Risk Factors For Overall Complications Research Articles

Evaluation of Clavien-Dindo classification in patients undergoing total gastrectomy for gastric cancer.

The Clavien-Dindo classification for postoperative complications has been established as a standardized system and applied in many fields of surgery. The aim of our study was to assess the complications after total gastrectomy using the Clavien-Dindo classification and identify risk factors related to them. Four hundred and fifteen patients who underwent total gastrectomy for gastric cancer between April 2009 and September 2014 were enrolled in this study. Postoperative complications were graded, and possible risk factors related to complications were analyzed. The overall complication rate was 13.3 %, with the severe complications classified as grade III or above accounting for 3.1 %. Age of 65 years old or more, higher TNM staging, and open surgery were identified as independent risk factors for overall complications. Age of 65 years old or more, ASA score of 3 or more, multiorgan resection, and retrieved lymph nodes of 30 or more were identified as independent risk factors for severe complications. The Clavien-Dindo system has a broad applicability and facilitates the assessment on the incidence and severity of complications. Large-scaled, prospective clinical trials using the classification are necessary to evaluate the postoperative complications of total gastrectomy for gastric cancer.

Skeletal Muscle Percentage: A Protective Factor for Postoperative Morbidity in Crohn’s Disease Patients with Severe Malnutrition

BackgroundThere are no appropriate variables for predicting postoperative morbidity in Crohn’s disease (CD) patients with severe malnutrition. We examined a retrospective cohort to clarify these. Materials and MethodsBetween 2005 and 2013, 138 CD patients with severe malnutrition underwent elective intestinal resection after preoperative management, consisting of nutritional support, abscess drainage, intravenous antibiotics, steroids tapering, and infliximab weaning, as appropriate. The severity of postoperative morbidity (within the first 30 days) was examined according to the Clavien–Dindo classification system. ResultsAfter a median duration of 26 days of preoperative management, Crohn’s disease activity index (CDAI) and C-reactive protein (CRP) significantly decreased, and body mass index (BMI), skeletal muscle percentage (SMP), body fat percentage (BFP), albumin, prealbumin, and hemoglobin significantly increased (P < 0.001). Postoperative overall morbidities occurred in 28 (20.3 %) patients including 15 (10.8 %) major complications (Clavien–Dindo classification ≥ III). In the multivariate logistic regression analysis, preoperative CRP (P = 0.044, OR 1.156, 95 % CI 1.004–1.331) was a significantly independent risk factor for overall complications, and preoperative SMP (P = 0.002, OR 0.487, 95 % CI 0.307–0.772) and BFP (P = 0.036, OR 0.691, 95 % CI 0.490–0.996) were significantly independent protective factors. Notably, only preoperative SMP (P = 0.002, OR 0.588, 95 % CI 0.422–0.820) was a significantly independent protective factor for major complications, and our threshold of SMP was 24.3 % (P < 0.001, sensitivity 83.7 %, specificity 95.9 %). ConclusionsPreoperative SMP is a protective factor for postoperative overall and major complications in CD patients with severe malnutrition and deserves further study.

Risk Factors Associated with Complication Following Gastrectomy for Gastric Cancer: Retrospective Analysis of Prospectively Collected Data Based on the Clavien–Dindo System

