Intraoperative Risk Factors Research Articles

Predictors associated with stroke after coronary artery bypass grafting in Turkish population

Background Objective: Postoperative stroke is a serious adverse event, a major cause of morbidity and mortality after coronary artery bypass grafting (CABG). This study is designed to determine the incidence of stroke after CABG and to identify the preoperative, intraoperative and postoperative risk factors associated with the development of a stroke. Methods: Between January 2019 and December 2022, 1.555 CABG were performed. Retrospective analysis of the patient files revealed that 24 (1.48%) patients had stroke in the postoperative period. Variables were compared with patients without neurological deficits (n=50) who had undergone CABG. Predictors of preoperative, intraoperative and postoperative stroke were identified. Results: The incidence of postoperative stroke was 1.48% (n=24). Mean age of these patients was 63.86 ± 8.58 years, and 59 (79.7%) were males. Chronic renal failure (p= 0.011), previous CABG (p=0.009), carotid artery disease (p=0.009), CRP levels (p=0.004) and Monocyte/Lymphocyte ratio (p=0.019) were identified as important preoperative risk factors for stroke development but there were no diffirence prevalence of age, sex, diabetes, hypertension, congestive heart failure and atrial fibrillation. Conclusion: Five variables (chronic renal failure, prior CABD, prior carotid artery disease, preoperative CRP levels and Monocyte/Lymphocyte ratio were found as risk factors for stroke after CABG. The development of postoperative stroke is associated with multiple morbidities and increased mortality. Careful assessment and management of risk factors should be implemented to reduce this important complication after CABG.

Hyperlactatemia in patients undergoing pulmonary endarterectomy with deep hypothermic circulatory arrest: Risk factors and its effects on the outcome.

To determine the risk factors of hyperlactatemia in pulmonary endarterectomy (PEA) surgery and assess whether elevated blood lactate levels are associated with adverse outcomes. In this retrospective observational study, a total of 111 consecutive patients who underwent PEA for chronic thromboembolic pulmonary hypertension at the XXX Hospital between December 2016 and January 2022 were included. We retrospectively evaluated arterial blood samples analyzed intraoperatively. The pre- and intraoperative risk factors for hyperlactatemia and the postoperative outcomes were recorded. Lactate levels gradually increased during surgery. The optimal cut-off lactate level for major postoperative complications, calculated using receiver operating characteristic analysis, was 7.0mmol/L. Deep hypothermic circulatory arrest (DHCA) duration, nadir hematocrit, and preoperative pulmonary vascular resistance were risk factors for lactate levels >7mmol/L. Moreover, the intraoperative peak lactate level during PEA under DHCA was found to be a statistically significant predictor of major complications being associated with longer mechanical ventilation time (r = 0.294; p = .003) and intensive care unit length of stay (r = 0.327; p = .001). Deep hypothermic circulatory arrest duration, nadir hematocrit, and preoperative pulmonary vascular resistance were associated with hyperlactatemia. Increased lactate levels were independent predictors of longer mechanical ventilation time, intensive care unit length of stay, and major complications.

Risk Factors for Postanesthetic Emergence Delirium in Adults: A Systematic Review and Meta-analysis.

Emergence delirium (ED) is delirium that occurs during or immediately after emergence from general anesthesia or sedation. Effective pharmacological treatments for ED are lacking, so preventive measures should be taken to minimize the risk of ED. However, the risk factors for ED in adults are unclear. In this systematic review and meta-analysis, we evaluated the evidence for risk factors for ED in adults. The PubMed, Scopus, Cochrane Library, Google Scholar, and Embase databases were searched for observational studies reporting the risk factors for ED in adults from inception to July 31, 2023. Twenty observational studies reporting 19,171 participants were included in this meta-analysis. Among the preoperative factors identified as risk factors for ED were age <40 or ≥65 years, male sex, smoking history, substance abuse, cognitive impairment, anxiety, and American Society of Anesthesiologists physical status score III or IV. Intraoperative risk factors for ED were the use of benzodiazepines, inhalational anesthetics, or etomidate, and surgical factors including abdominal surgery, frontal craniotomy (vs. other craniotomy approaches) for cerebral tumors, and the length of surgery. Postoperative risk factors were indwelling urinary catheters, the presence of a tracheal tube in the postanesthetic care unit or intensive care unit, the presence of a nasogastric tube, and pain. Knowledge of these risk factors may guide the implementation of stratified management and timely interventions for patients at high risk of ED. The majority of studies included in this review investigated only hyperactive ED and further research is required to determine risk factors for hypoactive and mixed ED types.

