Complication Of Major Surgery Research Articles

Oncologic Impact of Anastomotic Leakage Following Colorectal Cancer Surgery: A Systematic Review and Meta-Analysis.

Anastomotic leakage (AL) is a major complication of surgery for colorectal cancer (CRC), and is associated with increased morbidity and mortality; However, there are conflicting results on the impact of AL on long-term oncologic outcomes. The aim of this meta-analysis was to assess the oncologic outcomes of AL following restorative surgery for CRC. Multiple comprehensive databases, including PubMed, EMBASE, and The Cochrane Library, were searched for studies that assessed the oncologic effects of AL following surgery for CRC. The included studies evaluated local and distant recurrence, overall survival (OS), cancer-specific survival (CSS), and disease-free survival (DFS). Outcome data were pooled, and overall effect size was calculated using random effects models. Thirty-four nonrandomized studies including 78,434 patients met the inclusion criteria. The results show that AL was associated with increased local recurrence (relative risk [RR] 1.90, 95% confidence interval [CI] 1.48-2.44, I 2=78%) and reduced OS (RR 1.36, 95% CI 1.24-1.50, I 2=74%), CSS (RR 1.41, 95% CI 1.19-1.68, I 2=56%), and DFS (RR 1.40, 95% CI 1.20-1.63, I 2=86%). AL had no significant effect on distant recurrence (RR 1.20, 95% CI 0.94-1.53, I 2=61%). AL after restorative surgery for CRC is associated with increased local recurrence and reduced long-term survival, including OS, CSS, and DFS.

The incidence of postoperative infection in tertiary rural hospital

Background: Post-operative wound infections have been a problem since surgery was started as a treatment modality. Post-operative infections were responsible for 70-80% of deaths until Ignaz Semmelweis and Joseph Lister, in middle of 19th century, introduced methods of infection control by use of antiseptics. Objective was to study the incidence of postoperative infection in tertiary rural hospital.Methods: A hospital based cross sectional study was carried out at Department of General Surgery, SRTR Rural Government Medical College from September 2015 to August 2016 among 1250 patients. Detailed history, complete and thorough clinical examination was carried out for each and every individual included in the present study. The patients are assessed pre operatively and post operatively.Results: It was found that the maximum cases belong to the age group of 26-35 years i.e. 28.32% followed by age group of 36-45 years (25.68%). The proportion of males was slightly more than females. The most common surgical procedure done was inguinal hernioplasty in 24.96% of cases followed by internal appendectomy in 22.24% of cases. Maximum study subjects had clean surgical procedure in 62.08% of cases. The highest incidence (19.46%) was found in the age group of above 56 years followed by age more than 56 years in 19.46% of cases. It was found that the incidence of SSI was more among females than males. It was found that the incidence of SSI was more among those with some co-morbidity than among those who doesn’t have any co-morbidity.Conclusions: Surgical infections particularly, surgical site infections, have always been a major complication of surgery and trauma. The overall prevalence of surgical site wound infection in the surgical ward was 10.4%.

Operative versus Conservative Treatment for the Management of Displaced Midshaft Clavicle Fractures in Adults

Introduction: Displaced fractures of mid third clavicle are common in young athletic population and choice of management is still controversial. Recent studies have shown that these fractures do not have favourable outcomes with non-operative management and nonunion rates could be as high as 20%, in addition, there is symptomatic malunion with shortening.
 Objective: To compare the results of the operative versus that of conservative treatment for the management of displaced midshaft clavicular fractures.
 Materials and Methods: This prospective cross-sectional study was carried out in Orthopaedic and Trauma center, CMH, Dhaka, from the period of January 2014 to December 2016 to compare results of open reduction and internal fixation by plating with that of conservative management. Total 60 patients (30 in each group) were analyzed in terms of fracture union and functional outcome. Patients in the non-operative group were managed by triangular sling with or without strapping whereas in the operative group fractures were reduced and fixed with a contoured reconstruction plate. Patients were actively followed up for 12 months and functional outcome was measured by Rowe and Oxford shoulder scoring system. Complications were monitored clinically and radiologically.
 Results: All fractures in the operated group united compared with thirteen cases of symptomatic malunion (43.33%) in the non-operated group which is statistically significant. Rowe and Oxford scores was significantly higher in the operated group than the non-operated group in every occasion of follow-up. There was no major complication of surgery. In one patient (3.33%) plate had to be removed for hardware irritation and prominence.
 Conclusion: Open reduction and internal plate fixation in acute displaced midshaft clavicular fractures resulted in improved outcome decreased rate of non-union and symptomatic mal-union compared with non-operative treatment
 Journal of Armed Forces Medical College Bangladesh Vol.13(1) 2017: 81-85

