Risk Of Postoperative Complications Research Articles

7295 Giant Pituitary Adenoma with Rapid Symptomatic Progression and Postoperative Mortality

Abstract Disclosure: R.D. Kennedy: None. M. Nicholson: None. Introduction: Giant pituitary adenomas, defined as pituitary adenomas measuring greater than 4 cm, present a therapeutic challenge because of their size, clinical features, and increased potential for complications following surgical intervention. Early detection and intervention to prevent growth and progression is paramount. We present a case of a patient with a giant 6.3 cm pituitary adenoma who had significant neurologic compromise, requiring surgical intervention, with resultant postoperative complications and death. Case:Patient is a 41 year old male with known history of pituitary adenoma who presented on 11/1/2023, from outside hospital, to the Neuroendocrine clinic with complaints of excessive truncal obesity, impotence, fatigue, and apathy. Vital signs were within normal limits. Physical exam revealed clouding of consciousness, grossly intact cranial nerve function, truncal obesity, and diminished power, tone, and bulk of the extremities. Formal visual field testing revealed bitemporal hemianopsia. A head CT scan revealed a 6.3 cm sellar mass with expansion of the sella, invasion of soft tissue into the sphenoid sinus, and extension of soft tissue cranially to the level of the third ventricle eccentric to the left. There was no evidence of apoplexy. Lab results revealed Prolactin of 924 ng/mL. The patient had been taking Bromocriptine, 2.5 mg daily, for at least three weeks. Less than three weeks after his initial evaluation, he returned to the hospital with complaint of acute ataxia. Pituitary MRI revealed 6.3 cm sellar mass with evidence of acute and subacute blood products, stretching of the optic chiasm from mass effect, extension into the bilateral cavernous sinuses, superior left MCA displacement, posterior left PCA displacement, 5 mm midline shift, uncal herniation and descending transtentorial herniation. The patient underwent endoscopic transsphenoidal resection with subsequent craniotomy for debulking. Postoperatively, he developed new right sided hemiplegia with aphasia with subsequent MRI finding of watershed infarct at the left MCA/PCA lateral posterior border zone territories with increasing mass effect over a 30 day hospital stay. He developed progressive global edema with worsening uncal and tonsillar herniations. Brain death was pronounced on 11/30/23. Discussion:This case highlights the importance of early intervention in patients with giant pituitary adenomas. Our patient had been experiencing right sided weakness for at least one year prior to his admission to our facility. In this case, earlier treatment with a dopamine agonist may have decreased the size of the adenoma or prevented rapid growth. This may have precluded the need for surgical intervention on an adenoma of this size, which carries increased risk for postoperative complications. Presentation: 6/2/2024

Impact of rapid response system in mortality and complications post-orthopedic surgery: a retrospective cohort study

BackgroundRapid response systems (RRSs) are used in hospitals to identify and treat deteriorating patients. However, RRS implementation and outcomes in orthopedic and surgical patients remain controversial. We aimed to investigate whether the RRS affects mortality and complications after orthopedic surgery.MethodsThe National Health Insurance Service of South Korea provided the data for this population-based cohort study. Individuals who were admitted to the hospital that implemented RRS were categorized into the RRS group and those admitted to a hospital that did not implement the RRS were categorized into the non-RRS group. In-hospital mortality and postoperative complications were the endpoints.ResultsA total of 931,774 adult patients were included. Among them, 93,293 patients underwent orthopedic surgery in a hospital that implemented RRS and were assigned to the RRS group, whereas 838,481 patients were assigned to the non-RRS group. In multivariable logistic regression analysis, the RRS group was not associated with in-hospital mortality after orthopedic surgery compared with the non-RRS group (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.80, 1.08; P = 0.350). However, the RRS group was associated with a 14% lower postoperative complication rate after orthopedic surgery than the non-RRS group (OR 0.86, 95% CI 0.84, 0.86; P < 0.001).ConclusionsThe RRS was not associated with in-hospital mortality following orthopedic surgery in South Korea. However, RRS deployment was related to a decreased risk of postoperative complications in patients undergoing orthopedic surgery.

