Perioperative Surgical Complications Research Articles

Preoperative Mental Health Disorders Affect Opioid Consumption and Perioperative Complications After Total Shoulder Arthroplasty.

Limited evidence exists regarding the influence of mental health disorders (MHDs) on opioid use and complications after total shoulder arthroplasty (TSA). We aimed to identify the prevalence of common MHDs among patients undergoing anatomic TSA (aTSA) and reverse TSA (rTSA). The Premier Healthcare Database was queried for patients undergoing primary aTSA and rTSA from 2016 to 2020. International Classification of Diseases, Tenth Revision, diagnosis codes were used to identify MHDs. Primary outcomes included the prevalence of MHDs, perioperative opioid consumption, and 90-day risk of postoperative complications, revision, and readmission. Bivariate and multivariate regression analyses were performed to assess 90-day risk of primary endpoints while controlling for potential confounders. Statistical significance was defined as P<.05. From 2016 to 2020, 49,997 of 144,725 (34.55%) patients undergoing primary TSA had at least one diagnosed MHD. The most prevalent were depression (17.03%), anxiety (16.75%), and substance use disorder (10.20%). Patients with a MHD had higher mean hospital costs ($75,984±$43,129 vs $73,316±$39,046, P<.0001), longer mean length of stay (1.95±2.25 days vs 1.61±1.51 days, P<.0001), and higher mean total postoperative opioid use (72.00±231.55 morphine milligram equivalents [MMEs] vs 59.32±127.31 MMEs, P<.0001). Periprosthetic fractures (odds ratio, 1.20; P=.041), dislocation (odds ratio, 1.12; P=.042), and 90-day readmission rates (odds ratio, 1.26; P<.001) were significantly higher among patients with a MHD. This study found that MHDs are associated with significantly increased perioperative opioid consumption, medical and surgical complication rates, and risk of readmission after TSA. Recognition and optimization of MHDs is critical to minimizing complications and opioid consumption after TSA. [Orthopedics. 202x;4x(x):xx-xx.].

Transsphenoidal Approach for Pituitary Macroadenoma: Complications

Transsphenoidal surgery (TSS) is a popular method for resecting pituitary tumors, but it has been associated with severe consequences such as perioperative medical issues, endocrine problems, and surgical complications. The pituitary gland, a bilobed endocrine organ, contains eight hormones and is surrounded by the sella turcica, tuberculum sellae, dorsum sellae, and cavernous sinus dura. The gland's structure is complex, with the optic chiasm and sphenoid sinus being significant structures. The sphenoid sinus, which grows with age and has variable septal and cavitary architecture, can make the transsphenoidal approach more difficult to perform in cases of bleeding, vision loss, or cranial nerve palsy. Understanding the anatomy of the sphenoid sinus is crucial for a safe sellar approach and tumor removal. The operative microscope introduced in the 1960s has further improved surgical outcomes with low morbidity and mortality rates. Pituitary adenomas are extra-arachnoidal tumors that develop outside the boundaries of the cerebrospinal fluid (CSF). They can cause iatrogenic leaks if the arachnoid membrane is ruptured and a cerebrospinal fluid fistula is introduced. Delayed postoperative epistaxis can result from the sphenopalatine artery and the intracavernous internal carotid artery (ICA). Loss of vision can result from physical injuries to the optic nerves or chiasm, which can occur at multiple stages of the operation. Other causes include cerebral vasospasm, traction injury, empty sella syndrome with chiasm prolapse, ophthalmoplegia, and internal injuries to the carotid artery. Injuries to the sphenoid sinus, including proximity to essential tissues, thin or absent bone, and loss of bone, increase the risk of iatrogenic injury. Packing is the initial therapy, and postoperative angiography should be performed afterward. Embolization is considered in situations where packing is inadequate or when there is development to pseudo-aneurysms or carotid cavernous fistulae. Chronic Insipidus Diabetes (DI) is a common disturbance in patients following transsphenoidal surgery (TSS), causing water and electrolyte problems. DI can manifest in various clinical patterns, including transitory, permanent, and triphasic phenotypes. Postoperative syndrome of antidiuretic hormone secretion (SIADH) is also a risk factor, with hyponatremia often delayed and symptomatic. Improved or newly developed hypopituitarism is a risk, with the hypothalamic-pituitary-adrenal (HPA) axis being the most susceptible. Transcranial procedures with HPA or other axis deficits may cause damage to normal residual glands, especially in large tumors. Transsphenoidal techniques can mitigate the risk of dissecting an attenuated gland, but understanding pituitary physiology and sellar anatomy is crucial for improving the procedure and encouraging innovation. Transcranial procedures have a low death rate and risk of significant impairment, but understanding the underlying medical, endocrine, and surgical consequences is essential for successful PA excision.

