scholarly journals Outcomes of Open Complex Ventral Hernia Repairs With Retromuscular Placement of Poly-4-Hydroxybutyrate Bioabsorbable Mesh

2019 ◽  
Vol 27 (1) ◽  
pp. 32-37 ◽  
Author(s):  
Andrea Pakula ◽  
Ruby Skinner
Keyword(s):  
High Risk ◽  
Ventral Hernia ◽  
Class Iii ◽  
Mesh Placement ◽  
High Risk Patients ◽  
Institutional Review ◽  
Risk Patients ◽  
Fatal Arrhythmia ◽  
Grade 3 ◽  
American Society

Purpose. Optimal technique and mesh selection still debated for complex ventral hernias. Limited data exists on bioabsorbable meshes in high-risk patients. We evaluated our experience. Methods. Retrospective review was conducted following institutional review board approval for ventral hernia repairs using a single bioabsorbable mesh between February 2014 and November 2017. Patient and hernia details characterized. Outcomes evaluated. Results. 20 ventral hernia repairs identified, 10 males, 10 females. Mean body mass index was 35 ± 7.4 kg/m2, and mean age 47 ± 13 years. Comorbid conditions were diabetes 35% and hypertension 40%. Fifty-five percent had American Society of Anesthesiologist scores of 3. Hernia Characteristics: Ventral Hernia Working Group Grade 3 hernias were 80%, and remainder grade 2. Forty percent of hernias were Centers for Disease Control class III, and remainder were class I and II. The mean defect size was 533 cm2 ± 500. Repair for prior open abdomens was 45%, recurrent hernias 20%, incisional 15%, incarcerated 10%, incisional with parastomal 5%, and primary ventral 5%. Concomitant bowel procedures in 8, (40%). All cases had retromuscular mesh placement (transversus abdominus release 65%, Rives-Stoppa 35%). Surgical site occurrences were 20% (surgical site infection 10%, seroma 10%). Overall hospital stay 5 ± 3 days. Ileus occurred in 20%. One postoperative death due to fatal arrhythmia. There were no recurrences with mean follow-up 21.1 months. Conclusions. Complex hernia repairs using bioabsorbable mesh were conducted in a small cohort of high-risk patients. These data demonstrate good outcomes with limited morbidity and mortality. There were no recurrences.

Reduced Intensity Conditioning (RIC) with Fludarabine, Busulfan and Cyclophosphamide for High Risk Patients with Thalassemia Major Undergoing Allogeneic Bone Marrow Transplantation Results in High Rejection Rates.

Blood ◽  
2007 ◽  
Vol 110 (11) ◽  
pp. 1998-1998 ◽  
Author(s):  
Mammen Chandy ◽  
Vikram Mathews ◽  
Biju George ◽  
Auro Vishwabandya ◽  
Salamun Desire ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Bone Marrow Transplantation ◽  
High Risk ◽  
Graft Rejection ◽  
Thalassemia Major ◽  
Class I ◽  
Class Iii ◽  
High Risk Patients ◽  
Allogeneic Bmt ◽  
Risk Patients

