Safety Of Surgery In Patients Research Articles

Evaluation of lateral lymph node metastasis in mid-low rectal cancer and planning of multi-disciplinary treatment

After the implementation of neoadjuvant chemoradiotherapy and total mesorectal excision, lateral local recurrence becomes the major type of local recurrence after surgery in rectal cancer. Most lateral recurrence develops from enlarged lateral lymph nodes on an initial imaging study. Evidence is accumulating to support the combined use of neoadjuvant chemoradiotherapy and lateral lymph node dissection. The accuracy of diagnosing lateral lymph node metastasis remains poor. The size of lateral lymph nodes is still the most commonly used variable with the most consistent accuracy and the cut-off value ranging from 5 to 8 mm on short axis. The morphological features, differentiation of the primary tumor, circumferential margin, extramural venous invasion, and response to chemoradiotherapy are among other risk factors to predict lateral lymph node metastasis. Planning multiple disciplinary treatment strategies for patients with suspected nodes must consider both the risk of local recurrence and distant metastasis. Total neoadjuvant chemoradiotherapy is the most promising regimen for patients with a high risk of recurrence. Simultaneous Integrated Boost Intensity-Modulated Radiation Therapy seemingly improves the local control of positive lateral nodes. However, its impact on the safety of surgery in patients with no response to the treatment or regrowth of lateral nodes remains unclear. For patients with smaller nodes below the cut-off value or shrunken nodes after treatment, a close follow-up strategy must be performed to detect the recurrence early and perform a salvage surgery. For patients with stratified lateral lymph node metastasis risks, plans containing different multiple disciplinary treatments must be carefully designed for long-term survival and better quality of life.

Efficacy and safety of retrograde intrarenal surgery in patients with renal calculuses ≤ 2 cm

Efficacy and safety of retrograde intrarenal surgery in patients with renal calculuses ≤ 2 cm

Long-term oncologic safety of immediate reconstructive surgery in patients with invasive breast cancer: a retrospective matched-cohort study

ObjectiveImmediate reconstruction (IR) is a safe and effective surgical treatment for patients with breast cancer. We aimed to assess the prognosis, aesthetic outcomes, and patient satisfaction of IR compared with breast conservation surgery (BCS) and total mastectomy (TM).MethodsThis retrospective matched-cohort study was conducted between May 2005 and December 2014. We established two cohorts according to the tumor (T) size of breast cancer. In the T≤3cm group, cases (IR) and controls (BCS or TM) were matched for age, pathological tumor size, and pathologic nodal status in a 1:1:1 ratio. In the T>3cm group, cases (IR) and controls (TM) were matched with the same factors and ratio. The primary outcome was the 5-year disease-free survival (DFS). The secondary outcome was patient satisfaction and quality of life.ResultsA total of 12,678 breast cancer patients were assessed for eligibility, of which 587 were included (T≤3 cm group: 155 IR vs 155 BCS vs 155 TM; T>3cm group: 61 IR vs 61 TM). In the T≤3 cm cohort, patients who underwent IR had no difference compared with those who underwent BCS or TM regarding the 5-year DFS (P=0.539); however, an improved aesthetic satisfaction, psychosocial, and sexual well-being were achieved in the IR group (P<0.001). In the T>3 cm cohort, the IR group had a worse median 5-year DFS (P=0.044), especially for Her2+ or triple-negative breast carcinoma (TNBC) subtypes compared with the TM group.ConclusionsIR improves aesthetic satisfaction, psychosocial, and sexual well-being for breast cancer patients with T≤3 cm. For patients with T > 3 cm invasive breast cancer, TM is superior to IR as it predicts a better 5-year DFS.

Short-Term Efficacy and Safety of Cataract Surgery Combined with Iris-Fixated Phakic Intraocular Lens Explantation: A Multicentre Study.

