Morbidity In Multivariate Analysis Research Articles

Laparoscopic lavage for Hinchey III perforated diverticulitis: factors for treatment failure in two randomized clinical trials.

The Scandinavian Diverticulitis (SCANDIV) trial and the LOLA arm of the LADIES trial randomized patients with Hinchey III perforated diverticulitis to laparoscopic peritoneal lavage or sigmoid resection. The aim of this analysis was to identify risk factors for treatment failure in patients with Hinchey III perforated diverticulitis. This was a post hoc analysis of the SCANDIV trial and LOLA arm. Treatment failure was defined as morbidity requiring general anaesthesia (Clavien-Dindo grade IIIb or higher) within 90 days. Age, sex, BMI, ASA fitness grade, smoking status, previous episodes of diverticulitis, previous abdominal surgery, time to surgery, and surgical competence were all tested in univariable and multivariable logistic regression analyses using an interaction variable. The pooled analysis included 222 patients randomized to laparoscopic lavage and primary resection (116 and 106 patients respectively). Univariable analysis found ASA grade to be associated with advanced morbidity in both groups, and the following factors in the laparoscopic lavage group: smoking, corticosteroid use, and BMI. Significant factors for laparoscopic lavage morbidity in multivariable analysis were smoking (OR 7.05, 95 per cent c.i. 2.07 to 23.98; P = 0.002) and corticosteroid use (OR 6.02, 1.54 to 23.51; P = 0.010). Active smoking status and corticosteroid use were risk factors for laparoscopic lavage treatment failure (advanced morbidity) in patients with perforated diverticulitis.

CT-Derived Sarcopenia and Outcomes after Thoracoscopic Pulmonary Resection for Non-Small Cell Lung Cancer.

We aimed to evaluate whether computed tomography (CT)-derived preoperative sarcopenia measures were associated with postoperative outcomes and survival after video-assisted thoracoscopic (VATS) anatomical pulmonary resection in patients with early-stage non-small cell lung cancer (NSCLC). We retrospectively reviewed all consecutive patients that underwent VATS anatomical pulmonary resection for NSCLC between 2012 and 2019. Skeletal muscle mass was measured at L3 vertebral level on preoperative CT or PET/CT scans to identify sarcopenic patients according to established threshold values. We compared postoperative outcomes and survival of sarcopenic vs. non-sarcopenic patients. A total of 401 patients underwent VATS anatomical pulmonary resection for NSCLC. Sarcopenia was identified in 92 patients (23%). Sarcopenic patients were predominantly males (75% vs. 25%; p < 0.001) and had a lower BMI (21.4 vs. 26.5 kg/m2; p < 0.001). The overall postoperative complication rate was significantly higher (53.2% vs. 39.2%; p = 0.017) in sarcopenic patients and the length of hospital stay was prolonged (8 vs. 6 days; p = 0.032). Two factors were associated with postoperative morbidity in multivariate analysis: BMI and American Society of Anesthesiologists score >2. Median overall survival was comparable between groups (41 vs. 46 months; p = 0.240). CT-derived sarcopenia appeared to have a small impact on early postoperative clinical outcomes, but no effect on overall survival after VATS anatomical lung resection for NSCLC.

The Impact of Age and Need for Emergent Surgery in Paraesophageal Hernia Repair Outcomes

