Significant Predictors Of Postoperative Complications Research Articles

The impact of surgical volume on patient outcomes following thyroid surgery

This study aimed to evaluate the effects of indications for thyroidectomy on patient outcomes and to examine the impact of surgical volume on these outcomes. The nationwide inpatient sample was used to identify all patients who underwent total thyroidectomy (TT) between 2000 and 2009. We examined the effects of surgeon volume and hospital characteristics on predicting patient outcomes. Univariate and multivariate analyses were used to examine the effects of the indication for surgical care on postoperative outcomes. Overall, 46,261 procedures were identified. Patients with Graves disease had the highest postoperative complications (17.5%) compared to patients undergoing TT for other benign (13.9%) and malignant (13.2%) thyroid disease (P < .001). After stratification by surgeon volume, Graves disease was found to be a significant predictor of postoperative complications in surgeries performed by low- and intermediate-volume surgeons (P < .05). However, Graves disease was not a significant predictor of postoperative complications when performed by high volume surgeons (P = .81). Hospital volume had an inconsistent and marginal protective effect on postoperative outcomes. Surgery for Graves disease is associated with a higher risk for complications when performed by less experienced surgeons. This finding should prompt recommendations for increasing surgical specialization and referrals to high-volume surgeons in the management of Graves disease.

Can POSSUM accurately predict post-operative complications risk in patients with abdominal Crohn's disease?

Although the majority of patients with Crohn's disease (CD) are young, they are often seriously ill when surgery is required. The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) is a risk prediction scoring system estimating 30-day complications. The primary endpoint was to evaluate POSSUM efficacy in this subgroup. The secondary endpoint was to determine any potential correlation between POSSUM, Harvey-Bradshaw Index (HBI), length of stay (LOS) and anastomotic leak. All patients affected by abdominal CD who underwent elective and emergency surgery from 2006 to 2011 were prospectively enrolled in the study. POSSUM expected morbidity and mortality were compared to the observed outcomes (O/E ratio). Logistic regression analysis was performed to evaluate POSSUM and HBI adequacy. Correlation between POSSUM, HBI, LOS and anastomotic leak was investigated with linear regression analysis. One hundred twenty-three patients underwent abdominal surgery. The overall 30-day mortality rate estimated by the Portsmouth-POSSUM was 1.22% (95% confidence interval (CI) 0.4-3.6) while no deaths were observed (O/E = 0). The prediction regarding the post-operative complication rate was 22.04% (95% CI 11.1-51.2) and the observed overall morbidity rate was 21.95% (O/E = 0.99). The mean HBI score was 6.85 while LOS was 9.4 days. POSSUM and HBI were found to be significant predictors of post-operative complications at the univariate logistic regression analysis (OR 1.17 95% CI 1.06-1.30 and OR 1.25 95% CI 1.04-1.49, respectively). Linear regression analysis showed a significant correlation between POSSUM, HBI and LOS. POSSUM is precise in predicting post-operative complications in patients with abdominal CD. POSSUM correlates with HBI.

Cardiopulmonary exercise testing for preoperative risk assessment before hepatic resection

Contemporary liver surgery practice must accurately assess operative risk in increasingly elderly populations with greater co-morbidity. This study evaluated preoperative cardiopulmonary exercise testing (CPET) in high-risk patients undergoing hepatic resection. In a prospective cohort referred for liver resection, patients aged over 65 years (or younger with co-morbidity) were evaluated by preoperative CPET. Data were collected prospectively on functional status, postoperative complications and survival. Two hundred and four patients were assessed for hepatic resection, of whom 108 had preoperative CPET. An anaerobic threshold (AT) of 9·9 ml O(2) per kg per min predicted in-hospital death and subsequent survival. Below this value, AT was 100 per cent sensitive and 76 per cent specific for in-hospital mortality, with a positive predictive value (PPV) of 19 per cent and a negative predictive value (NPV) of 100 per cent: no deaths occurred above the threshold. Age and respiratory efficiency in the elimination of carbon dioxide (VE/VCO(2)) at AT were statistically significant predictors of postoperative complications. Receiver operating characteristic (ROC) curve analysis showed that a threshold of 34·5 for VE/VCO(2) at AT provided a specificity of 84 per cent and a sensitivity of 47 per cent, with a PPV of 76 (95 per cent confidence interval (c.i.) 58 to 88) per cent and a NPV of 60 (48 to 72) per cent for postoperative complications. Long-term survival of those with an AT of less than 9·9 ml O(2) per kg per min was significantly worse than that of patients with a higher AT (hazard ratio for mortality 1·81, 95 per cent c.i. 1·04 to 3·17; P = 0·036). CPET provides a useful prognostic adjunct in the preoperative assessment of patients undergoing hepatic resection.