Clinical Analysis of the Efficacy and Safety of Different Neoadjuvant Strategies in the Treatment of Locally Advanced Rectal Cancer

Objective In this study, we retrospectively analysed the efficacy and safety of three treatment models, namely, short-course radiotherapy sequential XELOX chemotherapy, neoadjuvant mFOLFOX6 concurrent radiotherapy and long-course concurrent radiotherapy with total mesorectal excision (TME) after treatment of locally advanced rectal cancer with high-risk factors. Methods We collected clinical data on 177 patients with locally advanced rectal cancer (cT3-4 and/or cN+) who were treated at the Department of Abdominal Oncology of the Affiliated Cancer Hospital of Guizhou Medical University from December 2017 to December 2022. All patients were associated with 2-3 risk factors [T4b, N2, Extramural Vascular Invasion (EMVI), Mesorectal Fascia (MRF) positivity], positive lateral lymph nodes. Among them, there were 45 cases in the short course radiotherapy sequential XELOX chemotherapy group (RT + XELOX group); 64 cases in the neoadjuvant mFOLFOX6 concurrent radiotherapy group (mFOLFOX6 + CRT group); and 68 cases in the long course concurrent radiotherapy group (CRT group). The RT + XELOX group and mFOLFOX6 + CRT group completed radiotherapy and 4 cycles of neoadjuvant chemotherapy, respectively, and then rested for 1-2 weeks before TME surgery; the CRT group completed concurrent radiotherapy and then rested for 6-8 weeks before TME surgery.Adjuvant chemotherapy was conducted after surgery in each of the three groups: 2 cycles of adjuvant chemotherapy with XELOX regimen in the RT + XELOX group, 4-6 cycles of adjuvant chemotherapy with mFOLFOX6 in the mFOLFOX6 + CRT group, and 8-12 cycles of adjuvant chemotherapy with mFOLFOX6 in the CRT group.The pathological complete response rate (pCR rate), tumour downstage rate, tumour complete resection rate (R0 resection rate), local recurrence rate, distant metastasis rate, overall survival rate, incidence of adverse reactions, surgical complications and completion rate of perioperative systemic chemotherapy were compared among patients in the three groups of cases after TME. Results The pCR rate (21.95% vs 17.24% vs 5.00%, p = 0.034) and and tumour downstage rate (78.05% vs 68.97% vs 53.33%, p = 0.029) were higher in the RT + XELOX group and mFOLFOX6 + CRT group compared to the CRT group. The RT + XELOX group had a lower 3-year distant metastasis rate (14.63% vs 36.67%, p = 0.048) and improved 3-year overall survival (76.57% vs 48.56%, p < 0.001) compared to the CRT group. There was no significant reduction in the 3-year distant metastasis rate in the mFOLFOX6 + CRT group versus the CRT group (27.59% vs 36.67%, p = 0.719), and the 3-year overall survival was similar (51.23% vs 48.56%, p = 0.35). Multi-logistic regression analysis and stratified analysis showed that patients in the RT + XELOX group and mFOLFOX6 + CRT group were more likely to achieve pCR than the CRT group (RT + XELOX group: OR 7.3, 95% CI [2.6-20.8], p < 0.001; mFOLFOX6 + CRT group OR 2.9, 95% CI [1.1-7.9], p = 0.036). The completion rates of perioperative systemic chemotherapy in the RT + XELOX, mFOLFOX6 + CRT, and CRT groups were 82.93% vs. 84.48% vs. 61.67% (χ2=9.95, p = 0.007), respectively. And there were significant differences in grade 3-4 leukopenia and thrombocytopenia (incidence of leukopenia: 15.50% vs. 7.81% vs. 1.47%, p = 0.045; incidence of thrombocytopenia: 13.33% vs 7.81% vs 1.47%, p = 0.027). There was no significant difference in the incidence of intraoperative and postoperative complications among the three groups (p > 0.05). Conclusions RT + XELOX group and mFOLFOX6 + CRT group significantly improved the near-term outcome (e.g., pCR rate) in patients with locally advanced rectal cancer with high-risk factors compared with CRT group. The RT + XELOX group also reduced the 3-year distant metastasis rate, increased the 3-year overall survival rate, and did not increase the incidence of perioperative surgical complications. It provides an effective means for the comprehensive treatment of locally advanced rectal cancer and has important clinical guidance and application value.

Impact of Depression on Postoperative Medical and Surgical Outcomes in Spine Surgeries: A Systematic Review and Meta-Analysis.

