Prognostic factors and predictive models in hot gallbladder surgery: A prospective observational study in a high-volume center

Backgrounds/Aims

The standard treatment for acute cholecystitis, biliary pancreatitis and intractable biliary colics ("hot gallbladder") is emergency laparoscopic cholecystectomy (LC). This paper aims to identify the prognostic factors and create statistical models to predict the outcomes of emergency LC for "hot gallbladder."

Methods

A prospective observational cohort study was conducted on 466 patients having an emergency LC in 17 months. Primary endpoint was "suboptimal treatment," defined as the use of escape strategies due to the impossibility to complete the LC. Secondary endpoints were postoperative morbidity and length of postoperative stay.

Results

About 10% of patients had a "suboptimal treatment" predicted by age and low albumin. Postop morbidity was 17.2%, predicted by age, admission day, and male sex. Postoperative length of stay was correlated to age, low albumin, and delayed surgery.

Conclusions

Several predictive prognostic factors were found to be related to poor emergency LC outcomes. These can be useful in the decision-making process and to inform patients of risks and benefits of an emergency vs. delayed LC for hot gallbladder.

Sex-related immunity: could Toll-like receptors be the answer in acute inflammatory response?

An increasing number of studies have highlighted the existence of a sex-specific immune response, wherein men experience a worse prognosis in cases of acute inflammatory diseases. Initially, this sex-dependent inflammatory response was attributed to the influence of sex hormones. However, a growing body of evidence has shifted the focus toward the influence of chromosomes rather than sex hormones in shaping these inflammatory sex disparities. Notably, certain pattern recognition receptors, such as Toll-like receptors (TLRs), and their associated immune pathways have been implicated in driving the sex-specific immune response. These receptors are encoded by genes located on the X chromosome. TLRs are pivotal components of the innate immune system, playing crucial roles in responding to infectious diseases, including bacterial and viral pathogens, as well as trauma-related conditions. Importantly, the TLR-mediated inflammatory responses, as indicated by the production of specific proteins and cytokines, exhibit discernible sex-dependent patterns. In this review, we delve into the subject of sex bias in TLR activation and explore its clinical implications relatively to both the X chromosome and the hormonal environment. The overarching objective is to enhance our understanding of the fundamental mechanisms underlying these sex differences.

Post-hepatectomy liver failure: A timeline centered review

BACKGROUND

Post-hepatectomy liver failure (PHLF) is a leading cause of postoperative mortality after liver surgery. Due to its significant impact, it is imperative to understand the risk stratification and preventative strategies for PHLF. The main objective of this review is to highlight the role of these strategies in a timeline centered way around curative resection.

DATA SOURCES

This review includes studies on both humans and animals, where they addressed PHLF. A literature search was conducted across the Cochrane Library, Embase, MEDLINE/PubMed, and Web of Knowledge electronic databases for English language studies published between July 1997 and June 2020. Studies presented in other languages were equally considered. The quality of included publications was assessed using Downs and Black's checklist. The results were presented in qualitative summaries owing to the lack of studies qualifying for quantitative analysis.

RESULTS

This systematic review with 245 studies, provides insight into the current prediction, prevention, diagnosis, and management options for PHLF. This review highlighted that liver volume manipulation is the most frequently studied preventive measure against PHLF in clinical practice, with modest improvement in the treatment strategies over the past decade.

CONCLUSIONS

Remnant liver volume manipulation is the most consistent preventive measure against PHLF.

Trends and Outcomes of Salvage Lobectomy for Early-stage Non-Small Cell Lung Cancer

OBJECTIVES

There is little data describing the outcomes for patients who develop local recurrences after stereotactic body radiation therapy (SBRT), a standard-of-care treatment for patients with early-stage non-small cell lung cancer. One emerging option is salvage lobectomy. We investigated trends in the use of salvage lobectomy after SBRT and described patient outcomes using a nationally representative sample.

METHODS

This is a retrospective study using the National Cancer Database of patients with non-small cell lung cancer diagnosed from 2004 to 2017. We used descriptive statistics to describe patients who underwent salvage lobectomy. Kaplan-Meier analysis was used to estimate overall survival (OS). Cox proportional modeling was used to identify factors associated with OS.

RESULTS

We identified 276 patients who underwent salvage lobectomy. Ninety-day mortality was 0%. The median survival time for the cohort was 50 months (95% CI, 44 to 58). Median follow-up was 65 months (Interquartile Range: 39 to 96). The factors associated with decreased OS include squamous cell histology (hazard ratio (HR)=1.72, P =0.005) and high grade (1.50, P =0.038). Increased OS was associated with lobectomy performed between 3 and 6 months after SBRT (HR=0.53, P =0.021), lobectomy performed >6 months after SBRT (HR=0.59, P =0.015), and female sex (HR=0.56, P =0.004).

CONCLUSIONS

Salvage lobectomy after local failures of SBRT was associated with no perioperative mortality and favorable long-term outcomes. Our data suggest that lobectomy performed within 3 months of SBRT is associated with worse OS.

