Incidence Of Major Perioperative Complications Research Articles

Propensity score matching analysis of early vs. delayed surgery for intertrochanteric fracture in older patients: a retrospective multicenter cohort study of 7414 patients with a mean 4-year follow up

BackgroundThe widespread acceptance of early surgery as a treatment for acute intertrochanteric fracture (ITF) has been accompanied by ongoing controversy due to conflicting conclusions presented in previous studies. This study aims to compare the occurrence of perioperative complications and mortality, as well as functional outcomes in older patients with ITF who underwent either early or delayed surgery.MethodsA retrospective multicenter cohort study involving 7414 patients with ITF between Jan. 2017 and Dec. 2021 was conducted. After predefined participants selection inclusion and exclusion criteria, 2323 surgically treated ITF patients were included and analyzed utilizing propensity score matching (PSM) method. Their demographics, injury-related data, surgery-related data, and perioperative adverse outcomes during hospitalization were collected and compared between the early or delayed surgery groups by PSM with a 1:4 ratio. All participants received a minimum of two-year follow-up and perioperative outcomes, functional outcomes, and survival analyses were conducted and compared.ResultsAfter adjustment for potential confounders, there were no significant difference in surgery duration, intraoperative blood loss, transfusion rate, mortality rates, functional outcomes, and perioperative complications rates including severe complications, cardiac complications, pulmonary complications, and neurological complications regardless of whether the patient was treated with early or delayed surgery (all P > 0.05). Although length of hospital stay (mean, 11.5 versus 14.4 days, P < 0.001), total hospital costs (mean, 39305 versus 42048 yuan, P < 0.001), and minor complications rates including hematological complications (31.7% versus 41.2%, P = 0.007) and nutritional/metabolic complications (59.3% versus 66.4%, P = 0.039) were lower in the early surgery group, our result indicated patients with early surgery were more inclined to receive more blood transfusion (mean, 2.8 versus 2.2 units, P = 0.004).ConclusionsOur findings suggest that a 48-hour delay in surgical intervention for older patients with an ITF does not result in a higher mortality rate, worse functional outcomes, and increased incidence of major perioperative complications when compared to early surgery. While expedited surgery is undoubtedly necessary for suitable patients, a reasonable preoperative delay of 48 h may be justified and safe for those with severe conditions, rather than strictly adhering to the current guidelines.

Thoracoscopic three-port single versus multiple intercostal for radical resection of esophageal cancer: a retrospective analysis

BackgroundThe purpose of this retrospective study was to compare the safety and feasibility of single-intercostal totally minimally invasive Ivor Lewis esophagectomy (MIIE) with those of multiple-intercostal MIIE.MethodsBetween January 2016 and December 2022, clinical data were collected for 528 patients who successfully underwent totally minimally invasive esophagectomy. Among these patients, 294 underwent MIIE, with 200 undergoing the single-intercostal approach and 94 undergoing the multiple-intercostal approach. Propensity score matching (PSM) was applied to the cohort of 294 patients. Subsequently, perioperative outcomes and other pertinent clinical data were analyzed retrospectively.ResultsA total of 294 patients were subjected to PSM, and 89 groups of patient data (178 persons in total) were well balanced and included in the follow-up statistics. Compared to the multiple intercostal group, the single intercostal group had a shorter operative time (280 min vs. 310 min; p < 0.05). Moreover, there was no significant difference in the incidence of major perioperative complications (p > 0.05). The total number of lymph nodes sampled (25.30 vs. 27.55, p > 0.05) and recurrent laryngeal nerve lymph nodes sampled on the both sides (p > 0.05) did not significantly differ. The single intercostal group had lower postoperative long-term usage of morphine (0,0–60 vs. 20,20–130; p < 0.01), total temporary addition (10,0–30 vs. 20,20–40; p < 0.01) and temporary usage in the first 3 days after surgery (0,0–15 vs. 10,10–20; p < 0.01) than did the multicostal group.There were no significant differences in age, sex, tumor location or extent of lymphadenectomy or in the clinical factors between the single-intercostal group (p > 0.05).ConclusionsBoth techniques can be used for the treatment of esophageal cancer. Compared to multiple intercostal MIIE, the feasibility of which has been proven internationally, the single intercostal technique can also be applied to patients of different age groups and sexes and with different tumor locations. It can provide surgeons with an additional surgical option.Trial registrationThis study was retrospectively registered by the Ethics Committee of the Second Affiliated Hospital of Zhejiang University School of Medicine, and written informed consent was exempted from ethical review. The registration number was 20,230,326. The date of registration was 2023.03.26.

