Surgery-related Risk Factors Research Articles

EValuating the Effect of periopeRaTIve empaGliflOzin on cardiac surgery associated acute kidney injury: rationale and design of the VERTIGO study.

Cardiac surgery-associated acute kidney injury (CSA-AKI) is a serious complication in patients undergoing cardiac surgery with extracorporeal circulation (ECC) that increases postoperative complications and mortality. CSA-AKI develops due to a combination of patient- and surgery-related risk factors that enhance renal ischemia-reperfusion injury. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) such as empagliflozin reduce renal glucose reabsorption, improving tubulo-glomerular feedback, reducing inflammation and decreasing intraglomerular pressure. Preclinical studies have observed that SGLT2i may provide significant protection against renal ischemia-reperfusion injury due to their effects on inadequate mitochondrial function, reactive oxygen species activity or renal peritubular capillary congestion, all hallmarks of CSA-AKI. The VERTIGO (EValuating the Effect of periopeRaTIve empaGliflOzin) trial is a Phase 3, investigator-initiated, randomized, double-blind, placebo-controlled, multicenter study that aims to explore whether empagliflozin can reduce the incidence of adverse renal outcomes in cardiac surgery patients. The VERTIGO study (EudraCT: 2021-004938-11) will enroll 608 patients that require elective cardiac surgery with ECC. Patients will be randomly assigned in a 1:1 ratio to receive either empagliflozin 10mg orally daily or placebo. Study treatment will start 5days before surgery and will continue during the first 7days postoperatively. All participants will receive standard care according to local practice guidelines. The primary endpoint of the study will be the proportion of patients that develop major adverse kidney events during the first 90days after surgery, defined as ≥25% renal function decline, renal replacement therapy initiation or death. Secondary, tertiary and safety endpoints will include rates of AKI during index hospitalization, postoperative complications and observed adverse events. The VERTIGO trial will describe the efficacy and safety of empagliflozin in preventing CSA-AKI. Patient recruitment is expected to start in May 2024.

Risk factors of postoperative urinary retention following total hip and knee arthroplasty.

The aim of this meta-analysis was to determine the pooled incidence of postoperative urinary retention (POUR) following total hip and knee arthroplasty (total joint replacement (TJR)) and to evaluate the risk factors and complications associated with POUR. Two authors conducted searches in PubMed, Embase, Web of Science, and Scopus on TJR and urinary retention. Eligible studies that reported the rate of POUR and associated risk factors for patients undergoing TJR were included in the analysis. Patient demographic details, medical comorbidities, and postoperative outcomes and complications were separately analyzed. The effect estimates for continuous and categorical data were reported as standardized mean differences (SMDs) and odds ratios (ORs) with 95% CIs, respectively. A total of 31 studies were included in the systematic review. Of these, 29 studies entered our meta-analysis, which included 3,273 patients diagnosed with POUR and 11,583 patients without POUR following TJR. The pooled incidence of POUR was 28.06%. Demographic risk factors included male sex (OR 1.81, 95% CI 1.26 to 2.59), increasing age (SMD 0.16, 95% CI 0.04 to 0.27), and American Society of Anesthesiologists grade 3 to 4 (OR 1.39, 95% CI 1.10 to 1.77). Patients with a history of benign prostatic hyperplasia (OR 1.99, 95% CI 1.41 to 2.83) and retention (OR 3.10, 95% CI 1.58 to 6.06) were more likely to develop POUR. Surgery-related risk factors included spinal anaesthesia (OR 1.44, 95% CI 1.19 to 1.74) and postoperative epidural analgesia (OR 2.82, 95% CI 1.65 to 4.82). Total hip arthroplasty was associated with higher odds of POUR compared to total knee arthroplasty (OR 1.10, 95% CI 1.02 to 1.20). Postoperatively, POUR was associated with a longer length of stay (SMD 0.21, 95% CI 0.02 to 0.39). Our meta-analysis demonstrated key risk variables for POUR following TJR, which may assist in identifying at-risk patients and direct patient-centered pathways to minimize this postoperative complication.

