Morbidity and mortality following colorectal surgery in patients with end-stage renal failure: a population-based study

Comparative analysis of short- and long-term outcomes in laparoscopic versus open surgery for colorectal cancer patients undergoing hemodialysis

PURPOSE

Although minimally invasive colorectal surgery has been proven to have a shorter hospital stay and fewer short-term complications than open surgery, the advantages of laparoscopic surgery for colorectal cancer patients undergoing hemodialysis have not been validated. This study compared the outcomes of open and laparoscopic approaches in these patients.

MATERIALS AND METHODS

Between January 2007 and December 2020, we retrospectively analyzed the clinical data of 78 hemodialysis patients who underwent curative-intent, elective colorectal surgery. Patients were divided into two groups according to the surgical method: open and laparoscopic.

RESULTS

Postoperative morbidity (p = 0.480) and mortality (p = 0.598) rates and length of hospital stay (28.8 vs. 27.5 days, p = 0.830) were similar between the groups. However, laparoscopic surgery patients had a shorter return to clear liquid, full liquid, or soft food time than open surgery patients (p < 0.001, p = 0.007, and p = 0.002, respectively). Disease-free survival and long-term cancer-specific survival rates were also similar between the two groups (p = 0.353 and p = 0.201, respectively). Multivariate analysis revealed that intraoperative blood transfusion was a risk factor for severe complications and mortality (OR 6.055; p = 0.046), and the odds ratio (OR) of laparoscopic surgery was not significantly greater than that of open surgery (OR = 0.537, p = 0.337).

CONCLUSION

Although laparoscopic surgery did not result in hemodialysis patients having a shorter postoperative hospital stay, our results suggest that the laparoscopic approach is as safe as open surgery for hemodialysis patients and may be beneficial for shortening the return time to food intake.

Real-world survival after colorectal surgery for malignancy in Korean patients with chronic kidney disease: an analysis of Korean healthcare big data, 2002-2019

Purpose

Globally, chronic kidney disease (CKD) is common and has been associated with an increased risk of colorectal cancer (CRC). There is a dearth of literature on the real-world morbidity and mortality associated with CKD comorbid with CRC. This study was performed to evaluate real-world survival outcomes of colorectal malignancy in Korean CKD patients.

Methods

The National Health Insurance Service of Korea provided data on patients who underwent surgical resection among patients diagnosed with CRC from 2002 to 2019.

Results

A total of 219,550 patients were included: 6,181 patients with underlying CKD and 213,369 patients without it. Each morbidity was significantly higher in the CKD-CRC group, and the postoperative mortality rates for the 30-day (3.11% vs. 1.78%, P < 0.001), 60-day (5.95% vs. 3.83%, P < 0.001), and 90-day mortality rate (8.12% vs. 5.32%, P < 0.001) were significantly higher in the CKD group. The median survival time (MST, year) was significantly lower in the CKD-CRC group (5.63; interquartile range [IQR], 5.26-5.91) than in the non-CKD-CRC group (8.71; IQR, 8.37-8.93). MST was significantly lower among CKD patients who received chemotherapy after adjustment by multivariate analysis (adjusted hazard ratio [HR], 1.43; 95% confidence interval [CI], 1.37-1.49; P < 0.001]). Subgroup analysis showed that in the CKD-CRC group, MST was lower in patients who received dialysis than in those who did not, even after multivariate analysis (adjusted HR, 2.38; 95% CI, 2.20-2.58; P < 0.001).

Conclusion

Prevention of CKD-to-end-stage renal disease progression should be adopted as a strategy to increase postoperative survival, along with active surveillance and cancer treatment.

Hip hemiarthroplasty for the treatment of femoral neck fractures in dialysis patients

OBJECTIVES

This study sought to delineate the postoperative outcomes in dialysis patients undergoing hip hemiarthroplasty (HHA) for the treatment of femoral neck fractures (FNF) in order to better optimise pre- and postoperative management and minimise short-term morbidity and mortality rates.

METHODS

16,955 patients who had undergone HHA for femoral neck fractures from 2005 to 2018 were isolated from a multi-institutional surgical registry, of which 343 (2.0%) were on dialysis and 16,612 (98.0%) were not. The cohorts were identified/analysed for differences in their comorbidities, demographic factors, and 30-day postoperative complications using Fischer's exact tests and Mann-Whitney U-tests. Coarsened exact matching (CEM) was implemented in order to control for baseline difference in demographics and comorbidities. Multivariate logistic regression analyses were used to assess the impact of dialysis as an independent risk factor for various complications, including reoperations, readmissions, and mortality.

RESULTS

Upon CEM-matching (L1-statistic <0.001), weighted multivariate logistic regression analyses demonstrated dialysis to be an independent risk factor for minor complications (OR 3.051, p < 0.001), pneumonia (OR 3.943, p < 0.001), urinary tract infections (UTIs) (OR 2.684, p < 0.001), major complications (OR 1.892, p < 0.001), unplanned intubation (OR 2.555, p = 0.047), cardiac arrest (OR 11.897, p < 0.001), deep vein thrombosis (DVT), (OR 2.610, p = 0.049), and mortality (OR 2.960, p < 0.001).

CONCLUSIONS

Dialysis independently increased the risk for unplanned intubation, cardiac arrest, blood transfusions, pneumonia, DVT, and mortality. In communicating postoperative expectations, surgeons should aim to clarify the patients' preferences and potential resuscitation designations prior to surgical intervention due to the increased risk of serious complications. A lower threshold of suspicion for DVT in this population is reasonable. Identifying high-risk patient populations that may experience increased rates of complications, with the ensuing financial expenditures, due to medical complexity rather than subpar management may help providers avoid penalties in caring for these patients.

Application of Propofol Target-Controlled Infusion for Optimized Hemodynamic Status in ESRD Patients Receiving Arteriovenous Access Surgery: A Randomized Controlled Trial

Background and Objectives: End-stage renal disease (ESRD) is associated with increased anesthetic risks such as cardiovascular events resulting in higher perioperative mortality rates. This study investigated the perioperative and postoperative outcomes in ESRD patients receiving propofol target-controlled infusion with brachial plexus block during arteriovenous (AV) access surgery. Materials and Methods: We recruited fifty consecutive patients scheduled to receive AV access surgery. While all patients received general anesthesia combined with ultrasound-guided brachial plexus block, the patients were randomly assigned to one of two general anesthesia maintenance groups, with 23 receiving propofol target-controlled infusion (TCI) and 24 receiving sevoflurane inhalation. We measured perioperative mean arterial pressure (MAP), heart rate, and cardiac output and recorded postoperative pain status and adverse events in both groups. Results: ESRD patients receiving propofol TCI had significantly less reduction in blood pressure than those receiving sevoflurane inhalation (p < 0.05) during AV access surgery. Perioperative cardiac output and heart rate were similar in both groups. Both groups reported relatively low postoperative pain score and a low incidence of adverse events. Conclusions: Propofol TCI with brachial plexus block can be used as an effective anesthesia regimen for ESRD patients receiving AV access surgery. It can be used with less blood pressure fluctuation than inhalational anesthesia.

Impact of comorbid renal dysfunction in patients with hepatocellular carcinoma on long-term outcomes after curative resection

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the most common malignancies worldwide. However, the number of patients with chronic kidney disease (CKD) is on the rise because of the increase in lifestyle-related diseases.

AIM

To establish a tailored management strategy for HCC patients, we evaluated the impact of comorbid renal dysfunction (RD), as stratified by using the estimated glomerular filtration rate (EGFR), and assessed the oncologic validity of hepatectomy for HCC patients with RD.

