Risk factors and prediction model for inpatient surgical site infection after elective abdominal surgery

BACKGROUND Surgical site infections(SSIs) are the commonest healthcare-associated infection. In addition to increasing mortality, it also lengthens the hospital stay and raises healthcare expenses. SSIs are challenging to predict, with most models having poor predictability. Therefore, we developed a prediction model for SSI after elective abdominal surgery by identifying risk factors.AIM To analyse the data on inpatients undergoing elective abdominal surgery to identify risk factors and develop predictive models that will help clinicians assess patients preoperatively.METHODS We retrospectively analysed the inpatient records of Shaanxi Provincial People’s Hospital from January 1, 2018 to January 1, 2021. We included the demographic data of the patients and their haematological test results in our analysis. The attending physicians provided the Nutritional Risk Screening 2002(NRS 2002)scores. The surgeons and anaesthesiologists manually calculated the National Nosocomial Infections Surveillance(NNIS) scores. Inpatient SSI risk factors were evaluated using univariate analysis and multivariate logistic regression. Nomograms were used in the predictive models. The receiver operating characteristic and area under the curve values were used to measure the specificity and accuracy of the model.RESULTS A total of 3018 patients met the inclusion criteria. The surgical sites included the uterus(42.2%), the liver(27.6%), the gastrointestinal tract(19.1%), the appendix(5.9%), the kidney(3.7%), and the groin area(1.4%). SSI occurred in 5% of the patients(n = 150). The risk factors associated with SSI were as follows: Age;gender;marital status;place of residence;history of diabetes;surgical season;surgical site;NRS 2002 score;preoperative white blood cell, procalcitonin(PCT), albumin, and low-density lipoprotein cholesterol(LDL) levels;preoperative antibiotic use;anaesthesia method;incision grade;NNIS score;intraoperative blood loss;intraoperative drainage tube placement;surgical operation items. Multivariate logistic regression revealed the following independent risk factors: A history of diabetes [odds ratio(OR) = 5.698, 95% confidence interval(CI): 3.305-9.825, P = 0.001], antibiotic use(OR = 14.977, 95%CI: 2.865-78.299, P = 0.001), an NRS 2002 score of ≥ 3(OR = 2.426, 95%CI: 1.199-4.909, P = 0.014), general anaesthesia(OR = 3.334, 95%CI: 1.134-9.806, P = 0.029), an NNIS score of ≥ 2(OR = 2.362, 95%CI: 1.019-5.476, P = 0.045), PCT ≥ 0.05 μg/L(OR = 1.687, 95%CI: 1.056-2.695, P = 0.029), LDL < 3.37 mmol/L(OR = 1.719, 95%CI: 1.039-2.842, P = 0.035), intraoperative blood loss ≥ 200 mL(OR = 29.026, 95%CI: 13.751-61.266, P < 0.001), surgical season(P < 0.05), surgical site(P < 0.05), and incision grade I or Ⅲ(P < 0.05). The overall area under the receiver operating characteristic curve of the predictive model was 0.926, which is significantly higher than the NNIS score(0.662).CONCLUSION The patient’s condition and haematological test indicators form the bases of our prediction model. It is a novel, efficient, and highly accurate predictive model for preventing postoperative SSI, thereby improving the prognosis in patients undergoing abdominal surgery.

Analysis of the impact of ERAS-based respiratory function training on older patients’ability to prevent pulmonary complications after abdominal surgery

