Postoperative Morbidity In Patients Research Articles

Anaesthetic management of a patient with Leigh’s syndrome with central hypoventilation and obstructive sleep apnoea

Leigh's syndrome, which is characterised by progressive neurodegeneration involving the brainstem and basal ganglia, belongs to a family of disorders classified as mitochondrial myopathies. It is most commonly transmitted by an autosomal recessive mode of inheritance, but can sometimes occur in a mitochondrial pattern. It typically presents during infancy with developmental delay and deterioration of brainstem function. Respiratory failure is the common cause of death and postoperative morbidity in patients with Leigh's disease. Herein, we report the case of a 17-year-old female patient with Leigh's syndrome who underwent general anaesthesia for a tracheostomy, which was performed in view of the patient's requirement for long-term ventilation and frequent toileting for secretions. Her respiratory complications included central hypoventilation secondary to brainstem involvement, and obstructive sleep apnoea due to obesity and muscle dystonia. She was hospitalised for acute respiratory decompensation secondary to hospital-acquired pneumonia. We review the anaesthetic implications of this disease and discuss its impact on preoperative, intraoperative and postoperative management.

Neurotologic Skull Base Access for Primary Tumors of the Temporomandibular Joint

To familiarize the physician with the clinical and radiographic features associated with primary tumors of the temporomandibular joint (TMJ) and to demonstrate the use of the neurotologic skull base techniques in the surgical extirpation of TMJ tumors. This was a retrospective chart review spanning the years 1988 to 2012. Tertiary care academic medical center. Any patient with diagnosis of a primary TMJ tumor who received surgical management at our institution. The surgical approaches used included preauricular infratemporal fossa, postauricular infratemporal fossa, and pterional infratemporal fossa. The most critical assessment measures were postoperative patient morbidity and evidence of disease at follow-up visits. The surgical approach was tailored according to the radiographic mapping of the size and location of the tumor. Trismus and jaw discomfort were the most common postoperative complications. Conductive hearing loss occurred only in patients who underwent oversewing of the cartilaginous ear canal. The presenting signs and symptoms of extremely rare primary TMJ tumors are those often seen by otolaryngologists. Contemporary neurotologic skull base surgical techniques can optimize the successful extirpation of these lesions.

Management of Split-Thickness Skin Graft Donor Sites: A Randomized Controlled Trial of Calcium Alginate versus Polyurethane Film Dressing

Background: Split-thickness skin graft (STSG) donor sites sometimes cause more postoperative morbidity for patients than the wound covered with the graft. Yet, there is no consensus on which dressings are best suited to treat these donor sites. Objective: To evaluate two commonly used modern wound dressings in the postoperative healing of STSG donor sites in a prospective randomized controlled trial. Methods: 38 patients were randomly assigned to treatment of an STSG donor site with an alginate dressing or a polyurethane film dressing. The primary outcome measures were postoperative pain scores, secondary outcome variables were time to epithelialization, dressing changes and complications. Results: Postoperative pain on day 1 was significantly lower in the polyurethane film group (2.05 vs. 0.79, p = 0.035) as compared to the alginate group. This difference was not detected on day 5 (0.89 vs. 0.53, p = 0.52). Time to epithelialization did not differ significantly between the two dressing groups. There were more dressing changes in the polyurethane film group and problems with leakage. Conclusion: Whereas film dressings resulted in initially lower pain scores, alginate dressings caused fewer additional dressing changes and less leakage.

Comparison of early postoperative morbidity after robot‐assisted and open radical cystectomy: results of a prospective observational study