Timing of total joint arthroplasty post-COVID-19: an evaluation of the optimal window to minimize perioperative risks

BackgroundTotal hip arthroplasty (THA) and total knee arthroplasty (TKA) are commonly performed orthopedic procedures. This study aimed to evaluate the impact of COVID-19 status on postoperative complications and mortality in patients undergoing THA and TKA.MethodsA total of 110,186 underwent either THA or TKA. Patients were grouped based on their COVID-19 status, gathered from the National COVID-19 Cohort Collaborative (N3C) in the 12 weeks preceding surgery and compared for various variables, including age, sex, BMI, and Charlson Comorbidity Index (CCI) scores. COVID-19 status was defined as a positive test result that was closest to the date of surgery regardless of testing positive previously. Postoperative complications such as venous thromboembolism (VTE), sepsis, surgical site infection, bleeding, acute kidney injury (AKI), 30-day, and 1-year all-cause mortality were examined. To compare the variables, an odds ratio with a 95% confidence interval was calculated with a significant level set at P < 0.05. Logistic regression using R programming was utilized for these calculations.ResultsUnivariate analysis was performed and rates of VTE (1.02% vs. 3.35%), 30-day mortality (0.25% vs. less than 5%), and 1-year mortality (1.42% vs. 5.43%) were higher in the COVID-19-positive group for THA patients (P < 0.001). For TKA patients, only 30-day mortality was significantly higher in the COVID-19-positive group (P = 0.034). Multivariate logistic regression revealed that a positive COVID-19 diagnosis within two weeks of surgery and a CCI score > 3 were significant predictors of postoperative complications and mortality for both TKA and THA.ConclusionsPatients with a positive COVID-19 diagnosis within 12 weeks of THA or TKA carried a significantly higher risk for postoperative complications and mortality. In addition, a CCI score > 3 is also a significant risk factor. These findings emphasize the importance of vigilant preoperative screening and risk stratification in the era of COVID-19.

Intraoperative Complications as Predictors of Flap Failure in Autologous Breast Reconstruction.

Intraoperative microvascular complications in autologous breast reconstruction significantly increase the risk of post-operative complications. No study has identified which specific intraoperative complications contribute to partial or total flap loss. A retrospective chart review of microsurgical breast reconstructions by five surgeons between 2009-2020 analyzed operative variables and patient outcomes, with complications determined from the operative report. Flap loss rates were compared between cases with and without intraoperative complications. Statistical analysis was performed using Fischer exact and t-tests for discrete and continuous variables, respectively. Intraoperative complications were analyzed for 1465 autologous breast flaps performed in 916 patients. Early partial flap loss was predicted by arterial anastomosis revision (2.90% vs 0.44%, p=.03) and alternate venous outflow (14.29% vs 0.41%, p=.002), with no association with intraoperative thrombosis, venous revision, or difficult recipient or flap dissection. In comparison, early total flap loss was predicted by intraoperative arterial revision (5.80% vs 0.51%, p=.001), venous revision (5.45% vs 0.57%, p=.007), intraoperative thrombosis (12.12% vs 0.49%, p<.001), and difficult flap dissection (2.91% vs 0.59%, p=.04). Difficult flap dissection was the only intraoperative variable associated with late partial flap loss (6.80% vs 1.69%, p=.004). Late total flap loss only occurred in 6/1465 flaps, the sole association being difficult recipient vessel dissection (2.78% vs 0.29%, p=.03). Post-operative arterial and venous compromise occurred in 1.10% (13/1187) and 2.53% (30/1187) of cases with no intraoperative complications, respectively, compared to 3.2% (9/278, p=0.02) and 6.12% (17/278, p=0.002) in cases with an intraoperative complication. Alternate venous outflow predicts early partial flap loss, while intraoperative thrombosis, and arterial and venous revision predict early total loss. Difficult flap dissection was associated with early total and late partial flap loss, while difficult recipient vessel dissection was associated with late total flap loss.

Clinical Impact of Obesity on Postoperative Outcomes of Patients With Thyroid Cancer Undergoing Thyroidectomy: A 5-Year Retrospective Analysis From the US National Inpatient Sample.

