Surgical resection plays pivotal role in the treatment of gastric cancer. Adequate preoperative evaluation, precise intraoperative maneuver and delicate postoperative management lay the foundation for successful gastrectomy. The aim of preoperative evaluation is to stage tumor and identify potential risk factors (including preoperative factors like age, ASA status, body mass index, comorbidity, hypoalbuminemia, and intraoperative factors like blood loss and combined resection) which could lead to postoperative complication. With the management of prehabilitation, adequate medical decision could be made and patient's fast recovery could be ensured. With the rapid adoption of ERAS concept, there is increasing attention to prehabilitation which focus on optimization of cardio-pulmonary capacity and muscular-skeletal capacity. Despite of the efficacy of prehabilitation demonstrated by randomized controlled trials, consensus has yet to be reached on the following items: specific intervention, optimal measurement, candidate population and optimal timing for intervention. Balancing the efficiency and safety, preoperative evaluation could be put into clinical practice smoothly.
Humans ; Stomach Neoplasms/complications* ; Preoperative Care/adverse effects* ; Postoperative Complications/etiology* ; Gastrectomy/adverse effects* ; Risk Factors

OBJECTIVE: To investigate the safety of laparoscopic pancreaticoduodenectomy (LPD) in elderly patients and the related risk factors admitted to the intensive care unit (ICU) after LPD. METHODS: The perioperative data of patients who underwent LPD in Tianjin Medical University General Hospital from February 2017 to June 2023 were retrospectively collected, including basic data, preoperative laboratory indicators, intraoperative and postoperative indicators, pathological results (tumor size, lymph node dissection and pathological type), postoperative complications, ICU postoperative management and prognosis. The patients were divided into the elderly group (≥ 65 years) and the non-elderly group (< 65 years) according to age. Perioperative data between two groups were compared. Kaplan-Meier survival curve was drawn to analyze the survival rate of the elderly group and the non-elderly group, and the pancreatic head carcinoma group and other type of tumors group after LPD. Logistic regression was used to analyze the risk factors of ICU stay (length of ICU stay > 1 day) after LPD in elderly patients. The receiver operator characteristic curve (ROC curve) was drawn to analyze the predictive value of this risk factor for ICU stay after LPD in elderly patients. RESULTS: A total of 160 patients were enrolled, including 57 cases in the elderly group (17 cases of vascular reconstruction) and 103 cases in the non-elderly group (40 cases of vascular reconstruction). All patients underwent R0 resection and were transferred to the comprehensive ICU for treatment. The follow-up time of patients with malignant tumors was 43 (6, 72) months. The elderly group had significantly longer surgery time, postoperative hospital stay and oral feeding time than the non-elderly group, and the incidence of delayed gastric emptying (DGE) was significantly higher than that in the non-elderly group. There were no significant differences in intraoperative blood transfusion rate, intraoperative blood loss, pathological results, short-term and severe postoperative complications, reoperation rate and 90-day mortality between the two groups. In patients with vascular resection reconstruction, the intraoperative blood loss in the elderly group was significantly higher than that in the non-elderly group, and the operation time and postoperative hospital stay were significantly longer. During ICU, the acute physiology and chronic health evaluation II [APACHE II: 12 (9, 14) vs. 8 (7, 10)], sequential organ failure assessment [SOFA: 6 (4, 8) vs. 3 (2, 5)] within 24 hours after admission to ICU were significantly increased in the elderly group (both P < 0.05), the time of mechanical ventilation [hours: 12 (10, 15) vs. 9 (5, 13)] and the length of ICU stay [days: 2 (1, 2) vs. 1 (1, 1)] were significantly increased in the elderly group (both P < 0.05), and the proportion of multi-disciplinary team (MDT) was also significantly increased in the elderly group (33.3% vs. 17.4%, P < 0.05), there were no significant differences in the levels of hemoglobin (Hb), albumin, and blood lactic acid between the two groups. Logistic regression analysis showed that the APACHE II score was an independent risk factor for ICU stay after LPD in elderly patients (β = 1.737, P = 0.028). ROC curve showed that the prediction performance was the best when the APACHE II score was 13, with the sensitivity of 72.41% and the specificity of 96.43%, and the area under the ROC curve (AUC) of 0.884. The Kaplan-Meier survival curve showed that there were no significant difference in median survival time (months: 24.1 vs. 24.7) and 5-year survival rate (19.01% vs. 19.02%) between the elderly group (52 cases) and the non-elderly group (92 cases) among the 144 patients with malignant tumors (both P > 0.05). The median survival time in the pancreatic head carcinoma group was significantly shorter than that in the other tumors group (63 cases; months: 20.2 vs. 40.1, P < 0.05), 5-year survival rate was significantly lower than that in the other tumors group (21.98% vs. 30.91%, P < 0.05). CONCLUSIONS LPD is a safe and feasible treatment for elderly patients. APACHE II score has a certain predictive value for ICU stay after LPD in elderly patients.
Humans ; Aged ; Middle Aged ; Sepsis/therapy* ; ROC Curve ; Pancreaticoduodenectomy/adverse effects* ; Retrospective Studies ; Blood Loss, Surgical ; Prognosis ; Pancreatic Neoplasms/surgery* ; Postoperative Complications ; Intensive Care Units

