Higher Rate Of Major Complications Research Articles

Predictors of bleeding or anemia requiring transfusion in complex endovascular aortic repair and its impact on outcomes in health insurance claims

ObjectiveThis study aimed to determine predictors and outcomes associated with bleeding or anemia requiring transfusion (BAT) after fenestrated or branched endovascular aneurysm repair (FB-EVAR). MethodsHealth insurance claims data of Germany's third largest insurance provider, DAK-Gesundheit, were used to investigate BAT in elective FB-EVAR performed between 2008 and 2017. International Classification of Diseases and German Operations and Procedure Key codes were used. ResultsA total of 959 patients (24.8% with BAT) matching the inclusion criteria were identified during the study period. Compared with patients without BAT, patients with BAT were older (74.4 vs 73.0 years; P = .015) and suffered more frequently from congestive heart failure (18.5% vs 9.4%), cardiac arrhythmias (26.9% vs 14.7%), and hereditary or acquired coagulopathy (31.9% vs 6.2%; all P < .001). Coagulopathy (odds ratio [OR], 3.65; 95% confidence interval [CI], 2.29-5.84), female sex (OR, 2.67; 95% CI, 1.78-4.00), and multiple comorbidities (OR, 1.10; 95% CI, 1.07-1.14) were independent predictors of BAT (all P < .001). BAT was associated with higher in-hospital (11.3% vs 2.6%), 30-day (12.2% vs 3.1%), and 90-day (18.5% vs 4.4%) mortality (all P < .001). Furthermore, myocardial infarction (23.9% vs 2.8%) and paraplegia (9.7% vs 0.7%) were more frequent in the BAT group (all P < .001). In multivariable analyses, BAT was associated with worse short-term (OR, 3.19; 95% CI, 1.63-6.33; P = .001) and long-term survival (hazard ratio, 1.62; 95% CI, 1.24-2.11; P < .001). ConclusionsPatients with hereditary or acquired coagulopathy, patients with multiple comorbidities, and women are at higher risk for development of BAT after FB-EVAR. The occurrence of this event was strongly associated with higher major complication rates and worse short-term and long-term survival. This emphasizes a need to further illuminate the value of patient blood management in FB-EVAR.

Intraoperative and major postoperative complications and survival of dogs undergoing surgical management of epiglottic retroversion: 50 dogs (2003-2017).

To report intraoperative and major postoperative complications in dogs treated surgically for epiglottic retroversion (ER), compare the incidence of major postoperative complications between procedures, and report survival of surgically treated dogs. Multi-institutional retrospective study. Fifty dogs treated with 78 procedures. Medical records of dogs diagnosed and surgically treated for ER from 2003 to 2017 at 11 institutions were reviewed. Complications were divided into intraoperative and major postoperative complications. Intraoperative complications occurred during 2 of 78 (2.6%) procedures. Thirty-six major postoperative complications were documented in 22 dogs after 36 of 74 (48.7%) procedures. Postoperative complications occurred after 7 of 12 (58.3%) nonincisional epiglottopexy, 23 of 43 (53.5%) incisional epiglottopexy, 2 of 4 (50%) partial epiglottectomy, 2 of 12 (16.7%) subtotal epiglottectomy, and 2 of 3 (66.7%) other surgical procedures. Epiglottopexy failure was the most common major postoperative complication. The incidence of major postoperative complications did not differ between procedures (P = .1239), although, when combined, epiglottopexy procedures (30/55) had a higher incidence of complications than epiglottectomy procedures (4/16; P = .048). Thirty (60%) dogs were alive at a median of 928 days (range, 114-2805), 8 (16%) were lost to follow-up after 411 days (range, 43-1158), and 12 (24%) were dead/euthanized after 301.5 days (range, 3-1212). Median survival time was not reached after a median of 716 days. Although intraoperative complications were uncommon, major postoperative complications were common, especially after epiglottopexy procedures. Although surgical treatment of ER is associated with a high rate of major postoperative complications, especially epiglottopexy procedures, long-term survival can be achieved.

Short- and Long-Term Outcomes of Liver Resection for Intrahepatic Cholangiocarcinoma Associated with the Metabolic Syndrome.