The clinical impact of obesity on postoperative outcomes of patients undergoing thyroidectomy remains controversial. Patients aged ≥ 18 years who were diagnosed with thyroid malignancy and underwent thyroidectomy between 2016 and 2020 were included, and divided into two groups: patients with body mass index (BMI) < 30 kg/m2 and those with BMI ≥ 30 kg/m2. Patients in the obese group were then subdivided into four groups: Group 1 (BMI 30.0-34.9 kg/m2), Group 2 (BMI 35.0-39.9 kg/m2), Group 3 (BMI 40.0-44.9 kg/m2), and Group 4 (BMI ≥ 45.0 kg/m2) to evaluate the association between degree of obesity and clinical outcomes. We performed propensity score matching, compared outcome variables between the groups, and conducted adjusted multivariate logistic regression analyses of postoperative outcomes. A total of 6778 patients diagnosed with thyroid cancer who underwent thyroidectomy were screened, of whom 1299 (19.2%) patients were obese. Patients in the obese group had higher total hospital charges (p < 0.001) and an increased risk of overall postoperative complications (34.7% vs. 30.5%, p = 0.023). Specifically, patients in the obese group had increased odds of respiratory complication (adjusted odds ratio (aOR) 1.66, 95% confidence interval (CI) [1.26-2.19]), acute renal failure (aOR 1.87, 95% CI [1.13-3.09]), and wound complication (aOR 2.77, 95% CI [1.21-6.37]) than those in the non-obese group. Moreover, trend tests showed that the risks of unfavorable discharge, infection, acute renal failure, and respiratory complication all exhibited an upward trend with increased BMI. Obesity is associated with an increased risk of postoperative complications in patients with thyroid cancer undergoing thyroidectomy. This finding suggests that obese patients should be treated with more caution during postoperative recovery.

The impact of chronic obstructive pulmonary disease on risk for complications after pancreatoduodenectomy - a single centre cohort study

BackgroundThe association between chronic obstructive pulmonary disease (COPD) and risk for postoperative complications after pancreatic surgery has not been clarified. The aim of this study was to investigate if COPD is associated with increased risk for postoperative complications after pancreatoduodenectomy. MethodsAll patients aged ≥18 years undergoing pancreatoduodenectomy from 2008 to 2019 at a high-volume tertiary centre for pancreatic cancer surgery were included. COPD was defined as an established diagnosis according to the International Statistical Classification of Diseases. The primary outcome was Clavien-Dindo-score (CD) ≥ IIIa. ResultsOut of 1009 available patients, 57 (5.6 %) had a diagnosis of COPD. There was no association between COPD and CD ≥ IIIa (25.5 % vs. 29.8 % p-value 0.471). COPD was associated with an increased risk for postoperative pancreatic fistula (odds ratio [OR] 3.06, 95 % confidence interval [CI] 1.62–5.89; p < 0.001). The 12 months mortality rate was higher among patients with COPD compared to patients without COPD, although not statistically significant (28.07 per cent vs., 18.17 per cent, p-value = 0.063). ConclusionCOPD was associated with increased risk for postoperative pancreatic fistula. These results imply that among patients deemed fit enough to undergo surgery, COPD should be thoroughly evaluated in the risk stratification.

Risk of Postoperative Complications After Total Hip and Total Knee Arthroplasty in Behcet Syndrome Patients.

Behcet syndrome (BS), a multisystem autoimmune disorder, has unclear effects on outcomes after total hip arthroplasty (THA) and total knee arthroplasty (TKA). This study assessed the relative risk of perioperative adverse events in patients with BS. This retrospective cohort study used the PearlDiver M157Ortho data set, a large national administrative database. Total hip arthroplasty and TKA patients with BS were identified and matched 1:4 to those without BS based on patient age, sex, Elixhauser Comorbidity Index scores, and procedure performed (THA or TKA). The incidence of 90-day adverse events was determined and compared by multivariate analysis. 5-year survival to revision surgeries was assessed and compared with the log-rank test. After matching, 282 THA/TKA patients with BS were identified and compared with 1127 without BS. On multivariate analysis, patients with BS were at independently greater risk of aggregated any (odds ratio [OR] 2.16, P < 0.0001), serious (OR 1.78, P = 0.0051), and minor (OR 2.39, P < 0.0001) adverse events compared with those without BS. No significant difference was observed in 5-year survival to revision surgery (P = 0.3). Patients with BS undergoing THA or TKA experienced markedly greater 90-day postoperative adverse events. The findings underscore the need for optimized perioperative management for patients with BS undergoing arthroplasty.

Short-term outcomes of minimally invasive total vs supracervical hysterectomy for uterine fibroids: a National Surgical Quality Improvement Program study

