Incidence Of Postoperative Morbidity Research Articles

Laparoscopic and Open Distal Pancreatectomy: A Comparison of Outcomes

Laparoscopic (lap) pancreatic surgery has been increasingly reported since its introduction in 1992. A retrospective analysis of consecutive patients undergoing elective lap and open distal pancreatectomy from 2002 to 2007 was performed. Univariate analysis was completed to evaluate perioperative variables. Logistic regression analysis was used to model predictors of postoperative pancreatic fistula. One hundred forty-eight subjects underwent distal pancreatectomy; 98 completed open, 44 lap, and six converted to open. There was no significant difference in the incidence of postoperative morbidity or mortality between the surgical approaches. Decreased operative time (156 vs 200 minutes, P < 0.01), blood loss (157 vs 719 mL, P < 0.01), and length of stay (5.9 vs 8.6 days, P < 0.01) were seen in the lap group. There was no significant difference in the rate of all pancreatic fistula formation (50 vs 46%, P = 0.94) or clinically significant leaks (18 vs 19%, P = 0.97) between techniques. A preoperative biopsy-proven cancer, increasing body mass index, history of pancreatitis, and male gender were significant predictors of having a pancreatic fistula. Lap and open distal pancreatectomy are performed safely at high-volume pancreatic surgery centers. This report provides ongoing support of the feasibility and safety of the lap approach with improved perioperative outcomes and equivalent pancreatic fistula rate.

Postoperative liver function recovery after hepatic resection for colorectal metastases previously treated with bevacizumab

4093 Background: The influence of bevacizumab on postoperative morbidity in patients with colorectal liver metastases (CLM) submitted to hepatectomy has been evaluated. However, in spite of a potential inhibition of liver regeneration, its impact on postoperative liver function recovery remains unknown. Methods: From July 2005 to December 2007, we evaluated 37 patients treated with bevacizumab prior to hepatectomy. Postoperative evolution of liver function variables was compared with that of 70 bevacizumab-naïve patients. Recorded parameters included prothrombin time, serum aspartate and alanine aminotransferase levels, and serum gamma-glutamyltransferase and total bilirubin levels. Results: Most patients of the bevacizumab group received 1 line of chemotherapy (62% vs 54% in the control group) (P=0.43). Bevacizumab was combined to 5-fluorouracil (5-FU), leucovorin (LV) and irinotecan or 5-FU, LV and oxaliplatin in the last preoperative line, in 57% and 30% of cases, respectively. Patients received a mean total number of 10.4+5.7 and 11.1+6.2 cycles of preoperative chemotherapy in the bevacizumab and control group (P=0.56). The median number of administered bevacizumab cycles was 6 (range: 3–25). Bevacizumab administration was stopped at a median of 7.9 weeks before surgery (range: 3.6–18.0). Major hepatectomies were performed in 41% and 36% of bevacizumab and control patients, respectively (P=0.62). Baseline liver function tests as well as postoperative liver function recovery were similar between patients treated with or without bevacizumab (Table). Postoperative morbidity occurred in 35% of bevacizumab patients and in 43% of control patients (P=0.44). Conclusions: Preoperative bevacizumab treatment has no impact on short-term liver function recovery after hepatic resection for CLM and has no deleterious effect on the incidence of postoperative morbidity. [Table: see text] No significant financial relationships to disclose.

Larynx preservation in surgical treatment of cervical esophageal cancer - combined procedure of laryngeal suspension and cricopharyngeal myotomy

From July 1994 to July 1998, a larynx-preserving procedure was performed on 10 out of 22 (45%) patients in the surgical treatment of hypopharyngeal and cervical esophageal cancer. At first, all 10 patients were treated with concurrent radiochemotherapy with cisplatin (10 mg/m2/day), 5-fluorouracil (500 mg/m2/day) and radiation (2 Gy/day) five times per week for 4 weeks. After preoperative radiochemotherapy, the larynx-preserving procedure, combining laryngeal suspension and cricopharyngeal myotomy, was performed. The operative and hospital mortality rate was 0%. The incidence of post-operative morbidity with minor complications was 70% in the present study. Laryngeal speech and oral food intake were preserved in all patients after this procedure. The new larynx-preserving procedure combining laryngeal suspension and cricopharyngeal myotomy for cervical esophageal cancer is a favorable operative method for retaining intelligible laryngeal speech and good food intake.