Preoperative Risk Factors for Lymphedema in Inflammatory Breast Cancer.

Prophylactic lymphatic bypass or LYMPHA (LYmphatic Microsurgical Preventive Healing Approach) is increasingly offered to prevent lymphedema following breast cancer treatment, which develops in up to 47% of patients. Previous studies focused on intraoperative and postoperative lymphedema risk factors, which are often unknown preoperatively when the decision to perform LYMPHA is made. This study aims to identify preoperative lymphedema risk factors in the high-risk inflammatory breast cancer (IBC) population. Retrospective review of our institution's IBC program database was conducted. The primary outcome was self-reported lymphedema development. Multivariable logistic regression analysis was performed to identify preoperative lymphedema risk factors, while controlling for number of lymph nodes removed during axillary lymph node dissection (ALND), number of positive lymph nodes, residual disease on pathology, and need for adjuvant chemotherapy. Of 356 patients with IBC, 134 (mean age: 51 years, range: 22-89 years) had complete data. All 134 patients underwent surgery and radiation. Forty-seven percent of all 356 patients (167/356) developed lymphedema. Obesity (body mass index > 30) (odds ratio [OR]: 2.7, confidence interval [CI]: 1.2-6.4, p = 0.02) and non-white race (OR: 4.5, CI: 1.2-23, p = 0.04) were preoperative lymphedema risk factors. Patients with IBC are high risk for developing lymphedema due to the need for ALND, radiation, and neoadjuvant chemotherapy. This study also identified non-white race and obesity as risk factors. Larger prospective studies should evaluate potential racial disparities in lymphedema development. Due to the high prevalence of lymphedema, LYMPHA should be considered for all patients with IBC.

Formation de membrane rétroprosthétique suite à la kératoprothèse de Boston de type 1 : incidence, facteurs prédisposants, complications et traitements

Evaluate the incidence and risk factors for retroprosthetic membrane (RPM) formation after Boston keratoprosthesis type 1 (BKpro), identify the associated complications and describe the treatments offered. Retrospective cohort study. In total, 133eyes of 115patients who underwent BKpro at Centre Hospitalier de l'Université de Montréal (CHUM) from 2008to 2017, with a minimum follow-up of 1year, were included in the study. Records were examined, and data was collected, including RPM incidence, preoperative and intraoperative risk factors, postoperative complications and treatments offered. Mean follow-up was 5.5years. Thirty-nine percent (n=52) eyes developed RPM. No particular etiology was significatively associated with RPM formation. Simultaneous lensectomy or IOL extraction were respectively positively and negatively correlated with RPM formation. As for postoperative complications, the strongest correlation was found between RPM formation and retinal detachment. RPM formation was also positively associated with hypotony and corneal melt. Nd:YAG membranotomy was the most frequently used treatment, in 83% of eyes with RPM (n=24), with resolution in 58%. Over one third of BKpro patients will develop a RPM, thus requiring monitoring for associated retinal detachment. IOL extraction appears to be protective, whereas lensectomy appears to increase RPM formation. Nd:YAG membranectomy is used as an initial, non-invasive approach.

Preoperative and Intraoperative Risk Factors for Conversion of Laparoscopic Cholecystectomy to Open Cholecystectomy: A Systematic Review of 30 Studies.

This systematic review aims to review articles that evaluate the risk of conversion from laparoscopic to open cholecystectomy and to analyze the identified preoperative and intraoperative risk factors. The bibliographic databases CINAHL, Cochrane, Embase, Medline, and PubMed were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Only English-language retrospective studies and systematic reviews with more than 200 patients were included. The time of publication was limited from 2012 to 2022. Our systematic review identified 30 studies with a total of 108,472 patients. Of those, 92,765 cholecystectomies were commenced laparoscopically and 5,477 were converted to open cholecystectomy (5.90%). The rate of conversion ranges from 2.50% to 50%. Older males with acute cholecystitis, previous abdominal surgery, symptom duration of more than 72 hours, previous history of acute cholecystitis, C-reactive protein (CRP) value of more than 76 mg/L, diabetes, and obesity are significant preoperative risk factors for conversion from laparoscopic to open cholecystectomy. Significant intraoperative risk factors for conversion include gallbladder inflammation, adhesions, anatomic difficulty, Nassar scale of Grades 3 to 4, Conversion from Laparoscopic to Open Cholecystectomy (CLOC) score of more than 6 and 10-point gallbladder operative scoring system (G10) score more than 3.

