Higher ASA Status Research Articles

THE LIFETIME REVISION RISK OF KNEE ARTHROPLASTY

Source of the study: University of Auckland, Auckland, New Zealand and University of Otago, Christchurch, New ZealandOutcomes following knee arthroplasty are typically defined as implant survivorship at defined timepoints, or revision incidence over time. These estimates are difficult to conceptualise, and lack context for younger patients with more remaining years of life. We therefore aimed to determine a ‘lifetime’ risk of revision as a more useful metric for total (TKA) and unicompartmental knee arthroplasty (UKA).The New Zealand Joint Registry was used to identify 96,497 primary TKAs and 13,481 primary UKAs performed between 1999 and 2019. Patient mortality and revision incidence were also extracted. Estimates of lifetime risk were calculated using an actuarial lifetable method. The estimates were stratified by age and gender. Reasons for revision were categorised using previously published standardised definitions.The lifetime risk of UKA revision was two-fold higher than TKA across all age groups (range 3.7-40.4% UKA, 1.6-22.4% TKA). Revision risk was higher for males with TKA (range 3.4%-25.2% males, 1.1%-20% females), but higher for females with UKA (range 4.3%-43.4% vs. 2.9%-37.4% for males). Revision due to infections were higher for TKA (1.5% males, 0.7% females) compared with UKA (0.4% males, 0.1% females). The increased risk in younger UKA patients was associated with higher incidence of aseptic loosening (UKA 2%, TKA 1%) and ‘unexplained pain’ (UKA 2%, TKA 0.2%).The risk for UKA was two-fold higher than TKA, and this was partially explained by a higher proportion of revisions due to ‘unexplained pain’. For TKA, males had higher risk of revision, in contrast to UKA where females had higher risk; this gender difference was associated with higher incidence of infections with TKA. Younger age, gender and higher ASA status were also associated with increased lifetime risk of UKA revision. Lifetime risk of revision can provide a meaningful measure of arthroplasty outcomes to aid patient counselling.

Omission of intraoperative pyloric procedures in minimally invasive esophagectomy: assessing the impact on patients.

Pyloroplasty or pyloromyotomy is often undertaken during esophagectomy to aid gastric emptying postoperatively. Minimally invasive esophagectomy (MIE) frequently omits a pyloric procedure. The impact on perioperative outcomes and the need for subsequent interventions is unclear. This study assesses the requirements for endoscopic balloon dilation of the pylorus (EPD) following MIE. Patients undergoing MIE from 2016 to 2020 were reviewed. Patients undergoing open resection, or an intraoperative pyloric procedure were excluded. Demographic, clinical and pathological data were reviewed. Univariable and multivariable analysis were performed as appropriate. In total, 171 patients underwent MIE. There were no differences in age (median 65 vs. 65years, P= 0.6), pathological stage (P= 0.10) or ASA status (P= 0.52) between those requiring and not requiring endoscopic pyloric dilation (EPD). Forty-three patients (25%) required EPD, with a total of 71 procedures. Twenty-seven patients (16%) had EPD on their index admission. Seventy-five patients (43%) had a postoperative complication. Higher ASA status was associated with increased requirement for EPD (odds ratio 10.8, P= 0.03). On multivariable analysis, there was no association between the need for a pyloric procedure and overall survival (P= 0.14). Eight patients (5%) required insertion of a feeding jejunostomy in the postoperative period, with no difference between those with or without EPD (P= 0.11). Two patients required subsequent surgical pyloromyotomy for delayed gastric emptying. Although pyloroplasty or pyloromyotomy can safely be excluded during MIE, a quarter of patients will require postoperative EPD procedures. The impact of excluding pyloric procedures on gastric emptying requires further study.

