Overall Number Of Complications Research Articles

Surgical management of lower limb fractures in patients with spinal cord injury less associated with complications than non-operative management: A retrospective series of cases

Objectives: To evaluate the difference in terms of overall complications between surgical and non-surgical management of lower limb fractures in patients with chronic spinal cord injury (SCI). Design: A 13-year retrospective study including patients with chronic spinal cord lesion admitted for sublesional lower limb fractures. Setting: University hospital SCI reference departments (Rehabilitation department and orthopedic department). Participants: Forty patients with SCI were included, 24 men and 16 women. Fifty-six distinct fracture occurrences were responsible for a total of 59 lower limb fractures. We compared the number of overall complications between surgical and non-surgical management of fractures. Results: Non-surgical management was realized for 19 fractures and surgery for 40. Characteristics of operated and non-operated patients at the time of each fracture occurrence did not differ concerning age (P = 0.430), sex (P = 0.890), lesion levels (P = 0.410) and AIS classification (P = 0.790). Data analysis highlighted 20 complications directly due to the fracture site for 16 distinct fractures. Seven medical complications were found in 5 distinct fracture events. Only 10 (25.0%) of 40 surgical managements had at least one medical or post-surgical complication, whereas 12 (63.2%) of 19 non-operative managements had at least one complication. Therefore, the overall rate of complications was significantly higher after non-surgical treatment (P = 0.044). Conclusion: Lower extremity fractures due to osteoporosis in patients with SCI are responsible for local and general complications. When possible, surgery may be the best management to propose because of fewer overall complications.

Outcomes of bilateral sequential implantation of the Boston keratoprosthesis type 1

ObjectiveTo evaluate the risks and benefits of sequential bilateral Boston type 1 keratoprosthesis (KPro) implantation for bilateral corneal blindness. DesignComparative retrospective study. ParticipantsPatients who underwent a sequential bilateral KPro surgery. MethodsAll 11 patients who underwent sequential bilateral KPro surgery at the Centre Hospitalier de l’Université de Montréal between October 2008 and October 2011 were recruited. Data from the 22 patient eyes in our study were separated in 2 groups based on the first (group 1) or second eye (group 2) implanted with the Kpro. Both groups were then compared for the best corrected visual acuity (BCVA) and complications. Bilateral BCVA following both surgeries and the overall number of complications that affected each patient after both interventions were also analyzed. ResultsAt 24 months, BCVA was 20/150 in group 1 and 20/200 in group 2 (p = 0.67). Throughout the study, there was no significant difference in BCVA between the 2 groups (p > 0.05), and bilateral BCVA was similar. The complication rate was comparable in the 2 groups. Patients had a mean of 2.45 complications following the first surgery and a mean of 5.27 in both eyes combined after the second intervention (p = 0.03). ConclusionsBecause visual gain observed following the second surgery was the same as that with the first and multiple surgeries increased the number of complications for each patient, we recommend saving bilateral KPro implantation for cases in which the first eye with KPro develops a disease limiting its visual potential.

A Comparative Analysis Among the SRS M&M, NIS, and KID Databases for the Adolescent Idiopathic Scoliosis

Study DesignRetrospective cohort analysis. ObjectivesA growing number of publications have utilized the Scoliosis Research Society (SRS) Morbidity and Mortality (M&M) database, but none have compared it to other large databases. The objective of this study was to compare SRS complications with those in administrative databases. Summary of Background DataThe Nationwide Inpatient Sample (NIS) and Kid's Inpatient Database (KID) captured a greater number of overall complications while the SRS M&M data provided a greater incidence of spine-related complications following adolescent idiopathic scoliosis (AIS) surgery. Chi-square was used to obtain statistical significance, with p < .05 considered significant. MethodsThe SRS 2004–2007 (9,904 patients), NIS 2004–2007 (20,441 patients) and KID 2003–2006 (10,184 patients) databases were analyzed for AIS patients who underwent fusion. Comparable variables were queried in all three databases, including patient demographics, surgical variables, and complications. ResultsPatients undergoing AIS in the SRS database were slightly older (SRS 14.4 years vs. NIS 13.8 years, p < .0001; KID 13.9 years, p < .0001) and less likely to be male (SRS 18.5% vs. NIS 26.3%, p < .0001; KID 24.8%, p < .0001). Revision surgery (SRS 3.3% vs. NIS 2.4%, p < .0001; KID 0.9%, p < .0001) and osteotomy (SRS 8% vs. NIS 2.3%, p < .0001; KID 2.4%, p < .0001) were more commonly reported in the SRS database. The SRS database reported fewer overall complications (SRS 3.9% vs. NIS 7.3%, p < .0001; KID 6.6%, p < .0001). However, when respiratory complications (SRS 0.5% vs. NIS 3.7%, p < .0001; KID 4.4%, p < .0001) were excluded, medical complication rates were similar across databases. In contrast, SRS reported higher spine-specific complication rates. Mortality rates were similar between SRS versus NIS (p = .280) and SRS versus KID (p = .08) databases. ConclusionsThere are similarities and differences between the three databases. These discrepancies are likely due to the varying data-gathering methods each organization uses to collect their morbidity data. Level of EvidenceLevel IV.