While the metabolic syndrome (MS) is being recognized as an important risk factor for intrahepatic cholangiocarcinoma (ICC), the outcomes of liver resection in this context remain poorly described. This study aims to report the short- and long-term results of hepatectomy for patients with MS as risk factor for the development of ICC (MS+). All patients undergoing hepatectomy for ICC between 2000 and 2016 at a single center were retrospectively analyzed. The perioperative outcomes of MS+ and ICCpatients without MS (MS-) were compared. Among 115 resected ICC patients, 40 (34.8%) were MS+ and 75 (65.2%) were MS-. MS+ exhibited an increased Charlson comorbidity index (5 ± 2 vs. 2 ± 2, p < 0.001) than MS- patients. While operative characteristics did not differ significantly between the 2 groups, MS+ experienced higher rate of major complications (62.5 vs. 29.3%, p = 0.001). On multivariate analysis, MS+ was an independent risk factor of major complication (HR 2.86, 95% CI 1.07-7.60, p = 0.036) and major cardiorespiratory complication (HR 4.35, 95% CI 1.50-12.62, p = 0.007). Pathological analysis revealed that MS+ displayed higher rates of non-alcoholic fatty liver disease (60.0 vs. 31.1%, p = 0.003) and non-alcoholic steatohepatitis (25 vs. 5.4%, p = 0.005). MS+ was independently associated with decreased risk of recurrence (HR 0.47, 95% CI 0.26-0.85, p = 0.001). MS+ accounts for 35% of resected ICC patients. The existence of significant cardiovascular comorbidities increases postoperative morbidity and requires specific management.

Robotic approach mitigates the effect of major complications on survival after pancreaticoduodenectomy for periampullary cancer

Background: Major complications (MC) after pancreaticoduodenectomy (PD) have been shown to be an independent predictor of worse oncologic outcomes. There is limited data on the effect of major complications on long-term outcomes after robotic PD (RPD). The aim of this current study is to compare the effect of MC on overall and disease-free survival (DFS) after RPD and open PD (OPD). Methods: This is a single-center, retrospective review of a prospectively maintained database of all patients undergoing PD for periampullary cancer including duodenal adenocarcinoma, ampullary carcinoma and distal cholangiocarcinoma from January 1, 2011 through November 30, 2017. Univariate analysis was performed on all clinical, pathologic and treatment factors. MC were defined as Clavien-Dindo grade 3 or higher complications. Kaplan-Meier survival analysis was performed with log-rank test for group comparison. Multivariate cox regression analysis was used to identify factors associated with overall survival (OS) in both the OPD and RPD groups. Results: A total of 190 patients with ampullary carcinoma (n = 98), cholangiocarcinoma (n = 55), duodenal adenocarcinoma (n = 37) were examined over the study period with 61.1% (n = 116) undergoing RPD and 38.9% (n = 74) undergoing OPD. Patient demographics were similar between the RPD and OPD cohorts regarding patient age (67.3 ± 10.3 vs 69.8 ± 10.2 yrs, p = 0.11), body-mass index (27.7±5.7 vs 29.5±7.1, p=0.06) and age-adjusted Charlson Comorbidity Index (aCCI) (5.0 ± 1.6 vs 5.2 ± 1.5, p = 0.33). R0 resection rates were similar between the RPD (94.0%, n = 109) and OPD cohorts (93.2%, n = 69, p = 0.84). Tumor size (2.8±1.8cm vs 2.9±1.8cm, p = 0.70) and lymph node involvement (lymph node positivity = 67.3% vs 66.2%, p = 0.88) were also similar between the two cohorts. OPD had higher rate of MC (40.5% vs 28.3% in RPD, p = 0.011) including clinically-significant pancreatic fistula (25.7% vs 8.6%, p = 0.001) and wound infection (34.5% vs 13.8%, p<0.001). Completion of adjuvant chemotherapy was higher in the RPD cohort (46.2% vs 28.6%, p = 0.048). OS and DFS for each cohort by MC status are depicted in Figure 1. Factors associated with OS on multivariate analysis in the OPD cohort included postoperative MC (hazard ratio (HR) = 2.18, 95%CI 1.04-4.55, p = 0.038), aCCI (HR = 1.50, 95%CI 1.16-1.93, p = 0.002), tumor grade (HR = 2.24, 95%CI 1.08-4.62, p = 0.03), tumor perineural invasion (HR=4.84, 95%CI 1.84-12.73, p = 0.001) and number of adjuvant therapy cycles (HR=0.84, 95%CI 0.72-.98, p = 0.03). Factors associated with OS on multivariate analysis in RPD cohort included T stage (HR = 1.58, 95%CI 1.10-2.28, p = 0.014), lymph node involvement (HR = 1.10. 95%CI 1.03-1.17, p = 0.004), lymphovascular invasion (HR = 2.77, 95%CI 1.08-7.11, p = 0.035), transfusion requirement (H = 2.62, 95%CI 1.34-5.13, p=0.005), reoperation (HR = 3.23, 95%CI 1.18-8.81, p=0.022), and completion of adjuvant therapy (HR = 0.34, 95%CI 0.17-0.68, p = 0.002). MC was not associated with OS in the RPD cohort (HR = 1.55, 95%CI 0.87-2.76, p=0.14). Conclusion: MC are associated with worse patient outcomes after OPD but not after RPD. Robotic approach abrogates the negative effects of MC on patient outcomes after PD for malignancy and is associated with improved adjuvant chemotherapy completion rates.

