Preoperative American Society Of Anesthesiologists Research Articles

Surgical Management of Thoracolumbar Adjacent Segment Disease: Techniques and Outcomes in 107 Patients Undergoing Surgical Intervention.

Adjacent segment disease (ASD) is a known sequela of thoracolumbar instrumented fusions. Various surgical options are available to address ASD in patients with intractable symptoms who have failed conservative measures. However, the optimal treatment strategy for symptomatic ASD has not been established. We examined several clinical outcomes utilizing different surgical interventions for symptomatic ASD. A retrospective review was performed for a consecutive series of patients undergoing revision surgery for thoracolumbar ASD between October 2011 and February 2022. Patients were treated with endoscopic decompression (N = 17), microdiscectomy (N = 9), lateral lumbar interbody fusion (LLIF; N = 26), or open laminectomy and fusion (LF; N = 55). The primary outcomes compared between groups were re-operation rates and numeric pain scores for leg and back at 2 weeks, 10 weeks, 6 months, and 12 months postoperation. Secondary outcomes included time to re-operation, estimated blood loss, and length of stay. Of the 257 patients who underwent revision surgery for symptomatic ASD, 107 patients met inclusion criteria with a minimum of 1-year follow-up. The mean age of all patients was 67.90 ± 10.51 years. There was no statistically significant difference between groups in age, gender, preoperative American Society of Anesthesiologists scoring, number of previously fused levels, or preoperative numeric leg and back pain scores. The re-operation rates were significantly lower in LF (12.7%) and LLIF cohorts (19.2%) compared with microdiscectomy (33%) and endoscopic decompression (52.9%; P = 0.005). Only LF and LLIF cohorts experienced significantly decreased pain scores at all 4 follow-up visits (2 weeks, 10 weeks, 6 months, and 12 months; P < 0.001 and P < 0.05, respectively) relative to preoperative scores. Symptomatic ASD often requires treatment with revision surgery. Fusion surgeries (either stand-alone lateral interbody or posterolateral with instrumentation) were most effective and durable with respect to alleviating pain and avoiding additional revisions within the first 12 months following revision surgery. This study emphasizes the importance of risk-stratifying patients to identify the least invasive approach that treats their symptoms and reduces the risk of future surgeries.

Thoracic skeletal muscle mass predicts mortality in patients with surgery for pleural empyema: A case control study.

This study investigated the role of the thoracic skeletal muscle mass as a marker of sarcopenia on postoperative mortality in pleural empyema. All consecutive patients (n = 103) undergoing surgery for pleural empyema in a single tertiary referral center between January 2020 and December 2022 were eligible for this study. Thoracic skeletal muscle mass index (TSMI) was determined from preoperative computed tomography scans. The impact of TSMI and other potential risk factors on postoperative in-hospital mortality was retrospectively analyzed. A total of 97 patients were included in this study. The in-hospital mortality rate was 13.4%. In univariable analysis, low values for preoperative TSMI (p = 0.020), low preoperative levels of thrombocytes (p = 0.027) and total serum protein (p = 0.046) and higher preoperative American Society of Anesthesiologists (ASA) category (p = 0.007) were statistically significant risk factors for mortality. In multivariable analysis, only TSMI (p = 0.038, OR 0.933, 95% CI: 0.875-0.996) and low thrombocytes (p = 0.031, OR 0.944, 95% CI: 0.988-0.999) remained independent prognostic factors for mortality. TSMI was a significant prognostic risk factor for postoperative mortality in patients with pleural empyema. TSMI may be suitable for risk stratification in this disease with high morbidity and mortality, which may have further implications for the selection of the best treatment strategy.

Incidence, risk factors, and outcomes of acute kidney injury in patients undergoing emergency laparotomy - A prospective observational exploratory study.

Acute kidney injury (AKI) can occur in post-laparotomy patients, with a variable incidence. This study aimed to determine the incidence of AKI in patients undergoing emergency laparotomy under general anaesthesia, the effect of preoperative variables on the development of AKI, and the association of post-operative AKI with patient outcomes. This prospective exploratory study in patients undergoing emergency laparotomy was followed up for 7 days to determine the incidence of post-operative AKI. We determined the patients developing different severity of AKI based on kidney disease improving global outcome staging. Fisher's exact test or Chi-squared test was used to study the association of demographic variables, and various periopertaive variables on the development of postoperative AKI. The association of AKI with the duration of hospital stay was estimated using the Wilcoxon-Mann-Whitney U Test, and Fisher's exact test was used to study the association between AKI and mortality. No patient had AKI in the pre-operative period. On day 3, 18 patients; on day 5, 28 patients; and on day 7, 24 patients developed AKI. Overall, a maximum of 33 patients (out of 100) developed AKI at any time. Our study found that the American Society of Anesthesiologists (ASA) IV and sepsis were independent risk factors for post-operative AKI. Our results also show a moderate-to-high independent association between AKI and duration of hospital stay and mortality (within 30 days). Incidence of post-operative AKI following emergency laparotomy was 33%. Higher preoperative ASA physical status and sepsis were significantly associated with postoperative AKI development.