Long-term outcome in 53 patients with homozygous familial hypercholesterolaemia in a single centre in France

Background and aimsHomozygous familial hypercholesterolaemia (HoFH) is a rare inherited condition characterized by elevated plasma low-density lipoprotein-cholesterol (LDL-C) levels, severe, accelerated atherosclerosis and premature coronary heart disease. We evaluated cardiovascular complications in HoFH patients over extended follow-up and investigated their association with changes in cholesterol over time, as well as total cholesterol burden. MethodsIn this retrospective single-centre study, 53 patients (baseline mean ± standard deviation [SD], total cholesterol 15.5 ± 3.7 mmol/L and LDL-C 13.2 ± 2.6 mmol/L) were followed for up to 38 years (21.2 ± 10 years). The primary outcome was an adverse clinical event, defined as cardiovascular death, nonfatal myocardial infarction, or angina. ResultsTwenty-eight patients experienced an event, of whom 8 died due to complications of major surgery (4), myocardial infarction (3) or stroke (1). While total cholesterol levels were comparable in patients with and without an event at baseline (20 mmol/L), those who subsequently experienced an event showed a slower decline in total cholesterol. Cumulative total cholesterol (i.e. total-cholesterol year score) was highly associated with the incidence of an adverse clinical event in a linear dose-response relation. A 100 mmol/L increase in cumulative total cholesterol (i.e. an average exposure of 10 mmol/L per 10 years or 20 mmol/L per 5 years) was associated with a doubling of the risk of a cardiovascular event (age-adjusted incidence rate ratio: 1.99, 95% CI, 1.16–3.41). ConclusionsOur findings reinforce the importance of early diagnosis and initiation of maximal treatment, including lipoprotein apheresis, to ensure long-term reduction in the cholesterol burden, expressed as the total-cholesterol year score, and risk of cardiovascular complications in HoFH.

The impact of the acute respiratory distress syndrome on outcome after oesophagectomy

BackgroundThe Acute Respiratory Distress Syndrome (ARDS) is a serious complication of major surgery and consumes substantial healthcare resources. Oesophagectomy is associated with high rates of ARDS. The aim of this study was to characterize patients and identify risk factors for developing ARDS after oesophagectomy. MethodsA secondary analysis of data from 331 patients gathered during the Beta Agonists Lung Injury Prevention Trial was undertaken. Characteristics and outcomes of patients with early (first 72 h postoperatively) and late (after 72 h) ARDS were determined. Linear and multivariate regression analysis was used to study the differences between early and late ARDS and identify risk factors. ResultsARDS was associated with more non-respiratory organ failure (early 44.1%, late 75.0%, no ARDS 27.6% P<0.001), longer ICU stay (mean early 12.1, late 20.2, no ARDS 7.3 days P<0.001) and longer hospital stay (mean early 18.1, late 24.5, no ARDS 14.2 days P<0.001) but no difference in mortality or quality of life. Older patients (OR 1.06 (1.00 to 1.13), P=0.045) and those with mid-oesophageal tumours (OR 7.48 (1.62–34.5), P=0.010) had a higher risk for ARDS. ConclusionsEarly and late ARDS after oesophagectomy increases intensive care and hospital length of stay. Given the high incidence of ARDS, cohorts of patients undergoing oesophagectomy may be useful as models for studies investigating ARDS prevention and treatment. Further investigations aimed at reducing perioperative ARDS are warranted.