Predicting Superficial Surgical Site Infections: A Study of the Risk Factors and an Assessment Scale From Western India.

Introduction Superficial surgical site infections (SSSIs) are very common nosocomial infections that can complicate a range of surgeries, resulting in increased morbidity and mortality, and an overall decreased benefit of surgical interventions, along with exorbitant expenditure of healthcare resources. An assessment scale could help in the segregation of the high-risk patient population, and appropriate resources could be directed toward them. Methods A prospective observational study was carried out in a tertiary care hospital in Western India with 200 participants. Certain probable preoperative, intraoperative, and postoperative risk factors for SSSIs were assessed for significance of association, and each patient was given a score according to the assessment scale. The predictive power of the scale was calculated. Results Body mass index (BMI), preoperative laboratory investigations, and preoperative hospital stay showed a significant association with the complication. Clean-contaminated wounds had a higher incidence of postoperative SSSIs as compared to clean wounds. Postoperatively, fever and the presence of open drains predisposed the patient to complications. The assessment scale was found to have a positive predictive value of 40.94% and a negative predictive value (NPV) of 86.30%. Conclusion The factors that could significantly prevent the development of SSSIs are normal preoperative laboratory investigations, less than three days of preoperative hospital stay, and avoiding the use of open drains. The high NPV of the assessment scale means that it can be used as a screening tool to segregate high-risk patients.

The association of intraoperative and early postoperative events with risk of pneumonia following cardiac surgery

BackgroundPneumonia, the most common infection following cardiac surgery, is associated with major morbidity and mortality. Although prior work has identified preoperative risk factors for pneumonia, the present study evaluated the role and associated impact of intraoperative and postoperative risk factors on pneumonia after cardiac surgery. MethodsThis observational cohort study evaluated 71,165 patients undergoing coronary and/or aortic valve surgery across 33 institutions between 2011 and 2021. Terciles of estimated pneumonia risk were compared between a validated preoperative model (Model One) and a model additionally accounting for significant intraoperative (eg, bypass duration) and postoperative (eg, extubation time) factors (Model Two). Logistic regression was used to develop and validate Model Two. ResultsPostoperative pneumonia occurred in 2.62% of the patients. A total of 9 significant intraoperative and early postoperative risk factors were identified. The absolute risk of pneumonia increased across Model One terciles: low (≤1.04%), medium (1.04%-2.40%), and high (>2.40%). Model two performed well (c-statistic = 0.771). Most patients (60.1%) had no change in their preoperative versus intraoperative/postoperative risk tercile. The 19.6% of patients who increased their risk tercile with Model Two accounted for 18.6% of all pneumonia events. ConclusionsThis study identified 9 significant perioperative risk factors for pneumonia. Nearly 1 of every 5 patients moved into a higher pneumonia risk category based on their intraoperative and postoperative course. These findings may serve as the focus of future quality improvement efforts to reduce a patient's risk of postoperative pneumonia.

Prevalence and risk factors of subsyndromal delirium among postoperative patients: A systematic review and meta-analysis.

The aim of this study is to determine the prevalence and risk factors for subsyndromal delirium in the postoperative patient. A systematic review and meta-analysis. The Review Manager 5.3 statistics platform and the Newcastle-Ottawa Scale were used for quality evaluation. The following databases were searched: PubMed, Web of Science, EMBASE, The Cochrane Library, Scopus and EBSCO from January 2000 to December 2021. Additional sources were found by looking at relevant articles' citations. A total of 1744 titles were originally identified, and five studies including 962 patients were included in the systematic review, with a pooled prevalence of postoperative subsyndromal delirium (PSSD) of 30% (95% CI: 0.28-0.32). Significant risk variables for PSSD were older age, low levels of education (≤9 years), cognitive impairment, higher comorbidity score, and the duration of operation. PSSD is prevalent and is associated with a variety of risk factors as well as low academic performance. Identification and clinical management of patients with PSSD should be improved. Future research on PSSD risk factors should look at a wider range of intraoperative and postoperative risk factors that can be changed. No Patient or Public Contribution.