BACKGROUND In China,as the population grows older,the number of elderly people who have died from respiratory problems has increased.AIM To investigate whether enhanced recovery after surgery(ERAS)-based respiratory function training may help older patients who had abdominal surgery suffer fewer pulmonary problems,shorter hospital stays,and improved lung function.METHODS The data of 231 elderly individuals having abdominal surgery was retrospectively analyzed.Based on whether ERAS-based respiratory function training was provided,patients were divided into ERAS group(n=112)and control group(n=119).Deep vein thrombosis(DVT),pulmonary embolism(PE),and respiratory tract infection(RTI)were the primary outcome variables.Secondary outcome variables included the Borg score Scale,FEV1/FVC and postoperative hospital stay.RESULTS The percentage of 18.75%of ERAS group participants and 34.45%of control group participants,respectively,had respiratory infections(P=0.007).None of the individuals experienced PE or DVT.The ERAS group’s median postoperative hospital stay was 9.5 d(3-21 d)whereas the control groups was 11 d(4-18 d)(P=0.028).The Borg score decreased on the 4th d following surgery in the ERAS group compared to the 2nd d prior(P=0.003).The incidence of RTIs was greater in the control group than in the ERAS group among patients who spent more than 2 d in the hospital before surgery(P=0.029).CONCLUSION ERAS-based respiratory function training may reduce the risk of pulmonary complications in older individuals undergoing abdominal surgery.

Recent evidence for subcutaneous drains to prevent surgical site infections after abdominal surgery:A systematic review and metaanalysis

BACKGROUND Surgical site infections(SSIs)increase mortality,hospital stays,additional medical treatment,and medical costs.Subcutaneous drains prevent SSIs in gynecological and breast surgeries;however,their clinical impact in abdominal surgery remains unclear.AIM To investigate whether subcutaneous drains were beneficial in abdominal surgery using a systematic review and meta-analysis.METHODS The database search used PubMed,MEDLINE,and the Cochrane Library.The following inclusion criteria were set for the systematic review:(1)Randomized controlled trial studies comparing SSIs after abdominal surgery with or without subcutaneous drains;and(2)Studies that described clinical outcomes,such as SSIs,seroma formation,the length of hospital stays,and mortality.RESULTS Eight studies were included in this meta-analysis.The rate of total SSIs was significantly lower in the drained group(54/771,7.0%)than in the control group(89/759,11.7%),particularly in gastrointestinal surgery.Furthermore,the rate of superficial SSIs was slightly lower in the drained group(31/517,6.0%)than in the control group(49/521,9.4%).No significant differences were observed in seroma formation between the groups.Hospital stays were shorter in the drained group than in the control group.CONCLUSION Subcutaneous drains after abdominal surgery prevented SSIs and reduced hospital stays but did not significantly affect seroma formation.The timing of drain removal needs to be reconsidered in future studies.

Bacterial Translocation and Change in Intestinal Permeability in Patients after Abdominal Surgery

The purpose of this study was to investigate bacterial translocation and change in intestinal permeability in patients after abdominal surgery. Sixty-three patients undergoing elective abdominal surgery were enrolled in the study. Blood samples were collected prior to operation and 2, 24, 48 h after surgery for bacterial culture, microbial DNA extraction, plasma D-lactate and endotoxin measurement. PCR analysis was performed after DNA extraction, with β-lactosidase gene of E. coli and 16S rRNA gene as target genes. All patients were observed for a period of 30 days for infectious complications. Our results showed that no bacterial DNA was detected before surgery, but after operation it was found in 12 patients （19.0%）. Bacterial DNA was detected in 41.7% （10/24） of SIRS patients and 5.1% （2/39） of non-SIRS patients （P〈0.01）. About 83.3% of PCR-positive patients developed systemic inflammatory response syndrome （SIRS）, but only 27.5% of PCR-negative patients did so （P〈0.01）. Two thirds of PCR-positive patients developed infectious complications, while none of PCR-negative patients did （P〈0.01）. The blood culture was positive only in 3 patients （4.8%）, who were all PCR-positive. E. coli DNA was found in 66.7% of the PCR-positive patients. The plasma levels of D-lactate and endotoxin were elevated significantly 2, 24 and 48 h after operation in PCR-positive patients, with a significant positive correlation found between them （r=0.91, P〈0.01）. It is concluded that increased intestinal permeability was closely related with bacterial translocation. Intestinal bacterial translocation （most commonly E. coli） might occur at early stage （2 h） after abdominal surgery. Postoperative SIRS and infection might bear a close relationship with bacterial translocation.

