Risk Factors For Severe Morbidity Research Articles

Relationship between the severity of emphysematous change in the lung and morbidity after esophagectomy for esophageal cancer: A retrospective study on a novel strategy for risk prediction.

Chronic obstructive pulmonary disease (COPD) prevalence increases post-esophagectomy morbidity. However, the association between COPD severity and post-esophagectomy morbidity remains unclear because of the lack of an objective method to classify COPD severity. Low attenuation volume ratio (LAVR) estimated using Ziostation2 may reflect the extent of emphysematous changes in the lungs and COPD severity, thereby predicting post-esophagectomy morbidity. A total of 776 patients who underwent curative McKeown esophagectomy for esophageal cancer between April 2005 and June 2021 were included. The patients were divided into high and low preoperative LAVR groups. Short-term outcomes between the groups were compared for patients who underwent open esophagectomy (OE) and minimally invasive esophagectomy (MIE). A total of 219 (28%) patients were classified into the high LAVR group. High LAVR was significantly associated with disadvantageous patient characteristics such as advanced age, heavy smoking, and impaired respiratory function. Patients with high LAVR had a significantly higher incidence of severe morbidity and pneumonia after OE. High LAVR was an independent risk factor for severe morbidity (odds ratio [OR], 2.52; 95% confidence interval [CI]: 1.237-5.143; p = 0.011) and pneumonia (OR, 2.12; 95% CI: 1.003-4.493; p = 0.049) after OE. Meanwhile, LAVR was not correlated with the incidence of post-MIE morbidity. LAVR may reflect COPD severity and predict severe morbidity and pneumonia after OE, but not after MIE. Less invasiveness of MIE may alleviate the effects of various disadvantageous backgrounds associated with high LAVR on worse short-term outcomes.

CADD Studies in the Discovery of Potential ARI (Aldose Reductase Inhibitors) Agents for the Treatment of Diabetic Complications.

The lack of currently available drugs for treating diabetes complications has stimulated our interest in finding new Aldose Reductase inhibitors (ARIs) with more beneficial biological properties. One metabolic method uses aldose reductase inhibitors in the first step of the polyol pathway to control excess glucose flux in diabetic tissues. Computer-aided drug discovery (CADD) is key in finding and optimizing potential lead substances. AR inhibitors (ARI) have been widely discussed in the literature. For example, Epalrestat is currently the only ARI used to treat patients with diabetic neuropathy in Japan, India, and China. Inhibiting R in patients with severe to moderate diabetic autonomic neuropathy benefits heart rate variability. AT-001, an AR inhibitor, is now being tested in COVID-19 to see how safe and effective it reduces inflammation and cardiac damage. In summary, these results from animal and human studies strongly indicate that AR can cause cardiovascular complications in diabetes. The current multi-center, large-scale randomized human study of the newly developed powerful ARI may prove its role in diabetic cardiovascular disease to establish therapeutic potential. During the recent coronavirus disease (COVID-19) outbreak in 2019, diabetes and cardiovascular disease were risk factors for severely negative clinical outcomes in patients with COVID19. New data shows that diabetes and obesity are among the strongest predictors of COVID-19 hospitalization. Patients and risk factors for severe morbidity and mortality of COVID- 19.

Benchmarking of minimally invasive distal pancreatectomy with splenectomy: European multicentre study

Benchmarking is the process to used assess the best achievable results and compare outcomes with that standard. This study aimed to assess best achievable outcomes in minimally invasive distal pancreatectomy with splenectomy (MIDPS). This retrospective study included consecutive patients undergoing MIDPS for any indication, between 2003 and 2019, in 31 European centres. Benchmarks of the main clinical outcomes were calculated according to the Achievable Benchmark of Care (ABC™) method. After identifying independent risk factors for severe morbidity and conversion, risk-adjusted ABCs were calculated for each subgroup of patients at risk. A total of 1595 patients were included. The ABC was 2.5 per cent for conversion and 8.4 per cent for severe morbidity. ABC values were 160 min for duration of operation time, 8.3 per cent for POPF, 1.8 per cent for reoperation, and 0 per cent for mortality. Multivariable analysis showed that conversion was associated with male sex (OR 1.48), BMI exceeding 30 kg/m2 (OR 2.42), multivisceral resection (OR 3.04), and laparoscopy (OR 2.24). Increased risk of severe morbidity was associated with ASA fitness grade above II (OR 1.60), multivisceral resection (OR 1.88), and robotic approach (OR 1.87). The benchmark values obtained using the ABC method represent optimal outcomes from best achievable care, including low complication rates and zero mortality. These benchmarks should be used to set standards to improve patient outcomes.

