Operative Morbidity Rates Research Articles

Percutaneous aspiration of the gall bladder for the treatment of acute cholecystitis: a prospective study.

Urgent laparoscopic cholecystectomy has been established as the best treatment for acute cholecystitis. However, conservative treatment is advocated for high-risk patients. Failure of conservative treatment can result in high-risk operations with relatively high rates of operative morbidity. Percutaneous cholecystostomy is a good option for these patients. Recently, percutaneous aspiration of the gall bladder without drain has been described. A protocol of initial conservative management in high-operative-risk patients admitted with acute cholecystitis was prospectively assessed. Patients who did not respond to antibiotics were treated with percutaneous trans-hepatic aspiration of the gall bladder under ultrasound guidance. Following discharge, the patients were seen in the outpatient clinic and elective laparoscopic cholecystectomy was considered and scheduled as necessary. Between January 2011 and December 2012, 33 patients with persistent clinical and sonographic signs of acute cholecystitis after failure of initial antibiotic treatment underwent gall bladder aspiration under ultrasound guidance. No complications related to the procedure were reported. In 25 patients (76%), the procedure was successful and they were discharged. Seven patients needed repeated aspiration. Eight patients (24%) who did not improve underwent percutaneous cholecystostomy and were discharged with a drain and later reevaluated for elective surgery. The mean hospital stay of patients with successful aspiration was 3days. During the follow-up period, 23 patients underwent elective interval laparoscopic cholecystectomy. Two were converted to open surgery (8.7%). Conservative treatment and delayed operation is an acceptable option for acute cholecystitis. Percutaneous gall bladder aspiration is a simple and effective procedure, with a high success rate and low morbidity. Laparoscopic cholecystectomy after drainage of the gall bladder has low morbidity with a relatively low conversion rate.

The Role of Extended Pulmonary Metastasectomy

The role of extended pulmonary resection for lung metastases is still unclear, and little information is available in the literature. This study was performed to analyze the outcomes and prognostic factors of patients who underwent extended resections for pulmonary metastases. From 1998 to 2013, 1027 patients underwent lung metastasectomy procedures. Twenty-nine patients had extended pulmonary resections: three resections of the chest wall, one azygos, one diaphragm, four vascular resections/reconstructions, six sleeve resections, and 14 pneumonectomies. Extended resection was performed for metastatic disease mainly from epithelial (62.1%) and sarcomatous (20.7%) tumors. Complete resection was obtained in all patients. Thirty-day operative morbidity and mortality rates were 38% (11 of 29) and 0%, respectively. Only one patient had a major complication due to a bronchopleural fistula. Mean hospital stay was 6.3 days. After a median follow-up of 27 months, 16 patients (55%) had died. At univariate analysis, survival was determined by primary tumor histology (p = 0.03); the number of metastases, nodal status, disease-free interval or extension of surgery (pneumonectomy vs. lobar resection) were not related to survival probably due to the low number of patients. Overall survival after a complete extended metastasectomy was 66% at 2 years, 42% at 5 years, and 36% at 10 years. Extended resections performed during pulmonary metastasectomies are associated with low mortality and morbidity rates and an acceptable long-term survival when performed in selected patients susceptible to complete resection.

Bilobectomy Versus Lobectomy for Non-Small Cell Lung Cancer: A Comparative Study of Outcomes, Long-Term Survival, and Quality of Life