Cranioplasty after Decompressive Craniectomy: The Effect of Timing on Postoperative Complications

Decompressive craniectomy (DC) due to intractably elevated intracranial pressure mandates later cranioplasty (CP). However, the optimal timing of CP remains controversial. We therefore analyzed our prospectively conducted database concerning the timing of CP and associated post-operative complications. From October 1999 to August 2011, 280 cranioplasty procedures were performed at the authors' institution. Patients were stratified into two groups according to the time from DC to cranioplasty (early, ≤2 months, and late, >2 months). Patient characteristics, timing of CP, and CP-related complications were analyzed. Overall CP was performed early in 19% and late in 81%. The overall complication rate was 16.4%. Complications after CP included epidural or subdural hematoma (6%), wound healing disturbance (5.7%), abscess (1.4%), hygroma (1.1%), cerebrospinal fluid fistula (1.1%), and other (1.1%). Patients who underwent early CP suffered significantly more often from complications compared to patients who underwent late CP (25.9% versus 14.2%; p=0.04). Patients with ventriculoperitoneal (VP) shunt had a significantly higher rate of complications after CP compared to patients without VP shunt (p=0.007). On multivariate analysis, early CP, the presence of a VP shunt, and intracerebral hemorrhage as underlying pathology for DC, were significant predictors of post-operative complications after CP. We provide detailed data on surgical timing and complications for cranioplasty after DC. The present data suggest that patients who undergo late CP might benefit from a lower complication rate. This might influence future surgical decision making regarding optimal timing of cranioplasty.

Zero mortality in more than 300 hepatic resections: validity of preoperative volumetric analysis

We reviewed a series of patients who underwent hepatic resection at our institution, to investigate the risk factors for postoperative complications after hepatic resection of liver tumors and for procurement of living donor liver transplantation (LDLT) grafts. Between April 2004 and August 2007, we performed 304 hepatic resections for liver tumors or to procure grafts for LDLT. Preoperative volumetric analysis was done using 3-dimensional computed tomography (3D-CT) prior to major hepatic resection. We compared the clinicopathological factors between patients with and without postoperative complications. There was no operative mortality. According to the 3D-CT volumetry, the mean error ratio between the actual and the estimated remnant liver volume was 13.4%. Postoperative complications developed in 96 (31.6%) patients. According to logistic regression analysis, histological liver cirrhosis and intraoperative blood loss >850mL were significant risk factors of postoperative complications after hepatic resection. Meticulous preoperative evaluation based on volumetric analysis, together with sophisticated surgical techniques, achieved zero mortality and minimized intraoperative blood loss, which was classified as one of the most significant predictors of postoperative complications after major hepatic resection.

Impact of nutritional status on postoperative outcomes for patients with colorectal cancer

To evaluate the impact of nutritional status on postoperative outcomes for patients with colorectal cancer. Data of 289 colorectal cancer patients from the Affiliated Hospital of Putian Medical College between January 2006 and December 2009 were collected prospectively. Nutritional status was evaluated according to Reilly Nutrition Risk Score(Reilly NRS) and Nutrition Risk Screening 2002(NRS-2002). The postoperative mortality was 3.5%(10/289) and the complication rate was 29.4%(82/297). Patients were stratified into those at nutrition risk(n=89) and those not at risk(n=200) according to Reilly NRS and the two groups were similar in mortality rate(5.6% vs. 2.5%, P>0.05) and complication rate(36.1% vs. 26.5%, P>0.05). When stratified using NRS-2002, patients at nutritional risk(n=105) had a similar mortality rate (5.7% vs. 2.2%, P>0.05) but a higher complication rate(38.4% vs. 24.4%, P<0.05). NRS-2002 remained as an significant predictor of postoperative complications(P=0.007, OR=3.14, 95% CI:1.63-6.29) on multivariable logistic regression analysis. As a nutritional evaluation tool, NRS-2002 may predict postoperative complication for colorectal cancer.

