Predictors Of Perioperative Mortality Research Articles

Potential value and advances in research on bone mineral density (BMD) measurement in the auxiliary clinical assessment of hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer death worldwide and its prognosis is highly heterogeneous, being related not only to underlying chronic liver disease but also to the severity of cancer cachexia. Nutritional factors play a crucial role in influencing the prognosis of HCC. Despite musculoskeletal imbalance being consistently reported as a predictor of perioperative mortality in patients with HCC, this condition is often overlooked in clinical management. Bone mineral density (BMD), which serves as a marker of nutritional status, can be assessed through CT by measuring the pixel density of the vertebral bone. Recent clinical studies have indicated that BMD serves not only as a significant risk factor for development of HCC in cirrhotic patients but also potentially functions as an independent prognostic indicator for post-treatment outcomes in patients with HCC. Preoperative abdominal CT scans provide a convenient and cost-effective method to measure BMD, offering significant assistance in prognostic evaluation of patients with HCC. A thorough grasp of the liver-bone connection, along with the conduct of higher-quality studies and the establishment of standardized methods and cutoff values for BMD measurement, could enhance approaches to manage HCC.

Thyroidectomy in elderly ; is it safe?

Background: The prevalence of thyroid nodules rise with age and different data available about the risks of thyroid surgery in old age people. In general, old age could be a predictor of perioperative mortality and morbidity. The aim of this study is to prove if there is increased risk accompanying thyroidectomy in elderly patients. Subjects and Methods: Prospective study of one surgeon of study sample undergoing thyroid surgery at Al-Kindy teaching hospital and Saint Raphael hospital .This study was including two groups; group (A) involved patients 65 years and older, group (B) involved patients below 65 years old who were subjected to thyroidectomy. Taking in consideration histopathology results, indications of surgery (compressive symptoms, suspicious or confirmed malignancy, toxic goiter and recurrent goiter) and complications (including rates of temporary and permanent hypocalcaemia, temporary and permanent RLN paralysis, postoperative hematoma, wound infection and seroma), in addition to the risk of perioperative mortality. Results: There were 574 patients below 65 years and 127 elderly patients (>=65 years) who underwent thyroidectomy between January 2015 and December of 2018. There were no deaths in either group; no one had bilateral RLN paralysis. Old age patients had a lower frequency of complications in comparison to the younger counterparts, including transient hypocalcaemia (3.1% vs 14.8%, respectively) and temporary RLN injury (0% vs 0.69%, respectively), in addition to permanent RLN injury (0% vs 0.34%, respectively). Conclusions: Thyroidectomy in elderly is safe as compared to younger patients regarding perioperative complications

Risk of perioperative death and sudden cardiac arrest: A study of 113 456 cases from the National Registry of Invasive Cardiology Procedures (ORPKI) for estimation of the perioperative prognosis.

Despite optimizing treatment of ST-segment elevation myocardial infarction (STEMI), a number of patients die during the invasive procedure or experience sudden cardiac arrest (SCA) that complicates further hospitalization. This study aimed to identify the most important risk factors leading to SCA and death in the cath lab among STEMI patients. We used data from the National Registry of Invasive Cardiology Procedures (ORPKI) collected between 2014 and 2019. The study population consisted of 113 465 patients. Descriptive statistics, univariate and multiple logistic regression analysis of factors affecting perioperative mortality (PM) and SCA in the cath lab were performed. Death and SCA occurred in 1549 (1.4%) and 945 (0.8%) patients, respectively. Diabetes (odds ratio [OR], 1.76; P <0.0001), previous brain stroke (OR, 2.26; P <0.0001), prior myocardial infarction (OR, 1.81; P <0.0001), psoriasis (OR, 1.79; P = 0.04), and chronic renal failure (OR, 2.79; P <0.0001) were the strongest predictors of PM. The occurrence of SCA was dependent mainly on diabetes (OR, 1.37; P = 0.0001), previous brain stroke (OR, 2.23; P <0.0001), prior myocardial infarction (OR, 1.73; P <0.0001), psoriasis (OR, 2.03; P = 0.04), and chronic renal failure (OR, 2.79; P <0.0001). Of the pre-hospital factors, the Killip-Kimball class showed the strongest relationship with the two endpoints (OR 3.53; P <0.0001 and OR 2.65; P <0.0001, respectively). Diabetes, previous brain stroke, myocardial infarction, psoriasis, chronic renal failure, and the Killip-Kimball class were the strongest predictors of PM and SCA in the cath lab among STEMI patients.