Risk factors for delirium in elderly patients after lumbar spinal fusion

ObjectiveTo identify perioperative risk factors for postoperative delirium (POD) in patients aged 65 or older undergoing lumbar spinal fusion procedures. Patients and MethodsA retrospective cohort analysis was performed on patients undergoing lumbar spinal fusion over an approximately three-year period at a single institution. Demographic and perioperative data were obtained from electronic medical records. The primary outcome was the presence of postoperative delirium assayed by the Delirium Observation Screening Scale (DOSS) and Confusion Assessment Method for the ICU (CAM-ICU). Univariate and multivariate analyses were performed on the data. ResultsOf the 702 patients included in the study, 173 (24.6%) developed POD. Our analysis revealed that older age (p < 0.001), lower preoperative hemoglobin (p < 0.001), and higher ASA status (p < 0.001), were significant preoperative risk factors for developing POD. The only significant intraoperative risk factor was a higher number of spinal levels that were instrumented (p < 0.001). Higher pain scores on postoperative day 1 (p < 0.001), and lower postoperative hemoglobin (p < 0.001) were associated with increased POD; as were ICU admission (p < 0.001) and increased length of ICU stay (p < 0.001). Patients who developed POD had a longer hospital stay (p < 0.001) with lower rates of discharge to home as opposed to an inpatient facility (p < 0.001). ConclusionRisk factors for POD in older adults undergoing lumbar spinal fusion surgery include advanced age, diabetes, lower preoperative and postoperative hemoglobin, higher ASA grade, greater extent of surgery, and higher postoperative pain scores. Patients with delirium had a higher incidence of postoperative ICU admission, increased length of stay, decreased likelihood of discharge to home and increased mortality, all consistent with prior studies. Further studies may determine whether adequate management of anemia and pain lead to a reduction in the incidence of postoperative delirium in these patients.

Are perioperative outcomes in cancer-related ventral incisional hernia repair worse than in the general population? An Abdominal Core Health Quality Collaborative (ACHQC) database study.

Patients with a history of cancer-related abdominal surgery undergoing incisional hernia repair (IHR) are highly heterogenous and increasingly prevalent. We explored whether cancer surgery should be considered an independent risk factor for worse IHR perioperative outcomes. Patients undergoing IHR between 2018 and 2020 were identified within the Abdominal Core Health Quality Collaborative (ACHQC). Regression models were used to assess associations between cancer operation history and 30 d surgical site occurrences-exclusive of infection (SSO-EIs), surgical site infections (SSIs), reoperations, time to recurrence, and quality of life (QoL) scores. Cancer cohort subgroup analysis was performed for operative approach and mesh location. 8019 patients who underwent IHR were identified in the ACHQC, 1321 of which had a history of cancer operation. Cancer cohort patients were more likely to be older, males with a higher ASA status and lower BMI, and have longer and wider hernias (p < 0.001). After adjusting for confounding, the cancer cohort was less likely to experience SSO-EIs (OR 0.74, 95% CI 0.59-0.94 p = 0.0092) and showed lower odds of SSIs, reoperations, and recurrence (SSI OR 0.7, 95% CI 0.47-1.05, p = 0.0542; reoperation OR 0.66, 95% CI 0.37-1.17, p = 0.1002; recurrence OR 0.8, 95% CI 0.63-1.02, p = 0.08). There was no difference in postoperative QoL scores between cohorts. There were also no differences in perioperative or QoL outcomes within the cancer cohort based on operative approach or mesh location. These data show no evidence that history of cancer operation predisposes patients to worse incisional hernia repair perioperative or quality of life outcomes.

EP.FRI.974 NELA 30 day mortality: A single centre experience

Abstract Aims National emergency laparotomy audit (NELA) developed in 2014 in the UK, aims to improve of quality of care of patients undergoing emergency laparotomy. NELA highlights the importance of identifying high risk patients for potential significant morbidity and mortality. The aim of this study is to review the NELA 30 day mortality at a single centre. Methods This is a retrospective review of all 30 day NELA mortality patients since 2014 carried out at East Cheshire NHS Trust until January 2020. The NELA survivors beyond 30 days were used as controls. Results Conclusion The overall NELA 30 day mortality rate was 9.8 %. NELA deaths occurred in the older, frail, multi-comorbid &amp; high ASA status patients. Most NELA deaths occur within 90 days, whereas patient survival curve appears to plateau out beyond 90 days. P possum can be used to identify high risk patients, where early collaborative senior assessment by consultant surgeons, anaesthetists and intensivists may identify and allocate appropriate surgical intervention.