BackgroundMost studies about complication after gastric cancer surgery have been performed without consideration of the severity of each complication. The purposes of this study were to prospectively analyze all postgastrectomy complications according to severity using Clavien–Dindo classification and to identify risk factors related to postoperative complications. MethodsComplication data were collected prospectively through weekly conferences with all gastric adenocarcinoma patients who underwent gastrectomy between March 2011 and February 2012 at Seoul National University Hospital. Complications were categorized according to the Clavien–Dindo classification. ResultsOut of the 881 patients who underwent gastrectomy, there were 254 events in 197 patients (22.4 %). The numbers of grade I, II, IIIa, IIIb, IVa, and V complications according to the Clavien–Dindo classification were 71 (8.1 %), 58 (6.6 %), 108 (12.3 %), 8 (0.9 %), 5 (0.6 %), and 4 (0.5 %), respectively. Extended gastrectomy (odds ratio [OR], 3.92; 95 % confidence interval [CI], 1.96–7.82, p < 0.001), total gastrectomy (OR, 1.97; 95 % CI, 1.24–3.14, p = 0.004), and age of 60 years or more (OR, 1.66; 95 % CI, 1.15–2.38, p = 0.007) were found to be significant independent risk factors for overall complications of gastrectomy. These three factors were also risk factors for the complications of grade IIIa or over and local and systemic complications. In addition, ASA 3 or 4 and moderate or severe malnutrition as well as those three factors were risk factors for systemic complications. ConclusionAge and the extent of gastrectomy were revealed as the prognostic factors for overall complications and the complications of grade IIIa or over according to the Clavien–Dindo classification following gastrectomy for gastric cancer.

Old age is associated with increased severity of complications in endoscopic biliary stone removal.

Various techniques are required in endoscopic biliary stone removal. Because the presence of biliary stones is a benign disease, it is essential to minimize procedure-related complications. Having a sound knowledge of the risk factors can help reduce the number and severity of complications. We determined the risk factors for complications in patients undergoing endoscopic biliary stone removal. This was a retrospective observational cohort study. We analyzed 743 consecutive patients with biliary stones who were treated with endoscopic retrograde cholangiopancreatography and identified the independent risk factors for complications. Complications occurred in 66 patients (8.9%). Pancreatitis occurred in 26 patients (3.5%), cholangitis in 16 (2.2%), bleeding in 12 (1.6%) and other in 12 (1.6%). Independent risk factors for overall complications were multiple biliary stones (P = 0.0480) and anti-thrombotic drugs (P = 0.0186).Independent risk factors for moderate or severe complications were old age (P = 0.0201), multiple biliary stones (P = 0.0300), anti-thrombotic drugs (P = 0.0131), and cirrhosis of the liver (P = 0.0013). The respective risk factors for pancreatitis, cholangitis, and bleeding were precut technique (P = 0.0005), endoscopic mechanical lithotripsy (P = 0.0421), and both anti-thrombotic drugs (P = 0.0228) and cirrhosis of the liver (P = 0.0115). Old age was associated with a similar complication rate to younger age but increased the severity of complications following endoscopic biliary stone removal. Improved awareness of the severity of complications may be of benefit during periprocedural management. Further studies are warranted.

Standardized assessment of complications in a contemporary series of European patients undergoing radical cystectomy

To examine postoperative complications in a contemporary series of patients after radical cystectomy using a standardized reporting system, and to identify readily available preoperative risk factors. Using the modified Clavien-Dindo classification, we assessed the 90-day postoperative clinical course of 535 bladder cancer patients who underwent radical cystectomy and urinary diversion (ileal conduit n = 349, ileal neobladder n = 186) between June 2003 and February 2012 at a single institution. All Martin criteria for standardized reporting of complications were met. Uni- and multivariable analyses for prediction of complications were carried out; covariates included body mass index, Charlson Comorbidity Index, age, sex, American Society of Anesthesiologists Score, neoadjuvant chemotherapy, prior abdominal or pelvic surgery, localized tumor and urinary diversion type. The 90-day rates for overall (Clavien-Dindo classification I-V) and high-grade complications (Clavien-Dindo classification III-V), as well as mortality (Clavien-Dindo classification V), were 56.4, 18.7 and 3.9%, respectively. Infections (16.4%), bleeding (14.2%) and gastrointestinal complications (10.7%) were the most common adverse outcomes. Independent risk factors for overall complications were body mass index (odds ratio 1.08) and Charlson Comorbidity Index ≥3 (odds ratio 1.93). Risk factors for high-grade complications were Charlson Comorbidity Index ≥3 (odds ratio 1.86), American Society of Anesthesiologists Score ≥3 (odds ratio 1.92) and body mass index (odds ratio 1.07, all P < 0.03). Radical cystectomy is associated with significant morbidity; nevertheless, the majority of complications are minor. Charlson Comorbidity Index, American Society of Anesthesiologists Score and body mass index might help to identify patients at risk for high-grade complications after radical cystectomy.

