Early Surgical Complications Research Articles

Long-term results of laparoscopic Roux-en-Y gastric bypass for morbid obesity: 105 patients with minimum follow-up of 15 years.

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the second most frequently performed bariatric procedure worldwide; however, long-term results are not frequently reported. To evaluate the outcomes of LRYGB on weight loss and co-morbidities in a single center 15 years after the operation. Tertiary-care referral hospital. From February 2000 to December 2003, 105 patients (86 women; mean age 39.9 ± 17.4; mean body mass index [BMI] 47.2 ± 6.4 kg/m2; 78 with BMI < 50 kg/m2 and 27 with BMI ≥ 50 kg/m2) underwent LRYGB. Retrospective analyses of a prospectively maintained database were carried out to evaluate weight loss; resolution of co-morbidities, including type 2 diabetes mellitus (T2D), hypertension (HTN), and dyslipidemia; complications; and nutritional status. The follow-up rate at 15 years was 87.6%. Mean excess weight loss was 58.6 ± 27%, with 74.1% of patients achieving a total weight loss ≥ 20%. According to the Biron etal. criteria, an inadequate outcome was found in 11/21 (52.4%) of patients with an initial BMI ≥ 50 kg/m2 versus 21/64 (32.8%) of patients with a preoperative BMI < 50 kg/m2 (P = .001). Both groups experienced gradual weight regain (WR); specifically, 34.1% of patients regained more than 15% of their lowest postoperative weight. The rates of reoperations due to early and late surgical complications were 3.8% and 9.5%, respectively. T2D was resolved in 50% of patients, HTN in 61.1%, and dyslipidemia in 58.3%. Iron deficiency anemia (53%) was the most common postoperative nutritional finding. LRYGB provides satisfactory weight loss and resolution of co-morbidities up to 15 years. WR was a common finding. A significant proportion of patients with a preoperative BMI ≥ 50 kg/m2 did not achieve a favorable weight loss outcome. Indications to perform LRYGB in this group of patientsshould be definitively reconsidered.

Covered versus bare metal kissing stents for reconstruction of the aortic bifurcation in the ILIACS registry

ObjectiveWe compared the early and midterm outcomes of polytetrafluoroethylene covered stents (CSs) vs bare metal stents (BMSs) used in the kissing conformation for the reconstruction of the aortic bifurcation in aortoiliac obstructive disease. MethodsA multicenter cohort registry (2015-2019) collected data from 1306 patients who had undergone endovascular treatment of aortoiliac arterial obstructive disease. Only patients who had received bilateral iliac kissing stents for TransAtlantic Inter-Society Consensus (TASC) class C and D lesions were included in the present analysis. The 30-day outcomes, midterm primary patency, and limb salvage rates were compared between the CSs and BMSs in matched patient cohorts after propensity score matching. The follow-up results were analyzed using Kaplan-Meier curves. Cox proportional hazards models were used to identify the predictors of primary patency. ResultsA total of 336 patients were treated with kissing stents, 201 with CSs (60%) and 135 with BMSs (40%). In the unmatched cohort, patients receiving CSs were more likely to have critical limb ischemia (41% vs 30%; P = .038), complex iliac lesions, such as TASC D (90% vs 56%; P < .01), and iliac occlusions (59% vs 44%; P < .01). After propensity score matching, 220 patients were selected (110 with CSs and 110 with BMSs), without differences in the clinical presentation (critical limb ischemia, 41% vs 33%; P = .167), or anatomic complexity (TASC D, 66% vs 60%, P = .21; iliac occlusion, 48% vs 49%, P = .89). The 30-day mortality was 0%. The early medical (unmatched, 5% vs 4%, P = 1.00; matched, 5% vs 4%, P = .75) and surgical (unmatched, 5% vs 5%, P = 1.00; matched, 5% vs 3%, P = .72) complication rates were similar between the CSs and BMSs. However, the CSs resulted in a lower risk of intraoperative iliac rupture (0% vs 3.5%; P = .013) and greater ankle-brachial index improvement (0.43 ± 0.22 vs 0.36 ± 0.24; P = .02). At 36 months, the overall primary patency (92% ± 7% vs 92% ± 8%; P = .38), secondary patency (98% ± 3% vs 98% ± 4%; P = .50), and limb salvage (93% ± 9% vs 97% ± 5%; P = .20) rates were similar. In cases of moderate to severe iliac calcification, the CSs showed better results in the matched cohort (100% vs 89% ± 9%; P = .048). On multivariate analysis, CS use (hazard ratio [HR], 1.67; P = .45) did not significantly affect primary patency, but older age (HR, 0.93; P = .03) and kissing stent diameter ≥8 mm (HR, 0.25; P = .03) were significantly associated. ConclusionsIn the present multicenter study, the use of kissing stents for the treatment of the aortic bifurcation provided good early and midterm results. CSs were preferred for more complex lesions, were protective from iliac rupture, and allowed for greater ankle-brachial index improvement. The 3-year patency rates were similar between the CSs and BMSs. However, CSs showed improved results in the case of moderate to severe calcification.