METHODS

We enrolled 800 HCC patients who underwent hepatectomy between 1997 and 2015 at our university hospital. We categorized patients into two (RD, EGFR < 60 mL/min/1.73 m²; non-RD, EGFR ≥ 60 mL/min/1.73 m²) and three groups (severe CKD, EGFR < 30 mL/min/1.73 m²; mild CKD, 30 ≤ EGFR < 60 mL/min/1.73 m²; control, EGFR ≥ 60 mL/min/1.73 m²) according to renal function as defined by the EGFR. Overall survival (OS) and recurrence-free survival (RFS) were compared among these groups with the log-rank test, and we also analyzed survival by using a propensity score matching (PSM) model to exclude the influence of patient characteristics. The mean postoperative observation period was 64.7 ± 53.0 mo.

RESULTS

The RD patients were significantly older and had lower serum total bilirubin, aspartate aminotransferase, and aspartate aminotransferase levels than the non-RD patients (P < 0.0001, P < 0.001, P < 0.05, and P < 0.01, respectively). No patient received maintenance hemodialysis after surgery. Although the overall postoperative complication rates were similar between the RD and non-RD patients, the proportions of postoperative bleeding and surgical site infection were significantly higher in the RD patients (5.5% vs 1.8%; P < 0.05, 3.9% vs 1.8%; P < 0.05, respectively), and postoperative bleeding was the highest in the severe CKD group (P < 0.05). Regardless of the degree of comorbid RD, OS and RFS were comparable, even after PSM between the RD and non-RD groups to exclude the influence of patient characteristics, liver function, and other causes of death.

CONCLUSION

Comorbid mild RD had a negligible impact on the prognosis of HCC patients who underwent curative hepatectomy with appropriate perioperative management, and close attention to severe CKD is necessary to prevent postoperative bleeding and surgical site infection.

Does chronic kidney disease affect the complications and prognosis of patients after primary colorectal cancer surgery?

BACKGROUND

The effect of chronic kidney disease (CKD) on the outcomes of colorectal cancer (CRC) patients after primary CRC surgery is controversial.

AIM

To analyze whether CKD had specific effect on the outcomes after CRC surgery.

METHODS

We searched the PubMed, Embase, Cochrane Library databases and CNKI, from inception to March 14, 2022. Newcastle-Ottawa Scale was used for the quality assessment in this meta-analysis, and we used RevMan 5.3 was used for data analysis.

RESULTS

A total of nine studies including 47771 patients were eligible for this meta-analysis. No significant difference was found in terms of overall postoperative complications [odds ratio (OR) = 1.78, 95%CI: 0.64-4.94, P = 0.27]. We analyzed the specific complications and found that the CKD group had higher rates of pulmonary infection (OR = 2.70, 95%CI: 1.82-4.00, P < 0.01), cardiovascular complications (OR = 3.39, 95%CI: 2.34-4.91, P < 0.01) and short-term death (OR = 3.01, 95%CI: 2.20-4.11, P < 0.01). After pooling the hazard ratio (HR), the CKD group had worse overall survival (OS) (HR = 1.51, 95%CI: 1.04-2.20, P = 0.03). We performed subgroup analyses of the dialysis and non-dialysis groups, and no significant difference was found in the non-dialysis group (HR = 1.20, 95%CI: 0.98-1.47, P = 0.08). The dialysis group had worse OS (HR = 3.36, 95%CI: 1.92-5.50, P < 0.01) than the non-dialysis group. The CKD group had worse disease-free survival (DFS) (HR = 1.41, 95%CI: 1.12-1.78, P < 0.01), and in the subgroup analysis of the dialysis and non-dialysis groups, no significant difference was found in the non-dialysis group (HR = 1.27, 95%CI: 0.97-1.66, P = 0.08). The dialysis group had worse OS (HR = 1.95, 95%CI: 1.23-3.10, P < 0.01) than the non-dialysis group.

CONCLUSION

Preexisting CKD was associated with higher rates of pulmonary infection, higher rates of short-term death, and worse OS and poorer DFS following CRC surgery.

Colorectal resection in end-stage renal disease (ESRD) patients: experience from a single tertiary center

BACKGROUND

End-stage renal disease (ESRD) and renal replacement therapy (RRT) are important risk factors for post-operative morbidity and mortality but remains poorly reported in colorectal surgery. This study aims to evaluate postoperative outcomes of ESRD patients under RRT undergoing colorectal resection.

METHODS

All ESRD patients under RRT who underwent colorectal resection between 2006 and 2019 were retrospectively reviewed. Perioperative outcomes were analysed, such as risk factors of postoperative complications.

RESULTS

Forty-two patients were analysed, including 27 emergency and 15 elective surgeries. The most frequent indication was acute colonic ischemia for emergency and malignancy for elective procedures. Laparoscopic approach was used in 12 patients (29%), without difference between elective and emergency groups. Postoperative severe complications rate (including deaths) was 50% (21/42), including 56% (15/27) and 40% (6/15) in emergency and elective groups, respectively (p = .334). Anastomotic leak was observed in 3 of the 23 patients (13%) undergoing digestive anastomosis, (1 in emergency and 2 in elective groups, p = .246). The postoperative mortality rate was 29%, not significantly different between groups. The median hospital stay was 14.5 days (8-42). At univariate analysis, history of cardiac event (p = .028) and open approach (p = .040) were associated with severe complications, and ASA score >3 (p = .043), history of cardiac event (p = .001) and diabetes (p = .030) associated with mortality.

CONCLUSIONS

Colorectal surgery in ESRD patient exposes to high risk of morbidity and mortality, even in the elective setting, especially in patients with comorbidities like cardiac event and diabetes. Careful patient selection and closed management is required in such fragile patients.

Effect of preoperative asymptomatic renal dysfunction on the clinical course after colectomy for colon cancer

PURPOSE

To evaluate the effect of mild renal dysfunction on the clinical course after colectomy in patients with colon cancer.

METHODS

The subjects of this retrospective study were 263 patients who underwent surgical resection for colon cancer at our hospital between 2011 and 2015. Renal function was assessed based on preoperative estimated glomerular filtration rate (eGFR) values. Patients were divided into groups based on their eGFR value of 55 ml/min/1.73 m². The Mann-Whitney U test, chi-square or Fisher exact test, and log-rank test were used in the data analysis.

RESULTS

There were 59 patients (22.4%) in the low eGFR group and 204 patients in the normal eGFR group. There were differences between the groups in age, comorbidities, and the levels of hemoglobin, albumin, and serum creatinine. The overall postoperative complication rate, frequency of severe complications, and length of stay were significantly higher in the low eGFR group than in the normal eGFR group. Multivariate analysis revealed that low eGFR was the only independent risk factor for severe complications (Clavien-Dindo classification III/IV). There were no differences in survival between the groups.

CONCLUSION

Preoperative asymptomatic renal dysfunction may be correlated with the development of postoperative complications and a possible significant risk factor for severe complications after colon cancer surgery.

Septicemia and mortality after noncardiac surgery associated with CHA2DS2-VASc score: a retrospective cohort study based on a real-world database

Background

Little was know about the association between the CHA2DS2-VASc score and postoperative outcomes. Our purpose is to evaluate the effects of CHA2DS2-VASc score on the perioperative outcomes in patients with atrial fibrillation (AF).

Methods

We identified 47,402 patients with AF over the age of 20 years who underwent noncardiac surgeries between 2008 and 2013 from claims data of the National Health Insurance in Taiwan. The CHA2DS2-VASc score was used to evaluate postoperative complications, mortality and the consumption of medical resources by calculating adjusted odds ratios (ORs) and 95% confidence intervals (CIs).

Results

Compared with patients with a CHA2DS2-VASc score of 0, patients with scores ≥ 5 had an increased risk of postoperative septicemia (OR 2.76, 95% CI 2.00–3.80), intensive care (OR 2.55, 95% CI 2.12–3.06), and mortality (OR 2.04, 95% CI 1.14–3.64). There was a significant positive correlation between risk of postoperative complication and the CHA2DS2-VASc score (P < 0.0001).