Introduction: The relationship between psychiatric disorders, including depression, and invasive interventions has been a topic of debate in recent literature. While these conditions can impact the quality of life and subjective perceptions of surgical outcomes, the literature lacks consensus regarding the association between depression and objective perioperative medical and surgical complications, especially in the neurosurgical domain. Methods: MEDLINE (PubMed), EMBASE, PsycINFO, and the Cochrane Library were queried in a comprehensive manner from inception until 10 November 2023, with no language restrictions, for citations investigating the association between depression and length of hospitalization, medical and surgical complications, and objective postoperative outcomes including readmission, reoperation, and non-routine discharge in patients undergoing spine surgery. Results: A total of 26 articles were considered in this systematic review. Upon pooled analysis of the primary outcome, statistically significantly higher rates were observed for several complications, including delirium (OR:1.92), deep vein thrombosis (OR:3.72), fever (OR:6.34), hematoma formation (OR:4.7), hypotension (OR:4.32), pulmonary embolism (OR:3.79), neurological injury (OR:6.02), surgical site infection (OR:1.36), urinary retention (OR:4.63), and urinary tract infection (OR:1.72). While readmission (OR:1.35) and reoperation (OR:2.22) rates, as well as non-routine discharge (OR:1.72) rates, were significantly higher in depressed patients, hospitalization length was comparable to non-depressed controls. Conclusions: The results of this review emphasize the significant increase in complications and suboptimal outcomes noted in patients with depression undergoing spinal surgery. Although a direct causal relationship may not be established, addressing psychiatric aspects in patient care is crucial for providing comprehensive medical attention.

Robotic-Assisted Laparoscopic Pyeloplasty in Challenging Cases of Ureteropelvic Junction Obstruction in the Pediatric Population: A Multicenter Review.

Purpose: To report a multi-institutional international experience in performing robotic pyeloplasty for complicated cases of ureteropelvic junction obstruction (UPJO) in the pediatric population and assess feasibility and outcomes. Materials and Methods: Retrospective chart review of all pediatric patients who underwent robotic-assisted laparoscopic pyeloplasty (RALP) for UPJO in challenging cases between 2013 and 2021 was included. Demographics, perioperative surgical data, complications, and results are described. Challenging cases were defined as bilateral UPJO, failure of previous open pyeloplasty (thus re-do cases), correction of UPJO in kidneys with anatomical variations, huge hydronephrosis, and low-weight infants (<6 kg). Results: Over an 8-year period, 36 children (62% males and 38% females) met the inclusion criteria for our study. Fifteen patients underwent RALP for recurrent UPJO; among them, 2 children required simultaneous surgery for renal stones, 3 cases of lower pole UPJO in double collecting system, 3 cases of pelvic and horseshoe kidneys, 10 cases of infants weighing <6 kg, 3 cases of huge hydronephrosis, and 2 cases of bilateral UPJO. The median age and weight were 36 months (interquartile range [IQR] 14-84) and 12 kg (IQR 10-20.5), respectively. All robotic cases were completed successfully with no conversion to an open procedure. The median operative time was 120 minutes (IQR 90-135). The mean length of hospital stay was 2.6 days. Four patients (17%) had postoperative complications-1 ileus (Clavien-Dindo grade [CDG] I) and 3 urinary tract infections (CDG II). No CDG III or higher complication was encountered. At a median follow-up of 36 months, the success rate was 95% with 1 patient requiring another re-do procedure due to recurrent obstruction. Conclusions: Our data suggest that RALP is safe and effective even for challenging cases of UPJO in children.

Perioperative Management of 6-way Simultaneous Paired Kidney Exchange Transplantation – An Observational Study

Objective: The presence of donor-specific antigens (human leukocyte antigen [HLA] incompatibility) leads to positive T-cell or B-cell crossmatch. Kidney transplant after desensitization protocols not only poses a financial burden on the patients but also there is an increased rate of infections and graft rejection. Paired kidney exchange (PKE) is cost-effective and offers better postoperative graft outcome. Methods: We included six pairs of kidney transplant donors and recipients for 6-way simultaneous PKE transplantation. These patients were ABO incompatible or HLA incompatible or both. Results: All patients underwent transplant in a single day without any perioperative surgical and anesthesia complications except for the need of mechanical ventilation in one patient in the postoperative care unit. The graft function was excellent in all recipients. Conclusion: This is the first 6-way simultaneous kidney exchange transplantation in the northwestern region of India. The inclusion of multiple donors and recipients for a paired exchange kidney transplant, although challenging, increases the donor pool and decreases the waiting time and financial constraints.

Clinical Outcomes of Transaxillary Reverse-Sequence Endoscopic Nipple-Sparing Mastectomy and Direct-to-Implant Prepectoral Breast Reconstruction: A Prospective Study of Initial 68 Procedures.

Minimal access breast surgery improves cosmetic outcomes over conventional breast surgery but still faces barriers in becoming standard procedure for breast reconstruction. This report introduces a novel technique of transaxillary reverse-sequence endoscopic nipple-sparing mastectomy (R-E-NSM) followed by direct-to-implant prepectoral breast reconstruction (DTI-PBR) and describes its clinical outcomes. This prospective study enrolled patients who underwent R-E-NSM and DTI-PBR from March 2021 to December 2021 at a single institution. Perioperative data, surgical complications, oncologic outcomes, and patient- and surgeon-reported cosmetic results were noted. The 60 patients in this study who underwent 68 R-E-NSM and DTI-PBR had a mean age was 40.4 ± 10.3 years. The average durations of uni- and bilateral operations were 156.5 ± 48.3 min and 191.3 ± 36.1 min, respectively. The overall surgical complication rate was 13.3%, including 10.0% of patients with minor complications and 3.3% of patients with major complications. The study had one case (1.7%) of implant loss and one case (1.7%) of skin flap necrosis treated by reoperation. During the median follow-up period of 24 months, one patient (1.7%) who discontinued chemotherapy for myelosuppression experienced liver metastases 5months postoperatively, and one patient experienced new-onset contralateral ductal carcinoma in situ 24 months postoperatively. The preoperative and 18-month postoperative Breast-Q scores for satisfaction with breasts, psychosocial well-being, sexual well-being, and chest well-being did not differ significantly, and the Scar-Q was 81.2 ± 14.5 points. The good-to-excellent rate in surgeon-reported cosmetic results reached 90%. Transaxillary R-E-NSM followed by DTI-PBR is a safe and efficient technique with high cosmetic outcomes and reliable medium-term oncologic results.