Immediate and Long-Term Results of the Spleen-Preserved Operations in the Surgical Treatment of Gastric Cancer

ntroduction. Currently, total gastrectomy with D2 lymphadenectomy is the standard surgical treatment for proximal gastric cancer at the resectable stages (I-III). The issue of advisability of splenectomy as a component of lymphadenectomy remains a controversial one, especially when the tumor is localized in the region of the body or cardiac region of the stomach.The aim of the study was to compare immediate and long-term outcomes, including the quality of life, between spleen preserving and spleen removing surgeries.Methods. The study included 363 patients with gastric cancer II-III stages, localized in the upper and/or the middle third of the stomach, who underwent surgery at the Voronezh Regional Clinical Oncology Hospital and the Voronezh Clinical Hospital of the Russian Railway-Medicine in 2015-2017. All patients were conditionally divided into 2 groups for comparative retrospective analysis. All patients of the first (experimental or spleen-preserved) group (144 patients) were performed R0 total gastrectomy with D2 lymphadenectomy, including splenic hilar nodes (№ 10,11) removal without splenectomy. Patients of the second (control or splenectomy) group (219 patients) were performed R0 total gastrectomy with D2 lymphadenectomy and prophylactic splenectomy (for splenic hilar nodes removal).Results. The average duration of the operation and the volume of blood loss did not differ in both groups. The incidence of early postoperative surgical complications was lower in the spleen-preserved group. Splenectomy was associated with more severe complications of class 4 and 5 according to the Clavien-Dindo classification. Conclusion. Parameters of the 1- and 3-year overall survival rate did not differ in both groups. The results of the GSRS questionnaire were similar in both groups, excluding reflux-esophageal symptoms scale. The reflux scale demonstrated a statistically and clinically significant advantage of spleen preservation.

Iron Deficiency Anemia is Associated with Increased Early Postoperative Surgical and Medical Complications Following Total Hip Arthroplasty

BackgroundIron deficiency anemia (IDA) is a medical comorbidity commonly diagnosed in those undergoing primary total hip arthroplasty (THA). The authors sought to evaluate IDA as a risk factor for early postoperative complications following discharge and describe the hospital resource utilization of this patient population. MethodsPatients with a diagnosis of IDA who underwent THA from 2005 to 2014 were identified in a national insurance database. The rates of postoperative medical complications and surgery-related complications, as well as hospital readmission, emergency department visits, and death were calculated. Additionally, 90-day and day of surgery cost and length of stay were calculated. IDA patients were then compared to a 4:1 matched control population without IDA using a logistic regression analysis to control for confounding factors. ResultsIn total, 98,681 patients with a preoperative diagnosis of IDA who underwent THA were identified and compared to 386,724 controls. IDA was associated with increased risk of 30-day emergency department visits (odds ratio [OR] 1.35, P < .001) and 30-day readmission (OR 1.49, P < .001). IDA was also associated with an increased 90-day medical complication rate (cerebrovascular accident OR 1.11, P = .003; urinary tract infection OR 1.14, P < .001; acute renal failure OR 1.24, P < .001; transfusion OR 1.40, P < .001), as well as 1-year periprosthetic joint infection (OR 1.27, P < .001), revision (OR 1.22, P < .001), dislocation (OR 1.25, P < .001), and fracture (OR 1.43, P < .001). Patients with IDA accrued higher hospital charges ($27,658.27 vs $16,709.18, P < .001) and lower hospital reimbursement ($5509.90 vs $3605.59, P < .001). ConclusionPatients with preoperative IDA undergoing THA are at greater risk of experiencing early postoperative complications and have greater utilization of hospital resources.