Transoral LASER microsurgery - A retrospective analysis on perioperative complications and safety

BackgroundComplications associated with transoral LASER microsurgery (TLM) approach for head and neck tumours seems to be not completely understood namely those related with airway management and intubation. AimTo evaluate the real dangers and safety problems associated with TLM. MethodsEvaluation of perioperative complications through a retrospective study involving all patients submitted to general anaesthesia with intubation for TLM for cancer of aerodigestive tract during a period of eleven years. Results1053 interventions met the inclusion criteria. At the end of the procedure, most of patients (97.3%) were extubated, 2.4% had postponed extubation and 0.3% had programmed tracheostomy. PVC microlaryngeal oral tracheal tubes (PVC-OTT) were used in 96% of cases. Only 28 major complications were registered, none being due to laser associated problems, namely airway ignition. ConclusionsTLM for cancer under general anaesthesia is associated with low incidence of major perioperative complications (2.7%), which are more relevant in the immediate postoperative period. Most of the patients may be extubated immediately, but in a few situations programmed postponed extubation or temporary tracheostomy may prevent some postoperative complications. The use of PVC –OTT was not associated with an increased risk of airway or equipment damage.

David reimplantation with simultaneous total arch replacement and stented elephant trunk for acute type A aortic dissection

ObjectivesTo compare early and mid-term outcomes between David reimplantation and the Bentall procedure with simultaneous total arch replacement (TAR) and stented elephant trunk (SET) implantation in acute type A aortic dissection (ATAAD). MethodsFrom January 2012 to June 2018, 148 patients underwent aortic root replacement combined with TAR and SET for ATAAD. Patients were evaluated retrospectively and categorized into David reimplantation (n = 55) and Bentall procedure (n = 93) groups. Propensity-matched analysis was performed to compare in-hospital and follow-up adverse events between the 2 groups. ResultsIn-hospital mortality and the incidence of major perioperative complications were comparable between the 2 groups (all P > .05). No significant difference in mean cardiopulmonary bypass time and circulatory arrest time was found between the 2 groups, although mean crossclamp time was longer in the David group (P = .02). During a follow-up period of 2.6 (interquartile range, 1.5-4.3) years, the Bentall group experienced rates of paravalvular leakage and prosthetic valve endocarditis of 2.3% and 2.3%, respectively, whereas the David group experienced rates of infective endocarditis and recurrent moderate aortic regurgitation of 1.9% and 1.9%, respectively. The overall survival was 82.9% for the David group and 89.2% for the Bentall group (P = .63), whereas the incidence of major cardiovascular-related events was 21.3% and 17.3% (P = .30) 5 years postoperatively. ConclusionsFor Chinese patients undergoing ATAAD, David reimplantation provided similar outcomes compared with the Bentall procedure, with simultaneous TAR and SET. David reimplantation is an appealing option for patients who suffer root ectasia or extensive sinus damage albeit normal leaflets.