Analysis of socioeconomic and demographic factors on post-treatment outcomes for metastatic spinal tumors

OBJECTIVE

Sociodemographic factors may play a role in incidence and treatment of metastatic spinal tumors, as there is a delay in diagnosis and increased incidence of relevant primaries. There has yet to be a detailed analysis of the impact of sociodemographic factors on surgical outcomes for spinal metastases. We sought to examine the influence of socioeconomic factors on outcomes for patients with metastatic spinal tumors.

METHODS

Two hundred and sixty-three patients who underwent surgery for metastatic spinal tumors were identified. Sociodemographic characteristics were then collected and assigned to patients based on their ZIP code. The Chi-square test and the Mann-Whitney-U test were used for binary and continuous variables, respectively. Multivariate regression models were also used to control for age, smoking status, body mass index, and Charlson Comorbidity Index.

RESULTS

Males had significantly lower rates of post-treatment complication compared to females (22.7 % vs 39.3 %, p = 0.0052), and those in high educational attainment ZIP codes had significantly shorter length of stay (LOS) compared to low educational attainment ZIP codes (9.3 days vs 12.2 days, p = 0.0058). Multivariate regression revealed that living in a high percentage white ZIP code and being male significantly decreased risk of post-treatment complication by 19 % (p = 0.042) and 14 % (p = 0.032), respectively. Living in a high educational attainment ZIP code decreased LOS by 3 days (p = 0.019).

CONCLUSIONS

Males had significantly lower rates of post-treatment complication. Patients in high percentage white areas also had decreased rate of post-treatment complications. Patients living in areas with high educational attainment had shorter length of stay.

Survivorship after reverse total shoulder arthroplasty and predictors of 1-year and overall mortality

BACKGROUND

Patient survivorship and risk factors of mortality after reverse total shoulder arthroplasty (RTSA) are seldom and inadequately studied. The purpose of this study was to evaluate the mortality rates and predictors of 1-year and overall mortality after RTSA.

METHODS

We retrospectively reviewed 1518 consecutive adult patients who underwent RTSA at our institution. The Social Security Death Index and institutional electronic medical records were queried to verify patient living status. Patients were censored at date of death if deceased, the date that living status was verified if alive, or latest follow-up if living status could not be verified. Mortality rates and risk factors of 1-year and overall mortality after RTSA were identified on univariate and multivariate analysis.

RESULTS

Mean follow-up was 5.1 ± 3.8 years. Thirty-day (0.1%), 90-day (0.7%), and 1-year (1.8%) mortality rates were low but increased to 11% at 5 years. Increased odds of 1-year mortality were independently associated with heart disease (odds ratio [OR] 2.64, 95% confidence interval [CI] 1.07-6.50, P = .035) and use of a cemented stem (OR 2.64, 95% CI 1.04-6.69, P = .041). Independent risk factors of overall mortality included older age at surgery (hazard ratio [HR] 1.05, 95% CI 1.03-1.07, P < .001), minority ethnicity (protective risk factor, HR 0.37, 95% CI 0.15-0.91, P = .031), heart disease (HR 1.42, 95% CI 1.00-2.02, P = .048), diabetes mellitus (HR 1.47, 95% CI 1.04-2.08, P = .028), tobacco use (HR 1.79, 95% CI 1.08-2.98, P = .025), post renal transplant (HR 12.69, 95% CI 3.92-41.05, P < .001), chronic liver failure (HR 4.40, 95% CI 1.38-14.09, P = .013), and receiving a cemented stem (HR 1.60, 95% CI 1.13-2.26, P = .008).

CONCLUSIONS

RTSA carries a low risk of short-term mortality postoperatively. When counseling patients preoperatively, surgeons should consider the predictors of mortality after RTSA reported herein to ensure appropriate patient selection and counseling.

Evaluation of Treatment Differences Between Men and Women Undergoing Ventral Hernia Repair: An Analysis of the Abdominal Core Health Quality Collaborative

BACKGROUND

Sex is emerging as an important clinical variable associated with surgical outcomes and decision making. However, its relevance in regard to baseline and treatment differences in primary and incisional ventral hernia repair remains unclear.

STUDY DESIGN

This is a retrospective cohort study using the Abdominal Core Health Quality Collaborative database to identify elective umbilical, epigastric, or incisional hernia repairs. Propensity matching was performed to investigate confounder-adjusted treatment differences between men and women. Treatments of interest included surgical approach (minimally invasive or open), mesh use, mesh type, mesh position, anesthesia type, myofascial release, fascial closure, and fixation use.

RESULTS

A total of 8,489 umbilical, 1,801 epigastric, and 16,626 incisional hernia repairs were identified. Women undergoing primary ventral hernia repair were younger (umbilical 46.4 vs 54 years, epigastric 48.7 vs 52.7 years), with lower BMI (umbilical 30.4 vs 31.5, epigastric 29.2 vs 31.1), and less likely diabetic (umbilical 9.9% vs 11.4%, epigastric 6.8% vs 8.8%). Women undergoing incisional hernia repair were also younger (mean 57.5 vs 59.1 years), but with higher BMI (33.1 vs 31.5), and more likely diabetic (21.4% vs 19.1%). Propensity-matched analysis included 3,644 umbilical, 1,232 epigastric, and 12,480 incisional hernias. Women with incisional hernia were less likely to undergo an open repair (60.2% vs 63.4%, p < 0.001) and have mesh used (93.8% vs 94.8%, p = 0.02). In umbilical and incisional hernia repairs, women had higher rates of intraperitoneal mesh placement and men had higher rates of preperitoneal and retro-muscular mesh placement.

