Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in New Zealand: peri-operative outcomes and service development over a decade

BACKGROUND

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is the standard of care for selected cases of peritoneal surface malignancy. However, due to its morbidity and learning curve, it is only delivered in six centres in Australia and Aotearoa New Zealand (AoNZ). In this study, we report peri-operative morbidity and mortality following CRS/HIPEC at Waikato and Braemar Hospitals, which have treated patients from all regions of AoNZ since 2008.

METHODS

We retrospectively reviewed a database of all patients undergoing CRS and HIPEC from 01/01/2008 to 01/11/2020 at Waikato and Braemar Hospitals.

RESULTS

Two-hundred and forty procedures were performed for 221 patients with a mean age of 55, including 22 (9.2%) re-do procedures. One hundred and eighty-six cases were European, 32 were Māori, and 16 were Pasifika. There were 152 pseudomyxoma peritonei, 39 colorectal adenocarcinomas, 29 appendiceal cancers, 8 ovarian cancers, 6 peritoneal mesothelioma, and 6 other tumour types. The median PCI was 16. HIPEC was administered to 196 out of 196 CC0/1 cases (100%) and 3 out of 44 CC2/3 cases (6.8%). Fifty-six cases (23.3%) had at least one major complication. There were two mortalities (0.8%) within 30 days. The median length of stay was 11 days. Operative duration was identified as an independent risk factor for major complications. There was considerable variation in the number of referrals from different regions of AoNZ. Over time, a decline in major complication rate is seen with increased case volume.

CONCLUSION

The Waikato region has achieved favourable short-term outcomes following CRS/HIPEC.

Abnormal Iron Status and Adverse Outcome After Elective Cardiac Surgery: A Prospective, Observational Multicenter Study

OBJECTIVES

To investigate the incidence of preoperative abnormal iron status and its association with packed red blood cell (PRBC) transfusion, postoperative major complications, and new onset of clinically significant disability in patients undergoing elective cardiac surgery.

DESIGN

A prospective, observational multicenter cohort study.

SETTING

Three cardiac surgical centers in the Netherlands between 2019 and 2021. Recruitment was on hold between March and May 2020 due to COVID-19.

PATIENTS

A total of 427 patients aged 60 years and older who underwent elective on-pump cardiac surgery.

MEASUREMENTS AND MAIN RESULTS

The primary endpoint was a 30-day PRBC transfusion. Secondary endpoints were postoperative major complications within 30 days (eg, acute kidney injury, sepsis), and new onset of clinically significant disability within 120 days of surgery. Iron status was evaluated before surgery. Abnormal iron status was present in 45.2% of patients (n = 193), and most frequently the result of iron deficiency (27.4%, n = 117). An abnormal iron status was not associated with PRBC transfusion (adjusted relative risk [ARR] 1.2; 95% CI 0.9-1.8: p = 0.227) or new onset of clinically significant disability (ARR 2.0; 95% CI 0.9-4.6: p = 0.098). However, the risk of postoperative major complications was increased in patients with an abnormal iron status (ARR 1.7; 95% CI 1.1-2.5: p = 0.012).

CONCLUSIONS

An abnormal iron status before elective cardiac surgery was associated with an increased risk of postoperative major complications but not with PRBC transfusion or a new onset of clinically significant disability.

Cost Benefit of Implementation of Risk Stratification Models for Adult Spinal Deformity Surgery

STUDY DESIGN/SETTING

Retrospective cohort study.

OBJECTIVE

Assess the extent to which defined risk factors of adverse events are drivers of cost-utility in spinal deformity (ASD) surgery.

METHODS

ASD patients with 2-year (2Y) data were included. Tertiles were used to define high degrees of frailty, sagittal deformity, blood loss, and surgical time. Cost was calculated using the Pearl Diver registry and cost-utility at 2Y was compared between cohorts based on the number of risk factors present. Statistically significant differences in cost-utility by number of baseline risk factors were determined using ANOVA, followed by a generalized linear model, adjusting for clinical site and surgeon, to assess the effects of increasing risk score on overall cost-utility.

RESULTS

By 2 years, 31% experienced a major complication and 23% underwent reoperation. Patients with ≤2 risk factors had significantly less major complications. Patients with 2 risk factors improved the most from baseline to 2Y in ODI. Average cost increased by $8234 per risk factor (R2 = .981). Cost-per-QALY at 2Y increased by $122,650 per risk factor (R2 = .794). Adjusted generalized linear model demonstrated a significant trend between increasing risk score and increasing cost-utility (r2 = .408, P < .001).

CONCLUSIONS

The number of defined patient-specific and surgical risk factors, especially those with greater than two, were associated with increased index surgical costs and diminished cost-utility. Efforts to optimize patient physiology and minimize surgical risk would likely reduce healthcare expenditures and improve the overall cost-utility profile for ASD interventions.Level of evidence: III.

Analysis of Hysterectomy Trends in the Last 5 Years at a Tertiary Center

Objectives

This study aimed to assess trends by evaluating the types and complications of hysterectomies performed for benign gynecological reasons at our clinic, which is one of the largest hospitals in Turkey.

