Risk Of Overall Complications Research Articles

Obesity is a predictor of increased morbidity after tracheostomy.

The purpose of this study was to analyze the relationship between body mass index (BMI) and 30-day morbidity and mortality risk in patients undergoing tracheostomy using the American College of Surgeons National Quality Improvement Program (ACS-NSQIP). This is a retrospective, cross-sectional, cohort study. Patients were identified with Current Procedural Terminology codes in the ACS-NSQIP database. Patients who underwent tracheostomy from 2005 to 2018 were queried. They were stratified into four BMI classes and matched to normal BMI cohorts. Multivariate logistic regression was used to identify independent predictors for complications, readmissions, and unplanned reoperations within 30days. Among 3784 patients meeting inclusion and exclusion criteria, obesity was shown to be a significant independent risk factor for overall complications (OR 1.439, 95% CI 1.226-1.689, p<0.001), postoperative acute renal failure (OR 10.715, 95% CI 1.213-94.646, p=0.033), and unplanned readmissions (OR 1.702, 95% CI 1.095-2.647, p=0.018). A significantly lower rate of postoperative transfusions was observed for obese patients (OR 0.581, 95% CI 0.432-0.781, p<0.001). Obesity was found to be independently associated with an increased risk of overall complication, developing acute renal failure, and having an unplanned 30-day readmission following tracheostomy. The risk of postoperative transfusion appears to be lower in obese patients. 4.

The effect of body mass index on outcomes following severe blunt chest trauma

IntroductionObesity has been described as a significant risk factor for adverse outcomes in hospitalized patients. However, recent literature reports an “obesity paradox”, suggesting that obesity may have a protective effect in a subset of surgical and critically ill patients. The present study assesses the effect of body mass index (BMI) on outcomes following severe isolated blunt chest trauma. MethodsThis was a TQIP database study including patients with severe isolated blunt chest injury (chest AIS 3–5, extrathoracic AIS <3). Patients were excluded for age <20 or >89, death on arrival, facility transfer, or BMI <10 or >55. Patients were divided into five groups according to BMI: underweight (BMI <18.5), normal weight (18.5–24.9), overweight (25.0–29.9), obesity class 1 (30.0–34.9), obesity class 2 (35.0–39.9) and obesity class 3 (≥40.0). Logistic regression models were constructed to evaluate the effect of BMI on outcomes. Results28,820 patients met criteria for inclusion in the analysis. After multivariable analysis, underweight patients as well as obesity class 2 and 3 patients had a significantly higher mortality (OR 1.86 [95% CI, 1.12–3.10], OR 1.48 [95% CI, 1.02–2.16], and OR 1.60 [95% CI, 1.03–2.50]), respectively. Underweight patients had significantly higher risk of overall complications as compared to normal weight patients (OR 1.58 [95% CI, 1.34–1.88]). Obesity class 2 and 3 were independently associated with increased respiratory complications (OR 1.60 [95% CI, 1.27–2.01] and OR 1.58 [95% CI, 1.20–2.09], respectively) and all classes of overweight and obese patients were associated with increased risk of VTE complications (OR 1.68 [95% CI, 1.23–2.27], OR 1.98 [95% CI, 1.42–2.77], OR 2.32 [95% CI, 1.55–3.48], OR 2.02 [95% CI, 1.23–3.33], respectively for overweight and obesity class 1, 2, 3). ConclusionsThe obesity paradox does not extend to severe blunt chest trauma. Underweight and obesity class 2 and 3 patients have worse mortality than normal weight patients. Obesity was independently associated with an increased risk of pulmonary and VTE complications.

A Systematic Review of Penile Prosthesis Surgery in Organ Transplant Recipients.

There is an increased prevalence of erectile dysfunction in patients with solid organ transplant (SOT) compared with the general population. Many of these patients may become refractory to medical treatment of erectile dysfunction and penile prosthesis (PP) is often recommended. Concerns regarding the safety of PP in patients with SOT are due to their immunosuppressed state. We aim to review all current literature on the outcomes of patients with SOT who have received PP. A PubMed search was performed to identify articles pertaining to the outcomes of PP in patients with SOT. We identified and included 14 studies that report on outcomes of PP placement in 143 patients with SOT and 191 non-SOT controls from interval period from 1979 to 2019. Studies included retrospective cohort studies, case series, and case reports. Compared with non-SOT controls who had PP, aggregate analysis demonstrated that patients with SOT who had PP did not develop significantly increased overall complications. However, they were significantly more likely to experience future surgical complications. Our aggregate analysis demonstrated that patients with SOT are not at a significantly increased risk of overall complications when receiving a PP. Nevertheless, there is an increased risk of experiencing PP injury during subsequent surgeries, which may be mitigated by the earlier involvement of a urologist. Given the lack of recent data, large studies are prerequisite to further evaluate the safety and overall outcome of PP surgery in patients with SOT. Dick B, Greenberg JW, Polchert M, etal. A Systematic Review of Penile Prosthesis Surgery in Organ Transplant Recipients. Sex Med Rev 2021;9:636-640.

