Intraoperative Risk Factors Research Articles

Assessment of risk factors for postoperative cognitive dysfunction after coronary artery bypass surgery: a single-center retrospective cohort study.

Aim: To find out risk factors for postoperative cognitive dysfunction (POCD) after coronary artery bypass grafting (CABG), and to provide basis for clinical prevention of POCD. A total of 88 patients who underwent CABG were surveyed with Telephone Questionnaire (TICS-M) for their cognitive impairment after 3, 7, 21, 90, 180 days post-surgery. The occurrence of POCD was diagnosed by Neuropsychological Battery which included Vocabular Learning Test (VLT), Wisconsin Card Sorting Test (WCST), Trail Making Test (TMT) and Symbol Digit Modalities Test (SDMT). The preoperative, intraoperative and postoperative risk factors were assessed by the χ2 or t test. Multivariate analysis was used to study the correlation between the risk factors and the occurrence of POCD. Age, aortic plaque, carotid artery stenosis, cerebrovascular disease, anesthesia time, the rate of decline in intraoperative hemoglobin concentration (ΔHb) and systemic inflammatory response syndrome (SIRS) score on postoperative day 2 had statistically significant (P<0.05) influence on the occurrence of POCD. Aortic plaque, carotid artery stenosis, anesthesia time and SIRS score (odds ratio (OR) value > 1, P<0.05) are the risk factors for POCD. The incidence of day-21 and -180 POCD was approximately 26.1 and 22.7%, respectively.

Clinical indicators for the incidence of postoperative ileus after elective surgery for colorectal cancer

BackgroundThe occurrence of postoperative ileus leads to increased patient morbidity, longer hospitalization, and higher healthcare costs. No clear policy on postoperative ileus prevention exists. Therefore, we aim to evaluate the clinical factors involved in the development of postoperative ileus after elective surgery for colorectal cancer.MethodsWe retrospectively analyzed patients who underwent elective surgery involving bowel resection with or without re-anastomosis for colon cancer between April 2015 and March 2020. The primary readout was the presence or absence of postoperative ileus. Univariate and multivariate analyses were used to identify pre- and intraoperative risk factors, and the incidence of postoperative ileus was assessed using independent factors.ResultsPostoperative ileus occurred in 48 out of 356 patients (13.5%). In multivariate analysis, male sex poor performance status, and intraoperative in–out balance per body weight were independently associated with postoperative ileus development. The incidence of postoperative ileus was 2.5% in the cases with no independent factors; however, it increased to 36.1% when two factors were observed and 75.0% when three factors were matched.ConclusionsWe discovered that male gender, poor performance status, and intraoperative in–out balance per body weight were associated with the development of postoperative ileus. Of these, intraoperative in–out balance per body weight is a controllable factor. Hence it is important to control the intraoperative in–out balance to lower the risk for postoperative ileus.

Iatrogenic Dry Eye Disease: Dealing with the Conundrum of Post-Cataract Discomfort. A P.I.C.A.S.S.O. Board Narrative Review.

The incidence and prevalence of dry eye disease (DED) after cataract surgery is greatly underestimated. The severity of dry eye symptoms has been reported to peak 7 days after cataract surgery and may persist for months, significantly affecting patients’ quality of life (QoL). The importance of considering surgical outcomes not only in terms of visual acuity, but also in terms of the patients’ QoL, necessitates the assessment and evaluation of the ocular surface by the cataract surgeon prior to the procedure. This narrative review, drafted by the P.I.C.A.S.S.O. (Italian Partners for the Correction of Ocular Surface Alterations) board, analyses the physiopathology of post-cataract surgery DED and highlights the pre-, intra- and postoperative risk factors that may alter ocular surface homeostasis; it proposes a practical comprehensive algorithm for the prevention, treatment and management of DED associated with cataract surgery. Particular attention needs to be paid to the pre- and intraoperative risk factors to reduce the incidence of postoperative dry eye and to improve cataract surgery outcome.

