Edward H. Chin

Risk Factors for Anastomotic Leak Following Colorectal Surgery: A Case-Control Study

OBJECTIVE To assess anastomotic leak (AL) risk factors in a large patient series. DESIGN Case-control study. SETTING The Mount Sinai Hospital. PATIENTS Ninety patients with AL following colorectal resection and 180 patients who underwent uncomplicated procedures. MAIN OUTCOME MEASURES Risk factors associated with development of AL. RESULTS The AL rate was 2.6%. Five risk factors for AL were identified: (1) preoperative albumin level lower than 3.5 g/dL (odds ratio [OR] 2.8; 95% confidence interval [CI], 1.3-5.1) (P = .03); (2) operative time of 200 minutes or longer (OR, 3.4; 95% CI, 2.0-5.8) (P = .01); (3) intraoperative blood loss of 200 mL or more (OR, 3.1; 95% CI, 1.9-5.3) (P = .01); (4) intraoperative transfusion requirement (OR, 2.3; 95% CI, 1.2-4.5) (P = .02); and (5) histologic specimen margin involvement in disease process in patients with inflammatory bowel disease (IBD) (OR, 2.9; 95% CI, 1.4-6.1) (P = .01). Patients with all 3 intraoperative risk factors had an OR of 22.1; 95% CI, 2.8-175.4 (P < .001) for development of AL. CONCLUSIONS Histologic resection margin involvement in disease process in patients with IBD, preoperative albumin levels lower than 3.5 g/dL, intraoperative blood loss of 200 mL or more, operative time of 200 minutes or more, and/or intraoperative transfusion requirement increased AL risk. Enteral nutritional optimization prior to elective surgery is essential. Proximal diversion should be considered for patients with all 3 intraoperative risk factors because they are at high risk for AL.

Factors That Predict Outcome of Abdominal Operations in Patients With Advanced Cirrhosis

BACKGROUND & AIMS Patients with cirrhosis have an increased risk of complications during surgery that is relative to the severity of liver disease; it is a challenge to determine which patients are the best candidates for surgery. We performed a hospital-based study to identify factors that might facilitate selection of operative candidates and guide their management. METHODS A retrospective review was performed of 100 cirrhotic patients (50 classified as Child-Turcotte-Pugh [CTP] A, 33 as CTP B, and 17 as CTP C) who underwent abdominal surgery at an institution specializing in liver medicine and transplant from 2002-2008. Significant univariate variables were evaluated by multivariate logistic regression models to identify factors that correlate with outcome. RESULTS The overall, 30-day postoperative mortality rate was 7%. The mortality for patients who were CTP A was 2%, CTP B was 12%, and CTP C was 12%; 33 patients had a Model for End-Stage Liver Disease (MELD) score >or=15, with 29% mortality. On the basis of multivariate analyses, risk factors for adverse outcome were American Society of Anesthesiologists (ASA) score >3; procedures being emergent; intraoperative blood transfusion; intraoperative blood loss >150 mL; presence of ascites; total bilirubin level >1.5 mg/dL; and albumin level <3 mg/dL. Addition of serum albumin to MELD score showed that patients with MELD score >or=15 and albumin <or=2.5 mg/dL (vs >2.5 mg/dL) had significantly increased mortality (60% vs 14%, P < .01) and independently increased probability of adverse outcome (odds ratio, 8.4; P = .015). CONCLUSIONS For patients with MELD scores >or=15, the preoperative albumin level correlates with outcome and could guide operative decisions. Intraoperative packed red blood cell transfusion correlates with adverse outcome and should be limited.

Laparoscopic donor nephrectomy

BackgroundSeveral large series of laparoscopic donor nephrectomy (LDN) have been published, largely focusing on immediate results and short-term complications. The aim of this study was to examine the results of LDN and collect medium-term and long-term donor followup.MethodsWe examined the results of two surgeons who performed 500 consecutive LDNs from 1996 to 2005. Prospective databases were reviewed for both donors and recipients to record demographics, medical history, intraoperative events, and complications. Patients were followed between 1 month and 9 years after surgery to assess for delayed complications, especially hypertension, renal insufficiency, incisional hernia, bowel obstruction, and chronic pain.ResultsLeft kidneys were procured in 86.2% of cases. Mean operative time was 3.5 h, and warm ischemia time averaged 3.4 min. Hand-assistance was used in 13.8%, and conversion rate was 1.8%. Intraoperative complication rate was 5.8% and was predominantly bleeding (93.1%). Most (86.2%) of the operative complications occurred during the initial 150 cases of a surgeon, compared with 10.3% in the subsequent 150 cases (p = 0.003). Operative time decreased by 87 min after the initial 150 cases (p < 0.001). Immediate graft survival was 97.5%. Delayed graft function occurred in 3.0% of recipients, and acute tubular necrosis occurred in 7.0%. Thirty-day donor complication rate was 9.8%. Mean donor creatinine was 1.24 on the first postoperative day, 1.27 at 2 weeks, and 1.24 at 1 year. At a mean followup of 32.8 months, long-term donor complications consisted of 11 cases of hypertension, 9 cases of prolonged pain or paresthesia, 2 incisional hernias, 1 small bowel obstruction requiring laparoscopic lysis of adhesions, and 1 hydrocele requiring repair.ConclusionsLDN can be performed with acceptable immediate morbidity and excellent graft function. Operative time and complications decreased significantly after a surgeon performed 150 cases. Long-term complications were uncommon but included a likely underestimated incidence of hypertension.