BackgroundUterine fibroids are the most common indication for benign hysterectomy in the United States, but data regarding the association of hysterectomy type and outcomes for this indication are lacking. ObjectiveWe aimed to describe the rate and odds of short-term (30 days) postoperative complications among patients undergoing minimally invasive total (TLH) compared to supracervical (LSCH) hysterectomy for uterine fibroids. Study DesignWe conducted a cohort study of prospectively collected data from the American College of Surgeons National Surgical Quality Improvement Program database from 2012-2020. We compared characteristics of women who underwent TLH and LSCH for uterine fibroids and identified risk factors associated with the occurrence of 30-days postoperative complications defined according to the Clavien-Dindo classification. Multivariable regression analysis including age, BMI, race, comorbidities, ASA classification, uterine weight and concomitant procedures, was performed to identify the adjusted odds of postoperative complications. The co-primary outcomes were the risk of (1) a composite of any postoperative complications and of (2) major postoperative complications according to surgical type. ResultsA total of 44,413 and 6,383 patients underwent minimally invasive TLH and LSCH respectively. Operative time was shorter (143.0 vs. 150.6 minutes, p<.001), and the proportion of uterine weight >250 g was lower (39.4% vs. 45.1%, p<.001) in the TLH group. The rates of any (6.6% vs. 5.3%, p<.001), and major (2.7% vs. 1.6%, p<.001) complications were higher in the TLH group, while minor complications rate was comparable (4.4% vs. 4.1%, p=.309). In multivariable regression analysis, LSCH was independently associated with lower risk of any [aOR 95% CI 0.79 (0.70-0.88)], and major [aOR 95% CI 0.55 (0.44-0.69)] complications compared to TLH. ConclusionCompared with TLH, LSCH is associated with a lower risk of short-term postoperative complications among patients with uterine fibroids. The current study findings can aid in shared decision-making prior to minimally invasive hysterectomy for uterine fibroids.

Effect of Neoadjuvant Immunotherapy Combined with Chemotherapy on Pulmonary Function and Postoperative Pulmonary Complications in Esophageal Cancer: A Retrospective Study.

Neoadjuvant immunotherapy, targeting the PD-1 or PD-L1, combined with chemotherapy (NICT), can improve the radical resection and survival rates for locally advanced EC. However, it may impair pulmonary function, and the effect of NICT on pulmonary function and postoperative pulmonary complications in EC patients remains unknown. This study aimed to investigate whether NICT can affect pulmonary functions and postoperative pulmonary complications in EC patients. The study retrospectively recruited 220 EC patients who received NICT at the Department of Esophageal Cancer in Tianjin Medical University Cancer Institute & Hospital from January 2021 to June 2022. Changes in pulmonary function before and after NICT were compared. Logistic regression analysis was performed to analyze the correlations of pulmonary functions and clinical characteristics with postoperative pulmonary complications, respectively. The FEV1% pred, FVC, FVC% pred, and FEV1/FVC% significantly increased after NICT, with a P-value of 0.018, 0.005, 0.001, and 0.036, respectively. In contrast, there was a significant decline in the DLCO (8.92 ± 2.34 L before NICT vs. 7.79 ± 2.30 L after NICT; P < 0.05) and DLCO% pred (102.97 ± 26.22% before NICT vs. 90.18 ± 25.04% after NICT; P < 0.05). High DLCO and DLCO% pred at baseline levels were risk factors for DLCO reduction in EC patients after NICT. Advanced age, smoking history, FEV1% pred after NICT, and FVC% pred baseline and after therapy were risk factors for postoperative pulmonary complications, with a P-value of 0.043, 0.038, 0.048, 0.034, and 0.004, respectively. Although the DLCO level decreased after NICT, it did not increase the incidence of postoperative pulmonary complications. NICT may improve pulmonary ventilation function but also lead to a decrease in DLCO and DLCO% pred in EC patients. Nevertheless, the decreased DLCO after NICT did not increase the risk of postoperative pulmonary complications.

Postoperative urinary retention - prevalence and risk factors: prospective, cohort study

Introduction Ensuring perioperative urination maintenance can often be challenging, as postoperative urinary retention is frequently overlooked in favor of more clearly defined goals such as successful surgery, comprehensive postoperative pain control, reducing the risk of postoperative cardiorespiratory complications and shortening the patient's overall hospital stay. However, the inability to initiate urination and empty the bladder in the early postoperative period may negatively affect each of the listed success criteria. Material and methods A single-center, prospective, observational, cohort study was conducted, enrolling elderly patients without severe comorbidities. A total of 127 complete datasets were analyzed. Anthropometric parameters, type of surgery, duration of anesthesia and surgery; and several parameters previously reported as risk factors for postoperative urinary retention were recorded. The main objective wasto identify the prevalence of postoperative urinary retention in a surgical group in the Republic of Moldova. The secondary objective was to test the predictive value of a series of parameters (modifiable and non-modifiable) related to the patient or surgical treatment received as risk factors for urinary retention in the first 24 hours postoperatively. Statistical software used: Social Science Statistics (https://www.socscistatistics.com). Results The studied surgical population was homogeneous in terms of body mass, height, duration of surgery and anesthesia; heterogeneous by gender (62.2% male) and type of anesthesia (64% general anesthesia). Depending on the definition criteria, the prevalence of postoperative urinary retention varied between 5.5% and 7.9%. The preoperative unmodifiable risk factors for postoperative urinary retention: positive history for hypertension OR = 9.0 (X2 (1, N = 127) = 5.6, p = 0.017), diabetes mellitus OR = 5.1 (X2 (1, N = 127) = 5.36, p = 0.021) and stroke OR = 4.83 (X2 (1, N = 127) = 2.098, p = 0.148). Conclusions The prevalence of postoperative urinary retention in a single-center surgical population from the Republic of Moldova varies between 5.5% and 7.9%, depending on the criteria for postoperative urinary retention applied. This variation highlights the need for a consensus on diagnostic criteria for postoperative urinary retention is needed. Patients with hypertension and diabetes mellitus were more likely to develop postoperative urinary retention. Patients with pre-existing neurological disorders such as positive history for stroke and diabetic polyneuropathy were more susceptible for postoperative urinary retention.