Materials and Methods

Hysterectomies performed for benign reasons at our gynecology and obstetrics clinic between January 1, 2015 and December 31, 2020 were retrospectively reviewed and included in the analysis. Of the 4288 patients who had undergone hysterectomy, 888 patients were excluded some reasons. The data of the remaining 3400 patients were analyzed.

Results

For the 3400 patients, the hysterectomy methods performed were as follows: Total Abdominal Hysterectomy (TAH (60%, n = 2055), Total Laparoscopic Hysterectomy (TLH), (27%, n = 948), Vaginal Hysterectomy (VH), (8.9%, n = 302), Conversion from laparoscopy to laparotomy (L / S > LT). (1.4%, n = 49), Robotic hysterectomy (RH), (1%, n = 33), and Subtotal hysterectomy (SH), (0.4%, n = 13). The length of hospital stay was statistically significantly lower in the TLH group than in the TAH group (P < 0.05). A statistically significant and moderate correlation was noted between the length of hospital stay and the duration of operation (r: 0.68 P = 0.00).

Conclusion

The ratio of TLH group among hysterectomy modalities has increased over the years. There are many factors that affect the surgeon's decision in determining the hysterectomy method. TLH is the first option in patients who are not suitable for vaginal hysterectomy.

Complications of Percutaneous Radiologic Gastrostomy Among Patients in a Tertiary Care Hospital in Riyadh, Saudi Arabia

BACKGROUND

Percutaneous radiologic gastrostomy (PRG) is the method of choice for patients incapable of ingesting nutrition orally. The complications related to PRG are classified into major and minor complications. This article presents the prevalence of major and minor complications of PRG among adult patients admitted to King Abdulaziz Medical City (KAMC) in Riyadh, Saudi Arabia between 2017 and 2018.

METHODS

This was a retrospective cross-sectional study, which included adult patients who underwent a new PRG intubation between 2017 and 2018 in KAMC in Riyadh, Saudi Arabia. The variables reviewed were the demographics, comorbidities, indications of tube insertion, major and minor complications, and mortality rates.

RESULTS

A total of 105 patients who underwent PRG were covered in this study with a mean age of 69.2 + 20.4 years. The most common indications were neurogenic pharyngeal dysphagia (31%) and dementia (29%). Most of the complications reported were minor (40%) and major complications were found in 2%. The percentage of patients with both minor and major complications was 37%. The patients who had no complications made up 21%. Major skin complication was reported in 19 patients (18%), while leakage was the most occurring minor complication found in 49 patients (47%). The 30-day mortality was observed in five patients (5%) and one-year mortality was observed in 21 patients (20%), and none of them were related to the PRG tube.

CONCLUSION

This study found that the PRG procedure had low rates of complications in KAMC. The majority were minor complications, and the mortality rate was low with none being related to the tube itself. So PRG may be considered to be a relatively safe procedure.

Covered TIPS Procedure-Related Major Complications: Incidence, Management and Outcome From a Single Center

Background and Objective

Transjugular intrahepatic portosystemic shunt (TIPS) is a well-established procedure for treating complications of portal hypertension. Due to the complexity of anatomy and difficulty of the puncture technique, the procedure itself might brought potential complications, such as puncture failure, bleeding, infection, and, rarely, death. The aim of this study is to explore the incidence, management, and outcome of TIPS procedure-related major complications using covered stents.

Methods

Patients who underwent TIPS implantation from January 2015 to December 2020 were recruited retrospectively. Major complications after TIPS were screened and analyzed.

Results

Nine hundred and forty-eight patients underwent the TIPS procedure with 95.1% (n = 902) technical success in our department. TIPS procedure-related major complications occurred in 30 (3.2%) patients, including hemobilia (n = 13; 1.37%), hemoperitoneum (n = 7; 0.74%), accelerated liver failure (n = 6; 0.63%), and rapidly progressive organ failure (n = 4; 0.42%). Among them, 8 patients died because of hemobilia (n = 1), accelerated liver failure (n = 4), and rapidly progressive organ failure (n = 3).

Conclusion

The incidence of major complications related to TIPS procedure is relatively low, and some of them could recover through effective medical intervention. In our cohort, the overall incidence is about 3%, which causes 0.84% death. The most fatal complication is organ failure and hemobilia.

The risks associated with percutaneous native kidney biopsies: a prospective study

BACKGROUND

The known risks and benefits of native kidney biopsies are mainly based on the findings of retrospective studies. The aim of this multicentre prospective study was to evaluate the safety of percutaneous renal biopsies and quantify biopsy-related complication rates in Italy.

METHODS

The study examined the results of native kidney biopsies performed in 54 Italian nephrology centres between 2012 and 2020. The primary outcome was the rate of major complications 1 day after the procedure, or for longer if it was necessary to evaluate the evolution of a complication. Centre and patient risk predictors were analysed using multivariate logistic regression.