New Progress in the Cause Analysis and Nursing of Respiratory Tract Infection after Abdominal Surgery under General Anesthesia

This article provides a review of the causes of respiratory tract infection after abdominal surgery. These causes include general anesthesia, intubation factors, factors inherent to the patient, surgical factors, the injudicious use of antimicrobial agents, and the environmental factors of the ward. The perioperative management of the respiratory tract should be strengthened. Health education, respiratory function training, oral nursing intervention,atomization inhalation, and personalized expectoration methods should receive more attention to decrease the complications and promote the early rehabilitation of patients after abdominal surgery.

Postoperative Outcome in Children Aged between 6 and 10 Years in Major Abdominal Surgery, Neurosurgery and Orthopedic Surgery

Background: Anticipating postoperative evolution in surgical patients is an important issue in our daily practice. We demonstrated in a previous study that there were multiple predictors of postoperative outcome, including American Society of Anesthesiologists status (ASA), transfusion, emergency, surgery and age. A secondary analysis describing intraoperative and postoperative outcomes was undertaken in children aged between 6 and 10 years old included in the initial study. Objective: To describe intraoperative and postoperative outcomes in children aged between 6 and 10 years old included in the initial cohort in abdominal surgery, neurosurgery and orthopedics. Methods: The secondary analysis of postoperative outcomes in children aged between 6 and 10 years old was retrospectively included in the initial study of 594 patients. The study was approved by the Ethics Committee. Results: There were 88 patients with a mean age of 98.7 ± 13.8 months. The most common surgical interventions were scoliosis in 23 patients (26.1%), limb tumor resection in 8 patients (9.1%), femoral osteotomy in 6 patients (6.8%), intracerebral tumor resection in 6 patients (6.8%), intestinal resection in 5 patients (5.6%), Chiari’s malformation in 4 patients (4.5%), pelvic osteotomy in 4 patients (4.5%) and renal transplantation in 4 patients (4.5%). Most patients (45%) were American Society of Anesthesiologists grade 3 (ASA 3), and 13 (14.8%) were ASA grade 4. Twenty-two (25%) patients had intraoperative and/or postoperative complications (organ dysfunction or sepsis). Two patients (2.3%) had intraoperative hemorrhage, 1 patient (1.1%) had intraoperative difficult intubation, and 1 patient experienced intraoperative anaphylaxis. Nine patients (10.2%) had postoperative neurologic failure, and 2 (2.3%) had postoperative cardio-circulatory failure. Three patients (3.4%) had postoperative septicemia, 2 patients (2.3%) had postoperative pulmonary and urinary sepsis, and 1 patient (1.1%) had postoperative abdominal sepsis. 3 patients (3.4%) had re-operations. 42 (47.7%) patients had intra-operative transfusion. There was 1 in-hospital death (1.1%). The median total length of hospital stay was 9 days [5 - 16]. Conclusion: Twenty-five percent of the patients had intraoperative and/or postoperative complications, and most of them were ASA grade 3 3. Integrating goal-directed therapies to optimize intraoperative management in these patients could be necessary to improve postoperative outcomes in surgical pediatric patients.

Postoperative Complications after Major Abdominal Surgery in Preterm Infants: A Single Institute Record

Backgrounds: Post-operative complications in pediatric surgery are important issues, especially that after major abdominal surgery for preterm infants: complications sometimes lead to mortality/morbidity even though the surgical procedures were successful. We here attempted to demonstrate and record post-operative complications in preterm infants after major abdominal surgery. This is a secondary analysis of our cohort (n = 594) previously reported regarding pediatric postoperative complications (not confined to preterm infants). Methods: Of 594 patients, 25 preterm (born <37 weeks of gestation) infants underwent major abdominal surgery. We identified their characteristics, especially the postoperative complications. The Ethics Committee approved this study. Results: The mean weight was 2.43 ± 0.75 kg. Of 25, nine suffered postoperative complications: postoperative respiratory failure (n = 4), pulmonary sepsis (n = 2), and the followings were observed in one patient: intra-operative cardiac arrest, wound sepsis, septicemia, and multi-organ sepsis. There was no in-hospital mortality. Conclusion: In preterm infants undergoing major abdominal surgery, the most common postoperative complication was respiratory;respiratory failure and pulmonary sepsis. This data is roughly the same as that observed in the previous studies, which made us reconfirm the importance of the vigilance on respiratory complications in this population.

