Risk Of Overall Complications Research Articles

Evidence from the 'PROspective MulticEnTer RadIcal Cystectomy Series 2011 (PROMETRICS 2011)' study: how are preoperative patient characteristics associated with urinary diversion type after radical cystectomy for bladder cancer?

The aim of this study was to examine preoperative patients' characteristics associated with the urinary diversion (UD) type (continent vs. incontinent) after radical cystectomy (RC) and UD-associated postoperative complications. In 2011, 679 bladder cancer patients underwent RC at 18 European tertiary care centers. Data were prospectively collected within the 'PROspective MulticEnTer RadIcal Cystectomy Series 2011' (PROMETRICS 2011). Logistic regression models assessed the impact of preoperative characteristics on UD type and evaluated diversion-related complication rates. Of 570 eligible patients, 28.8, 2.6, 59.3, and 9.3% received orthotopic neobladders, continent cutaneous pouches, ileal conduits, and ureterocutaneostomies, respectively. In multivariable analyses, female sex (odds ratio [OR] 3.9; p = 0.002), American Society of Anesthesiologists score ≥3 (OR 2.3; p = 0.02), an age-adjusted Charlson Comorbidity Index ≥3 (OR 4.1; p < 0.001), and a positive biopsy of the prostatic urethra in the last transurethral resection of the bladder prior to RC (OR 4.9; p = 0.03) were independently associated with incontinent UD. There were no significant differences in 30- and/or 90-day complication rates between the UD types. Perioperative transfusion rates and 90-day mortality were significantly associated with incontinent UD (p < 0.001, respectively). Limitations included the small sample size and a certain level of heterogeneity in the application of clinical pathways between the different participating centers. Within this prospective contemporary cohort of European RC patients treated at tertiary care centers, the majority of patients received an incontinent UD. Female sex and pre-existing comorbidities were associated with receiving an incontinent UD. The risk of overall complications did not vary according to UD type.

Does obesity affect outcomes of cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion for disseminated mucinous appendiceal neoplasms?

Obesity has been described as a risk factor for surgical complications and may play a prominent role in the progression, recurrence, and survival rates of various cancers. Our objective was to investigate the impact of being overweight or obese on perioperative and oncologic outcomes after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemoperfusion (HIPEC) for peritoneal carcinomatosis (PC) from mucinous appendiceal neoplasms (MAN). From a prospectively maintained database (2001-2010) of CRS/HIPEC for PC from MAN, we evaluated the body mass index (BMI) of patients, categorizing them into normal weight (NW<25kg/m(2)), overweight (OW=25 to 29.9kg/m(2)), and obese (OB≥30kg/m(2)). We compared the perioperative and oncologic outcomes among groups. Of the 282 patients in the database, 234 had BMI data available, and 81, 79, and 74 patients were categorized as NW, OW, and OB, respectively. Although there was a trend toward increased risk of overall complications, wound infections, deep vein thrombosis, respiratory and renal complications, and anastomotic leaks in the OW and OB groups, these differences only achieved statistical significance for renal (p=0.03) and pulmonary (p=0.02) complications in the OW and OB groups, respectively. The 5-year survival rate for NW, OW, and OB patients was 63.9, 48, and 54.4%, respectively (p=0.63). The median time to progression was 21.1 (NW), 21.7 (OW), and 23.9 (OB) months (p=0.83). OW and OB patients may have an increased risk of renal and pulmonary complications, respectively. Obesity has no major impact on perioperative mortality and long-term oncologic outcomes in patients undergoing CRS/HIPEC for MAN.

The use of bone morphogenetic protein in thoracolumbar spine procedures: analysis of the MarketScan longitudinal database

