Incidence Of Major Postoperative Complications Research Articles

Effects of Discontinuance of Preoperative Anti-Platelet Medication in Multi-Level Thoracolumbar Spine Surgery.

To evaluate the perioperative morbidities of patients taking anti-platelet medication prior to multi-level thoracolumbar spine surgery. < p < MATERIAL and METHODS: We retrospectively reviewed the medical records of 65 patients who underwent multi-level spine surgery from January 2009 to November 2014 at our institution. These patients were divided into two groups: the control group (n=45) did not take any anti-platelet medications prior to surgery; the anti-platelet group (n=20) discontinued the anti-platelet medication 7 days before the spine surgery. The patients" age, body mass index (BMI), medical history, operation time, and estimated intraoperative blood loss were assessed. The incidence of postoperative major complications, such as spinal epidural hematoma or operative site infection, was also compared. The overall postoperative complication rates were similar in both groups. The rates of major complications were 5% (1/20) for the anti-platelet group and 8.9% (4/45) for the control group. In the anti-platelet group, one patient experienced surgical site infection, which has no relationship with bleeding tendency. Severe bleeding-related complications in the perioperative period were not observed in either group. Multiple logistic regression analysis demonstrated that cancer history and long hospital stay were independent predictors of operation-related complications. Among intraoperative parameters such as estimated intraoperative blood loss and intraoperative transfusion rates, there were no statistical differences between the groups. Surgical complication-related perioperative bleeding has had a serious influence on surgical outcomes. According to our study, preoperative anti-platelet therapy did not increase bleeding-related complications. Spine operations can be performed relatively safely if the co-morbidities of patients are considered.

Transfusion Risk and Clinical Knowledge (TRACK) Score and Cardiac Surgery in Patients Refusing Transfusion.

The Transfusion Risk and Clinical Knowledge (TRACK) score is a simple tool to predict the chance of undergoing blood transfusion in cardiac surgery. The authors evaluated the relationship between the TRACK score and clinical outcomes of cardiac surgery in patients who refused blood transfusion. An observational study. A single hospital. Seventy-six adult Jehovah's Witnesses refusing blood transfusion who underwent cardiac surgeries. Patients were divided into 2 groups according to their TRACK score: low-risk group (n = 57, TRACK score of less than 13) and high-risk group (n = 19, TRACK score of 13 or more). Perioperative and long-term clinical outcomes were compared between the 2 groups. The operative mortality was 0% in the low-risk group, and 21.1% (n = 4) in the high-risk group (p = 0.003). The incidence of major postoperative complications was higher in the high-risk group (57.9%) than in the low-risk group (17.5%) (p = 0.002). The high-risk group had more postoperative bleeding-related complications (21.1%) than did the low-risk group (1.8%) (p = 0.013). There were no significant differences of predictive performance in mortality and morbidity between the TRACK score and EuroSCORE II. In cardiac surgery patients refusing transfusions, the TRACK score predicted postoperative morbidity and mortality of cardiac surgery.

Outcomes of Laparoscopic Partial Nephrectomy in Patients Continuing Aspirin Therapy

A clinical dilemma surrounds the use of aspirin therapy during laparoscopic partial nephrectomy. Despite reduced cardiac morbidity with perioperative aspirin use, fear of bleeding related complications often prompts discontinuation of therapy before surgery. We evaluate perioperative outcomes among patients continuing aspirin and those in whom treatment is stopped preoperatively. A total of 430 consecutive cases of laparoscopic partial nephrectomy performed between January 2012 and October 2014 were reviewed. Patients on chronic aspirin therapy were stratified into on aspirin and off aspirin groups based on perioperative status of aspirin use. Primary end points evaluated included estimated intraoperative blood loss and incidence of bleeding related complications, major postoperative complications, and thromboembolic events. Secondary outcomes included operative time, transfusion rate, length of hospital stay, rehospitalization rate and surgical margin status. Among 101 (23.4%) patients on chronic aspirin therapy, antiplatelet treatment was continued in 17 (16.8%). Bleeding developed in 1 patient in the on aspirin group postoperatively and required angioembolization. Conversely 1 myocardial infarction was observed in the off aspirin cohort. There was no significant difference in the incidence of major postoperative complications, intraoperative blood loss, transfusion rate, length of hospital stay and rehospitalization rate. Operative time was increased with continued aspirin use (181 vs 136 minutes, p=0.01). Laparoscopic partial nephrectomy is safe and effective in patients on chronic antiplatelet therapy who require perioperative aspirin for cardioprotection. Larger, prospective studies are necessary to discern the true cardiovascular benefit derived from continued aspirin therapy as well as better characterize associated bleeding risk.