Improving Surgical Care and Outcomes in Older Cancer Patients Through Implementation of a Presurgical Toolkit (OPTI-Surg)-Final Results of a Phase III Cluster Randomized Trial (Alliance A231601CD).

To assess the effect of a practice-level preoperative frailty screening and optimization toolkit (OPTI-Surg) on postoperative functional recovery and complications in elderly cancer patients undergoing major surgery. Frailty is common in older adults. It increases the risk of poor postoperative functional recovery and complications. The potential for a practice-level screening/optimization intervention to improve outcomes is unknown. Thoracic, gastrointestinal, and urologic oncological surgery practices within the National Cancer Institute Community Oncology Research Program (NCORP) were randomized 1:1:1 to usual care (UC), OPTI-Surg, or OPTI-Surg with an implementation coach. OPTI-Surg consisted of the Edmonton Frail Scale and guided recommendations for referral interventions. Patients 70 years old or above undergoing curative intent surgery were eligible. The primary outcome was 8 weeks postoperative function (kcal/wk). The key secondary outcome was complications within 90 days. Mixed models were used to compare UC to the 2 OPTI-Surg arms combined. From July 2019 to September 2022, 325 patients were enrolled in 29 practices. One hundred ninety-nine (64 UC, 135 OPTI-Surg) and 279 (78 UC, 201 OPTI-Surg) were evaluable for primary and secondary analysis, respectively. UC and OPTI-Surg patients did not significantly differ in total caloric expenditure (2.2 UC, 2.0 OPTI-Surg) after adjusting for baseline function ( P =0.53). UC and OPTI-Surg patients did not significantly differ in postoperative complications (25.6% UC, 35.3% OPTI-Surg, P =0.5). Frailty assessment was successfully performed, but the OPTI-Surg intervention did not improve postoperative function nor reduce postoperative complications compared with UC. Future analysis will explore practice-level factors associated with toolkit implementation and the differences between the coaching and noncoaching arms.

The role of prehabilitation in reducing the incidence of postoperative pulmonary complications in patients undergoing elective cardiac surgery: Results from the Pre Surgery Check Team study.

Despite its importance, prehabilitation, has only been implemented in very few cardiac surgery centers. The Pre Surgery Check Team study was designed to evaluate the impact of comprehensive interdisciplinary assessment and implementation of the prehabilitation program on the incidence of postoperative pulmonary complications after elective cardiac surgery. 725 adult patients (338 in the study group, 387 in the control group) were included in this single-center, prospective, observational study. Multimodal prehabilitation consisted of four elements: interdisciplinary medical assessment by cardiologist, anesthesiologist and cardiac surgeon, pulmonary assessment for patients at high risk of postoperative pulmonary complications, psychological assessment, and physiotherapeutic assessment and training. The primary endpoint was the occurrence of the postoperative pulmonary complications, and the secondary outcomes were: surgical site infection, rethoracotomy, ICU length of stay and hospital length of stay. Prehabilitation reduced the number of postoperative complications by 23%. Postoperative pneumonia was almost 3 times less common (5.33% vs 14.21%), and the surgical site infection - 1.4 times less common in the PreScheck group (8.28 vs 11.37%). In the logistic regression model, prehabilitation reduced the odds of postoperative pneumonia (by 0.346) and the odds of respiratory failure (by 0.479). Prehabilitation had no direct effect on ICU length of stay. Prehabilitation according to the Pre Surgery Check Team standard reduces the incidence of postoperative pulmonary complications and the total number of postoperative complications in patients undergoing elective cardiac surgery. The main benefit of attending the PreScheck Team visit is the opportunity to perform supportive preoperative interventions.

