High Risk Of Surgical Complications Research Articles

Instrumented cervical spinal fusions in children: indications and outcomes.

PurposeTo report indications, outcomes and complications of instrumented cervical spinal fusion in a consecutive series of children at major university hospitals.MethodsA retrospective, single surgeon series identified 35 consecutive children with a mean follow-up (FU) of 2.5 years undergoing instrumented cervical spinal fusion between 2005 and 2015.ResultsThe main indications were skeletal dysplasia and trauma associated cervical instability. Surgical complications were observed in 12 (34%) patients with multiple complications in four (11%). Four (11%) children required at least one revision surgery, three for nonunion and one for graft dislodgement. All were fused at FU. Surgical complications were more common in children undergoing occipitocervical (OC) fusion than in those avoiding fusion of the OC junction (60% versus 24%) (p = 0.043). Complications were found significantly more in children operated on under the age of ten years than above (50% versus 18%) (p = 0.004). The risk of complications was not dependent on the indications for surgery (skeletal dysplasia versus trauma) (p = 0.177),ConclusionSkeletal dysplasia associated cervical instability and cervical spine injuries represented the most common indications for instrumented cervical spinal fusion in children. Complications were observed in one-third of these children and 11% required revision surgery for complications. OC spinal fusion and spinal fusion before the age of ten years are associated with higher risk of surgical complications and increased mortality than non-OC fusions and cervical spinal fusions at an older age. We urge surgeons to employ caution to the patient, timing and procedure selection when treating paediatric cervical spine.

P-133 - Outcomes of gastric cancer surgery in elderly patients

Introduction: Average life expectancy has been increasing in recent years. The average life expectancy at birth in Portugal was 80.64 years in 2015. The elderly population in Portugal grew 9% between 2011 and 2015, and if this growth rate is maintained in 2050 Portugal will have 4 million elderly people. The population over 80 years of age will double every 15 years according to demographic projections. As we know, gastric cancer is linked to environmental factors and genetic alterations. Thus the increase in the average life expectancy and in the percentage of elderly people also results in an increase in the incidence of gastric cancer in this population. This population is at higher risk of surgical complications and mortality, given the high number of comorbidities and often the surgery is avoided. Our objective is to assed surgical outcomes in gastric cancer patients older than 80 years by comparing clinicopathological characteristics and oncological/surgical outcomes between patients older than 80 and younger Methods: Retrospective analysis of a prospective database (n = 476) with gastric cancer cases submitted to curative intent surgery between January 2010 and December 2015, in a Upper GI Surgery Unit. After applying exclusion criteria we analyzed 248 patients. We analyzed the following variables: age, gender, co-morbidities, ASA score, clinical stage, T-stage, tumour size, surgery type, duration of surgery, lymphadenectomy type, histological type, venous invasion, lymphatic invasion, neural invasion, Lauren’s and Ming’s classification, tumour location, number of resected lymph nodes, perioperative blood transfusions, macroscopic type of tumour, length of hospital stay and complications. Results: The variables gender, presence of co-morbidities, ASA score, histological type, T-stage, tumour size, Ming’ classification, duration of surgery, type of surgery, number of lymph nodes ressected, type of lymphadenectomy, lymphatic invasion, perioperative blood transfusions and length of hospital stay were significantly different between the 2 groups. There were no statistically significant differences between the 2 groups for complications (including anastomotic leakage), late complications, mortality, readmission rate, surgical reintervention, recurrence rate, disease-free survival and disease-specific survival. Conclusion: Resection surgery in elderly patients with gastric cancer presents similar results to those of younger patients, either at the level of complications, mortality, recurrence rate, disease-free survival and disease-specific survival. Gastric resection surgery is a safe, feasible and effective treatment, so it has to be included in the therapeutic options for this age group.

THE VULKAN TECHNIQUE: A NOVEL OSTOMY-CLOSURE TECHNIQUE THAT REDUCES COMPLICATIONS AND OPERATIVE TIMES.