Perioperative outcomes of Fontan operation: Impact of heterotaxy syndrome

Fontan operation is the standard surgical procedure for achieving long-term survival in single-ventricular complex congenital heart diseases (SV-CHD). We aim to identify the perioperative outcomes and impact of heterotaxy syndrome (HS) after Fontan operation in a tertiary pediatric cardiology center. Medical records were reviewed for all patients who received Fontan operation and who were born between 1997 and 2017 in our institution. Preoperative, operative, and postoperative risk factors for perioperative mortality and morbidity were analyzed. Totally, 154 patients were enrolled (103 SV-CHD and 51 HS), and the male to female ratio was 92:62. The mean age of Fontan operation was 5.1 years, and extracardiac conduit comprised the majority (90.9%) of Fontan operation. Overall perioperative event-free survival to discharge was 91.6% (84.3% in HS and 95.1% in other SV-CHD, P=0.032). For secondary outcomes, length of intensive care stay and duration of pleural effusion drainage were not significantly different between patients with HS and other SV-CHD, but postoperative arrhythmia was more common in HS group (31.4% vs. 12.6%, P=0.005). In multivariable regression analysis, preoperative risk factors including operation year before 2007 and high PAP and postoperative factors of elevated postoperative CVP were associated with worse outcomes. HS was not a predictor of worse outcome after adjusting for preoperative PAP and operation era. Surgical outcome has improved much in current era. Perioperative outcome is poorer in patients with HS than other SV-CHD, but HS is not a predictor of perioperative mortality after adjusting for hemodynamic factors.

Prediction of perioperative mortality in cardiac surgery – Risk scoring systems: In quest of the holy grail

Prediction of perioperative mortality in cardiac surgery – Risk scoring systems: In quest of the holy grail

Novel Predictors of Peri-Operative Mortality in a Series Of 931 Consecutive Patients with Intact Aortoiliac Aneurysms Managed at a Single Centre

Introduction - The aim of our study was to identify preoperative and intraoperative factors associated with in-hospital mortality after repair of intact abdominal aortic or iliac aneurysms. Methods - This was a retrospective analysis of prospectively collected information on patients undergoing repair of intact aortoiliac aneurysms during a 28-year period. Recorded information included preoperative demographics, risk factors and co-morbidities, aneurysm characteristics, investigations and operative variables including special aneurysm presentation (inflammatory, mycotic/infected, aortocaval fistula) and procedure type (open vs. endovascular repair). Univariate and multivariate logistic regression analyses (with odds ratios, OR) were performed, the latter performed to develop a predictive model using the generated output. The area under the curve of the receiver operating characteristics (ROC) curve of our score, the Glasgow aneurysm score (GAS),1 and the Vascular Study Group of New England (VSGNE) score,2 was calculated. Results - During the study period we operated on 931 patients with intact aortoiliac aneurysms, on an elective (n=882) or urgent (n=49) basis, and an in-hospital mortality of 1.7% and 8.2%, respectively (p=0.015). Endovascular aneurysm repair (EVAR, n=414) was a predictor of lower mortality (0.5% vs. 3.3% for open repair, n=517, p=0.003). Other significant predictors included the presence of abdominal or back pain (7.5% vs 1.3% for no pain, p<0.001), preoperative angiography (6.9% vs 1.6% for no angiography, p=0.01), special aneurysm presentation (10.7% vs 1.5% for 875 ordinary atherosclerotic aneurysms, p<0.001), concomitant major procedures (19% vs 1.6% for the rest, p<0.001), serious intraoperative complications (9.1% vs 1.5% for no such complications, p<0.001), median number of transfused units of blood intraoperatively (2 and 0 for cases with and without mortality, respectively, p<0.001) and duration of the procedure (300min and 150min for cases with and without mortality, respectively, p<0.001). On multivariate analysis, EVAR was an independent predictor of lower mortality (OR=0.22, p=0.05) and special aneurysm presentation (OR=6.45, p=0.001) and concomitant major procedures (OR=14.3, p<0.001) were independent predictors of higher mortality. The area under the ROC curve, and p values for the GAS, VSGNE score and our score was 0.46, 0.62 and 0.81, and 0.59, 0.084 and 0.00003, respectively (Figure). The difference between the VSGNE and our score was significant (p=0.029). Repeat analysis for electively operated cases demonstrated an area under the ROC curve of 0.66 (p=0.029) and 0.80 (p=0.000069), respectively, for the VSGNE and our score, with the difference becoming non-significant. Conclusion - Our study in patients undergoing aortoiliac aneurysm repair has demonstrated novel risk factors for mortality and externally validated VSGNE in different healthcare settings.