An Implantable Pressure Sensor for Long-term Wireless Monitoring of Cardiac Function -First Study in Man

Background: Heart failure is a huge health problem. The possibility of long-term monitoring heart function more accurately in these patients has gained increasing interest. The primary aim of this study was to see if a wireless pressure sensor can be safely implanted to give accurate and reproducible long-term intracardiac pressure recordings. Another aim was to see if there are any adverse effects connected with the implant. A control group was included for comparison of clinical data. Methods: Forty patients with heart failure, 31 scheduled for open heart surgery and 9 for transcatheter aortic valve replacement (TAVR) were included to test the safety and feasibility of the Titan™ pressure sensor. The patients were randomized to the implant or control group. Findings: Initial sensor measurements showed very good correlation with reference pressure values from a fluid-filled catheter, and there was no need for calibration of the sensor. At the 6-month follow-up 11 patients had been wearing the implant for >1 year with a median time of 560 days. Ten of these had adequate sensor function. Compared to the control group there was no difference in adverse clinical events and the overall number of complications was low. Conclusions: This first study in man on a new implantable wireless hemodynamic monitor showed favorable results regarding our primary endpoints; accuracy of recordings over time and safety profile. The technology has great potential for monitoring at home since it is easy to use in the out-patient setting.

Complications of cochlear implantations

Background: Cochlear implantation (CI) has become an effective measure for the treatment of many cases with profound deafness. Although it is viewed as a safe technique, minor and sometimes major complication are still taking place after the procedure. The frequency of these complications varies between operating centers. No previous documentation of the frequency of these complications was carried out in Saudi Arabia. Objectives: This study aimed at describing the pattern of complications following CI in one of the main hospitals in the Kingdom of Saudi Arabia. Methods: Through a retrospective study design, all medical records of cases who received CI in the period between January 2009 to January 2014 were obtained from the Health Information Department in King Fahd Hospital (n=142); a constructed checklist was used to systematically collect information regarding available demographic characteristics and complications after cochlear implantation.Data were coded and analyzed using Statistical Package for Social Science version 16.0 (SPSS program). Results: The overwhelming majority of patients were children;128(90%). The overall number of complications following cochlear implantation accounted for 18 cases who represented (12.7%) of all cases. Most of the complications occurred among children making an age adjusted rate of (11.4%). Overall complications were 4(2.8%) spontaneous device failure, 3(2.1%) device failure due to trauma, 2(1.4%) wound infection, 2(1.4%) wound dehiscence, 1(0.7%) hematoma, 1(0.7%) facial twitches, 1(0.7%) post-operative vertigo and 1(0.7%) otitis media. Conclusion: Cochlear implantation is a safe technique with a relatively low complication rate; the reported rates of complications among our patients are approximately similar to what has been recorded in other health institutions worldwide.

Evidence for Ureterorenoscopy and Laser Fragmentation (URSL) for Large Renal Stones in the Modern Era.