Covered Metal Stenting for Malignant Lower Biliary Stricture with Pancreatic Duct Obstruction: Is Endoscopic Sphincterotomy Needed?

Aims. To evaluate the need for endoscopic sphincterotomy (EST) before covered self-expandable metal stent (CSEMS) deployment for malignant lower biliary stricture with pancreatic duct obstruction. Methods. This study included 79 patients who underwent CSEMS deployment for unresectable malignant lower biliary stricture with pancreatic duct obstruction. Treatment outcomes and complications were compared between 38 patients with EST before CSEMS deployment (EST group) and 41 without EST (non-EST group). Results. The technical success rates were 100% in both the EST and the non-EST group. The incidence of pancreatitis was 2.6% in the EST, and 2.4% in the non-EST group (P = 0.51). The incidences of overall complications were 18.4% and 14.6%, respectively, (P = 0.65). Within the non-EST groups, the incidence of pancreatitis was 0% in patients with fully covered stent deployment and 3.6% in those with partially covered stent deployment (P = 0.69). In the multivariate analysis, younger age (P = 0.003, OR 12) and nonpancreatic cancer (P = 0.001, OR 24) were significant risk factors for overall complications after CSEMS deployment. EST was not identified as a risk factor. Conclusions. EST did not reduce the incidence of pancreatitis after CSEMS deployment in patients of unresectable distal malignant obstruction with pancreatic duct obstruction.

Preoperative immunonutrition in patients at nutritional risk: results of a double-blinded randomized clinical trial

To evaluate the impact of preoperative immunonutrition (IN) on postoperative morbidity in patients at risk of malnutrition undergoing major gastrointestinal (GI) surgery. The combination of malnutrition and major GI surgery entails high morbidity. The Nutritional Risk Score (NRS) reliably identifies patients who need preoperative nutrition; the optimal nutritional formula for these patients still needs to be defined. In all, 152 patients with a NRS≥3 and undergoing elective major GI surgery were randomized between IN or isocaloric-isonitrogenous nutrition (ICN) given for 5 days preoperatively. Patients and caregivers were blinded for the allocated intervention. Thirty days complication rate was the primary endpoint. Infections, length of hospital stay and compliance were considered as secondary outcomes. Overall, 145 patients were available for analysis; the 73 patients in the IN group matched well with the 72 ICN patients with regards to patient's and surgical characteristics. In all, 39 IN and 33 ICN patients experienced a total of 48 and 50 postoperative complications, respectively (P=0.723). Both groups did not differ significantly concerning infectious (13 vs 9) complications. Independent risk factors for overall complications were malignant disease (odds ratio (OR)=4.304; confidence interval (CI) 1.317-14.002) and operative time (OR=1.004; CI 1.000-1.008). In patients at nutritional risk, complications, infections and hospital stay after major GI surgery were comparable regardless of preoperative supplementation with IN or ICN.

Complications After Rectal Prolapse Surgery

Data comparing surgical outcomes following abdominal and transperineal approaches for rectal prolapse are limited. We sought to identify differences in postoperative complications following abdominal vs transperineal approaches to rectal prolapse. We studied a retrospective cohort in the American College of Surgeon's National Surgical Quality Improvement Program from January 2005 through December 2008. We identified all patients who underwent surgical treatment for rectal prolapse. We compared surgical outcomes of standard abdominal approaches compared with standard transperineal approaches to rectal prolapse. The primary outcomes measured were the validated morbidity outcomes and 30-day mortality. During the study period, 1485 patients underwent rectal prolapse surgery (706 abdominal and 779 transperineal). Patients treated with abdominal approaches had significantly higher rates of infectious (9.8% vs 3.7%) and overall (12.9% vs 7.6%) complications in comparison with those treated with transperineal approaches. On multivariate analysis, risk factors for overall complications were ASA class 4 (OR 6.4) and abdominal surgery (OR 2.3), whereas an albumin level of ≥ 2.5 was protective (OR 0.05). Significant predictors of infectious complications were ASA class 4 (OR 7.5), BMI >25 (OR 1.8), and rectal prolapse surgery performed with an abdominal approach (OR 2.8). The retrospective design introduces potential selection bias. Abdominal surgery for rectal prolapse is a predictor of both infectious and overall complications. Patients with significant comorbidities or a high BMI are at particularly high risk for complications and may be better suited for a transperineal rather than abdominal approach for the treatment of rectal prolapse.

