Preoperative American Society Of Anesthesiologists Research Articles

The association of preoperative serum albumin level and American Society of Anesthesiologists (ASA) score on early complications and survival of patients undergoing radical cystectomy for urothelial bladder cancer

To evaluate the impact of the preoperative American Society of Anesthesiologists (ASA) score and serum albumin level on complications, recurrences and survival rates of patients who underwent radical cystectomy (RC) for urothelial bladder cancer (UBC). In all, 1964 patients underwent RC for UBC at our institution between 1971 and 2008. Preoperative serum albumin and ASA score were available in 1471 and 1140 patients, respectively. A complication was defined as any surgery related/unrelated event leading to lengthening hospital stay or re-admission. Endpoints were 90-day complication (90dC) rate, recurrence-free survival (RFS) and overall survival (OS). The median (range) follow-up was 12.4 (0.2-27.3) years. In all, 197 patients (13.4%) had a low albumin level (<3.5 g/dL) and 740 (64.8%) had a high ASA score (3 or 4). Low serum albumin and a high ASA score were associated with higher 90dC rate (42% vs 34%, P = 0.03 and 40% vs 28%, P < 0.001, respectively). On multiple logistic regression analysis, a high ASA score remained independently associated with increased 90dC rate (hazard ratio [HR] 1.52, P = 0.005) and decreased OS (HR 1.45, 95% confidence interval [CI] 1.13-1.86). A low serum albumin level was also independently associated with RFS (HR 1.68, 95% CI 1.16-2.43) and OS (HR 1.93, 95% CI 1.43-2.63). A low serum albumin level was independently associated with cancer recurrence and decreased OS after RC. A high ASA score was also independently associated with decreased OS. These parameters potentially could be used as prognosticators after RC.

The timing of surgical staging has a significant impact on the complications and functional outcomes of adult spinal deformity surgery

Background contextTo our knowledge, the effect of the staging regimen on the surgical outcome in patients undergoing combined anterior/posterior surgery for the treatment of spinal deformity has not been previously studied. PurposeTo compare outcomes of anterior/posterior surgery for adult spinal deformity staged less than 21 days apart versus those 21 or more days apart. Study designA retrospective comparison study. Patient samplePatients aged 40 years or older who underwent combined anterior/posterior fusions for spinal deformities. Outcome measuresSelf-reported measures, physiological measures, and functional measures. MethodsWe retrospectively reviewed prospectively collected data for 63 consecutive patients (50 females and 13 males) older than 40 years who underwent combined anterior/posterior fusions for spinal deformities and who had a minimum of 2-year follow-up. We divided them into those who had surgery staged less than 21 days apart (Group 1, N=29) and those who had surgery staged 21 or more days apart (Group 2, N=34). The groups were not statistically different in age; preoperative American Society of Anesthesiologists, Scoliosis Research Society-22 (SRS-22) patient questionnaire, and Oswestry Disability Index (ODI) scores; number of previous surgeries; number of levels fused; or total operative time. Hotelling t square test and the chi-squared test were used to compare clinical and radiographic parameters, complications, and functional outcomes between groups (significance, p<.05). ResultsCompared with Group 1 patients, Group 2 (staged) patients had a lower total estimated blood loss (average, 4.5 L [range, 1.90–8.75 L] vs. 4 L [range, 1.8–10.1 L], respectively), fewer combined hospital days (average, 14 days [range, 7–70 days] vs. 12 days [range, 6–44 days], respectively), and fewer major complications (total, 10 [35%] vs. 6 [18%], respectively). Preoperative SRS-22 and ODI scores were significantly better in Group 2 than in Group 1 at 6 weeks (p<.001) and at final follow-up (p<.001), respectively. ConclusionFor patients who require both anterior and posterior surgery for spinal deformity correction, staging the two procedures 21 or more days apart decreases total perioperative transfusion requirements although significantly improving functional outcomes.