Large renal stones (>2 cm) are managed with percutaneous nephrolithotomy (PCNL), which has a good stone-free rate (SFR) but a relatively high incidence of complications graded Clavien ≥ 3. We wanted to review the literature for the use of ureterorenoscopy and laser fragmentation (URSL) for the management of these stones. A systematic review was done from 1990 to April 2014 for all English language articles reporting on a minimum of 10 patients for stones >2 cm in size (done by 2 reviewers independently) in accordance with the PRISMA and Cochrane review guidelines. A total of 379 articles were identified and after screening for the titles (54) and abstracts (29), 12 papers (651 patients) were included. The male to female ratio was 356:232 with a mean age of 54 years (range 16-86 years). With a mean stone size of 2.7 cm (2-3.15 cm) and the mean operating time of 96 min (28-238 min); the SFR was 91 % (1.45 procedures/patient). The overall number of complications was 58 (8.6 %) of which 26 (4.5 %) were complications classed Clavien ≥ 3 (haematuria with subcapsular haematoma/clot retention-7; ureteral perforation-7; steinstrasse-5; sepsis/pyelonephritis-5; prostatitis-1; cerebrovascular accident-1). Ureterorenoscopy for large renal stones in the modern era has good SFR with a small risk of major complications.

An Outcome Analysis of Intraoperative Angiography for Postmastectomy Breast Reconstruction

Intraoperative angiography is a useful tool for predicting both tissue perfusion during postmastectomy breast reconstruction and mastectomy flap and free flap survival. The authors determine whether the routine use of laser-assisted indocyanine green (ICG) fluorescence angiography (SPY Imaging; LifeCell Corp, Branchburg, New Jersey) in breast reconstruction decreases the incidence of complications and whether this new technology is cost-effective. A retrospective review was conducted for 184 consecutive patients who underwent breast reconstruction using intraoperative ICG angiography from April 2009 to December 2011 at Emory University (Atlanta, Georgia). The incidence of complications (including mastectomy skin necrosis, flap necrosis, fat necrosis, unexpected reoperations, infections, and dehiscence) among these patients was compared with data for 184 consecutive patients who underwent breast reconstruction at Emory University from October 2007 to April 2009, prior to the introduction of ICG angiography. Patient data recorded included age, body mass index, smoking status, and history of preoperative radiation as well as the timing and type of reconstruction, along with complications. The cost of unexpected reoperations for perfusion-related complications and associated hospital stays was calculated. The 184 patients who underwent procedures using ICG angiography imaging had a lower incidence of mastectomy skin necrosis (13% vs 23.4%; P = .010) and unexpected reoperations for perfusion-related complications (5.9% vs 14.1%, P = .009). The 184 patients who underwent procedures without ICG angiography had a higher mean degree of severity of mastectomy skin necrosis (2.22 vs 1.83 on a scale of 1-3; P = .065). There were no significant differences in the degree of flap necrosis, nipple necrosis, fat necrosis, dehiscence, infection, implant exposure, flap loss, seroma, hematoma, or the number of overall complications between the 2 groups. The use of ICG angiography saved patients an average of $610. The use of ICG angiography during postmastectomy breast reconstruction decreased the incidence and severity of mastectomy skin necrosis as well as the incidence of unexpected reoperations for perfusion-related complications. The technology was found to be cost-effective.

The Outcomes of Percutaneous Versus Open Placement of Peritoneal Dialysis Catheters

Peritoneal dialysis catheters (PDCs) can be inserted by a percutaneous, open surgical, or laparoscopic approach. Considerable controversy surrounds the mode of catheter placement and its impact on technical success. We compared the complications and survival characteristics of PDCs that were inserted by the open approach versus those inserted percutaneously. We reviewed the outcomes of 167 patients who received PDCs between September 2009 and February 2012. Of these, 89 were placed percutaneously and 78 were placed by open surgical techniques. The mechanical complication rates, including catheter bleeding, wrapping, migration, leakage, and technical failure of intraperitoneal placement were compared between the two groups. Additionally, peritonitis episodes, exit site infection rates, and tunnel infection rates were compared between groups. The incidence of one or more previous intra-abdominal surgeries was significantly higher in the open group (4.5 percutaneous vs 21.7 % open; P = 0.001). Although the overall number of complications did not differ between the two groups, the incidence of early mechanical complications (11.2 vs 0 %; P = 0.002) and the number of catheter removals due to mechanical complications (7.9 vs 1.3 %; P = 0.047) were higher in the percutaneous group. Of the 15 mechanical complications in the percutaneous group, one third were due to technical failures compared to none in the open group (5.6 vs 0 %; P = 0.034). The 1 year survival rate of the PDCs for the percutaneous and open groups was 89.9 and 93.3 %, respectively (P = 0.249). The placement modality did not affect catheter survival. However, early mechanical complications, including technical failures, were more frequent in the percutaneous group, despite the proportion of patients with a history of one or more previous intra-abdominal surgeries being significantly lower in that group. The direct visualized open method of catheter insertion may provide the most reliable and secure access for a PDC.