We aimed to compare long-term survival and quality of life (QOL) outcomes after bilobectomy and lobectomy for non-small cell lung cancer patients. A cohort of 951 consecutive patients was identified from a single treatment institution, of whom 128 underwent bilobectomy and 823, lobectomy. Propensity score matching (1:3) was applied to balance known confounders between the two surgical groups and resulted in 512 patients (matched cohort). Unmatched and matched analyses were performed to compare clinical outcomes between the two groups, including operative mortality rate, morbidity rate, long-term survival, overall QOL, and specific symptoms. Operative mortality was higher in the bilobectomy group than in the lobectomy group (2.3% versus 0.5%, p = 0.022). Morbidity rates did not differ significantly between the two groups in either unmatched or matched cohort. In the unmatched analysis, the overall survival (OS [p = 0.003]) and disease-free survival (DFS [p = 0.003]) were significantly lower in the bilobectomy group; whereas in the matched analysis, no significant difference was found in either OS (p = 0.473) or DFS (p = 0.387). Using multivariate analysis, the operation type was not found to be a significant factor for either OS (hazard ratio 1.18; 95% confidence interval: 0.91 to 1.52; p = 0.22) or DFS (hazard ratio 1.22; 95% confidence interval: 0.95 to 1.58; p = 0.13). Patients who underwent bilobectomy appeared to have similar measures of QOL as lobectomy patients, except for coughing and dyspnea. Our findings indicate that patients with non-small cell lung cancer treated with bilobectomy had similar morbidity, OS, DFS, and overall QOL as patients treated with lobectomy, but had higher mortality by matched analysis.

Repair or replace for severe ischemic mitral regurgitation: prospective randomized multicenter data.

Ischemic mitral regurgitation (IMR) is a subset of functional mitral regurgitation (MR) that has the potential to impact an increasing number of patients in the future. This is in the context of a worldwide population, which continues to live longer with improved survival after myocardial infarction. Substantial data have accumulated over the past few decades demonstrating the negative effects of IMR. Further, significant research has been done to define the optimal surgical approach and several studies have compared mitral repair versus replacement for patients with severe mitral regurgitation (SMR). Studies supporting performance of mitral repair cite superior operative morbidity and mortality rates, while proponents of mitral replacement cite improved long-term durability and correction of MR. Lack of clinically robust Level I randomized controlled trial data have curtailed attempts to better define appropriate surgical treatment allocation over the past few decades. Recently, however, the Cardiothoracic Surgical Trials Network (CTSN) conducted the first randomized controlled trial, funded by the National Heart, Lung, and Blood Institute, the National Institute for Neurological Diseases and Stroke and the Canadian Institute for Health Research, to compare the performance of mitral repair versus replacement for SMR. Herein, the present review describes the design, results and implications of the CTSN SMR trial and its efforts to identify the most efficacious surgical approach to SMR. This review also describes CTSN investigation to predict the recurrence of MR after mitral repair.

Improved Method of Reconstruction after Laryngo-Pharyngo-Esophagectomy for Squamous Cell Carcinoma of Pharyngo-Esophageal Junction or Synchronous Hypopharyngeal and Esophageal Cancer

Background: In this study, the advantages of a newly developed method of reconstruction following laryngo-pharyngo-esophagectomy were confirmed in patients with squamous cell carcinoma originating from the pharyngo-esophageal junction or with synchronously developed cancers of the hypopharynx and esophagus. Methods: Between 2003 and 2014, 11 patients underwent laryngo-pharyngo-esophagectomy at our institution. Eight patients had cancers simultaneously involving both the hypopharynx and the esophagus, two had carcinoma at the pharyngo-esophageal junction, and one had synchronously developed cancers of the hypopharynx, esophagus, and stomach. The prognosis and quality of life of these 11 patients were analyzed retrospectively, to establish the utility of a newly developed, improved (supercharged) method of reconstruction. Results:The mean operation time was 990 min (range: 635-1,320 min) and mean intraoperative blood loss was 1,236 ml (range: 240–2,500 ml). Operative morbidity, mortality, and 5-year survival rate were 45.5%, 9.1%, and 45.5%, respectively. Four patients underwent a traditional end-to-end anastomosis of the nasopharynx with the gastric tube. In all four patients, necrosis of the distal end of the gastric tube necessitated a skin flap reconstruction. One patient died from this complication. The supercharge method of reconstruction was performed in seven patients: in two using a reversed gastric tube, in four with a free jejunal graft, and in one with an ileocolic graft. None of these patients developed anastomotic leakage. Conclusion:The supercharged method yields improved reconstruction results in patients requiring laryngo-pharyngo-esophagectomy. Among the advantages of this method is better quality of life for these patients.

The Latest in Surgical Management of Stage IIIA Non-Small Cell Lung Cancer: Video-Assisted Thoracic Surgery and Tumor Molecular Profiling.