Surgical outcomes of cytoreductive nephrectomy in patients receiving systemic immunotherapy for advanced renal cell carcinoma

PurposeThe use of systemic immune checkpoint blockade before surgery is increasing in patients with metastatic renal cell carcinoma, however, the safety and feasibility of performing consolidative cytoreductive nephrectomy after the administration of systemic therapy are not well described. Patients and MethodsA retrospective review of patients undergoing nephrectomy was performed using our prospectively maintained institutional database. Patients who received preoperative systemic immunotherapy were identified, and the risk of postoperative complications were compared to those who underwent surgery without upfront systemic treatment. Perioperative characteristics and surgical complications within 90 days following surgery were recorded. ResultsOverall, we identified 220 patients who underwent cytoreductive nephrectomy from April 2015 to December 2022, of which 46 patients (21%) received systemic therapy before undergoing surgery. Unadjusted rates of surgical complications included 20% (n = 35) in patients who did not receive upfront systemic therapy and 20% (n = 9) in those who received upfront systemic immunotherapy. In our propensity score analysis, there was no statistically significant association between receipt of upfront immunotherapy and 90-day surgical complications [odds ratio (OR): 1.82, 95% confidence interval (CI): 0.59–5.14; P = 0.3]. This model, however, demonstrated an association between receipt of upfront immunotherapy and an increased odds of requiring a blood transfusion [OR: 4.53, 95% CI: 1.83–11.7; P = 0.001]. ConclusionIn our cohort, there was no significant difference in surgical complications among patients who received systemic therapy before surgery compared to those who did not receive upfront systemic therapy. Cytoreductive nephrectomy is safe and with low rates of complications following the use of systemic therapy.

Robotic posterior retroperitoneal adrenalectomy versus laparoscopic posterior retroperitoneal adrenalectomy: outcomes from a pooled analysis.

The comparative advantages of robotic posterior retroperitoneal adrenalectomy (RPRA) over laparoscopic posterior retroperitoneal adrenalectomy (LPRA) remain a topic of ongoing debate within the medical community. This systematic literature review and meta-analysis aim to assess the safety and efficacy of RPRA compared to LPRA, with the ultimate goal of determining which procedure yields superior clinical outcomes. A systematic search was conducted on databases including PubMed, Embase, Web of Science, and the Cochrane Library database to identify relevant studies, encompassing both randomized controlled trials (RCTs) and non-RCTs, that compare the outcomes of RPRA and LPRA. The primary focus of this study was to evaluate perioperative surgical outcomes and complications. Review Manager 5.4 was used for this analysis. The study was registered with PROSPERO (ID: CRD42023453816). A total of seven non-RCTs were identified and included in this study, encompassing a cohort of 675 patients. The findings indicate that RPRA exhibited superior performance compared to LPRA in terms of hospital stay (weighted mean difference [WMD] -0.78 days, 95% confidence interval [CI] -1.46 to -0.10; p = 0.02). However, there were no statistically significant differences observed between the two techniques in terms of operative time, blood loss, transfusion rates, conversion rates, major complications, and overall complications. RPRA is associated with a significantly shorter hospital stay compared to LPRA, while demonstrating comparable operative time, blood loss, conversion rate, and complication rate. However, it is important to note that further research of a more comprehensive and rigorous nature is necessary to validate these findings. https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=453816, identifier CRD42023453816.

Endoscopic Lung Volume Reduction Prior to Lung Transplantation Does Not Increase Postoperative Pulmonary Complications