The purpose of this study was to evaluate the short-term efficacy and safety of cataract surgery for patients with iris-fixated phakic intraocular lenses (pIOLs). This study included 96 eyes of 91 patients. The changes in the logMAR uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), subjective spherical equivalent (SE), astigmatism, and endothelial cell density (ECD) were collected retrospectively. The intraoperative and postoperative complications also were investigated to assess the surgical safety. The preoperative UCVA and BCVA improved significantly at month 1 postoperatively, respectively (p < 0.001 for both comparisons). The efficacy and safety index at month 1 postoperatively were 1.02 ± 0.56 and 1.31 ± 0.64, respectively. The SE at month 1 postoperatively was significantly (p < 0.001) higher compared to preoperatively, whereas the subjective astigmatism did not differ significantly (p = 0.078). The ECD significantly decreased at month 1 (p < 0.001). The most common postoperative complication was intraocular pressure elevation exceeding 25 mmHg in 10.4% of eyes, which was controlled with medications in all cases until month 1 postoperatively. No intraoperative complications developed. Cataract surgeries for patients with iris-fixated pIOLs were performed safely with good visual outcomes.

Safety of Bariatric Surgery in Patients With Congestive Heart Failure: Results of an 11-Year Retrospective Study.

Congestive heart failure (CHF) is a known risk factor for increased postoperative morbidity. However, the safety in patients with CHF has not been well established. The objective of this study was to assess the safety of surgery in patients with a history of CHF undergoing bariatric surgical procedures. Retrospective review of a prospectively maintained Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Center of Excellence database. Patients with known CHF undergoing bariatric procedures over an 11-year period were reviewed. Over the 11-year period, 4470 total bariatric surgeries were performed, of which 41 (.92%) patients had known CHF. Twenty-one patients were men (51.2%) with a mean age of 55.8years and mean body mass index (BMI) of 51.9. Comorbidities included hypertension (87.8%), obstructive sleep apnea (80.5%), osteoarthritis (63.4%), gastroesophageal reflux disease (56%), and diabetes (53.7%). Surgical procedures included 16 sleeve gastrectomies (SGs) (39%), 11 Roux-en-Y gastric bypasses (RYGBs) (26.8%), 10 laparoscopic adjustable gastric bands (LAGBs) (24.4%), 1 removal of a gastric band and conversion to SG (2.4%), 1 removal of a gastric band to RYGB (2.4%), 1 gastric band over RYGB pouch (2.4%), and 1 gastric band replacement (2.4%). All cases were performed minimally invasively (73.2% laparoscopic and 26.8% robotic). Mean LOS was 2.53days. Thirty-day complications included 2 readmissions (4.9% [1 small bowel obstruction and 1 pulmonary edema]), 1 reoperation (2.4% [small bowel obstruction]), and 1 mortality (2.4%) on postoperative day 30 unrelated to the surgery. Bariatric surgery can be performed safely in patients with CHF.

Safety of Single-Site Laparoscopic Surgery Requiring Perioperative Heparinization in Colorectal Cancer: Propensity Score-Matched Analysis.

We assessed the feasibility and safety of single-site laparoscopic surgery for patients with colorectal cancer who required perioperative heparinization. This retrospective study reviewed the medical records of 390 patients who underwent single-site laparoscopic surgery for colorectal cancer from January 2010 to December 2016. Antithrombotic drugs were stopped preoperatively and heparin was administered according to the operative risk of each patient, based on consultation with the cardiologist physician or neurosurgeon. Propensity score modeling was utilized to adjust for baseline characteristics. Of 390 patients, 29 were treated with standard bridging intravenous heparin therapy. Propensity matching identified 119 patients: 22 patients in the heparinization group and 97 in the control group. The matched groups were not significantly different in operation times, bleeding volumes, or conversion rate. The mean postoperative hospital stay was 17.9days in the heparinization group and 9.5days in the control group (p = 0.034). Postoperative bleeding was observed in 4 patients (18.2%) in the heparinization group and 11 patients (11.4%) in the control group (p = 0.646), while other complications were similar in the two study groups (p = 0.502). Of these other complications, thromboembolic events were observed in two patients in the heparinization group and one patient in the control group. We found that single-site laparoscopic surgery for colorectal cancer with heparinization was feasible and safe. Heparinization did not increase the risk of postoperative bleeding complications, but postoperative hospital stay was prolonged.

