Predictors Of Overall Complications Research Articles

Complications following cranioplasty: incidence and predictors in 348 cases.

The factors that contribute to periprocedural complications following cranioplasty, including patient-specific and surgery-specific factors, need to be thoroughly assessed. The aim of this study was to evaluate risk factors that predispose patients to an increased risk of cranioplasty complications and death. The authors conducted a retrospective review of all patients at their institution who underwent cranioplasty following craniectomy for stroke, subarachnoid hemorrhage, epidural hematoma, subdural hematoma, and trauma between January 2000 and December 2011. The following predictors were tested: age, sex, race, diabetic status, hypertensive status, tobacco use, reason for craniectomy, urgency status of the craniectomy, graft material, and location of cranioplasty. The cranioplasty complications included reoperation for hematoma, hydrocephalus postcranioplasty, postcranioplasty seizures, and cranioplasty graft infection. A multivariate logistic regression analysis was performed. Confidence intervals were calculated as the 95% CI. Three hundred forty-eight patients were included in the study. The overall complication rate was 31.32% (109 of 348). The mortality rate was 3.16%. Predictors of overall complications in multivariate analysis were hypertension (OR 1.92, CI 1.22-3.02), increasing age (OR 1.02, CI 1.00-1.04), and hemorrhagic stroke (OR 3.84, CI 1.93-7.63). Predictors of mortality in multivariate analysis were diabetes mellitus (OR 7.56, CI 1.56-36.58), seizures (OR 7.25, CI 1.238-42.79), bifrontal cranioplasty (OR 5.40, CI 1.20-24.27), and repeated surgery for hematoma evacuation (OR 13.00, CI 1.51-112.02). Multivariate analysis was also applied to identify the variables that affect the development of seizures, the need for reoperation for hematoma evacuation, the development of hydrocephalus, and the development of infections. The authors' goal was to provide the neurosurgeon with predictors of morbidity and mortality that could be incorporated in the clinical decision-making algorithm. Control of a patient's risk factors and early recognition of complications may help practitioners avoid the exhaustive list of complications.

Gender differences in in-hospital clinical outcomes after percutaneous coronary interventions: an insight from a Japanese multicenter registry.

BackgroundGender differences in clinical outcomes after percutaneous coronary intervention (PCI) among different age groups are controversial in the era of drug-eluting stents, especially among the Asian population who are at higher risk for bleeding complications.Methods and ResultsWe analyzed data from 10,220 patients who underwent PCI procedures performed at 14 Japanese hospitals from September 2008 to April 2013. A total of 2,106 (20.6%) patients were women. Women were older (72.7±9.7 vs 66.6±10.8 years, p<0.001), and had a lower body mass index (23.4±4.0 vs 24.3±3.5, p<0.001), with a higher prevalence of hypertension (p<0.001), hyperlipidemia (p<0.001), insulin-dependent diabetes (p<0.001), renal failure (p<0.001), and heart failure (p<0.001) compared with men. Men tended to have more bifurcation lesions (p = 0.003) and chronic totally occluded lesions (p<0.001) than women. Crude overall complications (14.8% vs 9.5%, p<0.001) and the rate of bleeding complications (5.3% vs 2.8%, p<0.001) were significantly higher in women than in men. On multivariate analysis in the total cohort, female sex was an independent predictor of overall complications (OR, 1.47; 95% CI, 1.26–1.71; p<0.001) and bleeding complications (OR, 1.74; 95% CI, 1.36–2.24; p<0.001) after adjustment for confounding variables. A similar trend was observed across the middle-aged group (≥55 and <75 years) and old age group (≥75 years).ConclusionsWomen are at higher risk than men for post-procedural complications after PCI, regardless of age.

Brief communication (Original). Predictive factors for postoperative complications in radical nephrectomy for renal cell carcinoma