Postoperative complications from cytoreductive nephrectomy after neoadjuvant targeted therapy for metastatic renal cell carcinoma.

300 Background: Neoadjuvant treatment of metastatic renal cell carcinoma (RCC) with targeted systemic therapies is under investigation. Postoperative complications that occurred after cytoreductive nephrectomy (CRN) preceded by neoadjuvant systemic therapy were assessed. Methods: A retrospective review of all patients with clinical evidence of metastasis that underwent CRN was performed. Of 683 surgical patients with metastatic disease, 67 had received preoperative targeted therapy. Preoperative, operative, and postoperative characteristics were evaluated for each patient. Surgical complications were assessed using the modified Clavien system. A multivariate was sued to determine preoperative variables in an attempt to predict surgical complications within 1 year of CRN. Results: Complications occurred in 64% (43/67) of patients within 365 days of CRN. Clavien grade ≥ 3 complications occurred in 30% (20/67) patients. The most common occurrences were superficial wound dehiscence (25%), and wound infection (15%). On univariate analysis there were no statistically significant differences between groups in regards to age, race, gender, smoking history, follow-up, Charlson comorbidity index, MSKCC risk groups, or time from cessation of targeted therapy to surgery. Significant predictors of complications included BMI ≥ 30 (p=0.007), EBL (p=0.019), matted nodes (p=0.043), and surgical approach (p=0.001). Clinical T-stage and N-stage (p=0.068, p=0.073) approached significance. On multivariate analysis Charlson comorbidity index ≥ 8(OR 5.2, 95% CI 1.23, 21.99) and clinical N-stage (OR 5.11, 95%CI 1.21, 21.66) were significant predictors of postoperative complications. Conclusions: In this series of patients treated with neoadjuvant targeted therapy, a majority of patients experienced a postoperative complication after CRN. A Charlson comorbidity index ≥ 8 or clinical node positivity predicted for an increased risk of postoperative complications. The use of neoadjuvant systemic targeted therapy prior to CRN is investigational and adequate assessment of operative morbidity is needed prior to wide spread adoption. No significant financial relationships to disclose.

Early Complications of Cystectomy After High Dose Pelvic Radiation

Radical cystectomy in patients with a history of pelvic radiation therapy is often a challenging and morbid procedure. We report early complication rates in patients undergoing cystectomy and urinary diversion after high dose pelvic radiation. From 1983 to 2008, 2,629 patients underwent cystectomy with urinary diversion at a single institution. Of these patients 148 received 60 Gy or greater pelvic radiation therapy before surgery. Patient medical records were retrospectively reviewed and any complication within 90 days of surgery was graded using the Clavien-Dindo system. Median patient age was 74 years with a median American Society of Anesthesiologists score of 3. Patients received a median of 70 Gy pelvic radiation therapy a median of 2.3 years before surgery. Urinary diversions performed were ileal conduit in 65 patients (43.9%), continent cutaneous pouch in 35 (23.6%) and orthotopic neobladder in 48 (32.4%). A total of 335 early complications were identified. The highest grade complication was 0 in 23% of the patients, grade 1 in 12.2%, grade 2 in 32.4%, grade 3 in 18.9%, grade 4 in 7.4% and grade 5 in 6.1%. Age older than 65 years and American Society of Anesthesiologists score were statistically significant predictors of postoperative complications (p=0.0264 and p=0.0252, respectively). The type of urinary diversion did not significantly affect the grade distribution or number of early complications per patient (p=0.7444 and p=0.1807, respectively). The early complication rate using a standardized reporting system in patients undergoing radical cystectomy after radiation therapy is higher than previously published in nonirradiated subjects. Age and American Society of Anesthesiologists score but not urinary diversion type were associated with early complications in this population.

