Early Perioperative Complications Research Articles

Barbed sutures versus conventional sutures for uterine closure at cesarean section; a randomized controlled trial

Introduction: The aim of this randomized control trial was to compare the operative data and the early postoperative outcomes of cesarean sections in which the uterine incision was closed with a barbed suture (STRATAFIX™ Spiral PDO Knotless Tissue Control Device, SXPD2B405, Ethicon Inc.) with those of cesarean sections in which the uterine incision was closed with a conventional smooth suture (VICRYL™; Ethicon Inc.).Materials and methods: One hundred pregnant patients were randomized in a 1:1 ratio to the Stratafix group or the Vicryl group. The uterine incision was closed by two layers of sutures in both groups. In the Vicryl group, the first layer was continuous and the second layer was interrupted. In the Stratafix group, both layers were continuous.Results: The uterine closure time was significantly lower in the Stratafix group (224 ± 46 versus 343 ± 75 s, p < .001). Operative time was comparable between both groups. Twelve patients in the Vicryl group and two patients in the Stratafix group required additional sutures to achieve hemostasis (p value = .009). The mean blood loss during closure of uterine incision and mean hospital stay were lower in the Stratafix group but these differences failed to reach statistical significance.Conclusion: The use of barbed suture for uterine incision closure at cesarean section is associated with shorter uterine closure time and similar early perioperative complications compared with conventional smooth suture. The difference between both groups in the technique of suturing the second layer of the uterine incision may be the cause of the reduction in the uterine closure time and the need for additional sutures to achieve hemostasis during suturing the uterine incision with a barbed suture. Further, well designed randomized controlled trials should be conducted to investigate the association between the type of suture (barbed or conventional smooth) and remote complications of cesarean section (infertility, pelvic pain, abnormal placentation and rupture uterus).

Spine deformity surgery in the elderly: risk factors and 30-day outcomes are comparable in posterior versus combined approaches

ObjectivesRisk factors portending poor outcome following elective spine deformity fusion remain in need of characterization and stratification in the elderly population.MethodsCases aged ≥60 years who underwent elective posterior or anterior-posterior (‘combined’) fusion were extracted from the American College of Surgeons National Surgical Quality Improvement Program years 2007–2013 and analyzed by surgical cohort (posterior vs. combined). The 30-day outcomes included operation time, hospital length of stay (HLOS), perioperative complications, and discharge destination. Multivariable regressions controlling for demographic/clinical variables were performed. Odds ratios (OR) and mean differences (B) were reported with 95% confidence intervals (CI).ResultsA total of 881 cases (18.2% combined; 81.8% posterior) aged 70 ± 6.2 years, 32.8% male, and 87.2% Caucasian were included. Posterior fusions associated with extreme body habitus (obese class II/III and underweight; P = 0.027), functional independence (97.5% vs. 91.8%; P = 0.010), and multi-level fusions (7–12 levels: 24.8% vs. 18.1%; ≥13 levels: 8.9% vs. 3.1%; P = 0.004). Overall operation time was 338.0 ± 150.2-min and HLOS 7.4 ± 6.6-days; 17.1% suffered early complications and 54.5% were discharged home. On multivariable analysis, combined (B = 63.8-min; P < 0.001), and multi-level fusions (7–12: 61.0-min; P < 0.001; ≥13: 133.8-min; p < 0.001) associated with increased operation time. HLOS increased for multi-level fusions (7–12 levels: 1.3-days; P = 0.012; ≥13 levels: 2.2-days; P = 0.008). Overall complications did not differ by cohort or levels; on post hoc analysis combined fusions associated with pneumonia (OR = 3.05; P = 0.008). Multi-level fusions showed decreased odds of discharge home (7–12 levels: OR = 0.57; P = 0.003; ≥13-levels: OR = 0.41; P = 0.003).ConclusionsThe 30-day outcomes and early perioperative complications are comparable for posterior vs. combined approaches to correct deformity in the elderly. Multi-level fusions are associated with increased operation time, HLOS, and discharge to higher level of care.

Percutaneous Dilatational Tracheostomy via Griggs Technique.

