Strategic Approaches to Intraflap Anastomosis: Navigating Conjoined DIEP Flap Reconstruction-A Comprehensive Roadmap

Background

For patients desiring autologous breast reconstruction without adequate abdominal tissue volume, the deep inferior epigastric perforator (DIEP) flap may be stacked or combined with other flaps for bilateral reconstruction. Various combinations of anastomoses have been described in the literature. We sought to describe a framework for intraflap anastomoses.

Methods

A retrospective review of 17 patients who underwent conjoined DIEP flaps with intraflap anastomoses with a single surgeon was performed. Patient demographics, comorbidities, operative details, and complications were reviewed. A framework scheme was developed for the type of intraflap anastomosis performed.

Results

Between 2016 and 2020, 17 patients underwent conjoined DIEP flaps for unilateral breast reconstruction. Fourteen patients had delayed reconstruction. Eleven patients underwent an intraflap anastomosis in which a medial perforator on the left hemiabdomen flap was anastomosed with a distal lateral row perforator in the right hemiabdomen flap (type A). Four patients underwent an intraflap anastomosis in which a left lateral perforator was anastomosed to a right distal lateral row perforator (type B). Two patients underwent an intraflap anastomosis in which the left superficial inferior epigastric vessel was anastomosed to a right lateral row perforator (type C). Complications included reoperation (11.8%), partial flap loss (5.9%), seroma (23.5%), and hematoma (11.8%).

Conclusions

We report a detailed framework for intraflap anastomoses of conjoined DIEP flap reconstruction including superficial inferior epigastric artery/superficial inferior epigastric vessel options. Knowledge of this comprehensive framework will allow surgeons to identify the type of intraflap anastomoses required for the anatomy they encounter and will standardize reporting of surgical technique in the literature.

Distal pancreatectomy outcomes: Perspectives from a community-based teaching institution

Backgrounds/Aims

Distal pancreatic resections are intricate operations with potential for significant morbidity; there is controversy surrounding the appropriate setting regarding surgeon/hospital volume. We report our distal pancreatectomy experience from a community-based teaching hospital.

Methods

This study includes all patients who underwent laparoscopic distal pancreatectomy (LDP) and open distal pancreatectomy (ODP) for benign and malignant lesions between June 2004 and October 2017. Both groups were compared for perioperative characteristics, parenchymal resection technique, and outcomes.

Results

138 patients underwent distal pancreatectomy during this time. The distribution of LDP and ODP was 68 and 70 respectively. Operative time (146 vs. 174 min), blood loss (139 vs. 395 ml) and mean length of stay (4.8 vs. 8.0 days) were significantly lower in the laparoscopic group. The 30-day Clavien Grade 2/3 morbidity rate was 13.7% (19/138) and the incidence of Grade B/C pancreatic fistula was 6.5% (9/138), with no difference between ODP and LDP. 30-day mortality was 0.7% (1/138). 61/138 resections had a malignancy on final pathology. ODP mean tumor diameter was greater (6.4 cm vs. 2.9 cm), but there was no significant difference in the mean number of harvested nodes (8.6 vs. 7.4). The cost of hospitalization, including readmissions and surgery was significantly lower for LDP ($7558 vs. $11610).

Conclusions

This series of distal pancreatectomies indicates a shorter hospital stay, less operative blood loss and reduced cost in the LDP group, and comparable morbidity and oncologic outcomes between LDP and ODP. It highlights the feasibility and safety of these complex surgeries in a community setting.