Factors Affecting Morbidity/Mortality of Emergency General Surgery

Introduction/Background: Emergency status has been documented as adversely affecting the outcome of general surgery. However, the predictors of increased morbidity and mortality of emergency general surgery (EGS) are unclear, including the possibility of modifying these factors. This study aims to determine the predictive factors for postoperative complications of EGS. Methods: A retrospective study of all randomly selected Brigham and Women's Hospital (BWH) American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) patients who had an EGS procedure from January 1, 2007 to December 31, 2008 were selected for this study. BWH IRB approved this study. The study applied the inclusion and exclusion criteria as defined by ACS NSQIP using select preoperative and all postoperative data variables. Additional non-ACS NSQIP data points were added and analyzed as possible predictors of poor outcomes. These included blood glucose levels closest to the time of surgical incision, length of time from ED arrival to incision, total volume of intravenous fluids (IVF) administered within 24 hours prior to incision, and time of antibiotic administration prior to incision. Our primary outcomes were whether or not the patient had experienced any of the pre-defined ACS NSQIP postoperative occurrences within 30 days and/or died while hospitalized for the target emergency procedure. Univariate statistical analyses were done using Wilcoxon signed rank sum test for continuous variables and Chi square test/Fisher Exact test for categorical variables. Multivariate analyses were done to identify independent predictors using logistic regression. Results: We identified 263 cases. 46.4% were male. 60 (22.8%) had complications, and 25 (9.5%) died within 30 days. Those without complications had a mean age of 51 years while those with complications had a mean age of 66 years. The most common procedures were appendectomies (22.4%), colectomies (18.6%) and enterectomies (17.1%). The most common postoperative occurrences were prolonged ventilator support>48hrs (12%), unplanned intubations (6%), and superficial incisional infections (5%). In univariate analyses, age (p<0.0001), male gender (p<0.001), length of operation (p<0.0001), preoperative blood transfusion (p<0.001), elevated blood glucose (p=0.026), elevated BUN (p<0.0001), functional health status (p=0.007), ASA (p<0.001), presence of COPD (p=0.002), and history of smoking (p=0.009) were found to be significant predictors of postoperative complications. Length of time from ED arrival to time of incision (p=0.42), total volume of IVF administered within 24 hours prior to incision (p=0.19), and time of antibiotic administration prior to incision (p=0.74) were not found to be significant. Multivariate analyses using stepwise logistic regression found male gender (OR 2.01, 95% CI 1.05, 4.10), smoking (OR 2.69, 1.15, 6.26), elevated BUN (OR 1.04, 95% CI 1.02, 1.06), and length of operation time (OR 1.001, 95% CI 1.000, 1.003) to be independent predictors for postoperative complications. Conclusions: Emergency general surgery patients who develop postoperative complications are more likely to be male, smokers, have a higher preoperative BUN, and experience longer operative times. Preoperative fluid resuscitation to address elevated BUN and experienced surgical teams to decrease operative times are potential targets to improve outcomes in emergency general surgery patients.

Perioperative Risk Factors for Surgical Complications in Pediatric Urology: A Pilot Study in Preoperative Risk Assessment in Children

To elucidate which perioperative patient characteristics are associated with an increased risk of complications in pediatric urological surgery. There are numerous published studies that have correlated comorbidities, preoperative, and intraoperative parameters with postoperative outcomes in adults. However, there is a paucity of similar data in the pediatric population. Between July 2003 and September 2006, a total of 93 children had an adverse or unexpected event within 35 days of urologic surgery. Thirty-eight preoperative patient characteristics and 20 perioperative parameters were evaluated. The severity of the complications was graded based on the Clavien classification. A total of 163 controls were randomly selected. Statistical significance was assessed by univariate and multivariate analysis. The overall complication rate was 1.1%. Most complications were technical in nature, occurred within 3 days after surgery, and classified as Clavien's grade 3 B. On multivariate analysis, weight less than fifth percentile, pulmonary or hematologic comorbidity, surgery duration >2 hours, first operation, low intraoperative heart rate, and the use of intravenous anesthesia were determined to be independent risk factors, whereas "other" medication was the only independent protective factor. We observed that some of the parameters conventionally thought to be risk factors for surgical complications such as multiple medical comorbidities, repeat operation, and American Society of Anesthesiologists' Classification of Physical Status score were not significant predictors of postoperative complications, whereas others were unexpectedly significant. Future prospective studies will be needed to fully stratify risk and guide risk interventions to improve postoperative outcomes.

