Influence of three different closure techniques on leakage pressures and leakage location following partial cystectomies in normal dogs.

BACKGROUND: Transitional cell carcinoma (TCC) is the most common neoplasia affecting the canine urinary bladder. Partial cystectomy, when used adjuctively with medical management, has been shown to meaningfully extend medial survival time. Surgical stapling devices have a wide variety of uses and advantages over traditional closure methods and, to date, investigation into their use in canine partial cystectomies has not been documented. OBJECTIVE: To determine the influence of three closure techniques on ex vivo leakage pressures and leakage location following canine partial cystectomy. METHODS: Specimens were assigned to one of three closure techniques: simple continuous appositional closure with 3-0 suture, closure with a 60 mm gastrointestinal stapler with a 3.5 mm cartridge, and placement of a Cushing suture to augment the stapled closure, with each group containing 12 specimens. Mean initial leakage pressure (ILP), maximum leakage pressure (MLP), and leakage location at the time that ILP was recorded were compared between groups. RESULTS: Oversewn stapled constructs leaked at significantly higher ILP (28.5 mmHg) than those in the sutured (17 mmHg) or stapled (22.8 mmHg) group, respectively. MLP was greater in the oversewn stapled construct group compared to other groups. Leakage was detected in 97% partial cystectomies, with leakage occurring from the needle holes in 100% of the sutured closure group, from the staple holes in 100% of the stapled only group, and from the incisional line in 83% and from bladder wall rupture in 8% of the augmented staple closure group. All closure methods withstood normal physiologic cystic pressures. CONCLUSIONS: Placement of a Cushing suture to augment stapled closures improved the ability of partial cystectomies to sustain higher intravesicular pressures compared with sutured or stapled bladder closures alone. Further in vivo studies are required to determine the clinical significance of these findings and the role of stapling equipment for partial cystectomy, as well as the clinical significance of suture penetration through the urinary bladder mucosa during closure.

Mortality and complications following surgery for diverticulitis: Systematic review and meta-analysis.

BACKGROUND: The surgical treatment of diverticulitis is in a state of evolution. Clinicians across many disciplines need to counsel patients regarding surgical choices. OBJECTIVES: A systematic review and meta-analysis was conducted to determine the mortality and complication rates following surgery for diverticulitis in both the emergent and elective setting. METHODS: We searched PubMed, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) for relevant articles published from 1980 to 2012. The primary outcome of interest was the point estimate of mortality, following surgery for diverticulitis. RESULTS: Of the 289 citations reviewed, we included 59 studies. Overall, the point estimate for mortality was 3.05%, with a 95% confidence intereval (CI) of 1.73-5.32 and p < 0.001. Mortality following emergent surgery was 10.64% (95% CI 7.95-14.11; p < 0.001), versus 0.50% (95% CI 0.46-0.54; p < 0.001) following elective operations. A laparoscopic approach had an estimated mortality of 0.75% (95% CI 0.35-1.58; p < 0.001), compared to an open surgical approach, which had a mortality of 4.69% (95% CI 2.29-9.36, p < 0.001). The mortality following a resection with primary anastomosis was 1.96% (95% CI 1.22-3.13; p < 0.001) and for the Hartmann's procedure was 14.18% (95% CI 9.83-20.03; p < 0.001). A comparative analysis found that the risk of post-operative mortality was significantly higher following emergent surgery, compared to elective surgery (odds ratio (OR): 6.12 with 95% CI 1.62-23.10; p = 0.008; Q = 2.56, p = 0.46 and I2 = 0); the open approach, compared to a laparoscopic approach (OR: 36.43 with 95% CI 9.94-133.6; p = 0.13; and Q = 2.79, p = 0.25 and I2 = 28.26); and for Hartmann's procedure, compared to primary anastomosis without diversion (OR: 25.45 with 95% CI 15.13-42.81, p < 0.001; and Q = 23.34, p = 0.14 and I2 = 27.16). The overall reported post-operative complication rate was 32.64% (95% CI 27.43-38.32; p < 0.00). The overall surgical and medical complication rates were 18.96% and 13.93%, respectively. CONCLUSIONS: Urgent surgical treatment of diverticulitis has a significant complication rate. Even elective surgery has a significant complication rate that needs to be considered when doing the clinical decision-making for recurrent diverticulitis.

Comparison of time to endoscopy and outcome between weekend/weekday hospital admissions in patients with upper GI hemorrhage.

OBJECTIVE: Recent findings suggest that time to endoscopy is prolonged in patients admitted on the weekend with upper gastrointestinal hemorrhage (UGIH), which may result in increased adverse outcomes. This study was designed to determine if these findings hold true for a community gastroenterology practice. METHODS: This retrospective study reviewed patients admitted to a community teaching hospital from January 1, 2008, through October 31, 2008 with the primary diagnosis of UGIH. UGIH was further defined as acute variceal hemorrhage (AVH) or non-variceal hemorrhage (NVUGIH). The primary groups were based on weekend vs weekday admission. Time to endoscopy, adverse outcomes, presenting symptom, and length of stay were analyzed. RESULTS: One hundred seventy-four patients were included (50 weekend; 124 weekday). Most patients (94.25%) received upper endoscopy within 24 hours of admission. Mean time to endoscopy was shorter for weekend admission compared to weekday (7.52 hours vs 10.82 hours; P=0.012) for the entire group. No statistically significant difference was detected in AVH patients (6.37 hours vs 4.37 hours; P=0.09), but a difference was observed in the NVUGIH group (7.65 hours vs 11.45 hours, P=0.015). Adverse outcomes were not associated with weekend admission (P=0.583). There was no difference in mean length of stay (3.08 days vs 3.85 days; P=0.131) or mean units of blood transfused (2.44 units vs 2.07 units, P=0.417) between admission groups. CONCLUSIONS: Patients admitted to this community teaching hospital with UGIH on the weekend did not experience delayed endoscopy, increased adverse outcomes, or longer length of stay compared to those admitted on a weekday. The previously reported "weekend effect" was not observed. In fact, patients admitted with NVUGIH on the weekend received upper endoscopy earlier than patients admitted during the week.