Risk Of Overall Complications Research Articles

HPB SO20 - Evaluating the Impact of Enhanced Recovery After Surgery Protocols Post Hepatectomy in Patients with Chronic Liver Disease: A Meta-Analysis

Abstract Background Defined criteria for the resectability of liver disease continue to be refined. In the era of enhanced recovery after surgery (ERAS), data regarding its safety and efficacy in specific patient populations is required. Patients with liver cirrhosis are particularly vulnerable, owing to both operative and peri-operative risk. However, the application of ERAS in cirrhotic patients undergoing hepatectomy is absent from the most recent ERAS Society Group recommendations from 2022. We present a meta-analysis assessing outcomes after liver resection in patients with cirrhosis following an ERAS protocol compared to standard post-operative care. Method A systematic literature search was performed using PubMed, Embase and Web of Science. Studies were included if comparing ERAS protocols versus standard post-operative care in patients undergoing liver resection in which more than 50% of the patient population had cirrhosis at time of surgery. The primary outcome analysed was overall complication rates with secondary outcomes of post-operative mortality, estimated blood loss, operation time, post-operative incidence of liver failure, readmission and reoperation rates. Statistical analysis was performed using Review Manager by the Cochrane Collaboration. Results 930 records were screened for eligibility. Five articles were eligible for inclusion(ERAS n = 425 vs control group n = 423 patients). Cirrhotic patients enrolled in an ERAS program post-hepatectomy had a significantly reduced risk of overall complications (OR 0.45, 95% CI 0.33, 0.61, p<0.00001) and a shorter hospital stay when compared to standard post-operative care by 1.8 days (mean difference -1.83, 95% CI -2.22, -1.45, p<0.00001). No significant differences were noted in post-operative mortality, estimated blood loss, operation time, post-operative incidence of liver failure, readmission or reoperation rates between the ERAS group and control. Conclusion Application of an ERAS protocol for patients undergoing liver resection is safe and feasible in cirrhotic patients. ERAS protocols were successful in significantly reducing overall complication rates and length of inpatient hospital stay, and did not negatively impact secondary post-operative outcomes or mortality. ERAS protocols should be reflected in future guidelines, specifically for cirrhotic patients undergoing hepatectomy, and additional research on the utility of ERAS in higher risk patients is encouraged.

Age-related and age-independent complications in atrial fibrillation ablation: insights from the Japan ablation registry

Abstract Background The growing prevalence of atrial fibrillation (AF) has intensified the focus on managing this condition in the elderly. Catheter ablation, a popular treatment option, requires more detailed examination due to limited data on its efficacy and risks in this age group. Aim To identify the types of complications of AF ablation correlated with advanced age and to differentiate them from age-independent complications. Method We conducted a prospective analysis of 170,017 AF ablation procedures from the Japan ablation registry, conducted across 482 facilities between 2017 and 2020. Complications in patients aged 80 and above (elderly group, n=14,389) were compared with those under 80 (control group, n=155,628). The overall complication rate was 2.77%, with a higher occurrence in the elderly group (elderly group vs. control group, 3.62% vs. 2.69%, p<0.001). Notably, the elderly experienced more cardiac tamponade/pericardial effusion (0.95% vs. 0.6%, p<0.001), symptomatic cerebral infarction or transient ischemic attacks (0.27% vs. 0.15%, p=0.001), and sick sinus syndrome (0.31% vs. 0.05%, p<0.001). While in-hospital mortality in the elderly group was relatively low (0.16%), it was significantly higher compared to the control group (0.06%, p<0.001). However, incidences of other complications like puncture-site complications (0.49% vs. 0.42%, p=0.28), non-puncture-site bleeding, esophagus-related complications (0.22% vs. 0.22%, p=0.72), and phrenic nerve palsy (0.44% vs. 0.43%, p=0.69) showed no significant age-related differences. Conclusion Elderly patients undergoing AF ablation are at a higher risk of overall complications, with particular susceptibility to cardiac tamponade/pericardial effusion, symptomatic cerebral infarction/transient ischemic attacks, and sick sinus syndrome. This highlights the need for careful monitoring of these specific complications in the elderly. Additionally, it is noteworthy that the risk of certain complications appears to be independent of age.

Impact of Preoperative Time Intervals for Neoadjuvant Chemoradiotherapy on Short-term Postoperative Outcomes of Esophageal Cancer Surgery: A Population-based Study Using the Dutch Upper Gastrointestinal Cancer Audit (DUCA) Data.

