Risk Factor For Perioperative Morbidity Research Articles

Preoperative Glycosylated Haemoglobin Screening to Identify Older Adult Patients with Undiagnosed Diabetes Mellitus-A Retrospective Cohort Study.

More than 25% of older adults in Europe have diabetes mellitus. It is estimated that 45% of patients with diabetes are currently undiagnosed, which is a known risk factor for perioperative morbidity. We investigated whether routine HbA1c screening in older adult patients undergoing surgery would identify patients with undiagnosed diabetes. We included patients aged ≥65 years without a diagnosis of diabetes who visited the preoperative assessment clinic at the Amsterdam University Medical Center and underwent HbA1c screening within three months before surgery. Patients undergoing cardiac surgery were excluded. We assessed the prevalence of undiagnosed diabetes (defined as HbA1c ≥ 48 mmol·mol-1) and prediabetes (HbA1c 39-47 mmol·mol-1). Using a multivariate regression model, we analysed the ability of HbA1c to predict days alive and at home within 30 days after surgery. From January to December 2019, we screened 2015 patients ≥65 years at our clinic. Of these, 697 patients without a diagnosis of diabetes underwent HbA1c screening. The prevalence of undiagnosed diabetes and prediabetes was 3.7% (95%CI 2.5-5.4%) and 42.9% (95%CI 39.2-46.7%), respectively. Preoperative HbA1c was not associated with days alive and at home within 30 days after surgery. In conclusion, we identified a small number of patients with undiagnosed diabetes and a high prevalence of prediabetes based on preoperative HbA1c screening in a cohort of older adults undergoing non-cardiac surgery. The relevance of prediabetes in the perioperative setting is unclear. Screening for HbA1c in older adult patients undergoing non-cardiac surgery does not appear to help predict postoperative outcome.

Perceptions of Frailty and Prehabilitation Among Thoracic Surgeons: Findings From a National Survey

BackgroundFrailty is associated with increased perioperative morbidity and mortality. How thoracic surgeons recognize, measure, and mitigate frailty in their daily clinical practice is unknown. We administered a national survey to determine the current practices of thoracic surgeons managing frail patients. MethodsA 144-question survey developed in collaboration with the University of Chicago Survey Lab was sent to CTSnet.org members who identified as general thoracic surgeons, practiced in the United States, and had publicly available emails. Responses were collected from August 12 to September 11, 2022. Both fully and partially (at least 20%) completed surveys were included in a descriptive statistical analysis. ResultsAfter 2796 surveys were administered, 342 surgeons responded. Surgeons were in practice a median of 23 years (range, 1-50 years) at academic (63.4% [187/295]) or community (36.6% [108/295]) centers. Most surgeons believed it important to assess frailty preoperatively (83.9% [287/342]), but only 28% (97/342) of surgeons performed routine frailty assessment. Barriers to routine frailty assessment included lack of tools (80.0% [32/40]), training (59.0% [23/39]), and staffing (56.4% [22/39]). Whereas most surgeons believed that frailty could be mitigated (72.2% [247/342]), only 49.5% (156/315) prescribed prehabilitation. Up to 78.7% (203/263) of surgeons would delay or cancel surgery for patient frailty, depending on disease cause. ConclusionsThoracic surgeons recognize that frailty is an established risk factor for perioperative morbidity and mortality; however, there is high variability in diagnosis and management of frailty. Guidelines are needed to establish best practices for screening and mitigation to optimally treat frail patients.

Prevalence and risk factors of preoperative anemia in patients undergoing elective orthopedic procedures in Northwest Ethiopia: a multicenter prospective observational cohort study