Failure to Rescue, Hospital Volume, and In-Hospital Mortality After Transcatheter Aortic Valve Implantation

Failure to rescue (FTR), death after major complications, has been well described in the surgical literature as a source of different outcomes in different hospitals. However, FTR has not been investigated in transcatheter aortic valve implantation (TAVI). Our aim was to assess the difference of in-patient mortality and FTR in different TAVI volume hospitals. We queried the Nationwide Inpatient Sample database from 2011 to 2015 to identify patients who had transarterial TAVI. FTR was calculated as those who had in-patient mortality with at least one with major perioperative complications. Hospitals were divided into three groups according to annual TAVI volume, the lowest quintile (≤30/year), second to fourth quintile (31 to 130/year), and highest quintile (≥130/year). Multivariate analysis was used to calculate risk adjusted in-patient mortality rate and FTR and was compared between these different volume hospitals. A total of 48,886 TAVI procedures were identified (10,407, 28,811, and 9,668 in low, intermediate, and high volume centers, respectively). Mean age, percentage of woman, and Elixhauser co-morbidity index was similar across different TAVI volume hospital. The incidence of major perioperative complications did not differ in different volume hospitals. Adjusted rate of in-patient mortality (2.3%, 1.87%, and 1.57% for low, intermediate, and high volume center, respectively, p <0.001) were significantly less with greater hospital volume but FTR (8.24%, 8.20%, and 6.12% for low, intermediate, and high volume center, respectively, p = 0.29) were the same in the three groups. Our results suggest that FTR does not explain the variation of in-hospital mortality in different hospital volumes.

Effect of Antifibrinolytic Therapy on Complications, Thromboembolic Events, Blood Product Utilization, and Fusion in Adult Spinal Deformity Surgery.

A multicenter, prospective, consecutive database of surgical patients with adult spinal deformity (ASD). This study investigated the use of antifibrinolytic (AF) therapy in ASD surgery. AF therapy has been shown to be effective in preventing blood loss in some settings. Its effect on major and minor perioperative complications, blood product utilization, vascular events, and postoperative fusion in patients undergoing ASD surgery remains unclear. All patients with data on AF use were included. Parameters of blood utilization included transfusion rates and units of packed red blood cells and fresh frozen plasma transfused. Thromboembolic events included stroke, deep vein thrombosis, and pulmonary embolus. Multivariate regression was used, accounting for confounders. Four hundred three patients were included. One hundred thirty-seven patients received aminocaproic acid (EACA), 81 received tranexamic acid (TXA), and 185 received no AFs. The use of AF was associated with a decrease in transfusion (EACA: odds ratio [OR] = 0.38, P = 0.043; TXA: OR = 0.31, P = 0.047), a decrease in the number of units of packed red blood cells transfused (EACA: incidence risk ratio [IRR] = 0.45, P = 0.0005; TXA: IRR = 0.7, P = 0.0005), and a decrease in the number of fresh frozen plasma transfused (EACA: IRR = 0.65, P = 0.003; TXA: IRR = 0.67, P = 0.006). AF use was associated with an increase in minor intraoperative complications (EACA: IRR = 2.15, P = 0.008; TXA: IRR = 2.12, P = 0.011). TXA use (but not EACA) was associated with a decrease in the incidence of major perioperative complications compared with no AF (IRR = 0.37, P = 0.019). There was no difference in the incidence of thromboembolic events. TXA or EACA use was associated with increased minor intraoperative complications. TXA was associated with decreased major perioperative complications. AF was associated with decreased utilization of blood products without an increased rate of thromboembolic events. Given the nature of this study, transfusion threshold was not standardized. Future studies with rigid criteria for transfusion should be prospectively performed to better evaluate the impact of AF during ASD surgery. 3.

