Causes Of Surgical Complications Research Articles

Intestinal dysbiosis as an intraoperative predictor of septic complications: evidence from human surgical cohorts and preclinical models of peritoneal sepsis

Major surgery exposes the intestinal microbiota to inflammatory and antibiotic stressors, which alter the microbiota composition of the intestinal lumen and fecal contents. However, it is not sufficiently understood, if such dysbiosis develops already during surgery and if alterations in microbiota may be the cause of surgical complications. End-of-surgery composition of the microbiota in the rectum was assessed in 41 patients undergoing either rectal or duodenopancreatic resection and was compared to baseline before surgery using 16S-rRNA sequencing. A subset of patients developed severe dysbiosis at the end of surgery, which was characterized by an overgrowth of the Proteobacteria phylum that includes the facultative pathogen E. coli. To test if dysbiosis impacts on surgical outcomes, dysbiosis was modeled in mice by a single oral administration of vancomycin prior to cecal ligation and puncture. Dysbiosis was associated with impaired post-surgical survival, dysregulation of the host’s immune response, elevated bacterial virulence and reduced bacterial metabolism of carbon sources. In conclusion, dysbiosis can be detected already at the end of surgery in a fraction of patients undergoing major surgery. Modelling surgery-associated dysbiosis in mice using single-shot administration of vancomycin induced dysbiosis and resulted in elevated mortality.

Rapid Peripheral Nerve Imaging by Fluorescent Polymer Dots for Minimizing the Risk of Intraoperative Nerve Injury

AbstractIatrogenic nerve injury is an important cause of surgical complications. We focused on improving intraoperative visualization of nerves through highly fluorescent polymer dots (Pdots) and in vivo optical imaging instrumentation. The prepared Pdots have good biocompatibility, fluorescence stability, and simple preparation. Peripheral nerves can be imaged quickly with Pdots through a simple direct administration method and process, low non‐specific absorption in the surrounding tissues. Moreover, the Pdots does not invade nerve cells but binds stably in the neural membrane structure. This study verifies that fluorescent Pdots have excellent neuroimaging capabilities and can be used for intraoperative visualization of peripheral nerves.

Antibacterial-coated silk surgical sutures by ex situ deposition of silver nanoparticles synthesized with Eucalyptus camaldulensis eradicates infections

Surgical site infection arising from microbial contamination of surgical wounds is a major cause of surgical complications and prolong hospital stay. In this study, silver nanoparticles (AgNPs) biosynthesized using Eucalyptus camaldulensis extract were deposited on silk surgical sutures by ex situ method. Adherence of AgNPs to the surface of sutures was observed, with significantly reduced surface roughness (323.7 ± 16.64 nm), compared with uncoated sutures (469.3 ± 7.31 nm) (P < .001). Elasticity of AgNPs-coated (13 ± 1.485%) and uncoated (8 ± 0.728%) sutures was also significantly different (P < .05). Quantification of AgNPs demonstrated release of 3.88, 5.33, 5.44, 6.14% on day 1, 3, 5, 7, respectively from total Ag+ concentration (6.14 ± 0.14 μg/mL). The coated sutures produced a strong bacteriostatic effect on Staphylococcus aureus, an important wound pathogen with approximately 99% reduction in growth. In contrast, bactericidal effects were observed with Gram-negative pathogens including Acinetobacter baumannii, Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa. Cytocompatibility tested on human keratinocyte cells exhibited approximately 80% cell viability. The coated sutures revealed stable antibacterial properties up to 12 weeks. This work suggested the potency of AgNPs-coated sutures as a suitable biocompatible medical device for the management of surgical site infections.

Best Prophylactic Strategy in Groups at Risk of Intraoperative Floppy Iris Syndrome Development: Comparison Between Atropine Instillation and Adrenaline Intracameral Injection.