BackgroundPreoperative anemia is a common hematologic problem in major orthopedic surgery in developing countries. It is a condition in which the number and size of red blood cells are insufficient to meet the body’s physiologic needs, consequently impairing the capacity of the blood to transport oxygen to the body. Preoperative anemia is common in elective orthopedic surgical patients and is an independent risk factor for perioperative morbidity and mortality. This study aimed to assess preoperative anemia prevalence and risk factors in patients undergoing elective orthopedic procedures.MethodA multicenter prospective observational cohort study was conducted from June 01 to August 30, 2022. A systematic random sampling technique was used to select the study unit. Data were collected using a structured questionnaire. Descriptive statistics were expressed in percentages and presented with tables and figures. Binary logistic regression was used to see the association between independent and dependent variables. A P-value < 0.05 was considered statistically significant.ResultPreoperative anemia’s prevalence and risk factors in patients undergoing elective orthopedic procedures was 24.1[95%CI= (18.2–30.6)]. Multivariable logistic analyses showed that low monthly income level [AOR:5,95%CI:(1.36–7.98)], patient with cancer [AOR:3.4,95%CI:(3.7–8.84)], patient with malaria infectious [AOR: 3.2,95%CI:( 1.13–8.91)], patient with anti-retroviral therapy [AOR: 5.2,95%CI:( 1.8-11.04)], and previous history of surgery [AOR:1,95%CI(1.43–2.4)], were factors significantly associated with preoperative anemia.ConclusionThe prevalence of preoperative anemia among adult patients who underwent elective orthopedics procedures was high. Low Monthly income, patients with cancer, patient with malaria infection, and patients with anti-retroviral therapy, previous histories of surgery were found significantly associated with preoperative anemia. So, we recommend to health professional’s early identification, diagnosis and treatment of preoperative anemia should be done to reduce the risks of anemia and related adverse outcomes.

The Impact of Fluid Therapy on Glycemic Variation in Non-diabetic Patients Undergoing Laparoscopy.

Background Hyperglycemia is a risk factor for perioperative morbidity and mortality. A surgical procedure triggers a physiological stress response, which culminates in insulin resistance by activating the sympathetic autonomic system. The impact of fluid management in the perioperative period on the glycemic variation of patients has not been thoroughly investigated. Methods This study, which included 42 non-diabetic patients undergoing laparoscopic surgeries, was an observational, prospective cohort study. The sample was split into two groups according to the type of fluid used intraoperatively: polyelectrolyte and 5% glucose polyelectrolyte. Results No significant differences were found between the groups in demographic and baseline data, including age, BMI, and American Society of Anesthesiologists (ASA) physical status. There were no differences in glycemic variation between the two groups. Blood glucose varied over time with statistical significance in the perioperative period but with no difference between the two groups. Conclusion Using 5% glucose polyelectrolyte in laparoscopic surgery for non-diabetic patients with ASA physical status 3 or lower did not significantly affect glycemic variation compared to polyelectrolyte. These results suggest the possibility of optimizing resources and minimizing waste without compromising patient homeostasis in perioperative care.

Risk factors for early and late morbidity in patients with cardiovascular disease undergoing inguinal hernia repair with a tailored approach: a single-center cohort study

BackgroundInguinal hernia repair is a common procedure in surgery. Patients with cardiovascular disease have an increased operative risk for postoperative morbidity. The study aimed to identify the most beneficial surgical procedure for these patients.MethodsPatients undergoing elective surgery for unilateral or bilateral inguinal hernia between December 2015 and February 2020 were included. The cohort was divided into the group of patients with (CVD group) and without (NO group) cardiovascular disease and analyzed according to the postoperative morbidity distribution and correlated to the surgical technique used.ResultsOf the 474 patients included 223 (47%) were operated on using the Lichtenstein technique and 251 (53%) using TAPP, respectively. In the CVD group the Lichtenstein procedure was more common (n = 102, 68.9%), in the NO group it was TAPP (n = 205, 62.9%; p < 0.001). 13 (8.8%) patients in the CVD group and 12 (3.7%) patients in the NO group developed a postoperative hematoma (p = 0.023). In the further subgroup analysis within the CVD group revealed cumarine treatment as a risk factor for postoperative hematoma development, whereas the laparoscopic approach did not elevate the morbidity risk.ConclusionCVD is a known risk factor for perioperative morbidity in general surgery, however, the TAPP method does not elevate the individual perioperative risk.

Analysis of the risk factors for perioperative morbidity after laparoscopic revisional bariatric procedures: results from the multicenter Polish Revision Obesity Surgery Study.

