Delayed Surgery Group Research Articles

Early Surgical Intervention for Acute Ulcerative Colitis Is Associated with Improved Postoperative Outcomes

BackgroundTiming of surgical intervention for acute ulcerative colitis has not been fully examined during the modern immunotherapy era. Although early surgical intervention is recommended, historical consensus for “early” ranges widely. The purpose of this study was to evaluate outcomes according to timing of urgent surgery for acute ulcerative colitis. MethodsAll non-elective total colectomies in ulcerative colitis patients were identified in the National Inpatient Sample from 2002 to 2014. Procedures, comorbidities, diagnoses, and in-hospital outcomes were collected using International Classification of Disease, 9th Revision codes. An operation was defined as early if within 24 hours of admission. Results were compared between the early versus delayed surgery groups. ResultsWe found 69,936 patients that were admitted with ulcerative colitis, and 2650 patients that underwent non-elective total colectomy (3.8%). Early intervention was performed in 20.4% of patients who went to surgery. More early operations were performed laparoscopically (28.1% versus 23.3%, p = 0.021) and on more comorbid patients (Charlson Index, p = 0.008). Median total hospitalization costs were $20,948 with an early operation versus $33,666 with a delayed operation (p < 0.001). Delayed operation was an independent risk for a complication (OR = 1.46, p = 0.001). Increased hospitalization costs in the delayed surgery group were statistically significantly higher with a reported complication (OR = 3.00, p < 0.001) and lengths of stay (OR = 1.26, p < 0.001). ConclusionDelayed operations for acute ulcerative colitis are associated with increased postoperative complications, increased lengths of stay, and increased hospital costs. Further prospective studies could demonstrate that this association leads to improved outcomes with immediate surgical intervention for medically refractory ulcerative colitis.

Delayed versus immediate surgery following short-course neoadjuvant radiotherapy in resectable (T3N0/N+) rectal cancer.

Preoperative short-course radiotherapy (SCRT) followed by surgery has shown advantage over surgery alone in patients with resectable rectal carcinoma (RC); however, the importance of the timing of surgery after SCRT has not been well defined. This study aimed to investigate the effect of this duration on treatment outcomes. Patients who underwent surgery after SCRT (25Gy/500cGy/daily/5fr, monday-friday) for resectable and infraperitoneal rectal adenocarcinoma (T3N0/(+)) were included into the study. Patients were divided into two groups in terms of the timing of surgery: delayed surgery (>4weeks) or immediate surgery (<4weeks). A hundred and thirty-six patients were included in the study. Median time between RT and surgery was 4 ± 5.7 (1-58)weeks, where 68% (n = 93) patients underwent delayed surgery (≥4weeks). The two groups did not differ in terms of surgical margin positivity, pathological tumor regression, N downstaging, or T downstaging (p > 0.05 for all). However, the number of positive lymph nodes was higher in the immediate surgery group [median 3 (0-18) vs. 1 (0-17), p = 0.009]. Median follow-up time was 36 ± 9 (6-93)months. Delayed surgery group had significantly longer mean overall survival (p = 0.038); however, the two groups did not differ in terms of local recurrence, mean time to local recurrence, or mean disease-free survival. Our findings seem to support the benefit of a longer time interval between radiotherapy and surgery after short-course neoadjuvant radiotherapy in resectable rectal cancer in terms of overall survival. However, there is a need to better define patient characteristics that might benefit from delayed surgery.

Effect of causes of surgical delay on early and late mortality in patients with proximal hip fracture