To clarify the impact of the preoperative time intervals on short-term postoperative and pathologic outcomes in patients with esophageal cancer who underwent neoadjuvant chemoradiotherapy (nCRT) followed by esophagectomy. The impact of preoperative intervals on patients with esophageal cancer who received multimodality treatment remains unknown. Patients (cT1-4aN0-3M0) treated with nCRT plus esophagectomy were included using the Dutch national DUCA database. Multivariate logistic regression was used to determine the effect of different time intervals upon short-term postoperative and pathologic outcomes: diagnosis-to-nCRT intervals (≤5, 5-8, and 8-12 weeks), nCRT-to-surgery intervals (5-11, 11-17, and >17 weeks) and total preoperative intervals (≤16, 16-25, and >25 weeks). Between 2010 and 2021, a total of 5052 patients were included. Compared with diagnosis-to-nCRT interval ≤5 weeks, the interval of 8 to 12 weeks was associated with a higher risk of overall complications ( P =0.049). Compared with nCRT-to-surgery interval of 5 to 11 weeks, the longer intervals (11-17 and >17 weeks) were associated with a higher risk of overall complications ( P =0.016; P <0.001) and anastomotic leakage ( P =0.004; P =0.030), but the interval >17 weeks was associated with lower risk of ypN+ ( P =0.021). The longer total preoperative intervals were not associated with the risk of 30-day mortality and complications compared with the interval ≤16 weeks, but the longer total preoperative interval (>25 weeks) was associated with higher ypT stage ( P =0.010) and lower pathologic complete response rate ( P =0.013). In patients with esophageal cancer undergoing nCRT and esophagectomy, prolonged preoperative time intervals may lead to higher morbidity and disease progression, and the causal relationship requires further confirmation.

Effect of peritoneal drainage on the prognosis following appendectomy in pediatric patients with appendicitis: a retrospective study based on appendicitis grade.

This study aimed to assess the impact of peritoneal drainage and its type on prognosis, encompassing postoperative recovery and complications, in pediatric patients (≤ 16years old) following appendectomy based on the grade of appendicitis. In this retrospective study, we analyzed pediatric patients (≤ 16years old) with appendicitis who met the inclusion and exclusion criteria in our center from January 2017 to January 2024 and classified them into grade I-V based on the grade of appendicitis, with V representing the most serious cases. The patients were grouped according to drainage status and type. The main clinical outcomes included postoperative rehabilitation indexes such as time to resume a soft diet, time to remove the drain, duration of postoperative antibiotic use and length of hospitalization (LOH), as well as postoperative complications including intra-abdominal abscess (IAA), ileus and wound infection (WI), and readmission within 30days after surgery. A total of 385 pediatric patients with appendicitis were included in the study and divided into No-drainage (ND) group (n = 74), Passive drainage (PD) group (n = 246) and Active drainage (AD) group (n = 65) according to drainage status and type. Compared to the other two groups, the ND group had a significantly shorter time to resume a soft diet, duration of postoperative antibiotic use and LOH, and these differences were statistically significant. Similar findings were observed in grade I patients too (P < 0.05). In all cases examined here, the AD group had a significantly shorter time for drain removal compared to the PD group (3.04 [1-12] vs 2.74 [1-15], P = 0.049); this difference was also evident among grade I patients (2.80 [1-6] vs 2.47 [1-9], P = 0.019). Furthermore, within the same grade, only in grade IV did the AD group exhibit a shorter duration of postoperative antibiotic use compared to the PD group (4.75 [4-5] vs 8.33 [5-15], P = 0.009). Additionally, the LOH in the AD group was longer than that in the PD group (8.00 [4-13] vs 4.75 [4-5], P = 0.025). Among all cases, the ND group exhibited significantly lower incidences of overall complications and WI compared to the other two groups (P < 0.05). Additionally, the incidence of IAA in the ND group was significantly lower than that in the PD group (0% vs 5.3%, P = 0.008 < 0.0167). Furthermore, although there were no statistically significant differences in the incidence of overall complications, IAA, ileus, and WI between the PD and AD groups during grade ≥ II analysis (P > 0.05), a higher readmission rate within 30days was observed in the PD group compared to the AD group; however, these differences were not statistically significant (P > 0.05). Moreover, multivariate analysis revealed that a higher grade of appendicitis was associated with an increased risk of overall complications and IAA as well as a longer duration of postoperative antibiotic use and LOH. The appendicitis grade is a crucial indicator for predicting postoperative IAA and LOH. In patients with grade I appendicitis, peritoneal drainage, even if active drainage, is not recommended; For patients with grade ≥ II appendicitis, active drainage may be more effective than passive drainage in reducing the duration of postoperative antibiotic use and LOH.

Outcomes of surgically treated sialoceles in 21 cats: A multi-institutional retrospective study (2010-2021).