The growing number of primary bariatric operations has led to an increase in demand for revision surgeries. Higher numbers of revisional operations are also observed in Poland, yet their safety and efficacy remain controversial because of a lack of current recommendations and guidelines. To review risk factors influencing perioperative morbidity. A retrospective study was conducted to analyze the results of surgical treatment among 12 Polish bariatric centers. Inclusion criteria were laparoscopic revisional bariatric surgeries and patients ≥18 years of age. The study included 795 patients, of whom 621 were female; the mean age was 47 years (range: 40-55 years). Perioperative morbidity occurred in 92 patients (11.6%) enrolled in the study, including 76 women (82.6%). The median age was 45 years (range: 39-54 years). Statistically significant risk factors in univariate logistic regression models for perioperative complications were the duration of obesity, revisional surgery after Roux-en-Y gastric bypass (RYGB) or adjustable gastric band (AGB), difference in body mass index before revisional surgery and the lowest achieved after primary surgery, and postoperative morbidity of the primary surgery as the cause for revisional bariatric surgery. These factors were included in the multivariate regression model. Revisional surgery after AGB (odds ratio [OR] = 2.18; 95% confidence interval [CI]: 1.28-3.69; P = .004), revisional surgery performed after RYGB (OR = 6.52; 95% CI: 1.98-21.49; P = .002), and revisions due to complication of the primary surgery (OR = 1.89; 95% CI: 1.06-3.34; P = .030) remained independent risk factors for perioperative morbidity. Revisional operations after RYGB or AGB and those performed because of postoperative morbidity after primary surgery as the main cause for revisional surgery were associated with a significantly increased risk of postoperative morbidity.

UpToDate®

UpToDate| December 2022 UpToDate® ASA Monitor December 2022, Vol. 86, 35. https://doi.org/10.1097/01.ASM.0000904280.11202.ba Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Cite Icon Cite Get Permissions Search Site Citation UpToDate®. ASA Monitor 2022; 86:35 doi: https://doi.org/10.1097/01.ASM.0000904280.11202.ba Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search Topics: antirheumatic drugs, disease-modifying, combination drug therapy, diabetic neuropathies, guidelines, heart failure, right-sided, pain, perioperative care, pulmonary hypertension UpToDate® and ASA Monitor are collaborating to present select content abstracts on “What's New in Anesthesiology.” UpToDate is an evidence-based, clinical support resource used worldwide by healthcare practitioners to make decisions at the point of care. For complete, current “What's New” content, or to become a subscriber for full content access, go to www.uptodate.com. “What's New” abstract information is free for all medical professionals. Pulmonary hypertension with right heart failure is a risk factor for perioperative morbidity and mortality. In a recently published consensus statement, the International Society for Heart and Lung Transplantation recommended a multidisciplinary approach to preoperative assessment to ensure that the indication and benefits of surgery are reasonable and that the patient's condition is optimal for surgery.1 Intraoperative considerations include use of invasive monitoring for higher-risk cases, use of slowly titrated epidural or spinal neuraxial anesthesia as appropriate, and induction of general anesthesia... You do not currently have access to this content.

P-148 EFFECT OF MEDICAL AND SURGICAL WEIGHT MANAGEMENT PROGRAMMES FOR PRE-OPERATIVE WEIGHT LOSS PRIOR TO VENTRAL HERNIA REPAIR