Silicone Stent Versus Fully Covered Metallic Stent in Malignant Central Airway Stenosis

Airway stenting to restore airway patency in cases of malignant central airway obstruction is an effective palliation treatment. Our goal was to compare the efficacy after deployment and complications of a fully covered self-expandable metal stent (SEMS) (Aerstent) and a silicone stent (Dumon). This was a retrospective cohort of 2 similar groups of patients with malignant central airway obstruction treated with stents between August 2012 and July 2017. Complications were assessed bronchoscopically. A competing risk for death analysis was performed to adjust the probability of developing a complication. Seventy patients (29 with silicone stents and 41 with SEMS) were included. Stent insertion was successful in all cases. Mucus retention was the most frequent complication (75.9% with silicone stents and 84.8% with SEMS; P= .51), followed by granulation tissue (51.7% with silicone stents and 41.3% with SEMS; P= .52) and migration (6.9% with silicone stents and 13.0% with SEMS; P= .47). In the first month, the cumulative incidence of a complication was 36.7% for silicone stents and 41.3% for SEMS and increased to 90.0% and 97.8% after 6 months, respectively (hazard ratio= 1.66; P= .04). A competing risk for death analysis showed an adjusted hazard ratio of 1.41 (P= .49) indicating no differences in overall complications between stents. Both stents were equally successful and safe. The incidence of complications increased over time to 90% at 6 months for both stents. The risk of overall complications was higher for SEMS; nevertheless, when mortality was measured in a competitive risk analysis, no differences were found between SEMS and silicone stents.

Enhanced recovery after surgery in emergency resection for obstructive colorectal cancer: a systematic review and meta-analysis.

Enhanced recovery after surgery (ERAS) improves outcomes after elective colorectal operations. Whether it is beneficial for emergency colorectal surgery is unclear. This study aimed to systematically review and summarize evidence from all studies comparing ERAS versus conventional care in patients having emergency colectomy and/or proctectomy for obstructive colorectal cancer. EMBASE, MEDLINE, and PUBMED from 1981 to December 2019 were systematically searched. Any studies comparing our primary outcome of interest (length of hospitalization) among patients having emergency resection for obstructive colorectal cancer who received ERAS versus conventional care were selected. Primary outcome was length of hospitalization. Secondary outcomes were gastrointestinal recovery, postoperative complication, 30-day readmission and mortality, and time to start adjuvant therapy. Three cohort studies with 818 participants (418 received ERAS and 400 received conventional care) were included. Length of hospitalization (mean reduction 3.07 days; 95% CI, - 3.91 to - 2.23) and risk of overall complication (risk ratio 0.78; 95% CI, 0.63 to 0.97) were significantly lower in ERAS than in conventional care. ERAS was also associated with quicker time to gastrointestinal recovery, a lower incidence of ileus, and a shorter interval between operation and commence of adjuvant chemotherapy. There was no significant difference in the rates of anastomotic leakage, surgical site infection, reoperation, readmission, and mortality within 30 days after surgery between groups. ERAS had advantages over conventional care in patients undergoing emergency resection for obstructive colorectal cancer-including a shorter length of hospitalization, a lower incidence of overall complication, and a quicker gastrointestinal recovery.

Perioperative Dexmedetomidine Improves Outcomes of Kidney Transplant.

Graft function is crucial for successful kidney transplantation. Many factors may affect graft function or cause delayed graft function (DGF), which decreases the prognosis for graft survival. This study was designed to evaluate whether the perioperative use of dexmedetomidine (Dex) could improve the incidence of function of graft kidney and complications after kidney transplantation. A total of 780 patients underwent kidney transplantations, 315 received intravenous Dex infusion during surgery, and 465 did not. Data were adjusted with propensity scores and multivariate logistic regression was used. The primary outcomes are major adverse complications, including DGF and acute rejection in the early post‐transplantation phase. The secondary outcomes included length of hospital stay (LOS), infection, overall complication, graft functional status, post‐transplantation serum creatinine values, and estimated glomerular filtration rate (eGFR). Dex use significantly decreased DGF (19.37% vs. 23.66%; adjusted odds ratio, 0.744; 95% confidence interval, 0.564–0.981; P = 0.036), risk of infection, risk of acute rejection in the early post‐transplantation phase, the risk of overall complications, and LOS. However, there were no statistical differences in 90‐day graft functional status or 7‐day, 30‐day, and 90‐day eGFR. Perioperative Dex use reduced incidence of DGF, risk of infection, risk of acute rejection, overall complications, and LOS in patients who underwent kidney transplantation.