The purpose of this study was to investigate the reasons for delayed surgery in patients with proximal hip fracture and to compare differences in mortality between delayed surgery cases and non-delayed surgery cases. In addition, we evaluated causal factors for delayed surgery that affected differences in mortality. From 2003 to 2013, 1290 patients (1290 hips) with unilateral femoral neck or intertrochanteric fractures who underwent surgery were categorized into Group Ia (402 patients, early surgery group) and Group Ib (888 patients, delayed surgery group). The delayed surgery group was categorized as Group IIa (270 patients, pre-hospital delay group) and Group IIb (618 patients, post-hospital delay group). Among 618 patients with post-hospital delay, 165 patients in Group IIIa were defined as delayed surgery cases due to patient factors, and 453 patients in Group IIIB were defined as delayed surgery cases due to hospital factors. Early and late mortality was compared between each group. Of 1290 patients, 888 patients underwent delayed surgery (mean 7.5days, range 3-167days) after hip fracture. The cumulative mortality rate at 30, 60days, 3, and 12months was 0.7, 2.0, 3.0, and 9.5% in Group Ia, respectively, and 2.4, 4.5, 5.2, and 14.5% in Group Ib, respectively (p = 0.047, p = 0.027, p = 0.078, and p = 0.012, respectively). Of 618 patients with post-hospital surgery delay, the cumulative mortality rate at 30days and 12months was 4.8 and 21.2% in Group IIIa, respectively, and 1.8, and 12.6% in Group IIIb, respectively (p = 0.033 and p = 0.008, respectively). After adjustments, patient factors for delayed surgery (HR 2.780; 95% CI 1.012-7.640, p = 0.047) were significantly associated with death after hip fracture. This study demonstrated that delayed surgery was significantly related to 30-day and 1-year mortality. Surgery delay due to drugs' hold and medical comorbidity was related to 30-day mortality after adjustment.

Surgery for cataracts in people with age-related macular degeneration.

Cataract and age-related macular degeneration (AMD) are common causes of decreased vision that often occur simultaneously in people over age 50. Although cataract surgery is an effective treatment for cataract-induced visual loss, some clinicians suspect that such an intervention may increase the risk of worsening of underlying AMD and thus have deleterious effects on vision. The objective of this review was to evaluate the effectiveness and safety of cataract surgery compared with no surgery in eyes with AMD. We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 11), Ovid MEDLINE, Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily (January 1946 to December 2016), Embase (January 1980 to December 2016), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to December 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 2 December 2016. We included randomized controlled trials (RCTs) and quasi-randomized trials that enrolled participants whose eyes were affected by both cataract and AMD in which cataract surgery was compared with no surgery. Two review authors independently evaluated the search results against the inclusion and exclusion criteria. Two review authors independently extracted data, assessed risk of bias for included studies, and graded the certainty of evidence. We followed methods as recommended by Cochrane. We included two RCTs with a total of 114 participants (114 study eyes) with visually significant cataract and AMD. We identified no ongoing trials. Participants in each RCT were randomized to immediate cataract surgery (within two weeks of enrollment) or delayed cataract surgery (six months after enrollment). The risk of bias was unclear for most domains in each study; one study was registered prospectively.In one study conducted in Australia outcomes were reported only at six months (before participants in the delayed-surgery group had cataract surgery). At six months, the immediate-surgery group showed mean improvement in best-corrected visual acuity (BCVA) compared with the delayed-surgery group (mean difference (MD) -0.15 LogMAR, 95% confidence interval (CI) -0.28 to -0.02; 56 participants; moderate-certainty evidence). In the other study, conducted in Austria, outcomes were reported only at 12 months (12 months after participants in the immediate-surgery group and six months after participants in the delayed-surgery group had cataract surgery). There was uncertainty as to which treatment group had better improvement in distance visual acuity at 12 months (unit of measure not reported; very low-certainty evidence).At 12 months, the mean change from baseline between groups in cumulated drusen or geographic atrophy area size was small and there was uncertainty which, if either, of the groups was favored (MD 0.76, 95% CI -8.49 to 10.00; 49 participants; low-certainty evidence). No participant in one study had exudative AMD develop in the study eye during 12 months of follow-up; in the other study, choroidal neovascularization developed in the study eye of 1 of 27 participants in the immediate-surgery group versus 0 of 29 participants in the delayed-surgery group at six months (risk ratio 3.21, 95% CI 0.14 to 75.68; 56 participants; very low-certainty evidence). Quality of life was measured using two different questionnaires. Scores on the Impact of Vision Impairment (IVI) questionnaire suggested that the immediate-surgery group fared better regarding vision-related quality of life than the delayed-surgery group at six months (MD in IVI logit scores 1.60, 95% CI 0.61 to 2.59; low-certainty evidence). However, we could not analyze scores from the Visual Function-14 (VF-14) questionnaire from the other study due to insufficient data. No postoperative complication was reported from either study. At this time, it is not possible to draw reliable conclusions from the available data as to whether cataract surgery is beneficial or harmful in people with AMD after 12 months.Although cataract surgery provides short-term (six months) improvement in BCVA in eyes with AMD compared with no surgery, it is unclear whether the timing of surgery has an effect on long-term outcomes. Physicians must make recommendations to their AMD patients regarding cataract surgery based on experience and clinical judgment until large controlled trials are conducted and their findings published.There is a need for prospective RCTs in which cataract surgery is compared with no surgery in people with AMD to better evaluate whether cataract surgery is beneficial or harmful in all or a subset of AMD patients. However, ethical considerations preclude withholding surgery, or delaying it for several years, if it may be a potentially beneficial treatment. Designers of future trials are encouraged to utilize existing standardized systems for grading cataract and AMD and for measuring key outcomes: visual acuity, change in visual acuity, worsening of AMD, quality of life measures, and adverse events.