Background contextThe use of recombinant human bone morphogenetic protein (BMP) in the thoracolumbar spine remains controversial, with many questioning the risks and benefits of this new biologic. PurposeTo describe national trends, incidence of complications, and revision rates associated with BMP use in thoracolumbar spine procedures. Study design/settingAdministrative database study. Patient sampleA matched cohort of 52,259 patients undergoing thoracolumbar fusion surgery from 2006 to 2010 were identified in the MarketScan database. Patients without BMP treatment were matched 2:1 to patients receiving intraoperative BMP. Outcome measuresRevision rates and postoperative complications. MethodsThe MarketScan database was used to select patients undergoing thoracolumbar fusion procedures, with and without intraoperative BMP. We ascertained outcome measures using either International Classification of Disease, ninth revision, or Current Procedural Terminology coding, and matched groups were evaluated using a bivariate and multivariate analyses. Kaplan-Meier estimates of fusions failure rates were also calculated. ResultsPatients receiving intraoperative BMP underwent fewer refusions, decompressions, posterior and anterior revisions, or any revision procedure (single level 4.53% vs. 5.85%, p<.0001; multilevel 5.02% vs. 6.83%, p<.0001; overall cohort 4.73% vs. 6.09%, p<.0001). After adjusting for comorbidities, demographics, and levels of procedure, BMP was not associated with the postoperative development of cancer (odds ratio 0.92). Bone morphogenetic protein use was associated with an increase in any complication at 30 days (15.8% vs. 14.9%, p=.0065), which is only statistically significant among multilevel procedures (19.74% vs. 18.02%, p=.0013). Thirty-day complications in multilevel procedures associated with BMP use included new dysrhythmia (4.68% vs. 4.01%, p=.0161) and delirium (1.08% vs. 0.69%, p=.0024). A new diagnosis of chronic pain was associated with BMP use in both single-level (2.74% vs. 2.15%, p=.0019) and multilevel (3.7% vs. 2.52%, p<.0001) procedures. Bone morphogenetic protein was negatively associated with infection in single-level procedures (2.12% vs. 2.64%, p=.0067) and wound dehiscence in multilevel procedures (0.84% vs. 1.18%, p=.0167). ConclusionsIn national data analysis of thoracolumbar procedures, we found that BMP was associated with decreased incidence of revision spinal surgery and with a slight increased risk of overall complications at 30 days. Although no BMP-associated increased risk of malignancy was found, lack of long-term follow-up precludes detection of between-group differences in malignancies and other rare events that may not appear until later.

Surgical correction of scoliosis in children with spastic quadriplegia: benefits, adverse effects, and patient selection.

Study Rationale Cerebral palsy (CP) is a group of nonprogressive syndromes of posture and motor impairment associated with lesions of the immature brain. Spastic quadriplegia is the most severe form with a high incidence of scoliosis, back pain, respiratory compromise, pelvic obliquity, and poor sitting balance. Surgical stabilization of the spine is an effective technique for correcting deformity and restoring sitting posture. The decision to operate in this group of patients is challenging. Objectives The aim of this study is to determine the benefits of surgical correction of scoliosis in children with spastic quadriplegia, the adverse effects of this treatment, and what preoperative factors affect patient outcome after surgical correction. Materials and Methods A systematic review was undertaken to identify studies describing benefits and adverse effects of surgery in spastic quadriplegia. Factors affecting patient outcome following surgical correction of scoliosis were assessed. Studies involving adults and nonspastic quadriplegia were excluded. Results A total of 10 case series and 1 prospective and 3 retrospective cohort studies met inclusion criteria. There was significant variation in the overall risk of complications (range, 10.9−70.9%), mortality (range, 2.8−19%), respiratory/pulmonary complications (range, 26.9−57.1%), and infection (range, 2.5−56.8%). Factors associated with a worse outcome were a significant degree of thoracic kyphosis, days in the intensive care unit, and poor nutritional status. Conclusion Caregivers report a high degree of satisfaction with scoliosis surgery for children with spastic quadriplegia. There is limited evidence of preoperative factors that can predict patient outcome after scoliosis. There is a need for well-designed prospective studies of scoliosis surgery in spastic quadriplegia.

Operative Duration as an Independent Risk Factor for Postoperative Complications in Single-Level Lumbar Fusion

Multicenter retrospective cohort study. To estimate the impact of increasing surgical duration on outcomes after single-level lumbar fusion. Lumbar fusion is a widely used practice for the treatment of disability and chronic low back pain. Longer operative duration is shown to correlate with increased morbidity and mortality in various surgical disciplines, but no large-scale study has been performed to validate this relationship in lumbar spine surgery. The American College of Surgeons National Surgical Quality Improvement Program was retrospectively reviewed to identify all patients who underwent lumbar fusion procedures during 2006 to 2011. Thirty-day morbidity and mortality rates were reported on the basis of operative time, whereas multivariate logistic regression model was used to examine operative duration as an independent risk factor for outcomes. A total of 4588 patients were included in the analysis. The mean operative duration for all patients was 197 ± 105 minutes. Our multivariate risk-adjusted regression models demonstrated that increasing operative time was associated with step-wise increase in risk for overall complications (odds ratio [OR], 2.09-5.73), medical complications (OR, 2.18-6.21), surgical complications (OR, 1.65-2.90), superficial surgical site infection (OR, 2.65-3.97), and postoperative transfusions (OR, 3.25-12.19). Operative duration of 5 hours or more was also associated with increased risk of reoperation (OR, 2.17), organ/space surgical site infection (OR, 9.72), sepsis/septic shock (OR, 4.41), wound dehiscence (OR, 10.98), and deep vein thrombosis (OR, 17.22). Our data suggest that increasing operative duration is associated with a wide array of complications. Operative duration is, therefore, an important quality metric in the performance of lumbar fusion. Strategies to reduce operative time and further research to identify risk factors that are associated with longer surgical duration are needed for improved patient outcomes. 3.