04:12 PM Abstract No. 361 Does implementation of an effective midline catheter program for vascular access in a large academic hospital decrease rates of bloodstream infections?

Recently, the use of peripherally inserted central catheters (PICCs) has increased dramatically and has been shown to contribute significantly to major complications such as central line associated blood stream infections (CLABSIs). Increasing midline use can reduce the rate of CLABSIs; however, this could potentially increase minor complications such as leaking and dislodgement. Therefore, this study aims to evaluate the ease of use and safety of midline catheters by surveying end users of vascular access devices (VAD) and comparing the rates of complications between PICCs and midlines. This was an IRB-approved study. Participants from a pool of nurse representatives from each unit throughout the hospital (n=24) were asked to identify complication trends and maintenance issues associated with VAD use. In addition, a single-center retrospective chart review was performed using a REDCap QA/AI database of all patients with midlines (n=510) and PICCs (n=510) inserted from March 2017-July 2018. The EMR was reviewed for the following complications: catheter-related bloodstream infection (CR-BSI) or CLABSI, phlebitis, infiltration, leaking, dislodgement, and thrombosis. Nurses reported that the most commonly seen complication was dislodgement, while thrombosis was seen the least. In addition, blood draw, labeling, and flushing were the most frequent issues with midline use. In the retrospective study, CLABSI/CR-BSI rate was significantly higher in PICCs than in midlines (χ2=9.43, p=0.002). Furthermore, there was no significant difference in the incidence of thrombosis and the minor complications of phlebitis, infiltration, and dislodgement; however, midlines were found to have a significantly higher rate of leaking (χ2=8.12, p=0.004). PICCs were found to have a significantly higher rate of major complications versus midlines, which were associated with a higher incidence of minor complications. The hospital wide VAD policy change to reduce PICC usage and increase midlines was warranted to reduce CLABSIs.

CT Fluoroscopic-Guided Coil Localization of Lung Nodules prior to Video-Assisted Thoracoscopic Surgical Resection Reduces Complications Compared to Hook Wire Localization

PurposeTo compare the safety and efficacy of hook wire versus microcoil localization of pulmonary nodules prior to video-assisted thoracoscopic resection (VATS). Materials and MethodsA retrospective comparative review was conducted of 46 patients (26 hook wire and 20 microcoil) who underwent computed tomography fluoroscopic-guided nodule localizations prior to VATS in a single center between January 2012 and August 2016. Nodule characteristics, procedural details, clinical outcomes, and pathologic findings were collected. Baseline characteristics and lung nodule distribution were not significantly different between the 2 groups. Nodule sizes ranged from 2 mm to 28 mm and were similar between groups. Twenty-nine patients (63%) were male, with mean (standard deviation) age of 61 (11) years. Adverse events were classified using standard criteria. Patients were followed for up to 90 days, and the clinical outcomes were compared. ResultsSuccessful resection of nodules was achieved in all patients. Twelve cases of displacement of the hook wire were observed compared to only 1 in the coil group (P < .01). The total complication rate was lower in the coil group (25% vs 54%, P = .04). Two patients required transition to thoracotomy in the hook wire group, compared to none in the coil group. Median blood loss was similar in both groups (median loss, 20–22 mL). One patient had positive margins in the hook wire group. There was a nonsignificant trend toward longer hospital stay and higher major complication rates after hook wire localization (P = .4). ConclusionsPulmonary nodule localization with coils prior to VATS resection demonstrated fewer displacements and fewer perioperative complications compared to hook wires.