Comparison of Aortomonoiliac Endovascular Aneurysm Repair Versus a Bifurcated Stent-Graft: Analysis of Perioperative Morbidity and Mortality

To compare the perioperative morbidity and mortality following endovascular aneurysm repair (EVAR) with a bifurcated stent-graft versus an aortomonoiliac stent-graft combined with a femorofemoral crossover graft. A prospectively maintained database of patients undergoing EVAR over a 7-year period (January 2001 to June 2008) was interrogated retrospectively to identify all patients receiving either a bifurcated or an aortomonoiliac stent-graft. Patients undergoing emergency treatment or renal/mesenteric fenestrated or iliac branched EVAR were excluded. Data retrieval found 210 patients (194 men; mean age 75 years) who had been treated with 41 aortomonoiliac stent-grafts and 169 bifurcated devices. The impact of preoperative and intraoperative variables on postoperative morbidity was assessed by means of univariate and multivariate logistic regression analysis. Significant postoperative complications occurred in 41% (17/41) of aortomonoiliac stent-graft patients compared to 14% (23/169) of bifurcated stent-graft patients (p = 0.0001). Univariate logistic regression analyses identified patient age, operating time, and implantation of an aortomonoiliac stent-graft as significant predictors of postoperative complications. In a multivariate logistic regression model, only implantation of an aortomonoiliac stent-graft was independently associated with postoperative complications (p = 0.003). Compared to EVAR with a bifurcated device, the implantation of an aortomonoiliac stent-graft and crossover bypass is associated with higher patient morbidity similar to rates reported after open repair. These patients comprise a high-risk endovascular group and require careful postoperative management in order to minimize complications.

Analysis of factors affecting operating time, postoperative complications, and length of stay for total knee arthroplasty: nationwide web-based survey

Background.This study aimed to clarify the impact of various factors on the operating time, postoperative complications, and length of stay (LOS) after total knee arthroplasty (TKA). Methods.We identified 3577 TKAs performed in 345 hospitals in Japan from November 2006 to March 2007. We examined the patient characteristics, surgical procedure details, hospital and surgeon volumes, and outcome variables (operating time, postoperative complications, LOS). Results.The average operating time was 127 ± 47 min. The rate of postoperative complications was 9.8%. The average LOS was 35.1 ± 15.9 days. In multivariate regression analyses, the average operating times were significantly shorter at hospitals with ≥50 cases per year compared to hospitals with <10 cases per year and for surgeons with >100 total cases compared to surgeons with <100 total cases. A longer operating time was associated with revision surgery and use of computer navigation. Significant predictors of postoperative complications were age, body mass index, and cerebrovascular disease. Shorter LOS was associated with higher hospital volume and use of a clinical pathway, whereas age, cardiovascular disease, and revision surgery increased the length of stay. Conclusions.Postoperative complications following TKA mainly depended on patient-based factors and were not significantly affected by the surgeon’s experience.