The effect of antifibrinolytic therapy on complications, blood product utilization, and fusion in adult spinal deformity

Antifibrinolytic therapy (AF) has been shown to be effective in preventing blood loss in some settings. Its effect in patients undergoing adult spinal deformity (ASD) surgery remains unclear. This study looks at the use of antifibrinolytic therapy in adult spinal deformity surgery and its effect on major and minor perioperative complications, blood product utilization, vascular events and postoperative fusion. A multicenter prospective consecutive database of surgical ASD patients was reviewed. Complications were divided into intra-operative and perioperative (within 6 weeks). Parameters of blood product utilization included the rate of transfusion, and the units of PRBCs and FFP transfused. Thromboembolic events included stroke, deep venous thrombosis (DVT) and pulmonary embolus (PE). Fusion rates at 2 years were measured on AP and lateral radiographs at using the Lenke classification. The impact of AF use on complications, blood product utilization, vascular events and fusion rates was studied using multivariate logistic, ordinal logistic, or poisson regression, as appropriate. Models accounted for confounders as determined by univariate analysis and expert opinion. In total, 403 patients were included, 137 patients received aminocaproic acid (ACA), 81 received tranexamic acid (TXA), 185 received no AF, 227 patients had two-year radiographic data. The use of AF was associated with a decrease in transfusion (ACA OR 0.38 P = 0.043, TXA 0.31 P = 0.047), a decrease in the number of units of PRBCs transfused (ACA IRR 0.45 P = 0.0005, TXA IRR 0.7 P = 0.0005), and a decrease in the number of FFP transfused (ACA IRR 0.65 P = 0.003, TXA IRR 0.67 P = 0.006). The use of TXA (but not ACA) was associated with a decrease the incidence of major perioperative complications compared to no AF (IRR 0.37, P = 0.019). AF use was not associated with an increase in thromboembolic events. The use of AF did not impact the fusion rates at 2 years. The use of TXA or ACA was associated with increased minor intra-operative complications. TXA was associated with decreased major perioperative complications. AF was associated with decreased utilization of blood products without an increased rate of thromboembolic events. Given the observational nature of this study, transfusion threshold was not standardized across the study sites. Future studies with rigid criteria for transfusion should be prospectively performed to better evaluate AF use in ASD.

Does the Impact of the Type of Anesthesia on Outcomes Differ by Patient Age and Comorbidity Burden?

Neuraxial anesthesia may provide perioperative outcome benefits versus general anesthesia in orthopedic surgical patients. As subgroup analyses are lacking, we evaluated the influence of the type of anesthesia on outcomes in patient groups of different age and the presence of cardiopulmonary disease. Data from approximately 500 hospitals in the United States regarding total hip and total knee arthroplasties performed between 2006 and 2012 were accessed. Patients were categorized by age (ie, <65, 65-74, or ≥75 years) as well as the presence of cardiopulmonary disease. Resulting groups were compared with regard to patient, hospital, procedure, and comorbidity-related variables, as well as incidence of major perioperative complications. A multivariable logistic regression analysis was performed to assess the independent influence of the type of anesthesia on complications within each patient subgroup. We identified 795,135 records of patients who underwent total hip arthroplasty or total knee arthroplasty. The incidence of major complications was highest in the oldest patient group with cardiopulmonary disease (26.1%) and the lowest in the youngest group without cardiopulmonary disease (4.5%).Multivariable logistic regressions showed that neuraxial anesthesia was associated with decreased odds for combined major complications, need for intensive care services, and prolonged length of stay compared with general anesthesia in all patient subgroups. For patients without major cardiopulmonary comorbidities, the positive impact of neuraxial anesthesia increased with increasing age. Neuraxial anesthesia is associated with decreased odds for major complications and resource utilization after joint arthroplasty for all patient groups, irrespective of age and comorbidity burden.

Same-Day Versus Staged Bilateral Total Knee Arthroplasty Poses No Increase in Complications in 6672 Primary Procedures

We examined the assumption that patients undergoing same-day bilateral total knee arthroplasty (TKA) have a higher incidence of major peri-operative complications than patients who stage their procedures over the course of a year. Between April 2001 and March 2007, prospective data were collected using a total joint registry. Patients undergoing primary, bilateral, same-day, TKAs were compared to patients undergoing primary, staged, bilateral TKAs within 12 months of the index operation. A total of 2441 TKAs were performed on the same day, while 4231 were staged. There were no significant differences in 90-day mortality, thrombotic events and infections between the two groups. Performing same-day bilateral TKA does not predispose patients to increased cumulative incidence of major complications over staged arthroplasty.