Introduction: Lung transplantation (LTx) remains the only therapeutic option for selected patients with end-stage lung disease. In comparison to surgical lung volume reduction, few data exist on the risks and benefits of pretransplant endoscopic lung volume reduction (eLVR). Here, we investigate the risk of postoperative pulmonary complications (PPCs) after LTx in patients with emphysematous lung disease bridged with eLVR until transplantation. Methods: Eighty-two patients with emphysematous lung disease who underwent double-LTx (DLTx) were included and retrospectively evaluated. Statistical analysis was performed using SPSS and GraphPad Prism software. Results: 28/82 patients underwent eLVR prior to DLTx. eLVR patients spent comparable time on the waitlist; however, they were older at the time of DLTx (median 60 vs. 58 years, p = 0.02). Both groups showed comparable 90-day (92%) and long-term survival (eLVR 1-/5-/10-year survival: 92/88/77%, vs. control: 89/77/67%, p = 0.5). The odds for PPCs were similar in patients with and without eLVR (OR 0.7; 95% CI: 0.3–1.7), as well as major perioperative surgical and cardiovascular complications. In the entire cohort, we found ≥1 PPC to be a risk factor for death within 90 days (OR 9.7, 95% CI: 1.3–110). Among the PPCs, pneumonia (HR 4.6 95% CI: 1.1–14.9, p = 0.02) and ARDS (HR 11.2 95% CI: 1.6–229.2, p = 0.04) were identified as independent risk factors for reduced long-term survival. Conclusions: eLVR does not increase the risk for PPCs, surgical complications, or reduced survival after LTx in patients with emphysematous lung disease and can serve as a bridge to LTx.

Reducing rate of total colectomies for ulcerative colitis but higher morbidity in the biologic era: an 18-year linked data study from New South Wales Australia.

This study aims to investigate the trends in UC surgery in New South Wales (NSW) at a population level. A retrospective data linkage study of the NSW population was performed. Patients of any age with a diagnosis of UC who underwent a total abdominal colectomy (TAC) ± proctectomy between Jul-2001 and Jun-2019 were included. The age adjusted population rate was calculated using Australian Bureau of Statistics data. Multivariable linear regression modelled the trend of TAC rates, and assessed the effect of infliximab (listed on the Pharmaceutical Benefits Scheme for UC in Apr-2014). A total of 1365 patients underwent a TAC ± proctectomy (mean age 47.0 years (±18.6), 59% Male). Controlling for differences between age groups, the annual rate of UC TACs decreased by 2.4% each year (95% CI 1.4%-3.4%) over the 18-year period from 1.30/100000 (2002) to 0.84/100000 (2019). An additional incremental decrease in the rate of TACs was observed after 2014 (OR 0.83, 95% CI 0.69-1.00). There was no change in the proportion of TACs performed emergently over the study period (OR 1.02, 95% CI 0.998-1.04). The odds of experiencing any perioperative surgical complication (aOR 1.54, 95% CI 1.01-2.33, P = 0.043), and requiring ICU admission (aOR 1.85, 95% CI 1.24-2.76, P = 0.003) significantly increased in 2014-2019 compared to 2002-2007. The rate of TACs for UC has declined over the past two decades. This rate decrease may have been further influenced by the introduction of biologics. Higher rates of complications and ICU admissions in the biologic era may indicate poorer patient physiological status at the time of surgery.

Comparison of oxybuprocaine and lidocaine topical anesthesia for pain control in radiofrequency ablation treatment of great saphenous vein insufficiency.

Topical anesthetics have been used for radiofrequency ablation of great saphenous vein insufficiency. A total of 74 patients with great saphenous vein insufficiency treated at our center between February 2021 and August 2022 were enrolled. The patients were selected and divided into an oxybuprocaine group(n = 30) and a lidocaine group (n = 44). The visual analogue scale (VAS) was used to evaluate intraoperative and postoperative pain. Patient satisfaction with anesthesia, maintenance time of anesthesia, and disturbance of the surgeons were also recorded and assessed. The VAS scores and other indices of the 2 groups were compared to assess the effectiveness of anesthesia. Perioperative surgical complications and painkiller use were also recorded. The median VAS score of the patients during the process was 2 in both groups, and the difference between the groups was not statistically significant. In the 2 groups, 93.33% of the patients in the oxybuprocaine group and 93.18% of the patients in the lidocaine group were satisfed with the anesthesia. Nine patients in the lidocaine group and 14 in the oxybuprocaine group received additional anesthetic drugs. The average maintenance time of anesthesia was longer in the lidocaine group. No serious complications occurred in either of the groups. Both oxybuprocaine and lidocaine topical anesthesia combined with tumescent anesthesia could provide effective pain control in radiofrequency ablation treatment of great saphenous vein insufficiency. Although the average maintenance time of anesthesia was longer in the lidocaine group, there was no difference in the associated complications and pain control.

Patients with Acute Limb Ischemia Might Benefit from Endovascular Therapy-A 17-Year Retrospective Single-Center Series of 985 Patients.