Conclusion

The CHA2DS2-VASc score was highly associated with postoperative septicemia, intensive care, and 30-day mortality among AF patients. Cardiologists and surgical care teams may consider using the CHA2DS2-VASc score to evaluate perioperative outcome risks in patients with AF.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01209-z.

Prognosis of hemodialysis patients undergoing surgery for gastric cancer: Results of a multicenter retrospective study

BACKGROUND

Little is known about the survival outcomes of and predictive factors for survival in hemodialysis patients undergoing surgery for gastric cancer.

METHODS

We performed a multicenter retrospective study from 9 institutions to investigate the survival outcomes of 75 hemodialysis patients with gastric cancer. Patient characteristics included demographic data, hemodialysis- and gastric cancer-related variables. Multivariate Cox hazards models were applied to determine independent predictors of poor overall survival and non-gastric cancer related death.

RESULTS

Stage I disease was predominant (58.7%) in our series. The overall morbidity and the 30-day mortality rates were 25.3% and 1.3%, respectively. The 5-year overall survival rates of patients with pStages I, II, III, and IV disease were 59.2%, 42.9%, 32.3%, and 0%, respectively. Eleven (14.7%) patients died of gastric cancer, whereas many more (40.0%) died owing to causes other than gastric cancer. Non-gastric cancer-related death was especially prevalent in patients with pStages I (95.2%) and II (75.0%) disease. Multivariable analysis revealed advanced age, long duration of hemodialysis (> 5 years), total gastrectomy, and pStage IV disease to be independently associated with poor overall survival. Notably, advanced age, long duration of hemodialysis, and the presence of cardiovascular disease were all independent predictors of non-gastric cancer-related death. Patients with all 3 factors had very poor survival outcomes (3-year overall survival; 14.3%).

CONCLUSION

The survival outcomes of hemodialysis patients with gastric cancer, especially those with early-stage gastric cancer, were clearly poor, largely owing to the increased risk of non-gastric cancer-related death. Preoperative comorbidities and hemodialytic features were useful for predicting long-term outcomes of this vulnerable population.

When ESKD complicates cancer screening and cancer treatment

End-stage kidney disease (ESKD) affects the recommended screening, incidence, treatment, and mortality of cancer. Cancer occurring in a patient with ESKD can influence candidacy for kidney transplantation as well as dialysis decision-making and cancer treatment. Certain cancers are more common among ESKD patients, notably, viral-mediated cancers that are associated with human papilloma or hepatitis viruses, and urothelial cancers associated with analgesic and Balkan nephropathies. Solid tumors are not believed to occur more frequently in ESKD patients. The presence of ESKD may confer a higher risk of post-surgical complications as well as mortality. The cost-effectiveness of cancer screening depends upon individual cancer risk and estimated overall survival. The high mortality associated with ESKD argues against routine cancer screening in dialysis patients. Cancer treatment in ESKD may be complicated by the need to avoid, adjust doses of and/or coordinate the timing of administration of imaging contrast, chemotherapy, and immunotherapy with dialysis treatments. There is a general dearth of information on the treatment of cancer in ESKD patients. These issues will be discussed, and some general guidelines presented based upon the current literature.

Association of pre-operative chronic kidney disease and acute kidney injury with in-hospital outcomes of emergency colorectal surgery: a cohort study

BACKGROUND

Pre-operative kidney function is known to be associated with surgical outcomes. However, in emergency surgery, the pre-operative kidney function may reflect chronic kidney disease (CKD) or acute kidney injury (AKI). We examined the association of pre-operative CKD and/or AKI with in-hospital outcomes of emergency colorectal surgery.

METHODS

We conducted a retrospective cohort study including adult patients undergoing emergency colorectal surgery in 38 Japanese hospitals between 2010 and 2017. We classified patients into five groups according to the pre-operative status of CKD (defined as baseline estimated glomerular filtration rate < 60 mL/min/1.73 m2 or recorded diagnosis of CKD), AKI (defined as admission serum creatinine value/baseline serum creatinine value ≥ 1.5), and end-stage renal disease (ESRD): (i) CKD(-)AKI(-), (ii) CKD(-)AKI(+), (iii) CKD(+)AKI(-), (iv) CKD(+)AKI(+), and (v) ESRD groups. The primary outcome was in-hospital mortality, while secondary outcomes included use of vasoactive drugs, mechanical ventilation, blood transfusion, post-operative renal replacement therapy, and length of hospital stay. We compared these outcomes among the five groups, followed by a multivariable logistic regression analysis for in-hospital mortality.

RESULTS

We identified 3002 patients with emergency colorectal surgery (mean age 70.3 ± 15.4 years, male 54.5%). The in-hospital mortality was 8.6% (169/1963), 23.8% (129/541), 15.3% (52/340), 28.8% (17/59), and 32.3% (32/99) for CKD(-)AKI(-), CKD(-)AKI(+), CKD(+)AKI(-), CKD(+)AKI(+), and ESRD, respectively. Other outcomes such as blood transfusion and post-operative renal replacement therapy showed similar trends. Compared to the CKD(-)AKI(-) group, the adjusted odds ratio (95% confidence interval) for in-hospital mortality was 2.54 (1.90-3.40), 1.29 (0.90-1.85), 2.86 (1.54-5.32), and 2.76 (1.55-4.93) for CKD(-)AKI(+), CKD(+)AKI(-), CKD(+)AKI(+), and ESRD groups, respectively. Stratified by baseline eGFR (> 90, 60-89, 30-59, and < 30 mL/min/1.73 m2) and AKI status, the crude in-hospital mortality and adjusted odds ratio increased in patients with baseline eGFR < 30 mL/min/1.73 m2 among patients without AKI, while these were constantly high regardless of baseline eGFR among patients with AKI. Additional analysis restricting to 2162 patients receiving the surgery on the day of hospital admission showed similar results.

CONCLUSIONS

The differentiation of pre-operative CKD and AKI, especially the identification of AKI, is useful for risk stratification in patients undergoing emergency colorectal surgery.

Perioperative outcomes and risk assessment in dialysis patients: current knowledge and future directions

Perioperative medicine is rapidly emerging as a key discipline to address the specific needs of high-risk surgical groups, such as those on chronic dialysis. Crude hospital separation rates for chronic dialysis patients are considerably higher than patients with normal renal function, with up to 15% of admission being related to surgical intervention. Dialysis dependency carries substantial mortality and morbidity risk compared to patients with normal renal function. This group of patients has a high comorbid burden and complex medical need, making accurate perioperative planning essential. Existing perioperative risk assessment tools are unvalidated in chronic dialysis patients. Furthermore, they fail to incorporate important dialysis treatment-related characteristics that could potentially influence perioperative outcomes. There is a dearth of information on perioperative outcomes of Australasian dialysis patients. Current perioperative outcome estimates stem predominantly from North American literature; however, the generalisability of these findings is limited, as the survival of North American dialysis patients is significantly inferior to their Australasian counterparts and potentially confounds reported perioperative outcomes; let alone regional variation in surgical indication and technique. We propose that data linkage between high-quality national registries will provide more complete data with more detailed patient and procedural information to allow for more informative analyses to develop and validate dialysis-specific risk assessment tools.

The impact of chronic kidney disease on bariatric perioperative outcome: a MBSAQIP matched analysis

BACKGROUND

Morbid obesity is considered a strong independent risk factor for chronic kidney disease (CKD), and bariatric surgery remains the most effective treatment for obesity-related co-morbidities. Previous large database analyses have suggested that CKD does not independently increase the risk of adverse outcomes after bariatric surgery. The safety of elective bariatric surgery in this patient population remains unclear. To this end, we compared 30-day outcomes in this patient population after laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass.

OBJECTIVES

To compare 30-day outcomes in CKD patients after laparoscopic sleeve gastrectomy or gastric bypass.