CONCLUSIONS

Small but statistically significant treatment differences in operative approach, mesh use, and mesh position exist between men and women undergoing ventral hernia repair. It remains unknown whether these treatment differences result in differing clinical outcomes.

Immediate and Delayed Complications of IVC Filters

OBJECTIVE

Inferior vena cava (IVC) filter placement has increased dramatically in the past two decades. However, literature supporting the efficacy of these devices has been limited and controversial. In the present study, we have evaluated the predictors and rates of technical complications after IVC filter insertion in a large national database.

METHODS

The Vascular Quality Initiative registry was explored (January 2013 to December 2020). Immediate complications were defined as venous injury requiring treatment, filter misplacement (failure to open, deployed >20 mm from intended site or in wrong vein, embolized to the heart), angulation >20°, and insertion site complications. Delayed complications were defined as migration, angulation >15°, fracture, caval and/or iliac thrombosis, filter thrombus, fragment embolization, and perforation. The Pearson χ² test was used to compare the baseline characteristics between the patients who had developed immediate and/or delayed complications and those who had not. The predictors of these complications were evaluated using multivariable logistic regression, Cox proportional hazard regression, and Kaplan-Meier survival analysis.

RESULTS

A total of 14,784 patients were included in the present analysis, with a median follow-up of 11 months (interquartile range, 4-16 months). The rate of immediate and delayed complications was 1.8% and 3.1%, respectively. Angulation (1.2%) was the most common immediate complication, and filter thrombosis (1.6%) was the most common delayed complication. Compared with the patients with no immediate complications, those with immediate complications were more likely to have had abnormal anatomy (6.0% vs 1.7%; P < .001) and a landing zone other than infrarenal (7.0% vs 4.2%; P = .02). Compared with their counterparts, those with delayed complications were less likely to have received statins (21.0% vs 29.5%; P = .006) and were more likely to have a family history of venous thromboembolism (8.0% vs 5.1%; P = .047). Logistic regression analysis revealed that renal vein visualization was associated a 50% reduction (adjusted odds ratio [aOR], 0.50; 95% confidence interval [CI], 0.27-0.92; P = .027) in the odds of immediate complications and female sex and abnormal anatomy were associated with a 41% (aOR, 1.41; 95% CI, 1.08-1.85; P = .013) and 244% (aOR, 3.44; 95% CI, 1.66-7.16; P < .001) increase in the odds of immediate complications, respectively. Immediate (P = .21) and delayed (P = .51) complications did not result in increased mortality.

CONCLUSIONS

The immediate and delayed IVC filter complication rates were 1.8% and 3.1%, respectively, but the occurrence of complications was not associated with increased mortality. Female sex was associated with an increase in the development of immediate complications. The incidence of immediate complications might be mitigated if advanced imaging were used for renal vein visualization before IVC filter deployment. Delayed complications might be avoided if IVC filter retrieval were performed in a timely fashion and institutional retrieval protocols were optimized.

Machine learning-driven identification of novel patient factors for prediction of major complications after posterior cervical spinal fusion

PURPOSE

Posterior cervical fusion is associated with increased rates of complications and readmission when compared to anterior fusion. Machine learning (ML) models for risk stratification of patients undergoing posterior cervical fusion remain limited. We aim to develop a novel ensemble ML algorithm for prediction of major perioperative complications and readmission after posterior cervical fusion and identify factors important to model performance.

METHODS

This is a retrospective cohort study of adults who underwent posterior cervical fusion at non-federal California hospitals between 2015 and 2017. The primary outcome was readmission or major complication. We developed an ensemble model predicting complication risk using an automated ML framework. We compared performance with standard ML models and logistic regression (LR), ranking contribution of included variables to model performance.

RESULTS

Of the included 6822 patients, 18.8% suffered a major complication or readmission. The ensemble model demonstrated slightly superior predictive performance compared to LR and standard ML models. The most important features to performance include sex, malignancy, pneumonia, stroke, and teaching hospital status. Seven of the ten most important features for the ensemble model were markedly less important for LR.

CONCLUSION

We report an ensemble ML model for prediction of major complications and readmission after posterior cervical fusion with a modest risk prediction advantage compared to LR and benchmark ML models. Notably, the features most important to the ensemble are markedly different from those for LR, suggesting that advanced ML methods may identify novel prognostic factors for adverse outcomes after posterior cervical fusion.

Inclusion, characteristics, and outcomes of male and female participants in large international perioperative studies

BACKGROUND

We compared baseline characteristics and outcomes and evaluated the subgroup effects of randomised interventions by sex in males and females in large international perioperative trials.

