Postoperative 1-year Mortality Research Articles

Retrospective comparison of the effects of epidural anesthesia versus peripheral nerve block on postoperative outcomes in elderly Chinese patients with femoral neck fractures.

BackgroundGeriatric patients with femoral neck fracture (FNF) have unacceptably high rates of postoperative complications and mortality. The purpose of this study was to compare the effects of epidural anesthesia versus peripheral nerve block (PNB) on postoperative outcomes in elderly Chinese patients with FNF.MethodsThis retrospective study explored mortality and postoperative complications in geriatric patients with FNF who underwent epidural anesthesia or PNB at the Chinese People’s Liberation Army General Hospital from January 2008 to December 2012. The electronic database at the Chinese People’s Liberation Army General Hospital includes discharge records for all patients treated in the hospital. Information on patient demographics, preoperative comorbidity, postoperative complications, type of anesthesia used, and in-hospital, 30-day, and 1-year mortality after surgery was obtained from this database.ResultsTwo hundred and fifty-eight patients were identified for analysis. The mean patient age was 79.7 years, and 71.7% of the patients were women. In-hospital, 30-day, and 1-year postoperative mortality was 4.3%, 12.4%, and 22.9%, respectively, and no differences in mortality or cardiovascular complications were found between patients who received epidural anesthesia and those who received PNB. More patients with dementia or delirium were given PNB. No statistically significant differences were found between groups for other comorbidities or intraoperative parameters. The most common complications were acute cardiovascular events (23.6%), electrolyte disturbances (20.9%), and hypoxemia (18.2%). Patients who received PNB had more postoperative delirium (P=0.027). Postoperative acute respiratory events were more common (P=0.048) and postoperative stroke was less common (P=0.018) in the PNB group. There were fewer admissions to intensive care (P=0.024) in the epidural anesthesia group. Key factors with a negative influence on mortality were acute cardiovascular events, dementia, male sex, age, American Society of Anesthesiologists score, acute respiratory events, intensive care admission, and comorbidities.ConclusionPNB was not associated with lower mortality or lower cardiovascular complication rates when compared with epidural anesthesia in elderly patients with FNF.

Pre-operative Pulmonary Function Tests and Outcomes After Heart Transplantation

The pulmonary function test (PFT) is a component of the evaluation for heart transplantation. Though data on the relationship between lung disease and post-transplantation outcomes are lacking, PFTs play a role in patient selection for transplantation. We aimed to characterize pulmonary disease in heart transplant recipients and to assess the impact of diminished lung function on post-operative outcomes. We studied a cohort of 136 patients who received a heart transplant at our institution between 2004 and 2014. Pre-operative PFTs, including forced expiratory volume in one second (FEV1), forced vital capacity (FVC), FEV1/FVC ratio, and total lung capacity (TLC), were documented. The incidence and severity of obstructive, restrictive, and mixed obstructive-restrictive lung disease were evaluated. Primary endpoints were post-transplantation hospital length of stay (LOS), intensive care unit (ICU) LOS, and days on ventilator. Secondary endpoint was mortality one year after transplant. Unadjusted and adjusted logistic and Poisson regression analyses were conducted to determine the association between measures of lung function and post-operative outcomes. Our heart transplant recipients, consisting primarily of males (82%) and Caucasians (88%), were on average 58±12 years old. At baseline, the mean body mass index (BMI) was 27±4 kg/m2 with 59% who were prior smokers and 39% who had previously received non-transplant cardiac surgery. Mean exercise oxygen consumption at baseline was 10.1±2.8 ml/min/kg. There were 12 (10%) patients with obstructive lung disease and 57 (50%) with restrictive disease. An additional 19 (17%) had mixed obstructive-restrictive lung disease. In the restrictive and mixed groups, severe-to-very severe disease was present in 7 (12%) and 2 (11%) patients, respectively. The median post-transplantation hospital LOS was 24 days (mean: 41±53), while the median post-transplantation ICU LOS was 5 days (mean: 17±44). Patients were intubated after transplant for a median duration of 3 days (mean: 8±17). There were 15 (11%) patients who experienced 1-year post-operative mortality. After adjustment for potential confounders such as age, smoking, and BMI, decreasing FEV1 and FEV1% predicted were significantly associated with increasing post-transplantation hospital LOS, ICU LOS, and ventilator days (p<0.05). Similarly, as FVC and FVC% predicted decreased, significantly higher post-transplantation hospital LOS, ICU LOS, and ventilator days were observed (p<0.05). Declining TLC and TLC% predicted were also associated with significantly rising post-transplantation hospital LOS, ICU LOS, and ventilator days (p<0.05). No relationship was found between PFTs and mortality. Pulmonary disease is common in heart transplant recipients with restrictive lung disease being more prevalent in our cohort. Reduction in lung function is significantly associated with increased post-transplantation hospital LOS, ICU LOS, and ventilator days.