SETTING

University Hospital, United States.

METHODS

Using the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program database, we identified patients with CKD who underwent laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass in 2015 or 2016. An unmatched cohort analysis, a propensity-matched analysis, and a case-control, matched-cohort analysis was performed of patients with and without CKD.

RESULTS

Of the 302,092 patients included in this study, 2362 (.7%) had CKD, of whom 837 (35.4%) required dialysis. CKD patients were older with significantly higher rates of co-morbid conditions. Hospital length of stay, intensive care unit admission, reoperation, readmission, bleeding, cardiopulmonary, infectious complications, and total morbidity were significantly higher in CKD patients. In propensity-matched and case-control matched analyses of 4006 patients and 2264 patients, respectively, poorer outcomes in CKD patients highlight it an independent risk factor for morbidity.

CONCLUSIONS

In contrast to previously reported large database analysis, CKD and dependence on dialysis independently increases the risk of 30-day adverse outcomes after primary bariatric surgery. The benefits conferred by bariatric surgery should be carefully weighed against the increased risk of complications in this challenging population.

Mortality and morbidity after pancreatoduodenectomy in patients undergoing hemodialysis: Analysis using a national inpatient database

BACKGROUND

Whether patients undergoing hemodialysis have greater risks of mortality and morbidity after pancreatoduodenectomy remains unknown.

METHODS

We used the Diagnosis Procedure Combination database, a national Japanese inpatient database, to identify patients who underwent pancreatoduodenectomy from July 2010 to March 2015. We conducted propensity-score-matching analyses to compare the outcomes, including postoperative complications and 30- and 90-day mortality after pancreatoduodenectomy between patients with and without hemodialysis.

RESULTS

Of 30,495 eligible patients, 307 (1.0%) received hemodialysis. In the unmatched cohort, the proportions of male sex, younger age, pancreatic cancer, ischemic heart disease, diabetes mellitus, and hypertension were greater in patients with hemodialysis than those without hemodialysis. A 1-to-4 propensity score matching created a total of 1,535 patients, including 307 with hemodialysis and 1,228 without hemodialysis. Patients undergoing hemodialysis had greater proportions of postoperative complications, including peritonitis (8.8% vs 4.8%, P = .012), sepsis or disseminated intravascular coagulation (3.6% vs 0.7%, P = .001), intra-abdominal bleeding (4.9% vs 0.7%, P < .001), and acute coronary event (4.2% vs 1.7%, P = .015). Propensity score matching showed that patients undergoing hemodialysis had an increased risk of postoperative complications (OR, 1.62; 95% CI, 1.23-2.14; P = .001), 30-day mortality (OR, 7.45; 95% CI, 3.26-17.0; P < .001), and 90-day mortality (OR, 10.9; 95% CI, 6.58-18.2; P < .001) than those not undergoing hemodialysis.

CONCLUSION

Patients undergoing hemodialysis had a significantly increased risk of postoperative complications and death after pancreatoduodenectomy. In particular, surgeons should consider the increased risk of intra-abdominal bleeding, peritonitis, sepsis or disseminated intravascular coagulation, and acute coronary event in patients with hemodialysis.

End Stage Renal Disease is Associated with Increased Mortality in Perforated Gastroduodenal Ulcers

Patients with end stage renal disease (ESRD) represent a growing subset of surgical candidates and ESRD status has been associated with increased morbidity and mortality in other operations. Using a national database, we examined outcomes and risk factors for patients presenting with perforated gastroduodenal ulcers undergoing omentopexy. We identified adult and emergent patients with perforated duodenal and gastroduodenal ulcers that underwent omentopexy using the 2005 to 2012 Nationwide Inpatient Sample. We identified patients with ESRD status and assessed comorbidity status using the Elixhauser–van Walraven score. Univariate and multivariable logistic regression analyses were performed. Inpatient mortality was the primary outcome. Six thousand five hundred and twenty-one patients were identified. Median age was 59.0 years, majority were male (55.56%), 79 (1.21%) patients had ESRD, 367 (5.63%) patients died during admission. Multivariable logistic regression showed age (OR 2.71, P < 0.0001), Elixhauser–van Walraven score (OR 2.69, P < 0.0001), and ESRD status (OR 3.88, P < 0.0001) as independent risk factors for mortality. ESRD was associated with increased mortality in patients undergoing omentopexy for perforated gastroduodenal ulcers. Future studies are necessary to identify methods to increase perioperative survival.

A Calculated Risk: Performing Laparoscopic Cholecystectomy for Acute Cholecystitis on Patients with End Stage Renal Disease

End-stage renal disease (ESRD) is a multifactorial disease linked to socioeconomic status and associated with worse surgical outcomes. We explore intraoperative and postoperative outcomes in patients with cholecystitis undergoing laparoscopic cholecystectomy (LC). The Nationwide Inpatient Sample from 2005 to 2012 was used to identify patients undergoing LC for cholecystitis using ICD-9 codes. Outcomes of interest were mortality, common bile duct injury, conversion to open, intraoperative complications, postoperative complications, length of stay (LOS), and total charge. Univariate analysis was performed using t test for continuous variables and chi-squared test for categorical variables. Multivariable models were created that adjusted for age, demographics, year of admission, comorbidities, and presence of ESRD. Of 225,058 patients that underwent LC, 2,115 had ESRD. On univariate analysis, the ESRD cohort had a higher incidence of mortality and complications: intraoperative, mechanical wound, respiratory, cardiovascular, and postoperative infections. ESRD patients had higher median LOS and total charge. Multi-variate analysis showed ESRD as an independent risk factor for mortality, mechanical wound complications, and intraoperative complications. Negative binomial regression analysis showed that ESRD patients had LOS 50.4 per cent longer than non-ESRD patients. Linear regression analysis showed that, after adjustment, ESRD patients had total charge 6.82 per cent higher than non-ESRD patients. In this large retrospective analysis, we find that after adjusting for clinical, socioeconomic, and demographic variables, ESRD is an independent risk factor for increased mortality, intraoperative complications, mechanical wound complications, increased LOS, and cost for patients undergoing LC. Prospective studies exploring risk optimization strategies for patients with ESRD are warranted.

Mortality and morbidity after hepatic resection in patients undergoing hemodialysis: analysis of a national inpatient database in Japan

BACKGROUND

Whether patients undergoing hemodialysis have greater risks of mortality and morbidity after hepatic resection remains unclear.

METHODS

We used the Diagnosis Procedure Combination database, a national inpatient database in Japan, to identify patients who underwent hepatic resection from July 2010 to March 2014. Propensity scorematching analysis was performed to compare morbidity and mortality between patients with and without hemodialysis.

RESULTS

Of 53,651 eligible patients, 498 (0.93%) underwent hemodialysis. Propensity score-matching analysis indicated greater in-hospital mortality in patients with than without hemodialysis (8.6% vs 2.0%; P < .001). Patients undergoing hemodialysis had more postoperative major complications than did patients not undergoing hemodialysis (18.1% vs 7.4%; P < .001). In the subgroup analyses for in-hospital mortality, the odds ratio of hemodialysis was 2.36 (95% confidence interval, 0.78-6.59; P = .067) in limited resection, 4.61 (95% confidence interval, 1.90-11.2; P < .001) in segmentectomy or sectoriectomy, and 5.58 (95% confidence interval, 3.40-14.9; P < .001) in bisectoriectomy or trisectoriectomy. In the age subgroup analyses, the odds ratio of hemodialysis was 4.38 (95% confidence interval, 2.66-7.21; P < .001) in patients aged <80 years and 7.20 (95% confidence interval, 1.55-36.7; P = .0011) in those aged ≥80 years.

