Is Primary Anastomosis Safe in the Surgical Management of Complications of Acute Diverticulitis?

2007 ◽  
Vol 73 (8) ◽  
pp. 787-791 ◽  
Author(s):  
Michael J. Stumpf ◽  
Fausto Y. Vinces ◽  
Joseph Edwards
Keyword(s):  
Surgical Management ◽  
Primary Anastomosis ◽  
Acute Diverticulitis ◽  
Statistical Significance ◽  
Low Risk ◽  
Apache Ii Score ◽  
Past Century ◽  
Management Of Complications ◽  
Diseased Segment ◽  
Risk Patients

The purpose of this article is to determine whether primary anastomosis is a safe option in the surgical management of complications of acute diverticulitis in low-risk patients. Over the past century, the management of diverticulitis has evolved from a three-stage procedure to resection and primary anastomosis. In the beginning of the century, Mayo described drainage and proximal colostomy, a three-stage procedure. This was done by performing a diverting colostomy but leaving the diseased segment of colon, hoping that the inflammation would subside. Later, the patient went back for resection of the diseased segment. Then a third procedure was performed for reversal of the colostomy. Around the late 1970s to early 1980s, it was found that patients had better outcomes if the diseased segment was resected during the first operation–the Hartman procedure. During the late 1990s to early 2000s, some surgeons began performing resection and primary anastomosis in selected groups of patients with diverticulitis. There have been a number of studies published showing that resection and primary anastomosis has an acceptable morbidity and mortality. However, most of these studies are retrospective and do not achieve statistical significance. They also do not attempt to establish guidelines to help decide which patients are good candidates for resection and primary anastomosis. The goal of this study is to establish safe and reasonable practice guidelines that can be applied to a selected group of (low-risk) patients. This study is a retrospective review of all the patients treated surgically for complications of acute diverticulitis from 1998 to 2003 at United Hospital Medical Center in Port Chester, New York. Patients were classified as high or low risk based on their age, APACHE II score, American Society of Anesthesiologists class, and Hinchey score. There were a total of 66 patients operated on for complications of acute diverticulitis (left-sided) over this 5-year period. Thirty-six of them underwent resection and primary anastomosis and 30 underwent the Hartman procedure. Of the 36 who underwent resection and primary anastomosis, 19 were considered low risk. There were no complications in this low-risk group who underwent primary anastomosis. Patients who were low risk based on the mentioned criteria can safely undergo resection and primary anastomosis.

scholarly journals Determining the molecular landscape and impact on prognosis in HPV-associated head and neck cancer

2020 ◽  
Vol 5 (1) ◽  
Author(s):  
Suchin Khanna ◽  
Sarah Palackdharry ◽  
Logan Roof ◽  
Christina A. Wicker ◽  
Jonathan Mark ◽  
...  
Keyword(s):  
Gene Expression ◽  
Head And Neck ◽  
Statistical Significance ◽  
Treatment Strategies ◽  
Primary Treatment ◽  
Low Risk ◽  
The Cancer Genome Atlas ◽  
Significant Heterogeneity ◽  
Protein Activity ◽  
Risk Patients

Abstract Background Human papillomavirus (HPV) associated head and neck squamous cell carcinoma (HNSCC) has a better prognosis than HNSCC due to other risk factors. However, there is significant heterogeneity within HPV-associated HNSCC and 25% of these patients still do poorly despite receiving aggressive therapy. We currently have no good molecular tools to differentiate and exclude this “high-risk” sub-population and focus on “low-risk” patients for clinical trials. This has been a potential barrier to identifying successful de-escalation treatment strategies in HPV-associated HNSCC. We conducted an analysis of molecular markers with a well-known role in the pathogenesis of HPV-associated HNSCC and hypothesized that these markers could help independently predict recurrence and prognosis in these patients and therefore help identify at the molecular level “low-risk” patients suitable for de-escalation trials. Methods We analyzed 24 tumor specimens of patients with p16+ HNSCC who underwent definitive resection as primary treatment. Tissue microarray (TMA) was generated from the 24 pathology blocks and immunohistochemistry (IHC) was performed using highly specific antibodies for our chosen biomarkers (PI3K-PTEN, AKT pathway, mTOR, 4EBP1, S6, and pAMPK, ERCC-1). Transcriptome data was also obtained for 7 p16+ HNSCC patients from The Cancer Genome Atlas (TCGA). Data from the TMA and TCGA were analyzed for association of relapse-free survival (RFS) and overall survival (OS) with protein and gene expression of the chosen biomarkers. Results Increased pAMPK protein activity by IHC and AMPK gene expression by TCGA gene expression data was correlated with improved RFS with a trend towards statistical significance. Conclusions This data suggests that increased pAMPK activity and expression may portend a better prognosis in HPV-associated HNSCC undergoing primary definitive resection. However, these findings require validation in larger studies.

scholarly journals Evaluation of the Results of Primary Closure/Resection and Primary Anastomosis with Colostomy in Acute Colonic Injured Patients.