METHODS

Nine randomised trials and two cohort studies recruiting adult patients, conducted between 1995 and 2020, were included. Baseline characteristics and outcomes common to six or more studies were evaluated. Regression models included terms for sex, study, and an interaction between the two. Comparing outcomes without adjustment for baseline characteristics represents the 'total effect' of sex on the outcome.

RESULTS

Of 54 626 participants, 58% were male and 42% were female. Females were less likely to have ASA physical status ≥3 (56% vs 64%), to smoke (15% vs 23%), have coronary artery disease (21% vs 32%), or undergo vascular surgery (10% vs 23%). The pooled incidence of death was 1.6% in females and 1.8% in males (risk ratio [RR] 0.92; 95% confidence interval [CI]: 0.81-1.05; P=0.20), of myocardial infarction was 4.2% vs 4.5% (RR 0.92; 95% CI: 0.81-1.03; P=0.10), of stroke was 0.5% vs 0.6% (RR 1.03; 95% CI: 0.79-1.35; P=0.81), and of surgical site infection was 8.6% vs 8.3% (RR 1.03; 95% CI: 0.79-1.35; P=0.70). Treatment effects of three interventions demonstrated statistically significant effect modification by sex.

CONCLUSIONS

Females were in the minority in all included studies. They were healthier than males, but outcomes were comparable. Further research is needed to understand the reasons for this discrepancy.

CLINICAL TRIAL REGISTRATION

International Registry of Meta-Research (UID: IRMR_000011; 5 January 2021).

Bacterial Patterns and Sensitivity to Antibiotics in Patients Treated with Ventilators at the Intensive Care Unit of Sanglah Hospital Denpasar, Bali, Indonesia

Abstract BACKGROUND: Ventilator use to treat patients with respiratory failure in the Intensive Care Unit (ICU) is crucial to prevent further organ failure caused by inadequate oxygenation. However, as an invasive procedure, the use of a ventilator could lead to nosocomial infection, such as Ventilator-Associated Pneumonia (VAP) caused by opportunistic microorganisms in the ICU. Hence, the author is interested in finding the microbial patterns and its antibiotic sensitivity as a source of data for further researches and providing consideration on antibiotics usage for patients treated with ventilators in the ICU of Sanglah Hospital Denpasar. AIM: This study is conducted to obtain the microbial pattern and antibiotics sensitivity on patients treated with ventilators in the ICU of Sanglah Hospital Denpasar. MATERIALS AND METHODS: This research is based on the cross-sectional descriptive method. Research samples were chosen with consecutive sampling that is included in the research’s inclusion criteria. Patient data were collected from the 1st January 2021 to 30th June 2021 within the ICU of Sanglah Hospital Denpasar. Variables in this research were listed as followed: demographic data of the patients that include age, gender, comorbid, diagnosis, ventilator usage indication, bacterial culture, and bacterial susceptibility test. RESULTS: 185 culture samples were obtained from 113 patients. 18 different species of bacterias were found with the three most common microorganisms being Pseudomonas aeruginosa (22.2%), Acinetobacter baumanii (20%), and Klebsiella pneumoniae (17.3%). Susceptibility pattern found as follows: The prevalence of P aeruginosa was found sensitive towards ceftazidime (68,3%), gentamicin (68,3%), and amikacin (65,9%), A. Baumanii are mostly sensitive to amikacin (56,8%), gentamicin (32,4%), and tigecyline (32,4%), K. Pneumoniae are mostly sensitive to amikacin (83,9%), meropenem (77,4%), and piperacillin/tazobactam (54,8%). Resistance pattern found as follows: The prevalence of P aeruginosa was found resistant towards cefixime (70,7%), cefazolin (58,5%), and cefuroxime (58,5%), A. baumanii are mostly resistant to cefixime (86,5%), cefoperazone (81,1%), and piperacillin/tazobactam (75,7%), K. pneumoniae are mostly resistant to ciprofloxacin (61,3%) and levofloxacin (48,4%). CONCLUSION: To decrease the spreading of multi-drug resistant organisms that have been found in ventilated patients, prevention strategies and rational use of antibiotics needs to be performed correctly. Key-words: Ventilator, microbial pattern, antibiotics, sensitivity, resistance

Surgical morbidity in the first year after resection for perihilar cholangiocarcinoma

BACKGROUND

Surgery for perihilar cholangiocarcinoma (pCCA) is associated with high morbidity and mortality rates. The impact of surgery for pCCA may affect patients after discharge. The aim of this study was to investigate all morbidity and mortality during the first year after surgery for pCCA.

METHODS

All consecutive liver resections for suspected pCCA between 2000 and 2019 at two tertiary referral centers were included. All morbidity and mortality until one year after surgery was collected retrospectively, including readmissions and reinterventions. All recurrences within the first year were scored to calculate disease-free survival.

RESULTS

In 250 patients, the major morbidity rate was 61% (152/250), in-hospital mortality was 15% (37/250) and 90-day mortality was 16% (40/250). In the 213 discharged patients, 98 patients (46%) suffered 260 surgical complications. These complications required 185 readmissions in 92 patients (43%) and 400 reinterventions in 110 patients (52%), including 330 radiological (83%), 61 endoscopic (15%) and 9 surgical reinterventions (2%). One-year overall survival was 77% and one-year disease-free survival was 70%. Out of the 20 patients who died within the first year after discharge, 15 died of recurrent disease and 3 due to surgery related complications and 2 of unknown causes.

