Daniel Dindo

Classification of Surgical Complications: A New Proposal With Evaluation in a Cohort of 6336 Patients and Results of a Survey

Objective:Although quality assessment is gaining increasing attention, there is still no consensus on how to define and grade postoperative complications. This shortcoming hampers comparison of outcome data among different centers and therapies and over time. Patients and Methods:A classification of complications published by one of the authors in 1992 was critically re-evaluated and modified to increase its accuracy and its acceptability in the surgical community. Modifications mainly focused on the manner of reporting life-threatening and permanently disabling complications. The new grading system still mostly relies on the therapy used to treat the complication. The classification was tested in a cohort of 6336 patients who underwent elective general surgery at our institution. The reproducibility and personal judgment of the classification were evaluated through an international survey with 2 questionnaires sent to 10 surgical centers worldwide. Results:The new ranking system significantly correlated with complexity of surgery (P < 0.0001) as well as with the length of the hospital stay (P < 0.0001). A total of 144 surgeons from 10 different centers around the world and at different levels of training returned the survey. Ninety percent of the case presentations were correctly graded. The classification was considered to be simple (92% of the respondents), reproducible (91%), logical (92%), useful (90%), and comprehensive (89%). The answers of both questionnaires were not dependent on the origin of the reply and the level of training of the surgeons. Conclusions:The new complication classification appears reliable and may represent a compelling tool for quality assessment in surgery in all parts of the world.

Obesity in general elective surgery

Summary Background Obese patients are generally believed to be at a higher risk for surgery than those who are not obese, although convincing data are lacking. Methods We prospectively investigated a cohort of 6336 patients undergoing general elective surgery at our institution to assess whether obesity affects the outcome of surgery. Exclusion criteria were emergency, vascular, thoracic, and bariatric operations; transplantation procedures; patients under immunosuppression; and operations done under local anaesthesia. Postoperative morbidity was analysed for non-obese and obese patients (body-mass index 2 vs 3=30 kg/m 2 ). Obesity was further stratified into mild obesity (30·0–34·9 kg/m 2 ) and severe obesity (⩾35kg/m 2 ). Risk factors were analysed with univariate and multivariate models. Findings The cohort consisted of 6336 patients, of whom 808 (13%) were obese, 569 (9%) were mildly obese, and 239 (4%) had severe obesity. The morbidity rates in patients who were obese compared with those who were not were much the same (122 [15·1%] of 808 vs 901 [16·3%] of 5528; p=0·26), with the exception of an increased incidence of wound infections after open surgery in patients who were obese (17 [4%] of 431 vs 92 [3%] of 3555, p=0·03). Incidence of complications did not differ between patients who were mildly obese (91 [16·0%] of 569), severely obese (36 [15·1%] of 239), and non-obese (901 [16·3%] of 5528; p=0·19). In multivariate regression analyses, obesity was not a risk factor for development of postoperative complications. Of note, the additional medical resource use as estimated by a new classification of complications showed no differences between patients who were and were not obese. Interpretation Obesity alone is not a risk factor for postoperative complications. The regressive attitude towards general surgery in obese patients is no longer justified.

Laparoscopic gastric bypass is superior to laparoscopic gastric banding for treatment of morbid obesity.

Objective:To define whether laparoscopic gastric banding or laparoscopic Roux-en-Y gastric bypass represents the better approach to treat patients with morbid obesity. Summary Background Data:Two techniques, laparoscopic gastric bypass or gastric banding, are currently widely used to treat morbid obesity. Since both procedures offer certain advantages, a strong controversy exists as to which operation should be proposed to these patients. Therefore, data are urgently needed to identify the best therapy. Methods:Since randomized trials are most likely not feasible because of the highly different invasiveness and irreversibility of these procedures, a matched-pair design of a large prospectively collected database appears to be the best method. Therefore, we used our prospective database including 678 bariatric procedures performed at our institution since 1995. A total of 103 consecutive patients with laparoscopic gastric bypass were randomly matched to 103 patients with laparoscopic gastric banding according to age, body mass index, and gender. Results:Both groups were comparable regarding age, gender, body mass index, excessive weight, fat mass, and comorbidites such as diabetes, heart disease, and hypertension. Feasibility and safety: All gastric banding procedures were performed laparoscopically, and one gastric bypass operation had to be converted to an open procedure. Mean operating time was 145 minutes for gastric banding and 190 minutes for gastric bypass (P < 0.001). Hospital stay was 3.3 days for gastric banding and 8.4 days for gastric bypass. The incidence of early postoperative complications was not significantly different, but late complications were significantly more frequent in the gastric banding group (pouch dilatation). There was no mortality in both groups. Efficiency: Body mass index decreased from 48.0 to 36.8 kg/m2 in the gastric banding group and from 47.8 to 31.9 kg/m2 in the gastric bypass group within 2 years of surgery. These differences became significant from the first postoperative month until the end of the follow-up (24 months). The gastric bypass procedure achieved a significantly better reduction of comorbidities. Conclusions:Laparoscopic gastric banding and laparoscopic gastric bypass are feasible and safe. Pouch dilatations after gastric banding are responsible for more late complications compared with the gastric bypass. Laparoscopic gastric bypass offers a significant advantage regarding weight loss and reduction of comorbidities after surgery. Therefore, in our hands, laparoscopic Roux-en-Y gastric bypass appears to be the therapy of choice.

