High Risk Of Perioperative Complications Research Articles

Are trainees working in obstetrics and gynecology confident and competent in the care of frail gynecological oncology patients?

IntroductionOlder patients undergoing cancer surgery are at increased risk of post-operative complications, prolonged hospital stay, and mortality. Identification of frailty can help predict patients at high risk of peri-operative complications...

Anesthetic Management of Patients with Sickle Cell Disease Posted for Bipolar Prosthesis

In case of surgical procedures in sickle cell disease (SCD), patients are associated with high risk ofperioperative complications like vaso-occlusive crisis, chest syndrome, post-operative infections, congestiveheart failure, cerebrovascular accident and acute kidney injury. Preoperative assessment and stabilizationlike control of sepsis, blood transfusion, correction of hypoxia, hypothermia, dehydration and acidosis isneeded to reduce peri-operative complications. Blood transfusion (Simple, manual exchange and automatedexchange) remains an important therapeutic intervention in patients with SCD. The case study below showsthe perioperative management of patients posted for bipolar prosthesis due to AVN (avascular necrosis).Adequate analgesia, incentive spirometry, early mobilisation and oxygen supplementation is the mainstayof post-operative management.

Stenting of the right ventricular outflow tract with subsequent radical correction in a child with a tetralogy of Fallot: results of six-year follow-up

Tetralogy of Fallot (ToF) is the most common cyanotic congenital heart defect. Since the first radical correction in 1954, treatment strategy has been constantly improving. Current treatment of ToF ensures the long-term survival (30-year survival ranges from 68.5% to 90.5%), yet it is still challenging in underweight patients. Here we present a clinical case of two-step surgery which included right ventricular outflow tract (RVOT) stenting and further radical correction in an underweight child who was then followed-up for six years. RVOT stenting is an appropriate alternative to the bypass surgery which has higher risk of perioperative complications. RVOT stenting significantly reduces hypoxia, enhances the development of the pulmonary vasculature and increases end-diastolic index ultimately permitting efficient radical correction after 4 months. The described approach resulted in a favorable outcome and quality of life after 6 years of follow-up.

A multi-center study on recurrent inguinal hernias: assessment of surgeons' compliance to guideline-based repair and evaluation of short-term outcomes.

As patients with recurrent inguinal hernia (RIH) are at a higher risk of perioperative complications, international guidelines have been developed to mitigate these risks by recommending the reverse approach for repair. We aim to study the characteristics of RIH, compliance to guidelines-based repair (GR) and determine factors influencing compliance to guidelines. A retrospective study of patients with RIH was carried out at two tertiary institutions in Singapore, over 10 years from January 2010 to 2020. There were 16 patients with bilateral recurrences and 214 patients with unilateral recurrences. The characteristics of patients with non-guidelines-based repair (NGR) versus GR were similar, p > 0.05. GR was performed for 128 (52.1%) hernias as compared to NGR for 118 (47.9%) hernias. The open approach was more common in NGR than GR, 115/118 (89.8%) versus 58/128 (45.3%), p < 0.001. Forty (n = 40, 16.3%) RIH presented emergently, of which 37 underwent NGR while 3 underwent GR, p < 0.0001. More consultants were present during GR 103/128 (80.5%) as compared to NGR 78/118 (66.1%), p = 0.018. Emergency presentation of hernia recurrence, OR 7.74 (CI 6.11-9.20), p = 0.005, and open repair during the index repair were significantly associated with NGR, OR 6.63 (CI 4.42-8.84), p = 0.01. Median length of stay was shorter in the GR 1day (IQR 1-2days) versus 2 days (IQR 2-5days) in the NGR group, p = 0.02. The compliance rate of GR for RIH is 52%. NGR for RIH had acceptable short-term outcomes. For elective presentation of RIH, GR should be encouraged given a shorter length of hospital stay.

Orthopedic Surgical Treatment and Perioperative Complications in Multiple Myeloma Bone Disease: Analysis of a Series (2009-2018).