To report the outcomes of cats that underwent surgical correction for sialoceles. Multi-institutional retrospective cohort study. Twenty-one client-owned cats. Medical records were examined of cats diagnosed with sialocele, which underwent surgical intervention over an 11-year period at one of 10 referral hospitals. The data collected included signalment, clinical signs, diagnostic imaging, histopathology, surgical procedures performed, and postoperative complications. The most common presenting complaints for cats with sialocele included dysphagia and ptyalism. Only two cats had a recent history of trauma, and one was diagnosed with a concurrent sialolith. Most displayed visible tissue swelling, with ranulae being most common. Surgical treatment consisted of sialoadenectomy and/or marsupialization. Intraoperative complications occurred in three cats, and postoperative complications in five cats. No recurrence or development of contralateral sialoceles were reported during the follow-up period (30-968 days). The majority of cats did not have a clear underlying cause for developing a sialocele. The sublingual and mandibular salivary glands were presumed to be the most commonly affected. Mandibular and sublingual sialoadenectomy and/or marsupialization provided resolution of clinical signs to the 21 cats that underwent these procedures. Sialocele, although rare, should remain a differential diagnosis when managing cats with relevant clinical signs. Surgical intervention appears to offer resolution of signs with apparently low overall risk of complication or short-term recurrence. In cats it is necessary to evaluate whether sialoadenectomy is necessary, or whether marsupialization alone should be attempted as a less invasive first-line surgical intervention.

Clinical and oncological outcomes of pelvic exenteration for rectal and gynaecological malignancies

Background: Pelvic exenteration (PE) is radical surgery which offers prospect of cure for patients with locally advanced pelvic malignancy. Methods: This is a retrospective cohort study evaluating patient outcomes over six-year period at James Cook University Hospital, a tertiary center in United Kingdom. Primary outcome measures included short-term (90 days) mortality and morbidity. Secondary outcome measures were survival and recurrence. Data was analysed by descriptive statistics and Kaplan-Meier curve used for survival estimation. Results: Out of 68 patients who underwent PE, 88% (n=61) was for primary locally advanced cancer and 10% (n=7) for recurrent cancer. The 31% (n=21) exenterations were for rectal cancer, 68% (n=46) for gynaecological cancer and 1% (n=1) for bladder cancer. Complete (R0) resection was achieved in 86% rectal exenteration versus 68% in gynaecological exenteration (p=0.1459). The overall 90-day mortality rate was 2.9% (n=2). The 19.1% developed major complications (Clavien-Dindo grades 3a-4). The estimated mean overall survival was 55 months (95% CI, 41-71) for rectal versus 44 months (95% CI, 35-53) for gynaecological (p=0.076). At a median follow-up of 19 months, the local and distal recurrence rate for rectal patients after PE was 4.7% and 14.3% respectively. The 41.3% of gynaecological patients developed recurrence and/ or progression of disease. Conclusions: PE for rectal and gynaecological cancers has low short-term mortality but is associated with high risks of overall complications, most of which were Clavien-Dindo grades &lt;3. The higher recurrence rate observed in the gynaecological cohort is in keeping with the varying intent of the surgery.

The Effectiveness and Safety of Leadless Pacemakers: An Updated Meta-Analysis.

Leadless pacemakers (LPs) are promising alternatives to traditional transvenous pacemakers (TVPs), but their comparative effectiveness and safety in clinical outcomes remain uncertain. We systematically searched PubMed, Embase, Scopus, Cochrane, and ClinicalTrials.gov for studies comparing LPs and TVPs. A restricted maximum likelihood random-effects model was used for all outcomes. Heterogeneity was assessed using I2 statistics. We performed a subgroup analysis with studies with multivariate-adjusted data. We included 21 studies involving 47,229 patients, of whom 12,199 (25.8%) underwent LP implantation. Compared with TVPs, LPs were associated with a significantly lower risk of overall complications (OR 0.61; 95% CI 0.45-0.81; p < 0.01), dislodgement (OR 0.34; 95% CI 0.20-0.56; p < 0.01), and pneumothorax (OR 0.27; 95% CI 0.16-0.46; p < 0.01). No significant difference in all-cause mortality was observed in the overall analysis (OR 1.43; 95% CI 0.65-3.15; p = 0.35) and in studies with multivariate-adjusted data (OR 1.34; 95% CI 0.65-2.78; p = 0.43). However, LPs were associated with a higher risk of pericardial effusion (OR 2.47; 95% CI 1.39-4.38; p < 0.01) and cardiac tamponade (OR 3.75; 95% CI 2.41-5.83; p < 0.01). LPs also demonstrated a lower pacing capture threshold (MD -0.19V; 95% CI [-0.23V]-[-0.16V]; p < 0.01), but no significant difference in impedance (MD 32.63 ohms; 95% CI [-22.50 ohms]-[87.76 ohms]; p = 0.25). These findings suggest that LPs were associated with lower overall complication rates and similar effectiveness to TVPs. However, randomized controlled trials are warranted to validate these results.