BackgroundObservation of paraesophageal hernias (PEHs) may lead to emergent surgery for hernia-related complications. This study evaluated urgent or emergent repair outcomes to quantify the possible sequelae of failed conservative PEH management. MethodsThe impact of operative status (elective vs urgent or emergent) on perioperative mortality or major morbidity for patients who underwent hiatal hernia repair for a PEH diagnosis from 2012 to 2021 in the Society of Thoracic Surgery General Thoracic Surgery Database was evaluated with multivariable logistic regression models. ResultsOverall, 2082 (10.9%) of 19,122 patients with PEHs underwent urgent or emergent repair. Patients undergoing nonelective surgery were significantly older than patients undergoing elective surgery (median age, 73 years [interquartile range, 63-82 years] vs 66 years [interquartile range, 58-74 years]) and had a lower preoperative performance score (P < .001). Nonelective surgical procedures were more likely to be performed through the chest or by laparotomy rather than by laparoscopy (20% vs 11.4%; P < .001), and they were associated with longer hospitalizations (4 days vs 2 days; P < .001), higher operative mortality (4.5% vs 0.6%; P < .001), and higher major morbidity (27% vs 5.5%; P < .001). Nonelective surgery was a significant independent predictor of major morbidity in multivariable analysis (odds ratio, 2.06; P < .001). Patients more than the age of 80 years had higher operative mortality (4.3% vs 0.6%; P < 0.001) and major morbidity (19% vs 6.1%; P < .001) than younger patients overall, and these older patients more often had nonelective surgery (26% vs 8.6%; P < .001) ConclusionsThe operative morbidity of PEH repair is significantly increased when surgery is nonelective, particularly for older patients. These results can inform the potential consequences of choosing watchful waiting vs elective PEH repair.

Is it worthy to perform total pancreatectomy considering morbidity and mortality?: Experience from a high-volume single center.

Total pancreatectomy (TP) is performed for diseases of the entire pancreas. However, reluctance remains regarding TP because of the fear of high morbidity and mortality. Our retrospective study aimed to evaluate the postoperative outcomes of TP performed at a high-volume single center and to identify the risk factors associated with major morbidities and mortality after TP. A total of 142 patients who underwent elective TP at Samsung Medical Center between 1995 and 2015 were included. TP was usually planned before surgery or decided during surgery [one-stage TP], and there were some completion TP cases that were performed to manage tumors that had formed in the remnant pancreas after a previous partial pancreatectomy [2-stage TP]. The differences between the 1-stage and 2-stage TP groups were analyzed. Chronological comparison was also conducted by dividing cases into 2 periods [the early and late period] based on the year TP was performed, which divided the total number of patients to almost half for each period. Among all TP patients, major morbidity occurred in 25 patients (17.6%), the rate of re-admission within 90-days was 20.4%, and there was no in-hospital and 30-days mortality. Between the 1-stage and 2-stage TP groups, most clinical, operative, and pathological characteristics, and postoperative outcomes did not differ significantly. Chronological comparison showed that, although the incidence of complications was higher, hospitalization was shorter due to advanced managements in the late period. The overall survival was improved in the late period compared to the early period, but it was not significant. A low preoperative protein level and N2 were identified as independent risk factors for major morbidity in multivariable analysis. The independent risk factors for poor overall survival were R1 resection, adenocarcinoma, and high estimated blood loss (EBL). TP is a safe and feasible procedure with satisfactory postoperative outcomes when performed at a high-volume center. More research and efforts are needed to significantly improve overall survival rate in the future.

The Role of Sarcopenia and Myosteatosis in Short- and Long-Term Outcomes Following Curative-Intent Surgery for Hepatocellular Carcinoma in a European Cohort.

Simple SummaryRecent studies have shown that pathological changes of body composition, in particular reduced muscle mass (sarcopenia) and impaired muscle quality (myosteatosis), are linked to poor outcomes in a variety of clinical conditions. Hepatocellular carcinoma (HCC) is the most frequent primary malignant tumor of the liver in the Western hemisphere and remains a prominent cause of cancer-associated mortality. The present study investigates the prognostic value of alterations in body composition in predicting perioperative morbidity, mortality and long-term oncological outcome in HCC using preoperative computed-tomography-based segmentation. Our study found supporting evidence for the relevance of muscle quality over quantity in a European population and verifies the predictive role of myosteatosis in patients suffering from HCC, with a particularly significant value in the earlier perioperative phase.Alterations of body composition, especially decreased muscle mass (sarcopenia) and impaired muscle quality (myosteatosis), are associated with inferior outcomes in various clinical conditions. The data of 100 consecutive patients who underwent partial hepatectomy for hepatocellular carcinoma (HCC) at a German university medical centre were retrospectively analysed (May 2008–December 2019). Myosteatosis and sarcopenia were evaluated using preoperative computed-tomography-based segmentation. We investigated the predictive role of alterations in body composition on perioperative morbidity, mortality and long-term oncological outcome. Myosteatotic patients were significantly inferior in terms of major postoperative complications (Clavien–Dindo ≥ 3b; 25% vs. 5%, p = 0.007), and myosteatosis could be confirmed as an independent risk factor for perioperative morbidity in multivariate analysis (odds ratio: 6.184, confidence interval: 1.184–32.305, p = 0.031). Both sarcopenic and myosteatotic patients received more intraoperative blood transfusions (1.6 ± 22 vs. 0.3 ± 1 units, p = 0.000; 1.4 ± 2.1 vs. 0.3 ± 0.8 units, respectively, p = 0.002). In terms of long-term overall and recurrence-free survival, no statistically significant differences could be found between the groups, although survival was tendentially worse in patients with reduced muscle density (median survival: 41 vs. 60 months, p = 0.223). This study confirms the prognostic role of myosteatosis in patients suffering from HCC with a particularly strong value in the perioperative phase and supports the role of muscle quality over quantity in this setting. Further studies are warranted to validate these findings.