Background:Intraoperative Floppy Iris Syndrome (IFIS) is an important cause of surgical complications and iris defects in patients undergoing phacoemulsification that were treated with selective subtype α1A receptor antagonists for a long period of time. To date, no definitive preventive strategy has emerged, yet. The need of prophylaxis is dictated by the high prevalence of males affected by benign prostatic hyperplasia undergoing cataract surgery.Objective:To identify the best prophylactic strategy in groups at risk of IFIS development by comparing two mydriatic treatments in course of phacoemulsification surgery.Methods:81 eyes of 81 patients in treatment with Tamsulosin were enrolled in the study. 43 eyes were treated with atropine sulfate 1% while 38 eyes received an injection of mydriatic solution containing epinephrine in the anterior chamber. All phacoemulsifications were videotaped in order to assess the occurrence of IFIS and the severity of the syndrome.Results:The treatment group showed a statistically significant reduction (p = 0.0115) of floppy iris syndrome incidence, from 86.05% (37/43) of the atropine group to 60.53% (23/38). The analysis showed a reduction of IFIS mild form only, whereas the incidence of severe forms remained unchanged.Conclusions:We believe that IFIS may arise through two different mechanisms: pharmacological antagonism and anatomical modifications. Patients suffering from mild forms of the disease showed a statistically significant reduction of IFIS incidence after intraoperative prophylaxis due to epinephrine’s ability to displace Tamsulosin, resulting in the increase of iris tone when the disease is caused mainly by receptorial antagonism. On the contrary, prophylaxis does not deliver any valuable result in case of severe forms where the anatomical variations play a major role.

Zonular instability in patients with pseudoexfoliative syndrome: the analysis of 1000 consecutive phacoemulsifications

Phacoemulsification (PHACO) is the gold standard of cataract surgery. Сataract surgery in eyes with pseudoexfoliative (PEX) syndrome is associated with increased risk of intra- and postoperative complications. Zonular laxity is one of the main causes of surgical complications.&#x0D; Purpose. To assess the degree of zonular weakness in patients with PEX.&#x0D; Materials and methods. 1010 eyes (580 eyes with PEX and 430 eyes without it) that underwent consecutive PHACO at the Ophthalmology Department No 5 of the City Multifunctional Hospital No 2 from May 2016 until October 2017 were enrolled in the study. The zonular laxity was assessed preoperatively and intraoperatively.&#x0D; Results. Zonular weakness was observed more often in patients with PEX, both at preoperative and intraoperative evaluation (p 0.05). However, in both groups, the percentage of zonular weakness estimated intraoperatively, was several times higher, than that estimated preoperatively. Nevertheless there was no difference in the rate of capsular bag related intraoperative complications between two groups.

Total hip replacement for neck of femur fracture: Comparing outcomes with matched elective cohort

IntroductionCurrent literature suggests that total hip replacement (THR) is superior to hemiarthroplasty (HA) for neck of femur fracture in selected group of patients. The outcomes of THR undertaken for trauma setting remain unclear when comparing with elective THR. We compared the outcomes of THR trauma cohort with best-matched elective cohort. MethodsWe retrospectively reviewed 102 patients that underwent THR due to trauma from 2011 to 2013. We had access to 90 cases with complete records. Another 90 matched elective cases were obtained from local arthroplasty database. The elective cases were matched for gender, surgical approaches, surgeon’s grade, types of implant, patient’s age at operation date of ±5 years and operation date of ±60days. Subsequently, the selection criteria were relaxed to patient’s age at operation date of ±10 years and operation date of ±60days. Unmatched cases were excluded. Complications and death rate were compared. ResultsThe average age for both cohorts was 70 years. The trauma cohort had statistically significant lower BMI and longer hospital stay (p=0.001). The Functional Comorbidity Index (FCI) and Charlson Age Comorbidity Index (CACI) were the same for both cohorts, reflecting an active patient selection for THR in our centre. The trauma cohort had higher surgical complication rate (9% vs 4%), particularly higher dislocation rate (7% vs 1%); and higher medical complication rate (32% vs 6%). These were consistent with the literature. Contrary to literature, the trauma cohort had six dislocations that five of them were done via anterolateral approach. Among the eight trauma cases with surgical complications, six cases were performed by trainees. The cause of surgical complications remains unclear due to the nature of retrospective study. The trauma cohort had higher death rate than the elective cohort (14% vs 4%), with one post-operative cardiac arrest in the trauma cohort. The rest were non-orthopaedic related deaths, ranging between four months to four years. ConclusionA more robust way of selecting trauma patients for THR is warranted to reduce morbidity and mortality. Follow-up for the trauma cohort is warranted, as the patients are likely to outlive the implants.