To evaluate early postoperative morbidity in patients undergoing either robot-assisted (RARC) or open radical cystectomy (ORC) for bladder cancer. A total of 100 patients underwent RARC (between August 2009 and August 2012) and 42 underwent ORC (between October 2007 and July 2009) as treatment for bladder cancer. Data on the patients' peri-operative course were collected prospectively up to the 90th postoperative day for the RARC group and up to the 60th postoperative day for the ORC group. Postoperative complications were recorded based on the Clavien-Dindo classification system. Both groups were compared with regard to patient and tumour characteristics, surgical and peri-operative outcomes. The RARC and ORC groups were well matched with regard to age, body mass index, gender distribution, type of urinary diversion and pathological tumour characteristics (all P > 0.1), but patients in the RARC group had more serious comorbidities according to the Charlson comorbidity index (P = 0.034). Although surgical duration was longer in the RARC group (P < 0.001) the estimated blood loss was lower (P < 0.001) and transfusion requirement was less (P < 0.001). Overall 59 patients (59%) in the RARC group and 39 patients (93%) in the ORC group experienced postoperative complications of any Clavien-Dindo grade <90 days and <60 days after surgery, respectively (P < 0.001; relative risk reduction 0.36). Major complications (grades 3a-5) were also less frequent after RARC (24 [24%] vs 18 patients [43%]; P = 0.029) with a relative risk reduction of 0.44. In the subgroup of patients with an ileum conduit as a urinary diversion (RARC, n = 76 vs ORC, n = 31) the overall rate of complications (43 [57%] vs 28 [90%] patients; P < 0.001) and the rate of major complications (17 [22%] vs 15 [48%] patients; P = 0.011) were lower in the RARC group with relative risk reductions of 0.37 and 0.54, respectively. A significant reduction in early postoperative morbidity was associated with the robotic approach. Despite more serious comorbidities and a 30-day longer follow-up in the RARC group, patients in the RARC group experienced fewer postoperative complications than those in the ORC group. Major complications, in particular, were less frequent after RARC.

Letter by Xue et al Regarding Article, “Perioperative Dexmedetomidine Improves Outcomes of Cardiac Surgery”

The retrospective study by Ji and colleagues1 showed that perioperative dexmedetomidine use was associated with a decrease in postoperative mortality up to 1 year and decreased the incidence of postoperative morbidity in patients undergoing cardiac surgery, though patients receiving dexmedetomidine presented with a higher incidence of a history of myocardial infraction, congestive heart failure, low ejection fraction, renal failure, and dyslipidemia. The results of this study are important because the reduction in in-hospital, 30-day, and 1-year mortality is relatively large (≈151%–191%). However, this retrospective search for statistical association of dexmedetomidine use with postoperative mortality and morbidity would have been complicated by the fact that the 2 treatment groups …

English

BACKGROUND SURVEY: Vital healthcare resources are devoted to caring patients with prolonged hospitalization after routine, moderate risk surgery. Complications are assessed using a postoperative morbidity. Methods for reducing pain, nausea and vomiting after tonsillectomy are important to improve the standard of care our patients receive. OBJECTIVE: To determine the effects of a single dose of dexamethasone on post operative morbidity in patients undergoing tonsillectomy/adenotonsillectomy. DESIGN: It is a prospective double-blind randomized placebo controlled clinical investigation with ethical approval. METHODS: 60 patients (41 male and 19 female) aged between 4-15 years of ASA I-II undergoing tonsillectomy/adenotonsillectomy were the participants in this study. Patients were randomized to receive a single dose of IV dexamethasone or Placebo (saline). Post operative pain was assessed using either objective pain scale (OPS) or visual analogue scale (VAS). Anesthetic and surgical techniques were standardized. RESULTS: Statistically significant relative decrease in incidence of post operative pain, nausea and vomiting was seen in those treated with dexamethasone. Even statistically significant differences were seen in tolerance to oral fluids and discharge from the hospital between two groups. Tramadol 1 mg/kg n the first 6 hours and oral paracetamol 10ug/kg in the next 6-24 hours were administered. If OPS > 6 or VAS> 40 occurred. Incidence of nausea, vomiting and tonsillar bed oedema was noted. Pain scores were significantly less in dexamethasone group compared to control group. CONCLUSION: Dexamethasone given as a single dose of 0.15mg/kg at the time of induction of anesthesia is an effective safe and inexpensive method of reducing morbidity in tonsillectomy.

