Complications In Surgical Patients Research Articles

The effect of hypocaloric nutrition on surgical complications in patients undergoing major surgery

Introduction: The response to the stress of injury has been divided into "ebb” and "flow” phases. The magnitude of injury influences both the degree and duration of each phases. High provisions of glucose-derived calories tend to accentuate these reactions and increase the degree of hyperglycaemia. Objectives/Aims: It was aimed that to evaluate hypocaloric-hyperproteinic regimen during the first days after elective surgery for morbidity, mortality and length of stay. Methods: Sixty patients undergoing elective major surgery were enrolled in this prospective, randomised, controlled study. These patients were divided three groups, designed Group I conventional therapy, Group II hypocaloric-hyperproteinic parenteral nutrition, Group III total parenteral nutrition. Postoperative morbidity, mortality and length of stay data were recorded. Results: Hypocaloric-hyperproteinic parenteral nutrition in major surgery patients did not increased or reduced on mortality, morbidity, infective complications, and postoperative stay in hospital. Hypocaloric- hyperproteinic parenteral nutrition declines of nutritional expenditure 60% accordance to TPN. Conclusion: In this study, postoperative hypocaloric-hyperproteinic parenteral nutrition did not affect mortality and morbidity. Larger randomised clinical trials are required especially about hyperproteinic parenteral nutrition

Late postoperative complications in surgical patients: an integrative review.

to identify the main complications in the late postoperative period of surgical patients. an integrative review from the CINAHL, LILACS, Science direct, Web of Science, SCOPUS, Europe PMC, and MEDLINE databases. Descriptors and keywords were combined without language or time restriction. ten primary studies were included. Infectious complications were the most common, especially surgical site infection, pneumonia and urinary tract infection. The presence of complications was linked to increased mortality, need for reoperations and worse survival. Few studies report on monitoring frequency, follow-up time and/or when complications started to be observed. infectious complications were the most prevalent postoperatively. The scarcity of guidelines that guide the monitoring of complications regarding monitoring frequency, follow-up time and classification makes it difficult to establish an overview of them and consequently propose intervention strategies.

Challenging the Surgical Axiom: Albumin Level Does Not Reliably Predict Development of Wound Complications in Patients Undergoing Body Contouring.

Hypoalbuminemia has traditionally been associated with a poor nutritional status and subsequent high incidence of postoperative wound complications in surgical patients. Recent evidence, however, suggests that traditional nutritional markers are inadequate in predicting postoperative morbidity. To test the hypothesis that preoperative albumin levels are not associated with adverse outcomes in patients undergoing body contouring. All patients undergoing body contouring from 2015 to 2017 were identified using the American College of Surgeons National Surgical Quality Improvement Program database. Demographics, comorbidities, and wound classification were extracted from the database. The independent predictors of developing wound complications were identified. Logistic regressions were used to identify the impact of albumin on outcomes. During the study period, 4496 patients were identified. Wound complications developed in 202 patients (4.5%). Increasing body mass index, history of diabetes mellitus, American Society of Anesthesiologists classification, history of prior open wound, and tobacco use were independently associated with the development of postoperative complications. Albumin levels were not associated with the development of wound complications. Similarly, albumin levels were not associated with the need for a repeated operation, with readmission, or with the total hospital length of stay. Albumin values were not associated with wound complications or need for reoperation in patients undergoing body contouring. Further research is warranted.

Effects of general anesthesia on systemic inflammatory response during cardiac surgery with extracorporeal circulation

Systemic inflammatory response syndrome (SIRS) is a severe complication in surgical patients associated with increased morbidity and mortality. Anesthetics are known to produce certain effects on the immune system and the manifestation of SIRS. The understanding of these beneficial mechanisms allows selecting optimal anesthetics in order to reduce the manifestation of SIRS and infectious complications in the postoperative period.

Does preoperative enteral nutrition reduce the incidence of surgical complications in patients with Crohn's disease? A case-matched study.