Surgical complications after transsphenoidal microscopic and endoscopic surgery for pituitary adenoma: a consecutive series of 506 procedures

This single-institution, consecutive series of transsphenoidal procedures included all patients in a defined population of 2.6 million inhabitants who underwent surgery during a specific time period. We sought to determine the surgical complication rate and overall survival rate after transsphenoidal surgery for pituitary adenoma. All transsphenoidal procedures for histologically verified pituitary adenomas performed between September 2002 and February 2011 at our institution were included in this study. The data were obtained from a prospectively collected database and from reviewing medical records. No patients were lost to follow-up, and the median follow-up time was 28 months. A total of 506 transsphenoidal procedures were performed on 446 patients. There were 268 microscopic and 238 endoscopic procedures involving 352 non-functioning and 154 hormone-secreting adenomas. A total of 73% of the procedures were primary surgeries, and 27% were repeat surgeries for tumor recurrence. The overall complication rate was 9.1%. The three most frequent complications were cerebrospinal fluid (CSF) leakage (4.7%), meningitis (2%), and visual deterioration (2%). Multivariate analyses showed that the overall risk for complications increased with older age, surgery for recurrent tumors, and surgery performed by a low-volume surgeon. There was no significant difference in the overall complication rate between the microsurgical and endoscopic techniques. The rate of surgical mortality was 0.6%, and the overall survival rates at 1 and 5 years were 95% and 90%, respectively. The only negative predictor of survival was older age. Transsphenoidal surgery for pituitary adenomas has a low complication rate and a low rate of mortality. We did not find a significant difference in the complication rate between endoscopic and microscopic techniques.

Improved perioperative and short-term outcomes of robotic versus conventional laparoscopic colorectal operations

BackgroundRobotic assistance may offer unique advantages over conventional laparoscopy in colorectal operations. MethodsThis prospective observational study compared operative measures and postoperative outcomes between laparoscopic and robotic abdominal and pelvic resections for benign and malignant disease. ResultsFrom 2005 through 2012, 200 (58%) laparoscopic and 144 (42%) robotic operations were performed by a single surgeon. After adjustment for differences in demographics and disease processes using propensity score matching, all laparoscopic operations had a significantly shorter operative time (P < .01), laparoscopic left colectomies had a longer length of hospital stay (2009 and 2010: 6.5 vs 3.6 days, P = .01); and laparoscopic right colectomies had a higher risk for overall complications (P = .03) and postoperative ileus (P = .04). There were no significant differences in the outcomes of pelvic operations (P = .15). ConclusionsCompared with conventional laparoscopy, some types of robotic-assisted colorectal operations may offer advantages regarding postoperative length of stay and perioperative complications.

Computed tomography-guided needle aspiration and biopsy of pulmonary lesions: a single-center experience in 1000 patients

Computed tomography (CT)-guided fine needle aspiration (FNA) and biopsies are well-established, minimally invasive diagnostic tools for pulmonary lesions. To analyze retrospectively the results of 1000 consecutive lung CT-guided FNA and/or core needle biopsies (CNB), the main outcome measures being diagnostic yield, and complication rates. Patients considered eligible were those referred to our department for lung lesions. The choice of FNA, CNB, or both was based upon the radiologist's judgment. Diagnostic yield was defined as the probability of having a definite result by cytology/histology. The study included 733 male patients and 267 female patients, with a mean (SD) age of 66.4 (11.4) years. The mean (SD) lesion size was 3.7 (2.4) cm in maximal diameter. Six hundred and forty-one (64%) patients underwent an FNA procedure, 245 (25%) a CNB, and 114 (11%) had been subjected to both. The diagnostic yield was 960/994 (96.6%); this decreased significantly with the use of CNB only (odds ratio [OR] 0.32; 95% CI 0.12-0.88; P = 0.03), while it increased with lesion size (OR 1.35; 95% CI 1.03-1.79; P = 0.03 per cm increase). In 506 patients (52.7%), a malignant process was diagnosed by cytopathology/histology. The complication rate reached 97/1000 (9.7%); complications included: hemorrhage, 62 (6.2%); pneumothorax, 28 (2.8%); hemorrhage and pneumothorax, 5 (0.5%); and hemoptysis, 2 (0.2%). It was not significantly affected by the type of procedure or localization of the lesion. The overall risk for complications was three times higher for lesions <4 cm (OR 3.26; 95% CI 1.96-5.42; P < 0.001). CT-guided lung biopsy has a high diagnostic yield using FNA, CNB, or both. The CNB procedure alone will not suffice. Complication rates were acceptable and correlated inversely with lesion size, not localization or type of procedure.