Preoperative infection risk assessment in hip arthroplasty a matched-pair study of the reliability of 3 validated risk scales.

Peri-prosthetic infection (PJI) represents one of the most devastating complications of total hip arthroplasty (THA). The aim of this study is to assess the reliability of different PJI risk assessment scales between two matched pairs of THA groups. This study included 37 patients with PJI following THA performed between 2012 and 2020 (Group A). Each patient in this group was matched, based on sex, age, and follow-up duration, with a control patient who underwent the same surgical procedure without any septic complications (Group B) during the same period. Each patient's assessment included the American Society of Anesthesiologists (ASA) score and a retrospective evaluation using three different preoperative, specific PJI risk assessment scales: the International Consensus Meeting (ICM) Preoperative Risk Calculator for PJI, the Mayo PJI Risk Score, and the KLIC-score. The two groups were statistically compared using descriptive analyses, both for binomial data and numerical variables. Statistically significant higher values were observed in the preoperative ASA score and surgical time in Group A. Statistically different higher scores were determined only with the ICM risk calculator score in Group A. No significant differences were found using the KLIC score and Mayo score between the two groups. We emphasize the reliability of the ASA score as a nonspecific preoperative assessment scale for PJI. The ICM risk calculator was confirmed as a reliable, specific preoperative assessment scale for PJI, suggesting its routine adoption in THA clinical practice.

Risk factors for surgical site infections following open reduction and internal fixation in patients with tibial plateau fractures.

This retrospective cohort study aimed to identify the risk factors associated with postoperative wound infections in patients undergoing open reduction and internal fixation for tibial plateau fractures. The study was conducted between January 2019 and December 2022, with stringent inclusion and exclusion criteria. Data were collected from the Electronic Health Record system, including demographic information, lifestyle habits, comorbid conditions and surgical variables like preoperative American Society of Anesthesiologists (ASA) scores. The IBM Statistical Package for the Social Sciences, version 27.0, was utilized for rigorous statistical analyses. Univariate analysis identified several factors, such as body mass index (BMI), smoking status and diabetes mellitus, as significant predictors of postoperative wound infection. Multivariate logistic regression revealed that BMI, type of fracture (open vs. closed), surgery duration exceeding 150 min, preoperative albumin levels below 35 g/L and preoperative ASA score of 3 or higher were significant independent risk factors (p < 0.05). Patients with open fractures, preoperative malnutrition, elevated preoperative ASA scores and a history of smoking are at a heightened risk of developing postoperative wound infections. Timely preoperative evaluation of these risk factors is crucial for minimizing the risk of surgical site infections and optimizing clinical management.

Mortality following proximal femoral fractures in elderly patients: a large retrospective cohort study of incidence and risk factors

BackgroundGlobal prevalence of osteoporosis and fragility fractures is increasing due to the aging population. Proximal femoral fractures are among the most common orthopedic conditions in elderly that significantly cause health deterioration and mortality. Here, we aimed to evaluate the mortality rates and risk factors, besides the functional outcomes after these injuries.MethodsIn a retrospective cohort study, all patients admitted with a femoral neck or intertrochanteric fracture between 2016 and the end of 2018 were enrolled in this study. Medical records were reviewed to include patients over 60 years of age who had a proximal femoral fracture and had a complete medical record and radiographs. Exclusion criteria included patients with pathological fractures, cancer under active treatment, follow-up loss, and patient access loss. Demographic and clinical features of patients alongside the details of fracture and patient management were recorded and analyzed. In-hospital and post-discharge mortalities due to included types of fractures at one and 12 months were the primary outcome. Modified Harris Hip Scores (mHHS) was the measure of functional outcome.ResultsA total of 788 patients including 412 females (52.3%) and 376 males (47.7%) with a mean age of 76.05 ± 10.01 years were included in this study. Among patients, 573 (72.7%) had an intertrochanteric fracture, while 215 (27.3%) had a femoral neck fracture, and 97.1% of all received surgical treatment. With a mean follow-up of 33.31 months, overall mortality rate was 33.1%, and 5.7% one-month and 20.2% 12-months rates. Analysis of 1-month mortality showed a significant mortality difference in patients operated after 48 h of fracture (p = 0.01) and in patients with American Society of Anesthesiologists (ASA) scores of 3–4 compared to ASA scores of 1–2 (p = 0.001). One-year mortality data showed that the mortality rate in femoral neck fractures was lower compared to other types of fracture. Surgical delay of > 48 h, ASA scores of 3–4, and treatment by proximal femoral plate were associated with shorter survival. The overall mean mHHS score was 53.80 ± 20.78.ConclusionWe found several risk factors of mortality, including age ≥ 80 years, a > 48-hour delay to surgery, and pre-operative ASA scores of 3–4 in patients with proximal femoral fracture. Furthermore, the use of a proximal femoral plate was a significant risk factor for mortality and lower mHHS scores.