Early carotid angioplasty and stenting may offer non-inferior treatment for symptomatic cases of carotid artery stenosis

ObjectiveEarly intervention is desirable in patients presenting with stroke or transient ischemic attack (TIA) referable to carotid artery stenosis because of the high incidence of recurrent ischemic events within 48...

Abstract 165: Is Sooner Better When It Comes To Carotid Artery Stenting In Patients With Transient Ischemic Attach (tia) Or Minor Stroke: Prospective Observational Study

Background: Patients with symptomatic carotid artery stenosis presenting with TIA or minor stroke have a risk of recurrent devastating stroke of 21% within 2weeks and 32% within 12 weeks. Efficacy of early endarterectomy (CEA) has already been proven. However, data on ideal timing of Carotid Artery Stenting (CAS) is still lacking. Methods: A prospective observational cohort of elective endovascular procedures at our hospital was queried for consecutive cases of internal carotid artery stenting for minor symptomatic atherosclerotic stenosis inclusive of the years 2009-2011. A total of 438 patients were studied with the primary outcome measured as a combined incidence of major perioperative complications (stroke, Myocardial Infarction MI or death) at 90 days from procedure time, was compared between patients based on timing of procedure relative to onset of symptoms. Patients were stratified into four treatment groups: those treated urgently (0-2 days), early (3-7 days), routinely (8-14 days), or late (15-90 days). Incidence of the primary outcome was compared between groups using the Fisher’s exact test (SAS software, Cary NC). Results: Stent implantation was successful in all cases (100%). Combined incidence of major perioperative complications of stroke, MI or death at 90 days was 7% in the urgently treated group 0-2 days (10 out of 143), 11% in the early treated group 3-7 days (10 out of 110), 3% in the routinely treated group 8-14 days (3 out of 100) and 7% in the late treatment group 15-90 days (6 out of 85). Mortality was only reported in the urgently treated group and it was as high as 3% (5 out of 143). Conclusion: Little data is available regarding urgent carotid stenting post minor stroke or TIA. Out data suggest that the safest period to perform carotid artery stenting in symptomatic atherosclerotic stenosis is between 8-14 days with a rate of all combined major perioperative complications as low as 3%. Randomized and double-blinded trial is warranted to study this further.

Resected Serous Cystic Neoplasms of the Pancreas: A Review of 158 Patients with Recommendations for Treatment