Development of machine learning models to predict perioperative blood transfusion in hip surgery

BackgroundAllogeneic Blood transfusion is common in hip surgery but is associated with increased morbidity. Accurate prediction of transfusion risk is necessary for minimizing blood product waste and preoperative decision-making. The study aimed to develop machine learning models for predicting perioperative blood transfusion in hip surgery and identify significant risk factors.MethodsData of patients undergoing hip surgery between January 2013 and October 2021 in the Peking Union Medical College Hospital were collected to train and test predictive models. The primary outcome was perioperative red blood cell (RBC) transfusion within 72 h of surgery. Fourteen machine learning algorithms were established to predict blood transfusion risk incorporating patient demographic characteristics, preoperative laboratory tests, and surgical information. Discrimination, calibration, and decision curve analysis were used to evaluate machine learning models. SHapley Additive exPlanations (SHAP) was performed to interpret models.ResultsIn this study, 2431 hip surgeries were included. The Ridge Classifier performed the best with an AUC = 0.85 (95% CI, 0.81 to 0.88) and a Brier score = 0.21. Patient-related risk factors included lower preoperative hemoglobin, American Society of Anesthesiologists (ASA) Physical Status > 2, anemia, lower preoperative fibrinogen, and lower preoperative albumin. Surgery-related risk factors included longer operation time, total hip arthroplasty, and autotransfusion.ConclusionsThe machine learning model developed in this study achieved high predictive performance using available variables for perioperative blood transfusion in hip surgery. The predictors identified could be helpful for risk stratification, preoperative optimization, and outcomes improvement.

Diabetes Insipidus after Endoscopic Endonasal Pituitary Macroadenoma Resection: Correlation of Patient and Surgery-Related Risk Factors.

Purpose This article aims to identify patient- and surgery-related factors that could predict the development of postoperative central diabetes insipidus (DI). Methods This is a retrospective case-control study conducted at a single-institution tertiary referral center. Patients undergoing endoscopic endonasal skull base surgery for pituitary adenoma between November 2018 and April 2023 were recruited. The main outcome measures collected include age, gender, comorbidities, tumor type, postoperative DI, intraoperative and postoperative cerebrospinal fluid (CSF) leak, flow of CSF leak, number of layers required for repair, the use of nasal packing, and hospital length of stay. Results A total of 20 patients developed DI postoperatively. Patients' demographic and comorbidity profile did not correlate with DI development. The encounter of an intraoperative CSF leak was correlated with postop DI (chi-square (1) = 18.35, p < 0.001) with a relative risk (RR) of 2.7 (confidence interval [CI] = 1.37-5.28). The use of nasal packs was also correlated with postop DI (chi-square (1) = 10.17, p = 0.001) with a RR of 1.8 (CI = 1.15-2.87). Defects requiring a two or more layers for reconstruction also correlated with postop DI compared to single layer repairs (chi-square (1) = 12.15, p < 0.001) irrelevant of the materials used. Development of DI postop correlated with an increased hospital length of stay ( t (64) = -3.35, p = 0.001). Conclusion The physician should be careful when evaluating patients with pituitary adenomas in the postoperative period, particularly those with intraoperative CSF leak, nasal packing, and those who underwent multilayer reconstruction of the surgical defect.

Microsurgical Clipping of Unruptured Anterior Circulation Aneurysms-A Global Multicenter Investigation of Perioperative Outcomes.

Microsurgical aneurysm repair by clipping continues to be highly important despite increasing endovascular treatment options, especially because of inferior occlusion rates. This study aimed to present current global microsurgical treatment practices and to identify risk factors for complications and neurological deterioration after clipping of unruptured anterior circulation aneurysms. Fifteen centers from 4 continents participated in this retrospective cohort study. Consecutive patients who underwent elective microsurgical clipping of untreated unruptured intracranial aneurysm between January 2016 and December 2020 were included. Posterior circulation aneurysms were excluded. Outcome parameters were postsurgical complications and neurological deterioration (defined as decline on the modified Rankin Scale) at discharge and during follow-up. Multivariate regression analyses were performed adjusting for all described patient characteristics. Among a total of 2192 patients with anterior circulation aneurysm, complete occlusion of the treated aneurysm was achieved in 2089 (95.3%) patients at discharge. The occlusion rate remained stable (94.7%) during follow-up. Regression analysis identified hypertension (P < .02), aneurysm diameter (P < .001), neck diameter (P < .05), calcification (P < .01), and morphology (P = .002) as preexisting risk factors for postsurgical complications and neurological deterioration at discharge. Furthermore, intraoperative aneurysm rupture (odds ratio 2.863 [CI 1.606-5.104]; P < .01) and simultaneous clipping of more than 1 aneurysm (odds ratio 1.738 [CI 1.186-2.545]; P < .01) were shown to be associated with an increased risk of postsurgical complications. Yet, none of the surgical-related parameters had an impact on neurological deterioration. Analyzing volume-outcome relationship revealed comparable complication rates (P = .61) among all 15 participating centers. Our international, multicenter analysis presents current microsurgical treatment practices in patients with anterior circulation aneurysms and identifies preexisting and surgery-related risk factors for postoperative complications and neurological deterioration. These findings may assist in decision-making for the optimal therapeutic regimen of unruptured anterior circulation aneurysms.