CERVICAL CORPECTOMY

Previously, information on cervical corpectomy complication rates has been obtained from retrospective analysis of single-institution data. The aim of this study was to report 30-day mortality and complication rates after cervical corpectomy using multicenter prospective data from the Veterans Affairs National Surgical Quality Improvement Program database. The National Surgical Quality Improvement Program database was used to identify 1560 patients who underwent cervical corpectomy in United States Veterans Affairs hospitals from 1997 to 2006. Multivariate analysis was performed to analyze the effects of patient and hospital characteristics on morbidity and mortality rates. A total of 1560 patients underwent corpectomy, with an overall in-hospital mortality rate of 1.6%, a complication rate of 18.4%, and a mean length of stay of 6 days. Multivariate analysis identified age older than 80 years (odds ratio [OR], 21.24), history of Type 1 diabetes (OR, 2.36), American Society of Anesthesiologists class greater than 3 (OR, 6.93), and dependent functional status (OR, 3.17) as the most significant preoperative predictors of complications. Three or more corpectomy levels (OR, 2.46) and operative duration longer than 6 hours (OR, 3.45) were also found to be significant predictors of postoperative complications. Patients who underwent 3 or more levels of corpectomy had a return-to-operating room rate of 17.9% and a graft/instrumentation failure rate of 5.4% compared with those who underwent single-level corpectomy, who had rates of 6.2 and 1.87%, respectively. Patients who were returned to the operating room had significantly higher mortality rates (7.0 versus 1.2%) and accounted for 39.9% of the total number of complications. Multivariate analysis identified age, American Society of Anesthesiologists class, history of disseminated cancer, and diabetes as the most significant predictors of mortality. Patients with Type 1 diabetes had 4-fold higher mortality rates compared with patients with no history of diabetes or diet-controlled diabetes. We have analyzed the morbidity and mortality data on the largest series of corpectomy reported to date. We have demonstrated the impact of age, American Society of Anesthesiologists class, and number of operated levels on complication rates. Type 1 diabetes was established as a strong risk factor for 30-day mortality after cervical corpectomy.

Umbilical Herniorrhapy in Cirrhosis: Improved Outcomes with Elective Repair

ObjectiveThis study was undertaken to examine the effect of cirrhosis on elective and emergent umbilical herniorrhapy outcomes. MethodsProcedures were identified from the Veterans’ Affairs National Surgical Quality Improvement Program at 16 hospitals. Medical records and operative reports were physician abstracted to obtain preoperative and intraoperative variables. ResultsOf the 1,421 cases reviewed, 127 (8.9%) had cirrhosis. Cirrhotics were more likely to undergo emergent repair (26.0% vs. 4.8%, p < 0.0001), concomitant bowel resection (8.7% vs. 0.8%, p < 0.0001), return to operating room (7.9% vs. 2.5%, p = 0.0006), and increased postoperative length of stay (4.0 vs. 2.0 days, p = 0.01). Best-fit regression models found cirrhosis was not a significant predictor of postoperative complications. Significant predictors of complications were emergent case (OR 5.4; 95% CI 3.1–9.4), diabetes (OR 2.1; 95% CI 1.2–3.8), congestive heart failure (OR 4.0; 95% CI 1.4–11.4), and chronic obstructive pulmonary disease (OR 2.0; 95% CI 1.1–3.6). Among emergent repairs, cirrhosis (OR 4.4; 95% CI 1.3–14.3) was strongly associated with postoperative complications. ConclusionElective repair in cirrhotics is associated with similar outcomes as in patients without cirrhosis. Emergent repair in cirrhotics is associated with worse outcomes. Early elective repair may improve the overall outcomes for patients with cirrhosis.

Reversal of Hartmann’s procedure: A high-risk operation?

Patients who undergo Hartmann's procedure often do not have their colostomy closed based on the perceived risk of the operation. This study evaluated the outcome of reversal of Hartmann's procedure based on preoperative risk factors. We retrospectively reviewed adult patients who underwent reversal of Hartmann's procedure at our tertiary referral institution. Patient outcomes were compared based on identified risk factors (age >60 years, American Society of Anesthesiologists [ASA] score >2, and >2 preoperative comorbidities). One-hundred thirteen patients were included. Forty-four patients (39%) had an ASA score of >or=3. The mean hospital duration of stay was 6.8 days. There were 28 (25%) postoperative complications and no mortality. Patients >60 years old had significantly longer LOS compared with the rest of the group (P = .02). There were no differences in outcomes between groups based on ASA score or the presence of multiple preoperative comorbidities. An albumin level of <3.5 was the only significant predictor of postoperative complications (P = .04). The reversal of Hartmann's operation appears to be a safe operation with acceptable morbidity rates and can be considered in patients, including those with significant operative risk factors.

