Postoperative Year In Patients Research Articles

Nationwide database analysis of one-year readmission rates after open surgical or thoracic endovascular repair of Stanford Type B aortic dissection

ObjectiveWe examined readmissions and resource use during the first postoperative year in patients who underwent thoracic endovascular aortic repair or open surgical repair of Stanford type B aortic dissection. MethodsThe Nationwide Readmissions Database (2016-2018) was queried for patients with type B aortic dissection who underwent thoracic endovascular aortic repair or open surgical repair. The primary outcome was readmission during the first postoperative year. Secondary outcomes included 30-day and 90-day readmission rates, in-hospital mortality, length of stay, and cost. A Cox proportional hazards model was used to determine risk factors for readmission. ResultsDuring the study period, type B aortic dissection repair was performed in 6456 patients, of whom 3517 (54.5%) underwent thoracic endovascular aortic repair and 2939 (45.5%) underwent open surgical repair. Patients undergoing thoracic endovascular aortic repair were older (63 vs 59 years; P < .001) with fewer comorbidities (Elixhauser score of 11 vs 17; P < .001) than patients undergoing open surgical repair. Thoracic endovascular aortic repair was performed electively more often than open surgical repair (29% vs 20%; P < .001). In-hospital mortality was 9% overall and lower in the thoracic endovascular aortic repair cohort than in the open surgical repair cohort (5% vs 13%; P < .001). However, the 90-day readmission rate was comparable between the thoracic endovascular aortic repair and open surgical repair cohorts (28% vs 27%; P = .7). Freedom from readmission for up to 1 year was also similar between cohorts (P = .6). Independent predictors of 1-year readmission included length of stay more than 10 days (P = .005) and Elixhauser comorbidity risk index greater than 4 (P = .033). ConclusionsApproximately one-third of all patients with type B aortic dissection were readmitted within 90 days after aortic intervention. Surprisingly, readmission during the first postoperative year was similar in the open surgical repair and thoracic endovascular aortic repair cohorts, despite marked differences in preoperative patient characteristics and interventions.

CHANGES IN BONE MINERAL DENSITY AFTER TOTAL KNEE ARTHROPLASTY.

ABSTRACTObjective: We aimed to investigate the change in bone mineral density (BMD) in the first postoperative year in patients that underwent total knee arthroplasty (TKA) due to primary osteoarthritis of the knee. Methods: Preoperative and first postoperative year dual-energy X-ray absorptiometry measurements of 76 patients with knee osteoarthritis, who undergone surgery between 2016 and 2018 due to the recommendation for TKA, were statistically evaluated in the study. Results: Of the 19 patients with a normal BMD in the preoperative period, 73.7% (n = 14) continued to have a normal BMD in the postoperative period. Of the 34 patients with a low BMD (osteopenia) in the preoperative period, 91.2% (n = 31) did not show any change, whereas osteoporosis was observed in two patients (5.9%) in the postoperative period. Of the 23 patients with osteoporosis in the preoperative period, 95.7% (n = 22) did not show any change, whereas osteopenia was observed in one patient (4.3%) in the postoperative period. Both the T and Z scores of the spine (L1-L4) and proximal femur showed a slightly positive trend, however, with an insignificant statistical difference (p ≥ 0.05). Conclusion: Patients that underwent TKA experienced a statistically insignificant bone gain at the spine and proximal femur twelve months after the surgery.Level of Evidence III, Therapeutic Studies Investigating the Results of Treatment.

Risk factors for postoperative opioid use after elective shoulder arthroplasty

The opioid epidemic remains a serious issue in the United States with significant impact to the medical and socioeconomic welfare of communities. We sought to determine baseline opioid use in patients undergoing shoulder arthroplasty (SA) and identify patient characteristics, comorbidities, and surgical risk factors associated with postoperative opioid use. A Shoulder Arthroplasty Registry identified the number of dispensed opioid medication prescriptions (Rxs) in the first postoperative year in patients who underwent elective primary SA from 2008 to 2014. We used Poisson regression to study the effect of preoperative risks factors on number of dispensed opioid Rxs in the first postoperative year, evaluated quarterly (Q1: days 0-90, Q2: days 91-180, Q3: days 181-270, Q4: days 271-360). Included were 4243 SAs from 3996 patients, and 75% used opioids in the 1-year preoperative period. The factors associated with increased opioid use in all postoperative quarters (Q4 incident rate ratio [IRR] shown) were age <60 years (IRR, 1.40; 95% confidence interval [CI], 1.29-1.51), preoperative opioid use (1-4 Rxs: IRR, 2.15; 95% CI, 1.85-2.51; ≥5 Rxs: IRR, 9.83; 95% CI , 8.53-11.32), anxiety (IRR, 1.11; 95% CI, 1.03-1.20), opioid dependence (IRR, 1.23; 95% CI, 1.05-1.43), substance abuse (IRR, 1.17; 95% CI, 1.07-1.28), and general chronic pain (IRR, 1.38; 95% CI, 1.28-1.50). Opioid usage in patients undergoing SA is widespread at 1 year, with three-fourths of patients having been dispensed at least one Rx. These findings emphasize the need for surgeon and patient awareness as well as education in the management of postoperative opioid usage associated with the indicated conditions. Surgeons may consider these risk factors for preoperative risk stratification and targeted deployment of preventative strategies.