Infección quirúrgica profunda en cirugía instrumentada de raquis toracolumbar. Diez años de experiencia

ObjectiveTo describe the characteristics and evolution of deep surgical site infection following thoracolumbar instrumented spinal surgery (DSITIS) in our centre over a period of ten years. Material and methodDescriptive retrospective study. Patient data (epidemiological/health status), surgical data, infection characteristics/presentation, isolated microorganisms, required surgical debridements, implant removal and major complications linked to infection were evaluated. ResultsWe included 110 patients (80 females). Median follow-up after infection diagnosis was 3.6years. Adolescent idiopathic scoliosis, adult deformity and degenerative lumbar stenosis were the most frequent aetiologies. Sixty-two percent of the patients had at least one clinical feature that made them prone to infection. Infection presentation was early (0-3months from first surgery) in 60.4% of the cases, delayed (3-24months) in 11.7%, and late (more than 24months) in 27%. All patients were treated by surgical debridement. Twenty-five percent needed more than one surgical debridement. Implants were removed in 46% of the patients (71% in the first surgical debridement). The most frequent isolated microorganisms were coagulasa-negative Staphylococcus, Propionibacterium acnes and Enterococcus. Major complications appeared in 15% of the patients, and 88% of them required major surgeries. ConclusionsLate DSITIS is more frequent than previously reported. Skin microorganisms predominate among the DSITIS culprits. DSIITS produce a high rate of major complications that usually require major surgery for treatment.

Complication rates of percutaneous biliary drainage in the presence of ascites

Ascites is a relative contraindication to percutaneous biliary drainage (PBD), but patients with biliary obstruction presenting with ascites may still undergo PBD insertion. We hypothesized that ascites increases the major complication rate of PBD. PBDs placed between January 2005 and August 2016 were identified (n = 491). Etiology and location of obstruction, the presence, and distribution of ascites based on abdominal imaging within 2weeks of PBD, INR, WBCE, and peri-procedural complications were reviewed in the EMR. A total of 491 PBD were placed during the study period of which 26.2% had ascites (n = 129), and 73.7% did not have ascites (n = 362). Ascites was categorized as perihepatic in 41 patients (32%), diffuse in 82 patients (64%), and non-perihepatic in 6 patients (4%). Overall, a significantly higher rate of major complications occurred in patients with ascites (19%) compared to that in patients without ascites (7.7%, P = 0.0004). Diffuse ascites was associated with a significantly higher major complication rate (26%) when compared to perihepatic ascites (7.3%, P = 0.014). In ascites patients, no association between the etiology of biliary obstruction or laterality of the PBD and the rate of major complications was identified. The major complication rate in patients with ascites not only exceeds SIR suggested threshold of 10% but is also significantly higher than that patients without ascites. The distribution of ascites had a significant effect on complication rate, with diffuse ascites being associated with increased major complication rates compared to those with perihepatic. These findings suggest careful consideration of patients for PBD with ascites, particularly diffuse ascites.

Mandibular distraction osteogenesis versus sagittal split ramus osteotomy in managing obstructive sleep apnea: A randomized clinical trial

PurposeTo compare mandibular distraction osteogenesis (MDO) to sagittal split ramus osteotomy (SSRO) to treat moderate-to-severe obstructive sleep apnea (OSA), and their surgical morbidities and skeletal stability. Materials and methodsA randomized clinical trial was conducted on non-syndromic adult patients with apnea-hypopnea index (AHI) 15 or above to receive MDO or SSRO as part or whole skeletal advancement surgery. Post-operative 1 year OSA cure rate (AHI < 5/hour) and treatment success rate (50% reduction of AHI and AHI< 20/hour) were compared. Polysomnography were conducted pre-operatively and post-operatively up to 2 years. Surgical morbidities and skeletal stability were analyzed. ResultsEighteen patients (9 in each group) were recruited. Patient recruitment was terminated after two major complications in the MDO group. The OSA cure rate and treatment success rate showed no statistical difference between MDO group or SSRO group at post-operative 1 year. Major complication rate was 44.4% in the MDO group and 0 in the SSRO group. No statistical difference was found in skeletal stability between the two groups. ConclusionBoth MDO and SSRO were highly effective to treat moderate-to-severe OSA. MDO had a high major complication rate and was not superior than SSRO in airway function improvement and skeletal stability.