Currently, the notion that preoperative optimization with enteral nutrition (EN) reduces the incidence of complication after surgery in Crohn's disease (CD) patients is being debated. This case-matched study was to evaluate the impact of preoperative EN on surgical outcomes in patients with CD. Twenty-four patients received EN therapy with an elemental diet (1800-2400kcal/day) for at least 2weeks before the planned surgery (EN group). A further 24 patients who underwent surgery without receiving preoperative EN or parenteral nutrition formed a control group based on four matched criteria: age (≤/>40years), the use of preoperative medications (corticosteroids/azathioprine/biologics), disease behaviour (inflammatory/stricturing/penetrating) and main surgical procedure (ileal resection/ileocolonic resection/colectomy). The incidence of complications observed within 30days after surgery was compared between the two groups. Septic complications were defined as anastomotic leak, intra-abdominal abscess, entero-cutaneous fistula or wound infection. In the EN group, the median serum albumin level significantly increased, while C-reactive protein (CRP) significantly decreased during the preoperative EN (albumin, from 3.0mg/dl to 3.1mg/dl, P=0.04; CRP, from 3.05mg/dl to 2.52mg/dl, P=0.02). The incidence of postoperative septic complications was significantly lower in the EN group compared with the control group (4% vs 25%, P=0.04). The occurrence rate of overall complications was lower in the EN group (21% vs 29%, P=0.51), but not statistically significant. In patients with CD, preoperative optimization with EN reduced the overall rate of postoperative complications and significantly decreased postoperative septic complications.

Prediction of the risk of surgical complications in patients undergoing monopolar transurethral resection of bladder tumour - a prospective multicentre observational study.

IntroductionThe aim of the study was to identify predictors of surgical complications of transurethral resection of bladder tumour (TURBT).Material and methodsWe prospectively recruited 983 consecutive patients undergoing TURBT within 7 months in six academic institutions. All patients were followed up from the surgery up to 30 days postoperatively with at least one telephone contact at the end of the observation. The primary study endpoint was any intra- or postoperative surgical complication. For the identification of predictors of complications, univariate and multivariate logistic regression models were used. Trial registration: ClinicalTrials.gov (NCT03029663). Registered 24 January 2017.ResultsSurgical complications were noticed in 228 (23.2%) patients, including 83 (8.4%) patients with more than one complication and 33 cases of Clavien-Dindo grade 3 complications (3.3%). The most common in-hospital complications were bleeding (n = 139, 14.1%) and bladder perforation (n = 46, 4.7%). In a multivariate analysis, nicotine use, high ASA score, and the presence of high-grade tumour were the most significant predictors of high-grade complications. The stage of the disease was the strongest predictor of bleeding, while the presence of muscle in the specimen and resident surgeon were the strongest predictors for bladder perforation.ConclusionsTURBT poses a significant risk of surgical complications, the majority of which are of low grade.

3057 Unusual Presentation of MRSA Colitis Complicated With Acute Appendicitis

INTRODUCTION: Clostridium difficile colitis has been the most aware bacterial enterocolitis for years and other bacteria been relegated such as Staphylococcus colitis. Staphylococcus enterocolitis following antibiotics had been one of the most frequent complications in surgical patients in 1950s and 1960s and now reappear with more resistance such as Methicillin-Resistant Staphylococcus Aureus (MRSA) colitis which brings a new challenge. CASE DESCRIPTION/METHODS: A 32-year-old Hispanic female with a history of Type I Diabetes Mellitus presenting with altered sensorium and a 2-day history of watery, non-bloody diarrhea, intractable emesis and diffuse crampy abdominal pain. About a month before the presentation, the patient had a soft-tissue laceration on left foot requiring a 7-day course of Cephalexin and Clindamycin that healed appropriately. On physical exam, she was tachycardic with HR of 110 bpm and tachypneic with RR of 28, somnolent but arousable with GCS >12. The abdomen was soft, tender diffusely to palpation without rebound or guarding. On the biochemical analysis, her blood glucose was 968 mg/dL with anion-gap metabolic acidosis (AG 46). In the ICU, she initiated on IV fluids, insulin and IV antibiotics for suspicion of colitis. C. diff testing was negative, but stool cultures grew MRSA for which she was started on Vancomycin and TMP-SMX. Due to continued abdominal pain on antibiotics, CT-Abdomen with Contrast showed acute appendicitis with inflammatory debris and without perforation or abscess (Figure 1) requiring laparoscopic appendectomy. DISCUSSION: Although Staphylococcal species are known to cause of antibiotic-associated colitis, MRSA colitis cases are unique and can pose a challenge in treatment if not ruled out and managed. When patients present with watery diarrhea, it is common to order C. diff testing, and stool culture is delayed or performed in an inappropriate time manner resulting in inconclusive cultures. Our case presented with DKA, which complicates the etiology of abdominal pain on admission for the clinician masking MRSA colitis associated with a rare complication of appendicitis double challenge and difficult to diagnose as most DKA patients present with abdominal pain. Oral Vancomycin is the treatment of choice, but our patient required coverage with TMP-SMX that proves to be effective double coverage. There were no case reports previously presenting with DKA or complication of acute appendicitis, which provides a learning opportunity in varied presentations.