ABSTRACTBackground: Ostomy reversals remain at high risk for surgical complications. Indeed, surgical-side infections due to bacterial contamination of the stoma lead to revision surgery and prolonged hospital stay. Aim: To describe the novel vulkan technique of ostomy reversal that aims to reduce operative times, surgical complications, and readmission rates. Methods: Ostomy closure was performed using the vulkan technique in all patients. This technique consists of external intestinal closure, circular skin incision and adhesiolysis, re-anastomosis, and closure of the subcutaneous tissue in three layers, while leaving a small secondary wound through which exudative fluid can be drained. The medical records of enterostomy patients were retrospectively reviewed from our hospital database. Results: The vulkan technique was successfully performed in 35 patients mainly by resident surgeons with <5 years of experience (n=22; 62.8%). The ileostomy and colostomy closure times were 53 min (interquartile range [IQR], 41-68 min; n=22) and 136 min (IQR: 88-188 min; n=13; p<0.001), respectively. The median hospital stay was seven days (IQR: 5−14.5 days); the length of hospital stay did not differ between ileostomy and colostomy groups. Major surgical complications occurred only in patients who underwent colostomy closure following the Hartmann procedure (n=2); grade≥IIIb according Clavien-Dindo classification. Conclusion: The vulkan technique was successfully applied in all patients with very low rates of surgical-site infections. Off note, residents with limited surgical experience mainly performed the procedure while operating time was less than one hour.

Surgical Complications in Early Post-transplant Kidney Recipients

BackgroundThe purpose of this study was to determine the incidence of early surgical complications of kidney transplantation in our institution and its association with donor and recipient factors, as well as patient and transplant outcome. MethodsA retrospective cohort study of all kidney transplants performed during 2015 was made. We evaluated the incidence of surgical complications and the outcome of patients and grafts at a 3-month follow-up interval. ResultsDuring the study period, 141 kidney transplants occurred. Seventeen patients had surgical complications (6 urologic, 6 vascular, and 5 other complications). Five patients lost the graft during the follow-up. Older age was associated with other surgical complications (P = .023), and graft loss was associated with the existence of surgical complications, namely, vascular complications (P <.001). For both surgical complications in general and urologic complications, a statistically significant relationship was found with patient weight (P = .003 and P = .034, respectively). The correlation between body mass index (BMI) and surgical complications was not statistically significant. ConclusionsOur study reveals that older and heavier patients have a higher risk of surgical complications and that vascular complications are associated with graft loss. A statistically significant relationship was not found between BMI and surgical complications, which could indicate that BMI is not the ideal obesity marker. The incidence of surgical complications found in our study is similar to the literature. The selection of transplant recipients is a difficult task, and the possibility of additional surgical complications in older and overweight patients should be taken into account.

Transesophageal echocardiography for incremental value of Amplatezer cribriform septal occluder for percutaneous transcatheter closure of complex septal defects: Case series

BackgroundThe anatomy of septal defects can be complex and morphologically unpredictable. Balloon sizing of such defects may not be feasible, and an appropriately sized commercial occluder may not be available. Therefore, percutaneous transcatheter closure of such defects can be challenging because of an increased risk of complications. In this study, we have described the efficacy and safety of transcatheter closure of complex septal defects using Amplatzer cribriform occluder devices, assessed by real time three-dimensional (RT 3D) color Doppler transesophageal echocardiography (TEE). Methods and ResultsFour complex septal defects were involved in this investigation: (1) reimplanted multiple atrial septal defects (ASD) with one device embolization; (2) postinfarction ventricular septal defect; (3) long tunnel patent foramen ovale; and (4) postoperative residual ASD. All patients underwent percutaneous transcatheter interventions due to the high risk of surgical complications, and one of the three available cribriform ASD device sizes (18 mm, 25 mm, or 35 mm) was implanted. Perioperative RT 3D TEE combined with fluoroscopy was used for monitoring during the procedure. All defects were successfully occluded by cribriform septal occluder devices using the transcatheter technique. ConclusionOur patients with complex septal defects were successfully treated by transcatheter closure using an Amplazter cribriform septal occluder device with careful planning based on patient presentation and close interdisciplinary collaboration. RT 3D color Doppler TEE provided precise information for the selection of the appropriate occluder device and facilitated the procedure by guiding the catheter through the often challenging patient anatomy.