Risk Factors for Symptomatic Cyclops Lesion Formation after Anterior Cruciate Ligament Reconstruction.

Objective To evaluate the incidence of symptomatic cyclops lesions requiring surgical treatment after anterior cruciate ligament (ACL) reconstruction and to establish possible intraoperative risk factors related to it. Methods Three hundred and eighty-nine patients aged between 18 and 50 years who underwent primary ACL reconstruction were retrospectively evaluated. Patients were divided into groups according to the presence or absence of symptomatic cyclops lesions, and their characteristics were compared. Patients with associated lesions that required additional surgical procedures (except anterolateral extra-articular procedures) were not included. The rate of symptomatic cyclops lesions was recorded and the following parameters were evaluated: age, gender, time from injury to surgery, graft type and diameter, femoral tunnel perforation technique, fixation type, presence of knee hyperextension, preservation of the ACL remnant, associated anterolateral extra-articular procedure, associated meniscal injury and participation in sports. Results 389 patients were evaluated and 26 (6.7%) patients developed cyclops. The patients with and without cyclops lesions did not differ in age, time from injury to surgery, graft type or diameter, surgical technique, femoral fixation method, presence of knee hyperextension, remnant preservation and associated meniscal injury. The group with cyclops lesion had a higher proportion of females (10 (38.4%) vs 68 (18.7%); OR = 2.7; p = 0.015), higher proportion of extra-articular reconstruction (18 (11.8%) vs 8 (3.4%); OR = 3.8; p = 0.001) and higher proportion of sports practice (23 (8.6%) vs 3 (2.5%); OR = 3.6; p = 0.026). Conclusion In our series, 6.7% of the patients required arthroscopic removal of cyclops lesions. Female gender, associated extra-articular reconstruction and sports practice were factors related to this lesion. Remnant preservation had no relationship with cyclops lesion formation.

Incidence and risk factors of postoperative pulmonary complications after oral cancer surgery with free flap reconstruction: A single center study

Postoperative pulmonary complications (PPCs) increase the risk of morbidity and mortality in patients who underwent oral cancer surgery with free flap reconstruction. The association between PPC and preoperative risk factors has been investigated; however, reports on intraoperative factors are limited. Therefore, we investigated PPC incidence and its associated preoperative and intraoperative risk factors in these patients. We retrospectively analyzed medical records of patients who underwent free flap reconstruction between 2009 and 2019. PPC was defined as presence of atelectasis, pneumonia, and respiratory failure based on radiological confirmation and clinical symptoms during hospitalization. Mortality, hospital stay, preoperative factors (including age and tumor stages), American Society of Anesthesiologists (ASA) classification, and intraoperative factors (including intraoperative fluids and medications) were recorded. PPC incidence among the 993 patients included in this study was 25.8% (256 patients). Six patients with PPCs died; death was not observed among patients without PPCs (p<0.001). Patients with PPCs had longer hospitalization than those without PPCs (30.3 vs 23.3 days; p<0.001). Tumor stage (stage I: reference; stage II [OR]: 3.3, p=0.019; stage III: 4.4, p=0.002; stage IV: 4.8, p=0.002), age (OR: 1.0; p<0.001), and ASA grade >2 (OR: 1.4; p=0.020) were independent risk factors of PPC; using labetalol was a borderline significant factor (OR: 1.4; p=0.050). The PPC incidence was 25.8% in patients undergoing oral cancer surgery with free flap reconstruction. Tumor stage, age, and ASA >2 were risk factors of developing PPC.

In Reply to the Letter to the Editor Regarding “Postnatal Surgical Correction of Myelomeningoceles: Preoperative and Intraoperative Risk Factors Associated with Postoperative Neurologic Outcomes”

In Reply to the Letter to the Editor Regarding “Postnatal Surgical Correction of Myelomeningoceles: Preoperative and Intraoperative Risk Factors Associated with Postoperative Neurologic Outcomes”

Letter to the Editor Regarding: Postnatal Surgical Correction of Myelomeningoceles: Preoperative and Intraoperative Risk Factors Associated with Postoperative Neurologic Outcomes