Risk factors affecting spinal fusion: A meta-analysis of 39 cohort studies.

We performed a meta-analysis to identify risk factors affecting spinal fusion. We systematically searched PubMed, Embase, and the Cochrane Library from inception to January 6, 2023, for articles that report risk factors affecting spinal fusion. The pooled odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using fixed-effects models for each factor for which the interstudy heterogeneity I2 was < 50%, while random-effects models were used when the interstudy heterogeneity I2 was ≥ 50%. Using sample size, Egger's P value, and heterogeneity across studies as criteria, we categorized the quality of evidence from observational studies as high-quality (Class I), moderate-quality (Class II or III), or low-quality (Class IV). Furthermore, the trim-and-fill procedure and leave-one-out protocol were conducted to investigate potential sources of heterogeneity and verify result stability. Of the 1,257 citations screened, 39 unique cohort studies comprising 7,145 patients were included in the data synthesis. High-quality (Class I) evidence showed that patients with a smoking habit (OR, 1.57; 95% CI, 1.11 to 2.21) and without the use of bone morphogenetic protein-2 (BMP-2) (OR, 4.42; 95% CI, 3.33 to 5.86) were at higher risk for fusion failure. Moderate-quality (Class II or III) evidence showed that fusion failure was significantly associated with vitamin D deficiency (OR, 2.46; 95% CI, 1.24 to 4.90), diabetes (OR, 3.42; 95% CI, 1.59 to 7.36), allograft (OR, 1.82; 95% CI, 1.11 to 2.96), conventional pedicle screw (CPS) fixation (OR, 4.77; 95% CI, 2.23 to 10.20) and posterolateral fusion (OR, 3.63; 95% CI, 1.25 to 10.49). Conspicuous risk factors affecting spinal fusion include three patient-related risk factors (smoking, vitamin D deficiency, and diabetes) and four surgery-related risk factors (without the use of BMP-2, allograft, CPS fixation, and posterolateral fusion). These findings may help clinicians strengthen awareness for early intervention in patients at high risk of developing fusion failure.

Predictive factors of postoperative anastomotic leakage after bowel surgeries, retrospective chart review

Objective: This study aimed to identify host-related and operation-related risk factors and recognize factors that can help in predicting postoperative anastomotic leakage. Methods: It was a retrospective analytical study, conducted in King Fahad Specialist Hospital, Saudi Arabia. Data were collected from medical records. Results: The current study revealed male predominance (57.8%) with 35.9% aged over 60 years. Most participants had no Crohn\&amp;apos;s Disease (81.4%). Hemicolectomy was the common procedure (50.8%), with tumor resection as the primary cause (49.5%). Anastomotic leakage (36.9%) was prominent, and associated with lower albumin levels. Surgery site, reason, and Crohn\&amp;apos;s Disease did not significantly correlate. Bowel resection/anastomosis and emergent surgeries showed notable associations with anastomotic leakage. Conclusion: The study highlighted male predominance and a significant occurrence of anastomotic leakage, correlated with lower albumin levels. Surgery site, reason, and Crohn\&amp;apos;s Disease did not show significant associations, contrasting with bowel resection/anastomosis and emergent surgeries.

Prevention, incidence, and risk factors of chyle leak after radical nephrectomy and thrombectomy.

To define the incidence and risk factors of chyle leak (CL) after radical nephrectomy and thrombectomy and to determine the impact of chyle leak on oncological outcomes. A total of 445 patients who underwent radical nephrectomy and thrombectomy between January 2014 and January 2023 were included. CL is defined as the drainage of chyle with a triglyceride level greater than 110 mg/dL after oral intake or enteral nutrition. Multivariate logistic regression analysis was performed to identify the risk factors of postoperative (CL). The Kaplan-Meier curves were used to compare overall survival and cancer-specific survival. 44 patients (9.9%) were diagnosed as (CL). All patients developed CL within 6 days after the operation with a median time of 3 days. In multivariate logistic regression analysis, Mayo grade and side were independent patient-related risk factors. In addition, operation approach, operation time, and number of lymph nodes harvested were independent surgery-related risk factors. Between the CL group and the non-CL group, neither overall survival nor cancer-specific survival showed statistical differences. Based on this retrospective study of renal cell carcinoma and tumor thrombus patients in our center, we found that the risk factors were Mayo grade, side, operation approach,operation time, and number of lymph nodes harvested, and the occurrence of CL significantly prolonged hospital stay, but had no effect on long-term oncological outcomes.