Perioperative risk factors for recovery room delirium after elective non-cardiovascular surgery under general anaesthesia

BackgroundAlthough postoperative delirium is a frequent complication of surgery, little is known about risk factors for delirium occurring in the post-anaesthesia care unit (PACU). The aim of this study was to determine pre- and intraoperative risk factors for the development of recovery room delirium (RRD) in patients undergoing elective non-cardiovascular surgery.MethodsRRD was diagnosed according to the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). We collected perioperative data in 228 patients undergoing elective non-cardiovascular surgery under general anaesthesia and performed univariate and multivariate logistic regression to identify risk factors related to RRD. PACU and postoperative events were recorded to assess the outcome of RRD.ResultsFifty-seven patients (25%) developed RRD. On multivariate analysis, maintenance of anaesthesia with inhalation anaesthetic agents (OR = 6.294, 95% CI 1.4–28.8, corrected p = 0.03), malignant primary disease (OR = 3.464, 95% CI = 1.396–8.592, corrected p = 0.018), American Society of Anaesthesiologists Physical Status (ASA-PS) III–V (OR = 3.389, 95% CI = 1.401–8.201, corrected p = 0.018), elevated serum total or direct bilirubin (OR = 2.535, 95% CI = 1.006–6.388, corrected p = 0.049), and invasive surgery (OR = 2.431, 95% CI = 1.103–5.357, corrected p = 0.035) were identified as independent risk factors for RRD. RRD was associated with higher healthcare costs (31,428 yuan [17,872–43,674] versus 16,555 yuan [12,618–27,788], corrected p = 0.002), a longer median hospital stay (17 days [12–23.5] versus 11 days [9–17], corrected p = 0.002), and a longer postoperative stay (11 days [7–15] versus 7 days [5–10], corrected p = 0.002]).ConclusionsIdentifying patients at high odds for RRD preoperatively would enable the formation of more timely postoperative delirium management programmes.

The assessment of intraoperative technique-related risk factors and the treatment of anastomotic leakage after esophagectomy: a narrative review.

Anastomotic leakage, including cervical anastomotic leakage and intrathoracic anastomotic leakage, is a serious complication of esophageal cancer and a leading cause of death after esophagectomy. In fact, anastomotic leakage after esophagectomy can be caused by numerous factors in the preoperative, intraoperative, and postoperative periods. Intraoperative technique-related risk factors, including surgical methods, anastomosis sites, anastomosis methods, the type of gastric tube, and reconstruction routes, are the key causes of its occurrence. Anastomotic leakage treatments include both surgical and non-surgical treatments, while surgical treatment has high risks, many complications, and high mortality. Actually, non-surgical methods including naso-leakage drainage, stent, negative pressure therapy, and so on, are also very critical in the treatment of anastomotic leakage. So, the selection of correct and appropriate treatment methods plays an important role in alleviating the suffering of patients, shortening hospitalization time, and reducing mortality. This study undertook a systematic review in which data in the PubMed database were searched and analyzed to assess the safety and efficacy of surgical technique-related factors in esophagectomy, and appropriate treatment of anastomotic leakage after esophagectomy. In conclusion, gastric tube, posterior mediastinal route and stapled anastomosis are safe among esophagectomy surgical techniques, and non-surgical treatment of anastomotic leakage such as naso-leakage drainage is feasible in the majority of cases.

Clinical, radiographic, and intraoperative risk factors for retinal detachment after open globe injury.

Retinal detachment (RD) is a vision-threatening complication of open globe injuries (OGI). This study sought to assess clinical, radiographic, and intraoperative risk factors for RD after OGI. A secondary goal was to test the retinal detachment after open globe injury (RD-OGI) score. Records of patients undergoing OGI repair at a single trauma center over 3years were reviewed using a retrospective case series design. Eyes that were enucleated or lost to follow up within 30days of OGI without evidence of RD were excluded. Potential risk factors for RD development were assessed by logistic regression or chi-square tests were appropriate and were entered into a multivariate logistic regression if significant on univariate analysis. Risk of RD for each eye was categorized by its RD-OGI score. Seventy-three eyes (72 patients) were included. In univariate analysis, afferent pupillary defect, worse visual acuity, posterior injury, vitreous hemorrhage, and posterior segment volume loss (PSVL) on CT were strong predictors of RD. In multivariate analysis, only PSVL on CT (adjusted OR 10.8, P = 0.025) maintained a statistically significant association with RD risk. At 1year, 5% of low-risk eyes, 20% of moderate-risk eyes, and 67% of high-risk eyes developed RD. These rates were not significantly different from the RD-OGI derivation or validation cohorts (P = 0.90 and P = 0.67, respectively). PSVL on CT increases the risk of RD after OGI. The RD-OGI Score was a good prognostic tool for assessing RD risk after OGI in this population.