Characterizing the Acute Phase Response in Healthy Patients Following Total Joint Arthroplasty: Predictable and Consistent

BackgroundDuring surgery, trauma to musculoskeletal tissue induces a systemic reaction known as the acute phase response (APR). When excessive or prolonged, the APR has been implicated as an underlying cause of surgical complications. The purpose of this study was to determine the typical APR following total joint arthroplasty in a healthy population defined by the Charlson Comorbidity Index (CCI). MethodsThis retrospective study identified 180 healthy patients (CCI < 2) who underwent total joint arthroplasty by a single surgeon for primary osteoarthritis from 2013 to 2015. Serial measurements of C-reactive protein (CRP) and fibrinogen were obtained preoperative, perioperative, and at 2 and 6 weeks postoperative. ResultsPostoperative CRP peaked during the inpatient period and returned to baseline by 2 weeks. Fibrinogen peaked after CRP and returned to baseline by 6 weeks. Elevated preoperative CRP correlated with a more robust postoperative APR for both total hip arthroplasty and total knee arthroplasty, suggesting that a patient's preoperative inflammatory state correlates with the magnitude of the postoperative APR. ConclusionMeasurement of preoperative acute phase reactants may provide an objective means to predict a patient's risk of postoperative dysregulation of the APR and complications.

Analysis and treatment of surgical complications after percutaneous transforaminal endoscopic discectomy for treating lumbar disc herniation and lumbar intervertebral foraminal stenosis

Objective To analyze the causes of surgical complications after treatment of lumbar disc herniation (LDH) and lumbar intervertebral foraminal stenosis by percutaneous transforaminal endoscopic discectomy (PTED). Methods From December 2009 to December 2014, 286 patients with LDH (N = 201) and lumbar intervertebral foraminal stenosis (N = 85) were confirmed by X-ray, CT or MRI and treated by PTED in our hospital. Visual Analogue Scale (VAS) was used to evaluate the degree of pain in each paitent before and after operation. The curative effect was evaluated by Macnab score. Surgical complications were recorded to find out the causes and methods to prevent them. Results All cases were followed up for 3 months, and the VAS score decreased significantly compared with preoperation [1.00 (0.00, 1.05) vs 8.50 (7.75, 9.25); Z = 2.825, P = 0.050]. According to Macnab score, the rate of excellent and good functional recovery was 95.45% (273/286). Procedure-related complications included nerve injury in 8 cases (2.80%), hemorrhage at the operation site and hematoma formation around nerve root in 6 cases (2.10%), rupture of dural sac in one case (0.35%), muscle cramps in 3 cases (1.05%), surgical infection in one case (0.35%), postoperative recurrence in 4 cases (1.40%). All patients with complications were cured after symptomatic treatment. Conclusions The overall effect of percutaneous transforaminal endoscopic discectomy for treating lumbar disc herniation and lumbar intervertebral foraminal stenosis is satisfactory, which has a low incidence rate of postoperative complications. Some tips can effectively reduce the rate of surgical complications such as preoperative evaluation, precise performance, careful hemostasis, shortening the operation time and postoperatively symptomatic treatment, etc. DOI: 10.3969/j.issn.1672-6731.2016.04.007

Supine No-Retractor Method in Microvascular Decompression for Hemifacial Spasm: Results of 100 Consecutive Operations.

Objectives In microvascular decompression (MVD) for hemifacial spasm (HFS), the patient is placed in the lateral or park-bench position that is complicated and uncomfortable for anesthesiologists, nurses, and even the patient. Careless retraction of the cerebellum by a spatula could be the major cause of surgical complications. In our method, a patient is laid supine avoiding the complicated positioning. The subfloccular approach from a small cranial window sited on the more lateral and basal side of the occipital cranium enables the surgeon to reach all the segments of the facial nerve root without a spatula. We introduce our surgical procedures in detail along with our excellent results. Methods A total of 100 consecutive patients experiencing primary HFS were operated on with MVD by a single surgeon in our institution from August 2012 to April 2014. Results Overall, 94 patients showed the complete disappearance or a satisfactory alleviation of HFS. De novo neurologic deficits were not encountered after surgery including hearing impairment. In 47 cases, multiple offending vessels were observed in multiple possible affected sites in addition to the root entry/exit zone. Conclusions We believe this approach is superior for the safe and precise decompression of any part of the facial nerve root.

