Higher Likelihood Of Postoperative Complications Research Articles

Association of Metabolic Derangement and Postoperative Outcomes in Hernia Repair With Component Separation: A Propensity Score-matched Nationwide Analysis

IntroductionMetabolic syndrome (MetS) is characterized by cardiometabolic abnormalities such as hypertension, obesity, diabetes, or dyslipidemia. This study aims to evaluate the association of MetS on the postoperative outcomes of ventral, umbilical, and epigastric hernia repair using component separation. MethodsThe American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients who underwent ventral, umbilical, and epigastric hernia repair with component separation between 2015 and 2021. MetS status was defined as patients receiving medical treatment for diabetes mellitus and hypertension, with a body mass index greater than 30 kg/m2. Propensity matching was performed to generate two balanced cohorts with and without MetS. T-tests and Fisher's Exact tests assessed group differences. Logistic regression models evaluated complications between the groups. ResultsAfter propensity score matching, 3930 patients were included in the analysis, with 1965 in each group (MetS versus non-MetS). Significant differences were observed in the severity and clinical presentation of hernias between the groups. The MetS cohort had higher rates of incarcerated hernia (39.1% versus 33.2%; P < 0.001), and recurrent ventral hernia (42.7% versus 36.5%; P < 0.001) compared to the non-MetS cohort. The MetS group demonstrated significantly increased rates of renal insufficiency (P = 0.026), unplanned intubation (P = 0.003), cardiac arrest (P = 0.005), and reoperation rates (P = 0.002) than the non-MetS cohort. Logistic regression models demonstrated higher likelihood of postoperative complications in the MetS group, including mild systemic complications (OR 1.25; 95%CI 1.030-1.518; P = 0.024), severe systemic complications (OR 1.63; 95%CI 1.248-2.120; P < 0.001), and reoperation (OR 1.47; 95%CI 1.158-1.866; P = 0.002). There were no significant differences in the rates of 30-d wound complications between groups. ConclusionsThe presence of metabolic derangement appears to be associated with adverse postoperative medical outcomes and increased reoperation rates after hernia repair with component separation. These findings highlight the importance of optimizing preoperative comorbidities as surgeons counsel patients with MetS.

Hyperthermic Intraperitoneal Chemotherapy (HIPEC), Oncological Outcomes and Long-Term Survival among Patients with Gastric Cancer and Limited Peritoneal Disease Progression after Neoadjuvant Chemotherapy.

The role of surgery in stage IV gastric cancer with peritoneal metastasis (PM) remains unclear. The objective of the current single-center study was to define the impact of gastrectomy with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) on outcomes among Central European GC patients with limited peritoneal disease progression after neoadjuvant chemotherapy (NAC). Patients with histologically confirmed GC who underwent curative-intent multimodal treatment between 2013 and 2023 were included. Patients without adenocarcinoma, who did not undergo gastrectomy, had early (cT1) or metastatic GC at the time of initial diagnosis, who underwent multivisceral resection, incomplete cytoreduction or palliative care, died before planned curative-intent treatment, or had incomplete clinical or pathological missing information were excluded. A total of 74 patients who underwent curative-intent treatment for GC with PM were included in the final analytic cohort. Patients who underwent gastrectomy with CRS+HIPEC were less likely to achieve TOO (CRS+HIPEC: 28% vs. CRS: 57.1%, p = 0.033) compared with individuals after CRS alone. Specifically, patients who underwent gastrectomy with CRS+HIPEC had a higher likelihood of postoperative complications (CRS+HIPEC: 48% vs. CRS: 20.4%, p = 0.018) and longer hospital LOS (median, CRS+HIPEC: 12 vs. CRS: 10, p = 0.019). While administration of HIPEC did not impact long-term survival (median OS, CRS+HIPEC: 16 months vs. CRS: 12 months, p = 0.55), postoperative complications (median OS, CCI < 30:16 months vs. CCI > 30:5 months, p = 0.024) and ICU stay (median OS, no ICU stay: 16 months vs. ICU stay: 5 months, p = 0.008) were associated with worsened long-term survival among GC patients with PM. Data from the current study demonstrated a lack of survival benefit among advanced GC patients with PM undergoing gastrectomy with CRS+HIPEC when compared with individuals after gastrectomy with CRS alone. Administration of perioperative chemotherapy and achievement of TO failed to withstand the peritoneal disease progression during NAC.