Strengthening Post-Operative Pain Assessment in Patients with Major Abdominal Surgery, University Teaching Hospitals, Zambia

Systematic, routine pain assessment using standardized clinical guidelines is the foundation of effective pain management for patients who are unable to self-report pain. In Zambia, there are no context appropriate standardised clinical guidelines for post-operative pain observations. This study sought to develop such a clinical guideline in form of an assessment tool. The study adopted an exploratory sequential mixed method through a three-phased approach and an adapted Clinical Decision Making Survey instrument was used. Snowball sampling was employed and in phases II and III, purposive sampling was used. The study was conducted at the University Teaching Hospitals where 120 participants were enrolled in the study. Phases II and III provided preliminary internal validation processes of the developed tool, where discussions, orientation and trial implementation of the tool were done. In phase II of the study, 47 participants comprising of nurses participated while in phase III, there were 11 nurses and 32 participants. The results yielded the first ever standardised post-operative pain assessment tool for patients with major abdominal surgery in Zambia. The tool is made up of six dimensions of the identified nonverbal indicators of post-operative pain in patients with major abdominal surgery namely: facial expressions, mobility, activity intolerance, behavioural disturbance, communication ability and vital signs. The present study showed that the developed post-operative pain assessment tool for Zambia is acceptable for use among patients who have had major abdominal surgery and can facilitate improved post-operative pain management for most patients.

Effects of Different Doses of BDNF on Postoperative Cognitive Function in Aged Rats Undergoing Abdominal Surgery

Objective:To investigate the effects of different doses of BDNF on postoperative cognitive function in aged rats undergoing abdominal surgery.Methods:72 aged healthy male SD rats of SPF grade were selected.According to the random number table method,the rats were randomly divided into the control group,model group,low dose BDNF injection group,and high dose BDNF injection group,with 18 rats in each group.The model group,low dose group,and high dose group underwent abdominal surgery after anesthesia,and 5μL/time of BDNF was intranasally administered to the rats in the low dose and high dose groups 6 hours after abdominal surgery,of which the dose of the low dose group was 0.1 g/L,while that of the high dose group was 0.2 g/L.The drug was administered alternately through both nostrils,with an interval of 2 minutes each time,for 5 times.The control group did not undergo surgery after anesthesia.The escape latency and swimming distance of the four groups of rats were compared before surgery,the first day,the third day,and the seventh day after surgery;similarly,the BDNF protein expression level in the hippocampus of the four groups of rats was compared on the first day,the third day,and the seventh day after surgery.Results:The escape latency and swimming distance of the control group were not statistically significant on the first day,the third day,and the seventh day after surgery,p>0.05;the escape latency and swimming distance of the model group,low dose group,and high dose group on the first day,the third day,and the seventh day after surgery were statistically significant,p<0.05.Before surgery,the escape latency and swimming distance of the four groups were not statistically significant,p>0.05;on the first day,the third day,and the seventh day after surgery,the escape latency and swimming distance of the model group>low dose group>high dose group>control group,p<0.05.The BDNF protein expression level in the hippocampus of the control group on the first day,the third day,and the seventh day after surgery showed no statistical significance p>0.05;the expression level of BDNF protein in the hippocampus of the model group,low dose group,and high dose group on the first day,the third day,and the seventh day after surgery was statistically significant,p<0.05.On the first day,the third day,and the seventh day after surgery,the expression level of BDNF protein in the hippocampus of the model group<low dose group<high dose group<control group,p<0.05.Conclusion:Compared with 0.1 g/L of BDNF,0.2 g/L of BDNF can improve the postoperative cognitive function of aged rats undergoing abdominal surgery.

Risk factors and strategy for surgical incision infection in department of abdominal surgery

Objective To study the risk factors of surgical wound infection among the patients in department of abodominal surgery. Methods The factors on surgical wound infection were investigated by retrospective study. The diagnosis standard was based on Diagnosis Standard of Hospital Infection published by Ministry of Health.