Isolated severe blunt traumatic brain injury: effect of obesity on outcomes.

Obesity has been widely reported to confer significant morbidity and mortality in both medical and surgical patients. However, contemporary data indicate that obesity may confer protection after both critical illness and certain types of major surgery. The authors hypothesized that this "obesity paradox" may apply to patients with isolated severe blunt traumatic brain injuries (TBIs). The Trauma Quality Improvement Program (TQIP) database was queried for patients with isolated severe blunt TBI (head Abbreviated Injury Scale [AIS] score 3-5, all other body areas AIS < 3). Patient data were divided based on WHO classification levels for BMI: underweight (< 18.5 kg/m2), normal weight (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), obesity class 1 (30.0-34.9 kg/m2), obesity class 2 (35.0-39.9 kg/m2), and obesity class 3 (≥ 40.0 kg/m2). The role of BMI in patient outcomes was assessed using regression models. In total, 103,280 patients were identified with isolated severe blunt TBI. Data were excluded for patients aged < 20 or > 89 years or with BMI < 10 or > 55 kg/m2 and for patients who were transferred from another treatment center or who showed no signs of life upon presentation, leaving data from 38,446 patients for analysis. Obesity was not found to confer a survival advantage on univariate analysis. On multivariate analysis, underweight patients as well as obesity class 1 and 3 patients had a higher rate of mortality (OR 1.86, 95% CI 1.48-2.34; OR 1.18, 95% CI 1.01-1.37; and OR 1.41, 95% CI 1.03-1.93, respectively). Increased obesity class was associated with an increased risk of respiratory complications (obesity class 1: OR 1.19, 95% CI 1.03-1.37; obesity class 2: OR 1.30, 95% CI 1.05-1.62; obesity class 3: OR 1.55, 95% CI 1.18-2.05) and thromboembolic complications (overweight: OR 1.43, 95% CI 1.16-1.76; obesity class 1: OR 1.45, 95% CI 1.11-1.88; obesity class 2: OR 1.55, 95% CI 1.05-2.29) despite a decreased risk of overall complications (obesity class 2: OR 0.82, 95% CI 0.73-0.92; obesity class 3: OR 0.83, 95% CI 0.72-0.97). Underweight patients had a significantly increased risk of overall complications (OR 1.39, 95% CI 1.24-1.57). Although there was an obesity-associated decrease in overall complications, the study data did not demonstrate a paradoxical protective effect of obesity on mortality after isolated severe blunt TBI. Obese patients with isolated severe blunt TBI are at increased risk of respiratory and venous thromboembolic complications. However, underweight patients appear to be at highest risk after severe blunt TBI, with significantly increased risks of morbidity and mortality.

Comparison of outcomes of central venous catheters in patients with solid and hematologic neoplasms: an Italian real-world analysis.

Although many reports have analyzed the outcomes of central venous catheters (CVCs) in oncologic and oncohematologic patients, current guidelines do not routinely recommend a specific type of CVC over the other. We retrospectively evaluated the outcomes of 178 patients with CVCs referred to an Italian specialized cancer center between January 2016 and December 2018. The analysis compares midterm peripherally inserted central venous catheters (PICCs) with long-term centrally inserted catheters, including totally implanted ports and tunneled catheters with central insertion (tCVCs). A total of 130 PICCs (73%) and 48 tCVCs (27%) were analyzed. The overall complication rate was significantly increased in the PICC cohort compared to the tCVC cohort (43.1% vs 25%, respectively; p = 0.037), leading to complication-related device removal in 30.8% of PICCs vs 12.5% of tCVCs (p = 0.013). No significant differences in terms of catheter-related thromboses (p = 0.676) or catheter-related infections (p = 0.140) were detected. Nonthrombotic obstructions were significantly higher in the PICC group compared to the tCVC cohort (p = 0.006). Overall complication-free survival was significantly longer for tCVCs compared to PICCs (hazard ratio [HR], 0.262; 95% confidence interval [CI], 0.128-0.536; p < 0.0001), as well as obstruction-free survival (HR, 0.082; 95% CI, 0.018-0.372; p < 0.0001). In multivariable analysis, the type of CVC was independently correlated with the occurrence of any complication (HR, 0.273; 95% CI, 0.135-0.553; p < 0.0001). This Italian real-world experience suggests that PICCs are associated with a higher risk of overall complications compared with tCVCs. Catheter choice in oncologic patients should be guided by treatment type and duration, risk-benefit assessment, patient preferences, and compliance.

