Murad A. Jabir

Using Modified Frailty Index to Predict Safe Discharge Within 48 Hours of Ileostomy Closure

BACKGROUND: Enhanced recovery pathways allow for safe discharge and optimal outcomes within 48 hours after ileostomy closure. Unfortunately, some patients undergoing ileostomy closure have prolonged hospital stays. We have shown previously that the Modified Frailty Index can help predict patients who will fail early discharge after laparoscopic colorectal surgery. OBJECTIVE: The purpose of this study was to use the Modified Frailty Index to identify patients who were safe for early discharge after ileostomy closure. DESIGN: This was a retrospective review. SETTINGS: The study was conducted at a tertiary referral center. PATIENTS: Patients who underwent ileostomy closure (2006–2015) were stratified into early (⩽48 hours) and late discharge groups. MAIN OUTCOME MEASURES: The Modified Frailty Index, morbidity, and readmission rates were measured. RESULTS: A total of 272 patients undergoing ileostomy closure were evaluated. Overall length of stay was 3.64 days (±3.23 days), with 114 patients (42%) discharged within 48 hours. Sex, age, and ASA scores were similar between early and later discharge groups (p > 0.2). Univariate logistic regression demonstrated that a Modified Frailty Index score of 0 was associated with early discharge (p = 0.03), whereas a Modified Frailty Index score ⩽1 and ⩽2 were not. There was no significant association between the Modified Frailty Index and complication or readmission rates. Postoperative complications occurred in 39 patients (14.3%), and 1 patient died secondary to an anastomotic leak. Fifteen patients (5.5%) were readmitted within 30 days. Readmission rate within 30 days was 3.2%, with a Modified Frailty Index score of 0, 6.1% for a Modified Frailty Index score of <1, and 5.9% for a Modified Frailty Index score of <2, for which there was not an association based on univariate logistic regression (Modified Frailty Index = 0, p = 0.13; <1, p = 0.55; <2, p = 0.53). LIMITATIONS: The study was limited by nature of being a retrospective review. CONCLUSIONS: Patients undergoing ileostomy closure with a Modified Frailty Index score of 0 are associated with higher rates of discharge within 48 hours of ileostomy closure surgery than those with a higher Modified Frailty Index, without higher readmission rates. This information can be helpful to better manage patient and resource use expectations for the duration of inpatient recovery.

Laparoscopy Assisted Distal Gastrectomy for Cancer at a Tertiary Center in Egypt. Is It Safe and Feasible

Background: Laparoscopic radical gastrectomy for cancer has significant short- and long-term advantages. The feasibility and safety of laparoscopicdistal gastrectomy for cancer (LADG) is unclear in low to middle income countries as resources are limited. Therefore, the aim of this study was to evaluate the safety and feasibility of (LADG) in low to middle income countries; Egypt as an example. Methods: Thirty four Patients with stage I-II cancer at the pylorus and antrum have been enrolled for LADG between 2012 and 2015 with the reuse of single use vascular sealing device has been evaluated. Results: Finally 27 patients had been included in the study and successful LADG has been done for all selected cases. The average operative time was 151 ± 10 minutes. The average estimated blood loss was 73.3 ± 13 ml. No intra-operative complications have been recorded. The average time for post-operative patient ambulation was 9 hours (SD ± 1.8) and for oral fluid intake was 3.5 SD ± 1 days. The average duration of the hospital stay was 9.3 ± 1.2 days. The average number of retrieved lymph nodes was 21.7 ± 3.8 days. All the cases had free surgical margin. The median number of reuse of the vascular sealing device was 3.8 times (3 - 5 times). Conclusion: Laparoscopic distal gastrectomy for cancer could be safe and feasible in developing countries and give similar results for that of developed countries. Safe reuse of single use expensive parts of some instruments for laparoscopy could help in utilization of these advanced surgeries in low to middle income countries. Long term follow up as well as comparative studies with open surgery are required.

Hepatocyte growth factor, hepatocyte growth factor activator and arginine in a rat fulminant colitis model

Introduction Dextran sodium sulfate (DSS) is commonly used to induce a murine fulminant colitis model. Hepatocyte growth factor (HGF) has been shown to decrease the symptoms of inflammatory bowel disease (IBD) but the effect of its activator, HGFA, is not well characterized. Arginine reduces effects of oxidative stress but its effect on IBD is not well known. The primary aim is to determine whether HGF and HGFA, or arginine will decrease IBD symptoms such as pain and diarrhea in a DSS-induced fulminant colitis murine model. Methods A severe colitis was induced in young, male Fischer 344 rats with 4% (w/v) DSS oral solution for seven days; rats were sacrificed on day 10. Rats were divided into five groups of 8 animals: control, HGF (700 mcg/kg/dose), HGF and HGFA (10 mcg/dose), HGF and arginine, and high dose HGF (2800 mcg/kg/dose). Main clinical outcomes were pain, diarrhea and weight loss. Blinded pathologists scored the terminal ileum and distal colon. Results DSS reliably induced severe active colitis in 90% of animals (n = 36/40). There were no differences in injury scores between control and treatment animals. HGF led to 1.38 fewer days in pain (p = 0.036), while arginine led to 1.88 fewer days of diarrhea (P = 0.017) compared to controls. 88% of HGFA-treated rats started regaining weight (P < 0.001). Discussion/Conclusion Although treatment was unable to reverse fulminant disease, HGF and arginine were associated with decreased days of pain and diarrhea. These clinical interventions may reduce associated symptoms for severe IBD patients, even when urgent surgical intervention remains the only viable option.