Acute lower limb ischemia (ALI) is a common vascular emergency, requiring urgent revascularization by open or endovascular means. The aim of this retrospective study was to evaluate patient demographics, treatment and periprocedural variables affecting the outcome in ALI patients in a consecutive cohort in a tertiary referral center. Primary outcome events (POE) were 30-day (safety) and 180-day (efficacy) combined mortality and major amputation rates, respectively. Secondary outcomes were perioperative medical and surgical leg-related complications and the 5-year combined mortality and major amputation rate. Statistical analysis used descriptive and uni- and multivariable Cox regression analysis. In 985 patients (71 ± 9 years, 56% men) from 2004 to 2020, the 30-day and 180-day combined mortality and major amputation rates were 15% and 27%. Upon multivariable analysis, older age (30 d: aHR 1.17; 180 d: 1.27) and advanced Rutherford ischemia stage significantly worsened the safety and efficacy POE (30 d: TASC IIa aHR 3.29, TASC IIb aHR 3.93, TASC III aHR 7.79; 180 d: TASC IIa aHR 1.97, TASC IIb aHR 2.43, TASC III aHR 4.2), while endovascular treatment was associated with significant improved POE after 30 days (aHR 0.35) and 180 days (aHR 0.39), respectively. Looking at five consecutive patient quintiles, a significant increase in endovascular procedures especially in the last quintile could be observed (17.5% to 39.5%, p < 0.001). Simultaneously, the re-occlusion rate as well as the number of patients with any previous revascularization increased. In conclusion, despite a slightly increasing early re-occlusion rate, endovascular treatment might, if possible, be favorable in ALI treatment.

The Increasing Burden of Depression in Patients Undergoing Head and Neck Cancer Operations.

Depression remains prevalent in patients undergoing head and neck cancer (HNCA) operations. The present study aimed to assess the impact of depression on perioperative and readmission outcomes following HNCA resection. All elective hospitalizations involving HNCA resection were identified from the 2010-2019 Nationwide Readmissions Database. Patients were stratified by history of depression. To perform risk-adjustment in assessing perioperative and readmission outcomes, 3:1 nearest neighbor matching was performed. A subpopulation analysis was also conducted to assess interval development of depression in the postoperative period. Of an estimated 133,018 patients undergoing HNCA operations, 8.9% (n = 11,855) had comorbid depression. Over the decade-long study period, the prevalence of depression in this population increased (7.8% in 2010 vs. 10.0% in 2019, NPTrend<0.001). Among 24,938 propensity matched patients, those with depression had similar incidence of in-hospital mortality (0.4 vs. 0.7%, p = 0.14) as well as perioperative medical (22.0 vs. 21.9%, p = 0.93) and surgical (10.2 vs. 10.3, p = 0.84) complications, though had higher rates of non-home discharge (16.9 vs. 13.5%, p < 0.001) and 30-day readmission (13.6 vs. 11.8%, p = 0.030). Predictors of depression in the postoperative period included primary coverage by Medicare or Medicaid as well as comorbid anxiety or drug use disorder. The prevalence of depression in HNCA patients continues to increase. Although depression was not associated with increased in-hospital mortality and complications, it did impact rates of rehospitalization as well as non-routine discharge. Screening and therapeutic interventions addressing such postoperative events may serve to improve long-term clinical and financial outcomes in this at-risk population. 3-Retrospective cohort study Laryngoscope, 133:3396-3402, 2023.

Double barrelled uro-colostomy versus Ileal conduit for urinary diversion following pelvic exenteration: a single centre experience.

The ideal method for urinary diversion following total pelvic exenteration (TPE) remains unclear. This study compares the outcomes of double-barrelled uro-colostomy (DBUC) and ileal conduit (IC) in a single Australian centre. All consecutive patients who underwent pelvic exenteration with the formation of either a DBUC or an IC between 2008 and November 2022 were identified from the prospective database from the Royal Adelaide Hospital and St. Andrews Hospital. Demographic, operative characteristics, general perioperative, long-term urological and other relevant surgical complications were compared via univariate analyses. Of 135 patients undergoing exenteration, 39 patients were eligible for inclusion: 16 patients with a DBUC, and 23 patients with an IC. More patients in the DBUC group had previous radiotherapy (93.8% vs. 65.2%, P = 0.056) and flap pelvic reconstruction (93.7% vs. 45.5%, P = 0.002). The rate of ureteric stricture trended higher in the DBUC group (25.0% vs. 8.7%, P = 0.21), but in contrast, urine leak (6.3% vs. 8.7%, P>0.999), urosepsis (43.8% vs. 60.9%, P = 0.29), anastomotic leak (0.0% vs. 4.3%, P>0.999), and stomal complications requiring repair (6.3% vs. 13.0%, P = 0.63) trended lower. These differences were not statistically significant. Rates of grade III or greater complications were similar; however, no patients in the DBUC group died within 30-days or had grade IV complications requiring ICU admission compared with two deaths and one grade IV complication in the IC group. DBUC is a safe alternative to IC for urinary diversion following TPE, with potentially fewer complications. Quality of life and patient-reported outcomes are required.

