Purpose The present study aimed to analyze the impact of perioperative fluid management on postoperative ileus (POI) after loop ileostomy closure. Methods Consecutive loop ileostomy closures over a 6-year period (May 2011-May 2017) were included. Main outcomes were POI, defined as time to first stool beyond POD 3, and postoperative complications of any grade. Critical fluid managementrelated thresholds including postoperative weight gain were identified through receiver operator characteristics (ROC) analysis and tested in a multivariable analysis. Results Of 238 included patients, 33 (14%) presented with POI; overall complications occurred in 91 patients (38%). 1.7 L IV fluids at postoperative day (POD) 0 was determined a critical threshold for POI (area under ROC curve (AUROC), 0.64), yielding a negative predictive value (NPV) of 93%. Further, a critical cutoff for a postoperative weight gain of 1.2 kg at POD 2 was identified (AUROC, 0.65; NPV, 95%). Multivariable analysis confirmed POD 0 fluids of > 1.7 L (OR, 4.7; 95% CI, 1.4-15.3; p = 0.01) and POD 2 weight gain of > 1.2 kg (OR, 3.1; 95% CI, 1-9.4; p = 0.046) as independent predictors for POI. Conclusions Perioperative fluid administration of > 1.7 L and POD 2 weight gain of > 1.2 kg represent critical thresholds for POI after loop ileostomy closure.
Objectives To assess the interobserver reliability (IOR) of the Tile classification system, and its potential influence on outcomes, for the interpretation of CT images of pelvic fractures by radiologists and surgeons. Methods Retrospective data (1/2008–12/2016) from 238 patients with pelvic fractures were analyzed. Mean patient age was 44 years (SD 20); 66% were male. There were 54 Tile A, 82 Tile B, and 102 Tile C type injuries. The 30-day mortality rate was 15% (36/238). Six observers, three radiologists, and three surgeons with different levels of experience (attending/resident/intern) classified each fracture into one of the 26 second-order subcategories of the Tile classification. Weighted kappa coefficients were used to assess the IORs for the three main categories and nine first-order subcategories. Results The overall IORs of the Tile system for the main categories and first-order subcategories were moderate (kappa = 0.44) and fair (kappa = 0.31), respectively. IOR was fair to moderate among radiologists, but only fair among surgeons. By level of training, IOR was moderate between attendings and between residents, whereas it was only fair between interns. IOR was moderate to substantial (kappa = 0.56–0.70) between the radiology attending and resident. Association of the Tile fracture type with 30-day mortality was present based on two out of six observer ratings. Conclusions The overall IOR of the Tile classification system is only fair to moderate, increases with the level of rater experience and is better among radiologists than surgeons. In the light of these findings, results from studies using this classification system must be interpreted cautiously. Key Points • The overall interobserver reliability of the Tile pelvic fracture classification is only fair to moderate. • Interobserver reliability increases with observer experience and radiologists have higher kappa coefficients than surgeons. • Interobserver reliability has an impact on the association of the Tile classification system with mortality in two out of six cases.
MUSEC is an effective and original educational format, enjoyed by candidates, that fills an educational gap for tailored US education as a procedural skill to acute care surgeons. Ongoing revisions should reduce the current limitations and increase the educational value, in terms of number of modules and post-course credentialing.
Introduction Normovolemia after major surgery is critical to avoid complications. The aim of the present study was to analyze correlation between fluid balance, weight gain, and postoperative outcomes. Methods All consecutive patients undergoing elective or emergency major abdominal surgery needing intermediate care unit (IMC) admission from September 2017 to January 2018 were included. Postoperative fluid balances and daily weight changes were calculated for postoperative days (PODs) 0–3. Risk factors for postoperative complications (30-day Clavien) and prolonged length of IMC and hospital stay were identified through uni- and multinominal logistic regression. Results One hundred eleven patients were included, of which 55% stayed in IMC beyond POD 1. Overall, 67% experienced any complication, while 30% presented a major complication (Clavien ≥ III). For the entire cohort, median cumulative fluid balance at the end of PODs 0–1–2–3 was 1850 (IQR 1020–2540) mL, 2890 (IQR 1610–4000) mL, 3890 (IQR 2570–5380) mL, and 4000 (IQR 1890–5760) mL respectively, and median weight gain was 2.2 (IQR 0.3–4.3) kg, 3 (1.5–4.7) kg, and 3.9 (2.5–5.4) kg, respectively. Fluid balance and weight course showed no significant correlation (r = 0.214, p = 0.19). Extent of surgery, analyzed through Δ albumin and duration of surgery, significantly correlated with POD 2 fluid balances (p = 0.04, p = 0.006, respectively), as did POD 3 weight gain (p = 0.042). Prolonged IMC stay of ≥ 3 days was related to weight gain ≥ 3 kg at POD 2 (OR 2.8, 95% CI 1.01–8.9, p = 0.049). Conclusion Fluid balance and weight course showed only modest correlation. POD 2 weight may represent an easy and pragmatic tool to optimize fluid management and help to prevent fluid-related postoperative complications.
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