Surgical outcomes of laparoscopic and open resection of benign liver tumours in the Netherlands: a nationwide analysis

BackgroundData on surgical outcomes of laparoscopic liver resection (LLR) versus open liver resection (OLR) of benign liver tumour (BLT) are scarce. This study aimed to provide a nationwide overview of postoperative outcomes after LLR and OLR of BLT. MethodsThis was a nationwide retrospective study including all patients who underwent liver resection for hepatocellular adenoma, haemangioma and focal nodular hyperplasia in the Netherlands from 2014 to 2019. Propensity score matching (PSM) was applied to compare 30-day overall and major morbidity and 30-day mortality after OLR and LLR. ResultsIn total, 415 patients underwent BLT resection of whom 230 (55.4%) underwent LLR. PSM for OLR and LLR resulted in 250 matched patients. Median (IQR) length of stay was shorter after LLR than OLR (4 versus 6 days, 5.0–8.0, p < 0.001). Postoperative 30-day overall morbidity was lower after LLR than OLR (12.0% vs. 22.4%, p = 0.043). LLR was associated with reduced 30-day overall morbidity in multivariable analysis (aOR:0.46, CI:0.22–0.95, p = 0.043). Both 30-day major morbidity and 30-day mortality were not different. ConclusionsLLR for BLT is associated with shorter hospital stay and reduced overall morbidity and is preferred if technically feasible.

Laparoscopic Sentinel Node Navigation Surgery Versus Laparoscopic Standard Gastrectomy with Lymph Node Dissection for Early Gastric Cancer: Postoperative Morbidity and Mortality Results of Prospective Multicenter Phase III Trial (SENORITA)