Effects of lornoxicam combining with fentanyl on postoperative arrhythmia and platelet function in patients with coronary artery disease after abdominal surgery

To investigate the effects of patient-controlled intravenous analgesia (PCIA) with lornoxicam and fentanyl on arrhythmia and the expression of platelet membrane glycoproteins in patients with coronary artery disease (CAD) after abdominal surgery.Methods Eighty ASA Ⅱ or Ⅲ patients with CAD aged 51～66 yrs weighing 59～68 kg presenting for abdominal surgery participated in this study.CAD was diagnosed by clinical symptoms and ischemic changes on ECG.The patients were premedicated with intramuscular henobarbital 0.1 g and scopolamine 0.3 mg.Anesthesia was induced with fentanyl,droperidol,propofol and vecuronium and maintained with propofol,fentanyl and vecuronium.The patients received PCIA after operation.The PCIA solution contained fentanyl 0.9 mg and droperidol 5 mg in 100 ml of normal saline (N.S.) in group A (n=40) or lornoxicam 56 mg,fentanyl 0.2 mg and droperidol 5 mg in 100 ml N.S. in group B (n=40).In group A the loading dose was fentanyl 0.05 mg and group B lornoxicam 4 mg.PCIA included a background infusion at 2 ml·h -1 and a bolus of 0.5 ml with a 15 min lock-out.VAS(0=no pain,10= worst pain) was used to measure pain intensity.In addition to BP,HR and SpO2 monitoring ECG was continuously monitored with a Holter monitor after operation.Blood samples were taken from peripheral vein before and 6 h after operation and on the 1st,2nd,7th and 8th postoperative days for determination of the expression of CD 62p ,CD 63 and CD 41 /CD 61 on the platelet membrane,platelet count,prothrombin time (PT) thrombin time (TT) and partial thromboplastin time (PTT).Results The two groups were comparable with respect to sex,age,body weight,severity of CAD,duration of operation and intraoperative blood loss.The patients received no blood transfusion during operation.There was no significant difference in VAS score,platelet count,PT,TT and PTT between the two groups.The incidence of atrial and ventricular premature beat on ECG and the expression of CD 41 /CD 61 ,CD 62p and CD 63 on the platelet membrane were significantly lower in group B than in group A on the 7th and 8th postoperative days(P<0.05 or 0.01).Conclusion Postoperative PCIA with lornoxicam and fentanyl can more effectively reduce the incidence of postoperative arrhythmia in patients with CAD.Suppression of activation of platelets by lornoxicam may contribute to the mechanism.10 refs,3 tabs.

Relationships betveen pain intensity and heart rate variability in patients after abdominal surgery： a pilot study

Background A link between postoperative pain intensity and heart rate variability （HRV） had not been well established. This study aimed to investigate the correlation between post-operative pain intensity and HRV. Methods The subjects in this cross-sectional correlation study comprised of patients who had undergone abdominal surgery in a regional teaching hospital in central Taiwan during the period July 2009-November 2009. The visual analogue scale （VAS） and the short-form McGill pain questionnaire （SF-MPQ） were used to measure post-operative pain. HRV was measured as the standard deviation of normal RR interval, and by power spectral analysis that included high frequency （HF）, low frequency （LF）, very low frequency power, and LF/HF ratio. Results A total of 34 subjects were included in this study. We found that the day after the surgery, the mean VAS score was 47.50±20.98 and the mean SF-MPQ score was 18.06±8.90, indicating a moderate degree of pain. Moderate to severe degrees of tenderness were reported by 70.6% of the patients, moderate to severe degrees of gnawing pain were experienced by 67.7% of the patients, moderate to severe degrees of tiring-exhaustion pain were reported by 64.7% of the patients, and 41.2% of the patients who experienced moderate to severe pain believed that the pain was punishing-cruel. The standard deviation of normal RR interval and high frequency values obtained from male patients or married patients were higher than female patients or unmarried （P 〈0.05）. The correlation of the standard deviation of normal RR interval, high frequency, very low frequency value and patient＇s age were negative （P 〈0.05）. The total SF-MPQ pain scores positively correlated with the LF/HF ratio （P 〈0.05）. Conclusions The multidimensional pain assessment tool （SF-MPQ） reflects better the patients＇ post-operative pain than the single-dimensional assessment tool （VAS）. HRV positively correlated with SF-MPQ scores in patients after abdominal surgery.

