Efficacy of Reinforced Stapler Versus Hand-sewn Closure of the Pancreatic Stump During Pure Laparoscopic Distal Pancreatectomy to Reduce Pancreatic Fistula.

BACKGROUND: Laparoscopic distal pancreatectomy (L-DP) is the standard procedure for treating left-sided pancreatic tumors. Stapler closure of the pancreas is the preferred method for L-DP; however, postoperative pancreatic fistula (POPF) remains a challenging problem. The present study aimed to compare the surgical outcomes of staple closure using a reinforcing stapler (RS) and transection using an ultrasonic dissector followed by hand-sewn (HS) closure in a fish-mouth manner in pure L-DP and to determine independent perioperative risk factors for clinically relevant postoperative pancreatic fistula (CR-POPF). PATIENTS AND METHODS: Among the 85 patients who underwent pure L-DP between February 2011 and August 2021, 80 of whom the pancreatic stump was closed with RS (n = 59) or HS (n = 21) were retrospectively investigated. Associations between potential risk factors and POPF were assessed using univariate analysis. The factors, of which the P value was determined to be <0.1 by univariate analysis, were entered into a multivariate regression analysis to ascertain independent predictive factors. RESULTS: The surgery time and estimated blood loss were not significantly different between the two groups. Overall, 13 patients (16.3%) developed CR-POPF ( B = 12 and C = 1). The rate of CR-POPF was lower in RS than in HS; however, the difference was not statistically significant (RS vs HS: 11.9% vs 28.9%, P = 0.092). Consistent with the results for CR-POPF, the rate of Clavien-Dindo IIIa or more postoperative complications and the length of hospital stay were also not significantly different between the two groups (RS vs HS: 10.2, 12% vs 14.3%, 14 d). In the univariate analysis of risk factors for CR-POPF, the pancreatic thickness at the transection site, procedure for stump closure, and estimated blood loss were associated with a significantly higher rate of CR-POPF. The multivariate analysis revealed that the pancreatic thickness at the transection site (cutoff: 12 mm) was the only independent risk factor for CR-POPF (odds ratio: 6.5l, 95% CI: 1.4-30.4, P = 0.018). The rate of CR-POPF was much lower in RS than in HS for pancreatic thickness <12 mm (RS vs HS: 4.1% vs 28.6%), whereas that was rather higher in RS than in HS for pancreatic thickness ≥12 mm (RS vs HS: 50% vs 28.6%). CONCLUSIONS: RS closure was superior to HS closure for pancreatic thickness <12 mm and for prevention of CR-POPF after pure L-DP. It is necessary to seek more reliable procedures for pancreatic stump closure in patients with a pancreatic thickness of ≥12 mm.

Impact of vaccination on keratoplasty.

PURPOSE OF REVIEW: Corneal graft rejection has been reported after coronavirus disease 2019 (COVID-19) vaccination. The purpose of this review is to evaluate the literature regarding corneal graft rejection after vaccination, including rejection rates and risk factors. We aim to create a framework to identify patients who are at higher risk for graft rejection and may warrant consideration of prophylactic interventions. RECENT FINDINGS: Graft rejection has been reported following administration of mRNA, viral vector, and inactivated whole-virion COVID-19 vaccines. Most cases had additional risk factors associated with rejection. Vaccination increases circulation of proinflammatory cytokines, CD4+ and CD8+ T-cell responses, and antispike neutralizing antibody, all of which may contribute to graft rejection. Two prospective studies have found no relationship between recent vaccination and rejection but 20% of cornea specialists report to have seen a vaccine-associated rejection and 22% recommend delaying vaccination in certain circumstances. Many specialists recommend prophylactic topical corticosteroids before and after vaccination to mitigate rejection risk but there is no evidence to support this practice on a wider scale. SUMMARY: Our framework identified 96.8% of penetrating keratoplasty patients with vaccine-associated rejection as higher risk. Further research is needed in order to develop evidence-based guidelines.

Management of placenta accreta spectrum disorders in COVID 19 patients.