Background: Risks and benefits of laparoscopic sentinel node navigation surgery (LSNNS) compared with laparoscopic standard gastrectomy (LSG) with lymph node dissection (LND) for early gastric cancer (EGC) are unknown. The SENORITA trial investigated the clinical impact of LSNNS for EGC regarding short-term surgical outcomes, long-term survival, and quality of life (QOL). Methods: Patients with preoperatively diagnosed T1N0 gastric adenocarcinoma with a diameter of 3 cm or smaller regardless of histology (except absolute indication for endoscopic resection) were eligible. Patients were randomized to LSG with LND or LSNNS. The primary endpoint was 3-year disease-free survival. Morbidity and mortality within 30 postoperative days were evaluated as secondary endpoints and graded by the Clavien-Dindo classification. Findings: From March 2013 to December 2016, 580 patients were randomized (LSG, 292; LSNNS, 288). Fifty-three patients dropped out before surgery due to various reasons. Surgery was performed for 527 patients (LSG, 269; LSNNS, 258) representing the full analysis set. LSNNS was not performed in 13 patients due to intraoperative findings. LSNNS was performed according to protocol for 245 patients, and detection of sentinel basin was possible for 237 patients (96.7%, 237/245). Stomach-preserving surgery was performed in 210 patients (81.4%. 210/258). Postoperative complications occurred in 51 LSG patients (19.0%) and 40 LSNNS patients (15.5%) (P=0.294). Clavien-Dindo grade III or higher complications occurred in 16 LSG patients (5.9%) and 13 LSNNS patients (5.0%) (P=0.647). Postoperative mortality occurred in one LSG patient. LSNNS was not a risk factor for postoperative morbidity in multivariate analysis except sex. Interpretation: LSNNS for EGC is a safe procedure in terms of postoperative morbidity and mortality when compared with LSG with LND. Results: From March 2013 to December 2016, 580 patients were randomized (LSG, 292; LSNNS, 288). Surgery was performed for 527 patients (LSG, 269; LSNNS, 258) representing the full analysis set. LSNNS was not performed in 13 patients due to intraoperative findings. LSNNS was performed according to protocol for 245 patients, and detection of sentinel basin was possible for 237 patients (96.7%, 237/245). Stomach-preserving surgery was performed in 210 patients (81.4%. 210/258). Postoperative complications occurred in 51 LSG patients (19.0%) and 40 LSNNS patients (15.5%) (P=0.294). Clavien-Dindo grade III or higher complications occurred in 16 LSG patients (5.9%) and 13 LSNNS patients (5.0%) (P=0.647). Postoperative mortality occurred in one LSG patient. LSNNS was not a risk factor for postoperative morbidity in multivariate analysis except sex. Conclusions: LSNNS for EGC is a safe procedure in terms of postoperative morbidity and mortality when compared with LSG with LND. Trial Registration Number: NCT01804998. Funding: National Cancer Center, Republic of Korea (grant number: 1710160-2). Declaration of Interest: The authors declare that they have no conflicts of interest or financial ties to disclose. Ethical Approval: All patients provided written informed consent before the surgery. This study was reviewed and approved by the local institutional review boards of all participating institutions.

Robotic versus laparoscopic elective colectomy for left side diverticulitis: a propensity score–matched analysis of the NSQIP database

Robotic surgery might have an advantage over conventional laparoscopy for colonic diverticulitis. We intend to compare both approaches in the elective management of left side diverticulitis. The National Surgical Quality Improvement Program (NSQIP) database (2012-2014) was surveyed for patients undergoing elective left/sigmoid colectomy for diverticulitis. Patient demographics, co-morbidities, disease complexity, and intraoperative details were matched on propensity scores derived from logistic regression model. We identified 441 robotic and 6584 laparoscopic cases. Mean age was 56.8years. Mean BMI was 29.5, and 46.5% of patients were males. Low preoperative albumin (< 3.5mg/dl, 11.1% vs. 6.8%, p = 0.003), splenectomy (0.45% vs. 0.05%, p = 0.002), and enterotomy repair (1.1% vs. 0.4%, p = 0.029) were higher in the robotic group than the laparoscopic group. Hand assistance (35.8% vs. 42.9%, p = 0.003), splenic flexure takedown (41.5% vs. 49.2%, p = 0.002), and ureteric stent placement (18.6% vs. 23.5%, p = 0.017) were less common in the robotic group than the laparoscopic group. Case-matched analysis showed that robotic surgery was associated with shorter hospital stay (3.89 ± 2.18days vs. 4.75 ± 3.25days, p < 0.001), lower conversion rate (7.5% vs. 14.3%, p = 0.001), and longer operative time (219.2 ± 95.6min vs. 188.8 ± 82.3min, p < 0.001) than laparoscopic surgery. Robotic approach was associated with lower overall morbidity in multivariate analysis (OR = 0.72, 95% CI = 0.55-0.96), but not in case-matched analysis (14.4% vs. 19.2%, p = 0.058). Robotic surgery is associated with shorter hospital stay and lower conversion rate and may offer lower overall morbidity than laparoscopy after elective left side colectomy for diverticulitis. Controlled prospective studies are needed to confirm these findings.

Desaturation during Six-Minute Walk Testing Predicts Major Morbidity Following Anatomic Lung Resection among Patients with COPD.