Complication rates of different discectomy techniques for symptomatic lumbar disc herniation: a systematic review and meta-analysis.

This meta-analysis aims to compare the complication rates of discectomy/microdiscectomy (OD/MD), microendoscopic discectomy (MED), percutaneous endoscopic lumbar discectomy (PELD), percutaneous laser disc decompression (PLDD), and tubular discectomy for symptomatic lumbar disc herniation (LDH) using general classification and modified Clavien-Dindo classification (MCDC) schemes. We searched three online databases for randomized controlled trials (RCTs) and cohort studies. Overall complication rates and complication rates per the above-mentioned classification schemes were considered as primary outcomes. Risk ratio (RR) and their 95% confidence intervals (CI) were evaluated. Seventeen RCTs and 20 cohort studies met the eligibility criteria. RCTs reporting OD/MD, MED, PELD, PLDD, and tubular discectomies had overall complication rates of 16.8% and 16.1%, 21.2%, 5.8%, 8.4%, and 25.8%, respectively. Compared with the OD/MD, there was moderate-quality evidence suggesting that PELD had a lower risk of overall complications (RR = 0.52, 95% CI 0.29-0.91) and high-quality evidence suggesting a lower risk of Type I complications per MCDC (RR = 0.37, 95% CI 0.16-0.81). Compared with the OD/MD data from cohort studies, there was low-quality evidence suggesting a higher risk of Type III complications per MCDC (RR = 10.83, 95% CI 1.29-91.18) for MED, higher risk of reherniations (RR = 1.67,95% CI 1.05-2.64) and reoperations (RR = 1.75, 95% CI 1.20-2.55) for PELD, lower risk of overall complication rates (RR = 0.42, 95% CI 0.25-0.70), post-operative complication rates (RR = 0.42, 95% CI 0.25-0.70), Type III complications per MCDC (RR = 0.39, 95% CI 0.22-0.69), reherniations (RR = 0.56, 95% CI 0.33-0.97) and reoperations (RR = 0.39, 95% CI 0.22-0.69) for PLDD. Compared with the OD/MD, results of this meta-analysis suggest that PELD has a lower risk of overall complications and a lower risk of complications necessitating conservative treatment. These slides can be retrieved under Electronic Supplementary Material.

Safety Analysis of Simultaneous Cranioplasty and Ventriculoperitoneal Shunt Placement.

To investigate the safety of combined cranioplasty (CP) and ventriculoperitoneal shunt (VPS) placement. Furthermore, we investigated whether the sequence of these procedures affects the postoperative complication rates associated with staged CP and VPS placement. We retrospectively investigated patients who developed communicating hydrocephalus after decompressive craniectomy and subsequently underwent VPS placement and CP at the hospital at which this study was performed between January 2009 and December 2019. Patients were categorized into group 1 (simultaneous CP and VPS placement) and group 2 (CP and VPS placement performed separately). Group 2 was subcategorized into subgroup 2a (CP performed before VPS placement) and subgroup 2b (VPS placement performed before CP). The Student?s t and Chi square tests were used to analyze intergroup differences. This study included 86 patients; 22 in group 1 and 64 in group 2 (24 patients in subgroup 2a and 40 patients in subgroup 2b). No statistically significant difference was observed in the overall complication rates between groups 1 and 2 (36.4% vs. 28.1%, P=0.591). However, the incidence of infections was significantly higher in group 1 than in group 2 (22.7% vs. 4.7%, P=0.024). Subgroup analysis showed that the overall complication rate was signi?cantly lower in subgroup 2a than in subgroup 2b (12.5% vs. 37.5%, P=0.031). Simultaneous CP and VPS placement is associated with a high incidence of infections. Moreover, compared with initial CP, initial VPS placement is associated with a significantly higher risk of overall complications in patients who undergo a staged procedure.

Updated evaluation of endoscopic submucosal dissection versus surgery for early gastric cancer: A systematic review and meta-analysis.

