High Risk Of Early Complications Research Articles

How to predict short- and long-term mortality in patients with pulmonary embolism?

Pulmonary embolism (PE) is a common disease with a considerable short- and long-term risk of death. An adequate evaluation of the prognosis in patients with PE may guide decision making in terms of the intensity of the initial treatment during the acute phase, duration of treatment, and intensity of follow-up control visits in the long term. Patients with shock or persistent hypotension are at high risk of early mortality and may benefit from immediate reperfusion. Several tools are available to define the short-term prognosis of hemodynamically stable patients. The Pulmonary Embolism Severity Index (PESI) score, simplified PESI score, and N-terminal pro-B-type natriuretic peptide levels are particularly useful for identifying patients at low risk of early complications who might be safely treated at home. However, the identification of patients who are hemodynamically stable at diagnosis but are at a high risk of early complications is more challenging. The current guidelines recommended a multiparametric prognostic algorithm based on the clinical status and comorbidities. Unfortunately, only a few studies have evaluated the role of risk factors potentially affecting the long-term prognosis of these patients. The available studies suggest a potential role of the PESI score and troponin levels evaluated at the time of an index event. However, further studies are warranted to confirm these preliminary findings and to identify other long-term prognostic factors in this setting.

Systematic review of central pancreatectomy and meta-analysis of centralversusdistal pancreatectomy

Central pancreatectomy (CP) is a parenchyma-sparing surgical procedure that enables the removal of benign and/or low-grade malignant lesions from the neck and proximal body of the pancreas. The aim of this review was to evaluate the short- and long-term surgical results of CP from all published studies, and the results of comparative studies of CP versus distal pancreatectomy (DP). Eligible studies published between 1988 and 2010 were reviewed systematically. Comparisons between CP and DP were pooled and analysed by meta-analytical techniques using random- or fixed-effects models, as appropriate. Ninety-four studies, involving 963 patients undergoing CP, were identified. Postoperative morbidity and pancreatic fistula rates were 45·3 and 40·9 per cent respectively. Endocrine and exocrine pancreatic insufficiency was reported in 5·0 and 9·9 per cent of patients. The overall mortality rate was 0·8 per cent. Compared with DP, CP had a higher postoperative morbidity rate and a higher incidence of pancreatic fistula, but a lower risk of endocrine insufficiency (relative risk (RR) 0·22, 95 per cent confidence interval 0·14 to 0·35; P < 0·001). The risk of exocrine failure was also lower after CP, although this was not significant (RR 0·59, 0·32 to 1·07; P = 0·082). CP is a safe procedure with good long-term functional reserve. In situations where DP represents an alternative, CP is associated with a slightly higher risk of early complications.

Frailty and Early Mortality after Lung Transplantation: Preliminary Results

Purpose Our group has hypothesized that the frailty phenotype might help identify those at high risk of early complications after lung transplantation. The prevalence of pre-transplant frailty among transplant recipients and the impact of frailty on outcomes after transplantation is not known. Methods and Materials We performed an interim analysis of the first 46 consecutive lung transplant recipients ≥50 years old enrolled in the Lung Transplant Body Composition (LTBC) study at our center. All LTBC participants undergo a structured frailty assessment during transplant evaluation. Frailty was defined as the presence of ≥3 of the following: unintentional weight loss ≥ 4.5kg, low walking speed, self-reported exhaustion, low activity level, and low grip strength. Wilcoxon rank sum tests, Chi-square tests, Fisher’s exact tests, and log-rank tests were used to compare frail and non-frail participants. Results The mean (SD) age was 62 (5) yrs, 34% were ≥ 65 yrs, 44% were female, 13% were African-American, 54% had ILD, 14% had COPD, 2% had CF, 4% were underweight, 13% were obese, the median LAS was 42 (IQR 33 to 51), 48% were bilateral, and 11 (24%) were frail. Frail recipients were more frequently African-American (37% vs. 6%, p = 0.02) but were similar with regard to age, gender, BMI, diagnosis, LAS score, PA pressure, and use of cardiopulmonary bypass. There were non-significant trends toward more intraoperative complications (28% vs 6%, p = 0.08), postoperative complications (64% vs 37%, p = 0.17), unplanned returns to the OR (18% vs 6%, p = 0.24), and deaths on the ventilator (18% vs 2%, p = 0.14) among frail vs non-frail recipients, respectively. The 30-day mortality rate was 18% among frail and 0% among non-frail (p = 0.01). Conclusions The frail phenotype is prevalent among lung transplant recipients over 50 years old at our center and is not associated with diagnosis or LAS score. Our finding of an unadjusted association of frailty with poor outcomes should be interpreted cautiously. These findings merit additional study.

