Higher Rate Of Major Complications Research Articles

Continuous warfarin versus periprocedural dabigatran to reduce stroke and systemic embolism in patients undergoing catheter ablation for atrial fibrillation or left atrial flutter

Left atrial catheter ablation for patients with atrial fibrillation (AF) requires periprocedural anticoagulation to minimize thromboembolic complications. High rates of major bleeding complications using dabigatran etexilate for periprocedural anticoagulation have been reported, raising concerns regarding its safety during left atrial catheter ablation. We sought to evaluate the safety and efficacy of a dabigatran use strategy versus warfarin, at a single high-volume AF ablation center. We performed a retrospective analysis on consecutive patients undergoing left atrial ablation at Vanderbilt Medical Center from January 2011 through August 2012 with a minimum follow-up of 3months. Patient cohorts were divided into two groups, those utilizing dabigatran etexilate pre- and post-ablation and those undergoing ablation on dose-adjusted warfarin, with or without low-molecular-weight heparin bridging. Dabigatran was held 24-30h pre-procedure and restarted 4-6h after hemostasis was achieved. We evaluated all thromboembolic and bleeding complications at 3months post-ablation. A total of 254 patients underwent left atrial catheter ablation for atrial fibrillation or left atrial flutter. Periprocedural anticoagulation utilized dabigatran in 122 patients and warfarin in 135 patients. Three late thromboembolic complications occurred in the dabigatran group (2.5%), compared with one (0.7%) in the warfarin group (p = 0.28). The dabigatran group had similar minor bleeding (2.5 vs. 7.4%, p = 0.07), major bleeding (1.6 vs. 0.7%, p = 0.51), and composite of bleeding and thromboembolic complications (6.6 vs. 8.9%, p = 0.49) when compared to warfarin. There were no acute thromboembolic complications in either group (<24h post-ablation). In patients undergoing left atrial catheter ablation for AF or left atrial flutter, use of periprocedural dabigatran etexilate provides a safe and effective anticoagulation strategy compared to warfarin. A prospective randomized study is warranted.

Laparoscopic pyloromyotomy, the tail of the learning curve

The debate whether laparoscopic pyloromyotomy (LP) is superior to open pyloromyotomy (OP) remains actual. A recent review showed no benefit between the LP or OP, but in the studied randomized, controlled trials the learning curve was not addressed. Comparing LP including the learning curve with OP after the learning curve is questionable. In previous research, the learning curve of LP was analyzed. It was concluded that the plateau was reached after 35 procedures with a steep decrease in complications when comparing before and after 35 procedures. This study was designed to retrospectively analyze the results obtained in HPS patients after the learning curve in LP has been reached. The results will be compared with results of OP in HPS patients in the same period. A retrospective analysis in 106 OP and 57 LP was performed from September 2008 to June 2012. The overall complication rate in the OP group was significantly higher than in the LP group (18% vs. 3.5%, p = 0.012). Also there was a higher major complication rate in the OP group (10.4% vs. 1.7%, p = 0.045). The median time to operate was with 28.5 min in OP and 30.0 min in LP (not significant), whereas the LOS was 2 days in both groups (not significant). In this study, a further decline in overall and major complications after the learning curve is seen in the LP group, the tail of the learning curve. The debate whether LP is superior to OP is not finished as long as it is not clear whether the minimally invasive operation is beyond the initial or tail of the learning curve.

Comparison of Long‐Term Outcomes Associated With Three Surgical Techniques for Treatment of Cranial Cruciate Ligament Disease in Dogs

To evaluate long-term (>1 year) outcomes with respect to function and complications in dogs undergoing TightRope (TR), tibial plateau leveling osteotomy (TPLO), or tibial tuberosity advancement (TTA) for treatment of cranial cruciate ligament (CCL) disease. Retrospective clinical cohort study. Medical records from 2006 to 2009 were searched and cases included when all data were available and clients returned a completed questionnaire based on their assessment of their dog at least 1 year after surgery. Outcomes associated with TPLO, TTA, and TR were determined and compared based on medical records and questionnaires data regarding return to function, presence and degree of pain, and complications. Case meeting inclusion criteria were: TPLO (n = 65), TR (n = 79), and TTA (n = 18). TTA was associated with significantly (P < .03) higher rates of major complications and subsequent meniscal tears than TPLO and TR, and TPLO had significantly higher rates of major complications and meniscal tears than TR. Percent of function >1 year after surgery was 93.1% + 10.0% for TPLO, 92.7% + 19.3% for TR, and 89.2% + 11.6% for TTA. Significantly (P = 0.016) more TPLO and TR cases were classified as reaching full function than TTA. The highest levels, frequency, and severity of pain were noted in TTA cases, however, no significant differences were noted among groups. Long-term outcomes for TPLO and TR were superior to TTA based on subjective client and DVM assessments. Each technique was associated with a high long-term success rate with TR showing the highest safety-to-efficacy ratio.

