Difference Between Delayed Anastomosis and Early Anastomosis in Damage Control Laparotomy Affecting the Infusion Volume and NPWT Output volume: Is Infusion Restriction Necessary in Delayed Anastomosis? A Single-Center Retrospective Analysis

Background: Delayed anastomosis is a treatment strategy used in damage control laparotomy (DCL). During temporary abdominal closure (TAC) with DCL, infusion volume, and negative-pressure wound therapy (NPWT) output volume are associated with the success and prognosis of primary fascial closure (PFC). The same may also hold true for anastomosis. The aim of this research is to evaluate whether the difference between early anastomosis and delayed anastomosis in DCL is related to infusion volume and NPWT output volume.Methods: This single-center retrospective analysis targeted patients managed with TAC during emergency surgery for trauma or intra-abdominal sepsis between January 2011 and December 2019. It included patients who underwent repair/anastomosis/artificial anus construction in the first surgery and patients who underwent intestinal resection in the first surgery followed by delayed anastomosis with no intestinal continuity. The main outcomes were infusion volume, NPWT output volume and complications.Results: One hundred nine patients who underwent emergency surgery were evaluated. Seventy-three patients were managed with TAC using NPWT. In 16 patients with early anastomosis and 21 patients with delayed anastomosis, there was no difference in the infusion volume (p=0.2318) or NPWT output volume (p=0.7128) 48 hours after surgery. Additionally, there was no difference in the occurrence of surgical site infection (p=0.315) and suture failure (p=0.8428). During the second-look surgery after 48 hours, the anastomosis was further postponed for 48% of the patients who underwent delayed anastomosis. There was no difference in the infusion volume (p=0.0783) up to the second-look surgery between the patients whose delayed anastomosis was postponed and those who underwent delayed anastomosis, but there was a tendency toward a large NPWT output volume (p=0.024) in the postponed delayed anastomosis group. Anastomosis and PFC were achieved for all patients whose delayed anastomosis was postponed.Conclusions: The presence or absence of anastomosis during TAC management does not affect NPWT output volume. Delayed anastomosis may be managed with the same infusion volume as that used for early anastomosis. There is also the option of postponing anastomosis if the planned delayed anastomosis is complicated.Trial RegistrationThe retrospective protocol of this study was approved by our institutional review board (MH2018-611).

Drain output volume after pancreaticoduodenectomy is a useful warning sign for postoperative complications

Introduction The drain output volume (DOV) after pancreaticoduodenectomy (PD) is an easily assessable indicator in clinical settings. We explored the utility of the DOV as a possible warning sign of complications after PD. Methods A total of 404 patients undergoing PD were considered for inclusion. The predictability of the DOV for overall morbidity, major complications, intraabdominal infection (IAI), clinically relevant (CR) postoperative pancreatic fistula (POPF), CR delayed gastric emptying (DGE), CR chyle leak (CL), and CR post-pancreatectomy hemorrhaging (PPH) was evaluated. Results One hundred (24.8%) patients developed major complications, and 131 (32.4%) developed IAI. Regarding CR post-pancreatectomy complications, 75 (18.6%) patients developed CR-POPF, 23 (5.7%) developed CR-DGE, 20 (5.0%) developed CR-CL, and 28 (6.9%) developed CR-PPH. The median DOV on postoperative day (POD) 1 and POD 3 was 266 and 234.5 ml, respectively. A low DOV on POD 1 was an independent predictor of CR-POPF, and a high DOV on POD 3 was an independent predictor of CR-CL. A receiver operating characteristics (ROC) analysis revealed that the DOV on POD 1 had a negative predictive value (area under the curve [AUC] 0.655, sensitivity 65.0%, specificity 65.3%, 95% confidence interval [CI]: 0.587–0.724), with a calculated optimal cut-off value of 227 ml. An ROC analysis also revealed that the DOV on POD 3 had a positive predictive value (AUC 0.753, sensitivity 70.1%, specificity 75.0%, 95% CI: 0.651–0.856), with a calculated optimal cut-off value of 332 ml. Conclusion A low DOV on POD 1 might be a postoperative warning sign for CR-POPF, similar to high drain amylase (DA) on POD 1, high DA on POD 3, and high CRP on POD 3. When the DOV on POD 1 after PD was low, surgeons should evaluate the reasons of a low DOV. A high DOV on POD 3 was a postoperative warning sign CR-CL, and might require an appropriate management of protein loss.