Tracheostomy is considered the airway management of choice for patients who need prolonged mechanical ventilation support. Percutaneous Dilatational Tracheotomy (PDT) is a technique that can be performed easily and rapidly at bedside and is particularly useful in the intensive care setting. The Griggs percutaneous tracheotomy is unique in its utilization of a guide wire dilator forceps. We aimed to describe the early perioperative and late postoperative complications of PDT using the Griggs technique in patients in the intensive care unit (ICU). This cross-sectional study was conducted on all patients who underwent tracheostomy in the ICU of the Imam Reza Hospital of Kermanshah, Iran, from June 2011 to June 2015. PDT was performed in 184 patients with the Griggs technique. Demographic variables, as well as perioperative and late postoperative complications were recorded. The mean age of patients was 57.3 ± 15.37 years. The most common primary causes of tracheostomy were hypoxic brain damage disorders (43.2%) and pneumonia (14.8%). Perioperative and early complications occurred in 16.7 % of procedures, of which 9.3% were bleedings (minor, significant and major). Furthermore, the incidence of late complications was 8.6%, including: stomal infection, difficult replace tracheostomy tube, tracheoesophageal fistula, tracheal stenosis, and tracheomalacia. PDT via Griggs technique is a safe, quick, and effective method. The low incidence of complications indicates that bedside percutaneous tracheostomy can be performed safely as a routine procedure for daily care implemented in the ICU.

Acute Arterial Hypertension in Patients undergoing Neurosurgery

Introduction Between 20–50% of neurosurgical patients may develop early perioperative complications, and ∼ 25% have more than one clinical complication. The most commons are high blood pressure (25%) and cardiovascular events (7%). Intraoperative hypertension is characterized by an increase of 20% in basal blood pressure. Objectives The aim of this paper is to review and discuss the pathophysiology, diagnosis and treatment of perioperative hypertension in patients undergoing neurosurgery, and to propose one table with therapeutic options. Methods A review using Scielo, PubMed, Ebsco and Artmed databases with inclusion and exclusion criteria. Articles published from 1957 to 2015 were selected. Discussion Five factors were established as causes: arterial hypertension, clinical conditions, surgical procedures, and operative and anesthetic factors. Specific causes preoperative, intraoperative and posoperative. The pathophysiology may have some relationship with catecholamines and sympathetic nervous system stimulation. Conclusion Perioperative hypertension in neurosurgery may have many causes, some of them recognizable and preventable. This increased pressure may be associated with intracranial hematomas in some cases. The recognition and treatment of this disease can be helpful in the management of the postoperative period.

The Effects of Patient Obesity on Early Postoperative Complications After Shoulder Arthroscopy

To report the prevalence of obesity in shoulder arthroscopy, determine a body mass index (BMI) threshold most predictive of complication within 30days, and evaluate obesity as an independent risk factor for medical and surgical complications. Using the National Surgical Quality Improvement Program database, we reviewed all patients who underwent shoulder arthroscopy during 2011 to 2013. Receiver operating characteristic and Youden coefficient were calculated to find an optimal BMI cutoff to predict complications within 30days of surgery. A case-control matched analysis was then performed by stratifying patient BMI by this cutoff and matching patients one to one according to age, sex, type of shoulder arthroscopy, American Society of Anesthesiology rating, surgical setting, and 8 comorbidities. Operating time, complications, and readmissions were also compared. Of the 15,589 patients who underwent shoulder arthroscopy, 6,684 (43%) were classified as obese when using the optimal cutoff point of BMI= 30 according to the Youden coefficient. Obese patients had a higher risk of superficial site infection than nonobese patients (0.3% vs 0.0%; odds ratio [OR]: 6.00; 95% confidence interval [CI], 1.3 to 26.8; P= .015). Obese patients did not have significantly increased risk for overall early postoperative complication (1.2% compared with nonobese 0.8%; OR: 1.54; 95% CI, 1.0 to 2.4), readmissions (OR: 0.85; 95% CI, 0.5 to 1.5), or increased operating time (P= .068). Up to 43% of patients undergoing shoulder arthroscopy can be classified as obese, but early perioperative complications are uncommon. Higher patient BMI is associated with increased risk of superficial site infection but not an overall risk for complication, readmission, or increased operating time. Level III, retrospective comparative study.