INTRODUCTION: The COVID-19 pandemic has made it difficult to respond to demands in maternal health around the world. Placenta accreta spectrum (PAS) is one of the most severe obstetric conditions and usually requires the use of multiple health resources We describe the clinical results of the management of PAS patients during the COVID-19 pandemic and analyze how the pandemic may affect the functioning of a PAS team. METHODOLOGY: This was a descriptive, retrospective study including all patients treated for PAS in two low- to middle-income country reference hospitals between January 2020 and March 2021. The clinical results of patients with SARS-CoV-2 infection during PAS surgery (Group 1) were compared with those of PAS patients without SARS-CoV-2 infection (Group 2). RESULTS: One hundred forty-five patients undergoing surgery for PAS were included. Group 1 patients (11 cases) showed a longer operative time (250 min, IQR 200-300) and a higher frequency of intra- or postoperative complications (54.5%) than group 2 patients (180 min [IQR 125-240], and 17.9%). CONCLUSION: Placenta accreta spectrum patients undergoing surgery during acute SARS-CoV-2 infection have a higher frequency of postoperative complications. PAS teams must prepare to modify their management protocols to minimize risks for patients and healthcare personnel.

Risk factors for postoperative medical morbidity and 3-month mortality in elderly patients with hip fracture following hip arthroplasty during COVID-19 pandemic.

BACKGROUND: The purpose of the current study was to investigate the incidence of postoperative medical complications and 3-month mortality in patients ≥ 70 years old with hip fracture following hip arthroplasty (HA) and independent risk factors associated with postoperative medical complications and 3-month mortality during the Coronavirus Disease 2019 (COVID-19) pandemic. METHODS: A multicenter retrospective study was conducted, patients ≥ 70 years old with HA for hip fracture under general anesthesia were included during COVID-19 and before COVID-19 pandemic. The outcome was defined as postoperative medical complications and 3-month mortality. The baseline characteristics and risk factors were collected, multivariable logistic regression was used to identify independent risk factors for postoperative medical complications and 3-month mortality. RESULTS: A total of 1096 patients were included during COVID-19 pandemic and 1149 were included before COVID-19 pandemic in the study. Patients ≥ 70 years with hip fracture for HA had longer fracture to operation duration (7.10 ± 3.52 vs. 5.31 ± 1.29, P < 0.001), and the incidence of postoperative medical complications (21.90% vs. 12.53%, P < 0.001) and 3-month mortality (5.20% vs. 3.22%, P = 0.025) was higher during COVID-2019 pandemic. Multivariate logistic regression analysis showed that dementia (OR 2.73; 95% CI 1.37-5.44; P = 0.004), chronic obstructive pulmonary disease (COPD) (OR 3.00; 95% CI 1.92-4.71; P < 0.001), longer fracture to operation duration (OR 1.24; 95% CI 1.19-1.30; P < 0.001) were associated with increased risk for postoperative medical complications. COPD (OR 2.10; 95% CI 1.05-4.17; P = 0.035), dementia (OR 3.00; 95% CI 1.11-7.94; P = 0.031), postoperative medical complications (OR 4.99; 95% CI 2.68-9.28; P < 0.001), longer fracture to operation duration (OR 1.11; 95% CI 1.04-1.19; P = 0.002) were associated with increased risk for 3-month mortality. CONCLUSIONS: In conclusion, we found that postoperative medical morbidity and 3-month mortality in patients with hip fracture underwent HA were 21.90% and 5.20%, respectively, during the COVID-19. COPD, dementia and longer fracture to operation duration were associated with negative outcome in patients with hip fracture underwent HA during the COVID-19.

eHealth Intervention via LINE® Social Media as an Adjunct for Postoperative Care After Bariatric-Metabolic Surgery: Single Institution Experience.