Can Nicotine Replacement Therapy Decrease Complications in Plastic Surgery?

Cigarette smoking has been well demonstrated to be associated with adverse outcomes and increased complications in surgical patients in the operative and postoperative periods. There is general agreement that smoking cessation decreases such risks; however, much debate still exists regarding the most effective modalities for risk mitigation, especially concerning modalities involving nicotine replacement in some form. This article reviews the discussion regarding smoking cessation therapies, in particular those involving nicotine replacement, in the context of mitigating risk in plastic surgery procedures. The recent rise in popularity of electronic cigarettes poses further challenges for clinicians in minimizing risk and optimizing outcomes for patients. Prospective studies including high-level evidence such as randomized controlled clinical trials will be required to help plastic surgeons develop guidelines that will enable optimization of patient safety and clinical outcomes.

Failure to Rescue: A Quality Improvement Imperative in Achieving Zero Death in Damage Control Laparotomy Patients

Failure to rescue (FTR), defined as death after a major complication in surgical patients, is being used to measure outcomes for quality improvement. Major complications frequently occur in patients undergoing damage control laparotomy (DCL). No previous FTR studies have looked specifically into DCL patients. The aim of this study was to examine risk factors of FTR and identify potential areas for targeted quality improvement in DCL patients. A 10-year retrospective review of all consecutive adult trauma patients who underwent DCL at a Level I trauma center was performed. Demographic and clinical variables were examined for association with FTR. Multivariate regression analysis was performed to identify risk factors of FTR in DCL patients. A total of 199 DCL patients were analyzed. Overall DCL mortality observed was 11.1 per cent (n = 22/199) and overall FTR for the cohort was n = 16/199. FTR represented 72 per cent (n = 16/22) of the total mortality. The significantly increased risk of FTR was associated with older age (P = 0.027), lower initial Glasgow Coma Scale score (P = 0.037), more units of packed red blood cells (P = 0.028), and respiratory complications (P = 0.035). Renal and infectious complications did not significantly increase the risk of FTR in this population. FTR is an important benchmark of quality for trauma patients. This study elucidates potential initial characteristics and complications related to FTR in DCL patients. Efforts in achieving zero death from FTR can potentially improve overall mortality in this subset of patients. Future quality interventions to help minimize FTR should target these specific areas.

Validation of new ICD-10-based patient safety indicators for identification of in-hospital complications in surgical patients: a study of diagnostic accuracy

ObjectiveAdministrative data systems are used to identify hospital-based patient safety events; few studies evaluate their accuracy. We assessed the accuracy of a new set of patient safety indicators (PSIs; designed...

Abdominal Wound Closure in Gynaecological or Obstetrical Surgery with Vicryl® (Polyglactin910) Versus Vicryl Plus® (Polyglactin910 with Triclosan Added): A Comparative Study

Background: Surgical site infection is the most common post-surgical complication in surgical patients. The incidence of surgical site infection varies from 3-20% (or even more) in different part of the world. To date, the best method and material for skin closure has not been recommended by anybody. Triclosan is an antiseptic agent used for coating a suture material to prevent the infections. This case-controlled study was carried out to determine the comparative efficacy of sutures;
 Objective: This case-controlled study was carried out to determine the comparative efficacy of sutures: vicryl® and vicryl plus® (triclosan, an antiseptic incorporated with suture), in reducing surgical site infection in laparotomy for clean Gyn/Obs operations.
 Material and method: This case-controlled study was carried out in Dept. Of Gynae/Obs at Nepalgunj Medical College Teaching Hospital, Kohalpur. The period of the study was from Jan 2018 to January 2019. A total of 50 participants were enrolled in the study, who met the inclusion criteria. The patients were divided into two groups A and B, each consisting of 25 patients. The patients were allocated in the groups alternately to remove bias. The Group A consisted of patients where Vicrylplus® (Ethicon, Johnson & Johnson Company, Ahmadabad, India) polyglactin910 with triclosan) was used and Group B consisted of patients where vicryl ® (Ethicon, Johnson & Johnson Company, Ahmadabad, India) polyglactin910 alone) was used. Patients whose abdominal wounds were found infected, pus swab for culture were taken and sent for aerobic culture and sensitivity. All patients received ceftriaxone and metronidazole single dose before operations prophylactically.
 Result: Surgical site infection ingroup A was 3 cases out of 25 (12%) and in group B it was 6 cases out of 25(24%). Triclosan added polyglactin910 suture found to be statistically non significant concerning prevention of SSI as compared to polyglactin910 (p=0.472). The mean age of the study population was in group A was (29.76±7.47) and in group B was (27.12±7.42).