Stair climbing test as a predictor of cardiopulmonary complications after pulmonary lobectomy in the elderly

Background The objective of this study was to assess the role of a symptom-limited stair climbing test in predicting postoperative cardiopulmonary complications in elderly candidates for lung resection. Methods A consecutive series of 109 patients more than 70 years of age who underwent pulmonary lobectomy for lung carcinoma from January 2000 through May 2003 formed the prospective database of this study. All patients in the analysis performed a preoperative symptom-limited stair climbing test. Univariate and multivariate analyses were performed to identify predictors of postoperative cardiopulmonary complications. Results At univariate analysis, the patients with complications had a lower forced expiratory capacity percentage of predicted ( p = 0.048), predicted postoperative forced expiratory volume in 1 second percentage of predicted ( p = 0.049), climbed a lower height at preoperative stair climbing test ( p = 0.0004), and presented a greater proportion of cardiac comorbiditiy with respect to the patients without complications ( p = 0.02). After logistic regression analysis, significant predictors of postoperative complications resulted in the presence of a concomitant cardiac disease ( p = 0.04) and a low height climbed preoperatively ( p = 0.0015). Conclusions A symptom-limited stair climbing test was a safe and simple instrument capable of predicting cardiopulmonary complications in the elderly after lung resection.

Localized cervical neuroblastoma: prevention of surgical complications

Objectives: The purpose of this study focused on cervical neuroblastoma (NB) was to assess the prognosis, define the most suitable methods of investigation, and evaluate risk factors for complications following primary surgery. Methods: Between 1990 and 1999, we conducted two consecutive prospective multicentric studies (NBL90 and NBL94) on localized NB. Because the first study (1990–1994) found surgery-related morbidity and mortality, several surgical risk factors (i.e. adhesion to major vessels, size, friability, and dumb bell tumor) were defined and used prospectively as criteria of resectability in the second study (1994–1999). Results: Of 617 cases included in the two studies, 43 involved cervical NB including 17 cervicothoracic tumors. With a median follow-up of 4 years, overall survival and event-free survival rates were 91 and 81%, respectively with no significant difference between cervical or cervicothoracic NB. Seventeen patients were included in the second study; surgery was used as the first line treatment in 11. Full pre-operative work-up was performed in eight patients, demonstrating one or more risk factors in three. The remaining three patients underwent emergency surgery with no pre-operative work-up or only ultrasound: two developed serious complications. All three patients presenting documented risk factors developed post-operative complications versus only two of the eight patients who presented no risk factor ( n=5) or were inadequately evaluated ( n=3) ( P=0.06). None of the five patients in whom full work-up demonstrated no risk factor had post-operative complications ( P=0.02). Conclusions: Cervical neuroblastoma has a favorable prognosis. Surgery is the treatment of choice but there is a risk of complications. Appropriate pre-operative work-up is mandatory to evaluate resectability. The surgical risk factors defined for our second study seem to be significant predictors of post-operative complications.

Predictors of complications and hospital stay in gynecologic cancer surgery

Objective: To test the hypothesis that comorbid medical conditions can predict length of hospital stay and incidence of postoperative complications. Methods: We reviewed the medical records of 187 women who had surgery for known or suspected gynecologic malignancies during 1996 and 1997, and 179 were included in the present study. Information on each woman’s comorbid medical conditions, surgical history, surgicopathologic cancer diagnosis, American Society of Anesthesiologists’ classification, surgical procedures, and postoperative complications was collected and analyzed. Results: Women with two or more comorbid medical conditions had significantly longer mean hospital stays (8.62 days) than those with none or one comorbid medical condition (6.43 days) ( P < .001). Women with two or more postoperative complications had significantly longer mean hospital stays (11.88 days) than those with none or one complication (6.02 days) ( P < .001). Women with two or more postoperative complications also had significantly more comorbid medical conditions (mean 2.5) than those with none or one complication (mean 1.7) ( P < .001). The American Society of Anesthesiologists class also was a significant predictor of postoperative complications and length of hospitalization. Age over 60 years also was associated with statistically significant increase in comorbid medical conditions and significantly longer hospitalizations. Conclusion: Our findings indicated that certain high-risk patients can be identified before hospital admission based on comorbid medical conditions. Certain risk indices, such as the American Society of Anesthesiologists classification score, also can predict postoperative complications and length of hospital stay. This information can be used to coordinate preoperative and postoperative hospital care and be a reference for certain future disease management systems.