Association between serosal intestinal microcirculation and blood pressure during major abdominal surgery

Background:In clinical practice,blood pressure is used as a resuscitation goal on a daily basis,with the aim of maintaining adequate perfusion and oxygen delivery to target organs.Compromised perfusion is often indicated as a key factor in the pathophysiology of anastomotic leakage.This study was aimed at assessing the extent to which the microcirculation of the bowel coheres with blood pressure during abdominal surgery.Methods:We performed a prospective and observational cohort study.In patients undergoing abdominal surgery,the serosal microcirculation of either the small intestine or the colon was visualized using handheld vital mi-croscopy(HVM).From the acquired HVM image sequences,red blood cell velocity(RBCv)and total vessel density(TVD)were calculated using MicroTools and AVA software,respectively.The association between microcircula-tory parameters and blood pressure was assessed using Pearson’s correlation analysis.We considered a two-sided P-value of<0.050 to be significant.Results:In 28 patients undergoing abdominal surgery,a total of 76 HVM images were analyzed.The RBCv was 335±96μm/s and the TVD was 13.7±3.4 mm/mm ^(2).Mean arterial pressure(MAP)was 71±12 mm Hg during microcirculatory imaging.MAP was not correlated with RBCv(Pearson’s r=−0.049,P=0.800)or TVD(Pearson’s r=0.310,P=0.110).Conclusion:In 28 patients undergoing abdominal surgery,we found no association between serosal intestinal microcirculatory parameters and blood pressure.

Determining the need for a thoracoscopic approach to treat a giant hiatal hernia when abdominal access is poor

BACKGROUND Giant hernias present a significant challenge for digestive surgeons.The approach taken(laparoscopic vs thoracoscopic)depends largely on the preferences and skills of each surgeon,although in most cases today the laparoscopic approach is preferred.AIM To determine whether patients presenting inadequate laparoscopic access to the intrathoracic hernial sac obtain poorer postoperative results than those with no such problem,in order to assess the need for a thoracoscopic approach.METHODS For the retrospective series of patients treated in our hospital for hiatal hernia(n=112),we calculated the laparoscopic field of view and the working area accessible to surgical instruments,by means of preoperative imaging tests,to assess the likely outcome for cases inaccessible to laparoscopy.RESULTS Patients with giant hiatal hernias for whom a preoperative calculation suggested that the laparoscopic route would not access all areas of the intrathoracic sac presented higher rates of perioperative complications and recurrence during follow-up than those for whom laparoscopy was unimpeded.The difference was statistically significant.Moreover,the insertion of mesh did not improve results for the non-accessible group.CONCLUSION For patients with giant hiatal hernias,it is essential to conduct a preoperative evaluation of the angle of vision and the working area for surgery.When parts of the intrathoracic sac are inaccessible laparoscopically,the thoracoscopic approach should be considered.

The Value of Continuous Noninvasive Hemoglobin Monitoring in Intraoperative Blood Transfusion Practice during Abdominal Cancer Surgery

Introduction: Patients undergoing major oncological surgery may suffer from severe bleeding. Sometimes, it is difficult to anesthesiologist to take decision about timing of administration blood products to such patients. The aim of this study is to evaluate the use of continuous noninvasive hemoglobin monitoring as a guide for blood transfusion practice. Methods: One hundred patients undergoing elective abdominal cancer surgeries were randomly allocated into two groups, Group I (n = 50): laboratory Hb was obtained at baseline (immediate preoperative), intraoperative (when to suggest transfusion triggering value) and immediate postoperative. Group II (n = 50): The probe of Masimo for SpHb monitoring was applied immediately after induction of anesthesia at the index finger. Laboratory Hb was obtained at baseline (immediate preoperative), intraoperative (when to suggest transfusion triggering value) and immediate postoperative. Results: A number of transfused units of RBC were significantly lower in SpHb group than in control group (p value 0.05). Conclusion: SpHb monitoring had clinically acceptable absolute and trend accuracy. SpHb monitoring altered transfusion decision making and resulted in decreased RBC utilization and decreased RBC costs while facilitating earlier transfusions when indicated.