OBJECTIVE: To find the pathogenies and risk factors related to surgical intensive care unit (SICU) readmission for patients who underwent hepatobiliary-pancreatic surgery, and to develop a predictive model for determining patients who are likely to be readmitted to SICU. METHODS: The patients who admitted to SICU of the Affiliated Hospital of Qingdao University from January 2013 to August 2018; who first stayed in SICU after hepatobiliary-pancreatic surgery; who were assessed and discharged from SICU by surgeons and SICU physicians after treatment, and then transferred to SICU again because of the change of their condition were enrolled. The unintended return to SICU within 3 days and 7 days were recorded. Patients who returned to SICU within 7 days were studied for the pathogenies, risk factors and predictive model of returning to SICU, and non-returning patients were enrolled according to 1:1 as the controls. A total of 43 indicators were divided into five categories, including general clinical data, medical history, surgical indicators before first admission of SICU, length of first SICU stay, and other indicators on the day of first discharge from the SICU. Logistic regression was used to screen the risk factors associated with SICU readmission, then the Nomogram diagram was drawn by using the R 3.4.1 software for predicting SICU readmission, and the classification performance of Nomogram was evaluated by self-help sampling test. RESULTS: Of the 763 patients discharged from the SICU, 2.10% (16/763) of them were readmitted within 3 days and 3.28% (25/763) were readmitted within 7 days to the SICU unexpectedly. The pathogenies of SICU readmission within 7 days included infection [56.00% (14/25)], heart failure [16.00% (4/25)], infarction [12.00% (3/25)], bleeding [12.00% (3/25)], and sutures splitting [4.00% (1/25)]. The pathogenies of SICU readmission within 3 days included infection [56.25% (9/16)], heart failure [18.75% (3/16)], infarction [12.50% (2/16)], and bleeding [12.50% (2/16)]. Nomogram analysis showed that the risk factors associated with unplanned SICU readmission were length of first SICU stay, history of hypertension, and activity of daily living (ADL) score, white blood cell count (WBC), arterial partial pressure of oxygen (PaO₂), prothrombin time (PT), fibrinogen (FIB) on the day of first SICU discharge. Self-help sampling test was carried out on the Nomogram map, and the results showed that the coherence index (C-index) was 0.962 [95% confidence interval (95%CI) = 0.869-1.057]. The classification performance of the model was good. CONCLUSIONS The common pathogenies of SICU readmission for patients who underwent hepatobiliary-pancreatic surgery were infection, heart failure, infarction and bleeding. Risk factors of readmission after SICU discharge included the length of first SICU stay, history of hypertension, and ADL score, WBC, PaO₂, PT, FIB on the day of first SICU discharge. The model consisted of above risk factors showed a good performance in predicting the probability of readmission after SICU discharge for patients who underwent hepatobiliary-pancreatic surgery.
Biliary Tract Diseases/surgery* ; Digestive System Surgical Procedures/adverse effects* ; Humans ; Intensive Care Units ; Liver Diseases/surgery* ; Models, Statistical ; Pancreatic Diseases/surgery* ; Patient Readmission/statistics & numerical data* ; Postoperative Complications/therapy* ; Risk Factors