Characteristics, outcomes, and risk factors of surgery for acute lower gastrointestinal bleeding: nationwide cohort study of 10,342 hematochezia cases.

Current evidence on the surgical rate, indication, procedure, risk factors, mortality, and postoperative rebleeding for acute lower gastrointestinal bleeding (ALGIB) is limited. We constructed a retrospective cohort of 10,342 patients admitted for acute hematochezia at 49 hospitals (CODE BLUE J-Study) and evaluated clinical data on the surgeries performed. Surgery was performed in 1.3% (136/10342) of the cohort with high rates of colonoscopy (87.7%) and endoscopic hemostasis (26.7%). Indications for surgery included colonic diverticular bleeding (24%), colorectal cancer (22%), and small bowel bleeding (16%). Sixty-four percent of surgeries were for hemostasis for severe refractory bleeding. Postoperative rebleeding rates were 22% in patients with presumptive or obscure preoperative identification of the bleeding source and 12% in those with definitive identification. Thirty-day mortality rates were 1.5% and 0.8% in patients with and without surgery, respectively. Multivariate analysis showed that surgery-related risk factors were transfusion need ≥ 6 units (P < 0.001), in-hospital rebleeding (P < 0.001), small bowel bleeding (P < 0.001), colorectal cancer (P < 0.001), and hemorrhoids (P < 0.001). Endoscopic hemostasis was negatively associated with surgery (P = 0.003). For small bowel bleeding, the surgery rate was significantly lower in patients with endoscopic hemostasis as 2% compared to 12% without endoscopic hemostasis. Our cohort study elucidated the outcomes and risks of the surgery. Extensive exploration including the small bowel to identify the source of bleeding and endoscopic hemostasis may reduce unnecessary surgery and improve the management of ALGIB.

A morbidly obese patient with large incisional hernia managed with posterior compartment separation sub-lay mesh placement

Most of the incisional hernias are diagnosed in first 3 years after the major abdominal surgery but some may take 9-10 years before the presentation after surgery. Risk factors to develop incisional hernia includes patient factors; advanced age, hypertension, diabetes, obesity, anemia, smoking, chronic obstructive pulmonary disease (COPD), immunosuppression, previous coronary intervention, renal disease requiring dialysis, recent weight loss and malnutrition. Surgery related risk factors includes intraoperative complication, suture technique, surgical site infections, fascial dehiscence and other postoperative complications. We are presenting of large incisional hernia, which have managed with posterior compartment separation. Large incisional ventral hernias following abdominal surgeries can pose significant challenges in management and quality of life for both patients. The Rives-Stoppa repair technique provides authentic and essential solution for management of large complex ventral hernias with reducing the risk of recurrence and providing long-term support to the abdominal wall.

Intra-operative drug level monitoring of pre-operative antibiotic for surgical prophylaxis inthe patients of elective spinal surgery.

Single dose prophylaxis is good enough for general surgery with low risk patients. However, the evidence for the effectiveness of single dose anti-microbial prophylaxis (AMP) is not conclusive in high risk patients andspinal surgeries requiring instrumentation or the use of implants in particular. No studies have explored the various concentration of ceftriaxone in plasma and tissue as well during an ongoing spinal surgery. Therefore, the objective of study was to correlate the serum and tissue concentrations of ceftriaxone with the SSI and identify patients with increased risk of SSI. It was an open label prospective study in 50 consecutive patients who underwent elective spine surgery under prophylactic cover of ceftriaxone. Serum and tissue concentration were estimated by high pressure liquid chromatography during the ongoing surgery. Subjects were observed for any post-operative complications including SSI. Serum (p=0.002) and tissue (p=0.012) concentrations of ceftriaxone at the closure of spinal surgery were associated with SSI. Duration of the surgery (p=0.04) and use of implants (p=0.02) were also important surgery related risk factors. Serum and tissue concentrations of ceftriaxone atthe closure and duration of surgery and instrumentation or use of implants in the spinal surgery are good predictors of SSI.