CONCLUSION

Readmissions, reinterventions and complications are frequent throughout the first year after surgery for pCCA in tertiary referral hospitals. These adverse events warrants treatment of these complex patients in high expertise centers offering intensive perioperative care and close follow-up of patients after discharge.

Impact of patients' gender on microvascular lower extremity reconstruction

The physiological differences between genders have significant implications for health and disease. With regard to microsurgery, results remain elusive as to whether male or female gender is an independent risk factor for free flap reconstruction. This study evaluated the impact of gender on outcomes of lower-extremity free-flap reconstructions. Within 7 years, 358 patients received 393 microvascular lower limb free flap reconstructions. The cases were divided into two groups according to patients' gender: male vs. female. Retrospective data analysis evaluated patients' demographics, perioperative details, surgical complications and flap outcomes over a 3-month follow-up period. Major and minor surgical complications, including total and partial flap loss, showed no significant differences between the investigated groups (p>.05). In addition, there was no significant difference with regard to the rate of surgical revision surgery, or the incidence of arterial and venous thrombosis (p>.05). Comparison of different flap types (fasciocutaneous ALT vs. gracilis muscle flaps) and type of anastomosis (end-to-end vs. end-to-side) also revealed no difference in outcomes in respect to gender. In conclusion, gender cannot be regarded as an independent risk factor for free flap reconstructions in patients with lower-extremity defects.

Acute and chronic hematologic implications of emergency and elective splenectomy

INTRODUCTION

Thrombocytosis and leukocytosis are common after splenectomy. The potential effect of emergency surgery on these postoperative findings is unknown. We hypothesized that emergency splenectomy leads to a more profound and persistent hematologic change as compared to elective splenectomy.

METHODS

A retrospective review was conducted of patients who underwent elective or trauma splenectomy. Records were queried for platelet (PLT) and white blood cell (WBC) count prior to splenectomy, on postoperative days 1-5, and at day 14, 1 month, 3 months, 6 months, and 1 year. Complications, including thromboembolic events, infection, need for repeat operation, and readmission within 30 days of discharge, were recorded.

RESULTS

463 patients were identified as being eligible for the study, with 173 patients in the elective cohort and 145 patients in each of the isolated trauma splenectomy and polytrauma cohorts. Both cohorts had peak thrombocytosis at week 2 postoperatively. However, polytrauma patients had a significantly higher peak platelet count (P < 0.01). The PLT:WBC ratio was lower in both trauma cohorts pre-operatively and postoperative day 1. Trauma splenectomy had a higher PLT:WBC ratio on days 2 and 3 whereas polytrauma had a lower ratio on days 4 and 5. Emergency cases had greater reoperation and infection rates, whereas elective cases were more likely to require readmission. Postoperative thromboembolic events were only higher in the polytrauma cohort.

CONCLUSIONS

While trauma splenectomy resulted in more profound postoperative leukocytosis and thrombocytosis, there was no correlation with timing of infection or risk of thromboembolic events. These findings suggest that thrombocytosis and leukocytosis may be associated with thrombotic and infectious events but their presence alone does not indicate direct risks of concomitant infection or thrombosis.

Male Sex Is Associated with Higher Mortality and Increased Risk for Complications after Surgical Treatment of Proximal Humeral Fractures

AIMS

The best surgical treatment of multi-fragmentary proximal humeral fractures in the elderly is a highly controversial topic. The aim of this study is to assess for sex-related differences regarding mortality and complications after reverse total shoulder arthroplasty (RTSA) and locking plate fixation (LPF).

PATIENTS AND METHODS

All patients from the largest German healthcare insurance (26.5 million policy holders) above the age of 65 years that were treated with LPF or RTSA after a multi-fragmentary proximal humerus fracture between January 2010 and September 2018 were included. Multivariable Cox regression models were used to assess the association of sex with overall survival, major adverse events and surgical complications.

RESULTS

A total of 8264 (15%) men and 45,707 (85%) women were followed up for a median time of 52 months. After 8 years, male patients showed significantly higher rates for death (65.8%; 95% CI 63.9-67.5% vs. 51.1%; 95% CI 50.3-51.9%; p < 0.001) and major adverse events (75.5%; 95% CI 73.8-77.1% vs. 61.7%; 95% CI 60.9-62.5%; p < 0.001). With regard to surgical complications, after adjustment of patient risk profiles, there were no differences between females and males after LPF (p > 0.05), whereas men showed a significantly increased risk after RTSA (HR 1.86; 95% CI 1.56-2.22; p < 0.001) with more revision surgeries performed (HR 1.76, 95% CI 1.46-2.12; p < 0.001) compared to women.

CONCLUSION

The male sex is an independent risk factor for death and major adverse events after both LPF and RTSA. An increased risk for surgical complications after RTSA suggests that male patients benefit more from LPF. Sex should be considered before making treatment decisions.