Abstract 18859: Staphylococcus aureus Infective Endocarditis is Associated with Worsened Clinical Characteristics than Non-Staphylococcus aureus Organisms

Background: Staphylococcus aureus remains a leading cause of IE, but it is unknown whether S. aureus is associated with more severe infections or worsened outcomes compared to other bacterial organisms. The primary purpose of this study was to compare the clinical characteristics and mortality in S. aureus (SA) versus non-S. aureus (NSA) IE patients undergoing valvular surgery. Methods: All patients undergoing valvular surgery for bacterial IE between 1995 and 2013 at our institution were included in this study. Clinical data were retrospectively collected from chart review. Patients were categorized according to causative organism: 1) SA: n=85, and 2) NSA: n=238, composed of coagulase-negative staphylococci (23%), streptococci (12% viridans; 19% non-viridans), enterococci (17%), and other (51%). Results: SA patients had a higher severity of illness compared to NSA patients due to higher rates of preoperative vascular complications (58.8% vs. 39.4%, p = 0.002), preoperative septic shock (23.5% vs. 13.9%, p = 0.039), preoperative embolic events (33.3% vs. 20.7%, p = 0.02), preoperative stroke (27.1% vs. 13.5%, p = 0.004), and annular abscess (44.7% vs. 27.3%, p = 0.003). There were no statistically significant differences in 30-day (9.4% vs. 8.0%, p = 0.68, OR = 1.20) or 1-year (20% vs. 14.3%, p = 0.22, OR = 1.50) post-operative mortality between SA and NSA IE patients, respectively. However, length of hospital stay, and 30-day post-operative development of new renal failure were higher in SA patients. There was a trend to more post-operative embolic events in SA patients. Conclusions: SA IE is associated with higher morbidity on presentation, such as pre-operative embolic events, stroke and annular abscess, compared to IE caused by other bacterial organisms, but does not lead to increased mortality after surgery. Further research is needed to investigate the differences in post-operative complications among patients.

Health Related Quality Of Life Outcome After Operative Treatment Of Traumatic Vertebral Fractures In Geriatric Patients.

Study Background: Quality of life survey conducted after the surgical stabilisation of traumatic thoracic and lumbar vertebral fractures in geriatric patients. Methods: Over a period of 5 years, 42 patients at an age of more than 65 years underwent surgical stabilisation due to an unstable traumatic fracture of the thoracic or lumbar spine. Initially, retrospective empiric data collection was conducted, followed by a prospective radiological and clinical follow-up, including VAS and SF-12. Results: It was possible to conduct a postoperative radiological and clinical follow-up in 31 out of 42 patients (74%) after a mean period of 27.3 months. In 11 out of 42 patients (26%), clinical outcome data were collected by relatives. The mean age at the time of surgery was 71.4 years (range 65 to 87 years), and the injury had almost exclusively been stabilised by using a dorsal internal fixator. The surgical revision rate was 12% (5 out of 42 patients), and postoperative 1-year mortality was also 12% (5 out of 42 patients). At the time of the follow-up, a significant loss of correction was observed in lateral x-ray images when compared to immediate postsurgical results. Quality of life (as measured by SF-12) was significantly reduced at the time of the follow-up compared to a healthy reference population. A significant postoperative decline was also observed with regard to homecare nursing and level of care categories. On the other hand, none of the patients lived in a nursing home, and 35 out of 42 patients (83%) were satisfied or very satisfied with the surgical treatment (as measured by a summary measure). Conclusions: The surgical treatment of traumatic vertebral fractures in geriatric patients resulted in high subjective patient satisfaction post surgery. However, quality of life (SF-12) after an average period of 27.3 months post surgery was still significantly reduced when compared to a healthy reference population.