Reverse shoulder arthroplasty for acute proximal humeral fractures: Postoperative complications at 7 days, 90 days and 1 year

BackgroundIn the last decade, the biomechanics of reverse shoulder arthroplasty (RSA) for proximal humeral fractures in the elderly have led to more functional outcomes and greater pain relief. However, its use has also introduced a significant rate of complications. The purpose of this study is to assess the complication rate of RSA in these cases as well as the relationship to ASA score and basic disease history. MethodsWe evaluate patients who underwent RSA due to acute proximal humeral fractures at three hospitals from 2010 to 2016. We analyze previous disease and anticoagulant treatment, American Society of Anesthesiologists (ASA) Physical Status Classification, and the transfusion rate to correlate these factors with major and minor postoperative complications at 7, 90, and 365 days. ResultsWe include 103 patients (104 shoulders) over 65 years of age. Mean age is 77.31 years (62–91), 20 of which are male. The overall rate of complications is 25%, with 17.4% minor and 7.6% major complications. We observe a statistically significant relationship between a higher ASA score (3,4) and major complication at 90 days (p = 0.024) and a trend (p = 0.072) towards a higher ASA score with minor complication during the first week. Rheumatoid disease significantly increases major complications at 90 days (p = 0.037). The transfusion rate is 11.5%. ConclusionsThe overall major complication rate of RSA for acute fractures is low in the elderly population. Although, the patient’s history (e.g. previous rheumatoid pathology, neurological diseases, or anticoagulant treatment) as well as their ASA score should be considered before RSA surgery. The higher the ASA score and the presence of rheumatoid disease, leads to a higher rate of major complications during the first 90 days after surgery. Level of evidenceLevel IV; Case series; Treatment study.

Surgical Management of Thoracic Disc Herniation: Anterior vs Posterior Approach.

To compare outcomes and complications in patients with thoracic disc herniation (TDH) undergoing surgery with either the posterior or anterior approach. A total of 86 patients, with 98 symptomatic TDHs, who underwent surgery in a single institution between 2007 and 2016, were included. Overall, 68 patients were in the anterior and 18 were in the posterior group. Ten patients underwent multilevel TDH surgery. The groups were similar in age, sex, body mass index, and clinical symptoms. In the anterior group, 4 patients (5.9%) had major complications, and 26 (38.2%) had minor complications. In the posterior group, 6 patients (33.3%) had major complications, and 4 (22.2%) had minor complications. Visual analog scores at the final follow-up improved in both groups as compared to baseline preoperative scores (p > 0.05). The rate of neurological improvement in patients with myelopathy was significantly higher in the anterior group (43/50) than in the posterior group (8/14) (p < 0.05). The current study showed that higher rates of major complications in central and calcified paracentral TDHs are associated with posterior approaches when compared to anterior approaches. In addition, anterior approaches had superior neurological recovery and clinical outcomes. Therefore, we recommend the anterior approach for the treatment of calcified and/or non-calcified central and calcified paracentral TDH, while reserving posterior approaches for small non-calcified paracentral disc herniations.

Comparison of microwave ablation and radiofrequency ablation for hepatocellular carcinoma: a systematic review and meta-analysis

Background: Microwave ablation (MWA) has several advantages over radiofrequency ablation (RFA) for the treatment of hepatocellular carcinoma (HCC). We aimed to compare the efficacy and safety of MWA with those of RFA for HCC from the perspectives of percutaneous and laparoscopic approaches.Methods: PubMed/MEDLINE, Embase, the Cochrane library, and China Biology Medicine databases were searched. Studies comparing the efficacy and safety of MWA with those of RFA in patients with HCC were considered eligible. Complete ablation (CA), local recurrence (LR), disease-free survival (DFS), overall survival (OS), and the major complication rate were compared between MWA and RFA.Results: Four randomized controlled trials and 10 cohort studies were included. For percutaneous ablation, no significant difference was found between MWA and RFA regarding CA, LR, DFS, OS, and the major complication rate. A subgroup analysis of tumors measuring ≥3 cm revealed no difference in CA and LR for percutaneous ablation. For laparoscopic ablation, a significantly lower LR rate and a non-significant trend toward a higher major complication rate were observed for the MWA group (odds ratio [OR] 2.16, 95% confidence interval [CI] 1.16–4.02, p = .01 for LR; OR 0.21, 95% CI 0.04–1.03, p = .05 for major complication rate). CA, DFS, and OS were similar between the two groups.Conclusions: Percutaneous (P)-MWA had similar therapeutic effects compared with P-RFA for HCC. Patients undergoing laparoscopic MWA had a lower LR rate; however, their major complication rate appeared to be higher. The superiority of MWA over RFA remains unclear and needs to be confirmed by high-quality evidence.