Abstract Usual cytoreductive therapy for bone marrow transplantation (BMT) for thalassemia major consists of busulfan (Bu) 14–16mg/kg and cyclophosphamide(Cy) 160–200mg/kg +/− anti-thymocyte globulin (ATG). In high risk patients, this is associated with significant regimen related toxicity and graft rejection. Fludarabine (Flu) containing conditioning has been used effectively by adding immunosuppression in RIC with reduced doses of myelosuppressive drugs to lower regimen related toxicities and graft rejection. There is also data to suggest that a 24-hour gap between Bu and Cy doses could reduce toxicities associated with this combination. We therefore treated 25 patients (median age: 7 years, range: 3–14), 12 males and 13 females, with beta thalassemia major with a regime of Flu 150mg/m2 (day-15 to -11), Bu 14mg/kg (day-10 to -7) and Cy 160mg/kg (day-5 to day-2). Most of these patients were heavily transfused (median red cell units:100, range: 21–250) and poorly chelated (median serum ferritin: 2510 ng/ml, range: 1039–6740). Their risk stratification (Lucarelli class) was as follows: Class I: 4 (16%), Class II: 8 (32%) Class III: 13 (52%). Allogeneic BMT was performed using a 6/6 matched related donor and bone marrow as the graft. Graft versus host disease (GVHD) prophylaxis consisted of cyclosporine A and mini-methotrexate. The median cell dose was 4.56 × 108 TNC/kg (range: 2.5–14.1). Three (20%) of 20 assessable patients developed grade I-II acute GVHD, 2 (10%) each had hemorrhagic cystitis and veno-occlusive disease. Mortality within the first 100 days were due to graft failure/rejection in 4 patients (16%) and one each of diffuse alveolar hemorrhage, intracranial hemorrhage and sepsis (4% each). With a mean follow-up of 8 months (range 0–11), 18 (72%) of 25 patients are alive. Among the 13 patients in class III, 5 (38.5%) rejected the graft (3 had primary failure and 2 after initial engraftment). In a historical cohort of 47 patients conditioned with Bu16, Cy200 and ATG, the rejection rate was only 8%. The regimen was very well tolerated by all patients and patients in class I had no rejection. Pharmacokinetic data was available on Bu and Cy from 14 of the 25 patients treated with this protocol. The mean values for Bu kinetics were: Cmax-1 (ng/ml): 1069.2±265.8, Cmin-1(ng/ml): 186.8±73.2, Cl-F-1 (l/h/kg): 0.281±0.081, AUC-1 (ng*h/ml): 3648±918 and Css-1 (ng/ml): 608±153. They are not significantly different from patients conditioned Bu16mg/kg without Flu (data not shown). The Cy kinetic data are as follows: Cmax-1(ng/ml): 441.4±188, AUC-1(ng*h/ml): 1431±791, Cl-F-1(l/h/kg): 0.0378±0.027. The Cmax-1 and AUC-1 were significantly lower compared to patients receiving 200mg/kg and dosed without a 24-hour gap between the Bu and Cy. Overall, these data suggest that Flu does not provide adequate immunosuppression for sustained engraftment after allogeneic BMT even when combined with Bu 14 and Cy160 (with a 24-hour gap between Bu and Cy) in high risk patients with thalassemia major (Lucarelli class III) but could be useful in the others (Class I and II). OUTCOME OF ALLOGENEIC BMT CLASS NUMBER (%) OVER ALL SURVIVAL (months) EVENT FREE SURVIVAL (months) REJECTION (%) MORTALITY (%) ALL PATIENTS 25 69±9.8 62.6±10.0 6 (24) 7 (28) CLASS I 4 (16%) 75±21.7 75±21.7 0 1 (25) CLASS II 8 (32%) 83.3±15.2 83.3±15.2 1 (12.5) 1 (12.5) CLASS III 13 (52%) 57.7±14.7 44.9±14.1 5(38.5) 5 (38.5)

scholarly journals Percutaneous Cholecystostomy for Severe Acute Cholecystitis: A Useful Procedure in High-Risk Patients for Surgery

2018 ◽  
Vol 108 (2) ◽  
pp. 124-129 ◽  
Author(s):  
S. Aroori ◽  
C. Mangan ◽  
L. Reza ◽  
N. Gafoor
Keyword(s):  
High Risk ◽  
Acute Cholecystitis ◽  
Open Cholecystectomy ◽  
Length Of Hospital Stay ◽  
Acalculous Cholecystitis ◽  
Percutaneous Cholecystostomy ◽  
High Risk Patients ◽  
Risk Patients ◽  
Physiological Reserve ◽  
American Society