Impact of diabetes mellitus on surgical complications in patients undergoing revision total knee arthroplasty: Insulin dependence makes a difference

ObjectivesAssessing the effects of diabetes mellitus (DM), non-insulin-dependent diabetes mellitus (NIDDM), and insulin-dependent diabetes mellitus (IDDM) on revision TKA (rTKA) has become increasingly imperative due to the increased rates of revisions associated with DM. This study sought to identify complications in rTKA that were independently associated with NIDDM/IDDM compared to non-diabetic (Non-DM) patients and whether IDDM was associated with specific postoperative complications compared to NIDDM. Methods and materials16,428 rTKA patients were identified from the ACS-NSQIP database from 2005 to 2016 and stratified into three separate cohorts. 12,922 (78.66%) were Non-DM, 2335 (14.21%) had NIDDM, and 1171 (7.13%) had IDDM. Univariate analyses were utilized to assess for differences in demographics, preoperative comorbidities, and postoperative complication rates. Multivariate logistic regression analyses were then employed to control for significant differences in patients characteristics to assess NIDDM and IDDM as independent risk factors for complications in comparison to Non-DM. IDDM was further analyzed as a risk factor in comparison to NIDDM for the purpose of elucidating the impact of insulin dependence on risk for postoperative complications. ResultsNIDDM was an independent risk factor for deep incisional surgical site infections (Odds Ratio (OR): 2.477) and urinary tract infections (UTI) (OR 1.862) (p < 0.05). Compared to NIDDM, IDDM was independently associated with greater risk for pneumonia (OR 2.603), septic shock (OR 6.597), blood transfusions (OR 1.326), and an extended length of stay (OR: 1.331) (p < 0.05). IDDM additionally increased the risk for acute renal failure (OR 3.269) and cardiac arrest (OR 3.268) (p < 0.05) when compared to Non-DM. DM patients overall had increased rates of worse outcomes and infectious complications. ConclusionAlthough differences between diabetes and non-diabetes rTKA patients were seen, differences in complication rates between diabetes patients further divided based on insulin dependence status were also noted. Future work examining whether targeting perioperative glucose levels <200 mg/dL in DM rTKA patients decreases infectious complications is warranted. Future work analyzing the role of tranexamic acid administration and 24-h postoperative antibiotics in rTKA IDDM patients may be warranted given the elevated risk of pneumonia, septic shock, and blood transfusions.

Impact of Preoperative Nutritional Status on the Incidence Rate of Surgical Complications in Patients With Inflammatory Bowel Disease With Vs Without Preoperative Biologic Therapy: A Case-Control Study.

OBJECTIVES:A case-control study was undertaken to assess the impact of preoperative nutrition on surgical outcomes in patients with inflammatory bowel disease with vs without preoperative biologic therapy.METHODS:Seventy patients who had received biologic therapy within 8 weeks before undergoing resection for active ulcerative colitis (n = 34) or Crohn's disease (n = 36) were included (BIO group). The control group comprised 70 patients without exposure to biologics, selected based on 5 matching criteria: inflammatory bowel disease subtype (ulcerative colitis/Crohn's disease), age (≤ or >40 years), disease severity (moderate/severe), surgical approach (open/laparoscopic), and main surgical procedure. Poor nutrition was defined as the presence of at least one of the following criteria: weight loss >10%–15% within 6 months, body mass index <18.5 kg/m2, Subjective Global Assessment Grade C, or serum albumin <30 g/L.RESULTS:The proportion of patients with preoperative poor nutrition was 43% in the BIO and 33% in the control groups (P = 0.22). The incidence of postoperative infectious complications (anastomotic leak, intra-abdominal abscess, enterocutaneous fistula, or wound infection) was 16% in the BIO and 14% in the control groups (P = 0.81). In the BIO group, poor nutrition significantly increased the risk of infectious complications (27% vs 8% without poor nutrition, P = 0.03). In addition, in the control group, the incidence of infectious complications was higher in patients with poor nutrition, but not significantly (22% vs 11%, P = 0.21).DISCUSSION:Poor nutrition increases the risk of infectious complications after surgery. The detrimental effects of poor nutrition on postsurgical infection may be enhanced in patients who have received biologic therapy preoperatively.

