Predictor Of Perioperative Morbidity Research Articles

Clinical Guideline on Perioperative Management of Patients with Advanced Chronic Liver Disease.

(1) Background: Patients with advanced chronic liver disease (ACLD) are living longer with more comorbidities because of improved medical and surgical management. However, patients with ACLD are at increased risk of perioperative morbidity and mortality; (2) Methods: We conducted a comprehensive review of the literature to support a narrative clinical guideline about the assessment of mortality risk and management of perioperative morbidity in patients with ACLD undergoing surgical procedures; (3) Results: Slight data exist to guide the perioperative management of patients with ACLD, and most recommendations are based on case series and expert opinion. The severity of liver dysfunction, portal hypertension, cardiopulmonary and renal comorbidities, and complexity of surgery and type (elective versus emergent) are predictors of perioperative morbidity and mortality. Expert multidisciplinary teams are necessary to evaluate and manage ACLD before, during, and after surgical procedures; (4) Conclusions: This clinical practice document updates the available data and recommendations to optimize the management of patients with advanced chronic liver disease who undergo surgical procedures.

Sarcopenia as a predictor of perioperative morbidity in metastatic renal cell carcinoma patients undergoing radical nephrectomy and IVC tumor thrombectomy.

388 Background: Preoperative sarcopenia, as determined by the lumbar skeletal muscle index (SMI), has shown potential value for predicting adverse survival outcomes in metastatic renal cell carcinoma (mRCC) patients undergoing cytoreductive surgery. However, its utility for predicting perioperative morbidity in mRCC patients with IVC involvement is poorly elucidated. We hypothesize that preoperative sarcopenia, a severe deficiency in lean muscle mass, will be associated with major surgical complications and longer lengths of hospital stay in mRCC patients managed with radical nephrectomy and tumor thrombectomy. Methods: We retrospectively analyzed 99 mRCC patients who underwent radical nephrectomy and tumor thrombectomy from 2005 to 2020. Sarcopenia was diagnosed using optimally fit body mass index (BMI) and sex-stratified thresholds. For patients with a BMI < 30 kg/m², sarcopenia was defined as a SMI < 47 cm2/m2 for males and SMI < 38 cm2/m2 for females and for those with a BMI≥30 kg/m², as a SMI < 54 cm2/m2 for males and SMI < 47 cm2/m2 for females. Outcome measures were the presence of any major complications within 90 days after surgery, major complications within 1 year after surgery, and length of hospital stay post-nephrectomy ≥7 days. Major complications were defined as grade ≥3a on the Clavien-Dindo classification system. Associations between sarcopenia and major surgical complications and length of hospital stay were evaluated using multivariable analysis. Multivariable models were adjusted for age, race, gender, BMI, Charlson comorbidity index, T and N staging, Fuhrman grade, ECOG Score, and extent of IVC tumor thrombus. Results: Median time from preoperative imaging to surgery was 22 days (IQR 15-29). Of the 57 (58%) patients with preoperative sarcopenia in our cohort, 19 (33%) and 20 (35%) patients experienced a major surgical complication within 3 and 12 months after surgery, respectively, and 34 (60%) patients had a length of stay ≥7 days. Preoperative sarcopenia was significantly associated with the occurrence of a major complication within 90 days (OR = 4.84, 95%CI: 1.30-18.06, p = 0.019) and 1 year (OR = 6.43, 95%CI: 1.66-24.89, p = 0.007) after surgery. The presence of sarcopenia did not significantly change the odds of staying in the hospital for more than 7 days post-nephrectomy (OR = 1.41, 95%CI: 0.45-4.41, p = 0.551). Conclusions: Preoperative sarcopenia was associated with major surgical complications occurring within 3 and 12 months among mRCC patients after radical nephrectomy and tumor thrombectomy. Screening for sarcopenia preoperatively may assist in identifying patients at high-risk for increased perioperative morbidity, which ultimately may permit the implementation of preventive therapeutic strategies. Future validation is needed.

