Surgical options for perianal fistula in patients with Crohn's disease: A comparison of seton placement, fistulotomy, and stem cell therapy.

OBJECTIVE: This study was designed to assess the demographic characteristics of patients with Crohn's perianal fistula (CPF) who were treated at a tertiary referral institution. Surgical outcomes were compared in groups of patients who underwent seton placement, fistulotomy, and stem cell therapy. METHODS: Patients who underwent surgery for CPF between 2015 and 2017 at Asan Medical Center, Seoul, Korea, were retrospectively evaluated. Patients were divided into groups who underwent seton placement, fistulotomy, and stem cell therapy. Their clinical variables and closure rates were compared. RESULTS: This study included 156 patients who underwent a total of 209 operations. More than half of the operations consisted of seton placement (67%), followed by stem cell therapy (18%) and fistulotomy (15%) patients. Of the 209 fistulas, 153 (73%) were complex, with an overall closure rate of 38% during a median follow-up of 29 months. Closure rates following fistulotomy, stem cell therapy, and seton placement were 90%, 70%, and 18%. Seton placement was more significantly frequently used than the other procedures in patients with complex fistula and those with abscesses. Of the 79 fistulas that achieved complete closure, 11 (14%) recurred. The recurrence rates did not differ among the various techniques. CONCLUSION: Surgical treatment of CPF is dependent on lesion type. Seton placement was the primary draining procedure for complex fistulas and abscesses, resulting in low closure rates. Fistulotomy was the definite procedure for low type and simple fistula. Stem cell therapy showed high closure rates as definitive treatment, even for complex fistulas.

Intraocular lens power estimation in combined phacoemulsification and pars plana vitrectomy in eyes with epiretinal membranes: a case-control study.

PURPOSE: To evaluate the accuracy of postoperative refractive outcomes of combined phacovitrectomy for epiretinal membrane (ERM) in comparison to cataract surgery alone. MATERIALS AND METHODS: Thirty-nine eyes that underwent combined phacovitrectomy with intraocular lens (IOL) implantation for cataract and ERM (combined surgery group) and 39 eyes that received phacoemulsification for cataract (control group) were analyzed, retrospectively. The predicted preoperative refractive aim was compared with the results of postoperative refraction. RESULTS: In the combined surgery group, refractive prediction error by A-scan and IOLMaster were -0.305±0.717 diopters (D) and -0.356±0.639 D, respectively, compared to 0.215±0.541 and 0.077±0.529 in the control group, showing significantly more myopic change compared to the control group (p=0.001 and p=0.002, respectively). Within each group, there was no statistically significant difference in refractive prediction error between A-scan and IOLMaster (all p>0.05). IOL power calculation using adjusted A-scan measurement of axial length based on the macular thickness of the normal contralateral eye still resulted in significant postoperative refractive error (all p<0.05). Postoperative refraction calculated with adjusted axial length based on actual postoperative central foveal thickness change showed the closest value to the actual postoperative achieved refraction (p=0.599). CONCLUSION: Combined phacovitrectomy for ERM resulted in significantly more myopic shift of postoperative refraction, compared to the cataract surgery alone, for both A-scan and IOLMaster. To improve the accuracy of IOL power estimation in eyes with cataract and ERM, sequential surgery for ERM and cataract may need to be considered.

Laparoscopic central pancreatectomy for benign or low-grade malignant lesions in the pancreatic neck and proximal body.

INTRODUCTION: Laparoscopic central pancreatectomy (LCP) is a parenchyma-sparing minimally invasive surgical technique for removal of benign or low-grade malignant lesions from the neck and proximal body of the pancreas. The aim of this study was to compare the short- and long-term clinical outcomes of LCP with those of other pancreatectomies. METHODS: During the study period, January 2007 to December 2010 (median follow-up 40.6 months), 287 pancreatectomies were performed for lesions in the neck and proximal body of the pancreas. To compare the clinical outcomes of LCP and other pancreatectomies, 26 cases of LCP, 14 cases of open central pancreatectomy (OCP), and 96 cases of extended laparoscopic distal pancreatectomy (E-LDP) were selected. RESULTS: Tumor sizes in the LCP (2.2 cm) and OCP (2.9 cm) groups were smaller than in the E-LDP (4.0 cm) group. Mean operation time in the LCP group (350.2 min) was longer than in the OCP (270.3 min) and E-LDP groups (210.6 min). There were more surgical complications in the LCP (38.5 %) and OCP groups (50 %) than in the E-LDP group (14.6 %). Mean duration of postoperative hospital stay was 13.8 days for the LCP group, which was significantly shorter than for the OCP group (22.4 days). New-onset diabetes was less frequent after LCP than after E-LDP (11.5 vs. 30.8 %). CONCLUSIONS: In selected patients with small and benign tumors in the pancreatic neck and proximal body LCP leads to increased postoperative morbidity but earlier postoperative recovery than OCP, and excellent postoperative pancreatic function (compared with E-LDP). LCP should, therefore, be considered a valid therapeutic option for selected patients.

Impact of critical pathway implementation on hospital stay and costs in patients undergoing pancreaticoduodenectomy.

BACKGROUNDS/AIMS: Recent studies have shown that pancreaticoduodenectomy (PD) can be performed quite safely. Critical pathway (CP) has been one of the key tools used to achieve excellent outcomes in high-quality, high-volume centers. This study was designed to evaluate the impact of CP implementation for PD patients. METHODS: The important components of CP for PD patients include the early start of an oral diet and removal of the abdomen drain following follow-up computed tomography, with the intention of shortening the postoperative hospital stay. The study group (CP group) comprised of 88 patients who underwent pylorus-preserving or classical PD from January 2009 to December 2010. The control group (pre-CP group) was 185 patients who underwent PD between January 2005 and December 2008. RESULTS: The two groups did not show significant differences in demographic profiles and the primary diagnosis. The incidences of overall postoperative complications such as delayed gastric emptying, fistula, and hemorrhage were similar or decreased in the CP group (54% vs. 40.9%). The incidence of clinically significant complications also showed a similar rate (5.4% vs. 4.5%) between the two groups. The nutritional status at discharge and re-admission rates were not different. The CP group showed a significantly shorter postoperative hospital stay (20.2±9.2 days vs. 14.9±5.1 days, p<0.001) and the total medical costs were also significantly reduced, by 15% (p<0.001). CONCLUSIONS: The results of this study indicated that the implementation of CP for PD patients can decrease the length of hospital stay and reduce medial costs, with maintenance or improvement of patient outcomes. Further investigation is necessary to validate the actual impact of CP for PD through multi-center high-volume studies.