Management of Choroid Plexus Tumors and the Benefit of Preoperative Embolization in Pediatric Patients: Report of 46 Cases from a Single Institution

Optimal choroid plexus tumor (CPT) treatment involves gross total resection; however, intraoperative hemorrhage risk remains significant given tumor vascularity. This study describes pediatric CPT management and identifies patients most likely to benefit from preoperative embolization. CPTs resected from 1997 to 2021 were included. The characteristics of embolized patients were compared to nonembolized patients; nonembolized patients were further stratified based on open vascular control-pedicle feeder ligation versus no pedicle ligation prior to tumor debulking. Statistical analyses identified factors associated with estimated blood loss (EBL), transfusion, length of stay, and complications. Among the 46 CPT cases identified, 98% achieved gross total resection, and 15% received embolization. Embolized patients were younger, smaller, and had larger tumors compared to nonembolized patients (median: 0.8 vs. 2.1years; 9.3 vs. 14.4kg; 91.08 vs. 5.5cm3). Transfused patients were similarly younger and smaller (P < 0.05) than nontransfused patients. Among nonembolized patients, open vascular control was achieved in smaller tumors (<13cm3) with significantly lower EBL (P= 0.002). Higher EBL was observed in patients with larger tumors, hydrocephalus, transependymal edema, vomiting, lethargy, and developmental regression (all P < 0.05). Patients with lethargy had longer hospital stays and a higher likelihood of postoperative complications (P < 0.05). There were no significant differences in complication rates between the embolization and nonembolization groups. Despite higher surgical risk profiles, embolized patients had similar complication rates and postoperative hydrocephalus management as nonembolized patients. Embolization was particularly beneficial in patients at high risk for surgical morbidity, such as those <2years, weighing <10kg, and with a tumor volume >15cm3.

Risk factors for postoperative complications following one-stage proximal hypospadias repair involving the disconnection of the urethral plate: a retrospective study

BackgroundChildren with hypospadias are at risk of serious physical and mental health problems, including abnormal urination, sexual dysfunction, and infertility. The sole available treatment is the surgical restoration of genital appearance and function. Proximal hypospadias (PH) correction is more challenging and carries a higher risk of complications than does distal hypospadias correction, with a higher likelihood of postoperative complications requiring additional surgery, resulting in considerable economic and psychological strain for families. Herein, we aimed to identify factors associated with complications following one-stage PH repair with urethral plate disconnection.MethodsWe retrospectively analyzed data from 236 children who underwent PH repair at our center between December 2020 and December 2022. We collected information on age, surgical procedure, length of the reconstructed urethra (LRU), glans width (GW), ventral curvature, surgical approach, preoperative androgen use, suture type, presence of prostatic utricle, body mass index, season of surgery, anesthesia type, low birth weight, preterm birth, follow-up period, and complications. Surgical complications included urethral fistulas, urethral diverticula, anastomotic strictures, urethral strictures, glans dehiscence, and penile curvature recurrences. The study population was divided into complication and no-complication groups, and univariate and multivariate analyses were conducted.ResultsOf the 236 patients with PH who had a median follow-up of 10.0 (8.0, 14.0) months, 79 were included (33.5%) in the complication group and 157 were included (66.5%) in the no-complication group. In the univariate analysis, age (P < 0.001), LRU (P < 0.001), degree of penile curvature (P = 0.049), and PH with prostatic utricle (P = 0.014) were significantly associated with complications after PH repair. In the multivariate logistic regression analysis, LRU (P<0.001, odds ratio [OR] = 3.396, 95% confidence interval [CI]: 2.229–5.174) and GW (P = 0.004, OR = 0.755, 95%CI: 0.625–0.912) were independent factors influencing postoperative complications. The optimal LRU threshold was 4.45 cm (area under the curve, 0.833; sensitivity, 0.873; specificity, 0.873; P<0.001, OR = 3.396, 95% CI: 2.229–5.174).ConclusionsLRU and GW are independent factors affecting PH complications. An LRU of < 4.45 cm and an increased GW can reduce the risk of complications.

