Development and internal validation of a clinical prediction model for serious complications after emergency laparotomy.

PURPOSE: Emergency laparotomy (EL) is a common operation with high risk for postoperative complications, thereby requiring accurate risk stratification to manage vulnerable patients optimally. We developed and internally validated a predictive model of serious complications after EL. METHODS: Data for eleven carefully selected candidate predictors of 30-day postoperative complications (Clavien-Dindo grade > = 3) were extracted from the HELAS cohort of EL patients in 11 centres in Greece and Cyprus. Logistic regression with Least Absolute Shrinkage and Selection Operator (LASSO) was applied for model development. Discrimination and calibration measures were estimated and clinical utility was explored with decision curve analysis (DCA). Reproducibility and heterogeneity were examined with Bootstrap-based internal validation and Internal-External Cross-Validation. The American College of Surgeons National Surgical Quality Improvement Program's (ACS-NSQIP) model was applied to the same cohort to establish a benchmark for the new model. RESULTS: From data on 633 eligible patients (175 complication events), the SErious complications After Laparotomy (SEAL) model was developed with 6 predictors (preoperative albumin, blood urea nitrogen, American Society of Anaesthesiology score, sepsis or septic shock, dependent functional status, and ascites). SEAL had good discriminative ability (optimism-corrected c-statistic: 0.80, 95% confidence interval [CI] 0.79-0.81), calibration (optimism-corrected calibration slope: 1.01, 95% CI 0.99-1.03) and overall fit (scaled Brier score: 25.1%, 95% CI 24.1-26.1%). SEAL compared favourably with ACS-NSQIP in all metrics, including DCA across multiple risk thresholds. CONCLUSION: SEAL is a simple and promising model for individualized risk predictions of serious complications after EL. Future external validations should appraise SEAL's transportability across diverse settings.

Diabetes Remission After LRYGBP With and Without Fundus Resection: a Randomized Clinical Trial.

BACKGROUND: Glycemic control, after metabolic surgery, is achieved in two stages, initially with neuroendocrine alterations and in the long-term with sustainable weight loss. The resection of the gastric fundus, as the major site of ghrelin production, is probably related with optimized glucose regulation. The aim of the present study is to investigate whether the modification of laparoscopic Roux-en-Y gastric bypass (LRYGBP) with fundus resection offers superior glycemic control, compared to typical LRYGBP. MATERIALS AND METHODS: Participants were 24 patients with body mass index (BMI) ≥40kg/m2 and type II diabetes mellitus (T2DM), who were randomly assigned to undergo LRYGBP and LRYGBP with fundus resection (LRYGBP+FR). Gastrointestinal (GI) hormones [ghrelin, glucagon-like-peptide-1 (GLP-1), peptide-YY (PYY)] and glycemic parameters (glucose, insulin, HbA1c, C-peptide, insulinogenic index, HOMA-IR) were measured preoperatively, at 6 and 12 months during an oral glucose tolerance test (OGTT). RESULTS: Ninety-five percent of patients showed complete remission of T2DM after 12 months. LRYGBP+FR was not related with improved glycemic control, compared to LRYGBP. Ghrelin levels were not significantly reduced at 6 and 12 months after LRYGBP+FR. GLP-1 and PYY levels were remarkably increased postprandially in both groups at 6 and 12 months postoperatively (p<0.01). Patients who underwent LRYGBP+FR achieved a significantly lower BMI at 12 months in comparison to LRYGBP (p<0.05). CONCLUSION: Fundus resection is not associated with improved glycemic regulation, compared to typical LRYGBP and the significant decrease in BMI after LRYGBP+FR has to be further confirmed with longer follow-up.

Risk Factors and Management Approaches for Staple Line Leaks Following Sleeve Gastrectomy: A Single-Center Retrospective Study of 402 Patients.