Postoperative Outcomes of Femoral Neck Fracture Management in Dialysis-Dependent Patients

AbstractFemoral neck fractures are common in patients with chronic kidney disease (CKD) due to abnormalities of bone metabolism. In patients on dialysis, femoral neck fractures have been shown to occur at a younger age than in nondialysis patients. The purpose of this study was to compare the associated complication rates of femoral neck fractures among dialysis patients treated with total hip arthroplasty (THA) versus hemiarthroplasty (HA) as well as evaluate for any differences in outcomes compared to the nondialysis patient population. This was a retrospective cohort study performed using the National Surgical Quality Improvement Program database that included 54,328 patients with femoral neck fractures managed surgically from 2006 to 2016. One-thousand seventy patients were identified as dialysis-dependent. Demographics, medical comorbidities, perioperative complication rates, and mortality rates were collected. Data was first analyzed descriptively and with analysis of variance or chi-squared analyses as appropriate. Odds ratios were then calculated for perioperative outcomes and complications. Femoral neck fractures in patients on dialysis occurred at a significantly younger age (73.3 vs. 77.0, p &lt; 0.001) than nondialysis patients. In dialysis patients who underwent THA, complication rates, postoperative length of stay, readmission rates, and 1-year mortality were greater when compared to nondialysis patients. There were no significant differences in perioperative medical or surgical complication rates within the dialysis population when comparing THA to HA. Dialysis patients treated with THA for femoral neck fracture experience more complications compared to nondialysis patients. However, among dialysis patients treated with THA compared to HA, there were no significant differences in outcomes. THA is, therefore, a viable option for dialysis-dependent patients with femoral neck fractures who are otherwise medically stable.

HBcAb positivity increases the risk of postoperative complications after extended hemihepatectomy for hilar cholangiocarcinoma.

Hepatitis B core antibody (HBcAb) positivity is considered a prior hepatitis B virus (HBV) infection. However, little is known about the effect of HBcAb positivity on surgical safety for hilar cholangiocarcinoma (hCCA). The present study aims to investigate the role of HBcAb positivity on postoperative complications of hCCA. A retrospective analysis was performed on the status of HBcAb positivity, liver fibrosis, perioperative surgical complications, and long-term outcomes of hCCA patients with Hepatitis B surface antigen (HBsAg) negativity who underwent surgical treatment in Tongji Hospital from April 2012 to September 2019. HBcAb positivity with negative HBsAg occurs in 137 hCCA patients (63.1%). A total of 99 hCCA patients with negative HBsAg underwent extended hemihepatectomy, of whom 69 (69.7%) and 30 (30.3%) were HBcAb-positive and HBcAb-negative, respectively. Significant fibrosis was detected in 63.8% of the patients with HBcAb-positive, which was markedly higher than those with HBcAb-negative (36.7%) (p=0.016). The postoperative complications and 90-day mortality rates were 37.4% (37/99) and 8.1% (8/99), respectively. The incidence of postoperative complications in HBcAb-positive patients (44.9%) was significantly higher than that in HBcAb-negative patients (20.0%) (p=0.018). All the patients who died within 30-day after surgery were HBcAb-positive. Multivariate analysis showed that the independent risk factors for complications were HBcAb positivity, preoperative cholangitis, portal occlusion >15 min, and significant fibrosis. There were no significant differences in recurrence-free survival (RFS) and overall survival (OS) between HBcAb-positive and HBcAb-negative patients (p=0.642 and p=0.400, respectively). HBcAb positivity is a common phenomenon in hCCA patients from China, a country with highly prevalent HBcAb positivity. The status of HBcAb-positive markedly increases the incidence of postoperative complications after extended hemihepatectomy for hCCA patients.

Cannabis use disorder is not a risk factor for thrombotic events or medical complications following total shoulder arthroplasty

BackgroundIn recent years, there has been an increase in utilization of cannabis. Existing studies have found cannabis use disorder (CUD) to be associated with increased incidence of perioperative complications in lower extremity arthroplasty. However, studies examining CUD following total shoulder arthroplasty (TSA) are limited. The aim of this study was to evaluate the effect of comorbid CUD on 2-year revision and 90-day postoperative outcomes in primary TSA for osteoarthritis. MethodsA retrospective cohort analysis was conducted using the PearlDiver database. Current Procedural Terminology, ICD-9, and ICD-10 codes were used to identify patients undergoing TSA for the indication of osteoarthritis and were divided into a CUD and control group. The primary outcomes of interest were 2-year all-cause revision, 90-day hospital readmission, and 90-day emergency department (ED) visit. Surgical perioperative complications included prosthetic joint infection, periprosthetic fracture, aseptic loosening, articular bearing surface wear, broken prosthesis, and prosthetic dislocation. Univariate analysis and multivariable logistic regression were conducted to analyze the data. ResultsA total of 205,792 patients undergoing TSA were identified. The CUD cohort contained 2058 patients, and the control cohort contained 203,734 patients. After controlling for comorbidities, there were statistically significant differences in 2-year revision outcomes. Multivariable results also showed no association with 90-day medical or surgical complications, with the exception of convulsions, 90-day presentation to an eED, and readmission. Discussion and ConclusionOur study showed that patients with CUD have an increased risk of 2-year all-cause revision, readmission, and ED presentation after undergoing TSA. However, CUD was not found to be an independent risk factor for adverse 90-day medical complications, deep vein thrombosis, or length of stay. The results of this research expand the literature on TSA and comorbid substance use. Further, our findings can assist orthopedic surgeons in counseling patients regarding CUD as a risk factor for complications of TSA.