Background: Acute cholecystitis has the potential to cause sepsis and death, particularly in patients with poor physiological reserve. The gold standard treatment of acute cholecystitis (cholecystectomy) is often not safe in high-risk patients and recourse is made to percutaneous cholecystostomy as either definite treatment or temporizing measure. The aim of this study is to evaluate early and late outcomes following percutaneous cholecystostomy in patients with acute cholecystitis treated at our institution. Methods: All patients who underwent percutaneous cholecystostomy for acute cholecystitis (excluding patients with malignancy) between January 2005 and September 2014 were included in the study. Results: A total of 53 patients (22 female, median age, 74 years; range, 27–95 years) underwent percutaneous cholecystostomy during the study period. In total, 12 patients (22.6%) had acalculous cholecystitis. The main indications for percutaneous cholecystostomy were significant co-morbidities (n = 28, 52.8%) and patients too unstable for surgery (n = 21, 39.6%). The median time to percutaneous cholecystostomy from diagnosis of acute cholecystitis was 3.6 days (range, 0–45 days). The median length of hospital stay was 27 (range, 4–87) days. The overall 90-day mortality was 9.3% with two further deaths at 12-month follow up. The mortality was significantly higher in patients with American Society of Anesthesiology grade 4–5 (18% vs 0% in American Society of Anesthesiology grade 2–3, p = 0.026) and in patients with acalculous cholecystitis (25% vs 4.5%, p = 0.035). The overall readmission rate was 18%. A total of 24 (45.2%) patients had surgery: laparoscopic cholecystectomy, n = 11; laparoscopic converted to open, n = 5; open total cholecystectomy, n = 5; open cholecystectomy, n = 1; laparotomy and washout, n = 1; laparotomy partial cholecystectomy and closure of perforated small intestine and gastrostomy, n = 1. Conclusion: Percutaneous cholecystostomy is a useful temporary or permanent procedure in patients with acute cholecystitis of both calculous and acalculous origin, who are unfit for surgery.

scholarly journals A Study of the Role of 180W XPS Lithium Triborate Laser in the Treatment of Patients With Lower Urinary Tracts Symptoms Due to Benign Prostatic Hyperplasia

2018 ◽  
Vol 9 (4) ◽  
pp. 261-267
Author(s):  
Omar Salim Akhtar ◽  
Shailesh Raina
Keyword(s):  
Benign Prostatic Hyperplasia ◽  
High Risk ◽  
Green Light ◽  
Prostatic Hyperplasia ◽  
Safe Alternative ◽  
Lithium Triborate ◽  
High Risk Patients ◽  
Risk Patients ◽  
American Society ◽  
Lower Urinary

Introduction: Benign prostatic hyperplasia (BPH) is a disease of the prostate commonly seen in elderly males known to cause lower urinary tract symptoms (LUTS) that may require surgery as a part of treatment. Transurethral resection of the prostate (TURP) is considered the gold standard of surgical treatment, but it is not without complications. Laser photoselective vaporisation of the prostate (PVP), introduced in 1998 as an 80 W Nd:YAG laser which passed through a KTP (potassium-titanylphosphate) crystal, emerged as a safe alternative to TURP in selected cases. A recent upgrade to the Greenlight XPS 180 W powered with an LBO (lithium triborate) crystal has been available for use since 2012. Data on the use of this new upgrade is still being collected and analysed, especially in patients with large prostates or high risk cases. We analysed cases done at Jaslok Hospital over a 2-year period. Methods: A total of 34 patients who underwent Laser PVP using XPS 180W for LUTS due to BPH at Jaslok Hospital were part of this study. We analysed the pre- and postoperative variables and the intraoperative parameters of all patients. Results: The XPS 180W was found to be safe and efficacious. Eighteen patients were high-risk cases, classified as ASA (American Society of Anesthesiologists) Classes 3 and 4. Average postoperative catheter duration was 40.18 hours. In prostates of size <80 mL, an average of 229 kJ of energy was used. In large prostates (>80 mL), an average of 390 kJ of energy was used. No major complications were seen in any of the high-risk patients, classified as Clavien Dindo Class 3 and 4. The postoperative drop in IPSS (International Prostate Symptom Score) was 8.7. Conclusion: We found that Green Light Laser XPS 180W may be used for large (>80 g) prostates, hitherto an indication for open surgery, and that it may be used in high-risk patients, who were otherwise unfit for TURP. It is safe and efficacious. Further, multicenter trials are required to confirm the findings.

scholarly journals 354 Thoracic Complex Case Review Meeting (CCRM): A Multidisciplinary Approach to Improving Patient Care and Service Efficiency

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
S Rozwadowski ◽  
E Teh ◽  
D West
Keyword(s):  
High Risk ◽  
Dynamic Testing ◽  
Surgical Strategy ◽  
Complex Case ◽  
Case Review ◽  
High Risk Patients ◽  
Risk Patients ◽  
American Society ◽  
Improving Patient Care