Endoscopic resection (ER) has been a standard treatment modality for early gastric cancer with ignorable risks of lymph node metastasis. As for EGCs within expanded indications, endoscopic submucosal dissection (ESD) has considerable advantages over endoscopic mucosal resection (EMR) regarding higher rate of en bloc resection, complete resection, but lower risk of local recurrence. Previous meta-analyses comparing ESD with surgery for EGC are scarce and not robust to reach definitive conclusions. We searched PubMed, Web of Science, EMBASE, Cochrane Library Databases and Google Scholar through July 2019 to identify studies evaluating ESD vs surgery for EGC. Newcastle-Ottawa Quality Assessment Scale was used to assess the quality of enrolled studies. Patient baseline characteristics, procedure-related and prognosis outcomes, and adverse event data were extracted and pooled for analyses by the Review Manager 5.3 software. Grading of Recommendations Assessment, Development and Evaluation guidelines (GRADE) were used to assess the quality of evidence. Trial Sequential Analysis (TSA) was conducted to weaken random error and enhance the reliability of evidence. Totally 18 retrospective studies, involving 5993 patients, were included. ESD benefits were 128.38min shorter operation duration [95%CI: (-204.68, -52.09), P=0.001], 7.13 days shorter hospital stay [95%CI: (-7.98, -6.28), P<0.00001], lower risk of procedure-related death [OR=0.21, 95%CI: (0.07, 0.68), P=0.009], lower risk of overall complication [OR=0.47, 95%CI: (0.34, 0.63), P<0.00001]. ESD was also associated with lower costs and better quality of life. However, ESD had lower rate of en bloc resection [OR=0.07, 95%CI: (0.03, 0.21), P<0.00001], histologically complete resection [OR=0.07, 95%CI: (0.03, 0.14), P<0.00001], curative resection [OR=0.06, 95%CI: (0.01, 0.27), P=0.002], and higher rate of local recurrence [OR=5.42, 95%CI: (2.91, 10.11), P<0.00001], metachronous cancer [OR=10.84, 95%CI: (6.43, 18.26), P<0.00001], synchronous cancer [OR=6.59, 95%CI: (1.96, 22.1), P=0.002]. ESD also led to lower disease-free survival [HR=4.58, 95%CI: (2.79, 7.52), P<0.00001] and recurrence-free survival [HR=1.99, 95%CI: (1.38, 2.87), P=0.0002]. No significant differences in overall survival (OS) and disease-specific survival (DSS) between ESD and surgery were observed. ESD offers a method of less expensive, less trauma, faster recovery and better quality of life compared to surgery for EGC. However, ESD is associated with higher risk of recurrence without compromising OS and DSS. Strict and careful surveillance after ESD is needed. Recurrent EGCs following ESD can usually be detected in early stage and successfully managed by repeated ESD. Accordingly, ESD technique provides an alternative to surgical resection for highly selected EGC patients.

2406Role of implantation access on complication rates in pacemaker implantation

Abstract Introduction The implantation access (IA) either via vena cephalica (VC) or vena subclavia (VS) is the usual procedure in pacemaker implantation (PI). Valid data on head-to head comparisons between access via CV and VS regarding serious complications are missing. Purpose We analyzed potential associations between the type of implantation access and complication rates in a real world data set with 69.957 cases. Methods The 2013 dataset of the German Federal Council, containing information about all 1st pacemaker implantations for Germanywas analyzed. First two cohorts of patients treated via CV or CS access were compared for all relevant variables through descriptive statistics. Secondly all patient-clusters with exactly the same risk-/condition-vector were identified based on the following variables: age, sex, ASA classification (ASA 1–ASA 5), leading symptom, indication for implantation, etiology, ejection fraction (EF), estimated need of stimulation, and all possible 1:1 exact matchings were compared. Results Out of the total cohort of 69,957 patients (mean age 76.2 years, 43.3% females, VC access 36%, VS access 64%) 19,643 pairs with identical profile of all factors contained in the database could be identified. These pairs of all 1:1 matchings had following profile: age 77.07 years, ASA 1 to 4 6.3%, 2 45.0%, 46.9%, 4 1.7%, leading symptoms (dizziness 51.9%, singular cardiac syncope 10.3%, recurring syncope 28,7%), pacemaker indication (AV-Block II/III 11.6%/26.3%, sick sinus syndrome 39,8%, bradycardia in atrial fibrillation 20.0%), unknown etiology 90.3%, estimated need of stimulation (permanent (&gt;90%) 20.9%, frequent (5–90%) 70.2%, rare (&lt;5%) 8.9%), EF (≤35%: 0.4%: 35, 50%: 9.1%, &gt;50%: 79.9%, unknown: 10.5%). Intra- and post-procedural complication [C] rates different between VC and VS are: at least one C: 2.6% (VC), 3.0% (VS) p=0.018; surgical C with need for intervention (haematothorax, pericardial effusion, pouch hematoma): 0.5% (VC), 1.0% (VS) p=0.005; asystole: 0.1% (VC), 0.2% (VS) p=0.047; pneumothorax: 0.1% (VC), 0.7% (VC) p&lt;0.001; dislocated atrial lead: 0.8% (VC), 0.6% (VS) p=0.027. Intra-hospital mortality was 1.0% (VC), 1.1% (VS) p=0.521. Conclusion Our analysis of a large-scale database shows that in patients with first pacemaker implantation the overall rate of complications is relatively low. But even after adjustment for available risk factors there are differences between the access routes: whereas VS access route is associated with statistically significant higher risk of overall complications, i.e. surgical complications, asystole, pneumothorax the VC access has a greater risk of dislocated atrial lead. In view of the two times higher rate of implantations via VS (64 vs. 36%) the clinical implications should be considered when choosing the access route and the VC access should be preferred. Acknowledgement/Funding None

Anti-TNF and Postoperative Complications in Abdominal Crohn's Disease Surgery.