Perioperative Transfusions and Postoperative Outcomes in Free Flap Reconstructive Surgery

INTRODUCTION: Our group previously established that preoperative anemia is independently associated with adverse outcomes in immediate breast reconstructive surgery. However, there remains a paucity of information on the frequency and impact of blood transfusions during free flap reconstruction.1,2 We aimed to assess the effect of perioperative transfusions on 30-day postoperative morbidity in patients undergoing microvascular free flap reconstructive surgery. METHODS: Patients who underwent any type of microvascular free flap reconstructive surgery from 2008 to 2011 were identified from the American College of Surgeons National Surgical Quality Improvement Program (a prospective, risk adjusted, outcomes-based registry).3 De-identified data were obtained for 30-day postoperative morbidity, as well as demographics, preoperative and perioperative risk factors. Specific morbidity variables included cardiac, respiratory, neurological, urinary tract, flap, wound and venous thromboembolism outcomes. Logistic regression was used to assess the crude and adjusted effect of perioperative transfusions (defined as a receiving > 1 unit of packed red blood cells within 72 hours before and after the surgery) on postoperative 30-day morbidity. RESULTS: The study population included 6,132 patients, of whom 608 (15.28 %) received perioperative transfusions. Crude odds ratios predicting 30-day post-operative morbidity were significantly higher in transfused patients than in those not receiving transfusions, OR_unadjusted = 3.89 (p<0.001). This trend prevailed after extensive adjustment for clinically and statistically relevant confounders, yielding a highly significant OR_adjusted = 2.69 (p<0.001) for 30-day morbidity (Table 1).Table 1: Logistic Models.CONCLUSION: These results provide strong evidence of an adverse effect of perioperative transfusions on the postoperative outcomes of free flap reconstructive surgery, demonstrating a strong independent association between perioperative transfusions and increased risk of 30-day morbidity.

Postoperative morbidity in patients with chronic viral hepatitis undergoing cardiac surgery: a retrospective study

Methods We studied 103 patients with documented chronic viral hepatitis who had cardiac surgery in our institution between 2001-2012. These subjects were evaluated for preoperative liver dysfunction with the Model for End Stage Liver Disease (MELD) Score. In subjects who were on anticoagulants, a modified score (MELD-XI) was used. Other comorbidities that were considered were diabetes, dyslipidemia, obesity, hypertension, COPD, history of stroke and smoking status.

Impact of Pre-Storage and Bedside Filtered Leukocyte-Depleted Blood Transfusions on Infective Morbidity after Colorectal Resection: A Single-Center Analysis of 437 Patients

Leukocyte-depleted blood transfusions were introduced to reduce transfusion-associated immunomodulation, but the clinical effects of different types of leukocyte depletion have been analyzed rarely. The aim of this survey was to analyze the clinical impact of pre-storage leukocyte-depleted blood transfusions (considered as pre-storage or bedside-filtered) on post-operative complications in patients undergoing elective or urgent colorectal resection. Data were collected retrospectively from the medical records of 437 consecutive patients who underwent colorectal resection from 2005 to 2010. All patients requiring transfusion received pre-storage or bedside-filtered leukocyte-depleted red blood cell concentrates according to availability at the blood bank. The outcomes were measured by the analysis of post-operative morbidity in patients receiving the different types of transfusions or having other potentially predictive risk factors. The overall morbidity rate, infective morbidity rate, and non-infective morbidity rate were, respectively, 35.6%, 28.1%, and 21.0%. Two hundred five patients (46.9%) received peri-operative transfusions. On multivariable analysis, leukocyte-depleted transfusion (odds ratio [OR] 3.33; 95% confidence interval [CI] 2.14-5.20; p<0.001) and both pre-storage (OR 2.82; 95% CI 1.73-4.59; p<0.001) and bedside-filtered (OR 4.69; 95% CI 2.54-8.67; p<0.001) transfusions were independent factors for post-operative morbidity. Prolonged operation (p=0.035), American Society of Anesthesiologists score≥3 points (p=0.023), diagnosis of cancer rather than benign disease (p=0.022), and urgent operation (p=0.020) were other independent predictors of post-operative complications. Patients transfused with bedside-filtered blood showed significantly higher rates of infective complications (51.4% vs. 31.8%; p=0.006), but not non-infectious complications (35.7% vs. 32.6; p=0.654) than patients who received pre-storage transfusions. Leukocyte-depleted blood transfusions and, in particular, bedside-filtered blood have a significant negative effect on infectious complications after colorectal resection.