More than 90% of patients with multiple myeloma (MM) develop lytic bone lesions that can be surgically treated for symptomatic relief and functional improvement. This was a retrospective observational analytic study conducted between 2009 and 2018, including 58 patients with MM bone disease who underwent 77 orthopedic surgical procedures and were co-managed by internal medicine. Analysis of data related to MM bone disease, different modalities of surgical treatment, perioperative complications, and survival was performed. Median age was 72years (66.5-77years) and 56.9% of patientswere males; 54.43% of injuries were located in the spine, 27.85% in the pelvis or lower limbs, 15.19% in the upper limbs, and 75.32% ofpatients had pathologic fractures. In 29.31% of the cases, the bone lesion was the debut of MM. Surgical procedures performed were mainly kyphoplasty (48.05%) and intramedullary nailing (29.87%). The overall complication rate following surgery was 74.03%. Only 20.78% of cases had a surgical complication. Among medical complications, we registered 28.57% transfusion requirements, 25.97% acute renal failures, 24.68% developed an infection, and 10.39% developed hypercalcemia. Patients were followed-up for a mean of 6.13years and 37.93% suffered a new fracture. The median overall survival time for patients after surgery was 32.9months (11.6-49). The estimated overall survival at 1, 3, and 5years after surgery was 81.17%, 57%, and 34.11%, respectively. The orthopedic surgical treatment of MM bone disease aims to improve symptomatology and patient quality of life; however, these patients have a high risk of perioperative complications and considerable early mortality, making multidisciplinary management with medical specialties essential.

The effects of COVID-19 on perioperative morbidity and mortality in patients with hip fractures.

During the COVID-19 pandemic, many patients continue to require urgent surgery for hip fractures. However, the impact of COVID-19 on perioperative outcomes in these high-risk patients remains unknown. The objectives of this study were to establish the effects of COVID-19 on perioperative morbidity and mortality, and determine any risk factors for increased mortality in patients with COVID-19 undergoing hip fracture surgery. This multicentre cohort study included 340 COVID-19-negative patients versus 82 COVID-19-positive patients undergoing surgical treatment for hip fractures across nine NHS hospitals in Greater London, UK. Patients in both treatment groups were comparable for age, sex, body mass index, fracture configuration, and type of surgery performed. Predefined perioperative outcomes were recorded within a 30-day postoperative period. Univariate and multivariate analysis were used to identify risk factors associated with increased risk of mortality. COVID-19-positive patients had increased postoperative mortality rates (30.5% (25/82) vs 10.3% (35/340) respectively, p < 0.001) compared to COVID-19-negative patients. Risk factors for increased mortality in patients with COVID-19 undergoing surgery included positive smoking status (hazard ratio (HR) 15.4 (95% confidence interval (CI) 4.55 to 52.2; p < 0.001) and greater than three comorbidities (HR 13.5 (95% CI 2.82 to 66.0, p < 0.001). COVID-19-positive patients had increased risk of postoperative complications (89.0% (73/82) vs 35.0% (119/340) respectively; p < 0.001), more critical care unit admissions (61.0% (50/82) vs 18.2% (62/340) respectively; p < 0.001), and increased length of hospital stay (mean 13.8 days (SD 4.6) vs 6.7 days (SD 2.5) respectively; p < 0.001), compared to COVID-19-negative patients. Hip fracture surgery in COVID-19-positive patients was associated with increased length of hospital stay, more admissions to the critical care unit, higher risk of perioperative complications, and increased mortality rates compared to COVID-19-negative patients. Risk factors for increased mortality in patients with COVID-19 undergoing surgery included positive smoking status and multiple (greater than three) comorbidities. Cite this article: Bone Joint J 2020;102-B(9):1136-1145.

Anticoagulant therapy in elderly patients and cardiac implantable electronic devices

The number of implantations of cardiac implantable electronic devices (CIED), as well as the prevalence of atrial fibrillation (AF), is on the rise as the population ages. At the same time, regardless of the need for CIED implantation, many elderly patients require long-term anticoagulation therapy to prevent stroke. Those patients are considered a group of higher risk of perioperative complications of CIED implantation. This review article provides a summary of the indications, possibilities, and challenges of anticoagulation treatment in elderly patients with indications for CIED implantation.

Do drains have an impact on the outcome after primary elective unilateral inguinal hernia repair in men?