CONCLUSION

Patients undergoing hemodialysis had a substantially increased risk of mortality and morbidity after hepatic resection. Surgical indications for major hepatectomy in patients undergoing hemodialysis who are ≥80 years of age may be limited and require careful scrutiny.

Morbidity and mortality after emergency lower extremity embolectomy

OBJECTIVE

Emergency lower extremity embolectomy is a common vascular surgical procedure that has poorly defined outcomes. Our goal was to define the perioperative morbidity for emergency embolectomy and develop a risk prediction model for perioperative mortality.

METHODS

The American College of Surgeons National Surgical Quality Improvement database was queried to identify patients undergoing emergency unilateral and lower extremity embolectomy. Patients with previous critical limb ischemia, bilateral embolectomy, nonemergency indication, and those undergoing concurrent bypass were excluded. Patient characteristics and postoperative morbidity and mortality were analyzed. Multivariate analysis for predictors of mortality was performed, and from this, a risk prediction model was developed to identify preoperative predictors of mortality.

RESULTS

There were 1749 patients (47.9% male) who met the inclusion criteria. The average age was 68.2 ± 14.8 years. Iliofemoral-popliteal embolectomy was performed in 1231 patients (70.4%), popliteal-tibioperoneal embolectomy in 303 (17.3%), and at both levels in 215 (12.3%). Fasciotomies were performed concurrently with embolectomy in 308 patients (17.6%). The 30-day postoperative mortality was 13.9%. Postoperative complications included myocardial infarction or cardiac arrest (4.7%), pulmonary complications (16.0%), and wound complications (8.2%). The rate of return to the operating room ≤30 days was 25.7%. Hospital length of stay was 9.8 ± 11.5 days, and the 30-day readmission rate was 16.3%. A perioperative mortality risk prediction model based on factors identified in multivariate analysis included age >70 years, male gender, functional dependence, history of chronic obstructive pulmonary disease, congestive heart failure, recent myocardial infarction/angina, chronic renal insufficiency, and steroid use. The model showed good discrimination (C = 0.769; 95% confidence interval, 0733-0.806) and calibrated well.

CONCLUSIONS

Emergency lower extremity embolectomy has high morbidity, mortality, and resource utilization. These data provide a benchmark for this complex patient population and may assist in risk stratifying patients, allowing for improved informed consent and goals of care at the time of presentation.

American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on prevention of postoperative infection within an enhanced recovery pathway for elective colorectal surgery

BACKGROUND

Colorectal surgery (CRS) patients are an at-risk population who are particularly vulnerable to postoperative infectious complications. Infectious complications range from minor infections including simple cystitis and superficial wound infections to life-threatening situations such as lobar pneumonia or anastomotic leak with fecal peritonitis. Within an enhanced recovery pathway (ERP), there are multiple approaches that can be used to reduce the risk of postoperative infections.

METHODS

With input from a multidisciplinary, international group of experts and through a focused (non-systematic) review of the literature, and use of a modified Delphi method, we achieved consensus surrounding the topic of prevention of postoperative infection in the perioperative period for CRS patients.

DISCUSSION

As a part of the first Perioperative Quality Initiative (POQI-1) workgroup meeting, we sought to develop a consensus statement describing a comprehensive, yet practical, approach for reducing postoperative infections, specifically for CRS within an ERP. Surgical site infection (SSI) is the most common postoperative infection. To reduce SSI, we recommend routine use of a combined isosmotic mechanical bowel preparation with oral antibiotics before elective CRS and that infection prevention strategies (also called bundles) be routinely implemented as part of colorectal ERPs. We recommend against routine use of abdominal drains. We also give consensus guidelines for reducing pneumonia, urinary tract infection, and central line-associated bloodstream infection (CLABSI).

Colorectal Surgery Outcomes in Chronic Dialysis Patients: An American College of Surgeons National Surgical Quality Improvement Program Study

BACKGROUND

More than 450,000 US patients with end-stage renal disease currently dialyze. The risk of morbidity and mortality for these patients after colorectal surgery has been incompletely described.

OBJECTIVE

We analyzed the 30-day morbidity and mortality rates of chronic dialysis patients who underwent colorectal surgery.

DESIGN

This was a retrospective analysis.

SETTINGS

Hospitals that participate in the American College of Surgeons National Surgical Quality Improvement Program were included.

PATIENTS

The study included adult patients who underwent emergency or elective colon or rectal resection between 2009 and 2014.

MAIN OUTCOME MEASURES

Baseline characteristics were compared by dialysis status. The impact of chronic dialysis on 30-day mortality and serious postoperative morbidity was examined using multivariate logistic regression.

RESULTS

We identified 128,757 patients who underwent colorectal surgery in the American College of Surgeons National Surgical Quality Improvement Program database. Chronic dialysis patients accounted for 1% (n = 1285) and were more likely to be older (65.4 vs 63.2 years; p < 0.0001), black (27.2% vs 8.7%; p < 0.0001), preoperatively septic (22.1% vs 7.1%; p < 0.0001), require emergency surgery (52.0% vs 14.7%; p < 0.0001), have ischemic bowel (15.7% vs 1.6%; p < 0.0001), or have perforation/peritonitis (15.5% vs 4.2%; p < 0.0001). Chronic dialysis patients were also less likely to have a laparoscopic procedure (17.3% vs 45.0%; p < 0.0001). Chronic dialysis patients had higher unadjusted mortality (22.4% vs 3.3%; p < 0.0001), serious postoperative morbidity (47.9% vs 18.8%; p < 0.0001), and median length of stay (9 vs 6 days; p < 0.0001). In emergent cases (n = 19,375), multivariate logistic regression models demonstrated a higher risk of mortality for dialysis patients (OR = 1.73 (95% CI, 1.38-2.16)) but not for serious morbidity. Models for elective surgery demonstrated a similar effect on mortality (OR = 2.47 (95% CI, 1.75-3.50)) but also demonstrated a higher risk of serious morbidity (OR = 1.28 (95% CI, 1.04-1.56)).

LIMITATIONS

The postoperative 30-day window may underestimate the true incidence of serious morbidity and mortality.

CONCLUSIONS

Chronic dialysis patients undergoing elective or emergent colorectal procedures have a higher risk-adjusted mortality.

Bariatric Surgery in Patients with Dialysis-Dependent Renal Failure

BACKGROUND

Laparoscopic procedures for the treatment of morbid obesity are commonly offered to patients with comorbidities previously thought to carry prohibitive operative risk. In this study, we reviewed characteristics and perioperative outcomes of patients with dialysis-dependent renal failure (DDRF) who underwent laparoscopic bariatric procedures.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2006 to 2011 was reviewed. Preoperative characteristics and 30-day outcome data of patients who underwent three common laparoscopic procedures were analyzed using ANOVA and Pearson chi-squared tests.

RESULTS

One hundred thirty-eight patients (52.5 % female) with DDRF and a median body mass index (BMI) of 45.5 kg/m(2) were identified; 33.8 % (n = 47) underwent laparoscopic banding (LAGB), 48.9 % (n = 68) laparoscopic Roux-en-Y gastric bypass (RYGB), and 16.5 % (n = 23) laparoscopic sleeve gastrectomy (LSG). No differences were found among groups in age, prevalence of American Society of Anesthesiology IV classification, BMI, weight, gender, prevalence of diabetes, and vascular or neurologic comorbidities. Total operation time and length of hospital stay were significantly different between groups. Mortality was 0.7 %, and overall morbidity was 5.8 %. The case mix reflected a decrease in LAGB procedures from 45.5 to 23.3 % from 2006-2009 to 2010-2011 and an increase in LSG procedures from 9.1 to 24.7 % (p < 0.006).

CONCLUSIONS

When performed in selected DDRF patients, bariatric surgery is safe. An increase in LSG with a concurrent decline in LAGB procedures was demonstrated over the period of the study.

