Risk Factors For Major Complications Research Articles

The comprehensive complication index is more sensitive than the Clavien-Dindo classification for grading complications in elderly patients after radical cystectomy and pelvic lymph node dissection: Implementing the European Association of Urology guideline.

Lack of assessment of 90-d perioperative morbidity in elderly patients after radical cystectomy and pelvic lymph node dissection (PLND) using a standard reporting methodology, and the Clavien-Dindo classification (CDC) does not accurately reflect the burden of complications. We aim to report the 90-d complications of elderly patients after radical cystectomy, and to compare the validity of the Comprehensive Complication Index (CCI) and CDC. Retrospective review of 280 patients aged ≥75 years who received radical cystectomy between 2006 and 2021. The 90-d complications of elderly patients after radical cystectomy were reported by implementing the EAU criteria. The CDC and CCI were both used for grading complications. The Spearman rank correlation coefficient was used to estimate the correlation between postoperative stay and CDC/CCI. Logistic regression was used to identify the risk factors for major complications. The sample size for a fictive superiority trial was calculated for different endpoints. A total of 225 (80.36%) patients suffered from 528 complications. The cumulative CCI had a more accurate prediction of postoperative stay than the CDC (r = 0.378, p < 0.001 vs. r = 0.349, p < 0.001). The need for sample size could decrease when CCI was used for the primary endpoint. More risk factors for major complications were identified when CCI ≥33.7 was defined as the endpoint of major complications. CCI is better than CDC for grading the severity of complications in elderly patients after radical cystectomy and PLND.

The frequency and risk factors of major complications after thermal ablation of liver tumours in 2,084 ablation sessions.

BackgroundTo assess the frequency of major complications after thermal ablation of liver tumours and to determine risk factors for adverse events.MethodsA retrospective study was conducted between January 2015 and January 2021. A total of 2,084 thermal ablation sessions in 1,592 patients with primary and metastatic liver tumours were evaluated. The frequency of major complications was evaluated according to the Society of Interventional Radiology Standards, and putative predictors of adverse events were analysed using simple and multivariate logistic regression.ResultsThermal ablation-related mortality was 0.1% (2/2,084), with an overall major complication rate of 5.6% (117/2,084). The most frequent major complication was symptomatic pleural effusion (2.9%, 60/2,084). Multivariate logistic regression analysis revealed that a total maximum diameter of lesions >3 cm, microwave ablation (MWA) and MWA combined with radiofrequency ablation, intrahepatic cholangiocarcinoma and postoperative systemic inflammatory response syndrome were independent prognostic factors for major complications.ConclusionsThermal ablation of liver tumours is a safe procedure with an acceptable incidence of major complications. The risk factors identified in this study will help to stratify high-risk patients.

Radiological Features for Frailty Assessment in Patients Requiring Emergency Laparotomy.

Introduction: As the number of elderly patients requiring surgical intervention rises, it is believed that frailty syndrome has a greater impact on perioperative course than on chronological age. The aim of this study was to evaluate the efficacy of various imaging features for frailty assessment in patients undergoing emergency laparotomy. Methods: The study included all patients that qualified for emergency surgery with preoperative CT scans between 2016 and 2020 in the Second Department of General Surgery. Multiple trauma patients were excluded from the analysis. The modified frailty index and brief geriatric assessment were used in the analysis. CT images were reviewed for the assessment of osteopenia, sarcopenia, sarcopenic obesity, renal volume and abdominal aorta calcification rate. Results: A total of 261 patients were included in the analysis. Multivariate logistic regression identified every next ASA class (OR: 4.161, 95%CI: 1.672–10.355, p = 0.002), intraoperative adverse events (OR: 12.397, 95%CI: 2.166–70.969, p = 0.005) and osteopenia (OR: 4.213, 95%CI: 1.235–14.367, p = 0.022) as a risk factor for 30-day mortality. Our study showed that every next ASA class (OR: 1.952, 95%Cl: 1.171–3.256, p = 0.010) and every point of the BGA score (OR: 1.496, 95%Cl: 1.110–2.016, p = 0.008) are risk factors for major complications. Conclusions: Osteopenia was the best parameter for perioperative mortality risk stratification in patients undergoing emergency surgical intervention. Sarcopenia (measured as psoas muscle area), sarcopenic obesity, aortic calcifications and mean kidney volume do not predict poor outcomes in those patients. None of the radiological markers appeared to be useful for the prediction of perioperative morbidity.