The use of drains continues to be a controversial topic in surgery. In a review of that topic for incisional hernia it was not possible to find sufficient evidence of the need for a drain. Likewise, for inguinal hernia surgery the data available are insufficient. In a multivariable analysis of data from the Herniamed Registry for 98,321 patients with primary elective unilateral inguinal hernia repair in men, the role of a drain was investigated. A drain was used in 24.7% (n = 24,287/98,321) of patients. These patients were on average older, had higher BMI, longer operating time and received a smaller mesh. Drains were also used more often for patients with higher ASA score, risk factors, larger defects and scrotal hernia localization as well as for Lichtenstein, TEP and suture repair. The use of drains was highly significantly associated with intra- and postoperative complications as well as with complication-related reoperations. Hence, drains are used selectively in inguinal hernia repair for patients at higher risk of perioperative complications. Despite the use of drains, the outcome in this risk group is less favorable. It remains unclear if drains prevent further complications in high-risk patients. Drains are used selectively in high-risk men with primary elective unilateral inguinal hernia repair. Drains are associated with intra- and postoperative complications rates and complication-related reoperation rate. Drains can serve as an indicator for early detection of complications.

Adjunctive Superior Mesenteric-Portal Venous Reconstruction in the Treatment of Borderline Resectable Pancreatic Adenocarcinoma

Pancreatic cancer is a leading cause of cancer death; it represents the ninth and tenth most common cancers in women and men, respectively, with only a 9% 5-year survival rate. Surgery remains the only potential curative therapy, but most patients present with advanced stage disease at the time of diagnosis. Patients with tumors that involve the superior mesenteric vein-portal vein (SMV-PV) confluence are considered “borderline resectable” and are at higher risk for perioperative complications and margin-positive resection. Regularly, neoadjuvant chemotherapy can be used to evaluate tumor behavior, to downstage tumors, to facilitate margin-negative resection, and to minimize the risk of recurrence. We present our single-institutional experience in the utility of adjunctive SMV-PV reconstruction for these tumors to assess viability and survival. A retrospective single-institution review identifying all patients who had a pancreaticoduodenectomy or total pancreatectomy during a 5-year period from January 2014 to December 2018 was completed. Multiplanar computed tomography angiography imaging was used to stage the tumors by objective radiologic classification determining extent of disease. Cases were presented preoperatively at a multidisciplinary tumor board. All vascular surgical reconstructions were performed by a multidisciplinary team approach with experienced hepatobiliary and vascular surgeons. During the 5-year period, 160 pancreatic resections (152 pancreaticoduodenectomies [95.0%] and 8 total pancreatectomies [(5.0%]) were performed, of which 85 (53.1%) were for pancreatic adenocarcinoma. The average age was 69.2 years (60.3% male, 39.7% female). Of the 85 operations for pancreatic adenocarcinoma, 35 (41.2%) underwent vascular reconstructions. Of these, 22 (62.9%) received neoadjuvant chemotherapy. Vascular reconstructions of the portal vein consisted of 16 (45.7%) primary repairs, 9 (25.7%) resections with cryopreserved vein allograft interposition grafting, 5 (14.3%) resections with primary end-to-end anastomosis, and 3 (8.6%) lateral venorrhaphy with patch angioplasty. There were also two (5.7%) concomitant arterial reconstructions (common hepatic artery). In the patients who underwent vascular reconstruction, margin-negative resection was achieved in 29 (85.3%). There were no in-hospital deaths; there was one (2.9%) 30-day death from a car accident. The 1-year survival was 74.3%. There were three (8.6%) thromboses requiring reintervention. This study validates a multidisciplinary surgical approach to the treatment of borderline resectable pancreatic cancers. When surgical treatment is deemed appropriate, adjunctive SMV-PV resection may further extend opportunity for a tumor-free margin (R0) of resection with comparable survival for stage II tumors. Vascular surgeons are being consulted to participate in these advanced vascular reconstructions with increased frequency and should be familiar with the various reconstruction techniques.