Feasibility and strategy for left tracheobronchial lymph node dissection in thoracolaparoscopic esophageal cancer surgery.

This study evaluates the feasibility and strategy of left tracheobronchial lymph node (LN) dissection in the surgical treatment of esophageal cancer, and its impact on surgical outcomes following thoracoscopic esophagectomy. Data of 265 patients with thoracic esophageal cancer who underwent thoracoscopic and laparoscopic esophagectomy was retrospectively reviewed. In 80 cases, thoracoscopic esophagectomy was performed without left tracheobronchial LN dissection (group non-4L), while 185 cases underwent thoracoscopic esophageal mobilization with routine left tracheobronchial node dissection (group 4L). We introduced a "mesoesophageal suspension" method in order to facilitate complete dissection of the left tracheobronchial nodes, along with left recurrent laryngeal nerve nodes. Both univariate and multivariate analyses were performed to evaluate risk factors correlated to left tracheobronchial node metastasis. The non-4L group experienced less blood loss than the 4L group (P = 0.009). More mediastinal LNs were dissected in the 4L group (P < 0.001). There was no significant difference with regard to the incidence of major postoperative complications between the two groups. Compared with other LN metastases, the metastatic rate of the left tracheobronchial LNs was relatively lower. Based on multivariate analysis of six factors, lymphatic invasion and subcarinal node metastasis were shown to be strong independent predictors of left tracheobronchial metastasis. Routine thoracoscopic extensive lymphadenectomy, including the left tracheobronchial LN, was technically feasible and safe in patients with esophageal cancer. Using a mesoesophagus suspension technique, we performed a meticulous LN dissection in the upper mediastinal space.

Overextended Criteria Donors: Experience of an Italian Transplantation Center

The increasing gap between the number of patients who could benefit from liver transplantation and the number of available donors has fueled efforts to maximize the donor pool using marginal grafts that usually were discarded for transplantation. This study included data of all patients who received decreased donor liver grafts between January 2004 and January 2013 (n = 218) with the use of a prospectively collected database. Patients with acute liver failure, retransplantation, pediatric transplantation, and split liver transplantation were excluded. Donors were classified as standard donor (SD), extended criteria donor (ECD), and overextended criteria donor (OECD). The primary endpoints of the study were early allograft primary dysfunction (PDF), primary nonfunction (PNF), and patient survival (PS), whereas incidence of major postoperative complications was the secondary endpoint. In our series we demonstrated that OECD have similar outcome in terms of survival and incidence of complication after liver transplantation as ideal grafts.

Contemporary outcomes of surgery for aortic root aneurysms: A propensity-matched comparison of valve-sparing and composite valve graft replacement

ObjectiveThe study objective was to give an overview of the current state of the art of the surgical treatment of aortic root pathologies in a high-volume center. MethodsFrom May 1997 to January 2014, aortic root replacement was performed in 890 consecutive patients; 289 received a mechanical composite valved graft, 421 received a biologic composite valved graft, and 180 received a valve-sparing reconstruction. Propensity matching analysis was used to neutralize the differences in baseline characteristics between patients assigned to the different procedures. ResultsOperative mortality was 0.2% (0% in the valve-sparing reconstruction group); the incidence of major postoperative complications was less than 0.5%. Predictors of adverse in-hospital outcome were age, nonelective operation, renal status, reoperation, New York Heart Association class, ejection fraction, and concomitant procedures. Five-year survival was 89.4%. Previous myocardial infarction, preoperative renal status, redo operation, and concomitant procedures were significantly associated with follow-up death. In the propensity-matched groups, the type of operation performed did not affect in-hospital and late outcome. Aortic reintervention rates at 5 years were 0% for the mechanical composite valved graft group, 2.4% for the biologic composite valved graft group, and 7.3% for the valve-sparing reconstruction series. ConclusionsIn the current era, aortic root replacement can be performed with low perioperative risk in high-volume aortic centers. The type of operation performed does not affect early or late survival. Although the mechanical composite valved graft remains the gold standard for durability, the biologic composite valved graft and valve-sparing reconstruction are excellent options for those who cannot take or want to avoid long-term anticoagulation.