Abstract Background: Radical nephrectomy is the treatment of choice for large renal cell carcinoma (RCC). Objectives: To describe the complications after radical nephrectomy for suspected or proven RCC and analyze the risk factors. Materials and methods: We retrospectively reviewed medical records from 110 patients who underwent radical nephrectomy for RCC in our institution between January 2007 and December 2013. The clinicopathological data of all patients were recorded and complications were graded using modified Clavien classification. Univariate and multivariate analysis was made of the predictive factors for complications. Results: Fifty postoperative complications occurred in 34 patients (31%) within 30 days, including 11% transfusion related complications. There were 22% minor complications (6% grade 1, 16% grade 2) and 9% major complication (5% grade 3, 2% grade 4, and 2% grade 5). The most common complications were transfusion-related, re-laparotomy because of bleeding, and prolong ileus. In univariate analysis, pathological T-stage (P = 0.001), American Society of Anesthesiologists (ASA) score (P = 0.007), tumor size (P = 0.01), and tumor diameter &gt;4 cm (P = 0.03) were significant predicting factors. Major Charlson comorbidity index (CCI &gt;2) was the only significant factor for major complications (P = 0.04). In multivariate analysis, ASA score was a significant independent predictor for overall complications (odds ratio 4.83, P = 0.01). Conclusions: ASA score was a significant predictive factor for overall postoperative complications. Comorbidities was also a predictor for major complications in radical nephrectomy. Preoperative risk stratification for complications should be considered during decision-making and for proper counseling of patients.

Short-term perioperative outcomes of patients treated with radical cystectomy for bladder cancer included in the National Surgical Quality Improvement Program (NSQIP) database.

We report the contemporary outcomes of radical cystectomy (RC) in patients with bladder cancer using a national, prospective perioperative database specifically developed to assess the quality of surgical care. The National Surgical Quality Improvement Program (NSQIP) database was queried from 2006 to 2011 for RC. Data on postoperative complications, operative time, length of stay, blood transfusions, readmission, and mortality within 30 days from surgery were abstracted. Overall, 1094 patients undergoing RC were identified. Rates of overall complications, transfusions, prolonged length of hospitalization, readmission, and perioperative mortality were 31.1%, 34.4%, 25.9%, 20.2%, and 2.7%, respectively. Body mass index represented an independent predictor of overall complications on multivariate analysis (p = 0.04). Baseline comorbidity status was associated with increased odds of postoperative complications, prolonged operative time, transfusion, prolonged hospitalization, and perioperative mortality. In particular, patients with cardiovascular comorbidities were 2.4 times more likely to die within 30 days following cystectomy compared to their healthier counterparts (p = 0.04). Men had lower odds of prolonged operative time and blood transfusions (p ≤ 0.03). Finally, the receipt of a continent urinary diversion was the only predictor of readmission (p = 0.02). Our results are limited by their retrospective nature and by the lack of adjustment for hospital and tumour volume. Complications, transfusions, readmission, and perioperative mortality remain relatively common events in patients undergoing RC for bladder cancer. In an era where many advocate the need for prospective multi-institutional data collection as a means of improving quality of care, our study provides data on short-term outcomes after RC from a national quality improvement initiative.

Complications Associated With Photoselective Vaporization of the Prostate: Categorization by a Panel of GreenLight Users According to Clavien Score and Report of a Single-center Experience

To devise and validate a system to categorize GreenLight photoselective vaporization of prostate (PVP) complications according to Clavien score (CS), to report complications of PVP using this categorization, and to determine risk factors. A survey questionnaire was distributed to all participants of the second meeting of the Group of GreenLight Users. They were asked to grade PVP complications according to CS. We calculated the mode CS for each complication from the survey data to propose a categorization system for complications of PVP. Complications encountered in a large single-center cohort of 370 patients were reported according to this system. We assessed the reproducibility of CS by estimating inter-rater agreement by the Fleiss kappa. We performed univariate and multivariate analyses to determine risk factors for complications. Of the 67 meeting participants, 42 (62.7%) completed the survey. Overall agreement between urologists was fair (Fleiss kappa = 0.356). Among the 370 patients, 21 (5.7%) had intraoperative complications, 147 (39.7%) had postoperative complications, and 70 (18.9%) had long-term complications. Among the postoperative complications, 125 patients (33.8%) were classified as Clavien grade I, 58 (15.7%) as Clavien grade II, 4 (1.1%) as Clavien grade IIIb, 5 (1.3%) as Clavien grade IVa, 1 (0.3%) as Clavien grade IVb, and 1 (0.3%) as Clavien grade V. In multivariate analysis, the only predictor of overall complications was a polymicrobial preoperative urine culture. The grading of PVP complications by CS is fairly reproducible. We are the first to propose a system for the categorization of PVP complications. PVP complications are frequent but most often minor.