The Role of Admission Hyperglycaemia as a Risk Factor for Surgical Site Infection in Orthopaedic Trauma Patients

Introduction: Acute hyperglycemia following traumatic injury is common. Studies have shown that 20– 30% of trauma patients present following injury with blood glucose values ≥ 200 mg/dL, and that a majority of patients demonstrate values ≥ 150 mg/dL. The relationship between hyperglycemia and adverse outcomes, such as infectious complications, has been well described in the surgical literature. Post-traumatic hyperglycemia is less well-documented in orthopaedic trauma patients. Aim of the Study: The aim of this study was to evaluate the role of admission hyperglycaemia as a risk factor for surgical site infection in orthopaedic trauma patients. Methods: This was a retrospective observational study and was conducted in the Department of Orthopaedics Surgery of Brahmanbaria medical college Hospital, Brahmanbaria, Bangladesh during the period from October, 2020 to October, 2022. We included 130 patients who were admitted to orthopaedics surgery department. Result: Majority of our patients (41.54%) were aged 41-50 years and 65% patients were male compared to female (35%). The mean age was 45.69 ± 22.83 years. Majority (41.54%) of our patients had a preoperative American Society of Anesthesiologists (ASA) classification of II. Majority of patients 36.15% had type 1 open fracture. We found 45 patients with surgical site infection. Admission glucose more than 200 mg/dL was found higher (26.67%) in infected group. Among the hyperglycemic patients 36.36% were classified as ASA III &amp; the surgical site infection for 30 days was found 54.55%. Conclusion: We found that orthopaedic trauma patients without a history of diabetes showed a significant independent correlation between an admission BG value of ≥200 mg/dL and 30-day surgical site infection (SSI). Because of this, admission glucose readings in orthopaedic trauma patients may be a key indicator of the risk of infection.

Enhanced recovery after surgery in patients with normal pressure hydrocephalus undergoing ventriculoperitoneal shunting procedures

ObjectivePatients with idiopathic normal pressure hydrocephalus (iNPH) who undergo ventriculoperitoneal shunt (VPS) placement often belong to an older demographic, putting them at increased risk of postoperative delirium and related complications. Recent literature documenting the use of Enhanced Recovery After Surgery (ERAS) protocols in various disciplines of surgery has shown improved clinical outcomes, faster discharge, and lower readmission rates. Early return to a familiar environment (i.e., discharged home) is a well-known predictor of reduced postoperative delirium. However, ERAS protocols are uncommon in neurosurgery, especially intracranial procedures. We developed a novel ERAS protocol for patients with iNPH undergoing VPS placement to gain further insight regarding postoperative complications, specifically delirium. MethodsWe studied 40 patients with iNPH with indications for VPS. Seventeen patients were selected at random to undergo the ERAS protocol, and twenty-three patients underwent the standard VPS protocol. The ERAS protocol consisted of measures to reduce infection, manage pain, minimize invasiveness, confirm procedural success with imaging, and shorten the length of stay. Pre-operative American Society of Anesthesiologists (ASA) grade was collected for each patient to indicate baseline risk. Rates of readmission and postoperative complications, including delirium and infection, were collected at 48 h, 2 weeks, and 4 weeks postoperatively. ResultsThere were no perioperative complications among the 40 patients. There was no postoperative delirium in any of the ERAS patients. Postoperative delirium was observed in 10 of 23 non-ERAS patients. There was no statistically significant difference between the ASA grade between the ERAS and non-ERAS groups. ConclusionsWe described a novel ERAS protocol for patients with iNPH receiving VPS focusing on an early discharge. Our data suggest that ERAS protocols in VPS patients might reduce the incidence of delirium without increasing the risk of infection or other postoperative complications.