Stage IIIA non-small cell lung cancer (NSCLC) remains a treatment challenge and requires a multidisciplinary care team to optimize survival outcomes. Thoracic surgeons play an important role in selecting operative candidates and assisting with pathologic mediastinal staging via cervical mediastinoscopy, endobronchial ultrasound, or esophageal ultrasound with fine needle aspiration. The majority of patients with stage IIIA disease will receive induction therapy followed by repeat staging before undergoing lobectomy or pneumonectomy; occasionally, a patient with an incidentally found, single-station microscopic IIIA tumor will undergo resection as the primary initial therapy. Multiple large clinical trials, including SWOG-8805, EORTC-8941, INT-0139, and ANITA, have shown 5-year overall survival rates of up to 30% to 40% using triple-modality treatments, and the best outcomes repeatedly are seen among patients who respond to induction treatment or who have tumors amenable to lobectomy instead of pneumonectomy. The need for a pneumonectomy is not a reason to deny patients an operation, because current operative mortality and morbidity rates are acceptably low at 5% and 30%, respectively. In select patients with stage IIIA disease, video-assisted thoracic surgery and open resections have been shown to have comparable rates of local recurrence and long-term survival. New developments in genetic profiling and personalized medicine are exciting areas of research, and early data suggest that molecular profiling of stage IIIA NSCLC tumors can accurately stratify patients by risk within this stage and predict survival outcomes. Future advances in treating stage IIIA disease will involve developing better systemic therapies and customizing treatment plans on the basis of an individual tumor's genetic profile.

Evaluation of the Safety and Feasibility of Laparoscopic Total Gastrectomy in Clinical Stage I Gastric Cancer Patients

This retrospective study was designed to assess the feasibility of laparoscopic total gastrectomy (LTG) in clinical stage I gastric cancer patients, and validate the appropriateness of the widespread adoption of LTG for experienced open surgeons. Eighty-eight patients with clinical stage I gastric cancer underwent LTG in our hospitals (n = 55) and affiliated hospitals (n = 33). Esophagojejunostomy was performed intracoporeally using a circular stapler with an incision in the left upper abdomen. We investigated the patients' clinicopathologic factor, and evaluated the effect of hospital volume on short-term outcomes. Fixed insertion of the anvil head was successfully achieved in all patients (lift-up method in 58 patients and transoral method in 28 patients), although 2 patients were converted to open surgery. The approach using a circular stapler through a small incision from the upper left quadrant of the abdomen facilitated a good laparoscopic visual field for the plane of the esophagojejunostomy. Fourteen patients developed Clavien-Dindo classification grade II or more postoperative complications, and the overall operative morbidity rate was 15.9 %. No anastomotic leakage was encountered in this series. No significant difference was observed in clinical outcomes between patients in the high- and low-volume hospital groups. Laparoscopic total gastrectomy can be performed safely on clinical stage I gastric cancer patients by surgeons with sufficient experience in open gastrectomy and therefore represents a feasible procedure that is not clinically impacted by hospital volume.

The Prognostic Significance of Elevated Troponin Levels in Patients with Normal Coronaries Undergoing Surgery for Aortic Valve Stenosis

The Prognostic Significance of Elevated Troponin Levels in Patients with Normal Coronaries Undergoing Surgery for Aortic Valve Steno Objective: The outcome of aortic valve replacement (AVR) in patients without occlusive coronary artery disease who present with raised pre-operative troponin is not clear. We therefore, investigated the operative mortality and morbidity in this subset of patients undergoing urgent surgery for aortic stenosis. Methods: From a pool of 595 AVR patients in our institution’s database from July 2007 to July 2013, we reviewed the notes of all patients who underwent urgent surgery for aortic stenosis (n=57) and identified those with raised pre-operative troponin (n=16). We compared the observed operative mortality and major morbidity rates between patients with raised preoperative troponin levels (group I) and those with normal troponin levels (group II), and also with their predicted outcomes. Results: The baseline and operative characteristics for the two groups were comparable. There was a trend towards higher operative mortality for group I patients (18.8% versus 7.3% for group II, P=.07). Whereas, the observed operative mortality for group I far exceeded the predicted (18.8% vs 12.5%, p=.05), for group II the observed was slightly lower than the predicted operative mortality (7.3% vs 9.3%, p=.63). On the other hand, the observed mortality was well below the predicted for the elective patients. Conclusion: Patients with aortic stenosis and raised preoperative troponin undergoing urgent AVR may be at risk of higher operative mortality than predicted by the EuroScore. Further studies in this high risk group are warranted.