Pregnancy outcomes among renal transplant recipients and patients with end-stage renal disease on dialysis

AIM

The purpose of our study is to compare pregnancy outcomes between women with a functioning renal transplant and women with end-stage renal disease (ESRD).

METHODS

We carried out a population-based retrospective cohort study using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database from 2006 to 2011. Logistic regression analysis was used to estimate the age-adjusted effect of functioning renal transplant vs. ESRD requiring dialysis on pregnancy outcomes.

RESULTS

We identified 264 birth records to women with a functional renal transplant and 267 birth records to women with ESRD on dialysis among 5,245,452 births. As compared to women with ESRD on dialysis, renal transplant recipients were less likely to have placental abruption [odds ratio, OR 0.23 (95% confidence interval, CI 0.08-0.70)], to receive blood transfusions [OR 0.17 (95% CI 0.09-0.30)], and to have growth-restricted and small-for-gestational-age babies [OR 0.45 (95% CI 0.23-0.85)]. Renal transplant recipients were more likely to have an instrumental delivery [OR 15.38 (95% CI 1.92-123.3)]. Among renal transplant women, there was a trend towards delivery by cesarean section as compared to patients with ESRD [OR 1.31 (95% CI 0.93-1.85)]. However, these results were not statistically significant. Fetal deaths were less likely to occur in women with a renal transplant [OR 0.41 (95% CI 0.17-0.96)]. There were four maternal deaths among patients with ESRD on dialysis and no maternal deaths among renal transplant patients.

CONCLUSION

Patients with a functional renal graft had an overall lower rate of morbidity and adverse pregnancy complications when compared to patients with ESRD on dialysis.

Association of dialysis with adverse postoperative outcomes in colorectal cancer-an analysis of ACS-NSQIP

PURPOSE

Dialysis is an important factor in predicting the risk associated with cardiovascular and general abdominal surgery. The association between cancer patients and dialysis was also studied, and in particular, the effects of dialysis on the postoperative outcomes of colorectal cancer which has not been widely reported in the literature.

METHODS

This is a retrospective, multi-institutional study of the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database, investigating preoperative dialysis status and its association with postoperative mortality and morbidity.

RESULTS

Among 42,403 colorectal cancer patients, 265 patients (0.6 %) were receiving dialysis. Patients undergoing dialysis had a higher risk of re-intubation (6.8 %, p < 0.001), on ventilator-support more than 48 h (7.2 %, p < 0.001), and sepsis (7.2 %, p < 0.05). Deep surgical site infection (adjusted odds ratio = 2.09), pneumonia (adjusted odds ratio = 1.86), and septic shock (adjusted odds ratio = 1.9) were significantly associated with dialysis status. The postoperative mortality rate of dialysis patients was 8.3 % (p < 0.001) and had significant association in a multivariate Cox proportional hazard model (hazard ratio = 1.63, p = 0.026). Total length of hospital stay (coefficient = 3.5, p < 0.001) and overall complication (coefficient = 0.134, p < 0.001) were prominent in the dialysis groups. The rate of laparoscopic surgery in dialysis and non-dialysis patients was 33 and 42 %, respectively (odds ratio = 0.693, p = 0.005).

CONCLUSIONS

In colorectal cancer, dialysis status significantly contributes to postoperative morbidity, length of total hospital stay, and mortality. In addition, the rates of preventable infection and pulmonary complications were shown to require more careful attention in the hospital setting, and particularly in dialysis patients. Preoperative dialysis patients are less likely than non-dialysis patients to undergo a minimally invasive approach.

Impact of chronic kidney disease on postoperative outcome following colorectal cancer surgery

AIM

Chronic kidney disease (CKD) is increasing in prevalence and is associated with cardiovascular events and mortality in asymptomatic and vascular surgery populations. This study aimed to determine the role of CKD in stratifying peri- and postoperative risk for colorectal cancer (CRC) patients with nonmetastatic disease undergoing elective curative resection.

METHOD

Patients diagnosed with nonmetastatic colorectal adenocarcinoma and undergoing surgical resection between 2006 and 2011 were identified from a prospectively collated database. Further information on survival and cause of death was gathered from a regional cancer registry. Estimated glomerular filtration rates were calculated using the Modification of Diet in Renal Disease (MDRD) equation. Kaplan-Meier survival curves were constructed for disease-free and overall survival. Multivariate Cox regression models were used to determine the role of CKD after stratification by several clinicopathological factors.

RESULTS

Seven-hundred and eight colorectal resections were studied [median follow up: 45 (interquartile range, 21-65) months). Overall postoperative complications were similar, but patients with CKD were more likely to develop cardiovascular morbidity (P < 0.001) and 30-day mortality [4.8% (six of 124) in the CKD group vs 2.1% (12/580) in the non-CKD group]. Kaplan-Meier analysis revealed poorer overall survival for localized (Stage I-II; P = 0.019) and Stage III (P = 0.001) CRC in the CKD population. Multivariate Cox regression analysis identified CKD as an independent prognostic factor for noncancer death [hazard ratio (HR) = 1.82 (95% CI: 1.07-3.10); P = 0.027] but not for overall survival [HR = 1.21 (95% CI: 0.90-1.47); P = 0.116].

CONCLUSION

Patients with CKD may be more likely to develop cardiovascular complications following CRC resection and have an increased risk of a noncancer death. Future research should explore the interaction of CKD in competing mortality risks following CRC surgery.

Hepatic and pancreatic resection in patients with end-stage renal disease: a propensity analysis

BACKGROUND

Hepatic and pancreatic surgery is rarely performed in patients with end-stage renal disease (ESRD). The present authors used a national clinical database to characterize outcomes and perioperative risk in ESRD patients who require hepatic or pancreatic resection.

METHODS

The 2005-2011 National Surgical Quality Improvement Program database was queried for all patients undergoing hepatic or pancreatic resection. Patients were classified by the presence or absence of ESRD. The independent effects of ESRD on outcomes were assessed after propensity score adjustment and multivariable logistic regression.

RESULTS

Of the 27 376 patients submitted to hepatic or pancreatic procedures identified in the database, 101 patients were found to have preoperative ESRD. Patients with ESRD experienced perioperative mortality at a rate similar to that in those without ESRD (5.0% versus 2.3%; P = 0.08). After risk adjustment, the presence of ESRD was associated with three-fold higher odds of postoperative sepsis (adjusted odds ratio: 2.98, P = 0.014), but no significant differences in mortality or major complication rates.

CONCLUSIONS

Hepatic and pancreatic resections can be performed safely in selected patients with ESRD. These patients may have an increased risk for the development of postoperative sepsis. Further study is needed to characterize modifiable risk factors that impact outcomes in patients with ESRD who require hepatic or pancreatic resection.

Validation of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) score for maintenance hemodialysis patients undergoing elective abdominal surgery

AIMS

This study assessed the validity of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) score in maintenance hemodialysis patients undergoing elective abdominal surgery.

METHODS

We retrospectively reviewed the medical records of 73 hemodialysis patients who underwent elective gastrointestinal surgery. The main outcomes analyzed were the E-PASS score and postoperative course, which were defined by mortality and morbidity. The discriminative capability of the E-PASS score was evaluated using receiver operating characteristic (ROC) curve analysis.

RESULTS

The overall mortality rate observed was 2.7% (2 patients) and the morbidity rate was 36.9%. There were no significant differences in the comprehensive risk score, preoperative score or surgical stress score for patients with or without complications (p = 0.556, 0.639 and 0.168, respectively). Subsequent ROC curve analysis demonstrated poor predictive accuracy for morbidity. When the results in our study population were compared with those in Haga's study population, our population exhibited a highly significant rightward shift (p < 0.001).

CONCLUSION

The E-PASS score was a poor predictor of complications because maintenance hemodialysis patients already have relatively high risk factors. This scoring system should not be applied in such a special group with high risk factors.