RESULTS

Analysis of 5304 biopsies of patients with a median age of 53.2 years revealed 400 major complication events in 273 patients (5.1%): the most frequent was a ≥2 g/dL decrease in haemoglobin levels (2.2%), followed by macrohaematuria (1.2%), blood transfusion (1.1%), gross haematoma (0.9%), artero-venous fistula (0.7%), invasive intervention (0.5%), pain (0.5%), symptomatic hypotension (0.3%), a rapid increase in serum creatinine levels (0.1%) and death (0.02%). The risk factors for major complications were higher plasma creatinine levels [odds ratio (OR) 1.12 for each mg/dL increase, 95% confidence interval (95% CI) 1.08-1.17], liver disease (OR 2.27, 95% CI 1.21-4.25) and a higher number of needle passes (OR for each pass 1.22, 95% CI 1.07-1.39), whereas higher proteinuria levels (OR for each g/day increase 0.95, 95% CI 0.92-0.99) were protective.

CONCLUSIONS

This is the first multicentre prospective study showing that percutaneous native kidney biopsies are associated with a 5% risk of a major post-biopsy complication. Predictors of increased risk include higher plasma creatinine levels, liver disease and a higher number of needle passes.

A Systematic Review and Meta-Analysis of Enhanced Recovery for Open Abdominal Aortic Aneurysm Surgery

Introduction: Open abdominal aortic aneurysm (AAA) surgery is associated with significant morbidity, mortality and high length of stay (LOS). Enhanced recovery is now commonplace and has been shown to decrease these in other non-vascular surgery settings. This systematic review and meta-analysis aimed to assess the benefits of enhanced recovery (ERAS) in aortic surgery. Method: Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were used to undertake a systematic review via Ovid MEDLINE and Embase on 10.07.2021. The search terms were "aortic aneurysm" and "fast track" or "enhanced recovery". Data was obtained on major complications, 30-day mortality and LOS. Results: 107 papers were identified and 10 papers included for meta-analysis. Complication rates were significantly reduced with ERAS compared to non-ERAS protocols (ERAS n = 709, non-ERAS n = 930) (odds ratio .38, .22 to .65: P = .0005). LOS was also significantly reduced with an ERAS protocol (ERAS n = 708, non-ERAS n = 956) with a mean reduction of 3 .18 days (-5.01 to -1.35 days) (P = .0007: I2 = 97%). There was no significant difference however in 30-day mortality (P = .92). Conclusion: This meta-analysis demonstrates significant benefits to an enhanced recovery programme in open AAA surgery. There is a need for a multi-centre randomized controlled trial to assess this further.

The Effect of Major and Minor Complications After Lung Surgery on Length of Stay and Readmission

The effect of post-operative adverse events (AEs) on patient outcomes such as length of stay (LOS) and readmissions to hospital is not completely understood. This study examined the severity of AEs from a high-volume thoracic surgery center and its effect on the patient postoperative LOS and readmissions to hospital. This study includes patients who underwent an elective lung resection between September 2018 and January 2020. The AEs were grouped as no AEs, 1 or more minor AEs, and 1 or more major AEs. The effects of the AEs on patient LOS and readmissions were examined using a survival analysis and logistic regression, respectively, while adjusting for the other demographic or clinical variables. Among 488 patients who underwent lung surgery, (Wedge resection [n = 100], Segmentectomy [n = 51], Lobectomy [n = 310], Bilobectomy [n = 10], or Pneumonectomy [n = 17]) for either primary (n = 440) or secondary (n = 48) lung cancers, 179 (36.7%) patients had no AEs, 264 (54.1%) patients had 1 or more minor AEs, and 45 (9.2%) patients had 1 or more major AEs. Overall, the median of LOS was 3 days which varied significantly between AE groups; 2, 4, and 8 days among the no, minor, and major AE groups, respectively. In addition, type of surgery, renal disease (urinary tract infection [UTI], urinary retention, or acute kidney injury), and ASA (American Society of Anesthesiology) score were significant predictors of LOS. Finally, 58 (11.9%) patients were readmitted. Readmission was significantly associated with AE group (P = 0.016). No other variable could significantly predict patient readmission. Overall, postoperative AEs significantly affect the postoperative LOS and readmission rates.

Skeletal Muscle Depletion and Major Postoperative Complications in Locally-Advanced Head and Neck Cancer: A Comparison between Ultrasound of Rectus Femoris Muscle and Neck Cross-Sectional Imaging

Simple Summary

Skeletal muscle mass (SMM) depletion is gaining popularity as independent predictor of postoperative complications in many surgical scenarios, even in the field of head and neck oncology. In this study, we demonstrate the value of ultrasound scans of the rectus femoris muscle together with the neck CT/MRI at C3 level in terms of estimation of SMM (through muscle cross sectional area), the identification of sarcopenic patients and as a predictor of major surgical morbidity in a cohort of locally-advanced head and neck cancer patients submitted to surgical treatment. This provides important tools for the on-going re-assessment of patients with regards to any pre-habilitation strategy aimed at reducing postoperative complications.