Mortality After Elective Surgery: The Potential Role for Preoperative Palliative Care

BACKGROUND

Preoperative optimization is increasingly emphasized for high-risk surgical patients. One critical component of this includes preoperative advanced care planning to promote goal-concordant care. We aimed to define a subset of patients that might benefit from preoperative palliative care consult for advanced care planning.

MATERIALS AND METHODS

We examined adult patients admitted from January 2016 to December 2018 to a university health system for elective surgery. Multivariate logistic regression was used to identify variables associated with death within 1 y, and presence of palliative care consults preoperatively. Chi-square analysis evaluated the impact of a palliative care consult on advanced care planning variables.

RESULTS

Of the 29,132 inpatient elective procedures performed, there was a 2.0% mortality rate at 6 mo and 3.5% at 1 y. Those who died were more likely to be older, male, underweight (BMI <18), or have undergone an otolaryngology, neurosurgery or thoracic procedure type (all P-values < 0.05). At the time of admission, 29% had an advance directive, 90% had a documented code status, and 0.3% had a preoperative palliative care consult. Patients were more likely to have an advanced directive, a power of attorney, a documented code status, and have a do not resuscitate order if they had a palliative care consult (all P-values <0.05). The mortality rates and preoperative palliative care rates per procedure type did not follow similar trends.

CONCLUSIONS

Preoperative palliative care consultation before elective admissions for surgery had a significant impact on advanced care planning.

The impact of gender on long-term outcomes following supratentorial brain tumor resection

PURPOSE

Gender is a known social determinant of health which has been linked disparities in medical care. This study intends to assess the impact of gender on 90-day and long-term morbidity and mortality outcomes following supratentorial brain tumor resection in a coarsened-exact matched population.

MATERIALS AND METHODS

A total of 1970 consecutive patients at a single, university-wide health system undergoing supratentorial brain tumor resection over a six-year period (09 June 2013 to 26 April 2019) were analyzed retrospectively. Coarsened Exact Matching was employed to match patients on key demographic factors including history of prior surgery, smoking status, median household income, American Society of Anesthesiologists (ASA) grade, and Charlson Comorbidity Index (CCI), amongst others. Primary outcomes assessed included readmission, ED visit, unplanned reoperation, and mortality within 90 days of surgery. Long-term outcomes such as mortality and unplanned return to surgery during the entire follow-up period were also recorded.

RESULTS

Whole-population regression demonstrated significantly increased mortality throughout the entire follow-up period for the male cohort (p = 0.004, OR = 1.32, 95% CI = 1.09 - 1.59); however, no significant difference was found after coarsened exact matching was performed (p = 0.08). In both the whole-population regression and matched-cohort analysis, no significant difference was observed between gender and readmission, ED visit, unplanned reoperation, or mortality in the 90-day post-operative window, in addition to return to surgery after throughout the entire follow-up period.

CONCLUSION

After controlling for confounding variables, female birth gender did not significantly predict any difference in morbidity and mortality outcomes following supratentorial brain tumor resection. Difference between mortality outcomes in the pre-matched population versus the matched cohort suggests the need to better manage the underlying health conditions of male patients in order to prevent future disparities.

Increasing age and modifiable comorbidities are associated with short-term complications after open reduction and internal fixation of ankle fractures

BACKGROUND

Ankle fractures are common orthopedic injuries with complication rates fixation of up to 40%. Limited evidence exists in the literature regarding complications in the elderly population, and moreover, these studies frequently define elderly arbitrarily at 60-65 years old. The purpose of the present study was to utilize a large, validated database to evaluate whether there is an inflection point of age when postoperative complications after an ankle fracture significantly increase.

METHODS

A retrospective review of all patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent fixation of an ankle fracture between 2012 and 2018 was performed. Patients were identified within the database using the Current Procedural Terminology codes. Appropriate statistical analysis was performed with p value less than 0.05 considered statistically significant.

RESULTS

A total of 27,633 fractures were including and comprised of 221 posterior malleolar, 1567 medial malleolar, 8495 lateral malleolar, 10,175 bimalleolar, and 7175 trimalleolar. A total of 1545 complications were encountered (5.6%). There was a statistically significant association between increasing age and complications (OR = 1.03; p < 0.001). Further analysis shows the largest spike in complications within the age 78 + bracket. There were no overall interaction effects between age and fracture subtype (p = 0.223).

CONCLUSION

ORIF of ankle fractures is a common orthopedic procedure performed on patients of all ages, with complications ranging in severity. In order to best counsel patients on their individual postoperative risks, large datasets are often necessary to prognosticate. This study found that postoperative complications increase with advanced age. The incidence of complications did not spike for patients around the age of 65, but rather followed an incremental linear pattern with the largest increase in odds ratio occurring at age 78 and above. Complication rate was not associated with specific fracture type based off of ICD codes.

Perioperative Risk Factors for One-Year Mortality in Patients With Free-Flap Reconstruction Due to Cancer of the Head and Neck

PURPOSE

Head and neck cancer requiring free-flap reconstruction is associated with relatively high mortality. We aimed to evaluate perioperative risk factors for 1-year mortality in this patient group.