PURPOSE: Applying eHealth interventions via social media is common in modern medicine. LINE® is a popular communication app in Taiwan that can deliver messages 24 h a day. In addition to being free of charge, it also allows bariatric nurses (BNs) and patients to enjoy bidirectional communication via telecommunication services instead of direct, face-to-face contact for patients undergoing bariatric-metabolic surgery (BMS). We conducted this retrospective study to determine the frequency and reasons for early post-discharge of LINE® messages/calls and investigate the relationship between this frequency and contents of these messages and postoperative outcomes after BMS. MATERIALS AND METHODS: A retrospective review of prospectively collected data was conducted in an Asian weight management center. The study period ran from August 2016 to December 2021, and a total of 143 native patients with severe obesity were enrolled. All patients were informed of the necessity of a postoperative dietitian consultation before bariatric surgery. The patterns of LINE® communication with the BN and associated actions to resolve patients' needs within 180 days after index BMS were analyzed. RESULTS: Among the 143 enrolled patients, 100 underwent laparoscopic sleeve gastrectomy and 43 underwent laparoscopic Roux-en-Y gastric bypass. A total of 1205 messages/calls were analyzed concomitantly; most LINE® communications focused on diet problems (47.97%; n = 578), weight problems (11.54%; n = 139), and medications (9.21%; n = 111). Most problems could be resolved by LINE® communications directly, and only a small portion (5.6%) was directed to local clinics or emergency departments. During the COVID-19 pandemic, the usage of LINE® communications significantly increased (12.2 ± 10.4 vs. 6.4 ± 4.9; p < 0.01); nonetheless, a higher frequency of LINE® communications would not hinder the regular clinic visits (r = 0.359; p = 0.01). CONCLUSION: Based on our limited experience, the LINE® consultation service operated by the BN could effectively address patients' problems. Moreover, it might reduce the need for emergency department visits or unexpected clinic appointments for patients after BMS.

Can revision of RYGB to sleeve gastrectomy be a solution to inadequate weight loss treatment?

We aimed to discuss the weight loss success of the revision of RYGB to sleeve gastrectomy (SG). Between January 2019 and June 2020, four patients' files were analyzed retrospectively. Post-RYGB mean minimal BMI was 27.4 ± 9.47 kg/m², before SG the mean BMI was 43.41 ± 4.16 kg/m2. Post-operative gastric fistula developed in two patients. The mean follow-up time after revision surgery was 17.25 ± 6.89 months, mean excess weight loss (EWL) was 74.77 ± 8.94%, and mean BMI was 32.65 ± 2.9 kg/m2. Despite high rate of major complications, revision of RYGB to SG is successful in weight loss and resolving certain complications of RYGB.

Nuestro objetivo era discutir el éxito en la pérdida de peso de la revisión de BGYR a gastrectomía en manga (SG). Entre enero de 2019 y junio de 2020, se analizaron retrospectivamente los archivos de cuatro pacientes. El IMC mínimo medio post BGYR fue 27.4 ± 9.47 kg/m², antes de SG el IMC medio fue 43.41 ± 4.16 kg/m2. En dos pacientes se desarrolló una fístula gástrica posoperatoria. El tiempo medio de seguimiento después de la cirugía de revisión fue de 17.25 ± 6.89 meses, la pérdida media de exceso de peso (PEP) fue de 74.77 ± 8.94% y el IMC medio fue de 32.65 ± 2.9 kg/m2. A pesar de la alta tasa de complicaciones mayores, la revisión de BGYR a SG tiene éxito en la pérdida de peso y la resolución de ciertas complicaciones de BGYR.

Late onset sclerotomy dehiscence in a patient with Marfan syndrome presenting as recurrent episodes of raised intraocular pressure.