Nonischemic Postoperative Seizure Does Not Increase Mortality After Cardiac Surgery

Postoperative seizure (PS) is an infrequent, yet distressing, complication after cardiac surgery. We wished to determine the prognostic significance of these complicated neurologic events. The Weill Cornell Medical College Department of Cardiothoracic Surgery database and the New York State Department of Health Database were reviewed to identify all patients having PS after cardiac surgery between January 1, 2008, and December 31, 2011. During the study period 3,518 patients had cardiac surgery at the index hospital; 45 of them had PS (1.27%). Overall, patients having PS had a significant increase in 30-day mortality when compared with those not having PS (6.7% versus 1.5%; p < 0.006). The incidence of major postoperative complications in those having PS was also significantly higher (53.3% versus 10.5%; p < 0.001). However, logistic regression failed to demonstrate PS as an independent predictor of perioperative mortality. When the PS group was further stratified by the presence or absence of cerebrovascular accident, those having both PS and cerebrovascular accident had substantially increased morbidity and mortality (mortality, 0 of 33 versus 3 of 12; major morbidity, 12 of 12 versus 12 of 33; p < 0.01 for both), whereas PS patients without cerebrovascular accident did not have greater risk for either major adverse events or mortality. When PS is associated with acute cerebrovascular accident, a significant increase in postoperative morbidity and mortality can be expected. However, in those with isolated PS (without evidence of new neurologic injury), perioperative mortality and morbidity are comparable to those without any neurologic complications.

Incidence and concurrent laparoscopic repair of hypertrophic pyloric stenosis and patent processus vaginalis.

Incidence and concurrent laparoscopic repair of hypertrophic pyloric stenosis and patent processus vaginalis.

IS IMPLEMENTATION OF WHO SURGICAL SAFETY CHECKLIST (2009) WILL REDUCE THE RATE OF MAJOR POST OPERATIVE COMPLICATIONS AT ZAGAZIG UNIVERSITY HOSPITAL? (AN INTERVENTION STUDY)

Background: Surgical care is associated with a considerable risk of complications and death that represents a substantial burden of disease worthy of attention from the public health community worldwide. A surgical checklist is an inexpensive tool that will facilitate effective communication and teamwork to prevent patient harm. Aim & Objectives: This study aims to improve the safety of surgical care to decrease morbidity and mortality associated with surgery at Zagazig University Hospital through the following objectives: 1- To assess the performance of surgical team (surgeons, anesthetists and nurses) about surgical safety before and after intervention. 2- To assess the incidence of major post-operative complications before and after intervention. 3- To assess surgical team attitude about patient safety in operating rooms (OR) before and after intervention. 4-To increase the awareness for all surgical team about surgical safety to decrease post operative complications. Subjects & Methods: an interventional study was conducted in general surgery department of Zagazig University Hospital during the Academic year 2012-2014. Comparing 157 patients before and 157 patients after intervention who are 16 years of age or older undergoing inpatient major surgical operation were consecutively enrolled in the study and all surgical teams (surgeons, anesthetists and nurses) of the selected group were included during the period of the study. The study was carried out through 3 phases. Results: Results of this study showed that there was a high statistically significant reduction in 30 days major post-operative complications after implementation of WHO surgical safety checklist, the total number of complications decreased from 50.96% to 27.39% (p = 0.0001), in-hospital mortality decreased from 3.18% to 0% (p = 0.02). There was statistical significant improvement of surgical team attitude about OR surgical safety after intervention (p<0.05), there was high statistical significant negative correlation between physician and nurse coordination and occurrence of postoperative complications(r= -0.27) (p<0.05). The checklist was considered easy to use by 94.6% of physicians, 62% of nurses. Conclusion: In conclusion, this study revealed that a relatively simple education program for implementation of WHO surgical safety checklist was associated with reduction in major post-operative complications and mortality in a hospital with a high standard of care. It is recommended to use the Surgical Safety Checklist in all operative procedures.