Perioperative and postoperative outcomes of perforated diverticulitis Hinchey II and III: Open Hartmann's procedure vs. laparoscopic lavage and drainage in the elderly

Hartmann's procedure (HP) is the most performed technique for acute diverticulitis. Laparoscopic lavage and drainage (LLD) is an option evaluated as definitive treatment for diverticulitis Hinchey grade II–III. Aim of the study is to analyze and compare LLD vs HP outcomes.From January 1st 2009 and December 31st 2012 we prospectively enrolled 30 patients with diagnosis of acute diverticulitis Hinchey grade II–III. Fourteen patients underwent to LLD (LLD group, LLDG) and 16 patients to HP (Hartmann group, HG). We evaluated: demographic variables, comorbidities, admission clinical status, radiological imaging, intraoperative outcomes (operative time), postoperative outcomes (admission to ICU, timing of drainage removal, restore of bowel functions, timing of oral solid intake), mortality rate (perioperative and after 12 months) and morbidity rate (surgical, infectious, cardiovascular, renal and systemic complications). Exclusion criteria were: other diseases, colon cancer's suspect or diagnosis, conversion to HP.Patients' mean age was 64.8 years in HG and 62.6 in LLDG. M:F ratio was 6:10 in HG, 8:6 in LLDG. Data showed improved outcomes in LLDG for: total operative time (p < 0.0001), admission to ICU (p 0.0447), restoration of bowel functions (p 0.0035 for gases, p 0.0152 for feces), mobilization (p 0.0087) and length of hospital stay (p 0.0132).According to literature, LLD is related to operative risk, morbidity and mortality rate and length of stay lower than HP. LLD also gives the possibility to avoid stoma. Despite limits of our study, we consider LLD as a “safe and effective” treatment for Hinchey grade II–III acute diverticulitis.

Management of petroclival meningiomas: a review of the development of current therapy.

The surgical management of petroclival meningioma remains challenging, due to the difficulty of accessing the region and the vital structures adjacent to the origin of these tumors. Petroclival meningiomas were originally considered largely unresectable. Until the 1970s, resection carried a 50% mortality rate, with very high rates of operative morbidity if attempted. However, in the past 40 years, advances in neuroimaging and approaches to the region were refined, and results from resection of petroclival meningiomas have become more acceptable. Today, the developments of a multitude of surgical approaches as well as innovations in neuroimaging and stereotactic radiotherapy have proved powerful options for multimodality management of these challenging tumors.

Biomechanical Evaluation of an Interfacet Joint Decompression and Stabilization System