Is Frailty Associated With Worse Outcomes After Head and Neck Surgery? A Narrative Review.

Frailty has emerged as an important determinant of many health outcomes across various surgical specialties. We examined the published literature reporting on frailty as a predictor of perioperative outcomes in head and neck cancer (HNC) surgery. Narrative review with limited electronic database search and cross-referencing of included studies. PubMed was searched from inception until June 2019 to capture studies evaluating an association between frailty and perioperative outcomes among patients undergoing HNC surgery. Primary outcomes included mortality and morbidity, whereas secondary outcomes included in-hospital cost, length of stay, readmission, and discharge disposition. We identified nine series examining frailty as a predictor of outcomes in HNC. The majority of studies (77%) identified patients using a large population-based database such as the National Surgical Quality Improvement Project or National Inpatient Sample. Frailty measures applied in the HNC surgery literature include the modified frailty index, Groningen Frailty Indicator, and John Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. Most studies demonstrated a significant association between frailty and perioperative outcomes, including mortality, perioperative complications, and Clavien-Dindo grade IV complications. Furthermore, frailty was associated with greater length of hospital stay, readmission rate, and likelihood of discharge to short-term or skilled nursing facilities. The current literature demonstrates the utility of frailty as a predictor of perioperative mortality and morbidity. Further research is needed to develop frailty screening measures in order to risk-stratify patients and optimize modifiable factors preoperatively. Laryngoscope, 130:1436-1442, 2020.

Pulmonary artery growth after Modified Blalock-Taussig shunt: A single center experience

This study evaluates growth of pulmonary artery (PA) between different age groups after Modified Blalock-Taussig shunt (MBTS) based on a single center experience. We retrospective analyzed outcomes of 90 patients undergoing MBTS in our institute from January 1, 2010 to May 1, 2018. Patients were divided into three groups: Group 1, ≦2 months, Group 2, >2 months, ≦24 wmonths, Group 3, >24 months. The outcome included PA growth, overall survival rates and postoperative complications. 23 patients were involved in Group 1, while 49 in Group 2 and 18 in Group 3. The diameter of the PA, McGoon ratio, Nakata index and the oxygen saturation increased significantly after MBTS. Compared to pre-MBTS, there was no statistically significant increase of McGoon ratio in Group 3 after performing MBTS, but it witnessed less secondary cardiac surgery rate compared with Group 2 (11.11% vs. 48.98%, P=0.005). Cumulative survival rates of three groups were 60.53%, 85.70%, 94.40% at 1 year; 60.53%, 78.30%, 87.75% at 3 years and 60.53%, 78.30%, 87.75% at 5 years. Multivariable analysis showed diastolic blood pressure <30mmHg [OR 14.14 (1.92-104.32), P=0.009], cardiopulmonary bypass use [OR 16.79 (2.05-137.67), P=0.009] and single ventricle anomaly [OR 8.80 (1.18-65.54), P=0.034] were predictors of perioperative mortality. MBTS in our institute is a conventional and effective procedure for growth of PA especially for patients younger than 24 months. Patients with biventricular anomaly, no cardiopulmonary bypass use in surgery and relatively high postoperative diastolic blood pressure will likely offer a good prognosis.

Development of a New Comorbidity Assessment Tool for Specific Prediction of Perioperative Mortality in Contemporary Patients Treated with Radical Cystectomy.