BackgroundSerous cystic neoplasms of the pancreas are regarded as a benign entity with rare malignant potential. Surgical resection is generally considered curative. ObjectiveTo perform the largest single institution review of patients who underwent surgical resection for serous cystic neoplasms of the pancreas in the hopes of guiding future management. MethodsBetween June 1988 and January 2005, 158 patients with serous cystic neoplasms of the pancreas underwent surgical resection. A retrospective analysis was performed. Univariate and multivariate models were used to determine factors influencing perioperative morbidity and mortality. Major complications were defined as pancreatic fistula or anastomotic leak, postoperative bleed, retained operative material, or death. Minor complications were defined as wound infection, postoperative obstruction/ileus requiring total parenteral nutrition (TPN), delayed gastric emptying, arrhythmia, or other infection. ResultsThe mean age of the patients was 62.1 years, with 75% being female. The majority of patients were symptomatic at presentation (63%), with abdominal pain as the most common symptom. Of the 158 patients, 75 underwent distal pancreatectomy, 65 underwent pancreaticoduodenectomy, nine underwent central pancreatectomy, five underwent local resection or enucleation, and four underwent total pancreatectomy. Mean tumor diameter was 5.1 cm. Mean operative time was 277 min. Mean postoperative length of hospital stay was 11 days. One patient was diagnosed at presentation with serous cystadenocarcinoma. The remaining 157 patients were initially diagnosed with benign serous cystadenoma. One of three patients with locally aggressive benign disease later presented with metastatic disease. Resection margins for all 158 patients were negative for tumor, and only one (0.6%) showed lymph node involvement. There was one intraoperative death. The incidence of major perioperative complications was 18%, whereas the incidence of minor complications was 33%. Men were significantly more likely to experience minor perioperative complications (OR = 3.74, P = 0.008), whereas patients greater than 65 years showed a trend toward fewer major complications (OR = 0.36, P = 0.09). ConclusionsSurgically resected serous cystic neoplasms of the pancreas are typically seen in asymptomatic women as 5 cm neoplasms and are predominantly benign. Most are resected via either a left- or right-sided pancreatectomy with low mortality risk, but with notable major or minor morbidity. Cystadenocarcinoma is a rare finding on initial resection of serous cystic neoplasms. However, initial pathology specimens exhibiting benign but locally aggressive neoplasia may indicate an increased likelihood of recurrence or metachronous metastasis, although this claim is limited by a small patient subpopulation in this study and warrants further review.

Total Laparoscopic Aortic Surgery Versus Minimal Access Techniques: Review Of More Than 600 Patients

In the following paper we describe our experience with a large number of patients in which either a laparoscopic assisted procedure or a total laparoscopic operation was performed. From 1996 until 2005 a total number of 638 aortic patients were operated on using a total laparoscopic or a laparoscopic assisted approach. A total laparoscopic operation was accomplished in 236 cases. A laparoscopic assisted aortic operation was performed in 402 patients. In aneurysm patients a tube graft was more frequently implanted. Thirty-day mortality was significantly higher in patients with a total laparoscopic abdominal aortic aneurysm repair (3.0%) compared to a laparoscopic assisted procedure (1.8%). There was no significant difference in mortality in patients with occlusive disease and a total laparoscopic aortofemoral bypass versus a laparoscopically assisted operation. The same tendency could be observed when analyzing the incidence of major perioperative complications. Again we found no significant difference in patients with occlusive disease yet more severe complications directly related to the operation in patients with a total laparoscopic aneurysm repair. There was a significantly increased complication rate in total laparoscopic aortoiliac repair with a bifurcated prosthesis compared to a tube graft repair: a tendency we could not observe in aneurysm patients with a laparoscopic assisted operation. Our data also show that there is a lot of room for technical improvements such as stapling devices or special grafts to reduce total operating times as well as the period of aortic crossclamping. The routine use of a minilaparotomy can hardly be a solution considering the technical drawbacks such as impaired vision and long term complications like ventral hernias. Compared to open surgery the midterm results of laparoscopic aortic procedures are promising. The time has come to prove that good results can be obtained in more than a few specialized centers.

The Safety of Fluoroscopically-Assisted Thoracic Pedicle Screw Instrumentation For Spine Trauma

Pedicle screw fixation is considered biomechanically superior to other stabilization constructs. However, the potential for severe complications have discouraged its use in the thoracic spine. Our goal is to determine the incidence of major perioperative complications following the placement of thoracic pedicle screws using anatomic landmarks and intraoperative fluoroscopy in patients with spine fractures. Retrospective review of 245 consecutive patients with spine fractures requiring pedicle screw fixation between T1 and T10 at a regional Level I trauma center between 1995 and 2001. Database and medical record review were used to identify the incidence of major perioperative complications. A major complication was defined as a potentially life-threatening vascular injury, neurologic deterioration, pneumothorax or hemothorax, and tracheoesophageal injury. Patients were monitored for these complications from the time of surgery until discharge. In all, 1,533 pedicle screws were placed between T1 and T10 in 245 patients. No patient sustained a major complication related to screw placement. Three patients (1.2%) required a secondary procedure for prophylactic revision of four (0.26%) malpositioned screws. This study supports the safety of pedicle screws in the thoracic spine using preoperative imaging evaluation, standard posterior element landmarks and intraoperative fluoroscopy.