2020 ◽  
Vol 10 (1) ◽  
Author(s):  
Habib ullah Shah ◽  
Nawab Zada ◽  
Muhammad Shoaib Khan ◽  
Ishfaqullah Shah ◽  
Atiq ullah Shah ◽  
...  
Keyword(s):  
High Risk ◽  
Abdominal Trauma ◽  
Primary Closure ◽  
Primary Anastomosis ◽  
Low Risk ◽  
Risk Category ◽  
Colonic Injury ◽  
High Risk Patients ◽  
Risk Patients ◽  
Injured Patients

Background: The management of acute colonic injury has been improved since several decades, treating low risk patients withprimary closure and high risk patients (duration 6 hours or more, shock, contamination, transfusions 6 unit or more and multipleorgans injury) with colostomy.Objective: To assess the outcomes of primary closure and exteriorization in acute colonic injuries.Material and Methods: This Comparative study was carried out in the Casualty Department DHQ teaching Hospital Bannu, fromJan.2009 to Dec.2010. Thirty Eight patients of acute abdominal trauma, who attended the emergency department, were included.Majority of the patients were those of fire arm injured, followed by blunt abdominal trauma. Less frequent were penetrating traumadue to stab and bomb blast pieces. As part of their resuscitation, they were shifted to operation theatre for abdominal explorationand either primary Closure/ Resection and primary anastomosis was done or colostomy of injured colon performed keeping in mindthe Protocol of low and high risk categories respectively. The results obtained were subjected to statistical analysis by using SPSSsoftware version 20, and showed significant differences except wound infection when compared complications between primaryclosure & Colostomy procedures.Results: Primary Closure was carried out in 18 of 38 patients (47.4%) in low risk category while Colostomy was done in 20 of 38(52.6%) in high risk patients. (69%) of the patients were below 40 years of their age and (31%) were above 40 years. In our seriesfire arm was more common (78.9%) weapon for penetrating abdominal trauma. Isolated Colonic injury was rare 10.6% as colonicinjury was usually associated with other organ injuries (89.4%). Morbidity was comparable in both procedures. Wound infectionrecorded was (22%) in Primary Closure & (20%) in Colostomy. Mortality recorded was (5.5%) in Primary Closure & (10%) inColostomy patients. Anastomotic leakage was recorded in one patient with primary closure where re colostomy saved the patient.Mean Hospital stay was 13days.Conclusion: Primary Closure/Resection and Primary Anastomosis is having good results, in low risk patients but Colostomy ofinjured Colon is valuable in high risk and in patients who develop complications after Primary Closure.

scholarly journals Clinical and prognostic significance of CD34 expression in bone marrow biopsies in myelodysplastic syndrome

2010 ◽  
Vol 63 (7-8) ◽  
pp. 487-491
Author(s):  
Aleksandar Savic ◽  
Nebojsa Rajic ◽  
Nada Vlaisavljevic ◽  
Vesna Cemerikic-Martinovic ◽  
Stevan Popovic
Keyword(s):  
Bone Marrow ◽  
High Risk ◽  
Statistical Significance ◽  
Prognostic Significance ◽  
Low Risk ◽  
Control Group ◽  
Bone Marrow Biopsies ◽  
Significant Difference ◽  
Risk Patients ◽  
Cd34 Expression

Introduction. The expression of CD34 antigen is increased in a substantial portion of MDS patients, particularly in high risk patients, which was associated with unfavorable survival in some studies. The aim of this study was to determine the CD34 expression in bone marrow biopsies and its prognostic significance in MDS patients and to analyze it in the context of different clinical, laboratory and prognostic parameters. Material and methods. The study was conducted in 53 MDS patients and 20 controls with normal bone marrow. The CD34 expression was determined by CD34 monoclonal antibody and labelled streptovidin biotin peroxidase method. The positivity was determined by counting the 500 cells and it was expressed as percentage. Results. Among the 53 MDS patients there were 37 males and 16 females with average age of 62. The average CD34 expression in the MDS group was 1.37%, the range being 0-8.8%, and in the control group 0.78%, the range being 0-1.60%. The difference was statistically significant (p<0.05). There was a statistically significant difference in the CD34 expression comparing RA and CMML group and high risk and low risk MDS (p<0.02). The median survival in the patients with the CD34 expression with less than 2% was 22 months, while it was 6 months in the patients with the CD34 expression over 2% (p<0.05). In a multivariate analysis the CD34 expression together with the karyotype and transfusion dependence had a statistical significance (p<0.05). Conclusion. The CD34 expression in bone marrow biopsies is higher in the MDS patients comparing with the controls as well as in high risk comparing with low risk patients. The cutoff 2% seems to have a prognostic significance.

scholarly journals Comparison of the FASTEST and the ZWOLLE risk scores for identification of very low-risk patients for all-cause mortality and MACE following primary PCI

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
S Zaharijev ◽  
Z Mehmedbegovic ◽  
D Milasinovic ◽  
D Jelic ◽  
V Zobenica ◽  
...  
Keyword(s):  
Statistical Significance ◽  
External Validation ◽  
Predictive Ability ◽  
Mortality Rates ◽  
Low Risk ◽  
Femoral Access ◽  
Femoral Approach ◽  
Discriminating Power ◽  
Risk Patients ◽  
One Year

