Rate Of Life-threatening Complications Research Articles

Impact of an Enhanced Recovery After Surgery (ERAS) program on the management of complications after laparoscopic or robotic colectomy for cancer.

Enhanced Recovery After Surgery (ERAS) reduces postoperative complications (POCs) after colorectal surgery; however, its impact on the management of POCs remains unclear. This study compared the diagnosis and management of POCs before and after implementing our ERAS protocol after laparoscopic or robotic colectomy for cancer and examined the short- and mid-term oncologic impacts. This single-center, retrospective study evaluated all consecutive patients who underwent laparoscopic or robotic colectomy for cancer between 2012 and 2021, focusing on the incidence of POCs within 90 days. We compared outcomes before (standard group) and after (ERAS group) the implementation of our ERAS protocol in January 2016. Significantly fewer patients in the ERAS group developed POCs (standard vs. ERAS, 136 of 380 patients [35.8%] vs.136 of 660 patients [20.6%]; P<0.01). The ERAS group had a significantly shorter mean total length of stay after POCs (13.1 days vs. 11.4 days, P=0.04), and the rates of life-threatening complications (6.7% vs. 0.7%) and 1-year mortality (7.4% vs. 1.5%) were significantly lower in the ERAS group than in the standard group. Among patients with anastomotic complications, laparoscopic reoperation was significantly more common in the ERAS group than in the standard group (8.3% vs. 75.0%, P<0.01). Among patients with postoperative ileus, the diagnosis and recovery times were significantly shorter in the ERAS group than in the standard group, resulting in a shorter total length of stay (13.5 days vs. 10 days, P<0.01). The implementation of an ERAS protocol did not eliminate all POCs, but it did accelerate their diagnosis and management and improved patient outcomes.

Outcomes of Reduction Mammaplasty in Adolescents vs Average-Age Patients: A 3-Year Single-Center Retrospective Analysis.

Background: The onset of macromastia symptomatology occurs most often at puberty, yet most females undergo breast reduction surgery during the fifth decade of life. Adolescent patients with macromastia may benefit from reduction mammaplasty, yet outcome data are limited to a small number of institutions. Methods: We conducted a retrospective medical records review of all patients who underwent reduction mammaplasty at our institution during the years 2016 to 2019. Patients were divided into 2 cohorts based on age: adolescent (10 to 24 years) and average age (≥44 years). Demographics and outcome measures were collected from follow-up evaluations at 1-week, 1-month, 3-month, 6-month, and 12-month intervals postoperatively. Results: A total of 141 patients met the inclusion criteria for the study. Mean age at surgery was 19 ± 3.2 years in the adolescent group and 53 ± 7.4 years in the average-age group. No significant differences in complications related to wound healing (42.9% vs 50.0%, P=0.418) or total postoperative complications (18.4% vs 19.6%, P=0.863) were found between adolescent and average-age patients, respectively. Conclusion: Complications related to wound healing are common in reduction mammaplasty, although rates of life-threatening complications are rare. In this 3-year review comparing the outcomes of adolescent vs average-age patients who underwent reduction mammaplasty at the same institution, no significant differences in postoperative complication rates were found. Our data suggest that adolescent patients with macromastia should not defer reduction mammaplasty out of concern for higher complication rates because of age alone.

Over-expansion of right ventricle to pulmonary artery conduits during transcatheter pulmonary valve placement.

To determine the safety and feasibility of over-expansion of right ventricle to pulmonary artery conduits during transcatheter pulmonary valve placement. Transcatheter pulmonary valve placement is an alternative to surgical pulmonary valve replacement. Traditionally, it was thought to be unsafe to expand a conduit to >110% of its original size. This retrospective cohort study from two centers includes patients with right ventricle to pulmonary artery conduits with attempted transcatheter pulmonary valve placement from 2010 to 2017. Demographic, procedural, echocardiographic and follow-up data, and complications were evaluated in control and overdilation (to >110% original conduit size) groups. One hundred and seventy-two patients (51 overdilation and 121 control) had attempted transcatheter pulmonary valve placement (98% successful). The overdilation group was younger (11.2 versus 16.7 years, p < 0.001) with smaller conduits (15 versus 22 mm, p < 0.001); however, the final valve size was not significantly different (19.7 versus 20.2 mm, p = 0.2). Baseline peak echocardiographic gradient was no different (51.8 versus 55.6 mmHg, p = 0.3). Procedural complications were more frequent in overdilation (18%) than control (7%) groups (most successfully addressed during the procedure). One patient from each group required urgent surgical intervention, with no procedural mortality. Follow-up echocardiographic peak gradients were similar (24.1 versus 26 mmHg, p = 0.5). Over-expansion of right ventricle to pulmonary artery conduits during transcatheter pulmonary valve placement can be performed successfully. Procedural complications are more frequent with conduit overdilation, but there was no difference in the rate of life-threatening complications. There was no difference in valve function at most recent follow-up, and no difference in rate of reintervention. The long-term outcomes of transcatheter pulmonary valve placement with conduit over-expansion requires further study.