Anterior subtemporal approach for severe upper pontine hematomas: A report of 28 surgically treated cases

The efficacy and safety of surgery for patients with primary pontine hemorrhage (PPH) remain debatable. Twenty-eight consecutive patients with huge upper PPH were included in this study. They underwent surgical management through a subtemporal approach between January 2009 and October 2013. We analyzed clinical and radiological parameters to assess the patient outcomes. The near-complete (>90%) evacuation rate was 67.9%, and there was no surgery-related death. The overall survival rate at 3 months was 64.3% (17/28), including 28.6% (8/28) with good function, 10.7% (3/28) with disability and 25% (7/28) in a vegetative state. The mortality rate was 35.7% (10/28). Preoperative hemorrhage volume (P = 0.019), preoperative (P = 0.017) and postoperative (P = 0.001) Glasgow coma scale (GCS) score, coma on admission (P = 0.001), ventricular extension (P = 0.001), preoperative mechanical ventilation (P = 0.001) and hydrocephalus (P = 0.007) were found to be statistically significant predictors for mortality on univariate analysis. On multivariate regression analysis, only GCS on admission and coma were found to be significant prognostic predictors. The subtemporal approach was found to be a safe method to treat upper PPH. Microsurgery may be beneficial for the treatment of PPH, but these results need further validation in a more comprehensive and comparative study. GCS on admission and coma were found to be the only significant prognostic predictors for mortality with multivariate regression analysis.

The Feasibility and Safety of Surgery in Patients Receiving Immune Checkpoint Inhibitors: A Retrospective Study

Immune checkpoint inhibitors (ICI) are revolutionizing care for cancer patients. The list of malignancies for which the Food and Drug Administration is granting approval is rapidly increasing. Furthermore, there is a concomitant increase in clinical trials incorporating ICI. However, the safety of ICI in patients undergoing surgery remains unclear. Herein, we assessed the safety of ICI in the perioperative setting at a single center. We conducted a retrospective review of patients who underwent planned surgery while receiving ICI in the perioperative setting from 2012 to 2016. We collected 30-day postoperative morbidity and mortality utilizing the Clavien–Dindo classification system. We identified 17 patients who received perioperative ICI in 22 operations. Patients were diagnosed with melanoma (n = 14), renal cell carcinoma (n = 2), and urothelial carcinoma (n = 1). Therapies included pembrolizumab (n = 10), ipilimumab (n = 5), atezolizumab (n = 5), and ipilimumab/nivolumab (n = 2). Procedures included cutaneous/subcutaneous resection (n = 6), lymph node resection (n = 5), small bowel resection (n = 5), abdominal wall resection (n = 3), other abdominal surgery (n = 3), orthopedic surgery (n = 1), hepatic resection (n = 1), and neurosurgery (n = 2). There were no Grade III–IV Clavien–Dindo complications. There was one death secondary to ventricular fibrillation in the setting of coronary artery disease. ICI appear safe in the perioperative setting, involving multiple different types of surgery, and likely do not need to be stopped in the perioperative setting. Further studies are warranted to confirm these findings.