Laparoscopic Distal Pancreatectomy Following Prior Upper Abdominal Surgery (Pancreatectomy and Prior Surgery)

Background and PurposePrevious abdominal surgery can be a risk factor for perioperative complications in patients undergoing laparoscopic procedures. Today, distal pancreatectomy is increasingly performed laparoscopically. This study investigates the consequences of prior upper abdominal surgery (PUAS) for laparoscopic distal pancreatectomy (LDP). MethodsPatients who had undergone LDP from April 1997 to January 2020 were included. Based on the history and type of PUAS, these were categorized into three groups: minimally invasive (I), open (II), and no PUAS (III). To reduce possible confounding factors, the groups were matched in 1:2:4 fashion based on age, sex, body mass index (BMI) and American Society of Anesthesiology grade. ResultsAfter matching, 30, 60, and 120 patients were included in the minimally invasive, open and no PUAS groups, respectively. No statistically significant differences were found in terms of intraoperative outcomes. Postoperative morbidity, mortality and length of hospital stay were similar. Open PUAS was associated with higher Comprehensive Complication Index (33.7 vs 20.9 vs 26.2, p = 0.03) and greater proportion of patients with ≥ 2 complications (16.7 vs 0 vs 6.7%, p = 0.02) compared with minimally invasive and no PUAS. Male sex, overweight (BMI 25–29.9 kg/m2), diagnosis of neuroendocrine neoplasia, and open PUAS were risk factors for severe morbidity in the univariable analysis. Only open PUAS was statistically significant in the multivariable model. ConclusionsPUAS does not impair the feasibility and safety of LDP as its perioperative outcomes are largely comparable to those in patients without PUAS. However, open PUAS increases the burden and severity of postoperative complications.

Impact of pretreatment asymptomatic renal dysfunction on clinical course after esophagectomy.

Recent large-scale clinical studies have shown that preoperative renal insufficiency is associated with an increased risk of postoperative complications after esophagectomy; however, it remains unclear whether asymptomatic renal dysfunction affects the postoperative course after esophagectomy. The subjects of this retrospective study were 177 patients who underwent esophagectomy between May, 2009 and December, 2018. Renal function was evaluated based on the pretreatment estimated glomerular filtration rate (eGFR). Patients were divided into two groups according to the eGFR cut-off value of 55ml/min per 1.73m2. There were 17 patients in the low eGFR group and 160 patients in the normal group eGFR group. The rate of severe complications was significantly higher in the low eGFR than in the normal eGFR group. A low eGFR was the only significant complication risk factor identified; however, there were no marked differences in mortality or survival between the low and normal eGFR groups. Our findings demonstrate that pretreatment asymptomatic renal dysfunction may be a significant risk factor for severe morbidity after esophagectomy.

Social deprivation aggravates post-operative morbidity in carcinologic colorectal surgery: Results of the COINCIDE multicenter study.

Evaluate the impact of social deprivation on morbidity and mortality in surgery for colorectal cancer. The COINCIDE prospective cohort included nearly 2,000 consecutive patients operated on for colorectal cancer at the Assistance Publique-Hospitals of Paris (AP-HP) from 2008 to 2010. The data on these patients were crossed with the PMSI administrative database. The European Social Deprivation Index (EDI) was calculated for each patient and classified into five quintiles (quintiles 4 and 5 being the most disadvantaged patients). Thirty-day post-operative morbidity was determined according to the Dindo-Clavien classification, with a Had®Hoc re-analysis of each file. Statistical analysis was performed using the proprietary Q-finder® algorithm. One thousand two hundred and fifty nine curative colorectal resections were analyzed. Mortality was 2.7% and severe morbidity (Dindo-Clavien≥3) occurred in 16.4%. Mortality was not statistically significantly increased among the most disadvantaged who made up almost two thirds of the population (64.2%). Patients in quintiles 4 and 5 had a statistically significant increase in severe morbidity. The relative risk remained 1.5 even after adjustment for the known risk factors found in the analysis: age>70 years, ASA score, urgency, and laparotomy. The EDI represents an independent risk factor for severe morbidity after carcinologic colorectal resection. This study suggests that the determinants of health are multidimensional and do not depend solely on the quality and performance of the care system. The inclusion of this index in our surgical databases is therefore necessary, as is its use in health policy for the distribution of resources.

