hospitalizations and diagnostic interventions and an open conversion into Roux-Y gastric bypass in a damage control manner.

Clinical discussion and conclusion

Conclusively, we advocate evaluating drug abuse, including OTC medications that patients might not report on a daily-based medical history, as an etiology for marginal ulcers and anastomosis perforation, especially in late and recurrent cases.

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Abuse of OTC sympathomimetic nasal spray can cause recurrent gastrojejunal anastomosis ischemia.

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Re-Do surgery cannot prevent recurrence of ischemia in these cases.

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In recurrence of ischemia, detailed medical history, including OTC drugs, is crucial.

Severe penetrating trauma in Switzerland: first analysis of the Swiss Trauma Registry (STR)

PURPOSE

The purpose of this study was to examine the epidemiology, demographics, injury characteristics and outcomes of patients who presented to Swiss trauma centers following severe penetrating trauma.

METHODS

Swiss Trauma Registry (STR)-cohort analysis including patients with severe (ISS ≥ 16 or AIS head ≥ 3) penetrating trauma between 2017 and 2019. Primary outcome was mortality. Secondary outcomes were hospital and intensive care unit (ICU) length of stay (LOS), and prehospital times.

RESULTS

During the 3-year study period, 134 (1.6% of entire STR) patients with severe penetrating trauma were identified [64 (48%) gunshot wounds (GSW), 70 (52%) stab wounds (SW)]. Median age was 40.5 (IQR 29.0-59.0) and 82.8% were male. Mortality rate was 50% for GSW; 9% for SW. Overall, prehospital time [incident to arrival emergency department (ED)] was 65 (IQR 45-94) minutes. The median number of patients admitted for a severe GSW/SW per center and year was 2 (range 0-14). Of 64 patients who sustained a GSW, 42 (65.6%) were self-inflicted. Mortality in self-inflicted GSW reached 66.7%, with the head being severely injured in 78.6%. The 67 patients with severe isolated torso GSW/SW had an ISS of 20 (IQR 16-26) and a mortality of 15%. Multivariable analysis identified severe chest trauma, ED Glasgow Coma Scale ≤ 8, age, self-infliction, massive blood transfusion and ISS as independent predictors for mortality.

CONCLUSION

Severe penetrating trauma is very rare in Switzerland. Mortality ranges from 9% in SW to 67% in self-inflicted GSW. Particularly in the setting of GSW/SW to the torso, reduction in prehospital time may further improve patient outcomes.

Value of 3-Dimensional Digital Subtraction Angiography for Detection and Classification of Intracranial Aneurysm Remnants After Clipping

BACKGROUND

The current gold standard for evaluation of the surgical result after intracranial aneurysm (IA) clipping is two-dimensional (2D) digital subtraction angiography (DSA). While there is growing evidence that postoperative 3D-DSA is superior to 2D-DSA, there is a lack of data on intraoperative comparison.

OBJECTIVE

To compare the diagnostic yield of detection of IA remnants in intra- and postoperative 3D-DSA, categorize the remnants based on 3D-DSA findings, and examine associations between missed 2D-DSA remnants and IA characteristics.

METHODS

We evaluated 232 clipped IAs that were examined with intraoperative or postoperative 3D-DSA. Variables analyzed included patient demographics, IA and remnant distinguishing characteristics, and 2D- and 3D-DSA findings. Maximal IA remnant size detected by 3D-DSA was measured using a 3-point scale of 2-mm increments.

RESULTS

Although 3D-DSA detected all clipped IA remnants, 2D-DSA missed 30.4% (7 of 23) and 38.9% (14 of 36) clipped IA remnants in intraoperative and postoperative imaging, respectively (95% CI: 30 [ 12, 49] %; P-value .023 and 39 [23, 55] %; P-value = <.001), and more often missed grade 1 (< 2 mm) clipped remnants (odds ratio [95% CI]: 4.3 [1.6, 12.7], P-value .005).

CONCLUSION

Compared with 2D-DSA, 3D-DSA achieves a better diagnostic yield in the evaluation of clipped IA. Our proposed method to grade 3D-DSA remnants proved to be simple and practical. Especially small IA remnants have a high risk to be missed in 2D-DSA. We advocate routine use of either intraoperative or postoperative 3D-DSA as a baseline for lifelong follow-up of clipped IA.

Hernia after retroperitoneoscopic adrenalectomy, case report

We report the first case of a previously undocumented complication after posterior retroperitoneal adrenalectomy (PRA). Extensive diagnostic procedures for persisting abdominal pain led to diagnosis of an incisional hernia (IH) approximately 2.5 years after surgery for a pheochromocytoma of the right adrenal gland. Thus, IHs need to be recognized as a potential complication after PRA, particularly if the symptoms are non-specific. The differential diagnosis of an IH after PRA includes a type of spontaneous lumbar hernia due to a pre-existing weakness of the abdominal wall however the treatment for both type of hernias is similar by mesh repair. A possible risk factor for IH after PRA might be obesity, due to different factors including difficulties in closing the fascia in depth under subcutaneous tissue.