METHODS

This is a single-center retrospective analysis of 204 patients operated during 2008 to 2018.

RESULTS

A total of 47 (23.0%) patients died within 1 year. In univariate analysis, there were no differences in the intraoperative course between 1-year survivors and nonsurvivors. Among the 1-year nonsurvivors, preoperative albumin level was lower (39 [36 to 43] vs 42 [39 to 44], P = .032) and the Sequential Organ Failure Assessment admission score was higher (4 [3 to 5] vs 3 [2 to 4], P = .003) than those of the 1-year survivors. Among the nonsurvivors, the preoperative and postoperative levels of leukocytes were higher (7.6 [6.7 to 9.5] vs 6.9 [5.5 to 8.4], P = .002; 11.4 [9.0 to 14.2] vs 8.7 [7.2 to 11.3], P < .001). The highest odds ratios for 1-year mortality in multivariate analysis were American Society of Anesthesiologists A classification greater than 2 (3.9 CI 1.4 to 10.5), male gender (4.0 CI 1.5 to 11), and increase in leukocyte count (1.3 CI 1.1 to 1.5).

CONCLUSIONS

One-year nonsurvivors had higher American Society of Anesthesiologists classification and were more often men. The postoperative inflammatory markers were higher in nonsurvivors, while the intraoperative course did not have a significant impact on the 1-year mortality.

Retrospective evaluation of association between perioperative antimicrobial protocol and complications following elective equine synovial endoscopy

Background

Prophylactic perioperative antimicrobial protocols in equine synovial endoscopy have been described but not compared with respect to post‐operative outcomes and complications. Increasing antimicrobial resistance in equine practice and interest in promoting judicious use of antimicrobials has prompted reevaluation of drug selection and dosing strategies.

Objectives

To determine the frequency of and compare post‐operative complications following elective synovial endoscopy between horses receiving different perioperative antimicrobial protocols.

Methods

Records from the Colorado State University Veterinary Teaching Hospital were evaluated (2014–2018) and equine patients undergoing elective synovial endoscopy were identified. Patients undergoing endoscopy for sepsis or internal fixation were excluded. Patient signalment, clinician, joint and limb involved, perioperative antimicrobial regimen, number endoscopic portals and closure technique, and post‐operative complications including incidence of joint infection were recorded. Generalized linear models were used to estimate the odds of post‐operative complications.

Results

Elective synovial endoscopies of 516 horses in 537 procedures evaluating 761 synovial structures were performed. No horses developed post‐operative septic synovitis. Administration of post‐operative antimicrobials, type used and patient sex were all significantly associated with increased risk of complications, which were predominantly gastrointestinal‐related. Complication rates in horses receiving a single preoperative dose of cefazolin were lower than in horses receiving potassium penicillin, gentamicin or multiple doses. Complication rates were lower in females compared to castrated or intact males. Other factors evaluated (breed, age, surgeon, anaesthesia duration or hospitalization, joint/limb operated, number endoscopic portals) were not associated with increased risk of complications post‐operatively in this case population.

Conclusions

Prophylactic perioperative antimicrobial protocols in equine practice deserve periodic reconsideration due to increased antimicrobial resistance. Prolonged antimicrobial usage beyond the time of surgery was unnecessary to prevent septic synovitis following synovial endoscopy in this case population and was furthermore associated with an increased risk of gastrointestinal complications.

Differences in Outcomes After Anesthesia-Related Adverse Events in Older and Younger Patients

Because more older adults undergo surgical procedures, it is incumbent on us to learn how to provide them with the safest possible perioperative care. We conducted a retrospective cohort study at a large tertiary care center to determine whether outcomes after anesthesia-related adverse events differed between patients aged 65 years and older versus patients under age 65. One thousand four hundred twenty-four cases were referred to the Performance Improvement committee of the Department of Anesthesiology from the years 2007-2015. After exclusions of cases that were not anesthesia-related, could not be identified, or were duplicates, 747 cases with anesthesia-related adverse events were included in the study. Two hundred eighty-six were aged 65 years and older and 461 were under age 65. Anesthesia-related adverse events occurred more commonly in the postoperative period in older patients relative to younger patients (37.7% vs. 21.9%, p = .001), and older patients had a greater incidence of mortality compared with a propensity-matched group of younger patients (adjusted odds ratio 1.87 [1.14-3.12], p < .05). We concluded that older patients have a greater likelihood of mortality as a result of suffering an anesthesia-related adverse event and may benefit from increased vigilance in the postoperative period.

Gender is associated with long-term mortality after cerebellopontine angle tumor resection

OBJECTIVE

Gender can contribute to adverse patient outcomes through social and biological factors. It is important to assess the effects of gender on long-term patient outcomes after care has already been accessed, in order to improve quality of care and mitigate healthcare disparities.

PATIENTS AND METHODS

277 consecutive patients undergoing cerebellopontine angle tumor resection over a six-year period (June 09, 2013 - April 29, 2019) at a university health system were retrospectively evaluated. Outcomes included 90-day emergency department (ED) visit, readmission, reoperation and mortality following resection. Male and female patients in the whole population were analyzed by logistic regression. Thereafter, Coarsened Exact Matching was used to match female and male on important demographic factors, including history of prior surgery, median household income, and Charlson Comorbidity Index (CCI) score, among others. Regression was carried out in the matched population, with significance set at a p-value < 0.05.