Usefulness of 18F-FDG PET/CT in Cutaneous Melanoma Patients with Negative Sentinel Lymph Nodes and High Clark Levels.

Objective:We investigated the utility of PET/CT in cutaneous melanoma (CM) patients with pathological negative sentinel lymph nodes (SLN), within the first year.Methods:The results of PET/CTs and SLN biopsy (SLNB) in 65 patients (39 male and 26 female, mean age 53.8) with a PET/CT in the first postoperative year were evaluated. Within this cohort, the utility of early PET/CT imaging was assessed in patients with negative SLNB. McNemar test was used to compare PET/CT findings with SLNB results.Results:Out of 43 patients with pathologically positive SLNs, 23 patients (53.5%) had positive and 20 patients (46.5%) had negative findings on PET/CT within the first postoperative year. On the other hand, PET/CT results of 22 patients with negative SLNBs were found to be negative in 19 patients (86.4%) and positive in 3 patients (13.6%). For the patients with negative SLNB results, the detection rate of distant metastasis with PET/CT was significantly lower (p<0.001) than that in patients with positive SLNBs.Conclusion:Our results showed that 18F-FDG PET/CT will most likely (86.4%) be negative during the first postoperative year in patients with a negative SLNB. Therefore, it is concluded that this modality would not provide any significant clinical contribution within this time frame.

Postoperative Atrial Fibrillation Predicts Long-Term Cardiovascular Events after Radical Cystectomy

Postoperative atrial fibrillation after radical cystectomy occurs in 2% to 8% of cases. Recent evidence suggests that transient postoperative atrial fibrillation leads to future cardiovascular events. The long-term cardiovascular implications of postoperative atrial fibrillation in patients undergoing radical cystectomy are largely unknown. The Healthcare Cost and Utilization Project State Inpatient Databases for California and Florida were used to identify patients who underwent radical cystectomy between 2007 and 2010. After excluding patients with a history of atrial fibrillation, coronary artery disease and/or stroke, patients were matched using propensity scoring on age, race, insurance status and preexisting comorbidities. Adjusted Kaplan-Meier time-to-event analysis and Cox proportional hazards models were used to assess the effect of postoperative atrial fibrillation on cardiovascular events (acute myocardial infarction and stroke) during postoperative year 1. Radical cystectomy was performed in 4,345 patients who met the study inclusion criteria, of whom 210 (4.8%) had postoperative atrial fibrillation. There was a significantly higher cumulative incidence of cardiovascular events during the first postoperative year in patients in whom postoperative atrial fibrillation developed (24.8% vs 10.9%, adjusted log rank p=0.007). Cox proportional hazards regression demonstrated an increased risk of cardiovascular events in patients with postoperative atrial fibrillation (HR 10, p=0.02). Our results demonstrate that patients undergoing radical cystectomy in whom transient postoperative atrial fibrillation develops are at significantly increased risk for cardiovascular events in the first postoperative year. Physicians should be vigilant in assessing postoperative atrial fibrillation, even when transient, and establish appropriate followup given the increased risk of cardiovascular morbidity.

Serial Changes in Knee Muscle Strength After Anterior Cruciate Ligament Reconstruction Using Hamstring Tendon Autografts

The purpose of this study was to evaluate serial changes in quadriceps and hamstring muscle strength over the first postoperative year in patients who underwent anterior cruciate ligament (ACL) reconstruction with an autologous hamstring tendon graft and to reveal which of these 2 muscles lost more strength and recovered more slowly after autologous hamstring ACL reconstruction. Isokinetic muscle strength was measured preoperatively and at 6months and 1 year postoperatively in 20 patients who underwent ACL reconstruction. The maximal torque (60°/s) and total work (180°/s) of the quadriceps and hamstring were evaluated using an isokinetic testing device. The isokinetic muscle strength and endurance of the injured legs were expressed as percentages of those of the uninjured legs at the same time point. Both quadriceps and hamstring muscle strength at 60°/s and endurance at 180°/s of the injured relative to the uninjured leg was 50% preoperatively. Quadriceps muscle strength and endurance of the injured leg increased to 70% at 6 months and 80% at 1 year postoperatively, whereas hamstring muscle strength and endurance increased to 80% at 6 months and 80% at 1 year. Knee muscle strength recovered progressively after ACL reconstruction using autologous hamstring tendons but did not fully recover, being about 80% that of the uninjured leg even 1 year after surgery. Level IV, therapeutic case series.