Combined Liver-Intestine Grafts Compared With Isolated Intestinal Transplantation in Children

Intestinal transplantation is known to be associated with a high risk of early complications and mortality. We analyzed prospective data of 51 primary small bowel transplantations from December 1999 to August 2009 and identified perioperative factors that impact on early mortality (≤6 months after transplantation) after isolated intestinal (IITx; n=12) and combined liver-intestinal transplantation (CLITx group; n=39). Ten patients died during the first 6 months after transplantation, all of them in CLITx group (n=10/51, 19%). Multivariate analyses demonstrated intraoperative red blood cell transfusion greater than 70 mL/kg (P=0.019, odds ratio [OR]=13.79) and base excess 30-min after reperfusion less than -16 (P=0.001, OR=14.05), thrombocytopenia (<50,000 per dL) between day 1 and day 15 after transplantation (P=0.047, OR=5.22), and occurrence of vascular complications (P=0.003, OR=8.96) during the posttransplantation period as predictors of early mortality in CLITx group. Risk of mortality at 6 months after intestinal transplantation increased when the liver is included as combined graft. Strategies to reduce mortality such as refining selection for transplantation and early referral before the development of liver failure should be a priority.

Anterolateral approach with tibial tubercle osteotomy versus standard medial approach for primary total knee arthroplasty: does it matter?

BackgroundThe purpose of this prospective consecutive multicenter study was to investigate whether the type of surgical approach (medial parapatellar (MPA) or lateral parapatellar with tibial tubercle osteotomy (TubOT)) influences the early clinical and radiological outcomes of primary total knee arthroplasty (TKA).MethodsLigament balancing primary TKA with a rotating platform was performed in 143 knees (m:w = 1:1.6; mean age 69 ± 8 years). The TKA was done by a lateral parapatellar subvastus approach with stepcut osteotomy of the tibial tubercle (53%; n = 76, group A) or medial parapatellar approach (47%; n = 67, group B). The outcome was assessed at 1 and 2 years postoperatively by the American Knee Society score (KSS) and the knee society total knee arthroplasty roentgenographic evaluation and scoring system (TKA-RESS). The patient's pain level and satisfaction was noted by a visual analogue scale (VAS). Data were analyzed by an independent statistician with a level of significance of p < 0.05. The Wilcoxon two sample test (two-sided) was used to investigate differences of patients between group A and B pre- and postoperatively. The paired t-test was used to evaluate differences over course of time within each group. For comparison of radiological alignment a Chi2-test was performed.ResultsAlthough having a lower degree of preoperative flexion (112° ± 15° versus 115° ± 15°) patients in group A showed a significantly (p = 0.027) higher degree of flexion (118° ± 10°) at their last follow-up than patients in group B (114° ± 10°). Patients in group A showed a significantly better mean VAS pain (p = 0.0001) and satisfaction (p = 0.0058) at 2 years follow-up. The pain free walking distance was significantly (p = 0.036) longer for group A than group B. Patients treated with a lateral approach were significantly more stable in terms of valgus stress (p = 0.049). The Knee society score was significantly (p = 0.0009) higher at two years follow up in group A compared to group B. The postoperative mechanical alignment and positioning of the prosthesis were not significantly different. Patients in group B presented with significantly (p = 0.0017) more tibial radiolucencies (> 2 mm) at their last follow-up than patients in group A. There was no prosthesis related revision in either group. The revision rate in group A (4%) was higher than in group B (1.5%), which was mainly due to two cases of traumatic secondary displacement of the tibial tubercle and need for refixation.ConclusionsThe TubOT led to slightly better functional results and less pain two years after primary TKA. It is however not clear if the improved outcome can outweigh the longer operation time and higher risk of early complications and revisions. Long-term studies are necessary to show whether there is any difference in prosthesis longevity between both types of approach.

