Jokubauskas, Mantas

Restoration of surgical capacity is essential to post-COVID-19 recovery. This study explored the use and safety of anaesthesia options for inguinal hernia surgery, a common tracer condition, to describe current global practice and highlight opportunities to build the capacity of health systems.

Įvadas. Peritonitas – tai ūminis pilvaplėvės uždegimas, kuris išsivysto bakterijoms ar cheminėms medžiagoms patekus į normaliomis sąlygomis sterilią pilvaplėvės ertmę. Tai kliniškai reikšminga ir gyvybei pavojinga patologija, kuri tinkamai negydoma gali greitai progresuoti ir baigtis mirtimi. Nors dažniausios ūmaus peritonito priežastys yra žarnyno opų ir divertikulitų perforacijos tam tikrais atvejais pilvaplėvės uždegimą gali sukelti ir retesni etiologiniai veiksniai tokie kaip į virškinamąjį traktą patekę svetimkūniai. Atsižvelgiant į tai, jog peritonitą gali sukelti įvairūs etiologiniai faktoriai, būtina atlikti išsamią diferencinę diagnostiką ir tiksliai nustatyti pagrindinę ligos priežastį. Detalus anamnezės surinkimas, įskaitant paciento įpročius, gali būti esminis veiksnys diagnozei ir tinkamai gydymo taktikai parinkti. Klinikinis atvejis. 22 metų vyras, skundęsis stipriu pilvo skausmu ir karščiavimu hospitalizuotas dėl neaiškios kilmės ūminio peritonito. Atlikta pažeistų žarnyno segmentų rezekcija. Operacinės medžiagos patologinio histologinio tyrimo metu, pasaito riebaliniame audinyje, rasti pavieniai mikroskopiniai svetimkūniai. Remiantis tyrimo rezultatais ir surinkta anamneze, nustatyta, jog svetimkūniai pateko į virškinamąjį traktą dėl paciento įpročio kramtyti medinius dantų krapštukus ir sukėlė peritonitą. Išvados. Peritonitas yra sudėtinga patologinė būklė, kuri, nesuteikus tinkamo gydymo, gali progresuoti į sunkias, gyvybei pavojingas komplikacijas. Dažniausiai peritonitas išsivysto dėl virškinamojo trakto organų perforacijų, tačiau kai kuriais atvejais jį gali sukelti ir retesnės priežastys, pavyzdžiui, į virškinimo traktą patekę svetimkūniai. Šių atvejų diagnostika standartiniais radiologiniais tyrimais yra sudėtinga, patologijos priežastį dažnai galima patvirtinti tik atlikus histologinį tyrimą. Analizuojamas klinikinis atvejis pabrėžia kruopščios anamnezės svarbą, kuri gali lemti tikslios diagnozės nustatymą ir tinkamo gydymo parinkimą.

There is low-certainty evidence on the impact of extended pharmacological prophylaxis on venous thromboembolism-associated morbidity and mortality. The aim of this study was to determine the efficacy and safety of extended prophylaxis after major abdominopelvic surgery for the prevention of clinically relevant venous thromboembolism after hospital discharge.

Cardiovascular complications after major surgery are associated with increases in morbidity and mortality. There is confusion over definitions of cardiac injury or complications, and variability in the assessment and management of patients. This international prospective cohort study aimed to define the incidence and timing of these complications and to investigate their impact on 30-day all-cause mortality. We performed a prospective, international cohort study between January 2022 and May 2022. Data were collected on consecutive patients undergoing major abdominal surgery in 446 hospitals from 28 countries across Europe. The primary outcome measure was cardiovascular complications as defined by the Standardised Endpoints for Perioperative Medicine-Core Outcome Measures for Perioperative and Anaesthetic Care initiative up to 30 days after surgery. The secondary outcome was 30-day postoperative mortality. This study included 24,203 patients, of whom 611 (2.5%) developed cardiovascular complications. In total, 458 (1.9%) patients died within 30 days of surgery, of which 123 (26.9%) deaths were judged to be cardiac-related. Mortality rates were higher in patients who developed postoperative cardiovascular complications than in those who did not (19.8% vs. 1.4%), which persisted after risk adjustment (hazard ratio (95%CI) 4.15 (3.14-5.48)). We estimated an absolute risk reduction (95%CI) of 0.4 (0.3-0.5) in mortality in the absence of all cardiovascular complications. This would confer a relative risk reduction in mortality of 21.1% if all cardiovascular complications were prevented. Postoperative cardiovascular complications are relatively common and occur early after major abdominal surgery. However, over 1 in 5 postoperative deaths were attributable to these complications, highlighting an important area for future randomised trials.