Endoscopic endonasal transsphenoidal approach to large and giant pituitary adenomas: institutional experience and predictors of extent of resection.

OBJECT.: While the use of endoscopic approaches has become increasingly accepted in the resection of pituitary adenomas, limited evidence exists regarding the success of this technique for patients with large and giant pituitary adenomas. This study reviews the outcomes of a large cohort of patients with large and giant pituitary adenomas who underwent endoscopic endonasal transsphenoidal surgery at the authors' institution and focuses on identifying factors that can predict extent of resection and hence aid in developing guidelines and indications for the use of endoscopic endonasal transsphenoidal surgery versus open craniotomy approaches to large and giant pituitary adenomas. The authors reviewed 487 patients who underwent endoscopic endonasal transsphenoidal resection of sellar masses. From this group, 73 consecutive patients with large and giant pituitary adenomas (defined as maximum diameter ≥ 3 cm and tumor volume ≥ 10 cm(3)) who underwent endoscopic endonasal transsphenoidal surgery between January 1, 2006, and June 6, 2012, were included in the study. Clinical presentation, radiological studies, laboratory investigations, tumor pathology data, clinical outcomes, extent of resection measured by volumetric analysis, and complications were analyzed. The mean preoperative tumor diameter in this series was 4.1 cm and the volume was 18 cm(3). The average resection rate was 82.9%, corresponding with a mean residual volume of 3 cm(3). Gross-total resection was achieved in 16 patients (24%), near-total in 11 (17%), subtotal in 24 (36%), and partial in 15 (23%). Seventy-three percent of patients experienced improvement in visual acuity, while 24% were unchanged. Visual fields were improved in 61.8% and unchanged in 5.5%. Overall, 27 patients (37%) experienced a total of 32 complications. The most common complications were sinusitis (14%) and CSF leak (10%). Six patients underwent subsequent radiation therapy because of aggressive tumor histopathology. No deaths occurred in this cohort of patients. Statistically significant predictors of extent of resection included highest Knosp grade (p = 0.001), preoperative tumor volume (p = 0.025), preoperative maximum tumor diameter (p = 0.002), hemorrhagic component (p = 0.027), posterior extension (p = 0.001), and sphenoid sinus invasion (p = 0.005). Endoscopic endonasal transsphenoidal surgery is an effective treatment method for patients with large and giant pituitary adenomas, which results in high (> 80%) rates of resection and improvement in visual function. It is not associated with high rates of major complications and is safe when performed by experienced surgeons. The preoperative Knosp grade, tumor volume, tumor diameter, hemorrhagic components on MRI, posterior extension, and sphenoid sinus invasion may allow a prediction of extent of resection and in these patients a staged operation may be required to maximize extent of resection.

Surgical versus conservative interventions for displaced intra-articular calcaneal fractures.