An optimal cortical bone trajectory technique to prevent early surgical complications

Background Cortical bone trajectory (CBT) technique has a theoretical benefit for patients with osteoporosis, and leads to reduce screw loosening. However, there are no reports of complications and outcomes of CBT. Methods Consecutive patients (n = 34) with degenerative lumbar spines who underwent PLIF between December 2013 and December 2015 and were followed up for at least six months were analyzed in this study. Bone mineral density, fusion rate, cage subsidence, C-arm, screw loosening, screw violation, trajectory angle of the screw, Hounsfield unit and extent of facetectomy were examined. Outcome assessments were obtained in all patients preoperatively and postoperatively. Results There were 34 patients and 73 screw levels. After the surgery with cortical screw fixation and PLIF, patients had good clinical outcomes. However, ten of the 34 patients had problems with cortical screw fixation such as screw loosening or cage migration. In the patients with screw loosening, two underwent revision surgery due to cage migration, and one had an infection. Incorrect trajectory angles of the screw were significantly related with screw loosening. Low BMD and HU at screw fixation level were associated with screw loosening. Cage subsidence was statistically related with clinical outcomes. Conclusion The cortical screw offers improved clinical outcomes since it requires minimal muscle dissection. However, we have experienced some early complications using this technique. To reduce complications such as screw loosening, an exact insertion angle of the screw and osteoporotic bone quality should be considered carefully.

Trauma fellowship impact on trends and complications of operatively treated clavicle fractures in recently trained orthopedic surgeons

PurposeThe purpose of this study was to evaluate whether fellowship training affected trends and complications of operative clavicle fracture treatment in newly trained orthopedic surgeons. MethodsThe American Board of Orthopedic Surgery (ABOS) database was utilized to identify cases of open treatment of clavicle fractures submitted by ABOS Part-II Board Certification candidates. From 2005 to 2017, 3148 candidates performed at least one open clavicle fracture treatment. Overall, 6919 cases were included; 3516 of these had over 6 weeks of follow-up. Candidates were divided by fellowship type into 5 groups: Trauma, Sports Medicine, Hand and Upper Extremity or Shoulder, multiple, and other or no fellowship(s). Group differences were analyzed with ANOVA and Bonferroni post hoc analysis. Complications, reoperations, nonunion rates, and readmissions between groups were evaluated with Chi-squared test and logistic regression analyses. ResultsCase volume during the study period was significantly higher after 2007. Trauma candidates performed significantly more operations for clavicle fracture per candidate while candidates with other or no fellowship(s) performed significantly fewer operations per candidate. Patients treated by Trauma candidates were significantly older, had significantly fewer early surgical complications and significantly more early medical complications. Nonunion rates were not significantly different between groups. ConclusionCandidates treated clavicle fractures surgically more often in 2007 and beyond. Trauma candidates treated older patients, had fewer early surgical complications, and had more medical complications. Reoperation, readmission and nonunion rates were not significantly different between groups.

A systematic review and meta-analysis of outcomes after elective surgery for ulcerative colitis.

Approximately 20%-30% of patients with ulcerative colitis (UC) will undergo surgery during their disease course, the vast majority being elective due to chronic refractory disease. The risks of elective surgery are reported variably. The aim of this systematic review and meta-analysis is to summarize the outcomes after elective surgery for UC. A systematic review was conducted that analysed studies reporting outcomes for elective surgery in the modern era (>2002). It was prospectively registered on the PROSPERO database (ref: CRD42018115513). Searches were performed of Embase and MEDLINE on 15 January 2019. Outcomes were split by operation performed. Primary outcome was quality of life; secondary outcomes were early, late and functional outcomes after surgery. Outcomes reported in five or more studies underwent a meta-analysis of incidence using random effects. Heterogeneity is reported with I2 , and publication bias was assessed using Doi plots and the Luis Furuya-Kanamori index. A total of 34 studies were included (11774 patients). Quality of life was reported in 12 studies, with variable and contrasting results. Thirteen outcomes (eight early surgical complications, five functional outcomes) were included in the formal meta-analysis, all of which were outcomes for ileal pouch-anal anastomosis (IPAA). A further 71 outcomes were reported (50 IPAA, 21 end ileostomy). Only 14 of 84 outcomes received formal definitions, with high inter-study variation of definitions. Outcomes after elective surgery for UC are variably defined. This systematic review and meta-analysis highlights the range of reported incidences and provides practical information that facilitates shared decision making in clinical practice.