Elderly trochanteric fracture outcomes: Unveiling the risks of excessive postoperative sliding - A retrospective multicenter (TRON group) investigation

BackgroundIntramedullary nailing (IMN) for femoral trochanteric fractures (FTF) is the primary surgical intervention. Excessive lag screw sliding (ES) of the femoral neck screw sometimes occurs. This multicenter investigation sought to 1) determine the prevalence of ES, 2) evaluate the relationship between ES and postoperative complications, and 3) identify the factors of ES in elderly patients with FTF undergoing IMN. MethodsFrom 2016 to 2020, 1448 patients with FTF were treated using a short IMN across 11 institutions (TRON group). Upon applying exclusion criteria, 519 patients (127 men, 392 women; mean age, 84.4 years) were included. The postoperative sliding distance was measured immediately after surgery and at final follow-up. A sliding distance of ≥8 mm categorized patients as having ES. We identify the factors contributing to ES using the logistic regression analysis, with a p < 0.05 as statistical significance. ResultsES was observed in 116 patients (22.4 %). Patients with ES had a higher incidence of postoperative cut-out and peri-implant fracture. Logistic regression analysis showed that achieving optimal reduction in both AP and lateral views (odds ratio (OR) 0.48, p = 0.0012) and the use of a double screw system or twin screws with integrated locking mechanism significantly reduced the risk of ES (OR 0.27, 0.17; p = 0.0027, <0.001). ConclusionsThe incidence rate of ES was 22.4 %. ES was associated with a higher risk of postoperative complications. The surgeons should aim for optimal reduction and use a double screw or twin screws with an integrated interlocking mechanism as the implant of choice.

Feasibility of major hepatectomy following preoperative chemotherapy for advanced perihilar cholangiocarcinoma

BackgroundThe safety of major hepatectomy following preoperative chemotherapy for perihilar cholangiocarcinoma (PHCC) is underexplored. This study evaluates the impact of preoperative chemotherapy on surgical outcomes and assesses chemotherapy-induced liver injury in patients with advanced PHCC. MethodsThis retrospective study included 62 PHCC patients who underwent surgery between January 2019 and January 2024. Patients were divided into an upfront surgery group (UFS, n = 31) and a preoperative chemotherapy group (POC, n = 31). Preoperative chemotherapy was indicated when R0/R1 resection was unachievable, complex surgery was needed, or future liver reserve was insufficient. Baseline characteristics, surgical procedures, postoperative complications, and pathological findings were compared. ResultsPostoperative complications were comparable between groups, with Clavien-Dindo grade ≥3a rates of 30.7 % in the POC group and 24.3 % in the UFS group. Despite longer operative times and hospital stays in the POC group, no significant differences in hepatotoxicity or pathological findings, including Kleiner and Rubbia-Brandt scores, were observed. Notably, a pathological complete response was achieved in 12.9 % of the POC group. ConclusionMajor hepatectomy following preoperative chemotherapy for PHCC is safe and does not increase the risk of postoperative complications or hepatotoxicity. Further studies are warranted to refine resectability criteria and optimize patient selection.

Total Hip Arthroplasty in Hip Osteoarthritis with Subtrochanteric Localized Periosteal Thickening: Preoperative Planning Using Finite Element Analysis to Determine the Optimal Stem Length

Background: Owing to the risk of atypical femoral fractures, total hip arthroplasty presents unique challenges for patients with ipsilateral osteoarthritis and localized periosteal thickening in the femoral subtrochanteric region. Stem length selection is critical for minimizing stress concentration in the thickened cortex to avoid such fractures. Herein, we report the case of a 78-year-old woman with ipsilateral hip osteoarthritis and localized subtrochanteric periosteal thickening. Methods: Preoperative planning included a finite element analysis to assess the stress distribution across various stem lengths. A simulation was conducted to determine the optimal stem length to span the cortical thickening and reduce the risk of postoperative complications. Results: The finite element analysis indicated that a stem length of &gt;150 mm was required to effectively reduce the stress at the site of cortical thickening. A 175 mm stem was selected for total hip arthroplasty, which provided a favorable stress distribution and avoided the risk of stress concentration. Conclusions: In cases of ipsilateral osteoarthritis with localized subtrochanteric periosteal thickening, finite element analysis can be valuable for preoperative planning to determine the optimal stem length, thereby reducing the risk of atypical femoral fractures. Further studies with multiple cases are recommended to validate these findings and improve surgical outcomes.