Fractures of the calcaneus (heel bone) comprise up to 2% of all fractures. These fractures are mostly caused by a fall from a height, and are common in younger adults. Treatment can be surgical or non-surgical; however, there is clinical uncertainty over optimal management. To assess the effects of surgical compared with conservative treatment of displaced intra-articular calcaneal fractures in adults. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (to July 2011), the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2011 Issue 3), MEDLINE (1948 to July 2011), EMBASE (1980 to 2011 Week 27), the WHO International Clinical Trials Registry Platform, Current Controlled Trials, and Orthopaedic Trauma Association annual meeting archives (1996 to 2011). Reference lists of retrieved articles were checked. No language restrictions were applied. Randomised and quasi-randomised controlled clinical studies comparing surgical versus conservative management for displaced intra-articular calcaneal fractures. Two review authors independently screened search results, selected studies, extracted data and assessed risk of bias. Primary outcomes were function (e.g. walking ability) and chronic pain. Risk ratios were calculated for dichotomous outcomes and mean differences for continuous outcomes. Missing standard deviations were calculated from P values. Four trials were included (602 participants). Three trials were small single-centre trials, and the fourth a large multi-centre trial including 424 participants. All trials had methodological flaws, usually failure to conceal allocation and incomplete follow-up data, which put them at high risk of bias. Follow-up ranged from 1 to 15 years after treatment.Data for functional outcomes, including walking ability, from three trials could not be pooled. The strongest evidence was from the multi-centre trial. This showed no statistically or clinically significant differences between the surgical and conservatively treated groups at three years follow-up in the ''validated disease-specific" score (0 to 100: perfect result; 424 participants; mean difference (MD) 4.30, 95% confidence interval (CI) -1.11 to 9.71; P = 0.12). There was no significant difference between the two groups in the risk of chronic pain at follow-up (19/40 versus 24/42; risk ratio (RR) 0.79, 95% CI 0.53 to 1.18; 2 trials). The multi-centre trial found no statistically or clinically significant difference between the two groups in health-related quality of life at three years follow-up (SF-36 (0 to 100: best outcome): MD 4.00, 95% CI -1.16 to 9.16; P = 0.13).Two small trials provided some limited evidence of a tendency for a higher return to previous employment after surgery (27/34 versus 15/27; RR 1.45, 95% CI 0.75 to 2.81; I² = 55%; 2 trials). One small trial found no difference between the two groups in the ability to wear normal shoes, whereas another small trial found that surgery resulted in more people who were able to wear all shoes comfortably. There was a higher rate of major complications, such as surgical site infection, after surgery compared with conservative treatment (57/206 versus 42/218; RR 1.44, 95% CI 1.01 to 2.04; 1 trial). Conversely, significantly fewer surgical participants had subtalar arthrodeses due to the development of subtalar arthritis (7/206 versus 37/218; RR 0.20, 95% CI 0.09 to 0.44; 1 trial). There were no significant differences between the two groups in range of movement outcomes or radiological measurements (e.g. Bohler's angle). The bulk of the evidence in this review derives from one large multi-centre but inadequately reported trial conducted over 15 years ago. This found no significant differences between surgical or conservative treatment in functional ability and health related quality of life at three years after displaced intra-articular calcaneal fracture. Though it reported a greater risk of major complications after surgery, subtalar arthrodeses for the development of subtalar arthritis was significantly greater after conservative treatment.Overall, there is insufficient high quality evidence relating to current practice to establish whether surgical or conservative treatment is better for adults with displaced intra-articular calcaneal fracture. Evidence from adequately powered randomised, multi-centre controlled trials, assessing patient-centred and clinically relevant outcomes is required. However, it would be prudent to reassess this need after an update of the review that incorporates new evidence from a currently ongoing multi-centre trial.

Abstract P4-17-08: Tissue Expander/Implant Breast Reconstruction with and without Postmastectomy Radiation: Predictive Factors for Complications

Abstract Purpose: 1) Review our complication rates with implant/expander reconstruction for breast cancer 2) Determine factors for complications, especially with postmastectomy radiation (PMRT) Materials and Methods: Data were collected through chart review of all patients (2004–2008) from an academic hospital undergoing implant/expander reconstruction. SAS was used for two or multi-variable analyses (logistic regression) to determine predictive factors for complications. Among PMRT patients, we evaluated complications rates by risk factors. Results: 237 patients underwent implant/expander reconstruction. Median time from implant placement until last follow-up was 173 days. 21.5% developed major complications (needing operative time or infection needing intravenous treatment). Diabetes was the most consistent factor associated with major complications (46.7 vs 20.1%, p = 0.02 and p = 0.009 in multivariable analysis). Radiation was linked to capsular contractures (18.6 vs 10.1%, p = 0.02). Chemotherapy (25.0 vs 19.0%, p = 0.26) or radiation (26.3 vs 19.1%, p = 0.21) did not predict major complications. Among patients receiving PMRT (80 patients), 26.2% had major complications, 34 had immediate PMRT on the expander and 44 had PMRT to the chest wall, followed by delayed reconstruction with expander/implant placement. In these, delayed reconstruction increased dehiscence (0 vs 18.2%, p = 0.009) compared to immediate reconstruction, with a trend for higher incidence of major complications in the delayed reconstruction group (14.7 vs 34.1%, p = 0.05). 40 Gy/16 versus 50–50.4 Gy/25-28 (28 vs 24%, p = 0.78) was not associated with major complications. Diabetes and smoking were associated with several complications. Conclusions: Diabetes is associated with a higher rate of major complications after expander/implant reconstruction while radiation increases capsular contractures. If PMRT is indicated, putting in an expander before radiation results in less morbidity than delayed reconstruction. Also, 40 Gy/16 versus 50–50.4 Gy/25-28 do not differ much in terms of complication rates. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-17-08.