Risk Factors for ERCP-Related Complications: A Prospective Multicenter Study

To investigate the potential risk factors for endoscopic retrograde cholangiopancreatography (ERCP) complications and to identify whether the risk factors are different for pancreatitis and asymptomatic hyperamylasemia. Consecutive ERCP procedures were studied at 14 centers in China from May 2006 to April 2007. The complications after the patients' first-only procedures were evaluated. Multivariate analysis based on the first-only procedures was used to identify the risk factors. A total of 3,178 procedures were performed on 2,691 patients. Overall, complications developed in 213 (7.92%) patients, pancreatitis in 116 (4.31%), and asymptomatic hyperamylasemia in 396 (14.72%). In the multivariate analysis, female gender (adjusted odds ratios (ORs): 1.52, 95% confidence interval (CI): 1.14-2.02, P=0.004), periampullary diverticulum (OR: 2.02, 95% CI: 1.49-2.73, P<0.001), cannulation time >10 min (OR: 1.51, 95% CI: 1.08-2.10, P=0.016), > or =1 pancreatic deep wire pass (OR: 1.80, 95% CI: 1.33-2.42, P<0.001), and needle-knife precut (OR: 2.70, 95% CI: 1.42-5.14, P=0.002) were risk factors for overall complications. Female gender (OR: 1.84, 95% CI: 1.25-2.70, P=0.002), age < or =60 year (OR: 1.59, 95% CI: 1.06-2.39, P=0.025), cannulation time>10 min (OR: 1.76, 95% CI: 1.13-2.74, P=0.012), > or =1 pancreatic deep wire pass (OR: 2.77, 95% CI: 1.79-4.30, P<0.001), and needle-knife precut (OR: 4.34, 95% CI: 1.92-9.79, P<0.001) were risk factors for pancreatitis. Cannulation time>10 min (OR: 1.96, 95% CI: 1.52-2.54, P<0.001), > or =1 pancreatic deep wire pass (OR: 2.24, 95% CI: 1.74-2.89, P<0.001), needle-knife precut (OR: 2.34, 95% CI: 1.32-4.14, P=0.004), and major papilla pancreatic sphincterotomy (OR: 1.71, 95% CI: 1.23-2.37, P=0.001) were risk factors for asymptomatic hyperamylasemia. Patient-related factors are as important as procedure-related factors in determining high-risk predictors for post-ERCP overall complications and pancreatitis. However, the risk factors for asymptomatic hyperamylasemia may be mostly procedure related.

Impact of Induction Chemotherapy and Preoperative Chemoradiotherapy on Operative Morbidity and Mortality in Patients with Locoregional Adenocarcinoma of the Stomach or Gastroesophageal Junction