25. Total psoas area does not associate with perioperative mortality or morbidity after lumbar spine surgery

BACKGROUND CONTEXT In various surgical settings, single measures of frailty are increasingly used to guide patient selection and inform risk modification. Since a cardinal aspect of frailty is loss of functional capacity associated with loss of muscle mass, measures of sarcopenia have been looked to as indicators of frailty. Psoas muscle area (TPA) has emerged as a particularly practical and effective measure of sarcopenia. The present study aims to assess the utility of TPA as a predictor of perioperative morbidity and mortality. METHODS A retrospective review was conducted on 367 consecutive patients undergoing lumbar spinal surgery at our institution from January 2016 to February 2017. Demographic information was collected from review of the electronic medical record. Morphometric measurements including vertebral body area and right and left psoas muscle area were recorded by 2 independent readers at the mid-L3 level from MRI or CT within 1 year of index surgery. Outcomes included perioperative adverse events, rehospitalization within 90 days, and 90-day mortality. TPA and TPA indexed to vertebral area were calculated for all patients. RESULTS The overall rate of perioperative complication was 26%, rate of rehospitalization within 90 days was 15%, and 90-day mortality was 0.8%. Age, sex, history of hypertension, hyperlipidemia, diabetes, and former or current smoking were not associated with the incidence of adverse events, rehospitalization or death. Surgical characteristics including fusion type and number of vertebral levels treated were also not significantly associated with morbidity or mortality. Both TPA and TPA indexed to vertebral area did not associate with perioperative adverse events, rehospitalization, or 90-day mortality in both univariate regression and multivariate regression adjusting for age and for sex. Only a history of prior lumbar surgery was significantly associated with perioperative complication (OR 1.67, CI 1.04-2.68, p=0.03). CONCLUSIONS In an adult lumbar spine surgery population, morphometric measurements of TPA and TPA indexed to vertebral area were not associated with perioperative adverse event, rehospitalization, or mortality. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. In various surgical settings, single measures of frailty are increasingly used to guide patient selection and inform risk modification. Since a cardinal aspect of frailty is loss of functional capacity associated with loss of muscle mass, measures of sarcopenia have been looked to as indicators of frailty. Psoas muscle area (TPA) has emerged as a particularly practical and effective measure of sarcopenia. The present study aims to assess the utility of TPA as a predictor of perioperative morbidity and mortality. A retrospective review was conducted on 367 consecutive patients undergoing lumbar spinal surgery at our institution from January 2016 to February 2017. Demographic information was collected from review of the electronic medical record. Morphometric measurements including vertebral body area and right and left psoas muscle area were recorded by 2 independent readers at the mid-L3 level from MRI or CT within 1 year of index surgery. Outcomes included perioperative adverse events, rehospitalization within 90 days, and 90-day mortality. TPA and TPA indexed to vertebral area were calculated for all patients. The overall rate of perioperative complication was 26%, rate of rehospitalization within 90 days was 15%, and 90-day mortality was 0.8%. Age, sex, history of hypertension, hyperlipidemia, diabetes, and former or current smoking were not associated with the incidence of adverse events, rehospitalization or death. Surgical characteristics including fusion type and number of vertebral levels treated were also not significantly associated with morbidity or mortality. Both TPA and TPA indexed to vertebral area did not associate with perioperative adverse events, rehospitalization, or 90-day mortality in both univariate regression and multivariate regression adjusting for age and for sex. Only a history of prior lumbar surgery was significantly associated with perioperative complication (OR 1.67, CI 1.04-2.68, p=0.03). In an adult lumbar spine surgery population, morphometric measurements of TPA and TPA indexed to vertebral area were not associated with perioperative adverse event, rehospitalization, or mortality.

Frailty as a Predictor of Postoperative Complications Following Skull Base Surgery.

Frailty has emerged as a powerful risk stratification tool across surgical specialties; however, an analysis of the impact of frailty on outcomes following skull base surgery has not been published. The aim of this study was to assess the validity of the 5-factor modified frailty index (mFI-5) as a predictor of perioperative morbidity and mortality in patients undergoing skull base surgery. A mFI-5 score was calculated for patients undergoing skull base surgeries using the National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2018. Multivariate logistic regression analysis was used to evaluate the association of increasing frailty with complications in the 30-day postoperative period, with a subanalysis by operative location. A total of 17,912 patients who underwent skull base procedures were identified, with 45.5% of patients having a frailty score of one or greater; 44.9% were male and the mean age was 52.0 (±16.1 SD) years. Multivariable regression analysis revealed frailty to be an independent predictor of overall complications (odds ratio [OR]: 1.325, P < .001), life-threatening complications (OR: 1.428, P < .001), and mortality (OR: 1.453, P < .001). Higher frailty also correlated with increased length of stay. When procedures were stratified by operative location, frailty correlated significantly with overall complications for middle, posterior, and multiple-fossae operations but not the anterior fossa. Frailty demonstrates a significant and stepwise association with life-threatening postoperative morbidity, mortality, and length of stay following skull base surgeries. mFI-5 is an objective and easily calculable measure of preoperative risk, which may facilitate perioperative planning and counseling regarding outcomes prior to surgery. 3 Laryngoscope, 131:1977-1984, 2021.