Perioperative Complications and Oncologic Outcomes after Radical Cystectomy in End-Stage Renal Disease Patients with Bladder Cancer Obtained Using a Standardized Reporting System.

Simple SummaryUrothelial carcinoma (UC) of the bladder is the most common malignancy in dialysis patients in Taiwan compared with renal cell carcinoma in Western countries. Radical cystectomy is the standard of care for localized muscle-invasive bladder cancer (MIBC), as well as for selected patients with high-risk non-MIBC. Despite improvements in anesthetic competency, surgical techniques, and postoperative care, dialysis patients undergoing radical cystectomy are at a higher risk of perioperative morbidity and mortality than non-dialysis patients. Due to the relative rarity of the condition, published data on predictors of outcome in ESRD patients undergoing radical cystectomy are scant. Our study revealed that accurate reporting of complications is necessary for preoperative counseling, identifying modifiable risk factors, and planning risk mitigation strategies. High comorbidity and low-volume surgeons were interrelated as notable risk factors for major complications. In addition to tumor-related factors, male sex, older age, and major complications significantly influence survival.Background: We investigated the use of a standardized reporting system to study perioperative complications and oncologic outcomes after radical cystectomy in end-stage renal disease (ESRD) patients with bladder cancer. Methods: We reviewed retrospective outcomes in 141 ESRD patients with bladder cancer who underwent radical cystectomy between 2004 and 2015. Complications were graded using the Clavien–Dindo classification system with 0–2 classified as “No Major Complications” and Clavien 3–5 as “Major Complications”. Low-volume surgeons were classified as those performing fewer than nine cases during the study. Fisher’s exact test along with the chi-squared test, two-tailed t tests, logistic regression, and the Cox proportional hazard model were used to evaluate all clinically meaningful covariates. Results: Ninety-nine (99, 70.2%) patients had no major complications, and forty-two (29.8%) patients had major complications. Patients in the major complications group were older, had a higher Charlson comorbidity index (CCI), and had a longer hospitalization duration than those in the no major complications group (all, p < 0.05). Major complications were also more common when the procedure was performed by low-volume surgeons (p = 0.003). In multivariate logistic regression models, CCI ≥ 5 (p = 0.006) and low-volume surgeon (p = 0.004) were independent predictors of major complications. According to multivariate analysis with the Cox hazards regression, male sex, age > 70 years, CCI ≥ 5, bladder cancer stage ≥ 3, lymphovascular invasion, and experiencing major complications were significant poor prognostic factors for overall survival (all, p < 0.05). Conclusions: Accurate reporting of complications is necessary for preoperative counseling, identifying modifiable risk factors, and planning risk mitigation strategies. High comorbidity and low-volume surgeons were interrelated as notable risk factors for major complications. In addition to tumor-related factors, male sex, older age, and major complications significantly influence overall survival.

Predictors of Morbidity and Mortality After Colorectal Surgery in Patients With Cirrhotic Liver Disease-A Retrospective Analysis of 54 Cases at a Tertiary Care Center.

BackgroundDespite various existing scores that predict morbidity and mortality of patients with cirrhotic liver disease (CLD), data on specific risk stratification of patients with CLD undergoing colorectal surgery (CRS) are rare. The aim of this study was to assess in-hospital morbidity and mortality of patients with liver cirrhosis scheduled for CRS, with specific focus on possible pitfalls of surgery in this special cohort.MethodsBetween 1996 and 2018, 54 patients with CLD undergoing CRS were identified and included in this study cohort. Postoperative morbidity and mortality were assessed using the Clavien/Dindo (C/D) classification as well as by type of complication. Univariate and multivariate analyses were performed to analyze the predictive factors for increased postoperative morbidity.ResultsOf the patients, 37% patients died during the procedure or postoperatively. Major complications were seen in 23.1% of patients (>C/D IIIb). Patients with Child B or C cirrhosis as well as patients undergoing emergency surgery experienced significantly more major complications (p = 0.04 and p = 0.023, respectively). The most common complications were bleeding requiring blood transfusion (51.1%) and cardiocirculatory instability due to bleeding or sepsis (44.4%). In 53.7% of patients, an anastomosis was created without a protective ostomy. Anastomotic leakage occurred in 20.7% of these patients. Multivariate analysis showed that a primary anastomosis without a protective ostomy was the strongest risk factor for major complications (p = 0.042).DiscussionMorbidity and mortality after CRS in patients with CLD remains high and is not only influenced by liver function but also by surgical variables. Considering the high rate of anastomotic leakage, creating a protective or definitive ostomy must be considered with regard to the underlying pathology, the extent of CLD, and the patient's condition. Moreover, our data suggest that surgery in these most fragile patients should be performed only in experienced centers with immediate contact to hepatologists and experts in hemostasis.