Background: Pulmonary function testing (PFT) is commonly used to risk-stratify patients prior to lung resection. Guidelines recommend that patients with reduced lung function, due to chronic lung conditions such as Chronic Obstructive Pulmonary Disease (COPD), should receive additional physiologic testing to determine fitness for resection. We reviewed our experience with six-minute walk testing (SMWT) to determine the association of test results and post-operative complications. Methods: Consecutive adult patients undergoing segmentectomy, lobectomy, bilobectomy or pneumonectomy between 1 January, 2007 and 1 January, 2017 were identified in a prospectively maintained database. Patients with poor lung function, as defined by percent predicted forced expiratory volume in 1 s (FEV1) or diffusion capacity of carbon monoxide (DLCO) ≤60%, had results of SMWT extracted from their chart. Association of test result to post-operative events was performed. Results: 581 patients had anatomic lung resections with predicted post-operative FEV1 or DLCO values ≤60%, consistent with a diagnosis of COPD. Among them, 50 (8.6%) had preoperative SMWT performed. Patients who received SMWT were more likely to have a FEV1 or DLCO less than 40 percent predicted (24/50 (48.0%) vs 166/531 (31.3%), p = 0.016). Post-operatively, patients who had SMWT performed had higher rates of pneumonia, but similar rates of major morbidity. The post-exercise oxygen saturation and the amount of desaturation correlated with the occurrence of major morbidity. In multivariable regression, oxygen desaturation was an independent risk factor for the occurrence of major morbidity, and desaturation was an excellent predictor of major morbidity by receiver operating characteristic curves analsysis. Conclusions: Among patients with elevated risk, oxygen desaturation during SMWT was independently associated with the occurence of major morbidity in multivariable analysis, while pulmonary function testing was not. SMWT is an important tool for risk-stratification, and may be underutilized.

Visceral fat area, not body mass index, predicts postoperative 30-day morbidity in patients undergoing colon resection for cancer.

Colectomy for cancer in obese patients is technically challenging and may be associated with worse outcomes. Whether visceral obesity, as measured on computed tomography, is a better predictor of complication than body mass index (BMI) or determines long-term oncologic outcomes has not been well characterized. This study examines the association between derived anthropometrics and postoperative complication and long-term oncologic outcomes. Retrospective review of patients undergoing elective colectomy for cancer at a single tertiary-care center from 2010 to 2016. Adipose tissue distribution measurements, including visceral fat area (VFA), were determined from preoperative imaging. The primary outcome was 30-day postoperative complication; secondary outcomes included overall and disease-free survival. Multivariable logistic regression was performed to determine association between obesity metrics and outcome. Two hundred and sixty-four patients underwent 266 primary resections of colon cancer. Twenty-eight patients (10.5%) developed major morbidity (Clavien-Dindo grade ≥ III). VFA but not BMI was significantly associated with morbidity in multivariate analysis (p = 0.004, odds ratio 1.99, 95% confidence interval 1.25-3.19). No other imaging-derived anthropometric was associated with increased morbidity. In receiver operating characteristic analysis, VFA was predictive of major morbidity (area under curve 0.660). A cutoff value of VFA ≥ 191cm2 was associated with 50% sensitivity and 76% specificity for predicting major morbidity. Patients with VFA ≥ 191cm2 had 19.4% risk of morbidity, whereas those with < 191cm2 had 7.2% risk (relative risk ratio 2.69, unadjusted p = 0.004). Neither VFA nor BMI was associated with overall or disease-free survival. VFA but not BMI predicts morbidity following elective surgery for colon cancer.

Factors affecting the postoperative morbidity and survival of patients with liver cirrhosis following colorectal cancer surgery.

Data are lacking on the appropriate risk stratification of patients undergoing surgery for colorectal cancer (CRC). This study aimed to evaluate the predictive factors for perioperative morbidity and oncological outcomes in CRC patients with liver cirrhosis (LC). A retrospective analysis of prospectively collected data was conducted. A total of 161 LC patients who underwent surgery for CRC were identified between January 2001 and December 2010. The mean patient age was 60±10years, and the median follow-up period was 54.0months (range 0.5-170.0). The proportions of patients with Child-Pugh classifications for LC were as follows: A (n=118; 73.3%), B (n=39; 24.2%), and C (n=4; 2.5%). The median model for end-stage liver disease (MELD) score was 8 (range 6-21). The postoperative morbidity rate was 37.3% (60/161). Hyperbilirubinemia (p=0.002), prothrombin time (PT) prolongation (p=0.020), and intraoperative transfusion (p=0.003) were the significant factors for postoperative morbidity in multivariate analysis. The postoperative mortality rate was 3.1% (5/161), and the 5-year cancer-specific and 5-year overall survival rates were 86.1 and 59.9%, respectively. The significant clinical risk factors by multivariate analysis that influenced overall survival were the TNM stage of CRC (p=0.035), MELD score (>8 points) (p<0.001), and the coexistence of hepatocellular carcinoma (HCC) (p=0.012). Hyperbilirubinemia, PT prolongation, and intraoperative transfusion are significant risk factors for postoperative morbidity in LC patients who undergo surgery for CRC. Additionally, not only advanced TNM stage but also a high MELD score and the coexistence of HCC are associated with poor overall survival in CRC patients with LC.