The impact of previous abdominal surgery on colorectal cancer patients undergoing laparoscopic surgery.

The current study aimed to investigate whether previous abdominal surgery (PAS) could affect the outcomes of colorectal cancer (CRC) surgery. We conducted the search strategy in three databases (PubMed, Embase, and the Cochrane Library) from inception to May 26, 2022. The short-term and long-term outcomes were compared between the PAS group and the non-PAS group. Odds ratios (ORs) and 95% confidence intervals (CIs) were pooled up. Stata (V.16.0) software was used for data analysis. We included 34,827 patients from 14 studies in the current study. After pooling up all the data, we found that there were higher proportions of overall complications (OR = 1.12, I2 = 4.65%, 95% CI 1.03 to 1.23, P = 0.01), ileus (OR = 1.96, I2 = 59.74%, 95% CI 1.12 to 3.44, P = 0.02) and mortality (OR = 1.26, I2 = 0.00%, 95% CI 1.11 to 1.42, P = 0.00) in the PAS group than the non-PAS group. Patients with a history of PAS had higher risks of overall complications and death following CRC surgery. However, it did not appear to significantly affect the short-term outcomes apart from ileus. Surgeons should raise awareness of patients with a history of PAS, and take steps to reduce postoperative complications and mortality.

Postoperative morbidity following Hartmann's procedure in comparison to anterior resection and abdominoperineal resection for rectal cancer-a population-based study.

There is ongoing controversy regarding the extent to which Hartmann's procedure (HP) should be used in rectal cancer treatment. This study was designed to investigate 30-day postoperative morbidity and mortality following HP, anterior resection (AR) and abdominoperineal resection (APR) for rectal cancer using a national registry. All patients operated for rectal cancer, tumour height 5-15 cm, between the years 2010 and 2017, were identified through the Swedish colorectal cancer registry. A total of 8476 patients were included: 1210 (14%) undergoing HP, 5406 (64%) AR and 1860 (22%) APR. HP was associated with an increased risk of intra-abdominal infection (OR 1.7, CI 1.26-2.28, P = 0.0004) compared to AR and APR, while APR was related to an increased risk of overall complications (OR 1.18, CI 1.01-1.40, P = 0.040). No significant difference was observed in the rate of reoperations and readmissions between HP, AR and APR, and type of surgical procedure was not a risk factor for 30-day mortality. Findings from a subgroup analysis of patients with a tumour 5-7 cm from the anal verge revealed that HP was not associated with increased risk for complications or 30-day mortality. For patients where AR is not appropriate HP is a valid alternative with a favourable outcome. APR was associated with the highest overall 30-day complication rate.

Malnutrition Screening with Nutritional Risk Screening 2002 prior to Assessment as Part of GLIM Criteria in Patients Undergoing Major Abdominal Surgery for Gastrointestinal Cancer

Introduction: For diagnosing malnutrition as an important modifiable risk factor in surgical cancer patients, GLIM criteria offer a standardised diagnostic pathway. Before assessing malnutrition, it is suggested to screen for malnutrition with an implemented screening tool, i.e., the NRS-2002. Validated data regarding the applied screening tool and its relevance for predicting outcome parameters in surgical patients is sparse. Methods: 260 patients undergoing major abdominal surgery for cancer were retrospectively analysed. Between January 2017 and December 2019, patients were prospectively screened for malnutrition with the Nutritional Risk Score 2002 (NRS). Irrespective of their screening result malnutrition was assessed with GLIM criteria using CT scan at lumbar level 3 for measuring skeletal muscle mass (GLIM MMCT). Patients with negative screening results (NRS ≤2) were analysed regarding their malnutrition assessment and outcome parameters. Results: Thirty four of 67 patients with NRS ≤2, posing no risk for malnutrition, were diagnosed malnourished according to GLIM MMCT (n = 34, 50.7%). 19 patients (55.9%) with NRS ≤2 and malnutrition according to GLIM had at least one complication, 12 patients (35.3%) had a severe complication (Clavien-Dindo grade ≥ 3a), in 26.5% re-laparotomy was necessary, readmission within 1 month in 20.6% of patients, and length of hospital stay was 18.76 ± 12.66, which was in total worse in outcome compared to the whole study group (n = 260). Patients with NRS ≤2 but diagnosed malnourished by GLIM were at significant higher risk to develop a severe complication (OR 2.256, 95% CI: 1.038–4.9095, p = 0.036) compared to patients with NRS ≤2 but not being diagnosed malnourished. The risk for overall complications was significantly increased in patients with malnutrition diagnosed by the GLIM criteria using MMCT (OR 2.028, 95% CI: 1.188–3.463, p = 0.009). Patients screened at risk with NRS ≥3 and diagnosed malnourished by GLIM were also at significant higher risk for developing complications (OR 1.728, 95% CI: 1.054–2.832, p = 0.029). Conclusion: GLIM MMCT is suitable for diagnosing malnutrition and estimating postoperative risk in gastrointestinal cancer patients. Nutritional assessment only in patients with NRS >2 may bear the risk to miss malnourished patients with high risk for poor clinical outcome. In every patient undergoing major cancer surgery, regular assessment of nutritional status regardless of screening result should be performed exploiting CT body composition analysis.

