Management of colorectal anastomotic leakage using endoscopic negative pressure therapy with or without protective ostomy: a retrospective study

Purpose Management of colorectal anastomotic leakage (AL) is patient-oriented and requires an interdisciplinary approach. We analyzed the management of AL according to its severity and presence of ostomy and proposed a therapy algorithm. Methods We identified all patients who underwent colorectal surgery and developed an AL in our clinic between 2012 and 2017. The management of AL was retrospectively analyzed according to the severity grade: asymptomatic (A), requesting interventional or antibiotic therapy (B), undergoing re-operation (C). The groups were compared according to the leakage characteristics, presence of ostomy, and patient clinical conditions. Results We identified 784 consecutive patients meeting the inclusion criteria. Of these, 10.8% experienced an AL (A = 18%, B = 48%, and C = 34%). The rate of successful ostomy closure was 100% (A), 68% (B), and 62% (C), respectively. Within group B, 91% of the patients were treated solely by endoscopic negative pressure therapy (ENPT), whereas 37% of the patients within group C required ENPT in addition to surgery. Seven cases within group B (17%) required no protective ostomy (nOB) during ENPT which was itself shorter and required less cycles in comparison to group B with ostomy (OB) (p = 0.017 and 0.111, respectively). Moreover, the leakage distance to anal verge was higher in the OB subgroup (p < 0.001). Conclusion ENPT for the treatment of colorectal AL is efficient in combination with operative revision or protective ostomy. In selected patients, it is feasible also in the absence of a protective ostomy.

Comorbidities, substance abuse, weight and age are independent risk factors for postoperative complications following operation for proximal humerus fractures: a retrospective analysis of 1109 patients

Introduction This study aimed to investigate the influence of epidemiologic parameters on complications that needed operative revision of operatively treated proximal humerus fractures. Methods We performed a retrospective single-center study in a level 1 trauma center. We included all patients with operatively treated proximal humerus fractures from January 1 2005 to December 31 2015. We characterized our cohort and subgroup using descriptive statistics. The primary outcome was postoperative complications. For this purpose, postoperative complications were defined in advance, an operative revision was necessary on a general rule. The secondary outcome was a model of the risk factors for complications created with multiple logistic regression. Results We included 1109 patients. The average age was 67.2 years (± 16.4), and 71.4% of the fractures occurred in women. A total of 644 patients (58.1%) had between one to three comorbidities, and 27.8% had four or more. The fracture morphology was as follows: 3 part 41.8%, 4 part 26.9%, 2 part 24.3%, and dislocation fracture 6.7%. Complications occurred in 150 patients (13.5%). The number of comorbidities [odds ratio (OR) 2.85, p < 0.01], body weight (OR 1.15, p = 0.02), and substance abuse (OR 1.82, p = 0.04) significantly correlated with the risk of complications. We achieved a sensitivity of 48% and a specificity of 74% for the variables body weight, substance abuse, age, and comorbidities Conclusion The epidemiologic parameters, comorbidities, substance abuse, weight, and age are independent risk factors for complications. If these factors are present, one can predict a postoperative complication requiring surgical revision with low sensitivity and moderate specificity. Therefore, concerning the high number of multi-morbid patients with proximal humerus fractures, an increased postoperative complication rate can be expected. Level of evidence Level of evidence IV

Trans-sacral bar osteosynthesis provides low mortality and high mobility in patients with fragility fractures of the pelvis

Operative treatment of osteoporosis-associated fragility fractures of the pelvis (FFP) and the sacrum is advocated with immobilizing or longstanding pain, fracture progression and displacement. We analyzed clinical outcomes regarding mobility, quality of life, and mortality of patients with FFP treated with trans-sacral bar (TB) osteosynthesis through S1. Demographics, clinical data, and operation-related data of patients with an FFP treated with TB were acquired from chart review. We assessed mortality, quality of life (EQ-5D), mobility, and residential status at follow-up. Seventy-nine females and six males with a median age of 78.0 years (IQR 73–84) were included, median follow-up was 3.2 years. Medical complications during hospitalization occurred in 28%. Operative revision was carried out in 15% of patients. One-year survival was 90.4%, this was associated with shorter preoperative and total length of stay in hospital (p 0.006 and 0.025, respectively). At follow-up, 85% lived at home and 82% walked with or without walking aid. Higher EQ-5D was reached with higher mobility status and living at home (p < 0.001 and < 0.001, respectively). TB osteosynthesis is an adequate and reliable method for fixation of FFP in the posterior pelvic ring to ensure timely mobilization. Shorter preoperative and total length of stay had lower mortality rates, advocating a standardized management protocol to limit time delay to operative therapy. Patients treated with TB osteosynthesis had low 1-year mortality of less than 10%.