Effect of Bilateral Ultrasound-Guided Quadratus Lumborum Block versus Lumbar Epidural Block on Postoperative Analgesia following Major Lower Abdominal Cancer Surgery

Background: Poor postoperative pain control leads to longer postoperative care, longer hospital stay and decreased patient overall satisfaction. Aim: To compare the efficacy and safety of bilateral ultrasound-guided quadratus lumborum block versus lumbar epidural block on the management of postoperative pain following major lower abdominal cancer surgery. Methods: The study was a double-blinded, and randomized study, conducted in South Egypt Cancer Institute, Assiut University, Egypt. It included cancer patients scheduled for major lower abdominal cancer surgery in the period from 2019 to 2020. They were divided into two groups: Group Ι received pre-emptive ultrasound-guided Quadratus Lumborum Block (QLB) with 25 mL of 0.25% bupivacaine on each side of the abdominal wall before induction of General Anesthesia (GA), and Group II received pre-emptive lumbar epidural block with 15 mL of 0.25% bupivacaine before induction of GA. VAS score, and time of the first analgesic request and postoperative total analgesic consumption were evaluated. Results: Sixty patients were included in our study. VAS score at rest was comparable between both studied groups in the first 6 h. At 8 and 10 h, Group II had a significantly higher VAS score at rest (P < 0.001 and 0.026 respectively). Meanwhile, at 12 h, patients in Group I had a significantly higher VAS score (P = 0.026). Mean time of the first request for rescue analgesia was significantly prolonged in Group I (13.27 ± 2.38 hrs.) compared to Group II (10.20 ± 1.42 hrs.) (P < 0.001) respectively, mean total morphine consumption, over the first 24 hours postoperatively, was significantly lower in Group I (5.17 ± 1.32 mg) than in Group II (7.33 ± 1.45 mg) (P < 0.001). A larger number of patients in Group II had nausea at different time points postoperatively than in Group I (P < 0.001), but no significant difference was observed between both studied groups regarding the incidence of vomiting. Limitation: Small sample size and shorter period for postoperative follow-up. Conclusions: Management of postoperative pain following major lower abdominal cancer surgery with US-guided QLB was associated with the reduction in the total analgesic consumption and delayed the first request of analgesia as compared to lumbar epidural block technique.

Critical considerations for the management of acute abdomen in transplant patients

The number of solid organ transplantations performed annually is increasing and are increasing in the following order:Kidney,liver,heart,lung,pancreas,small bowel,and uterine transplants.However,the outcomes of transplants are impro-ving(organ survival>90%after the 1st year).Therefore,there is a high probability that a general surgeon will be faced with the management of a transplant patient with acute abdomen.Surgical problems in immunocompromised patients may not only include graft-related problems but also nongraft-related problems.The perioperative regulation of immunosuppression,the treatment of accompanying problems of immunosuppression,the administration of cortisol and,above all,the realization of a rapidly deteriorating situation and the accurate evaluation and interpretation of clinical manifestations are particularly important in these patients.The perioperative assessment and preparation includes evaluation of the patient’s cardiovascular system and determining if the patient has hypertension or suppression of the hypothalamic-pituitary-adrenal axis,or if the patient has had any coagulation mechanism abnormalities or thromboembolic episodes.Immunosuppression in transplant patients is associated with the use of calci-neurin inhibitors,corticosteroids,and antiproliferation agents.Many times,the clinical picture is atypical,resulting in delays in diagnosis and treatment and leading to increased morbidity and mortality.Multidetector computed tomo-graphy is of utmost importance for early diagnosis and management.Transplant recipients are prone to infections,especially specific infections caused by cytomegalovirus and Clostridium difficile,and they are predisposed to intraop-erative or postoperative complications that require great care and vigilance.It is necessary to follow evidence-based therapeutic protocols.Thus,it is required that the clinician choose the correct therapeutic plan for the patient(conservative,emergency open surgery or minimally invasive surgery,including laparoscopic or even robotic surgery).