The First Decade of a Laparoscopic Donor Nephrectomy Program: Effect of Surgeon and Institution Experience with 512 Cases from 1996 to 2006

BACKGROUND Although the procedure is generally safe, significant morbidity and even mortality have occurred after laparoscopic donor nephrectomy (LDN). The learning curves for both surgeons and institutions with LDN have not been well delineated, and longterm donor data are not well reported. STUDY DESIGN A retrospective study of the initial 512 patients undergoing LDN performed at Mount Sinai Medical Center between October 1996 and March 2006 was performed. Intraoperative and immediate postoperative surgical outcomes were reviewed. Univariate analysis and multivariate logistic regressions were performed to identify predictors of outcomes, including the experience level of individual surgeons and of the institution. Longitudinal followup data of donor patients between 1 month and 9 years were obtained. RESULTS Mean donor age was 39.2 years, and 54.6% of patients were women. Left kidneys were procured in 84.0%. Operative time averaged 215.2 minutes, and warm ischemia time, 166.6 seconds. The conversion rate was 1.4%, and hand-assistance was used in 49.9%. The intraoperative complication rate was 5.5%, 30-day complication rate 9.4%, and 1.4% of patients required reoperation. Immediate graft survival was 97.1%, acute tubular necrosis occurred in 8.5%, and delayed graft function in 3.7%. At a mean followup of 37.2 months, delayed donor complications were infrequent, but included chronic pain, hypertension, incisional hernia, and small bowel obstruction. Although individual surgeons and our institution gained experience, operative and warm ischemia times decreased significantly, but complication rates were unchanged. CONCLUSIONS Although a learning curve was discovered for operative time and warm ischemia time, excellent results can be achieved during the early experience of both surgeons and institutions with LDN, and maintained over time. Younger, female, and nonobese donors were associated with fewer complications. Longterm donor morbidity is uncommon, but mandates better followup.

Safety of Outpatient Laparoscopic Cholecystectomy in the Elderly: Analysis of 15,248 Patients Using the NSQIP Database

BACKGROUND Studies have shown that laparoscopic cholecystectomy (LC) in an ambulatory setting is a safe alternative to the traditional overnight hospital stay. However, there are limited data on the morbidity and mortality of outpatient LC in elderly patients. We evaluated the safety of ambulatory LC in the elderly and identified risk factors that predict inpatient admission. STUDY DESIGN A retrospective analysis was performed using the American College of Surgeons NSQIP database between 2007 and 2010. The database was searched for patients older than 65 years of age who underwent elective LC at all participating hospitals in the United States. Data from 15,248 patients were collected and we compared patients who underwent ambulatory procedures with those patients who were admitted for an inpatient stay. RESULTS Seven thousand four hundred and ninety-nine (48.9%) patients were ambulatory and 7,799 (51.1%) were nonambulatory. Postoperative complications included mortality (0.2% vs 1.5%; p < 0.001), stroke (0.1% vs 0.3%; p < 0.001), myocardial infarction (0.1% vs 0.6%; p < 0.001), pulmonary embolism (0.1% vs 0.3%; p = 0.005), and sepsis (0.2% vs 0.7%; p < 0.001) for ambulatory and nonambulatory cases, respectively. We identified significant independent predictors of inpatient admission and mortality, including congestive heart failure, American Society of Anesthesiologists class 4, bleeding disorder, and renal failure requiring dialysis. CONCLUSIONS We believe ambulatory LCs are safe in elderly patients as demonstrated by low complication rates. We identified multiple risk factors that might warrant inpatient hospital admission.

Comparison of iatrogenic splenectomy during open and laparoscopic colon resection.

Iatrogenic splenic injury requiring splenectomy is a well-recognized and potentially serious complication of colon resection. Iatrogenic splenectomy is associated with significant morbidity and mortality, including bleeding and the postsplenectomy sepsis syndrome. Our study aims to compare the incidence of iatrogenic splenectomy in laparoscopic colon resection with that of open colon resection over an 11-year-period at Mount Sinai. A retrospective chart review of all patients undergoing colon resection at Mount Sinai Medical Center during the last 11 years was performed to identify patient demographics, procedure, indication, and outcome. There was a significant difference (P=0.03) in the incidence of iatrogenic splenectomy during open colectomy (13/5477, 0.24%) versus laparoscopic colectomy (0/1911, 0%). All cases complicated by iatrogenic splenectomy involved splenic flexure mobilization. Laparoscopy has many recognized advantages over open procedures, including shorter recovery and length of stay. This retrospective review of our experience at Mount Sinai presents another potential benefit of the laparoscopic approach to colon resection.