Abstract

Skeletal muscle mass (SMM) depletion has been validated in many surgical fields as independent predictor of complications through cross-sectional imaging. We evaluated SMM depletion in a stage III-IV head and neck cancer cohort, comparing the accuracy of CT/MRI at C3 level with ultrasound (US) of rectus femoris muscle (RF) in terms of prediction of major complications. Patients submitted to surgery were recruited from 2016 to 2021. SMM was estimated on CT/MRI by calculating the sum of the cross-sectional area (CSA) of the sternocleidomastoid and paravertebral muscles at C3 level and its height-indexed value (cervical skeletal muscle index, CSMI) and on US by computing the CSA of RF. Specific thresholds were defined for both US and CT/MRI according to ROC curve in terms of best prediction of 30-day major complications to detect sarcopenic subjects (40–53%). Sixty-five patients completed the study. At univariate analysis, major complications were associated to lower RF CSA, lower CSA at C3 level and lower CSMI, together with previous radiotherapy, higher ASA score and higher modified frailty index (mFI). At multivariate analysis RF CSA (OR 7.07, p = 0.004), CSA at C3 level (OR 6.74, p = 0.005) and CSMI (OR 4.02, p = 0.025) were confirmed as independent predictors in three different models including radiotherapy, ASA score and mFI. This analysis proved the value of SMM depletion as predictor of major complications in a head and neck cancer cohort, either defined on cross-sectional imaging at C3 or on US of RF.

Factors predicting major complications, mortality, and recovery in percutaneous endoscopic gastrostomy

Background and Aim

Percutaneous endoscopic gastrostomy (PEG) has been used in patients with dysphagia and inadequate food intake via an oral route. Despite being a procedure with a high success rate, complications and death have been reported. The aim was to identify the factors related to major complications and mortality, as well as PEG removal prognostic factors due to improvement of their general condition.

Methods

Patient characteristics, comorbidities, laboratory data, concomitant medication, sedation, and indication for PEG placement were collected. Major complications, mortality, and PEG removal factors were assessed.

Results

A total of 388 patients were enrolled. There were 15 (3.9%) cases of major complications, with major bleeding being the most frequent in 6 (1.5%) patients. Corticosteroids were the independent variable associated with major complications (odds ratio [OR] 5.85; 95% confidence interval [CI] 1.71–20; P = <0.01). Advanced cancer (hazard ratio [HR] 0.5; 95% CI 0.3–1; P = 0.05), albumin (HR 0.6; 95% CI 0.4–0.9; P = <0.01), and C‐reactive protein (CRP) (HR 1.1; CI 1–1.2; P = 0.01) were considered risk factors for mortality. Previous pneumonia (HR 0.4; CI 0.2–0.9; P = 0.02) was a factor for permanent use of a PEG; however, oncological indication (HR 8.2; CI 3.2–21; P = <0.01) was factors for PEG withdrawal.

Conclusions

Chronic corticosteroid users potentially present with major complications. Low albumin levels and elevated CRP were associated with death. Previous aspiration pneumonia was a factor associated with permanent use of PEG; however, patients with oncological indication were the most benefited.

Pulmonary artery size on computed tomography is associated with major morbidity after pulmonary lobectomy

OBJECTIVE

To investigate the relationship of pulmonary artery diameter (PAD) measured by computed tomography (CT) with outcomes following lobectomy.

METHODS

Records of patients undergoing pulmonary lobectomy for lung cancer between 2011 and 2018 were reviewed. Baseline characteristics and postoperative outcome data were derived from the institutional Society of Thoracic Surgeons database. Luminal diameter of the central pulmonary arteries and ascending aorta were measured on preoperative CTs. Logistic regression analyses were performed to test the association of PAD with complications.

RESULTS

A total of 736 lobectomy patients were included, who had a preoperative CT scan (25% with contrast, 75% noncontrast) available for review. A total of 141 (19.2%) patients had an enlarged main PAD ≥30 mm, and 58 (7.9%) patients had a main PAD that was larger than the ascending aorta (PA/ascending aorta ratio > 1). The right or left PAD on the surgical side was associated with major complication (odds ratio per mm, 1.12; 95% confidence interval, 1.05-1.18; P < .001), unexpected intensive care unit admission (odds ratio per millimeter, 1.11; 95% confidence interval, 1.04-1.19; P = .002), and 30-day mortality (odds ratio per millimeter, 1.25; 95% confidence interval, 1.06-1.46; P = .007). On multivariable analysis, adjusted for cardiovascular comorbidities, pulmonary function, and the operative approach, surgical side PAD remained an independent factor associated with major complication.

CONCLUSIONS

CT-based measurements of the PAD on the operative side may inform of the about the risk of major complications after lobectomy. Review of PA size on preoperative CT scans may help identify patients who would benefit from formal evaluation of PA pressures to improve the operative risk assessment.

Trends in operative time and outcomes in minimally invasive hysterectomy from 2008 to 2018

BACKGROUND

There is a national shift toward laparoscopic hysterectomy as the predominant form of minimally invasive hysterectomy. Previous research suggests that vaginal hysterectomy is associated with lower operative time and improved outcomes; however, this has not been validated in a modern cohort of women.

OBJECTIVE

This analysis aims to evaluate whether total vaginal hysterectomy remains associated with lower operative times and fewer postoperative complications than total laparoscopic hysterectomy or laparoscopic-assisted vaginal hysterectomy, given recent shifts in clinical practice patterns and training experience.