Efficacy and complications of urinary drainage procedures in idiopathic retroperitoneal fibrosis complicated by extrinsic ureteral obstruction

To investigate the efficacy and complications of urinary drainage procedures in patients with idiopathic retroperitoneal fibrosis complicated by ureteral obstruction. A retrospective study of 30 idiopathic retroperitoneal fibrosis patients involving 44 obstructed urinary units who underwent urinary drainage from January 2002 through April 2010 was carried out. Data of all diagnostic procedures, blood and urine cultures, and hospital admissions were collected and analyzed. In 12 of 44 (27%) cases, percutaneous nephrostomy was carried out at the first step. Attempted ureteral stenting at the first step was successful in 25 of 32 (79%) cases, of which 20 (80%) cases could be managed successfully by ureteral stenting alone throughout the study period. Successful prolonged urinary drainage with percutaneous nephrostomy alone was accomplished in 10 cases, three at the first step and seven at the second step after failed intraureteral stent insertion or after unsuccessful maintenance of urinary drainage with an intraureteral stent. A total of 21 urinary tract infection episodes occurred in 11 patients. The incidence and accumulated incidence of acute pyelonephritis was 0.062 episodes/100 person-days and 30%, respectively. The incidence and accumulated incidence of urosepsis was 0.015 episodes/100 person-days and 6.6%, respectively. The overall number of complications did not differ between external and internal urinary drainage procedures (percutaneous nephrostomy, 21% vs intraureteral stent, 17.9%; P = 0.79). Both intraureteral stent and percutaneous nephrostomy placement are a safe way to relieve urinary obstruction in idiopathic retroperitoneal fibrosis patients, and they have comparable complication rates. Over time, the need for using both management options in the same patient might be required. Hence, these techniques should be regarded as complementary.

The learning curve in the use of trans-oral laser microsurgery for cancer treatment

The authors from the University of Barcelona present their experience of using trans-oral laser micro-surgery (TOLMS) in the management of laryngeal and hypopharyngeal cancers over a 14-year period and extrapolate from analysis of the data [1], with surgeons graded by levels of experience addressing early and locally advanced tumours, as well as stage of disease and comment on patient outcome using analysis of number of surgeries per patient, rate of complications, rates of positive and negative tumour margins, rate if tumour relapse, type of surgical salvage procedure employed and disease-specific survival. The difference between the mean of surgical interventions was statistically significant, and the number of total laryngectomy employed as a salvage procedure was lower in the group of patients operated upon by more experienced surgeons. Tumour-free margins and tumour relapse were not influenced by experience. The number of overall complications and the disease-specific survival rates was significantly lower in the ‘‘expert’’ group. The authors do agree that the learning curve of TOLMS for glottis, supraglottic and hypopharyngeal lesions may be different, and suggest that further analysis with larger numbers in each sub-site is necessary. They also suggest that for TOLMS ‘‘beginners’’ that early teaching, confidence and analysis of competency should be gained with early tumours. Based on their results it is suggested that experience in the use of TOLMS should be gained in a levelled approach graduating from early tumours to intermediate and then advanced T stage disease. This paper is a first attempt to review a large series of treated patients and analyse the involvement of surgeons of differing experiences against a number of outcome measures. However, of the 5 surgeons work reported, all were ‘‘experienced’’ head and neck surgeons. The majority (80 %) had more than 15 years of surgical experience before commencing TOLMS, and the other surgeon was less than 7 years experienced. Thus, the surgeons in this report, while ‘‘new’’ to TOLMS had already got experience of micro-laryngoscopy and bimanual surgical excisions, identification of tumours and their margins prior to being introduced to TOLMS. This may not be universally equivalent when starting up a practice employing TOLMS for the management of laryngeal and hypopharyngeal cancers. The most important steps when considering introducing ‘‘new technologies’’ into surgery is to ensure that a ‘‘team approach’’ is agreed and developed—this naturally in cancer surgery will involve the surgeon, the anaesthetist and the histopathologist. The introduction of such new clinical interventions and surgical techniques may need to be approved by the local hospital clinical governance board, and comply with clinicians being able to demonstrate that they can meet externally set of standards on appropriate training, as in the UK NHS [2]. It is also important not to ignore that the data need to be collected prospectively, documentation of duration of surgery, hospital stay, complications, tumour status of resection margins achieved, ability to salvage close or positive margins, functional outcome—objective and subjective evaluation of voice and swallowing outcomes, as well as disease-specific survival. The ability of residents (training grade) to achieve TOLMS expertise is strongly influenced by the personal skills and P. Bradley (&) Department of Otorhinolaryngology Head and Neck Surgery, Nottingham University Hospitals, Queens Medical Centre Campus, Nottingham, UK e-mail: pjbradley@zoo.co.uk