Predictors of morbidity and mortality for patients with peritoneal carcinomatosis secondary to colorectal cancer following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

Introduction: Even though cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has been associated with high morbidity and mortality rates, it has been reported that CRS and HIPEC improved survival of selected patients with peritoneal carcinomatosis. This study aimed to identify risk factors for severe morbidity and mortality after CRS + HIPEC in patients with peritoneal carcinomatosis secondary to colorectal cancer. Methods: Patients diagnosed with peritoneal carcinomatosis secondary to colorectal origin from March 2012 to December 2017 who underwent CRS + HIPEC were included in the study. All data prospectively entered in the HIPEC registry was analyzed with main focus on grade III–IV morbidity and mortality and factors predicting them. Risk factors were identified using logistic regression analysis. Results: The study included 163 cases of colorectal cancer with peritoneal metastasis; 20 were upfront, 94 interval, and 49 recurrent cases. Mean duration of surgery was 9.5 hours, blood loss 1250 mL and PCI 19. Total, upper quadrant, pelvic, paracolic peritonectomy, glissons capsulectomy, and mesenteric stripping was done in 42.5%, 68.1%, 69.3%, 72.5%, 14.7%, and 4.3%, respectively. Multivisceral resection, diaphragmatic resection, and bowel resection were done in 20.9%, 40.5%, and 57.5%, respectively. Based on Common Terminology Criteria for Adverse Events, the overall rate of morbidity grade III–IV was 18.4 %, the major being surgical 26%, hematological 20%, and electrolyte imbalance 19%. The 60-day mortality rate was 5%. Re-operation rate was 9%. Re-operation was needed in 11% and the mortality rate was 2.4%. In multivariate analysis the identified risk factors for severe morbidity were performance status, mean PCI >14, duration of surgery >10 hours, multivisceral resection, total peritonectomy, upper quadrant peritonectomy, more than one. Conclusion: On evaluating the perioperative outcomes following CRS + HIPEC for peritoneal carcinomatosis secondary to colorectal cancer, the impact on early mortality and morbidity was acceptable. The low mortality rate and 18.4 % grade III–IV morbidity of CRS and HIPEC when weighed against overall benefit is reasonable. Optimal patient selection, such as patients with PCI < 14 with good performance status, seems to be of paramount importance to CRS and HIPEC. This multimodal treatment appears feasible for selected patients and in trained HIPEC centers.

Domestic violence and perinatal outcomes \u2013 a prospective cohort study from Nepal

BackgroundDomestic violence is one of the most common forms of violence against women. Domestic violence during pregnancy is associated with adverse perinatal and maternal outcomes. We aimed to assess whether domestic violence was associated with mode of delivery, low birthweight and preterm birth in two sites in Nepal.MethodsIn this prospective cohort study we consecutively recruited 2004 pregnant women during antenatal care at two hospitals between June 2015 and September 2016. The Abuse Assessment Screen (modified) was used to assess fear and violence. Having ever experienced either fear or violence was defined as any domestic violence. Obstetric outcomes were obtained from hospital records for 1381 (69%) women, selecting singleton pregnancies only. Mode of delivery was assessed as birth by cesarean section or not. A birthweight of less than 2500 g was defined as low birthweight and preterm birth as birth before completion of 37 weeks gestation. Descriptive and multiple logistic regression analyses were performed to assess associations.ResultsTwenty percent of the women reported any domestic violence. Among all 1381 women, 37.6% gave birth by cesarean section. Of those women who delivered by cesarean section, 84.7% had an emergency cesarean section. Less than 10% of the babies were born prematurely and 13.5% were born with low birthweight. We found no significant association between exposure to any domestic violence during pregnancy and risk of a low birthweight baby or birth by cesarean section. However, having experienced both violence and fear was significantly associated with giving birth to a preterm infant [aOR 2.33 (95% CI;1.10–4.73)].ConclusionsDomestic violence is common in Nepal. This is a potential risk factor for severe morbidity and mortality in newborns. We found that the risk of having a preterm baby was higher for pregnant women who experienced both fear and violence. This should be recognized by the health sector. In this study, no significant differences were found in the rate of cesarean section nor low birthweight for women who had experienced any domestic violence compared to those who did not.