Évaluation de la courbe d’apprentissage de la cystectomie radicale laparoscopique pour cancer : morbidité et résultats oncologiques

The objective of this work was to evaluate the impact of the laparoscopic radical cystectomy learning curve on perioperative and oncological outcomes. This is a retrospective and single-center study of all patients who underwent laparoscopic radical cystectomy for bladder cancer from February 2007to March 2016, (93patients) Perioperative and oncological data were collected. We used mixed statistical models to predict the number of patients needed in the learning phase. We compared the perioperative parameters of the patients in the learning phase with those of the rest of the patients. Overall survival was estimated using the Kaplan-Meier method. Thirty-six patients are required for the learning phase (P1). The expertise phase begins after the 36th LRC (P2). In both phases, there was no significant difference in age, ASA score, and tumor stage (P=0.237, P=0.577, P=0.998). Mean operative time was 328.3min and 262.4min in P1and P2 (P=0.0001), mean blood loss was 333.7mL and 194.3mL in P1and P2respectively (P=0.0003). The rate of major complications was high in the learning phase (P=0.042). There was no significant difference in lymph node yield, positive surgical margins and overall survival (P=0.068, P=0.194, P=0.703). This learning experience was evaluated without compromising oncological results, but with a significantly higher rate of major complications. 3.

Short-term outcomes after elective colon cancer surgery: an observational study from the Norwegian registry for gastrointestinal and HPB surgery, NoRGast.

To describe the real burden of major complications after elective surgery for colon cancer in Norway, and to assess which predictors that are significantly associated with the short-term outcome. An observational, multi-centre analysis of prospectively registered colon resections registered into the Norwegian Registry for Gastrointestinal Surgery, NoRGast, between January 2014 and December 2016. A propensity score-adjusted subgroup analysis for surgical access groups was attempted, with laparoscopic resections grouped as intention-to-treat. Out of 1812 resections, 14.0% of patients experienced a major complication within 30 days following surgery. The over-all reoperation rate was 8.7%, and rate of reoperation for anastomotic leak was 3.8%. Twenty patients (1.1%) died within 30 days after surgery. Higher age was not a significant predictor of major complications, including 30-day mortality. After correction for all co-variables, open access surgery was associated with higher rates of major complications (OR 1.67 (CI 1.22-2.29), p = 0.002), higher 30-day mortality (OR 4.39 (CI 1.19-16.13) p = 0.026) and longer length-of-stay (HR 0.58 (CI 0.52-0.65) p < 0.001). Our results indicate a low complication burden and high rate of uneventful patient journeys after elective surgery for colon cancer in Norway. Age was not associated with higher morbidity or mortality rates. Open access surgery was associated with an inferior short-term outcome.

Diaphyseal Femoral Fractures in Children: Comparison Between Elastic Stable Intramedullary Nailing and Conservative Management

Background:Femoral shaft fractures are one of the most common fractures of the lower extremities in children. Although many approaches and options are available for their treatment, the most appropriate treatment option for school going children is still debatable.Objective:This study investigated the efficacy, safety, and outcome of surgical intervention with Elastic Stable Intramedullary Nailing (ESIN) in 3–12-year-old children with diaphyseal femoral fractures and compared them with those of conservative management.Methods:In this prospective study, 41 children with diaphyseal femoral fractures were recruited between April 2013 and April 2016. The fractures were divided into two equal groups: one treated with ESIN, and the other with early spica casting or noninvasive traction followed by hip spica casting. Demographic data, clinical information, and serial radiographic findings were collected and compared between the two groups. Flynn’s scoring criteria pertaining to time to union, assisted weight bearing, independent ambulation, return to school, and complications were applied. Fischer’s exact test was used for statistical analyses.Results:Compared with spica casting-treated fractures, ESIN-treated fractures healed faster with lower average time to assisted weight bearing, independent ambulation, and return to school. Hip spica-treated children had a higher rate of major complications than ESIN-treated children. At 1-year follow-up, higher limb length discrepancy was reported in hip spica-treated children than in ESIN-treated children (P&lt; 0.001).Conclusion:ESIN is a safe and effective approach for treating femoral shaft fractures in children; it provides better functional and radiographic outcomes than spica casting and can be used in preschool-age children.