Predictors of perioperative morbidity and mortality in adult living donor liver transplantations: report of results of a tertiary hospital

BackgroundThe aim of this study was to investigate the risk factors effective in perioperative morbidity and mortality in 161 living donor liver transplantations (LDLT).ResultsThe most common indication for living donor transplantation was cryptogenic cirrhosis. The most common complication was biliary problems in 62.16% cases. Sepsis was the most common cause of in 52%. Patients in whom sepsis was observed, significantly prolonged stay under mechanical ventilation and prolonged ICU stay were detected. In patient group in whom mortality was observed, higher amounts of erythrocytes, fresh frozen plasma (FFP), and platelets were transfused, and patients remained longer under mechanical ventilation treatment, and in the ICU.ConclusionPerioperative morbidity and mortality was found to be significantly related with higher amounts of erythrocytes and FFP transfusions and longer operative and warm ischemia times. Sepsis was found to be the most common cause of mortality.

Predictors of perioperative morbidity and mortality in open abdominal aortic aneurysm repair

IntroductionThe major advantage of endovascular abdominal aortic aneurysm repair (EVAR) over open repair (OAR) is improved perioperative morbidity and mortality. Long term results of the two modalities are comparable. We sought to quantify factors predicting perioperative morbidity and mortality in patients undergoing OAR. MethodsConsecutive non-ruptured OAR were analyzed for patient demographic factors, perioperative variables including blood pressure, temperature, and glucose control, intraoperative factors, and complications including wound, pulmonary, renal and cardiac, and 30-day mortality. Uni- and multivariate analysis was performed to determine predictors of morbidity and mortality. Results240 elective open AAA repairs over 10 consecutive years were performed. 46% required suprarenal clamping. At least one complication occurred in 47% and 30-day mortality was 5.4%. By multivariate analysis, independent predictors of morbidity (any complication) were suprarenal clamping (OR 1.8, 95% CI 1.1–3.2, p = 0.029), operative time (OR 1.005, 95% CI 1.002–1.008, p = 0.002), and low postoperative temperature (OR 1.6, 95% CI 1.1–2.3, p = 0.025). Multivariate predictors of 30 day mortality included advanced age (OR 1.2, 95% CI 1.1–1.3, p = 0.002) and operative time (OR 1.007, 95% CI 1.001–1.013, p = 0.024). Glucose control did not predict morbidity or mortality. ConclusionsControl of postoperative temperature is a potentially modifiable factor that may reduce morbidity in patients undergoing open AAA repair, thereby minimizing the early advantage of EVAR.

Inflammatory and Nutritional Serum Markers as Predictors of Peri-operative Morbidity and Survival in Ovarian Cancer.

To identify preoperative nutritional and inflammatory markers that predict perioperative outcomes in patients with ovarian cancer (OC). Fifty patients who underwent primary debulking for advanced (stage III/IV) OC were selected from a cohort of patients who underwent surgery between 2002 and 2009. We analyzed C-reactive protein (CRP), interleukin-6 (IL6) and albumin and their impact on mortality and surgical outcomes. Two patients were excluded since they did not have adequate measurements of CRP and IL6. Among the remaining patients, 25 (52%) were ≥70 years old. Nine (19%), 12 (25%) and 12 (25%) patients had low serum albumin (<3.0 g/dl), elevated CRP (≥70 mg/l) and elevated IL6 (≥24 pg/ml), respectively. Age was a significant predictor of non-home discharge (p=0.01). Low serum albumin (<3.0 g/dl) was a predictor of death within 6 month (p=0.03). Elevated CRP (≥70 mg/l) was a predictor of non-home discharge (p=0.02), death within 6 months (p=0.02), death within 12 months (p=0.04), and longer hospital stay (p=0.01). Elevated IL6 (≥24 pg/ml) was a predictor of non-home discharge (p=0.002) and surgical complications (p=0.02), and also associated with longer hospital stay (p=0.03). Poor nutrition and high inflammatory status negatively influence surgical and oncological outcomes of patients with OC. These preoperative markers can be used for selection of patients for neoadjuvant chemotherapy at high risk of short survival, non-home discharge and long hospital stay.