STUDY DESIGN

A secondary analysis of the National Surgical Quality Improvement Program database was performed. Three primary outcomes were defined for the analysis: operative time, rate of major complications, and rate of minor complications. Secondary outcomes included changes in route of surgery over time. Descriptive analyses were performed for all outcomes of interest. Operative time, rate of major complications, and rate of minor complications were compared for each of the 3 forms of minimally invasive hysterectomy: total laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, and total vaginal hysterectomy. Bivariate analyses were performed using analysis of variance, Kruskal-Wallis, Pearson chi-square, or Fisher exact tests where appropriate. Multivariable ordinary least squares and logistic regression were used to assess for overall differences in outcomes and trends over time, controlling for sociodemographic factors and medical comorbidities. Sensitivity analyses were performed using a propensity score-matched cohort created to balance groups across time.

RESULTS

A total of 161,626 women met criteria for inclusion. Rates of total vaginal hysterectomy dropped from 51% to 13% between 2008 and 2018, whereas rates of total laparoscopic hysterectomy increased from 12% to 68% (P<.001). In multivariable analyses, total laparoscopic hysterectomy and laparoscopic-assisted vaginal hysterectomy were associated with lower odds of major complications (adjusted odds ratio [95% confidence interval]: 0.813 [0.750-0.881] and 0.873 [0.797-0.957], respectively) and minor complications (adjusted odds ratio [95% confidence interval]: 0.723 [0.676-0.772] and 0.896 [0.832-0.964], respectively) than total vaginal hysterectomy. Temporal trends show an increase in total vaginal hysterectomy operative time and decreases in total laparoscopic hysterectomy and laparoscopic-assisted vaginal hysterectomy operative times over the 11-year analysis period (P<.001), although total vaginal hysterectomy continues to have the shortest median operative time overall. No temporal trends were observed in rates of complications.

CONCLUSION

This analysis highlights recent shifts in rates of minimally invasive hysterectomy. Alongside this change in practice pattern, this study also brings to light a resultant shift in the complication rates associated with each surgical approach, as laparoscopic hysterectomy has lower rates of complications than vaginal hysterectomy despite longer operative times.

Incidence and preoperative predictors for major complications following radical nephroureterectomy

Background

Radical nephroureterectomy (RNU) is the referent standard for managing bulky, invasive, or high grade upper-tract urothelial carcinoma (UTUC). The UTUC patient population, however, generally harbor medical comorbidities thereby placing them at risk of surgical complications. This study reviews a large international cohort of RNU patients to define the risk of major complications and preoperative factors associated with their occurrence.

Methods

Patients undergoing RNU at 14 academic medical centers between 2002 and 2015 were retrospectively reviewed. Preoperative clinical, demographic, operative, and comorbidity indices were recorded. The modified Clavien-Dindo index was used to grade complications occurring within 30 days of surgery. The association between preoperative variables and major complications occurring after RNU was determined by multivariable logistic regression.

Results

One thousand two hundred and sixty-six patients (707 men; 559 women) with a median age of 70 years and BMI of 27 kg/m² were included. Over three-quarters of the cohort was white, 50.1% had baseline chronic kidney disease (CKD) ≥ stage III, 22.4% had a Charlson comorbidity index (CCI) score >5, and 17.1% had an Eastern Cooperative Oncology Group (ECOG) performance status ≥2. Overall, 413 (32.6%) experienced a complication including 103 (8.1%) with a major event. Specific distribution of major complications included 49 Clavien III, 44 Clavien IV, and 10 Clavien V. On univariate analysis, patient age (P=0.006), hypertension (P=0.002), diabetes mellitus (P=0.023), CKD stage (P<0.001), American Society of Anesthesiologists (ASA) score (P=0.022), ECOG (P<0.001), and CCI (P<0.001) all were associated with major complications. On multivariate analysis, ECOG ≥2 (OR 2.38, 95% CI, 1.46–3.90), P=0.001), CCI >5 (OR 3.45, 95% CI, 1.41–8.33, P=0.007), and CKD stage ≥3 (OR 3.64, P=0.008) were independently associated with major complications.

Conclusions

Major complications following RNU occurred in almost 10% of patients. Impaired preoperative performance status and baseline CKD are preoperative variables associated with these major post-surgical adverse event. These easily measurable indices warrant consideration and discussion prior to proceeding with RNU.

Early fixation of traumatic spinal fractures and the reduction of complications in the absence of neurological injury: a retrospective cohort study from the American College of Surgeons Trauma Quality Improvement Program

OBJECTIVE

The optimal timing of operative stabilization of patients with traumatic spinal fractures without spinal cord injury (SCI) has not been established. The challenges of early operative intervention, which may require prone positioning in a patient with multisystem injuries, must be balanced with the disadvantages of prolonged immobilization. The authors set out to define the optimal timing of surgical repair of traumatic spinal fractures in patients without SCI and the effect of delayed repair on the incidence of major complications.