Clinical Characteristics and Outcomes of Donor Nephrecomy for Obese Living Kidney Donors

Introduction: Superior outcomes for recipients of live donor kidney transplantation and serious shortage of deceased-donors have led to a rise in the volume of live donor transplants, especially in Japan. Recently, there is increasing evidence that obese patients are more susceptible to the development of chronic kidney disease (CKD) either a direct result of their weight or as a consequence of their obesity-related comorbidities, such as hypertension and diabetes. Accordingly, recognition of increasing body mass index (BMI) as a risk factor for CKD, however, has raised concerns about the appropriateness of accepting obese live kidney donors. Open surgical nephrectomry in obese subjects is associated with higher rates of post-operation complicating, primarily wound related. Furthermore, some centers reported longer operative time and higher conversion rates for obese donors. Conversely, the introduction of laparoscopic techniques facilitates use of obese donors. Little is known about the baseline clinical characteristics and subsequent outcomes for obese donors beyond the perioperative period. Therefore, acceptance of obese individuals as living kidney donors is still controversial related to possible increased risk for surgical complications and concern that obesity may contribute to long-term kidney disease. Objectives: The primary objectives of this study was to address this issue by examining short-term outcomes for live donors according to BMI category (ie; nonobese [BMI< 25] and obese [BMI≥25]) at Osaka University Hospital (OUH). Materials and methods: The study involved a retrospective review of the records of living kidney donors who underwent donor laparoscopic nephrectomy at OUH during the period from 1/1/2005 through 12/31/2010. The institutional review board of OUH approved the data collection procedures for those individuals who had not declined use of their medical records for research at the time their clinical care commenced. Based on the information in the medical record, donors were divided into two groups according to BMI:< 25 kg/m2 and ≥25 kg/m2 for analysis. Surgical outcomes including operation time, operation bleeding and perioperative complications were compared across BMI group. Baseline clinical characteristics recorded at the time of donor evolution, including BMI, blood pressure, fasting plasma glucose, lipids levels and renal function wore compared across BMI groups. Results: The results are summarized in the table as described below.Table: [E Ueda et al. table for result]Conclusion: These results demonstrate that donor nephrectomy is generally safe in selected obese donors and does not result in a high rate of major perioperative complications. While early results are encouraging, we advocate careful study of long-term follow-up for obese donors and more intensive preoperative education and postoperative health care maintenance should be needed in obese donor groups.

Robotic Partial Nephrectomy: Imperative vs Elective Indications

To assess the impact of imperative or elective indications on the perioperative outcomes of patients undergoing robotic partial nephrectomy. Between January 2008 and August 2011, 381 consecutive robotic partial nephrectomies were retrospectively included. Two groups of patients were identified: those who underwent the procedure for an imperative indication (n = 98) and those who underwent the procedure for an elective indication (n = 283). Perioperative and renal function outcomes were compared between the 2 groups. Multivariate analysis was performed to determine whether imperative indications were predictors of complications, chronic kidney disease stage upstaging, postoperative estimated glomerular filtration rate, and percentage of estimated glomerular filtration rate decrease. There were no differences between the 2 groups with respect to RENAL score and tumor size. Patients in the imperative group were more likely to have a higher Charlson Comorbidity Index score (6 vs 4, P < .001), higher chronic kidney disease stage (P < .001), and lower estimated glomerular filtration rate (61.9 vs 88.6 mL/min/1.73 m(2), P < .001). Perioperative outcomes were similar with respect to warm ischemia time, estimated blood loss, operative time, transfusion rate, positive surgical margin rate, and length of stay. Imperative indications were associated with higher major complication rate (7.22% vs 2.47%, P = .032), but not with overall (31.6% vs 26%, P = .62) and intraoperative complications (6.1% vs 3.2%, P = .22). In multivariate analysis, imperative indication was an independent predictor of postoperative estimated glomerular filtration rate but was not a predictor of percentage of estimated glomerular filtration rate decrease and chronic kidney disease upstaging. Patients undergoing robotic partial nephrectomy for an imperative indication have similar functional outcomes than those with an elective indication. However, they are at higher risk of major complications.

