Independent Predictive Factors For Mortality Research Articles

Predictive factors of the mortality of digestive hemorrhage caused by esophageal varices in elderly patients

Complications of liver cirrhosis are increasingly frequent in elderly patients due to increased life expectancy and better management of cirrhotic patients. However, the influence of this condition on the evolution of variceal bleeding has not been well established. The aim of the present study was to determine the characteristics of esophagogastric variceal bleeding in elderly patients and the possible influence of advanced age on hemorrhage-related mortality. We analyzed 321 episodes of variceal bleeding in 227 cirrhotic patients. One hundred and thirteen (35.2%) episodes occurred in patients older than 65 years. No differences were found among patients older or younger than this age in terms of bleeding characteristics or Child-Pugh score. Patients older than 65 years more frequently presented serious associated diseases, hepatocellular carcinoma and hepatic encephalopathy during the episode (52.7% vs. 14%, p < 0.001; 19.7% vs. 8.7%, p = 0.01 and 17.4% vs. 10%, p = 0.09 respectively). Although hemorrhage-related mortality was higher in elderly patients (23.2% vs. 13.5%, p = 0.04), only the Child-Pugh score, definitive hemostasis, hepatocellular carcinoma and the development of encephalopathy or bacterial infection were independent predictive factors of mortality. A considerable proportion of the patients with esophagogastric variceal bleeding were older than 65 years. Advanced age does not independently influence mortality due to variceal bleeding.

Facteurs de risque de mortalité après chirurgie de l’aorte abdominale

Objective: To analyse pre and peroperative variables for predicting mortality after abdominal aortic surgery. Study design: Prospective study. Patients: We prospectively included 658 consecutive patients undergoing abdominal aortic surgery from January 1993 to July 1997. Methods: Age, gender, hypertension, history of myocardial infarction or coronary revascularization, angina pectoris, diabetes, arrhythmia, cardiac insufficiency, serum creatinine > 150 μmol·L –1, beta-blockers therapy, calcium channel inhibitors, angiotensin converting enzyme inhibitors were preoperative analysed variable. Type of aortic disease (anevrysms versus aortic occlusion), duration of surgery, blood loss, type of laparotomy (medium versus lombotomy) were peroperative analysed variables. Haemoglobinemia was monitored during surgery and patients were transfused if haemoglobinaemia < 80 g·L –1. Results: Thirty-three patients died after aortic surgery (5%). In multivariate analysis, angina pectoris (OR = 5.47, P < 0.001), chronic obstructive bronchopulmonary disease (OR = 2.27, P = 0.05) and duration of surgery (OR = 1.60, P < 0.001) were the independent predictive factors of mortality. Age, blood loss were predictive factors only in univariate analysis. Conclusion: Angina pectoris and COBP were the two independent preoperative factors of mortality. The duration of surgery was the only peroperative factor. Well monitored blood loss was not a predictive factor.

4750 Efficacy of n-butyl 2-cyanoacrylate injection therapy for gastric variceal bleeding and the factors related to its clinical outcome.

Background and Aims: Cyanoacrylate has been used for the control of bleeding from gastric varices. The aim of the study was to evaluate the efficacy and the safety of n-butyl 2-cyanoacrylate injection therapy for gastric variceal bleeding and to find out the factors related to the failure of therapy, rebleeding, and survival after the therapy. Patients and methods: Sixtyseven patients who treated with n-butyl 2-cyanoacrylate injection therapy for active (spurting or oozing) or recent hemorrhage (adherent clot or fibrin clot over varices) from gastric varices were retrospectively reviewed. Results: Initial hemostasis, defined as complete control of active bleeding, was achieved in all 12 patients. Success of therapy, defined as absence of rebleeding or death during the 5 days after the therapy, was achieved in 88% of patients. A stepwise logistic regression analysis including age, sex, cause of cirrhosis, Child-Pugh class, variceal form, bleeding site (cardia or fundus), initial hemoglobin and presence of hepatocellular carcinoma as variables indicated that only the Child-Pugh class was an independent predictive factor of treatment failure (Odds ratio, 14.7; 95% CI, 1.69-128.4; <i>P</i>= 0.015). Rebleeding occurred in 13 patients (19%) during 4 weeks after the therapy. The actuarial probability of 4-week remaining free of rebleeding after initial therapy was 77.6% and it was significantly higher in patients with Child-Pugh A and B than in patients with Child-Pugh C (95.1% vs 50%; P=0.0001). Mortality at 4 weeks was 15%. A stepwise logistic regression analysis including the same variables used for failure of therapy indicated that the Child-Pugh class (Odds ratio, 16.8; 95% CI, 1.8- 154.5; P=0.01) and the presence of hepatocellular carcinoma (Odds ratio, 14; 95% CI, 1.5-130.3; <i>P</i>= 0.02) were the independent predictive factors of mortality at 4 weeks. The actuarial probability of survival at 4 weeks after initial therapy was 85.1%. There were 2 cases (2.7%) of major complications due to cyanoacrylate embolism (pulmonary embolism and splenic infarction). However these complications spontaneously resolved and caused no death. Transient fever was found in 10.4% of patients. Conclusion: N-butyl 2-cyanoacrylate injection therapy is highly effective in the management of bleeding from gastric varices. Child-Pugh class is an important predictive factor of treatment failure, rebleeding, and survival after the therapy.