METHODS

A retrospective cohort study was conducted using data derived from the American College of Surgeons Trauma Quality Improvement Program. Adult trauma patients who underwent operative fixation of a spinal fracture within 7 days of admission were included. Patients with SCI were excluded. The primary outcome was the occurrence of a major complication. Secondary outcomes included death and length of stay. Restricted cubic splines were used to model the nonlinear effects of time to spinal fixation and determine a threshold beyond which stabilization was associated with a higher rate of major complications. Logistic regression and propensity score matching were then used to derive estimates for the association between delayed fixation and major complications.

RESULTS

The authors identified 19,310 patients treated at 389 centers who met the inclusion criteria. Modeling identified fixation beyond 24 hours as a risk for major complications. Adjusting for potential confounders using multivariable logistic regression showed that late fixation was associated with a 1.30 (95% CI 1.15-1.46) times increased odds of developing a major complication. After propensity score matching, late fixation remained associated with a 1.25 (95% CI 1.13-1.39) times increased risk of experiencing a major complication.

CONCLUSIONS

In the absence of clear contraindications, surgeons should strive to stabilize traumatic spinal fractures without SCI within 24 hours. Early fixation can be expected to reduce major complications by 25%-30%.

Development of a model predicting the risk of eight major postoperative complications after esophagectomy based on 10 826 cases in the Japan National Clinical Database

BACKGROUND

Esophagectomy is a highly invasive procedure with a high incidence of complications. The objectives of this study were to create risk prediction models for postoperative morbidity associated with esophagectomy and to test their performance using a population-based large database.

METHODS

A total of 10 862 patients who underwent esophagectomy between January 2011 and December 2012 derived from the Japanese national clinical database (NCD) were included. Based on the 148 preoperative clinical variables collected, risk prediction models for eight major postoperative morbidities were created using 80% (8715 patients) of the study population and validated using the remaining 20% (2147 patients) of the patients.

RESULTS

The mortality rate was 3.1% and postoperative morbidity was observed in 42.6% of the patients. The c-statistics of the eight risk models established by the training set were surgical site infection (0.564), anastomotic leakage (0.531), need for transfusion (0.636), blood loss >1000 mL (0.644), pneumonia (0.632), unplanned intubation (0.607), prolonged mechanical ventilation over 48 hours (0.614), and sepsis (0.618) in the validation analysis.

CONCLUSIONS

Risk prediction models for postoperative morbidity after esophagectomy using the population-based large database showed relatively fair performance. The current models may offer baseline information for risk stratification in clinical decision makings and help select more suitable surgical and nonsurgical treatment options and future clinical studies.

Clinical parameters predicting complications in native kidney biopsies

Background

Renal biopsies are essential in nephrology but they are invasive and complications can occur. The aim of this study was to explore clinical parameters that can be used as predictors for biopsy complications.

Methods

Clinical parameters such as demographics, biopsy indications, serology, comorbidities and clinical chemistry were retrieved from a regional biopsy registry between 2006 and 2015 and from a nationwide registry between 2015 and 2017. Clinical data before biopsy were compared with data on major biopsy complications. Fisher’s exact and χ² tests were used and odds ratios (ORs) with 95% confidence intervals (CIs) were presented. Univariate and multiple binary logistic regression analyses were performed with complications as outcome. A two-sided P-value <0.05 was considered significant.

Results

In total, 2835 consecutive native kidney biopsies were analysed (39% women and 61% men, median age 57 years). No death and nephrectomy due to biopsy complications were registered. The frequency of major biopsy complications was 5.65%. In the multiple logistic regression, the risk for complications increased in women [OR 1.51 (95% CI 1.08–2.11)] and decreased with age: 45–64 years age group [OR 0.66 (95% CI 0.44–0.99)] and >74 years age group [OR 0.51 (95% CI 0.27–0.96)]. Among comorbidities, patients with diabetes mellitus type 2 [OR 2.07 (95% CI 1.15–3.72)] and non-ischaemic heart disease [OR 3.20 (95% CI 1.64–6.25)] had a higher risk for major biopsy complications.

Conclusions

Female gender, younger age (≤44 years), diabetes mellitus type 2 and non-ischaemic heart disease were found as risk factors for major biopsy complications.

Outcomes of major complications after robotic anatomic pulmonary resection

BACKGROUND

There is a paucity of robust clinical data on major postoperative complications following robotic-assisted resection for primary lung cancer. This study assessed the incidence and outcomes of patients who experienced major complications after robotic anatomic pulmonary resection.

METHODS

This was a multicenter, retrospective review of patients who underwent robotic anatomic pulmonary resection between 2002 and 2018. Major complications were defined as grade III or higher complications according to the Clavien-Dindo classification. Statistical analysis was performed based on patient-, surgeon-, and treatment-related factors.

RESULTS

During the study period, 1264 patients underwent robotic anatomic pulmonary resections, and 64 major complications occurred in 54 patients (4.3%). Univariate analysis identified male sex, forced expiratory volume in 1 second, diffusion capacity of the lung for carbon monoxide, neoadjuvant therapy, and extent of resection as associated with increased likelihood of a major postoperative complication. Patient age, performance status, body mass index, reoperation status, and surgeon experience did not have a significant impact on major complications. Patients who experienced at least 1 major complication were at higher risk for an intensive care unit stay of >24 hours (17.0% vs 1.4%; P < .001) and prolonged hospitalization (8.5 days vs 4 days; P < .001). Patients who experienced a major postoperative complication had a 14.8% risk of postoperative death.