Sleeve gastrectomy (SG) has gained ever-increasing popularity among laparoscopic surgeons involved in bariatric surgery. This single-institution, retrospective cohort study aims to evaluate the prevalence of postoperative staple line leakage (PSLL) after LSG and identify risk factors for its development. We included patient data that underwent LSG at our institution for a span of 17 years-starting in January 2005 and ending in December 2022. We set the investigation of correlations of patient-related factors (age, weight, BMI, smoking status, presence of diabetes mellitus) with the occurrence of postoperative leaks. A total of 402 patients were included in our study. Of them, 26 (6.46%) developed PSLL. In total, 19 (73%) patients underwent percutaneous drainage and 14 patients (53.8%) were treated with intraluminal endoscopic stenting. Finally, five patients (19.2%) were treated with endoscopic clipping of the defect. Operative management was required in only one patient. There were no statistically significant differences in patient age, mean weight at the time of operation, and mean BMI. Abnormal drain amylase levels were associated with earlier detection of PSLL. More consideration needs to be given to producing a consensus regarding the management of PSLL, prioritizing nonoperative management with the combination of percutaneous drainage and endoscopic stenting as the safest and most efficient approach.

Minimally invasive surgery for paraduodenal hernias: report of a case and mini-review of operative techniques.

BACKGROUND: Paraduodenal hernias (PDHs) are the most common congenital internal hernias. Herein, we present a successful laparoscopic repair of a left PDH and we review the minimally invasive techniques that have been used to treat PDHs. MATERIALS AND METHODS: An 18-year-old female patient with multiple visits to the emergency department for abdominal pain was ultimately diagnosed with a left PDH. She underwent a four-port laparoscopic repair. In order to review the minimally invasive PDH repair techniques used, we searched the PubMed® database and found 53 original studies with a total of 66 minimally invasive PDH repairs (51 left PDH repairs, 15 right PDH repairs) over a period of 24 years (1998-2022). RESULTS: The patient's postoperative course was uneventful and she was discharged on the 7th postoperative day. The literature review showed that closure of the hernia orifice was performed in 88% of left PDH repairs, whereas wide opening of the hernia orifice with or without mobilization of the right colon was performed in 81% of right PDH repairs. Of the patients with available postoperative data, none experienced complications other than grade Ι according to the Clavien-Dindo classification in the early postoperative period, and only one patient presented symptomatic hernia recurrence at a median follow-up of 1 year. CONCLUSIONS: Based on limited publications and our own experience, minimally invasive repair of PDHs has so far been shown to be feasible and safe in the great majority of cases without irreversible small intestine ischemia/peritonitis.

Prospective multicenter external validation of postoperative mortality prediction tools in patients undergoing emergency laparotomy.

BACKGROUND: Accurate preoperative risk assessment in emergency laparotomy (EL) is valuable for informed decision making and rational use of resources. Available risk prediction tools have not been validated adequately across diverse health care settings. Herein, we report a comparative external validation of four widely cited prognostic models. METHODS: A multicenter cohort was prospectively composed of consecutive patients undergoing EL in 11 Greek hospitals from January 2020 to May 2021 using the National Emergency Laparotomy Audit (NELA) inclusion criteria. Thirty-day mortality risk predictions were calculated using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), NELA, Portsmouth Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (P-POSSUM), and Predictive Optimal Trees in Emergency Surgery Risk tools. Surgeons' assessment of postoperative mortality using predefined cutoffs was recorded, and a surgeon-adjusted ACS-NSQIP prediction was calculated when the original model's prediction was relatively low. Predictive performances were compared using scaled Brier scores, discrimination and calibration measures and plots, and decision curve analysis. Heterogeneity across hospitals was assessed by random-effects meta-analysis. RESULTS: A total of 631 patients were included, and 30-day mortality was 16.3%. The ACS-NSQIP and its surgeon-adjusted version had the highest scaled Brier scores. All models presented high discriminative ability, with concordance statistics ranging from 0.79 for P-POSSUM to 0.85 for NELA. However, except the surgeon-adjusted ACS-NSQIP (Hosmer-Lemeshow test, p = 0.742), all other models were poorly calibrated ( p < 0.001). Decision curve analysis revealed superior clinical utility of the ACS-NSQIP. Following recalibrations, predictive accuracy improved for all models, but ACS-NSQIP retained the lead. Between-hospital heterogeneity was minimum for the ACS-NSQIP model and maximum for P-POSSUM. CONCLUSION: The ACS-NSQIP tool was most accurate for mortality predictions after EL in a broad external validation cohort, demonstrating utility for facilitating preoperative risk management in the Greek health care system. Subjective surgeon assessments of patient prognosis may optimize ACS-NSQIP predictions. LEVEL OF EVIDENCE: Diagnostic Test/Criteria; Level II.