Mahuang Fuzi Xixin Decoction recorded in Treatise on Febrile Diseases by Zhang Zhongjing in the Han Dynasty have been widely used in treating Yang deficiency and exogenous wind-cold syndrome by traditional Chinese medicine physicians for thousands of years. The indications of Mahuang Fuzi Xixin Decoction include bradyarrhythmia,sinus bradycardia,sick sinus node syndrome,senile exogenous,asthmatic cold,rhinitis,bronchial asthma,optic neuritis,optic atrophy,sudden blindness,sudden onset of cough,laryngeal obstruction,migraine,joint pain,low back pain,insomnia,shock,heart failure,renal failure,accompanied by fever or nosocomial infection,and hyperpyrexia after tracheotomy; dark complexion,chills,cold limbs,listlessness,fatigue,insomnia,lack of thirst,liking hot drinks,slightly swollen limbs or whole body,pale fat tongue,greasy fur,and deep pulse. Mahuang Fuzi Xixin Decoction is a potential drug for Shaoyin disease complicated with fever and pain. Tracheal intubation is an artificial ephedrine syndrome. It is necessary to distinguish Yin and Yang syndrome in treating hyperpyrexia after tracheotomy. However,it belongs to Yin syndrome,which could be treated by Mahuang Fuzi Xixin Decoction. Mahuang Fuzi Xixin Decoction is effective in the treatment of sick sinus syndrome,second degree atrioventricular block and third degree atrioventricular block. It can significantly alleviate symptoms,improve heart rate,and heart rhythm in a short period of time. However,after one year of drug withdrawal,the diseases may recur,indicating that Mahuang Fuzi Xixin Decoction may not improve the long-term prognosis of slow arrhythmia. Mahuang Fuzi Xixin Decoction is often used for fever or nosocomial infection in critical care medicine. In the treatment of critical care medicine complicated with high fever,Mahuang Fuzi Xixin Decoction is often taken continuously by stomach tube.
Critical Care ; Cross Infection/drug therapy* ; Diabetes Mellitus ; Diabetic Neuropathies/complications* ; Drugs, Chinese Herbal/pharmacology* ; Fever/drug therapy* ; Humans ; Medicine, Chinese Traditional ; Myocardial Infarction/complications* ; Pain, Postoperative/drug therapy* ; Phytotherapy ; Syndrome ; Tracheotomy/adverse effects*

PURPOSETo investigate the early and mid-term results of open reduction and internal fixation (ORIF) with transarticular external fixation (TEF) but no deltoid ligament repair (DLR) in the treatment of supination-external rotation type IV equivalent (SER IV E) ankle fractures (AO/OTA classification 44-B 3.1) and provide evidence for clinical practice.

METHODSThis study cohort consisted of 22 patients with SER IV E ankle fractures that underwent ORIF with TEF but no DLR between December 2011 and December 2014. There were 13 males and 9 females, mean age 38.9 years (range, 17-73 years). Eight cases involved the left side and 14 the right side. The causes of fractures included road traffic accidents (11 cases), falling from height (6 cases) and sports injuries (5 cases). The mean period of hospitalization was 9.8 days (range, 6-14 days). For all the patients, MRI and three-dimensional CT were done before surgery and X-rays done preoperatively and during follow-ups. The external frame was kept for 8-10 weeks. The preoperative American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was 56.86 ± 4.400, the Medical Outcomes Short Form 36-item (SF-36) questionnaire score was 57.41 ± 4.102 and the visual analog score (VAS) was 5.50 ± 1.058. Patients' main complaints about inconvenience of daily life were also recorded.