Early Neuroendoscope-assisted Evacuation of Spontaneous Intracranial Hematomas. Preliminary Report

Purpose: The surgical techniques, effectiveness and indications of microsurgical neuroendoscopic assisted evacuation of spontaneous intracranial hematomas (SICH) is still uncertain. This minimal invasive technique remains investigational and controversal with regard to patient selection, timing of operation and method of the management. The purpose of this study was to investigate the early postoperative results in patients with SICH underwent endoscopic evacuation and to give evaluation and eventual prognosis of the clinical outcomes after this procedure. Material and Methods: A retrospective analysis of 56 patients SICH treated in the Neurosurgical clinic with endoscopic assisted evacuation was performed. Hematoma volume and its localization (subcortical – 11 patients, in basal ganglia – 12 – 7 of them with propagation to ventricular system, 6 infratentorial and 27 subdural), comorbidity, clinical features and timing of surgical procedures was made. The GCS rate by admission and GOS by discharging of patients was analyzed, also the postoperative complications and causes of death. Results: 52 patients (92, 9%) were operated within the first 24 hours of the onset. Patients operated between the 12 and 24 hours had better outcome in comparison to these operated after the 24 hours period. The authors analyzed their experience with endoscopic technique, effectiveness of the method, results and complications. Mortality rate in our series was 23, 2% (13 patients). The causes of surgical complications and causes of death were analyzed. Conclusion: The endoscopic assisted evacuation of SICH is a short, safe and very effective method when the surgical procerure is provided within the first 12–24 hours. Our results showed that early and complete evacuation of hematoma volume may promote to recovery of the general condition of the patient and improved outcomes.

Short and Long-Term Outcomes of Systemic Drainage to IVC: A New Technique for Pancreas Transplantation

Ninety-eight percent of the whole pancreas does not serve the purpose of pancreatic transplantation and it is a major cause of surgical complications. Up to 30% of pancreas transplant recipients experience surgical complications and require reoperation. Graft thrombosis and pancreatitis are the most common complications of pancreas transplantation (PT). Thus, different surgical techniques have been described to overcome the surgical hurdles and reduce surgical complications. In this study, for the first time, we report short- and long-term outcomes of PT with inferior vena cava (IVC) venous drainage. Forty-five PTs (22 simultaneous pancreas and kidney [SPK] transplantations and 23 pancreas after kidney [PAK] transplantations) were performed with this technique in our center. Sixty-eight percent of the donors were imported from outside of our area after they were declined by their local transplantation center. Patient and graft survival rates were 100% at 1 year. No graft thrombosis or pancreatitis occurred with this technique. Six patients (13.3%) required reoperation (3 bleeding, 2 anastomotic leak, and 1 small bowel perforation). No patient or graft loss occurred due to surgical complications. We conclude that this technique provides fast and easy dissection of the venous drainage of the PT without the need of complete occlusion of venous outflow. Surgical complication rates were lower with this technique compared with other reported techniques.

Transplant nephrectomy: What are the surgical risks?

Whether or not to remove a failed renal graft has been the subject of much debate. One reason for a cautious approach to graft removal is its high morbidity and mortality rates. We analyzed the morbidity, mortality, and risk factors of transplant nephrectomy at our center. We included 157 cases of transplant nephrectomy in 143 patients, performed between January 2000 and May 2012 at the Academic Medical Center, Amsterdam. Patient data were collected retrospectively. A total of 32 surgical complications occurred after transplant nephrectomy (20%) and 16 patients needed surgical re-intervention (10%). Hemorrhage and infection are the most frequent causes of surgical complications (14%). The mortality rate was 3.2%. There were no significant differences in characteristics and timing of transplant nephrectomy between the group with surgical complications and the group without. A total of 59 re-transplantations were performed in 57 patients (38%). Transplant nephrectomy is associated with high morbidity and mortality rates. We found no significant risk factors for surgical complications following transplant nephrectomy and no significant association between timing of transplant nephrectomy and surgical complications. Steps to reduce these complications need further investigation.