Comparison of outcomes in ideal donor and extended criteria donor in deceased donor liver transplant: A prospective study

IntroductionThe number of patients who could benefit from liver transplantation markedly exceeds the number of available donors. This increasing gap has fuelled efforts to maximize existing donor pool and identify new avenues. Aims and objectivesTo compare the outcome in deceased donor liver transplant (DDLT) based on extended donor selection criteria. Materials and methodsDonor and recipients' data were analyzed following DDLT from Mar 2007 to Feb 2013. Donors were grouped into either ideal donor (ID) or extended criteria donor (ECD) based on donor and graft related characteristics. Primary nonfunction (PNF) and patient survival were the primary endpoints while early graft dysfunction (EGD) and incidence of major postoperative complications were the secondary endpoints of the study. ResultsWe had a total of 6 mortalities (13%) at the end of 1 year. The Kaplan Meier survival analysis at 7 days, 3, 6 and 12 months were not statistically different (p > 0.05). PNF occurred in three (6.5%) patients and was not significantly different nor influenced by cumulative number of risk factors in the subgroup analysis (p < 0.3). However, the incidence of EGD was significantly influenced by the cumulative number of risk factors (p < 0.005). A total of 12 (26.1%) patients were graded with 3 or more complications according to the 'Clavien Dindo Grade' for major post operative complications, although it did not reach a statistical significance in the various subgroups. Univariate analysis of the donor risk factors showed that none of these factors were predictive for PNF and mortality in deceased donor liver transplant recipients. ConclusionAlthough the incidence of early graft dysfunction is statistically more with increase in number of donor risk factors, the overall survival and outcome in extended criteria liver donors are similar to that of an ideal donor. With the supply demand gap widening, extended criteria for selection of deceased donors will definitely expand the donor pool without adversely affecting the outcome of liver transplantation.

Surgeon volume and disparities in post-operative complications among black men.

66 Background: Racial and ethnic disparities related to prostate cancer treatment are well-described. Lower rates of postoperative complications are noted in men who undergo radical prostatectomy (RP) at high-volume centers or by high-volume surgeons. We assessed whether access to high-volume providers might account for ethnic disparities in postoperative complications from RP. Methods: Using a nationally representative dataset of hospital discharge information, the Perspective Database (Premier Inc, Charlotte, NC), we examined all men who underwent RP (ICD9 60.5) between 2003 and 2010. Data were stratified based on patient characteristics (age, race, marital status, insurance status, Charlson Comorbidity Index), hospital characteristics (number of beds, teaching vs. nonteaching, urban vs. rural, and geographic region), surgical approach (robotic vs. nonrobotic), surgeon volume (low [less than 5], intermediate [5 to 24], and high [more than 24]), and complications (based on Clavien classifications I-V), if any. A logistic regression model accounting for clustering &amp; survey weights was constructed to assess the association of surgeon volume &amp; ethnicity on postoperative major complications (i.e., Clavien III-V). Results: In a multivariate model incorporating clinicodemographic and hospital information, black men continued to demonstrate a higher odds for major complication (OR 1.3 [1.02-1.7]). However, when further incorporating surgeon volume to the multivariate model, there was no longer any difference in the odds for a major complication for black men (OR 1.2 [0.97-1.6]). Patients who underwent RP by intermediate-volume surgeons and high-volume surgeons had a lower incidence of postoperative major complications compared to those treated by a low-volume surgeon (OR 0.6 [0.5-0.7] &amp; 0.4 [0.3-0.5], respectively). Compared to white men, the odds of undergoing RP by a high-volume surgeon are lower for black men (OR 0.6 [0.5-0.8]). Conclusions: Our data demonstrate that access to high-volume surgeons may explain the increased odds for postoperative major complications among black men undergoing RP. Further research related to barriers to health care access &amp; further efforts at removing said barriers for black men is warranted.

Major complications and risk factors associated with surgical correction of congenital medial patellar luxation in 124 dogs.

Dogs treated for congenital medial patellar luxation were reviewed for the purpose of determining the incidence of postoperative major complications requiring surgical revision and the risk factors for their occurrence. Major complications occurred in 18.5% of the patellar luxation stabilization procedures with implant associated complications being the most frequent, patellar reluxation the second, and tibial tuberosity avulsion the third most common major complication. Other complications included patellar ligament rupture and trochlear wedge displacement. When recession trochleoplasty was performed in addition to tibial tuberosity transposition, a 5.1-fold reduction in the rate of patellar reluxation was observed. Release of the cranial belly of the sartorius muscle further reduced the incidence of patellar reluxation, while patella alta (pre- or postoperative) and patellar luxation grade were not found to influence the rate of reluxation. Tibial tuberosity avulsion was 11.1-times more likely when using a single Kirschner wire to stabilize a transposition, compared with two Kirschner wires. Independent to the number of Kirschner wires used, the more caudodistally the Kirschner wires were directed, the higher the risk for tibial tuberosity avulsion. Tension bands were used in 24.4% of the transpositions with no tuberosity avulsion occurring in stifles stabilized with a tension band. Overall, grade 1 luxations had a significantly lower incidence of major complications than other grades, while body weight, age, sex, and bilateral patellar stabilization were not associated with risk of major complication development.