The learning curve in transoral laser microsurgery for malignant tumors of the larynx and hypopharynx: parameters for a levelled surgical approach

The goal of the study was to identify parameters helpful to define a learning curve for laser microsurgery (TLM). 587 patients with malignant tumors of larynx and hypopharynx treated with TLM were divided into groups depending on the number of interventions their surgeons had performed. Outcome measures were obtained for the number of revision surgeries and complications, rates for tumor-free margins, tumor relapse and disease-specific survival rates for early and advanced tumors, serving to evaluate their potential influence on the learning curve. Surgery of early tumors was not influenced by the grade of experience. For locally advanced tumors the learning curve was statistically related to the number of surgeries needed per patient (p = 0.018). The number of overall complications (p = 0.000) and the disease-specific survival rate (p = 0.019) was significantly lower in the "expert" group. The percentage of postoperative bleedings was similar between all groups. Tumor-free margins and tumor relapse were not influenced by experience. In TLM, a learning curve could be observed for locally advanced tumors.

The Effects of Intermittent Inflow Occlusion and Hepatic Steatosis on Postoperative Liver Functions in Living Liver Donors Undergoing Right Hepatectomy

BackgroundIntermittent inflow occlusion (IIO) is a safe, effective method to reduce blood loss during liver resection and preserve function even among patients with underlying diseases such as steatosis and cirrhosis. Therefore, we evaluated the impact of IIO on postoperative liver function tests (LFT) and on morbidity among living liver donors undergoing a right hepatectomy, including donors with mild degrees (5%–30%) of macrovesicular steatosis (MaS). MethodsWe retrospectively reviewed the medical records of 186 living liver donors from August 2008 to September 2010. Donors were divided into two groups according to group IIO (n = 81) versus Controls (no IIO, n = 105). Within each group, donors were subdivided to evaluate Peak values of LFTs and complications into according the degree of MaS: group I_5 (n = 36); IIO + <5% MaS, group I_30 (n = 45); IIO + 5%–30% MaS, group C_5 (n = 55); Control + <5% MaS, and group C_30 (n = 50); Control + 5%–30% MaS. ResultsPeak aspartate aminotransferase (AST) and alanine aminotransferase (ALT) among IIO were significantly higher than Non-IIO. These values in groups I_5 and I_30 were significantly higher than groups C_5 and C_30, respectively (all, P < .01). The overall postoperative complications were comparable between groups IIO and Non-IIO, but significantly higher among group I_30 than groups I_5 (P = 0.024) and C_30 (P = .012). ConclusionsApplication of IIO in donors with mild macrosteatosis undergoing right hepatectomy showed significantly higher postoperative peak liver functions tests and number of overall complications than those without IIO.