Therapeutic Advances in Pancreatic Cancer

Despite our improved understanding of pancreatic cancer biology and ability to perform more complex pancreatic cancer surgeries that produce better short-term outcomes, major progress toward increasing survival times has been painstakingly slow. Through the often-repeated, dismal survival statistics, it is easy to lose sight of real progress that has been made in pancreatic cancer therapy. It is particularly interesting to observe the extent to which these advances are interdependent and the effects they have had on practice. For example, during the past 5-10 years, we have seen widespread adoption of pancreatic imaging protocols that allow for objectively defined criteria of resectability. This has led to the definition of "borderline resectable pancreatic cancer"--a new clinical category that has affected the design of clinical trials. A major change in our surgical approach has been the move to minimally invasive pancreatectomy, which continues to gain broader acceptance and use, particularly for left-sided lesions. Although many new agents have been developed aimed at putative molecular targets, recent breakthroughs in therapy for advanced disease have arisen from our ability to safely give patients combination cytotoxic chemotherapy. We are now faced with the challenge of combining multidrug, cytotoxic chemotherapies with newer-generation agents. Ultimately, the hope is that drug combinations will be selected based on biomarkers, and strategies for pancreatic cancer therapy will be personalized, which could prolong patients' lives and reduce toxicity. We review the major advances in pancreatic cancer therapy during the last 5 years, and discuss how these have set the stage for greater progress in the near future.

Perioperative Dexmedetomidine Improves Outcomes of Cardiac Surgery

Cardiac surgery is associated with a high risk of cardiovascular and other complications that translate into increased mortality and healthcare costs. This retrospective study was designed to determine whether the perioperative use of dexmedetomidine could reduce the incidence of complications and mortality after cardiac surgery. A total of 1134 patients who underwent coronary artery bypass surgery and coronary artery bypass surgery plus valvular or other procedures were included. Of them, 568 received intravenous dexmedetomidine infusion and 566 did not. Data were adjusted with propensity scores, and multivariate logistic regression was used. The primary outcomes measured included mortality and postoperative major adverse cardiocerebral events (stroke, coma, perioperative myocardial infarction, heart block, or cardiac arrest). Secondary outcomes included renal failure, sepsis, delirium, postoperative ventilation hours, length of hospital stay, and 30-day readmission. Dexmedetomidine use significantly reduced postoperative in-hospital (1.23% versus 4.59%; adjusted odds ratio, 0.34; 95% confidence interval, 0.192-0.614; P<0.0001), 30-day (1.76% versus 5.12%; adjusted odds ratio, 0.39; 95% confidence interval, 0.226-0.655; P<0.0001), and 1-year (3.17% versus 7.95%; adjusted odds ratio, 0.47; 95% confidence interval, 0.312-0.701; P=0.0002) mortality. Perioperative dexmedetomidine therapy also reduced the risk of overall complications (47.18% versus 54.06%; adjusted odds ratio, 0.80; 95% confidence interval, 0.68-0.96; P=0.0136) and delirium (5.46% versus 7.42%; adjusted odds ratio, 0.53; 95% confidence interval, 0.37-0.75; P=0.0030). Perioperative dexmedetomidine use was associated with a decrease in postoperative mortality up to 1 year and decreased incidence of postoperative complications and delirium in patients undergoing cardiac surgery. URL: www.clinicaltrials.gov. Unique identifier: NCT01683448.