Perioperative management of pancreatoduodenectomy patients: Are North American practices any different? A survey involving IHPBA/AHPBA members

447

Background: Pancreatoduodenectomy is performed worldwide with significant variations in the perioperative management. The aim of this study is to evaluate the practice patterns across regions of the world. Methods: A pilot cross-sectional 25-item survey questionnaire was electronically distributed using Survey Monkey to IHPBA and AHPBA members between May and August 2015 regarding practice patterns and perioperative care of patients undergoing pancreatoduodenectomy. Results: A total of 285 responses were obtained. The majority of participants were from United States (34.7%), Europe (28.1%) and Asia (14.3%). North American (NA) surgeons are less likely to culture intraoperative bile (36.5% vs. 53.1%, p<0.02), routinely check postoperative drain amylase (80.5% vs. 91.3%, p<0.03) or irrigate the wound with Betadine solution (7.7% vs. 29.1%, p<0.001) as compared to European members. Overall, NA surgeons are more likely to use 1 drain (46.3% vs. 88.7% other regions (2 drains), p<0.001), limit the prophylactic antibiotic use within 24 hours of surgery (70.1% vs. 68.5%, p<0.001) and do not culture drain fluid routinely (91.5% vs. 67.1%, p<0.001). Conclusions: Our survey evaluated a wide range of practice patterns globally amongst surgeons performing pancreatoduodenectomy. North American surgeons do not routinely check for amylase rich fluid in the drains, utilize one drain routinely when compared to European surgeons. Further studies are warranted to evaluate if these variations translate into impacts upon surgical outcomes on patients undergoing Whipple operation.

Variations in the perioperative management of pancreatoduodenectomy between academic and community institutions: An IHPBA/AHPBA web-based survey

448

Background: Pancreatoduodenectomy is the surgical treatment for pancreatic head and periampullary malignancy and is performed by surgeons practicing in all kinds of hospital settings, academic, community and hybrid. The perioperative management is varied amongst surgeons owing to diverse training experience. We aim to evaluate these variations by comparing the hospital settings. Methods: A pilot 25-item survey questionnaire was electronically distributed using Survey Monkey to IHPBA and AHPBA members between May and August 2015 regarding practice patterns and perioperative care of pancreatoduodenectomy. Results: We received 285 responses with participants from academic (56.1%), community (12.6%) or hybrid institutions (31.2%). Most participants performed 10-25 cases annually in each group (46.9%, 50%, 51.7%, respectively). Surgeons from academic institutions routinely culture bile intraoperatively more often than in community institutions (46.3% vs. 22.2%, p<0.01). However, surgeons from community programs tend to continue prophylactic antibiotics beyond 24 hours (30.6% vs. 44.4%, p<0.01) and are more likely to use antibiotic abdominal irrigation (2.5% vs. 11.1%, p<0.01) as compared to those from academic institution. Routine postoperative culture and measurement of amylase rich drain fluid, types of drains (self-suction or gravity), length of postoperative antibiotic regimen, type of skin closure and wound care were statistically similar Conclusions: Our survey included a wide range of members from academic, community and hybrid centers. Practice patterns vary significantly among surgeons practicing in academic, community or hybrid institutions and are not standardized. Further studies are warranted to elucidate the impact of these variations on surgical outcomes of patients undergoing pancreatoduodenectomy.

Are practice patterns of high-volume pancreatic surgeons distinct from low-volume pancreatic surgeons? A IHPBA/AHPBA web-based survey study

449

Background: Pancreatoduodenectomy (PD) is still one of the most complex operations with varied intraoperative techniques and postoperative management. The surgeon volume performing this complex surgery can determine patient outcomes and they might have distinct practice patterns. We aim to compare the practice patterns in perioperative management between high- (HV) and low-volume (LV) hepatobiliary surgeons. Methods: A 25-item survey questionnaire was electronically distributed using Survey Monkey to IHPBA and AHPBA members between May and August 2015 regarding their practice patterns for PD. HV surgeons were defined as those performing greater than 10 PD per year. Results: A total of 285 responses were included (HV, n=229; LV, n=57). The majority of participants were from United States (34.7%), Asia (14.3%) and Europe (28.1%). A significant higher proportion of LV surgeons were observed in Europe (p=0.04) and Asia (p=0.003). LV surgeons are more likely to continue perioperative antibiotics beyond 24 hours postoperatively (57.1% vs. 36.2%, p=0.009) and use more drains (p=0.04), however less likely to routinely measure postoperative drain amylase (73.6% vs. 85.6%, p=0.003). No significant difference was observed regarding management of infection, bile culture, or wound care. Conclusions: Practice patterns are variable between LV and HV pancreatic surgeons. LV surgeons are more likely to prolong prophylactic antibiotics, and use more suction drains, however HV surgeons have closer monitoring for signs of pancreatic leak. Further studies are warranted to elucidate the impact of these variations on surgical outcomes of patients undergoing pancreatoduodenectomy.