Association between timing of cervical excision procedure to minimally invasive hysterectomy and surgical complications

ObjectiveTo determine if the time interval between excision procedure and definitive minimally invasive surgery (MIS) for cervical cancer impacts 30-day postoperative complications. MethodsA retrospective cohort of patients diagnosed with cervical cancer from January 2000 to July 2015 was evaluated. Patients who underwent a cervical excision procedure followed by definitive MIS within 90days were included. Early definitive surgery was defined as ≤6 weeks following excision procedure, while delayed was defined as 6weeks to 3months. The primary outcome was 30-day complications. Statistical analysis included descriptive statistics and modified Poission regression. ResultsOverall, 138 patients met inclusion criteria. Of these, 33% (n=46) had early definitive surgery and 67% (n=92) had delayed definitive surgery. Median age was 42years (range 23–72years) and median BMI was 28kg/m2 (range 16–50kg/m2). Within demographic and surgical factors collected, only smoking status differed between groups with those in the delayed surgery group more likely to be non-smokers than those in the early surgery group (p=0.04). When adjusting for relevant demographic and surgical factors, patients in the early group were twice as likely to have 30-day complication (aRR 2.6, 95%CI 1.14–5.76, p=0.02). Evaluating only women who underwent a radical procedure, 30-day complications remained higher in the early surgery group (RR 2.56; 95%CI 1.22–5.38, p=0.01). ConclusionsPerforming definitive MIS for cervical cancer within 6weeks after cervical excision is associated with increased risk for 30-day complications. Providers should consider delaying definitive surgical procedures for at least 6weeks following excision to reduce surgical complications.

Inflammatory cytokine levels in synovial fluid 3, 4days postoperatively and its correlation with early-phase functional recovery after anterior cruciate ligament reconstruction: a cohort study.

BackgroundSynovial fluid was collected prior to and at 3 to 4 days after ACL reconstruction to investigate the correlation between inflammatory cytokine levels in the acute phase after surgery and physical functional recovery at 3 months postoperatively.Methods For this purpose, 79 patients with ACL reconstruction using semitendinosus tendons were included in the study. Median days from injury to surgery were 80 days (13–291 days). Synovial fluid was obtained just before surgery and at 3 to 4 days after surgery. Physical activity of each patient was evaluated at 3 months postoperatively, and scored from 0 (hard to walk) to 5 (run). Patients able to jog (score 4) or run (score 5) were considered as the “quick recovery” group and others (scores 1–3) as the “delayed recovery” group.ResultsPhysical activity recovery scores in the early surgery group (preoperative period less than 60 days; Group I) were significantly better than those in the delayed surgery group (Group II). Among the cytokines tested, TNF-alpha and IL10 levels in synovial fluid were significantly higher in Group II at 3 to 4 days postoperatively, while levels of these cytokines were quite comparable preoperatively between the groups. Increased IL1-beta expression was noted in the delayed recovery group at 3 to 4 days postoperatively. In addition, levels of IL6, IL10 and IFN-gamma also tended to increase in patients with delayed recovery.ConclusionDelayed ACL reconstruction increases levels of inflammatory cytokines in synovial fluid after surgery and correlates with a prolonged recovery of short-period physical activity of the patients.