Abstract Introduction Obesity is a recognised risk factor for perioperative morbidity in patients undergoing complex incisional hernia repair. Weight reduction can reduce risk of perioperative complications. The aim of this study was to assess the effects of the different weight management modalities prior to planned incisional hernia repair upon the Carolinas equation for Determining Associated Risks (CeDAR) score. Method A prospectively maintained database of patients who were referred to the weight management clinic prior to planned incisional hernia repair was reviewed. Patients’ demographics, weight loss outcomes and CeDAR scores were calculated before and after the intervention. Results 9 patients were enrolled onto the weight management programme prior to the planned incisional hernia repair (defect size 4 – 14cm), 3 underwent bariatric surgery whilst 6 had medical weight management in the form of a 12-week pre-operative diet programme. The mean age was 54 ± 9.4 years with a mean weight pre-intervention of 110.5 ± 7.4 kg and the mean BMI was 41.78 ± 1.98 kg/m2. Bariatric surgery was associated with a higher percentage weight loss (22.6%) compared to 12week diet programme (10.4%) with an associated higher reduction of CeDAR score (14% and 4% reduction in risk respectively). Conclusion Formal weight management programmes prior to complex abdominal wall reconstruction leads to clinically significant weight loss with reduced CeDAR score. Patients with raised BMI considering incisional hernia repair should be counselled for this and where possible offered a suitable weight management to reduce peri-operative risk.

Serum Glucose Variability Increases the Risk of Complications Following Aseptic Revision Hip and Knee Arthroplasty.

Increased serum glucose variability has been proposed as a risk factor for perioperative morbidity and mortality. Given the greater surgical complexity and complication risk of revision total joint arthroplasty (TJA), previous findings may not be generalizable to the revision population. The purpose of this study was to investigate the association between glucose variability and postoperative complications following aseptic revision TJA. We identified 1,983 patients who underwent an aseptic revision TJA (636 total knee arthroplasties [TKAs] and 1,347 total hip arthroplasties [THAs]) from 2001 to 2019. Patients with ≥2 postoperative glucose values per day or ≥3 values during hospitalization were included in this study. Glucose variability was assessed using the coefficient of variation (COV). Outcomes included length of hospital stay, 90-day complications, mortality, and periprosthetic joint infection (PJI) as defined by the 2018 International Consensus Meeting criteria. Multivariate regression was used to determine the association between glucose variability and each end point, using COV as continuous and categorical variables (that is, COV tertiles). Patients with high glycemic variability were at 1.7 times greater risk for 90-day complications (odds ratio [OR], 1.664 [95% confidence interval (CI), 1.266 to 2.188]; p < 0.001) and 2 times greater risk for PJI at a minimum 1-year follow-up (OR, 1.984 [95% CI, 1.270 to 3.100]; p = 0.003). The risk of 90-day complications increased by 2.2% (OR, 1.022 [95% CI, 1.012 to 1.032]; p < 0.001) and the risk of PJI increased by 1.8% (OR, 1.018 [95% CI, 1.003 to 1.034]; p = 0.013) for every percentage-point increase in COV. Patients with higher glucose variability also had a longer length of stay (beta, 1.028 days [95% CI, 0.590 to 1.466 days]; p < 0.001). These associations were independent of age, sex, body mass index, Charlson Comorbidity Index, involved joint, operative time, history of diabetes, and mean glucose levels. Higher glucose variability was associated with an increased risk of medical complications and PJI following aseptic revision TJA. Patients undergoing these complex procedures should have glucose levels monitored closely in the perioperative period. Future studies should evaluate the utility of continuous glucose monitoring in this high-risk population. Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

The Role of Sarcopenia and Myosteatosis in Short- and Long-Term Outcomes Following Curative-Intent Surgery for Hepatocellular Carcinoma in a European Cohort.