Biological therapy with anti-Tumour Necrosis Factor (TNF)-α agents revolutionised the treatment of inflammatory bowel disease over the last decades. However, there may be an increased risk of postoperative complications in Crohn's disease (CD) patients treated with anti-TNF-α agents prior to abdominal surgery. To evaluate the effects of preoperative anti-TNF-α therapy on the incidence of complications after surgery. A critical assessment of the results of clinical trial outcomes and meta-analyses on the available data was conducted. Based on the outcomes of previous reports including meta-analyses, preoperative use of anti- TNF-α agents modestly increased the risk of overall complications and particularly infectious complications after abdominal surgery for CD. Nevertheless, previous studies have several limitations. The majority of them were retrospective research with heterogeneous outcome measures and single centre trials with relatively small sample size. In retrospective studies, the standard protocol for assessing various types of postoperative complications was not used. The most serious limitation of the previous studies was that multiple confounding factors such as malnutrition, use of corticosteroids, and preoperative sepsis were not taken into consideration. Among patients treated with preoperative anti-TNF-α therapy, the risk of overall complications and infectious complications may slightly increase after abdominal surgery for CD. Nevertheless, the previous reports reviewed in this study suffered from limitations. To rigorously evaluate the risk of anti-TNF-α therapy prior to surgery, large prospective studies with standardised criteria for assessing surgical complications and with proper adjustment for confounding variables are warranted.

Early cholecystectomy (≤ 8weeks) following percutaneous cholecystostomy tube placement is associated with higher morbidity.

Percutaneous cholecystostomy tube (PCT) placement is often the initial management approach to severe acute cholecystitis in the unstable patient. However, the timing of cholecystectomy after PCT has not been carefully examined. The purpose of this study was to compare outcomes of early versus late cholecystectomy following PCT placement. The New York SPARCS administrative database was searched for all patients undergoing PCT placement between 2000 and 2012. Patients were followed for subsequent cholecystectomy (CCX) procedures up to 2014. Subsequent cholecystectomies were divided into early (≤ 8weeks) versus late (> 8weeks) groups. Outcomes included overall complications, 30-day readmissions, 30-day Emergency Department (ED) visits, and length of stay (LOS). Multivariable regression models were used to examine the differences in clinical outcomes between these two groups, after adjusting for possible confounding factors. There were 9728 patients who underwent PCT placement identified during the time period, as early subsequent cholecystectomy was performed in 1211 patients (40.4%), while 1787 (59.6%) patients had a late cholecystectomy. Average time to cholecystectomy was 38days in the early group, versus 203days in the late group. After adjusting for other confounding factors, patients with early CCX had a significantly higher risk of overall complications and longer LOS compared to the late CCX group (P = 0.01 and P = 0.0004, respectively). There were no significant differences in 30-day readmissions and 30-day ED visits. Furthermore, there was no significant difference in the risk of CBD injury between the two groups (n = 21, 1.7% in the early cholecystectomy group and n = 26, 1.5% in the late cholecystectomy group). Early cholecystectomy (≤ 8weeks) is associated with a higher risk of complications and longer hospital LOS compared to cholecystectomy performed at > 8weeks. Surgeons should be aware and should delay cholecystectomy beyond 8weeks to improve outcomes.

Duration of surgery affects the risk of complications following total hip arthroplasty

The aim of this study was to assess the influence of operating time on 30-day complications following total hip arthroplasty (THA). We identified patients aged 18 years and older who underwent THA between 2006 and 2016 from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. We identified 131 361 patients, with a mean age of 65 years (sd 12), who underwent THA. We used multivariable regression to determine if the rate of complications and re-admissions was related to the operating time, while adjusting for relevant covariables. The mean operating time decreased from 118.3 minutes (29.0 to 217.0) in 2006, to 89.6 minutes (20.0 to 240.0) in 2016. After adjustment for covariables, operating times of between 90 and 119 minutes increased the risk of minor complications by 1.2 (95% confidence interval (CI) 1.1 to 1.3), while operating times of between 120 and 179 minutes increased the risk of major complications by 1.4 (95% CI 1.3 to 1.6) and minor complications by 1.4 (95% CI 1.2 to 1.5), and operating times of 180 minutes or more increased the risk of major complications by 2.1 (95% CI 1.8 to 2.6) and minor complications by 1.9 (95% CI 1.6 to 2.3). There was no difference in the overall risk of complications for operating times of between 20 and 39, 40 and 59, or 60 and 89 minutes (p > 0.05). Operating times of between 40 and 59 minutes decreased the risk of re-admission by 0.88 (95% CI 0.79 to 0.97), while operating times of between 120 and 179 minutes, and of 180 minutes or more, increased the risk of re-admission by 1.2 (95% CI 1.1 to 1.3) and 1.6 (95% CI 1.3 to 1.8), respectively. These findings suggest that an operating time of more than 90 minutes may be an independent predictor of major and minor complications, as well as re-admission, following THA, and that an operating time of between 40 and 90 minutes may be ideal. Prospective studies are required to confirm these findings. Cite this article: Bone Joint J 2019;101-B(6 Supple B):51-56.