A man in his 50s presented to the eye emergency department on three separate occasions complaining of blurred vision and discomfort in the left eye. He had a history of Marfan syndrome and had undergone bilateral 20-gauge (G) pars plana vitrectomy and lensectomy 20 years prior for ectopia lentis. On examination he had epithelial corneal oedema, raised intraocular pressure >40 mm Hg and conjunctival chemosis, which later appeared as a bleb-like conjunctival elevation. Acute treatment with oral acetazolamide and topical ocular hypotensive agents produced a marked reduction in intraocular pressure to 2-4 mm Hg. A presumed diagnosis of a leaking scleral wound was made. He underwent scleral exploration under general anaesthesia and a leaking sclerotomy was uncovered. The defect was repaired successfully using a scleral patch graft. Late dehiscence of a sclerotomy has been reported rarely in patients with Marfan syndrome. This is the first reported case to present atypically with intermittent episodes of raised intraocular pressure rather than with hypotony.

COVID-19 Vaccination May Not Increase Rates of Corneal Graft Rejection.

PURPOSE: The aim of the study was to present the rates of rejection from 2018 to 2021 and evaluate the purported association between COVID-19 vaccination and corneal graft rejection. METHODS: Cases of corneal graft rejection diagnosed between January 2018 and December 2021 were reviewed. The conditional Poisson regression model of the self-controlled case series method was used to estimate the incidence risk ratio of graft rejection after COVID-19 vaccination risk period compared with the control period. Based on outcomes of eyes that underwent keratoplasty from January 2018 to December 2020, Cox proportional hazard models were fitted with previous COVID-19 vaccination as a time-varying covariate. RESULTS: Over the past 4 years, the annual tally of diagnosed cases of graft rejection (19 cases in year 2018, 19 cases in year 2019, 21 cases in year 2020, and 18 cases in year 2021) has remained relatively stable. Using the conditional Poisson regression analysis, no significant increase in the incidence rate of rejection in the risk period after COVID-19 vaccination was found (incidence risk ratio = 0.56, 95% confidence interval [CI] = 0.13-2.28, P = 0.70). Fitted as a time-varying covariate, previous COVID-19 vaccination was not associated with graft rejection in both unadjusted (hazard ratio =0.77, 95% CI = 0.29-5.46, P = 0.77) and adjusted Cox models (hazard ratio = 0.75, 95% CI = 0.10-5.52, P = 0.78). CONCLUSIONS: No notable increase in rates of corneal graft rejection was noted in year 2021 when COVID-19 vaccination was broadly implemented. The apparent temporal relationship between COVID vaccination and corneal graft rejection may not represent a causative association.

Postoperative pneumonia after bariatric surgery during the COVID-19 pandemic: a National Surgical Quality Improvement Program study.

BACKGROUND: During the COVID-19 pandemic, surgical centers had to weigh the benefits and risks of conducting bariatric surgery. Obesity increases the risk of developing severe COVID-19 infections, and therefore, bariatric surgery is beneficial. In contrast, surgical patients who test positive for COVID-19 have higher mortality rates. OBJECTIVE: This study investigates the national prevalence of postoperative pneumonia during the COVID-19 pandemic in the bariatric surgery population. SETTING: The American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database. METHODS: This is a cross-sectional study using the ACS-NSQIP database. The population of concern included patients who underwent sleeve gastrectomy and Roux-en-Y gastric bypass procedures. Information was extracted on rate of postoperative pneumonia and other 30-day complications between 2018 and 2020. RESULTS: All baseline characteristics were similar among patients who underwent bariatric surgery between 2018 and 2020. However, there was a 156% increase in postoperative pneumonia in 2020 compared with the previous year. Furthermore, despite the similar postoperative complication rates across the years, there was a statistically significant increase in all-cause mortality in 2020. The multivariate analysis showed that having surgery in 2020 was a statistically significant risk factor for pneumonia development postoperatively. CONCLUSIONS: This study showed a statistically significant increase in the prevalence of postoperative pneumonia during the COVID-19 pandemic among bariatric surgery patients. Surgical centers must continuously evaluate the risks associated with healthcare-associated exposure to COVID-19 and weigh the benefits of bariatric surgery.

Have acute appendicitis complications increased in children as a result of SARS-CoV-2? / ¿Han aumentado las complicaciones de las apendicitis agudas en niños por el impacto del SARS-CoV-2?