The role of the gastric fundus in glycemic control.

PURPOSE: Ghrelin, one of the most studied gut hormones, is mainly produced by the gastric fundus. Abundant evidence exists from preclinical and clinical studies underlining its contribution to glucose regulation. In the following narrative review, the role of the gastric fundus in glucose regulation is summarized and we investigate whether its resection enhances glycemic control. METHODS: An electronic search was conducted in the PubMed® database and in Google Scholar® using a combination of medical subject headings (MeSH). We examined types of metabolic surgery, including, in particular, gastric fundus resection, either as part of laparoscopic sleeve gastrectomy (LSG) or modified laparoscopic gastric bypass with fundus resection (LRYGBP + FR), and the contribution of ghrelin reduction to glucose regulation. RESULTS: Fourteen human studies were judged to be eligible and included in this narrative review. Reduction of ghrelin levels after fundus resection might be related to early glycemic improvement before significant weight loss is achieved. Long-term data regarding the role of ghrelin reduction in glucose homeostasis are sparse. CONCLUSION: The exact role of ghrelin in achieving glycemic control is still ambiguous. Data from human studies reveal a potential contribution of ghrelin reduction to early glycemic improvement, although further well-designed studies are needed.

The Hellenic Emergency Laparotomy Study (HELAS): A Prospective Multicentre Study on the Outcomes of Emergency Laparotomy in Greece.

BACKGROUND: Emergency laparotomy (EL) is accompanied by high post-operative morbidity and mortality which varies significantly between countries and populations. The aim of this study is to report outcomes of emergency laparotomy in Greece and to compare them with the results of the National Emergency Laparotomy Audit (NELA). METHODS: This is a multicentre prospective cohort study undertaken between 01.2019 and 05.2020 including consecutive patients subjected to EL in 11 Greek hospitals. EL was defined according to NELA criteria. Demographics, clinical variables, and post-operative outcomes were prospectively registered in an online database. Multivariable logistic regression analysis was used to identify independent predictors of post-operative mortality. RESULTS: There were 633 patients, 53.9% males, ASA class III/IV 43.6%, older than 65 years 58.6%. The most common operations were small bowel resection (20.5%), peptic ulcer repair (12.0%), adhesiolysis (11.8%) and Hartmann's procedure (11.5%). 30-day post-operative mortality reached 16.3% and serious complications occurred in 10.9%. Factors associated with post-operative mortality were increasing age and ASA class, dependent functional status, ascites, severe sepsis, septic shock, and diabetes. HELAS cohort showed similarities with NELA patients in terms of demographics and preoperative risk. Post-operative utilisation of ICU was significantly lower in the Greek cohort (25.8% vs 56.8%) whereas 30-day post-operative mortality was significantly higher (16.3% vs 8.7%). CONCLUSION: In this study, Greek patients experienced markedly worse mortality after emergency laparotomy compared with their British counterparts. This can be at least partly explained by underutilisation of critical care by surgical patients who are at high risk for death.

Cardiac valve calcification in patients on maintenance dialysis. The role of malnutrition-inflammation syndrome, adiposity andcomponents of sarcopenia. A cross-sectional study.