The weekend effect and workforce in kidney transplantation.

The weekend effect, an association of increased mortality with admission to hospital on the weekend, appears to be true albeit contested. Its cause is unknown but may be weekend staffing. Studies of transplant registries in the U.S., U.K., Australia and New Zealand, and now France, and a single center study in Germany, gratifyingly have shown no weekend effect on patient and graft survival in deceased donor kidney transplantation. However, an increase in early surgical complications has been shown, possibly reflecting technical error as a manifestation of fatigue due to weekend staffing. This observation should be acknowledged in the design and staffing of the workforce of transplant programs.

Complications after different surgical methods for suburethral implantation of polypropylene slings in women with stress urinary incontinence

Objective: to identify the proportion of complications after suburethral implantation of polypropylene slings in women with stress urinary incontinence based on a seven-year experience. Material and Methods. We conducted the analysis of а seven-year experience in various implantation techniques of suburethral slings in 1260 women with stress urinary incontinence: inside-out and outside-in obturator sling fixation; suprapubic sling fixation and non-trocar mini-sling installment. Results. The highest incidence of complications was observed over the first two years after suburethral sling implantation was performed. Subsequently, the proportion of complications declined progressively to the lower limit values of 7-8% in the course of three last years. An incidence of early surgical complications among various suburethral sling implantation techniques had no statistically significant differences. However, after the suprapubic sling implantation, intraoperative and mesh-associated complications prevailed. Conclusion. Our study confirmed that suburethral sling implantation using suprapubic fixation method was associated with a higher incidence of complications and should have been performed exclusively for the target group of the patients, for whom safer surgical procedures were contraindicated.

The Association Between Surgeon Age and Early Surgical Complications of Elective Total Hip Arthroplasty: Propensity-Matched Cohort Study (122,043 Patients)

BackgroundThe aim of this study was to examine the relationship between surgeon age and early surgical complications following primary total hip arthroplasty (THA), within a year, in Ontario, Canada. MethodsIn a propensity-matched cohort, we defined consecutive adults who received their first primary THA for osteoarthritis (2002-2018). We obtained hospital discharge abstracts, patient’s demographics and physician claims. Age of the primary surgeon was determined for each procedure and used as a continuous variable for spline analysis, and as a categorical variable for subsequent matching (young <45; middle-age 45-55; older >55). The primary outcome was early surgical complications (revision, dislocation, infection). Secondary analyses included high-volume vs low-volume surgeons (≤35 THA per year). ResultsWe identified 122,043 THA recipients, 298 surgeons with median age 49 years. Younger, middle-aged, and older surgeons performed 39%, 29%, and 32% THAs, respectively. Middle-aged surgeons had the lowest rate of complications. Younger surgeons had a higher risk of composite complications (odds ratio [OR] 1.25, 95% confidence interval [CI] 1.09-1.44, P = .002), revision (OR 1.28, 95% CI 1.07-1.54, P = .007), and infection (OR 1.39, 95% CI 1.12-1.71, P = .003). Older surgeons also had higher risk for composite complications (OR 1.18, 95% CI 1.03-1.36, P = .019), revision (OR 1.33, 95% CI 1.10-1.62, P = .004), and dislocation (OR 1.37, 95% CI 1.08-1.73, P = .009). However, when excluding low-volume surgeons, older high-volume surgeons had similar complications to middle-aged surgeons. ConclusionYounger surgeons (<45 years) had the highest recorded complications rate while the lowest rate was for surgeons aged 45-55. Volume rather than age was more important in determining rate of complications of older surgeons. Level of EvidenceIV.