The Relationship between Preoperative Wound Classification and Postoperative Infection: A Multi-Institutional Analysis of 15,289 Patients

BackgroundDespite advances in surgical techniques, sterile protocols, and perioperative antibiotic regimens, surgical site infections (SSIs) remain a significant problem. We investigated the relationship between wound classification (i.e., clean, clean/contaminated, contaminated, dirty) and SSI rates in plastic surgery.MethodsWe performed a retrospective review of a multi-institutional, surgical outcomes database for all patients undergoing plastic surgery procedures from 2006-2010. Patient demographics, wound classification, and 30-day outcomes were recorded and analyzed by multivariate logistic regression.ResultsA total of 15,289 plastic surgery cases were analyzed. The overall SSI rate was 3.00%, with superficial SSIs occurring at comparable rates across wound classes. There were similar rates of deep SSIs in the clean and clean/contaminated groups (0.64%), while rates reached over 2% in contaminated and dirty cases. Organ/space SSIs occurred in less than 1% of each wound classification. Contaminated and dirty cases were at an increased risk for deep SSIs (odds ratios, 2.81 and 2.74, respectively); however, wound classification did not appear to be a significant predictor of superficial or organ/space SSIs. Clean/contaminated, contaminated, and dirty cases were at increased risk for a postoperative complication, and contaminated and dirty cases also had higher odds of reoperation and 30-day mortality.ConclusionsAnalyzing a multi-center database, we found that wound classification was a significant predictor of overall complications, reoperation, and mortality, but not an adequate predictor of surgical site infections. When comparing infections for a given wound classification, plastic surgery had lower overall rates than the surgical population at large.

Predictive factors of complications after robot‐assisted laparoscopic partial nephrectomy: a retrospective multicentre study

To analyse the predictive factors of complications after robot-assisted laparoscopic partial nephrectomy (RALPN). Data from six French institutions on 240 patients who underwent RALPN between 2009 and 2011 were retrospectively reviewed. Clinical (age, body mass index, American Society of Anesthesiologists and Charlson comorbidity index scores, anticoagulant treatment), tumoral (size, R.E.N.A.L nephrometry score) and operative (surgeon experience, blood loss, opening of the collecting system, operating time) variables were considered. Univariate and multivariate regression models were used to assess the impact of these variables on the occurrence of global and major postoperative complications, classified according to the Clavien system. The median (range) patient age was 61 (26-83) years. Tumours were of low complexity in 62% of cases. Median (range) operating time, blood loss and warm ischaemia time were 161 (45-425) min, 100 (0-2500) mL and 20 (0-59) min, respectively. Postoperative complications occurred in 79 (33%) patients. Complications were ≥ grade III in 25 (10%) patients and were mostly haemorrhagic. In multivariate analysis, surgeon's experience (hazard ratio [HR]: 2.14 [1.07-4.27], P = 0.03) and blood loss (HR: 1.002 [1.001-1.003], P < 0.001) were independent predictors of overall complications. When considering major complications, opening of the collecting system was the only factor that was significant (OR: 2.99 [1.2-7.26], P = 0.02). Nephrometry R.E.N.A.L. score was not associated with postoperative complications. In our experience, RALPN is associated with a 30% risk of postoperative complications; surgeon's experience, blood loss and opening of the collecting system were the three predictors of postoperative complications.

631 RENAL TUMOR CONTACT SURFACE AREA: A NOVEL CT-PARAMETER FOR PREDICTING PERI-OPERATIVE OUTCOMES USING ADVANCED IMAGE-PROCESSING SOFTWARE