Surgical Versus Nonsurgical Treatment of Acute Achilles Tendon Rupture

Surgical repair is a common method of treatment of acute Achilles rupture in North America because, despite a higher risk of overall complications, it has been believed to offer a reduced risk of rerupture. However, more recent trials, particularly those using functional bracing with early range of motion, have challenged this belief. The aim of this meta-analysis was to compare surgical treatment and conservative treatment with regard to the rerupture rate, the overall rate of other complications, return to work, calf circumference, and functional outcomes, as well as to examine the effects of early range of motion on the rerupture rate. A literature search, data extraction, and quality assessment were conducted by two independent reviewers. Publication bias was assessed with use of the Egger and Begg tests. Heterogeneity was assessed with use of the I2 test, and fixed or random-effect models were used accordingly. Pooled results were expressed as risk ratios, risk differences, and weighted or standardized mean differences, as appropriate. Meta-regression was employed to identify causes of heterogeneity. Subgroup analysis was performed to assess the effect of early range of motion. Ten studies met the inclusion criteria. If functional rehabilitation with early range of motion was employed, rerupture rates were equal for surgical and nonsurgical patients (risk difference = 1.7%, p = 0.45). If such early range of motion was not employed, the absolute risk reduction achieved by surgery was 8.8% (p = 0.001 in favor of surgery). Surgery was associated with an absolute risk increase of 15.8% (p = 0.016 in favor of nonoperative management) for complications other than rerupture. Surgical patients returned to work 19.16 days sooner (p = 0.0014). There was no significant difference between the two treatments with regard to calf circumference (p = 0.357), strength (p = 0.806), or functional outcomes (p = 0.226). The results of the meta-analysis demonstrate that conservative treatment should be considered at centers using functional rehabilitation. This resulted in rerupture rates similar to those for surgical treatment while offering the advantage of a decrease in other complications. Surgical repair should be preferred at centers that do not employ early-range-of-motion protocols as it decreased the rerupture risk in such patients.

Complications and Reinterventions in Uterine Artery Embolization for Symptomatic Uterine Fibroids: A Literature Review and Meta Analysis

To perform a literature review of the spectrum of complications associated with UAE relative to surgery and compare the risk of reintervention as well as minor, major, and overall complications. Literature review was conducted in PubMed, MEDLINE, Cochrane, and CINAHL databases, and meta-analysis was performed. In randomized clinical trials, common complications were discharge and fever (4.00 %), bilateral uterine artery embolization (UAE) failure (4.00 %), and postembolization syndrome (2.86 %). Two trials showed a significantly decreased risk in major complications with UAE, with odds ratios (ORs) of 0.07143 (0.009426-0.5413) and 0.5196 (0.279-0.9678). None of the trials showed a significant difference in OR for minor complications of UAE. None of the trials showed a significant difference in risk for overall complications of UAE. Three trials showed a significantly increased risk for reintervention with UAE with ORs of 10.45 (2.654-41.14), 2.679 (1.289-5.564), and 9.096 (1.269-65.18). In 76 nonrandomized studies, common complications were amenorrhea (4.26 %), pain (3.59 %), and discharge and fever (3.37 %). In 41 case studies, common complications were discharge and fever (n = 22 cases), repeat UAE (n = 6 cases), and fibroid expulsion (n = 5 cases). Overall, UAE has a significantly lower rate of major complications relative to surgery, but it comes at the cost of increased risk of reintervention in the future. Educating patients about the rate and types of complications of UAE versus surgery, as well as the potential for reintervention, should help the patient and clinician come to a reasoned decision.