Relationship between age and outcome in thyroid surgery: a prospective observational study.

Background:The occurrence of thyroid nodules and goiter increases with age. In general, surgery age is a predictor of perioperative morbidity. In thyroid surgery, there are different data on the role of age on morbidity. We investigated the influence of age on the outcome in thyroid surgery in a prospective single cohort study with a follow-up after 1 year.Methods:Total thyroidectomy or hemithyroidectomy was performed in euthyroid benign thyroid goiters (n=152). The primary endpoint was surgery duration. The secondary endpoints were weight of resected tissue, body mass index (BMI), amount and type of perioperative and long-term complications, and quality of life (QoL) preoperatively and 1 year postoperatively.Results:A significant three-way interactive relationship between age, surgery duration, and amount of resected tissue was found. An increase in any of these variables results in an increase in both other variables. The amount of perioperative complications was associated with resected tissue size. The QoL increases significantly after surgery by up to 10% and decreases significantly with age (mean QoL after surgery=84.9 of 100 for the youngest group and 75.7 of 100 for the oldest group). No long-term complications were recorded.Conclusion:The number of thyroid operations, especially of benign thyroid goiters, decreases annually in Germany. This can be explained by the fact that, on the one hand, the surgical indications are made more restrictive as conspicuous nodes are better clarified by improved technical aids. On the other hand, conservative measures (i.e. L-thyroxine and iodide administration) are used to achieve a size regimen of the goiter. Our results show that perioperative complications increase with patients’ age and surgery duration. However, the more restrictive surgical decision also entails the risk that patients will have to be operated at an older age and possibly with a bigger goiter, which is associated with higher operative morbidity. Therefore, in addition to the possibility of conservative therapy of the symptomatic goiter, the affected patients should also be thoroughly informed about the option to perform elective early thyroid surgery with regard to improved postoperative QoL and to keep the overall stress at a minimum for elderly patients.

Morphometrics as a predictor of perioperative morbidity after lumbar spine surgery.

OBJECT Improved objective assessments of perioperative risk after spine surgery are necessary to decrease postoperative morbidity and mortality rates. Morphometric analysis has proven utility in predicting postoperative morbidity and mortality in surgical disciplines. The aim of the present study was to evaluate whether morphometrics can be applied to the cases of patients undergoing lumbar spine surgery. METHODS The authors performed a retrospective review of the perioperative course of 395 patients who underwent lumbar surgery at their institution from 2013 to 2014. Preoperative risk factors such as age, diabetes, smoking, coronary artery disease, and body mass index (BMI) were recorded. Preoperative MRI was used to measure the psoas muscle area at the L-4 vertebra and paraspinal muscle area at the T-12 vertebra. Primary outcomes included unplanned return to the operating room, 30- and 90-day readmissions, surgical site infection, wound dehiscence, new neurological deficit, deep vein thrombosis, pulmonary embolism, myocardial infarction, urinary tract infection, urinary retention, hospital-acquired pneumonia, stroke, and prolonged stay in the intensive care unit. RESULTS The overall rate of adverse events was 30%, the most common event being urinary retention (12%). Greater age (p = 0.015) and tobacco usage (p = 0.026) were both significantly associated with complications for all patients, while diabetes, coronary artery disease, and high BMI were not. No surgery-related characteristics were associated with postoperative morbidity, including whether surgery required instrumentation, whether it was a revision, or the number of vertebral levels treated. Using multivariate regression analysis, male and female patients with the lowest psoas tertile had an OR of 1.70 (95% CI 1.04-2.79, p = 0.035) for having postoperative complications. Male patients in the lowest psoas tertile had an OR of 2.42 (95% CI 1.17-5.01, p = 0.016) for having a postoperative complication. The paraspinal muscle groups did not provide any significant data for postoperative morbidity, even after multivariate analysis. CONCLUSIONS The morphometric measurement of psoas muscle size may be a sensitive predictive tool compared with other risk factors for perioperative morbidity in male patients undergoing lumbar surgery.