INTRODUCTION: The impact of the SARS-CoV-2 pandemic on healthcare has already been described, since it has caused an increase in diagnostic delay and morbidity. Our objective was to assess its influence on the development of complications in children with acute appendicitis. MATERIALS AND METHODS: A retrospective cohort study was carried out. It included acute appendicitis patients under 15 years of age treated from January 1, 2019 to December 31, 2020. They were classified according to diagnosis date as before the pandemic (B) (January 2019-February 2020) and during the pandemic (D) (March 2020-December 2020). According to operative findings, they were classified as complicated appendicitis (perforated/abscess/plastron/peritonitis) and non-complicated appendicitis (catarrhal/phlegmonous/gangrenous). Demographic data, progression time, and postoperative complications were analyzed. RESULTS: A total of 309 patients were included, 193 (62.5%) in Group B, and 116 (37.5%) in Group D, with an age of 9.2 ± 0.4 and 9.4 ± 0.6 years, respectively (CI = 95%). Diagnostic time was 1.35 and 1.43 days (p>0.05) in Groups B and D, respectively, with ≥ 3 days representing 15.5% of cases in Group B, and 16.4% of cases in Group D (p = 0.84). The proportion of complicated appendicitis was 23.3% in Group B vs. 21.6% in Group D (p>0.05). Postoperative complications were observed in 11.4% of patients in Group B, and in 13.8% of patients in Group D (p>0.05), with intra-abdominal abscess being the most frequent complication in both groups (54.5% of the total complications in Group B vs. 65.5% in Group D; p>0.05). CONCLUSIONS: The management of acute appendicitis and its complications in pediatric patients has not been impacted by the SARS-CoV-2 pandemic or the safety measures enforced.

INTRODUCCION: Se ha descrito el impacto de la pandemia del SARS-CoV-2 en la atención sanitaria, al suponer un aumento del retraso diagnóstico y morbilidad. Nuestro objetivo es evaluar su influencia en el desarrollo de complicaciones en las apendicitis agudas en niños. METODOLOGIA: Estudio retrospectivo de cohortes, incluyendo los pacientes menores de 15 años tratados por apendicitis aguda desde 01/01/2019 hasta 31/12/2020. Se distribuyeron según su fecha de diagnóstico en: antes de la pandemia (A) (enero/2019-febrero/2020) y durante la pandemia (P) (marzo-diciembre/2020). Según los hallazgos quirúrgicos se clasificaron en: apendicitis complicadas (perforadas/abscesos/plastrones/peritonitis) y no complicadas (catarrales/flemonosas/gangrenosas). Se analizaron datos demográficos, tiempo de evolución y complicaciones postoperatorias. RESULTADOS: Se incluyeron un total de 309 pacientes, 193 pacientes (62,5%) en el grupo A y 116 (37,5%) en el P, con edades de 9,2 ± 0,4 y 9,4 ± 0,6 años respectivamente (IC = 95%). Los días al diagnóstico fueron 1,35 y 1,43 (p>0,05) en A y P respectivamente, siendo ≥ 3 días en 15,5% de A y 16,4% en P (p = 0,84). La proporción de apendicitis complicada fue un 23,3% en A vs. 21,6% en P; con p>0,05. Se observaron complicaciones postoperatorias en 11,4% de A y 13,8% de P (p>0,05), siendo la más frecuente el absceso intraabdominal en ambos grupos (54,5% del total de complicaciones vs 65,5%; en A y P respectivamente; p>0,05). CONCLUSIONES: La atención sanitaria de la apendicitis aguda y sus complicaciones en pacientes pediátricos no se ha visto modificada por la pandemia del SARS-CoV-2 o las medidas de seguridad adoptadas durante la misma.

Intensive care unit versus floor admission following lower extremity free flap surgery: Is there a difference in outcomes?