Is social support associated with greater weight loss after bariatric surgery?: a systematic review

Social support may be associated with increased weight loss after bariatric surgery. The objective of this article is to determine impact of post-operative support groups and other forms of social support on weight loss after bariatric surgery. MEDLINE search (1988-2009) was completed using MeSH terms including bariatric procedures and a spectrum of patient factors with potential relationship to weight loss outcomes. Of the 934 screened studies, 10 reported on social support and weight loss outcomes. Five studies reported on support groups and five studies reported on other forms of social support (such as perceived family support or number of confidants) and degree of post-operative weight loss (total n = 735 patients). All studies found a positive association between post-operative support groups and weight loss. One study found a positive association between marital status (being single) and weight loss, while three studies found a non-significant positive trend and one study was inconclusive. Support group attendance after bariatric surgery is associated with greater post-operative weight loss. Further research is necessary to determine the impact of other forms of social support. These factors should be addressed in prospective studies of weight loss following bariatric surgery, as they may represent ways to improve post-operative outcomes.

Behavioral Factors Associated with Successful Weight Loss after Gastric Bypass

Patients undergoing bariatric surgery lose substantial weight (≥50% excess weight loss [EWL]), but an estimated 20 per cent fail to achieve this goal. Our objective was to identify behavioral predictors of weight loss after laparoscopic Roux-en-Y gastric bypass. We retrospectively surveyed 148 patients using validated instruments for factors predictive of weight loss. Success was defined as ≥50 per cent EWL and failure as <50 per cent EWL. Mean follow-up after laparoscopic Roux-en-Y gastric bypass was 40.1 ± 15.3 months, with 52.7 per cent of patients achieving successful weight loss. After controlling for age, gender, and preoperative body mass index, predictors of successful weight loss included surgeon follow-up (odds ratio [OR] 8.2, P < 0.01), attendance of postoperative support groups (OR 3.7, P = 0.02), physical activity (OR 3.5, P < 0.01), single or divorced marital status (OR 3.2, P = 0.03), self-esteem (OR 0.3, P = 0.02), and binge eating (OR 0.9, P < 0.01). These factors should be addressed in prospective studies of weight loss after bariatric surgery, as they may identify patients at risk for weight loss failure who may benefit from early tailored interventions.

Behavioral factors associated with successful weight loss after gastric bypass

Patients undergoing bariatric surgery lose substantial weight (> or = 50% excess weight loss [EWL]), but an estimated 20 per cent fail to achieve this goal. Our objective was to identify behavioral predictors of weight loss after laparoscopic Roux-en-Y gastric bypass. We retrospectively surveyed 148 patients using validated instruments for factors predictive of weight loss. Success was defined as > or =50 per cent EWL and failure as <50 per cent EWL. Mean follow-up after laparoscopic Roux-en-Y gastric bypass was 40.1 +/- 15.3 months, with 52.7 per cent of patients achieving successful weight loss. After controlling for age, gender, and preoperative body mass index, predictors of successful weight loss included surgeon follow-up (odds ratio [OR] 8.2, P < 0.01), attendance of postoperative support groups (OR 3.7, P = 0.02), physical activity (OR 3.5, P < 0.01), single or divorced marital status (OR 3.2, P = 0.03), self-esteem (OR 0.3, P = 0.02), and binge eating (OR 0.9, P < 0.01). These factors should be addressed in prospective studies of weight loss after bariatric surgery, as they may identify patients at risk for weight loss failure who may benefit from early tailored interventions.