Letter to the Editor Regarding: Postnatal Surgical Correction of Myelomeningoceles: Preoperative and Intraoperative Risk Factors Associated with Postoperative Neurologic Outcomes

A comprehensive analysis of intraoperative factors associated with acute-on-chronic kidney injury in elderly trauma patients: blood loss as a key predictor

BackgroundPostoperative acute kidney injury (AKI) is a critical issue in geriatric patients with pre-existing chronic kidney disease (CKD) undergoing orthopedic trauma surgery. The goal of this study was to investigate modifiable intraoperative risk factors for AKI.MethodsA retrospective study was conducted on 206 geriatric patients with CKD, who underwent orthopedic trauma surgery. Several variables, including intraoperative blood loss, postoperative hypoalbuminemia, intraoperative blood pressure and long-term use of potentially nephrotoxic drugs, were analyzed.ResultsPostoperative AKI (KIDGO) was observed in 25.2% of the patients. The 1-year mortality rate increased significantly from 26.7% to 30.8% in patients who developed AKI. Primary risk factors for AKI were blood loss (p < 0.001), postoperative hypoalbuminemia (p = 0.050), and potentially nephrotoxic drugs prior to admission (angiotensin-converting enzyme inhibitors, angiotensin-II receptor antagonists, diuretics, antibiotics, NSAIDs) (p = 0.003). Furthermore, the AKI stage negatively correlated with propofol dose per body weight (p = 0.001) and there was a significant association between AKI and the use of cement (p = 0.027). No significant association between intraoperative hypotension and AKI was observed in any statistical test. Femur fracture surgeries showed the greatest blood loss (524mL ± 357mL, p = 0.005), particularly intramedullary nailing at the proximal femur (598mL ± 395mL) and revision surgery (769mL ± 436mL).ConclusionIn geriatric trauma patients with pre-existing CKD, intraoperative blood loss, postoperative hypoalbuminemia, and pre-admission use of potentially nephrotoxic drugs are associated with postoperative AKI. The findings highlight the necessity to mitigate intraoperative blood loss and promote ortho-geriatric co-management to reduce the incidence and subsequent mortality in this high-risk population.

Preoperative and Intraoperative Risk Factors for Surgical Site Infection in Pediatric Cardiac Surgery.

Surgical site infection (SSI) is a major complication of pediatric cardiac surgery. If the risk of developing SSI can be predicted based on the patient's preoperative background, appropriate preoperative management to prevent the development of SSI can be achieved. We retrospectively studied cases for patients younger than 7 years of age among surgeries performed through a median sternotomy at Kagoshima University Hospital from April 2011 to March 2021. SSI was diagnosed according to the Centers for Disease Control and Prevention guidelines and classified into 3 types: superficial incisional SSI (SiSSI), deep incisional SSI (DiSSI) and mediastinitis. Of the 765 consecutive pediatric cardiac surgeries, 597 were included in the analysis based on the exclusion criteria. Of these, 17 (2.8%) developed SSI (3 SiSSI cases, 2 DiSSI cases and 12 mediastinitis cases), with Staphylococcus aureus as the major pathogen. Univariate analysis revealed that low preoperative serum protein ( P = 0.049) and low serum albumin levels ( P = 0.023) were risk factors for the development of SSI. No findings suggested impaired hepatic synthesis, inflammatory disease or protein loss from the kidney or intestinal tract. We concluded that malnutrition caused low serum protein and albumin levels. Low preoperative serum protein and albumin levels are risk factors for SSI development of SSI. Nutritional status should be regularly assessed in children scheduled for cardiac surgery, and interventions, such as nutritional guidance, should be considered if malnutrition is suspected.