Anterior lumbar interbody fusion: single institutional review of complications and associated variables

As more patients undergo anterior lumbar interbody fusion (ALIF) procedures and more devices are created for that purpose, it is important to understand the complications that can arise and the variables that mitigate risk for major and minor complications. To assess complication rates after ALIF with or without posterior instrumentation and variables associated with increased likelihood of postoperative complications. We aim to provide this data as benchmarking to improve patient safety and surgical care. A single-center retrospective cohort study. All adult patients who underwent ALIF between 2017 and 2019 was performed OUTCOME MEASURES: Post-operative major and minor complications were evaluated. Complications were recorded and presented as percentages. Patient demographics, perioperative, and postoperative data were also collected and analyzed between patients who had no complications and those that had any complication. Subgroup analysis of surgical complications were performed by nonparametric Chi-square tests. Continuous variables were compared using Mann-Whitney U tests. Ninty-five of three hundred sixty-two (26.2%) of patients experienced a minor or major complication. Among the most common complications found were surgical site infections (5.8%), neurological complications (4.1%), vascular complications (3.6%), and urinary tract infections (3.3%). Patients undergoing ALIF alone with post-operative complications had higher mean age, higher BMI, higher ASA status, and experienced higher estimated blood loss. Patients undergoing ALIF and posterior instrumentation with post-operative complications were more likely to have diabetes and had a higher ASA status. Patients with any complications from both groups had longer length of stay, discharge to a non-home setting and were more likely to be readmitted or return to the operating room. Our study reveals variables associated with complications at our institution, including age of the patient, BMI, and ASA status leading to higher complications and greater LOS, higher readmission rates, and disposition to skilled facilities.

A prospective cohort register-based study of chronic postsurgical pain and long-term use of pain medication after otorhinolaryngological surgery

Data on chronic postsurgical pain (CPSP) after otorhinolaryngological surgery are sparse. Adult in-patients treated in 2017 were included into the prospective PAIN OUT registry. Patients’ pain on the first postoperative day (D1), after six months (M6) and 12 months (M12) were evaluated. Determining factor for CPSP was an average pain intensity ≥ 3 (numeric rating scale 0–10) at M6. Risk factors associated with CPSP were evaluated by univariate and multivariate analyses. 10% of 191 included patients (60% male, median age: 52 years; maximal pain at D1: 3.5 ± 2.7), had CPSP. Average pain at M6 was 0.1 ± 0.5 for patients without CPSP and 4.2 ± 1.2 with CPSP. Average pain with CPSP still was 3.7 ± 1.1 at M12. Higher ASA status (Odds ratio [OR] = 4.052; 95% confidence interval [CI] = 1.453–11.189; p = 0.007), and higher minimal pain at D1 (OR = 1.721; CI = 1.189–2.492; p = 0.004) were independent predictors of CPSP at M6. Minimal pain at D1 (OR = 1.443; CI = 1.008–2.064; p = 0.045) and maximal pain at M6 (OR = 1.665; CI = 1.340–2.069; p < 0.001) were independent predictors for CPSP at M12. CPSP is an important issue after otorhinolaryngological surgery. Better instrument for perioperative assessment should be defined to identify patients at risk for CPSP.

Health literacy and optimizing education materials in a surgical population

Objective: The aim is to examine and compare the level of health literacy (HL) amongst surgical vascular and abdominal patients and measuring the understandability and actionability of current and optimized education materials.Methods: A cross-sectional design was utilized. Patients undergoing abdominal or vascular surgery, were included for measuring HL with the Newest Vital Sign Dutch (NVS-d) tool. The Dutch version of the Patient Education Materials Assessment Tool (PEMAT) was used to measure the understandability and actionability of current and optimized patient education materials.Results: A total of 101 patients were included, of those 54 (53.5%) have limited HL. Patients with limited HL were significantly older (p &lt; .001), lower educated (p &lt; .001), and had a higher ASA status (p = .005) and Charlson Comorbidity Index score (p &lt; .001). The occurrence of limited HL differed significantly (p = .046) between abdominal versus vascular patients. The understandability varied between 24%-59% and the actionability between 40%-67% of the current education materials. The optimized education materials had a understandability score of 86% and a actionability score of 100%.Conclusions: The high prevalence of inadequate HL emphasizes the importance of nursing and medical staff providing clear information to enable shared decision-making. Besides, it is necessary to evaluate current education materials and optimize these materials according to the level of health literacy to provide health information that is understandable.