BACKGROUND: Free tissue transfer (FTT) lower limb salvage requires costly multidisciplinary care. Traditionally, patients who undergo FTT reconstruction for lower extremity (LE) wounds were admitted to the intensive care unit (ICU) in the immediate postoperative period for close monitoring. During the COVID-19 pandemic, our practice shifted toward admitting FTT patients to the floor postoperatively instead of the ICU. The purpose of this study is to compare surgical outcomes in patients admitted to the floor versus ICU immediately following LE free flap reconstruction. METHODS: We retrospectively reviewed patients undergoing LE FTT reconstruction from 2011 to 2021. Flap monitoring consisted of an implantable Cook-Swartz Doppler probe for muscle flaps and ViOptix tissue oximetry for fasciocutaneous flaps; clinical exam and hand-held dopplers were not the primary flap monitoring techniques. Patients were divided into two groups depending on whether they went to the ICU or floor postoperatively. To ensure proper comparability between cohorts, we corrected for age, BMI and Charlson Comorbidity Index (CCI) using 1:2 propensity score matching (floor: ICU). Primary outcomes included early postoperative complications, flap takeback and salvage, flap success, and postoperative length of stay (LOS). RESULTS: A total of 252 patients were identified. Forty-five patients (17.9%) were admitted to the floor postoperatively and 207 patients (82.1%) to the ICU. Overall, microsurgical success rate was 97.2%, which was similar for floor and ICU patients. Flap takeback and salvage were similar between cohorts. Average postoperative LOS was significantly shorter in floor patients (15.7 vs. 19.1 days, p = 0.043). CONCLUSION: Our findings suggest that postoperative floor admission does not decrease flap success rates and should be considered in patients who undergo FTT to LE reconstruction and are otherwise stable. In the ongoing era of health care cost containment, microsurgery centers should consider appropriate floor training to allow medically stable free flap patients to avoid an ICU stay.

Early versus delayed ileocolic resection for complicated Crohn's disease: is "cooling off" necessary?

BACKGROUND: Ileal Crohn's disease (CD) complicated by intraabdominal abscess, phlegmon, fistula, and/or microperforation is commonly treated with antibiotics, bowel rest, and percutaneous drainage followed by interval ileocolic resection (ICR). This "cool off" strategy is intended to facilitate the safe completion of a one-stage resection using a minimally invasive approach and minimize perioperative complications. There is limited data evaluating the benefits of delayed versus early resection. METHODS: A retrospective review of a prospectively maintained inflammatory bowel disease (IBD) database at a tertiary center was queried from 2013-2020 to identify patients who underwent ICR for complicated ileal CD confirmed on preoperative imaging. ICR cohorts were classified as early (≤ 7 days) vs delayed (> 7 days) based on the interval from diagnostic imaging to surgery. Operative approach and 30-day postoperative morbidity were analyzed. RESULTS: Out of 474 patients who underwent ICR over the 7-year period, 112 patients had complicated ileal CD including 99 patients (88%) with intraabdominal abscess. Early ICR was performed in 52 patients (46%) at a median of 3 days (IQR 2, 5) from diagnostic imaging. Delayed ICR was performed in 60 patients (54%) following a median "cool off" period of 23 days of non-operative treatment (IQR 14, 44), including preoperative percutaneous abscess drainage in 17 patients (28%). A higher proportion of patients with intraabdominal abscess underwent delayed vs early ICR (57% vs 43%, p = 0.19). Overall, there were no significant differences in the rate of laparoscopy (96% vs 90%), conversion to open surgery (12% vs 17%), rates of extended bowel resection (8% vs 13%), additional concurrent procedures (44% vs 52%), or fecal diversion (10% vs 2%) in the early vs delayed ICR groups. The median postoperative length of stay was 5 days in both groups with an overall 25% vs 17% (p = 0.39) 30-day postoperative complication rate and a 6% vs 5% 30-day readmission rate in early vs delayed ICR groups, respectively. Overall median follow-up time was 14.3 months (IQR 1.2, 24.1) with no difference in the rate of subsequent CD-related intestinal resection (4% vs 5%) between the two groups. CONCLUSIONS: In this contemporary series, at a high-volume tertiary referral center, a "cool off" delayed resectional approach was not found to reduce perioperative complications in patients undergoing ICR for complicated ileal Crohn's disease. Laparoscopic ICR can be performed within one week of diagnosis with low rates of conversion and postoperative complications.