MP72-15 PREOPERATIVE MEDICAL CLEARANCE: UNVEILING PRIMARY CARE NEEDS AT A PUBLIC URBAN MEDICAL CENTER USING UROLOGIC CASE CANCELATION RATES

You have accessJournal of UrologyCME1 Apr 2023MP72-15 PREOPERATIVE MEDICAL CLEARANCE: UNVEILING PRIMARY CARE NEEDS AT A PUBLIC URBAN MEDICAL CENTER USING UROLOGIC CASE CANCELATION RATES Lauren Fink, Matthew Bruha, Frederick Okoye, Lauren Namkoong, Brian McNeil, and Llewellyn Hyacinthe Lauren FinkLauren Fink More articles by this author , Matthew BruhaMatthew Bruha More articles by this author , Frederick OkoyeFrederick Okoye More articles by this author , Lauren NamkoongLauren Namkoong More articles by this author , Brian McNeilBrian McNeil More articles by this author , and Llewellyn HyacintheLlewellyn Hyacinthe More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003340.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Elective surgical case cancelations are a common problem in healthcare, causing patient and staff dissatisfaction, and a financial burden on institutions. Underserved communities have unmet primary care needs, and case cancelations in these populations may reflect chronic disease burdens. We evaluate the role of urologic consultation in improving overall health by identifying undiagnosed or undermanaged conditions during preoperative evaluation METHODS: All canceled elective urologic procedures from two surgeons at one urban center were retrospectively analyzed from 1/2015-12/2019. Chart reviews were performed to obtain reason(s) for cancelation, demographics, medical interventions performed, and American Society of Anesthesiologists (ASA) score pre- and post-operatively. Age-adjusted odds ratio (OR) was calculated for the association between preoperative ASA and medical interventions RESULTS: 1780 total elective cases were scheduled in our review. 551 canceled elective cases were identified with a 30% overall cancelation rate. 250 of those canceled cases were due to >1 undiagnosed or under-managed medical condition(s), representing 14% of the overall cancelation rate. 91.2% of patients were over 60 years old and African American. Notes were available for 111 (44.4%) of the 250 total cases canceled due to undiagnosed or under-managed medical conditions. 83% of these patients received their intended procedures. 35.1% of cases received medication adjustments, most commonly for cardiology and diabetes. Preoperative ASA>3 was found to be significantly associated with medical interventions of any kind (OR 2.6923 [1.1188-6.4788] p=0.0271) CONCLUSIONS: Elective urologic case cancelations were frequent and often related to comorbid conditions. Most patients canceled for medical reasons received optimization and then underwent surgery. ASA scores>3 may assist urologists in underserved urban areas in identifying patients who require medical intervention before elective surgery. Urologic consultation and subsequent preoperative clearance seem to provide a safety net for patients to receive optimization of their medical conditions that otherwise might go unmanaged. Case cancellations can have economic effects, also. Procedure slots are difficult to fill in on short notice. This paired with a high cancelation rate prevents opportunities to generate revenue. Appropriate consultation can eliminate pitfalls by allowing patients to obtain preoperative clearance prior to scheduling their elective cases Source of Funding: SUNY Downstate Medical Center © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1030 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Lauren Fink More articles by this author Matthew Bruha More articles by this author Frederick Okoye More articles by this author Lauren Namkoong More articles by this author Brian McNeil More articles by this author Llewellyn Hyacinthe More articles by this author Expand All Advertisement PDF downloadLoading ...

Predictive Factors of Intraoperative and Early Postoperative Outcome Measures After Anterior Lumbar Interbody Fusions Based on American Society of Anesthesiologists Score

Anterior lumbar interbody fusion (ALIF) is a surgical treatment that requires a close operative plane to the great vessels, which increases the risk of perioperative complications. To our knowledge, no previous study has investigated the American Society of Anesthesiologists (ASA) Physical Status Classification System as a predictive factor for unfavorable perioperative outcomes in ALIF procedures. We aimed to analyze the ASA score as a predictive factor of intraoperative and postoperative outcomes in patients undergoing ALIFs. A retrospective chart review was completed at each center to identify a consecutive set of patients who underwent an ALIF. Univariate and multivariate analyses between patients with preoperative ASA scores of ≤2 and >2 were performed to identify predictive factors that may contribute to adverse intraoperative and early postoperative outcomes. Among 210 patients identified, 59 (28.1%) had an ASA score >2 and 151 (71.9%) had an ASA score ≤2. On multivariate analysis, an ASA score >2 was predictive of increased 90-day reoperations (P= 0.02), estimated blood loss (EBL) (P= 0.02), and operative time (P= 0.02). Previous lumbar surgery was predictive of increased length of stay (P= 0.005), EBL (P < 0.001), 90-day readmission (P= 0.02), and operative time (P < 0.001). Posterior supplemental fixation was predictive of increased length of stay (P= 0.04). Increased number of operative levels was predictive of increased EBL (P < 0.001) and operative time (P < 0.001). Perioperative anticoagulation use was predictive of increased EBL (P < 0.001) CONCLUSIONS: Increased ASA scores were associated with unfavorable outcomes after ALIF and also can be used as a predictive tool for the risk of reoperations.