Multicenter analysis of the efficacy of early cholecystectomy and preoperative cholecystostomy for severe acute cholecystitis: a retrospective study of data from the multi-institutional database of the Hiroshima Surgical Study Group of Clinical Oncology

BackgroundSevere acute cholecystitis (AC) is a challenging disease because it comprises coexisting systemic infections that lead to vital organ dysfunction. This study evaluated the optimal surgical timing and efficacy of preoperative percutaneous cholecystostomy (PC) for patients with severe AC.MethodsData of 142 patients who underwent cholecystectomy for severe AC between 2011 and 2021 were retrospectively collected from the multi-institutional database of the Hiroshima Surgical Study Group of Clinical Oncology. Patients were divided into the early cholecystectomy (EC) group (within 72 h of symptom onset) and delayed cholecystectomy (DC) group. They were also subdivided into the upfront cholecystectomy group and preoperative PC before cholecystectomy group. The diagnosis and severity of AC were graded according to the Tokyo Guidelines 2018. Clinicopathological variables and outcomes were compared.ResultsNo significant differences in age, body mass index, American Society of Anesthesiologists (ASA) classification, and Charlson comorbidity index between the EC and DC groups were observed. Preoperative drainage was more commonly performed for the DC group than for the EC group. Local severe AC features were more commonly detected in the DC group than in the EC group. The postoperative outcomes of the EC and DC groups were comparable. Compared to the PC before cholecystectomy group, the upfront cholecystectomy group included more patients with ASA physical status ≥ 3 and more patients who used oral warfarin. Warfarin usage and cardiovascular dysfunction rates of the PC after cholecystectomy group were higher than those of the upfront cholecystectomy group. PC was associated with significantly less intraoperative bleeding and shorter hospital stays.ConclusionsPatients who can tolerate general anesthesia are good candidates for EC. Patients who use warfarin and those with cardiovascular dysfunction are considered to be at high risk for postoperative complications; therefore, to prevent AC recurrence during the waiting period, PC before cholecystectomy during the same admission is more appropriate than upfront cholecystectomy for these patients.

The Role of Preoperative Breathing Exercises in Reducing Postoperative Respiratory Complications in Coronary Artery Bypass Grafting: A Comparative Review of On-Pump and Off-Pump Techniques

Objectives: This review aims to evaluate the efficacy of preoperative breathing exercises in reducing postoperative respiratory complications, particularly respiratory failure, in patients undergoing CABG surgery. The review also compares the outcomes of these interventions in patients undergoing on-pump (ONCAB) versus off-pump (OPCAB) procedures. Methodology: A comprehensive literature search was conducted across multiple databases, including PubMed, Scopus, and Cochrane Library, to identify studies that examined the impact of preoperative breathing exercises on respiratory outcomes in CABG patients. The review focused on randomized controlled trials (RCTs) that compared the effectiveness of these exercises in ONCAB and OPCAB settings. Results: The review identified several studies supporting the role of preoperative breathing exercises in reducing postoperative respiratory complications. These exercises, including diaphragmatic breathing, incentive spirometry, and deep breathing, were associated with improved pulmonary outcomes, such as reduced incidence of respiratory failure, shorter durations of mechanical ventilation, and decreased hospital length of stay. While the overall results were positive for both ONCAB and OPCAB patients, variations were observed based on the surgical technique and patient-specific factors. Conclusion: Preoperative breathing exercises are an effective intervention for reducing the risk of postoperative respiratory complications in CABG patients. The benefits were observed in both ONCAB and OPCAB procedures, with particular advantages noted in the ONCAB group due to the higher baseline risk. Further research is needed to optimize these interventions, considering the individualized nature of patient responses and the specific characteristics of each surgical technique.

Features of vascular anatomy in pancreaticoduodenal resection

In about 55–79% of patients, the vascular anatomy of the hepatic-pancreaticoduodenal area is characterized by a typical structure. In the rest of patients, the vascular and, primarily, arterial anatomy may vary due to both different variants of branches and additional arteries. Undoubtedly, this creates difficulties in surgical planning and performing pancreaticoduodenal resection. Vascular anatomic variations may contribute to increased intraoperative blood loss, postoperative complications, changes in the course and volume of surgery, and increased duration of hospital stay after surgery. Modern diagnostic methods, CT angiography in particular, facilitate the process of surgical planning and reduce the risk of unforeseen situations related to ligation or damage of arterial vessels, which are to be preserved during operations. In this work, we carry out a review of publications on the topography of arterial vessels in the area of pancreaticoduodenal resection. The issues related to anatomical variations in both trunk and pancreatic vessels are considered. Special attention is paid to the possible influence of variations in the vascular network structure on the course and volume of surgery, as well as the risk of intraoperative and postoperative complications.