The Deyo adaptation of the Charlson comorbidity index (DaCCI), which relies on 17 comorbid condition groupings defined with 200 ICD-9-CM diagnostic codes, lacks specificity in the context of radical cystectomy (RC) for bladder cancer (BCa). We attempted to develop a new comorbidity assessment tool based on individual comorbid conditions and/or BCa manifestations for specific prediction of perioperative mortality after RC. We relied on 7076 T1-T4 nonmetastatic BCa patients treated with RC between 2000 and 2009 in the SEER-Medicare linked database. Within the development cohort (n = 6076), simulated annealing (SA) was used to identify (1) individual comorbid conditions, (2) individual BCa manifestations, and (3) the combination of both, that satisfy the criteria of maximal accuracy and parsimony for prediction of 90-day mortality after RC, after adjusting for several confounders. The accuracy of the newly identified groups of individual comorbid conditions and/or BCa manifestations and of the original DaCCI was tested in a 1000-patient external validation cohort. The combination of six individual comorbid conditions and two individual BCa disease manifestations (type II diabetes without complications, anemia, chronic obstructive pulmonary disease, congestive heart failure, aortocoronary bypass, cardiomegaly, urinary tract infection, and hydronephrosis), and seven individual comorbid conditions (type II diabetes without complications, anemia, chronic obstructive pulmonary disease, congestive heart failure, aortocoronary bypass, osteoarthrosis, and cardiomegaly) respectively showed 71.1 and 70.2% accuracy versus 68.0% for the original DaCCI. These new approaches are specific to contemporary RC patients and represent simpler methods compared with the original DaCCI, without any compromise in accuracy.

Clinical performances of EuroSCORE II risk stratification model in Serbian cardiac surgical population: A single centre validation study including 10,048 patients

Background/Aim. The EuroSCORE II has recently been developed with an idea to provide better accuracy in prediction of perioperative mortality in the patients who underwent open heart surgery. The aim of this study was to validate clinical performances of the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II risk stratification model in the Serbian adult cardiac surgical population undergoing open heart surgery. Methods. The Euro- SCORE II values on 10,048 consecutive patients undergoing major adult cardiac surgery from 1st January 2012 to 31st March 2017, were prospectively calculated and entered the institutional database. The discriminative power of the model was tested by calculating the area under the receiver operating characteristic curve (AUC). The calibration of the model was assessed by the Hosmer-Lemeshow (H-L) statistics and the observed to expected (O/E) mortality ratio. The patients with the EuroSCORE II values of 0.5?2.50%, &gt; 2.50?6.50%), and &gt; 6.50% were defined to be at low, moderate, and high perioperative risk, respectively. Results. The observed in-hospital mortality was 3.86% (388 of 10,048) and the mean predicted mortality by the Euro- SCORE II was 3.61%. The discriminatory power was very good for the entire cohort as well as for all subgroups [coronary, valve(s), combined (coronary plus valve), aortic and other] of performed cardiac procedures (all AUCs &gt; 0.75). The H-L test confirmed good calibration only for category other cardiac procedures. The O/E mortality ratio confirmed good calibration for the whole sample [O/E ratio 1.07, 95% confidence interval (CI) 0.96?1.18] and for all subgroups of performed cardiac procedures, excluding significant underprediction of mortality for aortic surgery (O/E ratio 1.64; 95% CI 1.31?1.97). The EuroSCORE II overestimated perioperative risk in a low and underestimated perioperative risk in a high risk group, with acceptable discrimination (both AUCs = 0.72). On the contrary, the O/E mortality ratio confirmed good calibration for all three subcategories of high risk group. Conclusion. The results of our study confirmed acceptable overall performances of the EuroSCORE II risk stratification model in terms of discrimination and the accuracy of model when applied to the contemporary Serbian cardiac surgical cohort undergoing open heart surgery at our Institute.