Abstract Objectives The profile of thoracic patients and the indications for surgery are becoming increasingly complex. A multidisciplinary perioperative approach can optimise patients, improve outcomes and prevent high-risk patients being inappropriately declined surgery. We aim to retrospectively review the first 100 patients discussed at the CCRM in 2016-17 with a primary outcome of number of on-the-day cancellations. Secondary outcomes include unplanned critical care (HDU) admissions, 30 and 90-day morbidity and mortality. Method Data was collected retrospectively for demographics, co-morbidities, lung-function and dynamic testing, diagnosis and proposed surgical approach. CCRM outcomes included need for HDU, requiring further optimisation, change in surgical strategy or patient deemed too high risk. Results Average age was 69 years (IQR 12.5) (65 M: 35 F). American Society of Anaesthesiologists’ classification of 3 with predicted of mortality of 2 % (IQR 0.8). Maximal oxygen uptake (VO2 max) was 18.6ml/kg/min (SD ± 4.2). 24 patients were recommended for optimisation and 34 to proceed with HDU. 14 were deemed too high-risk and 30 had a change in surgical strategy. Only 1 patient was cancelled on-the-day due to a recent deterioration in health. 30 and 90-day mortality rates were 1% and 2% respectively, and 2 patients required unplanned HDU. Conclusions CCRM is a simple approach to optimise high-risk patients and minimise unplanned HDU. No patients were cancelled on-the-day due to inadequate optimisation or unexpected need for HDU. Mortality was acceptable and lower than predicted. Our study established CCRM as a safe and effective way of selecting high-risk patients for further optimisation and appropriate perioperative care.

Grade 2–4 Acute Graft-Versus-Host Disease and Extensive Chronic Graft-Versus-Host Disease Are Associated with Significantly Decreased Survival Following Reduced Intensity Allogeneic Stem Cell Transplantation.

Blood ◽  
2004 ◽  
Vol 104 (11) ◽  
pp. 1246-1246
Author(s):  
Geoffrey W. Chan ◽  
Andreas K. Klein ◽  
Kellie A. Sprague ◽  
Kenneth B. Miller ◽  
Francine M. Foss
Keyword(s):  
Overall Survival ◽  
Stem Cell ◽  
High Risk ◽  
Graft Versus Host Disease ◽  
Host Disease ◽  
Graft Versus Host ◽  
High Risk Patients ◽  
Risk Patients ◽  
Grade 3 ◽  
Reduced Intensity

Abstract Grade 2–4 acute graft versus host disease (aGVHD) is associated with decreased overall survival following conventional allogeneic stem cell transplantation but its impact on reduced intensity transplantation remains controversial. We evaluated the impact of grade 2–4 aGVHD on survival in a retrospective review of 112 high-risk patients, median age 50 (range 18 to 70), with AML (n=29), MDS (n=19), CML (n=9), CLL (n=5), ALL (n=3), HD (n=10), NHL (n=16), MM (n=9), MMM (n=7), PNH (n=2), or renal cell carcinoma (n=3), who underwent a reduced intensity preparative regimen of extracorporeal photopheresis day −7, −6, pentostatin 8mg/m2 by continuous intravenous infusion day −5 thru −4, and total body irradiation in three 200cGy fractions day −3, −2, followed by allogeneic bone marrow stem cell infusion from a 6/6 HLA matched related (n=70), 5/6 HLA matched related (n=10), or matched unrelated (n=32) donor. All patients were high-risk, including 30 patients with a prior autologous stem cell transplant and 5 patients with a prior allogeneic stem cell transplant. Full donor chimerism at the time of neutrophil engraftment was achieved in 89% of patients. The median time to neutrophil and platelet engraftment were 19 and 21 days respectively. Day 100 transplant related mortality(TRM) was 20%. Disease relapse occurred in 22% of patients. Grade 0 or 1 aGVHD occurred in 27 patients (27%) and 54 patients (54%) respectively. Grade 2, 3 or 4 aGVHD occurred in 7 patients (7%), 6 patients (6%), and 7 patients (7%) respectively. The one-year overall survival (OS) by aGVHD grade was 70% for grade 0, 69% for grade 1, 29% for grade 2, 17% for grade 3, and 0% for grade 4. Grade 2–4 aGVHD was associated with a significantly increased day 100 TRM (37% vs 14%: p=0.03), decreased median failure-free survival (5 months vs 35 months: p=0.001), and decreased median OS (5 months vs “not reached”: p=0.001). The decrease in median OS among patients with grade 2–4 aGVHD was significant among matched related donor transplants (5 months vs “not reached”: p=0.002) and among mismatched related or matched unrelated donor transplants (6 months vs 35 months: p=0.0004). There was no significant difference in median OS between patients with grade 2 aGVHD and patients with grade 3–4 aGVHD (6 months vs 3 months: p=0.24). Patients with limited or no chronic GVHD (cGVHD) had similar one-year OS (90% vs 79%) but patients who developed extensive chronic GVHD had a significantly worse median OS (56% vs “not reached”: p=0.001). In conclusion, high-risk patients who undergo reduced intensity transplantation and develop grade 2–4 aGVHD or extensive cGVHD have a significantly decreased overall survival. Patients with grade 2 aGVHD have similarly poor OS as patients with grade 3–4 aGVHD. High-risk patients tolerate GVHD poorly with a significantly decreased overall survival. To improve survival, reduced intensity transplantation regimens that decrease the incidence of grade 2–4 aGVHD or extensive cGVHD need to be developed. Figure Figure