Perioperative nutrition and postoperative complications in patients undergoing spinal surgery.

The authors undertook a three-part study to better understand the impact of perioperative nutritional status on postoperative complications in patients undergoing spinal surgery. In preliminary Parts I and II, the authors targeted two groups of patients who are particularly nutritionally challenged. In Part III, they studied a large group of consecutive patients undergoing routine lumbar spinal fusion. To determine whether preoperative nutritional status was a significant predictor of postoperative complications in patients undergoing elective lumbar spinal fusion. In Part I, 27 patients treated surgically for vertebral osteomyelitis were divided into two groups based on their preoperative nutritional status. Twenty-four of the 26 postoperative complications were in the malnourished group (P < 0.001). In Part II, 15 (75%) of 20 patients treated surgically for spinal cord injury were found to become malnourished in the postoperative period. Seventeen complications were noted, all in the malnourished group (P = 0.001). One hundred fourteen consecutive patients undergoing selective lumbar decompression and fusion were identified and their records reviewed. In addition to preoperative nutritional status, data gathered included age, sex, height, weight, past medical history, steroid use, alcohol use, tobacco use, type of bone graft (allograft vs. autograft), history of previous lumbar surgery, number of levels fused, and use of spinal instrumentation. Eleven of 13 postoperative infectious complications (10 deep wound infections) were noted in the malnourished group (P < 0.001). By stepwise logistic regression analysis, preoperative nutritional status was an extremely significant independent predictor of postoperative complications in patients undergoing elective lumbar spinal fusion (P = 0.0018). The prevalence data in our study population suggest that a large number (25%) of patients undergoing elective lumbar spine surgery are nourished inadequately at surgery. This number is higher (42%) in older patients. The authors recommend that close attention be paid to the perioperative nutritional status of patients undergoing lumbar spinal surgery. Patients with suboptimal nutritional parameters should be supplemented and replenished before elective surgery.

The Importance of Co-existent Disease in the Occurrence of Postoperative Complications and One-Year Recovery in Patients Undergoing Total Hip Replacement

Co-existent or comorbid diseases are appreciated as prognostic factors in studies of quality and effectiveness of care when mortality is the end point. The need to measure and adjust for comorbidity in studies of postoperative hospital complications or long-term recovery from surgery has not been documented. In this study, we determined the impact of co-existent disease on post-operative complications and 1-year health-related quality of life in patients hospitalized for a total hip replacement. The study population consisted of a cohort of 356 patients who were hospitalized in four teaching hospitals in California and Massachusetts for a total hip replacement. Patients' medical records were reviewed to collect information regarding severity of illness, co-existent disease, and postoperative complications. The kind and amount of baseline preoperative co-existent disease was measured from medical record information at admission using a four level Index of co-existent Disease (ICED). Approximately 12 months after hospital discharge, 283 (80%) of the patients were surveyed by questionnaire. The presence and amount of co-existent disease were significant predictors of postoperative complications. The complication rates ranged from 3% to 41% between the lowest and highest levels of the ICED. Patients treated at the four study hospitals differed in functional outcomes 1 year after surgery. Functional outcomes were strongly related to ICED scores: patients in Level 4 ICED scored 26.8 points lower in instrumental activities of daily living than patients in Level 1. After controlling for gender, age, education, and marital status, ICED remained a significant predictor of functional status at 1 year. Furthermore, differences among hospitals in functional outcomes disappeared when the ICED was included in the model to adjust for patient characteristics at the time of surgery. A measure of co-existent disease was crucial in explaining differences among hospitals in recovery from total hip replacement patients.