Pancreatic resections in renal failure patients: is it worth the risk?

Background. Chronic kidney disease affects 20 million US patients, with nearly 600,000 on dialysis. Long-term survival is limited and the risk of complex pancreatic surgery in this group is questionable. Previous studies are limited to case reports and small case series and a large database may help determine the true risk of pancreatic surgery in this population. Methods. The American College of Surgeons National Surgical Quality Improvement Program database was queried (2005–2011) for patients who underwent pancreatic resection. Renal failure was defined as the clinical condition associated with rapid, steadily increasing azotemia (rise in BUN) and increasing creatinine above 3 mg/dL. Operative trends and short-term outcomes were reviewed for those with and without renal failure (RF). Results. In 18,533 patients, 28 had RF. There was no difference in wound infections, neurologic or cardiovascular complications. Compared to non-RF patients, those with RF had more unplanned intubation (OR 4.89, 95% CI 1.85–12.89), bleeding requiring transfusion (OR 3.12, 95% CI 1.37–14.21), septic shock (OR 8.86, 95% CI 3.75–20.91), higher 30-day mortality (21.4% versus 2.3%, P < 0.001) and longer hospital stay (23 versus 12 days, P < 0.001). Conclusions. RF patients have much higher morbidity and mortality after pancreatic resections and surgeons should consider this before proceeding.

Risk factors for maintenance hemodialysis patients undergoing elective and emergency abdominal surgery

Purpose

To identify the risk factors for morbidity and mortality after elective and emergency abdominal surgeries in maintenance hemodialysis patients.

Methods

We retrospectively evaluated the medical records of 63 hemodialysis patients who underwent elective (group 1) and 24 who underwent emergency (group 2) abdominal surgeries, and classified them according to the presence/absence of postoperative complications. The clinical, laboratory and procedure-related data were obtained and compared between the groups.

Results

Group 2 had significantly higher morbidity and mortality rates than group 1 (58.3 and 16.6 % vs. 33.3 and 16.6 %, respectively, P < 0.05). The patients in group 1 with and without complications had significantly different blood urea nitrogen (BUN) levels of 52.3 vs. 41.6 mg/dL (P = 0.03). There were significant differences in the patients in group 2 in terms of the age (72.7 vs. 55.0 years old; P < 0.002), the length of the operation (141 vs. 107 min; P < 0.02), the total protein levels (6.2 vs. 6.7 g/dL; P < 0.03), albumin levels (3.2 vs. 3.7 g/dL; P < 0.04) and need for intra- or postoperative blood transfusions (71.4 vs. 10.0 %; P < 0.005).

Conclusions

The risk factors for a poor surgical outcome included high BUN levels in the elective surgery patients and hypoproteinemia, hypoalbuminemia, a longer operation and older age in patients undergoing emergency surgery. Perioperative blood transfusion was also associated with a high complication rate in the emergency surgery group.

Adverse outcomes after noncardiac surgery in patients with diabetes: a nationwide population-based retrospective cohort study

OBJECTIVE

To investigate whether diabetes affects perioperative complications or mortality and to gauge its impact on medical expenditures for noncardiac surgeries.

RESEARCH DESIGN AND METHODS

With the use of reimbursement claims from the Taiwan National Health Insurance system, we performed a population-based cohort study of patients with and without diabetes undergoing noncardiac surgeries. Outcomes of postoperative complications, mortality, hospital stay, and medical expenditures were compared between patients with and without diabetes.

RESULTS

Diabetes increased 30-day postoperative mortality (odds ratio 1.84 [95% CI 1.46-2.32]), particularly among patients with type 1 diabetes or uncontrolled diabetes and patients with preoperative diabetes-related comorbidities, such as eye involvement, peripheral circulatory disorders, ketoacidosis, renal manifestations, and coma. Compared with nondiabetic control patients, coexisting medical conditions, such as renal dialysis (5.17 [3.68-7.28]), liver cirrhosis (3.59 [2.19-5.88]), stroke (2.87 [1.95-4.22]), mental disorders (2.35 [1.71-3.24]), ischemic heart disease (2.08 [1.45-2.99]), chronic obstructive pulmonary disease (1.96 [1.29-2.97]), and hyperlipidemia (1.94 [1.01-3.76]) were associated with mortality for patients with diabetes undergoing noncardiac surgery. Patients with diabetes faced a higher risk of postoperative acute renal failure (3.59 [2.88-4.48]) and acute myocardial infarction (3.65 [2.43-5.49]). Furthermore, diabetes was associated with prolonged hospital stay (2.30 [2.16-2.44]) and increased medical expenditures (1.32 [1.25-1.40]).

CONCLUSIONS

Diabetes increases postoperative 30-day mortality, complications, and medical expenditures in patients undergoing in-hospital noncardiac surgeries.

Predicting risk of death in general surgery patients on the basis of preoperative variables using American College of Surgeons National Surgical Quality Improvement Program data

OBJECTIVES

To use the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database to develop an accurate and clinically meaningful preoperative mortality predictor (PMP) for general surgery on the basis of objective information easily obtainable at the patient's bedside and to compare it with the preexisting NSQIP mortality predictor (NMP).

METHODS

Data were obtained from the ACS NSQIP Participant Use Data File (2005 to 2008) for current procedural terminology codes that included open pancreas surgery and open/laparoscopic colorectal, hernia (ventral, umbilical, or inguinal), and gallbladder surgery. Chi-square analysis was conducted to determine which preoperative variables were significantly associated with death. Logistic regression followed by frequency analysis was conducted to assign weight to these variables. PMP score was calculated by adding the scores for contributing variables and was applied to 2009 data for validation. The accuracy of PMP score was tested with correlation, logistic regression, and receiver operating characteristic analysis.

RESULTS

PMP score was based on 16 variables that were statistically reliable in distinguishing between surviving and dead patients (p < 0.05). Statistically significant variables predicting death were inpatient status, sepsis, poor functional status, do-not-resuscitate directive, disseminated cancer, age, comorbidities (cardiac, renal, pulmonary, liver, and coagulopathy), steroid use, and weight loss. The model correctly classified 98.6% of patients as surviving or dead (p < 0.05). Spearman correlation of the NMP and PMP was 86.9%.

CONCLUSION

PMP score is an accurate and simple tool for predicting operative survival or death using only preoperative variables that are readily available at the bedside. This can serve as a performance assessment tool between hospitals and individual surgeons.

Are non-cardiac surgeries safe for dialysis patients? - A population-based retrospective cohort study

BACKGROUND

End-stage renal disease represents a risk complex that complicates surgical results. The surgical outcomes of dialysis patients have been studied in specific fields, but the global features of postoperative adverse outcomes in dialysis patients receiving non-cardiac surgeries have not been examined.

METHODS

Taiwan's National Health Insurance Research Database was used to study 8,937 patients under regular dialysis with 8,937 propensity-score matched-pair controls receiving non-cardiac surgery between 2004 and 2007. We investigated the influence of hemodialysis and peritoneal dialysis, effects of hypertension and diabetes, and impact of additional comorbidities on postoperative adverse outcomes.

RESULTS

Postoperative mortality in dialysis patients was higher than in controls (odds ratio [OR] 3.33, 95% confidence interval [CI] 2.56 to 4.33) when receiving non-cardiac surgeries. Complications such as acute myocardial infarction, pneumonia, bleeding, and septicemia were significantly increased. Postoperative mortality was significantly increased among peritoneal dialysis patients (OR 2.71, 95% CI 1.70 to 4.31) and hemodialysis patients (OR 3.42, 95% CI 2.62 to 4.47) than in controls. Dialysis patients with both hypertension and diabetes had the highest risk of postoperative complications; these risks increased with number of preoperative medical conditions. Patients under dialysis also showed significantly increased length of hospitalization, more ICU stays and higher medical expenditures.