Large posterior mediastinal retrosternal goiter managed by a transcervical and lateral thoracotomy approach

Most retrosternal goiters are situated in the anterior mediastinal compartment. Posterior mediastinal goiters are uncommon, comprising 10%-15% of all mediastinal goiters. Although most of the anterior mediastinal goiters can be removed by a transcervical approach, posterior mediastinal goiters may require additional extracervical incisions. We report the case of a large posterior mediastinal goiter extending retrotracheally beyond the aortic arch and azygous vein with crossover from the left to the right side. It was excised using a transcervical and right thoracotomy approach. The literature is reviewed to clarify the management of retrosternal goiters with regard to the various approaches, indications for extracervical incisions, and their complications. In conclusion, whereas most retrosternal goiters can be resected through a transcervical approach, those extending beyond the aortic arch into the posterior mediastinum are better dealt with by sternotomy or lateral thoracotomy. The overall number of complications associated with this approach, however, is higher than that seen with the transcervical approach.

Early complications and symptoms of cerebellopontine angle tumor surgery: a prospective analysis

Our objective is to prospectively report very early complications and outcomes of cerebellopontine angle (CPA) surgery. Between January and August 2007, 72 patients were operated on by different transpetrosal approaches in a tertiary referral center. During preoperative assessment, facial nerve function (House-Brackmann grading system), the presence of vertigo or tinnitus and caloric test results were recorded and correlated with complications and symptoms occurring daily from day (D) 1 to D 8. The overall number of complications did not differ from those of former retrospective studies; nevertheless, the prospective feature of this study prompts several comments. Even slight (grade II) preoperative facial impairments increased the risk of severe postoperative facial dysfunction. Keratitis was frequent (42%) even in patients with normal facial function. Thrombo-embolic complications only occurred after long air-travel (≥5 h). Preoperative caloric test status was predictive of postoperative vestibular disturbance occurrence. With respect to the activity recovery; younger patients (<40 years old) displayed faster central compensations than the older (>60 years old) patients. This study highlights several features that may be used for preoperative patient counseling and complication management. In particular, the practitioner has to pay attention to even minor preoperative clinical signs of facial dysfunction to properly inform the patient of facial outcome. Routine ophthalmologic evaluation should be practiced, even when facial function is normal or subnormal. 1b.

Laparoscopic Adhesiolysis - An Initial Experience of 15 Cases

Post-operative adhesions frequently occur and can account for various symptoms like chronic abdominal pain and small bowel obstruction. Conventional adhesiolylis by laparotomy results in an unacceptably high rate of recurrence. A minimally invasive procedure (laparoscopic adhesiolysis) might improve she outcome by inflicting less surgical trauma, but well-documented reports focusing on laparoscopic adhesiolysis for chronic abdominal pain and small bowel obstruction is lacking. The aim of this study was to evaluate the efficiency. safety. and outcome of laparoscopic adhesiolysis for recurrent adhesive small-bowel obstruction. Eighty nine patiencs (median age 48 years: range: 25-83 years) operated for small bowel obstruction and chronic abdominal pain in the Depanment of General Surgery, Holy Family Red Crescent Medical College hospital were included for the study. Pre-pensive urgent blood teas and ubdontinal s- ay were done in all patients; 74 patients were treated with traditional laparotomy, while 15 selected patients underwent laparoscopy. For one (6.67%) of the 15 patients treated wits laparoscopy a conversion was necessmy because of the adhesion localization in the posterior abdominal wall, The median stay in hospital was 4.7 days for patients who underwent laparoscopy and 14.3 days for patients treated by traditional laparotonsy. Only one (6.67%) case in laparoscopv group needed to be re-operated, while five (6.76%) cases in laparntonty group needed to be re-operated because of recurrence of obstruction by new adhesions. Overall number of complications contributing to morbidity were significantly lower in those who underwent laparoscopic adhesiolysis. Laparoscopic adhesiolysis is an effective treatment for small bowel obsommion, morbidity is lower. hospital stay is shorter. and resumption of a novael diet is foster.