The dramatic reality of biliary tract injury during laparoscopic cholecystectomy

Most reports concerning the outcome of patients with biliary tract injury during laparoscopic cholecystectomy come from tertiary referral centers, and results could be very different in the everyday practice of community surgeons. The objective is to define the presentation, mechanisms, results of treatment, and long-term outcome of biliary tract injuries during laparoscopic cholecystectomy in the setting of a community surgeon's practice. An anonymous retrospective multicenter survey of 9,959 patients who underwent laparoscopic cholecystectomy was conducted by the Belgian Group for Endoscopic Surgery, composed mainly of community general surgeons. Sixty-five patients with bile duct injury were reported on; the incidence was 0.5%, varying from 0. 35 to 1.3% according to the experience of the surgeon. Thirty-four percent of ductal injuries occurred with experienced surgeons, often in association with local predisposing risk factors. Injury occurred in 87% of cases during dissection of the Calot triangle, with severe injury occurring in 46% of patients. Intraoperative cholangiography was performed in 34% of patients and was associated with a significantly improved operative detection rate of injury (68% vs 32%, p = 0.007). Operative detection of injury occurred in 45% of patients; diffuse bile ascitis was encountered postoperatively in 29%. The overall mortality was 9%, the postoperative biliary complication rate 31%, and the reintervention rate 14%. During a median follow-up of 49 months (range, 3-78 months), 20 of the 61 surviving patients (33%) had recurrent biliary strictures. Multivariate analysis demonstrated that the age of the patient (odds ratio: 0.893) and the presence of biliary peritonitis (odds ratio: 0.061) were independent predictive factors for mortality and that the age of the patient (odds ratio: 1.049) and the occurrence of postoperative biliary complications (odds ratio: 0.161) after the initial biliary repair were independent predictive factors for late biliary stricture. Biliary tract injury is associated with significant mortality and complications in the practice of Belgian community surgeons. Intraoperative detection of ductal injury by the routine use and a correct interpretation of intraoperative cholangiography improved outcome. The impact of the primary biliary repair on long-term outcome is an argument to refer these patients to specialized multidisciplinary experts. The results highlight the importance of surgical experience, proper selection of patients for laparoscopic cholecystectomy, and conversion to laparotomy in difficult cases.

Surgery for aortic stenosis in elderly patients. A study of surgical risk and predictive factors.

Aortic stenosis is the most common valvular lesion occurring among elderly patients and has become extremely frequent because of changing demographics in industrialized countries. Surgical risk after the age of 70 has increased. The increasing older age of patients having surgery justifies an analysis of mortality predictive factors. Between 1976 and February 1993, we performed 2871 operations for aortic stenosis. This study concerns 675 patients (278 men and 397 women) who were > or = 75 years old. Mean age was 78.5 +/- 3 years. Associated lesions were found in 226 patients. A bioprosthesis was implanted in 632 patients (93.6%). Concomitant surgical procedures were performed in 133 patients. Surgical mortality was 12.4% (84 deaths). A longitudinal analysis has been carried out over four successive time periods to evaluate population evolution during these 17 years. Statistical analysis was performed on 46 variables. Multivariate analysis found age (P < .0001), left ventricular failure (P < .0001), lack of sinus rhythm (P < .01), and emergency status (P < .02) to be presurgical independent predictive factors of mortality. Risk-reducing strategy should both favor relatively early surgery to avoid cardiac failure and emergency situations and pay careful attention to the use of myocardial protection and cardiopulmonary bypass. Indications for surgery should remain broad since analysis failed to determine specific high-risk groups to be eliminated, and surgery remains the only treatment for aortic stenosis.