Preoperative Predictors of Survival in Patients With Spinal Metastatic Disease.

There remains a number of factors thought to be associated with survival in spinal metastatic disease, but evidence of these associations is lacking. In this study, we examined factors associated with survival among patients undergoing surgery for spinal metastatic disease. We retrospectively examined 104 patients who underwent surgery for spinal metastatic disease at an academic medical center. Of those patients, 33 received local preoperative radiation (PR) and 71 had no PR (NPR). Disease-related variables and surrogate markers of preoperative health were identified, including age, pathology, timing of radiation and chemotherapy, mechanical instability by spine instability neoplastic score, American Society of Anesthesiologists (ASA) classification, Karnofsky performance status (KPS), and body mass index (BMI). We performed survival analyses using a combination of univariate and multivariate Cox proportional hazards models to assess significant predictors of time to death. Local PR (Hazard Ratio [HR] = 1.84, P = 0.034), mechanical instability (HR = 1.11, P = 0.024), and melanoma (HR = 3.60, P = 0.010) were significant predictors of survival on multivariate analysis when controlling for confounders. PR vs NPR cohorts exhibited no statistically significant differences in preoperative age (P = 0.22), KPS (P = 0.29), BMI (P = 0.28), or ASA classification (P = 0.12). NPR patients had more reoperations for postoperative wound complications (11.3% vs 0%, P < 0.001). In this small sample, PR and mechanical instability were significant predictors of postoperative survival, independent of age, BMI, ASA classification, and KPS and in spite of fewer wound complications in the PR group. It is possible that PR was a surrogate of more advanced disease or poor response to systemic therapy, independently portending a worse prognosis. Future studies in larger, more diverse populations are crucial for understanding the relationship between PR and postoperative outcomes to determine the optimal timing for surgical intervention. These findings are clinically relevent as they provide insight into factors associated with survival in metastatic spinal disease.

Hemorragia digestiva baja: factores de riesgo de gravedad, necesidad de cirugía de urgencia y mortalidad hospitalaria

Background: Background: There has been a growing interest in determining those risk factors associated with adverse outcomes in early stages of lower gastrointestinal bleeding (LGIB). Objective: The aim of our study was to analyze the risk factors associated with severe bleeding, emergency surgery and in-hospital mortality. Material and methods: We conducted an observational and retrospective study on 1850 patients consecutive managed between January 1999 and December 2018 for LGIB. We analyzed thirteen variables within the first four hours of hospitalization to evaluate risk severity. Diverticular disease was considered to determine factors associated with emergency surgery, and the preoperative American Society of Anesthesiologists (ASA) score was used to assess mortality and emergency surgery. Results: Out of 1850 cases, 194 were severe and 1656 were mild/moderate, Patients &gt; 70 years, with HR &gt; 120 beats/min, BP &lt; 90 mm Hg, oliguria, massive hematochezia, hematocrit &lt; 30%, hemoglobin &lt; 7 g% and need for transfusions presented statistically significant associations with severe bleeding. Age &gt; 70 years, anticoagulation, hypotension, tachycardia, hemoglobin &lt; 7 g%, oliguria, need for transfusion and massive hematochezia were significant predictors of emergency surgery. A prognostic formula was constructed to predict the need for surgery (sensitivity 94%, specificity 74%, positive predictive value 91% and negative predictive value 81%). AUC-ROC: 0,89%. Age &gt; 70 years, anticoagulation, massive hematochezia transfusions and emergency surgery were identified as predictors of mortality. Fifteen of the sixteen patients who underwent surgery and died had ASA ≥ grade 4. Conclusions: The variables analyzed are simple, reliable and statistically significant to estimate the risk of severe bleeding, need for emergency surgery and mortality.