Efficacy of laparoscopy-assisted distal gastrectomy for gastric cancer in the elderly

To date, it has been unclear whether laparoscopy-assisted distal gastrectomy (LADG) is a suitable treatment for elderly patients with early gastric cancer. This study retrospectively compared surgical outcomes between elderly and nonelderly patients with gastric cancer. The study group was comprised of 211 patients who underwent distal gastrectomy between April 2000 and March 2007. Of these, 130 patients (26 aged >or=75 years and 104 aged <75 years) underwent LADG, and the remaining 81 patients underwent conventional open distal gastrectomy (ODG). Short- and long-term patient outcomes were evaluated. The operation time was significantly longer in the LADG group than in the ODG group (262.6 versus 234.3 min, p = 0.005), but the other short-term outcomes did not differ between the two groups. When performed by an experienced surgeon, blood loss was significantly reduced, while operation time for LADG was similar to that for ODG. Within the LADG group, incidences of comorbid disease and lymph-node metastasis were significantly greater, the histological tumor type was significantly more differentiated, and the macroscopically depressed tumor type was less common in elderly patients. However, the incidence of postoperative morbidity did not differ between the elderly and nonelderly groups (11.5% versus 3.8%, p = 0.1201), and there was no significant difference in postoperative course. Logistic regression analysis showed that body mass index, but not chronological age, was an independent predictive factor of postoperative morbidity (odds ratio = 3.674, p = 0.045). There were no significant differences in overall or disease-specific survival between elderly and nonelderly patients. LADG is an effective treatment for elderly patients with early gastric cancer if it is performed by an experienced surgeon. A high-volume study is needed to confirm this rationale.

Endovascular Management of a Left Subclavian Artery Lesion Following Thoracoplasty for Bronchopleural Fistula and Empyema Secondary to Aspergillus fumigatus

Massive and/or recurrent hemoptysis is a clear indication for surgical treatment of pleuropulmonary aspergilloma, despite the incidence of postoperative morbidity and mortality. Thoracoplasty has been widely used for 20 years and is still indicated in these cases, following lobectomy, even though the procedure is not free of complications. We report the case of a patient who required thoracoplasty to treat a pleuropulmonary aspergilloma invading the chest wall. Subsequent placement of an aortic stent-graft was required due to tearing of the left subclavian artery.

Management of obstructive colorectal cancer with endoscopic stenting followed by single-stage surgery: open or laparoscopic resection?

About one-third of patients with colorectal carcinoma present with acute colonic obstruction requiring emergency surgery. Current surgical options are intraoperative lavage and resection of the colonic segment involved with primary anastomosis, subtotal colectomy with primary anastomosis, colostomy followed by resection, and resection of the colonic segment involved with end colostomy (Hartmann's procedure) requiring a second operation to reconstruct the colon. These procedures present risks and a poor quality of life. Endoscopic colonic stent insertion can effectively decompress the obstructed colon, allowing bowel preparation and elective resection. The authors present their experience managing 31 patients with obstructing colorectal cancer who underwent endoscopic colonic decompression with self-expanding metallic stents. A total of 16 patients were treated with open resection, and 6 underwent a laparoscopic resection. The remaining 9 patients were managed with endoscopic palliation and adjuvant therapy. Of the 31 patients, 17 were treated with postoperative chemotherapy. The mean interval between stenting and surgery was 11 days (range, 1-21 days). There was no intraoperative morbidity. The incidence of postoperative morbidity was 20% for open surgery and 0% for laparoscopic surgery. The mean postoperative hospital stay was 13 days for the open surgery group, and 7 days for the laparoscopic group (p = 0.003). The hospital mortality rate was 3.2%. Follow-up evaluation was completed for 96% of the patients. The minimum follow-up period was 15 months. All the patients in the palliative group died of disease, with a median survival of 3 months. Of the 22 surgically treated patients, 17 (77%) are alive at this writing. This initial experience shows that after successful endoscopic stenting of malignant colorectal obstruction, elective surgical resection can be performed safely. The presence of the endoluminal stent does not prevent a laparoscopic approach. The combined endoscopic and laparoscopic procedures are a less invasive alternative to the multistage open operations and offer a faster recovery.