Background. Identification of patients at high risk of surgical-site infections may allow surgeons to minimize associated morbidity. However, there are significant concerns regarding the methodological quality and transportability of models previously developed. The aim of this study was to develop a novel score to predict 30-day surgical-site infection risk after gastrointestinal surgery across a global context and externally validate against existing models.
Methods. This was a secondary analysis of two prospective international cohort studies: GlobalSurg-1 (July–November 2014) and GlobalSurg-2 (January–July 2016). Consecutive adults undergoing gastrointestinal surgery were eligible. Model development was performed using GlobalSurg-2 data, with novel and previous scores externally validated using GlobalSurg-1 data. The primary outcome was 30-day surgical-site infections, with two predictive techniques explored: penalized regression (least absolute shrinkage and selection operator (‘LASSO’)) and machine learning (extreme gradient boosting (‘XGBoost’)). Final model selection was based on prognostic accuracy and clinical utility.
Results. There were 14 019 patients (surgical-site infections = 12.3%) for derivation and 8464 patients (surgical-site infections = 11.4%) for external validation. The LASSO model was selected due to similar discrimination to extreme gradient boosting (AUC 0.738 (95% c.i. 0.725 to 0.750) versus 0.737 (95% c.i. 0.709 to 0.765)), but greater explainability. The final score included six variables: country income, ASA grade, diabetes, and operative contamination, approach, and duration. Model performance remained good on external validation (AUC 0.730 (95% c.i. 0.715 to 0.744); calibration intercept −0.098 and slope 1.008) and demonstrated superior performance to the external validation of all previous models. Conclusion. The ‘Global Surgical-Site Infection’ score allows accurate prediction of the risk of surgical-site infections with six simple variables that are routinely available at the time of surgery across global settings. This can inform the use of intraoperative and postoperative interventions to modify the risk of surgical-site infections and minimize associated harm.

Background: Multimorbidity poses a global challenge to healthcare delivery. This study aimed to describe the prevalence of multimorbidity, common disease combinations and outcomes in a contemporary cohort of patients undergoing major abdominal surgery. Methods: This was a pre-planned analysis of a prospective, multicentre, international study investigating cardiovascular complications after major abdominal surgery conducted in 446 hospitals in 29 countries across Europe. The primary outcome was 30-day postoperative mortality. The secondary outcome measure was the incidence of complications within 30 days of surgery. Results: Of 24,227 patients, 7006 (28.9%) had one long-term condition and 10,486 (43.9%) had multimorbidity (two or more long-term health conditions). The most common conditions were primary cancer (39.6%); hypertension (37.9%); chronic kidney disease (17.4%); and diabetes (15.4%). Patients with multimorbidity had a higher incidence of frailty compared with patients ≤ 1 long-term health condition. Mortality was higher in patients with one long-term health condition (adjusted odds ratio 1.93 (95%CI 1.16-3.23)) and multimorbidity (adjusted odds ratio 2.22 (95%CI 1.35-3.64)). Frailty and ASA physical status 3-5 mediated an estimated 31.7% of the 30-day mortality in patients with one long-term health condition (adjusted odds ratio 1.30 (95%CI 1.12-1.51)) and an estimated 36.9% of the 30-day mortality in patients with multimorbidity (adjusted odds ratio 1.61 (95%CI 1.36-1.91)). There was no improvement in 30-day mortality in patients with multimorbidity who received pre-operative medical assessment. Conclusions: Multimorbidity is common and outcomes are poor among surgical patients across Europe. Addressing multimorbidity in elective and emergency patients requires innovative strategies to account for frailty and disease control. The development of such strategies, that integrate care targeting whole surgical pathways to strengthen current systems, is urgently needed for multimorbid patients. Interventional trials are warranted to determine the effectiveness of targeted management for surgical patients with multimorbidity.