Short-Term Postoperative Outcomes after Resective Colorectal Surgery in Elderly vs. Nonelderly Patients: A Single Centre Retrospective Analysis

Background/Objectives: Life expectancy for people in their 60s is 24.3 years in high-income countries. Health systems face the burden of disease in the elderly population and must assess the impact of treatments such as major surgery. The aim of this study is to quantify the impact of advanced age on short-term postoperative outcomes after resective colorectal surgery (RCRS). Methods: All patients who underwent RCRS at our institution between July 2022 and November 2023 were entered into a database. Preoperative, perioperative, and early (within 30 days) postoperative data were recorded. Patients were categorized into a young group (under 75 years, YG) and an elderly group (over 75 years, EG). A retrospective comparative analysis of postoperative outcomes was performed between the two groups; postoperative complications were graded according to the Clavien classification. Results: Fifty-three and ninety-five patients were in the EG and YG, respectively. Indications for RCRS was cancer in 83% of EG patients and 61.1% of YG patients (p = 0.006), and the clinical presentation, localization, and rate of neoadjuvant treatment in oncological patients were comparable. Another indication for RCRS was complicated diverticular disease (17% of EG patients and 38.9% of YG patients; p = 0.006). With respect to the baseline characteristics, the ASA and CCI scores were worse in the EG (p = 0.001). No significant differences in the surgical approach, mini-invasive approach, conversion rate, definitive stoma creation, or number of harvested lymph nodes were found between the two groups. Overall, EG reported a higher relative risk (RR) of short-term postoperative complications (1.64, CI: 1.03–2.63), but no significant differences were found in terms of grade ≥3 complications (RR: 0.9, CI: 0.23–3.44). In the EG, a higher risk of ICU admission (RR:2.69, CI: 1.5–4.8) and a one-day longer postoperative hospital stay (6 vs. 5 days) were reported. Conclusions: Advanced age does not seem to contraindicate RCRS, especially in colorectal cancer patients. The impact of elderly age on short-term outcomes seems to be minimal and acceptable.

Development of a P(L-D,L)LA Foam as a Dura Substitute and Its In Vitro Evaluation

Dura substitutes are used to reduce the risk of postoperative complications following neurosurgical interventions, and to facilitate the healing of dura damages or defects caused by injuries. Traditional tissue transplants have limitations like limited tissue availability, potential risk of immune rejection and disease transmission. The use of biomaterials composed of synthetic polymers as dura substitutes offers a promising approach to overcome these limitations to replace and treat damaged dura mater. Potential biocompatible porous scaffolds still need to be developed to minimize the risks of immune response and disease transmission, while also ensuring effective cell migration and cell ingrowth in three dimension. The aim of the present study was to develop a poly(L-lactide-co-D,L-lactide) (P(L-D,L)LA) foam with an optimal pore size for dura mater substitution, investigate its morphological characteristics, and evaluate its potential for dura mater regeneration by assessing the spreading and growth of meningeal cells within it through in vitro studies. Foams were produced by lyophilization using different concentrations of P(L-D,L)LA solution. A GMP-grade P(L-D,L)LA, suitable for medical device applications, was used in this study. Morphological analysis was performed using scanning electron microscopy, and porosity of the foams was studied with mercury porosimetry. In in vitro studies, meningeal cells were seeded onto the polymeric foams, and their behavior and proliferation in these scaffolds were investigated with cytoskeleton and nucleus staining, and colorimetric cell proliferation assay, respectively. Scanning electron microscopy results showed that the foams prepared with 2.5% and 3% polymer solutions displayed good structural integrity and convenient interconnectivity, with pore sizes ranging from 80 to 150 µm. However, the foams prepared with 2% and 4% polymer solution demonstrated poor structural integrity and low interconnectivity, respectively. In vitro studies showed that the foams prepared with 2.5% and 3% polymer solutions served effectively as scaffolds for meningeal cells, and the cells attached, spread and homogeneously distributed. In addition, the cells proliferated and increased in number over time within these polymeric scaffolds. These findings suggest that the foams produced with 2.5% and especially 3% P(L-D,L)LA polymer solutions could effectively serve as a suitable substitute for the dura mater, providing an appropriate environment for cell ingrowth and tissue integration. This indicates that the developed foam could be a promising treatment for dura mater damage or defects, with the potential approach to promote regeneration in future in vivo and clinical studies.