Outpatient endoscopic retrograde cholangiopancreatography: Safety and efficacy of anesthetic management with a natural airway in 653 consecutive procedures

Background:Endoscopic retrograde cholangiopancreatography (ERCP) is a unique diagnostic and therapeutic procedure performed in high risk patients in prone/semi-prone position. Propofol based deep sedation has emerged as the method of choice however, the ability to predict possible complications is yet un-explored.Aims:The present study aimed to evaluate known high risk-factors for general anesthesia (American Society of Anesthesiologists (ASA) status, body mass index (BMI), and Mallampati class) for their ability to affect outcomes in ERCP patients.Study Design:Retrospective data of 653 patients who underwent ERCP during a period of 26 months at university hospital of Pennsylvania was reviewed. Patient-specific and procedure specific data was extracted. Desaturation was defined by fall of pulse oximeter saturation below 95% and its relation to patient specific high risk-factors was analyzed.Results:Only 45 patients had transient de-saturation below 95% without any residual sequlae. No statistically significant relation between desaturation episodes and patients higher ASA status or BMI or modified Mallampati (MMP) class was found. Despite 60% patients being ASA III/IV none required emergency intubation or procedural interruption. Optimal oxygenation and airway patency was maintained with high degree of success using simple airway maneuvers or conduit devices (nasal/oral trumpet) with oxygen supplementation in all patients.Conclusions:Unlike general anesthesia, pre-operative patient ASA status, higher MMP or increasing BMI does not bear relation with likelihood of patients desaturating during ERCP. In presence of vigilant apnea monitoring and careful dose titration of maintenance anesthetics with airway conduits, general anesthesia, emergency intubations, and procedure interruptions can be avoided.

The Relationship Between the American Society of Anesthesiologists Physical Rating and Outcome Following Total Hip and Knee Arthroplasty

The purpose of this study was to review the results of the first four years of use of the American Society of Anesthesiologists (ASA) physical status rating system in the New Zealand Joint Registry. Our hypothesis was that patients with a higher ASA score would have an increased mortality rate, an increased early revision arthroplasty rate, and poorer clinical outcomes at six months after total hip or knee arthroplasty. We prospectively evaluated the preoperative ASA classes for all patients in the registry who underwent primary total hip or knee arthroplasty from 2005 to 2008 with regard to the six-month mortality rate and the Oxford Hip and Knee Scores at six months. Survival curves were constructed with use of revision joint replacement as the end point. Twenty-two thousand six hundred patients who underwent total hip arthroplasties and 18,434 patients who underwent total knee arthroplasties were recorded in the New Zealand Joint Registry. The six-month mortality rate was 0.77% following hip arthroplasty and 0.40% following knee arthroplasty. Significant differences were observed in the mortality rate between all ASA classes following hip arthroplasty (p &lt; 0.001). Similarly, significant differences were observed in the mortality rate between ASA classes after knee arthroplasty, except between ASA classes 1 and 2 and between ASA classes 3 and 4. The mortality rate was significantly higher (p &lt; 0.001) following hip arthroplasty compared with knee arthroplasty. A significant difference (p &lt; 0.001) in Oxford scores was observed when ASA class 1 and ASA class 2 were compared with ASA class 3 and ASA class 4, independent of age and sex, following both hip or knee arthroplasty. A significant difference was observed in the rate of early revision (revision less than two years after the index procedure) following total hip arthroplasty when ASA class 1 (hazard ratio, 1.39 [95% confidence interval (CI), 1.04 to 1.95]; p = 0.015) and ASA class 2 (hazard ratio, 1.24 [95% CI, 1.02 to 1.55]; p = 0.030) were compared with ASA class 3, which was independent of age and sex. No significant difference was observed in the rate of early revision after total knee arthroplasty. The ASA physical status score can be used as a predictor of postoperative mortality and functional status following both hip and knee arthroplasty and may predict early failure of total hip arthroplasty necessitating revision. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Prognostic factors for survival following emergency Hartmann's procedure

IntroductionPatients presenting with peritonitis require rapid treatment initiation including laparotomy. In the older population, this often leads to Hartmann's procedure being performed. The decision to perform surgery may be a...

Laparoscopic left hepatectomy in patients with intrahepatic duct stones and recurrent pyogenic cholangitis.