Use of morselized allografts for acetabular reconstruction during THA revision: French multicenter study of 508 cases with 8 years’ average follow-up

BackgroundIn the context of acetabular reconstruction, bone defects can be filled with processed or unprocessed bone allografts. Published data are often contradictory on this topic and few studies have been done comparing processed allografts to fresh-frozen ones. This led us to conduct a large study to measure the factors impacting the survival of THA revision: (1) type of allograft and cup, (2) technical factors or patient-related factors. HypothesisAcetabular reconstruction can be performed equally well with frozen or processed morselized allografts. Materials and methodsThis retrospective, multicenter study of acetabular reconstruction included 508 cases with a minimum follow-up of 5 years. The follow-up for the frozen grafts was shorter (7.86 years±1.89 [5–12.32]) than that of the processed grafts (8.22 years±1.77 [5.05–15.48]) (p=0.029). However, the patients were younger at the time of the primary THA procedure in the frozen allograft group (51.5 years±14.2 [17–80]) than in the processed group (57.5 years±13.0 [12–94]) (p<0.001) and were also younger at the time of THA revision (67.8 years±12.2 [36.9–89.3] versus 70 years±11.7 [25–94.5]) (p=0.041). ResultsThere were more complications overall in the frozen allograft group (46/242=19.0%) than the processed allograft group (35/256=13.2%) (p=0.044) with more instances of loosening in the frozen group (20/242 [8.2%]) than in the processed group (6/266 [3.3%])(p=0.001). Conversely, the dislocation rate (16/242=6.6% vs. 17/266=6.4%) (p=0.844) and infection rate (18/242=7.4% vs. 15/266=5.7%) (p=0.264) did not differ between groups. The subgroup analysis reveal a correlation between the occurrence of a complication and higher body mass index (BMI) (p=0.037) with a higher overall risk of complications in patients with a BMI above 30 or under 20 (p=0.006) and a relative risk of 1.95 (95% CI: 1.26–2.93). Being overweight was associated with a higher risk of dislocation (relative risk of 2.46; 95% CI: 1.23–4.70) (p=0.007). Loosening was more likely to occur in younger patients at the time of the procedure (relative risk of 2.77; 95% CI: 1.52–6.51) (p=0.040) before 60 years during the revision. Lastly, patients who were less active preoperatively based on the Devane scale had an increased risk of dislocation (relative risk of 2.51; 95% CI: 1.26–8.26) (p=0.022). DiscussionOur hypothesis was not confirmed. The groups were not comparable initially, which may explain the differences found since the larger number of loosening cases in the frozen allograft group can be attributed to group heterogeneity. Nevertheless, morselized allografts appear to be suitable for acetabular bone defect reconstruction. A randomized study would be needed to determine whether frozen or processed allografts are superior. Level of evidenceIII, comparative retrospective study.

Increasing body mass index increases complications but not failure rates in microvascular breast reconstruction: A retrospective cohort study

Obesity is often considered a relative contra-indication for microvascular autologous breast reconstruction. We hypothesize that although obesity is associated with increased post-operative complications, abdominally based microvascular post mastectomy breast reconstruction can still be achieved with high rates of success. This study analyses the relationship between increasing body mass index (BMI) and post-operative complications at a high volume specialist centre, with a particular focus on serious complications. Nine hundred and sixty patients undergoing 1460 microvascular breast reconstructions were included in the study. Obese patients (BMI ≥ 30 kg/m2) accounted for 37.7% of the cohort and were more likely to have co-morbidities, a history of smoking and bilateral reconstruction. Post-operative surgical complications occurred in 156 patients (16.3%) and medical complications occurred in 10 patients (1.0%). There was no significant difference between the flap failure rates in patients with normal BMI < 25 kg/m2 (1.2% of patients, 0.9% of flaps) and obese patients (1.9% of patients, 1.2% of flaps, p = 0.07). Obesity was an independent predictor of overall complications (OR 1.7, CI 0.81-2.74, p = 0.001) but not medical complications or flap failure (OR 1.3, CI 0.43-5.8, p = 0.161 and OR 1.2, CI 0.66-6.1, p = 0.091). There was a linear relationship between increasing BMI and overall complication rates, but serious complications remained uncommon even in morbidly obese patients. This large single-centre study demonstrates that although obesity increases the risk of overall complications, microvascular breast reconstruction can be safely and successfully achieved in the vast majority of patients. Obese patients should be carefully counselled pre-operatively, but increased BMI should not be considered a contra-indication for microvascular breast reconstruction.