BACKGROUND & AIMS: Cardiac valve calcification (CVC) is a predictor of cardiovascular disease and all-cause mortality in end stage kidney disease (ESKD) patients. Several risk factors are related to CVC in patients with ESKD including traditional ones as well as inflammation, bone mineral disease and malnutrition. Adiposity is associated with dyslipidemia and proinflammatory activity which could predispose for CVC. Sarcopenia or dynapenia is a state common in patients with ESKD. This study aimed to investigate the relationship of adiposity, sarcopenia and malnutrition-inflammation markers with CVC in patients on maintenance hemodialysis. METHODS: CVC in aortic (AVC), mitral valves (MVC) and systolic and diastolic dysfunction (DD) were assessed by using two-dimensional echocardiography. Nutritional, adiposity and anthropometric assessments were made using several indices respectively. Creatinine index and muscle strength measurements were also performed. Biochemical parameters such as total proteins, albumin, calcium, phosphate, plasma lipoproteins, C-Reactive Protein and parathyroid hormone were also measured. RESULTS: Adiposity, nutritional, and sarcopenia parameters did not show any difference between patients with or without CVC. Age ≥ 65 years [PR: 1.47 p = 0.012], DD [PR: 2.31, p = 0.005], high CRP/albumin ratio [PR: 1.46, p = 0.01], mid arm circumference (MAC) < 26 cm [PR: 1.37, p = 0.03] were associated with increased prevalence of AVC, while DD [PR: 1.97 p = 0.02], high CRP/albumin ratio [PR: 1.56, p = 0.02], and MAC < 26 cm [PR: 1.52, p = 0.01], showed positive correlation with MVC. Age ≥ 65 years [PR: 1.33, p = 0.028], DD [PR: 1.72, p = 0.01], high CRP/albumin ratio [PR: 1.53, p = 0.003], and MAC < 26 cm [PR: 1.4, p = 0.006], related to greater prevalence of calcification at any valve. CONCLUSIONS: Ageing, diastolic dysfunction, MAC and increased CRP/albumin ratio were powerful predictors of CVC in patients on hemodialysis.

Long-term (11 + years) efficacy of sleeve gastrectomy as a stand-alone bariatric procedure: a single-center retrospective observational study.

INTRODUCTION: Sleeve gastrectomy (SG) is currently the most commonly performed bariatric procedure worldwide. The aim of the present study was to evaluate the long-term efficacy of SG as a stand-alone bariatric procedure. METHODS: A single-center retrospective analysis of 104 patients who underwent SG as a stand-alone bariatric procedure between January 2005 and December 2009. Weight loss, weight regain, remission or improvement of comorbidities and the new onset of comorbidities were the main outcomes of the study. RESULTS: The percent excess body weight loss (%EBWL), percent excess body mass weight (BMI) loss (%EBMIL), and percent total body weight loss (%TBWL) were 59 ± 25, 69 ± 29, and 29 ± 12, respectively, after a mean follow-up of 13.4 years. At the last follow-up, nearly two thirds of patients (67.3%) had an %EBWL greater than 50. The percentage of patients who experienced significant weight regain ranged from 47 to 64%, depending on the definition used for weight regain. The rate of improvement or remission of hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea, and degenerative joint disease at a mean follow-up of 13.4 years was 40%, 94.7%, 70%, 100%, and 42.9%, respectively. The new onset of gastroesophageal reflux disease (GERD) symptoms in the same period was 43%. CONCLUSION: Our data supports that SG results in long-lasting weight loss in the majority of patients and acceptable rates of remission or improvement of comorbidities. Weight regain and GERD may be issues of particular concern during long-term follow-up after SG.

Ghrelin, glucagon-like peptide-1, and peptide YY secretion in patients with and without weight regain during long-term follow-up after bariatric surgery: a cross-sectional study.

Introduction: Weight loss after bariatric surgery is attributed, at least in part, to the altered gastrointestinal (GI) hormone secretion, which is thought to be responsible for a number of beneficial metabolic effects. Material and methods: We conducted a cross-sectional study. Twelve patients who underwent laparoscopic sleeve gastrectomy (SG) and 20 patients who underwent a variant of biliopancreatic diversion with Roux-en-Y gastric bypass and long limbs (BPD/RYGB-LL) were evaluated ≥ 7 years postoperatively. Ghrelin, glucagon-like peptide-1 (GLP-1), and peptide YY (PYY) secretion were compared between patients with successful weight loss maintenance (WM group) and patients with weight regain (WR group). Results: In both types of surgery, standard liquid mixed meal (SLMM) ingestion did not result in significant changes in fasting GI hormone levels. Fasting ghrelin levels did not differ between the WM group and the WR group in both types of surgery. In SG patients, SLMM ingestion elicited greater suppression of ghrelin levels in the WM group (p = 0.032). No difference in GLP-1 secretion was observed between the 2 groups of patients in both types of surgery. When patients were examined, regardless of the type of bariatric surgery they had undergone, postprandial PYY levels were lower in the WM group (p < 0.05), while fasting and postprandial PYY levels were correlated positively with an increase in body mass index (BMI) in the evaluation (Spearman's rho ≥ 0.395, p < 0.03). Conclusions: Our data do not support the hypothesis that long-term weight regain after bariatric surgery is associated with an unfavourable GI hormone secretion pattern.