Backgrounds/AimsRecently many studies have been reported the early results of a hepatectomy for various intrahepatic lesions. Also various types of laparoscopic hepatectomies are being performed in many centers. Some reports about the safety of laparoscopic parenchymal dissection of the liver have been published. In this study, we reported our experiences of laparoscopic left hepatectomies in patients with an intrahepatic duct (IHD) stone with recurrent pyogenic cholangitis (RPC), and investigated whether the total laparoscopic parenchymal dissection is as safe as open surgery.MethodsFrom April 2008 to December 2010, 25 patients had been admitted for left IHD stones with RPC. Preoperatively, the type of surgery was decided with the intention of treating each patient. Initially 10 patients underwent a laparoscopy-assisted left hepatectomy and the next 15 patients underwent total laparoscopic left hepatectomy as our experience grew. Demographics, peri- and postoperative results were collected and analyzed comparatively.ResultsThe mean age, gender ratio, preoperative American Society of Anesthesiologists (ASA) score, accompanied acute cholangitis and biliary pancreatitis, and the number of preoperative percutaneous transhepatic biliary drainage (PTBD) inserted cases were not different between the two groups who had undergone laparoscopy-assisted and totally laparoscopic left hepatectomy. The operation time, intraoperative transfusions and postoperative complications also showed no difference between them. The postoperative hospital stay did not show a significant difference statistically.ConclusionsIn this study, we concluded that a laparoscopic left hepatectomy can be adapted to the patients with a left IHD stone with RPC. Also laparoscopic parenchymal dissection is safe and equivalent to an open procedure.

Comparison of proximal femoral nail antirotation blade and reverse less invasive stabilization system‐distal femur systems in the treatment of proximal femoral fractures

To compare the effects of proximal femoral nail antirotation blade (PFNA) and reverse less invasive stabilization system-distal femur (Liss-DF) systems in the treatment of proximal femoral fractures. Between June 2007 and October 2009, 41 proximal femoral fractures were treated, 22 with PFNA (group A) and 19 with reverse LISS-DF plates (group B). The time to starting full weight-bearing, fracture healing time, functional recovery (Parker and Palmer mobility score), neck-shaft angle discrepancies with the intact contralateral hip, preoperative American Society of Anesthesiologists (ASA) scores, the operation durations and amount of intraoperative bleeding were recorded and compared. The mean follow-up period was 11.2 months (range, 10-12 months). Compared with Group A, Group B showed a statistically longer mean time to bear full body weight and heal their fractures, but a smaller neck-shaft angle discrepancy (all P < 0.05). The groups were similar in ASA score, operation duration, amount of intraoperative bleeding and Parker and Palmer mobility score. Both PFNA and reverse Liss-DF were satisfactory for the treatment of proximal femoral fractures, but had different advantages. PFNA allowed earlier weight-bearing and accelerated fracture healing. Reverse Liss-DF more effectively avoided coxa vara and may be indicated for patients with very severe osteoporosis.