Morbid obesity and short-term complications following acetabular fracture surgery: A comparative cohort study

IntroductionObesity is an epidemic facing the United States affecting nearly 40% of the population (93.3 million adults). The objective of this study was to compare early perioperative complications in patients with a normal BMI to patients who are pre-obese, obese, and morbidly obese. Materials and methodsThe study was conducted at a Level-I trauma center. Patients were separated into 4 groups based on their BMI. Group 1 had a BMI < 25 (normal), Group 2 had a BMI between 25-29.9 (pre-obesity), Group 3 had a BMI between 30-39.9 (obese), and Group 4 had a BMI ≥40 (morbidly obese). Outcome variables included total operative time (OT), estimated blood loss (EBL), length of stay (LOS), and early medical and surgical complications. A comparison between groups was performed for each outcome variable and surgical complication. ResultsWe identified 333 patients and the number of patients in Groups 1-4 were 86, 96, 121, and 30, respectively. The average BMI for Groups 1-4 was 22.3, 27.3, 35.9, and 44.9, respectively (p < 0.001). OT, EBL, and LOS did not differ between groups or between the surgical approach utilized. There were no significant relationships when comparing complication rates between groups. Patients in Group 4 experienced significantly more PE compared to patients in Group 2 (p=0.01). Additionally, patients in Group 4 experienced a significantly more PE than patients in Groups 1 and 2 combined (p<.01). The relative risk of having a PE if BMI is ≥40, compared to a BMI <30 is 18.40 (95% CI = 1.98 – 171.13). The PEs were not fatal in all cases. ConclusionsIn the treatment of the obese and morbidly obese with acetabular fractures, we find that these cohorts are not at a greater risk of wound complications or infection. The higher rate of pulmonary embolism seen in the morbidly obese should be considered when evaluating these patients for appropriate thromboembolic prophylaxis.

Interval Between Staged Bilateral Total Knee Arthroplasties Does Not Affect Early Medical or Surgical Complications

BackgroundThe purpose of this study is to evaluate early postoperative surgical and medical complications in patients undergoing staged bilateral total knee arthroplasty (TKA) and determine if the interval to the second stage influences the risk of complications. MethodsA retrospective review was performed from 2016 through 2018 of all staged bilateral primary TKA procedures, yielding a cohort of 1005 patients (2010 TKAs). Four groups were created based on the timing of the second stage: 3 to 6 weeks, 7 to 12 weeks, 13 to 24 weeks, and >24 weeks. Clinical data compared between groups included demographics, knee range of motion, University of California, Los Angeles (UCLA) activity score, Knee Society pain score, Knee Society clinical score, and Knee Society functional score. Postoperative complications within 90 days were evaluated, with complications after the second knee being the primary outcome. ResultsThe mean follow-up after second stage was 10.7 months (range, 3 to 37 months). No significant differences were found between groups in the range of motion, Knee Society pain, Knee Society clinical score, Knee Society functional score, or University of California Los Angeles activity score in either the first or second knee. After the first knee surgery, medical complications were highest in the >24-week group. After the second knee, there were no significant difference in manipulation (P = .9), wound complications (P = .7), venous thromboembolism (P = .8), or other medical complications (P = 1) based on the interval duration. ConclusionThe interval between staged TKA did not affect early medical or surgical complications after the second stage. Early clinical and function results were not different based on timing of the second surgery.

Early surgical complications of total hip arthroplasty related to surgical approach.

Total hip arthroplasty (THA) can be performed through a number of surgical approaches. The aim was to compare the incidence of early surgical complications in THA related to approach. A retrospective review of prospectively recorded data extracted from St. Vincent's Melbourne Arthroplasty Registry was performed between January 2006 and December 2016. Surgical approach was identified: lateral, posterior, anterior and superior. Primary outcome measure was return to theatre (RTT) for any cause within 1 year. Age, comorbidity, body mass index and femoral fixation were assessed for potential confounding. Secondary outcomes were RTT for revision procedure and for specific complications: intra or post-operative fracture, dislocation/instability, aseptic loosening and prosthetic joint injection (PJI). Variables were assessed for their association with outcome using unadjusted and adjusted quantile median regression for continuous outcomes and Cox proportional hazards regression for binary time-to-event outcomes. There were a total of 2906 consecutive THA's recorded, 1413 lateral, 1188 posterior, 233 anterior and 72 superior. A total of 140 cases (4.5%) required RTT within 1 year. No approach was associated with RTT on unadjusted analyses or multivariate modelling. There was no association between approach and revision, PJI or periprosthetic fracture. The posterior approach was associated with 2.90 times the rate of dislocation relative to the lateral (P = 0.005). There was no difference in the RTT rate between surgical approaches for THA. There was no difference in revision rates, PJI or periprosthetic fracture. The posterior approach was associated with a higher rate of dislocation relative to the lateral, but not the anterior.