A 10-year retrospective review of perioperative mortality in pediatric general surgery at Ile-Ife Hospital, Nigeria

Background/PurposeThe analysis of perioperative mortality as well as surgery- and anesthesia-related death in pediatric patients may serve as a potential tool to improve outcome. The aim of this study is to report the 24-h and 30-day overall, and surgery and anesthesia-related, mortality in a tertiary hospital. MethodsThis is a retrospective review of perioperative mortality in children ≤15years at a general pediatric surgery unit. All pediatric general surgery cases operated under general anesthesia between January 2007 and December 2016 were included in the study and data analyzed. ResultsA total of 4108 surgical procedures were performed in 4040 patients. The age was 1day to 15years with a median age of 2years. The all cause 24-h mortality was 34 per 10,000 procedures and the all cause 30-day mortality was 156 per 10,000 procedures. Septicemia was the most common cause of death. The determinants of mortality were neonatal age group (Adjusted Odd Ratio (AOR)=0.033, 95% CI=0.015–0.070, p=0.001), emergency surgery (AOR=90.91, 95% CI=27.78–333.33, p=0.001), higher ASA status (AOR=0.014, 95% CI=0.005–0.041, p=0.001) and multiple operative procedures (AOR=38.46, 95% CI=10.64–142.85, p=0.001). ConclusionsNeonatal age group, children with poorer ASA status, emergency and multiple surgeries were predictors of perioperative mortality. Level of evidenceRetrospective study.

Predictors for Perioperative Mortality following Tricuspid Valve Surgery

Predictors for Perioperative Mortality following Tricuspid Valve Surgery

Development of a Pediatric Risk Assessment Score to Predict Perioperative Mortality in Children Undergoing Noncardiac Surgery.

Although there have been numerous attempts to predict perioperative mortality in adults, an objective model to predict mortality in children has not been developed. In this study, we aimed to develop a Pediatric Risk Assessment (PRAm) score to predict perioperative mortality in children undergoing noncardiac surgery. We included all children recorded in the 2012 and 2013 American College of Surgeons National Surgical Quality Improvement Program Pediatric databases in a derivation cohort and those from the 2014 database in a validation cohort. The primary outcome was the incidence of in-hospital mortality. A total of 115,229 (63%) were included in the derivation cohort and 68,194 (37%) in the validation cohort. We used multivariable logistic regression to determine the predictors for mortality and designed the PRAm score. On the basis of the multivariable regression model, we created a simplified risk assessment tool (PRAm score) ranging from 0 to ≥9, including the presence of any comorbidities, factors of critical illness, age <12 months, the requirement for an urgent procedure, and the diagnosis of a neoplasm. The PRAm score showed an excellent discriminative ability with an apparent "optimistic" area under the receiver operating characteristic curve (AUC) of 0.950 (95% confidence interval [CI], 0.942-0.957) in the derivation cohort. In the validation cohort, we observed similar performances with an area under the "naive" receiver operating characteristic curve of 0.950 (95% CI, 0.938-0.961). The AUC was also calculated from a bootstrap procedure and then applied to the original derivation sample to estimate "optimism" for each bootstrap sample with an AUC of 0.943 (95% CI, 0.929-0.9956). The optimism in apparent performance was 0.007, corresponding to an optimism-corrected area of 0.943. Calibration was assessed graphically by plotting the observed outcome against the predicted mortality (Pearson correlation coefficient = 0.995, calibration in the large = 0.001 [P = .974], calibration slope = 0.927). In this study, we developed a simplified PRAm tool (PRAm score) as a predictor of perioperative mortality in children undergoing noncardiac surgery. The PRAm score has excellent accuracy. In patients assigned American Society of Anesthesiologists physical status classification ≥4, there is wide variability in objectively obtained PRAm scores.

MP63-01 A PROPOSAL FOR A NOVEL PERI-OPERATIVE MORTALITY RISK ASSESSMENT TOOL IN CONTEMPORARY PATIENTS TREATED WITH RADICAL CYSTECTOMY