Immediate postoperative morbidity in patients with indwelling double-J stent versus overnight-externalized ureteral catheter after tubeless percutaneous nephrolithotomy: a prospective, randomized study

The conventional technique for percutaneous nephrolithotomy (PNL) ends by placing a nephrostomy tube within the access tract. However, feasibility and safety of tubeless PNL have been widely demonstrated. In this modification, a ureteral stent is usually left in place instead of the nephrostomy tube. The aim of this study is to compare the use of a postoperative indwelling double-J stent versus an overnight-externalized ureteral catheter in patients undergoing tubeless PNL. Sixty-eight patients undergoing tubeless PNL were randomized either for a postoperative double-J stent (group 1) or for an overnight-externalized ureteral catheter (group 2). Outcomes evaluated included postoperative pain, hospital stay length, incidence of hemorrhagic complications, residual lithiasis and urinary leakage. Groups were similar according to age, sex, body mass index and stone burden. There were no significant differences in terms of postoperative pain, incidence of perirenal hematomas, residual lithiasis and urinary leakage. However, patients in group 1 presented longer hospital stays (3.7±1.7 vs. 1.9±0.3days; p<0.001) and greater hematocrit drops (4.9±2.2 vs. 2.1±1.8%; p<0.001). Our results confirm that among patients undergoing tubeless PNL, both alternatives (i.e. leaving a double-J stent or an overnight-externalized ureteral catheter) are reliable and safe. However, further considerations, like the need of double-J stent removal under cystoscopy, need to be taken into account when deciding which modality to use.

Surgical Management of Complicated Diverticulitis: A Comparison of the Laparoscopic and Open Approaches

Laparoscopy has become a commonly used method of performing colectomies, but the outcomes associated with laparoscopy in the emergency setting have not been well studied. The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for patients with diverticulitis without hemorrhage who underwent a colectomy. Patient data retrieved included demographics and preoperative comorbidities. Each member of the cohort received either a primary anastomosis (PA) or a colostomy. Open and laparoscopic procedures were compared within these subgroups. Multivariate logistic regression analyses were performed to compare the risk-adjusted odds of postoperative morbidity and mortality for laparoscopic and open procedures. The risk-adjusted impact of preoperative comorbidities was also assessed. A total of 11,981 patients in the database met the study criteria. The majority were female (53%) and Caucasian (82%), and the mean age was 58 (±13) years. Comorbidities of the cardiovascular, pulmonary, or renal systems were present in 47%, 5%, and 1% of the cohort, respectively. On bivariate analysis, patients undergoing laparoscopy experienced lower rates of complications with both PA (14% vs 26%, p < 0.001) and colostomy (30% vs 37%, p = 0.02). The laparoscopic approach was associated with decreased mortality rates for patients undergoing PA (0.24% vs 0.79%, p < 0.001). Multivariate analysis revealed that preoperative cardiovascular and pulmonary comorbidities were each associated with increased postoperative morbidity, and that the laparoscopic approach was associated with lower postoperative morbidity for patients undergoing PA. The reduced risk of death for patients undergoing laparoscopic PA (vs open approach) did not achieve statistical significance (odds ratio 0.68, p = 0.3). A small number of patients underwent laparoscopic colostomy (n = 237, 2.4%), and they did not have a significantly different risk of death. The laparoscopic approach is associated with lower complication rates compared with the open approach for the surgical treatment of diverticulitis with a primary anastomosis.

Estimation of potential cost-savings related to the implementation of perioperative hemodynamic goal-directed therapy

Many studies have demonstrated the ability of perioperative hemodynamic goal-directed therapy (pGDT) to decrease postoperative morbidity in patients undergoing medium-to-high-risk surgery [1]. As a result, pGDT may be a cost-saving strategy. Our goal was to provide an estimation of potential cost-savings based on recent literature.

Measuring outcomes after major abdominal surgery during hospitalization: reliability and validity of the Postoperative Morbidity Survey