Effects of Aesthetic Abdominoplasty on Abdominal Wall Perfusion: A Quantitative Evaluation

Abdominoplasty procedures involve a high risk of early complications, including hematomas, seromas, necrosis, and wound-healing problems. Their rationale is evident from the vascular anatomy of the abdominal wall, as traditional abdominoplasty includes a division of the main perforating vessels. No studies exist to quantitatively assess the consequences of abdominoplasty on the perfusion of the random pattern abdominal flap. To address this issue and quantify the influence of classic abdominoplasty on the perfusion of the abdominal skin, the authors performed a prospective clinical trial including 15 low-risk patients undergoing abdominoplasty for aesthetic purposes. Perfusion of the abdominal flap was measured intraoperatively using the technique of dynamic laser-fluorescence-videoangiography. In the region between the umbilicus and the transverse scar (zone 1), the increment of fluorescence (the slope of the intensity curve during inflow of the indocyanine green) was recorded and compared with the intensity curve of normal tissue that was not involved in surgery (thoracic wall). The results of the intraoperative indocyanine green perfusography showed a significant impairment of the vascular supply of zone 1 in all patients. The mean perfusion index in this region was 17.2 percent (range, 5 to 32 percent) of the perfusion of the surrounding skin that was not involved in surgery. The complication rate was 33 percent (five patients) and included two cases of hematoma and three cases of scar dehiscence with skin and/or fat necrosis. These data indicate that conventional abdominoplasty including extended undermining and division of the superficial and the deep arterial systems causes profound devascularization of the abdominal flap. This might explain the high incidence of complications following this procedure.

Repeat thrombolysis for acute myocardial infarction

Background Thrombolysis is still the first line of treatment for acute myocardial infarction in the United Kingdom. In a significant proportion of these patients thrombolytic therapy fails to restore patency of the occluded artery or is followed by early re-infarction. The best management of this group of patients is not clear although repeat doses of thrombolysis are commonly administered especially in the district general hospitals that do not have access to invasive facilities. We performed a retrospective clinical study to determine the outcome of repeat thrombolysis for acute myocardial infarction in patients with failed initial thrombolysis or early re-infarction. Methods Ninety-two patients who received two or more doses of thrombolysis for acute myocardial infarction were compared with 98 contemporary similar patients who received only one dose of thrombolysis. Case notes of all patients were examined for retrospective analysis. Main outcome measures were death, heart failure and need for in-hospital revascularization. Results Compared to the group thrombolysed once, in the rethrombolysed group there were significantly more deaths at 30 days ( p=0.0016), more heart failure (with lower mean ejection fraction), more cardiac arrests as well as more frequent coronary angiography and percutaneous coronary interventions (PCIs). The incidence of haemorrhage in the two groups did not differ. Conclusions The need for repeat thrombolysis identifies a group of patients with a high risk of early complications. Although repeat thrombolysis is safe, these patients then need close monitoring with a view to early intervention. For such patients admitted to district general hospitals without interventional facilities early referral to a tertiary center should be considered.

Outcomes and costs of outpatient and inpatient cataract surgery: a randomised clinical trial