Evaluation of liver function tests after coronary artery bypass surgery (CABG).

Background:Coronary artery bypass graft surgery (CABG) may have systemic effects on the body organs as liver. The purpose of present study was to evaluate changes in liver function tests(LFT) after on-pump CABG surgery and risk factors associated with LFT changes.Also, the incidence of acute liver injury after on-pump CABG is determined.Methods:385 patients who underwent on-pump CABG surgery were randomly selected.Preoperative and intraoperative risk factors were obtained from their medical records .Postoperative liver function tests at 24, 48 and 72 hours following surgery and discharge time were compared with the preoperative ones. A univariate linear regression analysis was used to assess the possible relationships between these changes and the preoperative and intraoperative risk factors.Results:Statisitcal analysis revealed direct and significant relationship between LFT changes and pump time, aortic cross-clamp clamp time and use of intra-aortic balloon pump(IABP). Also a medical history of previous myocardia infarction was significantly related to the changes in direct bilirubin in the first 48 hours following surgery.level of preoperative left ventricle ejection fraction,smoking and using opium had significant correlation with postoperative AST changes in different days.In 12.9% of patients, the aminotransferases levels increased to more than three folds over normal upper limit but the probability for incidence of acute ischemic liver injury (transient increase in aminotransferases to over 500IU/L) was 0.77%.Conclusion: Using techniques to reduce clamp and pump time when possible is important during CABG. Probable liver injuries post inserting IABP should be expected for appropriate monitoring and treatment.

Investigation of Risk Factors Related to the Development of Hepatic Dysfunction in Patients with a Low and Moderate Cardiac Risk During Open-Heart Surgeries.

ObjectiveTo determine the possible risk factors associated with hepatic dysfunction during open-heart surgeries.MethodsAfter excluding 71 patients, 307 patients with possible low and moderate cardiac risk who underwent either coronary artery bypass graft surgery (CABG) (n=176) or valve repair surgery (mitral valve, mitral and aortic valves and/or tricuspid valve) (n=131) were investigated prospectively during a 6-month period. Hyperbilirubinemia is defined as an occurrence of a plasma total bilirubin concentration >34 µmol/L (2 mg/dL) in any measurement during the postoperative period; the patients were divided into groups with or without postoperative hyperbilirubinemia. The collected parameters were: alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatase (ALP), total bilirubin (TBil), gamma-glutamyl transpeptidase (GGT) and albumin. The parameters were collected preoperatively and postoperatively on days 1, 3 and 7. Preoperative, intraoperative, and postoperative risk factors were investigated. Logistic regression analysis was performed to identify the risk factors for postoperative hyperbilirubinemia.ResultsPostoperative hyperbilirubinemia was observed in 7 of 176 patients (4%) who underwent CABG, and in 11 of 131 patients (8.4%) who underwent valve replacement surgeries. Independent risk factors for early postoperative hyperbilirubinemia were found as: ejection fraction (EF), aortic cross-clamp (ACC) time, intensive care unit stay and extubation time (P<0.001). In comparison to CABG procedures, postoperative hyperbilirubinemia was observed more frequently in patients undergoing valve surgeries (P=0.027).ConclusionLow EF and prolonged ACC time are significant independent risk factors for early postoperative hyperbilirubinemia during open-heart surgeries with cardiopulmonary bypass. Valve surgeries show a higher incidence of hyperbilirubinemia in comparison to CABG.