Preventive analgesia and novel strategies for the prevention of chronic post-surgical pain.

Chronic post-surgical pain (CPSP) is a serious complication of major surgery that can impair a patient's quality of life. The development of CPSP is a complex process which involves biologic, psychosocial, and environmental mechanisms that have yet to be fully understood. Currently perioperative pharmacologic interventions aim to suppress and prevent sensitization with the aim of reducing pain and analgesic requirement in acute as well as long-term pain . Despite the detrimental effects of CPSP on patients, the body of literature focused on treatment strategies to reduce CPSP remains limited and continues to be understudied. This article reviews the main pharmacologic candidates for the treatment of CPSP, discusses the future of preventive analgesia, and considers novel strategies to help treat acute post-operative pain and lessen the risk that it becomes chronic. In addition, this article highlights important areas of focus for clinical practice including: multimodal management of CPSP patients, psychological modifiers of the pain experience, and the development of a Transitional Pain Service specifically designed to manage patients at high risk of developing chronic post-surgical pain.

The Prevention of Delirium and Complications Associated with Surgical Treatments (PODCAST) study: protocol for an international multicentre randomised controlled trial

IntroductionPostoperative delirium is one of the most common complications of major surgery, affecting 10–70% of surgical patients 60 years and older. Delirium is an acute change in cognition that manifests...

Postoperative delirium: disconnecting the network?

Postoperative delirium: disconnecting the network?

Intensive alveolar recruitment after cardiac surgery: a randomized controlled clinical trial

Protective mechanical ventilation has been associated with lower incidence of pulmonary and extrapulmonary complications in major surgery. The aim of the present study is evaluate whether adding an intensive alveolar recruitment protocol improves clinical outcomes and reduces healthcare utilization in patients undergoing cardiac surgery.

Performance of urinary NGAL and L-FABP in predicting acute kidney injury and subsequent renal recovery: a cohort study based on major surgeries

Acute kidney injury (AKI) is a frequent complication of major surgery. The current study evaluated the power of two biomarkers [urinary neutrophil gelatinase-associated lipocalin (NGAL) and liver-type fatty acid binding protein (L-FABP)] to detect the occurrence of AKI and to predict the recovery from renal dysfunction in a major surgery cohort. In this prospective study, 199 patients undergoing major surgery were enrolled. Urinary samples collected from participants before surgery, and 0, 4, and 12 h and 1, 2, 7, and 14 days after surgery were tested for NGAL and L-FABP. Thirty-seven (18.6%) subjects developed AKI. Urinary NGAL and L-FABP were significantly increased from the time surgery was completed (p<0.05). The peak levels of NGAL and L-FABP occurred 12 and 4 h postoperatively (16.4- and 172.0-fold compared to baseline) in AKI group, respectively. The area under the receiver operating characteristic (ROC) curve (AUC) in NGAL (at 12 h), L-FABP (at 4 h), the most predictive model (NGAL at 12 h+L-FABP at 4 h), and the best combination at the same time point (12 h) was 0.83 [95% confidence interval (CI), 0.74-0.91], 0.85 (95% CI 0.77-0.93), 0.94 (95% CI 0.89-0.98), and 0.91 (95% CI 0.85-0.97), respectively. However, the largest AUC of single and combined biomarkers for predicting non-recovery after AKI only reached 0.70. Urinary NGAL and L-FABP can be used to detect AKI and combining NGAL and L-FABP may improve the diagnostic performance; however, NGAL and L-FABP may be poor predictors for renal recovery after AKI.