The key role of time in predicting progression-free survival in patients with renal cell carcinoma treated with partial or radical nephrectomy: Conditional survival analysis

IntroductionIn surgically treated patients with renal cell carcinoma (RCC), the progression-free survival (PFS) rate may significantly change according to the progression-free postoperative period. To test this hypothesis, we set to evaluate the conditional PFS rate in surgically treated patients with RCC. MethodsWe evaluated 1,454 patients with RCC, surgically treated between 1987 and 2010, at a single institution. Cumulative survival estimates were used to generate conditional PFS rates. Separate Cox regression models were fitted to predict clinical-progression risk in patients who were progression free from 1 to 10 years after surgery. ResultsDuring the immediate postoperative period, the 5-year PFS rate was 88%, and it increased to 92%, 94%, and 97% in patients who remained progression free at, respectively, 1, 5, and 10 years after surgery. At multivariable analyses, where patients with stage I disease were considered as a reference, the highest clinical-progression risk was observed at the eighth postoperative year in patients with stage II disease (hazard ratio [HR]: 2.9) and during the immediate postoperative period in patients with stage III to IV disease (HR: 5.5). In comparison with patients with grade I disease, the highest clinical-progression risk was observed at the fourth (as well as eighth) postoperative year in patients with grade II disease (HR: 5.7), sixth postoperative year in patients with grade III disease (HR: 7.2), and during the immediate postoperative period in patients with grade IV disease (HR: 8.5). ConclusionsThe postoperative progression-free period has an important effect on the subsequent clinical-progression risk. This aspect should be considered along with tumor characteristics to plan the most cost-effective follow-up scheme for surgically treated patients with RCC.

Femoral Fractures in Revision Hip Surgeries with Impacted Bone Allograft

Impacted allograft bone in hip revision arthroplasty is a biologic reconstruction method that restores bone loss. Periprosthetic femoral fracture is one of the most frequent complications. However, the incidence, types of fracture, time of occurrence, predisposing factors, and whether and how complication affects the reconstruction are unknown. We analyzed 285 femoral revisions performed with this technique. Fractures occurred in 64 patients (22.4%). Fifty-nine of these 64 incidents (92%) occurred during surgery and five within the first postoperative year. Of the 59 intraoperative lesions, 34 were fractures (57.6%) and 25 were incidental perforations (42.3%). Most fractures and incidental perforations were associated with cement removal rather than the reconstructive technique. The reconstruction was compromised in two of the 34 fractures, but the remainder healed without complications. Five patients had a diaphyseal fracture develop within the first postoperative year, four of whom had an intraoperative incidental perforation. There was an increased risk of fractures within the first postoperative year in patients who had an incidental perforation during surgery and in those with severe bone defects. Despite the high rate of femoral complications associated with this reconstructive technique, most did not influence the reconstruction and only the intraoperative and postoperative complete diaphyseal fractures underwent additional treatment.

Clinical and Angiographic Effects of Chronic Calcium Channel Blocker Therapy Continued Beyond First Postoperative Year in Patients With Radial Artery Grafts

Background This study was conceived to elucidate the clinical and angiographic effects of chronic calcium channel blocker therapy (CCCBT) continued after the first postoperative year in patients in whom the radial artery (RA) was used for myocardial revascularization. Methods and Results Patients who received RA grafts at our institution and who at 1 year had no scintigraphic evidence of ischemia in the RA territory or angiographic evidence of RA malfunction (n=120) were randomly assigned to continue (n=63) or suspend (n=57) the CCCBT with diltiazem (120 mg/d). After 5 years, all patients were reassessed clinically and by stress myocardial scintigraphy, and 87 of them (45 from the continued group that continued CCCBT and 42 from the group that suspended CCCBT) were restudied angiographically. No differences regarding either the clinical and scintigraphic results or the RA angiographic status were demonstrated between the 2 groups. Conclusions After the first postoperative year, the continuation of CCCBT does not affect RA graft patency or clinical and scintigraphic results.