Exercise following bariatric surgery: systematic review

The contribution of physical activity on the degree of weight loss following bariatric surgery is unclear. To determine impact of exercise on postoperative weight loss. Medline search (1988–2009) was completed using MeSH terms including bariatric procedures and a spectrum of patient factors with potential relationship to weight loss outcomes. Of the 934 screened articles, 14 reported on exercise and weight loss outcomes. The most commonly used instruments to measure activity level were the Baecke Physical Activity Questionnaire, the International Physical Activity Questionnaire, and a variety of self-made questionnaires. The definition of an active patient varied but generally required a minimum of 30 min of exercise at least 3 days per week. Thirteen articles reported on exercise and degree of postoperative weight loss (n = 4,108 patients). Eleven articles found a positive association of exercise on postoperative weight loss, and two did not. Meta-analysis of three studies revealed a significant increase in 1-year postoperative weight loss (mean difference = 4.2% total body mass index (BMI) loss, 95% confidence interval (CI; 0.26–8.11)) for patients who exercise postoperatively. Exercise following bariatric surgery appears to be associated with a greater weight loss of over 4% of BMI. While a causal relationship cannot be established with observational data, this finding supports the continued efforts to encourage and support patients’ involvement in post-surgery exercise. Further research is necessary to determine the recommended activity guidelines for this patient population.

What is the rate of small bowel obstruction after colectomy?

The rate of small bowel obstruction (SBO) after colectomy is unknown. Given the large number of colectomies performed in the United States, elucidating SBO rates, outcomes, and identifying predictors of readmission is important. Using the California Inpatient File, we identified all patients readmitted with a principle diagnosis of SBO at least once in the 3 years after colectomy (n = 4555). Patients admitted with a diagnosis of SBO in the 3 years before surgery were excluded. Overall, 10 per cent of patients were readmitted for SBO at least once after colectomy. Approximately 58 per cent were readmitted in the first year and 22 per cent of these patients required surgery. The most common operation performed was lysis of adhesions. Median length of stay was twice as long in the surgery group versus the no surgery group (12 vs 6 days). Overall mortality was higher in the nonsurgery group compared with the surgery group (33% vs 21%, P < 0.001) and highest in the elderly (44% vs 30%, P < 0.001). One in 10 patients without a history of SBO who undergoes a colectomy will be readmitted at least once in the subsequent 3 years for SBO, and there is a high mortality rate in this group, especially in the elderly.

What is the Rate of Small Bowel Obstruction after Colectomy?

The rate of small bowel obstruction (SBO) after colectomy is unknown. Given the large number of colectomies performed in the United States, elucidating SBO rates, outcomes, and identifying predictors of readmission is important. Using the California Inpatient File, we identified all patients readmitted with a principle diagnosis of SBO at least once in the 3 years after colectomy (n = 4555). Patients admitted with a diagnosis of SBO in the 3 years before surgery were excluded. Overall, 10 per cent of patients were readmitted for SBO at least once after colectomy. Approximately 58 per cent were readmitted in the first year and 22 per cent of these patients required surgery. The most common operation performed was lysis of adhesions. Median length of stay was twice as long in the surgery group versus the no surgery group (12 vs 6 days). Overall mortality was higher in the nonsurgery group compared with the surgery group (33% vs 21%, P < 0.001) and highest in the elderly (44% vs 30%, P < 0.001). One in 10 patients without a history of SBO who undergoes a colectomy will be readmitted at least once in the subsequent 3 years for SBO, and there is a high mortality rate in this group, especially in the elderly.