The Management and Surgical Intervention Timing of Enchondromas

Objective: To investigate the impact of pathological fractures on the treatment outcomes in patients with fractures due to enchondromas and evaluate the optimal surgical intervention timing for these patients. Patients and Methods: Medical records and x-ray studies of patients treated for enchondroma of hand between 2005 and 2015 were retrospectively reviewed. Enchondromas located in phalanges and metacarpal bones were included in the study. There were 92 patients with solitary enchondromas of the hand, including 52 males (56.5%) and 40 females (43.5%) in this series, aged from 2 to 69 years (mean, 29.4 years). Based on the clinical data, patients with pathologic fractures were assigned into the group with fractures (n = 27) and those without fractures, who were diagnosed by accident, or routine physical examinations were assigned into the group without fractures (n = 65). All the patients were treated with operation. According to the timing of surgical intervention, the patients in the group with fractures were divided into two subgroups: primary (≤ 4 weeks; mean, 16 days) and delayed surgery (&gt; 4 weeks; mean, 87 days) groups. The operative methods were simple curettage or combined with bone grafting with autologous or bioactive materials. The Disabilities of the Arm, Shoulder and Hand (DASH) upper limb function scale was used to evaluate the function of the affected hand. The time of returning to work, complications, as well as the recurrence rate and in-hospital costs were recorded. Results: No significant differences in terms of consolidation time after surgery, recurrence rate, and DASH scores were noted between the groups with and without fractures (all P &gt; .05); the in-hospital costs were higher in the group with fractures than those in the group without fractures ( P &lt; .05); however, patients without fractures returned to work much earlier than those with fractures ( P &lt; .01). Of the patients with fractures, there were no significant differences in terms of consolidation time after surgery, recurrence rate, DASH scores, as well as the occurrence rate of complications between the primary surgery group and the delayed surgery group (all P &gt; .05); however, the time returning to work was statistically longer in the delayed surgery group, with an average 76 days than that of the primary surgery group, with an average 36 days ( P &lt; .001). Of all the patients, different surgical options of curettage only or combined with different filling materials had no effects on the follow-up outcomes (all P &gt; .05). Healing was noted to be progressive and complete in all cases, and no functional restriction was observed. Conclusion: The pathological fractures associated with enchondromas have no significant impact on the treatment outcomes compared with those with simple non-fractured endochondromas. Although a little bit more expense was needed for patients treated primarily with pathological fractures due to enchondroma, these patients could resume to their original work much earlier than those treated by a delayed surgery. Early surgical intervention is recommended with similar results and no increased risks for patients with pathological fractures caused by endochondromas.

Damage Control Orthopedics Management as Vital Procedure in Elderly Patients with Femoral Neck Fractures Complicated with Chronic Renal Failure: A Retrospective Cohort Study.

BackgroundChronic renal failure (CRF) predisposes to hip fractures in elderly patients, with high subsequent mortality. Selection and timing of the surgical procedure of such patients is a serious challenge. Many clinicians believe in earlier surgery as preferable and providing better outcomes. Damage control orthopedics (DCO) aids to adjust and optimize the overall condition of patients.MethodsIn 32 patients with femoral neck fractures complicated with CRF, we evaluated how the timing of the surgery determines the mortality rates if the DCO approach is applied. Preoperative ASA grading, POSSUM score, P-POSSUM score and DCO were carried out. Based on the assessment, timing of the surgery was ascertained.ResultsOf a total of 32 patients, twenty-nine patients were accepted for either early (< 48 hours; n = 18) or delayed (3–10 days; n = 10) surgery. Hip arthroplasty (total hip arthroplasty and hemiarthroplasty) was the principal surgery option. All patients survived operation and were followed up postoperatively with the average time of 30 days. Postoperative complications tended to occur at higher rates in the early vs. delayed surgery group (7/18 vs. 5/10). During follow up, a total of 3 patients died in both groups (2/18 in the early surgery and 1/10 in the delayed surgery group), mostly from multi-organ failures and acute respiratory distress syndrome. There was no significant difference in complication rates and Harris hip score between both groups.ConclusionIn patients with femoral neck fracture complicated with CRF, delaying the surgery for several days does not increase the incidence of postoperative adverse events.

Gallstone pancreatitis management: Are we following the guidelines?