Pharyngeal reflux after gastric pull-up esophagectomy with neck and chest anastomoses

Objective: Pharyngeal reflux after a gastric pull-up esophagectomy may cause aspiration. This study evaluates acid exposure to the esophageal remnant and to the pharynx after gastric pull-up esophagectomy and evaluates the impact of additional dissection of the esophagus that is necessary for neck anastomoses versus no neck exploration and proximal chest anastomoses. Methods: Forty-seven patients had circular stapled anastomoses in the apex of the right chest (n = 27 patients) or manually sutured neck anastomoses (n = 20 patients). A 24-hour double-pH study with the probes placed 3 cm cranial and 3 cm distal to the cricopharyngeal muscle was performed. The percent time pH less than 4 was registered 3, 6, and 12 months after the operation. Results: Mean acid exposure to the proximal pH probe ranged between 0.2% and 0.96% and between 1.45% and 6.5% to the distal pH probe during the 3 measurements. Acid exposure was always lower to the proximal than to the distal probe ( P = .001). Patients with neck anastomoses had increasing acid exposure to the distal ( P = .023) and proximal ( P = .002) pH probes during the study year, whereas patients with chest anastomoses had similar acid exposure. Conclusions: Acid exposure to the esophageal remnant and to the pharynx increased during the first postoperative year in patients with neck anastomoses but not in patients with proximal chest anastomoses. The results suggest a less favorable acid clearance in patients with the neck approach. (J Thorac Cardiovasc Surg 1999;118:1078-83)

Intermediate and long-term results after pediatric heart transplantation: incidence and role of pretransplant diagnosis.

From November 1985 to 31 July 1997, 65 pediatric patients underwent heart transplantation at Bambino Gesù Hospital in Rome. Two of them underwent retransplantation, both 6 years after the first transplant. The 67 transplant patients had a mean age of 59 months; 11 were under 1 year of age. Their indications for transplantation were cardiomyopathies (38), lymphocytic myocarditis (8), and congenital heart diseases (19). Two patients of the first group successfully received a combined heart and kidney transplant. The 1-, 5-, and 11-year actuarial survival rates for the 65 patients who underwent heart transplantation were 68%, 62%, and 42%, respectively. In the 1st postoperative year in patients who had had cardiomyopathy, a total of 50 episodes of acute rejection (AR), with one death, occurred (mean 1.7 AR/patient per year +/- 1.5) and, in patients who had had congenital heart diseases, 19 ARs (one death) occurred with a mean of 1.58 AR/patient per year +/- 1.4. The incidence of AR was significantly higher in patients who had had myocarditis with a total of 26 episodes (mean 3.7 AR/patient per year +/- 2) and one death. Rehabilitation of heart transplanted children and infants was complete (NYHA class 1) in 52% of patients of this series. We conclude that heart transplantation may give a good intermediate and long-term survival in selected patients; the extension of indications to desperately ill patients, or patients with systemic diseases or complex congenital heart diseases may bring less encouraging results, but should not be definitely excluded. Scarcity of donors remains the main limit, being still the first cause of death for patients on our waiting list. Our limited experience seems to suggest that, as described in adults, the cellular amplification of the immune response might affect the post-heart transplant follow up of pediatric patients with myocarditis resulting in a poor outcome for this population.

Prostate-specific antigen failure despite pathologically organ-confined and margin-negative prostate cancer: the basis for an adjuvant therapy trial.

A multivariable analysis to evaluate the potential clinical and pathologic factors that predict for early biochemical failure in patients with pathologically organ-confined and margin-negative disease was performed to define patients who may benefit from adjuvant therapy. Three hundred forty-one prostate cancer patients treated with a radical retropubic prostatectomy between January 1989 and June 1995 and found to have pathologically organ-confined and margin-negative disease comprised the study population. A logistic regression multivariable analysis to evaluate the predictive value of the preoperative prostate-specific antigen (PSA) level, pathologic (prostatectomy) Gleason score, and pathologic stage on PSA failure occurring during the first postoperative year was performed. Predictors of PSA failure during the first postoperative year in patients with pathologically organ-confined disease included pathologic Gleason score > or = 7 (P = .0007) and preoperative PSA level greater than 10 (P < .0001). Corresponding 3-year freedom-from-PSA-failure rates for these pathologic organ-confined patients with both, one, or neither of these factors were 60%, 75% to 84%, and 95%, respectively (P < .0001). Prostate cancer patients with pathologically organ-confined and margin-negative disease and a preoperative PSA level greater than 10 ng/mL or a pathologic Gleason score > or = 7 have significant decrements in short-term PSA-failure-free survival. Therefore, these patients should be considered for adjuvant therapy in the setting of a phase III clinical trial.