Comparison of clinical outcome of fixed-dose subcutaneous low molecular weight heparin (tinzaparin) with conventional heparin in unstable angina: a pilot study

Forty patients who were hospitalized for unstable angina were randomized to receive treatment with either regular heparin (Group I) in conventional dose as continuous infusion for 5 days or fixed-dose low molecular weight heparin (LMWH) (Group II), 3500 units subcutaneous twice daily for a period of 5 days. Both the groups were evenly matched with regard to age, sex presence of risk factors and adjunctive drug therapy. The clinical endpoints at the end of 5 day therapy were: recurrence of angina, occurrence of myocardial infarction and need for urgent revascularization. In Group I, 6 out of 20 patients had recurrence of angina, of whom 3 required urgent coronary angiography and revascularization. In Group II, 4 out of 20 patients had recurrence of angina, of whom one patient required urgent angiography and angioplasty. There were no bleeding complications in either of the groups. The recurrent anginal episodes in the conventional heparin group correlated with low aPTT values at the time of angina. Thus, this pilot study suggests that LMWH is equally effective in the treatment of unstable angina, the advantage of LMWH being the ease of administration and no need for monitoring aPTT levels during therapy.

Percutaneous transluminal coronary angioplasty (PTCA) in unstable angina

We performed percutaneous transluminal coronary angioplasty in 33 highly selected patients of unstable angina, a majority of whom were initially stabilized by medical therapy. All these patients had single vessel disease with type A lesion. The initial success rate was 91% with recurrence of 17% at the end of 1 year.

Prognostic significance of predischarge 2D-echocardiography after first transmural myocardial infarction

Predischarge two dimensional echocardiography (2D Echo) was performed in 45 survivors of first transmural myocardial infarction to assess its value in predicting major cardiac complications (MCC) during convalescence. Wall motion score was derived for each patient by analysing endocardial motion in 11 left ventricular segments. In 18 months follow up 11 of 14 patients (78%) who had major cardiac complications had wall motion score of at least 5. Wall motion score of less than 5 was present in 29 of the 31 (94%) of patients in asymptomatic group. Non-invasively obtained wall motion score helps in risk stratification of survivors of AMI. Wall motion score at predischarge 2D Echo or more identifies high risk cases from a relatively asymptomatic group (Killip Class I & II).

Coronary arteriographic findings soon after non Q wave myocardial infarction

We performed early coronary arteriography in 27 patients (23 males, 4 females) having non Q wave MI. Infarct related vessel (IRV) was totally blocked in 25.9%, whereas 66.7% had severe residual stenosis (greater than or equal to 70%). Left main was involved in 7.5%, and at least 2 major coronary arteries were involved in 51.8%. Visible collaterals were seen in 11%. We feel, as compared to transmural MI, where total occlusion of IRV is common, the higher incidence of subtotal occlusion of IRV with severe residual stenosis, poor collaterals and significant involvement of at least one other major coronary artery may be responsible for observation of early recurrent ischemic episodes in non Q wave MI.

Pulsed Doppler derived indices in predicting noninvasively, pulmonary arterial pressures

The pulsed doppler (P.D.) signals obtained in RVOT just below the pulmonary leaflets were used to calculate acceleration time (AcT), pre-ejection period (PEP) and their ratios. These indices were correlated in 31 patients (2 1/2-49 yrs. age) having varying cardiac lesions to Pulmonary arterial pressure (P.A.P) measured during cardiac catheterisation. The mean values of AcT for those with normal PAP was 137 +/- 19.9ms, as compared to 105 +/- 37 ms in those in whom PAP greater than 20mm of Hg. (t = 3.0.p less than .01). The P value was less than 0.001 when comparison was between normal PAP and severe PH. The ratios of PEP upon AcT was 0.87 +/- 0.18 for normal PAP, as compared to 1.39 +/- 0.74 in those with PH (t = 0.31, p less than 0.01). The PEP/AcT predicted systolic PAP 35.49 PEP/AcT + 3.22 (r = 0.77, p less than 0.001). The mean PAP was best predicted by 23.94 PEP/AcT + 2.44 (r = 0.75, p less than 0.001). The quantitative assessment showed presence of presystolic 'a' wave in all with normal PAP; this was absent in all the 9 patients with severe PH (MAPA greater than 40mm of Hg.). We conclude that noninvasively obtained P.D. derived indices can help accurately to predict PAP.