Perioperative risk factors for delayed gastric emptying after pancreaticoduodenectomy: a meta-analysis of the complications

Objective: To evaluate the correlation between the incidence of delayed gastric emptying (DGE) in pancreaticoduodenectomy (PD) and the perioperative possible risk factors. Methods: We searched PubMed, Embase, Cochrane Library, and Medline for studies describing complications related to PD from 2018 to 2022. Statistical analysis was performed using Stata/SE16.0 software. Results: In 6 retrospective studies, 1 systematic review, and 1 randomized controlled trial (RCT) experiment, 12,419 patients (2174 and 10,245 patients, respectively, in DGE and no delayed gastric emptying [NDGE] groups). The preoperative American Society of Anesthesiologists (ASA) score between DGE and NDGE groups (log odds ratio [OR] = 0.23, 95% credible interval [CI]: 0.11–0.35, P &lt; .01), operation time (mean diff. = 21.87, 95% CI: 15.96–27.78, P &lt; .01), estimated intraoperative blood loss (EIBL; mean diff. = 70.67, 95% CI: 17.75–123.58, P &lt; .05), postoperative pancreatic fistula (POPF) (log OR = 0.85, 95% CI: 0.24–1.46, P &lt; .05) were statistically significant. No significant differences in preoperative body mass index (BMI), preoperative biliary drainage, and pancreatic texture were observed (P &gt; .05). Conclusion: The incidence of DGE is significantly correlated with the operation time, preoperative ASA score, POPF, and EIBL,which suggests that the surgeon should thoroughly evaluate the patient through adequate preoperative examination before the operation. Finally, standardized practice and perfect technology are undoubtedly necessary to reduce complications.

Phosphodiesterase-5 Inhibitor Use in Robot Assisted Radical Prostatectomy Patients Is Associated with Reduced Risk of Death: A Propensity Score Matched Analysis of 1,058 Patients.

We investigated whether the use of a phosphodiesterase-5 inhibitor (PDE5i) after robot assited radical prostatectomy has a survival benefit over non-use patients because there are controversial results on the association between PDE5i use and survival outcomes for prostate cancer patients in literature. We designed a retrospective, matched, large-sample cohort study of 5,545 patients who underwent robot assisted radical prostatectomy (RARP) during 2013-2021 in a single institute. The exclusion criteria was patients who were aged >70 years at surgery, American Society of Anesthesiologists (ASA) physical status classification grade 4 or 5, history of other malignancies, patients who started PDE5i 6 months after survery and patients with follow up period less than 24 months after surgery. Among the 1,843 included patients, 1,298 were PDE5i users, and 545 were PDE5i non-users. We performed propensity score matching (PSM) of PDE5i users (n=529) with non-users (n=529) by adjusting for the variables of age, Gleason grade group, pathological T stage, preoperative ASA physical status grade, and International Index of Erectile Function score. There were no significant difference in patient characteristics according to PSM. Kaplan-Meier curve revealed the difference of overall survival for PDE5i users and non-users (clustered log-rank test p<0.05). In a stratified Cox regression analysis, PDE5i use after RARP was associated with improved overall survival and reduced risk of death (hazard ratio 0.43; confidence interval 0.24-0.79; p=0.007). The limitation of this study was that the indication for the prescription of PDE5i was not given. PDE5i administration after RARP were associated with overall survival of patients with prostate cancer. A further randomized control trial may reveal whether routine use of PDE5i after prostatectomy can improve survival of prostate cancer patient.

Operative Outcomes After Cervical Diffuse Idiopathic Skeletal Hyperostosis Fracture in the Elderly.

Cervical diffuse idiopathic skeletal hyperostosis (DISH) fractures are frequently unstable and carry significant risk of neurologic injury and death. Most patients with DISH fractures are elderly (>70 years) with significant comorbidities. We assessed factors that contribute to outcomes in elderly patients with cervical DISH fractures. Elderly patients with cervical DISH fractures from 2008 to 2017 were included in this retrospective multi-institutional cohort study. Predictor variables included injury level, surgical approach, preinjury comorbidities, American Society of Anesthesiologists (ASA) score, American Spinal Injury Association (ASIA) impairment scale grade, preoperative anticoagulation status, and the subaxial cervical spine injury classification system (SLIC) score. Univariate and multivariate analyses were utilized to identify factors associated with 30-day mortality and ambulatory status at discharge. A total of 48 patients, mean age 74.7 years old (range 60-96), underwent cervical fixation for DISH fractures. Average SLIC score was 6.30 ± 1.2 (range 5-8), and most frequent fracture level was at C6 to -C7 (31.3%) followed by C7-T1 (25.0%). Forty (83.3%) patients underwent posterior fixation, 7 (14.6%) with anterior fixation, and 1 (2.1%) had combined approach. Ten (20.4%) patients died within 30 days of surgery. Multivariate analysis demonstrated that poorer preoperative ASIA grade (OR 2.35, P = 0.003, CI = 1.33-4.14) and ASA score >3 (P = 0.027) had increased risk of being nonambulatory at discharge. Higher SLIC score was associated with increased 30-day mortality (P = 0.021, CI = 1.20-9.60). Cervical DISH fractures can be highly unstable, for which instrumentation and fixation are indicated. Surgical decision-making should focus on preoperative ASIA grade, SLIC score, and ASA score. The study is relevant due to an aging poulation predisposed to cervical DISH fractures.