Mortality and cause of death in hip fracture patients aged 65 or older - a population-based study

BackgroundThe high mortality of hip fracture patients is well documented, but sex- and cause-specific mortality after hip fracture has not been extensively studied. The purpose of the present study was to evaluate mortality and cause of death in patients after hip fracture surgery and to compare their mortality and cause of death to those in the general population.MethodsRecords of 428 consecutive hip fracture patients were collected on a population-basis and data on the general population comprising all Finns 65 years of age or older were collected on a cohort-basis. Cause of death was classified as follows: malignant neoplasms, dementia, circulatory disease, respiratory disease, digestive system disease, and other.ResultsMean follow-up was 3.7 years (range 0-9 years). Overall 1-year postoperative mortality was 27.3% and mortality after hip fracture at the end of the follow-up was 79.0%. During the follow-up, age-adjusted mortality after hip fracture surgery was higher in men than in women with hazard ratio (HR) 1.55 and 95% confidence interval (95% CI) 1.21-2.00. Among hip surgery patients, the most common causes of death were circulatory diseases, followed by dementia and Alzheimer's disease. After hip fracture, men were more likely than women to die from respiratory disease, malignant neoplasm, and circulatory disease. During the follow-up, all-cause age- and sex-standardized mortality after hip fracture was 3-fold higher than that of the general population and included every cause-of-death category.ConclusionDuring the study period, the risk of mortality in hip fracture patients was 3-fold higher than that in the general population and included every major cause of death.

Elective colonic surgery for cancer in the elderly: an investigation into postoperative mortality in English NHS hospitals between 1996 and 2007

This study was primarily aimed to quantify perioperative mortality risk in elderly patients undergoing elective colonic resectional surgery. In addition, the safety of minimally invasive colonic surgery in this patient group was evaluated. All patients aged > 75 undergoing elective colonic resection for colorectal malignancy between 1996 and 2007 in English NHS hospitals were included from the Hospital Episode Statistics (HES) dataset. Between the study dates, 28,746 patients > 75 years underwent elective colonic resection. The national annual number of colonic excisions carried out amongst elderly patients increased from 2188 patients in 1996/7 to 3240 patients in 2006/7. Following adjustment for gender, comorbidity and surgical approach, advancing age was an independent predictor for 30-day mortality (OR 2.47 for patients aged 85-89 vs 75-79, P < 0.001). Use of laparoscopy was a significant predictor of reduced perioperative mortality (OR 0.56, P = 0.003) once adjusted for advancing age, gender and comorbidity. Comparison of 30-day and 1-year postoperative mortality following elective colonic resection in patients aged 90 revealed a large excess of patients dying outside of the immediate perioperative period (10.1% and 26.2% for proximal cancers, respectively; 12.9% and 36.1% for distal colonic resections, respectively). Advancing age is an independent risk factor for postoperative death in elderly patients undergoing elective colonic resection for cancer. The risk of death in the elderly is extremely high and surgical decision-making should incorporate the mortality risk that occurs outside the immediate perioperative period. In this national series, patients selected for a laparoscopic procedure were at lower risk of perioperative death than those undergoing the conventional approach.

Nonelective Excisional Colorectal Surgery in English National Health Service Trusts: A Study of Outcomes from Hospital Episode Statistics Data between 1996 and 2007

Nonelective colorectal surgery is associated with substantial patient morbidity and mortality. This study sought to describe the practice of emergency colorectal surgery in the United Kingdom during an 11-year period using the Hospital Episode Statistics (HES) database. All nonelective admissions in patients undergoing 1 of 8 colorectal resectional procedures between 1996 and 2007 were included. Time trends, univariate, and multivariate mortality and length of stay outcomes were analyzed. A total of 102,236 major urgent/emergency procedures were performed in English National Health Service Trusts between April 1996 and March 2007. Thirty-day in-hospital postoperative mortality rates in patients with colorectal cancer and diverticular disease were 13.3% and 15.4%, respectively. The corresponding 1-year postoperative mortality was 34.7% and 22.6%. On multivariate analysis, benign diagnosis, advanced age, high comorbidity score, social deprivation, and specific procedure types were independent predictors of early and 1-year postoperative mortality (p < 0.001). Independent risk factors for extended hospital stay were advanced age, social deprivation, distal (compared with proximal) bowel resection, and a diagnosis of ulcerative colitis (p < 0.001). HES data suggest that in everyday practice, postoperative mortality among patients undergoing nonelective admission followed by colorectal resection is high. Additional investigation is required to assess the reliability of HES data for monitoring institutional variation in this context.