Should Chronological Age be a Consideration in Patients Undergoing Elective Primary Total Knee Arthroplasty?

BackgroundThe optimal time for total knee arthroplasty (TKA) requires a balance between patient disability and health state to minimize complications. While chronological age has not been shown to be predictive of complications in elective surgical patients, there is a point beyond which even optimized elderly patients would be at increased risk for complications. The purpose of this study was to examine the impact of chronological age on complications following primary TKA. MethodsUsing an administrative database, the records of 2,129,191 patients undergoing elective unilateral TKA between 2006 and 2021 were reviewed. The primary outcomes of interest were cardiac and pulmonary complications, and their relationship to the Charlson-Deyo Comorbidity Index (CDI) and chronological age. Secondary outcomes included risk of renal, neurologic, infection, and intensive care utilization postoperatively. The results were analyzed using a graphical method. The impact of chronological age as a modifier of overall risk for complications was modeled as a continuous variable. An age cutoff threshold of 80 years was also assigned for clinical convenience. ResultsThe risk of complications correlated more closely to the CDI (odds ratio (OR) 1.37 to 2.1) than chronological age (OR 1.0 to 1.1) across the various complications [Table 1. However, beyond age 80 years, the risks of cardiac, pulmonary, renal, and cerebrovascular complications were significantly increased for all CDI categories (OR 1.73 to 3.40) compared to patients below age 80 years [Table 2] [Figures 1A and 1B]. ConclusionsChronologic age can impact the risk of complications even in well-optimized elderly patients undergoing primary TKA. As arthroplasty continues to transition to outpatient settings and inpatient denials increase, these results can help patients, physicians, and payors mitigate risk while optimizing the allocation of resources.

Smoking impacts outcomes in transcervical Zenker's diverticulectomy

PurposeThere is sparse literature discussing the impact of smoking on postoperative outcomes following surgical treatment of Zenker's diverticulum. In this study, we seek to characterize differences in the management and outcomes of open Zenker's diverticulectomy based on patient smoking status. Methods and materialsThis paper is a retrospective cohort review. The 2005–2018 American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database was queried for patients undergoing open Zenker's diverticulectomy. Chi-square and multivariable logistic regression were performed to determine statistical associations between postoperative outcomes and smoking status. ResultsOf the 715 identified patients, 70 (9.8 %) were smokers and 645 (91.2 %) were non-smokers. Smokers were younger than non-smokers (mean 63.9 vs. 71.7 years, p < 0.001) and more likely to have a prolonged operative time (20.0 % vs. 11.6 %, p = 0.044). On multivariable regression analysis controlling for demographics and comorbidities, smokers had greater odds than non-smokers for developing overall postoperative complications (OR: 2.776, p = 0.013), surgical infections (OR: 3.194, p = 0.039), medical complications (OR: 3.563, p = 0.011), and medical infections (OR: 1.247, p = 0.016). Smokers also had greater odds for requiring ventilation/intubation (OR: 8.508, p = 0.025) and having a prolonged postoperative stay (OR: 2.425, p = 0.030). ConclusionIn a cohort of patients undergoing transcervical Zenker's diverticulectomy, smokers are at increased risk for overall complications, medical complications, medical infections, surgical infections, prolonged postoperative stay, and ventilation/intubation.

Risk of complications and implant survival of surgical treatment of proximal femoral metastasis: a meta-analysis.