Comparison of one anastomosis gastric bypass versus standard Roux-en-Y gastric bypass versus a variant of biliopancreatic diversion, in a case-matched, non-superobese population: 6 years of follow-up.

INTRODUCTION: One anastomosis gastric bypass (OAGB) is gaining increasing acceptance as a simple, safe, and effective operation for treating morbid obesity. Data comparing this procedure with the most effective biliopancreatic diversions (BPD) remain scarce, and most studies evaluate OAGB against standard Roux-en-Y gastric bypass (RYGB). AIM: To present the mid-term results of a comparison of RYGB, OAGB, and our modification of BPD in an exclusively non-superobese population, regarding safety, efficacy, preservation of weight loss, as well as late postoperative metabolic and non-metabolic complications. MATERIAL AND METHODS: From our cohorts of patients treated for morbid obesity with OAGB, RYGB, and BPD at Patras University Hospital, we identified patients who had case-matched preoperative profiles regarding age, preoperative body mass index (BMI), and obesity-related comorbidities (diabetes mellitus, hypertension, and dyslipidaemia). Thirty-four patients from each group were included in the study. Bariatric outcomes, non-metabolic complications, and postoperative metabolic parameters were followed until the 6th postoperative year. RESULTS: The average patient age was 37.4 years (range: 19-57), 85.3% were female and 14.7% were male, with a mean BMI of 46.3 kg/m2 (range: 38.3-49.7). Regarding weight loss and glycaemic control, OAGB had comparable results to BPD and was significantly better than RYGB. The safety profile was analogous to RYGB, with the exception of calcium levels, which, even though they were within normal range, were significantly lower than those in RYGB. Comorbidities were successfully treated with all operations at comparable rates. In this cohort, no other major complications were observed. CONCLUSIONS: OAGB offered mid-term results comparable to BPD while being safe and with minimal impact on the patient's nutritional state. It is an effective procedure for treating morbid obesity, which results in sustained weight loss and a high rate of resolution of comorbidities.

Favorable effects of peritoneal dialysis in patients with refractory heart failure and overhydration.

BACKGROUND: Patients with refractory to optimal pharmacological treatment heart failure (HF) require frequent hospitalization. Peritoneal dialysis (PD) has been part of the management of such patients mainly for promoting ultrafiltration and management of overhydration independently of kidney function. The aim of this study was to evaluate the efficacy of PD, especially the use of icodextrin solutions and intermittent PD, in the hospitalization rate and cardiac functional status of patients with HF. METHODS: We conducted a retrospective study involving patients with New York Heart Association (NYHA) class IV HF and preserved renal function (estimated glomerular filtration rate (eGFR) > 25 ml/min), who were refractory to conservative treatment. Clinical data on weight loss, hospitalization rate before and after PD initiation, cardiac functional status, and technique complications during a 6-month observational period were analyzed. RESULTS: PD treatment was performed in 32 patients with a mean age of 63.8 ± 11.9 years and a follow-up of 20.78 ± 14.24 months. Hospitalizations were significantly reduced from 20.7 ± 13.7 to 7.7 ± 8.9 days/patients at 6 months. All patients showed improvement in NYHA class as well as in left ventricular ejection fraction. Overall, eGFR showed a significant decrease but only six patients reached end-stage renal disease. Complications included 18 cases of peritonitis. PD was well tolerated and no patient dropped out of the method. Survival rate reached 72% at 12 months but mortality rate was high with 23 patients dying at 16.65 ± 12.3 months after the initiation of treatment. Patients survival was not influenced by the type of PD modality or weight reduction achieved. CONCLUSIONS: PD showed to be a viable option for the treatment of patients with refractory HF leading to a better cardiac functional status and diminishing the number of hospital admissions.