CONCLUSION

Surgical patients under dialysis encountered significantly higher postoperative complications and mortality than controls when receiving non-cardiac surgeries. Different dialysis techniques, pre-existing hypertension/diabetes, and various comorbidities had complication-specific impacts on surgical adverse outcomes. These findings can help surgical teams provide better risk assessment and postoperative care for dialysis patients.

Recognizing risk: bowel resection in the chronic renal failure population

BACKGROUND

There is a paucity of quality data on the effects of chronic kidney disease in abdominal surgery. The aim of this study was to define the risk and outcome predictors of bowel resection in stage 5 chronic kidney disease using a large national clinical database.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried from years 2005-2010 for major bowel resection in dialysis-dependent patients. Patient demographics, preoperative risk factors, and intraoperative variables were evaluated. Primary endpoints were mortality and morbidity after 30 days. Predictors of outcome were assessed by multivariate regression.

RESULTS

The study included 1,685 patients with chronic kidney disease undergoing bowel resection. Overall mortality and morbidity were 27.5 and 58.3 %, respectively. Acute presentation was the strongest predictor of mortality (OR 2.39, CI 1.54-3.72, p < 0.001). Other predictors of mortality included hypoalbuminemia (OR 2.12, CI 1.39-3.24, p < 0.001), pulmonary comorbidity (OR 2.25, CI 1.67-3.03, p < 0.001), and cardiac comorbidity (OR 1.54, CI 1.16-2.05, p = 0.003).

CONCLUSION

This study demonstrates that bowel resection in patients with chronic kidney disease confers a high mortality risk. Preoperative optimization of comorbid conditions may reduce mortality after bowel resection in dialysis-dependent patients. In addition, laparoscopy was associated with a reduction in postoperative morbidity suggesting that it should be used preferentially.

Variations in the quality of care at radical prostatectomy

Postoperative morbidity and mortality is low following radical prostatectomy (RP), though not inconsequential. Due to the natural history of the disease process, the implications of treatment on long-term oncologic control and functional outcomes are of increased significance. Structures, processes and outcomes are the three main determinants of quality of RP care and provide the framework for this review. Structures affecting quality of care include hospital and surgeon volume, hospital teaching status and patient insurance type. Process determinants of RP care have been poorly studied, by and large, but there is a developing trend toward the performance of randomized trials to assess the merits of evolving RP techniques. Finally, the direct study of RP outcomes has been particularly controversial and includes the development of quality of life measurement tools, combined outcomes measures, and the use of utilities to measure operative success based on individual patient priority.

Predictive factors of in-hospital mortality in colon and rectal surgery

BACKGROUND

Knowledge of the independent risk factors for mortality in colon and rectal surgery can aid surgeons in surgical decision making and in providing patients with appropriate information about the risks of surgery. This study endeavors to identify the risk factors for mortality that are associated with colon and rectal surgery.

STUDY DESIGN

Using the Nationwide Inpatient Sample database, we examined the clinical data of patients who underwent colon and rectal resection from 2006 to 2008. Multivariate regression analysis was performed to identify factors predictive of in-hospital mortality.

RESULTS

A total of 975,825 patients underwent colon and rectal resection during this period. Overall, the rate of in-hospital mortality was 4.50% (elective surgery, 1.42% vs emergent surgery, 8.76%; p < 0.01). Mortality was lower after laparoscopic compared with open operation (1.43% vs 4.74%; p < 0.01). Using multivariate regression analysis, significant risk factors for in-hospital mortality were emergent surgery (adjusted odds ratio [AOR] = 3.53), liver disease (AOR = 3.02), age older than 65 years (AOR = 2.92), total colectomy (AOR = 2.88), chronic renal failure (AOR = 2.37), malignant tumor (AOR = 2.0), open operation (AOR = 1.85), peripheral vascular disease (AOR = 1.81), diverticulitis (AOR = 1.77), transverse colectomy (AOR = 1.43), chronic lung disease (AOR = 1.41), ulcerative colitis (AOR = 1.40), left colectomy (AOR = 1.31), alcohol abuse (AOR = 1.21), male sex (AOR = 1.12), nonteaching hospital (AOR = 1.11), and African-American race (AOR = 1.09). There was no association between hypertension, diabetes, congestive heart failure, obesity, smoking, proctectomy, sigmoidectomy, or Crohn disease and in-hospital mortality.

CONCLUSIONS

In patients undergoing colorectal surgery, emergent surgery, liver disease, total colectomy, age older than 65 years, chronic renal failure, and malignant tumor are the major risk factors for in-hospital mortality.

Mortality and morbidity in dialysis-dependent patients undergoing spinal surgery: analysis of a national administrative database in Japan

BACKGROUND

The impact of dialysis dependence on perioperative risks following spinal surgery is not fully understood. The purposes of the present study were to determine the perioperative risks in dialysis-dependent patients treated with spinal surgery and to examine whether the presence of destructive spondyloarthropathy further increases perioperative risks.

METHODS

We examined abstracted data from the Diagnosis Procedure Combination database in a retrospective analysis of a nationally representative inpatient database. The survey of the database is conducted annually for a six-month period between July 1 and December 31. The data from 2007 and 2008 were used for this study. We included all patients who had undergone any combination of laminectomy, laminoplasty, discectomy, and/or spinal arthrodesis. For analysis, dialysis-dependent patients were further classified into subgroups with or without destructive spondyloarthropathy.

RESULTS

We identified 51,648 eligible patients (30,743 men and 20,905 women; mean age, sixty-two years), including 869 (1.7%) who were dialysis-dependent. Of the latter, ninety-five had destructive spondyloarthropathy. Overall in-hospital mortality was 0.41%. Dialysis-dependent patients had a significantly higher in-hospital mortality rate than non-dialysis-dependent patients. After adjustment, dialysis-dependent patients remained at a tenfold higher risk for in-hospital death. Dialysis-dependent patients were also at significantly greater risk for postoperative major complications. The rate of complications in dialysis-dependent patients with destructive spondyloarthropathy was 65% higher than that in those without destructive spondyloarthropathy, but this difference did not reach significance.

CONCLUSIONS

Dialysis-dependent patients had a tenfold higher risk of in-hospital death than did non-dialysis-dependent patients. Dialysis-dependent patients were also more likely to have major complications such as cardiac events, sepsis, and respiratory complications. Our data also indicate that the presence of destructive spondyloarthropathy is associated with a higher rate of postoperative complications in dialysis-dependent patients.

The effect of insurance status on outcomes after partial nephrectomy

BACKGROUND

Privately insured patients may have favorable health outcomes when compared to those covered by federally funded initiatives. This study explored the effect of insurance status on five short-term outcomes after partial nephrectomy (PN).

METHODS

Within the Health Care Utilization Project Nationwide Inpatient Sample (NIS), we focused on PNs performed between 1998 and 2007. We tested the rates of in-hospital mortality, blood transfusions, prolonged length of stay, as well as intraoperative and postoperative complications, stratified according to insurance status. Multivariable logistic regression analyses fitted with general estimation equations for clustering among hospitals further adjusted for confounding factors.

RESULTS

Overall, 8,513 PNs were identified. Of those, most patients were privately insured (53.5%), followed by Medicare (37.5%), uninsured (4.6%) and Medicaid (4.4%). Medicare and Medicaid patients had higher rates of transfusions (P < 0.001) and overall postoperative complications (P < 0.001). In multivariable analyses, when compared to privately insured patients, Medicaid patients had higher rates of transfusions (OR = 1.91, P < 0.001) and prolonged length of stay (OR = 1.49, P < 0.001). Medicare patients had higher rates of overall postoperative complications (OR = 1.24, P = 0.015) and length of stay beyond the median (OR = 1.4, P < 0.001).

CONCLUSION

Patients with private insurance undergoing PN have better short-term outcomes, when compared to their publicly insured counterparts.