Holmium laser enucleation of the prostate: efficacy, safety and preoperative management in patients presenting with anticoagulation therapy

PurposeWe evaluated efficacy and safety profile of patients with anticoagulation therapy (AT) undergoing holmium laser enucleation of the prostate (HoLEP).MethodsWithin our prospective institutional database (11/2017 to 11/2019), we analyzed functional outcomes and 30-day complication rates of HoLEP patients according to Clavien–Dindo classification (CLD), stratified according to specific AT vs. no AT. Further analyses consisted of uni- and multivariate logistic regression models (LRM) predicting complications.ResultsOf 268 patients undergoing HoLEP, 104 (38.8%) received AT: 25.7% were treated with platelet aggregation inhibitors (PAI), 8.2% with new oral anticoagulants (NOAC) and 4.9% with AT-combinations or coumarins bridged with low molecular weight heparins (LMWH/combination). Patients receiving AT were significantly more comorbid (p < 0.01). Pre- and postoperative maximal flow rates, residual void urine and IPSS at 3 months after surgery were invariably improved after HoLEP for patients with/ without AT. Overall complication rate was 19.5% in patients with no AT vs. 26.1% vs. 27.3 vs. 46.2%, respectively, in patients with PAI, NOAC and LMWH/combination (p < 0.01). Major complications (CLD ≥ 3b) occurred in 6.1% of no AT patients vs. 4.3% vs. 4.5 vs. 0% in patients with PAI, NOAC and LMWH/combination, respectively (p < 0.01). In multivariate LRM, AT was not significantly associated with higher complication rates, whereas high ASA status (OR 2.2, p = 0.04), age (OR 1.04, p = 0.02) and bioptical or incidental prostate cancer (OR 2.5, p = 0.01) represented independent risk factors.ConclusionDespite higher overall complication rates in AT patients, major complications were not more frequent in AT patients. HoLEP is safe and effective in anticoagulated patients.

Perioperative aspiration events in children: A report from the Wake Up Safe Collaborative.

Perioperative aspiration, while rare, is a serious complication of anesthetic care. Consequences of aspiration may include physical obstruction, wheezing, and pneumonia, resulting in mild to severe hypoxemia and even death. We used a multi-institutional registry of pediatric patients to identify factors that influence the rate and resulting harm of perioperative pulmonary aspiration. The Wake Up Safe registry was queried for all severe adverse events reported from 29 institutions from 2010 to 2017. Aspiration events were identified through the "respiratory adverse event" data entry form or through free text search. Multivariable regression was used to predict aspiration events, and contributory factors were identified by reviewing free text case comments. Analysis included 2440810 anesthetics administered involving patients ≤18years of age. There were 135 pulmonary aspiration events, for an incidence of 0.006%. Within these 135 cases, 110 cases (82%) resulted in escalation of care and 51 (38%) resulted in patient harm, including 2 deaths (1.5%). In multivariable analysis, patients undergoing emergency surgery (OR 2.0 [1.2-3.5]) or with higher ASA status were more likely to experience aspiration (ASA 3 (OR 5.0 [2.6-9.1]); ASA≥4 (OR 5.5 [3.8-16.8])). Noted causes of aspiration included gastrointestinal comorbid conditions (19%), postcoughing event or laryngospasm (14%), nil per os (NPO) violation (11%), blood or secretions in the airway following or during the procedure (6%), and oral premedication reaction (3%). Although infrequent, death was reported as a consequence of perioperative aspiration in two patients. The frequency with which NPO violations were identified as a potential cause of aspiration highlights the struggles institutions face with adherence to NPO regulations, as these cases may be preventable. Furthermore, preventive measures may be needed to address other common causes of aspiration, such as gastrointestinal comorbid conditions.