Improved Survival after Repeat Lung Transplantation at Cystic Fibrosis Care Centers

Patients who undergo repeat lung transplantation (LT) are at high risk for perioperative complications. The complexity of their care requires specialized multidisciplinary collaboration, particularly among people with cystic fibrosis (CF). Since 1961, the Cystic Fibrosis Foundation has established a network of accredited Cystic Fibrosis Care Centers (CFCCs) dedicated to the treatment of people with CF, including LT. We hypothesize that patients undergoing repeat lung transplantation at CFCCs will have improved postoperative outcomes compared to those at non-CFCC centers. Using the Scientific Registry of Transplant Recipients, we identified adults with cystic fibrosis who received a repeat LT at a CFCC between 2005 and 2018. We compared clinical, demographic, and donor characteristics between groups. We then used multivariable Cox proportional hazards modeling to compare graft survival (defined as freedom from death, graft failure, or further retransplantation) in people with CF treated at CFCCs and non-CFCC centers during the study period. Our cohort included 303 people with CF who underwent repeat LT from 2005-2018. Median age at repeat transplantation was 30 years (SD 8) and 50% were male. During 877 person-years of observation, 159 (53%) patients died, 7 (2%) underwent another transplant, and 4 (1%) were lost to follow-up. In a multivariable model, graft survival was significantly improved at CFCC centers compared to non-CFCCs (adjusted HR 0.62, 95% CI 0.42-0.94). Median survival was 4.2 years among people treated at CFCCs and 2.8 years among those treated at non-CFCCs. In people with CF, repeat LT at CFCCs is associated with improved graft and overall survival compared to repeat LT at non-CFCCs. Treatment at a CFCC provides specialized, multidisciplinary care for people with CF and can lead to improved outcomes even among high acuity patient subgroups.

Anterior cranial fossa dural arteriovenous fistula with pial arterial supply

Anterior cranial fossa (ACF) dural arteriovenous fistulas (DAVFs) are mainly fed by the ethmoidal arteries and sometimes have pial arterial feeders. DAVFs with pial arterial supply in ACF are extremely rare because most of the reported cases of DAVFs with pial arterial supply are located at the transverse sigmoid sinus and tentorium. A 68-year-old male presented with dizziness. Angiography showed cortical venous reflex (CVR) through an ACF DAVF fed by both bilateral ethmoidal arteries and by the right orbitofrontal artery as a pial feeder. The ethmoidal feeders were disconnected by craniotomy. The pial arterial feeder from the anterior cerebral artery was not found during surgery, and disconnection of the draining vein was not performed. CVR showed a significant reduction after the surgery. After 2 years of follow-up, angiography revealed an increased shunt flow from the pial feeder. Endovascular treatment using n-butyl-2-cyanoacrylate was performed, resulting in the complete occlusion of the fistula. DAVFs with pial supply are reported to carry a high risk of perioperative complications because of the restriction of the venous outflow and retrograde thrombosis of the pial artery. Endovascular pial feeder occlusion after surgical dural arterial feeder disconnection might achieve a safe and effective outcome. With close follow-up, the recurrence of increased shunt flow may be an appropriate timing for additional treatment. This rare condition may offer a new insight into the mechanisms of pial feeder development.

Perioperative risks in neuromuscular diseases: An update

Patients with neuromuscular diseases are at a high risk of peri-operative complications. Recent advances in the management of these disorders have increased the survival rates and the need for surgical procedures related or non-related to the primary disorder. Cardiac and respiratory failure are by far the commonest complications in addition to rhabdomyolysis, malignant hyperthermia, myotonic contractures and peri-operative drug induced complications. Meticulous preoperative assessment, optimization and a high index of suspicion for complications reduce the risks. Regional anesthesia is generally safer. If general anesthesia is required special precautions should be taken. These may vary form disease to disease and thus a multi-disciplinary approach involving the parent surgical team, neurology team, medical team, intensivist and anesthetist is of paramount importance. In this brief update the perioperative assessment and management of the common complications have been discussed along with a brief insight into the anesthetic drugs that may potentiate complications. A very brief description of the common neuromuscular disorders and respective anesthetic considerations has also been mentioned.