IJU this issue

This issue features one Perspective article, one Guideline, four Review Articles, four Original Articles, one Case Report, one Procedure and one Letter to the Editor. In the Perspective, Nishizawa et al. (Matsumoto, Japan) focused on female urology. They described self-tailored mesh in the transvaginal mesh technique for the repair of vaginal prolapse, together with an interesting case. The Guideline is reported by Fujioka et al. (Morioka, Japan). The Japanese Urological Association (JUA) originally published the clinical guideline for renal cell carcinoma in 2007. This time, JUA updated and published the revised version of the guideline in 2011. In this article, they described the main revision points, such as clinical questions. As for the Review Articles, the first Review is on the biology of testicular germ cell tumors. Okamoto (Otsu, Japan) summarized recent research regarding the epigenetics of the tumors in explaining the biological and clinical characteristics of the tumors. The second Review by Kawashima and Nakatani (Osaka, Japan) was on estrogen receptors in benign prostatic hyperplasia and prostate cancer. They summarized the recent data providing evidence for estrogen signaling in the prostate; in particular, the direct action of estrogens through estrogen receptors on prostate cells, including cancer cells. They also discussed estrogen receptor targeted therapy for BPH and prostate cancer. The third Review regards stress urinary incontinence by Yoshimura and Miyazato (Pittsburgh, PA, USA and Okinawa, Japan). They focused on the recent advances in the neurophysiological mechanisms of the lower urinary tract, and discuss the potential targets for pharmacotherapy of stress urinary incontinence. The fourth Review by Shiraishi et al. (Yamaguchi, Japan) is about varicocele in male infertility. They reviewed the pathophysiology of the varicocele, and discussed the indication of varicocelectomy in the era of assisted reproductive technology. Four interesting Original Articles appear in this issue. One is on the prediction of the complication risk of partial nephrectomy. Kong et al. (Shanghai, China) retrospectively analyzed preoperative images and clinical records of 195 renal tumor patients. They reported that preoperative aspects and dimensions used for anatomical classification predicted the risk of overall complications in patients undergoing nephron-sparing surgery. As an Original Article, Sugihara et al. (Tokyo, Japan) reported the characteristics and the therapeutic trends of renal trauma in Japan using a nationwide database. They analyzed 1505 renal trauma cases and they reported that angioembolization failure is not rare, and nephrectomy is still an effective last resort. Neuropeptides and their signaling effects are known to be one of the potent growth stimulators for several cancers. As an Original Article, Tsapakidis et al. (Larissa, Greece) reported the effect of a proteasome inhibitor, bortezomib, in neuropeptides signaling stimulation on prostate cancer cells. They showed that bortezomib blocked the neuropeptide and induced the cell-proliferative and antiapoptotic signaling. Kadekawa et al. (Okinawa, Japan) reported, as an Original Article, the effect of the antimuscarinic agent, propiverine hydrochloride (propiverine), on the bladder and urethra in rats. The mechanism by which antimuscarinic agents improve stress incontinence has not yet been clarified. They concluded that an increase of catecholamines after propiverine treatment might activate smooth muscle of the proximal urethra α1A and α1D adrenergic receptors, as well as activating urethral and pelvic floor striated muscle through the spinal motoneurons. One interesting Case Report and one surgical Procedure also appear in this issue. Atsuta et al. (Kyoto, Japan) reported a case of bilateral idiopathic segmental ureteritis successfully treated by steroid therapy. In the Procedure, Orikasa et al. (Miyagi, Japan) described suprapubic cystostomy drainage after radical prostatectomy, and suggested that urethral catheter-free prostatectomy is a good alternative to that with a urethral Foley catheter. One Letter to the Editor regards population screening for prostate cancer by Van Meerhaeghe and Velkeniers (Brussels, Belgium). None declared.

Total Knee Arthroplasty Has Higher Postoperative Morbidity Than Unicompartmental Knee Arthroplasty: A Multicenter Analysis

A total of 2235 primary total knee arthroplasties (TKAs) and 605 unicompartmental knee arthroplasties performed at 3 institutions over 5 years were reviewed to compare the incidence of postoperative complications between these groups. The overall risk of complications for patients undergoing TKA was 11.0%, compared with 4.3% for patients undergoing unicompartmental knee arthroplasty (P < .0001). Total knee arthroplasty was associated with increased rates of manipulation (odds ratio [OR], 13.0; P < .0001), transfusion (OR, 8.5; P = .036), intensive care unit admission (OR, 7.4; P = .049), discharge to a rehabilitation facility (OR, 5.2; P < .0001) and had longer hospital stays (mean, 3.3 vs 2.0 days; P < .0001). There was a trend toward an increased risk of deep infection (0.8% vs 0.2%, P = .13), readmission (4.2% vs 2.7%, P = .0795), thromboembolic events (1.0% vs 0.64%, P = .398), and any reoperation (1.4% vs 0.6%; P = .064). The increased risk of perioperative complications after TKA should be considered when counseling patients if they are an appropriate candidate for either procedure.