The influence of leukoreduction on the acute transfusion‐related complication rate in 455 dogs receiving 730 packed RBCs: 2014–2017

To investigate the influence of prestorage leukoreduction of packed RBCs (pRBCs) on acute transfusion-related complication rate in dogs. Two private referral hospitals. Retrospective case study. Four hundred and fifty-five dogs receiving nonleukoreduced (nLR) or leukoreduced (LR) pRBC between January 1, 2014 and July 31, 2017. Transfusions were retrospectively reviewed to record data about the patient, donor, unit, transfusion event, acute complications, hospital discharge, and cause of death. Of 730 transfusion events in 455 dogs, 288 used LR pRBC and 442 used nLR pRBC. There was a 18.9% (138/730) overall complication rate. Seven (0.96%) complications were life-threatening. The most common complications were pyrexia (5.6%), gastrointestinal signs (4.9%), and hemolysis with no other signs (4.1%). Pyrexia with no other clinical signs, consistent with a febrile nonhemolytic transfusion reaction (FNHTR), occurred in 3.2% of transfusion events. There was a significant (P=0.03) decrease in the rate of FNHTR with LR pRBC (1%) versus nLR pRBC (4.5%). Use of LR pRBC did not decrease in-hospital mortality. The odds of any complication, hemolysis only, FNHTR, and more severe complications increased with pRBC age. Leukoreduction did not decrease the impact of pRBC age on these complications. Use of older pRBC did not increase the incidence of life-threatening complications or mortality. Dogs receiving pRBC for blood loss were more likely to have gastrointestinal and more severe complications than those dogs that had hemolysis. The effect of pRBC unit age on complications was not influenced by the underlying reason for transfusion. Dogs that received a previous transfusion were more likely to have respiratory complications. In this study, the use of LR pRBC was associated with a decreased rate of FNHTR but no other complications. Unit age was associated with the incidence of hemolysis, FNHTR, and complication severity but not the rate of life-threatening complications or mortality.

Real-world etiologies and treatments of pediatric short bowel syndrome in Japan.

Short bowel syndrome (SBS) is a rare disease that can result in intestinal failure (IF). Short bowel syndrome intestinal failure leads to stunted growth and development and high mortality rates. The primary goal of treatment is to enhance intestinal adaptation and nutrient absorption. Parenteral nutrition (PN) is used to support this process until enteral autonomy can be restored. Some patients experience prolonged partial or complete dependency on PN and face an increased risk of life-threatening catheter-related bloodstream infections and intestinal failure-associated liver disease. This study aimed to provide real-world insights into the patient characteristics and treatment dynamics of PN-dependent children with SBS-IF in Japan. This retrospective observational study used anonymized information from a large hospital-based medical insurance database to identify pediatric patients who received PN for ≥6 months between April 2008 and January 2020. The primary endpoint was weaning from PN. Secondary endpoints included duration and complications of PN. Forty-eight children (mean age, 2.9 years) were eligible for inclusion. The most common causes of SBS-IF were mechanical bowel obstruction, functional bowel disorders, and Hirschsprung's disease. Twenty-two patients (45.8%) were weaned from PN during the study. The mean time to first weaning was 464.2 days and five patients (22.7%) restarted PN. The mean total duration of PN was 692.6 days in weaned patients and 1,170.9 days in unweaned patients. The most frequent complications were sepsis, catheter infections (both 79.2%), and liver dysfunction (64.6%). Pediatric patients with SBS-IF faced difficulties when weaning off PN and rates of life-threatening complications were high.

Abstract P244: Scleroderma Renal Crisis Among Systemic Sclerosis Patients; A Large Cohort Study From The United States National Emergency Department Database.