Open Reduction in Subtrochanteric Femur Fractures Is Not Accompanied by a Higher Rate of Complications

Background and Objectives: Hip fractures are among the most typical geriatric fractures. Subtrochanteric fractures are considered difficult to treat, and, to date, there is no consensus on the optimal surgical treatment. Materialis and Methods: We analyzed data from the Registry for Geriatric Trauma, which includes patients ≥ 70 years old with hip fractures or periprosthetic fractures requiring surgery (21,734 patients in 2017–2019). For this study, we analyzed only the subgroup of patients with a subtrochanteric fracture. We analyzed the difference between closed and open surgical methods on a range of outcomes, including mortality, mobility, length of acute hospital stay, and the need for surgical revisions. Results: A total of 506 patients with subtrochanteric fractures were analyzed in this study. The median age was 85 years (interquartile range of 81–89). About 21.1% (n = 107) were operated on with a closed technique, 73.3% (n = 371) with open reduction without using a cerclage, and 5.53% (n = 28) with open reduction with the additional use of one or more cerclage wires. A total of 3.56% (n = 18) of the patients had complications requiring operative revision, most commonly soft tissue interventions (open vs. closed reduction—3.26% vs. 4.67%) (p = 0.687). Patients treated with open reduction were significantly more mobile 7 days after surgery (p = 0.008), while no significant effects on mortality (p = 0.312), length of hospital stay (p = 0.968), or surgical complications (p = 0.687) were found. Conclusion: Proper reduction is the gold standard practice for successful union in subtrochanteric fractures. This study shows that open reduction is not associated with a higher complication rate but does lead to increased mobility 7 days after operation. Therefore, in case of doubt, a good reduction should be aimed for, even using open techniques.

Implementation of a multidisciplinary infections conference improves the treatment of spondylodiscitis

Establishing a multidisciplinary approach regarding the treatment of spondylodiscitis and analyzing its effect compared to a single discipline approach. 361 patients diagnosed with spondylodiscitis were included in this retrospective pre-post intervention study. The treatment strategy was either established by a single discipline approach (n = 149, year 2003–2011) or by a weekly multidisciplinary infections conference (n = 212, year 2013–2018) consisting of at least an orthopedic surgeon, medical microbiologist, infectious disease specialist and pathologist. Recorded data included the surgical and antibiotic strategy, complications leading to operative revision, recovered microorganisms, as well as the total length of hospital and intensive care unit stay. Compared to a single discipline approach, performing the multidisciplinary infections conference led to significant changes in anti-infective and surgical treatment strategies. Patients discussed in the conference showed significantly reduced days of total antibiotic treatment (66 ± 31 vs 104 ± 31, p < 0.001). Moreover, one stage procedures and open transpedicular screw placement were more frequently performed following multidisciplinary discussions, while there were less involved spinal segments in terms of internal fixation as well as an increased use of intervertebral cages instead of autologous bone graft (p < 0.001). Staphylococcus aureus and Staphylococcus epidermidis were the most frequently recovered organisms in both patient groups. No significant difference was found comparing inpatient complications between the two groups or the total in-hospital stay. Implementation of a weekly infections conference is an effective approach to introduce multidisciplinarity into spondylodiscitis management. These conferences significantly altered the treatment plan compared to a single discipline approach. Therefore, we highly recommend the implementation to optimize treatment modalities for patients.

Interrupted sutures prevent recurrent abdominal fascial dehiscence: a comparative retrospective single center cohort analysis of risk factors of burst abdomen and its recurrence as well as surgical repair techniques