Effects of preoperative sarcopenia on postoperative complications of minimally invasive oesophagectomy for oesophageal squamous cell carcinoma.

Sarcopenia is closely associated with surgical complications in patients with certain cancers. In this study we assessed the relationship between sarcopenia and postoperative complications in patients with oesophageal squamous cell carcinoma. We retrospectively analysed of patients who underwent thoracoscopic combined with laparoscopic radical resection of oesophageal cancer. Preoperative computed tomography to evaluate skeletal muscle mass to diagnose sarcopenia and to evaluate associations with age, body mass index (BMI), lung function and postoperative complications. Among 141 patients, 73 presented with sarcopenia (sarcopenia group) and 68 did not (non-sarcopenia group). The mean skeletal muscle index in all patients was 49.5±9.0 cm2/m2; median, 49.3 cm2/m2. The sarcopenia group included a higher proportion of men (P=0.039) and had a lower BMI than the non-sarcopenia group (P=0.001). There were no significant differences in any other clinical and pathological features. The incidences of postoperative complications in the sarcopenia and non-sarcopenia groups were 63.0% and 36.8%, respectively (P=0.002). The incidences of pulmonary infections and postoperative pleural effusions were 28.8% vs. 11.8% (P=0.011) and 38.4% vs. 20.6% (P=0.020) in the sarcopenia and non-sarcopenia groups, respectively. The incidences of other complications were not significantly different between the two groups. Univariate and multivariate analyses of pulmonary infection-related clinical factors revealed that sarcopenia and forced expiratory volume in the first second as a percent of forced vital capacity (FEV1.0%) were independent risk factors for pulmonary infection after minimally invasive surgery. Preoperative sarcopenia is an independent risk factor for pulmonary infection after minimally invasive oesophagectomy (MIE). Evaluation of preoperative sarcopenia will thus help to prevent postoperative complications.

The high stakes of head and neck surgery following radiation and chemotherapy – An assessment of complications and survival

ObjectivesTo investigate variables that predict medical and surgical complications in patients undergoing salvage surgery after primary organ-preserving therapy for head and neck cancer and to investigate the effect of complications on 5-year overall survival. Materials and methodsA retrospective study was conducted on patients undergoing salvage surgery after primary organ-preserving therapy for head and neck cancer at a tertiary institution from 2006 to 2011. Multivariable regression analysis was used to assess association between independent variables and medical and surgical complications. A Kaplan-Meier survival curve was plotted to assess effect of surgical and medical complications on 5-year overall survival. ResultsOne hundred thirty-six patients undergoing salvage surgery after primary organ-preservation surgery met inclusion criteria. Surgical complications occurred in 68/136 (50.0%) of patients. After adjusting for confounders, young age and history of hypothyroidism were significant predictors of surgical complications (p < 0.05). Medical complications occurred in 37/136 (27.2%) of patients. After adjusting for confounders, older age and history of hepatic disease were significant predictors of having a medical complication (p < 0.05). Patients with no complications had better overall survival than patients with medical complications (p = 0.009). There was no difference in overall survival between patients without complications and patients with surgical complications only (p = 0.259). ConclusionRisk factors for medical and surgical complications include history of hypothyroidism, liver disease, and age. Survival outcomes are not affected by surgical complications but are significantly affected by medical complications highlighting the importance of personalized patient care and medical co-management.

Patient education in relation to informational needs and postoperative complications in surgical patients.

To study surgical patients' informational expectations and the level of received knowledge at the time of hospital discharge. To examine if there is an association with postoperative complications and the patient´s level of received knowledge. Comparative descriptive design. The data on patients admitted for non-cardiac surgery were collected in three phases during an eight-month period. 258 in-ward non-cardiac general surgery and orthopedic surgery adult patients. Questionnaires before admission (knowledge expectations) and at discharge (received knowledge). A telephone interview 30 days after discharge. Received knowledge (as much or more / less) compared to expectations, and its association with post-discharge complications. There were differences between patient groups in their perception of receiving enough knowledge and they were connected to gender (male vs. female OR 2.67, 95% CI 1.55-4.60, P = 0.0004) and procedure (elective orthopedic implant surgery vs. elective minor orthopedic and hand surgery: OR 3.25, 95% CI 1.72-6.17, P = 0.0003). Patients who received less knowledge than expected had more postoperative complications than those who received sufficient (as much or more than expected) information. Patients differ in terms of informational needs, and preoperative education prepares the patient for the information provided postoperatively. Patient education may have an influence on recovery from surgery.