RESULTSAll the 22 patients were followed up for 24-63 months (mean, 33.6 months). None of them developed nonunion during the follow-up; pin site infection was observed in one patient and posttraumatic osteoarthritis in another. At the final follow-up, the average AOFAS score, SF-36 score and VAS score were respectively 90.59 ± 5.096, 79.59 ± 5.394 and 1.82 ± 1.181, which were significantly improved compared with the preoperative data (t = 26.221, p < 0.001; t = 11.910, p < 0.001; t = 11.571, p < 0.001). The therapeutic effect was excellent in 13 cases, good in 7 cases and fair in 2 cases, with a good-excellent rate of 90.9%. Patients' main complaints were inconvenience of clothing (17 cases) and extremity cleaning (5 cases).

CONCLUSIONIn the treatment of SER IV E ankle fractures, ORIF with TEF but no DLR can achieve satisfactory outcome, but long-term effect should be confirmed by large sample randomized controlled trials.

Adolescent ; Adult ; Aged ; Ankle Fractures ; surgery ; Female ; Fracture Fixation ; adverse effects ; methods ; Humans ; Ligaments, Articular ; surgery ; Male ; Middle Aged ; Open Fracture Reduction ; methods ; Postoperative Care ; Retrospective Studies ; Rotation ; Supination ; Young Adult

INTRODUCTIONKnowing how patients value the quality of anaesthesia helps anaesthesiologists to customise their service. However, generalising findings from Western population-based willingness-to-pay studies across different cultures and societies might result in the oversight of some contextualised perspectives of the anaesthesia experience. This study aimed to capture the Singapore perspective of undesired post-anaesthesia outcomes.

METHODS132 patients recruited in a pre-anaesthetic evaluation clinic were given questionnaires describing ten possible post-anaesthetic outcomes. Outcomes were ranked for undesirability and assigned relative value through the hypothetical proportioning of SGD 100 to avoid their occurrence. Data was analysed with reference to patients' background and anaesthetic history.

RESULTSA response rate of 69.1% (n = 132/191) was achieved. Outcomes from the most to least undesirable were pain; vomiting; nausea; shivering; orodental trauma; sore throat; abrasions; somnolence; and thirst. Relative values allocated, in descending order, were pain; vomiting; nausea; orodental trauma; abrasions; sore throat; shivering; somnolence; and thirst.

CONCLUSIONSimilar to previous studies in Western populations, pain, vomiting and nausea were the top three adverse outcomes that Singapore patients wished to avoid. However, discrepancies with Western patients were seen in spending attitudes, possibly accounted for by differences in healthcare socioeconomics. This study provided a better understanding of Singapore patients' perspectives on post-anaesthesia adverse outcomes and could help to improve treatment strategy and resource management.

Adult ; Aged ; Aged, 80 and over ; Anesthesia ; adverse effects ; Anesthesiology ; methods ; Anesthetics ; Attitude to Health ; Female ; Health Care Costs ; Humans ; Language ; Male ; Middle Aged ; Pain ; etiology ; Postoperative Nausea and Vomiting ; Postoperative Period ; Singapore ; Surveys and Questionnaires ; Treatment Outcome ; Young Adult

Enteral Nutrition ; instrumentation ; methods ; Female ; Fluoroscopy ; methods ; Gastrostomy ; adverse effects ; instrumentation ; methods ; Humans ; Male ; Middle Aged ; Outcome and Process Assessment (Health Care) ; Postoperative Complications ; classification ; diagnosis ; therapy ; Reproducibility of Results ; Retrospective Studies ; Singapore ; Surgery, Computer-Assisted ; methods ; Treatment Outcome