Risk factors for postoperative severe morbidity after pheochromocytoma surgery: A single center retrospective analysis of 262 patients

PurposeSurgical resection is the primary treatment strategy for pheochromocytoma; however, it carries a high risk of morbidity and mortality. The risk factors for severe morbidity remain unclear and require further exploration. We aimed to identify the risk factors for severe morbidity after pheochromocytoma surgery in Chinese patients. MethodsWe retrospectively reviewed 262 patients who underwent unilateral laparoscopic or open pheochromocytoma surgery at our center between January 1, 2007 and December 31, 2016. Patient demographics, as well as extensive perioperative data were recorded. Adjusted odds ratios and 95% confidence intervals were determined by multivariate binary logistic regression. Cutoff values and the area under the curve for continuous risk factors were calculated through receiver operating characteristic curve analysis. A P < 0.05 was considered statistically significant. ResultsOf the 262 patients, 78 (29.8%) had severe morbidity. The independent risk factors for severe morbidity were female sex, lower body mass index, coronary heart disease, longer duration of surgery, and intraoperative hemodynamic instability, with odds ratios of 2.624 (P = 0.003), 0.780 (P < 0.001), 2.098, (P = 0.024), 1.005 (P = 0.031), and 2.920 (P = 0.005). The optimal cut off values for body mass index and duration of surgery were 24.25 kg/m2 and 203 min. ConclusionsSevere morbidity is common in patients after pheochromocytoma surgery. We identified five independent risk factors for severe morbidity: female sex, lower body mass index, coronary heart disease, longer duration of surgery, and intraoperative hemodynamic instability. Identification of these risk factors may help to improve perioperative strategy.

Severe morbidity after pancreatectomy is accurately predicted by preoperative pancreatic resection score (PREPARE): A prospective validation analysis from a medium-volume center

BackgroundMajor morbidity in pancreatic surgery remains high. Different scores for predicting complications have been described. Preoperative pancreatic resection (PREPARE) score is based on objective preoperative variables and offers good predictive accuracy for Clavien ≥ III complications. This study aimed to validate this score and analyze other preoperative variables in a prospective study performed in a medium-volume center. MethodsA total of 50 pancreatic resections were included. Preoperative variables were registered and PREPARE was calculated. The main outcome was severe morbidity (Clavien ≥ III) up to 30 days after discharge. The secondary outcomes were length of stay (LOS) and readmission. Statistical validation was performed to compare severe morbidity rate among the scores categories. Association with other preoperative variables (not included in PREPARE) was also tested. ResultsOf the 50 pancreatic resections, the severe morbidity was 34.0%, with median LOS of 11 days. Readmission rate was 25.5%. Severe morbidity rates according to PREPARE categories were 18.5% in low-risk group, 41.7% in intermediate-risk group, and 63.6% in high-risk group, respectively (P = 0.023). The accuracy was 72% (Hosmer–Lemeshow, P = 0.86). ROC curve was obtained both for PREPARE score expressed as incremental values and categorized as the three risk groups, showing an area under curve (AUC) of 0.736 (95% CI: 0.586–0.887; P = 0.007) and 0.712 (95% CI: 0.555–0.869; P = 0.015), respectively. PREPARE was significant in multivariate analysis. Median LOS was statistically higher as PREPARE category increases (9, 11 and 15 days in low-, intermediate- and high-risk groups, respectively; P = 0.009). Readmission was not associated with any variables. ConclusionsPREPARE behaves as an independent risk factor for severe morbidity after pancreatic surgery. Score validation shows good accuracy prediction. Increasing PREPARE category is also associated with longer LOS.