Background: Literature regarding trends for incidence and mortality of Scleroderma renal crisis (SRC) in systemic sclerosis (SSc) within the United States (US) emergency departments (ED) is limited. Objective: To study the trends for incidence and mortality of SRC among SSc patient encounters within the US EDs. Methods: Data from the national emergency department sample (NEDS) constitutes 20% sample of hospital-owned EDs and in-patient sample in the United States. All ED encounters were included in the analysis. Major complications related to each ED encounter were obtained by using ICD codes. A Linear p-trend was used to assess the trends. Results: Of the total 180,435 ED encounters with a diagnosis of SSc in NEDS for the years 2009-2014, 771 (4.27/1,000) (mean age of 59.6 ± 15.5 years, 75.4% females) patients were recorded with SRC. A total of 32 (4.1%) patients had died during these ED hospital encounters. The SSc with SRC subgroup was associated with higher rates of life-threatening complications when compared to SSc without the SRC subgroup. Cerebrovascular complications include acute ischemic stroke 44 (5.6%). Cardiac complications include new-onset atrial fibrillation 62 (8%), conduction block 13 (1.6%) and acute onset heart failure 186 (24.1%). Other complications include pulmonary arterial hypertension 122 (15.8%), respiratory failure 212 (27.5%), and deep vein thrombosis 36 (4.7%). The yearly trend for the incidence of SRC every 1,000 ED SSc encounters in the United States increased over the study years from 2.11/1,000 in 2009 to 5.79/1,000 in 2014 (linear p-trend 0.002). The yearly trend for the mortality related to SRC in the United States remained steady over the study years 2009-2014 (linear p-trend 0.3187). Conclusion: SRC is a relatively rare medical emergency among patients with SSc. Although there has been a significant rise in the incidence of SRC among SSc patients over the study years, mortality rates had remained steady. Proper management of the underlying risk factors can prevent the development of SRC and associated complications. Keywords: Systemic sclerosis, Scleroderma renal crisis, pulmonary hypertension, deep vein thrombosis.

Videothoracoscopic lobectomy training in non-small cell lung cancer.

This study aims to evaluate the outcomes of video-assisted thoracoscopic surgery lobectomies performed by a training consultant or an experienced consultant. The study included 103 patients (81 males, 22 females; mean age 59.6±9.5 years; range, 32 to 84 years) who underwent video-assisted thoracoscopic surgery lobectomy due to non-small cell lung cancer. The training consultant assisted on the same side with the experienced consultant during the operations of the experienced consultant. The experienced consultant observed in the operating room and provided advice from a distance during the first five operations of the training consultant. Comorbidities, postoperative complications, and mortality were evaluated. Patients" demographic characteristics, comorbidities, and postoperative complications were similar between the two surgeons (p>0.05). Operative time, incidence of prolonged air leak, and length of hospital stay were higher in procedures performed by the training consultant (p<0.05). There were no significant differences in rates of life-threatening complications or mortality. Video-assisted thoracoscopic surgery lobectomy can be performed safely by surgeons in training. Effective training programs may produce outcomes comparable to those of experienced surgeons.

Principles of safe laparoscopic entry

Laparoscopy is now the preferred approach for performing diagnostic procedures and therapeutic interventions in gynaecology. Minimally invasive surgery is less disabling, reduced hospital stay and more cost effective to health care systems, when compared with conventional open operations [1–6]. Although the risk of major complications does not significantly differ between benign gynaecological laparoscopic and conventional open procedures, laparotomy has been associated with a 40% higher risk of minor complications [6]. Most often the risk of complications during laparoscopy occurs during initial entry into the abdominal cavity. The rates of life-threatening complications at the time of abdominal entry are low – 0.4 gastrointestinal iatrogenic injuries and 0.2 major blood vessel injuries per 1000 laparoscopies [7]. However these represent approximately 50% of all serious laparoscopic complications [8] and laparoscopic medico-legal litigations (http://www. piaa.us/LaparoscopicInjuryStudy/pdf/PIAA_2000). Minor complications include extra-peritoneal insufflation, which also occurs prior to the initiation of the intended surgical procedure, and postoperative wound infection. On reviewing the published literature (gynaecology, urology, general surgery), it appears that most practitioners use one of three blind primary entry methods to access the peritoneal cavity during laparoscopic surgery: (1) the closed (classic or Veress needle) technique, (2) the open (Hasson) technique, and (3) the direct trocar insertion described by Dingfelder in 1978 [9,10]. Variations of these three techniques such as visual entry systems and radially expanding trocars are less frequently utilized. Evidence based risk management methods can be applied to deconstruct the primary abdominal entry into its three distinctly separate, interdependent and salient components; entry methods, entry instruments and entry sites [11]. Based on currently available data, no one abdominal entry method appears to be generally considered superior over another and recommended as the technique of choice [2,12–14]. However, in the large majority of trials, there is a type II error to detect complications. Since the complication rates are low, most trials are inadequately powered to detect statistically significant differences between the comparison techniques. For example, to show a difference in bowel injury rate of say 50%, i.e.