The Effect of Body Mass Index on Free Flap Breast Reconstruction.

Literature addressing the risks associated with increasing body mass index (BMI) for patients undergoing free flap breast reconstruction is limited. Often, an arbitrary BMI cutoff (i.e., BMI of 30 kg/m2) is used to determine candidacy for a free flap without substantial backing evidence. This study utilized a national multi-institutional database to analyze outcomes of free flap breast reconstruction and stratified complications by BMI class. Using the 2010 to 2020 National Surgical Quality Improvement Program database, patients who underwent free flap breast reconstruction were identified. Patients were divided into six cohorts based on the World Health Organization BMI classes. Cohorts were compared by basic demographics and complications. A multivariate regression model was created to control for age, diabetes, bilateral reconstruction, American Society of Anesthesiologists class, and operative time. Surgical complications increased with each BMI class, with the highest rates occurring in class I, II, and III obesity, respectively. In a multivariable regression model, the risk for any complication was significant for class II and III obesity (odds ratio [OR]: 1.23, p < 0.004; OR: 1.45, p < 0.001, respectively). Diabetes, bilateral reconstruction, and operative time were independently associated with an increased risk of any complication (OR: 1.44, 1.14, 1.14, respectively, p < 0.001). This study suggests that the risks of postoperative complications following free flap breast reconstruction are highest for patients with a BMI greater than or equal to 35 kg/m2, having nearly 1.5 times higher likelihood of postoperative complications. Stratifying these risks by weight class can help guide preoperative counseling with patients and help physicians determine candidacy for free flap breast reconstruction.

Cognitive status predicts preoperative instruction compliance.

The most common postoperative complication for older adults is perioperative neurocognitive disorder (PNCD). Its greatest risk factor is preoperative cognitive impairment. Cognitive impairment also predicts higher likelihood of postoperative complications. While the cause of disparity in outcomes is likely multifactorial, the ability to correctly follow perioperative instructions may be one modifiable component. The purpose of this study was to determine whether cognitive impairment led to reduced preoperative instruction compliance and if so, identify barriers and enact a tailored care-plan to close the gap. Our preoperative clinic implemented routine Mini-Cog screening to identify older (age ≥ 65) surgical patients at increased risk. All patients received the same instructions and, on day of surgery, were surveyed to determine correct execution of nil per os guidelines, chlorhexidine wipe use and medication management. Data was stratified by cognitive status to evaluate whether impairment predicted instruction execution. Feedback from patients and families were compiled. Of those who screened negative for impairment, 68% correctly followed instructions, while 84.2% of those impaired struggled with ≥1 instruction(s); impaired patients were more likely to incorrectly follow instructions (OR = 10.5, p-value = 0.001). Areas for change were identified and team-based solutions were enacted with additional support for those with impairment. We found a clear difference in correct execution with respect to cognitive status. By improving instructions as an institution and adding additional support for those with impairment, the compliance gap was significantly reduced. Targeting perioperative instructions and tailoring care in this population may be one modifiable component in the outcome disparity they face.

Analysis of Lactate Monitoring Requirement in Emergent Surgical Interventions in Noncritical Traumatic Long Bone Fractures

INTRODUCTION: Serum lactate has been utilized as a standard in guiding management of orthopedic injuries. Elevated preoperative lactate has been associated with a higher likelihood of postoperative complications. However, lactate’s role in guiding operative timing in non-critical long-bone fractures has not been explored. This study investigates lactate’s role in guiding surgical timing and predicting complications secondary to delayed definitive correction in non-critical long-bone fractures with ISS < 16. METHODS: Retrospective review of 167 patients age ≥ 18 with long-bone fractures and ISS < 16. Demographic data was included. Two cohorts were considered: subjects with preoperative lactate ≥ 2.0 mmol/L and preoperative lactate < 2.0 mmol/L. Primary endpoints included mortality, perioperative complications, length of stay (LOS), and discharge disposition. Chi-square tests were conducted to assess the association between categorical variables and preoperative lactate groups. RESULTS: Among the 167 patients included, 148 patients had lactate < 2.0 mmol/L and 16 had lactate ≥ 2.0 mmol/L. There was no significant difference in age (p = 0.379), gender (p = 0.3061), BMI (p = 0.5655), ISS (p = 0.1297), days until surgery (p = 0.4759), surgery length (p = 0.1180), and preoperative vital signs (p Values varied) between these two preoperative lactate groups. Moreover, there was no difference in clinical outcomes between these two preoperative lactate groups, including mortality (p = 1), disposition (p = 0.415), hospital length of stay (p = 0.7722), and postoperative complications (p = 0.1). CONCLUSION: Normalization of preoperative serum lactate levels is not correlated with morbidity, mortality, or decreased LOS in trauma patients with an ISS < 16. This study shines new perspective on the role of perioperative lactate monitoring in guiding surgical timing, meriting further investigation.