Epilepsy surgery in patients older than 50 years: Effectiveness, safety, and predictors of outcome

PurposeSurgery is an effective treatment for drug resistant focal epilepsy. Predictors of seizure outcome have been extensively addressed in the general population but similar data on older patients are still lacking. The aim of this study is to evaluate effectiveness and safety of surgery for patients over 50 years and to investigate variables associated to seizure outcome. MethodsWe performed a single center retrospective study including 50 patients over 50 years treated surgically for drug resistant focal epilepsy between 1997 and 2014. We analyzed the rate of success of seizure control, the association of several clinical variables with seizure outcome and the rate of surgery-related complications. We also investigated the impact of surgery on the patients’ cognitive performances and mood profile. ResultsAt last follow-up 78% of our patients were seizure-free, similar to patients younger than 50 years operated on in the same period (p=1). The rate of surgery-related complications was 10%, higher compared to younger patients (p<0.0001). Pre-surgical daily seizure frequency (p=0.0040) and the histological diagnosis of LEAT (p=0.0233) were associated to a poorer seizure outcome. No significant differences were evidenced between pre- and postoperative neuropsychological profiles. A slight, not statistically significant improvement of the mood profile was observed postoperatively. ConclusionOur results suggest that surgery is an effective treatment option also for older epileptic patients, although it is burdened by a higher surgical risk as compared to younger patients. The availability of predictors of outcome also for these patients may be helpful for pre-surgical counseling.

Safety of surgery in patients with rheumatoid arthritis treated by abatacept: data from the French Orencia in Rheumatoid Arthritis Registry.

To investigate the frequency and risk factors of postoperative complications in RA patients treated with abatacept (ABA). The Orencia RA registry recruited 1012 patients receiving ABA for RA in routine care. Data from patients treated with ABA who underwent surgery were reviewed to describe the frequency of postoperative complications. Characteristics of patients and surgeries with and without complications were compared to identify factors associated with complications. We identified 205 (20.3%) patients who underwent 263 surgeries, including 176 (66.9%) orthopaedic surgeries. Nineteen (7.2%) surgeries, in 19 patients (9.3%), entailed complications, including 7 delayed wound healing (2.7% of surgeries) and 6 surgical site infections (2.3% of surgeries). The median time between the last infusion of ABA and surgery was 5.9 weeks (range: 0.3-12.0 weeks), with no significant difference between patients with and without complications. The median corticosteroids daily dosage was higher in the group with complications [10.0 (6.25-15.0) vs 6.0 (5.0-10.0) mg/day, P = 0.042]. In multivariate analysis, only the duration of ABA treatment was significantly associated with postoperative complications [adjusted odds ratio (aOR) = 0.94 (95% CI: 0.89, 0.99) for each month of treatment], as were orthopaedic surgeries compared with other kinds of surgery [aOR = 4.45 (95% CI: 1.01, 20.2)]. In RA patients treated with ABA, the rate of surgical complications was low: 7.2% and higher in case of orthopaedic procedure and a more recent initiation of ABA. The median time between surgery and the last infusion of ABA was short and did not influence the rate of postoperative complications.

Intraoperative identification of the facial nerve by needle electromyography stimulation with a burr.

The purpose of this research is to improve the safety of surgery for patients with a pathology of the middle and inner ear by preventing damage to the facial nerve by conducting intraoperative monitoring of the facial nerve by needle electromyography with continuous stimulation with a burr. The clinical part of the prospective study was carried out on 48 patients that were diagnosed with suppurative otitis media. After the surgery with intraoperative monitoring, the facial nerve with an intact bone wall was stimulated electrically in the potentially dangerous places of damage. Minimum (threshold) stimulation (mA) of the facial nerve with a threshold event of 100 μV was used to register EMG events. The anatomical part of the study was carried out on 30 unformalinized cadaver temporal bones from adult bodies. The statistical analysis of obtained data was carried out with parametric methods (Student's t-test), non-parametric correlation (Spearman's method) and regression analysis. It was found that 1 mA of threshold amperage corresponded to 0.8 mm thickness of the bone wall of the facial canal. Values of transosseous threshold stimulation in potentially dangerous sections of the injury to the facial nerve were obtained. These data lower the risk of paresis (paralysis) of the facial muscles during otologic surgery.