Background: Advances in the management of biliary pancreatitis were summarized in major international guidelines. Speedy diagnosis and stabilization, followed by definitive treatment during the index admission have been shown to reduce complications and cost. Objectives: To determine the compliance of a tertiary care center in Saudi Arabia with published guidelines on gallstone management of patients with acute gallstone pancreatitis. Settings: King Fahad Medical City, Riyadh, Saudi Arabia. Patients and Methods: Seventy-five consecutive patients presenting with gallstone pancreatitis from January 2010 to January 2012 were audited retrospectively. We assessed the definitive diagnosis method, the Ranson's severity score on admission, method of common bile duct (CBD) clearance, and the definitive treatment (cholecystectomy), if was done during index admission. We used practice guidelines of the American College of Gastroenterology and JPN guidelines for gallstone pancreatitis as reference. Complications of treatment and readmissions, as well as the length of stay, were also recorded. Results: A total of 68 patients fulfilled our criteria. Etiology was confirmed in all patients within 48 h. Overall, 24 (35%) patients underwent endoscopic retrograde cholangiopancreatography. Magnetic resonance cholangiopancreatography was done in 10 (15%) patients and 4 (6%) had both. Intraoperative cholangiogram was done in 5 (7%) patients, giving a definitive CBD clearance in 35 patients (51%). Twenty-seven (40%) patients had index admission cholecystectomy, whereas 41 (60%) were discharged for interval cholecystectomy. Among the delayed group, 10 (24%) were readmitted with recurrent pancreatitis while awaiting surgery, whereas 2 (7.4%) patients in the early surgery group were readmitted with obstructive jaundice ( P = 0.016). Conversion to open cholecystectomy occurred in 4 patients (10%) in the delayed surgery group and none in the index admission surgery group ( P = 0.098). Overall complication rates were 19% in the delayed surgery group and 11% in the index admission surgery group ( P = 0.16) Median length of hospital stay was 12.5 days and 9.5 days, respectively ( P = 0.028). Conclusion: The management of gallstone pancreatitis could be improved with greater adherence to international published guidelines in terms of timing of definitive treatment and method of CBD clearance, which in turn may result in a reduction of the rate of complications and length of overall hospital stay.

Risk Factors for Difficult Laparoscopic Cholecystectomy in Acute Cholecystitis.

Background and Objectives:Factors that contribute to difficult laparoscopic cholecystectomy (LC) in acute cholecystitis (AC) that would affect the performance of early surgery remain unclear. The purpose of this study was to identify such risk factors.Methods:One hundred fifty-four patients who underwent LC for AC were retrospectively analyzed. The patients were categorized into early surgery and delayed surgery. Factors predicting difficult LC were analyzed for each group. The operation time, bleeding, and cases of difficult laparoscopic surgery (CDLS)/conversion rate were analyzed as an index of difficulty. Analyses of patients in the early group were especially focused on 3 consecutive histopathological phases: edematous cholecystitis (E), necrotizing cholecystitis (N), suppurative/subacute cholecystitis (S).Results:In the early group, the CDLS/conversion rate was highest in necrotizing cholecystitis. Its rate was significantly higher than that of the other 2 histopathological types (N 27.9% vs E and S 7.4%; P = .037). In the delayed-surgery group, a higher white blood cell (WBC) count and older age showed significant correlations with the CDLS/conversion rate (P = .034 and P = .004).Conclusion:In early surgery, histopathologic necrotizing cholecystitis is a risk factor for difficult LC in AC. A higher WBC count and older age are risk factors for delayed surgery.

Early Vitrectomy for Spontaneous, Fundus-Obscuring Vitreous Hemorrhage.

To examine the visual outcomes of early intervention in the setting of fundus-obscuring vitreous hemorrhage (VH) presumed to be due to posterior vitreous detachment. Retrospective comparative case series. All eyes that presented with a fundus-obscuring VH, defined as vision of 20/400 or worse and requiring a B-scan at presentation from 2003 to 2013, were evaluated. Eyes with any history of retinopathy, macular degeneration, recent trauma, presentation greater than 2weeks after onset of symptoms, or follow-up of less than 2months were excluded. The main outcome measure studied was final best-corrected visual acuity (BCVA) as dependent on the time to surgery. Ninety-two eyes met inclusion criteria with a mean follow-up of 490days. Initial BCVA was logMAR 2.218 (Snellen equivalent 20/3000-20/4000, range 20/400-light perception); final BCVA was 0.318 (Snellen equivalent of 20/40-20/50, range 20/20-light perception, P < .001). Fifty-six patients (60.8%) had either a retinal tear or a retinal detachment. Patients who underwent surgery within 1week had no significant improvement over all others; however, a significant improvement was found when comparing early vs delayed surgery groups (P<.05). There was a significantly increased risk ofdeveloping a macula-off retinal detachment in patients who did not undergo surgery within 1week of presentation. Early surgical intervention results in similar visual outcomes compared to a conservative approach. However, early intervention significantly reduces the incidence of severe vision loss related to macula-involving retinal detachment. This study highlights the importance of close follow-up given the high risk of retinal detachment in fundus-obscuring vitreous hemorrhage.

