Diabetes Resolution at 10 Years After Biliopancreatic Diversion in Overweight and Class 1 Obese Patients with Type 2 Diabetes

Background Long-term anti-diabetic effects of BPD in overweight or class 1 obese T2DM patients were investigated reporting the results at 10 years after BPD performed in severely non-obese T2DM patients. Material and Methods Thirty T2DM patients with BMI lower than 35 kg/m2 were investigated at 1, 5, and 10 years after BPD, and the results are compared with those of 30 T2DM patients followed for 10 years on pharmacological and/or behavioral conventional therapy. Results Mean levels of fasting blood glucose (FBG) and serum glycated hemoglobin (HbA1C) showed a marked reduction 1 year after BPD, values remaining slightly above the diabetic range throughout the entire follow-up. T2DM remission was observed in about 50% of the cases at 5 and 10 years after the operation. In 16 patients (53%), severe BPD-related complications developed, in ten cases requiring a surgical revision of the operation. In the BPD group, one patient died for malignant lymphoma and two patients after surgical revision. Within the control group, during the 10-year follow-up, no changes in the diabetic status were observed, being the FBG and HbA1C mean values higher than those recorded in the BPD patients at any follow-up time. All T2DM subjects of the control group were alive at the end of the 10-year follow-up. Conclusion Despite satisfactory long-term metabolic outcomes, these data indicate that BPD should be used with caution as a metabolic procedure in the treatment of T2DM in overweight or class 1obese patients. Graphical abstract

A multicenter cohort study of early complications after cranioplasty: results of the German Cranial Reconstruction Registry

OBJECTIVE Cranioplasty (CP) is a crucial procedure after decompressive craniectomy and has a significant impact on neurological improvement. Although CP is considered a standard neurosurgical procedure, inconsistent data on surgery-related complications after CP are available. To address this topic, the authors analyzed 502 patients in a prospective multicenter database (German Cranial Reconstruction Registry) with regard to early surgery-related complications. METHODS Early complications within 30 days, medical history, mortality rates, and neurological outcome at discharge according to the modified Rankin Scale (mRS) were evaluated. The primary endpoint was death or surgical revision within the first 30 days after CP. Independent factors for the occurrence of complications with or without surgical revision were identified using a logistic regression model. RESULTS Traumatic brain injury (TBI) and ischemic stroke were the most common underlying diagnoses that required CP. In 230 patients (45.8%), an autologous bone flap was utilized for CP; the most common engineered materials were titanium (80 patients [15.9%]), polyetheretherketone (57 [11.4%]), and polymethylmethacrylate (57 [11.4%]). Surgical revision was necessary in 45 patients (9.0%), and the overall mortality rate was 0.8% (4 patients). The cause of death was related to ischemia in 2 patients, diffuse intraparenchymal hemorrhage in 1 patient, and cardiac complications in 1 patient. The most frequent causes of surgical revision were epidural hematoma (40.0% of all revisions), new hydrocephalus (22.0%), and subdural hematoma (13.3%). Preoperatively increased mRS score (OR 1.46, 95% CI 1.08–1.97, p = 0.014) and American Society of Anesthesiologists Physical Status Classification System score (OR 2.89, 95% CI 1.42–5.89, p = 0.003) were independent predictors of surgical revision. Ischemic stroke, as the underlying diagnosis, was associated with a minor rate of revisions compared with TBI (OR 0.18, 95% CI 0.06–0.57, p = 0.004). CONCLUSIONS The authors have presented class II evidence–based data on surgery-related complications after CP and have identified specific preexisting risk factors. These results may provide additional guidance for optimized treatment of these patients.

Hemostatic Efficacy of a Flowable Collagen-Thrombin Matrix During Coronary Artery Bypass Grafting: A Double-Blind Randomized Controlled Trial

Background Flowable hemostatic agents are advantageous in that they can be applied to irregular wound surfaces and to areas that are difficult to approach directly. We sought to compare the effectiveness and safety of the flowable hemostatic sealants Collastat® (collagen hemostatic matrix, [CHM]) and Floseal® (gelatin hemostatic matrix, [GHM]) during off-pump coronary artery bypass (OPCAB). Methods In this prospective, randomized trial, 160 patients undergoing elective OPCAB surgery were enrolled between March 2018 and February 2020. After primary suture of the aortocoronary anastomosis, an area of hemorrhage was identified, and patients were double blind randomized to receive either CHM or GHM (n = 80, each). Study endpoints were the following: rate of successful intraoperative hemostasis and time required for hemostasis overall postoperative bleeding, rate of transfusion of blood products, rate of surgical revision for bleeding, postoperative morbidity, and intensive care unit stay. Results Of the total patients, 23% were female, and the mean age was 63 years (range: 42–81 years). Successful hemostasis within 5 min was achieved for 78 patients (97.5%) in the GHM group, compared to 80 patients (100%) in the CHM group (p = 0.497). Two patients receiving GHM required surgical revision to achieve hemostasis. There were no differences in the mean time required to obtain hemostasis (GHM vs. CHM, 1.49 ± 0.94 vs. 1.35 ± 0.60 min, p = 0.272), as confirmed by time-to-event analysis (p = 0.605). The two groups had similar amounts of mediastinal drainage for 24 h postoperatively (p = 0.298). The CHM group required less packed red blood cells, fresh frozen plasma, and platelets for transfusion than the GHM group (0.5 vs. 0.7 units per patient, p = 0.047; 17.5% vs. 25.0%, p = 0.034; 7.5% vs. 15.0%, p = 0.032; respectively). Conclusions CHM performed similarly to a commonly used hemostatic agent with regard to achieving effective and fast interoperative hemostasis during OPCAB. The topical flowable hemostatic agent, CHM, could be effectively used during cardiac surgery for intraoperative hemostasis of great vessels with high pressure. Trial registration : ClinicalTrials.gov, NCT 04310150