LASIK in selected patients with posterior polymorphous corneal dystrophy

Purpose The aim of the present study was to evaluate the safety of LASIK surgery in patients with posterior polymorphous corneal dystrophy. Patients and methods A total of 25 eyes of 13 patients with posterior polymorphous dystrophy with various refractive errors were selected for LASIK treatment and were followed up for 2 years after surgery. Results All eyes included in the study showed an improvement in unaided visual acuity with no postoperative complications. Conclusion LASIK can be a safe procedure in patients with posterior polymorphous dystrophy and proper selection criteria.

THE ROLE OF METABOLIC SURGERY FOR PATIENTS WITH OBESITY GRADE I ANDCLINICALLY UNCONTROLLED TYPE 2 DIABETES

ABSTRACT Introduction : Even considering the advance of the medical treatment in the last 20 years with new and more effective drugs, the outcomes are still disappointing as the control of obesity and type 2 Diabetes Mellitus (T2DM) with a large number of patients under the medical treatment still not reaching the desired outcomes. Objective : To present a Metabolic Risk Score to better guide the surgical indication for T2DM patients with body mass index (BMI) where surgery for obesity is still controversial. Method : Research was conducted in PubMed, Medline, PubMed Central, Scielo and Lilacs between 2003-2015 correlating headings: metabolic surgery, obesity and type 2 diabetesmellitus. In addition, representatives of the societiesinvolved, as an expert panel, issued opinions. Results : Forty-five related articles were analyzed by evidence-based medicine criteria. Grouped opinions sought to answer the following questions: Why metabolic and not bariatric surgery?; Mechanisms involved in glycemic control; BMI as a single criterion for surgical indication for uncontrolled T2DM; Results of metabolic surgery studies in BMI&lt;35 kg/m2; Safety of metabolic surgery in patients with BMI&lt;35 kg/m2; Long-term effects of surgery in patients with baseline BMI&lt;35 kg/m2 and Proposal for a Metabolic Risk Score. Conclusion : Metabolic surgery has well-defined mechanisms of action both in experimental and human studies. Gastrointestinal interventions in T2DM patients with IMC≤35 kg/m2 has similar safety and efficacy when compared to groups with greater BMIs, leading to the improvement of diabetes in a superior manner than clinical treatment and lifestyle changes, in part through weight loss independent mechanisms . There is no correlation between baseline BMI and weight loss in the long term with the success rate after any surgical treatment. Gastrointestinal surgery treatment may be an option for patients with T2DM without adequate clinical control, with a BMI between 30 and 35, after thorough evaluation following the parameters detailed in Metabolic Risk Score defined by the surgical societies. Roux-en-Y gastric bypass (RYGB), because of its well known safety and efficacy and longer follow-up studies, is the main surgical technique indicated for patients eligible for surgery through the Metabolic Risk Score. The vertical sleeve gastrectomy may be considered if there is an absolute contraindication for the RYGB. T2DM patients should be evaluated by the multiprofessional team that will assess surgical eligibility, preoperative work up, follow up and long term monitoring for micro and macrovascular complications.

Strabismus surgery in patients receiving warfarin anticoagulation

Many ophthalmologists consider switching patients on chronic warfarin anticoagulation to enoxaparin or discontinuing their anticoagulant for strabismus surgery. We report 3 successful cases of strabismus surgery on patients taking warfarin. No excessive bleeding was encountered intraoperatively or during the recovery period. To our knowledge, this is the first report regarding the safety of strabismus surgery in patients who are maintained on warfarin during strabismus surgery.

Effect of body mass index on operative complications after robotic-assisted Ivor-Lewis esophagogastrostomy: Retrospective analysis of 133 cases at a single high-volume tertiary care center.