Safety of Contemporary Carotid Artery Stenting and Associated Risk Factors for Treatment of Carotid Artery Stenosis

The prevalence of carotid artery atherosclerosis and stroke is increasing. Carotid artery stenting (CAS), which treats carotid artery stenosis and prevents strokes, has benefited from advances in techniques and technology. In this study, we aimed to identify significant risk factors for major complications following contemporary CAS. Utilizing the National Surgical Quality Improvement Program registry, we investigated individuals who underwent CAS between the years 2015-2018. Multivariable logistic regression was performed to identify risk factors associated with stroke, myocardial infarction (MI), and death within 30days of CAS. Of the 770 patients within the National Surgical Quality Improvement Program registry who met study criteria, 3.2% experienced strokes, 1.6% experienced MIs, and 2.2% died within 30days of CAS. A total of 6.1% of patients experienced any of these major complications. Of the 395 asymptomatic patients, 3.5% suffered a stroke, 1.5% experienced an MI, and 1.0% died for a total of 5.6% patients suffering from any event. Of the 375 symptomatic patients, there were 2.9% strokes, 1.6% MIs, and 3.5% deaths with 6.7% suffering any event. Age, race, and hyponatremia were significantly associated with stroke, and hyponatremia was associated with MI. Age, anemia, hypoalbuminemia, international normalized ratio, and emergency case were associated with death. These results suggest that preoperative risk stratification of CAS patients may not be straightforward as each adverse event has its own risk factors, precluding a generalized CAS risk stratification scoring system from being created. This paper can aid in patient selection for CAS by highlighting risk factors in modern CAS.

Association between thoracic epidural block and major complications after pleurectomy/decortication for malignant pleural mesothelioma under general anesthesia

IntroductionA curative-intent surgical procedure, pleurectomy/decortication, for malignant pleural mesothelioma is accompanied by a high incidence of major postoperative complications. Although epidural block, which suppresses nociception during and after surgery, reportedly...

Major procedure-related complications in a real-world cohort of patients undergoing transvenous lead extraction

Abstract Funding Acknowledgements Type of funding sources: None. Background Transvenous lead extraction (TLE) is the mainstay therapy for device-related infections. Though TLE procedures are associated with low complication and high success rates, risk factors for major procedure-related complications remain not well defined. Purpose To evaluate the safety and efficacy of TLE in a large single centre cohort and to identify risk factors for major complications. Methods All consecutive patients undergoing TLE in our department between May 2012 and December 2021 were included in a prospective registry. Our protocol for TLE followed a stepwise approach according to lead dwell time and estimated complexity of the procedure: use of simple traction ± locking stylet (LS) ± mechanical and/or powered sheaths ± snare technique via a femoral or jugular access. Patient characteristics, procedural data and complications were gathered and analysed. Logistic regression analysis was applied to identify risk factors for major procedure related complications. Results A total of 2218 leads (25.7% ICD leads) were targeted for TLE in 1060 patients (67.7 ± 14.8 years; 74% male). The mean lead dwell time was 82 ± 62 months. The leading indication for TLE was cardiac device related infection (CDRI) in 695 patients (65.6%), 373 (35.2%) had systemic and 322 (30.4%) localized infection. Leads were extracted by simple traction in 30%, traction with LS in 3.7%, dilator sheaths with LS in 47.7%, and additional use of powered mechanical sheaths in 14.6%. The snare technique was used in 3.9%, with additional venous entry from femoral in 3.5% and jugular in 1.0% of all targeted leads. TLE was completely successful in 92.6%, partially successful with lead fragments &amp;lt;4cm in 4.2%, and failed in 3.1% of all patients, which translated to a clinical success rate of 96.9%. Twenty-nine patients (2.7%) experienced minor and 18 patients (1.7%) had major procedure-related complications (cardiac tamponade/perforation) including 2 intraprocedural deaths (0.2%). Presence of abandoned leads (HR 8.41, 95% CI 3.21–22.02; p&amp;lt;0.001), lead-years-per-patient (HR 1.063, 95% CI 1.037–1.090; p&amp;lt;0.001), dwelling time of the oldest lead (HR 1.011, 95% CI 1.006–1.016; p&amp;lt;0.001), and a right-sided implantation (HR 2.68, 95% CI 1.05–6.83; p=0.04) were significant predictors of major complications in logistic regression analysis. Conclusion TLE is feasible, effective and safe in our large single centre experience. Overall complication and failure rates are low. Following our TLE protocol, the presence of abandoned leads, a right-sided implantation and dwelling time of the extracted leads were associated with major procedure-related complications.