Hemoroidinių arterijų embolizacija – naujas hemorojaus gydymo metodas: atvejo pristatymas

Įvadas / tikslas Keturiasdešimt ketverių metų vyrui dėl lėtinio hepatito B išsivysčiusios kepenų cirozės 2011 m. rugsėjo 30 d. atlikta kepenų transplantacija. Progresuojant hepatitui po 4 metų išsivystė kepenų transplantato cirozė, hepatorenalinis sindromas, porti­nės hipertenzijos sindromas (splenomegalija ir hipersplenizmas, stemplės venų varikozė, tiesiosios žarnos venų varikozė), hiperurikemija. III° hemorojus komplikavosi gausiais kraujavimais. Dėl posthemoraginės anemijos kelis kartus atliktos hemo­transfuzijos. Konservatyvus gydymas buvo neveiksmingas. Dėl trombocitopenijos (45x10⁹/l), tiesiosios žarnos venų varikozės, gausaus kraujavimo operacijos metu arba po operacijos didelio pavojaus klasikinės hemoroidektomijos arba mikroinvazinių operacijų (LHP, THD) nebuvo galima atlikti. Situacija buvo aptarta konsiliume dalyvaujant intervenciniams radiologams. Buvo nuspręsta atlikti hemoroidinių arterijų embolizaciją. 2015 m. liepos 30 d. buvo atliktos visceralinė ir selektyvi angiografija. Į apatinę mezenterinę arteriją buvo įvesta kaniulė. Hemoroidinių arterijų embolizacija atlikta „Interblock 18“ mikrospiralėmis. Panaudotos trys 3 mm 6 cm ilgio spiralės. Introdiuseris pašalintas. Punkcijos vieta užsiūta „Angioseal“ prietaisu. Po embolizacijos praėjus 3 savaitėms atlikta RRS. Kraujavimo iš tiesiosios žarnos požymių neaptikta, hemorojiniai mazgai sumažėjo, apie 70 % sumažėjo tiesiosios žarnos venų varikozė. Per 23 mėn. po procedūros kraujavimų iš tiesiosios žarnos nepastebėta.Išvados Hemoroidinių arterijų embolizacija reikalauja įvairių sričių gydytojų specialistų komandos darbo – intervencinio radiologo, proktologo, pilvo chirurgo, transplantologo. Viršutinės tiesiosios žarnos arterijos (retais atvejais ir papildoma apatinės tiesio­sios žarnos arterijos) embolizacija yra patikimas, efektyvus, saugus mikroinvazinis kraujuojančio hemorojaus gydymo meto­das, taikytinas pacientams, sergantiems kepenų ciroze arba turintiems kraujo krešėjimo sutrikimų.

Does Hepatitis C Affect the Clinical and Patient-Reported Outcomes of Primary Total Hip Arthroplasty at Midterm Follow-Up?

BackgroundIt is estimated that 3%-6% of orthopedic patients, many of whom may undergo lower extremity total joint arthroplasty, are infected with hepatitis C. The purpose of this study was to assess the outcomes of patients with hepatitis C who undergo total hip arthroplasty (THA) in comparison with a matched control cohort in terms of (1) patient-reported outcomes, (2) implant survivorship, and (3) complications. MethodsFifty-four hips in 49 hepatitis C–infected patients who underwent a primary THA between 2002 and 2011 were reviewed. This included 10 women and 39 men who had a mean age of 57 years and a mean 6.5-year follow-up. These patients were matched to 163 THAs (148 patients) who did not have this disease and underwent a THA during the same period. We compared implant survivorship, complication rates, Harris hip scores, and University of California, Los Angeles, activity scores. Radiographs were evaluated for loosening, fracture, malalignment, and osteolysis. ResultsThe implant survivorship in the hepatitis C–infected patients and comparison group was 96.2% and 98.7%, respectively. The risk of revision surgery in the hepatitis C cohort was 3-fold higher than the comparison group; however, this difference was not significant (P = .26). The hepatitis C–infected cohort had a higher risk of surgical complications (odds ratio = 6.5; P = .034). There were no differences in postoperative Harris hip scores or University of California, Los Angeles, activity scores between the cohorts. ConclusionHepatitis C patients can achieve good implant survivorship and clinical outcomes after THA. However, these patients may be at an increased risk for surgical complications and revision rate.