Thyroid surgery outcomes analysis in an oral and maxillofacial surgery department

The purpose of this study was to identify complication rates of thyroidectomies performed within the Department of Oral and Maxillofacial Surgery, University of Florida Health – Jacksonville, and to compare these with quantified data regarding complications of thyroidectomies performed by other specialties. A retrospective cohort analysis was implemented to determine complication rates amongst patients treated in the department between January 2012 and December 2017. Data variables included demographics, ASA status, social history, and preoperative signs and symptoms. The primary outcome variables were length of hospital length, secondary procedures in the same admission, and postoperative complications including hypocalcemia, hematoma, and voice changes. A total of 402 patients were identified, of whom six were excluded for insufficient data. The mean age of the 396 patients included was 47.9 years and 84.6% were female. Of the patients included, 338 experienced no complications; 86 patients spent more than one postoperative day in the hospital. A statistically significant (P=0.033) correlation was found between higher ASA status (III, IV, V) and increased length of stay. The results indicated safe and efficient thyroid surgery within a department of oral and maxillofacial surgery by current prevailing standards.

Increased Morbidity and Mortality of Emergency Laparotomy in Elderly Patients.

There is an increasing incidence of elderly patients requiring emergency laparotomy. Our study compares the outcomes of elderly patients undergoing emergency laparotomy against the outcomes of non-elderly patients. Patients who underwent emergency laparotomy between 2015 and 2017 from the National University Hospital, Singapore, were included. Apart from demographic data, indication of surgery and surgical procedure performed were collected. Prospectively collected nutritional scores were evaluated. Outcome measures included duration of surgery, length of ICU and total hospital stay, post-operative complications, and mortality indices. We performed multivariate Cox regression analysis to determine the contribution of various risk factors towards overall survival following emergency laparotomy. A total of 170 emergency laparotomies were performed. Compared to non-elderly patients, elderly patients had a significantly longer mean stay in hospital (31.5 vs. 18.6days, p = 0.006) and mean stay in ICU (13.1 vs. 5.3days, p = 0.003). More elderly patients suffered from post-laparotomy complications compared with non-elderly patients (65.8% vs. 37.4%, p < 0.001). 30-day mortality (31.5% vs. 8.8%, p = 0.019) and 1-year mortality (27.9% vs. 14.3%, p = 0.023) were higher in elderly patients compared with non-elderly patients. Interestingly, there was no statistically significant difference between elderly and non-elderly groups in both the global 3-MinNS as well as the global SGA nutritional scores. ASA status (HR 2.61, 95% CI 1.05-6.45, p = 0.038) was an independent risk factor for decreased survival following emergency laparotomy. Notably, while age ≥ 65 demonstrated a significant correlation with survival on univariate analysis (HR 1.03 (1.01-1.05), p = 0.003), this effect was lost following multivariate regression (HR 1.01 (0.453-2.23), p = 0.989). Elderly patients suffer worse morbidity and mortality following emergency laparotomy. This is likely contributed by comorbidities resulting in higher ASA status.

The Impact of Obstructive Sleep Apnea on Clinical, Perioperative, and Cost Outcomes in Patients Who Underwent Posterior Cervical Discectomy and Fusion: A Single Center Retrospective Analysis from 2008 to 2016

Abstract INTRODUCTION Obstructive sleep apnea (OSA) is a chronic condition that results from upper airway narrowing during sleep, with an increasing prevalence estimated to be around 9% to 24%. The combination of an unstable, recently fused or immobile cervical spine and OSA may reasonably lead to special considerations, although this topic has not been well studied. METHODS We retrospectively obtained 1191 posterior cervical discectomy and fusion (PCDF) cases, of which 93 subjects (7.81%) had a history of OSA and 1098 subjects (92.19%) did not. The primary outcome selected was prolonged intubation. Secondary outcomes included intensive care unit (ICU) admission, overall complications, extended hospitalization, nonhome discharge, readmission within 30 and 90 d, emergency room visit within 30 and 90 d, and higher total costs. Univariate and multivariate logistic regression analyses were conducted to assess OSA-affected clinical and perioperative outcome measures. RESULTS Compared to the control cohort, the OSA cohort had more subjects with body mass index (BMI) &gt;30 (P &lt; .0001) and ASA status &gt;2 (P &lt; .0001). After controlling for age, sex, obesity, and ASA status, multivariate regression analyses revealed no difference in the odds of a prolonged intubation (P = .4092). However, a difference was noted in the odds of ICU admission (P = .0038), extended hospitalization (P = .0223), and nonhome discharge (P = .0218). Variables predictive of higher direct cost included a higher ASA status (&lt;0.0001), higher Elixhauser Comorbidities Index (ECI) score (P = .004), and more segments involved in the procedure (P &lt; .0001). Conversely, our models suggested that the 2 cohorts did not differ significantly in the odds of increased complications, readmission at 30 and 90 d, and ER visit at 30 or 90 d. CONCLUSION This study is the largest retrospective review, to our knowledge, of patients who have undergone PCDF with a specific focus on OSA. The results from this study suggest that OSA status is an important determinant of primary and secondary clinical outcomes following posterior cervical fusion procedures.