Variation in Patient Characteristics and Outcomes Between Early and Delayed Surgery in Poor-Grade Aneurysmal Subarachnoid Hemorrhage.

There is no consensus regarding the optimal timing for surgery for poor-grade aneurysmal subarachnoid hemorrhage. To retrospectively evaluate variation in patient characteristics and outcomes between early and delayed surgery groups. Poor-grade aneurysmal subarachnoid hemorrhage was defined as a World Federation of Neurosurgical Societies grade of IV or V after resuscitation. Early surgery was defined as surgery performed within 72 hours of ictus, and delayed surgery was defined as surgery after 72 hours. Outcomes were assessed by modified Rankin score. The mean time of follow-up was 12.5 ± 3.4 months. Of the 118 patients included in the study, 80 (68%) underwent early surgery and 38 (32%) underwent delayed surgery. Patients with brain herniation (P < .001) and a lower Fisher grade (P = .02) more often underwent early surgery. Patients in the early group more often underwent decompressive craniectomy (P < .001). Postoperative complications and length of hospital stay did not differ, and outcomes were similar between the 2 groups. Forty (34%) patients had an excellent outcome (modified Rankin score 0-1). Multivariate analysis showed a slight trend toward an excellent outcome in the early surgery group. Younger age, World Federation of Neurosurgical Societies grade IV after resuscitation, and middle cerebral artery aneurysms were independent predictors of an excellent outcome. Although patients with brain herniation and a lower Fisher grade were more likely to undergo early surgery, there was a slight trend toward an excellent outcome in the early surgery group. Patients with a younger age, World Federation of Neurosurgical Societies grade IV after resuscitation, and middle cerebral artery aneurysms were more likely to experience an excellent outcome.

Risk assessment of rebleeding after cerebral hemorrhage surgery for oral administration of aspirin

Objective To investigate the rebleeding risk after cerebral hemorrhage surgery for oral administration of aspirin and the development of treatment decision. Methods A total of 306 patients with intracerebral hemorrhage surgery with a history of oral administration of aspirin at the Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University from January 2009 to December 2014 were analyzed retrospectively. The influencing factors of postoperative rebleeding were analyzed by using a case-control study. Preoperative thrombelastography (TEG) was used to examine the arachidonic acid (AA) pathway induced platelet inhibition rate, and the inhibition rate ≥75% was used as the criterion of postponing emergency surgery. The postoperative rebleeding risk differences between the different treatment regimens and between the different surgical procedures were compared. Results The postoperative rebleeding rate of the inhibition rate ≥75% group was 26.9%, the delayed surgery group was 4.1% (OR, 8.566, 95% CI 2.279-32.190; P=0.001). The rebleeding rate of the inhibition rate <75% group was 7.6% (OR, 1.923, 95% CI 0.594-6.224; P=0.275); the inhibition rate ≥75% group compared with the inhibition rate <75% group (OR, 4.455, 95% CI 1.539-12.891; P=0.006). The emergency craniotomy group compared with the delayed surgery group, the rebleeding rate was 15.9% (OR, 4.399, 95% CI 1.215-15.919; P=0.024). Conclusions The platelet inhibition rate ≥75% induced by AA pathway can be used as a predictor for the high risk of postoperative rebleeding in patients with cerebral hemorrhage for oral administration of aspirin. The surgical methods and treatment choice can be chosen reasonably according to the own experiences and technological advantages of surgeons Key words: Cerebral hemorrhage; Aspirin; Neurosurgical procedures; Thrombelastography

Adhesive Small Bowel Obstruction: Early Operative versus Observational Management