Risk Factors for Stroke Development After Thoracic Aortic Surgery

Stroke after thoracic aortic surgery is a complication that is associated with poor outcomes. The aim is to characterize the intraoperative risk factors for stroke development. A retrospective analysis. Tertiary, high-volume cardiac surgery center. Patients who had surgical repair of thoracic aortic diseases from January 1, 2017, through December 31, 2021. None. A total of 704 patients were included, of whom 533 had ascending aortic aneurysms, and 171 had type A aortic dissection. The incidence of postoperative stroke was 4.5% (95% CI 2.9%-6.6%) for ascending aortic aneurysms compared with 12.3% (95% CI 7.8%-18.16%) in type-A aortic dissections. Patients who developed postoperative strokes had significantly lower intraoperative hemoglobin median (7.5 gm/dL [IQR 6.8-8.6] v 8.55 gm/dL [IQR 7.3-10.0]; p < 0.001). The median cardiopulmonary bypass time was 185 minutes (IQR 136-328) in the stroke group versus 156 minutes (IQR 113-206) in the nonstroke group (p=0.014). Circulatory arrest was used in 57.8% versus 38.5% of the nonstroke patients (p=0.017). The initial temperature after leaving the operating room was lower, with a median of 35.0°C (IQR 34-35.92) in the stroke group versus 35.5°C (IQR 35-36) in the nonstroke cohort (p=0.021). This single-center study highlighted the potential importance of intra-operative factors in preventing stroke. Lower hemoglobin, longer duration of cardiopulmonary bypass, deep hypothermic circulatory arrest, and postoperative hypothermia are potential risk factors for postoperative stroke. Further studies are needed to prevent this significant complication in patients with thoracic aortic diseases.

The prediction model for intraoperatively acquired pressure injuries in orthopedics based on the new risk factors: a real-world prospective observational, cross-sectional study.

Introduction: Orthopedic patients are at high risk for intraoperatively acquired pressure injuries (IAPI), which cause a serious issue and lead to high-expense burden in patient care. However, there are currently no clinically available scales or models to assess IAPI associated with orthopedic surgery. Methods: In this real-world, prospective observational, cross-sectional study, we identified pressure injuries (PI)-related risk factors using a systematic review approach and clinical practice experience. We then prepared a real-world cohort to identify and confirm risk factors using multiple modalities. We successfully identified new risk factors while constructing a predictive model for PI in orthopedic surgery. Results: We included 28 orthopedic intraoperative PI risk factors from previous studies and clinical practice. A total of 422 real-world cases were also included, and three independent risk factors-preoperative limb activity, intraoperative wetting of the compressed tissue, and duration of surgery-were successfully identified using chi-squared tests and logistic regression. Finally, the three independent risk factors were successfully used to construct a nomogram clinical prediction model with good predictive validity (area under the ROC curve = 0.77), which is expected to benefit clinical patients. Conclusion: In conclusion, we successfully identified new independent risk factors for IAPI-related injury in orthopedic patients and developed a clinical prediction model to serve as an important complement to existing scales and provide additional benefits to patients. Our study also suggests that a single measure is not sufficient for the prevention of IAPI in orthopedic surgery patients and that a combination of measures may be required for the effective prevention of IAPI.

A Practical Approach to Predicting Surgical Site Infection Risk Among Patients Before Leaving the Operating Room.

A surgical site infection (SSI) prediction model that identifies at-risk patients before leaving the operating room can support efforts to improve patient safety. In this study, eight pre-operative and five perioperative patient- and procedure-specific characteristics were tested with two scoring algorithms: 1) count of positive factors (manual), and 2) logistic regression model (automated). Models were developed and validated using data from 3,440 general and oncologic surgical patients. In the automated algorithm, two pre-operative (procedure urgency, odds ratio [OR]: 1.7; and antibiotic administration >2 hours before incision, OR: 1.6) and three intraoperative risk factors (open surgery [OR: 3.7], high-risk procedure [OR: 3.5], and operative time OR: [2.6]) were associated with SSI risk. The manual score achieved an area under the curve (AUC) of 0.831 and the automated algorithm achieved AUC of 0.868. Open surgery had the greatest impact on prediction, followed by procedure risk, operative time, and procedure urgency. At 80% sensitivity, the manual and automated scores achieved a positive predictive value of 16.3% and 22.0%, respectively. Both the manual and automated SSI risk prediction algorithms accurately identified at-risk populations. Use of either model before the patient leaves the operating room can provide the clinical team with evidence-based guidance to consider proactive intervention to prevent SSIs.