Abstract Background Prior studies suggest that low-risk ST-segment-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (pPCI) can be considered for early discharge in order to reduce healthcare costs and improve resource utilization. Novel, simple, the FASTEST score, demonstrated additional prognostic value over guideline recommended ZWOLLE score in a derivation cohort, but robust data about external validation are lacking. Purpose We aimed to compare overall predictive ability and discriminating power in identification of low-risk patients of novel FASTEST score compared to validated ZWOLLE score. Methods From a high-volume, single-center, prospective registry, in a period from 2009–2019, we included STEMI patients who underwent successful pPCI in whom both, FASTEST (1 point added for: femoral access, age&gt;65, LVEF &lt;50, TIMI &lt;3, creatinine &gt;1.5 mg/dl; left main disease; and Killip≥2) and ZWOLLE (age, anterior infarct, Killip class, TIMI flow, ischemia time, 3 vessel disease) scores were both calculated. Predictive ability of scores for in-hospital, 30 days and 1 year mortality and hospital MACE was tested using ROC analysis and comparing AUC. Also, event rate was compared between low-risk patients as classified by FASTEST (score=0) or ZWOLLE (score≤3). Results We included 5650 patients (age 60.8±11.4, male (71%), anterior STEMI (44%) and femoral approach (81%)). Overall, mortality rates were 2.1%, 3.1% and 8.1% for hospital, 30 days and one-year. As Low-risk subjects, ZWOLLE identified broader proportion of population compared to FASTEST (67% vs. 5.5%) mainly due to high prevalence of femoral approach (FASTEST low-risk 30% in radial approach subset), still, later had numerically lower mortality rates at hospital (0.7% vs. 0.3% (only 1 pt); p=0.62), 30 days (1.3% vs. 0.7%; p=0.39) and at one-year (4% vs. 2%; p=0.14). Both scores showed similar and very good predictive ability for in-hospital (AUC 0.81 vs. 0.81; p=0.66) and 30 days mortality (AUC 0.79 vs. 0.77; p=0.29), while at one-year, discrimination of crude mortality by FASTEST trended, but didn't reach statistical significance compared to ZWOLLE score, respectively (AUC 0.77 vs. 0.75; p=0.07). FASTEST showed better prediction for composite endpoint of in-hospital MACE - death, stroke, reinfarction and bleeding BARC class 3 or higher (AUC 0.71 vs. 0.67; p&lt;0.000) (Figure 1). Conclusion Both the FASTEST and the ZWOLLE scores showed very good discriminating power for in-hospital, 30 day mortality and one-year mortality, yet the FASTEST score offered comparative advantage for prediction of in-hospital MACE and could be used to identify selected patients where an early hospital discharge can be considered. ZWOLLE vs FASTEST ROC analisys Funding Acknowledgement Type of funding source: None

Exploring the Validity and Operational Impact of Using Allied Health Assistants to Conduct Dysphagia Screening for Low-Risk Patients Within the Acute Hospital Setting

2020 ◽  
Vol 29 (4) ◽  
pp. 1944-1955 ◽  
Author(s):  
Maria Schwarz ◽  
Elizabeth C. Ward ◽  
Petrea Cornwell ◽  
Anne Coccetti ◽  
Pamela D'Netto ◽  
...  
Keyword(s):  
At Risk ◽  
Allied Health ◽  
Assessment Tool ◽  
Hospital Setting ◽  
Low Risk ◽  
False Negatives ◽  
Exact Agreement ◽  
Risk Patients ◽  
Impact Phase ◽  
Operational Impact

Purpose The purpose of this study was to examine (a) the agreement between allied health assistants (AHAs) and speech-language pathologists (SLPs) when completing dysphagia screening for low-risk referrals and at-risk patients under a delegation model and (b) the operational impact of this delegation model. Method All AHAs worked in the adult acute inpatient settings across three hospitals and completed training and competency evaluation prior to conducting independent screening. Screening (pass/fail) was based on results from pre-screening exclusionary questions in combination with a water swallow test and the Eating Assessment Tool. To examine the agreement of AHAs' decision making with SLPs, AHAs ( n = 7) and SLPs ( n = 8) conducted an independent, simultaneous dysphagia screening on 51 adult inpatients classified as low-risk/at-risk referrals. To examine operational impact, AHAs independently completed screening on 48 low-risk/at-risk patients, with subsequent clinical swallow evaluation conducted by an SLP with patients who failed screening. Results Exact agreement between AHAs and SLPs on overall pass/fail screening criteria for the first 51 patients was 100%. Exact agreement for the two tools was 100% for the Eating Assessment Tool and 96% for the water swallow test. In the operational impact phase ( n = 48), 58% of patients failed AHA screening, with only 10% false positives on subjective SLP assessment and nil identified false negatives. Conclusion AHAs demonstrated the ability to reliably conduct dysphagia screening on a cohort of low-risk patients, with a low rate of false negatives. Data support high level of agreement and positive operational impact of using trained AHAs to perform dysphagia screening in low-risk patients.

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