Outcome of laparoscopic surgery in colorectal cancer: a critical appraisal

Despite the wide application of laparoscopic surgery for various common surgical conditions, the development of laparoscopic colorectal surgery has been slow. The obstacle for its advancement is formed by a steep learning curve and concerns about the oncologic safety in cases of malignant diseases. With refinement in instrumentation and improvement in surgical techniques in recent years, laparoscopic colectomy has become a safe and feasible procedure. The short-term advantages in terms of quicker recovery of bowel function, less postoperative pain and shorter hospital stay of laparoscopic colectomy over conventional treatment seem to be indisputable. Results from large prospective randomized trials revealed the oncologic outcome to be comparable between the two treatments. Furthermore, the incidence of port-site metastasis was shown to be similar between the two approaches. For rectal cancer, laparoscopic-assisted total mesorectal excision has been shown to be a safe and feasible procedure. The incidence of postoperative morbidity including anastomotic leakage appears to be comparable between the two treatments. However, the long-term outcome especially for local recurrence and overall survival remains uncertain. Prospective randomized study with long follow-up is required to elucidate this issue.

Predictors of Early Postoperative Quality of Life after Elective Resection for Colorectal Cancer

Measurement of quality of life (QoL) is assuming increasing importance in cancer care. Predictors of early postoperative QoL after colorectal cancer resection are not clear and the aim of this study was to identify these factors. A consecutive series of eligible patients undergoing elective resection for colorectal cancer were invited to participate. Standardised, reliable and validated psychological questionnaires (HADS, PANAS, MRS, FACT-C, EQ-5D) were administered seven days prior to surgery and then six weeks after discharge. One hundred and four patients with colorectal cancer were recruited. There were 70 males (67.3%) and the mean age of the group was 67.6 years. Postoperative anxiety and depression were closely related to the preoperative anxiety and depression scores (p < 0.001). Other QoL scores also showed significant correlation with the respective preoperative scores. Anxiety, depression, and FACT functional wellbeing scores were also correlated with the incidence of postoperative morbidity. On multiple regression analysis postoperative morbidity, tumour node metastasis (TNM) stage, presence of stoma and preoperative QoL scores were found to independently predict postoperative QoL scores. Routine preoperative QoL measurement in cancer patients can identify patients at risk of having a poor QoL postoperatively. Suitable psychological and pharmaceutical intervention can be planned in advance for this group.

Estimation of physiologic ability and surgical stress (E-PASS) as a predictor of immediate outcome after elective abdominal aortic aneurysm surgery

Background The Estimation of Physiologic Ability and Surgical Stress (E-PASS) score was designed on the premise that the balance between the patient’s physiologic reserve capacity and the surgical stress inflicted at operation was important in the occurrence of postoperative complications. The aim of this study was to assess its value in predicting mortality and morbidity after open elective abdominal aortic aneurysm (AAA) repair. Methods E-PASS data items were collected prospectively in a group of 204 patients undergoing elective open AAA repair over a 6-year period. The operative morbidity and mortality rates were compared with the preoperative risk score (PRS), surgical stress score (SSS) and comprehensive risk score (CRS) of E-PASS. The group comprised 180 (88%) males and the median age was 73 (range 44 to 86) years. Results There were 13 (6%) deaths and 121 (59%) experienced a postoperative complication. As the PRS, SSS and CRS increased, the incidence of postoperative morbidity and mortality significantly increased ( P < .0001). Overall mean CRS was .52 (±.27). Mean CRS in the groups of patients who survived and died were .49 (±.24) and .98 (±26), respectively. PRS, SSS, and CRS all had extremely good predictive power for both mortality and morbidity as demonstrated by high areas under the receiver operator curve (range .799 to .953). CRS also showed a strong statistically significant association with the severity of postoperative complication ( P < .0001) and length of hospital stay ( P < .0001). Conclusions The E-PASS model appears to be a promising method of predicting death and the development of postoperative complications in patients undergoing elective open AAA surgery. It requires further validation in arterial surgery at different geographical locations.