Management of the staple line in laparoscopic sleeve gastrectomy: comparison of three different reinforcement techniques.

Nowadays, laparoscopic sleeve gastrectomy (LSG) is one of the most widely performed bariatric procedures. Different techniques have been described to reduce the rate of complications associated with the staple line, but no consensus has been reached. The aim of this study was to determine the incidence of surgical complications after LSG with three different approaches to the staple line. A retrospective matched analysis was performed, comparing three groups of 100 patients each: partial oversewing of the staple line (PO group), complete oversewing of the staple line (CO group), and reinforcement with buttress material (BM group). Operative time, early surgical complications (superficial surgical site infection, leakage and hemorrhage), length of stay, weight evolution, and revisional surgery rates were analyzed. All three groups were comparable at baseline. All surgeries were performed laparoscopically. Operative time was significantly longer in the CO group (PO: 84.2 ± 22; CO: 104.7 ± 17; BM: 82.3 ± 22; PO vs CO, p = 0.021; BM vs CO, p = 0.011). There were no differences in length of stay, early surgical complications, and weight outcomes at 36 months between the groups. The need for a revisional surgery was significantly higher in the CO group compared to the PO group (PO: 3%; CO: 14%; BM: 9%; PO vs CO, p = 0.005). The CO group required a longer operative time. There were no differences in early surgical complications between the groups. The CO group had a higher need for revisional surgery than the PO group.

Factors Associated With Surgical Mortality and Complications Among Patients With and Without Coronavirus Disease 2019 (COVID-19) in Italy

There are limited data on mortality and complications rates in patients with coronavirus disease 2019 (COVID-19) who undergo surgery. To evaluate early surgical outcomes of patients with COVID-19 in different subspecialties. This matched cohort study conducted in the general, vascular and thoracic surgery, orthopedic, and neurosurgery units of Spedali Civili Hospital (Brescia, Italy) included patients who underwent surgical treatment from February 23 to April 1, 2020, and had positive test results for COVID-19 either before or within 1 week after surgery. Gynecological and minor surgical procedures were excluded. Patients with COVID-19 were matched with patients without COVID-19 with a 1:2 ratio for sex, age group, American Society of Anesthesiologists score, and comorbidities recorded in the surgical risk calculator of the American College of Surgeons National Surgical Quality Improvement Program. Patients older than 65 years were also matched for the Clinical Frailty Scale score. Patients with positive results for COVID-19 and undergoing surgery vs matched surgical patients without infection. Screening for COVID-19 was performed with reverse transcriptase-polymerase chain reaction assay in nasopharyngeal swabs, chest radiography, and/or computed tomography. Diagnosis of COVID-19 was based on positivity of at least 1 of these investigations. The primary end point was early surgical mortality and complications in patients with COVID-19; secondary end points were the modeling of complications to determine the importance of COVID-19 compared with other surgical risk factors. Of 41 patients (of 333 who underwent operation during the same period) who underwent mainly urgent surgery, 33 (80.5%) had positive results for COVID-19 preoperatively and 8 (19.5%) had positive results within 5 days from surgery. Of the 123 patients of the combined cohorts (78 women [63.4%]; mean [SD] age, 76.6 [14.4] years), 30-day mortality was significantly higher for those with COVID-19 compared with control patients without COVID-19 (odds ratio [OR], 9.5; 95% CI, 1.77-96.53). Complications were also significantly higher (OR, 4.98; 95% CI, 1.81-16.07); pulmonary complications were the most common (OR, 35.62; 95% CI, 9.34-205.55), but thrombotic complications were also significantly associated with COVID-19 (OR, 13.2; 95% CI, 1.48-∞). Different models (cumulative link model and classification tree) identified COVID-19 as the main variable associated with complications. In this matched cohort study, surgical mortality and complications were higher in patients with COVID-19 compared with patients without COVID-19. These data suggest that, whenever possible, surgery should be postponed in patients with COVID-19.