Pain on the first postoperative day after tonsillectomy in adults: A comparison of metamizole versus etoricoxib as baseline analgesic

ObjectiveTo compare the effect of metamizole versus etoricoxib as baseline analgesic for treating postoperative pain after tonsillectomy.DesignSingle centre prospective cohort study.SettingTwo consecutive cohorts of tonsillectomy patients.Participants124 patients (n = 55 treated with etoricoxib, n = 69 with metamizole); median age 30.5 years; 50% women.Main outcome measuresPatients rated their pain on first postoperative day using the questionnaires of the German-wide project Quality Improvement in Postoperative Pain Treatment (QUIPS) including numeric rating scales (NRS, 0–10) for pain determination. The influence of preoperative and postoperative parameters on patients' pain was estimated by univariate and multivariate statistical analysis.ResultsThe demographic parameters showed no differences between the patients in the metamizole group and the etoricoxib group (all p>0.05) with one exception: Patients in the metamizole group had significantly more preoperative pain than patients in the etoricoxib group (p = 0.001). The metamizole group had a mean postoperative pain in activity of 4.4 ± 2.1 and the etoricoxib group of 4.5 ± 2.2. Maximal pain for the metamizole group and the etoricoxib group were 5.6 ± 2.2 and 6.1 ± 1.9, respectively. Pain in activity, maximal pain and minimal pain were not different between both groups (p = 0.652, p = 0.113, p = 0.276, respectively). Patients of the etoricoxib group received more frequently piritramide in recovery room as demand medication (p = 0.046). In the whole cohort, patients with peritonsillar abscess had more preoperative pain in comparison to chronic tonsillitis (p<0.001). Patients under 30.5 years reported higher maximal pain than older patients (p = 0.049). On the other hand, a significant influence of patients’ age on the pain in activity and minimal pain could not be demonstrated (p = 0.368, p = 0.508, respectively). Men reported lower minimal pain than women (p = 0.041). Also, patients with ASA status I had lower minimal pain than patients with higher ASA status (p = 0.019). The multivariate analysis did not show an association between postoperative pain in activity and preoperative counseling on postoperative pain management (p = 0.588, p = 0.174, respectively). Special preoperative counseling on postoperative pain management resulted in lower levels of maximal pain (p = 0.024). Linear regression demonstrated an independent association of higher pain in activity with higher mobility impairment (p = 0.034) and respiratory impairment (p = 0.002). The linear regression of minimal pain identified female gender (p = 0.005) as an independent influencing factor with higher pain levels. In terms of satisfaction, no preoperative pain therapy (p = 0.016) could be found as an independently significant influencing factor with higher satisfaction.ConclusionEtoricoxib does not have an advantage as baseline analgesic for post tonsillectomy pain in comparison to metamizole.

Laparoscopic versus open right hemicolectomy in colon carcinoma: A propensity score analysis of the DGAV StuDoQ|ColonCancer registry.