Simple SummaryRecent studies have shown that pathological changes of body composition, in particular reduced muscle mass (sarcopenia) and impaired muscle quality (myosteatosis), are linked to poor outcomes in a variety of clinical conditions. Hepatocellular carcinoma (HCC) is the most frequent primary malignant tumor of the liver in the Western hemisphere and remains a prominent cause of cancer-associated mortality. The present study investigates the prognostic value of alterations in body composition in predicting perioperative morbidity, mortality and long-term oncological outcome in HCC using preoperative computed-tomography-based segmentation. Our study found supporting evidence for the relevance of muscle quality over quantity in a European population and verifies the predictive role of myosteatosis in patients suffering from HCC, with a particularly significant value in the earlier perioperative phase.Alterations of body composition, especially decreased muscle mass (sarcopenia) and impaired muscle quality (myosteatosis), are associated with inferior outcomes in various clinical conditions. The data of 100 consecutive patients who underwent partial hepatectomy for hepatocellular carcinoma (HCC) at a German university medical centre were retrospectively analysed (May 2008–December 2019). Myosteatosis and sarcopenia were evaluated using preoperative computed-tomography-based segmentation. We investigated the predictive role of alterations in body composition on perioperative morbidity, mortality and long-term oncological outcome. Myosteatotic patients were significantly inferior in terms of major postoperative complications (Clavien–Dindo ≥ 3b; 25% vs. 5%, p = 0.007), and myosteatosis could be confirmed as an independent risk factor for perioperative morbidity in multivariate analysis (odds ratio: 6.184, confidence interval: 1.184–32.305, p = 0.031). Both sarcopenic and myosteatotic patients received more intraoperative blood transfusions (1.6 ± 22 vs. 0.3 ± 1 units, p = 0.000; 1.4 ± 2.1 vs. 0.3 ± 0.8 units, respectively, p = 0.002). In terms of long-term overall and recurrence-free survival, no statistically significant differences could be found between the groups, although survival was tendentially worse in patients with reduced muscle density (median survival: 41 vs. 60 months, p = 0.223). This study confirms the prognostic role of myosteatosis in patients suffering from HCC with a particularly strong value in the perioperative phase and supports the role of muscle quality over quantity in this setting. Further studies are warranted to validate these findings.

Early Outcomes of Coronary Artery Bypass Grafting in Patients with Preoperative Renal Dysfunction

Background: Chronic kidney disease combined with coronary artery disease is a growing public health issue. Preoperative renal dysfunction is one of the major risk factors for perioperative morbidity and mortality in patients undergoing coronary artery bypass grafting (CABG). This study aimed to analyze the early clinical outcomes of CABG in patients with preoperative renal impairment.&#x0D; Methods: The study was conducted from July 2017 to July 2019. We included 100 patients who underwent CABG. Group A (n= 50) included patients with preoperative renal impairment and group B (n= 50) had patients with normal renal functions.&#x0D; Results: The mean age was 63.3±9.1 years in Group A and 57.1±8.5 years in Group B (P&lt;0.001). There were 35 males in Group A and 47 in Group B (P&lt;0.001). Blood transfusion was more in Group A (47 (94%) vs. 32 (64%) patients; P=0.001). There was no difference in mortality between both groups.&#x0D; Conclusion: Preoperative renal impairment in patients undergoing CABG is more common in elder females. Patients undergoing CABG with preoperative renal impairment could have a higher risk for blood transfusion.

Process and Systems: Making the case for spirometry as part of the perioperative multidisciplinary team assessment

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality and is significantly underdiagnosed in the community. Respiratory impairment is a key risk factor for perioperative morbidity and mortality. The National Institute for Health and Care Excellence (NICE) does not recommend routine spirometry before major surgery. However, in this article, we present the potential benefits of targeted spirometry in high-risk patient groups. Of 183 patients who underwent targeted preoperative spirometry, 25/70 (35.7%) of those with airflow obstruction had no previously known respiratory diagnosis. Of patients with known COPD, 20/46 (43.5%) were not prescribed optimum inhaled therapies for their degree of lung function deficit. Knowledge of lung function in respiratory disease helps to optimise patients perioperatively and facilitate shared decision making regarding the benefits and risk of surgeries. We propose that targeted spirometry should be used as part of the perioperative multidisciplinary team assessment of selected patients.

Primary and revision shoulder arthroplasty in patients with pulmonary hypertension: an underlying condition associated with high perioperative mortality and complications