You have accessJournal of UrologyKidney Cancer: Evaluation & Staging (I)1 Apr 2013631 RENAL TUMOR CONTACT SURFACE AREA: A NOVEL CT-PARAMETER FOR PREDICTING PERI-OPERATIVE OUTCOMES USING ADVANCED IMAGE-PROCESSING SOFTWARE Scott Leslie, Andre Luis de Castro Abreu, Hamed Ahmadi, Andre K Berger, R James Yu, Sheaumei Tsai, Steve Dong, Raed A Azhar, Mehrdad Alemozaffar, Arnaud Marien, Sunao Shoji, Monish Aron, Inderbir S Gill, Vinay A Duddalwar, and Mihir M Desai Scott LeslieScott Leslie Los Angeles, CA More articles by this author , Andre Luis de Castro AbreuAndre Luis de Castro Abreu Los Angeles, CA More articles by this author , Hamed AhmadiHamed Ahmadi Los Angeles, CA More articles by this author , Andre K BergerAndre K Berger Los Angeles, CA More articles by this author , R James YuR James Yu Los Angeles, CA More articles by this author , Sheaumei TsaiSheaumei Tsai Los Angeles, CA More articles by this author , Steve DongSteve Dong Los Angeles, CA More articles by this author , Raed A AzharRaed A Azhar Los Angeles, CA More articles by this author , Mehrdad AlemozaffarMehrdad Alemozaffar Los Angeles, CA More articles by this author , Arnaud MarienArnaud Marien Los Angeles, CA More articles by this author , Sunao ShojiSunao Shoji Los Angeles, CA More articles by this author , Monish AronMonish Aron Los Angeles, CA More articles by this author , Inderbir S GillInderbir S Gill Los Angeles, CA More articles by this author , Vinay A DuddalwarVinay A Duddalwar Los Angeles, CA More articles by this author , and Mihir M DesaiMihir M Desai Los Angeles, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.183AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The surface area of contact that a tumor has with the adjacent renal parenchyma considerably determines the extent of resection of kidney tissue during partial nephrectomy (PN), and thus may impact on peri-operative outcomes. We present a novel method of calculating renal tumor contact surface area (CSA) using image-processing technology and correlate it with peri-operative variables in patients undergoing PN. METHODS From January 2010 - August 2011, 162 patients underwent minimally invasive PN for tumor, and had CSA data available using image rendering software (3D Synapse - Fuji film&©). Pre-operative CT scans were evaluated using 3D synapse to calculate CSA for each tumor (figure). This was performed by first calculating the tumor volume and percentage of tumor located within the renal parenchyma. The total surface area (4πr2) of the tumor was then multiplied by the percent intra-parenchymal component to give the CSA for each tumor. CSA was then correlated with baseline demographics and peri-operative outcomes. RESULTS Mean tumor size was 3.1 cm and mean CSA was 18.3 cm2. Univariate analysis demonstrated that CSA significantly correlated with blood loss (p=0.0001), operative time (p=0.003), length of hospital stay (p=0.0028), and post-operative eGFR (0.0124). On multivariable logistic regression a CSA ≥ 20 cm2 was an independent predictor of overall complications and adverse perioperative outcomes. CONCLUSIONS In patients undergoing partial nephrectomy, tumors with greater contact surface area with surrounding renal parenchyma require a more extensive resection, thus impacting on peri-operative outcomes including blood loss, operative duration, complications and renal function. If these findings are validated in larger cohorts, future nephrometry systems could incorporate CSA measurements to objectively quantify renal tumor complexity and predict peri-operative outcomes of partial nephrectomy surgery. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e258 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Scott Leslie Los Angeles, CA More articles by this author Andre Luis de Castro Abreu Los Angeles, CA More articles by this author Hamed Ahmadi Los Angeles, CA More articles by this author Andre K Berger Los Angeles, CA More articles by this author R James Yu Los Angeles, CA More articles by this author Sheaumei Tsai Los Angeles, CA More articles by this author Steve Dong Los Angeles, CA More articles by this author Raed A Azhar Los Angeles, CA More articles by this author Mehrdad Alemozaffar Los Angeles, CA More articles by this author Arnaud Marien Los Angeles, CA More articles by this author Sunao Shoji Los Angeles, CA More articles by this author Monish Aron Los Angeles, CA More articles by this author Inderbir S Gill Los Angeles, CA More articles by this author Vinay A Duddalwar Los Angeles, CA More articles by this author Mihir M Desai Los Angeles, CA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Prediction of perioperative outcomes following minimally invasive partial nephrectomy: role of the R.E.N.A.L nephrometry score