Laparoendoscopic single site (LESS) splenectomy with a conventional laparoscope and instruments.

LESS splenectomy appears to be a feasible procedure that can be performed safely and may have higher patient satisfaction that conventional laparoscopic splenectomy.

Laparoscopic-Assisted Transversus Abdominis Plane Block for Postoperative Pain Control in Laparoscopic Ventral Hernia Repair: A Randomized Controlled Trial

BACKGROUND Laparoscopic ventral hernia repair (LVHR) is associated with considerable postoperative pain. Transversus abdominis plane (TAP) blocks have proven effective in controlling postoperative pain in a variety of laparoscopic abdominal operations. To date, no studies have focused on TAP blocks in LVHR. Our goal was to assess whether TAP blocks reduce opioid requirements and pain scores after LVHR. STUDY DESIGN Patients undergoing LVHR were randomly assigned to receive a TAP block or placebo injection. The primary end points were cumulative opioid use at 1, 3, 6, 12, 18, and 24 hours postoperatively and pain scores recorded at 1 and 24 hours postoperatively. RESULTS Patients in the experimental TAP group (n = 52) and control group (n = 48) were comparable with respect to patient demographics and clinical characteristics. In the postanesthesia care unit, the TAP group had significantly lower pain scores than the control group (p < 0.05). Patients in the TAP group used less opioids than the control group at each time point assessed after 6 hours postoperatively (p < 0.05). There was no significant difference in pain scores at 24 hours postoperatively (p > 0.05). CONCLUSIONS Transversus abdominis plane blocks given during LVHR significantly decrease both short-term postoperative opioid use and pain experienced by patients.

Diagnosis of gastrointestinal anastomotic dehiscence after hospital discharge: Impact on patient management and outcome

BACKGROUND Anastomotic leaks are inevitable complications of gastrointestinal surgery. Early hospital discharge protocols have increased concern regarding outpatient presentation with anastomotic leaks. METHODS One hundred anastomotic leaks in 5,387 intestinal operations performed at a single institution from 2002 to 2007 were identified from a prospectively maintained database. Statistical analysis was conducted by the unpaired t test, Chi-square test, and analysis of variance. RESULTS Overall anastomotic leak with a rate of 2.6% for colonic and 0.53% for small bowel anastomoses. Mean time to anastomotic leak diagnosis was 7 days after operation. Twenty-six patients presented after discharge, with mean time to diagnosis 12 days versus 6 days for inpatients (P<.05). Patients presenting after hospital discharge were younger, had lesser American Society of Anesthesiologists (ASA) scores, and were more likely to have colon cancer and less likely to have Crohns disease. Ninety-two patients required operative management, of whom 81 (90%) underwent diversion. No difference in management, intensive care unit (ICU) requirement, duration of stay, or mortality between inpatient versus outpatient diagnosis was demonstrated. Follow-up at mean of 36 months demonstrated no difference in readmission, reoperation, or mortality rate between outpatient and inpatient diagnosis. Restoration of gastrointestinal continuity was achieved in 61-67% in the outpatient and 59% in the inpatient group (P=NS). CONCLUSION Outpatient presentation delays diagnosis but does not alter management or clinical outcome, or decrease the probability of ostomy reversal. Prolonging hospital stay to capture patients who develop anastomotic leak seems to be unwarranted. For patients requiring operative management, we recommend diversion as the safest option with a subsequent 61% reversal rate.

Laparoscopic retrieval of intraabdominal foreign bodies

The use of laparoscopy has been described as the means of removing intraabdominal foreign bodies, both intraperitoneal and intraluminal, from the stomach or bowel. An early report detailed the laparoscopic removal of translocated intrauterine devices from the peritoneal cavity [2]. Laparoscopic removal of a retained surgical sponge also has been reported [1]. For large ingested objects that cannot be retrieved by flexible endoscopy, laparoscopic gastrotomy and foreign body removal have been described [3] . The authors recently had three cases of laparoscopic foreign body retrieval. The first case involved a young man who had ingested latex gloves, causing gastrointestinal bleeding. Endoscopic retrieval was unsuccessful. A laparoscopic gastrotomy was performed, with the retrieval of four gloves, followed by intracorporeal, sutured closure of the gastrotomy. The second case involved the laparoscopic removal of a Penrose drain around the distal esophagus. The patient had initially undergone a laparoscopic Nissen fundoplication, vagotomy, and gastrojejunostomy for the management of reflux and a duodenal stricture. He had persistent dysphagia after surgery, prompting takedown of the fundoplication several months later. When his dysphagia did not improve, a retained Penrose drain that had been placed around the distal esophagus at the initial operation was discovered on computed tomography. This was removed laparoscopically. At this writing, 18 months after the initial operation, the patient has complete resolution of dysphagia. The third case involved a duodenojejunal fistula caused by multiple ingested magnets that had eroded through the bowel wall. The fistula was divided laparoscopically, and 16 disk-shaped magnets were removed. The duodenum and jejunum were repaired with laparoscopic suturing and stapling. All three patients did well after surgery. Laparoscopy can be an excellent method for abdominal foreign body retrieval.