A majority of the middle-aged population exhibit cervical spondylosis that may require decompression and fusion of the affected level. Minimally invasive cervical fusion is an attractive option for decreasing operative time, morbidity, and mortality rates. A novel interfacet joint spacer (DTRAX facet screw system, Providence Medical) promises minimally invasive deployment resulting in decompression of the neuroforamen and interfacet fusion. The present study investigates the effectiveness of the device in minimizing intervertebral motion to promote fusion, decompression of the nerve root during bending activity, and performance of the implant to adhere to anatomy during repeated bending loads. We observed flexion, extension, lateral bending, and axial rotation resonant overshoot mode (ROM) in cadaver models of c-spine treated with the interfacet joint spacer (FJ spacer) as stand-alone and supplementing anterior plating. The FJ spacer was deployed bilaterally at single levels. Specimens were placed at the limit of ROM in flexion, extension, axial bending, and lateral bending. 3D images of the foramen were taken and postprocessed to quantify changes in foraminal area. Stand-alone spacer specimens were subjected to 30,000 cycles at 2 Hz of nonsimultaneous flexion-extension and lateral bending under compressive load and X-ray imaged at regular cycle intervals for quantitative measurements of device loosening. The stand-alone FJ spacer increased specimen stiffness in all directions except extension. 86% of all deployments resulted in some level of foraminal distraction. The rate of effective distraction was maintained in flexed, extended, and axially rotated postures. Two specimens demonstrated no detectable implant loosening (<0.25 mm). Three showed unilateral subclinical loosening (0.4 mm maximum), and one had subclinical loosening bilaterally (0.5 mm maximum). Results of our study are comparable to previous investigations into the stiffness of other stand-alone minimally invasive technologies. The FJ spacer system effectively increased stiffness of the affected level comparable to predicate systems. Results of this study indicate the FJ spacer increases foraminal area in the cervical spine, and decompression is maintained during bending activities. Clinical studies will be necessary to determine whether the magnitude of decompression observed in this cadaveric study will effectively treat cervical radiculopathy; however, results of this study, taken in context of successful decompression treatments in the lumbar spine, are promising for the continued development of this product. Results of this biomechanical study are encouraging for the continued investigation of this device in animal and clinical trials, as they suggest the device is well fixated and mechanically competent.

Robotic right colectomy for hemorrhagic right colon cancer: a case report and review of the literature of minimally invasive urgent colectomy.

Right colon cancer rarely presents as an emergency, in which bowel occlusion and massive bleeding are the most common clinical presentations. Although there are no definite guidelines, the first line treatment for massive right colon cancer bleeding should ideally stop the bleeding using endoscopy or interventional radiology, subsequently allowing proper tumor staging and planning of a definite treatment strategy. Minimally invasive approaches for right and left colectomy have progressively increased and are widely performed in elective settings, with laparoscopy chosen in the majority of cases. Conversely, in emergent and urgent surgeries, minimally invasive techniques are rarely performed. We report a case of an 86-year-old woman who was successfully treated for massive rectal bleeding in an urgent setting by robotic surgery (da Vinci Intuitive Surgical System®). At admission, the patient had severe anemia (Hb 6 g/dL) and hemodynamic stability. A computer tomography scanner with contrast enhancement showed a right colon cancer with active bleeding; no distant metastases were found. A colonoscopy did not show any other bowel lesion, while a constant bleeding from the right pre-stenotic colon mass was temporarily arrested by endoscopic argon coagulation. A robotic right colectomy in urgent setting (within 24 hours from admission) was indicated. A three-armed robot was used with docking in the right side of the patient and a fourth trocar for the assistant surgeon. Because of the patient’s poor nutritional status, a double-barreled ileocolostomy was performed. The post-operative period was uneventful. As the neoplasia was a pT3N0 adenocarcinoma, surveillance was decided after a multidisciplinary meeting, and restoration of the intestinal continuity was performed 3 months later, once good nutritional status was achieved. In addition, we reviewed the current literature on minimally invasive colectomy performed for colon carcinoma in emergent or urgent setting. No study on robotic approach was found. Seven studies evaluating the role of laparoscopic colectomy concluded that this technique is a safe and feasible option associated with lower blood loss and shorter hospital stay. It may require longer operative time, but morbidity and mortality rates appeared comparable to open colectomy. However, the surgeon’s experience and the right selection of candidate patients cannot be understated.

A Propensity-Matched Comparison of Pleurodesis or Tunneled Pleural Catheter for Heart Failure Patients With Recurrent Pleural Effusion