Catheter-based intervention for pulmonary vein stenosis due to fibrosing mediastinitis: The Mayo Clinic experience

IntroductionFibrosing mediastinitis (FM) is a rare but fatal disease characterized by an excessive fibrotic reaction in the mediastinum, which can lead to life-threatening stenosis of the pulmonary veins (PV). Catheter-based intervention is currently the only viable option for therapy. However, the current literature on how best to manage these difficult cases, especially in regards to sequential interventions and their potential complications is very limited. MethodsWe searched through a database of all patients who have undergone PV interventions at the Earl H. Wood Cardiac Catheterization Laboratory in Mayo Clinic, Rochester. From this collection, we selected patients that underwent PV intervention to relieve stenosis secondary to FM. ResultsEight patients were identified, with a mean age of 41years (24–59years). Five were men, and three were women. Three patients underwent balloon angioplasty alone, and five patients had stents placed. The majority of patients had acute hemodynamic and symptomatic improvement. More than one intervention was required in five patients, four patients had at least one episode of restenosis, and four patients died within four weeks of their first PV intervention. ConclusionsWe describe the largest reported case series of catheter-based intervention for PV stenosis in FM. Although catheter-based therapy improved hemodynamics, short-term vascular patency, and patient symptoms, the rate of life-threatening complications, restenosis, and mortality associated with these interventions was found to be high. Despite these associated risks, catheter-based intervention is the only palliative option available to improve quality of life in severely symptomatic patients with PV stenosis and FM. Patients with PV stenosis and FM (especially those with bilateral disease) have an overall poor prognosis in spite of undergoing these interventions due to the progressive and recalcitrant nature of the disease. This underscores the need for further innovative approaches to manage this disease.

Otamixaban versus UFH, enoxaparin and fondaparinux in the prevention of cardiac catheter thrombosis in vitro (electron microscopic results from the OPEN-CATH study)

Efficient and safe anticoagulation is crucial in patients requiring percutaneous coronary intervention (PCI), where remaining rates of life-threatening complications trigger the development of new anticoagulants with improved efficacy/safety ratios. This in vitro study compared the efficacy of otamixaban, a new synthetic parenteral direct factor Xa inhibitor, with unfractionated heparin, enoxaparin and fondaparinux with/without combination with eptifibatide in the prevention of cardiac catheter thrombosis. Blood (49 ml each) from 10 healthy male volunteers pretreated with oral 500 mg aspirin was anticoagulated with unfractionated heparin (0.9 UI/ml), enoxaparin (0.6 IE/ml) or fondaparinux (0.5 μg/ml) at PCI-recommended doses, or with otamixaban at concentrations of 250 or 500 ng/ml. Each group was combined with/without 1.7 μg/ml eptifibatide (n=10 groups). The blood-anticoagulant mixtures were circulated continuously through a cardiac catheter for 60 min or until the catheter became blocked by thrombotic debris. Overall thrombus weight, global and specific coagulation parameters, and electron microscopic features such as deposits of platelets, erythrocytes and fibrin on the catheter surface were quantified as endpoints. The otamixaban regimes differed not statistically relevant from UFH and enoxaparin groups regarding the deposition of erythrocytes and demonstrated similar or even significantly reduced platelet deposition, whereas fondaparinux treatment resulted in significant increases of both values (p<0.05). Fibrin deposition was significantly reduced by all UFH and otamixaban regimes compared to the enoxaparin and fondaparinux treatment groups (p<0.05). Moreover, otamixaban, unfractionated heparin and enoxaparin in combination with/without eptifibatide ensured maximum circulation time (60 min), while the fondaparinux regimes caused premature catheter occlusions after 27±1 and 22±2 minutes (+/- eptifibatide), respectively. Regarding the generated thrombus weight, all otamixaban regimes did not differ significantly from the UFH and enoxaparin groups, while thrombus generation was significantly increased by both fondaparinux regimes compared to all other treatment options. In conclusion otamixaban, proved to be as effective as unfractionated heparin and enoxaparin and superior to fondaparinux with/without additional eptifibatide treatment in the prevention of cardiac catheter thrombosis in vitro. These data suggest that otamixaban might be a worthwhile alternative to currently recommended anticoagulants used for an invasive strategy.

Does Bilobectomy Offer Satisfactory Long-Term Survival Outcome for Non-Small Cell Lung Cancer?