BackgroundPulmonary hypertension is a progressive medical condition that has been identified as a risk factor for perioperative morbidity and mortality in both cardiac and non-cardiac surgery, including hip arthroplasty. Currently, there is very limited information on the impact of pulmonary hypertension (PHTN) on patients undergoing shoulder arthroplasty. This investigation analyzed the mortality, perioperative medical complications, implant survivorship, and clinical outcomes in this medically complex cohort. MethodsBetween January 2000 and July 2018, 380 primary and 59 revision shoulder arthroplasties were performed at a single institution in patients with a diagnosis of pulmonary hypertension prior surgery. Average age was 72.8 ± 11.0 and 72.1 ± 9.5 years for the primary and revision SA groups, respectively (P= .65). The median American Society of Anesthesiologists (ASA) scores were predominantly class 3 in both cohorts. Descriptions of group characteristics were calculated with student tests for numerical values. Mortality after primary and revision shoulder arthroplasties were individually calculated through a cumulative incidence analysis. Implant survivorship was analyzed with a competing risk model selecting death as the competing risk. ResultsThe 90-day mortality was 1.6% for primary and 3.4% for revision SA, respectively. The cumulative incidences of death at 2, 5, 10, and 15 years were 16.5%, 43.3%, 80.8%, and 88.5% for primary and 12.1%, 44.7%, 64.4%, and 100% for revision arthroplasties, respectively. Medical complications were observed in 13.4% of primary and 42.4% of revision shoulder arthroplasties. These included respiratory failure and/or acute respiratory distress syndrome (3.2%), arrhythmia (2.7%), deep vein thrombosis (1.8%), and pulmonary embolism (1.6%). The 10-year cumulative incidences of revision for any reason were 4.5% in primary and 10.4% in revision shoulder arthroplasties. At final follow-up, the mean VAS and ASES scores were 2.3 ± 2.5 and 72.0 ± 18.5 in primary SA and 4.1 ± 2.9 and 51.8 ± 21.8 in revision SA. ConclusionsA concomitant diagnosis of PHTN in patients undergoing primary or revision shoulder arthroplasty was associated with a high rate of perioperative medical complications and mortality rates at 90 days and at 10 years in both cohorts. This information should be considered to counsel patients, optimize their perioperative management, and anticipate a more complicated and costly postoperative recovery. Level of EvidenceLevel IV; Case Series with no Comparison Group

Risk Factors for Perioperative Morbidity in Adults Undergoing Cardiac Surgery at Children’s Hospitals

BackgroundIncreasing numbers of adults with congenital heart disease (ACHD) undergo cardiac surgical procedures in children’s hospitals, yet surgical outcomes data are limited. We sought to better understand the impact of preoperative risk factors on postoperative complications and cardiac intensive care unit (CICU) length of stay (LOS). MethodsSurgical CICU admissions for patients aged 18 years and older in the Pediatric Cardiac Critical Care Consortium registry from August 2014 to January 2019 in 34 hospitals were included. Primary outcomes included prolonged LOS (defined as LOS ≥90th percentile) and major complications (cardiac arrest, extracorporeal membrane oxygenation, arrhythmia requiring intervention, stroke, renal replacement therapy, infection, and reoperation/reintervention). ResultsWe analyzed 1764 surgical CICU admissions. Prolonged LOS was 7 days or longer. Eighteen patients (1.0%) died, of whom 9 (0.5%) died before the LOS cutoff and were excluded from analysis. Of 1755 CICU admissions, 8.8% (n = 156) had prolonged LOS, and 23.3% (n = 413) had 1 or more major complications. Several variables, including The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery 4/5 operation, 3 or more previous sternotomies, and preoperative renal dysfunction/dialysis were independent risk factors for both prolonged LOS and major complications (P < .05). Preoperative ventilation was associated with increased odds of prolonged LOS and preoperative arrhythmia with major complications. ConclusionsThis analysis of postoperative ACHD care in pediatric CICUs found high complexity operations, 3 or more previous sternotomies, preoperative arrhythmias, renal dysfunction, and respiratory failure are associated with prolonged LOS and/or major complications. Future quality improvement initiatives focused on preoperative optimization and implementation of adult-specific perioperative protocols may mitigate morbidity in these patients undergoing cardiac surgical procedures at children’s hospitals.

Clinical-pathological features and treatment of acute appendicitis in the very elderly: an interim analysis of the FRAILESEL Italian multicentre prospective study.