DIFFERENCE IN PREDICTORS OF ANASTOMOTIC LEAKAGE DEPENDING ON THE LEVEL OF ANASTOMOSIS AFTER COLORECTAL CANCER SURGERY.

SUMMARYAnastomotic leak (AL) after colorectal cancer surgery is one of the most serious postoperative complications which has major impact on outcomes. The aim of this study was to investigate preoperative and intraoperative risk factors for AL, as well as to examine whether there are differences in risk factors for AL depending on the primary tumor location. We retrospectively reviewed records of patients having undergone colorectal surgical procedures for malignancies between January 2013 and December 2017 in a single institution. Only procedures with primary anastomosis were included. Of the 153 patients, AL occurred in 10.6% of patients with primary tumor in the sigmoid colon and rectum, and in 8.2% of patients with primary tumor in the proximal sections of the colon. On univariate analysis, delayed oral intake and more advanced histologic stages of the tumor were significantly correlated with AL in patients with tumors in the sigmoid colon and rectum, and multiorgan resection and distant metastases in patients with tumors in the proximal sections of the colon. In conclusion, risk factors for the occurrence of AL vary depending on the primary tumor location and further investigation is needed to provide better insight into these differences.

Analysis of Preoperative and Intraoperative Risk Factors Of Surgical Site Infection In Gastrointestinal Surgeries

Introduction. Surgical site infection (SSI) after gastrointestinal surgery can affect the mortality and morbidity of the patients. Risk factors are needed to prevent and decrease the number of SSI. This study investigated the incidence of SSI, the preoperative and intraoperative risk factors of gastrointestinal surgeries.. Method. A retrospective audit analysis of age, nutritional status, preoperative length of stay, length of surgery, type of surgery, degree of contamination in adult gastrointestinal surgery patients at dr. Cipto Mangunkusumo General Hospital from 2012 to 2016. Outcomes consisted of incidence, and potential univariate risk factors were determined to investigate the independently associated factors using multivariate logistic regression. Results. In four years, the incidence of SSI is 3.4% among 4,357 gastrointestinal surgeries, with 86.4% of surgical site infections appears in contaminated wound operations. Our study included 116 subjects. From univariate analysis between SSI as dependent factors and the risk factors, age (p = 0.2), preoperative length of stay (p=0,06), length of surgery (p = 0.1), and degree of contamination (p = 0.003) have correlative association with SSI. The risk factor with surgical site infection is surgical wound contamination (OR = 1.233, p = 0.011) and independent from other risk factors.. Conclusion: Four factors correlate with SSI; there are age, preoperative length of stay, length of surgery, and degree of contamination. The degree of contamination is a significant risk factor for SSI.

The neck-shaft angle is the key factor for the positioning of calcar screw when treating proximal humeral fractures with a locking plate.

AimsThe aim of this study was to explore why some calcar screws are malpositioned when a proximal humeral fracture is treated by internal fixation with a locking plate, and to identify risk factors for this phenomenon. Some suggestions can be made of ways to avoid this error.MethodsWe retrospectively identified all proximal humeral fractures treated in our institution between October 2016 and October 2018 using the hospital information system. The patients’ medical and radiological data were collected, and we divided potential risk factors into two groups: preoperative factors and intraoperative factors. Preoperative factors included age, sex, height, weight, body mass index, proximal humeral bone mineral density, type of fracture, the condition of the medial hinge, and medial metaphyseal head extension. Intraoperative factors included the grade of surgeon, neck-shaft angle after reduction, humeral head height, restoration of medial support, and quality of reduction. Adjusted binary logistic regression and multivariate logistic regression models were used to identify pre- and intraoperative risk factors. Area under the curve (AUC) analysis was used to evaluate the discriminative ability of the multivariable model.ResultsData from 203 patients (63 males and 140 females) with a mean age of 62 years (22 to 89) were analyzed. In 49 fractures, the calcar screw was considered to be malpositioned; in 154 it was in the optimal position. The rate of malpositioning was therefore 24% (49/203). No preoperative risk factor was found for malpositioning of the calcar screws. Only the neck-shaft angle was found to be related to the risk of screw malpositioning in a multivariate model (with an AUC of 0.72). For the fractures in which the neck-shaft angle was reduced to between 130° and 150°, 91% (133/46) of calcar screws were in the optimal position.ConclusionThe neck-shaft angle is the key factor for the appropriate positioning of calcar screws when treating a proximal humeral fracture with a locking plate. We recommend reducing the angle to between 130° and 150°.Cite this article: Bone Joint J 2020;102-B(12):1629–1635.