Associated Risks of Obesity and/or Metabolic Syndrome with Intra-operative or Post-Operative Occurrences in Patients with Open Ventral Hernia Repair

Metabolic syndrome and obesity are increasing in incidence worldwide and they carry with them a lot of health issues that might directly affect individuals or might be associated with higher risk of surgical complications represented in this study by open ventral hernia repair. A cohort study of 132 patients admitted electively for open ventral hernia repair to the surgical wards at Al-Sader teaching hospital in Najaf /Iraq from December 1st/ 2015 to October 1st/ 2016. All patients were followed for intra-operative occurrences and followed for 2 weeks postoperatively for any early post-operative complications. Of the total 132 patients, there were 44 patients (33.3%) having metabolic syndrome and there were 68 obese patients (66.6%) of which 37 having metabolic syndrome (54.4%). There was no significant association between intra-operative occurrences or early post-operative complications in obese patients with or without metabolic syndrome but there was a significant association between intra-operative occurrences and metabolic syndrome in patients having body mass index (BMI) below 30 Kg/m2. Diabetes was the only significant factor for early postoperative wound complications whether the patient had metabolic syndrome or not.

Expanding indications for TAVR: The preferred procedure in intermediate-risk patients?

Transcatheter aortic valve replacement (TAVR) has steadily replaced surgical aortic valve replacement (SAVR) in symptomatic patients with severe aortic stenosis, primarily those at high risk for surgical complications. As TAVR use increases, spurred by technological advances in valve design and patient preferences for the less-invasive procedure, studies have provided data supporting the efficacy and safety of TAVR. Recently, TAVR has expanded to intermediate-risk patients, increasing the potential patient population. Although emerging evidence supports its use in lower-risk patients, some adverse events may limit its adoption in a wider patient population. These include stroke, paravalvular leak, valve durability, valve thrombosis, and need for pacemaker replacement. Ongoing clinical trials are expected to provide answers.

Masquelet technique: myth or reality? A systematic review and meta-analysis

IntroductionThe induced membrane technique (IMT) or Masquelet technique, is a two-step surgical procedure used to treat pseudoarthroses and bony defects. Many authors have introduced variants to the technique. This study aims to compare the surgical variants of IMT and to evaluate its efficacy in achieving infection eradication and bone union. MethodsA systematic review was carried out following the PRISMA guidelines. PubMed and other medical databases were explored using keywords “Masquelet technique” and “induced membrane technique”. Articles were included if written in English, French or Italian, dealing with IMT employed to long bones in adults, reporting at least 5 cases with a 12 months-mean follow-up. Patients’ clinical features, bone defect features, aetiologies, surgical data, complications, reinterventions, union rates and infection eradication rates were searched. Fischer's exact test, chi-square test and unpaired t-test were used for the statistical analysis on the individual patient's data. ResultsSeventeen papers met the inclusion criteria (427 patients). Among these, only 10 studies reported individual patient's data (137 cases). The union rate was 89.7% and the infections rectified in 91.1% of cases. The bone defect length ranged from 0.6 to 26 cm. The main complications were superficial (21; 4.9%) and deep surgical site infections (19; 4.4%), failure of one of the IMT steps (persistence of infections or non unions, 77, 18%), with subsequent requirement for further surgery. The surgical variants included the use of antibiotic-coated spacers, internal fixation during the first step, use of Reamer-Irrigator-Aspirator technique, iliac crest grafting, bone substitutes and growth factors. However, univariate analysis only showed a positive correlation of the need for reinterventions with poorer bone union rates (p = 0.005) and complications (p <0.001), while patients undergoing IMT because of bone infections had a higher risk of surgical complications (p <0.001). DiscussionIMT aims to achieve bone union and infection eradication, but persistence of infection or non-union was noted in 18% of cases necessitating re-interventions. This may be related to the different anatomical sites that the technique has been applied and different local and patient related conditions. We believe the choice of a surgical technique to achieve union should be tailored to the individual patient's needs. This systematic review was limited by the few studies meeting our inclusion criteria, and their high variability in data reporting, making it impossible to undertake a meta-analysis. ConclusionFurther studies are needed to demonstrate the role the patients’ clinical features and IMT variants have upon achieving bone union and infection eradication.