1802 SURGICAL OUTCOME AND PROGNOSTIC FACTOR FOR PT3B RENAL CELL CARCINOMA

You have accessJournal of UrologyKidney Cancer: Advanced II1 Apr 20101802 SURGICAL OUTCOME AND PROGNOSTIC FACTOR FOR PT3B RENAL CELL CARCINOMA Jung Kwon Kim, Min Chul Cho, Yong Hyun Park, Seung Baik, Chang Wook Jeong, Ja Hyeon Ku, Cheol Kwak, and Hyeon Hoe Kim Jung Kwon KimJung Kwon Kim More articles by this author , Min Chul ChoMin Chul Cho More articles by this author , Yong Hyun ParkYong Hyun Park More articles by this author , Seung BaikSeung Baik More articles by this author , Chang Wook JeongChang Wook Jeong More articles by this author , Ja Hyeon KuJa Hyeon Ku More articles by this author , Cheol KwakCheol Kwak More articles by this author , and Hyeon Hoe KimHyeon Hoe Kim More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1726AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To analyze the surgical outcome and determine the prognostic factors influencing on survival in patients with pT3b renal cell carcinoma (RCC). METHODS From Feburary 1988 to April 2009, a total of 121 patients with pT3b RCC who underwent radical nephrectomy and thrombectomy were identified. Disease-specific survival (DSS) and overall survival (OS) rates were analyzed retrospectively according to various prognostic factors, including age, gender, body mass index (BMI), clinical symptoms, tumor side (Rt. vs. Lt.), tumor size, thrombus position (renal vein vs. IVC), invasion to perinephric fat or adrenal gland, lymph node involvement, distant metastasis at presentation, histological type of RCC, Fuhrmann nuclear grade, gross tumor necrosis, preoperative American Society of Anesthesiologists (ASA) score. RESULTS There are 84 men (69.4%) and 37 women (30.6%) whose mean age and mean follow-up duration was 56.6 years (range 26 to 78) and 37.3 months (range 1 to 211), respectively. The tumor was right-sided in 50 patients and left-sided in 71 patients. 78 patients (64.5%) presented with clinical symptoms, including palpable mass, gross hematuria, weight loss, flank pain. Of all patients, 96 had level I tumor thrombus, 19 had level II, and 6 had level III tumor thrombus. Of 54 patients who simultaneously received lymph node dissection, 5 had N1 disease and 13 had N2 disease. Histological types of RCC were conventional type in 85, chromophilic type in 7, chromophobic type in 5, collecting duct subtype in 2,unclassified type in 4 and unknown in 18. Sarcomatoid features were present in 9 patients. For Fuhrmann grade, grade 2 was present in 12 patients, 3 in 44, 4 in 23, unknown in 42, respectively. A total of 49 patients died. 5-year DSS and OS rate was 47% and 47%, respectively. On univariate analysis, BMI, presence of clinical symptom, pathological N stage, distant metastasis at presentation, tumor size, invasion to perinephric fat or adrenal gland, gross necrosis, sarcomatoid feature were associated with worse DSS and OS. On multivariate analysis, the presence of clinical symptom, distant metastasis at presentation, gross necrosis, pathological N stage was the independent prognostic factors for both DSS and OS. CONCLUSIONS Our data suggests that the presence of clinical symptom, distant metastasis at presentation, gross necrosis, pathological N stage was the independent prognostic factors for both disease-specific survival and overall survival rate in patients with pT3b RCC. Seoul, Republic of Korea© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e699 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jung Kwon Kim More articles by this author Min Chul Cho More articles by this author Yong Hyun Park More articles by this author Seung Baik More articles by this author Chang Wook Jeong More articles by this author Ja Hyeon Ku More articles by this author Cheol Kwak More articles by this author Hyeon Hoe Kim More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Steroids and Risk Factors for Airway Compromise in Multilevel Cervical Corpectomy Patients

Prospective, randomized, double-blind study. To evaluate intravenous corticosteroids in preventing delayed extubation after multilevel corpectomy and strut graft reconstructive procedures and to identify risk factors for delayed extubation in these patients. We performed a prospective, randomized double-blind study in patients undergoing multilevel cervical corpectomy procedures. Our hypothesis was that high-dose perioperative steroids would decrease edema and thus decrease the incidence of delayed extubation. We studied patients undergoing 2- or 3-level anterior cervical corpectomy procedures with anterior strut graft reconstruction. Sixty-six patients were randomized to receive 3 doses of either intravenous dexamethasone (n = 35) or saline (n = 31). The first dose was given before the incision, with subsequent doses given 8 and 16 hours later. Patients remained intubated until postoperative day 1, at which time a cuff leak test was performed by the anesthesiology attending. If a leak was present, the patient was extubated. If not, the test was repeated each postoperative day until a leak was present, indicating a patent airway. Five of 35 (14%) in the steroid group and 6 of 31 (19%) in the saline group required delayed extubation (P = 0.22). There were no statistical differences in preoperative parameters of age, gender, diagnosis, smoking history, BMI, number of operative levels, or preoperative American Society of Anesthesiologists rating between the 2 groups. Similarly there were no differences between the groups for duration of anesthesia, intraoperative colloids or crystalloids, intraoperative blood loss, or intraoperative urine output. The data for both groups were pooled to evaluate risk factors for delayed extubation. The only statistically significant risk factor for delayed extubation in this study was female gender (P = 0.0001). Based on our data, we cannot recommend intravenous dexamethasone for prevention of delayed extubation after multilevel anterior cervical corpectomy and strut grafting procedures.