You have accessJournal of UrologyBladder Cancer: Invasive V1 Apr 2016MP63-01 A PROPOSAL FOR A NOVEL PERI-OPERATIVE MORTALITY RISK ASSESSMENT TOOL IN CONTEMPORARY PATIENTS TREATED WITH RADICAL CYSTECTOMY Paolo Dell’Oglio, Zhe Tian, Sami-Ramzi Leyh-Bannurah, Vincent Trudeau, Alessandro Larcher, Umberto Capitanio, Alberto Briganti, Francesco Montorsi, and Pierre Karakiewicz Paolo Dell’OglioPaolo Dell’Oglio More articles by this author , Zhe TianZhe Tian More articles by this author , Sami-Ramzi Leyh-BannurahSami-Ramzi Leyh-Bannurah More articles by this author , Vincent TrudeauVincent Trudeau More articles by this author , Alessandro LarcherAlessandro Larcher More articles by this author , Umberto CapitanioUmberto Capitanio More articles by this author , Alberto BrigantiAlberto Briganti More articles by this author , Francesco MontorsiFrancesco Montorsi More articles by this author , and Pierre KarakiewiczPierre Karakiewicz More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.930AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The Charlson comorbidity index (CCI) is the most widely used index score in retrospective analyses. However, several comorbid conditions included in this index, such as sever liver disease, AIDS, leukemia/lymphoma, are never seen in patients candidate to radical cystectomy (RC). Some other comorbid conditions, such as diabetes, and chronic pulmonary disease, are very frequently seen. Conversely, other conditions that are not accounted within that CCI index may represent better predictors of perioperative mortality. The purpose of this study was to identify such predictors. METHODS We relied on 7,076 T1-T4 non-metastatic bladder cancer patients treated with RC between 2000 and 2009 in the SEER-Medicare linked database. Of those, 6,076 patients were randomly included within the development cohort and the remaining 1,000 were used for validation. Within the development cohort we relied on simulated annealing on cross-validated c-index to identify the most parsimonious and highly predictive set of conditions (using unique ICD-9 diagnostic code) predicting 90-day mortality after RC, adjusting for T stage, N stage, age, gender and race. The final set of conditions identified was tested within the validation cohort for the ability to predict 90-day mortality. The validated adaptation of CCI by Deyo et al. was also tested in the validation cohort for purpose of comparison after adjusting for T stage, N stage, age, gender and race. RESULTS Within respectively development and validation cohort, 630 (10.4%) and 131 (13.1%) patients died within 90 days. Within the development cohort, 7 conditions that are based on a single ICD-9 code, were identified and satisfied the parsimony and accuracy criteria: 1. congestive hearth failure, (11.9 % prevalence) 2. urinary tract infection, (60.0% prevalence) 3. anemia, (24.4% prevalence) 4. chronic pulmonary disease, (23.4% prevalence) 5. cardiomegaly, (9.4% prevalence) 6. hematuria (81.3% prevalence) 7. hydronephrosis (22.9% prevalence) Within the validation cohort, the 7 conditions resulted in 71% accuracy in prediction of 90-day mortality relative to 68% for the adapted CCI by Deyo et al. that relied on 17 groupings of comorbid conditions (33 conditions with 187 ICD-9 codes). CONCLUSIONS In external validation cohort, our new proposed tool for prediction of perioperative mortality after RC was 3% more accurate and relied on 7 instead of 187 ICD-9 codes. In consequence, our method appears to offer a significant advantage compared to the adapted CCI by Deyo et al, based on simplicity and better accuracy. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e821 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Paolo Dell’Oglio More articles by this author Zhe Tian More articles by this author Sami-Ramzi Leyh-Bannurah More articles by this author Vincent Trudeau More articles by this author Alessandro Larcher More articles by this author Umberto Capitanio More articles by this author Alberto Briganti More articles by this author Francesco Montorsi More articles by this author Pierre Karakiewicz More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Regional Differences in Case Mix and Peri-operative Outcome After Elective Abdominal Aortic Aneurysm Repair in the Vascunet Database