Emergency abdominal surgery in the elderly represents a global issue. Diagnosis of AA in old patients is often more difficult. Appendectomy remains the gold standard of treatment and, even though it is performed almost exclusively with a minimally invasive technique, it can still represent a great risk for the elderly patient, especially above 80years of age. A careful selection of elderly patients to be directed to surgery is, therefore, fundamental. The primary aim was to critically appraise and compare the clinical-pathological characteristics and the outcomes between oldest old (≥ 80years) and elderly (65-79years) patients with Acute Appendicitis (AA). The FRAILESEL is a large, nationwide, multicentre, prospective study investigating the perioperative outcomes of patients aged ≥ 65years who underwent emergency abdominal surgery. Particular focus has been directed to the clinical and biochemical presentation as well as to the need for operative procedures, type of surgical approach, morbidity and mortality, and in-hospital length of stay. Two multivariate logistic regression analyses were performed to assess perioperative risk factors for morbidity and mortality. 182 patients fulfilled the inclusion criteria. Mean age, ileocecal resection, OAD and ASA score ≥ 3 were related with both overall and major complication. The multivariate analysis showed that MPI and complicated appendicitis were independent factors associated with overall complications. OAD and ASA scores ≥ 3 were independent factors for both overall and major complications. Age ≥ 80years is not an independent risk factor for morbidities. POCUS is safe and effective for the diagnosis; however, a CECT is often needed. Having the oldest old a smaller functional organ reserve, an earlier intervention should be considered especially because they often show a delay in presentation and frequently exhibit a complicated appendicitis.

Minimally Invasive Paraesophageal Hernia Repair in the Elderly: Is Age Really Just a Number?

Introduction: Paraesophageal hernias readily affect the elderly with a median age of presentation between 65 and 75 years. Laparoscopic paraesophageal hernia repair (PEHR) is a technically challenging operation with potential for dire complications. Advanced age and medical comorbidities may heighten perioperative risk and limit surgical candidacy, potentially refusing patients an opportunity toward symptom resolution. Given the increased prevalence in the elderly and associated surgical risks, we aim to assess age as an independent risk factor for perioperative morbidity and mortality after PEHR. Methods: A retrospective analysis using a prospectively maintained database assessed patients undergoing PEHR from 2007 to 2018. Patients were stratified by age: Group A (age <65 years), Group B (65≤ age <80 years), and Group C (age ≥80 years). Patient demographics, preoperative symptoms, postoperative outcomes, and mortality rate were analyzed. Barium esophagram was performed on symptomatic postsurgical patients. Recurrence was confirmed radiologically. Results: In total, 143 patients underwent laparoscopic (94.4%) or robotic-assisted (5.6%) PEHR. Average age per group was Group A (n = 49) 55.4 years (standard deviation [SD] ±8.91), Group B (n = 76) 71.4 years (SD ±4.40), and Group C (n = 17) 84.1 (years) (SD ±3.37). Group C had significantly higher rates of nonelective surgery (P = .018), preoperative weight loss (P = .014), hypertension (P = .031), ischemic heart disease (P = .001), and cancer (P = .039); preoperative body mass index was significantly lower (P = .048). Charlson comorbidity index differences between groups were significant (2.00 versus 3.61 versus 5.28, P < .001). Median follow-up was 426 days (6-3199). Symptom improvement was seen in 78.3% of patients. Recurrence and reoperation rates were not significantly different between groups. No differences were seen in mortality, length of stay, or postoperative complications between groups. Conclusions: PEHR in elderly patients proved to be safe and effective. Avoidance of emergent intervention may be achieved through a judicious elective approach to this anatomic problem. Symptom resolution and quality-of-life improvement can be safely achieved with surgical repair in this patient population, demonstrating that age is truly just a number for PEHR.