Comparison of Risk-Adjusted 30-Day Postoperative Mortality and Morbidity in Department of Veterans Affairs Hospitals and Selected University Medical Centers: Vascular Surgical Operations in Women

Women with peripheral vascular disease requiring vascular operations are less well studied than their male counterparts. The surgical outcomes of female vascular patients in the Department of Veterans Affairs (VA) and private sector hospitals have not previously been compared, and their preoperative risk profile, postoperative morbidity, and mortality need to be better elucidated. Patients undergoing vascular operations at 14 private sector and 128 VA hospitals, from October 2001 through September 2004, had their preoperative characteristics, operative data, and 30-day postoperative morbidity and mortality compared, as part of the Patient Safety in Surgery (PSS) Study. Logistic regression analysis was performed to develop predictive models for morbidity and mortality, which allowed for a comparison of risk-adjusted outcomes between the two hospital groups. There were 458 vascular surgical operations performed in women in the VA, and 3,535 vascular operations were performed in women in the private sector. Eighteen of 45 preoperative comorbidities and laboratory variables differed considerably between the institutions, and 16 of 18 were adverse among the private sector patients. The unadjusted 30-day mortality rate was higher in the private sector compared with the VA (5.2% versus 2.4%, p=0.008); the unadjusted morbidity rate was higher in the private sector compared with the VA sector (23.4% versus 13.3%, p < 0.0001). After risk adjustment, there was no marked difference between the VA and the private sector in mortality (p=0.12), but the difference in morbidity rates remained pronounced, with an odds ratio of 0.60 for VA versus private sector (95% CI=0.44, 0.81). Compared with their VA counterparts, women undergoing vascular operations at private sector hospitals had a higher incidence of preoperative comorbidities; after risk adjustment, mortality did not differ substantially. Despite risk adjustment, the incidence of postoperative morbidity in the VA patients was considerably lower, suggesting unidentified differences in the hospital populations, their processes of care, or both.

Long-term outcomes after hepatectomy for recurrences after prior local ablation for hepatocellular carcinoma

Intrahepatic recurrence is the most common manifestation of failure after local ablation therapy for hepatocellular carcinoma. The present study evaluates the safety and efficacy of partial hepatectomy for intrahepatic recurrence after prior local ablation. A retrospective analysis was conducted of 188 consecutive patients with hepatocellular carcinoma who underwent either partial hepatectomy for recurrence after prior local ablation (n=13) or partial hepatectomy as initial local treatment (n=175). The 13 patients with recurrence after prior local ablation were referred to our division after the resectable recurrences were considered to be resistant to non-surgical treatment modalities. The incidences of postoperative morbidity and mortality were similar for patients with prior local ablation and patients without prior local ablation (p=0.75 and p=0.52, respectively). The overall survival rates after hepatectomy were comparable between patients with prior local ablation (median survival time of 86months; cumulative 5-year survival rate of 63%) and patients without prior local ablation (median survival time of 76months; cumulative 5-year survival rate of 54%; p=0.60). The disease-free survival rates after hepatectomy were significantly worse for patients with prior local ablation based on both univariate (p=0.01) and multivariate (relative risk, 2.73; p<0.01) analyses. Hepatectomy can be performed safely and may be efficacious, in terms of overall survival, for selected patients with intrahepatic recurrence after prior local ablation for hepatocellular carcinoma. On the other hand, prior local ablation appears to increase the probability of failure after hepatectomy.

Colorectal Clinical Pathways: A Method of Improving Clinical Outcome?

Clinical pathways are intended to improve the quality of care. In March 2001, our unit implemented a pathway for patients undergoing major colorectal surgery. The aim of this study was to assess its impact on the quality of patient care. We reviewed 204 patients managed using this pathway in 2001, and compared their outcomes with those of a control group of 204 patients who had undergone similar procedures the year before. The endpoints measured were postoperative morbidity, length of stay and readmission rates. Both groups were similar in terms of patient demographics, diagnosis, and nature of surgery performed. In the study group, 61% of patients underwent elective surgery compared with 62% in the control group. The incidence of postoperative morbidity in the study group was 20% compared with 33% in the control group (p = 0.003). The rate of readmission as a result of surgical complications was 6% in the study group versus 13% in the control group (p = 0.029). The average length of stay was 10.4 days in the study group and 12.1 days in the control group (p = 0.105). The introduction of a colorectal clinical pathway significantly improved the outcome of patients undergoing major colorectal surgery.