Bleeding complications after pacemaker or cardioverter-defibrillator implantation in patients receiving dual antiplatelet therapy

Introduction. The aim of the study was to define the prevalence of bleeding events in patients treated with dual antiplatelet therapy (DAT) in comparison with patients receiving only acetylsalicylic acid (ASA).Methods. Prospective two-centre registry of all first implantations of pacemakers, cardioverter-defibrillators and cardiac resynchronisation therapy units in patients receiving ASA (n=194) or DAT (n=53).Results. Bleeding complications were detected in 27 (16.2%) patients in the ASA group and in 13 (24.5%) in the DAT group. There was no significant difference in the overall number of complications between the patients receiving ASA or DAT, although there was a trend towards a higher incidence of overall complication rates in the DAT group (p=0.0637). The incidence of major complications (requiring blood transfusion or surgical intervention or prolonging hospital stay) was low (3.6%), and similar in both groups (3.6 and 3.8% respectively, ns). The rate of minor complications (subcutaneous haematomas) was greater in the DAT group (p=0.015).Conclusions. Treatment with DAT does not increase the risk of major bleeding complications as a result of device implantation; however, minor complications are significantly more frequent. Our results suggest that DAT could be continued in patients undergoing device implantation with a moderate risk of bleeding complications. (Neth Heart J 2010;18:230-5.).

Extended Esophagectomy in Elderly Patients with Esophageal Cancer: Minor Effect of Age Alone in Determining the Postoperative Course and Survival

BackgroundElderly patients who undergo esophagectomy for cancer often have a high prevalence of coexisting diseases, which may adversely affect their postoperative course. We determined the relationship of advanced age (i.e., ≥70 years) with outcome and evaluated age as a selection criterion for surgery.MethodsBetween January 1991 and January 2007, we performed a curative-intent extended transthoracic esophagectomy in 234 patients with cancer of the esophagus. Patients were divided into two age groups: <70 years (group I; 170 patients) and ≥70 years (group II; 64 patients).ResultsBoth groups were comparable regarding comorbidity (American Society of Anesthesiologists classification), and tumor and surgical characteristics. The overall in-hospital mortality rate was 6.2% (group I, 5%, vs. group II, 11%, P = 0.09). Advanced age was not a prognostic factor for developing postoperative complications (odds ratio, 1.578; 95% confidence interval, 0.857–2.904; P = 0.143). The overall number of complications was equal with 58% in group I vs. 69% in group II (P = 0.142). Moreover, the occurrence of complications in elderly patients did not influence survival (P = 0.174). Recurrences developed more in patients <70 years (58% vs. 42%, P = 0.028). The overall 5-year survival was 35%, and, when included, postoperative mortality was 33% in both groups (P = 0.676).The presence of comorbidity was an independent prognostic factor for survival (P = 0.002).ConclusionsAdvanced age (≥70 years) has minor influence on postoperative course, recurrent disease, and survival in patients who underwent an extended esophagectomy. Age alone is not a prognostic indicator for survival. We propose that a radical resection should not be withheld in elderly patients with limited frailty and comorbidity.

Intraoperative fluid optimization using stroke volume variation in high risk surgical patients: results of prospective randomized study

IntroductionStroke volume variation (SVV) is a good and easily obtainable predictor of fluid responsiveness, which can be used to guide fluid therapy in mechanically ventilated patients. During major abdominal surgery, inappropriate fluid management may result in occult organ hypoperfusion or fluid overload in patients with compromised cardiovascular reserves and thus increase postoperative morbidity. The aim of our study was to evaluate the influence of SVV guided fluid optimization on organ functions and postoperative morbidity in high risk patients undergoing major abdominal surgery.MethodsPatients undergoing elective intraabdominal surgery were randomly assigned to a Control group (n = 60) with routine intraoperative care and a Vigileo group (n = 60), where fluid management was guided by SVV (Vigileo/FloTrac system). The aim was to maintain the SVV below 10% using colloid boluses of 3 ml/kg. The laboratory parameters of organ hypoperfusion in perioperative period, the number of infectious and organ complications on day 30 after the operation, and the hospital and ICU length of stay and mortality were evaluated. The local ethics committee approved the study.ResultsThe patients in the Vigileo group received more colloid (1425 ml [1000-1500] vs. 1000 ml [540-1250]; P = 0.0028) intraoperatively and a lower number of hypotensive events were observed (2[1-2] Vigileo vs. 3.5[2-6] in Control; P = 0.0001). Lactate levels at the end of surgery were lower in Vigileo (1.78 ± 0.83 mmol/l vs. 2.25 ± 1.12 mmol/l; P = 0.0252). Fewer Vigileo patients developed complications (18 (30%) vs. 35 (58.3%) patients; P = 0.0033) and the overall number of complications was also reduced (34 vs. 77 complications in Vigileo and Control respectively; P = 0.0066). A difference in hospital length of stay was found only in per protocol analysis of patients receiving optimization (9 [8-12] vs. 10 [8-19] days; P = 0.0421). No difference in mortality (1 (1.7%) vs. 2 (3.3%); P = 1.0) and ICU length of stay (3 [2-5] vs. 3 [0.5-5]; P = 0.789) was found.ConclusionsIn this study, fluid optimization guided by SVV during major abdominal surgery is associated with better intraoperative hemodynamic stability, decrease in serum lactate at the end of surgery and lower incidence of postoperative organ complications.Trial registrationCurrent Controlled Trials ISRCTN95085011.