Endovascular Management of a Saccular Aneurysm in the Supra-Sma Region of Aorta Occluding the Celiac Trunk, in a Patient with Behcets Disease

Introduction - Behcets disease is a multisystem disorder which can present with various vascular manifestations in 12% of the patients(1). Being classified under variable vessel vasculitis, it may involve both the arteries and the veins of all sizes(2). The spectrum of presentation includes venous thrombosis, systemic or pulmonary arterial anuerysms, stenosis or occlusions. The most common vascular presentation is venous thrombosis(3). The incidence of arterial manifestations in Behcets disease is comparably less(4). The aorta is the mostly commonly involved artery reported in literature followed by the femoral artery and the pulmonary artery. Aneurysm is the most common presentation in the aorta and rupture of a large artery aneurysm is the most common cause of death(1). The pathogenesis involved is the inflammation of the vasa vasorum leading to medial destruction and fibrosis(5). Management options include open surgical repair or endovascular approach, both done under a cover of immunosuppressive regimen. In the present era, open vascular repair can be avoided as it involves a high risk of perioperative complications in view of the inflammatory pathology leading to fragile vessel walls and also due the high risk of post operative psuedoaneurysm formation(6). Endovascular treatment options for an aortic aneurysm include stent grafts or coil embolisation, with the former being the most commonly reported modality in literature(7) . Coil embolisation has been used for both saccular aneurysms of the aorta and intracranial vessels(8). Methods - We report a case of saccular aneurysm in the celiac region of the abdominal aorta of size 2.8cm anteroposterior X 2.2cm transverse X 2.1cm superioinferior, occluding the celiac trunk in an 18 year old young male with Behcets disease. On initial evaluation his systemic inflammatory markers (ESR and CRP) were raised and the SMA origin was partially occluded by acute thrombus. In view of the same he was started on steroids, immunosuppressive medications and anticoagulation. His symptoms improved well on conservative management. On one month follow up the saccular aneurysm showed significant increase in size of 3.7cm anteroposterior X 2.9cm transverse X 3.6cm superioinferior necessitating urgent intervention to prevent life threatening complications like rupture. He underwent supra-SMA aortic stenting with bare metal stent and coil embolisation of the aneurysm sac. Post operatively he was discharged on steroids and immunosupression. Results - Immediate post operative and 1st month follow up duplex showed no flow in the aneurysm sac. Conclusion - This case report exemplifies that an endovascular approach can be used to treat a saccular aneurysm of the aorta with bare metal stent and coils without the risk of distal embolisation of coils. References1)Park JH, Han MC, Bettmann MA. Arterial manifestations of Behcet’s disease. AJR Am J Roentgenol 1984; 143:821–825.2)Lie.JT, Vascular involvement in Bechets disease: arterial and venous and vessels of all sizes, J Rheumatol 1992; 19:402-10 .3)Koc Y, Gullu I, Akpek G, et al. Vascular involvement in Behcet’s disease. J Rheumatol 1992; 19:402–410.4)N. Y. Jung, S. K. Kim, E. C. Chung, H. Park, and Y. K. Cho, Endovascular treatment for rupture of intrahepatic artery aneurysm in a patient with Behcet’s syndrome,” American Journal of Roentgenology, vol. 188, no. 5, pp.W400–W402, 2007.5)A. Freyrie, O. Paragona, G. Cenacchi, G. Pasquinelli, G. Guiducci, and G. L. Faggioli, True and false aneurysms in Behcet’s disease: case report with ultrastructural observations, Journal of Vascular Surgery, vol. 17, no. 4, pp. 762–767, 1993.6)Sasaki S, Yasuda K, Takigami K, Shiiya N, Matsui Y, Sakuma M. Surgical experiences with peripheral arterial aneurysms due to vasculo-Behcet’s disease. J Cardiovasc Surg (Torino) 1998; 39:147–150.7)J. H. Park, J. W. Chung, J. H. Joh, et al., Aortic and arterial aneurysms in Behcet disease: management with stent-grafts- Initial experience, Radiology, vol. 220, no. 3, pp. 745–750, 2001.8)W. H. Kim, D. Choi, J.-S. Kim, Y.-G. Ko, Y. Jang, and W. H. Shim, “Effectiveness and safety of endovascular aneurysm treatment in patients with vasculo-Behc¸et disease,” Journal of EndovascularTherapy, vol. 16, no. 5, pp. 631–636, 2009.

Patient preferences for attributes of primary surgical debulking versus neoadjuvant chemotherapy for treatment of newly diagnosed ovarian cancer.