The Occipital Flap for Reconstruction After Lateral Temporal Bone Resection

To investigate the use of the occipital rotational flap as an alternative reconstructive technique following lateral temporal bone resection. A retrospective medical record review of 10 patients who underwent reconstruction with an occipital rotational flap after auriculectomy or lateral temporal bone resection. Patient and operative variables included age, preoperative ASA (American Society of Anesthesiologists) classification, operative time, total length of hospital stay, and use of preoperative and postoperative radiotherapy. Patient demographic characteristics and medical comorbidities were also recorded. Clinical outcomes included medical complications, minor and major wound complications, and donor site complications. Patients' mean age was 73.9 years, and mean ASA classification was 2.8. The mean operative time was 8.1 hours, and the mean length of hospital stay was 5.3 days. Three patients received preoperative radiotherapy, and 7 received postoperative radiotherapy. Two patients developed postoperative medical complications, 2 developed minor wound breakdown, and 1 developed a donor site complication. The occipital flap method is reliable and should be considered as an option for reconstruction after lateral temporal bone resection in select patients.

Anti-Platelet Agents and Surgical Delay in Elderly Patients with Hip Fractures

To assess the risk of surgical delay in elderly hip fracture patients on anti-platelet agents. Records of 180 patients aged over 65 years with either an intertrochanteric or femoral neck fracture were reviewed. The clopidogrel group included 10 patients on clopidogrel alone and 11 others on clopidogrel and aspirin, whereas the control group included 69 on aspirin alone and the remaining 90 not on any anti-coagulants. The 2 groups were compared with regard to time to surgery, preoperative American Society of Anesthesiologists (ASA) score, pre- and post-operative haemoglobin levels, in-patient complication rates, duration of hospital stay, and 30-day mortality. In the clopidogrel and control groups respectively, the mean times to surgery were 7.2 and 2.1 days (p=0.03, t-test), the mean preoperative ASA scores were 3.35 and 2.8 (p=0.29, t-test), the mean preoperative haemoglobin levels were 119 and 115 g/l (p=0.5, t-test), the mean postoperative haemoglobin levels were 98 and 96 g/l (p=0.68, t-test), the mean durations of hospital stay were 7.4 and 3.1 days (p=0.02, t-test). The 30-day mortalities were 6/21 (29%) and 6/159 (4%) [p=0.0003, Fisher's exact test]. Surgical delay in elderly patients on anti-platelet agents with hip fracture was associated with higher mortality. Despite the risk of increased blood loss, we suggest early surgery be carried out by an experienced surgeon to expedite the operating time. Pooled platelets should be given intravenously one to 2 hours preoperatively.

Laparoscopic Nephrectomy Outcomes of Elderly Patients in the 21stCentury

As life expectancy continues to increase, we will be faced with the need to counsel older patients on the risks and benefits of undergoing surgery. It is clear that laparoscopic renal surgery has significant benefits over open renal surgery. However, contemporary data on whether these benefits carry over to the elderly is less robust. The objective of this study is to compare the perioperative outcomes of laparoscopic nephrectomy in patients age 70 and over to those under age 70. Outcomes from the study can be used to assist in preoperative counseling for older patients. Between February 2000 and December 2005, 405 consecutive patients underwent laparoscopic nephrectomy for benign or malignant conditions. To decrease selection bias, kidney donors, bilateral nephrectomies, partial nephrectomies, as well as patients under the age of 17 were excluded. Laparoscopic nephrectomies included simple nephrectomies, radical nephrectomies, and nephroureterectomies. A total of 158 patients were included in the analysis. Patient demographics and perioperative data were recorded prospectively. The preoperative American Society of Anesthesiologists (ASA) score was used to reflect patient co-morbidity. Subset analysis between pure laparoscopic nephrectomy (LN) and hand-assisted laparoscopic nephrectomy (HALN) was also performed. Average hospital stay for patients 70 years and older was 3.6 days versus 2.6 days for their younger counterparts (p = 0.02). All other demographic and perioperative parameters were comparable between groups, including incidence of intraoperative or postoperative complications, blood transfusions, and conversions to open surgery. In a subset analysis of patients undergoing HALN, despite having similar co-morbid conditions (ASA score 2.57 vs. 2.56, p = 0.9), the elderly group had a significantly increased length of stay compared to patients younger than 70 years (3.0 vs. 4.2 days, p < 0.05). However, in the group undergoing LN, there was no statistically significant difference in hospital stay (3.1 vs. 2.4 days, p = 0.22), despite the older group having higher co-morbid conditions (ASA score 2.55 vs. 2.10, p < 0.01). Other than an increased hospital stay by one day, patients 70 years and older undergoing laparoscopic nephrectomy can expect comparable perioperative outcomes to those achieved in younger patients. Such differences in the length of hospital stay may be mitigated by pure laparoscopic nephrectomy as opposed to hand-assisted laparoscopic nephrectomy in patients 70 years or older. These data may be useful in preoperative decision-making and counseling in this growing subset of patients.