The Effect of Osteoporosis on Outcomes of Operatively Treated Distal Radius Fractures

We hypothesized that postmenopausal osteoporotic women with distal radius fractures treated with open reduction internal fixation had worse functional outcomes than women without osteoporosis sustaining similar injuries. We retrospectively reviewed prospectively collected data for 64 postmenopausal women treated with open reduction internal fixation for distal radius fractures between 2006 and 2010 with known bone mineral density measured by dual-energy x-ray absorptiometry at the time of injury (osteopenia, n = 44; osteoporosis, n = 20). Data collected included age, mechanism of injury, fracture severity, and associated comorbidities. Outcomes included range of motion, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, and radiographic parameters of fracture reduction. We calculated patients' Charlson Comorbidity Index and tabulated complications. The primary outcome was DASH score at 12 months after injury. We applied multiple linear regression to determine whether bone mineral density status was predictive of functional outcomes 12 months after injury. We used logistic regression analysis to identify factors independently associated with poor outcomes and applied likelihood estimation to determine predictors of a high DASH score at 12 months. At 1 year postoperatively, women with osteoporosis had average DASH scores 15 points higher than those with osteopenia. Both osteoporosis and the Charlson Comorbidity Index were strong positive independent predictors of higher DASH scores (ie, poorer functional outcomes). There were no significant differences in range of motion or radiographic data between groups. Patients with osteoporosis had a higher rate of major complications. Osteoporosis had a negative impact on functional outcomes for women with distal radius fractures treated with open reduction internal fixation. Surgeons should identify high-risk patients, ensure close monitoring, and initiate appropriate preventative measures in this patient population. Prognostic II.

Comparison of 2 expandable stents for malignant esophageal disease: a randomized controlled trial

Self-expanding metal stents (SEMSs) provide effective palliation in patients with malignant dysphagia. However, although life expectancy is generally limited, reintervention rates because of stent dysfunction are significant. New SEMSs are being designed to overcome this drawback. To investigate whether the results of SEMS placement could be improved with a new SEMS design. Consecutive patients with dysphagia or leakage caused by malignant esophageal disease. In a multicenter randomized clinical trial, consecutive patients with dysphagia or leakage because of malignant esophageal disease were randomized to placement of a conventional stent or the new stent. Patients were followed up by scheduled telephone calls 1 and 3 months after SEMS insertion. A total of 80 patients (73% male; median age, 67 years [range, 40-92 years]) were included. One patient refused follow-up. Technical success was 100% in both groups. The reintervention rate was 15/40 (38%) for the conventional stent and 4/39 (10%) for the new stent (P = .004). Major complications, including aspiration pneumonia and bleeding, occurred more frequently with the conventional stent (10/40, 25%) than with the new stent (3/39, 8%, P = .04). There was no difference in overall survival between the 2 groups. Inclusion of patients with a perforation or fistula. The conventional stent and the new stent were equally effective in the relief of malignant dysphagia and sealing fistulae. The conventional stent was associated with more stent dysfunction and a significantly higher rate of major complications. Patients treated with the new stent also needed significantly fewer reinterventions than did those treated with a conventional stent. This sets the preference for the new stent over the conventional stent for patients with malignant esophageal disease.

Combination of biodegradable stent placement and single-dose brachytherapy is associated with an unacceptably high complication rate in the treatment of dysphagia from esophageal cancer

For the palliative treatment of dysphagia, esophageal stent placement provides immediate improvement, whereas brachytherapy offers better long-term relief. To evaluate safety and efficacy of concurrent brachytherapy and biodegradable stent placement. Prospective, single-arm study. Two tertiary-care referral centers. Nineteen consecutive patients with significant dysphagia resulting from unresectable esophageal cancer, with a life expectancy of more than 3 months. Single-dose brachytherapy (12 Gy) on day 1 followed by biodegradable stent placement on day 2. Intervention-related major complications (determined by an expert panel) and dysphagia. Nineteen patients (13 men, median age 66 years [interquartile range (IQR) 59-71] years) were included; 7 patients (37%) also received palliative chemotherapy. After inclusion of 19 patients, the study was ended prematurely because the safety threshold was exceeded. In total, 28 major complications occurred in 17 patients (89%). In 9 patients (47%), major complications were determined intervention-related (severe retrosternal pain with or without vomiting [n = 6], hematemesis [n = 1], recurrent dysphagia [n = 2]. Dysphagia scores decreased significantly from a median of 3 (IQR 3-4) to a median of 1 (IQR 0-3) after 1 month (P < .001). Despite adequate luminal patency in 17 patients (89%), normal diet could not be tolerated in 7 patients (37%) because of retrosternal pain and vomiting. Lack of routine endoscopy or contrast esophagram to evaluate recurrent dysphagia during follow-up. Despite restoration of luminal patency, a combined treatment of brachytherapy and biodegradable stent placement cannot be recommended for the palliative treatment of esophageal cancer because of an unacceptably high intervention-related major complication rate.