A critical review of recent developments in radiotherapy for non-small cell lung cancer.

Lung cancer is the leading cause of cancer mortality, and radiotherapy plays a key role in both curative and palliative treatments for this disease. Recent advances include stereotactic ablative radiotherapy (SABR), which is now established as a curative-intent treatment option for patients with peripheral early-stage NSCLC who are medically inoperable, or at high risk for surgical complications. Improved delivery techniques have facilitated studies evaluating the role of SABR in oligometastatic NSCLC, and encouraged the use of high-technology radiotherapy in some palliative settings. Although outcomes in locally advanced NSCLC remain disappointing for many patients, future progress may come about from an improved understanding of disease biology and the development of radiotherapy approaches that further reduce normal tissue irradiation. At the moment, the benefits, if any, of radiotherapy technologies such as proton beam therapy remain unproven. This paper provides a critical review of selected aspects of modern radiotherapy for lung cancer, highlights the current limitations in our understanding and treatment approaches, and discuss future treatment strategies for NSCLC.

A5010 - Reversal of Roux-en-y gastric bypass at a tertiary center with a large experience in laparoscopic gastric bypass revision: indications and outcomes

No large single institution experience in reversal of Roux-en-y gastric bypass (RYGB) to normal anatomy has been previously published. Most published series are small, suggesting that bariatric surgeons may reserve reversal to normal anatomy for rare situations, perhaps due to concern about a high risk for surgical complications. We have been fairly aggressive at recommending reversal to normal anatomy for patients with a variety of chronic serious complications after RYGB. In this report, we describe our large experience with laparoscopic reversal of RYGB over 4 years, our indications for reversal and our post-operative outcomes. The goal of our study is to advance understanding of how reversal to normal anatomy may be applied after previous RYGB, to further define the risks of complications and to identify factors that would prevent the need for reversal.

Randomized Trial of Stent Versus Surgery for Asymptomatic Carotid Stenosis

Stenting is non-inferior to carotid endarterectomy for treatment of asymptomatic patients with severe carotid artery stenosis who are not at high risk for surgical complications.

Day case laparoscopic cholecystectomy in patients with high BMI: Experience from a UK centre.

Symptomatic gall stones may require laparoscopic cholecystectomy (LC), which is one of the most commonly performed general surgical operations in the western world. Patients with a high body mass index (BMI) are at increased risk of having gall stones, and are often considered at high risk of surgical complications due to their increased BMI. We believe that day case surgery could nevertheless have significant benefits in terms of potential cost savings and patient satisfaction in this population. We therefore compared the outcomes of day case patients undergoing LC stratified by BMI, with a specific focus on the safety and success of the procedure in obese and morbidly obese groups. We reviewed a database of day case procedures performed between January 2004 and December 2012, including all patients with symptomatic gall stone disease who underwent LC. The patients were divided in four BMI groups: less than 25 kg/m(2), 25-29 kg/m(2), 30-39 kg/m(2) and 40 kg/m(2) or above. The overall success rate for day case surgery was 78%. There were no significant differences in rates of intra-abdominal collection or readmission with increasing BMI. However, increasing BMI was associated with a significant increase in the rate of wound infection. LC in patients with a high BMI is safe and can be performed effectively as a day case procedure.