Postoperative Morbidity and Mortality Following D2 Gastrectomy-an Audit of 456 Cases.

D2 gastrectomy is routinely performed in Japanese centres for carcinoma stomach with low morbidity and mortality. There were concerns in Western centres with regard to D2 gastrectomy in view of high morbidity and mortality rates. This study was aimed to study the postoperative morbidity and mortality following D2 gastrectomy for carcinoma stomach in a high volume centre in India. It was a retrospective analysis of all the patients who underwent D2 gastrectomy from 1991 to 2010. D2 gastrectomy was performed in 456 patients during this period. Respiratory events were the most common cause of morbidity in the study group (2.4%). Male gender (p=0.007), presence of gastric outlet obstruction (p=0.01) and pathological T4 (p=0.05) independently predicted increased post operative morbidity in multivariate analysis. The morbidity and mortality rates declined with increase in hospital volume and experience of the surgeon. D2 gastrectomy for carcinoma stomach can be performed safely in specialized centres with low morbidity and mortality rates.

Modified Robicsek procedure for pectus excavatum in adult patients

The aim of this study was to clarify the short-term and mid-term outcomes of the modified Robicsek procedure using polypropylene mesh for adult pectus excavatum patients. Retrospective chart review was performed. Between 2001 and 2012, 46 consecutive adult patients underwent modified Ravitch repair using polypropylene mesh for pectus excavatum at our institution. There were 30 males and 16 females, with a median age of 25.5 (range: from 17 to 60). Potential risk factors for perioperative complications and early failure in pectus repair were analysed with χ(2) test or Fisher's exact test and Mann-Whitney test. Potential risk factors for postoperative mid-term recurrence were analysed using Cox proportional hazard regression model. The postoperative follow-up interval was 7.0 ± 15.1 months (mean ± standard deviation). No mortality and 11 patients (24.0%) of morbidity, including 2 patients with temporary mesh infection, were noted. A lower preoperative %FEV1.0 predicted was a significant factor (P = 0.0088) of morbidity in multivariate analysis. Regarding chest morphology, early failure in 1 patient (2.2%) and mid-term recurrence in 1 patient (2.2%) were seen. Previous pectus repair (P = 0.0324) and severe asymmetry (P = 0.04) were significant factors of early failure in multivariate analysis, while no significant factor for mid-term recurrence was found. Modified Robicsek procedure with a polypropylene mesh is associated with low incidences of early failure and mid-term recurrence. The procedure is recommended for adult pectus excavatum patients, including those with asymmetric or combined deformity as an initial or reoperative procedure.

515: Cesarean delivery in extreme preterm birth does not improve survival or survival without severe morbidity