Elective Neck Dissection for N0 Neck During Salvage Total Laryngectomy

Optimum management of the clinically negative neck in the presence of primary site recurrence of laryngeal or hypopharyngeal cancer remains unclear. To examine the incidence of occult cervical nodal metastatic disease in patients undergoing salvage laryngectomy with necks clinically staged as N0 at the time of recurrence and to define the role of elective neck dissection in this population with regard to risk of complications and oncologic outcomes. Retrospective study of patients treated from 1996 through 2011. Academic teaching hospital. All patients undergoing salvage total laryngectomy for squamous cell carcinoma of larynx or hypopharynx after failed initial radiotherapy or chemoradiotherapy with radiographically N0 neck at time of recurrence. Primary outcome measure was incidence of cervical nodal metastases detected by means of pathological examination of elective neck dissection specimens. Secondary outcome measures were incidence of major postoperative complications and regional cancer control. Forty-five patients were included. Thirty-eight underwent elective unilateral (20) or bilateral (18) ND at the time of laryngectomy. Three patients (8%) had occult metastases (3 of 56 dissected heminecks [5%]). The incidence of major wound complications was significantly greater in patients undergoing bilateral ND (12 of 18 [67%]) than in patients undergoing unilateral or no ND (8 of 27 [30%]) (P = .03). There was no significant difference in regional control according to whether bilateral, unilateral, or no ND was performed. The incidence of occult metastatic disease in N0 necks in patients undergoing salvage surgery after radiotherapy is low. Neck dissection in this population does not seem to have a significant impact on regional cancer control. The need for elective ND, particularly bilateral ND, should be balanced against possible increased risk of morbidity in this group.

Endovascular Treatment of Thoracic Aortic Aneurysm: A Single-Center Experience

We assess the effectiveness of thoracic endovascular aortic repair (TEVAR) in patients with thoracic artery aneurysm with a retrospective analysis of our experience and a review of the literature. Between January 2005 and December 2011, 53 patients with thoracic aortic aneurysm underwent TEVAR. We evaluated the technical success, periprocedural and long-term mortality and morbidity, and follow-up by enhanced computed tomographic scans at 1, 6, and 12 months and annually thereafter. TEVAR was performed in good general conditions in 62.3% of cases and in emergency conditions in 37.7% of cases. A total of 85 endoprostheses were correctly placed, with technical success of 100%. In 18.8% of cases, a carotid-subclavian bypass was performed; 35.8% of cases required drainage of cerebrospinal fluid. Postoperative mortality was 7.5%, and in all cases patients were treated in emergency regimen. The incidence of major postoperative complications was 9.4%, with 2 cases of paraplegia. At a mean follow-up of 25.6 months, 12 cases (22.6%) of endoleak were observed: 5 cases of type IB endoleak were treated with prosthetic extensions; 7 cases of type II endoleak were not treated. There were no thrombotic occlusions, stent migrations, or fractures. TEVAR represents an effective option in the treatment of thoracic aortic aneurysms, with good immediate and long-term results.

Should High Thoracic Epidural Analgesia Be Dismissed in Cardiac Surgery?

We read with interest the recent paper of Nielsen et al, regarding high thoracic epidural analgesia (HTEA) in cardiac surgery. They studied 60 low-risk patients, 65 to 80 years of age, scheduled for elective coronary artery bypass graft surgery with or without aortic valve replacement and found that HTEA did not reduce the time in the intensive care unit or improve the quality of recovery in the intensive care unit. Should HTEA be dismissed in cardiac surgery? HTEA has the following potential to improve outcome after cardiac surgery: attenuation of perioperative stress response, better analgesia, better left ventricular function, better myocardial protection, and better pulmonary outcome. Unfortunately, these beneficial effects are only potential; in fact, they have not improved clinical outcomes in patients receiving this additional anesthetic technique. The use of HTEA in patients who receive perioperative anticoagulation increases the risk of epidural hematoma formation facilitated by full anticoagulation. In addition, HTEA increases the risk of severe perioperative hypotension and requires more vasopressor because of its sympathicolysis. However, we think HTEA should not be dismissed in cardiac surgery. First, randomized studies have been unable to report reduced mortality rates in patients undergoing HTEA, probably because of insufficient statistical power. The incidence of major postoperative complications is too low to detect significant differences. To be able to show a difference in a rare event, taking into account numerous other confounding factors, a very large population is necessary. The potential advantages of HTEA may become evident in high-risk patients, who have higher complication rates. Second, the potential advantages of HTEA need to be supported by a change in all aspects of postoperative patient management to adapt fast-track-surgery, which involves lower doses of opioids, aggressive temperature and fluid management, strict anticoagulation guidelines, and clear staff information. These adaptations are mandatory to minimize the risks related to the use of epidural catheters in cardiac anesthesia and to gain the maximum benefits from the technique. HTEA combined with fast-track-surgery may improve the main outcomes in patients undergoing cardiac surgery.