National differences exist in the outcome of elective abdominal aortic aneurysm (AAA) repair. The role of case mix variation was assessed based on an international vascular registry collaboration. All elective AAA repairs with aneurysm size data in the Vascunet database in the period 2005-09 were included. AAA size and peri-operative outcome (crude and age adjusted mortality) were analysed overall and in risk cohorts, as well as per country. Glasgow Aneurysm Score (GAS) was calculated as risk score, and patients were stratified in three equal sized risk cohorts based on GAS. Predictors of peri-operative mortality were analysed with multiple regression. Missing data were handled with multiple imputation. Patients from Australia, Finland, Hungary, Norway, Sweden and the UK (n = 5,895) were analysed; mean age was 72.7 years and 54% had endovascular repair (EVAR). There were significant variations in GAS (lowest = Finland [75.7], highest = UK [79.4], p for comparison of all regions < .001), proportion of AAA < 5.5 cm (lowest = UK [6.4%], highest = Hungary [29.0%]; p < .001), proportion undergoing EVAR (lowest = Finland [10.1%], highest = Australia [58.9%]; p < .001), crude mortality (lowest = Norway [2.0%], highest = Finland [5.0%]; p = .006), and age adjusted mortality (lowest = Norway [2.5%], highest = Finland [6.0%]; p = .048). Both aneurysm size and peri-operative mortality were highest among patients with a GAS >82. Of those with a GAS >82, 8.4% of men and 20.8% of women had an AAA <5.5 cm. Important regional differences exist in case selection for elective AAA repair, including variations in AAA size and patient risk profile. These differences partly explain the variations in peri-operative mortality. Further audit is warranted to assess the underlying reasons for the regional variation in case-mix.

Survival after hepatectomy for metastatic colorectal cancer in the presence of resectable extrahepatic disease

Background: The presence of extrahepatic disease, bilobar disease or greater than four hepatic lesions were once considered contraindications to hepatectomy for colorectal metastases but are being reconsidered. We reviewed our experience with resection of extrahepatic disease (EHD) at the time of hepatectomy for metastatic colorectal cancer to determine the impact on perioperative and long-term outcome. Methods: The medical records of 441 patients who underwent hepatectomy for colorectal cancer metastases from 1989 to 2010 were reviewed. Demographics, clinicopathologic characteristics, and outcomes were compared between those with and without extrahepatic disease. Overall survival curves were constructed using the Kaplan Meier method and compared with the log rank test. Multivariate analysis using logistic and Cox proportional hazards regression were used to determine predictors of perioperative mortality and longterm survival, respectively. Results: Fifty-nine (13%) patients presented with EHD at the time of hepatectomy. There were no significant differences between patients with and without EHD with regard to age, gender, disease free interval, or the number and distribution of hepatic metastases. Patients with EHD were as likely to undergo complete (i.e. R0) resection as those with isolated liver metastases (59% vs. 74%. p&gt;0.05). Perioperative mortality in the 441 patients was 2.3%. Only increasing number of liver segments resected and perioperative complications were predictive of perioperative mortality by multivariate analysis. Median overall survival was 20.5 months in patients with EHD compared to 35.2 months in patients without EHD (p&lt;0.001). Increasing age, the presence of EHD, bilobar disease, and length of stay in the ICU were significant predictors of decreased overall survival by multivariate analysis. Conclusion: Despite similar populations, extrahepatic disease remains a poor prognostic indicator for survival after hepatectomy for colorectal metastasis. Though a low perioperative mortality coupled with median survival of 20.5 months emphasizes the potential of a curative approach to patients with traditionally incurable disease, resection of EHD should be carefully weighed. The presence of resectable extrahepatic disease should not be a contraindication to hepatectomy for colorectal metastases but should be approached cautiously due to its poor prognostic factors.

A nomogram to calculate the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM)

The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) is a well validated model for the prediction of perioperative mortality and morbidity with application to surgery and intensive care medicine. The outcome measure calculations are time-consuming, complex and potentially error-prone. Nomograms are low-cost easy-to-use graphic devices that can be used to make repeated calculations to an acceptable level of accuracy for most clinical purposes. This paper describes a nomogram to aid calculation of POSSUM scores. This graphic solution consists of two sections: a tally sheet to calculate physiological and operative severity scores (PS and OS), and a nomogram to calculate mortality and morbidity. The latter was designed using standard mathematical methods, and drafted with the aid of commercially available software. Accuracy was confirmed by using a spreadsheet to generate 120 random sets of simulated values for PS and OS, and corresponding calculated values for predicted mortality and morbidity. The outcome values in each case were derived using the nomogram and compared with the spreadsheet values using Bland-Altman analysis. Bland-Altman analysis showed close agreement between nomogram and spreadsheet. Bias of the nomogram was -0·1 percentage points for mortality and 0·1 percentage points for morbidity, with limits of agreement of -2·1 to +1·9 and -1·4 to +1·6 percentage points for mortality and morbidity respectively. Correlation coefficients were r > 0·999 and P < 0·001 for both mortality and morbidity. The nomogram provides a rapid, accurate, low-cost means of performing, visualizing and cross-checking POSSUM calculations.