The impact of intraoperative hypothermia on early postoperative adverse events after radical esophagectomy for cancer: a retrospective cohort study.

To investigate the correlation between intraoperative body temperature and postoperative adverse effects in patients who underwent esophagectomy procedures. Retrospective cohort study. University Hospital. One hundred twenty-one patients undergoing esophagectomy were enrolled. None. Various perioperative and intraoperative variables were recorded. Hypothermia was defined as a urinary bladder temperature<35°C. Multiple logistic regression analysis was conducted to identify independent significant predictors of postoperative complications. In addition, the authors also determined a cutoff point for intraoperative minimum urinary bladder temperature by analyzing receiver operating characteristic (ROC) curves for occurrence of adverse events at 1 month after surgery. No patients died within 1 month after the surgery. There were 53 patients with early postoperative complications, and 51 had experienced intraoperative hypothermia. Factors that were correlated significantly with complications included age (p=0.02); hypothermia (p<0.01); and doses of ephedrine (p<0.01), phenylephrine (p<0.01), and fentanyl (p<0.01). Multiple logistic regression analysis identified intraoperative hypothermia as a significant independent predictor for the development of early perioperative complications (odds ratio 2.57; 95% confidence interval 1.09-6.08). The area under the ROC curve for body temperature was 0.71, and the cutoff point was 35°C (sensitivity=0.65, specificity=0.72). Intraoperative hypothermia was identified as an independent risk factor for early postoperative adverse events following esophagectomy.

Development of Acquired von Willebrand Syndrome During Short-Term Micro Axial Pump Support

Percutaneous continuous-flow (CF) micro axial blood pumps, like the Impella 5.0, are commonly used for short-term (ST) mechanical circulatory support in patients with acute decompensated heart failure. The Impella device often serves as a bridge to implantation of a long-term (LT) CF left ventricular assist device (CF-LVAD), such as the centrifugal-flow HeartWare (HVAD). All patients supported with axial CF-LVADs develop acquired von Willebrand syndrome (AVWS) as a result of mechanical shear stress. Increased shear stress leads to excessive proteolysis of von Willebrand factor and loss of high molecular weight multimers, thus contributing to platelet dysfunction and increased gastrointestinal bleeding. Bleeding events associated with AVWS have been reported in patients supported with LT CF-LVADs; however, the relation between early perioperative bleeding complications and AVWS remains poorly characterized in ST CF-LVADs. We sought to describe the relation between the development of AVWS and excessive intraoperative bleeding in a patient who was sequentially bridged with an ST micro axial device to a LT centrifugal CF-LVAD. This case highlights the importance of monitoring these hemostatic changes when bridging to LT CF-LVADs.

Elbow arthroscopy: early complications and associated risk factors

Elbow arthroscopy is increasingly used to treat complex pathology. The purpose of this study was to investigate early complication rates after elbow arthroscopy and identify risk factors for adverse events. Consecutive elbow arthroscopies performed during a 13-year period were reviewed, identifying early perioperative complications. Major complications included deep infection, permanent nerve injury, or complications requiring additional anesthesia. Minor complications included superficial wound complications and transient nerve palsies. Complications were compared with a surgical complexity scale based on the procedure performed, the number of arthroscopic portals, and tourniquet time. Of 417 procedures, there were 37 minor (8.9%) and 20 major (4.8%) complications. The rates of superficial and deep infections were 6.7% and 2.2%, respectively. Major complications included 9 deep infections, 6 cases of heterotopic ossification requiring further surgery, and 4 manipulations under anesthesia. There were 7 transient sensory nerve complications, and no motor deficits. No differences in complication rates were seen between low-, moderate-, and high-complexity (10.2%, 16.3% and 14.4%, respectively) cases. Intraoperative steroid injections were strongly associated with postoperative superficial (14.1% vs 2.0%) and deep infection (4.9% vs 0.4%) in elbows receiving vs those not receiving steroid (P < .0001). Complications of elbow arthroscopy are seen in approximately 14% of cases. Most complications are minor, not affecting clinical outcome. Major complications occur in 5% of cases, often requiring repeat surgery. Intraoperative postsurgical steroid injections are associated with increased risk of perioperative infections. Case complexity does not appear to affect the rate of complications with modern surgical techniques.