Flap Reconstruction of Gastrointestinal-to-Genitourinary Fistulas: A 20-Year Experience.

Gastrointestinal-to-genitourinary fistulas may occur secondary to obstetric complications, radiation therapy, cancer without radiation, inflammatory bowel disease, or previous surgery. Flap reconstruction is useful for complex cases refractory to standard techniques, separating the fistula tracts to aid healing. The purpose of this study was to investigate outcomes and risk factors for complications in flap reconstruction of fistulas from several different etiologies performed over a 20-year period. All patients who underwent flap reconstruction between January 1995 and December 2014 were reviewed. Patient demographics, prior treatment failures, surgical indications, and comorbidities were obtained. Operative and postoperative data were collected, including flap type, length of stay, early and late complications, recurrences, and follow-up time. Operative success was defined as definitive treatment of the fistula without recurrence within 6 months. There were 59 patients who underwent 66 reconstructions. The overall complication rate was 59.1%. Complications included infection (21%), dehiscence (17%), and partial flap loss (1.5%). Operative success rate was 51.5%. Smoking history (p = 0.021) and body mass index (BMI) > 35 (p = 0.003) were significantly associated with increased likelihood of postoperative complications following flap reconstruction in these patients. Additionally, fistulas due to cancer resections had a higher likelihood of postoperative complications compared with fistulas due to bowel disease or obstetric complications (p = 0.04). Flap reconstruction can be successfully used for complex or refractory gastrointestinal-to-genitourinary fistulas. However, considerable complication and recurrence rates were found in this population. Patients with a BMI > 35 and a history of smoking were at greatest risk in this cohort of experiencing postoperative complications.

Outcomes following neuromuscular blockade in patients receiving tracheostomies

ObjectiveThe purpose of this study is to determine whether the use of neuromuscular blockade agents (NMBAs) in pediatric patients following tracheostomy is associated with increased rates of complications or a prolonged length of stay. MethodsThis was a single-center retrospective chart review of pediatric patients undergoing tracheostomy placement between 2010 and 2013 who were admitted to the pediatric or neonatal intensive care units and did or did not receive NMBA within 7 days post-procedure. ResultsOut of 114 included patients, 26 (23%) received NMBAs during the postoperative period. Patients receiving NMBAs were more likely to have cardiac disease and preoperative respiratory failure but less likely to have neurologic disease. Patients receiving NMBAs had a longer median postoperative length of stay (33 vs. 23 days, p=0.043) and were more likely to have postoperative ileus (12% vs. 3%, p=0.037). ConclusionIn patients undergoing tracheostomy placement, use of NMBAs is associated with prolonged postoperative hospital courses. NMBAs are not associated with a higher likelihood of postoperative complications.

Immediate breast volume replacement using a free dermal fat graft after breast cancer surgery: multi-institutional joint research of short-term outcomes in 262 Japanese patients.

Immediate volume replacement using a free dermal fat graft (FDFG) has been proven safe with early postoperative benefits. The aims of the present study were to clarify adequate indications and risk factors associated with operative morbidity. A multi-institutional analysis of partial mastectomy with immediate volume replacement with FDFG was undertaken in 14 hospitals specializing in breast cancer treatment. Clinical and oncological variables were analyzed to identify factors associated with postoperative complications. A total of 262 cases were analyzed. Considering the observation period and overlap of patients, 13 (5.4%) out of 242 patients had complications within 1 month of surgery while 7 (4.6%) out of 151 patients developed complications 1-12 months after surgery. Two hundred and eleven out of 242 patients were statistically examined using a multivariate analysis, which revealed that the weight of resected breast tissue, size of implanted FDFG (cranio-caudal length), and weight of implanted FDFG were associated with a higher likelihood of postoperative complications. Immediate breast volume replacement using a FDFG after breast cancer surgery should be done for selected patients with breast cancer to avoid postoperative complications. The prospective and larger investigations are warranted for the establishment of appropriate guidelines.