Determining the optimal timing for radical cystectomy after neoadjuvant chemotherapy.

339 Background: We present the largest series reviewing complications and pathologic outcomes following neoadjuvant chemotherapy (NAC) and radical cystectomy (RC), to determine whether the interval between chemotherapy and surgery (ICS) affects 90-day post-operative morbidity and lymph node metastasis. Methods: We analyzed 338 patients treated with NAC followed by RC from January 1995 through December 2013. The association of ICS with 90-day surgical morbidity, incidence of major complication, 90-day readmission, and lymph node metastasis was determined. Generalized linear models were used to determine potential predictors of each endpoint. Patients were stratified into four groups by ICS days (18 – 42; 43 – 64; 64 – 85; &gt; 85). Complications were classified using the Clavien system. Results: The overall morbidity of the cohort was 59%, with 66% being minor, and 34% being major complications. The median ICS was 46 days (18 – 199 days). There was no difference in the overall morbidity, readmission, or major complication rates among the four groups. Patients with an ICT &gt; 85 days had the highest incidence of lymph node metastasis (40%), though this was not found to be significant (p = 0.1). On multivariate analysis including predictors of perioperative morbidity, extravesical (pT3 – 4) disease (OR = 1.97; p = 0.01) was an independent predictor of overall morbidity, while age at cystectomy (OR = 1.05; p = 0.004), and surgical time ≥ 7 hrs (OR = 2.87; p = 0.001) were independent predictors of major complications. Only surgical time ≥ 7 hrs (OR = 2.24; p = 0.006) was found to be a predictor of readmission. In a separate multivariate analysis that included risk factors for pathological node positivity, the predictors for lymph node metastasis included variant histology (OR = 2.06; p = 0.026) and extravesical disease (OR = 2.76; p = 0.002). Patients with an ICT &gt; 85 days had a higher risk of node metastasis though this was not significant. Conclusions: Patients can undergo RC anytime between 2.5 – 12 weeks after NAC with no difference in risk of surgical complications or nodal metastasis.

Heart Rythm Society expert consensus statement on electrophysiology laboratory standards: process, protocols, equipment, personnel, and safety.

ABBREVIATIONS CIED = cardiovascular implantable electronic device; CT=computed tomography; EP=electrophysiology; FDA= U.S. Food and Drug Administration; ICD=implantable cardioverterdefibrillator; MRI = magnetic resonance imaging; QA = quality assurance; QI = quality improvement; RF = radiofrequency; VT = ventricular tachycardia (Heart Rhythm 2014;11:e9–e51)

Is the American Society of Anesthesiologists classification useful in risk stratification for endoscopic procedures?

The American Society of Anesthesiologists (ASA) physical status classification is a measurement of comorbidity and a predictor of perioperative morbidity and mortality. To assess the predictive ability of the ASA class for periendoscopic adverse events. Retrospective cohort analysis. A total of 74 sites in the United States comprising academic, community/health maintenance organization, and Veterans Affairs/military practices affiliated with the Clinical Outcomes Research Initiative (CORI) database. Patients who were 18 years or older who underwent an endoscopic procedure between 2000 and 2008. EGD, colonoscopy, flexible sigmoidoscopy, and ERCP. Immediate adverse event requiring an unplanned intervention. A total of 1,590,648 endoscopic procedures were performed on 1,318,495 individual patients. The majority of patients were designated as ASA class I or II (I: 27%, II: 63%). An immediate adverse event occurred in 0.35% of all endoscopic procedures (n = 5596) and was proportionally highest for ERCPs (1.84%). Increasing ASA class was associated with higher prevalence and a stepwise increase in the odds ratio of serious adverse events for EGD (II: 1.54 [95% confidence interval (CI), 1.31-1.82]; III: 3.90 [95% CI, 3.27-4.64]; IV/V: 12.02 [95% CI, 9.62-15.01]); and colonoscopy (II: 0.92 [95% CI, 0.85-1.01]; III: 1.66 [95% CI, 1.46-1.87]; IV/V: 4.93 [95% CI, 3.66-66.3]). This trend was not significant for flexible sigmoidoscopy and ERCP. Retrospective; endpoint was a surrogate for periprocedure morbidity. ASA class is associated with increased risk of adverse events at endoscopy, particularly for EGD and colonoscopy. It is useful in endoscopic risk stratification and an important quality indicator for endoscopy.