Pylorus-preserving Pancreaticoduodenectomy with External Pancreatic Remnant Drainage

Background : Pancreaticoduodenectomy is the mainstay of surgical treatment for various benign and malignant diseases of the head of the pancreas and the periampullar region. The incidence of postoperative morbidity remains significantly high. Various modifications have been advocated for the restoration of the digestive continuity and drainage of bile and pancreatic ducts in order to diminish this high morbidity rate.Methods : A new modification with the combination of an end-to-end duodenojejunal anastomosis and creation of an external pancreatic fistula following pylorus-preserving pancreaticoduodenectomy is described. Our initial experience with this modification in seven patients is reported and its advantages are discussed.Results : There was no mortality, while morbidity was 29%, including postoperative pneumonia and psychosis in one patient, and intra-abdominal abscess in another patient. No significantly delayed gastric emptying was observed and no patient developed diabetes, anastomotic ulcer or reflux cholangitis postoperatively.Conclusions : The reported technique seems to be a safe modification of restoration after pancreaticoduodenectomy, with maintenance of anatomical gastrointestinal continuity, avoidance of complications from anastomosis with the pancreatic remnant, as well as maintenance of endocrine pancreatic function. However, long-term follow-up and larger comparative studies are needed to evaluate the impact of this modification on morbidity and mortality, including longterm nutritional complications.

Effect of adding dopexamine to intraoperative volume expansion in patients undergoing major elective abdominal surgery

The contribution of low-dose dopexamine to outcome, when given to increase cardiac output in patients already treated with fluids during major abdominal surgery, is not yet known. We carried out a randomized double-blind placebo-controlled trial. All 100 patients studied were given fluid infusions during surgery guided by stroke volume measurements made with an oesophageal Doppler probe. Patients were randomized to receive dopexamine at the rate of 0.25 microg kg(-1) min(-1) or saline 0.9% (control) for the first 24 h after the start of surgery. The primary outcome measure was the incidence of postoperative morbidity. There were no statistically significant differences between groups in the incidence of postoperative complications, the length of hospital stay, the incidence of morbidity and the use of critical care facilities. The patients randomized to receive dopexamine had significantly more pre-existing disease than the control patients. Mortality in both groups was significantly less than predicted by the POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) risk prediction score. We could not demonstrate an advantage to using low-dose dopexamine in high-risk patients during major abdominal surgery.

Abdominal surgery in patients aged over 90 years old at a provincial general hospital

It has been commonly accepted that age itself is never an absolute contraindication for surgical treatment. Some many problems could be solved through surgical intervention, we studied perioperative status, postoperative morbidity and mortality, and short-and-long-term outcomes after abdominal surgery in a series of patients 90 year old or older, operated at a provincial General Hospital. Seven patients were treated using elective surgical procedures, while 6 had emergency surgery. The incidence of postoperative morbidity was fairly high after both elective and emergency operations. Major complications occurred in one patient who died on the 20th postoperative day, due to multiple organ failure. One case of hospital death occurred when a patient died on the 240th day after a gastrectomy. There was long-term survival of over five years occurred among the patients in the study who had reviewed elective operations for malignant lesions. No definite relation was revealed between the risk score and post-operative morbidity or mortality. No evident change in performance status was found even aged patient who underwent abdominal surgical procedures. These results indicate the need for more meticulous consideration, including more precise decisions regarding the indication for surgical intervention, and more intensive perioperative management, in order to secure more favorable therapeutic outcomes and quality of life for high-risk patients over 90 year of age.

Surgery for colorectal cancer in elderly patients: a systematic review

<h2>Summary</h2><h3>Background</h3> The effectiveness of surgery for colorectal cancer depends on it being carried out safely, which allows most patients to return to productive lives, with an improved postoperative life expectancy, or at least one that is not diminished by the surgery. Because colorectal cancer is a major cause of morbidity and mortality in elderly people, we have examined how the outcomes of surgery in elderly patients differ from those in younger patients. <h3>Methods</h3> We did a systematic review of published and aggregate data provided by investigators. Studies were identified by computerised and manual searches of published and unpublished reports, scanning references, and contacting investigators. Within each study, outcomes for patients aged 65–74 years, 75–84 years, and 85+ years were expressed in relation to those aged less than 65 years. <h3>Findings</h3> From 28 independent studies, and a total of 34194 patients, we found that elderly patients had an increased frequency of comorbid conditions, were more likely to present with later-stage disease and undergo emergency surgery, and less likely to have curative surgery than younger patients. The incidence of postoperative morbidity and mortality increased progressively with advancing age. Overall survival was reduced in elderly patients, but for cancer specific survival age-related differences were much less striking. <h3>Interpretation</h3> The relation between age and outcomes from colorectal cancer surgery is complex and may be confounded by differences in stage at presentation, tumour site, pre-existing comorbidities, and type of treatment received. However, selected elderly patients benefit from surgery since a large proportion survive for 2 or more years, irrespective of their age.