Narrative review regarding the applicability, accuracy, and clinical outcome of flapless implant surgery with or without computer guidance.

BackgroundThe advent of computer‐guided surgery removed the need for complex surgical interventions such as extensive flap elevations, second stage implant exposure, and complications usually associated with conventional protocols.Purpose(a) Analyze available literature reporting on applicability, accuracy, clinical outcome of flapless surgery with or without computer guidance. (b) Evaluate quality of studies, in terms of scientific level of evidence and ethical committee approval.Materials and methodsA PUBMED search was performed in July 2018. A first search was based on a general search string limited to “Dental Implants” and “flapless surgery.” A second search focused on accuracy of computer‐guided surgery using search string “Surgery, Computer‐Assisted” or “guided surgery,” and “Dental implants.” The following inclusion criteria were applied: (a) studies in English; (b) human studies (excluding cadaver); (c) systematic reviews; (d) systematic reviews with meta‐analysis. Reviews not mentioning accuracy were excluded in search 2.ResultsNine reviews included in total. Implant survival ranged between 89% and 100%. Early surgical and prosthetic complications reported in 9.1% to 36.4% of reviewed papers. Tooth‐supported guides show more accuracy than bone or mucosa‐supported guides. Fully guided surgery yields higher accuracy, with lower values for horizontal coronal, horizontal apical and angular deviation (1.00, 1.23, and 3.13°mm, respectively) than those placed with half guided surgery (1.44, 1.91, and 4.30 mm, respectively). Thirty‐four of 71 human studies included in nine reviews, mentioned ethical committee approval or compliance with Declaration of Helsinki.ConclusionsGuided flapless surgery is comparable to free‐hand surgery in terms of implant survival, marginal bone remodeling, and peri‐implant variables. Clinicians advised to take care in all steps of the protocol, and include safety margins around virtually planned implants. Regarding compliance with research ethics, we should question whether scientific reports of clinical trials performed without an ethical umbrella are trustworthy. Compliance of ethics standards is imperative for submitted research papers.

Beyond 10years, with or without an intestinal graft: Present and future?

Long-term outcomes in children undergoing intestinal transplantation remain unclear. Seventy-one children underwent intestinal transplantation in our center from 1989 to 2007. We report on 10-year posttransplant outcomes with (group 1, n=26) and without (group 2, n=9) a functional graft. Ten-year patient and graft survival rates were 53% and 36%, respectively. Most patients were studying or working, one third having psychiatric disorders. All patients in group 1 were weaned off parenteral nutrition with mostly normal physical growth and subnormal energy absorption. Graft histology from 15 late biopsies showed minimal abnormality. However, micronutrient deficiencies and fat malabsorption were frequent; biliary complications occurred in 4 patients among the 17 who underwent liver transplantation; median renal clearance was 87mL/min/1.73m2 . Four patients in group 1 experienced late acute rejection. Among the 9 patients in group 2, 4 died after 10years and 2 developed significant liver fibrosis. Liver transplantation and the use of a 3-drug regimen including sirolimus or mycophenolate mofetil were associated with improved graft survival. Therefore, intestinal transplantation may enable a satisfactory digestive function in the long term. The prognosis of graft removal without retransplantation is better than expected. Regular monitoring of micronutrients, early psychological assessment, and use of sirolimus are recommended.

Medical optimization of modifiable risk factors before thoracolumbar three-column osteotomies: an analysis of 195 patients.