The patients with femoral metastasis in the inter- or subtrochanteric area could be treated with intramedullary nailing or prosthetic reconstruction, however, it is controversial which surgical treatment could offer less complications and implant failure. Our purpose was to define the risk of complications and implant survival in patients treated with intramedullary nailing or prosthetic reconstruction. We analyzed studies reporting the risk of complications, reoperations and removal of the implant in patients treated with intramedullary nailing, hemiarthroplasty, arthroplasty or megaprosthesis. We analyzed 27 studies (1346 patients) reporting patients treated with intramedullary nail (51%), hemiarthroplasty (15%), arthroplasty (2%), megaprosthesis with (25%) or without (7%) acetabular component. No difference was found in the overall risk of complications between patients treated with intramedullary nailing 6%, hemiarthroplasty or total hip arthroplasty 7% and megaprosthesis 11% (p = 0.23). However, patients treated with megaprosthesis had increased risk of reoperation due to infection (70%), compared to the patients treated with intramedullary nail (13%), and patients treated with hemiarthroplasty or total hip arthroplasty (23%) (p = 0.02). Revision due to disease progression was required in 61% of the patients treated with intramedullary nail, but not in patients treated with hemiarthroplasty, total arthroplasty, and megaprosthesis (p = 0.03). Patients treated with megaprosthesis had higher risk of reoperation due to infection, while patients treated with intramedullary nailing had higher risk of revision due to disease progression. Regarding patients treated with megaprosthesis, the risk of reoperation due to dislocation was higher in those treated with acetabular component.

Twelve Years and over 2400 Implants Later: Augmentation Mammoplasty Risk Factors Based on a Single Plastic Surgeon’s Experience

Background: Breast augmentation is one of the most commonly performed aesthetic surgery procedures. Yet, few reports in the literature analyze individual surgeon experiences with a unified surgical method on a large group of patients. This study aimed to analyze a single surgeon’s complications rate and experience with the Akademikliniken augmentation mammaplasty method from the beginning of his career. Methods: A retrospective outcome analysis of all patients (n = 1646) who underwent breast augmentation between 2009 and 2021 performed by a single surgeon was conducted. Complications and reoperation rates were evaluated. In addition, correlations with the patient and implant characteristics and insertion-method–related risk factors were analyzed. Results: In total, 1212 female patients (mean age, 31.47 years) were analyzed. The minimal follow-up for every patient was 6 months (mean follow-up, 18.35 months). The total complication rate was 7.1%, and the most common complication (2.64%) was capsular contracture (Baker scale III/IV). Implant insertion with a funnel significantly lowered the overall risk of complications (P = 0.009). Statistical analysis indicates that the single independent risk factors for primary breast augmentation are patient age younger than 27 years, initial breast size B and C, and tobacco smoking. Conclusions: This study indicated that capsular contracture and implant rotation are the most common complications of analyzed primary augmentation mammoplasty. It also identifies various risk and protection factors, such as funnel usage, which should be considered by the surgeon when performing this type of procedure.

Comparison of Outcomes in Below-Knee Amputation Based on Surgeon Specialty

Introduction/Purpose: Orthopaedic, vascular, and general surgeons all perform lower extremity amputations. Previous studies have indicated that outcomes may be related surgeon experience or skill, with a similar study indicating that general surgeons experience worst postoperative outcomes than vascular surgeons. In spite of these studies, there is a paucity of literature investigating the difference in outcomes between amputations performed by orthopaedic and vascular surgeons. This study aims to analyze the effect of surgeon specialty on 30-day complication, readmission, reoperation, and mortality rates following below-knee amputation (BKA) procedures between orthopaedic and vascular surgeons. Methods: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was queried from 2010-2019 to identify 28,776 patients undergoing BKA by either orthopaedic, general, or vascular surgeons using Current Procedural Terminology (CPT) codes 27880, 27881, and 27882. Patients were stratified into groups based on surgeon specialty with 18,935 (66.4%) cases performed by vascular surgeons, 6,146 (21.6%) cases by general surgeons, and 3,429 (15.3%) cases were performed by orthopaedic surgeons. Demographics, comorbid conditions, hospital length of stay (LOS), and 30-day complications, readmission, reoperation, and mortality rates were compared between groups. Univariate and multivariate analysis were performed to examine the associations between outcomes and surgical specialty, while controlling for comorbid conditions as measured by ASA score and 5-factor modified frailty index (mFI-5) score. Results: The cohort was predominantly male (68.4%), white (61.9%), and the mean age was 63.54 (range, 18-90) years. The cohort of patients treated by vascular and general surgeons had significantly higher rates of numerous comorbidities, including mFI-5 score (p &lt;.001) and ASA score (p &lt;.001). When controlling for age, gender, BMI, and comorbid conditions, BKAs performed by vascular and general surgeons experienced an increased risk overall complication (General: Odds ratio [OR]=1.158, 95% confidence Interval [CI]=1.055-1.271; p=.002) (Vascular: OR=1.167, 95%CI=1.074-1.268; p&lt;.001), readmission (General: OR=1.208; p=.011) (Vascular: OR=1.191; p=.009), and reoperation (General: OR=1.71;, p&lt;.001) (Vascular: OR=1.975; p&lt;.001). However, both general (OR=0.361, 95%CI=0.27-0.482; p&lt;.001) and vascular surgeons (OR=0.367, 95%CI= 0.256-0.526; p&lt;.001) surgeons experience decreased risk for organ/space SSI as compared to orthopaedic surgeons. Overall risk of mortality between specialties was not significantly different. Conclusion: There was no significant difference in rates of overall 30-day mortality in patients undergoing between surgical specialties when employing multivariate controls. However, patients undergoing BKA by vascular or general surgeons were found to have an increased risk of overall complication, readmission, and reoperation.