Risk factors for neurological complications in severe and rigid spinal deformity correction of 177 cases

BackgroundDifficult procedures of severe rigid spinal deformity increase the risk of intraoperative neurological injury. Here, we aimed to investigate the preoperative and intraoperative risk factors for postoperative neurological complications when treating severe rigid spinal deformity.MethodsOne hundred seventy-seven consecutive patients who underwent severe rigid spinal deformity correction were assigned into 2 groups: the neurological complication (NC, 22 cases) group or non-NC group (155 cases). The baseline demographics, preoperative spinal cord functional classification, radiographic parameters (curve type, curve magnitude, and coronal/sagittal/total deformity angular ratio [C/S/T-DAR]), and surgical variables (correction rate, osteotomy type, location, shortening distance of the osteotomy gap, and anterior column support) were analyzed to determine the risk factors for postoperative neurological complications.ResultsFifty-eight patients (32.8%) had intraoperative evoked potentials (EP) events. Twenty-two cases (12.4%) developed postoperative neurological complications. Age and etiology were closely related to postoperative neurological complications. The spinal cord functional classification analysis showed a lower proportion of type A, and a higher proportion of type C in the NC group. The NC group had a larger preoperative scoliosis angle, kyphosis angle, S-DAR, T-DAR, and kyphosis correction rate than the non-NC group. The results showed that the NC group tended to undergo high-grade osteotomy. No significant differences were observed in shortening distance or anterior column support of the osteotomy area between the two groups.ConclusionsPostoperative neurological complications were closely related to preoperative age, etiology, severity of deformity, angulation rate, spinal cord function classification, intraoperative osteotomy site, osteotomy type, and kyphosis correction rate. Identification of these risk factors and relative development of surgical techniques will help to minimize neural injuries and manage postoperative neurological complications.

Low surgical Apgar score in older patients with gynecological cancer is a risk factor for postoperative complications and 1-year mortality: A multicenter retrospective cohort study.

Little is known about preoperative and intraoperative risk factors for postoperative complications in older patients with gynecological cancer. The present retrospective multi-institutional study included 173 older patients with primary gynecological cancer between January 2015 and December 2015 at four institutions. The cancer stage, medical history, Charlson comorbidity score, body mass index (BMI), subjective global assessment, fall risk assessment, American Society of Anesthesiologists physical status classification, surgical Apgar score (SAS), type of surgery and 1-year postoperative mortality were investigated. Multivariate analysis revealed that BMI and mental illness were risk factors for postoperative complications, and low SAS increased the risk for both postoperative complications and mortality within 1 year. Receiver operating characteristic curve analysis of postoperative complications in terms of SAS revealed that low SAS predicted high risk with a sensitivity of 85.7% and a specificity of 46.5%, and high SAS predicted low risk with a sensitivity of 21.4% and a specificity of 95%. The present results suggest that SAS, which is an intraoperative assessment, may be useful for assessing the risks of postoperative complications and mortality within 1 year. It is important to develop a preoperative assessment tool that can predict a low SAS score and reflect the postoperative prognosis of older patients with gynecological cancer.

Elevated Procalcitonin as a Risk Factor for Postoperative Delirium in the Elderly after Cardiac Surgery-A Prospective Observational Study.