Long-term results of elective open repair for abdominal aortic aneurysm

腹的大动脉的动脉瘤(AAA ) 有高倾向破裂。自从他们，由有接枝的常规外科的代替的修理 ofAAA 是治疗的标准标志 1960 年代。因为进展在外科，麻木并且特别护理技术，选任的开的 AAA 修理的结果常常改善了。与 endovasculartechniques 的改进，然而，开的修理的角色正在被质问。越来越多的 stents 正在被部署住院病人因为他们的不太侵略的特征。我们我们经验的十年关于 endoluminal 和开的修理与选任的开的 AAA 修理和最近的报纸考察了让 AAA 在中国为 AAA 讨论开的修理的地位和未来。

Pancreaticoduodenectomy After Placement of Endobiliary Metal Stents

Contemporary treatment programs for patients with potentially resectable pancreatic cancer often involve preoperative therapy. When the duration of preoperative therapy exceeds 2 months, the risk of plastic endobiliary stent occlusion increases. Metal stents have much better patency but may complicate subsequent pancreaticoduodenectomy (PD). We evaluated rates of perioperative morbidity, mortality, and stent complications in 272 consecutive patients who underwent PD at our institution from May 2001 to November 2004. Of these 272 patients, 29 (11%) underwent PD after placement of a metal stent, 141 underwent PD after placement of a plastic stent, 10 had PD after biliary bypass without stenting, and 92 had PD without any form of biliary decompression. No differences were found between the Metal Stent group and all other patients in median operative time, intraoperative blood loss, or length of hospital stay. No perioperative deaths occurred in the Metal Stent group versus 3 (1.2%) deaths in the other 243 patients. The incidence of major perioperative complications was similar between the two groups, including the rates of pancreatic fistula, intra-abdominal abscess, and wound infection. Furthermore, there were no differences in the perioperative morbidity or mortality rates between patients who underwent preoperative biliary decompression with a stent of any kind (metal or plastic) and those patients who underwent no biliary decompression at all. Metal stent-related complications occurred in 2 (7%) of 29 patients during a median preoperative interval of 4.1 months; in contrast, 75 (45%) of the 166 patients who had had plastic stents experienced complications, including 98 stent occlusions, during a median preoperative interval of 3.9 months (P < 0.001). We conclude that the use of expandable metal stents does not increase PD-associated perioperative morbidity or mortality, and as such an expandable metal stent is our preferred method of biliary decompression in patients with symptomatic malignant distal bile duct obstruction in whom surgery is not anticipated, or in whom there is a significant delay in the time to surgery.

The Cost Effectiveness of Laparoscopic versus Open Gastric Bypass Surgery

Over the last decade, laparoscopic gastric bypass (LGBP) has been proven to be a safe and well-tolerated approach to the Roux-en-Y gastric bypass, despite its increased cost when compared to the open approach (OGBP). This increased expense has led many to question whether LGBP is a cost effective alternative to OGBP. The aim of this study is to determine which approach is most cost effective, considering costs associated with the operation itself, perioperative complications, and income lost during convalescence. A PubMed search of the National Library of Medicine online journal database was conducted. Studies that met predetermined criteria for selection were included in the analyses of patient demographics, perioperative complications, length of hospital stay, excess weight loss, and time to recovery. Data on 6,425 OGBP and 5,867 LGBP patients were used to compare the outcomes associated with each approach. Significant differences were found in the perioperative complication profiles, time to recovery, and overall expense of the two approaches. OGBP was associated with an increased incidence of major perioperative complications, especially extraintestinal complications, and greater perioperative mortality. LGBP was associated with shorter hospital stays, increased incidence of intestinal complications, and a 2.25% incidence of conversion to OGBP. Patient demographics and percent excess weight loss (%EWL) at 3 years follow-up were found to be similar with both OGBP and LGBP. LGBP is a cost effective alternative to OGBP for surgical weight loss. Despite the increased cost of LGBP, patients suffer fewer expensive and lifethreatening perioperative complications.