Jump in Elective Total Hip and Knee Arthroplasty Numbers at Age 65 Years: Evidence for Moral Hazard?

Introduction:Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are outstanding options for many older patients at the discretion of the patient and the surgeon. As patients turn 65 years, greater than 98% of the US population becomes eligible for Medicare, and this represents a time of changing healthcare coverage for many.Methods:Patients undergoing elective TKA and THA were abstracted from the 2012 to 2018 National Surgical Quality Improvement Program database. Incidences of TKA and THA (combined and separate) were plotted and assessed by age. To assess factors associated with who “delayed” surgery until 65 years, demographic and preoperative characteristics, and postoperative adverse events were compared for the 2 years above and the 2 years below the 65-year-old mark with multivariate analysis. Significance was set at P < 0.05.Results:In total, 515,139 TKA and THA patients were identified (62.04% TKA and 37.95% THA). When the number of procedures was plotted by age, a discontinuity in the bell-shaped curve was noted at age 65 years. Highlighting this finding, the changes in percent population between 63 and 64 years was −1.52%, between 64 and 65 years was +15.36%, and between 65 and 66 years was −2.32%. Relative to those who were 63 and 64 years (n = 36,511), those who were 65 and 66 years (n = 41,671) were more likely to be female, be non-Hispanic White, have a lower body mass index, and have a lower functional status but were not different in the preoperative American Society of Anesthesiologists class.Conclusion:In this large national sample, there was a clear step increase in undergoing TKA or THA once patients reached the age of 65 years (Medicare eligibility). This discontinuity in the bell-shaped curve may be evidence for a moral hazard in healthcare markets. Although factors in decision-making were not assessed, there were demographic factors associated with this step finding.

What patient factors influence bariatric surgery outcomes? A multiple regression analysis of Ontario Bariatric Registry data.

Background:As bariatric surgery evolves and gains popularity, statistical analysis of its outcomes could improve the process of decision-making and risk assessment. This study aimed to evaluate the influence of age and other factors on bariatric surgery outcomes in order to improve patient selection and outcomes.Methods:We analyzed data from the Ontario Bariatric Registry to evaluate the influence of age and 10 other factors on early (< 90 d) and 1-year surgical outcomes among patients aged 18 years or older who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) between January 2010 and May 2013. Early outcomes included composite adverse events and readmission. The 1-year outcomes included percent excess body weight loss (%EBWL), and remission of diabetes mellitus and hypertension. We performed multiple regression analysis to identify independent variables that influenced these outcomes.Results:We identified 3166 patients (2655 women [83.9%] and 511 men [16.1%], mean age 44.8 yr, mean body mass index [BMI] 48.4) who underwent LRYGB (2839 [89.7%]) or LSG (327 [10.3%]) over the study period and completed their 1-year follow-up. Preoperative American Society of Anesthesiologists (ASA) score and history of angina were independent variables that influenced the composite adverse event outcome. Obstructive sleep apnea was the only factor that influenced early readmission. The independent factors that influenced %EBWL were age, type of surgery, BMI and baseline glycosylated hemoglobin (HbA1c) level: age was found to influence hypertension remission, and HbA1c level and obstructive sleep apnea were found to influence diabetes remission.Conclusion:Complications after bariatric surgery can be predicted by preoperative ASA score and history of angina; patient age was not related to an increase in postoperative complications. These factors could help both surgeon and patient make appropriate surgical decisions.

Higher American Society of Anesthesiologists Classification Does Not Limit Safety or Improvement Following Minimally Invasive Transforaminal Lumbar Interbody Fusion.

ObjectiveThe American Society of Anesthesiologists (ASA) physical status classification has been used to risk stratify surgical candidates. Our study compares outcomes of minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) procedures based on preoperative ASA physical status classification. MethodsA surgical registry was reviewed for primary, single-level MIS TLIF patients. Patients were categorized by preoperative ASA physical status classification: ASA I, ASA II, ASA III+. Perioperative complications were compared among groups. Patient-reported outcome measures (PROMs) for back pain, leg pain, physical function, and disability were recorded preoperatively and at 6-week, 12-week, 6-month, 1-year, and 2-year postoperative timepoints. PROM improvement from baseline (ΔPROM) and minimum clinically important difference (MCID) achievement was calculated for each timepoint and compared among groups. MCID achievement was determined as ΔPROMs that surpassed previously established MCID values. ResultsOf the 487 patients, 64 had an ASA classification of I, whereas 336 had an ASA of II, and 87 had an ASA of III or greater. Rates of complications were not associated with ASA classification (all p>0.050). Neither mean PROM scores nor ΔPROM scores were significantly associated with ASA classification at any timepoint (all p>0.050). MCID achievement was significantly associated with ASA classification for back pain at 1 year only (p=0.041). Overall MCID achievement was not significantly associated with ASA classification for any PROM (p>0.050). ConclusionWhile ASA classification has been commonly used to risk stratify surgical candidates for spinal procedures, patients with an ASA of III or greater may be able to achieve similar long-term outcomes following MIS TLIF given proper selection criteria.