One of the most common complications after cardiac surgery with cardiopulmonary bypass (CBP) is delirium. The purpose of this study was to prospectively investigate the risk of developing postoperative delirium in a group of elderly patients using a multivariate assessment of preoperative and intraoperative risk factors. A total of 149 elderly patients were included. Thirty patients (20%) developed post-operative delirium. Preoperative procalcitonin (PCT) above the reference range (>0.05 ng/mL) was recorded more often in patients who postoperatively developed delirium than in the non-delirium group (50% vs. 27%, p = 0.019). After surgery, PCT was significantly higher in the delirium than the non-delirium group: ICU admission after surgery: 0.08 ng/mL vs. 0.05 ng/mL p = 0.011), and for consecutive days (day 1: 0.59 ng/mL vs. 0.25 ng/mL, p = 0.003; day 2: 1.21 ng/mL vs. 0.36 ng/mL, p = 0.006; day 3: 0.76 ng/mL vs. 0.34 ng/mL, p = 0.001). Patients with delirium were older (74 vs. 69 years, p = 0.038), more often had impaired daily functioning (47% vs. 28%, p = 0.041), depressive symptoms (40% vs. 17%, p = 0.005), and anemia (43% vs. 19%, p = 0.006). In a multivariable logistic regression model, preoperative procalcitonin (odds ratio (OR) = 3.05), depressive symptoms (OR = 5.02), age (OR = 1.14), impaired daily functioning (OR = 0.76) along with CPB time (OR = 1.04) were significant predictors of postoperative delirium.

An exploratory study of risk factors for pressure injury in patients undergoing spine surgery.

BackgroundPerioperative patients are potentially at risk for pressure injuries due to anesthetic agents and surgical positioning. Pressure injury increases discomfort and pain in patients and causes complications, which lead to an increase in mortality and hospitalization duration. Most previous studies did not focus on specific types of surgery or surgical positioning. We tried to identify the incidence of perioperative pressure injury during spinal surgery and perioperative risk factors that contribute to pressure injury.MethodsWe retrospectively analyzed electronic medical records of 663 patients who underwent spinal surgery between March 2016 and May 2018. The primary outcome was occurrence of pressure injury. Potential risk factors of pressure injury were selected based on previous studies and expert opinion, and divided into two sub-categories: preoperative and intraoperative risk factors. We compared the clinical characteristics of patients in the pressure injury and non-injury groups. Perioperative risk factors for pressure injury were analyzed by logistic regression.ResultsAmong 663 patients, the incidence of all stages of pressure injury was 5.9%. The face and inguinal regions were the most injured sites (both 28.6%). The pressure injury group showed a 13% longer hospitalization period. Preoperative plasma concentration of protein was associated with 0.5-fold lower pressure injury (OR: 0.50; 95% CI: 0.27 to 0.95; P = 0.034).ConclusionsThe incidence of pressure injury was similar to that previously reported and occurred in the direct weight-bearing areas, which led to longer hospitalization. We found that a lower preoperative serum protein level is significantly associated with intraoperative pressure injury occurrence during spinal surgery.

Risk Factors for Delirium and Cognitive Decline Following Coronary Artery Bypass Grafting Surgery: A Systematic Review and Meta-Analysis.

BackgroundCoronary artery bypass grafting (CABG) is known to improve heart function and quality of life, while rates of surgery‐related mortality are low. However, delirium and cognitive decline are common complications. We sought to identify preoperative, intraoperative, and postoperative risk or protective factors associated with delirium and cognitive decline (across time) in patients undergoing CABG.Methods and ResultsWe conducted a systematic search of Medline, PsycINFO, EMBASE, and Cochrane (March 26, 2019) for peer‐reviewed, English publications reporting post‐CABG delirium or cognitive decline data, for at least one risk factor. Random‐effects meta‐analyses estimated pooled odds ratio for categorical data and mean difference or standardized mean difference for continuous data. Ninety‐seven studies, comprising data from 60 479 patients who underwent CABG, were included. Moderate to large and statistically significant risk factors for delirium were as follows: (1) preoperative cognitive impairment, depression, stroke history, and higher European System for Cardiac Operative Risk Evaluation (EuroSCORE) score, (2) intraoperative increase in intubation time, and (3) postoperative presence of arrythmia and increased days in the intensive care unit; higher preoperative cognitive performance was protective for delirium. Moderate to large and statistically significant risk factors for acute cognitive decline were as follows: (1) preoperative depression and older age, (2) intraoperative increase in intubation time, and (3) postoperative presence of delirium and increased days in the intensive care unit. Presence of depression preoperatively was a moderate risk factor for midterm (1–6 months) post‐CABG cognitive decline.ConclusionsThis meta‐analysis identified several key risk factors for delirium and cognitive decline following CABG, most of which are nonmodifiable. Future research should target preoperative risk factors, such as depression or cognitive impairment, which are potentially modifiable.RegistrationURL: https://www.crd.york.ac.uk/prosp​ero/; Unique identifier: CRD42020149276.