Increasing incidence of methicillin-resistant Staphylococcus aureus skin and soft-tissue infections: reconsideration of empiric antimicrobial therapy

Background Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) rates are at an all time high. MRSA rates as high as 60% have been reported in patients presenting with skin and soft-tissue infections (SSTIs). Our objectives were to (1) examine the incidence of MRSA over a 7-year period in surgical patients with SSTIs, (2) examine the choice of empiric antibiotic therapy, and (3) evaluate the vancomycin minimum inhibitory concentration (MIC) in MRSA isolates. Methods The medical records of all patients who underwent operative debridement of SSTIs from 2000 to 2006 were retrospectively reviewed. Demographic data such as age, race, and gender as well as co-morbid risk factors were collected. Preoperative American Society of Anesthesiologists (ASA) score, temperature, WBC, creatinine, HgbA1c, albumin, and empiric antimicrobial of choice were also included. Microbiology of all operative cultures was recorded. Available vancomycin MIC data were collected. All data are presented as mean ± standard error of the mean. A chi-square test was used for statistical analysis. Results From 2000 to 2006, 288 patients with operative debridement for SSTIs were identified. The mean age was 54 ± 11 years. Fifty-two percent of patients had diabetes mellitus, 55% were tobacco users, 34% alcohol users, and 23% had hepatitis C. The mean temperature at presentation was 99.2° ± 1.5°F. The mean white blood cell count was 13.8 ± .9. The mean HgbA1c was 8.6 ± 2.5. The mean body mass index was 30.1 ± 8. Sixty-seven percent of patients had an ASA ≥ 3. There was a significant increase in MRSA SSTIs in 2006 (77%) compared with 2000 (34%, P < .001). Correspondingly, there was a significant increase in empiric administration of vancomycin in 2006 (93%) compared with 2000 (18%, P < .001). The examination of vancomycin MIC shows a shift for MRSA isolates over this time period (MIC ≤ = .5 μg/mL, 62%, MIC = 1 μg/mL, 7%, and MIC = 2 μg/mL, 31%). Conclusion Our study shows a significant and ongoing increase in the incidence of MRSA in patients with SSTIs. Empiric coverage with an MRSA antimicrobial should be used as first-line therapy. However, given the observed increase in vancomycin MIC, alternative MRSA antimicrobials should be considered.

Portal Venous Gas Detected on Computed Tomography in Emergency Situations: Surgery Is Still Necessary

Portal venous gas (PVG) has been reported to be associated with lethal surgical diagnosis. Recent studies tend to confirm the clinical significance of gas in the portal vein; however, some patients are managed without surgical treatment. The aim of this study was to assess both the diagnoses and the treatment of patients with PVG in an emergency surgical setting. We performed a retrospective chart review of 15 patients with PVG in the emergency setting detected by computed tomography (CT) between July 1999 and July 2004. Characteristics assessed included age, sex, clinical presentation, first CT diagnosis of both PVG and the underlying pathology, American Society of Anesthesiologists (ASA) score, surgical findings, final clinical diagnosis, duration of hospitalization, and evolution of the illness/mortality. All patients were examined one month after operation. This series of 5 women and 10 men ranged in age from 38 to 90 years at the time they underwent emergency surgical treatment. The mean preoperative ASA score was 4.20. Computed tomography diagnosed the underlying pathology in all cases: bowel obstruction (4 cases), bowel necrosis (9 cases), and diffuse peritonitis (2 cases). The mean length of hospital stay was 12.4 days. The mortality rate was 46.6%; (7 patients). A wide range of pathologies can generate PVG. Computed tomography can detect both the presence of gas and the underlying pathology. In emergency situations, all the diagnosed causal pathologies required a surgical procedure without delay. We report that the prognosis was related to the pathology itself and was not influenced by the presence of PVG.