Identification of factors contributing to the development of postoperative delirium in geriatric patients with hip fractures- A prospective study.

Geriatric hip fractures are a major cause of concern globally and often a frequent reason for morbidity and mortality. Postoperative delirium (POD) is a frequent but often under-diagnosed complication, especially after a major hip surgery. Some of the factors that have been associated with POD are diabetes, high American Society of Anesthesiologists (ASA) grading, electrolyte imbalance, and blood pressure fluctuations. Malnutrition as a risk factor is only recently being recognized. Although there are many possible risk factors reported, they are quite conflicting and not very clear. Therefore, we have attempted to conduct this study to identify the potential risk factors for the development of POD in patients with hip fractures. A prospective observational study was performed on 110 geriatric hip fracture patients admitted to tertiary health care in South India. Data regarding preoperative blood investigations, ASA grading, hypertension and diabetes status, MNA (mini nutritional assessments) status, serum albumin, and serum electrolytes values were recorded. The Confusion Assessment Method tool (CAM) was used to diagnose delirium in the postoperative period. Statistical analysis was done for various factors influencing the occurrence of POD. Among the total of 110 cases of geriatric hip fractures patients, 44.5% of the patients developed postoperative delirium. Advancing age, hypoalbuminemia, malnourishment, and uncontrolled diabetes played an important role to the development of post operative delirium in patients with hip fractures. Advancing age, hypoalbuminemia, malnourishment, and uncontrolled diabetes are strong predictors for the development of postoperative delirium in geriatric hip fracture patients. Since age is a non-modifiable risk factor, interventional strategies aimed at correcting modifiable risk factors like nutrition, serum albumin levels, and diabetes control play an important part in preventing delirium in the postoperative period in elderly hip fracture patients.MeSH terms: Hip Fractures, Postoperative Complication, Delirium, Nutrition Assessment, Serum Albumin.

Analysis of risk factors affecting mortality in elderly patients operated on for hip fractures: A retrospective comparative study.

The aims of this study were (1) to investigate the effects of different demographic and perioperative modalities on mortality rates and (2) to compare mortality rates between different implants in elderly patients operated on for hip fractures. In this retrospective study, a total of 314 patients who were operated on for hip fractures were included study. Patients were then divided into four groups based in their implant types: long-stem cementless bipolar hemiarthroplasty (n = 124; 102 female, 22 male; mean age = 84.2 ± 6.4 years), standard-stem cementless bipolar hemiarthroplasty (n = 74; 48 female, 26 male; mean age = 83.5 ± 6.9 years), antegrade intertrochanteric nail (n = 61; 35 female, 26 male; mean age = 78.5 ± 6.8 years), and total hip arthroplasty (n = 55; 34 female, 21 male; mean age = 72.5 ± 4.3 years). Data including gender, age, duration from injury to surgery, American Society of Anesthesiologists (ASA) score, comorbidities, use of antiplatelet agents, Barthel Index of Activities of Daily Living, type of anesthesia, operation time, preoperative hemoglobin values, blood transfusions given, duration of hospital stay, complications, and type of fracture were recorded. Overall, the mean follow-up was 36.5 (range = 0 - 107) months. The overall mortality rate was 53.2%. The median survival duration was 44.2 ± 5 months (range = 34.3 - 54). Survival rates were found significantly different among the groups (P = 0.001). In the first three years postoperatively, the mortality rate was higher in the standard-stem bipolar hemiarthroplasty group, but in the long-term follow-up, the long-stem bipolar hemiarthroplasty group exhibited the higher mortality rates. It was observed that some parameters had statistically significant effects on the mortality rates. Male gender, higher age, lower hemoglobin values, increased number of blood transfusions, ASA scores ≥3, the existence of ≥ 3 comorbidities were found as main predictors of increased mortality rates. The results of this study have shown that age, gender, preoperative hemoglobin levels, ASA scores, and comorbidities are significant factors affecting mortality in elderly patients operated on for hip fractures. Long-stem cementless bipolar hemiarthroplasty appears to show similar rates of mortality with standard-stem cementless bipolar hemiarthroplasty. Level III, Therapeutic Study.