A prospective cohort study of patients with peptic perforation to identify high-risk clinical characteristics

Introduction: Peptic ulcer perforation is the most common complication in peptic ulcer disease and can lead to serious complications and mortality; however, despite the widespread use of antisecretory agents and eradication of Helicobacter pylori, the incidence of peptic ulcer perforation remains largely unchanged. This study aimed to evaluate the risk factors for perioperative morbidity and mortality in patients with peptic ulcer perforation. Methods: This was a prospective, observational study involving patients with perforated peptic ulcer disease admitted to the Al-Basra Teaching Hospital from January 2017 to December 2019. A total of 100 patients were followed for 4 weeks. Patients’ demographic data, history of chronic diseases, American Society of Anesthesiologist (ASA) score, nonsteroidal anti-inflammatory drug (NSAID) and steroid use, duration before surgery, preoperative shock status, previous symptoms of peptic ulcer disease, smoking habits, and fasting status were evaluated, and significant correlations with postoperative complications were analyzed statistically. Results: A total of 100 patients aged 16–87 years were included in the study, and the male-to- female ratio was 3:1. Sixty-seven (67%) patients underwent surgery within 12 h after admission, 41% of patients had a history of chronic disease, 54% of patients had an ASA score of 1, 57% of patients were smokers, 45% of patients reported previous peptic ulcer symptoms, and 22% of patients had preoperative shock status. Thirty-seven (37%) patients developed postoperative complications, and 8% of patients died. Conclusion: This study confirmed that advanced age, a high ASA score, preoperative shock, comorbidities, and delayed presentation before surgery were all risk factors for postoperative complications and mortality in patients with perforated peptic ulcer disease. Habitual smoking, fasting status, and NSAID and steroid use were not correlated with mortality.

Sex and gender differences in anesthesia: Relevant also for perioperative safety?

Sex (a biological determination) and gender (a social construct) are not interchangeable terms and both impact perioperative management and patient safety. Sex and gender differences in clinical phenotypes of chronic illnesses and risk factors for perioperative morbidity and mortality are relevant for preoperative evaluation and optimization. Sex-related differences in physiology, as well as in pharmacokinetics and pharmacodynamics of anesthetic drugs may influence the anesthesia plan, the management of pain, postoperative recovery, adverse effects, patient satisfaction, and outcomes. Further studies are needed to characterize outcome differences between men and women in non-cardiac, cardiac, and transplantation surgery in order to individualize perioperative management and improve patient safety. Transgender patients represent a vulnerable population who need special perioperative care. Gender balance increases team performance and may improve perioperative outcomes.

Surgical prehabilitation using mobile health coaching in patients with obesity: A pilot study.

Many patients spend months waiting for elective procedures, and many have significant modifiable risk factors that could contribute to an increased risk of perioperative morbidity and mortality. The minimal direct contact that usually occurs with healthcare professionals during this period represents a missed opportunity to improve patient health and surgical outcomes. Patients with obesity comprise a large proportion of the surgical workload but are under-represented in prehabilitation studies. Our study piloted a mobile phone based, multidisciplinary, prehabilitation programme for patients with obesity awaiting elective surgery. A total of 22 participants were recruited via the Wollongong Hospital pre-admissions clinic in New South Wales, Australia, and 18 completed the study. All received the study intervention of four text messages per week for six months. Questionnaires addressing the self-reported outcome measures were performed at the start and completion of the study. Forty percent of participants lost weight and 40% of smokers decreased their cigarette intake over the study. Sixty percent reported an overall improved health score. Over 80% of patients found the programme effective for themselves, and all recommended that it be made available to other patients. The cost was A$1.20 per patient per month. Our study showed improvement in some of the risk factors for perioperative morbidity and mortality. With improved methods to increase enrolment, our overall impression is that text message-based mobile health prehabilitation may be a feasible, cost-effective and worthwhile intervention for patients with obesity.

Preoperative Anemia Management: Value-based Care for Orthopedic Surgery

Preoperative anemia is common in elective orthopedic surgical patients and is an independent risk factor for perioperative morbidity and mortality. The detrimental effects of anemia on surgical outcomes impact the costs associated with perioperative care as well. In addition to the direct expenditures related to the complications of anemia, perioperative anemia is the leading predictor of perioperative transfusion and it is estimated that up to 6 million dollars are spent on transfusion-related costs per hospital per year. Anemia is a preventable and manageable condition that can often be treated effectively without relying on blood transfusion. In addition to providing optimal outcomes for orthopedic patients, preoperative anemia management is an effective strategy to lower the overall cost of care of surgical patients.