Randomized Trial of Stent versus Surgery for Asymptomatic Carotid Stenosis

BackgroundPrevious clinical trials have suggested that carotid-artery stenting with a device to capture and remove emboli (“embolic protection”) is an effective alternative to carotid endarterectomy in patients at average or high risk for surgical complications.MethodsIn this trial, we compared carotid-artery stenting with embolic protection and carotid endarterectomy in patients 79 years of age or younger who had severe carotid stenosis and were asymptomatic (i.e., had not had a stroke, transient ischemic attack, or amaurosis fugax in the 180 days before enrollment) and were not considered to be at high risk for surgical complications. The trial was designed to enroll 1658 patients but was halted early, after 1453 patients underwent randomization, because of slow enrollment. Patients were followed for up to 5 years. The primary composite end point of death, stroke, or myocardial infarction within 30 days after the procedure or ipsilateral stroke within 1 year was tested at a noninferiority margin of 3 percentage points.ResultsStenting was noninferior to endarterectomy with regard to the primary composite end point (event rate, 3.8% and 3.4%, respectively; P=0.01 for noninferiority). The rate of stroke or death within 30 days was 2.9% in the stenting group and 1.7% in the endarterectomy group (P=0.33). From 30 days to 5 years after the procedure, the rate of freedom from ipsilateral stroke was 97.8% in the stenting group and 97.3% in the endarterectomy group (P=0.51), and the overall survival rates were 87.1% and 89.4%, respectively (P=0.21). The cumulative 5-year rate of stroke-free survival was 93.1% in the stenting group and 94.7% in the endarterectomy group (P=0.44).ConclusionsIn this trial involving asymptomatic patients with severe carotid stenosis who were not at high risk for surgical complications, stenting was noninferior to endarterectomy with regard to the rate of the primary composite end point at 1 year. In analyses that included up to 5 years of follow-up, there were no significant differences between the study groups in the rates of non–procedure-related stroke, all stroke, and survival. (Funded by Abbott Vascular; ACT I ClinicalTrials.gov number, NCT00106938.)

Surgical safety and personal costs in morbidly obese, multimorbid patients diagnosed with early-stage endometrial cancer having a hysterectomy

BackgroundMany women who develop endometrial cancer (EC) or endometrial hyperplasia with atypia are obese and therefore at high risk of surgical complications. Recently clinical trials have been initiated offering non-surgical treatment to these women, but not all may agree to participate in such trials. This paper aims to describe the patient characteristics, and surgical outcomes of women with suspected early stage endometrial cancer and body mass index (BMI) of 30 or greater, who declined enrolment in the feMMe trial, which offers non-surgical hormonal treatment, hormonal plus metformin or hormonal plus weight loss as primary treatment.MethodsConsecutive case series from a tertiary gynaecological oncology unit. Over the course of the first 2 years of the feMMe trial, 27 patients met the initial eligibility screening, but declined enrolment in the feMMe trial and opted for upfront surgery. The main surgical outcome measures were type of surgical approach, need for conversion from laparoscopic to open approach, length of stay in hospital and adverse events.ResultsPatients’ median age was 63 years (range 40 to 86); median BMI was 37.3 kg/m2 (range 30.7 to 54.7); median medical co-morbidities were six (range 3–10). Of the 26/27 surgeries planned to be undertaken laparoscopically, 2/26 patients had to be converted (7 %). Overall, the average hospital stay was 4.5 days, and 11/27 (41 %) of the patients developed one or more adverse events grade 2+ rated according to the Common Toxicity Criteria Version 3.ConclusionsAdverse surgical outcomes are common in multi-morbid, obese or morbidly obese patients diagnosed with early stage EC or endometrial hyperplasia with atypia and who have a hysterectomy.

Therapeutic Strategy for Cavernous Sinus-Invading Non-Functioning Pituitary Adenomas Based on the Modified Knosp Grading System.