Intraoperative risk factors for major complications after oesophagectomy: the surgical Apgar score.

Intraoperative risk factors for major complications after oesophagectomy: the surgical Apgar score.

Surgical Apgar Score and Controlling Nutritional Status Score are significant predictors of major complications after cervical spine surgery

Nutritional screening scores, including Controlling Nutritional Status (CONUT) Score and Surgical Apgar Score (SAS), which reflect intraoperative hemodynamics, have been reported to be useful for predicting major postoperative complications in various kinds of surgery. We assessed independent risk factors for major complications after cervical spine surgery using those scoring measurements. We retrospectively reviewed medical records of patients who underwent cervical spine surgery at our institution from 2014 to 2019. Baseline clinical information, including the CONUT Score, and surgical factors, including the SAS, were assessed as risk factors for major postoperative complications. We analyzed 261 patients. Major postoperative complications occurred in 40 cases (15.3%). In the multivariate analysis, SAS (odds ratio [OR], 0.42; P < 0.01), CONUT (OR, 1.39; P < 0.01), and operative time (OR, 1.42; P < 0.01) were significant independent risk factors of major complications. The area under the SAS curve was 0.852 in the receiver operating characteristic curve analysis. Postoperative hospitalization duration was significantly longer in major complications group. Evaluating preoperative nutritional condition and intraoperative hemodynamics with CONUT score and SAS was useful for predicting major postoperative complications of cervical spine surgery. In addition, both scoring measurements are easily calculated, objective evaluations. Perioperative management utilizing those scoring measurements may help prevent them.

Adverse Effects of Sarcopenic Obesity on Postoperative Complications after Major Hepatectomy in Patients with Hilar Cholangiocarcinoma.

Sarcopenic obesity (SO), which is defined as a high ratio of visceral adipose tissue to skeletal muscle, is a well-known risk factor for post-hepatectomy outcomes in patients with hepatocellular carcinoma. However, few studies have evaluated the effect of SO on postoperative outcomes in patients with hilar cholangiocarcinoma (CCC). This retrospective study aimed to evaluate the effect of preoperative SO on postoperative outcomes in patients with hilar CCC following major hepatectomy. Preoperative SO was assessed in 328 patients undergoing hepatectomy for hilar CCC at three institutions between 2006 and 2016. SO was calculated from cross-sectional visceral fat and muscle area displayed on preoperative CT imaging. Preoperative SO was present in 98 patients (29.9%). The major complication rate in patients with SO was higher than in those without SO (54.1% vs. 37.0%, p = 0.004). Additionally, postoperative hospital stays were prolonged in patients with SO (18.5 vs. 16.5 days, p = 0.038). After multivariable analysis, SO was identified as an independent risk factor for major complications after hepatectomy in hilar CCC patients (OR = 0.866, 95% CI: 1.148–3.034, p = 0.012). Careful postoperative management is needed after major hepatectomy in hilar CCC patients with SO.

Late is too late? Surgical timing and postoperative complications after primary ileocolic resection for Crohn’s disease