Do pelvic dimensions and prostate location contribute to the risk of experiencing complications after radical prostatectomy?

To assess if pelvic size, such as a narrow, steep pelvis, as well as prostate location in relation to the pelvic anatomy might have an impact on the likelihood of experiencing complications after radical prostatectomy. In a standardized manner, different bony and soft tissue dimensions on preoperative staging MRI were retrospectively measured in a study cohort of 934 patients undergoing radical prostatectomy. Measurements were defined aimed at assessing pelvic size and prostate location. Medical and surgical complications after radical prostatectomy were meticulously reviewed and grouped into subcategories to assess whether a narrow, steep pelvis and an anatomically deeply situated prostate (which is thought to be more surgically challenging) might be associated with a higher likelihood of postoperative complications. Multivariate Cox regression was performed to assess if dimensions have a significant impact on the likelihood of postoperative complications. While known parameters such as a higher preoperative PSA and presence of comorbidities were associated with an increased risk of experiencing complications after surgical treatment, none of the dimensions assessed on preoperative MRI had a significant impact on the development of any medical or surgical complication. We report the largest cohort of patients where pelvic dimensions were evaluated in a standardized manner on preoperative MRI aimed at assessing anatomic factors and their impact on complications after radical prostatectomy. None of the measurements could significantly predict the likelihood of developing medical or surgical complications.

Relationship Between Provider Volume and Postoperative Complications for Bariatric Procedures in New York State

Although the number of bariatric procedures has grown recently, few studies have focused on the relationship between provider volume and outcomes among patients undergoing a bariatric procedure. Using New York State's inpatient discharge database, we identified adults undergoing a bariatric procedure in New York State between January 1, 2003 and December 31, 2003 (n=7,868). Separate multivariable statistical models were constructed to examine the relationship between surgeon volume and hospital volume and postoperative complications (using surgeon volume cutpoints of 25, 50, 100, 150 and hospital volume cutpoints of 100, 125, 150, 200) while controlling for demographic characteristics and comorbidity. There was a considerably higher likelihood of postoperative complications among surgeons performing 100 or fewer bariatric procedures compared with those performing more than 100 procedures (odds ratio [OR]: 2.39, 95% CI: 1.59 to 3.59) and for those performing 150 or fewer procedures compared with those performing more than 150 procedures (odds ratio: 2.05, 95% CI: 1.29 to 3.25) after risk adjustment. Likewise, for each of the four hospital volume cutpoints, there was a notably higher likelihood of postoperative complications in the lower volume hospitals. Analyses of the interaction between surgeon and hospital volume indicated a markedly higher likelihood of postoperative complications among patients operated on by a low-volume surgeon (100 procedures or fewer) in a low-volume hospital (150 procedures or fewer) or a low-volume surgeon in a high-volume hospital than among patients operated on by a high-volume surgeon in a high-volume hospital. The likelihood of postoperative complications from bariatric procedures is greater for patients with low-volume surgeons or in low-volume hospitals.

High Hospital Volume Is Associated with Better Outcomes for Breast Cancer Surgery: Analysis of 233,247 Patients