Timing of diagnosis of complex lower urinary tract injury in the 30-day postoperative period following benign hysterectomy

Complex lower urinary tract injury resulting from hysterectomy is a rare but highly morbid complication. Although intraoperative recognition reduces the risk of serious sequelae, observational studies have shown that most complex lower urinary tract injuries are recognized in the postoperative period. To date, limited research exists describing the timing of diagnosis of complex lower urinary tract injury or risk factors associated with complex lower urinary tract injury diagnosed in the postoperative period. This analysis aimed to describe the time to diagnosis of complex lower urinary tract injury among women undergoing benign hysterectomy. We also aimed to identify the intraoperative risk factors for differences in type and timing of complex lower urinary tract injury in the 30-day postoperative period using a large prospective national surgical database. This was a retrospective analysis using the National Surgical Quality Improvement Program hysterectomy data set from 2014 to 2018. All benign hysterectomies were included. Sociodemographic factors, health status, surgeon type, and other operative characteristics were extracted. A complex lower urinary tract injury was defined as at least 1 ureteral obstruction, ureteral fistula, or bladder fistula diagnosed within the first 30 days following surgery. Bivariate and multivariate logistic regression and cox proportional hazards assessed differences in odds of and time until diagnosis of complex lower urinary tract injury. Proportional hazard assumptions were evaluated with martingale residuals and supremum tests. Significance thresholds were 0.05 for all analyses. In this study, 100,823 women met the inclusion criteria. Median time to diagnosis of complex lower urinary tract injury was 10 days (interquartile range, 3-19) and varied significantly based on type of injury (P<.01) with ureteral obstruction (6; interquartile range, 2-16) recognized earlier than ureteral fistula (12; interquartile range, 7-21) and bladder fistula (14; interquartile range, 4-23). In addition, 8.65% of complex lower urinary tract injury were diagnosed on the day of surgery. Total laparoscopic hysterectomy had the lowest rate of complex lower urinary tract injury in unadjusted and adjusted analysis, with abdominal hysterectomy (adjusted odds ratio, 2.02; 95% confidence interval, 1.21-3.36) and vaginal hysterectomy (adjusted odds ratio, 2.05; 95% confidence interval, 1.16-3.62) having greater odds of ureteral obstruction, whereas laparoscopic assisted vaginal hysterectomy had the greatest odds of fistula (adjusted odds ratio, 2.10; 95% confidence interval, 1.26-3.48). Concomitant apical suspension was associated with a 6-day reduction in median time to diagnosis (P=.01), and surgery with a gynecologic oncologist was associated with a 9.5-day increase in median time to diagnosis (P=.01). Cox proportional hazards analysis confirmed these findings when controlling for confounders. Greater than 91% of complex lower urinary tract injury diagnoses in the National Surgical Quality Improvement Program hysterectomy database were diagnosed after the day of surgery. Route of hysterectomy, concomitant apical suspension, and primary surgeon specialty are associated with differences in both type of injury and time until diagnosis. These intraoperative risk factors should be considered when assessing for complex lower urinary tract injury in the 30-day postoperative period.

Long-term survival in patients who had CABG with or without prior coronary artery stenting

ObjectiveTo conduct a large-scale, single-centre retrospective cohort study to understand the impact of prior percutaneous coronary intervention (PCI) on long-term survival of patients who then undergo coronary artery bypass graft...