Influence of obesity on surgical complications of patients with ovarian tumors.

Influence of obesity on surgical complications and survival of patients with ovarian tumors were investigated. In total, 362 patients who were diagnosed with ovarian cancer by biopsy in the Department of Pathology of Shanxi Dayi Hospital Affiliated to Shanxi Medical University from April 2012 to July 2017 were selected as research subjects for retrospective analysis. The patients were divided into the obesity group [body mass index (BMI) ≥28] (n=64), the overweight group (≥24 BMI <28) (n=124), the normal body weight group (≥18.5 BMI <24) (n=108) and the low body weight group (BMI <18.5) (n=66). The surgical conditions and postoperative complications of patients in the 4 groups were compared, and the patients were followed up for prognosis for one year, and their mortality rates were recorded. The surgical time, intraoperative blood loss amount and blood transfusion amount of the patients in the obesity group were the highest, followed by the overweight group (P<0.05). Among the 4 groups, the prognosis of patients in the obesity group was also the worst. The incidence rates of complications among all groups were compared, and the incidence rate of complications in the obesity group was the highest (50.00%), followed by the overweight group (30.65%), the low body weight group (13.64%) and the normal body weight group (4.63%), (P<0.05). The prognosis follow-up results showed that the 1-year mortality rate in the obesity group was the highest (35.94%), followed by the overweight group (28.23%). For patients with ovarian cancer, obesity raises the risks of postoperative complications and worsens their prognosis. Therefore, indexes of patients with tumors associated with high BMI should be monitored more strictly after surgeries.

Evaluation of BMI as a Risk Factor for Complications following Gender-affirming Penile Inversion Vaginoplasty.

Background:Gender affirmation surgery (GAS) has a positive impact on the health of transgender patients; however, some centers employ body mass index (BMI) as a strict selection criterion for surgical candidacy. Several single-center studies have found no clear correlation between BMI and complication rates. We conducted a retrospective multicenter study at 2 university-based centers to test the null hypothesis: obesity is not a significant determinant of the risk of acute surgical complications in patients undergoing penile inversion vaginoplasty (PIV).Methods:This is a retrospective chart review of all adult patients at the University of Michigan and the University of Miami undergoing gender-affirming PIV with minimum follow-up time of 3 months between 1999 and 2017. A logistic regression model of analysis is used to examine the predictive factors for surgical complications and delayed revision urethroplasty in our patient sample.Results:One hundred and one patients met inclusion criteria for this study. The mean BMI at the time of procedure was 26.9kg/m2 (range 17.8–48.2). Seventeen patients (16.8%) had major complications and 36 patients (35.6%) had minor complications. On logistic regression analysis, none of the recorded covariates were significant predictors of delayed revision urethroplasty or major, minor, or any complications.Conclusions:We found that obese patients can safely undergo GAS and that BMI alone should not preclude appropriately selected patients from undergoing GAS. We acknowledge that selection based on overall health and other medical comorbidities is certainly warranted for gender-affirming PIV and all other surgical procedures.

Effects of the extent of regional lymph node dissection on the prognosis of patients with T4 gallbladder carcinoma: a multi-center retrospective analysis