Management of synchronous renal neoplasm and abdominal aortic aneurysm

Objectives: Renal neoplasm (RN) and abdominal aortic aneurysm (AAA) are occasionally discovered concurrently. The approach to synchronous malignancy and aortic aneurysm is controversial. Methods: Between 1981 and 1999, concurrent RN and AAA were diagnosed in 50 patients at the Cleveland Clinic Foundation. Twenty-three patients were managed conservatively because of small asymptomatic AAA or metastatic disease; these patients were excluded from the study. The remaining 27 patients underwent operative management of both entities with a staged or simultaneous approach, and they form the basis of this article. Results: AAA diameter ranged from 4.8 to 13 cm (mean, 6.0 ± 1.8 cm). RNs were managed with radical nephrectomy in 11 patients (41%), partial nephrectomy in 10 patients (37%), or both in 6 patients with bilateral renal tumors (22%). The AAA repair was performed at the time of the urologic procedure in 11 patients (41%), before the urologic procedure in 13 patients (48%), or after the urologic procedure in 3 patients (11%). The AAA was addressed with open surgical repair in 24 patients (89%); recently, three patients (11%) underwent endovascular repair of the aneurysm and staged partial nephrectomy. The incidence of major perioperative complications was 23% (6 patients). Acute renal failure was the most common complication (3 [11%]) followed by acute respiratory failure (2 [7.4%]), pulmonary embolism (1 [3.7%]), and stroke (1 [3.7%]). At the mean follow-up of 57 months, there were no graft infections reported. The 5-year overall and cancer-specific survival rates were 62% and 81%, respectively. There was a significant difference in 5-year cancer-specific survival when comparing patients managed simultaneously versus staged (80% versus 35%, P =.007). Conclusions: The concurrent presentation of RN and AAA should not discourage one from treating both entities simultaneously because long-term survival is common. Endovascular repair of AAA holds promise as an attractive strategy in these complex patients. (J Vasc Surg 2000;32:1102-10.)

Complications of endoscopic sinus surgery: Analysis of 2108 patients—incidence and prevention

The incidence of complications of endoscopic sinus surgery (ESS) in a combined experience with 2108 total patients is compared to complications in 11 other series of patients (2583 total) who underwent ESS and 6 series of patients (2110 total) who underwent traditional endonasal sinus surgery. The incidence of major perioperative complications was 0.85%, with cerebrospinal fluid (CSF) leak being the most common. The most common minor complications of ESS were those related to orbital penetration and middle turbinate adhesions; minor complications occurred in 6.9% of the 2108 patients. There were no statistically significant differences in the overall incidences of major complications between this series and the other two groups. Recommendations are made for the prevention of complications during ESS.

Transurethral resection of prostate immediately after renal transplantation

The subject of transurethral resection of the prostate (TURF) after renal transplantation has not been evaluated in the urologic literature. We retrospectively compared the outcome of renal transplantation in 8 patients who underwent transurethral resection of the prostate within ten days of renal transplantation with 8 patients who did not undergo prostate surgery. Patients were computer-matched for seven parameters. There was no statistically significant difference in patient survival (6 vs 7) and graft survival (56% vs 88%) between the two groups. However, there was a 25 percent incidence of major perioperative complications (including one mortality) in the TURP group directly attributable to the procedure. Transurethral resection of the prostate can be safely performed immediately after renal transplantation only if urine is sterile, antibiotics and steroids are carefully administered perioperatively, low-gravity irrigation is used, and hemostasis is meticulous.