Treating renal cell cancer in the elderly

To determine whether age and comorbidity are predictors of peri-operative complications and/or mortality in surgery for renal cell cancer in a retrospective study of patients aged >75 years. Between 1993 and 2003, 1023 radical nephrectomies or nephron-sparing surgery for renal cell cancer were performed in 115 consecutive patients aged > or = 75 years and in 908 consecutive patients aged <75 years. The preoperative American Society of Anesthesiologists (ASA) score was used for risk stratification. Operative mortality and early complications (within 30 days of surgery) were reviewed. The younger patients had significantly lower ASA scores than the older patients. There were early complications in 31 of the 908 younger patients (3.4%) and in two of the 115 older patients (1.7%). Peri-operative mortality was higher in the older than in the younger patients (1.7% vs 0.3%; P = 0.29). Overall morbidity and mortality correlated with increasing ASA score but not with age (P < 0.05). Despite greater comorbidity in older patients, their morbidity and mortality did not differ significantly from that of younger patients. Advanced age alone should thus not be used as a criterion to deny surgery for renal cell carcinoma. However, older patients should be counselled regarding a tendency for increased comorbidity-related peri-operative mortality.

Free flaps in the elderly population

Microsurgery continues to be considered as a demanding and risky surgical procedure, especially in old people. Moreover, some surgeons are afraid to perform microsurgery in the elderly, because of fear of additional preoperative and postoperative complications. However, in selected cases a microsurgical reconstruction by free tissue transfer is the best reconstructive solution, in order to obtain a good quality of life for those patients. The aim of this paper is to highlight that age itself is not a contraindication for microsurgery, and is not responsible for additional preoperative and postoperative surgical complications. The authors will also indicate that the preoperative American Society of Anesthesiologists (ASA) score and the length of the operation are important indicators for postoperative medical complications.

Inguinal hernia: challenging the traditional indication for surgery in asymptomatic patients.

It is generally accepted that most inguinal hernias should be operated on electively in order to avoid the high morbidity and mortality associated with incarceration and small bowel obstruction. The present study reassesses the indication for surgery in asymptomatic inguinal hernia patients. We analyzed profiles, separately, for elective and emergency inguinal herniorrhaphies and compared the morbidity and mortality rates. Two hundred randomly selected elective hernia repairs were compared with 67 incarcerated cases. Postoperative complications were more common following emergency (23.9%) than elective repair (10.5%); however, in both groups, minor complications predominated. The mortality rate in the incarcerated group (6%) was clearly linked with a high preoperative American Society of Anesthesiologists (ASA) score. A bowel resection rate of 4.5% was found in the incarcerated cases, which was not correlated with mortality. Patients with asymptomatic inguinal hernia and unfavorable medical conditions should be recommended an elective repair, preferably under local anesthesia, to avoid the high mortality associated with an emergency operation.

Evaluation of Age and Comorbidity as Risk Factors After Laparoscopic Urological Surgery

Few reports in the urological literature have focused on the growing population of elderly (65 years or older) patients. Coexistent medical conditions, which are more prevalent in elderly individuals, can confound results of outcome studies in this population. This single center, retrospective study was done to determine whether age and comorbidity are predictors of outcome in patients undergoing laparoscopic renal and adrenal surgery. From 1997 to 2001 laparoscopic radical nephrectomy, partial nephrectomy, nephroureterectomy and adrenalectomy were performed in 399 consecutive adults. Patient demographics and preoperative, intraoperative and postoperative parameters were extracted from a prospectively designed computerized database. Risk stratification was based on preoperative American Society of Anesthesiologists (ASA) score. Additional risk stratification was constructed using the Charlson comorbidity index. Univariate and multivariate analyses were also performed. Age 65 years or older was not associated with an increased incidence of intraoperative, postoperative or late operative complications on univariate or multivariate analyses. However, patients 65 years or older were hospitalized significantly longer than those younger than 65 years (43 vs 24 hours, p = 0.02). Blood loss and the requirement for blood transfusion were associated with longer operative time, a higher incidence of intraoperative and postoperative complications on univariate analysis, and longer hospitalization. No association of blood loss with postoperative complications was noted on multivariate analysis. Patients with a higher ASA score were more likely to receive blood transfusion. On univariate analysis risk stratification using the ASA score and the Charlson comorbidity index was not associated with intraoperative or postoperative complications. However, on multivariable analysis patients with the lowest indexes were less likely to experience postoperative complications than those with the highest indexes (less than vs greater than 3, p = 0.04). The comorbidity index had a marginal association with the incidence of late complications (p = 0.06). Laparoscopic renal and adrenal surgery in patients 65 years or older is well tolerated. Age 65 years or older is predictive of a significantly increased hospital stay of approximately 1 day after major renal and adrenal laparoscopic surgery and it does not appear to increase independently the risk of intraoperative, postoperative or late operative complications.