The Simplified PADUA REnal (SPARE) nephrometry system: a novel classification of parenchymal renal tumours suitable for partial nephrectomy.

To simplify the original Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) classification of renal tumours, generating a new system able to predict equally or better the risk of overall complications in patients undergoing partial nephrectomy (PN); and to test if the addition of the contact surface area (CSA) parameter improves the accuracy of the original PADUA and new Simplified PADUA REnal (SPARE) nephrometry classification systems. We analysed the clinical records of 531 patients who underwent PN (open, laparoscopic and robot-assisted) for renal tumours at five tertiary academic referral centres from January 2014 to December 2016. The ability of each variable included in the PADUA classification to predict overall complications was tested using binary logistic regression analysis. The variables that were not statistically significant were excluded from the SPARE classification. In addition to the original PADUA and SPARE systems, another two models were generated adding tumour CSA. Receiver operating characteristic curve analysis was used to compare the ability of the four different models to predict overall complications. Binary logistic regression was used to perform both univariable and multivariable analyses looking for predictors of postoperative complications. Linear regression analysis was used to identify independent predictors of absolute change in estimated glomerular filtration rate (eGFR; ACE). The SPARE nephrometry score system including: (i) rim location, (ii) renal sinus involvement, (iii) exophytic rate, and (iv) tumour dimension; showed equal performance in comparison with the original PADUA score (area under the curve [AUC] 0.657 vs 0.664). Adding tumour CSA to the original PADUA (AUC 0.661) or to the SPARE (AUC 0.658) scores did not increase the accuracy of either system to predict overall complications. The SPARE system (odds ratio 1.2, 95% confidence interval 1.1-1.3) was an independent predictor of postoperative overall complications. Age (P < 0.001), body mass index (P < 0.001), Charlson Comorbidity Index (P = 0.02), preoperative eGFR (P < 0.001), and tumour CSA (P = 0.005) were independent predictors of ACE. Limitations include the retrospective design and the lack of central imaging review. The new SPARE score is comprised of only four variables instead of the original six and its accuracy to predict overall complications is similar to that of the original PADUA score. Addition of tumour CSA was not associated with an increase in prognostic accuracy. The SPARE system could replace the original PADUA score to evaluate the complexity of tumours suitable for PN.

Predictive Value of Body Mass Index for Short-Term Outcomes of Patients with Esophageal Cancer After Esophagectomy: A Meta-analysis.

The association between body mass index (BMI) and short-term outcomes after esophagectomy remains controversial. A meticulous search for articles describing the association between BMI and perioperative outcomes after esophagectomy was conducted using PubMed, EMBASE, and the Cochrane Library. The study classified BMI according to the World Health Organization definitions and Asian-specific BMI cutoff values. Normal weight was selected as the comparator, and the odds ratio (OR) was calculated as the primary effect. This meta-analysis included 13 studies with 5480 patients. Obese patients exhibited higher risks of overall complication (OR 1.37; P = 0.013), anastomotic leakage (OR 1.74; P = 0.001), and thromboembolic complications (OR 2.05; P = 0.039). Subgroup analysis indicated that obese patients from Western countries had a higher risk of wound infection (OR 2.22; P = 0.022), whereas obese Asians were more likely to experience pulmonary complications (OR 1.64; P = 0.002). Overweight patients displayed no significant differences in major complications relative to normal-weight patients, except for the increased risk of overall complications (OR 1.32; P = 0.030). Additionally, underweight patients showed increased incidence of pulmonary complications (OR 1.92; P = 0.020 and anastomotic leakage (OR 1.64; P = 0.034). Morbid obesity also was analyzed separately with limited data, and this group displayed a higher risk of wound infection (OR 1.62; P = 0.027) and thromboembolic complications (OR 2.65; P = 0.003). No significant differences in mortality were observed among patients in different BMI categories. Obesity and underweight statuses were confirmed risk factors for several complications after esophagectomy, whereas overweight patients tended to experience greater benefit from surgery.

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