BackgroundMeasurement of outcomes after major abdominal surgery has traditionally focused on mortality, however the low incidence in elective surgery makes this measure a poor comparator. The Postoperative Morbidity Survey (POMS) prospectively assesses short-term morbidity, and may have clinical utility both as a core outcome measure in clinical trials and quality of care. The POMS has been shown to be a valid outcome measure in a mixed surgical population, however it has not been studied in patients undergoing major abdominal surgery. This study assessed the inter-rater reliability and validity of the POMS in patients undergoing major abdominal surgery.MethodsPatients undergoing elective major abdominal surgery were visited on postoperative day 1 until discharge by two novice observers who administered the POMS in order to assess inter-rater reliability. Subjects who had previously had the POMS performed prospectively on postoperative days 3 and 5 were identified from a database. The pattern and prevalence of morbidity was analyzed against hospital length of stay (LOS) in order to validate the POMS in this patient group.ResultsFifty one patients were recruited to the inter-rater reliability study giving a total of 263 POMS assessments. Inter-rater reliability showed a 97.7% agreement with a κ coefficient of 0.912 (95% CI: 0.842 to 0.982). On domain analysis percentage agreement was lowest in the gastrointestinal domain (87.5%), whilst correlation was lowest in the wound (κ: 0.04; 95% CI: −1.0 to 1.0) and hematological domains (κ: 0.378; 95% CI: 0.035 to 0.722). All other domains showed at least substantial agreement. POMS assessments were analyzed for postoperative days 3 (n = 258) and 5 (n = 362). The absence or presence of morbidity as measured by the POMS was associated with a hospital LOS of 6 (IQR: 4 to 7) vs. 11 (IQR: 8 to 15) days on postoperative day 3 (P <0.0001), and 7 (IQR: 6 to 10) vs. 13 (IQR: 9 to 19) days on postoperative day 5 (P <0.0001). The presence of any morbidity on postoperative day 5 conferred an odds ratio for a prolonged hospital LOS of 11.9 (95% CI: 5.02 to 11.92).ConclusionsThis study shows that the POMS is both a reliable and valid measure of short-term postoperative morbidity in patients undergoing major abdominal surgery.

Effect of Aspirin Continuation on Blood Loss and Postoperative Morbidity in Patients Undergoing Laparoscopic Cholecystectomy or Colorectal Cancer Resection

No consensus exists whether to continue or withdraw aspirin therapy perioperatively in patients undergoing major laparoscopic abdominal surgery. To investigate whether preoperative continuation of aspirin therapy increases blood loss and associated morbidity during laparoscopic cholecystectomy and colorectal cancer resection, we compared duration of surgical procedures, amount of intraoperative blood loss, rate of blood transfusion, length of postoperative stay, rate of conversion to open surgery, and reoperation within 48 hours between patients with and without aspirin therapy preoperatively. Twenty-nine of 270 patients who underwent laparoscopic cholecystectomy and 23 of 218 patients who underwent laparoscopic colorectal cancer resection, respectively, were on aspirin therapy. We found no significant difference in the investigated outcome between groups with the exception of longer surgical duration of laparoscopic cholecystectomy in aspirin-treated patients. Although underpowered, above findings may suggest that aspirin continuation is unlikely to increase blood loss or postoperative morbidity in patients undergoing laparoscopic cholecystectomy or colorectal cancer resection.

Impact of cirrhosis on surgical outcome after pancreaticoduodenectomy

To elucidate surgical outcomes of pancreaticoduodenectomy (PD) in patients with liver cirrhosis. We studied retrospectively all patients who underwent PD in our centre between January 2002 and December 2011. Group A comprised patients with cirrhotic livers, and Group B comprised patients with non-cirrhotic livers. The cirrhotic patients had Child-Pugh classes A and B (patient's score less than 8). Preoperative demographic data, intra-operative data and postoperative details were collected. The primary outcome measure was hospital mortality rate. Secondary outcomes analysed included duration of the operation, postoperative hospital stay, postoperative morbidity and survival rate. Only 67/442 patients (15.2%) had cirrhotic livers. Intraoperative blood loss and blood transfusion were significantly higher in group A (P = 0.0001). The mean surgical time in group A was significantly longer than that in group B (P = 0.0001). Wound complications (P = 0.02), internal haemorrhage (P = 0.05), pancreatic fistula (P = 0.02) and hospital mortality (P = 0.0001) were significantly higher in the cirrhotic patients. Postoperative stay was significantly longer in group A (P = 0.03). The median survival was 19 mo in group A and 24 mo in group B. Portal hypertension (PHT) was present in 16/67 cases of cirrhosis (23.9%). The intraoperative blood loss and blood transfusion were significantly higher in patients with PHT (P = 0.001). Postoperative morbidity (0.07) and hospital mortality (P = 0.007) were higher in cirrhotic patients with PHT. Patients with periampullary tumours and well-compensated chronic liver disease should be routinely considered for PD at high volume centres with available expertise to manage liver cirrhosis. PD is associated with an increased risk of postoperative morbidity in patients with liver cirrhosis; therefore, it is only recommended in patients with Child A cirrhosis without portal hypertension.