Complications of total hip arthroplasty: periprosthetic fractures of the acetabulum.

Periprosthetic fractures of the acetabulum are a rare but potentially disastrous complication of total hip arthroplasty. Such fractures occur either as early perioperative complications or late complications when they are associated with either significant trauma or as a result of the loss of the structural integrity of the bone supporting the prosthesis, such as aseptic osteolysis. The incidence of such fractures appears to be increasing with the increased use of uncemented acetabular components. This article explores the current literature on the epidemiology, etiology, and classification of periprosthetic acetabular fractures as well as offering potential treatment strategies.

Ileal Pouch Anal Anastomosis

Ileal pouch anal anastomosis (IPAA) is the treatment of choice for chronic, medically refractory mucosal ulcerative colitis, indeterminate colitis, familial adenomatous polyposis (FAP), and a select group of patients with Crohn's disease. : We report outcomes, complications, and quality of life (QOL) in a cohort of 3707 patients treated at our institution from January 1984 to March 2010. Data were collected from a prospectively maintained database and chart review of 3707 consecutive primary IPAA cases. Patient demographics, postoperative complications, functional outcomes, and QOL data were available. Follow-up consisted of clinical examination with assessment of pouch function and QOL. A total of 3707 patients underwent primary pouch and 328 underwent redo pouch surgery. Postoperative histopathological diagnoses were mucosal ulcerative colitis (n = 2953, 79.7%), indeterminate colitis (n = 63, 1.7%), FAP (n = 223, 6%), Crohn's disease (n = 150, 4%), cancer/dysplasia (n = 97, 2.6%), and others (n = 221, 6.0%). Early perioperative complications were encountered in 33.5% of patients with a mortality rate of 0.1%. Excluding pouchitis, late complications were experienced by 29.1% of patients. Of those patients who had IPAA at our institution, pouch failure occurred in 197 patients (5.3%). During a median follow-up of 84 months, 119 patients (3.2%) required excision of the pouch, 32 (0.8%) had a nonfunctioning pouch, and 46 patients (1.2%) had redo IPAA. Functional outcomes and QOL were good or excellent in 95% of patients and similar in each histopathological subgroup. IPAA is an excellent option for patients with MUC, IC, FAP, and select patients with Crohn's disease.

Intraoperative Hypothermia During Cytoreductive Surgery for Ovarian Cancer and Perioperative Morbidity

To evaluate intraoperative hypothermia as a predictor for morbidity after open abdominal surgery for ovarian cancer. This cohort study included 146 women with stage IIIC and IV ovarian cancer who underwent debulking surgery at our institution from January 1, 2001, through December 31, 2003. Hypothermia was defined as end operative temperature lower than 36°C. Early complications (occurring within 30 days of surgery) included: mortality, infectious morbidities, cardiovascular events, venous thromboembolic (VTE) events, anastomotic leak, readmission, and reoperation. Survival was also evaluated. Logistic regression models were used to adjust for known confounders. The mean age was 63.9 ± 11.7 years; 46 (32%) patients had a body mass index higher than 30; mean operative time was 239 ± 85 minutes. There were five deaths perioperatively, all in the hypothermic group. Hypothermia was associated with an increased risk of any early complications (34 [42.0%] compared with 11 [16.9%]) with an adjusted odds ratio (OR) of 3.40 (95% confidence interval [CI] 1.48-8.33). For individual complications, hypothermic patients were at higher risk for VTE events with an adjusted OR of 3.53 (95% CI 1.02-16.44); infectious morbidity with an adjusted OR of 2.99 (95% CI 0.97-11.35); and reoperation with an adjusted OR of 4.96 (95% CI 0.80-95.7). The overall survival was shorter in hypothermic group with a median of 34 compared with 45 months (P=.045); this remained significant for an optimally resected subgroup with a median overall survival of 40 compared with 48 months (P=.049). Surgical hypothermia is an independent predictor of early perioperative complications and overall survival after cytoreductive surgery for ovarian cancer. This is a critically important finding, because maintaining normothermia is an inexpensive modifiable factor, which could result in reduced morbidity.