Surgery combined with brachytherapy in patients with retroperitoneal sarcomas.

PurposeThe primary aim of this work was to analyze feasibility of combined treatment of retroperitoneal sarcomas (RS): surgery (S) and intraoperative brachytherapy (IOBRT). The secondary aim was to analyze results and complications after this treatment.Material and methods84 patients with retroperitoneal sarcomas were qualified for combined treatment (S and IOBRT) between June 1998 and September 2006. 65 of the patients (77.4%) had local recurrences. Sarcomas with intermediate and high grade of histological malignancy (G2, G3 – 76.2%) were the most frequent within the all surgically treated patients. Resection ability (R0/R1) in analyzed group of patients was estimated as 85% (74 cases). After intraoperative evaluation, 57 (67.8%) patients were qualified for IOBRT. Since 2000, in 34 patients (60%) an adjuvant postoperative external beam radiation therapy (EBRT) in dose of 50 Gy was applied. Median follow-up of the surviving patients was 40 months.ResultsOn the basis of the univariate analysis, relevant aspects negatively influencing overall survival rate within the RS group treated with IOBRT were as follows: surgery of sarcoma recurrence (p = 0.002), higher grade of histological malignancy (p = 0.05), histological type different than liposarcoma (p = 0.05) as well as no adjuvant EBRT (p = 0.05). On the basis of multivariate analysis one can ascertain that relevant factors negatively influencing LRFS in RS patients treated with IOBRT were: surgery due to recurrence of sarcoma (p = 0.008) and lack of EBRT (p = 0.01).ConclusionsCombined treatment (surgery and brachytherapy) was possible to be carried out on 68% of RS patients. The overall number of complications was quite high, however acceptable, taking into consideration the application of extensive, multi-organ treatments in case of sarcoma recurrences in this localization. The results suggest that the method of treatment will improve the final outcome when most of patients will be qualified for treatment of primary sarcomas in experienced centre.

Primary total hip arthroplasty: a comparison of the lateral Hardinge approach to an anterior mini-invasive approach

The anterior mini-invasive (MI) approach to performing total hip arthroplasty (THA) is associated with less soft tissue damage and shorter postoperative recovery than other methods. Our hospital recently abandoned the traditional lateral Hardinge (LH) approach in favour of this new method. We compared the first 100 patients operated after the changeover to the new method (MI group) to the last 100 patients operated using the traditional method (LH group). Clinical and radiological parameters and complications were recorded pre- and postoperatively and the collected data of the two groups were statistically compared. There were no statistically significant differences between either group with regard to patient demographics or procedural data, placement of the femur component, postoperative leg discrepancy, prosthesis dislocation, blood transfusion, or postoperative dislocation of the components. The MI group had a significantly longer operating time, more bleeding, higher rate of nerve damage, and a higher percentage of acetabular component malposition whilst having a significantly shorter hospital stay and significantly fewer infections of the operative site in comparison to the LH group. Additionally, and perhaps most worrying was the clinically significant increase in intraoperative femur fractures in the MI group. The changeover to the anterior mini-invasive approach, which was the surgeons' initial experience with the MI technique, resulted in a drastic increase in the number of overall complications accompanied by less soft tissue damage and a shorter period of rehabilitation. Our results suggest that further analysis of this surgical MI technique will be needed before it can be recommended for widespread adoption.