Objective To investigate the effects of the extent of regional lymph node dissection on the prognosis of patients with T4 gallbladder carcinoma. Methods The retrospective cohort study was conducted. The clinicopathological data of 64 patients with T4 gallbladder carcinoma who underwent radical cholecystectomy in the 4 medical centers between January 2013 and December 2016 were collected, including 31 in the Eastern Hepatobiliary Surgery Hospital of Naval Medical University, 16 in the First Affiliated Hospital of Xi′an Jiaotong University, 11 in the Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine and 6 in the Affiliated Hospital of North Sichuan Medical College. There were 27 males and 37 females, aged from 35 to 77 years, with a median age of 59 years. Sixty-four patients underwent radical cholecystectomy and regional lymph node dissection. According to the extent of intraoperative lymph node dissection, 25 patients (13 in the Eastern Hepatobiliary Surgery Hospital of Naval Medical University, 6 in the First Affiliated Hospital of Xi′an Jiaotong University, 4 in the Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine and 2 in the Affiliated Hospital of North Sichuan Medical College) whose extent of lymph node dissection involved lymph nodes next to cystic duct, hepatoduodenal ligament, back of head of pancreas, next to common hepatic artery and celiac trunk were allocated into the extended dissection group, 39 patients (18 in the Eastern Hepatobiliary Surgery Hospital of Naval Medical University, 10 in the First Affiliated Hospital of Xi′an Jiaotong University, 7 in the Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine and 4 in the Affiliated Hospital of North Sichuan Medical College) whose extent of lymph node dissection involved lymph nodes next to cystic duct and hepatoduodenal ligament were allocated into the control group. Observation indicators: (1) postoperative complications; (2) follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed to detect postoperative overall survival up to January 2018. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was evaluated with the independent-sample t test. Count data were represented as absolute number or percentage, and comparison between groups was analyzed using the chi-square test and Fisher exact probability. The survival curve was drawn using the Kaplan-Meier method, and the comparison of survival rates was done by the Log-rank test. Results (1) Postoperative complications: 64 patients with T4 gallbladder carcinoma underwent successful radical cholecystectomy and regional lymph node dissection, without intraoperative death. Twelve patients had different degrees of postoperative complications. Four of 7 patients undergoing extended radical cholecystectomy had postoperative complications. Twenty-five patients in the extended dissection group were cured by conservative treatment, including 4 with intraperitoneal infection and 2 with pancreatic leakage, with a complication incidence of 24.0%(6/25). Thirty-nine patients in the control group were cured by conservative treatment, including 5 with intraperitoneal infection and 1 with gastric retention, with a complication incidence of 15.4%(6/39). There was no statistically significant difference in the complication incidence between the two groups (χ2=0.284, P>0.05). (2) Follow-up and survival situations: 64 patients were followed up for 1-60 months. The postoperative overall median survival time was 11 months. The postoperative median survival time, 1-, 3- and 5-year cumulative survival rates were respectively 18 months, 80%, 16%, 9% in the extended dissection group and 8 months, 21%, 4%, 0 in the control group, with a statistically significant difference in the prognosis between the two groups (χ2=14.744, P<0.05). Conclusions On the premise of practiced surgical skill, extended regional lymph node dissection cannot increase incidence of surgical complication in patients with T4 gallbladder carcinoma after radical resection. Actively extending lymph node dissection up to near common hepatic artery, peri-celiac trunk and back of head of pancreas can improve long-term survival and prognosis. Key words: Biliary tract neoplasms; Gallbladder carcinoma, stage T4; Radical resection; Regional lymph node dissection; Multi-center; Retrospective research

Nomogram for predicting the likelihood of postoperative surgical complications in patients treated with partial nephrectomy: a prospective multicentre observational study (the RECORd 2 project).

To identify meaningful predictors and to develop a nomogram of postoperative surgical complications in patients treated with partial nephrectomy (PN). We prospectively evaluated 4308 consecutive patients who had surgical treatment for renal tumours, between 2013 and 2016, at 26 Italian urological centres (RECORd 2 project). A multivariable logistic regression for surgical complications was performed. A nomogram was created from the multivariable model. Internal validation processes were performed using bootstrapping with 1000 repetitions. Overall, 2584 patients who underwent PN were evaluated for the final analyses. The median (interquartile [IQR]) American Society of Anesthesiologists (ASA) score was 2(2-3). In all, 72.4% of patients had clinical T1a (cT1a) stage tumours. The median (IQR) Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score was 7(6-8). Overall, 34.3%, 27.7%, 38% of patients underwent open PN (OPN), laparoscopic PN (LPN), and robot-assisted PN (RAPN). Overall and major postoperative surgical complications were recorded in 10.2% and 2.5% of patients, respectively. At multivariable analysis, age, ASA score, cT2 vs cT1a stage, PADUA score, preoperative anaemia, OPN and LPN vs RAPN, were significant predictive factors of postoperative surgical complications. We used these variables to construct a nomogram for predicting the risk of postoperative surgical complications. At decision curve analysis, the nomogram led to superior outcomes for any decision associated with a threshold probability of >5%. Several clinical predictors have been associated with postoperative surgical complications after PN. We used this information to develop and internally validate a nomogram to predict such risk.