BackgroundDespite the recent advances in medical therapy, the majority of patients with Crohn’s disease (CD) still require surgery during the course of their life. While a correlation between early primary surgery and lower recurrence rates has been shown, the impact of surgical timing on postoperative complications is unclear. The aim of this study is to assess the impact of surgical timing on 30-day postoperative morbidity.MethodsThis is a retrospective analysis of a prospectively collected database of 307 consecutive patients submitted to elective primary ileocolic resection for CD at our institution between July 1994 and July 2018. The following variables were considered: age, gender, year of treatment, smoking habits, preoperative steroid therapy, presence of fistula or abscess, type of anastomosis, and time interval between diagnosis of CD and surgery. Univariate and multivariate logistic regressions were performed to examine the association between risk factors and complications.ResultsMajor complications occurred in 29 patients, while anastomotic leak was observed in 16 patients. Multivariate logistic regression analysis showed that surgical timing in years (OR 1.10 p = 0.002 for a unit change), along with preoperative use of steroids (OR 5.45 p < 0.001) were independent risk factors for major complications. Moreover, preoperative treatment with steroids (6.59 p = 0.003) and surgical timing (OR 1.10 p = 0.023 for a unit change) were independently associated with anastomotic leak, while handsewn anastomosis (OR 2.84 p = 0.100) showed a trend.ConclusionsOur results suggest that the longer is the time interval between diagnosis of CD and surgery, the greater is the risk of major surgical complications and of anastomotic leak.

Impact of myopenia and myosteatosis in patients undergoing abdominal surgery for chronic pancreatitis

BackgroundSurgery for chronic pancreatitis is associated with major morbidity and mortality. The aim of this study is to examine the role of preoperative muscle volume and quality on postoperative outcomes in patients with chronic pancreatitis. MethodsAll patients who underwent abdominal surgery for chronic pancreatitis between 2011 and 2018 were identified from an institutional surgical database. Patient demographics, clinical indices, and perioperative computed tomography scans were collected. Myopenia and myosteatosis were measured at the L3 vertebral level. Regression analysis was used to identify risk factors for major complications (Clavien-Dindo ≥3a) and length of stay. ResultsSeventy-five patients were identified. Toxic-metabolic or obstructive causes were the main underlying etiologies. Thirty patients were myopenic (40%), and 36 patients were myosteatotic (48%). Sixteen patients (21%) had a major complication. Median length of stay was 10 days. Both myopenia and myosteatosis were associated with major complications (hazard ratio = 7.85, 95% confidence interval: 1.91–32.29, P = .004 and hazard ratio = 4.351, 95% confidence interval: 1.22–15.52, P = .023). Myosteatosis was associated with increased length of stay (parameter estimate = 0.297, 95% confidence interval: 0.012–0.583, P = .041). ConclusionMyopenia and myosteatosis were common and significant risk factors for adverse postoperative events. Preoperative muscle assessment may help in the risk stratification of surgical patients and identify patients that require preoperative nutritional and physical optimization.

Evidence-based risk factors for major complications during Ramadan fasting in people with diabetes grouped under IDF-DAR risk categories

AimTo identify evidence-based risk factors for major complications during Ramadan fasting in people with diabetes grouped under IDF-DAR risk categories. MethodsThis prospective observational multicenter study was conducted by Baqai Institute of Diabetology and Endocrinology (BIDE) between April-June 2019. People with diabetes having intention to fast during Ramadan were recruited. Demographic data collection along with risk categorization was done during pre-Ramadan visit. Structured education was given on one- to-one basis to each of the study participants. Assessment of complications was done during post Ramadan visit. ResultsA total of 1045 people with diabetes participated with near equal gender distribution. Two thirds of study population was grouped into very high- and high-risk categories. Frequencies of major hypoglycemia, major hyperglycemia, hospitalization & need to break the fast were 4.4%, 10.8%, 0.8% & 3.1% respectively.On multivariate analysis, the risk factors found for major hypoglycemia during Ramadan were male gender, use of sedatives & antidepressants & having type1 diabetes mellitus, history of DKA/HHS during last 3 months for major hyperglycemia, major hypoglycemia & hospitalization for breaking of fast while older age, acute illness, and major hypoglycemia were identified factors for hospitalization. ConclusionIn this prospective study evidence-based risk factors for fasting related major complications were identified in people with diabetes. It is imperative to recognize these factors during pre-Ramadan risk assessment visit.

Comparative Study of Perioperative and Oncological Outcomes Between Elderly Patients and Younger Patients Who Received Radical Cystectomy and Pelvic Lymph Node Dissection: A Single-Center Retrospective Study.