The comparative efficacies of intravenous administration and intra-articular injection of tranexamic acid during anterior cruciate ligament reconstruction for reducing postoperative hemarthrosis

Background Hemarthrosis after anterior cruciate ligament (ACL) reconstruction can create many adverse joint effects. Tranexamic acid (TXA) can be used to minimize hemarthrosis and associated pain after ACL reconstruction. We aimed to compare the efficacies of intravenous (IV) administration and intra-articular (IA) injection of TXA during ACL reconstruction for reducing postoperative hemarthrosis. Methods A total of 120 patients who underwent arthroscopic ACL reconstruction were included in this prospective and randomized study. All patients were randomized into three groups: IV group, IA group and placebo group. Patients in the IV group received intravenously administered TXA (15 mg/kg in 100 mL of saline solution) 10 minutes before tourniquet release; patients in the IA group received intra-articular TXA (15 mg/kg in 100 mL of saline solution) injected via the drainage tube; and patients in the placebo group received an equivalent volume of normal saline administered into the knee joint cavity and intravenously. Drainage tubes were removed 24 hours after surgery, and all enrolled patients experienced a 4-week follow-up period. The drain output volume, visual analogue scale (VAS) score, patellar circumference, hemarthrosis grade and Lysholm score of all patients were recorded. Results Both the IV group and the IA group had significantly lower drain output volumes at day 1, lower VAS scores at weeks 1 and 2, smaller patellar circumferences at weeks 1 and 2, and lower hemarthrosis grades at weeks 1 and 2 than the placebo group. There were no significant differences in drain output volume, VAS score, patellar circumference or hemarthrosis grade between the IV group and the IA group at any time point. No obvious differences in Lysholm score were observed between any pair of groups at week 4. Neither infection nor deep vein thrombosis occurred in any group. Conclusion Both intravenous administration and intra-articular injection can reduce intra-articular hemarthrosis, joint pain and swelling. No significant difference in the efficacies of reducing hemarthrosis, joint pain and swelling was found between intravenous administration and intra-articular injection. Trial registration: The study was registered by the Chinese Clinical Trial Registry (ChiCTR-INR-17012217, 1 August 2017)