Acute kidney injury increases the rate of major morbidities in cytoreductive surgery and HIPEC.

IntroductionAcute kidney injury (AKI) following cardiovascular surgery has been shown to increase costs and overall morbidity and mortality. The incidence, risk factors, and outcomes of AKI following other types of major surgeries have not been as well characterized. We sought to study the incidence of AKI following cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) per the Kidney Disease: Improving Global Outcomes (KDIGO) criteria.Materials and methodsPatients undergoing CRS and HIPEC between 2013 and 2015 were included. Demographic and perioperative data were compared between patients who experienced AKI versus controls using appropriate statistical analysis between categorical and continuous variables. AKI was recorded by a Certified Professional in Healthcare Quality (CPHQ) and defined as a rise in serum creatinine by ≥ 0.3 mg/dL within 48 h (KDIGO criteria).ResultsFifty-eight consecutive patients undergoing CRS and HIPEC were included. Twelve (20.7%) patients were recorded to develop AKI. This was the most common complication recorded by the CPHQ member. There was one 30-day mortality secondary to cerebral infarction. AKI patients had a longer hospitalization period (14.2 ± 6.9 vs. 9.5 ± 3.3 days, p = 0.002), and a higher rate of major complications (50.00% vs. 15.21%; p = 0.018). Readmission rate was similar (p = 0.626). Multivariate regression identified excessive blood loss during surgery as a major predictor of AKI occurrence, and pre-existing comorbidities and postoperative AKI as predictors of major morbidities following CRS and HIPEC.ConclusionAKI following CRS and HIPEC appears to be a common complication which is associated with further major morbidities. Current quality improvement programs may be under-reporting this incidence.

Postoperative bleeding after laparoscopic Roux en Y gastric bypass: predictors and consequences.

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a common, safe and effective bariatric procedure. Bleeding is a significant source of postoperative morbidity. We aimed to determine the incidence, outcomes, and predictors of postoperative bleeding after LRYGB. LRYGB patients included in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) 2015 dataset were identified. Preoperative and intraoperative factors were tested for associations with bleeding using univariable and multivariable logistic regression analysis. Outcomes of length of stay, in-hospital mortality, 30-day mortality, discharge disposition, and 30-day complications among patients with and without clinically significant postoperative bleeding were compared using multivariable regression. In the 43,280 LRYGB patients included in this analysis, postoperative bleeding occurred in 652 (1.51%) patients. Of these, 165 (25.3%) underwent a re-operation and 97 (14.9%) underwent an unplanned endoscopy for 'bleeding'. Postoperative bleeding was associated with a longer median postoperative length of stay (4 vs. 2 days), higher in-hospital mortality (1.23 vs. 0.04%), higher 30-day mortality (1.38 vs. 0.15%), discharge to an extended-care facility (3.88 vs. 0.6%), and higher rates of major complications (all P < 0.05). Independent predictors of postoperative bleeding included; a history of renal insufficiency (OR 2.55, 95% CI 1.43-4.52), preoperative therapeutic anticoagulation (OR 2.44, 95% CI 1.69-3.53), and revisional surgery (OR 1.45, 95% CI 1.06-1.97). Intraoperative associated factors included conversions (OR 3.37, 95% CI 1.42-7.97), and drain placement (OR 1.40, 95% CI 1.18-1.67). Robotic approaches resulted in independently lower postoperative bleeding rates (OR 0.50, 95% CI 0.32-0.77). Postoperative bleeding occurs in 1.5% of patients undergoing a LRYGB and is associated with significantly increased morbidity and mortality. We have identified patient and operative factors that are independently associated with postoperative bleeding.