The Morbidity and Mortality of Fusions from the Thoracic Spine to the Pelvis in the Adult Population

A retrospective analysis. To quantify the risks of surgery and explore the associations of early perioperative complications with patient demographics and surgical variables. Long fusions extending from the thoracic spine to the pelvis in adults are increasingly common. Currently, there are few studies detailing the overall risks of such comprehensive reconstructions or how preoperative demographics may be associated with potential complications. A retrospective study was performed at two tertiary referral institutions. Preoperative patient demographics and intraoperative surgical variables were analyzed to explore the potential association with outcomes. The outcomes recorded were death, length of hospital and intensive care unit (ICU) stay, discharge to a rehabilitation facility, major medical complications, neurologic deficits, and the additional unplanned surgeries that patients subsequently underwent. One hundred three consecutive patients underwent a fusion extending from the thoracic spine to the pelvis for degenerative conditions from 2003 to 2007. There was a 4% mortality rate. The mean hospital stay and mean ICU stay was 12 ± 7 and 2.7 ± 4 days, respectively. Fifty-eight percent of patients were discharged to a rehabilitation facility. Twelve percent of patients experience at least one major medical complication. Seventeen percent of patients had a documented new persistent neurologic deficit that was still present at the final clinic visit. Thirty-five percent of patients underwent at least one unplanned return to the operating theater. There were no perioperative demographics or surgical variables that had a statistically significant association with mortality. Major medical complications were associated with the American Society of Anesthesiologists' (ASA) score (P = 0.030) and the Charlson Comorbidity Index (P = 0.028) but not age (P = 0.273). Complex spine reconstruction involving fusions from the thoracic spine to the pelvis continues to be a high-risk procedure in spite of more advanced surgical and perioperative techniques.

Statins Reduce Incidence of Early Perioperative Complications and Length of in-Hospital Stay after Coronary Artery Bypass Graft Surgery

Background: Coronary artery bypass grafting (CABG) is associated with several perioperative complications that may significantly prolong length of in-hospital stay, increase costs and provide worse long term outcome. The 3-hydroxy-3-methylglutaryl-CoA (HMG-CoA) reductase inhibitors, or statins, exert anti-inflammatory and vascular protective effects. We hypothesized that pre-operatory statin therapy may reduce incidence of early perioperative complications and length of in-hospital stay following CABG.Methods: We retrospectively enrolled 103 patients (age 67±3; 18 females), who underwent CABG. Patients were allocated into 2 groups: 57 patients on statin therapy prior to CABG (St Group) and 46 patients not on statin therapy (n-St group). Demographic and clinical features, pre-operative medications use and the incidence of early adverse postoperative events were collected. Pre-operative risk of death using the European System for Cardiac Operative Risk Evaluation (EuroSCORE) was also calculated. The primary end-point was the composite of early complications occurring after surgery, including infections, bleedings, sustained ventricular and supra-ventricular tachyarrhythmias, cardiogenic shock, myocardial infarction and mortality. As secondary end-points single perioperative complications were considered. In-hospital stay length was also evaluated.Results: Clinical features, cholesterol levels and EuroSCORE were similar between two groups. Statin therapy and EuroSCORE emerged as predictors of the composite adverse outcome. n-St patients had a significant higher rate of early complications if compared with St patients: the primary endpoint occurred in 18 St patients (31%) versus 25 (54%) non-St patients (p=0.019). Multivariate analysis confirmed pre-operative statin therapy and EuroSCORE as independent predictors of the primary endpoint (OR=0.307, 95% CI=0.123-0.766, p=0.011 and OR= 2.114, 95% CI= 1.213- 4.407, p= 0.002 respectively) showing a protective role of the statin therapy.The incidence of secondary end-points did not differ significantly between the groups, while in-hospital stay was longer in n-St group if compared with St group (7.7±3,9 days vs 5,6±1,8 days; p=0,001).Conclusion: Our data suggest that statin therapy may reduce early perioperative complications after coronary artery bypass grafting. This effect is independent from cholesterol basal levels, thus supporting pre-operative statin use in patients undergoing CABG.