The aim of this study was to compare clinical and perceived health outcomes and cost between ambulatory and inpatient cataract surgery. An unmasked randomised clinical trial was undertaken. Cataract surgery patients of three public hospitals in Barcelona (Spain) who met inclusion criteria for ambulatory surgery were randomly assigned to two groups: outpatient hospital and inpatient hospital. Primary outcome measures were early and late postoperative surgical complications and visual acuity. Secondary outcome measures were perceived visual function, overall perceived health status, and costs. A total of 464 outpatients and 471 inpatients were analysed. No statistically significant differences were observed between the two groups in visual acuity ( P = .48), nor for the other clinical and perceived health outcome measures, except for early postoperative complications. Outpatients presented at least one complication in the first 24 h after surgery more frequently than inpatients (64 vs. 43; RR 1.6, 95% CI 1.1, 2.4), but 4 months after surgery the differences in complications rates between groups disappeared. The cost of surgery was lower for outpatients than for inpatients (1001 vs. 1218 Euros; P < .001). Ambulatory cataract surgery was more cost-effective than inpatient surgery. Despite the higher risk of early complications in the outpatient hospital group, these differences may not be clinically relevant because the 4-month postoperative outcomes were not affected.

Abdominal dermolipectomies: early postoperative complications and long-term unfavorable results.

A retrospective study was done on a population of 258 women who had undergone surgery for abdominal dermolipectomy between January of 1991 and May of 1996. The postoperative complications and flaws seen at long-term follow-up are discussed. The surgical techniques used, with or without lipoaspiration, were the infraumbilical plasty and full plasties with horizontal or inverted T scars. Six types of postoperative complications were noted: hemorrhage in 1.2 percent, lymphorrhea in 10.9 percent, infection in 7 percent, skin necrosis in 6.6 percent, secondary dehiscence of the scar in 2.3 percent, and thromboembolic accidents in 1.2 percent. No significant difference was found in the rate of necrosis development between patients who did and did not undergo lipoaspiration. However, a statistically significant difference was seen in the rate of skin necrosis between the T-type plasty (35.5 percent) and the other two procedures (1.43 percent for infraumbilical plasties and 4.60 percent for full plasties with horizontal scar). With regard to the flaws found at long-term follow-up, the rate of above-scar fat folds and/or dog-ears was 27.9 percent, and the rate of defective scars was 26 percent. No significant difference was found with regard to the rate of flaws. The rate of all secondary surgical procedures was 29.1 percent, but performance of secondary procedures depended on the willingness of the patient and on the surgeon's judgment. Abdominoplasty procedures involve a high risk of early complications. The rate of skin necrosis is clearly augmented in cases of T-type plasty. The need for secondary surgical correction is frequent, and the patient should be reminded of this possibility during preoperative consultation.

Quantitative ST-segment recovery following angiographically successful angioplasty: A useful warning of early complications

The angiographic/anatomic appearance of the TCA site and transstenotic gradient trending are two available intraprocedural variables that help to identify patients at high risk for early complications after successful angioplasty. We have reported on an additional variable, the rate of ST recovery following the final balloon deflation as a physiologic marker to identify patients at risk for early complications. Slow ST recovery was present in 52% of patients with early complications of myocardial infarction, urgent or emergent coronary bypass surgery, and/or death, whereas normal ST recovery was seen in 97% of patients with uncomplicated courses. ST trending is a non-invasive modality that is available in all patients undergoing TCA and should be a useful adjunct in identifying patients at high and low risk for early major complications following angiographically successful angioplasty. A prospective study of ST recovery during TCA deserves consideration.

Outcome of Peritoneal Catheter Placement in the High-Risk Patient

Serious early complications of catheter insertion and catheter outcomes are compared in patients with or without a history of major abdominal surgery or peritonitis. Previous major surgery and peritonitis are important risk factors for early serious complications of catheter placement. Despite the higher risk of early complications, subsequent attempts at catheter placement were successful in all but one of the high risk patients.Patients with previous major abdominal surgery or peritonitis generally are considered to be at high risk for complications of permanent peritoneal catheter placement. However, few physicians would refuse to attempt catheter insertion in patients highly motivated to undergo peritoneal dialysis. In this setting, the patient and the physician must decide whether the motivation and potential benefit justify the risk. Unfortunately, extensive quantitative data on the success rate and the likelihood of complications in the high-risk patient are not available. In order to determine the success rate and relative risk, we reviewed the outcome of catheter placement for continuous ambulatory peritoneal dialysis (CAPD) in our patients. In this report, we identify the serious early complications of catheter insertion and compare the outcomes in patients with and without a history of major abdominal surgery or peritonitis.