Decreasing methicillin-resistant Staphylococcus aureus surgical site infections with chlorhexidine and mupirocin

Surgical site infections (SSIs) associated with methicillin-resistant Staphylococcus aureus (MRSA) are a major complication of surgery. This study is part of a large infection control quality improvement effort to eliminate MRSA SSIs. This is an Institutional Review Board-approved, case-control study examining MRSA SSI rates before and after implementation of a facility-wide MRSA SSI prevention protocol in 2007. The protocol involved a 5-day course of intranasal mupirocin and nonrinse 2% chlorhexidine gluconate cloths. In 2006, a total of 39 MRSA SSIs occurred after 9,976 procedures in patients who underwent orthopedic, vascular, cardiac, or neurosurgical procedures (rate=0.39 per 100 procedures). The highest incidence occurred after cardiac surgery (rate=1.24/100 procedures), and the lowest occurred after orthopedic surgery (rate=0.28/100 procedures). In 2007, the MRSA SSI rate decreased to 20 of 9,818 procedures (rate=0.20/100 procedures) in the 4 categories (P=.016; odds ratio, 1.92). In 2008, the MRSA SSI rate dropped again to 13 of 10,068 procedures (rate=0.13/100 procedures) in the 4 categories (P=.0003; odds ratio, 3.04). A 5-day course of intranasal mupirocin and nonrinse 2% chlorhexidine gluconate cloths may be beneficial in preventing MRSA SSIs in the non-general surgery population.

Transfusion and risk of acute kidney injury in cardiac surgery

Acute kidney injury (AKI) is a serious and common complication of major surgery. This narrative review focuses on the relationship between perioperative red blood cell transfusion and AKI after cardiac surgery with cardiopulmonary bypass (CPB). Numerous observational studies have shown that these two factors are independently associated with each other. Several lines of evidence suggest that the nature of this association is one of cause and effect. The pathophysiological mechanism by which transfusions might harm the kidney has not been fully elucidated, but it is known that erythrocytes undergo irreversible morphological and biochemical changes during storage. As a result, after transfusion, they can promote a pro-inflammatory state, impair tissue oxygen delivery, and exacerbate tissue oxidative stress. This in turn can cause AKI in susceptible patients undergoing cardiac surgery with CPB, such as those with pre-existing kidney dysfunction or anaemia. Interventions aimed at avoiding perioperative blood transfusion might, therefore, reduce the risk of AKI after cardiac and other types of surgery.

A brief review of practical preoperative cognitive screening tools

Preoperative cognitive impairment is associated with the development of postoperative delirium, a common and consequential complication of major surgery in older patients. Screening for cognitive impairment should become a routine part of the preoperative evaluation of older patients; however, its implementation is hampered by limited clinical time and resources. The objective of this review was to identify cognitive screening tools that could be easily incorporated into the evaluation of older patients before major surgery. Using strict inclusion and exclusion criteria, we searched PubMed over a 15-year period for short and simple cognitive screening tools. In addition, we reviewed studies that examined these cognitive screening tools in a perioperative environment. SEARCH RESULTS: We identified six cognitive screening tools that could each be administered in 2.5 min or less. Among the tools, sensitivity for cognitive impairment ranged from 79-99%, while specificity ranged from 70-98%. Only one (Mini-Cog) of the six tools we identified had been tested in a perioperative environment. Incorporating a cognitive screening assessment into the preoperative evaluation of older patients is feasible. More research is needed to validate cognitive screening tools in the perioperative setting.