544 MANAGEMENT OF ACUTE ANASTOMOTIC COMPLICATIONS AFTER IVOR-LEWIS ESOPHAGECTOMY

Anastomotic leak (AL) and conduit necrosis (CN) are among the most serious surgical complications after esophageal resection. Endoscopic, radiological and surgical methods are used in their treatment. The aim of this paper is to evaluate the results of the treatment of acute anastomotic complications after Ivor-Lewis esophagectomy in a single high-volume center. Methods We performed a retrospective audit of a consecutive cohort of 815 patients undergoing transthoracic esophagectomy with intrathoracic esophago-gastric anastomosis from 2005 to 2019. AL was graded according to Esophagectomy Complications Consensus Group recommendation. Results There were 79 patients with AL and 6 patients with CN (10%). AL type I, II and III was diagnosed in 33 (39%), 25 (29%) and 27 (32%) patients, respectively. Esophageal stent was used in 40 patients. Primary surgical revision (with/without stent insertion) was performed in 14 patients. Reoperation was necessary overall in 25 patients (29%). Seventeen patients (20%) ended-up with esophageal diversion. Treatment with esophageal stent was successful in 28/40 patients (70%). Endoscopic vacuum-therapy was successfully used in three patients for peristent leak after stent extraction. Mortality of severe AL (type II and III) was 10/52 patients (19%). Conclusion Successful management of acute anastomotic complications requires early diagnosis and an individual treatment approach with the use of endoscopic, radiological and surgical methods. The primary attempt for anastomosis preservation using esophageal stent is desirable. Considering the clinical condition and CT finding, we recommend not to hesitate with surgical revision with debridement and drainage of pleural cavity and mediastinum. If primary therapy fails, life-saving procedure is the esophageal diversion.

879 Running a Regional Teaching Programme Through the COVID19 Pandemic

Aim The COVID19 pandemic has changed medical education and encouraged a more virtual approach. We aimed to assess the effectiveness of developing and running an online regional teaching programme for medical students. In additions, through feedback, we were able to establish the important suggestions which medical students found useful. Method We developed a four-month surgical revision teaching programme for medical students in both Nottingham and Leicester Medical Schools. We analyzed the feedback forms we received from medical students attending the teachings in the first three months. Results In total, there were 12 teachings and 138 feedback forms across the first three months. The overall rating for teaching programme was 4.8 out of 5. The main comments medical students found useful to improve our teaching were: using pictures to illustrate pathology, including questions during the lecture, simplifying the knowledge and using mnemonics and presenting a case scenario for the topic. Conclusions Medical students find revision teaching programmes useful in supporting their medical education. Comments from their feedback are a useful tool in improving teaching sessions. Medical educators can utilize the pointers we received in improving their teaching programmes.

Incidental Durotomy Following Surgery for Degenerative Lumbar Disease and the Impact of Minimally Invasive Surgical Technique on the Rate and Need for Surgical Revision: A Case Series

BACKGROUND Incidental durotomy (ID) is a common complication during lumbar spine surgery. A paucity of literature has studied the impact of minimally invasive surgery (MIS) on durotomy rates and strategies for repair as compared to open surgery. OBJECTIVE To examine the impact that MIS techniques have on the durotomy rate, repair techniques, and need for surgical revision following surgery for degenerative lumbar disease as compared to open technique. METHODS A single-center retrospective review of consecutive cases between 2013 and 2016 was performed. All patients underwent lumbar decompression with or without instrumented fusion for degenerative pathology using either open posterior or MIS techniques. ID rate, closure technique, and need for surgical revision related to the durotomy were recorded. RESULTS A total of 1,196 patients were included with an overall ID rate of 6.8%. There was no difference between open or minimally invasive surgical techniques (P = .14). There was a higher durotomy rate with open technique in patients that underwent decompression with fusion (P = .03) as well as in revision cases (P = .02). Primary repair was feasible more frequently in the open group (P = .001), whereas use of dural substitute (P < .001) was more common in the MIS group. Fibrin sealant was used routinely in both groups (P = .34). There were no failed repairs, regardless of technique used. CONCLUSION MIS techniques may reduce durotomies in cases involving instrumentation or revisions. Use of dural substitute onlay and fibrin sealant was effective at preventing reoperation. Both MIS and open techniques result in a low rate of future surgical revision when a durotomy occurs.