Application of a standardized anatomical classification in a Chinese partial nephrectomy series

Preoperative aspects and dimensions used for an anatomical classification is a standardized system to assess the anatomical complexity of renal tumors and its impact on perioperative outcomes of partial nephrectomy. The objective is to apply the preoperative aspects and dimensions used for an anatomical classification in a series of Chinese patients undergoing open or laparoscopic partial nephrectomy. A total of 195 consecutive renal tumors treated with open partial nephrectomy or laparoscopic partial nephrectomy between June 2008 and May 2011 were included in this analysis. All the preoperative images and clinical records were retrospectively evaluated. Complication rate, warm ischemia time, operation time and degree of blood loss were compared among different risk groups (low risk: preoperative aspects and dimensions used for an anatomical score 6-7; intermediate risk: preoperative aspects and dimensions used for an anatomical score 8-9; high risk: preoperative aspects and dimensions used for an anatomical score ≥10). The original preoperative aspects and dimensions used for an anatomical score system was modified by replacing rim location with hilar vasculature involvement and tested for prediction of overall complications. The median preoperative aspects and dimensions used for an anatomical score was 8. Overall complication rate was 17.9%. Preoperative aspects and dimensions used for an anatomical score was an independent predictor for perioperative complications. Intermediate and high-risk patients had a four- and 37-fold higher risk of complications respectively (P = 0.012, P < 0.001). Higher preoperative aspects and dimensions used for an anatomical score predicted longer operation time (P = 0.007), warm ischemia time (P < 0.001) and higher degree of blood loss (P = 0.003) in open partial nephrectomy patients. In laparoscopic partial nephrectomy patients, preoperative aspects and dimensions used for an anatomical score was also a predictor for warm ischemia time (P = 0.033); however, it was not significant for operation time and degree of blood loss (P = 0.325, P = 0.302). The modified preoperative aspects and dimensions used for an anatomical score was an independent predictor for overall complications (P < 0.001); however, its superiority could not be verified (P = 0.847). The preoperative aspects and dimensions used for an anatomical classification predicts the risk of overall complications in Chinese patients undergoing nephron-sparing surgery. Replacing the rim location with hilar vasculature involvement might be a promising modification of this scoring system.

Medial Achilles tendon island flap—a novel technique to treat reruptures and neglected ruptures of the Achilles tendon

There is a strong consensus for surgical treatment of reruptures and neglected ruptures of the Achilles tendon. A number of different surgical techniques have been described and several of these methods include extensive surgical exposure to the calf and technically demanding tendon transfers. The overall risk of complications is high and in particular the risk for wound healing problems, which are triggered by an increased tension in the skin when inserting a bulky graft to cover the rupture. In order to reduce the risk for wound healing problems a new, less complicated surgical technique was developed, as described in this study. Nine consecutive patients (including six chronic ruptures and three reruptures) with complicating co-morbidities and with a tendon defect between three and eight centimetres were operated upon using the described novel technique. Patient-reported functional outcome was reported after two to eight years. All tendon defects were successfully repaired. Neither early nor late surgical complications occurred. High patient satisfaction was reported for all patients. The new surgical technique with a medial Achilles tendon island flap seems to be safe and results in a good patient reported outcome.

Overweight and obesity knowledge prior to pregnancy: a survey study

BackgroundOverweight and obesity are associated with increased risk for pregnancy complications. Knowledge about increased risks in overweight and obese women could contribute to successful prevention strategies and the aim of this study is to assess current levels of knowledge in a pregnant population.MethodsCross sectional survey of 412 consecutive unselected women in early pregnancy in Brisbane, Australia: 255 public women attending their first antenatal clinic visit and 157 women at private maternal fetal medicine clinics undergoing a routine ultrasound evaluation prior to 20 weeks gestation. The cohort was stratified according to pre pregnancy BMI (< 25.0 or ≥ 25.0). The main outcome measure was knowledge regarding the risks of overweight and obesity in pregnancy.ResultsOver 75% of respondents identified that obese women have an increased risk of overall complications, including gestational diabetes and hypertensive disorders of pregnancy compared to women of normal weight. More than 60% of women asserted that obesity would increase the risk of caesarean section and less than half identified an increased risk of adverse neonatal outcomes. Women were less likely to know about neonatal complications (19.7% did not know about the effect of obesity on these) than maternal complications (7.4%). Knowledge was similar amongst women recruited at the public hospital and those recruited whilst attending for an ultrasound scan at a private clinic. For most areas they were also similar between women of lower and higher BMI, but women with BMI < 25.0 were less likely to know that obesity was associated with increased rate of Caesarean section than those with higher BMI (16.8% versus 4.5%, P < 0.001). Higher educational status was associated with more knowledge of the risks of overweight and obesity in pregnancy.ConclusionsMany women correctly identify that overweight and obesity increases the overall risk of complications of pregnancy and childbirth. The increased risks of maternal complications associated with being obese are better known than the increased risk of neonatal complications. Maternal education status is a main determinant of the extent of knowledge and this should be considered when designing education campaigns.