ObjectiveTo assess whether laparoscopy has any advantages over open resection for right-sided colon cancer.Summary background dataRight hemicolectomy can be performed using either a conventional open or a minimally invasive laparoscopic technique. It is not clear whether these different access routes differ with regard to short-term postoperative outcomes.MethodsPatients documented in the German Society for General and Visceral Surgery StuDoQ|ColonCancer registry who underwent right hemicolectomy were analyzed regarding early postoperative complications according to Clavien-Dindo (primary endpoint), operation (OP) time, length of postoperative hospital stay (LOS), MTL30 and number of lymph nodes retrieved (secondary endpoints).ResultsA total of 4.997 patients were identified as undergoing oncological right hemicolectomy without additional interventions. Of these, 4.062 (81.3%) underwent open, 935 (18.7%) laparoscopic surgery. Propensity score analysis showed a significantly shorter LOS (OR: 0.55 CI 95%0.47-.64) and a significantly longer OP time (OR2.32 CI 1.98–2.71) for the laparoscopic route. Risk factors for postoperative complications, anastomotic insufficiency, ileus, reoperation and positive MTL30 were higher ASA status, higher age and increasing BMI. The surgical access route (open / lap) had no influence on these factors, but the laparoscopic group did have markedly fewer lymph nodes retrieved.ConclusionThe present registry-based analysis could detect no relevant advantages for the minimally invasive laparoscopic access route. Further oncological analyses are needed to clarify the extent to which the smaller lymph node harvest in the laparoscopic group is accompanied by a poorer oncological outcome.

Outcomes of Ambulatory Upper Extremity Surgery Patients Discharged Home with Perineural Catheters from a Veterans Health Administration Medical Center.

The feasibility and safety of managing ambulatory continuous peripheral nerve blocks (CPNB) in Veterans Health Administration (VHA) patients are currently unknown. We aimed to characterize the outcomes of a large VHA cohort of ambulatory upper extremity surgery patients discharged with CPNB and identify differences, if any, between catheter types. With institutional review board approval, we reviewed data for consecutive patients from a single VHA hospital who had received ambulatory CPNB for upper extremity surgery from March 2011 to May 2017. The composite primary outcome was the occurrence of any catheter-related issue or additional all-cause health care intervention after discharge. Our secondary outcome was the ability to achieve regular daily telephone contact. Five hundred one patients formed the final sample. The incidence of any issue or health care intervention was 104/274 (38%) for infraclavicular, 58/185 (31%) for interscalene, and 14/42 (33%) for supraclavicular; these rates did not differ between groups. Higher ASA status was associated with greater odds of having any issue, whereas increasing age was slightly protective. Distance was associated with an increase in catheter-related issues (P < 0.01) but not additional health care interventions (P = 0.51). Only interscalene catheter patients (3%) reported breathing difficulty. Infraclavicular catheter patients had the most emergency room visits but rarely for CPNB issues. Consistent daily telephone contact was not achieved. For VHA ambulatory CPNB patients, the combined incidence of a catheter-related issue or additional health care intervention was approximately one in three patients and did not differ by brachial plexus catheter type. Serious adverse events were generally uncommon.

A 10-year retrospective review of perioperative mortality in pediatric general surgery at Ile-Ife Hospital, Nigeria

Background/PurposeThe analysis of perioperative mortality as well as surgery- and anesthesia-related death in pediatric patients may serve as a potential tool to improve outcome. The aim of this study is to report the 24-h and 30-day overall, and surgery and anesthesia-related, mortality in a tertiary hospital. MethodsThis is a retrospective review of perioperative mortality in children ≤15years at a general pediatric surgery unit. All pediatric general surgery cases operated under general anesthesia between January 2007 and December 2016 were included in the study and data analyzed. ResultsA total of 4108 surgical procedures were performed in 4040 patients. The age was 1day to 15years with a median age of 2years. The all cause 24-h mortality was 34 per 10,000 procedures and the all cause 30-day mortality was 156 per 10,000 procedures. Septicemia was the most common cause of death. The determinants of mortality were neonatal age group (Adjusted Odd Ratio (AOR)=0.033, 95% CI=0.015–0.070, p=0.001), emergency surgery (AOR=90.91, 95% CI=27.78–333.33, p=0.001), higher ASA status (AOR=0.014, 95% CI=0.005–0.041, p=0.001) and multiple operative procedures (AOR=38.46, 95% CI=10.64–142.85, p=0.001). ConclusionsNeonatal age group, children with poorer ASA status, emergency and multiple surgeries were predictors of perioperative mortality. Level of evidenceRetrospective study.