Primary aortoenteric fistula: is endovascular repair the prime option? A review of the literature.

Primary aortoenteric fistula (PAEF) is a rare entity that demands high clinical suspicion and efficient management in a limited time. The evolution of interventional radiology established endovascular repair (EVAR) as an attractive option. The English literature was searched using the PubMed database with the terms "primary aortoenteric fistula", "primary aortoduodenal fistula" or "aortoduodenal fistula", and "endovascular repair" in different combinations. Studies and original articles that described the role and the outcomes of EVAR for primary aortoenteric fistula were included. Fourteen articles with a total of 15 patients with primary aortoenteric fistula who were managed with EVAR were included in our literature review. PAEF is a rare and lethal entity that everyone should be aware of. EVAR is a salvage option and a valuable weapon in our armamentarium. Is EVAR really a "bridge to surgery" or is it the birth pangs of a minimally invasive definite treatment of PAEF?

Comparison of intra-abdominal abscess formation after laparoscopic and open appendectomy for complicated and uncomplicated appendicitis: a retrospective study.

INTRODUCTION: Acute appendicitis (AA) is one of the most common causes of acute abdominal pain seen in emergency departments and appendectomy has been the preferred treatment of this disease for decades. Postoperative intra-abdominal abscess (PIAA) complicates 3% to 25% of appendectomies and the risk is highest following complicated appendicitis. However, the risk for intra-abdominal abscess formation after appendectomy is still a matter of debate. AIM: To evaluate PIAA formation after open appendectomy (OA) and laparoscopic appendectomy (LA), in particular in complicated appendicitis. MATERIAL AND METHODS: From January 2003 to December 2018, records of patients who underwent appendectomy with diagnosis of appendicitis were retrieved from a computer database for analysis. RESULTS: During the study period, 1809 appendectomies were performed in our institution (939 LAs and 850 OAs). Twenty conversion cases were recorded. There was no difference between the incidences of PIAA (LA, 3.73% (35/939) and OA, 3.41% (29/850); p > 0.05). The incidence of PIAA in those with complicated appendicitis was: LA, 11/212 (5.19%) vs. OA 14/198 (7.07%); p > 0.05. CONCLUSIONS: This retrospective study shows that the technique of appendectomy does not appear to affect the incidence of IAAs either in uncomplicated or in complicated appendicitis. However, laparoscopic appendectomy has the advantages of laparoscopic procedures, such as lower hospital stay and earlier return to activities, and should therefore be preferred for acute appendicitis.

An enormous pelvic tumor in a 46-year-old woman with an elevated serum CA 125 level, what lies beneath it? Investigation of uterine tumors in postmenopausal women.

Abdominal and pelvic pain with an associated pelvic mass is a very common emergency situation. There is always a management dilemma for most emergency physicians regarding these patients. A 46-year-old postmenopausal woman was admitted to our emergency department (ED) with complaints of massive abdominal distention. Abdominal and pelvis magnetic resonance imaging (MRI) was performed, which revealed a huge pelvic abdominal mass. All tumor markers were within normal limits. However, the ovarian cancer antigen (CA 125) level was elevated. As there was a strong suspicion of malignancy, the patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy. Her final histopathology report was suggestive of uterine leiomyoma. Uterine leiomyomas are the most common benign uterine tumors in women. Surgical treatment is the gold standard, especially for older women with severe symptoms and no desire for future fertility. Although the combination of a pelvic tumor and a high-level of CA 125 arouses suspicion of gynecological malignancy, other benign conditions should always be considered in the differential diagnosis. There is limited evidence to support an association between elevated CA 125 levels and uterine fibroids so far. However, conditions such as the coexistence of adenomyosis and tumor size can affect the level of this marker in uterine fibroids.