Comparison of 23G and 20G vitrectomy for treatment of infectious endophthalmitis

Objective To compare the outcomes and safety of 23G and 20G vitrectomy for treatment of infectious endophthalmitis.Methods This was a retrospective case study.Sixty-seven eyes of 67 eyes suffering from infectious endophthalmitis with a history of trauma or intraocular operation history were enrolled in this study.They were diagnosed by the examinations of best corrected visual acuity,intraocular pressures,slit lamp microscope,indirect ophthalmoscopy,B-scan ultrasound and CT.There were 49 males (49 eyes) and 18 females (18 eyes).The patients aged from 18 to 72 years with a mean age of (43±13)years.There were 60 patients (60 eyes) with a history of trauma,7 patients (7 eyes) with intraocular operation history.The patients were enrolled into 20G vitrectomy group (35 patients,35 eyes) before December,2009 and 23G vitrectomy group (32 patients,32 eyes) after January,2010 when 23G vitrectomy system was imported in this hospital.Vitreous purulence was taken in all patients at the beginning of the surgery for bacteria and fungal culture and drug sensitivity test. A standard vitrectomy with artificial posterior vitreous detachment followed by internal limiting membrane peeling,and (or) intraocular laser photocoagulation,cryocoagulation,fluid-air exchange with intraocular silicone oil or gas tamponade were performed in all eases.Broad-spectrum antibiotics and glucocorticoids were used systematically for one week after surgery,but glucocorticoids were not used for fungal infections.The follow-up was ranged from two to nine months with a mean of (7 ± 1) months.The surgical time,inflammation situation,visual acuity,intraocular pressure, retinal reattachment rare,iatrogenic retinal hole rate, bulbar conjunctiva scar formation rate,reoperation rate and eye retention situation before and after surgery were comparatively analyzed.Results The mean surgical times were (126 ± 12) and (89 ± 12) minutes in 20G and 23G group,which was significantly different (t=3.125,P＜0.05).The major surgery complications were ora serrata dialysis and other iatrogenic retinal breaks,and were occurred in 34 eyes,including 30 eyes (85.71％) in 20G group and 4 eyes (12.50％) in 23G group (x2 =35.85,P＜0.05).These 4 eyes in 23G group received foreign body removal surgery previously.The inflammation was controlled in 65 eyes (97.01％) including 34 eyes (97.14％) and 31 eyes (96.88％) in 20G and 23G group respectively,which was not significantly different (x2=0.004,P＞0.05).At last follow-up,There was no statistical difference of visual acuity between the two groups (t=3.12,P＞0.05).Fourteen eyes underwent silicone oil tamponade including 13eyes (37.14％) and 1 eye (3.13％) in 20G and 23G group respectively,which was significantly different (x2=11.703,P＜0.05).Nine eyes underwent reoperation (13.43％),including 8 eyes (22.86％) and 1eye (3.13％) in 20G and 23G group respectively,which was significantly different (x2=5.597,P＜0.05).The 8 re-operated eyes in 20G group included 1 eye of recurrent endophthalmitis and 7 eyes with retinal detachment,the 1 re-operated eye in 23G group was of recurrent endophthalmitis.There was significantly different (x2=7.147,P＜0.05) for the rate of retinal detachment between the 2 groups.There were 40eyes with bulbar conjunctiva scar including 35 eyes (100.00％) and five eyes (15.63％) in 20G and 23G group.Conclusion 23G vitrectomy is an effective treatment for infectious endophthalmitis with shorter surgery time,lower reoperation rate,lower retinal reattachment rate and fewer bulbar conjunctiva scar. Key words: Endophthalmitis/surgery; Vitrectomy; Comparative study

Synthesis and evaluation of tetracycline encapsulated in poly (lactic-co-glycolic acid) on porous titania formed by using plasma electrolytic oxidation

Despite a relatively high success rate in treating bacterial infection, it is still the major complication following dental implant surgery. Many attempts have been carried out to produce antibacterial effects on implant metals, and there have included coating of antibiotics encapsulated in polymers by using the electro-spray deposition (ESD) method. However, remnant polymer following full release of the medication, resulting in delamination between the surface layers of the implant and newly formed bone, has been a major problem. Hence, different organic polymer of poly (lactic-co-glycolic acid) (PLGA) were used in this study. Commercially pure titanium was used in this experiment and was anodized to improve biocompatibility. The PLGA was dissolved in dichloromethane along with tetracycline, and the fabricated tetracycline encapsulated in PLGA was then coated on a porous oxide layer of titanium by using the ESD method. The surface characteristics were analyzed, and the antibacterial effects of the specimen were assessed using bacteria of Staphylococcus aereus. Finally, the cytotoxicity and cell proliferation on the surface was evaluated. The results indicated that such titanium formed by a coating of tetracycline encapsulated in PLGA on a porous titania structure exhibited antibacterial effects and was both non-cytotoxic and biocompatible. Also, PLGA seemed to be an ideal candidate as the medium to encapsulate antibiotics or other medications such as growth factors due to its rapid degradation compared to other organic polymer. From this experiment, we conclude that porous titania coated by tetracycline encapsulated in PLGA by using ESD method is appropriate for use in dental or medical implants to prevent the major complication of surgery, infection.