We assessed the nonoperative and operative management of adhesive small bowel obstruction (ASBO) and compared complication rates and surgical outcomes. ASBO is a common complication of abdominopelvic surgery. Although patients may respond to nonoperative management, many require surgery. We retrospectively studied patients admitted to Mount Sinai Hospital with a diagnosis of complete ASBO to determine outcomes of nonoperative management. Patients admitted with complete ASBO from 2001 to 2011 were included. Patients with no previous abdominopelvic surgery, surgery within the six weeks preceding admission and obstruction due to other identifiable causes, such as incarcerated hernia, were excluded. Complication rates and outcomes were compared between patients managed with immediate surgery and those managed initially with nonoperative strategies. Of 460 patients admitted with complete ASBO, 106 (23.0%) had surgery within 24 hours of admission. At surgery, 20 (18.9%) had ischemic bowel and 8 (7.5%) had perforations. The remaining 354 patients had a trial of nonoperative management lasting at least 24 hours. Of 354 patients managed initially without surgery, 100 (28.2%) patients were discharged without operative intervention during their index admissions. Among the patients having surgery more than 24 hours after admission, indications for surgery were generally failure to resolve, worsening clinical status, and change in imaging findings. Of those patients observed for at least 24 hours, 40 (15.7%) were found to have ischemic bowel and 5 (2.0%) had perforation at surgery. Rates of bowel resection, stoma creation and postoperative complications were similar for the immediate and delayed surgery groups. Among the delayed surgery group, 71 (28.0%) required a bowel resection and 11 (4.3%) stoma creation. Twenty one per cent had postoperative complications, most commonly ileus. There were no statistically significant differences in the outcomes between immediate and delayed groups regardless of duration of delay. Among patients observed with complete ASBO, 24.6 per cent of patients with adhesive obstruction resolved without surgery or readmission. Delaying operative management did not affect surgical findings or complication rates.

Factors and outcomes associated with ultra-early surgery for poor-grade aneurysmal subarachnoid haemorrhage: a multicentre retrospective analysis

ObjectiveTo determine factors and outcomes associated with ultra-early surgery for poor-grade aneurysmal subarachnoid haemorrhage (aSAH).DesignA multicentre retrospective analysis, observational study.SettingHigh-volume teaching hospitals (more than 150 aSAH cases per year).Participants118 patients...

Is early hip fracture surgery safe for patients on clopidogrel? Systematic review, meta-analysis and meta-regression

IntroductionHip fracture is a common presentation in the elderly population, many of whom will be taking the antiplatelet clopidogrel, which has the potential to increase perioperative bleeding. The aim of this systematic review and meta-analysis was to answer the questions: (1) is early hip fracture surgery for patients on clopidogrel associated with worse postoperative outcomes compared to patients not on clopidogrel? (2) is early versus delayed surgery for these patients associated with worse postoperative outcomes? MethodsA systematic search was conducted of MEDLINE, EMBASE, Cinahl and AMED databases. Results from patients undergoing early surgery on clopidogrel were compared to a control group not taking clopidogrel. In addition, patients taking clopidogrel undergoing early and delayed surgery were compared. ResultsFor patients taking clopidogrel undergoing early surgery, there was no associated increase in overall mortality (OR 0.89; 95% CI: 0.58–1.38) or 30-day mortality (OR 1.10 95% CI: 0.48–2.54). However, there was an associated increase in blood transfusion (OR 1.41 95% CI: 1.00–1.99). There was an associated decreased length of stay in the early surgery versus delayed surgery group (weighted mean difference −7.09 days (95% CI: −10.14 to −4.04). DiscussionEarly surgery appears safe for patients with hip fracture though there may be a small increase in the rate of blood transfusion. However, larger prospective trials are required to confirm these findings.

Thirty-day Outcome of Delayed Versus Early Management of Symptomatic Carotid Stenosis

The aim of this study was to compare outcomes of early (<15 days) versus delayed carotid endarterectomy (CEA) in symptomatic patients. All CEA procedures performed for symptomatic carotid stenosis between January 2006 and May 2010 were retrospectively reviewed. Postoperative mortality (within 30 days), stroke, and myocardial infarction (MI) rates were analyzed in the early and delayed CEA groups. During the study period, 149 patients were included. Carotid revascularization was performed within 15 days after symptom onset in 62 (41.6%) patients and longer than 15 days after symptom onset in 87 (58.4%) patients. The mean time lapse between onset of neurological symptoms and surgery was 9.3 days (range 1-15) in the early surgery group and 47.9 days (range 16-157) in the delayed surgery group. Thirty-day combined stroke and death rates were, respectively, 1.7% and 3.5% in the early and the delayed surgery groups. Thirty-day combined stroke, death, and MI rates were, respectively, 1.7% and 5.9% in the early and the delayed surgery groups. During the study period, the reduction of the symptom-to-knife time in application to the carotid revascularization guidelines did not impact our outcomes suggesting that early CEA achieves 30-day mortality and morbidity rates at least equivalent to those of delayed CEA.