Comparison of percutaneous decannulation and open surgical repair for large-bore arterial access sites of extracorporeal membrane oxygenation.

Following weaning of peripheral venoarterial extracorporeal membrane oxygenation (ECMO) support, removal of cannulas and repair of large-bore arterial sites is traditionally by open surgical repair (OSR). The use of a percutaneous vascular closure device (VCD) offers a minimally invasive alternative to OSR with potential for reduced operative complications, reduced hospital length of stay and in-hospital mortality. A systematic review of Medline and Embase databases was conducted for studies comparing VCD-assisted decannulation with OSR following decannulation of peripheral ECMO. The primary endpoint was rate of post-procedural complications, namely wound infection and limb ischaemia. The secondary endpoint was in-hospital mortality. Eight studies, with a total of 685 patients, met inclusion criteria. Forty-eight percent (n = 328) of patients underwent VCD-assisted decannulation with the remainder decannulated by OSR. Pooled analysis demonstrated that patients undergoing VCD-assisted decannulation are at significantly lower risk of overall complications than surgical repair (OR 4.34; 95% CI 2.19-8.57; p < .001). Specifically, there was a substantial decrease in groin infections (OR 6.77; 95% CI 3.07-14.97; p < .001) without notable differences in limb ischaemia or pseudoaneurysm occurrence between the VCD and OSR cohorts. There was a lower incidence of intra-operative bleeding and haematoma in the VCD cohort (p < .001 and p = .002, respectively). Vascular closure device-assisted decannulation of peripheral ECMO offers a significantly reduced risk of complications, particularly groin infections and bleeding. Future research should encompass larger cohorts, randomised controlled trials, cost-benefit analyses, and the training of surgeons, cardiologists and intensivists in VCD-assisted decannulation, potentially through the integration of simulation-based training.

Evaluation of Outcomes Between the Top-down Versus the Bottom-up Approach for Retropubic Midurethral Sling

Introduction and hypothesisRetropubic midurethral sling (MUS) placement is the gold standard for the treatment of stress urinary incontinence in the USA. The procedure can be approached from either a top-down or a bottom-up direction, but there is a paucity of contemporary data regarding outcomes between these approaches. The aim of this study was to provide updated clinical outcomes data.MethodsThis was a retrospective cohort study of women undergoing the retropubic MUS procedure alone or at the time of pelvic organ prolapse repair between 2010 and 2020 at a single academic medical center. The electronic medical record was used to extract demographic data, operative approach, and perioperative complications. The primary outcome was a composite incidence of any perioperative complication.ResultsOf the 309 patients analyzed, 140 (45.3%) underwent top-down and 169 (54.7%) underwent bottom-up retropubic MUS placement. Patients undergoing top-down MUS placement were more likely to be older (mean age 58 vs 54, p=0.02), have a history of diabetes mellitus (20% vs 8.9%, p=0.004), and have had a prior hysterectomy (27% vs 16%, p=0.02). They were less likely to have a concurrent anterior (p<0.001) or posterior repair (p<0.001). Patients undergoing the top-down procedure were less likely to experience sling exposure (p=0.02); complications in the two groups were otherwise similar.ConclusionsThe top-down approach to retropubic MUS placement was associated with lower rates of mesh erosion in this population of patients. Neither approach is associated with an increased overall risk of complications or de novo overactive bladder symptoms.

Brachial Tunneled Peripherally Inserted Central Catheters and the Risk of Catheter Complications: A Systematic Review and Meta-Analysis.