Effect of the COVID-19 pandemic on bariatric surgery in North America: a retrospective analysis of 834,647 patients.

BACKGROUND: COVID-19 has transformed surgical care, yet little is known regarding implications for bariatric surgery. OBJECTIVE: We sought to characterize the effect of COVID-19 on bariatric surgery delivery and outcomes. SETTING: The Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) collects data from 885 centers in North America. METHODS: The MBSAQIP database was evaluated with 2 cohorts described: the COVID-19 and the pre-COVID-19, with patients receiving surgery in 2020 and 2015-2019, respectively. Yearly operative trends were characterized, and bivariate analysis compared demographics and postoperative outcomes. Multivariable modeling evaluated 30-day readmission, reintervention, and reoperation rates and factors associated with undergoing Roux-en-Y gastric bypass. RESULTS: We evaluated 834,647 patients, with 155,830 undergoing bariatric surgery during the 2020 pandemic year. A 12.1% reduction in total cases (177,208 in 2019 versus 155,830 in 2020; P < .001) and 13.8% reduction in cases per center occurred (204.2 cases per center in 2019 versus 176.1 cases per center in 2020; P < .001). Patients receiving bariatric surgery during the pandemic were younger and had fewer co-morbidities. Use of sleeve gastrectomy increased (74.5% versus 72.5%; P < .001), and surgery during COVID-19 was associated with reduced Roux-en-Y gastric bypass procedure selection (odds ratio = .83; 95% CI: .82-.84; P < .001). Length of stay decreased significantly (1.4 ± 1.4 days versus 1.6 ± 1.4 days; P < .001), yet postoperative outcomes were similar. After adjusting for co-morbidities, patients during COVID-19 had decreased 30-day odds of readmission and reintervention and a small increase in odds of reoperation. CONCLUSION: The COVID-19 pandemic dramatically changed bariatric surgery delivery. Further studies evaluating the long-term effects of these changes are warranted.

Early outcomes of lung resections in non-small cell lung cancer after COVID-19 pneumonia.

OBJECTIVE: There is limited literature on patients with a history of COVID-19 pneumonia who underwent anatomical lung resection for non-small cell lung cancer (NSCLC). This study was aimed to share the early postoperative outcomes in patients who underwent lung resection after COVID-19 pneumonia. MATERIALS AND METHODS: We retrospectively evaluated 30 patients who underwent lobectomy with thoracotomy and systematic mediastinal lymph node dissection due to NSCLC in a single center between November 2018 and September 2021. The patients were divided into two groups regarding COVID-19 pneumonia history; the COVID-19 group consisted of 14 patients (46.7%) and the non-COVID-19 group 16 (53.3%) patients. The patients' age, gender, comorbidity, Charlson Comorbidity Index (CCI) score, forced expiratory volume in 1 s (FEV1) value, tumor type and size, resection type, postoperative air leak duration, total drainage volume, drain removal time, postoperative complications, and length of stay (LOS) were recorded. RESULTS: 9 (30%) patients were female, and 21 (70%) were male. The mean age was 62.1 ± 8.91 years. Our comparison of postoperative air leak duration, total drainage volume, time to drain removal, postoperative complications, and LOS between the COVID-19 and non-COVID-19 groups revealed no statistically significant difference. CONCLUSION: Anatomical lung resection can be performed safely in NSCLC patients with a history of COVID-19 pneumonia without significant difference in early postoperative morbidity and mortality.

Safety and economics of an enhanced recovery after surgery protocol in pelvic reconstructive surgery.