Does obesity impact postoperative outcomes following robotic-assisted surgery for rectal cancer?

Obesity has been identified as a risk factor for both conversion and severe postoperative morbidity in patients undergoing laparoscopic rectal resection. Robotic-assisted surgery (RAS) is proposed to overcome some of the technical limitations associated with laparoscopic surgery for rectal cancer. The aim of our study was to determine if obesity remains a risk factor for severe morbidity in patients undergoing robotic-assisted rectal resection. This study was a retrospective review of a prospective database. A total of 183 patients undergoing restorative RAS for rectal cancer between 2007 and 2016 were divided into 2 groups: control (BMI < 30kg/m2; n = 125) and obese (BMI ≥ 30kg/m2; n = 58). Clinicopathologic data, 30-day postoperative morbidity, and perioperative outcomes were compared between groups. The main outcome was severe postoperative morbidity defined as any complication graded Clavien-Dindo ≥ 3. Control and obese groups had similar clinicopathologic characteristics. Severe complications were observed in 9 (7%) and 4 (7%) patients, respectively (p > 0.99). Obesity did not impact conversion, anastomotic leak rate, length of stay, or readmission but was significantly associated with increased postoperative morbidity (29 vs. 45%; p = 0.04) and especially more postoperative ileus (11 vs. 26%; p = 0.01). Obesity and male gender were the two independent risk factors for postoperative overall morbidity (OR 1.97; 95% CI 1.02-3.94; p = 0.04 and OR 2.23; 95% CI 1.10-4.76; p = 0.03, respectively). ‎Obesity did not impact severe morbidity or conversion rate following RAS for rectal cancer but remained a risk factor for overall morbidity and especially postoperative ileus.

Preoperative Smoking Cessation is Integral to the Prevention of Postoperative Morbidities in Minimally Invasive Esophagectomy.

Preoperative smoking cessation is considered integral to decreasing postoperative morbidities after esophagectomy. To our knowledge, the association of the duration of smoking cessation with the occurrence of postoperative morbidity has never been investigated in minimally invasive esophagectomy (MIE). A total of 198 consecutive MIEs for esophageal cancer between June 2011 and December 2017 were eligible for the study. According to the length of smoking cessation, patients were separated into three groups: ≤ 30, 31-90, and ≥ 91days. Incidence of postoperative morbidities was retrospectively analyzed among the groups. In patients with smoking cessation ≤ 30days, morbidities of Clavien-Dindo classification (CDc) ≥ II, severe morbidities of CDc ≥ IIIb, pneumonia, and any pulmonary morbidities were frequently observed. Morbidities of CDc ≥ II, pneumonia, and any pulmonary morbidities increased as the length of cessation became shorter. Smoking cessation ≤ 30days was a significant risk factor for severe morbidity (hazard ratio [HR] 4.89, 95% confidence interval [CI] 1.993-12.011; P < 0.001). Smoking cessation ≤ 90days (HR 3.98, 95% CI 1.442-10.971; P = 0.008), past smoking (per 100 increase in Brinkman index), and cardiovascular comorbidity were significant risk factors for pneumonia. Smoking cessation ≤ 30days (HR 3.13, 95% CI 1.351-7.252; P = 0.008) and past smoking were significant risk factors for any pulmonary morbidity. Preoperative smoking cessation is considerably important to prevent postoperative morbidities, even in MIE. At least, preoperative cessation ≥ 31days is preferable to decrease considerable morbidities after MIE.

Late-onset sepsis due to Staphylococcus capitis ‘neonatalis’ in low-birthweight infants: a new entity?

During hospitalization, sepsis occurs in one of every five very-low-birthweight infants. The emergence of Staphylococcus capitis (SC)-related sepsis in preterm infants was observed recently. This study aimed to evaluate the clinical severity of SC-related sepsis in preterm infants. Of the 105 infants who presented with sepsis related to coagulase-negative staphylococci, 74 were SC. Severe morbidity was more common in the SC group (55.4%) than in the non-SC coagulase-negative staphylococci group (32.0%) (P=0.03). Multi-variate analysis identified SC-related sepsis as an independent risk factor for severe morbidity.