Patients with severe heart failure often have recurrent pleural effusions that produce dyspnea and shortness of breath. It is unclear whether chemical pleurodesis or the placement of a tunneled pleural catheter that can be used for intermittent pleural drainage produces superior palliation, a shorter hospital stay, and less morbidity. This investigation compares these two treatments. Patients with a recurrent, symptomatic, pleural effusion secondary to advanced heart failure who had undergone at least two unilateral thoracenteses were identified. Two patient groups were formed by propensity matching patients who received either talc pleurodesis or a tunneled pleural catheter. Patient demographics, length of stay, need for further intervention for the pleural effusion, and procedural morbidity and mortality were collected and compared. Patients who had undergone ventricular assist device placement or cardiac transplant were excluded. Over a 5-year period, 80 patients undergoing treatment were identified and propensity matched. All 80 patients were classified as having class III or IV heart failure. No significant differences in palliation from their effusion were identified. However, the group treated with a tunneled pleural catheter realized a significantly shorter hospital stay as well as a lower rate of operative morbidity and readmissions than patients undergoing talc pleurodesis. This investigation found that a tunneled pleural catheter provided palliation of patients' pleural effusions and freedom from reintervention equal to that of talc pleurodesis using thoracoscopy while resulting in a shorter mean length of hospital stay. Lower rates of operative morbidity and readmission related to the pleural effusion were also seen in the tunneled catheter treatment group. This method of palliation of recurrent pleural effusion should be considered for symptomatic patients with advanced heart failure.

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): A new strategy to increase resectability in liver surgery

BackgroundPartial hepatectomy with clear surgical margins is the main curative treatment for hepatic malignancies. The safety of liver resection, to a great extent, depends on the volume of future liver remnant. This manuscript reviews some important strategies that have been developed to increase resectability for patients with borderline volume of future liver remnant, particularly associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). MethodsTo identify potentially relevant articles, we searched Medline and PubMed from January 2010 to December 2013 using the keywords “Associating liver partition and portal vein ligation for staged hepatectomy”, “ALPPS”, “portal vein embolization”, “future liver remnant”, “liver hypertrophy”, and “liver failure”. A number of references from the key articles were also cited. There were no exclusion criteria for published information to the topics. ResultsPortal vein ligation (PVL) or embolization (PVE) are traditional approaches to induce liver hypertrophy of the future liver remnant (FLR) prior to hepatectomy in primarily non-resectable liver tumors. However, about 14 percent of patients fail to this approach. Adequate hypertrophy of the FLR using PVL or PVE generally takes more than four weeks. ALPPS can induce rapid growth of the FLR, which is more effective than by portal vein embolization or occlusion alone. Reportedly, the hypertrophy extent of FLR was 40%–80% within 6–9 days in contrast to approximately 8%–27% within 2–60 days by PVL/PVE. However, ALPPS was reported to have high operative morbidity (16%–64% of patients), mortality (12%–23% of patients) and bile leakage rates. Bile leakage and sepsis remain a major cause of morbidity, and the main cause of mortality includes hepatic insufficiency. ConclusionALPPS has emerged as a new strategy to increase resectability of hepatic malignancies. Due to high morbidity and mortality rates of ALPPS procedure, the surgical candidates should be selected carefully. Moreover, there are very limited available evidence for its technical feasibility, safety and oncological outcome which are needed for further evaluation in larger scale of studies.

Aortic Root Enlargement in Octogenarian Patients Results in Less Patient Prosthesis Mismatch

Aortic root enlargement has not been well studied as a modality to prevent patient prosthesis mismatch in octogenarian patients with a small aortic root. We reviewed the records of 117 octogenarian patients who received surgical aortic valve replacement (AVR) between 1993 and 2010. From this group, 87 patients received a 19-mm AVR (small aortic valve, SAV group) and 30 received an aortic root enlargement and a 21-mm AVR (aortic root enlargement, ARE group). The median age of the patients was 84 years (range, 80 to 93) and there were 111 women (95%). Aortic cross-clamp time was 50 minutes (26 to 116) in the SAV group and 67 (26 to 136) in the ARE group (p=0.02). There were no differences in the operative morbidity or morality rates between the groups. Postoperative aortic valve area index was 0.77 cm2/m2 (0.25 to 1.47) in the SAV group and 1.06 (0.51 to 1.94) in the ARE group (p<0.001). Severe patient prosthesis mismatch occurred in 23 patients (32%) in the SAV group in comparison with 3 (12%) in the ARE group (p=0.04). There were no differences in the mid-term outcomes of New York Heart Association functional class (p=0.230) or survival between patients with or without mismatch (p=0.84). Aortic root enlargement in octogenarian patients allows for insertion of larger aortic valve prostheses without any apparent increase in operative morbidity or mortality. The larger prostheses demonstrate better hemodynamic performance and less patient prosthesis mismatch, but no apparent functional or survival advantage.