Postoperative ileus on a gynecologic oncology service—do abdominal X-rays have a role?

Objective The objective was to estimate the role of abdominal radiographs in the management of the patient with gastrointestinal dysfunction in the early postoperative period following intra-abdominal gynecologic surgery. Methods Hospital records were reviewed for 84 patients from the gynecologic oncology service having a clinical diagnosis of either ileus or bowel obstruction immediately after intra-abdominal gynecologic surgery. Patient history, clinical signs and symptoms, findings of plain radiographs, and clinical course were studied to determine whether plain abdominal radiographs were useful in the management of these patients. Results At least one set of abdominal X-rays was obtained for 56 (66.7%) patients, of which 24 (42.9%) were considered radiographically diagnostic. A lower preoperative American Society of Anesthesiologists (ASA) physical status score correlated with a greater likelihood of having abdominal films ( P = 0.005). No single clinical finding correlated with either the decision to obtain films or X-ray diagnosis of ileus or bowel obstruction. Use of any nonsurgical treatment modality was not significantly different for patients who had films versus those who did not. Mean length of hospital stay was significantly prolonged for patients who had abdominal X-rays. Seven patients were subjected to reoperation; however, no association was found between X-ray diagnosis of ileus or bowel obstruction and the need for reoperation. Conclusion Plain abdominal radiographs have little clinical utility in the evaluation of patients with gastrointestinal dysfunction in the early postoperative period following intra-abdominal gynecologic surgery. Diagnostic studies such as CT scanning or a GI contrast study may be more helpful in the management of these patients.

Hip fracture surgery: is the pre-operative American Society of Anesthesiologists (ASA) score a predictor of functional outcome?

Many studies have identified specific demographic, social, health or life-style pre-operative indicators of long-term outcome among older hip fracture patients who underwent surgical treatment. The purpose of this study was to determine the predictive value of peri- and intra-operative factors, and more specifically of the pre-operative American Society of Anesthesiologists (ASA) score on functional outcome in these patients. A questionnaire designed to assess pre-fracture functional and health status was administered to surgically treated hip fracture patients. Post-fracture functional and health status was further ascertained by in-home interview one year after the operation. Among 140 consecutive eligible patients older than 65 years, 10 either refused subsequent interviews or could not be contacted; an additional 16 patients died during the year of follow-up, leaving 114 patients available for this study. The average age of the patients was 82.4 years. Almost two-thirds of them suffered from severe systemic disease, whether or not incapacitating (ASA grades III-IV). Subjects classified in these categories presented more frequently with cardiovascular disorders, were more frequently disoriented, and already had some pre-fracture difficulty with ambulation. The mortality at one year was almost nine times higher in severely impaired patients (grades III-IV) than in healthy or mildly affected patients (grades I-II). Functional outcome and/or ambulatory ability assessed at one year did not reveal any statistically significant difference between the ASA I-II and III-IV groups. The most pronounced difference was noticed for the functional independence measured by the ADL score (p = 0.236). Better prognoses were consistently recorded for patients with an intracapsular fracture, for those who were operated within 24 hours, for those treated with a prosthesis as opposed to internal fixation, and for those whose operating time was less than 1 1/2 hours. Although the ASA classification is a good predictor of long-term mortality, the findings of the present investigation do not conclusively associate ASA score with post-operative restoration of mobility and functional independence.