Complications in Surgery

Patients expect to receive quality medical care by relying on the concepts of evidence-based medicine. This quality care is expected to be provided at decreased costs for payors, some of whom have stopped reimbursement for cases involving "reasonably preventable" surgical complications. The purpose of this article is to introduce root cause analysis as a tool for identifying the causes of surgical complications. The authors also discuss preventive measures, such as improved communication, checklists, reporting systems, and the use of evidence-based medicine, that have been implemented to decrease surgical complications. These preventive measures can be used alone or together to decrease complications and improve overall patient care.

CT and MR cholangiography: advantages and pitfalls in perioperative evaluation of biliary tree

Recent developments in imaging technology have enabled CT and MR cholangiopancreatography (MRCP) to provide minimally invasive alternatives to endoscopic retrograde cholangiopancreatography for the pre- and post-operative assessment of biliary disease. This article describes anatomical variants of the biliary tree with surgical significance, followed by comparison of CT and MR cholangiographies. Drip infusion cholangiography with CT (DIC-CT) enables high-resolution three-dimensional anatomical representation of very small bile ducts (e.g. aberrant branches, the caudate branch and the cystic duct), which are potential causes of surgical complications. The disadvantages of DIC-CT include the possibility of adverse reactions to biliary contrast media and insufficient depiction of bile ducts caused by liver dysfunction or obstructive jaundice. Conventional MRCP is a standard, non-invasive method for evaluating the biliary tree. MRCP provides useful information, especially regarding the extrahepatic bile ducts and dilated intrahepatic bile ducts. Gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced MRCP may facilitate the evaluation of biliary structure and excretory function. Understanding the characteristics of each type of cholangiography is important to ensure sufficient perioperative evaluation of the biliary system.

Significance of intraoperative endoscopy in total gastrectomy for gastric cancer

Anastomotic impairment can be a major cause of surgical complications in gastrointestinal surgery. The aim of this study was to evaluate the efficacy of intraoperative endoscopy (IOE) in esophagojejunal anastomosis for detection of anastomotic impairment. Forty-eight patients who underwent total gastrectomy were evaluated for the integrity of the esophagojejunostomy using IOE at completion of mechanical esophagojejunal anastomosis. Overall postoperative anastomotic leakage (PAL) rate was 4.2% (n = 2/48). Both patients who developed PAL had abnormal findings such as mucosal defect in the esophageal mucosa or incomplete anastomotic stapling. Also, IOE revealed inadvertent anastomotic failure in three patients: two jejunal and one esophageal occlusion. There were no complications due to IOE. IOE is safe and may easily provide significant information that can minimize PAL by detecting anastomotic failure on esophagojejunal anastomosis.

Transdiscal Cement Leakage During Vertebroplasty

Bone cement leakage is a major cause of surgical complications during percutaneous vertebroplasty. A 78-year-old woman experienced transdiscal cement leakage during vertebroplasty for painful compression fractures of thoracic vertebrae 9 and 10 (T9 and T10). During surgery, bone cement leaked from T9 to T10, passing through the right anterior intervertebral disc space. We have had no prior experience with this complication and, to our knowledge, there are no similar cases in the literature. Nevertheless, the patient's back pain was relieved to a considerable degree. Related imaging findings and possible reasons for leakage are discussed.

Surgical Complications in Abdominal Tumor Surgery in Children. Experiences at a Single Oncological Center