1934 TREATMENT OF UPPER URINARY CALCULI WITH MPCNL A SINGLE-CENTER EXPERIENCE OF 19 YEARS

1934 TREATMENT OF UPPER URINARY CALCULI WITH MPCNL A SINGLE-CENTER EXPERIENCE OF 19 YEARS

Phase II Trial of Full-Dose Gemcitabine and Bevacizumab in Combination With Attenuated Three-Dimensional Conformal Radiotherapy in Patients With Localized Pancreatic Cancer

To evaluate response rate, survival, and toxicity in patients with nonmetastatic pancreatic cancer treated with gemcitabine, bevacizumab, and radiotherapy. Patients received three cycles of therapy over 10 weeks. In total, treatment consisted of intravenous (IV) gemcitabine, 1,000 mg/m(2), every 1 to 2 weeks (7 doses), IV bevacizumab, 10 mg/kg every 2 weeks (5 doses), and 36 Gy of radiotherapy (2.4-Gy fractions during cycle two). Response was assessed by cross-sectional imaging and carbohydrate antigen 19-9 (CA 19-9) levels. Patients with resectable tumors underwent surgery 6 to 8 weeks after the last dose of bevacizumab. Maintenance gemcitabine and bevacizumab doses were delivered to patients who had unresected tumors and no progression. Twenty-eight of the 32 enrolled patients completed all three cycles. The median follow-up was 11.07 months. Most grade 3 or 4 toxicities occurred in the initial treatment phase; the most frequent toxicities were leukopenia (21%), neutropenia (17%), and nausea (17%). At week 10, 1 patient (4%) had a complete response, 2 patients (7%) had partial responses, 21 patients (75%) had stable disease, and 4 patients (14%) had progressive disease. The median pretreatment and posttreatment CA 19-9 levels (25 patients) were 184.3 and 57.9 U/ml, respectively (p = 0.0006). One of 10 patients proceeding to surgery experienced a major complication. Two of 6 patients undergoing resection had complete pathologic responses. The median progression-free and overall survival durations were 9.9 months and 11.8 months, respectively. The combination of full-dose gemcitabine, bevacizumab, and radiotherapy was active and was not associated with a high rate of major surgical complications.

Comparative Systematic Review of the Open Dislocation, Mini-Open, and Arthroscopic Surgeries for Femoroacetabular Impingement

To analyze the current approaches to the surgical management of symptomatic femoroacetabular impingement (FAI). Thirteen relevant queries were used in four search engines (PubMed, EMBASE, Ovid, and the Cochrane Review) with a resultant 5,856 articles. Eighteen peer-reviewed treatment outcome studies met the inclusion criteria with minimum 1-year follow-up of the surgical treatment of skeletal pathoanatomy and associated chondrolabral pathology in skeletally mature patients with FAI. There were 6 open surgical dislocation, 4 mini-open, and 8 arthroscopic studies, all with Levels of Evidence III or IV. The only prospective studies were in the arthroscopic category. Outcome data were extracted and analyzed with respect to surgical efficacy, failure rates, and complications. The open dislocation, mini-open, and arthroscopic methods for treating symptomatic FAI are effective in improving pain and function in short-term to midterm studies and are relatively safe procedures. The historical gold standard of open dislocation surgery had a comparatively high major complication rate primarily because of trochanteric osteotomy-related issues. The mini-open method showed comparable efficacy but a significant incidence of iatrogenic injury to the lateral femoral cutaneous nerve in some studies. The arthroscopic method had surgical outcomes equal to or better than the other methods with a lower rate of major complications when performed by experienced surgeons.