scholarly journals Somatostatin administration following pancreatoduodenectomy: a case-matched comparison according to surgical technique, body mass index, American Society of Anesthesiologists’ score and Fistula Risk Score

Surgery Today ◽  
2020 ◽  
Author(s):  
Niccolò Furbetta ◽  
Desirée Gianardi ◽  
Simone Guadagni ◽  
Gregorio Di Franco ◽  
Matteo Palmeri ◽  
...  
Keyword(s):  
Body Mass Index ◽  
High Risk ◽  
Body Mass ◽  
Risk Score ◽  
Digestive Bleeding ◽  
High Risk Patients ◽  
Risk Patients ◽  
American Society ◽  
American Society Of Anesthesiologists ◽  
Fistula Risk Score

Abstract Purpose This study evaluated the controversial role of somatostatin after pancreatoduodenectomy (PD), stratifying patients for the main risk factors using the most recent postoperative pancreatic fistula (POPF) classification and including only patients who had undergone PD with the same technique of pancreatojejunostomy. Methods Between November 2010 and February 2020, 218 PD procedures were carried out via personal modified pancreatojejunostomy (mPJ-PD). Somatostatin was routinely administered between 2010 and 2016, while from 2017, 97 mPJ-PD procedures without somatostatin (WS) were performed. The WS group was retrospectively compared with a control (C) group obtained with one-to-one case–control matching according to the body mass index, American Society of Anesthesiologists’ score, and Fistula Risk Score (FRS). Results A total of 144 patients (72 WS group versus 72 C group) were compared. In the WS group. 6 patients (8.3%) developed clinically relevant POPF, compared with 8 patients (11.1%) in the C group (p = 0.656). In addition, on analyzing the subgroup of high-risk patients according to the FRS, we did not note any significant differences in POPF occurrence. Furthermore, no marked differences in the morbidity or mortality were found. Digestive bleeding and diabetes onset rates were higher in the WS group than in the control group, but not significantly so. Conclusions The results of the present study confirm no benefit with the routine administration of somatostatin after PD to prevent POPF, even in high-risk patients. However, a possible role in the prevention of postoperative digestive bleeding and diabetes was observed.

Prophylactic Mesh Placement in High-Risk Patients Undergoing Elective Laparotomy: A Systematic Review

2013 ◽  
Vol 37 (8) ◽  
pp. 1861-1871 ◽  
Author(s):  
Subramanian Nachiappan ◽  
Sheraz Markar ◽  
Alan Karthikesaligam ◽  
Paul Ziprin ◽  
Omar Faiz
Keyword(s):  
Systematic Review ◽  
High Risk ◽  
Prophylactic Mesh ◽  
Mesh Placement ◽  
High Risk Patients ◽  
Risk Patients
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