Distal pancreatic resection via laparo-endoscopic single site surgery – development of the technique

Aim: To present a novel technique of a laparo-endoscopic single site (LESS) distal pancreatic resection via the umbilicus with use of the QuadPort TM Access System. Material and methods: The technique of distal pancreatic resection through a 30 mm longitudinal incision in the umbilicus is described. Medial to lateral approach of pancreas preparation using a harmonic scalpel and regular laparoscopic instruments is applied. The described technique was successfully applied in a 26-year-old female patient with tumour of the pancreatic body and tail (90/41/27 mm). Pancreatectomy was followed by splenectomy due to infiltration of the splenic vessels. Results: Total operative time was 160 min. Blood loss was 800 ml. Initial wound size was 30 mm. Splenic vein and artery infiltration forced augmentation of the wound to 80 mm. The patient required only per request medication. Peristalsis returned spontaneously on the first postoperative day. Hospital stay was 4 days. There were no early perioperative complications. The patient required readmission due to electrolyte imbalance 7 weeks after the operation. Conclusions: The proposed operative technique of single incision laparoscopic distal pancreatectomy is difficult and challenging. Nonetheless, the authors proved that it is safe and feasible when performed by an experienced laparoscopic team.

Pneumonectomy After Chemoradiation Therapy for Non-Small Cell Lung Cancer: Does “Side” Really Matter?

The long-term benefits and risks of pneumonectomy after neoadjuvant chemoradiation therapy remain controversial. This study evaluated our experience with pneumonectomy for advanced non-small cell lung cancer (NSCLC) after concurrent chemoradiation therapy. We reviewed medical records from patients undergoing concurrent chemoradiation therapy, followed by pneumonectomy (1983 to 2007). Clinical variables affecting Kaplan-Meier survival were analyzed. After chemoradiation therapy, 129 pneumonectomies (right, 65; left, 64) were performed. Postoperative pathologic stages were complete responders (CR), 21; I, 23; II, 19; III, 62; and IV, 4. The 90-day perioperative mortality was 20% (13 of 65) after right-sided pneumonectomy vs 9% (6 of 64) after left-sided pneumonectomy (p = 0.084). Complications occurred in 33% (43 of 129), including bronchopleural fistula in 12% (16 of 129) and acute respiratory distress syndrome in 2% (3 of 129). Overall 5-year survival was 33%. Survival was 32% for right-sided sections vs 34% for left-sided. CR patients had a 5-year survival of 48%. Survival of patients with postoperative N0, N1, and N2 nodes was 42%, 26%, and 28%, respectively. Multivariate analysis showed the development of major complications negatively affected 5-year survival for patients undergoing right-sided pneumonectomy (hazard ratio, 0.462; p = 0.0399). Pneumonectomy after concurrent chemoradiation therapy achieved long-term survival. When neoadjuvant therapy resulted in complete response or nodal downstaging, survival was improved. The risk of early perioperative death and complications was higher for right-sided procedures, but long-term survival did not differ between right- and left-sided pneumonectomy. Major complications negatively affected 5-year survival with right-sided pneumonectomies.