EARLY POSTOPERATIVE OUTCOMES IN PATIENTS WITH UTERINE CERVICAL CANCER

EARLY POSTOPERATIVE OUTCOMES IN PATIENTS WITH UTERINE CERVICAL CANCER (Abstract): BACKGROUND: Uterine cervical cancer still presents high percentages of locally advanced tumors on diagnosis due to the lack of screening programs. The multidisciplinary approach in these cases requires neoadjuvant radio-chemotherapy followed in selected cases by surgery. The aim of this study was the assessment of early postoperative outcomes in a consecutive series of cervical cancer patients. METHODS: We performed a comparative analysis in terms of patients and tumor characteristics, type of surgery and postoperative complications on 83 patients with radical surgery divided in terms of neoadjuvant treatment protocol. Two groups were designed: group A, patients who underwent neoadjuvant therapy (n=38; 45.78%) and group B, patients operated without neoadjuvant therapy (n=45; 54.22%). RESULTS: The patients mean age was 54.1±11.6 years old. Most cases on diagnosis were stage IIB (41 cases, 49.39%) followed by stage IB (24 cases, 28.9%). Neoadjuvant treatment was performed in 38 patients (45.78%) (stage IIA - 1 patient, IIB - 31 patients, IIIA - 1 patient and IIIB - 5 patients), with a complete response in 16 (42.1%). Most common intervention was type II radical hysterectomy with pelvic lymphadenectomy in 54 cases (65%). There was no difference in terms of deep vein thrombosis, postoperative urinary and medical morbidity. Digestive complications were relatively higher in neoadjuvant group (28.94% in group A vs. 6.66% in group B, P=0.008) with a longer hospitalization (8.1±2.7 days for group A vs. 6.6±1.6 for group B, P=0.01). CONCLUSION: Radical hysterectomy is a relatively safe technique in terms of postoperative morbidity for patients with cervical cancer despite the use of neoadjuvant therapy. This provides the chance for cure in early stages and a local control for more advanced cases.

Malnutrition and pancreatic surgery: Prevalence and outcomes

Pancreatic surgery is associated with severe postoperative morbidity. Identification of patients at high risk may provide a way to allocate resources objectively and focus care on those patients in greater need. The Authors evaluate the prevalence of malnutrition and its effect on the postoperative morbidity of patients undergoing pancreatic surgery for malignant tumors. Data were collected from 143 patients who had undergone pancreatic resection for cancer. Prevalence of malnutrition was evaluated by several validated screening tools and correlated to the incidence of surgical site infection, overall morbidity, mortality, and hospital stay. Overall, 88% of patients were at medium-high risk of malnutrition. Patients at high risk of malnutrition presented a fourfold longer postoperative hospitalization period and a higher morbidity rate (53.2%) than those patients at low risk of malnutrition. Malnutrition, evaluated by MUST and NRI, was an independent predictor of overall morbidity using multivariate analysis (P = 0.00145, HR = 2.6581, 95% CI = 1.3589-8.5698, and P = 0.07129, HR = 1.9953, 95% CI = 0.9723-13.548, respectively). Malnutrition is a relevant predictor of post-operative morbidity and mortality after pancreatic surgery. Patients underwent pancreatic resection for malignant tumors are usually malnourished. Preoperative malnutrition screening is mandatory in order to assess the risk and to treat the malnutrition.