Larynx preservation in surgical treatment of cervical esophageal cancer--combined procedure of laryngeal suspension and cricopharyngeal myotomy.

From July 1994 to July 1998, a larynx-preserving procedure was performed on 10 out of 22 (45%) patients in the surgical treatment of hypopharyngeal and cervical esophageal cancer. At first, all 10 patients were treated with concurrent radiochemotherapy with cisplatin (10 mg/m2/day), 5-fluorouracil (500 mg/m2/day) and radiation (2 Gy/day) five times per week for 4 weeks. After preoperative radiochemotherapy, the larynx-preserving procedure, combining laryngeal suspension and cricopharyngeal myotomy, was performed. The operative and hospital mortality rate was 0%. The incidence of post-operative morbidity with minor complications was 70% in the present study. Laryngeal speech and oral food intake were preserved in all patients after this procedure. The new larynx-preserving procedure combining laryngeal suspension and cricopharyngeal myotomy for cervical esophageal cancer is a favorable operative method for retaining intelligible laryngeal speech and good food intake.

Postoperative hepatic dysfunction in perspective. 1970.

Postoperative hepatic dysfunction will remain a difficult entity to place in perspective until increased data are obtained from prospective clinical trials. Ideally these data should compare hepatic dysfunction not only to other postoperative complications, both with regard to overall incidence and to mortality, but also to the overall risks of anesthesia and surgery. The contribution of drug-induced hepatic damage to postoperative hepatic dysfunction has remained unsettled since chloroform was first incriminated during the nineteenth century. The drug was condemned in 1912, without any attempt being made to determine the incidence of the so-called delayed chloroform poisoning, with the result that the drug is still in use and the chloroform controversy remains unsettled to this day. The halothane controversy is also unsettled and currently overshadows the former controversy, although academically of no greater importance. Although not an anesthetic, cincophen is another drug about which there is controversy concerning its hepatotoxic potential. Babior and Davidson noted that it was the first drug implicated in hepatic necrosis--presumably with the exception of chloroform--the first report appearing in 1922. In 1941 the Council on Pharmacy and Chemistry of the American Medical Association concluded that the case against cincophen was not proved and that an urgent need existed for controlled clinical studies. Twenty-five years later Babior and Davidson noted that such studies had still not been undertaken and that the situation was the same as it was a quarter of a century earlier. Perhaps the time has come for a prospective, randomized, controlled clinical trial to be undertaken so as to evaluate the hepatotoxicity of one of these drugs. Perhaps an anesthetic agent such as halothane, concerning multiple administrations of which there is currently serious question, would be a suitable choice for such a study. The drug is in wide use today, partly because of evidence of satisfactory death rates following its administration, but also because on the basis of much excellent physiological data--but an almost total lack of any confirmatory epidemiological evidence--it is thought to contribute positively toward a low overall incidence of postoperative morbidity. Perhaps in addition, as a corollary, the time has come when, as attempts to illuminate a well--enunciated problem of this nature--that is, to test a clearly formulated hypothesis--the isolated case report, the collection of isolated case reports, the series of patients reported in the absence of a proven comparable control group, and the uncontrolled survey, should be "laid to rest." At best they provide only additional hypothesis-formulating information. At worst, however, they give increased exposure to a suggestion concerning cause and effect upon which physicians may act to their patients' detriment if the hypothesis ultimately proves to be erroneous. MacMahon et al. have stated that although there is no clear-cut dividing line between descriptive and analytical epidemiology, most epidemiological studies can indeed be classified primarily as either hypothesis-formulating or hypothesis-testing. Just as we have conducted the definitive retrospective hypothesis-testing study--the National Halothane Study--demanded by the "halothane hepatitis" controversy, so must we now move to the final stage of epidemiological investigation (experimental epidemiology) by investigating the effects of multiple administrations of the drug. On this point the National Halothane Study acts more as a hypothesis-formulating study than as a hypothesis-testing study. Hill has noted that statistical problems must be dealt with by the statistical method. (ABSTRACT TRUNCATED)

Resection of hilar cholangiocarcinoma.