Efficacy of early surgery and causes of surgical delay in patients with hip fracture

BackgroundWhether early surgery for hip fractures is effective remains controversial. The current Japanese medical system poses some constraints on conducting early surgery. We examined the usefulness of early surgery and factors that delay surgery in patients with hip fractures treated at our hospital. MethodsAmong 314 patients aged ≥60 years treated for hip fractures since January 2006, 270 patients (55 men, 215 women; mean age 84.1 years; femoral neck fracture in 111, trochanteric fracture in 159) who underwent surgery were studied. They were divided into an early surgery group (surgery up to 1 day after admission) and a delayed surgery group (later than 1 day). Clinical parameters analyzed included age, gender, pre-injury residence, pre-injury ambulatory ability, admission during public holiday, fracture site, fracture type, blood tests and urinalysis at admission, chest radiography, electrocardiography, number of systemic chronic diseases, dementia, surgical modality, blood transfusion, length of hospital stay, ambulatory ability at discharge, and hospital death. After performing univariate analysis between two groups, the parameters that were identified as significant were further tested by multivariate analysis. ResultsAmong 270 patients treated for hip fracture, 112 patients (41.5%) received early surgery. Multivariate analysis identified admission during public holiday, electrocardiographic abnormalities, femoral head replacement, and length of hospital stay as significant independent factors. ConclusionThe causes of surgical delay were admission during public holiday, electrocardiographic abnormalities, and femoral head replacement. Although length of hospital stay was shorter in patients with early surgery, there was no difference in outcome.

Clinical Analysis of Delayed Surgical Epidural Hematoma.

ObjectiveA small epidural hematoma (EDH) that has been diagnosed to be nonsurgical by initial brain computed tomography (CT) can increase in size and need surgical removal, resulting in a poor prognosis. However, there have been few studies, which focused delayed operated EDH. Therefore, we analyzed the clinical factors to determine the predicting factors of delayed operated EDH.MethodsBetween January 2011 and January 2014, 90 patients, who were admitted due to EDH, were enrolled in this study. None of the patients were indicated for operation initially. Based on the presence of surgery, we classified the patients into a delayed-surgery group (DG) and a non-surgical group (NG). Additionally, we analyzed them according to the following: time interval between the trauma and the initial CT, gender, age, medical history, drinking, change of mean arterial pressure (MAP), volume of EDH and other traumatic brain lesion.ResultsAmong the 90 patients, the DG was 19 patients. Compared with NG, the DG revealed increased MAP, less presence of drinking, and a short time interval (DG vs. NG: +9.684 mm Hg vs. -0.428 mm Hg, 5.26% vs. 29.58%, 1.802 hours vs. 5.707 hours, respectively, p<0.05). Analyzing the time interval with receiver operating characteristic, there was 88.2% sensitivity and 68.3% specificity at the 2.05-hour cut-off value (area under the curve=0.854).ConclusionAccording to our results, the time interval between the trauma and the initial CT along with blood pressure change are potential predicting factors in the cases of delayed operation of EDH.

The efficacy of delayed surgery in children with high-risk neuroblastoma.

Surgery is an important part of treatment in children with neuroblastoma; however, exact timing is unclear. Both initial and delayed surgery was suggested as the best by numerous studies. Thus, we aimed to investigate the role of delayed surgery on 31 children with high-risk neuroblastoma. Thirty-one children with high-risk neuroblastoma were enrolled into the study. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) for windows 10.0. There 'were 15 male and 16 female patients with a median age of 3.0 ± 3.2 years. Primary tumor site was adrenal in 27, non-adrenal in two, pelvic in one, and mediastinal in one patient. MYCN gene was amplified in four and non-amplified in 11 children on totally 15 children with available data. Lactate dehydrogenase was elevated in 30 children. The tumor volumes at diagnosis and before surgery in the whole group were 154.3 and 12.5 mL, respectively. The decline in tumor volume was statistically significant (P < 0.0001). Initial surgery was performed in three and delayed in 20 children, and eight children were inoperable. Surgical complication rate was 66.6% (two out of three patients) in initial surgery group; however, the rate was 15% (3 out of 20 patients) in delayed surgery group. The 5-year event-free survival and overall survival rates in the whole group were 44.8% and 50.8%, respectively. Primary tumor area control rate was 95% In conclusion, the delayed surgery with intensive chemotherapy and radiotherapy has been successful for primary control in high-risk neuroblastoma patients.