Is there concordance between the Cellvizio system and pathology in determining microscopic inflammation at the ileal resection margins in Crohn's ileal disease? The CELLVICROHN study

BackgroundCrohn's disease is an inflammatory bowel disease for which surgery is required in approximately 80% of cases. However, surgery does not cure Crohn's disease. The type of surgery is important, as there are intraoperative risk factors for recurrence, including microscopic inflammation at the resection margins. This point is crucial, as a too large resection may result in short bowel syndrome and a too short resection (microscopic inflammation at the resection site) a higher risk of postoperative recurrence (75% vs 46% at 18 months). Based on the results of a randomised control trial, surgeons are encouraged to perform a limited resection (2 cm from macroscopic Crohn's disease). However, such a macroscopically non-inflamed resection margin may show microscopic inflammation (up to 80%). Thus, it would be useful to evaluate whether there is microscopic inflammation at the resection margin. Moreover, there is an increasing interest in the role of the mesentery in recurrence, which is still unclear. Thus, it would be informative to also clarify the border between inflamed and non-inflamed mesentery. Cellvizio is a type of confocal laser endomicroscopy system that provides the possibility to obtain high-magnification in-vivo images of the gut epithelium. This allows real-time examination of the gastrointestinal mucosa at the cellular and subcellular level. Cellvizio has never been used during surgery for Crohn's disease. PurposeThe aim of this study is to evaluate the intraoperative use of Cellvizio to determine the optimal ileal resection margins in Crohn's disease. Primary outcomeThe primary outcome is the concordance between the evaluation of microscopic inflammation at the ileal resection margin by the Cellvizio system and pathology. Secondary outcomesThe secondary outcomes are the concordance between the Cellvizio system and pathology in evaluating inflammation of the serosa (transmural inflammation) and mesentery and the length of the ileum (in cm) between the surgical margin and the theoretical resection site to have a resection margin free of microscopic inflammation as determined by the Cellvizio system (for the mucosa and serosa). Study designThis is a prospective, single centre, interventional study. Eligibility criteriainclusion criteria: Patients who require an ileocecal resection for Crohn's disease, regardless of the phenotype. exclusion criteria: Patients who are under 18 years of age, are pregnant or breastfeeding, have had an ileocolic resection for a surgical recurrence of Crohn's disease, have had emergency surgery for peritonitis, and those who have a contra indication for fluoresceine injection or severe allergy to any drug. Arm number or label and arm typeThis is a single-arm study. InterventionsDuring surgery an intravenous injection of fluoresceine will be performed. The surgeon will then evaluate the ileal section margins of the mucosa, serosa, and mesentery to evaluate whether the section margin shows microscopic inflammation. The surgeon will then evaluate (in cm) the length between this section margin and the theorical section margin to be within non-inflamed tissue of the mucosa, serosa, and mesentery. The data will be recorded during surgery, blind from the pathological analysis. The pathological analysis will also be performed blind from the Cellvizio data. A video collection will be performed anonymously. Number of participants41 patients Statistical analysisWe assume an estimated Kappa coefficient of 90%, a lower bound of 70%, and a frequency of microscopic inflammation at the ileal resection margin of 70%. Given this hypothesis and an alpha risk of 5%, the inclusion of 41 patients will be necessary.

Determination of Risk Factors for Postoperative Acute Kidney Injury in Patients With Gynecologic Malignancies.

Background Postoperative acute kidney injury (AKI) is an important cause of mortality and morbidity among surgical patients. There is little information on the occurrence of AKI after operations for gynecologic malignancies. This study aimed to determine the incidence of AKI in patients who underwent surgery for gynecological malignancies and determine the risk factors in those who developed postoperative AKI. Methodology A total of 1,000 patients were enrolled retrospectively from January 2007 to March 2013. AKI was defined according to the Kidney Disease Improving Global Outcomes 2012 Clinical Practice Guideline for Acute Kidney Injury. Perioperative variables of patients were collected from medical charts. Results The incidence of postoperative AKI was 8.8%, with stage 1 occurring in 5.9%, stage 2 in 2.4%, and stage 3 in 0.5% of the patients. Patients who had AKI were significantly older, had higher body mass index (BMI) higher preoperative C-reactive protein (CRP) levels, and more frequently had a history of distant organ metastasis when compared with those who did not have AKI. When compared with patients who did not develop AKI postoperatively, longer operation times and intraoperative usage of higher amounts of erythrocyte suspension and fresh frozen plasma were seen in those who developed AKI. Conclusions Patients who had AKI were older, had higher BMI with higher preoperative CRP levels, more frequent distant organ metastasis, longer operation times, and higher amounts of blood transfused intraoperatively. Defining preoperative, intraoperative, and postoperative risk factors for postoperative AKI and taking necessary precautions are important for the early detection and intervention of AKI.