Enhanced Recovery After Surgery (ERAS) programme versus conventional perioperative care in patients undergoing major intra-abdominal surgical procedures

Aim-Background Enhanced Recovery After Surgery (ERAS) programmes have been applied mainly in patients undergoing major lower gastrointestinal surgery, to attenuate stress response to surgery and enable rapid recovery. The aim of this study was to evaluate whether the implementation of ERAS care, as compared to traditional care, is associated with less morbidity (decreased incidence of major postoperative complications) and improved outcome in patients undergoing elective major upper and lower intra-abdominal surgery.

Is a minimally invasive approach for resection of benign cardiac masses superior to standard full sternotomy?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'is a minimally invasive approach for resection of benign cardiac masses superior to standard full sternotomy?' A total of 50 papers were found using the reported search, of which, 11 represented the best evidence to answer the clinical question. The authors, country, journal, date of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. All 11 papers were retrospective studies, from which 4 were case-control studies comparing the minimally invasive approach with conventional full sternotomy, and 7 were case series. There were two minimally invasive techniques used, a right mini-thoracotomy and a partial hemi-sternotomy, the former being the most commonly used. The resection of benign cardiac masses is a low-risk procedure, with no mortality or conversions to full sternotomy reported. From the 4 case-control studies, cross-clamp time was similar in both groups, and only one report found a prolonged perfusion time with the minimally invasive approach. The incidence of major postoperative complications, including bleeding requiring reoperation (average from case-control studies: 0-4.5 vs 0-5.8%), renal failure (0 vs 0-10%) and prolonged ventilation (6-13 vs 11-19%), for the two approaches was similar. The incidence of postoperative stroke was better for the minimally invasive approach in one study (0 vs 14%, P = 0.023). The main advantages of this technique are shorter intensive care unit (26-31 vs 46-60 h) and hospital stay (3.6-5.2 vs 6.2-7.4 days), the minimally invasive approach being significantly better in one and three reports, respectively. We conclude that minimally invasive resection of a benign cardiac mass using a right mini-thoracotomy approach can be performed with an operative morbidity and mortality at least similar to the standard full sternotomy approach. The information currently available for the minimally invasive approach for the resection of benign cardiac masses is limited and based only on retrospective studies and, therefore, prospective studies are required to confirm the potential benefits of minimally invasive surgery.

Dual-Epidural Catheter Technique and Perioperative Outcomes After Ivor-Lewis Esophagectomy

Ivor-Lewis esophagectomy is associated with significant postoperative analgesic requirements and perioperative complications. A dual-epidural technique may improve perioperative outcomes compared with single thoracic epidural analgesia. This study identified all cases of Ivor-Lewis esophagectomy over a 3-year period. Eighty-one patients undergoing Ivor-Lewis esophagectomy who received general anesthesia supplemented by neuraxial analgesia with dual-epidural catheters (DECs) were matched 1:1 with patients who received general anesthesia and a single thoracic epidural catheter. Primary outcomes included quality of analgesia at rest and with movement on each of the first 3 postoperative days. Secondary outcomes included adverse events and the incidence of 4 major postoperative complications (anastomotic leak, pulmonary complications, atrial fibrillation, and sepsis). A DEC technique significantly improved analgesia (evidenced by reduced pain with movement on each of the first 3 postoperative days) when compared with a single epidural catheter technique. The placement of DECs did not increase catheter-related adverse events. A DEC technique was associated with a 50% reduction in the combined rate of major postoperative complications (36% vs. 18%; odds ratio, 0.40; P = 0.01) and increased number of hospital-free days measured at day 28 (21.2 vs. 22.3; P = 0.04). The DEC technique improved postoperative analgesia and reduced the incidence of major postoperative complications and hospital length of stay in patients undergoing Ivor-Lewis esophagectomy. Future studies should evaluate the efficacy of this technique in a controlled randomized clinical trial.