Pathologic fracture and metastatic spinal cord compression in patients with prostate cancer and bone metastases

BackgroundThe purpose of this study was to determine the risk factors for and incidence as well as prognostic impact of pathologic fracture (PF) and metastatic spinal cord compression (MSCC) in patients with bone metastases (BM) from prostate cancer.MethodsRetrospective cohort study including 61 consecutive patients seen at Nordland hospital's department of oncology between 2007 and 2009. The initial diagnosis of BM might have been made earlier. Twenty-nine patients (48%) received taxotere and 72% zoledronic acid after diagnosis of BM.ResultsMedian actuarial survival after diagnosis of BM was 23 months. Six patients (10%) were alive at 5 years. Bone pain at baseline was present in 49% of patients. Eighty-nine percent required external beam radiotherapy and/or radioisotopes after diagnosis of BM. Seventeen patients (28%) developed at least one major skeletal complication, i.e. MSCC or PF (4 of them developed more than one). The actuarial risk was 44% at 4 and 5 years. Most events developed before treatment with zoledronic acid and/or taxotere. Median survival from diagnosis of either MSCC or PF was 11 months (5 months from MSCC). We did not identify statistically significant risk factors for development of major skeletal complications. Serum alkaline phosphatase above median value and age less than or equal to 70 years were the only risk factors approaching significance.ConclusionsWe found high rates of major skeletal complications in this unselected contemporary group of patients. Identification of risk factors might guide the development of early interventions aiming at prevention of MSCC and PF.

Impact of obesity on surgical and oncological outcomes in the management of colorectal cancer

Obesity is an established risk factor for colorectal cancer, particularly in males, and may negatively impact on oncologic outcomes. The aim of this study was to examine the impact of body mass index (BMI) on mortality and morbidity, tumour pathology, and overall survival in a consecutive cohort of Irish colorectal cancer patients treated with curative intent. A retrospective analysis of BMI data entered prospectively into a comprehensive electronic database of colorectal cancer patients was undertaken. Patients were excluded if they had emergency surgery, previous malignancy or the BMI was not recorded. Analysis was performed comparing genders, obese with non-obese and comparing BMI categories. Of the 414 patients, 10% were underweight (<20 kg/m(2)); 35% were normal weight (20-25 kg/m(2)); 37% were overweight (25-30 kg/m(2)), and 18% were obese (≥ 30.00 kg/m(2)). Obesity overall was not significantly associated with pathological stage (p=0.099) or positive lymph node status (p=0.109) or degree of nodal involvement (p=0.068). Obesity was significantly (p<0.05) associated with more advanced pathological stage, node positivity and degree of nodal involvement in male only and colon cancer only analysis. There was no difference in the overall incidence of major (p=0.244) and minor complications (p=0.078) when comparing obese with non-obese, but pelvic abscesses were more common in obese patients (p=0.037). The underweight cohort had a higher rate of major complications (p=0.041), sepsis (p=0.024) and post-operative death (p=0.006). Survival was equivalent between BMI categories and obese and non-obese groups (p=0.469). Obesity was associated with more advanced tumours in males and in colon cancer patients only and with a higher risk of post-operative pelvic abscesses but no significant differences with non-obese cohorts in the main outcome measures of in-hospital mortality, major morbidity and survival. Conversely, the adverse consequences of under-nutrition were highlighted in this study.

Complications of Abdominal Contouring Surgery in Obese Patients

Medical records of 122 patients who underwent an abdominoplasty or panniculectomy from 2003 to 2008 were reviewed to determine current rates of wound complications associated with these procedures in the presence of obesity. An additional aim was to determine current rates of complications as compared with those found 10 years ago at our institution to determine if the finding of obesity alone continues to adversely affect wound outcomes. Sixty-three of 122 patients (51.6%) experienced 1 or more wound-related complications. Major complications occurred in 13 patients (10.7%). A striking finding was that the lowest major complication rate 4.5%, was found in patients with extreme obesity (BMI >40). Comparisons between the 1999 and current studies found that the difference in major complications in those classified as obese, with 2 (9%) in the current study and 8 (40%) in the 1999 study, was significant (P = 0.039). Our findings suggest that high rates of major complications found in those with obesity in the 1999 study are not found today. Extreme obesity is not an absolute contraindication to operation and may be performed safely.