Central necrosis in isolated hypoxic human pancreatic islets: evidence for postisolation ischemia.

A variety of explanations have been provided to elucidate the requirement of the large islet mass that is essential for a successful treatment of patients with type I diabetes by intrahepatic transplantation. The purpose of this study was to investigate islet cell survival under the effect of prolonged hypoxia and/or nutrient withdrawal, which mimics posttransplantation environment of transplanted islets in the liver. We studied the influence of 24 h of hypoxia (1% O2) in intact isolated human and rat islets as well as the effect of combined oxygen/nutrient deprivation in a mouse insulinoma cell line (MIN6). In intact human islets, 24 h of hypoxia led to central necrosis combined with apoptotic features such as nuclear pyknosis and DNA fragmentation. In the course of hypoxic treatment, ultrastructural analysis demonstrated a gradual transition from an apoptotic to a necrotic morphology particularly pronounced in central areas of large islets. In MIN6 cells, on the other hand, hypoxia led to a twofold (p < 0.01) increase in caspase-3 activity, an indicator of apoptosis, but not to necrosis, as determined by release of lactate dehydrogenase (LDH). Only in combination with nutrient/serum deprivation was a marked increase in LDH release observed (sixfold vs. control, p < 0.01). We therefore conclude that, similar to MIN6 cells, central necrosis in isolated hypoxic islets is the result of the combined effects of hypoxia and nutrient/serum deprivation, most likely due to limited diffusion. Provided that transplanted islets undergo a similar fate as shown in our in vitro study, future emphasis will require the development of strategies that protect the islet graft from early cell death and accelerate the revascularization process.

Atraumatic Chylous Ascites: Systematic Review on Symptoms and Causes

Chylous ascites, or chylaskos, is a rare form of ascites characterized by a milky-appearing fluid containing high levels of triglycerides. Its incidence ranges from 1 in 20,000 to 1 in 187,000 admissions at large tertiary referral hospitals. Therapeutic interventions and trauma are well-known causes of chylous ascites. In a cohort of 1,103 patients undergoing abdominal surgery, the incidence of postoperative chylous ascites was reported to be 1.1%. When retroperitoneal, esophageal, gastric, or cytoreductive surgeries were performed, the postoperative incidence was even higher, amounting to 7.4%. Apart from oncologic thoacic and abdominal surgery, chylous ascites can also occur fter abdominal aortic surgery and very rarely after donor nephrectomy. In contrast to the direct injury of lymphatic vessels during surgery, the hyperextension and hyperflexion of the body during a blunt abdominal trauma entail a rupture of lymphatic vessels, thus causing chylous ascites. An additional cause of indirect injury leading to the development of chylous ascites is radiotherapy. Abdominal radiation is thought to induce fibrosis of the lymphatic vessels within the small bowel and the mesentery, causing obstruction and subsequent extravasation of chylous. In patients fter radiation of the whole abdomen for gynecologic maignancies, the incidence was reported to be as high as 3%. The most common clinical presentation of chylous ascites is supposed to be increasing painless abdominal distension. Less frequently, postinterventional and posttraumatic chylous ascites can induce an acute abdomen. Although the clinical features and causes of chylous ascites secondary to surgery or trauma are familiar to most clinicians, little is known about the incidence, etiology, and distribution of different clinical symptoms of atraumatic chylous ascites. The incidental finding of a few milliliters of chylous ascites during a routine inguinal hernia repair in a 28-year-old man finally leading to the diagnosis of non-

Cationic long-chain ceramide LCL-30 induces cell death by mitochondrial targeting in SW403 cells