Randomized trials have reported conflicting findings on survival for advanced-stage ovarian cancer treated with primary debulking surgery (PDS) versus neoadjuvant chemotherapy with interval debulking; surgical complications and mortality are higher with PDS. We assessed women's preferences for tradeoffs related to this important clinical decision. Ovarian cancer patients were recruited to complete a discrete-choice experiment (DCE) consisting of 8 choice tasks presenting experimentally designed treatment alternatives in terms of treatment order, extent of surgery including risk of ostomy, chance of death from surgical complications (1%-10%), readmission for surgical complications (5%-50%), progression-free survival (1-3years), and overall survival (3-5years). Random-parameters logit regression was applied to model participants' choices as a function of attribute levels. A total of 101 ovarian cancer survivors completed the DCE survey; of these participants, 30% were receiving chemotherapy at the time, and 33% had prior recurrence. Overall survival was of greatest importance to participants (36/100), followed by risk of readmission due to complications (23/100), progression-free survival (19/100), surgical mortality (16/100), extent of surgery (4/100), and order of surgery and chemotherapy (2/100). Overall, the participants would tolerate a 15-percentage point increase in risk of major complications (95% confidence interval [CI], 3%-29%) or a 4-percentage point increase in the risk of surgical mortality (95% CI, 2%-13%) in order to increase their expected overall survival from 3 to 3.5years. Patients would accept a moderately higher risk of perioperative complications and surgical mortality in exchange for substantial gains in survival. These quantitative findings provide clinicians with a framework to discuss preferences with patients and to incorporate preferences into clinical trial design.

Risk factors for pulmonary complications after posterior spinal instrumentation and fusion in the treatment of congenital scoliosis: a case-control study

BackgroundAlthough surgery prevents the progression of deformity and maintains the overall balance of the spine in congenital scoliosis (CS) patients, it is associated with a high risk of perioperative complications. Pulmonary complication is one of the most common complications. This retrospective study aimed to investigate the risk factors for pulmonary complications in CS patients after posterior spinal instrumentation and fusion.MethodsAnalysis of consecutive patients who underwent posterior spinal instrumentation and fusion for congenital scoliosis was performed. Preoperative clinical data, intraoperative variables, and perioperative radiographic parameters were collected to analyze the risk factors for pulmonary complications. Patients were separated into groups with and without postoperative pulmonary complications. Potential risk factors were identified by univariate testing. Multivariate logistic regression was used to evaluate independent predictors of pulmonary complications.ResultsThree hundred and twenty-three CS patients were included. Forty-five (13.9%) patients developed postoperative pulmonary complications, which included pleural effusion in 34 (75.6%) cases, pneumonia in 24 (53.3%) cases, pneumothorax in 3 (6.7%) cases, atelectasis in 4 (8.9%) cases, pulmonary edema in 2 (4.4%) cases, respiratory failure in 2 (4.4%) cases, and prolonged mechanical ventilation in 4 (8.9%) cases. The independent risk factors for development of pulmonary complications included age (Odds ratio (OR) = 1.088, P = 0.038), reoperation (OR = 5.150, P = 0.012), preoperative pulmonary disease (OR = 10.504, P = 0.004), correction rate (OR = 1.088, P = 0.001), middle thoracic screw-setting (OR = 12.690, P = 0.043), and thoracoplasty (OR = 5.802, P = 0.001). The area under the receiver operating characteristic (ROC) curve based on predicted probability of the logistic regression was 0.903.ConclusionsAge, reoperation, preoperative pulmonary disease, correction rate, middle thoracic screw-setting, and thoracoplasty were independent risk factors for pulmonary complications after posterior spinal instrumentation and fusion in CS patients.