Impact of Preoperative and Postoperative FOLFOX Chemotherapies in Patients with Resectable Colorectal Liver Metastasis

Whether the survival benefit of perioperative FOLFOX in patients with liver metastases of colorectal cancer (LMCRC) is provided by preoperative chemotherapy (CT), postoperative CT, or both remains unclear. This study aimed to evaluate, in patients with resectable LMCRC, the survival impact of preoperative and postoperative separately. Between 2000 and 2010, the 179 patients (126 men, age 61 ± 11 years) with initially resectable LMCRC, who underwent liver resection (LR) and were offered pre- and/or postoperative FOLFOX were included. Twenty-four (13%) patients did not receive CT, 27(15%) patients received only preoperative CT, 71 (40%) patients received only postoperative CT, and 57 (32%) patients received both pre- and postoperative CT. Operative morbidity and mortality rates were 19 and 0.6%, respectively. At 1, 3, and 5 years, OS and DFS rates were 97, 66, 46 and 60, 32, and 24%, respectively. Postoperative FOLFOX was an independent predictor of increased OS (HR = 0.55 [95% CI, 0.35-0.87] p = 0.01) and DFS (HR = 0.54 [0.36-0.82] p = 0.0017), whereas the synchronous onset of the metastasis and the presence of radiographically occult liver metastases were independent predictors of poorer OS. Alternatively, preoperative FOLFOX had no significant influence on OS (HR = 0.96 [0.57-1.60] p = 0.83) or DFS (HR = 1.05 [0.66-1.66] p = 0.87). The survival benefit of FOLFOX in patients with resectable LMCRC may be provided by postoperative rather than preoperative administration.

Splenectomy results from an 18-year single centre experience.

Splenectomy is performed both as an emergency procedure following trauma and electively when indicated for haematological disease. Postsplenectomy patients receive immunotherapy vaccines and continuous antibiotic prophylaxis. Despite well documented concerns regarding complications and overwhelming postsplenectomy infection (OPSI) risk, there appears to be only a small amount of consistent data on long-term outcomes. The authors therefore present their postsplenectomy patient outcomes over an 18-year follow-up period. One hundred and five postsplenectomy patients operated on between 1991 and 2011 were identified from pathology codes and their case notes were reviewed. Eighty-eight patients (83.8%) were followed up for at least five years or until death. Of the 105 splenectomy patients (58 were male), the median age was 54 years (range: 10-87 years) and the median survival was 80 months. Operative morbidity and mortality rates were 21.0% (n=22) and 8.6% (n=9) respectively. Thirty-seven patients (27 males) underwent an emergency splenectomy with a median age, operative morbidity and operative mortality of 51 years, 13.5% and 21.6% (n=8) respectively. This compares with 68 patients (35 males) undergoing an elective splenectomy with the same parameters respectively of 55 years, 25.0% and 1.5% (n=1). Excluding operative deaths, multivariate analysis revealed age (p=0.002) as the only significant and independent prognostic indicator. Immunotherapy and antibiotic prophylaxis rates for the emergency cohort were 92.6% and 88.9% respectively, compared with 90.2% and 93.4% for the elective cohort. At follow-up, no patients were readmitted with OPSI. Over an 18-year period and a diverse indication for splenectomy, we have identified no evidence of OPSI. However, a significant operative mortality was associated with traumatic splenic rupture.