Correlation Between Intraoperative Hypothermia and Perioperative Morbidity in Patients With Head and Neck Cancer

To determine if intraoperative hypothermia correlates with perioperative complications in patients undergoing head and neck surgery with regional or free flap reconstructions. Retrospective medical chart review. Academic tertiary care hospital. A sample of 136 patients who underwent ablative surgery for head and neck cancer and subsequently required reconstruction with free tissue or a regional flap in the last 10 years. Rate of early (within 3 weeks of surgery) perioperative complications and its correlation with patient hypothermia (core body temperature, <35 degrees C). There were 43 patients with complications. Two patients died. Complications included 10 partial or total flap losses, 9 hematomas, 8 episodes of pneumonia, 7 fistulas, 7 wound infections, 5 wound breakdowns, and 2 cerebrospinal fluid leaks. Factors that did not correlate with complications included having received prior chemotherapy (P = .84), having stage IV cancer (P = .16), sex (P = .43), tobacco use (P = .58), prior radiotherapy (P = .30), the presence of comorbidities (P = .43), age (P = .27), length of surgery (P = .63), and the use of blood products perioperatively (P = .73). Patients who were hypothermic had a significantly higher rate of complications that normothermic patients (P = .002). Stepwise logistic regression analysis identified intraoperative hypothermia as a significant independent predictor for the development of early perioperative complications (odds ratio, 5.122; 95% confidence interval, 1.317-19.917). Intraoperative hypothermia in head and neck surgery is correlated with perioperative complications. Maintaining normothermia through aggressive warming may decrease the incidence of perioperative morbidity for these patients.

Complications of decompressive craniectomy for traumatic brain injury

Decompressive craniectomy is widely used to treat intracranial hypertension following traumatic brain injury (TBI). Two randomized trials are currently underway to further evaluate the effectiveness of decompressive craniectomy for TBI. Complications of this procedure have major ramifications on the risk-benefit balance in decision-making during evaluation of potential surgical candidates. To further evaluate the complications of decompressive craniectomy, a review of the literature was performed following a detailed search of PubMed between 1980 and 2009. The author restricted her study to literature pertaining to decompressive craniectomy for patients with TBI. An understanding of the pathophysiological events that accompany removal of a large piece of skull bone provides a foundation for understanding many of the complications associated with decompressive craniectomy. The author determined that decompressive craniectomy is not a simple, straightforward operation without adverse effects. Rather, numerous complications may arise, and they do so in a sequential fashion at specific time points following surgical decompression. Expansion of contusions, new subdural and epidural hematomas contralateral to the decompressed hemisphere, and external cerebral herniation typify the early perioperative complications of decompressive craniectomy for TBI. Within the 1st week following decompression, CSF circulation derangements manifest commonly as subdural hygromas. Paradoxical herniation following lumbar puncture in the setting of a large skull defect is a rare, potentially fatal complication that can be prevented and treated if recognized early. During the later phases of recovery, patients may develop a new cognitive, neurological, or psychological deficit termed syndrome of the trephined. In the longer term, a persistent vegetative state is the most devastating of outcomes of decompressive craniectomy. The risk of complications following decompressive craniectomy is weighed against the life-threatening circumstances under which this surgery is performed. Ongoing trials will define whether this balance supports surgical decompression as a first-line treatment for TBI.

Novel Approach to the Sphenoid Sinus

Objective Transnasal approaches to the pituitary and beyond are increasingly being utilized. Surgical access to the sphenoid sinus is the first step in any of these approaches. In order to allow a binostril approach, the posterior septum is removed, resulting in a large posterior septal perforation. Another consideration in many cases is harvesting material for repair of any cerebrospinal fluid (CSF) leak. We describe a novel endoscopic transseptal approach using a posterior nasal septal mucosal flap that allows a binostril approach for the surgeons, can cover skull base defects, and avoids posterior nasal septal perforations. Methods Retrospective chart review of endoscopic pituitary surgery patients, in a tertiary referral center between 2006 and 2008, was performed. Relevant post-operative complications of CSF leak, epistaxis, crusting, synechiae and septal perforation were documented. Results 20 consecutive patients undergoing pituitary surgery were reviewed: 12 males and 8 females aged 24 to 76 years old. No early perioperative complications were encountered. Surgical time was not increased. Two minor postoperative complications: 1 epistaxis and 1 partial flap retraction were noted. There were no CSF leaks and no septal perforations. Conclusions The approach has the advantage of allowing two surgeons to manipulate surgical instruments and a more robust pedicled flap is raised to assist the closure of a skull base defect. The nasal septal mucosa from one side is preserved, avoiding a nasal septal perforation. There is minimal additional morbidity.