Long-term Outcomes of an Endovascular-First Approach for Diabetic Patients With Predominantly Tibial Disease Treated in a Multidisciplinary Setting

Randomized studies suggest that open lower extremity revascularization procedures are associated with improved outcomes compared with endovascular peripheral vascular interventions (PVIs). However, advances in endovascular technologies and treatment by multidisciplinary limb preservation teams have shown improved outcomes. The aim of our study was to compare perioperative and long-term outcomes after open versus PVI procedures in diabetic patients with chronic limb-threatening ischemia (CLTI) treated in a multidisciplinary setting. All patients presenting to our multidisciplinary diabetic limb-preservation service from 6/2012 to 07/2018 were enrolled in a prospective database. Patients who underwent either an open lower extremity bypass (LEB) or a PVI for CLTI were included in the analysis. Perioperative (30-day) complications and 4-year patency and limb salvage rates were compared between PVI and LEB using chi-squared tests, Kaplan-Meier curve analyses, and stepwise multivariable Cox proportional hazards models. A total of 195 lower extremity revascularization procedures were performed in 120 patients (mean age: 65.0±1.0years, 61.7% male, 63.3% black), including 53 (27.2%) open procedures and 142 (72.8%) PVIs. Nearly two-thirds of procedures (65.6%) treated multilevel diseases, while 27.2% treated isolated tibial disease and 7.2% treated isolated femoropopliteal disease. More than half of the procedures (53.3%) were performed for Wound, Ischemia, and foot Infection (WIfI) classification stage 4 limbs, 25.1% for stage 3, and 21.6% for stage 1/2. In the LEB group, 67.9% of targets were infrapopliteal. In the PVI group, 63.4% of procedures were isolated tibial interventions or were multilevel interventions including the tibial segment. Perioperative complications occurred in 52.8% of LEB versus 12.0% of PVI (P<0.001). At 4years postoperatively, there was no significant difference in crude (unadjusted) primary patency for PVI versus LEB (34.5±6.6% vs. 49.6±8.1, P=0.89). Secondary patency was better for the LEB group (50.3±7.4% vs. 55.4±7.5%; P=0.04), but amputation-free survival was similar (65.1±6.7% vs. 60.9±9.7%; P=0.79). After adjusting for baseline differences between groups, primary patency (hazard ratio [HR]: 0.61; 95% confidence interval [CI]: 0.34 to 1.10) and amputation-free survival (HR: 1.51; 95% CI: 0.71 to 2.34) remained similar for PVI versus LEB, but secondary patency was persistently lower for PVI (HR: 0.35; 95% CI: 0.14 to 0.90). In this cohort of diabetic patients with CLTI undergoing predominantly tibial interventions, open revascularization was associated with a higher risk of perioperative complications than PVIs. While secondary patency rates were better after LEBs, our data suggest that an endovascular-first approach results in equivalent long-term amputation-free survival for diabetic patients treated in a multidisciplinary setting.

Outcomes and resource utilization in surgery for Chiari I malformation in a national network of children's hospitals.

Chiari malformation type 1 (CM-1) is a common congenital or acquired malformation of the posterior fossa. We aimed to characterize preoperative risk factors, perioperative complications, and postoperative outcomes related to CM-1 surgery in pediatric populations across a nationwide network of pediatric hospitals in the United States (US). The Children's Hospital Association's Pediatric Health Information System (PHIS) database was used to examine patients < 21years old in the US-based nationwide database who underwent inpatient surgery for CM-1 from 2007 to 2015. Data analyzed included patient characteristics, preoperative comorbidities, perioperative outcomes, short-term postoperative surgical and medical complications, and healthcare resource utilization. Among the 5976 patients identified, those age 0-4years had higher medical and surgical complication rates compared to older patients. Those with pre-existing comorbidity of hydrocephalus had higher odds of 30- and 90-day medical and surgical complications. Those with any complications at 90days had an increased length of stay and higher healthcare costs compared to those without complications. 6.88% of complications were surgical and 1.67% medical. Patients with medical complications had the longer mean stay and associated costs compared to those with surgical complications (13 vs. 6.9 at 95% CI, and $71,300-94,500 vs. $110,400-195,000 at 95% CI). Use of a US-based national children's hospital database presents outcomes and resource utilization from a multi-institutional, real-world experience in pediatric hospitals. There was a higher risk of perioperative complications in younger patients and those with pre-existing comorbidities, namely hydrocephalus. Understanding preoperative risk factors, perioperative complications, and postoperative outcomes, as well as healthcare utilization and costs, can help target areas for improvement and guide preoperative counseling and risk stratification.

Perioperative management of obese patient.