With the development of laparoscopic techniques and equipments, laparoscopic-assisted, even total laparoscopic radical surgery for gastric cancer can be performed successfully. However, the incidence of postoperative complications is higher in the laparoscopy group as compared to the open-surgery group, which is still the barrier for the total laparoscopic radical gastrectomy. Similar to open surgery, the major complications of digestive tract reconstruction after laparoscopic radical gastrectomy are anastomotic leakage, anastomotic bleeding, anastomotic stricture and stenosis of input or output loop. Moreover, due to the lack of tactile feedback and a narrow field of vision, the laparoscopic operation may be associated with complications due to technical reasons. In clinic, we tried to reduce the incidence of these complications by improving surgical skills and strengthening the perioperative treatment of patients. According to our experience, the complications mainly occur in the early stage, and with the cumulative experience, the complications can be effectively reduced.
Anastomotic Leak ; prevention & control ; therapy ; Constriction, Pathologic ; prevention & control ; therapy ; Education, Medical, Continuing ; Gastrectomy ; adverse effects ; methods ; Gastrointestinal Hemorrhage ; prevention & control ; therapy ; Humans ; Laparoscopy ; adverse effects ; Perioperative Care ; Postoperative Complications ; prevention & control ; therapy ; Postoperative Hemorrhage ; prevention & control ; therapy ; Reconstructive Surgical Procedures ; adverse effects ; Stomach Neoplasms ; surgery

The anastomotic complications following radical gastrectomy mainly include anastomotic leakage, anastomotic hemorrhage, and anastomotic stricture. Theanastomotic complications are not rare and remain the most common complications resulting in the perioperativedeath of patients with gastric cancer. Standardized training could let surgeons fully realize that strict selection of operative indications, thorough preoperative assessment and preparation, and refined operation in surgery are the essential measures to prevent the anastomotic complications following radical gastrectomy. In addition, identifying these complications timely and taking effective measures promptly according to the clinical context are the keys to treating these complications, reducing the treatment cycle, and decreasing the mortality.
Anastomosis, Surgical ; adverse effects ; Anastomotic Leak ; prevention & control ; therapy ; Constriction, Pathologic ; prevention & control ; therapy ; Gastrectomy ; adverse effects ; methods ; Gastrointestinal Hemorrhage ; prevention & control ; therapy ; Humans ; Postoperative Complications ; diagnosis ; therapy ; Preoperative Care ; methods ; standards ; Risk Assessment ; methods ; standards ; Risk Factors ; Stomach Neoplasms ; complications ; mortality ; surgery

Postoperative complications are important outcome measurements for surgical quality and safety control. However, the complication registration has always been problematic due to the lack of definition consensus and the other practical difficulties. This narrative review summarizes the data registry system for single institutional registry, national data registry, international multi-center trial registries in the western world, aiming to share the experience of complication classification and data registration. We interviewed Dr. Koh from Royal Prince Alfred Hospital in Australia for single institutional experience, Dr. van der Wielen and Dr. Desideriofor, from two international multi-center trial(STOMACH) and registry (IMIGASTRIC) respectively, and Prof. Dr. Wijnhoven from the Dutch Upper GI Audit(DUCA). The major questions include which complications are obligated to report in the respective registry, what are the definitions of those complications, who perform the registration, and how are the complications evaluated or classified. Four telephone conferences were initiated to discuss the above-mentioned topics. The DUCA and IMGASTRIC provided the definition of the major complications. The consent definition provided by DUCA was based on the LOW classification which came out after a four-year discussion and consensus meeting among international experts in the according field. However, none of the four registries asked for an obligatory standardization of the diagnostic criteria among the participating centers or surgeons. Instead, all the registries required a detailed recording of the diagnostic strategy and classification of the complications with the Clavien-Dindo scoring system. Most data were registered by surgeons or data managers during or immediately after the hospitalization. The investigators or an independent third party conducted the auditing of the data quality. Standardization of complication diagnosis among different centers is a difficult task, consuming much effort and time. On top of that, standardization of the complication registration is of critical and practical importance. We encourage all centers to register complications with the diagnostic criteria and following intervention. Based on this, the Clavien-Dindo classification can be properly justified, which has been widely accepted by most centers and should be routinely used as the standard evaluation system for postoperative complications in gastric tumor surgery.
Australia ; epidemiology ; Data Collection ; standards ; statistics & numerical data ; Diagnostic Techniques and Procedures ; standards ; statistics & numerical data ; Digestive System Surgical Procedures ; adverse effects ; statistics & numerical data ; Health Care Surveys ; Humans ; Netherlands ; epidemiology ; Postoperative Complications ; classification ; diagnosis ; epidemiology ; Registries ; standards ; Risk Assessment ; methods ; standards ; Stomach Neoplasms ; complications ; surgery