The outcome of surgical management of type A aortic dissection.

Type A aortic dissection is a serious and fatal condition. We retrospectively evaluated the outcome following repair of ascending aortic dissection in a contemporary cohort of 108 patients with a mean age of 59.5 ± 13.8 years, who were treated between 2006 and 2011. Most patients were male (70, 65%). Circulatory arrest with a mean duration of 22 ± 16 min was performed in 42 (38.9%) patients. Perioperative mortality was 15.7% (n = 17). Univariate analysis showed that cardiopulmonary bypass time (p = 0.0006), age >60 years (p = 0.028), cardiogenic shock at presentation (p = 0.02), New York Heart Association class II-IV (p = 0.038), hemopericardium (p = 0.0035), and preoperative cerebrovascular accident (p = 0.02) were predictors of mortality. Multivariate analysis indicated that age >60 years (odds ratio 7.7, 95% confidence interval: 1.52-38.96, p = 0.0136), preoperative cerebrovascular accident (odds ratio 25.2, 95% confidence interval: 2.45-258.9, p = 0.0066), hemopericardium (odds ratio 41.6, 95% confidence interval: 5.38-320.7, p = 0.0003), and cardiopulmonary bypass time (odds ratio 1.85, 95% confidence interval: 1.32-2.57, p = 0.0003) were independent predictors of perioperative mortality. The 1- and 4-year survival was 80% ± 3.8% and 69% ± 5.7%, respectively. Age >60 years (hazard ratio 3.3, 95% confidence interval: 1.4-7.9, p = 0.0064) was the only independent predictor of long-term mortality. Our results identify the major risk factors for perioperative and long-term mortality. Age is an independent risk factor for mortality.

Influence of Increased Left Ventricular Myocardial Mass on Early and Late Mortality After Cardiac Surgery

Background Increased left ventricular mass (LVM) is a well-recognized predictor of cardiovascular morbidity and mortality in epidemiological studies, but its impact on mortality after cardiac surgery is poorly defined. We hypothesized that patients with increased LVM index (LVMI) were more likely to have greater 30 day and 1 yr mortality. Methods With IRB approval, intraoperative transoesophageal echocardiography images of 844 cardiac surgical patients were reviewed. LVMI was calculated using the American Society of Echocardiography recommended formula. Outcome variables studied were 30 day and 1 yr mortality. Results Mortality within 30 days occurred in 28 patients (3.3%) and within 1 yr in 91 patients (10.8%). An almost linear relationship was found between increasing LVMI and the risk of mortality within 30 days of cardiac surgery. The odds ratio (OR) of dying within 30 days of surgery was 1.15 (95% confidence interval 1.01–1.31) per 20 g m−2 increase in LVMI. This finding remained statistically significant in multivariate analysis controlling for the effects of age, weight, gender, surgery type, LV function, and functional status [OR=1.36 (1.11–1.66) per 20 g m−2 increase]. Increased LVMI was not found to be a statistically significant predictor of 1 yr mortality. Conclusions Increased LVMI, but not LV systolic function as measured by the fractional area of contraction (FAC) was identified as a strong independent predictor of perioperative mortality after adult cardiac surgery. The relationship between LVMI and risk of 30 day mortality was nearly linear. Furthermore, decreased FAC, and not LVMI, was a strong independent predictor of 1 yr mortality.

Genotype Assessment as a Tool for Improved Risk Prediction in Cardiac Surgery

PREDICTION OF PERIOPERATIVE mortality and morbidity risks remains an important issue in adult cardiac surgery for both the patient and the physician. One objective method to estimate the perioperative risk involves the use of risk prediction models (RPMs). These statistical tools have been utilized for more than 30 years and primarily are based on the correlations that exist among a patient's preoperative health condition, the type of surgical procedure, and the frequency of postoperative complications that result from surgery.