A study on sublabial transsphenoidal treatment of pituitary tumor under microscope with aid of endoscope

BackgroundA pituitary tumor is a tumor with a high incidence among brain tumors. Microscopic traditional STT approach with aid of endoscope has a high therapeutic effect and few complications.MethodsThe authors reviewed 146 patients who underwent STT resection of sellar masses between January 1, 2006, and December 31, 2013. From this group, 40 patients who underwent microscopic STT surgery with aid of endoscope were included in the study. In this series, there were many nonfunctional and Growth Hormone(GH) secreting adenoma. In the study group, tumor size ranged from 60 to 79 mm in 3 cases. Pathophysiological studies, tumor sizes, clinical outcomes, extent of resection, visual function and complication were estimated.ResultsIn our study, gross-total resection(GTR) was achieved in 33 patients (82.5%), subtotal in 3 (7.5%), and partial in 4 (10%). Visual acuity were improved in 82.1%, while 17.9% were unchanged. Visual fields were improved in 81.2%. No deaths occurred in this cohort of patients.ConclusionsPituitary adenoma surgery under microscope with aid of endoscope is an effective treatment method, which results in high (> 90%) rates of resection. It is not associated with high rates of major complications and is safe when performed by experienced surgeons.

Intrahepatic cholangiocarcinoma associated with the metabolic syndrome: characteristics and results of liver resection

Objective: To report short and long-term outcomes after hepatectomy for intrahepatic cholangiocarcinoma (ICC) related to metabolic syndrome (MS). Background: While the metabolic syndrome is being recognized as an important risk factor for ICC, MS-related ICC (MS+) remains poorly described. Methods: All patients undergoing hepatectomy for ICC between 2000-2016 at a single center were retrospectively analyzed. The peri-operative characteristics, pathological analysis and long-term outcomes of MS+ and ICC without MS (MS-) were compared. Results: Among 115 resected ICC patients, 40 (34.8%) were MS+ and 75 (65.2%) were MS-. MS+ patients were more frequently classified ASA>2 (37.5 vs. 5.3%, p=0.001) and exhibited increased Charlson comorbidity index (5±2 vs. 2±2, p< 0.001) than MS- patients. While operative characteristics did not differ significantly between the two groups, MS+ experienced higher rates of major complications (62.5 vs. 29.3%, p=0.001). On multivariate analysis, MS+ was an independent risk factor for both major complications (HR: 2.855, 95% CI: 1.072-7.599, p=0.036) and major cardiorespiratory complications (HR=4.356, 95% CI: 1.503-12.622, p=0.007). Pathological analysis revealed that MS+ displayed higher rates of non-alcoholic fatty liver disease (60.0 vs. 31.1%, p=0.003) and non-alcoholic steatohepatitis (25 vs. 5.4%, p=0.005) but significantly smaller lesions (64 vs. 76 mm, p=0.048). MS+ was independently associated with decreased risk of recurrence (HR: 0.462, 95% CI: 0.241-0.887, p=0.020). Conclusion: MS+ accounts for 35% of resected ICC patients. The prognosis of these patients seems to be more favorable but the existence of significant cardiovascular comorbidities increases postoperative morbidity and requires specific management.

The impact of conversion on the risk of major complication following laparoscopic colonic surgery: an international, multicentre prospective audit.

Laparoscopy has now been implemented as a standard of care for elective colonic resection around the world. During the adoption period, studies showed that conversion may be detrimental to patients, with poorer outcomes than both laparoscopic completed or planned open surgery. The primary aim of this study was to determine whether laparoscopic conversion was associated with a higher major complication rate than planned open surgery in contemporary, international practice. Combined analysis of the European Society of Coloproctology 2017 and 2015 audits. Patients were included if they underwent elective resection of a colonic segment from the caecum to the rectosigmoid junction with primary anastomosis. The primary outcome measure was the 30-day major complication rate, defined as Clavien-Dindo grade III-V. Of 3980 patients, 64% (2561/3980) underwent laparoscopic surgery and a laparoscopic conversion rate of 14% (359/2561). The major complication rate was highest after open surgery (laparoscopic 7.4%, converted 9.7%, open 11.6%, P<0.001). After case mix adjustment in a multilevel model, only planned open (and not laparoscopic converted) surgery was associated with increased major complications in comparison to laparoscopic surgery (OR 1.64, 1.27-2.11, P<0.001). Appropriate laparoscopic conversion should not be considered a treatment failure in modern practice. Conversion does not appear to place patients at increased risk of complications vs planned open surgery, supporting broadening of selection criteria for attempted laparoscopy in elective colonic resection.