A METHOD OF CALCULATION OF DIRECT AND INDIRECT SALES REVENUE GROWTH AT AGROINDUSTRIAL ENTERPRISES

Introduction. Calculation of economic efficiency for the purpose of increasing sales revenues at agroindustrial enterprises has its own specifics. Implementation of new organisational and economic initiatives leads not only to a direct economic impact, but likewise to a significant indirect effect as well. The analysis of scientific publications on this problem allowed to find out that the existing techniques of the analysis of influence of factors on financial results of activity of the enterprises of agro-industrial complex are characterized by the high level of adaptedness to conditions of practical economic activity and provide needs of financial managers at adoption of optimal management decisions. However the high level of production diversification of the enterprises of agro-industrial complex demands further improvement of the factorial analysis taking into account branch features of the enterprises of the agro-industrial sector. Purpose of the research is to elaborate and to demonstrate – based on specific examples – a method of calculation of direct and indirect effect of marginal sales revenues at agroindustrial enterprises. The important question is due to what factors is the increase in profits from product sales. Results. The specifics of calculations of economic efficiency of innovative developments at agroindustrial enterprises are provided. Furthermore, a method of calculating revenue per unit of production and in total across an enterprise, including those achieved due to output volume growth, a decrease in the cost of production and an increase in realised output prices, is presented. However, both in academic and practical production conditions the method of calculating the values and interrelations between a direct and an indirect effect are elaborated on insufficiently. It is quite obvious that the revenue per unit of output and total revenue realised across an enterprise tends to increase alongside an increase in the total sales volume respectively. However, hereby the following relationship is identified: marginal revenue due to a decrease in the cost of production typically exceeds marginal revenue due to an increase in sales revenues. This relationship is confirmed based on an example of an industrial enterprise. Therefore was executed research of interrelation of direct and concomitant effect growth of volume of realization for what were executed calculations of gain of profit both due to growth of the sum of realization, and due to decrease in prime cost (at the invariance of prices for products). Conclusions. The conducted research allowed to find out that the concomitant effect, that is profit mark-up due to decrease in product cost, exceeds a direct effect, received for the account of growth of volume of realization, is reached in case when coefficient of a ratio of concomitant effect to direct effect directly proportional the specific weight of constant expenses in structure of prime cost and inversely proportional coefficient of profitability of the sold products. The conducted research demonstrated that the efficiency of implementation of innovative developments at industrial enterprises which are directed towards an increase in sales volumes depend not only on marginal output volume, a decrease in the cost of production and an increase in sales prices, but also on an initial state of production expressed via a ratio of fixed costs to variable costs and a resulting level of production profitability accordingly. A higher economic effect if provided by an innovative development which – all else equal – is implemented on industrial enterprises which have a higher share of fixed costs in the total structure and a lower output profitability respectively.

Gastrointestinal fistulas: An Update

A gastrointestinal (GI) fistula is an abnormal connection between gut (GI tract) and an epithelialized surface of skin or another hollow organ or another part of gut. These GI fistulas can cause profound GI bleeding, which may need emergency surgery. Other complications include Malnutrion, Undernutrion, Anaemias, Fluid, and Electrlyte imbalances, Hypovolemic shock, Septic shock, Pyaemic abscesses, Kidney malfunction and failure, Cardiac dysrhythmias, and failure, Hepatitis, Cerebral dysfynction and strokes, DIC etc if neglected, maltreated or untreated. Most GI fistulas occur as a complication of abdominal surgery. However, some fistulas evolve spontaneously and are usually the result of intra-abdominal inflammation or infection. Several classification systems for GI fistulas exist, none of which are used exclusively. The most commonly used classification systems are based on anatomic, physiologic (output volume), and etiologic characteristics. Used in combination, these classifications can help to provide an integrated understanding and optimal management scheme for the fistula. History taking, Physical examination, Endoscopy, Imaging studies and other laboratory tests are variably required for total assessment, evaluation, and concrete diagnosis. Intensive medical, and surgical therapies are now quite dramatically helpful to reduce the morbidity and mortality. This treatise on GI fistula is here to update the information about the latest developments of GI fistula.KYAMC Journal Vol. 9, No.-2, July 2018, Page 87-94

Central European Blocking Anticyclones and the Influences Imprint over the Romania’s Climate

Blocking anticyclonic circulations from Europe are provoking climatic episodes responsible for discomfort, human and financial loses. During the summer, these episodes are known for prolonged droughts and maximum temperatures often exceeding 35 °C to 40 °C. In the cold season, the rainfalls are close to 0 while the daily minimum temperatures are low under the average period. For this study, we used a synoptic classification which is available especially for Central Europe but works similarly for Romanian territory too. We aim to follow what kind of climatic conditions these circulations are producing in Romania during their presence in Europe. ECA&D daily gridded climatic dataset was used in this study. The study period lasts from 1961 to 2012. We used the minimum and maximum daily temperatures as well the rainfall quantities recorded. Since the output volume of data was too high, we aggregated the results into yearly multiseasonal average. In order to classify the synoptic patterns as blocking anticyclones, we used two synoptic situations from Hess-Brezowsky defined as Anticyclone High Central (HM) and High British Isles (HB). We calculated the thermic anomalies as well the rainfall quantities recorded in Romania during the presence of these circulations in central Europe. The results shows a perspective over the synoptic conditions in Romania during the presence of the above mentioned synoptic types in Central Europe.