Timely and safe elective health care facilitates return to normal activities for patients and prevents emergency admissions. Surgery is a cornerstone of elective care and relies on complex pathways. This study aimed to take a whole-system approach to evaluating access to and quality of elective health care globally, using inguinal hernia as a tracer condition.

Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks.

Objective Advancement in radiological diagnostics lead to better detection of pancreatic lesions which results in more patients undergoing minimally invasive surgical treatment. Laparoscopic resection or laparoscopic tissue sparing technique (enucleation) are often chosen in case of benign lesion. However, pancreas surgery carries high risk of postoperative pancreatic fistula and there is conflicting data whether enucleation result in more fistulas. Aim of this study is to determine and compare the rate of postoperative pancreatic fistula following laparoscopic enucleation or laparoscopic distal pancreatectomy in case of benign pancreatic lesion. Methods A retrospective study of patients who underwent elective laparoscopic enucleation (LE) or laparoscopic distal pancreatectomy (LDP) for benign pancreatic lesion in the Department of Surgery of Lithuanian University of Health Sciences was performed. Patients’ characteristics and medical data were extracted from medical case files. Postoperative complications were analyzed according to Clavien-Dindo classification. Postoperative pancreatic fistula (POPF) was evaluated in accordance to revised 2016 definition and grading of POPF by International Study Group on Pancreatic Surgery (ISGPS). Student’s t-test was used to compare parametric, chi-square test and Mann-Whitney U test – nonparametric variables between groups. Results are reported as mean (SD). Results 46 patients underwent laparoscopic procedure for benign pancreatic lesion between September 2015 and March 2023. Median follow-up time was 35.5 months (1-75). There were 15 males (32.6%) and 31 females (67.4%). The mean age of patients was 60.87 (16.31) years. Median postoperative hospital stay was 8 days (2-59). 13 patients underwent LE (28.3%) and 33 patients – LDP (71.7%). Both groups were similar by gender distribution (p=0.869), age (p=0.557), median postoperative hospital stay (p=0.867). Lesions that were removed during LDP were larger by diameter in milimeters (15.3 (3.8) vs 27.1 (14.6), p=0.006). Overall POPF grade B rate in our study was 17.4% (8 patients). 10 patients (21.7%) developed biochemical leak (BL). We had no grade C fistulas. Difference of POPF rate between LE and LDP groups was not significant (15.4% (n=2) vs. 18.2% (n=6), p=0.520). Complication rate and severity were not different between LE and LDP (grades 1-5, 53.8% vs. 42.4%, p=0.495). There were no differences in reoperation and readmission within 90 days. Postoperative mortality rate was similar in both groups (LE 7.7% (n=1) vs. LDP 3.0% (n=1), p=0.496). Conclusions Laparoscopic enucleation did not result in more postoperative pancreatic fistulas and complication rates were similar in both groups. It is a safe and feasible alternative to laparoscopic distal pancreatectomy when performed in expert centers for select group of patients. Brief description of the abstract In this retrospective study we compared the rate of postoperative pancreatic fistula following elective laparoscopic enucleation or laparoscopic distal pancreatectomy for benign pancreatic lesion. Postoperative pancreatic fistula, complication, reoperation and readmission rates were similar in both groups. According to our data laparoscopic enucleation is a safe and feasible alternative to laparoscopic distal pancreatectomy when performed in expert centers for select group of patients.