The relationship between hospital volume and outcomes needs to be further elucidated for low-risk procedures such as surgical therapy of localized breast cancer. The objective of this investigation was to assess the relationship between hospital volume and outcomes for breast cancer surgery. A total of 233,247 patients who underwent breast-conserving therapy (BCT) and breast-ablative therapy (BAT) for localized breast cancer were extracted from 13 years (1988-2000) of the Nationwide Inpatient Samples. Hospital volume was classified as low (<30 cases/year), intermediate (> or =30 to <70 cases/year), and high (> or =70 cases/year). Multiple linear and logistic regression analyses were used to assess the risk-adjusted association between hospital volume and outcomes. In risk-adjusted analyses, patients operated on at low-volume hospitals were 3.04 (p = 0.03) times more likely to die after BCT compared with patients operated on at high-volume hospitals. Similarly, low-volume hospitals had a significantly higher likelihood of postoperative complications (odds ratio [OR] = 1.73, p = 0.01 for BCT; OR = 1.44, p < 0.001 for BAT) compared with high-volume hospitals. Compared with low-volume hospitals, length of hospital stay was significantly shorter and nonroutine patient discharge significantly lower for high-volume providers for both BCT and BAT (all p < 0.001). Patients were also significantly less likely to undergo BCT if operated on in a low- or intermediate-volume hospital compared with a high-volume provider (p < 0.001). High-volume hospitals had significantly lower nonroutine patient discharge, postoperative morbidity and mortality, shorter length of hospital stay, and higher likelihood of performing BCT. Referral of patients with localized breast cancer to high-volume hospitals may be justified.

Comorbidities Increase Complication Rates in Patients Having Arthroplasty

The objective of our study was to assess the effect of comorbidities (hypertension, diabetes, obesity, and their combinations) on postoperative complications and discharge status in patients having shoulder, hip, and knee arthroplasty (n = 959,839). The association between outcomes and each of the comorbidities was assessed using multivariable logistic regression after adjusting for age, race, household income, gender, and hospital volume. In the multivariable models, postoperative complications were more likely in patients with hypertension, diabetes, or obesity as compared with patients without these comorbidities (for hypertension, odds ratio = 1.07; 95% confidence interval range, 1.04-1.11; for obesity, odds ratio = 1.3; 95% confidence interval range, 1.22-1.41). The likelihood of a nonhomebound disposition of patients on discharge was 1.30 times (95% confidence interval range, 1.27-1.32) in patients with diabetes and 1.45 times (95% confidence interval range, 1.40-1.49) in patients who were obese as compared with patients without these respective comorbidities. Patients with a combination of comorbidities also had a higher likelihood of postoperative complications and nonhomebound discharge. Results of our study showed that hypertension, diabetes, and obesity are independent predictors of increased postoperative complications and non-homebound discharge in patients undergoing shoulder, hip, or knee arthroplasty. Prognostic study, Level II-1 (retrospective study). See the Guidelines for Authors for a complete description of levels of evidence.

Aqueous shunt devices compared with trabeculectomy with Mitomycin-C for children in the first two years of life

Purpose To compare the outcomes of children 24 months of age or younger treated with aqueous shunt devices or with mitomycin-C (MMC) trabeculectomy. Design Retrospective, age-matched, comparative case series. Methods Forty-six eyes of 32 patients with mean age of 7.0 ± 5.1 month (range, 1 to 22 months) and uncontrolled glaucoma, which received an aqueous shunt device (Ahmed glaucoma valve or Baerveldt implant), compared with 24 eyes of 19 patients with mean age of 5.3 ± 4.8 months (range, 0.5 to 24 months), which received an MMC trabeculectomy. Surgical success was defined as intraocular pressure < 23 mm Hg on maximal glaucoma medication, no further glaucoma surgery performed or recommended, no devastating complication, and stable ocular dimensions (axial length and corneal diameter). Results Cumulative probabilities of success were 87% ± 5.0% for the aqueous shunt group compared with 36% ± 8.0% success in the trabeculectomy group at 12 months and 53% ± 12% in the aqueous shunt group compared with 19% ± 7% in the trabeculectomy group at 72 months (χ 2 of 23.5, P < .0001). Aqueous shunt implantation was associated with significantly more postoperative complications requiring a return to the operating room (21 of 46 eyes, 45.7%) compared with trabeculectomy with MMC (3 of 24 eyes, 12.5%, P = .0074). The most common postoperative procedure in the aqueous shunt group was tube repositioning, performed in 16 of 46 eyes (34.8%). Conclusions Aqueous shunt implantation offers a significantly greater chance of successful glaucoma control in the first 2 years of life, compared with trabeculectomy with MMC. However, the enhanced success with aqueous shunt devices is associated with a higher likelihood of postoperative complications requiring surgical revision, most commonly tube repositioning.