Ceramides are sphingolipid second messengers that are involved in the mediation of cell death. There is accumulating evidence that mitochondria play a central role in ceramide-derived toxicity. We designed a novel cationic long-chain ceramide [ω-pyridinium bromide d-erythro-C16-ceramide (LCL-30)] targeting negatively charged mitochondria. Our results show that LCL-30 is highly cytotoxic to SW403 cells (and other cancer cell lines) and preferentially accumulates in mitochondria, resulting in a decrease of the mitochondrial membrane potential, release of mitochondrial cytochrome c, and activation of caspase-3 and caspase-9. Ultrastructural analyses support the concept of mitochondrial selectivity. Interestingly, levels of endogenous mitochondrial C16-ceramide decreased by more than half, whereas levels of sphingosine-1-phosphate increased dramatically and selectively in mitochondria after administration of LCL-30, suggesting the presence of a mitochondrial sphingosine kinase. Of note, intracellular long-chain ceramide levels and sphingosine-1-phosphate remained unaffected in the cytosolic and extramitochondrial (nuclei/cellular membranes) cellular fractions. Furthermore, a synergistic effect of cotreatment of LCL-30 and doxorubicin was observed, which was not related to alterations in endogenous ceramide levels. Cationic long-chain pyridinium ceramides might be promising new drugs for cancer therapy through their mitochondrial preference. [Mol Cancer Ther 2006;5(6):1520–9]

Prospective randomized study of monopolar scissors, bipolar vessel sealer and ultrasonic shears in laparoscopic colorectal surgery

Many instruments are used for laparoscopic dissection, including monopolar electrosurgery scissors (MES), electrothermal bipolar vessel sealers (BVS) and ultrasonically coagulating shears (UCS). These three devices were compared with regard to dissection time, blood loss, safety and costs.

Transanal minimal invasive surgery for rectal lesions: Should the defect be closed?

Transanal minimal invasive surgery (TAMIS) of rectal lesions is increasingly being used, but the technique is not yet standardized. The aims of this study were to evaluate peri‐operative complications and long‐term functional outcome of the technique and to analyse whether or not the rectal defect needs to be closed.

Kinetics of D-dimer after general surgery

D-dimers may be elevated after surgery. However, the kinetics of postoperative D-dimers remains unknown hampering the use of D-dimer testing in surgical patients with suspected venous thromboembolism. D-dimer levels were prospectively measured in 154 patients after general surgery at predefined time points (kinetics were determined in an initial cohort of 108 patients; for validation, these findings were applied to a second cohort of 46 patients). Clinical factors influencing the peak of D-dimers were analyzed using multivariate regression. Surgical operations were stratified based on severity (type I: not entering abdominal cavity; type II: intraabdominal; type III: retroperitoneal/liver surgery). D-dimer levels increased postoperatively reaching a peak on day 7. After type I surgery, peak D-dimer levels did not exceed normal range (300 ng/ml, 100–500). After type II procedures, peak D-dimer level was 1500 ng/ml (200–7800) and returned to normal values after 25 days (±14). Peak level was 4000 ng/ml (500–14 400) after type III surgery normalizing within 38 days (±11). Clearance of D-dimer was exponential after having reached the peak with 6.0% per day (95% confidence interval 4.8–7.1%). By this clearance, D-dimer values could be adequately predicted in the validation cohort after day 7 (r2 = 0.63). Peak D-dimer levels were independently influenced by the type of surgery (P < 0.001), the operation time (P < 0.001) and by preoperatively elevated D-dimer levels (P < 0.001). Based on this data, duration of postoperative D-dimer elevation after abdominal surgery is predictable. This study indicates for the first time when D-dimers may be used again in the diagnostic algorithm for venous thromboembolism exclusion after surgery in patients with low or moderate clinical probability.

Sinusectomy for primary pilonidal sinus: Less is more

BACKGROUND Wide excision with secondary wound healing is a frequently performed surgical procedure for pilonidal sinus. This intervention requires general anesthesia and has a wound healing time of up to several months with a long time to return to work. Sinusectomy of the track is an alternative operation. We here describe the long-term outcome of 257 patients operated between 2001 and 2010. METHODS Sinusectomy consisted of a selective minimal invasive excision of the sinus after marking the track with methylene blue. Data were collected retrospectively with questionnaires and telephone survey. The main endpoints of the study were recurrence and time off work. RESULTS With a median follow-up of 3.6 years, the overall recurrence rate was 7%. The median time to return to work was 7 days. The proportion of sinusectomies performed under local anesthesia increased from 59% to 93%. Consistently, the proportion of patients treated in 1-day surgery setting increased from 53% to 93%. One-day surgery had a clear impact on time to return to work in uni- and multivariate analyses (HR 1.959 {1.224, 3.137}, P = .005). CONCLUSION Sinusectomy for pilonidal sinus can be performed with a low recurrence rate. An outpatient setting, including operations under local anesthesia, allows a fast return to normal activity. Sinusectomy should become the first choice for primary non-infected symptomatic pilonidal sinus.