Effect of Esophagus Position on Surgical Difficulty and Postoperative Morbidities After Thoracoscopic Esophagectomy

The objective include thoracoscopic esophagectomy for the deep-seated (left-sided) esophagus has several technical difficulties, which may affects the intraoperative or postoperative outcomes. However, no previous studies have focused on the correlation between the position of the esophagus and short-term outcome after thoracoscopic esophagectomy. Of 470 esophagectomies between April 2005 and April 2015 in Kumamoto University Hospital, 112 patients who underwent thoracoscopic esophagectomy for esophageal cancer were examined. The position of the esophagus was divided into 2 types: deep-seated esophagus or another type based on computed tomographic images in the supine position. In results, the deep-seated esophagus was associated with a longer operation time in the thorax and high incidence of severe morbidity of Clavien-Dindo classification ≥IIIb, pneumonia, and any pulmonary morbidity. The deep-seated esophagus was also an independent risk factor for severe morbidity (hazard ratio [HR] = 5.37, 95% CI: 1.307-22.03; P = 0.020), pneumonia (HR = 9.23, 95% CI: 2.150-39.60; P = 0.003), and any pulmonary morbidity (HR = 10.3, 95% CI: 2.714-38.78; P < 0.001). In conclusion, the position of the esophagus had a strong influence on the difficulty of thoracoscopic esophagectomy and the incidence of postoperative morbidities. Surgeons would be well advised to keep a careful watch perioperatively for patients with a deep-seated esophagus.

Predictors of Severe Morbidity After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Patients With Colorectal Peritoneal Carcinomatosis.

Severe morbidity after cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC) is, besides the obvious short-term consequences, associated with impaired long-term outcomes. The risk factors for severe morbidity in patients with peritoneal carcinomatosis (PC) of colorectal origin are poorly defined. This study aimed to identify risk factors for severe morbidity after CRS + HIPEC in patients with colorectal PC. Patients with colorectal PC who underwent CRS + HIPEC between 2007 and 2015 were categorized and compared between those with and those without severe morbidity. Risk factors were identified using logistic regression analysis. Morbidity was graded according to the Clavien-Dindo classification, with grade 3 or higher indicating severe morbidity. This study included 211 patients, of whom 53 patients (25.1%) experienced morbidity of grade 3 or higher. The identified risk factors for severe morbidity were extensive prior surgery [odds ratio (OR) 4.3], a positive recent smoking history (OR 4.0), a poor physical performance status (OR 2.9), and extensive cytoreduction (OR 1.2 per additional resection). Patients with a greater number of risk factors more often had severe morbidity and higher reoperation, readmission, and mortality rates. Furthermore, an internally validated preoperative prediction model for severe morbidity with an area under the curve of 70% was constructed. The current study identified risk factors for severe morbidity after CRS + HIPEC in patients with colorectal PC. Patients with a combination of risk factors have a substantial risk of severe morbidity and therefore should be carefully selected for CRS + HIPEC. The preoperative decision model can be a valuable additional tool in this process of patient selection.

Severe morbidity after coronary artery surgery: development and validation of a simple predictive clinical score.

To develop a predictive clinical risk score of post-operative morbidity after coronary artery bypass grafting. Data were collected retrospectively from 679 patients undergoing emergency or planned bypass surgery between 1 January and 31 December 1996. The incidence of morbidity was 23%. Multivariate stepwise logistic regression analysis on two-thirds of the patients identified eight independent risk factors for severe morbidity. Six of these were pre-operative: symptomatic right heart failure, previous ventricular arrhythmias, previous coronary bypass surgery, chronic pulmonary disease, ST changes on pre-operative electrocardiogram, body mass index <24 kg. m-2, and two were intra-operative factors: the surgeon who operated, and the cardiopulmonary bypass time. A predictive clinical risk score was developed with the six pre-operative risk factors. The negative predictive value of the model is 87% and the area under the receiver operating characteristic curve is 0.77. When tested on the remaining patients not used for developing the model, the area under the curve is 0.65. This pre-operative risk score provides a simple method of risk stratification for patients undergoing coronary artery surgery. However, as for all predictive models, the performance of the score decreases when applied to a population other than that used to develop it.