Surgical complications after tumor operations are frequent in children, with rates of up to 30% cited in the literature. Various approaches to reduce these complication rates have been attempted, with preoperative chemotherapy holding pride of place. One approach to minimize surgical complications is better preoperative preparation. In a retrospective analysis, we evaluated the complications associated with tumor surgery. We retrospectively analyzed patient data from 1991 to 2007. The distribution of the various tumors, the type of surgery, and complications were evaluated. For neuroblastomas a differentiated analysis of complications was performed, which included staging and radiologically defined surgical risk factors (SRFs). Patients were divided into two groups: A and B. Intensified surgical planning with 3D visualization was used in patients of group B. A total of 145 operations for abdominal tumors were performed in 123 patients. The three most common diseases were neuroblastoma (36%), nephroblastoma (26%), and ovarian tumor (19%). In 68% of patients complete resection and in 19% of cases partial resection of the tumor was carried out; open biopsy was performed in 13%. A total of 15 (10.3%) complications developed: the incidence of complications for group A was 11.8% and 7.7% for group B (p=0.5). For nephroblastoma these figures were 27.9% and 21.2% (p=1.0). In the group of patients with neuroblastoma, six complications developed in patients from group A (21.4%) and one in a group B patient (4.2%) (p=0.107). 54% of neuroblastomas were completely and 33% partially resected; these figures and the distribution of SRFs were similar in the two groups. A significant increase in the risk of complications could be seen with an increase in SRFs (p=0.0267) and with disease stages 2 and 3 (p=0.016). Tumor reduction surgery was also associated with an increase in complications (p=0.086). In summary, tumor surgery is associated with considerable risks in children. Therefore it is very important to look for new approaches that could potentially minimize these risks. As the causes of surgical complications are multifactorial, we are of the opinion that intensified surgical planning can contribute to reducing risks. Particularly neuroblastoma surgery could profit from an increased use of 3D visualization and improved preoperative planning.

Analysis of the causes of surgical complications of medial sphenoidal ridge meningioma

To find out the causes of severe surgical complications of sphenoidal ridge meningioma of and the methods to avoid them. The clinical data of 56 cases of sphenoidal ridge meningioma, 37 being medial (clinoidal) type, 5 being middle (alar) type, and 14 being lateral (pterional) type, with the diameters of 3.5 - 7 cm, 3.8 - 5.2 cm, and 3.8 - 7.5 cm respectively, who underwent operation. The tumors of 19 cases of lateral and middle types were resected completely without surgical complication. Facial nerve injury occurred in 2 cases of medial type because of failure to know well the course of facial nerve and over-stretching of skin flap. Oculomotor nerve injury occurred in 7 cases, 5 of which were transient, and trochlear nerve injury occurred in 1 case, all caused by inappropriate manipulations. Too early resection of tumor-related vessel caused middle cerebral artery injury in one case. Resection of the tumor infiltrating the carotid artery inadequately caused injury of the carotid artery. Lenticulostriate artery injury was caused in 2 cases by over-separation of the lateral fissure. Severe surgical complications can be avoided if the surgeons, with great skills, are able to predict different topographic changes and difficulties encountered during operation in the light of the specific conditions in operation.

The impact of experience of a transplantation center on the outcomes of orthotopic liver transplantation

The so-called learning factor has been disregarded for many years in analyzing the causes of surgical complications and post-operative mortality; it is also the case for OLT. In our center until April 2003, 209 OLT were performed in 196 patients. We evaluated the impact of experience of the transplantation team on the outcomes of liver transplantation. Thirty-four patients died (mortality rate, 16%) and 1-year survival rate, 64%. Mortality rates varied during different periods of observation due to increasing experience of the transplantation team. The causes of mortality were assessed for a series of 34 patients: it was 75% at the beginning of transplantation procedures while recent deaths have not recently exceeded 10% of cases.

A randomized trial in simultaneous pancreas–kidney transplantation: portal versus systemic venous drainage of the pancreas allograft

Ninety-eight percent of the whole pancreas does not serve the purpose of pancreatic transplantation and it is a major cause of surgical complications. Up to 30% of pancreas transplant recipients experience surgical complications and require reoperation. Graft thrombosis and pancreatitis are the most common complications of pancreas transplantation (PT). Thus, different surgical techniques have been described to overcome the surgical hurdles and reduce surgical complications. In this study, for the first time, we report short- and long-term outcomes of PT with inferior vena cava (IVC) venous drainage. Forty-five PTs (22 simultaneous pancreas and kidney [SPK] transplantations and 23 pancreas after kidney [PAK] transplantations) were performed with this technique in our center. Sixty-eight percent of the donors were imported from outside of our area after they were declined by their local transplantation center. Patient and graft survival rates were 100% at 1 year. No graft thrombosis or pancreatitis occurred with this technique. Six patients (13.3%) required reoperation (3 bleeding, 2 anastomotic leak, and 1 small bowel perforation). No patient or graft loss occurred due to surgical complications. We conclude that this technique provides fast and easy dissection of the venous drainage of the PT without the need of complete occlusion of venous outflow. Surgical complication rates were lower with this technique compared with other reported techniques.