BackgroundNon-functioning pituitary adenomas (NFPA) invading into the cavernous sinus are surgically challenging. To decrease recurrence rate, surgeon makes a strong endeavor to resect tumor gross totally. However, gross total resection (GTR) is difficult to achieve with cavernous sinus invasion. Recently, a new classification system for cavernous invasion of pituitary adenomas was suggested. The aim of this study is to validate this new classification system and to identify limitations and considerations in designing treatment strategies for patients with NFPA involving the cavernous sinus.MethodsBetween January 2000 and January 2012, 275 patients who underwent operation for NFPA were enrolled in the study. Median age was 50 years (15–79 years). There were 145 males and 130 females. The median follow-up duration was 4 years (range 1–12.5 years).ResultsRelated to extent of tumor removal, GTR was obtained in 184 patients (66.9%), near total resection (NTR) was obtained in 45 patients (16.3%), and sub-total resection (STR) was obtained in 46 patients (16.7%) of a total 275 patients. There were statistically significant differences between the extent of resection and the new Knosp classification (p<0.001). In the high-grade group of the new Knosp classification, there was no difference in recurrence between patients who underwent GTR or NTR only and those who underwent STR with adjuvant radiation therapy (p=0.515).ConclusionIn case of high risk of surgical complications, STR with adjuvant radiation therapy can be considered as an alternative strategy for safe treatment of cavernous-invading adenomas.

Head and Neck Reconstruction with Chimeric Anterolateral Thigh Free Flap

Chimeric anterolateral thigh free flaps are composed of multiple skin paddles or muscular components that allow for the reconstruction of complex 3-dimensional defects. We present our experience with the technique and applications for various head and neck defects. Retrospective chart review. Academic tertiary care center. Subjects include 24 consecutive patients undergoing reconstruction with a chimeric anterolateral thigh free flap by a single surgeon. Our algorithm for pharyngeal reconstruction with this technique is described. Data include demographics, indications, comorbidities, operative findings, and surgical outcomes. The most frequent defects were pharyngocutaneous (n = 12, 50%) and skull base (n = 6, 25%). The flap consisted of a double skin paddle in 11 cases (45.3%) and a skin paddle with an independent component of vastus lateralis muscle in 13 cases (54.7%). Revision surgery was required in 4 cases and was associated with malnutrition (P = .022). There were no total flap losses, but partial loss (distal skin paddle in all the cases) was observed in 3 patients and was related to severe congestive heart failure (P = .021) and malnutrition (P = .021). All except 1 patient who underwent pharyngeal reconstruction resumed oral diet and achieved alaryngeal speech. Chimeric anterolateral thigh free flaps represent an excellent option for reconstruction of complex head and neck defects. Modifications to the technique are proposed in patients at high risk of surgical complications.

III. Current concepts in primary central nervous lymphoma.

III. Current concepts in primary central nervous lymphoma.

Clinical assessment before hepatectomy identifies high-risk patients

BackgroundLiver resection is associated with significant morbidity, and assessment of risk is an important part of preoperative consultations. Objective methods exist to assess operative risk, including cardiopulmonary exercise testing (CPX). Subjective assessment is also made in clinic, and patients perceived to be high-risk are referred for CPX at our institution. This article addresses clinicians' ability to identify patients with a higher risk of surgical complications after hepatectomy, using selection for CPX as a surrogate marker for increased operative risk. Materials and methodsProspectively collected data on patients undergoing hepatectomy between February 2008 and November 2013 were retrieved and the cohort divided according to CPX referral. Complications were classified using the Clavien–Dindo system. ResultsCPX testing was carried out before 101 of 405 liver resections during the study period. The median age was 72 and 64 in CPX and non-CPX groups, respectively (P < 0.001). The resection size was similar between the groups. No difference was noted for grade III complications between CPX and non-CPX tested-groups; however, 19 (18.8%) and 28 (9.2%) patients suffered grade IV–V complications, respectively (P = 0.009). There was no difference in long-term survival between groups (P = 0.63). ConclusionsThis study attempts to assess clinicians' ability to identify patients at greater risk of complications after hepatectomy. The confirmation that patients identified in this way are at greater risk of grade IV–V complications demonstrates the value of preoperative counseling. High-risk patients do not have worse long-term outcomes suggesting survival is determined by other factors, particularly disease recurrence.