Head and neck reconstruction in the elderly patient: a safe procedure?

Demographic changes strongly affect industrialized countries. While free tissue transfer was initially believed to be beneficial only for younger patients, there is an increasing number of elderly patients requiring microvascular operations in our aging society. Medical and surgical risks for head and neck cancer patients over a certain age who undergo free tissue transfer has hardly been investigated. A retrospective mono-center cohort study was performed. All patients with the age 75 or higher undergoing microvascular operations were reviewed. Patient characteristics including the ASA-status, the ACE-27-score, flap survival and postoperative medical and surgical complications were evaluated. The Clavien-Dindo-classification system for postoperative complications was applied to assess the severity of the complications. A total of 31 patients with an average age of 78.8years were included. 4 patients suffered from venous congestion and had to undergo revision surgery. All flaps could successfully be salvaged. Higher ASA-status and ACE-score were significantly associated with postoperative medical and surgical complications and a higher severity of the complications. However , neither age nor operating time had influence on the complication rate. Microvascular free tissue transfer can be performed with a high degree of security in selected elderly patients. However, serious medical complications remain a concern, correlating strongly with high ASA and ACE-score. Careful patient selection is mandatory to reduce complications to a minimum.

Surgical treatment of colorectal carcinoma in the elderly

Colorectal carcinoma is one of the most frequent tumor entities worldwide. The treatment of elderly and mostly polymorbid patients is an outstanding challenge in view of the demographic change with acontinuously aging community. Due to the demographic changes the numbers of elderly (>65years) and very old (≥80years) patients are steadily increasing in surgical cohorts. This has resulted in higher morbidity and mortality rates in comparison to younger patients, with increased wound healing and cardiovascular complications but with comparable numbers of anastomotic insufficiency. Multivariate analysis revealed age ≥80years, higher ASA status and emergency operations as independent risk factors for increased in-hospital mortality. With respect to the localization of colorectal cancer ashift to the right has been observed with increasing patient age. Whether minimally invasive surgical techniques can reduce postoperative morbidity and mortality rates in elderly patients requires further evaluation. Nevertheless, areduction of both was reported without compromising the oncological result. Elderly patients require individualized treatment modalities, which take the extent of comorbidities and personal environment into consideration. So far, the cohort of octogenarians has not been adequately considered in current guidelines; therefore, geriatric expertise is recommended to be able to make a better assessment of benefit-risk ratios, as age itself has no impact on the decision for therapy.

Unilateral vs. bilateral total knee arthroplasty with 90-day morbidity and mortality: A retrospective cohort study

BackgroundThe decision to adopt a unilateral vs. a bilateral approach while performing a total knee arthroplasty (TKA) for a patient with bilateral knee involvement remains a matter of much debate. Previous literature has claimed the supremacy of unilateral surgery in terms of complications where as some evidence supporting no significant difference between the two approaches also exists. In this study, we aim to compare the morbidity and mortality of unilateral with bilateral TKA. MethodologyA review of 658 patients who underwent TKA (2005–2015) was carried out. Details of patient characteristics, hospital course and complications occurring within 90 post-operatively were recorded. Data was analyzed using both univariate testing and multivariate regression analysis with a threshold for significance at p < 0.2 and p < 0.05 respectively. ResultsThe study showed that there is no statistically significant difference in the mortality and major complication between unilateral TKA and bilateral TKA. Further analysis revealed that only higher ASA status (3-4) is associated with higher risk of SSI (RR = 3.42,p-value = 0.034). No variables were found to be significant predictors for cardiac complications and UTI. Interestingly, all 3 cases of DVT occurred in bilateral TKR. ConclusionsThere is no significant difference between unilateral and bilateral TKA in terms of mortality and morbidity except for DVT. This tips the balance in favor of the simultaneous bilateral approach owing to the added benefits of a combined lower cost of surgery, faster recovery, less work absence, single anesthesia session, single hospital admission and fewer follow-ups. Hence, it can be preferred in selected patients with bilateral osteoarthritis.