P-0154 Enhanced Recovery After Surgery (Eras) Program Versus Conventional Perioperative Care in Patients Undergoing Major Gastrointestinal Surgical Procedures

ABSTRACT Introduction Enhanced Recovery After Surgery (ERAS) programs have been introduced with aims of attenuating the stress response to surgery and enabling rapid recovery, without an increase in complications or readmissions. There is strong evidence of the usefulness of ERAS programs in patients undergoing colorectal surgery, but there is limited evidence about their safety in upper gastrointestinal surgery patients because surgeons are hesitant to allow early feeding in this patient population due to the concern of the effect of eating on gastric distention and potential anastomotic leaks. The aim of this study was to evaluate whether the implication of ERAS care, when compared to traditional care, is associated with impoved morbidity and outcome in patients undergoing elective major upper and lower gastrointestinal surgery. Methods The patients operated by two individual surgeons of the department following the ERAS regime were prospectively studied and compared with those operated by the rest four surgeons following the conventional perioperative care, during a six-month period. The ERAS regime consisted of preoperative patient education, removal of nasogastric tubes immediately after surgery, total fluid intake not exceeding 2.5L/24h, management of postoperative pain with systemic administration of paracetamol and non-steroid anti-inflammatory drugs, early feeding and ambulation. The outcome measures were incidence of major postoperative complications, length of postoperative hospital stay, number of relaparotomies and readmissions, and mortality within 30 days. Data analysis was done by the use of Fisher's exact test and Student's t-test. Values of p Results Sixteen patients, treated according to the ERAS program, were compared with 38 controls who had conventional perioperative care during the same time period. The two groups were similar with respect to age (p=0.9), gender (p=0.1), ASA grade (p=0.6), type of disease (p=0.1) and type of surgery (p=0.1). There was a trend toward significantly lower incidence of major postoperative complications in the ERAS group compared to the control group (12.5% vs 42.1% respectively; p=0.052). Overall, length of stay was significantly shorter in the ERAS group (5+/_1.6 days vs 12.2+/_ 5.9 days; p Conclusion ERAS program significantly reduces the length of hospital stay and has a trend toward significantly lower incidence of major postoperative complications in patients undergoing major elective upper and lower gastrointestinal surgery. Further research is required to define its essential elements and to establish the indications and patient populations that will most greatly benefit of its implementation.

Open Versus Laparoscopic Pyloromyotomy for Hypertrophic Pyloric Stenosis: A Systematic Review and Meta-Analysis Focusing on Major Complications

BackgroundThere is an ongoing debate about whether laparoscopic pyloromyotomy (LP) or open pyloromyotomy (OP) is the best option for treating hypertrophic pyloric stenosis (HPS). The aim of this study was to compare the results of both surgical strategies by means of a systematic review and meta-analysis of the available literature.MethodsA systematic search for randomized clinical trials (RCTs) comparing OP and LP was conducted. Studies were reviewed independently for quality, inclusion and exclusion criteria, and outcomes. Primary outcome was major postoperative complications (i.e., incomplete pyloromyotomy, perforation, and need for reoperation). Secondary outcomes were time to full feed, postoperative hospital stay, and any other postoperative complications.ResultsFour RCTs with a total of 502 patients (OP 255, LP 247) fulfilled the inclusion criteria and were analyzed in this review. These trials showed an absolute incidence of major postoperative complications of 4.9% in the LP group. Meta-analysis showed that LP did not lead to significantly more major postoperative complications (ARR 3%, 95% CI −3 to 8%) than OP. The mean difference in time to full feed was significant (2.27 h, 95% CI −4.26 to −0.29 h) and the mean difference in postoperative hospital stay tended to be shorter (2.41 h, 95% CI −6.10 to 1.28 h), both in favor of LP.ConclusionSo far, the major postoperative complication rate after LP for HPS is not substantially higher than after OP. Because time to full feed and postoperative hospital stay are at best a few hours shorter after LP than after OP, the laparoscopic technique might be acknowledged as the standard of care if the major postoperative complication rate is low. Hence, this laparoscopic procedure should preferably be performed in centers with pediatric surgeons with expertise in this procedure.