PurposeTo compare the perioperative and survival outcomes of patients over 75 years and younger patients who received radical cystectomy.Patients and methodsA total of 119 patients aged ≥75 years and 488 patients aged <75 years were enrolled. All patients underwent radical cystectomy with pelvic lymph node dissection. Clinical characteristics and perioperative outcomes were compared between the two groups. Overall survival and progression-free survival were analyzed by using the Kaplan–Meier method. Cox regression analysis and logistic regression analysis were used to identify the risk factors affecting the outcomes observed.ResultsThere was no significant difference in perioperative complications between the elderly patient group and the younger patient group (p = 0.349). The 5-year overall survival of elderly patients was lower than that of young patients (p < 0.001). Age ≥75 years was a risk factor for overall survival (HR = 1.69 [95% CI: 1.22–2.35]; p = 0.002) and progression-free survival (HR = 1.69 [95% CI: 1.14–2.50]; p = 0.008) for patients who received radical cystectomy but was not a poor risk factor for major complications (HR = 1.25 [95% CI: 0.47–3.31]; p = 0.658) after radical cystectomy. In addition, preoperative renal insufficiency was associated with a higher risk of major complications.ConclusionIn our cohort, compared with younger patients, elderly patients aged ≥75 years had worse survival outcomes, but age ≥75 years was not a risk factor for major complications after radical cystectomy with pelvic lymph node dissection. Radical surgery should be encouraged for elderly patients who can tolerate aggressive treatments.

A Meteorological Paradox: Low Atmospheric Pressure-Associated Decrease in Blood Pressure Is Accompanied by More Cardiac and Cerebrovascular Complications: Five-Year Follow-Up of Elderly Hypertensive Patients

Background: Variations in atmospheric pressure (AP) are known to affect blood pressure (BP). We assessed the effect of AP on BP, and the major fatal and nonfatal complications thereof (i.e., stroke, myocardial infarction, and pulmonary emboli). Methods: In this observational cohort study, 250 hypertensive patients (aged 65–92 years old) were followed for 3.5–5.4 years in a primary care clinic. Cox proportional hazard regression was performed to define the associations between AP, clinical, demographic and environmental factors, and major complications such as stroke, myocardial infarction, etc. Results: AP fluctuated between 1007 and 1024 millibars (MB). A total of 132 patients (53%) developed various complications, of which 13 (9.8%) were fatal. Among all fatalities, 93 of 119 nonfatal cases and 7 of 13 fatal cases occurred at AP &lt; 1013 MB. A Cox regression analysis showed that low AP (AP &lt; 1013 MB) had a higher hazard ratio (HR) on hypertension (HTN) complications among all demographic, clinical and environmental parameters. Conclusions: Most major complications were associated with very low APs. Low AP was the best predictive risk-factor for major complications of HTN.

Incidence and Preoperative Risk Factors for Major Complications After Capsulectomy: Analysis of 3048 Patients

Although there are many indications for periprosthetic breast capsulectomy, heightened public attention surrounding breast implant illness has resulted in increased rates of capsulectomy. This study aimed to identify the incidence of major complications and risk factors associated with capsulectomy. From an examination of a prospectively enrolled cosmetic surgery insurance database, CosmetAssure (Birmingham, AL), patients undergoing capsulectomy between January 2, 2017 and July 31, 2019 were identified. Outcomes measured included the occurrence of and risk factors for major complication(s) necessitating an emergency department visit, hospitalization, or reoperation within 45 postoperative days. Among 76,128 patients evaluated, 3048 (4.0%) underwent capsulectomy. There was a significant increase in number of capsulectomies following January 6, 2019 (2.7/day vs 5.2/day, P < 0.05). Capsulectomy patients were more likely to have any complication and specifically hematoma than those undergoing breast implant removal or replacement without capsulectomy (2.8% vs 1.9% and 1.6% vs 0.9%, respectively, P < 0.05). Eighty-four (2.8%) developed at least 1 complication. The most common complications included hematoma (1.6%) followed by infection (0.5%). American Society of Anesthesiologists Class III/IV was an independent risk factor for any complication and BMI ≥30 kg/m2 and office-based surgical suites were risk factors for infection. A growing number of capsulectomies are being performed. The most common major complication is hematoma. Patients undergoing capsulectomy experience a higher complication rate than those undergoing breast implant removal or replacement without capsulectomy. Patients should be counseled regarding the potential for major complications.