Risk-adjusted mortality rate cumulative sum analysis based on the Japan SCORE represents a learning curve in mitral valve reparative surgery

We calculated the cumulative sum analysis of an individual surgical learning curve for mitral valve reconstructive surgery to monitor quality control. Between April 2003 and March 2009, 25 consecutive patients underwent mitral valve reconstructive surgery for mitral regurgitation (MR). All operations were performed by a single surgeon. We analyzed the operative variables, mortality, and major morbidities and calculated the learning curve, using descriptive statistics and cumulative sum analysis based on the Japan SCORE calculator. In this series, the Japan SCORE calculator predicted a 30-day operative mortality rate of 3.07 ± 3.48 % and a 30-day operative mortality and morbidity rate of 14.9 ± 9.58 %s. In reality, there was no operative or in-hospital death and the major postoperative morbidity rate was 6.0 % (two patients). The risk-adjusted cumulative sum analysis revealed that the learning curve for mortality and morbidity shifted downward below the lower confident interval for all the patients, on completion of mitral valve repair. Coefficient analysis revealed a significant negative correlation between the aortic cross-clamp time and the cardiopulmonary time and case load. There was no correlation between the operation time and the case load. Routine reconstructive mitral valve surgery for MR can be performed at the professionally permissive level from the beginning, even in low-volume case loads.

Surgery of massive hemoptysis in pulmonary tuberculosis: Immediate and long-term outcomes

To determine the current role of surgery and the risks and operative outcomes in patients with massive hemoptysis caused by pulmonary tuberculosis. A retrospective review of patients treated in the Department of Thoracic Surgery, Shanghai Pulmonary Disease Hospital between January 2001 and December 2010 was undertaken. The inclusion criteria were massive hemoptysis defined as expectoration of at least 200 mL of blood on each occasion or more than 600 mL in 24 hours; anatomic major pulmonary resection including lobectomy, bilobectomy, and pneumonectomy; histologic or bacteriologic pulmonary tuberculosis. Sixty-eight men (76.4%) and 21 women (23.6%) aged 41.3 ± 11.7 years met the criteria. The cumulative amount of bleeding on admission was 558 ± 272 mL. A total of 36 patients (40.4%) underwent an emergency operation and 53 (59.6%) had a delayed operation. The operative morbidity rate was 31.5% (28 of 89) and mortality was 2.2% (2 of 89). Only 2 (2.2%) of the 89 patients had a recurrent episode of hemoptysis. Multivariate analysis showed that patients who received antituberculous therapy before surgery (odds ratio [OR], 0.12; 95% confidence interval [CI], 0.04-0.38; P=.0003) had a decreased risk of developing postoperative complications and that patients who underwent an emergency operation (OR, 3.9; 95% CI, 1.29-11.5; P=.0154) had an increased risk. In the present study, the immediate and long-term outcomes after surgery for patients with massive hemoptysis caused by pulmonary tuberculosis were fairly satisfactory. The morbidity and mortality were also acceptable. However, delayed elective surgery is preferred and emergency surgery should be reserved for patients with persistent life-threatening hemoptysis despite a multidisciplinary intervention.

Long-term outcomes of survival and freedom from reoperation on the aortic root or valve after surgery for acute ascending aorta dissection

Limited long-term outcome data are available on survival and the need for aortic root or valve reoperation after surgery for acute ascending aorta dissection. We report our 42-year experience. We reviewed the records of 269 patients who had undergone surgery for acute ascending aorta dissection from July 1969 to June 2011. The mean age at surgery was 62.1±15.2 years, and 181 were men (67.3%). The distal operation was limited to hemiarch replacement. The proximal aortic operation groups included a composite valve conduit in 66 patients (24.5%), aortic root repair in 112 (41.6%), and isolated supracoronary ascending aorta replacement in 91 (33.8%). Operative morbidity occurred in 224 patients (83.3%) and mortality in 44 (16.4%), with similar rates among the groups (P=.894 and P=.466, respectively). The mean follow-up was 9.7±7.5 years. The Kaplan-Meier survival estimate at 10 and 20 years was 65.5%±3.6% and 28.7%±4.3%, respectively, and was similar among the groups (P=.227). Reoperation on the aortic root or valve occurred in 20 patients (8.9%) at a median of 6.8 years (range, 0.2-20.3). The freedom from reoperation rate at 10 and 20 years was 91.5%±2.3% and 79.3%±6.1%, respectively, with no difference among the groups (P=.605). Operative morbidity and mortality rates are significant after repair of acute ascending aorta dissection. Aortic root surgery can be performed without an apparent increase in the prevalence of operative morbidity or mortality; however, patients remain at risk of subsequent aortic root or valve surgery.