Situations involving increased workloads and stress (i.e., the COVID-19 pandemic) underline the need for healthcare professionals to minimize patient complications. In the field of vascular access, tunneling techniques are a possible solution. This systematic review and meta-analysis aimed to compare the effectiveness of tunneled Peripherally Inserted Central Catheters (tPICCs) to conventional Peripherally Inserted Central Catheters (cPICCs) in terms of bleeding, overall success, procedural time, and late complications. Randomized controlled trials without language restrictions were searched using PUBMED®, EMBASE®, EBSCO®, CINAHL®, and the Cochrane Controlled Clinical Trials Register from August 2022 to August 2023. Five relevant papers (1238 patients) were included. There were no significant differences in overall success and nerve or artery injuries between the two groups (p = 0.62 and p = 0.62, respectively), although cPICCs caused slightly less bleeding (0.23 mL) and had shorter procedural times (2.95 min). On the other hand, tPICCs had a significantly reduced risk of overall complications (p < 0.001; RR0.41 [0.31-0.54] CI 95%), catheter-related thrombosis (p < 0.001; RR0.35 [0.20-0.59] IC 95%), infection-triggering catheter removal (p < 0.001; RR0.33 [0.18-0.61] IC 95%), wound oozing (p < 0.001; RR0.49 [0.37-0.64] IC 95%), and dislodgement (p < 0.001; RR0.4 [0.31-0.54] CI 95%). The tunneling technique for brachial access appears to be safe concerning intra-procedural bleeding, overall success, and procedural time, and it is effective in reducing the risk of late complications associated with catheterization.

Close lateral internal sphincterotomy versus open lateral internal sphincterotomy for chronic anal fissure: a systematic review and meta-analysis

Background: Lateral internal sphincterotomy (LIS) has been the gold standard for treating chronic anal fissure (CAF) that persists despite other measures. The authors aim to evaluate the effects of the close method (CLIS) of performing LIS as compared to the open method (OLIS). Methods: Databases were searched for relevant studies and results were screened to identify eligible articles, and all concerned outcomes were pooled as odd ratio (OR) or mean difference (MD) with 95% CI in the meta-analysis models using RevMan 5.4. Results: Pooled data from 16 trials with 1,711 patients with idiopathic CAF showed that the CLIS has significant lower risk of delayed fissure healing [OR: 0.28, 95% CI (0.10, 0.77), P = 0.01], duration of hospital stay [MD: -0.82 with 95% CI (−1.07, −0.57), P &lt; 0.00001] and postoperative visual analogue pain score (VAPS) at 24 h [MD: −0.30 with 95% CI (−0.39, −0.21), P &lt; 0.00001]. Also, the risk of overall complications [OR: 0.33 with 95% CI (0.19, 0.55), P &lt; 0.0001], incontinence [OR: 0.28 with 95% CI (0.20, 0.38), P &lt; 0.00001], and postoperative pain [OR: 0.56 with 95% CI (0.35, 0.91), P = 0.02] was significantly lower with CLIS. Conclusion: CLIS is a safer option than OLIS for treating anal fissure. The risk of delayed fissure healing, incontinence, post-op pain and overall complication was significantly lower. However, the risk of surgical site infection, postoperative bleeding and recurrence did not differ. Future research with more prolonged follow-up is necessary to document recurrence reliably.

Lupus and Total Knee Arthroplasty: A Systematic Review of Inpatient Outcomes

Introduction An increasing number of people diagnosed with systemic lupus erythematosus (SLE) will undergo total knee arthroplasty (TKA) for end-stage knee osteoarthritis. The purpose of this systematic review was to assess the cumulative inpatient complications of those with SLE who underwent TKA in comparison to those without this diagnosis. Methods A thorough review of 3 databases was performed to evaluate all potential complications of those who underwent TKA with and without a diagnosis of SLE. Following the completion of our search and review of manuscripts, we found 4 studies that were included in this systematic review consisting of 55,381 arthroplasties in patients with a diagnosis of SLE with 12,835,627 arthroplasties in the comparison cohort. Results The SLE cohort had an overall higher complication rate (25% versus 22%; p = 0.001). This cohort had a higher chance of postoperative anemia (11.7 versus 10.6%; p = 0.001) and a subsequent need for transfusion (11.1 versus 10.1%; p = 0.001), prosthetic joint infection (0.17 versus 0.11%; p = 0.001), wound infection (0.13 versus 0.09%; p = 0.001), pneumonia (0.5 versus 0.34%; p = 0.001), and cerebrovascular accident (0.03 versus 0.01%; p = 0.001). Mortality risk was lower within the SLE cohort ((0.04 versus 0.06%; p = 0.047). There was no difference in the risk of acute kidney injury (p = 0.15), venous thromboembolic disease (p = 0.33), periprosthetic fracture (p = 0.23), prosthetic dislocation (p = 0.53), and myocardial infarction (p = 0.11). Discussion Our results show that a diagnosis of SLE confers a higher risk of overall complications and multiple specific complications. However, SLE patients had a lower rate of mortality. Furthermore, there were multiple complications that those with SLE were not found to have a higher risk of suffering. Future studies should focus on how to optimize the safety and efficacy of TKA in the short- and long-term outcomes of patients with a diagnosis of SLE.