Significant tumor downstaging has been achieved in patients with localized gastric or gastroesophageal adenocarcinoma by induction chemotherapy and preoperative chemoradiotherapy (CTX-CTXRT). However, the influence of CTX-CTXRT on operative morbidity and mortality has not yet been clarified. The aim of the present study was to document the frequency and nature of morbidity and mortality after surgery combined with CTX-CTXRT, and identify factors predictive of postoperative complications in patients with localized gastric or gastroesophageal adenocarcinoma. A prospectively collected database on 71 consecutive patients who underwent CTX-CTXRT at M.D. Anderson Cancer Center between January 1997 and August 2004 was reviewed. Postoperative morbidity and mortality were investigated, and risk factors for overall complications were identified by multivariate logistic regression analysis. Overall morbidity and mortality rates were 38.0% (27 patients) and 2.8% (2 patients), respectively. Age greater than 60 years [relative risk 11.3 (95% confidence interval 2.50-50.6)] and body mass index (BMI) of 26 kg/m(2) or above [relative risk 4.08 (95% confidence interval 1.08 to 15.4)] were significant risk factors for overall complications. CTX-CTXRT can be performed safely with an acceptable operative morbidity and a low operative mortality rate in patients with gastric or gastroesophageal cancer, with careful consideration of added risk associated with age and obesity.

Age as a Risk Factor for Overall Complications Following Third Molar Removal

Statement of the Problem: Third molar (M3) surgery is one of the most common procedures performed by oral and maxillofacial surgeons. The purpose of this study was to estimate the frequency of overall complications and identify risk factors associated with overall complications following third molar surgery with a focus on age as a primary predictor variable.

Identification of risk factors for the development of complications following extended and superextended lymphadenectomies for gastric cancer

Extended lymphadenectomy for gastric carcinoma has been associated with high mortality and morbidity rates in several multicentre randomized trials. Using data from 523 patients registered for a prospective randomized trial comparing extended (D2) and superextended (D3) lymphadenectomies, risk factors for overall complications and major surgical complications (anastomotic leakage, intra-abdominal abscess and pancreatic fistula) were identified by multivariate logistic regression analysis. Mortality and morbidity rates were 0.8 per cent (four of 523) and 24.5 per cent (128 of 523) respectively. Pancreatectomy (relative risk 5.62 (95 per cent confidence interval (c.i.) 1.94 to 16.27)) and prolonged operating time (relative risk 2.65 (95 per cent confidence interval 1.34 to 5.23)) were the most important risk factors for overall complications. A body mass index of 25 kg/m2 or above, pancreatectomy and age greater than 65 years were significant predictors of major surgical complications. Pancreatectomy should be reserved for patients with stage T4 disease. Age and obesity should be considered when planning surgery.

Same-day discharge after endoscopic biliary sphincterotomy: observations from a prospective multicenter complication study

Background: Same-day discharge after endoscopic biliary sphincterotomy (ES) is a common clinical practice, but there have been few data to guide appropriate selection of patients. Using a prospective, multicenter database of complications, we examined outcomes after same-day discharge as it was practiced by a variety of endoscopists and evaluated the ability of a multivariate risk factor analysis to predict which patients would require readmission for complications. Methods: A 150-variable database was prospectively collected at time of ES, before discharge and again at 30 days in consecutive patients undergoing ES at 17 centers. Complications were defined by consensus criteria and included all specific adverse events directly or indirectly related to ES requiring more than 1 night of hospitalization. Results: Six hundred fourteen (26%) of 2347 patients undergoing ES were discharged on the same day as the procedure, ranging from none at 6 centers to about 50% at 2 centers. After initial observation and release, readmission to the hospital for complications occurred in 35 (5.7%) of 614 same-day discharge patients (20 pancreatitis and 15 other complications, 3 severe). Of the same-day discharge patients, readmission was required for 14 (12.2%) of 115 who had at least one independently significant multivariate risk factor for overall complications (suspected sphincter of Oddi dysfunction, cirrhosis, difficult bile duct cannulation, precut sphincterotomy, or combined percutaneous-endoscopic procedure) versus 21 (4.2%) of 499 without a risk factor (odds ratio 3.1: 95% confidence interval [1.6, 6.3], p < 0.001). Of complications presenting within 24 hours after ES, only 44% presented within the first 2 hours, but 79% presented within 6 hours. Conclusions: Same-day discharge is widely utilized and relatively safe but results in a significant number of readmissions for complications. For patients at higher risk of complications, as indicated by the presence of at least one of five independent predictors, observation for 6 hours or overnight may reduce the need for readmission. (Gastrointest Endosc 1999;49:580-6.)