515 Cesarean delivery in extreme preterm birth does not improve survival or survival without severe morbidity Michael Trifiro, Sima Parmar, Guibo Xing, Bryon Jacoby University of California Davis Medical Center, Obstetrics and Gynecology, Sacramento, CA, University of California Davis Medical Center, Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, Sacramento, CA, University of California Davis Medical Center, Center for Healthcare Policy and Research, Sacramento, CA OBJECTIVE: To determine if mode of delivery affects survival of extremely preterm neonates. STUDY DESIGN: This is a retrospective cohort study of early preterm deliveries between 22 weeks 0 days and 27 weeks 6 days occurring between January 1, 2000 and December 31, 2009 at the University of California Davis Medical Center. Genetic abortions and inductions for stillbirths were not included. Maternal characteristics, obstetrical data, and neonatal information were collected. Statistical analysis was performed to evaluate obstetrical and neonatal factors associated with total survival and survival without a severe morbidity. Severe morbidities included intraventricular hemorrhage 3, periventricular leukomalacia, retinopathy of prematurity 3, necrotizing enterocolitis, or broncho-pulmonary dysplasia. RESULTS: Over the study period, 238 early preterm births occurred. Factors associated with improved survival included weeks gestation (p 0.0001), birthweight (p 0.0001), female gender (OR 2.12 95% CI 1.20-3.72), and steroid administration (OR 4.85 95% CI 2.678.83). 146 deliveries were by cesarean section and 92 deliveries were vaginal. Delivery by cesarean section was associated with improved survival in univariate analysis (OR 2.15 95% CI1.23-3.77), but this association was not significant in multivariate analysis adjusting for birthweight, gender and steroid administration (OR 1.85 95% CI 0.89-3.87). There was no association with cesarean section and survival to discharge without severe morbidity in univariate (OR 1.35 95% CI 0.79-2.28) or multivariate analyses (OR 1.15 95% CI 0.582.27). CONCLUSION: Delivery of the extremely preterm neonate is complicated with limited data to guide care and counseling. A limited number of studies have compared mode of delivery in extreme preterm birth and there is insufficient evidence to support cesarean delivery in extremely preterm neonates. In this study, cesarean delivery was not associated with total survival or survival without severe morbidity in multivariate analysis.

Impact of T status and N status on perioperative outcomes after thoracoscopic lobectomy for lung cancer

We sought to evaluate the effect of tumor size, location, and clinical nodal status on outcomes after thoracoscopic lobectomy for lung cancer. All patients who underwent attempted thoracoscopic lobectomy for lung cancer between June 1999 and October 2010 at a single institution were reviewed. A model for morbidity including published risk factors as well as tumor size, location, and clinical N status was developed by multivariable logistic regression. During the study period, 916 thoracoscopic lobectomies met study criteria: 329 for peripheral, clinical N0 tumors ≤ 3 cm and 504 for tumors that were central, clinical node positive, or >3 cm. Tumor location could not be documented for 83 patients. Conversions to thoracotomy occurred in 36 patients (4%); patients with clinically node-positive disease had higher conversion rates (11 conversions in 153 clinical N1 to N3 patients [7.2%] vs 25 in 763 clinical N0 patients [3.3%, P = .03]. Overall operative mortality was 1.6% (14 patients) and morbidity was 32% (296 patients). Although patients with larger tumors (P = .006) and central tumors (P = .01) had increased complications by univariate analysis, tumor size >3 cm (P = .17) and central location (P = .5) did not predict significantly overall morbidity in multivariate analysis. Clinical node status did not predict increased complications by univariate or multivariate analysis. Significant predictors of morbidity in multivariable analysis were increasing age, decreasing forced expiratory volume in 1 second, prior chemotherapy, and congestive heart failure. Thoracoscopic lobectomy for lung cancers that are central, clinically node positive, or >3 cm does not confer increased morbidity compared with peripheral, clinical N0 cancers that are <3 cm.

Plasma adrenomedullin as an independent predictor of future cardiovascular events in high-risk patients: Comparison with C-reactive protein and adiponectin

This study investigated the predictive power of plasma adrenomedullin (AM) for future cardiovascular (CV) events. In 121 patients with multiple CV risk factors and/or disease, plasma concentrations of AM, high sensitive C-reactive protein (hs-CRP), and adiponectin were measured. During follow-up periods (mean, 3.5 years) after the baseline assessment, 28 patients newly experienced CV events such as stroke/transient ischemic attack, acute coronary syndrome, and congestive heart failure. The plasma level of AM, but not hs-CRP or adiponectin, was significantly higher in patients who had CV events than in event-free subjects. When the patients were divided into three groups by tertiles of basal levels of AM (<10.1, 10.1–13.1, and ≥13.1 fmol/mL), cumulative event-free rates by the Kaplan–Meier method were decreased according to the increase in basal AM levels (83.2%, 68.6%, and 52.8% in the lowest, middle, and highest tertiles of AM, respectively; log-rank test, P = 0.033). By univariate Cox regression analysis, previous coronary artery disease, creatinine clearance, and plasma AM and hs-CRP levels were significantly associated with CV events during follow-up. Among these possible predictors, high plasma AM ( P = 0.004) and low creatinine clearance ( P = 0.043) were independent determinants for morbidity in multivariate analysis. These findings indicate that plasma AM is a powerful independent predictor of future CV events in high-risk patients, suggesting its predictive value is superior to that of hs-CRP or adiponectin.