913 The ASA Classification: Does It Predict Adverse Events in Endoscopic Procedures?

The American Society of Anesthesiologists' (ASA) physical status classification has been used for over 50 years by anesthesiologists and surgeons as a predictor of peri-operative morbidity and mortality. The ability of ASA class to predict peri-endoscopy adverse events has not been studied. We hypothesize that increasing ASA class is associated with higher rates of peri-procedural adverse events in endoscopic procedures. Our aim was to describe the prevalence of immediate endoscopic adverse events stratified by ASA class and endoscopic procedure type.

Racial Differences in Short-term Surgical Outcomes Following Surgery for Diverticulitis

BackgroundDiverticular disease ranks as one of the more common gastrointestinal disorders among westernized nations. Few studies have examined racial differences in the care and surgical outcomes of diverticulitis. The aim of this study was to determine if race is a predictor of peri-operative morbidity and mortality following surgery for diverticulitis. MethodsThe American College of Surgeons National Surgical Quality Improvement Program (2005–2008) was queried with the primary dependent variables being 30-day morbidity and mortality. Differences in morbidity and mortality between races were compared using χ2 and Student t tests. Logistic regression was used to calculate odds ratios for morbidity and mortality. To determine if the effect of race is modified by insurance status and case complexity, additional models were developed across age subgroups (<65 vs ≥65) and levels of case complexity. ResultsWe identified 4,709 white and 360 African American patients. Despite being younger (57.6±0.74 vs 59 ± 0.2, p < 0.05), African Americans were more likely to present with hypertension, diabetes, renal failure, dependent functional status, American Society of Anesthesiology class ≥3 (all p < 0.0001) and were more likely to require urgent surgery (p < 0.05), intra-operative blood transfusions(p < 0.0001), and undergo open colectomy (p < 0.0001). On adjusted analysis, African American race emerged as an independent predictor of morbidity (p < 0.05) and mortality (p < 0.05), without differences across insurance categories and less complex procedures. African American race remained a strong predictor of morbidity in more complex procedures (p < 0.05). ConclusionAfrican Americans undergoing surgery for diverticulitis are more likely to have associated co-morbidities, require urgent surgery, undergo open surgery, and are at increased risk of morbidity and mortality. These findings highlight a need to address the root cause for disparities in care and outcomes after surgery.

Effect of chronic dissection on early and late outcomes after descending thoracic and thoracoabdominal aneurysm repair

Although chronic aortic dissection (CD) has traditionally been considered a predictor of perioperative morbidity and mortality after descending thoracic/thoracoabdominal aneurysm repair (thoracoabdominal aortic aneurysm [TAA]), recent reports have rejected this assertion. Still, few contemporary studies document late outcomes after TAA for CD, which is the goal of this study. From August 1987 to December 2005, 480 patients underwent TAA; 73 (15%) CD and 407 (85%) degenerative aneurysms (DA). Operative management consisted of a clamp-and-sew technique with adjuncts in 53 (78%) CD and 355 (93%) DA patients (P < .001). Epidural cooling was used to prevent spinal cord injury (SCI) in 51 (70%) CD and 214 (53%) DA patients (P = .007). Study end points included perioperative SCI/mortality, freedom from reintervention, and long-term survival. CD patients were younger (mean age 64.5 years CD vs 72.5 years DA, P < .001) and more frequently had a family history of aneurysmal disease (23% CD vs 6% DA, P < .001). Forty-three (59%) CD patients had elective TAA (vs 322 (79%) DA, P = .001). Eleven (15%) CD patients had Marfan's syndrome (vs 0% DA, P < .001), and 17 (23%) CD patients had a prior arch or ascending aortic repair (vs 16 [4%] DA, P < .001). CD patients were more likely to have Crawford type I & II thoracoabdominal aneurysms (44 [60%] vs 120 [29%] DA, P < .001), while only two (3%) CD patients had type IV aneurysms (vs 99 [24%] DA). There was no difference in perioperative mortality between the two groups (11% CD vs 8.6% DA, P = .52), nor was there a difference in flaccid paralysis, which occurred in five (7%) CD and 22 (5%) DA patients (P = .92). At 5 years, 70% of CD patients were free from reintervention versus 74% of DA (P = .36). The actuarial survival was 53% and 32% at 5 and 10 years for CD versus 47% and 17% for DA (P = .07). Despite increased operative complexity, CD does not appear to increase perioperative SCI or mortality after TAA when compared with DA. Long-term freedom from aneurysm-related reintervention is similar for both groups as is survival, despite patients with CD being of younger age at presentation.