Objective: Morbidity and mortality involved in the resection of hilar cholangiocarcinoma were reviewed retrospectively. The clinicopathologic and laboratory parameters that might influence the patient's survival also were re-evaluated. Summary Background Data: Although much progress has been made in the diagnosis and management of hilar cholangiocarcinoma, long-term outlook for most patients remains poor. Surgical resection is usually prohibited because of its local invasiveness, and most patients can only be managed by palliative drainage. Recently, many surgeons have adopted a more aggressive resection with varying degrees of success. Several prognostic factors in bile duct carcinoma have been proposed; however, no reports have specifically focused on resected hilar cholangiocarcinoma and its prognostic survival factors using multivariate analysis. Methods: The clinical records and pathologic slides of 49 cases with resected hilar cholangiocarcinoma were reviewed retrospectively. Twenty clinical and laboratory parameters were evaluated for their correlation with postoperative morbidity and mortality, whereas 31 variables were evaluated for their significance with postoperative survival. Variables showing statistical significance in the first univariate analysis were included in the following multivariate analysis using stepwise logistic regression test for factors affecting morbidity and mortality and Cox stepwise proportional hazard model for factors influencing survival. Results: There were 5 in-hospital deaths, and the cumulative 5-year survival rate in 44 patients who survived was 14.9%, with a median survival of 14.0 months. Multivariate analysis disclosed that coexistent hepatolithiasis and lower serum asparate aminotransferase levels (90 U/L) had a significant low incidence of postoperative morbidity, whereas a serum albumin of less than 3 g/dL was the only significant factor affecting mortality. Regarding survival, univariate analysis identified eight significant factors: 1) total bilirubin 10 mg/dL, 2) curative resection, 3) histologic type, 4) perineural invasion, 5) liver invasion, 6) depth of cancer invasion, 7) positive proximal resected margin, and 8) positive surgical margin. However, multivariate analysis disclosed total bilirubin ≥ 10 mg/dL, curative resection, and histologic type as the three most significant independent variables. Conclusions: Surgical resection provides the best survival for bilar cholangiocarcinoma. An adequate nutritional support to increase serum albumin over 3g/dL is the most important factor to decrease postoperative mortality. Moreover, preoperative biliary drainage to decrease jaundice and a curative resection with adequate surgical margin are recommended if longer survival is anticipated. Patients with well differentiated adenocarcinoma seem to survive longer compared to those with moderately or poorly differentiated tumors.

Surgical patch ostiumplasty of the left main coronary artery.

The prevalence of ostium stenosis of the left main coronary artery, isolated or not, varies from 0.1% to 1.9%. Could ostium angioplasty and reconstruction of the proximal left main coronary artery be a real surgical alternative for this condition? What are the risks and which are the results? In the present study we have reviewed our experience of 10 patients undergoing ostium angioplasty (mean age 55 years; male/female 6/4). Four of the operations were reoperations. There was only one hospital mortality and the incidence of postoperative morbidity was low. Only one patient (a reoperation) required blood transfusion to compensate for a minor diffuse postoperative bleeding. All hospital survivors were followed up for an average period of 7 months (range 3-56). Eight of the 9 surviving patients were in perfect clinical condition at the end of the follow-up, only one was in NYHA class II and CCS class 2. The mean LVEF at the end of the follow-up was normal and the mean ergometry capacity was 159 +/- 18W. Follow-up coronary angiography showed no tendency to restenosis in any of the cases. Ostium patch angioplasty offers several advantages over conventional coronary artery bypass grafting. Reoperation, preoperative unstable angina, or poor left-ventricular function pose no contraindications for ostium angioplasty. Presence of aortic and/or ostium calcifications, however, constitutes an absolute contraindication. Ostium patch angioplasty of the proximal left main coronary artery should be considered a surgical alternative in selected patients.