Clinical Pearls

The death of a loved one in the intensive care unit may cause prolonged grief, social distress, and even symptoms of posttraumatic stress in family members. End-of-life interventions, such as grief education materials, telephone follow-up, and cards, are an important part of bereavement care for families. However, use of these interventions varies across institutions, and research findings on their effectiveness are conflicting.Takaoka and colleagues examined the use of multiauthored, customized handwritten sympathy cards mailed to families 2 to 8 weeks post mortem. They interviewed family members and clinicians and identified 3 themes: The use of personalized, written condolences from staff was experienced as a meaningful and compassionate intervention for bereaved families.See Article, pp 422-428Pressure injuries occur twice as often in intensive care unit (ICU) patients as in other acute care patients, with estimated costs of care exceeding $26.8 billion in the United States. Although there are known risk factors for hospital-acquired pressure injury (HAPI), such as decreased mobility, having surgery, and age greater than 65 years, little research has examined the relationship between skin status and HAPI in ICU patients.Alderden and colleagues examined data from routine nursing skin assessments to identify risk factors for HAPI in adult surgical ICU patients. They found the following: Although further study is warranted to examine intraoperative risk factors, the authors recommend nurses consider the impact of skin changes on the development of HAPIs and remove causes of skin irritation.See Article, pp e128-e134Catheter-associated urinary tract infections continue to occur in both intensive care unit (ICU) patients and non-ICU patients, despite national prevention initiatives. Use of bladder scanning and ultrasound technology has helped to decrease the number of indwelling urinary catheter days, but the technology yields inaccuracies in patients with acute kidney injury, especially those with abdominal fluid/ascites.Schallom et al compared the accuracy of new bladder scanning technology and 2-dimensional ultrasound in measuring bladder volume in ICU patients unable to void 6 hours after catheter removal or patients receiving dialysis. They found Both bladder scanning and ultrasound can be used to measure bladder volumes accurately, but findings suggest that ultrasound should be used to measure bladder volume in patients with ascites.See Article, pp 458-467Many intensive care unit (ICU) patients require feeding tubes for nutritional support and medication delivery. Traditional practice includes every-4-hour assessment to verify tube placement. However, complications from malplaced feeding tubes continue to occur owing to inaccurate verification methods and lack of knowledge about tube migration.Using an electromagnetic placement device (EMPD) for tube placement, Bourgault and colleagues explored the factors associated with tube migration in adult ICU patients. They found See Article, pp 439-447

Outcome of Biliary Fistula After Liver Hydatid Cyst SurgeryHydatid cyst, biliary fistulae, Outcome, surgery.

Background: Biliary fistula after liver hydatid cyst surgery was occur in about 17.8 percent of patients inour center.Objective: To study the outcome of biliary fistula regarding factors related to its causes and management.Patients and Methodology: This is a prospective study of 241cases submitted to liver hydatid surgery inAl-Sader teaching hospital in Al-Najaf city, from October 2015 to April 2019. A total of 43 patients whounderwent surgery complicated with persistent leakage of bile from externaldrain. Prospectively collecteddatabase were gathered from patients medical records,sent for essential investigations, and treated eitherconservatively to give a chance for spontaneous closure, or by intervention with ERCP.Results: Forty three patients who develop postoperative biliary fistula after hydatid cyst surgery from 241patients(17,8 %),230 patients treated with conservative surgery (95,4 %), 2 patients treated with radicalsurgery(0,82 %) and 9 patients treated with percutaneous aspiration injection reaspiration (3.7%).All the 43patients in this search treated with conservative surgery. Size more than 15 cm is a risk factors. Intraoperativerisk factor is mainly presence of cystobiliary communication which occur in 16 patients (37,2%). Treatment;isconservative in about 23 patients(53.4%).Treatment with ERCP in 19 patients (44.1%).Time of interventionis from 9 – 15 days.Conclusion: Most of patient with external biliary fistula after hydatid liver surgery can be treatedconservatively and resolve spontaneously specially low output fistula.