Combined versus Single Perforator Propeller Flaps for Reconstruction of Large Soft Tissue Defects: A Retrospective Clinical Study

Sufficient wound closure of large soft tissue defects remains a challenge for reconstructive surgeons. We aimed to investigate whether combined perforator propeller flaps (PPFs) are suitable to expand reconstructive options. Patients undergoing PPF reconstruction surgery between 2008 and 2021 were screened and evaluated retrospectively. Of 86 identified patients, 69 patients received one perforator propeller flap, while 17 patients underwent combined PPF reconstruction with multiple flaps. We chose major complications as our primary outcome and defined those as complications that required additional surgery. Postoperatively, 27 patients (31.4%) suffered major complications. The propeller flap size, the type of intervention as well as the operation time were not associated with a higher risk of major complications. A defect size larger than 100 cm2, however, was identified as a significant risk factor for major complications among single PPFs but not among combined PPFs (OR: 2.82, 95% CI: 1.01−8.36; p = 0.05 vs. OR: 0.30, 95% CI: 0.02−3.37; p = 0.32). In conclusion, combined PPFs proved to be a reliable technique and should be preferred over single PPFs in the reconstruction of large soft tissue defects at the trunk and proximal lower extremity.

One-step laparoscopic pancreatic necrosectomy verse surgical step-up approach for infected pancreatic necrosis: a case-control study.

The surgical step-up approach often requires multiple debridements and might not be suitable for infected pancreatic necrosis (IPN) patients with various abscesses or no safe route for percutaneous catheter drainage (PCD). This case-control study aimed to investigate the safety and effectiveness of one-step laparoscopic pancreatic necrosectomy (LPN) in treating IPN. This case-control study included IPN patients undergoing one-step LPN or surgical step-up in our center from January 2015 to December 2020. The short-term and long-term complications after surgery, length of hospital stay, and postoperative ICU stays in both groups were analyzed. Univariate and multivariate logistic regression analyses were performed to explore the risk factors of major complications or death. A total of 53 IPN patients underwent one-step LPN and 37 IPN patients underwent surgical step-up approach in this study. There was no significant difference in the incidence of death, major complications, new-onset diabetes, or new-onset pancreatic exocrine insufficiency between the two groups. However, the length of hospital stay in the one-step LPN group was significantly shorter than that in the surgical step-up group. Univariate regression analysis showed that the surgical approach (one-step/step-up) was not the risk factor for major complications or death. Multivariate logistic regression analysis indicated that computed tomography (CT) severity index, American Society of Anesthesiologists (ASA) class IV, and white blood cell (WBC) were the significant risk factors for major complications or death. One-step LPN is as safe and effective as the surgical step-up approach for treating IPN patients, and reduces total hospital stay.

Is laparoscopic major hepatectomy feasible and safe in Swiss cantonal hospitals?

The number of laparoscopic liver resections is increasing worldwide, including in Switzerland. However, laparoscopy is mostly used for minor resections. Little is known about indications for and outcomes of major liver resections performed laparoscopically. The aim of this study was to compare the clinical outcome of open and laparoscopic major liver resection cohorts in two Swiss centres. Patients undergoing open or laparoscopic major hepatectomy (>3 segments) in two cantonal hospitals from January 2015 to December 2019 were analysed. All disease types except perihilar cholangiocarcinomas, rare malignancies and resections with biliary reconstruction were included. The primary outcome was the number of complications incurred. Operation time, blood loss, hospital stay and 90-day mortality were secondary outcomes investigated. A separate analysis was performed for colorectal liver metastases, the most common indication. Potential risk factors for major complications were evaluated in a multivariate analysis. A total of 88 patients were identified. Among those, 34 patients underwent laparoscopic major hepatectomy (LAPH) and 54 patients open major hepatectomy (OH). The two groups did not differ in demographics. The most common indication was malignancy (LAPH 94% vs OH 98%), mainly colorectal liver metastases (LAPH 53% vs OH 59%). There was no significant difference in major complications (21% vs 15%, p = 0.565). Median operation time (LAPH 433 minutes, interquartile range [IQR 351-482 vs OH 397 minutes, IQR 296-446; p = 0.222), blood loss (325 ml, IQR 200-575 vs 475 ml, IQR 300-800; p = 0.150) and hospital stay (9 days, IQR 8-14 vs 11 days, IQR 9-14; p = 0.441) were comparable between the two cohorts. There was no significant difference in 90-day mortality (3% vs 7%, p = 0.881). The laparoscopic technique was not identified as a risk factor for major complications in a multivariate analysis. This first report from Switzerland evaluating outcomes of laparoscopic major hepatectomies showed no difference in complications and clinical non-inferiority compared with open major hepatectomy.