Management of Postoperative Ileus

Postoperative ileus, a temporary cessation in bowel motility, is a common and significant complication of major surgery. Consequences of postoperative ileus include increased patient discomfort, delayed time to adequate nutrition, prolonged length of stay, and increased cost to the patient and healthcare system. The traditional, multi-modal approach to the resolution of postoperative ileus includes opioid minimization, early ambulation, and early feeding. Newer medications, such as methlynaltrexone and alvimopan (which are peripherally acting mu opioid receptor antagonists), have become available and have proven beneficial for use with postoperative ileus.

Venous Thromboembolism Following Major Surgery and Risk of Recurrence: A Population-Based Cohort Study

Abstract 5243 Background:Venous thromboembolism (VTE) which includes deep vein thrombosis (DVT) and pulmonary embolism (PE) is a common complication of major surgery. Little is known of the risk of recurrent VTE following postoperative VTE. Objectives:We used the administrative health claims (RAMQ) and hospital discharge (MED ECHO) databases of Quebec, Canada to conduct a population-based retrospective cohort study to describe the time to VTE following general surgery and to assess the risk of VTE recurrence among patients with surgery-provoked VTE. Methods:Using a previously defined cohort of individuals who had a first-time discharge diagnosis of VTE between January 1996 and December 2004 in MED ECHO, which systematically records information on all hospital admissions in the province of Quebec, we identified patients who had undergone major surgery in the 3 months prior to the VTE. Subjects were followed from the time of incident VTE until first VTE recurrence, death, or end of study (December 31, 2005). Results:Our study population consisted of 9629 patients with new VTE up to 3 months following major surgery. The mean age was 63.9 years (SD=15.2) and 53% were female. General surgery (32%) was the most common procedure. The mean time to VTE after surgery was 29.5 days (SD=62.6) with 30% of events diagnosed after discharge. The 5-year adjusted cumulative risk of recurrence was 7.9%. Patients with VTE diagnosed after discharge had an adjusted relative risk of recurrence of 1.43 (95% confidence interval (1.21, 1.69)) compared to patients with VTE diagnosed before discharge. Conclusions:Our results suggest that surgery-provoked VTE occurs frequently after discharge and is associated with an elevated risk of recurrence, and that patients with post-discharge VTE are at a higher risk of recurrence than patients with VTE diagnosed before discharge. Thromboprophylaxis strategies post-discharge should be considered in this population. Disclosures:Tagalakis:Sanofi Aventis: Research Funding; Pfizer: Research Funding.

Preventive Measures to Reduce Thromboembolism following Cosmetic Surgery

One of the most widely recognized and fortunately infrequent complications of major surgery is having a patient develop thromboembolism and die after an elective procedure. Patients should be evaluated for risk factors for thromboembolism before surgery, and measures should be taken to reduce this risk. This article will present the various risks for thromboembolism and suggest the means to prevent or avoid this complication. Special emphasis will be placed on one of the most common errors in cosmetic surgery that increase the risk of thromboembolism: the failure to have the patient stop the use of estrogens at least 4 weeks before surgery and 2 weeks after surgery.

Glycemic Control in the Intensive Care Unit and during the Postoperative Period

Glycemic Control in the Intensive Care Unit and during the Postoperative Period

Osteoradionecrosis

ABSTRACT Osteoradionecrosis (ORN) is a major complication of surgery or trauma in previously irradiated bone. This condition is often painful, debilitating and may result in significant bone loss. ORN of the mandible is the commonest site in patients who receive radiotherapy for head and neck cancer because of the relatively poor vascularization in this area. Risk factors include the total radiation dose, modality of treatment, fraction size and dose rate, oral hygiene, timing of tooth extractions as well as the continued use of tobacco and alcohol. Conversely, steroid use before or after radiation may have a protective effect related to the inhibition of the initial inflammatory phase of ORN. The management of this side effect is difficult and can result in bone or soft tissue loss, affecting the quality of life. The recommended treatment guidelines are irrigation, antibiotics, hyperbaric oxygen therapy and surgical techniques, including hemimandibulectomy and graft placements.