Background Burst abdomen (BA) is a severe complication after abdominal surgery, which often requires urgent repair. However, evidence on surgical techniques to prevent burst abdomen recurrence (BAR) is scarce. Methods We conducted a retrospective analysis of patients with BA comparing them to patients with superficial surgical site infections from the years 2015 to 2018. The data was retrieved from the institutional wound register. We analyzed risk factors for BA occurrence as well as its recurrence after BA repair and surgical closure techniques that would best prevent BAR. Results We included 504 patients in the analysis, 111 of those suffered from BA. We found intestinal resection (OR 172.510; 22.195–1340.796, p < 0.001), liver cirrhosis (OR 4.788; 2.034–11.269, p < 0.001) and emergency surgery (OR 1.658; 1.050–2.617; p = 0.03) as well as postoperative delirium (OR 5.058; 1.349–18.965, p = 0.016) as the main predictor for developing BA. The main reason for BA was superficial surgical site infection (40.7%). 110 patients received operative revision of the abdominal fascial dehiscence and 108 were eligible for BAR analysis with 14 cases of BAR. Again, post-operative delirium was the patient-related predictor for BAR (OR 13.73; 95% CI 1.812–104-023, p = 0.011). The surgical technique of using interrupted sutures opposed to continuous sutures showed a preventive effect on BAR (OR 0.143, 95% CI 0.026–0,784, p = 0.025). The implantation of an absorbable IPOM mesh did not reduce BAR, but it did reduce the necessity of BAR revision significantly. Conclusion The use of interrupted sutures together with the implantation of an intraabdominal mesh in burst abdomen repair helps to reduce BAR and the need for additional revision surgeries.

Neues vom Grand Hotel Abgrund. Der Paradigmenwechsel vom Kosmopolitismus zur Kosmo-Politik

ZusammenfassungDie altehrwürdige, stets bestrittene und leicht angegraut wirkende Tradition des Weltbürgertums (Kosmopolitismus) steht (I) vor drei neuen Herausforderungen: (a) postkolonial, insofern die westlichen Ursprünge universaler Ideen auf der Hand liegen und daraus eventuell Verengungen und Einseitigkeiten folgen, (b) als Eliten-Projekt, das die breite Bevölkerung nie erreicht hat bzw. diese ignoriert, gepaart (c) mit Einwänden von kommunitaristischer Seite, wonach alle Vorstellungen von Zugehörigkeit, Solidarität und Hospitalität in lokalen Gemeinschaften geerdet sein müssen. Die Idee des Kosmopolitismus kann sich diesen Herausforderungen stellen, wenn sie (II) stärker implementiert und operationalisiert wird: Dazu tragen Ansätze eines „globalen Konstitutionalismus“ bei, der über den Nationalstaat als überkommener Stütze von Regierung und kollektiver Identität hinausreicht und Problemlagen angeht, die diesen Souveränitäts- und Identitätsrahmen gesprengt haben. Im Zeitalter des Anthropozän (III) ist eine Erweiterung des Kosmopolitismus angebracht, nämlich die überfällige Einbeziehung der belebten und unbelebten Natur als einem virtuellen Mit-Akteur internationaler Beziehungen. Diese konzeptionelle und operative Revision kosmopolitischer Ideen mündet in eine übergreifend planetare „Kosmo-Politik“.

Effectiveness of reverse total shoulder arthroplasty for primary and secondary fracture care: mid-term outcomes in a single-centre experience

Background The introduction of reverse total shoulder arthroplasty (RSA) as a treatment option in complex proximal humeral fractures, has significantly extended the surgical armamentarium. The aim of this study was to investigate the mid-term outcome following fracture RSA in acute or sequelae, as well as salvage procedures. It was hypothesized that revision RSA (SRSA) leads to similar mid-term results as primary fracture treatment by RSA (PRSA). Methods This retrospective study describes the radiological and clinical mid-term outcomes in a standardized single-centre and Inlay design. Patients who underwent RSA in fracture care between 2008 and 2017 were included (minimum follow-up: 2 years, minimum age: 60 years). The assessment tools used for functional findings were range of motion (ROM), Visual Analogue Scale, absolute (CS) plus normative Constant Score, QuickDASH, and Subjective Shoulder Value. All adverse events as well as the radiological results and their clinical correlations were statistically analysed (using p < .05and 95% confidence intervals). Results Following fracture RSA, 68 patients were included (mean age: 72.5 years, mean follow-up: 46 months). Forty-two underwent primary RSA (PRSA), and 26 underwent revision RSA (SRSA). Adverse advents were observed in 13% (n = 9/68). No statistically significant results were found for the scores of the PRSA and SRSA groups, while the failed osteosynthesis SRSA subgroup obtained statistically significantly negative values for ROM subzones (flexion: p = .020, abduction: p = .020). Decreased instances of tubercle healing were observed for the in PRSA group relative to the SRSA group (p = .006). The absence of bony healing of the tubercles was related to significant negative clinical and subjective outcomes (all scores: p < .05, external rotation: p= .019). Significant postoperative improvements were evaluated in the SRSA group (CS: 23 to 56 at mean, p = .001), the time from index surgery to operative revision revealed no associations in functional findings. Conclusions RSA is an effective option in severe shoulder fracture management with predictable results for salvage as well as first-line treatment. Promising mid-term functional results, reasonable implant survival rates, and high patient satisfaction can be achieved. Level of evidence Level III.