CONCLUSIONS

In this series, the major complication rate during the postoperative period was 4.3%. A number of identified patient- and treatment-related factors were associated with an increased risk of major complications. Major complications had a significant impact on mortality and duration of stay.

[The complications of cochlear implantation and the methods for their treatment]

The objective of the present study was to improve the surgical component of cochlear implantation (CI) with special reference to the prevention and correction of its complications. A total of 967 cochlear implantation were performed on 847 patient treated based at the A. Geidarov Republican Hospital, Ministry of Internal Affairs of Azerbaijan, and the Research and Clinical Centre of Otorhinolaryngology, FMBA of Russia during the period from 2014 till 2017. The majority of the patients (n=540) were the children at the age varying from 1 to 4 years. All surgical interventions were carried out under the supervision of a single experienced specialist. The check-up examinations were performed every three months during the postoperative period. The postoperative complications were categorized in terms of severity (as major and minor) and time of the first manifestation (intraoperative and delayed). The detailed analysis of all documented complications was performed including the description of their variants and causes as well as of the surgical strategy applied in each concrete case. The frequency of major and minor complications was estimated at 2.6 and 1.6% respectively. It is concluded that cochlear implantation performed by an experienced surgeon provides a relatively safe method for the treatment of the patients in the clinics with a low frequency of complications of such interventions. The most common cause of the major complications of cochlear implantation is the technical defect of the implants the frequency of which amounted to 68% in the present study.

Factors associated with complications in total laryngectomy without microvascular reconstruction

BACKGROUND

There is little population-level data evaluating risk factors for postoperative complications after total laryngectomy.

METHODS

We conducted a retrospective review of the American College of Surgeons National Quality Improvement Program identifying patients who underwent total laryngectomy as a primary procedure from 2005 to 2014. Multivariate analysis was performed to identify variables that were independently associated with overall and major complications.

RESULTS

Eight hundred seventy-one cases met inclusion criteria. Three hundred twenty-eight patients (37.7%) had complications, with operative time (hours; P < .0001), class III (P < .001) wound status, and patient age (decade; P = .003) associated with overall complications. Two hundred one patients had major complications that were associated with steroid use (P = .01) and class III (P = .0083) wound classification. Preoperative hematocrit was correlated with a reduction of all and major complications on multivariate analysis (P < .0001 and P = .036).

CONCLUSION

Identifying and optimizing risk factors may improve outcomes in total laryngectomy.

Additional data from clinical examination on site significantly but marginally improve predictive accuracy of the Revised Trauma Score for major complications during Helicopter Emergency Medical Service missions

INTRODUCTION

The Revised Trauma Score (RTS) accurately identifies trauma patients at high risk of adverse events or death. Less is known about its usefulness in the general population and non-trauma recipients of Helicopter Emergency Medical Service (HEMS). The RTS is a simple tool and omits a lot of other data obtained during clinical evaluation. The aim was to assess the role of the RTS to identify patients at risk of major complications (death, cardiopulmonary resuscitation, defibrillation, intubation) in the general population of HEMS patients. Clinical factors beyond the RTS were analyzed to identify additional prognostic factors for predicting major complications.

MATERIAL AND METHODS

A retrospective analysis of medical records of adult patients routinely collected during HEMS missions in the years 2011-2014 was performed.

RESULTS

The analysis included 19 554 HEMS missions. Patients were 55 ±20 years old and 68% were male. The most common indication for HEMS was diseases of the circulatory system - 41%. Major complications occurred in 2072 (10.6%) cases. In the general population of HEMS patients, the RTS accurately identified individuals at risk of major complications at a cut-off value of 10.5 and area under the curve (AUC) of 93.5%. In multivariate analysis, additional clinical data derived from clinical examination (ECG; skin, pupil and breathing examination) significantly but marginally improved the accuracy of RTS assessment: AUC 95.6% (p < 0.001 for the difference).

CONCLUSIONS

The Revised Trauma Score accurately identifies individuals at risk of major complications during HEMS missions regardless of the indication. Additional clinical data significantly but marginally improved the accuracy of RTS in the general population of HEMS patients.

Predicting critical care unit-level complications after long-segment fusion procedures for adult spinal deformity

Background

To identify predictive factors for critical care unit-level complications (CCU complication) after long-segment fusion procedures for adult spinal deformity (ASD).

Methods

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database [2010-2014] was reviewed. Only adult patients who underwent fusion of 7 or more spinal levels for ASD were included. CCU complications included intraoperative arrest/infarction, ventilation >48 hours, pulmonary embolism, renal failure requiring dialysis, cardiac arrest, myocardial infarction, unplanned intubation, septic shock, stroke, coma, or new neurological deficit. A stepwise multivariate regression was used to identify independent predictors of CCU complications.