Superior vena cava resection with prosthetic replacement for non-small cell lung cancer: long-term results of a multicentric study.

Superior vena cava (SVC) resection with prosthetic replacement for non-small cell lung cancer (NSCLC) is infrequently performed and oncological results are unclear. To establish a historical benchmark for this extended surgery, we have updated and reviewed data from four international centers. Data were obtained through retrospective chart review. Prognostic factors were analyzed using first univariate techniques and subsequently multiple regression (logistic regression). Kaplan-Meier overall survival was calculated and prognostic factors examined by log-rank test and the estimation of hazard ratios using Cox regression. From 1985 to 2000, 28 patients underwent SVC resection with prosthetic replacement for NSCLC. During the same period, 65 patients underwent partial SVC resection. Induction treatment was performed in 25% of patients. The resection was done for T involvement in 22 patients (79%), and for N2 involvement in the remaining. There were 12 tracheal sleeve resections, four pneumonectomies, and 12 lobar or sublobar resections with or without bronchoplasty. The median clamping time was 40 min. The median diameter of the prosthesis used was No. 14. Pathological examination showed direct SVC invasion (T4) in 79% of patients, whereas N2 disease was present in 50% of patients. Median intensive care unit and hospital stay were 3 and 20 days, respectively. The postoperative morbidity and mortality were 39 and 14%, respectively. The overall 5-year probability of survival was 15% (median of 9 months, range 0-105 months). Patients who underwent partial SVC resection during the same period had a significantly higher probability of survival (P=0.03). Induction chemotherapy was associated with a significant increase of postoperative morbidity in multivariate analysis. None of the potential prognostic factors analyzed in multivariate analysis were associated with survival, but the type of resection (sleeve pneumonectomy/pneumonectomy) were borderline significant. SVC resection with prosthetic replacement should not be considered an absolute contraindication in patients with NSCLC; however, the poor oncological results suggest more restrictive and severe criteria of patient selection (mediastinoscopy, induction treatment, no pneumonectomy, no N2 disease).

Transfusion timing and postoperative septic complications after gastric cancer surgery: a retrospective study of 179 consecutive patients.

Immunosuppression associated with homologous blood transfusion was first observed in renal allograft transplantation. Clinical effects of transfusion-induced immunosuppression in surgical patients have been debated in the literature for more than a decade with contradictory results. To investigate whether homologous blood transfusions significantly affect postoperative septic morbidity and mortality in patients undergoing elective surgery for gastric cancer. Case series. Hospitalized care. The hospital records of 209 patients who underwent elective surgery for gastric cancer at the Department of Surgery of the Hospital del Mar, Autonomous University of Barcelona in Spain, and at the Department of Surgery of the Catholic University of Rome in Italy from April 1984 to December 1990 were reviewed, and 179 patients were included in the study. The following variables were entered into univariate and multivariate analyses to identify factors potentially affecting postoperative septic morbidity: demographic data, weight loss, preoperative serum albumin level and lymphocyte count, type and duration of operative procedure, amount and timing of blood transfusion, and stage of disease. Univariate analysis showed that a large quantity of blood transfused (> 1500 mL) and transfusion in the postoperative period (group C) were associated with a worse clinical outcome. Postoperative transfusion was an independent predictor of septic morbidity in multivariate analysis. Despite transfusion-induced immunomodulation, homologous blood transfusion should not be considered a risk factor for postoperative septic morbidity in patients undergoing elective major abdominal surgery. The timing-response relationship between transfusions and septic morbidity in multivariate analysis may be the effect of uncontrolled confounders such as variation of volemia induced by stress response in patients who were developing or had just developed infectious complications.