Traditional and Laparoscopic Appendectomy in Adults

This study investigated length of stay, readmission rates, and postoperative mortality in adult patients undergoing traditional and laparoscopic appendectomy in England between April 1, 1996, and March 31, 2006. All procedures coded to the "H01-Emergency Excision of Appendix" procedure code in the Hospital Episode Statistics database were included. Multivariate analyses were used to identify independent predictors of length of hospital stay, 30-day and 365-day mortality. A total of 259,735 procedures were assigned to the H01-Emergency excision of appendix OPCS-4 3-digit code procedure between 1996 and 2006. A laparoscopic technique was employed in 16,315 (6.3%). A greater proportion of deaths occurred in hospital within 30 days of "open" appendectomy surgery (0.25%) compared with procedures utilizing a laparoscopic technique (0.09%, P < 0.001). One-year mortality rates, measured over a 5-year period, were also higher after open surgery (0.64% vs. 0.29%, P < 0.001). Multiple logistic regressions demonstrated that an open operative technique, older age, male gender, and increasing comorbidity were strong independent determinants of early and 1-year postoperative mortality after emergency appendectomy. The duration of stay for patients undergoing open emergency appendectomy exceeded that for patients undergoing the laparoscopic technique (P < 0.001). Patients undergoing a laparoscopic technique were, however, more likely to be readmitted within 28 days of surgery (7.10% vs. 4.95%, P < 0.001). Laparoscopic appendectomy is safe and associated with lower postoperative mortality rates than open procedures. The cost implications are uncertain as this technique is associated with shorter hospital stay but higher subsequent readmission rates.

Associations of Matrix Metalloproteinase-9 Protein Polymorphisms with Lymph Node Metastasis but not Invasion of Gastric Cancer

Like most cancers, gastric cancer has a complex multistep etiology that involves both environmental and genetic factors. Matrix metalloproteinase-9 (MMP-9) is frequently overexpressed in gastric cancer. We investigated the effect of the genetic differences in MMP-9 coding region on the occurrence and progression of gastric cancer. A case-control study was conducted in a population of 74 patients and 100 healthy people in southeast China. Individuals were genotyped for two single nucleotide polymorphisms (SNP) in MMP-9: R279Q and P574R. Genotypic distributions between patient and control groups were compared for correlations with cancer occurrence. Associations between genotypic distributions and several clinicopathologic features were also analyzed using univariate tests, multivariate logistic regression modeling, and stratified analyses. Significant associations were revealed between both SNPs and lymph node metastasis [P = 0.012 and 0.025; odds ratio (OR), 3.4 and 2.8, respectively]. After adjustment using logistic regression for the potential confounding effects of gender, age, and location of the tumors, homozygous MMP-9 279RR and 574PP are more evidently associated with lymph node metastasis with OR(adjusted) of 5.7 [95% confidence interval (95% CI), 1.80-18.34] and 4.2 (95% CI, 1.37-12.69). The homozygous 279R-574P haplotype showed a stronger association by an OR(adjusted) of 6.1 (95% CI, 1.92-12.29) and was also associated with the 1-year postoperative mortality (OR(adjusted), 6.5; 95% CI, 1.18-35.74). Interestingly, our data also suggested that the MMP-9 polymorphisms seem to result in higher risk of lymph node metastasis through a pathway independent of cancer invasion because no positive associations were found between these polymorphisms and cancer invasion (OR, 0.59 < 1). The stratified analyses indicated a synergistic interaction between the MMP-9 polymorphisms and the type of diffuse in affecting lymph node metastasis (OR, 13.4; P(between strata) = 0.04). Significant association between both SNPs and the overall occurrence of gastric cancer was not observed. The present study has shown significant associations between the two nonsynonymous MMP-9 polymorphisms with lymph node metastasis in gastric cancer, especially with the diffuse type. The relatively large values of ORs and disassociation with cancer invasion suggest that the genetic differences of MMP-9 protein play an important and specific role in lymph node metastases, and therefore, further investigation of the underlying molecular mechanism is warranted.