The volume of bariatric and nonbariatric surgical procedures on obese patients is dramatically increasing worldwide over the past years. In this review, we discuss the physiopathlogy of respiratory function during anesthesia in obese patients, the stratification of perioperative risk to develop intraoperative and postoperative pulmonary complications, the optimization of airway management, and perioperative ventilation, including postoperative respiratory assistance. Scores have been proposed to stratify the risk of surgical patients, some of which were specifically developed for obese patients. Most scores identify obstructive sleep apnea and elevated BMI as independent risk factors. Obese patients might be at risk of difficult intubation and mask ventilation, and also of developing postoperative pulmonary complications. Intraoperative ventilation settings affect clinical outcome, but the optimal ventilation strategy is still to be determined. Opioid-free regimens are being widely investigated. Postoperative monitoring and respiratory assistance are necessary in selected patients. Early mobilization and physiotherapy are mandatory. Obese patients are at higher risk of perioperative complications, mainly associated with those related to the respiratory function. An appropriate preoperative evaluation, intraoperative management, and postoperative support and monitoring is essential to improve outcome and increase the safety of the surgical procedure.

Sleep-disordered breathing and reaction time in children.

BackgroundThe incidence of obstructive sleep apnea (OSA) and sleep-disordered breathing (SDB) in children exceeds the availability of polysomnography (PSG) to definitively diagnose OSA and identify children at higher risk of perioperative complications. As sleep deficits are associated with slower reaction times (RTs), measuring RT may be a cost-effective approach to objectively identify SDB symptoms.AimThe aim of this study is to compare RT on a standard 10-minute psychomotor vigilance test (PVT) based on children’s history of OSA/SDB.MethodsChildren, 6–11 years of age, were enrolled from two different clinical groups. The SDB group included children undergoing adenotonsillectomy with a clinical history of SDB, OSA, or snoring. The control group included children with no history of SDB, OSA, or snoring who were scheduled for surgery other than adenotonsillectomy. RT was measured via 10-minute PVT (Ambulatory Monitoring Inc., Ardsley, NY, USA). Median RT was calculated for each patient based on all responses to stimuli during the PVT assessment and was compared to published age-sex-specific norms. The proportion of children exceeding RT norms was compared between study groups.ResultsThe study included 72 patients (36/36 male/female, median age 7 years), 46 with SDB and 26 without SDB. There was no difference in the RT between the two groups. Fifty-four percent of patients with SDB exceeded norms for median RT vs 42% of control patients (95% CI of difference: – 12, 36; P=0.326).ConclusionApproximately half of the patients in both groups exceeded published norms for median RT on PVT. Despite its convenience, measurement of RT did not distinguish between patients with probable SDB/OSA for preoperative risk stratification.

Best perioperative practice in management of ambulatory patients with obstructive sleep apnea.

The perioperative outcome in obstructive sleep apnea (OSA) patients undergoing ambulatory surgery can be potentially impacted by the type of anesthetic technique, fluid management and choice of anesthetic agents. This review highlights the best perioperative practices in the management of OSA patients undergoing ambulatory surgical procedures. A recent meta-analysis found that STOP-Bang might be used as a perioperative risk stratification tool. Patients with high-risk OSA (STOP-Bang ≥3) were found to be associated with an increased risk of postoperative complications and prolonged length of hospital stay compared with low-risk OSA (STOP-Bang 0-2) patients undergoing noncardiac surgical procedures. A bidirectional relationship exists between OSA and difficult airway. Both suspected or diagnosed OSA may be associated with either difficult intubation or difficult mask ventilation or both. A recent meta-analysis identified OSA as an important risk factor for opioid-induced respiratory depression. A dose-response relationship was shown between the morphine equivalent daily dose and death or near-death events in OSA patients undergoing surgery. Postoperative continuous monitoring is recommended for high-risk OSA patients receiving opioids. Minimising the dose of muscle relaxant, neuromuscular monitoring and ensuring complete reversal of neuromuscular blockade before extubation is essential in OSA patients to avoid postoperative complications. Whenever feasible, regional anesthesia with multimodal analgesia may be considered as a better alternative to general anesthesia in OSA patients. Patients with OSA and associated comorbidities present a challenge to anesthesiologists as they are at a high risk of perioperative complications. It is important to identify patients with OSA, with the goal to raise awareness among providers, mitigate risk and improve outcomes.