To determine the rate of preoperative modifiable laboratory abnormalities (both major and minor) and the association with early postoperative medical and surgical complications. All patients undergoing thoracolumbar three-column osteotomy between 2013 and 2016 with preoperative laboratory data were identified. Potential preoperative modifiable laboratory abnormalities (major and minor) were assessed including hyponatremia (sodium < 130 and < 135mEq/L), anemia (hematocrit < 25% and < 30%), renal insufficiency (creatinine ≥ 1.8 and ≥ 1.2mg/dL), coagulopathy (INR ≥ 1.8 and ≥ 1.2), and hypoalbuminemia (albumin < 2.5 and < 3.5g/dL). Multivariate logistic regression was used to determine associations with 30-day complications after controlling for possible confounding factors. A total of 195 patients were identified. The rates of major and minor preoperative laboratory abnormalities were 7.7% and 31.3%, respectively. The rates of serious medical, minor medical, and surgical complications over 30-days were 6.7%, 21.5%, and 10.3%, respectively. In multivariate analysis the presence of major preoperative laboratory abnormalities had a significant association with serious medical complications (odds ratio [OR] 77.8, P < 0.001), and minor medical complications (OR 13.3, P < 0.001), but not surgical complications (P = 0.243). The presence of minor preoperative laboratory abnormalities had a significant association with serious medical complications (OR 10.4, P = 0.041) and minor medical complications (OR 2.4, P = 0.045), but not surgical complications (P = 0.490). While major laboratory abnormalities had a strong association with complications, even minor modifiable laboratory abnormalities had a significant association with both serious and minor medical complications.

Early Surgical Complications of Total Hip Arthroplasty in Patients With Morbid Obesity: Propensity-Matched Cohort Study of 3683 Patients

BackgroundThe aim of this study is to determine whether the high risk of surgical complications within 1 year of total hip arthroplasty (THA) is due to associated comorbidities or morbid obesity alone as measured by body mass index (BMI ≥ 40 kg/m2). MethodsPopulation-based retrospective cohort study was conducted of all adults in Ontario undergoing primary THA for osteoarthritis (2012-2018). All patients were followed for 1 year. Outcomes were compared among matched groups (hypertension, diabetes, chronic obstructive pulmonary disease, frailty, congestive heart failure, coronary artery disease, asthma, and Charlson score). Primary outcome measure was major surgical complications within 1 year (composite of deep infection requiring surgery, dislocation requiring closed or open reduction, and revision surgery). ResultsA total of 3683 patients with morbid obesity were matched and had a significantly greater risk of major complications within 1-year (132 [3.6%] vs 54 [1.5%]; hazard ratio [HR] 2.54, 95% confidence interval [CI]; 1.98-3.25). This included greater risk for deep infection requiring surgery (100 [2.8%] vs 26 [0.7%]; HR 3.85, 95% CI; 2.70-45.48) and revision arthroplasty (86 [2.4%] vs 34 [0.9%]; HR 2.61, 95% CI; 1.92-3.55). Operative time was also longer with a median 116 (99-138) vs 102 (87-121) minutes. There were no significant differences in hospital stay, cost of acute care episode, or medical complications. ConclusionPatients’ large body habitus seems to contribute to the increased risk of surgical complications within 1-year of THA. Future research is needed to identify ways of mitigating surgical complications such as centralizing care for this complex group of patients in specialist centers.

Incidence and risk factors of early postoperative complications in patients after decompressive craniectomy: a5-year experience.

Decompressive craniectomy is an effective measure to reduce apathologically elevated intracranial pressure. Patients' survival and life quality following this surgery have been asubject of several studies and significantly differ according to the primary diagnosis. Since this operation is often associated with awide spectrum of possibly serious complications, we aimed to describe their incidence and possible associated risk factors. We evaluated 118 patients who underwent decompressive craniectomy at our clinic during years 2013-2017. The indications included traumatic brain injuries, ischaemic or haemorrhagic strokes and postoperative complications of planned neurosurgical procedures. Subsequently, we assessed the incidence of early postoperative complications (occurring during the first 3 postoperative weeks). The results were statistically analysed with relation to awide selection of possible risk factors. At least one early surgical postoperative complication occurred in 87 (73.73%) patients, the most frequent being adevelopment of an extraaxial fluid collection in 41 (34.75%) patients. We were able to identify risk factors linked with extraaxial fluid collections, subcutaneous and extradural haematomas, postoperative seizures and meningitis. An overall need for reoperation was 13.56%. Neither the duration of the surgery nor the qualification of the operating surgeon had any effect on the complications' occurrence. Decompressive craniectomy is associated with numerous early postoperative complications with avarious degree of severity. Most cases of complications can, however, be managed in aconservative way. The risk factors linked with postoperative complications should be taken into account during the indication process in each individual patient.