Objective characterization of renal mass anatomy facilitates treatment selection and prediction of surgical outcomes. We investigated R.E.N.A.L nephrometry score (NS) efficacy in predicting outcomes after minimally invasive nephron-sparing surgery (MINSS). A total of 250 patients with 252 renal masses underwent MINSS by a surgeon between January 2003 and July 2011. Preoperative films were available for 181 (72 %) renal masses, which were retrospectively assigned a NS. NS was categorized as low, moderate or high, reflecting tumor complexity. Perioperative outcomes were analyzed by NS category. Outcomes for laparoscopic (LPN) versus robotic (RALPN) partial nephrectomy were compared. Multivariable regression was used to investigate predictors of postoperative complications. Among 181 renal masses, 128 (71 %) were managed by LPN and 53 were (29 %) by RALPN. And 103, 74 and 4 renal lesions were low, medium and high complexity, respectively. For low versus medium versus high NS, respective overall complication rate was 5.8 versus 16.0 versus 50.0 % (p = 0.01); mean warm ischemia time (WIT) was 29 versus 33 versus 39 min (p = 0.02); and transfusion rate was 5/103 (4.8 %) versus 6/74 (8.1 %) versus 1/4 (25 %) (p = 0.20). NS category was significantly associated with overall complication rate (p = 0.04) and Clavien grade III complication rate (p = 0.05). Nearness to the collecting system ("N") was significantly associated with overall complications (p = 0.02) and postoperative hemorrhage (p = 0.02). Postoperative outcomes for LPN versus RALPN were statistically similar across all categories. R.E.N.A.L NS is predictive of overall complications and WIT during MINSS. Our data also suggest that "N" score may be used as a single predictor of overall complications and postoperative hemorrhage following MINSS.

Application of a standardized anatomical classification in a Chinese partial nephrectomy series

Preoperative aspects and dimensions used for an anatomical classification is a standardized system to assess the anatomical complexity of renal tumors and its impact on perioperative outcomes of partial nephrectomy. The objective is to apply the preoperative aspects and dimensions used for an anatomical classification in a series of Chinese patients undergoing open or laparoscopic partial nephrectomy. A total of 195 consecutive renal tumors treated with open partial nephrectomy or laparoscopic partial nephrectomy between June 2008 and May 2011 were included in this analysis. All the preoperative images and clinical records were retrospectively evaluated. Complication rate, warm ischemia time, operation time and degree of blood loss were compared among different risk groups (low risk: preoperative aspects and dimensions used for an anatomical score 6-7; intermediate risk: preoperative aspects and dimensions used for an anatomical score 8-9; high risk: preoperative aspects and dimensions used for an anatomical score ≥10). The original preoperative aspects and dimensions used for an anatomical score system was modified by replacing rim location with hilar vasculature involvement and tested for prediction of overall complications. The median preoperative aspects and dimensions used for an anatomical score was 8. Overall complication rate was 17.9%. Preoperative aspects and dimensions used for an anatomical score was an independent predictor for perioperative complications. Intermediate and high-risk patients had a four- and 37-fold higher risk of complications respectively (P = 0.012, P < 0.001). Higher preoperative aspects and dimensions used for an anatomical score predicted longer operation time (P = 0.007), warm ischemia time (P < 0.001) and higher degree of blood loss (P = 0.003) in open partial nephrectomy patients. In laparoscopic partial nephrectomy patients, preoperative aspects and dimensions used for an anatomical score was also a predictor for warm ischemia time (P = 0.033); however, it was not significant for operation time and degree of blood loss (P = 0.325, P = 0.302). The modified preoperative aspects and dimensions used for an anatomical score was an independent predictor for overall complications (P < 0.001); however, its superiority could not be verified (P = 0.847). The preoperative aspects and dimensions used for an anatomical classification predicts the risk of overall complications in Chinese patients undergoing nephron-sparing surgery. Replacing the rim location with hilar vasculature involvement might be a promising modification of this scoring system.

Predictors of Warm Ischemia Time and Perioperative Complications in a Multicenter, International Series of Robot-Assisted Partial Nephrectomy

Background Warm ischemia time (WIT) and complication rates are two important parameters for evaluating the perioperative results of robot-assisted partial nephrectomy (RAPN). Few data are available about the clinical predictors of WIT and overall complications. Objective To identify clinical predictors of WIT and perioperative complications. Design, setting, and participants This is a retrospective study including 347 patients who underwent RAPN for suspicious renal cell carcinoma (RCC) at four referral centers from September 2008 to September 2010. Intervention All patients underwent RAPN using the da Vinci S Surgical System with hilar clamping. Measurements WIT >20 min and overall complication rates were the main outcomes. Postoperative complications were classified according to the Clavien/Dindo system. Moreover, the following perioperative variables were considered: clinical tumor size, anatomical tumor characteristics according to Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) classification score, surgeon experience, console time, blood loss, and upper collecting system (UCS) repair. Results and limitations WIT >20 min was reported in 125 (36%) cases. Intraoperative and postoperative complications were observed in 10 (2.9%) and 41 (11.8%) cases, respectively. Surgeon experience (odds ratio [OR]: 6.381; 95% confidence interval [CI], 3.687–11.042; p < 0.001), clinical tumor size (OR: 1.022; 95% CI, 1.002–1.044; p = 0.03), the other anatomic characteristics determined by the PADUA classification score (OR: 1.294; 95% CI, 1.080–1.549; p = 0.005), and the UCS repair (OR: 2.987; 95% CI, 1.728–5.165; p < 0.001) turned out to be independent predictors of WIT >20 min. Similarly, surgeon experience (OR: 3.937; 95% CI, 2.011–7.705; p < 0.001), clinical tumor size (OR: 1.033; 95% CI, 1.009–1.058; p = 0.007), and the other anatomical characteristics determined by the PADUA classification score (OR: 1.427; 95% CI, 1.149–1.773; p < 0.001) turned out to be independent predictors of overall complication rates. The retrospective design is the main limitation of this multicenter, international study. Therefore, some patient characteristics and comorbidities were not recorded. Conclusions Anatomic tumor characteristics as determined by the PADUA classification score were independent predictors of WIT and overall complications, once adjusted for the effects of surgeon experience and clinical tumor size.