RESULTS

In the matched population analysis, males were significantly more likely to experience mortality during the length of follow-up (p = 0.03) but not within 90-days of resection. There were no significant differences in 90-day mortality or reoperation during the length of follow-up in either the matched or pre-matched populations. No significant differences were found in any of the 90-day morbidity outcomes in either the matched or pre-matched populations.

CONCLUSION

Gender may predict long-term outcomes in patients following CPA tumor resection. It is possible that gender also contributes to outcome disparities in other neurosurgical procedures, which future studies should evaluate.

Morbidity and Mortality of Total Pelvic Exenteration for Malignancy in the US

BACKGROUND

Total pelvic exenterations (TPEs) for malignancies are complex operations often performed by multidisciplinary teams. The differences among primary cancer for TPE and multicentered results are not well described. We aimed to describe TPE outcomes for different malignant origins in a national multicentered sample.

METHODS

Patients from the National Surgical Quality Improvement Program (NSQIP) database who underwent TPE between 2005 and 2016 for all malignant indications (colorectal, gynecologic, urologic, or other) were included. Chi square and Kruskal-Wallis tests were used to compare patient characteristics by primary malignancy. Multivariate logistic and linear regression models were used to determine factors associated with any 30-day Clavien-Dindo grade 3 or higher complication, length of hospital stay (LOS; days), 30-day wound infection, and 30-day mortality.

RESULTS

Overall, 2305 patients underwent TPE. Indications for surgery included 33% (749) colorectal, 15% (335) gynecologic, 9% (196) other, and 45% (1025) urologic malignancies. Median LOS decreased from 10 to 8 days during the study period (p < 0.001), 36% were males, and 50% required blood transfusion. High-grade complications occurred in 15% of patients and were associated with bowel diversion [odds ratio (OR) 1.6, 95% confidence interval (CI) 1.1-2.4], disseminated cancer (OR 1.8, 95% CI 1.4-2.3), and gynecologic cancers (OR 2.9, 95% CI 1.8-4.7). Mortality was 2% and was associated with disseminated cancer (OR 2.2, 95% CI 1.1-4.3) and male sex (OR 2.4, 95% CI 1.3-4.4).

CONCLUSIONS

TPE is associated with high rates of complications, however mortality rates remain low. Preoperative and perioperative outcomes differ depending on the origin of the primary malignancy.

Hypotension during hip fracture surgery and postoperative morbidity

Background

Hip fracture is a growing healthcare challenge, with 6–8% 30-day mortality and 20–30% of patients incurring major morbidity, including impaired mobilisation and ability to live independently. While observational studies have shown no benefit of general versus spinal anaesthesia on 30-day mortality, intraoperative hypotension during hip fracture surgery is associated with increased 30-day mortality regardless of anaesthetic technique. Although a recent trial on younger patients demonstrated reduced postoperative complications by maintaining intraoperative arterial blood pressure close to preoperative baseline, there are no data correlating intraoperative hypotension during hip fracture surgery with postoperative morbidity.

Objective

We evaluated the hypothesis that duration and severity of intraoperative hypotension during hip fracture surgery is associated with increased postoperative morbidity.

Methods

A retrospective analysis was carried out on n = 52 patients undergoing hip fracture surgery between January and June 2017. Measurements of patients’ intraoperative systolic arterial pressure (SAP) and mean arterial pressure (MAP) during anaesthesia, logged electronically through an anaesthesia information management system, were reviewed. We calculated the total duration of time where SAP or MAP were below pre-defined thresholds for hypotension (MAP < 75 mmHg, MAP < 55 mmHg, SAP ≤ 80% admission baseline or SAP ≤ 80% pre-induction baseline). Univariate and bivariate descriptive statistics were generated for all relevant variables. With multivariable regression models containing known predictors, cumulative duration of hypotension was correlated with postoperative comorbidities as quantified by the Clavien-Dindo and Comprehensive Complication Indices.

Results

Mean age (± SD) was 78 ± 13 years, 75% were female, 87% were ASA II or III and 60% underwent spinal anaesthesia. Mean Comprehensive Complication Index was 20.4 ± 19.2. Lowest absolute SAP and MAP values were 82 ± 18 mmHg and 55 ± 12 mmHg respectively. Cumulative time of SAP < 80% pre-induction value adjusted to gender, age and the Charlson Comorbidity Index was associated with progression to a higher Clavien-Dindo classification (odds ratio 1.020 per additional minute; 95% CI 1.008–1.035; P = 0.003).

Conclusions

In this exploratory retrospective analysis, the cumulative time of hypotension during hip fracture surgery correlated with extensive postoperative morbidity when adjusting to other known predictors. Intraoperative cumulative time of hypotension may be a good candidate for larger prediction studies as a predictor of postoperative complications. A randomised controlled trial evaluating the effect of actively minimising intraoperative hypotension on postoperative morbidity in hip fracture patients seems warranted.