INTRODUCTION AND HYPOTHESIS: We hypothesized that an enhanced recovery after surgery (ERAS) protocol for patients undergoing female pelvic reconstructive surgery would conserve hospital resources without compromising patient safety. METHODS: In June 2020, an ERAS protocol designed to promote same-day discharge was initiated that included pre-operative hydration, a urinary anesthetic, non-narcotic analgesia, perineal ice, a bowel regimen, enrollment of the family to assist with care, and communication regarding planned same-day discharge. We compared demographic, operative, hospital stay, complications, and cost data in patients undergoing pelvic organ prolapse or incontinence surgery over 4 sequential months pre (PRE; N = 82) and post (POST; N = 91) ERAS implementation using univariate statistics. RESULTS: There were no differences in demographics, operative details, or complications (p > 0.05). There were no significant differences in overall revenues or expenses (p > 0.05), but bed unit cost was significantly lower in the POST group ($210 vs $533, p < 0.0001). There was a trend toward an increased operating margin in POST patients ($4,554 vs $2,151, p = 0.1163). Significantly more POST surgeries were performed in an ambulatory setting (73.6% vs 48.8%, p = 0.0008) and resulted in same-day discharge (80.2% vs 50.0%, p = 0.0003). There were no differences in the rates of emergency room or unexpected clinic visits (p > 0.05). Prescribed post-operative opiate dose was significantly reduced in POST patients (p < 0.0001). CONCLUSIONS: In patients undergoing female pelvic reconstructive surgery, an ERAS protocol facilitated transfer of procedures to an ambulatory surgical site and permitted same-day discharge without increasing complications, clinic visits, or emergency room visits. It also reduced bed unit cost and may improve operating margins.

How to perform an anastomosis following a low anterior resection by transanal total mesorectal excision surgery: from top to bottom techniques.

AIM: The aim was to describe the range of possibilities and our group's clinical outcomes when performing different types of anastomosis during transanal total mesorectal excision (taTME). METHOD: A retrospective analysis was performed based on four taTME series from 2016 to 2021. Inclusion criteria were patients with rectal cancer in whom a sphincter-saving low anterior resection by taTME was performed. Four different techniques were employed for the anastomosis construction: (A) abdominal view, (B) transanal view, (C) hand-sewn coloanal anastomosis and (D) pull-through. Intra-operative and postoperative data were collected and compared. RESULTS: A total of 161 patients were included. Tumour height was lower in groups C and D (4 [3-5] vs. 7 [6-8] group A vs. 6 [5-7] group B, P = 0.000), requiring a hand-sewn anastomosis. A transanal extraction of the specimen was more commonly performed in groups C and D (over 60% vs. 30% in groups A and B, P = 0.000). The rate of temporary stoma was similar between groups A, B and C (ranging from 84% to 98%) but was significantly lower in group D (P = 0.000). The overall rate of complications was similar between groups; however, group D had longer length of stay (15 days vs. 5-6 in groups A, B and C, P = 0.026). CONCLUSION: Every type of anastomosis construction after a taTME procedure seems to be safe and feasible and should be chosen based on surgeon's experience, tumour height and the length of the rectal cuff after the rectal transection. Colorectal surgeons should be familiar with these techniques in order to choose the one that benefits each patient the most.

Mechanical thrombectomy of COVID-19 DVT with congenital heart disease leading to phlegmasia cerulea dolens: a case report.

BACKGROUND: COVID-19 and Fontan physiology have each been associated with an elevated risk of venous thromboembolism (VTE), however little is known about the risks and potential consequences of having both. CASE PRESENTATION: A 51 year old male with tricuspid atresia status post Fontan and extracardiac Glenn shunt, atrial flutter, and sinus sick syndrome presented with phlegmasia cerulea dolens (PCD) of the left lower extremity in spite of supratherapeutic INR in the context of symptomatic COVID-10 pneumonia. He was treated with single session, catheter directed mechanical thrombectomy that was well-tolerated. CONCLUSIONS: This report of acute PCD despite therapeutic anticoagulation with a Vitamin K antagonist, managed with emergent mechanical thrombectomy, calls to attention the importance of altered flow dynamics in COVID positive patients with Fontan circulation that may compound these independent risk factors for developing deep venous thrombosis with the potential for even higher morbidity.