109 Background: The impact of body weight on robotic-assisted surgical morbidity has not been studied in esophageal cancer. We thus examined operative outcomes in patients according to their body mass index (BMI) following robotic-assisted Ivor-Lewis Esophagogastrostomy (RAIL) at a high-volume tertiary-care referral cancer center and evaluated the safety of robotic surgery in patients with an elevated BMI. Methods: We retrospectively studied patients who underwent RAIL for pathologically confirmed malignancy in the distal esophagus and assessed morbidity and intraoperative outcomes relative to BMI. We evaluated operative complications from surgery to discharge, including average operating time, estimated blood loss (EBL), pneumonia, atrial fibrillation, pulmonary embolism, deep vein thrombosis, wound infection, and surgical leaks. Median ICU days after surgery and 30 day operative mortality was assessed. Wilcoxon Rank-Sum and Spearman Coefficient were used. Results: Of 134 total patients, 106 were male and 28 were female, with an average age of 67 years. Among patients, 76% (N=102) received neoadjuvant therapy. According to BMI, 3 patients were underweight, 35 were normal weight, 62 were overweight, and 34 were obese. All patients had R0 resection, with a median of 19 lymph nodes removed. Among evaluated surgical complications, anastomotic leak rate was significantly higher in patients with high BMI (p=0.01). Median operating time was 407 mins and EBL was 150cc. High BMI was significantly associated with increased operation time and EBL (p=0.01 &amp; p=0.05, respectively). Conclusions: This retrospective study shows that patients with distal esophageal cancer and an elevated BMI undergoing RAIL have increased operative times and EBL during the procedure. An elevated postoperative risk for anastomotic leak also exists and must be carefully monitored. However, BMI does not affect the quality of oncological resection as determined by the number of harvested lymph nodes and rates of R0 resection, suggesting similar outcomes irrespective of BMI among all patients undergoing RAIL at a high volume tertiary center.

Safety of Surgery After Rituximab Therapy in 133 Patients With Rheumatoid Arthritis: Data From the AutoImmunity and Rituximab Registry

We used data from the AutoImmunity and Rituximab (AIR) registry to investigate the safety of surgery for patients with rheumatoid arthritis receiving rituximab (RTX) in routine care. Data for patients included in the AIR registry and undergoing surgery during the year following an infusion of RTX were reviewed to describe the frequency of postsurgical complications, compare patients with and without complications, and identify factors associated with complications. We examined data for 133 patients with a known date of surgery and at least 1 followup visit, corresponding to 140 procedures, including 94 orthopedic surgeries (67%) and 23 abdominal surgeries (16.5%). The median delay between surgery and the last RTX infusion was 6.4 months (interquartile range 4.3– 8.7 months), without any difference between patients with and without complications. Nine patients (6.7%) experienced 12 complications (8.5%), including 8 surgical site infections (5.7%) and 1 death due to septic shock. Postoperative complications occurred after 4.3% of abdominal surgeries (1 of 23) and 7.4% of orthopedic surgeries (7 of 95). On univariate analysis, spine surgery was associated with postoperative complications (P = 0.048). In common practice, the risk of complications may be more important in case of spine surgery, but does not seem to be linked to the time between the last RTX infusion and surgery.

Presentation and surgical results of incidentally discovered nonfunctioning pituitary adenomas: evidence for a better outcome independently of other patients' characteristics

Few data are available on the surgical results in patients with incidentally discovered nonfunctioning pituitary adenoma (NFPA). We investigated the efficacy and safety of surgery in patients with incidentally discovered NFPA. Retrospective analysis of prospectively recorded outcomes. From 1990 to 2011, of 804 consecutive patients undergoing surgery for NFPA, 212 cases had an incidentally discovered tumor (26.4%). Among them, 117 patients were asymptomatic, while 95 had some visual and/or hormonal deficit. The main outcome of the study was to evaluate the frequency of radical resection as judged on the first postoperative neuroimaging study and detection of recurring disease during long-term follow-up. Postoperative residual tumor was detected in 8.9% of patients with asymptomatic incidentalomas as compared with 31.2% of patients with symptomatic incidentalomas (P<0.001) and 41.2% of patients in the control group (P<0.001). Multivariate analysis confirmed that having an asymptomatic incidentaloma was independently associated with a better outcome. The 5-year recurrence-free survival in patients with incidentaloma was 86.8% (95% CI 80.2-92.4%) as compared with 77.9% (95% CI 73.6-82.2%; P<0.01) in the control group. This difference was almost completely due to a lower frequency of relapse in asymptomatic patients. Multivariate analysis confirmed the independent lower risk of tumor recurrence in asymptomatic NFPA. Our study shows for the first time that surgically treated patients with asymptomatic NFPA have a better early and long-term outcome that is independent from all the other demographic, clinical, and morphologic characteristics of the patients.