Exocrine pancreatic insufficiency following esophagectomy

Weight loss following esophagectomy is a management challenge for all patients. It is multifactorial with contributing factors including loss of gastric reservoir, rapid small bowel transit, malabsorption, and adjuvant chemotherapy. The development of a postoperative malabsorption syndrome, as a result of exocrine pancreatic insufficiency (EPI), is recognized in a subgroup of patients following gastrectomy. This has not previously been documented following esophageal resection. EPI can result in symptoms of flatulence, diarrhea, steatorrhea, vitamin deficiencies, and weight loss. It therefore has the potential to pose a significant level of morbidity in postoperative patients. There is some evidence that patients with proven EPI (fecal elastase-1 < 200 μg/g) may benefit from a trial of pancreatic enzyme replacement therapy (PERT). We observed symptoms compatible with EPI in a subgroup of patients following esophagectomy. We hypothesized that this was contributing to malabsorption and malnutrition in these patients. To investigate this, fecal elastase-1 was measured in postoperative patients, and in those with proven EPI, a trial of PERT was commenced in combination with specialist dietary education. At routine postoperative follow-up, which included assessment by a specialist dietitian, those patients with symptoms suggestive of malabsorption were given the opportunity to have their fecal elastase-1 measured. PERT was then offered to patients with fecal elastase-1 less than 200 μg/g (EPI) as well as those in the 200-500 μg/g range (mild EPI) with more severe symptoms. Fecal elastase-1 was measured in 63 patients between June 2009 and January 2011 at a median of 4 months (range 1-42) following surgery. Ten patients had fecal elastase-1 less than 200 μg/g, and all had failed to maintain preoperative weight. All accepted a trial of PERT. Nine (90%) had symptomatic improvement, and seven (70%) increased their weight. Thirty-nine patients had a fecal elastase-1 in the 200-500 μg/g range. Twelve were given a trial of PERT based on level of symptoms, five (42%) reported an improvement in symptoms, but only two (17%) gained weight. Our early results support the observation that EPI is a factor contributing to postoperative morbidity in patients recovering from esophagectomy and that these patients can benefit from a trial of PERT. Our study has limitations, and a formal trial is required to evaluate the impact of EPI and PERT following esophagectomy. Currently, our practice is to measure fecal elastase-1 in any patient with unexplained weight loss or symptoms of malabsorption. In patients with proven EPI or those who are symptomatic with mild EPI, a trial of PERT should be offered and symptoms reassessed.

Prognostic Factor Analysis in Patients with Metastatic Spine Disease Depending on Surgery and Conservative Treatment: Review of 577 Cases

To date, skillful medical management and advanced surgical techniques have provided increased quality of life with less postoperative morbidity in patients with spinal metastasis. We assessed the survival of patients with spinal metastasis according to two treatment modalities: surgery and conservative treatment. From 2005 to 2010, a total of 577 patients (200 surgery, 377 conservative treatment) who had spinal metastasis were enrolled. Prognostic factors and survival were assessed by Cox regression and Kaplan-Meier analyses in patients receiving either surgery or conservative treatment. The mean age was 59.7 (range 21-87) years in the surgery group and 59.9 (range 28-90) years in the conservative treatment group. The major primary cancers were of lung, liver, and colorectal origin in the surgery group and lung, liver, and breast in the conservative group. The mean±SD Tokuhashi score in the surgery group was 8.12±3.09 and in the conservative group was 8.0±2.8 (not significant). The hazard ratio of the primary cancer group ranged from 1.870 to 3.217 compared to that of the most favorable primary cancer group in all patients. Survival was affected significantly by sex, adjuvant therapy, and postoperative survival in the surgery group and by clinical symptom, metastasis to major internal organ, and primary cancer origin in the conservative group. With this retrospective review of 577 cases of spinal metastasis, different prognostic factors depending on the treatment modality were discovered. Hence, consideration of these factors depending on the treatment modality could be helpful in treating patients with spinal metastasis.

Root coverage in molar teeth: a comparative controlled randomized clinical trial

To compare the clinical outcomes of laterally moved, coronally advanced flap (LMCAF) versus Bilaminar technique (BT) in the treatment of single gingival recession on molar teeth. Fifty patients showing Miller I and II gingival recessions at first molar teeth were treated: 25 were randomly assigned to the BT group and 25 belonged to the LMCAF group. Patient's post-operative morbidity was assessed 1 week after the surgery, while aesthetic evaluation and the clinical evaluation were made 1 year later. No statistically significant difference was demonstrated in terms of recession and PPD reduction. Statistically greater probability of complete root coverage (CRC, Odds Ratio 22.1) and greater increase in gingival thickness were observed in the BT group. Greater increase in keratinized tissue was obtained in the LMCAF. Patient satisfaction with aesthetics was very high in both treatment groups. Better post-operative course was observed in the LMCAF, while better post-operative sensitivity and root coverage evaluation were demonstrated in patients treated with BT. Gingival recession at first molar teeth can be successfully treated with LMCAF and BT. Better CRC was achieved with BT, while more comfortable post-operative course was associated with the LMCAF.