Laparoscopic Hysterectomy in the Presence of Previous Caesarean Section: A Review of One Hundred Forty-One Cases in the Sydney West Advanced Pelvic Surgery Unit

Objective To examine whether laparoscopic hysterectomy is safe in the presence of previous caesarean section (CS). Design Canadian Task Force Classification II-2. Setting Laparoscopic hysterectomies performed for nonmalignant conditions by 7 gynecologic surgeons in public and private hospitals in Western Sydney. Patients Data were collected from January 2001 through December 2007, involving 574 patients, of which 141 patients had 1 or more previous CS. Intervention Laparoscopic hysterectomy. Measurements Conversions to laparotomy and major intraoperative and postoperative complications (within 6 weeks of surgery) were recorded and compared between cohorts of patients with and without previous caesarean sections. Main Results Of the 574 laparoscopic hysterectomies identified, 141 (24.6%) patients had at least 1 previous CS. Most women with previous CS had only 1 CS (51.8%), whereas 13.5% had 3 or more CS. The overall major complication rate among patients undergoing laparoscopic hysterectomy was 10.1%. The most common complication was hemorrhage (7.3% of patients) and inadvertent cystotomy (2.1%). The rate of major complications varied between the CS and non-CS groups. Among the non-CS group, the complication rate was 8.8%, whereas the complication rate among the CS group was 14.2%. The rate of inadvertent cystotomy in the group with no previous CS was 5 in 433 patients (1.2%). The rate of bladder complications showed an increase with the number of previous CS: 2.5% of patients with 1 or 2 previous CS and 21.1% of patients with 3 or more previous CS. The rate of inadvertent cystotomy in patients with 3 or more CS was 18 times that of patients with no CS (95% CI 5.1, 66.0). Twenty-four (5.5%) patients without previous CS and 15 (10.6%) patients with previous CS required conversion to laparotomy because of dense bladder or bowel adhesions. Conclusion Laparoscopic hysterectomy in the setting of previous CS is recommended because long-term sequelae are rare. There are higher rates of major complications in patients undergoing laparoscopic hysterectomy with previous CS; the higher the number of previous CS, the higher the rate of complications. The most significant increase is seen in patients with more than 2 previous CS.

Adverse Outcomes in Patients with Chronic Liver Disease Undergoing Colorectal Surgery

Objective We sought to use a multi-institutional, prospective, clinical database to better understand adverse outcomes in chronic liver disease (CLD) patients undergoing colorectal surgery. Background CLD confers significant perioperative risk. However, there are little population-based data available for prognostication and risk stratification in these patients. Methods We used data from the 2005-2007 American College of Surgeons National Surgical Quality Improvement Project to study 30,927 patients undergoing colorectal resections. We first identified patients with CLD (n = 1565) with any of the following clinical characteristics: ascites, esophageal varices, or total bilirubin greater than 2 mg/dL. Postoperative complications and mortality rates were then compared between CLD and non-CLD patients. Results CLD patients have a nearly 6.5-fold increased risk of mortality following colorectal operations (Relative Risk [RR], 6.53; 3.2% in non-CLD group versus 21.5% in CLD group). Patients with CLD also had significantly higher major complication rates (RR, 2.72; 15.4% vs. 41.9%, respectively). The failure to rescue rate (ie, proportion of deaths following major complications) was also markedly higher in patients with CLD (RR, 2.27; 15.1% vs. 34.2%, respectively). Furthermore, stratification of CLD patients by Model for End-stage Liver Disease (MELD) score demonstrated significantly higher rates of complications (RR, 2.41; 2.31-2.51), failure to rescue (RR, 2.62; 2.35-2.90), and mortality (RR, 8.92; 8.11-9.78) in CLD patients with MELD > or =15 compared with CLD patients with MELD Conclusions Colorectal surgery in CLD patients is associated with significant morbidity and mortality. Furthermore, those who develop major complications have a significantly higher risk of death compared to non-CLD. These very high risks should be discussed at length with patients prior to undertaking major surgical procedures.

Locked volar plating for unstable distal radial fractures: Clinical and radiological outcomes

We studied 40 patients treated with locked volar plates for unstable distal radial fractures. Outcome was assessed at a mean of 59 weeks, both radiologically and functionally using the Disability of the Arm, Shoulder and Hand (DASH) questionnaire, range of motion and grip strength. The complication rate in our series was 48%. In 11 cases, screw penetration into the radiocarpal joint occurred as a consequence of postoperative collapse. Of these, 25% had malunited and 12.5% ruptured their extensor pollicus longus (EPL) tendon. Functionally, when compared with the contralateral side, 74% of extension, 67% of flexion, 91% of pronation and supination and 81% of grip strength were regained. The mean DASH score was 23. Although locked volar plates can achieve good results in the management of unstable distal radial fractures, there remains a high major complication rate. They should be used with caution particularly in fractures with significant metaphyseal comminution.