Pneumonectomy in Octogenarian Patients

Recent decades have witnessed a progressive aging of the population and a resulting increase in the numbers of elderly patients seeking health care. Since age and pneumonectomy are independent predictors of perioperative morbidity and mortality, such surgery is not recommended for octogenarian patients. We report the experience of 6 such patients who underwent pneumonectomy for squamous cell carcinoma in 5 cases and a typical carcinoid tumor in the sixth. There was no perioperative mortality; morbidity and survival rates were acceptable.

Off-Pump Revascularization for Significant Left Ventricular Dysfunction

Left ventricular dysfunction is a predictor of perioperative morbidity and mortality in on-pump coronary artery bypass grafting. Obligatory global myocardial ischemia and injury induced during crossclamping as well as adverse systemic effects of cardiopulmonary bypass may induce a disproportionately greater overall physiologic insult in patients with poor ventricular function. All patients undergoing nonemergency off-pump coronary artery bypass by a single surgeon during an 18-month period were retrospectively analyzed. Two groups with preoperative ejection fraction classified as poor (10%-35%; n = 31) or normal (55%-80%; n = 60) were compared. The mean ejection fractions were 26% +/- 1% and 63% +/- 1% respectively, p < 0.000001. In those with significant left ventricular dysfunction, there were 2.8 +/- 0.1 grafts per patient, time to extubation was 8.4 +/- 1.2 hours, and discharge was after 4.9 +/- 0.6 days. These results were statistically equivalent to those in the group with normal left ventricular function. There was no intraaortic balloon pump insertion or mortality in either group. This technique provides an effective means of safely revascularizing patients with significant left ventricular dysfunction, and it may provide a valuable alternative approach in patients with ischemic cardiomyopathy.

Impact of Pulmonary Hypertension on the Outcomes of Noncardiac Surgery: Predictors of Perioperative Morbidity and Mortality

Impact of Pulmonary Hypertension on the Outcomes of Noncardiac Surgery: Predictors of Perioperative Morbidity and Mortality

Impact of Pulmonary Hypertension on the Outcomes of Noncardiac Surgery: Predictors of Perioperative Morbidity and Mortality

We sought to determine the predictors of short-term morbidity and mortality (< 30 days) after noncardiac surgery in patients with pulmonary hypertension (PH). Pulmonary hypertension is considered to be a significant preoperative risk factor. The PH and surgical data bases were matched from 1991 to 2003. Patients were excluded if PH was secondary to left heart disease, not present before surgery, or the procedure involved cardiopulmonary bypass. Univariate and multivariate logistic regression analyses were used to identify variables associated with short-term morbidity and mortality. Of 1,276 patients in the PH database, 145 patients (73% female) met all study criteria. The mean age (+/-SD) was 60.1 +/- 16.0 years. Right ventricular systolic pressure (RVSP) (mean +/- SD) on the two-dimensional echocardiogram was 68 +/- 21 mm Hg. There were 60 patients (42%) who experienced one or more short-term morbid event(s) (1.8 events/patient experiencing any event). A history of pulmonary embolism (p = 0.01), New York Heart Association functional class > or = II (p = 0.02), intermediate- to high-risk surgery (p = 0.04), and duration of anesthesia > 3 h (p = 0.04) were independent predictors of short-term morbidity. There were 10 early deaths (7%). A history of pulmonary embolism (p = 0.04), right-axis deviation (p = 0.02), right ventricular (RV) hypertrophy (p = 0.04), RV index of myocardial performance > or = 0.75 (p = 0.03), RVSP/systolic blood pressure > or = 0.66 (p = 0.01), intraoperative use of vasopressors (p < 0.01), and anesthesia when nitrous oxide was not used (p < 0.01) were each associated with postoperative mortality. In patients with PH undergoing noncardiac surgery with general anesthesia, specific clinical, diagnostic, and intraoperative factors may predict worse outcomes.

Predictors of perioperative morbidity and mortality after Roux-En-Y gastric bypass

Predictors of perioperative morbidity and mortality after Roux-En-Y gastric bypass