Assessment of Advanced Age as a Risk Factor in Microvascular Breast Reconstruction

The population of elderly people is the fastest growing population in the United States. Because breast cancer typically affects the elderly population, surgeons will be performing more mastectomies in older patients. In this study, we evaluate the risks of microvascular breast reconstruction as a function of increasing age. Between July 2002 and September 2009, a retrospective analysis of 818 free-flap breast reconstructions was used to assess the risk of age on surgical outcomes. Patient comorbidities, the American Society of Anesthesiologists (ASA) classification, and length of hospital stay were used to assess the rates of complications among our age cohorts. Advanced age was not associated with increased complications (P > 0.69). ASA class was a significant predictor of overall complications (P < 0.03) as well as the rate of fat necrosis (P < 0.01) and hematoma (P < 0.001). Flap loss occurred in 1.5% of operations, but there was no difference among the various age groups. Previous surgery was associated with an increased risk of flap loss (P < 0.001), and hypertension also increased the risk of thrombosis (P < 0.04). There was no difference in mean length of hospital stay (4.27 days). Advanced age should not be considered a risk factor for microvascular breast reconstruction. Because ASA status did predict overall surgical complications, surgeons should consider the patients' overall health status in deciding whether to operate.

Bile cultures: A guide to infectious complications after pancreaticoduodenectomy

The aim of this study was to evaluate the utility of intraoperative bile cultures on the outcome of patients undergoing pancreaticoduodenectomy. A review of a hepato-pancreato-biliary database was performed to identify all patients who had a pancreaticoduodenectomy from 1/1998 to 8/2008. Two hundred twenty-eight patients were evaluated, with preoperative biliary stenting performed in 129 out of 229 patients (57%), with 63/129(49%) had bile cultures taken intraoperatively, 39/129(30%) having positive bile cultures. Neither preoperative biliary stenting (incidence of complication: 54% with stent vs. 51% without, P = 0.9) nor positive bile culture (incidence of complication: 54% with positive bile culture vs. 53% without, P = 0.9) were predictors of overall complications. Length of operating time, length of hospital stay, blood loss, blood transfusion, and severity of complications were similar in the group with and without stent. There were 19 different organisms identified with not a single species was a statistically significant predictor of neither severity of complication nor increased length of stay. Preoperative biliary stenting correlates with similar rate of biliary infections, however, intraoperative bile culture allows for early appropriate antibiotic use, which maintains a similar morbidity and infectious incidence as in patients without stents.

Modeling major lung resection outcomes using classification trees and multiple imputation techniques