THU0122 Safety of surgery in patients with rheumatoid arthritis treated by rituximab in routine care: Data from the french air registry

BackgroundThe risk of post-surgical complications related to the use of non anti-TNF biological agents in patients with rheumatoid arthritis (RA) remains unclear. The aim of this study was to investigate...

Immunological Insights from Patients Undergoing Surgery on Ipilimumab for Metastatic Melanoma

The tumor microenvironment after treatment with ipilimumab is not well described. Furthermore, the safety of surgery for patients being treated with ipilimumab for metastatic melanoma has not been well reported. This study analyzed the safety of surgery and the immune phenotype of tumors resected while on ipilimumab. From our prospective melanoma database, we identified patients undergoing surgery for any indication within 30 days of receiving a dose of induction ipilimumab or while on maintenance ipilimumab therapy. Surgical toxicity was graded 1-5 by the Clavien classification. Tumor-infiltrating lymphocytes were classified by flow cytometry and compared with peripheral blood. 23 patients were identified who underwent 34 operations a median of 27 weeks after initiation of ipilimumab (1-123 weeks). Subcutaneous resections were the most frequent, followed by intra-abdominal and nodal procedures. Grade 1 or 2 wound complications were seen in 22% of patients. No Grade 3-5 complications were seen. Analysis of the T cell infiltrate and matched peripheral blood from ten patients showed an elevated % of CD4+FOXP3+ T-regulatory cells and a 2.8-fold lower ratio of CD8+/CD4+FOXP3+ in the tumor compared with blood (p=0.02). In addition, all CD8+ T cells had a higher expression of PD-1 in the tumor, compared with peripheral blood. Surgery for patients on ipilimumab is safe. This study highlights the immunosuppressive phenotype in tumors not responding to immunotherapy. The high percentage of T-regulatory cells and low T-effector cells in progressive tumors suggests a possible mechanism of immune escape.

Bariatric Surgery is Associated with a Reduced Risk of Mortality in Morbidly Obese Patients with a History of Major Cardiovascular Events

Although the safety of bariatric surgery in patients with established cardiovascular disease has been demonstrated, little is known about the mid- to long-term survival of these patients after surgery. We conducted a retrospective cohort study of bariatric surgical patients (n = 349) compared with morbidly obese surgical controls (n = 903). Data were obtained on all patients 40 to 79 years of age, from 1996 to 2008, with a diagnosis code of morbid obesity, a primary surgical procedure of interest, and a cardiovascular event history. Data sources were the statewide South Carolina UB92 inpatient hospitalization database and death records. The primary outcome was all-cause mortality. A total of 349 bariatric and 903 control patients with cardiovascular event histories were identified. Among bariatric patients, 19 deaths occurred in 986 person-years of follow-up versus 150 deaths among controls in 3138 person-years of follow-up. Unadjusted all-cause mortality was estimated at 7 ± 2 per cent at 5 years in bariatric patients compared with 19 ± 2 per cent (P < 0.001) in controls. Adjusting for age, comorbidities, and event history, the relative risk of mortality was reduced by 40 per cent in bariatric patients compared with controls [hazard ratios (95% confidence interval): 0.60 (0.36, 0.99)]. In patients with a history of cardiovascular events, bariatric surgery is associated with a significantly decreased risk of all-cause mortality.