Results

Among 826 patients, the rate of CCU complications was 6.4%. On multivariate regression analysis, dependent functional status (P=0.004), combined approach (P=0.023), age (P=0.044), diabetes (P=0.048), and surgery for over 8 hours (P=0.080) were significantly associated with complication development. A simple scoring system was developed to predict complications with 0 points for patients aged <50, 1 point for patients between 50-70, 2 points for patients 70 or over, 1 point for diabetes, 2 points dependent functional status, 1 point for combined approach, and 1 point for surgery over 8 hours. The rate of CCU complications was 0.7%, 3.2%, 9.0%, and 12.6% for patients with 0, 1, 2, and 3+ points, respectively (P<0.001).

Conclusions

The findings in this study suggest that older patients, patients with diabetes, patients who depend on others for activities of daily living, and patients who undergo combined approaches or surgery for over 8 hours may be at a significantly increased risk of developing a CCU-level complication after ASD surgery.

Surgery-related complications of ventral hernia reported to the Finnish Patient Insurance Centre

AIM

Our aim was to evaluate the incidence and type of severe complications in adult primary and incisional ventral hernia surgery reported to the National Patient Insurance Centre in Finland during 2003-2010.

MATERIAL AND METHODS

The Finnish National Patient Insurance Centre covers the whole country and handles financial compensation for patients' injuries without proof of malpractice. All the claims concerning ventral hernioplasties in the Centre between the years 2003 and 2010 were retrospectively analyzed. The annual numbers of primary and incisional ventral hernioplasties in Finland were obtained from the National Hospital Discharge Register.

RESULTS

During the study years, 25,738 ventral hernia operations were performed and 127 claims from the whole country were reported to the Patient Insurance Centre. Overall rate of claims was 4.9/1000 hernia procedures. For primary hernias, 16,243 ventral hernioplasties (817 laparoscopic, 15,426 open) were performed and 41 complications were reported. The most common complication was infection (n = 28, 68%) followed by pain and hernia recurrence (n = 6, 15% in both), large hematoma (7%), bowel lesion (5%), urological injuries (2%), or severe bleeding (2%). In incisional hernioplasties, the rate of claims was 9.1/1000 operations (9495 operations, 86 claims). The most common complication reported was infection (n = 42, 49%) followed by hernia recurrence in 25 cases (29%) and bowel lesion in 24 cases (28%). Major complications (n = 15, 17%) consisted mainly of bowel lesions in laparoscopic operations. There was significantly more claims after laparoscopic than open hernioplasties (p = 0.001).

CONCLUSIONS

The claims for financial compensation for injuries related to primary and incisional hernioplasties are quite uncommon. Major complications, though comparatively rare, are significantly more common after laparoscopic operations.

[The gastric balloon--a retrospective cohort analysis of 634 patients]

HINTERGRUND

Der temporÄre Einsatz eines Magenballons zur Behandlung der Adipositas Grad1 und 2 nimmt weltweit zu; bei der Adipositas Grad 3 wird der Magenballon als adjuvantes Hilfsmittel zur prÄoperativen Gewichtsreduktion implantiert. Ziel dieser retrospektiven Kohorten analyse ist, die Wirksamkeit des Magenballons auf Gewichtsreduzierung und das Risikoprofil der Methode zu evaluieren.

METHODEN

Retrospektive Kohortenanalysen aus 4 Adipositas-Zentren, in denen der Magenballon seit 2001 regelmÄßig implantiert wurde.

ERGEBNISSE

Von Februar2001 bis April 2008 wurde bei 634 Patienten ein Magenballon implantiert (BIBTM Intragastric Balloon System; Allergan Medical, Irvine, CA, USA). Die Geschlechterverteilung war 31,5% MÄnnerzu 68,5% Frauen; das Durchschnittsalter betrug 41,5 Jahre. Das durchschnittliche Ausgangsgewicht lag bei 126 kg. Der initiale BMI bei Implantation des Magenballons war 42,5 kg/m². Die Implantation der Prothese war in allen FÄllen unkompliziert. Der durchschnittliche Gewichtsverlust lag bei 20,75 kg bzw. 7,05 BMI-Punkten.

SUMMARY

The Gastric Balloon — a Retrospective Cohort Analysis with 634 Patients

BACKGROUND

The temporary use of a gastric balloon for the treatment of obesity grade 1 and 2 is increasing worldwide, whereas in grade 3 obesity, it is implanted as a tool for preoperative adjuvant weight loss. The aim of this retrospective cohort analysis is to evaluate the effectiveness of weight reduction and to describe the risk profile of the method.

METHODS

Retrospective cohort analysis of 4 obesity centers where gastric balloons had been regularly implanted since 2001.

RESULTS

Between February 2001 and April 2008, the gastric balloon (BIBTM Intragastric Balloon System; Allergan Medical, Irvine, CA, USA) was implanted in 634 patients. The gender ratio was 31.5% males to 68.5% females; the average age was 41.5 years. The average initial weight was 126 kg. The initial BMI at implantation of the gastric balloon was 42.5 kg/m2. The implantation of the prosthesis was uncomplicated in all cases. Average weight loss was 20.75 kg or 7.05 BMI points, respectively.