Ureteroscopic holmium laser to transect the greater omentum to remove an abdominal drain:Four case reports

BACKGROUND Drainage tube removal is difficult when the greater omentum becomes incarcerated in the drainage tube through the side holes.Currently,known removal methods are either ineffective or will cause additional damage to the patient in a secondary operation.Ureteroscopy and the holmium laser have been used in various surgical techniques in urology,and in theory,they are expected to be a good strategy for solving the problem of tissue incarceration.CASE SUMMARY Four patients diagnosed with difficult removal of an abdominal drainage tube following abdominal surgery are reported.All patients underwent surgery to remove the incarcerated greater omentum in the drainage tube using a holmium laser and a ureteroscope,and a new 16-F drain was then placed in the abdominal or pelvic cavity.The efficacy of this technique was evaluated by intraoperative conditions,success rate,and operating time;safety was evaluated by perioperative conditions and the probability of postoperative complications.All four operations went smoothly,and the drains were successfully removed in all patients.The average operating time was 24.5 min.Intraoperatively,the average irrigation volume was 892.0 mL,the average drainage volume was 638.5 mL,and no bleeding or damage to surrounding tissues was observed.Postoperatively,the average drainage volume was 32.8 mL and the new drains were removed within 36 h.All patients were able to get out of bed and move around within 12 h.Their visual analogue pain scores were all below 3.The average follow-up duration was 12.5 mo and no complications such as fever or bleeding were noted.CONCLUSION Ureteroscopic holmium laser surgery is an effective,safe and minimally invasive technique for removing drains where the greater omentum is incarcerated in the abdominal drain.

Multiple recurrent neurofibromas in the abdominal wall:A case report

BACKGROUND Neurofibroma can be a clinical manifestation of neurofibromatosis,which is a benign neurogenic tumor that occurs sporadically.Neurofibromas in the abdomen usually appear in the retroperitoneal space.Reports on neurofibromas in the abdominal wall are rare,and multiple recurrent neurofibromas in this area have not yet been reported.CASE SUMMARY This is a case of a 73-year-old man who suffered from multiple recurrent neurofibromas in the abdominal wall for 16 years and received 13 surgical treatments.CONCLUSION We need to pay due attention to its treatment,and primary surgery should be designed thoroughly.

Extensive complex thoracoabdominal aortic aneurysm salvaged by surgical graft providing landing zone for endovascular graft:A case report

BACKGROUND Surgical repair of complex abdominal aortic aneurysm is associated with a higher perioperative mortality and morbidity.The advent of endovascular aortic repair(EVAR)has reduced perioperative complications,although the utilization of such techniques is limited by lesion characteristics,such as involvement of the visceral or renal arteries(RA)and/or presence of a sealing zone.CASE SUMMARY A 60-year-old male presented with a Crawford type IV complex thoracoabdominal aortic aneurysm(CAAA)starting directly distal to the diaphragm extending to both common iliac arteries(CIAs).The CAAA consist of a proximal and distal aneurysmal sac separated by a 1 cm-healthy zone in the infrarenal level.Due to the poor performance of the patient and the expansive disease,we planned a stepwise-combined surgery and EVAR to minimize invasiveness.A branched graft was implanted after surgical debranching of the visceral and RA.Since the patient had renal and liver injury after surgery,the second stage EVAR was performed 10 mo later.The stent graft was implanted from the distal portion of surgical branched graft to both CIAs during EVAR.The patient has been uneventful for 5-years after discharge and is being followed in the outpatient clinic.CONCLUSION The current case demonstrates that the surgical graft can provide a landing zone for second stage EVAR to avoid aggressive surgery in patients with poor performance with a long hostile CAAA.