Effectiveness of Reverse Total Shoulder Arthroplasty for Primary and Secondary Fracture Care: Mid-Term Outcomes in a Single-Centre Experience

Background The introduction of reverse total shoulder arthroplasty (RSA) as a treatment option in complex proximal humeral fractures, has significantly extended the surgical armamentarium.The aim of this study was to investigate the mid-term outcome following fracture RSA in acute or sequelae, as well as salvage procedures. It was hypothesized that revision RSA (SRSA) leads to similar mid-term results as primary fracture treatment by RSA (PRSA).Methods This retrospective study describes the radiological and clinical mid-term outcomes in a standardized single-centre and Inlay design. Patients who underwent RSA in fracture care between 2008 and 2017 were included (minimum follow-up: two years, minimum age: 60 years).The assessment tools used for functional findings were range of motion (ROM), Visual Analogue Scale, absolute (CS) plus normative Constant Score, QuickDASH, and Subjective Shoulder Value. All adverse events as well as the radiological results and their clinical correlations were statistically analysed (using p < .05 and 95% confidence intervals).Results Following fracture RSA, 68 patients were included (mean age: 72.5 years, mean follow-up: 46 months). Forty-two underwent primary RSA (PRSA), and 26 underwent revision RSA (SRSA). Adverse advents were observed in 13% (n = 9/68).No statistically significant results were found for the scores of the PRSA and SRSA groups, while the failed osteosynthesis SRSA subgroup obtained statistically significantly negative values for ROM subzones (flexion: p = .020, abduction: p = .020). Decreased instances of tubercle healing were observed for the in PRSA group relative to the SRSA group (p = .006). The absence of bony healing of the tubercles was related to significant negative clinical and subjective outcomes (all scores: p < .05, external rotation: p = .019). Significant postoperative improvements were evaluated in the SRSA group (CS: 23 to 56 at mean, p = .001), the time from index surgery to operative revision revealed no associations in functional findings.Conclusions RSA is an effective option in severe shoulder fracture management with predictable results for salvage as well as first-line treatment. Promising mid-term functional results, reasonable implant survival rates, and high patient satisfaction can be achieved.Trial RegistrationNot applicable, level of evidence III.

Abstract 15142: Left Bundle Branch Pacing, Procedure Characteristics, Feasibility and Long-term Safety: Insights From a Large Sample Single Center Study

Introduction: Left bundle branch pacing (LBBP) is a novel pacing method and has been proven to have low and stable pacing thresholds. However, data on large numbers of patients with long-term follow-up is still needed to evaluate its feasibility and safety. Hypothesis: To evaluate the feasibility and safety of LBBP in a large sample with long-term follow up. Methods: This study prospectively enrolled 632 consecutive patients with left bundle branch block, AV block or sick sinus syndrome with attempted LBBP from April 2017 to July 2019. Pacing parameters, ECG, echocardiographic measurements, complications were assessed at implant, and during follow-up of 1, 6, 12 and 24 months. Results: LBBP was successful in 618/632 (97.8%) patients according to the strict criteria for LBB capture. Mean follow-up time was 17.8±6.9 months. LBB capture threshold at implant was 0.65±0.27 [email protected] and 0.71±0.35 [email protected] at 2-year follow-up (n=166). Left ventricular ejection fraction were improved in QRS≥120ms and <120ms groups (60.62±14.22% vs. 63.95±11.29 %, p<0.001; 49.77±17.58 % vs. 58.58±12.79 %, p<0.001; respectively). The number of patients with moderate and sever tricuspid regurgitation decreased at 1-year (120 to 66;28 to 16; respectively). Permanent right bundle branch injury occurred in 55 (8.9%) patients. LBB capture threshold increased greater than 2 V in 6 patients, loss of capture in 2 patients, two lead dislodgements requiring operative revision within 1 month after implantation during 2-years follow-up. Conclusions: Feasibility and safety of LBBP were confirmed by this large sample size and long-term follow-up study. It is a reliable physiologic method for standards pacing indications.