Laparoscopic entry: a review of Canadian general surgical practice

Laparoscopic surgery has gained popularity over open conventional surgery as it offers benefits to both patients and health care practitioners. Although the overall risk of complications during laparoscopic surgery is recognized to be lower than during laparotomy, inadvertent serious complications still occur. Creation of the pneumoperitoneum and placement of laparoscopic ports remain a critical first step during endoscopic surgery. It is estimated that up to 50% of laparoscopic complications are entry-related, and most injury-related litigations are trocar-related. We sought to evaluate the current practice of laparoscopic entry among Canadian general surgeons.We conducted a national survey to identify general surgeon preferences for laparoscopic entry. Specifically, we sought to survey surgeons using the membership database from the Canadian Association of General Surgeons (CAGS) with regards to entry methods, access instruments, port insertion sites and patient safety profiles. Laparoscopic cholecystectomy was used as a representative general surgical procedure.The survey was completed by 248 of 1000 (24.8%) registered members of CAGS. Respondents included both community and academic surgeons, with and without formal laparoscopic fellowship training. The demographic profile of respondents was consistent nationally. A substantial proportion of general surgeons (> 80%) prefer the open primary entry technique, use the Hasson trocar and cannula and favour the periumbilical port site, irrespective of patient weight or history of peritoneal adhesions. One-third of surgeons surveyed use Veress needle insufflation in their surgical practices. More than 50% of respondents witnessed complications related to primary laparoscopic trocar insertion.General surgeons in Canada use the open primary entry technique, with the Hasson trocar and cannula applied periumbilically to establish a pneumoperitoneum for laparoscopic surgery. This surgical approach is remarkably consistent nationally, although considerably variant across other surgical subspecialties. Peritoneal entry remains an important patient safety issue that requires ongoing evaluation and study to ensure translation into safe contemporary clinical practice.

Additive Risk of Tumescent Technique in Patients Undergoing Mastectomy with Immediate Reconstruction

The potential advantages of tumescent mastectomy technique have been increasingly discussed within the literature. However, there is concern that tumescent solution may also affect postoperative complication rates. This study evaluates patient outcomes following tumescent mastectomy and immediate implant reconstruction. Retrospective review of 897 consecutive patients (1,217 breasts) undergoing mastectomy with immediate implant reconstruction between 4/1998 and 10/2008 at a single institution was performed. Demographic and operative factors, postoperative outcomes, and overall follow-up were recorded. Complications were categorized by type and end-outcome. Fisher's exact test, Student t-test, and multiple linear regression were used for statistical analysis. Tumescent (n = 332, 457 breasts) and nontumescent (n = 565, 760 breasts) patients were clinically similar. Mean follow-up was 36.5 months. Regression analysis demonstrated that tumescent technique increased the risk of overall complications [odds ratio (OR) 1.36, 95% confidence interval (CI) 1.02-1.81, p = 0.04]. In particular, nonoperative and operative complications (OR 1.53, 95% CI 1.04-2.26, p = 0.04; OR 1.58, 95% CI 1.11-2.23, p = 0.01, respectively), and the rate of major mastectomy flap necrosis (OR 1.57, 95% CI 1.05-2.35, p = 0.03) were significantly affected. In patients with other, more significant risk factors, tumescent technique had an additive effect on complication rates. Additionally, the majority of tumescent breast complications (78.6%, 81/103) had at least one other significant risk factor. Our review demonstrates that tumescent mastectomy with immediate implant reconstruction, although possessing distinct advantages, can increase postoperative complication rates. This additive effect is particularly apparent in patients with elevated complication risk at baseline. Choice of mastectomy technique should be made with careful consideration of patient comorbidities.

Radioembolization Complicated by Dissection of the Common Femoral Artery

The common femoral artery is the most frequently used access site for angiographic procedures in interventional radiology. Potential complications of common femoral arteriotomy include hematoma formation, pseudoaneurysm, uncontrolled groin or retroperitoneal bleeding, acute arterial occlusion, dissection, and arteriovenous fistula formation. In a case such as the one described here, with a common femoral artery dissection with intraluminal thrombus and vessel occlusion, the complication may have occurred at the time of access or at the time of closure, with both procedure-associated and patient-specific risk factors affecting the overall risk of complications. Though some studies have shown an increased risk of complications with the use of arterial closure devices, others have found no increase. In any patient with symptoms following a femoral arteriotomy, rapid diagnosis and treatment is necessary to avoid further complications. Both patient-specific and procedure-associated risk factors should be considered prior to arteriotomy and usage of an arterial closure device.