Short fusion versus long fusion for degenerative lumbar scoliosis

The extent of fusion for degenerative lumbar scoliosis has not yet been determined. The purpose of this study was to compare the results of short fusion versus long fusion for degenerative lumbar scoliosis. Fifty patients (mean age 65.5 +/- 5.1 years) undergoing decompression and fusion with pedicle screw instrumentation were evaluated. Short fusion was defined as fusion within the deformity, not exceeding the end vertebra. Long fusion was defined as fusion extended above the upper end vertebra. The lower end vertebra was included in the fusion in all the patients. The short fusion group included 28 patients and the long fusion group included 22 patients. Patients' age and number of medical co-morbidities were similar in both the groups. The number of levels fused was 3.1 +/- 0.9 segments in the short fusion group and 6.5 +/- 1.5 in the long fusion group. Before surgery, the average Cobb angle was 16.3 degrees (range 11-28 degrees ) in the short fusion group and 21.7 degrees (range 12-33 degrees ) in the long fusion group. The correction of the Cobb angle averaged 39% in the short fusion group and 72% in the long fusion group with a statistical difference (P = 0.001). Coronal imbalance improved significantly in the long fusion group more than in the short fusion group (P = 0.03). The correction of lateral listhesis was better in the long fusion group (P = 0.02). However, there was no difference in the correction of lumbar lordosis and sagittal imbalance between the two groups. Ten of the 50 patients had additional posterolateral lumbar interbody fusion at L4-5 or L5-S1. The interbody fusion had a positive influence in improving lumbar lordosis, but was ineffective at restoring sagittal imbalance. Early perioperative complications were likely to develop in the long fusion group. Late complications included adjacent segment disease, loosening of screws, and pseudarthrosis. Adjacent segment disease developed in ten patients in the short fusion group, and in five patients in the long fusion group. In the short fusion group, adjacent segment disease occurred proximally in all of the ten patients. Loosening of distal screws developed in three patients, and pseudarthrosis at L5-S1 in one patient in the long fusion group. Reoperation was performed in four patients in the long fusion group and three patients in the short fusion group. In conclusion, short fusion is sufficient for patients with small Cobb angle and good spinal balance. For patients with severe Cobb angle and rotatory subluxation, long fusion should be carried out to minimize adjacent segment disease. For patients who have severe sagittal imbalance, spinal osteotomy is an alternative technique to be considered. As long fusion is likely to increase early perioperative complications, great care should be taken for high-risk patients to avoid complications.

Delayed recovery of human leukocyte antigen-DR expression after cardiac surgery with early non-lethal postoperative complications: only an epiphenomenon?

HLA-DR expression on peripheral blood monocytes is reduced after cardiac surgery. Little is known about the reconstitution of HLA-DR expression on peripheral blood monocytes in patients suffering from early non-fatal perioperative complications. We conducted a prospective study to prove whether these complications adversely affect the recovery of HLA-DR expression. Before surgery (d0), on the first (d1), third (d3), fifth (5th) postoperative days, blood samples were collected from 90 patients who underwent elective cardiac surgery with cardiopulmonary bypass (CPB). HLA-DR expression was analysed flow cytometrically. Eleven patients experienced postoperative complications [mechanical ventilation of 24-48 h (n=6); reinstitution of CPB (n=2) intraoperatively; laparotomy (n=1), re-thoracotomy (n=1), re-intubation (n=1) within the first 24 h after surgery]. All patients showed a reduced HLA-DR expression after surgery with nadirs at d1 and d3. Whereas the values increased from d3 to d5 in patients with an uneventful clinical course, HLA-DR expression remained suppressed in patients with complications. HLA-DR expression is reduced after cardiac surgery with CPB. A delayed recovery of HLA-DR expression is seen in patients with early perioperative complications. These non-fatal complications appear to represent a 'second hit' resulting in a prolonged deficiency of the innate immune system. This might predispose to further infectious and septic complications.