A retrospective analysis of the incidence of postoperative delirium and the importance of database selection for its definition

BackgroundPostoperative delirium (POD) is a common complication after major surgery, resulting in various adverse reactions. However, incidence and risk factors associated with POD after shoulder arthroplasty (SA) have not been well studied using a large-scale national database.MethodsA retrospective database analysis was performed based on the Nationwide Inpatient Sample (NIS) from 2005 to 2014, the largest fully paid hospital care database in the United States. Patients undergoing SA were included. The patient’s demographics, comorbidities, length of stay (LOS), total costs, type of insurance, type of hospital, in-hospital mortality, and medical and surgical perioperative complications were assessed.ResultsA total of 115,147 SA patients were obtained from the NIS database. The general incidence of delirium after SA was 0.89%, peaking in 2010. Patients with delirium after SA had more comorbidities, prolonged LOS, increased hospitalization costs, and higher in-hospital mortality (P < 0.0001). These patients were associated with medical complications during hospitalization, including acute renal failure, acute myocardial infarction, pneumonia, pulmonary embolism, stroke, urinary tract infection, sepsis, continuous invasive mechanical ventilation, blood transfusion, and overall perioperative complications. Risk factors associated with POD include advanced age, neurological disease, depression, psychosis, fluid and electrolyte disturbances, and renal failure. Protective factors include elective hospital admissions and private insurance.ConclusionThe incidence of delirium after SA is relatively low. Delirium after SA was associated with increased comorbidities, LOS, overall costs, Medicare coverage, mortality, and perioperative complications. Studying risk factors for POD can help ensure appropriate management and mitigate its consequences. Meanwhile, we found some limitations of this type of research and the need to establish a country-based POD database, including further clearly defining the diagnostic criteria for POD, investigating risk factors and continuing to collect data after discharge (30 days or more), so as to further improve patient preoperative optimization and management.

What Are the Functional and Surgical Outcomes of Tibial Turnup-plasty for Salvage in Patients With Chronic Lower Extremity Infection?

Tibial turnup-plasty is a rarely performed surgical option for large bone defects of the distal or entire femur and can serve as an alternative to hip disarticulation or high above-knee amputation. It entails pedicled transport of the ipsilateral tibia with or without the proximal hindfoot for use as a vascularized autograft. It is rotated 180° in the coronal or sagittal plane to the remaining proximal femur or pelvis, augmenting the functional length of the thigh. Prior reports consist of small case series with heterogeneous surgical techniques. Patient-reported outcome measures after the procedure have not been reported, and ambulatory status after the procedure is also unknown. (1) What proportion of patients underwent reoperation after tibial turnup-plasty? (2) What is the ambulatory status and what proportion of patients used a prosthesis after tibial turnup-plasty? (3) What are the Patient-Reported Outcome Measurement Information System (PROMIS) Global-10 mental and physical function scores after tibial turnup-plasty? A retrospective analysis was performed of 11 patients who underwent tibial turnup-plasty between 2003 and 2021 by a single orthopaedic oncology division in collaboration with a reconstructive plastic surgery team. Nine patients were men, with a median age of 55 years (range 34 to 75 years). All had chronic infections after arthroplasty or oncologic reconstructions, with a median number of 13 surgeries before turnup-plasty. All were considered to have no other surgical options other than hip disarticulation or high transfemoral amputation. All patients who were offered this possibility accepted it. Data of interest included patient demographics and comorbidities, surgical history that led to limb compromise, medical and surgical perioperative complications, date of prosthesis fitting, and functional capacity at the most recent follow-up interval based on ambulatory status and PROMIS Global-10 mental and physical function scores. The statistical analysis was descriptive. The median number of reoperations after turnup-plasty was one (range 0 to 11). Of the six patients who underwent at least one reoperation, indications for surgery included wound infection (four patients), nonunion of the osteosynthesis site (two), heterotopic ossification (one), tumor recurrence (one), and flap hypoperfusion treated with local tissue revision (one). One patient underwent conversion to external hemipelvectomy for tumor recurrence. Ten of the 11 patients were ambulatory at the final follow-up interval with standard above-knee amputation prostheses. Two ambulated unassisted, four used a single crutch or cane, and four used two crutches or a walker. Of the nine patients for whom scores were available, the median PROMIS Global-10 physical and mental health scores were 48 (range 30 to 68) and 53 (range 41 to 68), both within the standard deviation of the population mean of 50. The tibial turnup-plasty is a complex surgical option for patients with large bone defects of the femur for whom there are no alternative surgeries capable of producing residual extremities with acceptable functional length. This should be viewed as a procedure of last resort to avoid a hip disarticulation or a high transfemoral amputation in patients who have typically undergone numerous prior operations. Although ambulation with a prosthesis within 1 year can be expected, almost all patients will require an assistive device to do so, and reoperations are frequent. Level IV, therapeutic study.