Results of bilobectomy for non-small cell lung cancer have rarely been studied. Retrospective analysis was conducted on patients with non-small cell lung cancer having undergone bilobectomy from January 1999 to June 2012 at our institution. Analysis aimed at determining perioperative mortality and morbidity, and at studying prognostic factors for long-term survival using the 7th TNM classification. A total of 103 patients (85 males; mean age 62years) underwent upper-middle bilobectomy (n= 54) or lower-middle bilobectomy (n= 49). Histologic examination revealed 51 adenocarcinomas, 43 squamous cell carcinomas and 9 other cell carcinomas. Perioperative mortality was 0.97%. The overall morbidity rate was 71%, whereas the rate of life-threatening complications was 9.6%. Complications were more frequent in men (p= 0.032), in patients with chronic pulmonary obstructive diseases (p= 0.030) and after lower-middle bilobectomy (p= 0.0016). The overall 5-year Kaplan-Meier survival rate was 57.8%. In univariate analysis, factors associated with increased survival were the following: pathologic stage (stage I 74.9%, stage II 64.1%, stage III 28.8%, p=0.0018); nodal status (N0 vs N1, p= 0.011; N0 vs N2, p= 0.0015; N0 vs N+, p= 0.0008); R status (R0 vs R1, p= 0.0032), and smoking status (past smoker or nonsmoker vs active smoker, p= 0.00054). Multivariate analysis revealed that active smokers (RR= 3.87, CI 95% [1.83 to 8.21]; p= 0.00042) and increasing stage (stage 0: RR=1; stage I: RR= 1.98, CI 95% [1.38 to 2.83]; stage II: RR= 3.90, CI 95% [1.90 to8.02]; stage III: RR=7.72, CI 95% [2.62 to 22.73]; stage IV: RR= 15.25, CI 95% [3.61 to 64.40]; p= 0.0042) were significantly associated with poorer survival. Bilobectomy can be performed with low mortality, acceptable morbidity and long term survival in accordance with TNM staging.

A Multi-Institutional Perspective of Complication Rates for Elective Nonreconstructive Breast Surgery: An Analysis of NSQIP Data From 2006 to 2010

As elective nonreconstructive breast surgery increases in popularity, there is greater demand for accurate multi-institutional data on minor and major postoperative complications. The authors utilized a multi-institutional database to compare 30-day morbidities and reoperation rates among the different types of elective nonreconstructive breast surgery. Patients in the National Surgical Quality Improvement Program (NSQIP) participant use file who underwent elective nonreconstructive breast surgery between 2006 and 2010 were identified. Twenty defined morbidities were compared among mastopexy, reduction mammaplasty, and augmentation mammaplasty patients using analysis of variance and χ(2) tests for continuous variables and categorical variables, respectively. Logistic regression modeling was employed to identify preoperative risk factors for complications. Of the 3612 patients identified, 380 underwent mastopexy, 2507 underwent reduction mammaplasty, and 725 underwent augmentation mammaplasty. Complication rates were low in all cohorts, and patients undergoing augmentation mammaplasty had the lowest overall complication rate compared with mastopexy and reduction mammaplasty (1.24%, 2.37%, and 4.47%). Patients undergoing reduction mammaplasty had a modestly elevated incidence of overall morbidity, superficial surgical site infections, and wound disruptions (P < .05). Moreover, 30-day reoperation rates for mastopexy, reduction mammaplasty, and augmentation mammaplasty were low (1.58%, 2.07%, and 0.97%), as were the rates of life-threatening complications (0%, 0.16%, and 0%). One death was observed for all 3612 procedures (0.03%). Elective breast surgery is a safe procedure with an extremely low incidence of life-threatening complications and mortality. Comprehensive data collated from the NSQIP initiative add to the literature, and the findings of this multi-institutional study may help further guide patient education and expectations on potentially deleterious outcomes.

The Halo Fixator

The halo fixator may be used for the definitive treatment of cervical spine trauma, preoperative reduction in the patient with spinal deformity, and adjunctive postoperative stabilization following cervical spine surgery. Halo fixation decreases cervical motion by 30% to 96%. Absolute contraindications include cranial fracture, infection, and severe soft-tissue injury at the proposed pin sites. Relative contraindications include severe chest trauma, obesity, advanced age, and a barrel-shaped chest. In children, a computed tomography scan of the head should be obtained before pin placement to determine cranial bone thickness. Complications of halo fixation include pin loosening, pin site infection, and skin breakdown. A concerning rate of life-threatening complications, such as respiratory distress, has been reported in elderly patients. Despite a paucity of contemporary data, recent retrospective studies have demonstrated acceptable results for halo fixation in managing some upper and lower cervical spine injuries.