Modeling of operative risks associated with major lung resection is potentially inaccurate and inefficient because of incomplete observations for predictor variables (covariates). Missing values do not usually occur randomly, potentially introducing an important source of bias in modeling. Deletion of cases with missing data also results in loss of precision. The current study analyzes incomplete variables as potential predictors of outcomes after major lung resection using imputation techniques. We analyzed major lung resection patients treated from 1980 to 2006 for predictors of pulmonary, cardiovascular, and overall complications, as well as mortality. Predictive variables were initially determined using classification and regression tree (CART) methods. Imputation models were developed and variables with missing values were multiply imputed. We fit a logistic regression model for each outcome using CART variables and any covariates that were of interest clinically. Of 1046 resected patients, serum albumin and diffusing capacity (DLCO%) had a large number of missing values (32% and 13% missing, respectively). Models included 10 covariates for pulmonary complications (p<0.05 for DLCO% and forced expiratory volume in the first second [FEV1%]), 12 covariates for cardiovascular complications (p<0.05 for FEV1%, extent of resection, year of operation, and age), 15 covariates for overall complications (p<0.05 for DLCO%, performance status, serum albumin, and FEV1/FVC ratio), and 12 covariates for death (p<0.05 for DLCO%, extent of resection, and operation year). We identified serum albumin as a previously under-reported and strong predictor of overall complications. Serum albumin was marginally significantly related to pulmonary and cardiovascular outcomes after major lung surgery. Use of imputation techniques for modeling surgical risks has potential value in identifying important predictive variables that may ordinarily be eliminated from analysis or not identified as predictors because of incomplete observations in clinical databases.

Obesity Predicts Increased Overall Complications Following Pancreas Transplantation

Purpose We sought to evaluate the role of recipient body mass index (BMI) on postoperative complications in patients receiving pancreas transplants. Methods A single-institution retrospective study of 145 consecutive patients undergoing either simultaneous kidney pancreas (SPK) or pancreas after kidney (PAK) transplantation from January 1997 through December 2003. Variables analyzed included: age, sex, BMI, number of prior transplants, cytomegalovirus status of donor and recipient, postoperative insulin resistance, complications, and overall patient and graft survival. Differences in continuous variables and dichotomous variables were evaluated using two-tailed t test and Fisher exact test, respectively. Univariate and multivariate logistic regression analyses were employed to identify predictors of overall complications following surgery. Results Obesity was defined by a BMI ≥ 30. Of the 145 patients, 33 (23%) had a BMI ≥ 30 and 112 (77%) had a BMI < 30. There was no significant difference in age or sex between obese and nonobese patients ( P = .98 and P = .56, respectively). The type of transplantation, SPK or PAK, did not affect the complication rate ( P = .36). Overall complications (infection, dehiscence, evisceration, ventral hernia, allograft failure, gangrene, necrotizing fasciitis, postoperative bleeding, or death) were significantly higher in the obese group (81% vs 40%, P < .001). Obesity was specifically associated with increased frequency of dehiscence, ventral hernia, intra-abdominal infection, gangrene, necrotizing fasciitis, and repeat laparotomy. Obese patients also had a threefold higher rate of graft pancreatitis/enteric leak. Multivariate logistic regression analysis identified age ≥ 50 and BMI ≥ 30 as independent predictors of overall complications following surgery (odds ratio 4.0, P = .014 and OR 6.8, P < .001, respectively). There was no difference identified between groups with regards to allograft failure, posttransplant insulin resistance, and death. Conclusion Obese patients are at increased risk of overall complications following pancreas transplantation. Specifically, obese patients experience higher frequency of dehiscence, ventral hernia, intra-abdominal infection, gangrene, and necrotizing fasciitis. This study demonstrates the need for careful postoperative monitoring in the obese patient.

Correlation of smoking history and other patient characteristics with major complications of pelvic radiation therapy for cervical cancer.

The purpose of this study was to identify patient-related factors that influence the risk of serious late complications of pelvic radiation therapy. The records of 3,489 patients treated with radiation therapy for International Federation of Gynecology and Obstetrics stage I or II carcinoma of the cervix were reviewed for information about patient characteristics, treatment details, and outcomes. Any complication occurring or persisting more than 3 months after treatment that required hospitalization, transfusion, or an operation or caused severe symptoms or the patient's death was considered a major late complication. Complication rates were calculated actuarially. The median duration of follow-up was 85 months, and 99% of patients were followed for at least 3 years or until they died. Heavy smoking was the strongest independent predictor of overall complications (multivariate hazard ratio, 2.30; 95% confidence interval [CI], 1.84 to 2.87). The most striking influence of smoking was on the incidence of small bowel complications (hazard ratio for smokers of one or more packs per day, 3.25; 95% CI, 2.21 to 4.78). Hispanics had a significantly lower rate of small bowel complications than whites, and blacks had higher rates of bladder and rectal complications than whites. Thin women had an increased risk of gastrointestinal complications, and obese women were more likely to have serious bladder complications. Complications of pelvic radiation therapy are strongly correlated with smoking, race, and other patient characteristics. These factors should be considered before the results of clinical studies are generalized to different cultural and racial groups.