Assessment of long-term cognitive dysfunction in older patients who undergo heart surgery

IntroductionOlder patients are more likely to have cognitive dysfunction, and a great proportion of patients undergone surgical procedures are older adults. Postoperative cognitive dysfunction (POCD) has been shown as a consistent complication after major surgical procedures such as heart surgery. AimTo determine the presence of long-term POCD in ≥65-year-old patients undergoing coronary artery bypass grafting and aortic valve replacement, and to establish related risk factors. MethodsWe prospectively and sequentially included 44 patients with coronary disease and aortic stenosis scheduled for heart surgery. Follow-up of all patients was standardized and a neurocognitive evaluation were performed preoperatively and at 1, 6 and 12 months after surgery. ResultsPatients experienced a significantly postoperative cognitive dysfunction (33.5%, 63.4% and 38.9% at 1, 6 and 12 months, respectively) from baseline (20.5%). Patient-associated aspects such as age (p<0.01), history of smoking (p<0.01), arterial hypertension (p=0.022), diabetes mellitus (p=0.024), heart failure (p=0.036) and preoperative cognitive dysfunction (p<0.01), and surgery-associated aspects such as EuroSCORE (p<0.01) and operation time (p<0.01) were identified as related risk factors. ConclusionsOlder patients who underwent heart surgery had long-term POCD. Both patient- and surgery-related risk factors were established as related risk factors. These findings suggest that the prevalence of cognitive dysfunction after cardiac surgery in older patients could be related to a possible progression to dementia. In addition, many of the risk factors identified may be modifiable but in practice, these patients are not attended to for their possible cognitive impairment.

Risk factors of epidural hematoma in patients undergoing spinal surgery: a meta-analysis of 29 cohort studies.

The authors conducted this meta-analysis to identify risk factors for spinal epidural haematoma (SEH) among patients following spinal surgery. The authors systematically searched Pub: Med, Embase, and the Cochrane Library for articles that reported risk factors associated with the development of SEH in patients undergoing spinal surgery from inception to 2 July 2022. The pooled odds ratio (OR) was estimated using a random-effects model for each investigated factor. The evidence of observational studies was classified as high quality (Class I), moderate quality (Class II or III) and low quality (Class IV) based on sample size, Egger's P value and between-study heterogeneity. In addition, subgroup analyses stratified by study baseline characteristics and leave-one-out sensitivity analyses were performed to explore the potential sources of heterogeneity and the stability of the results. Of 21791 articles screened, 29 unique cohort studies comprising 150252 patients were included in the data synthesis. Studies with high-quality evidence showed that older patients (≥60years) (OR, 1.35; 95% CI, 1.03-1.77) were at higher risk for SEH. Studies with moderate-quality evidence suggested that patients with a BMI greater than or equal to 25kg/m² (OR, 1.39; 95% CI, 1.10-1.76), hypertension (OR, 1.67; 95% CI, 1.28-2.17), and diabetes (OR, 1.25; 95% CI, 1.01-1.55) and those undergoing revision surgery (OR, 1.92; 95% CI, 1.15-3.25) and multilevel procedures (OR, 5.20; 95% CI, 2.89-9.37) were at higher risk for SEH. Meta-analysis revealed no association between tobacco use, operative time, anticoagulant use or American Society of Anesthesiologists (ASA) classification and SEH. Obvious risk factors for SEH include four patient-related risk factors, including older age, obesity, hypertension and diabetes, and two surgery-related risk factors, including revision surgery and multilevel procedures. These findings, however, must be interpreted with caution because most of these risk factors had small effect sizes. Nonetheless, they may help clinicians identify high-risk patients to improve prognosis.

Analysis of Postoperative Clinical Outcomes in Cervical Myelopathy due to Ossification of Posterior Longitudinal Ligament Involving C2.

Retrospective study. To investigate the radiological phenotype, patient and surgery-related risk factors influencing postoperative clinical outcome for cervical myelopathy caused by ossification of the posterior longitudinal ligament involving C2 following posterior instrumented laminectomy and fusion. Ossified posterior longitudinal ligament (OPLL) is caused by ectopic ossification of the posterior longitudinal ligament. It can cause neurological impairment and severe disability. For multilevel cervical OPLL, studies have shown good neurological recovery following cord decompression via either an anterior or posterior approach. There is, however, a lacunae in the literature regarding the outcomes of patients with OPLL extending to C2 and above (C2 [+]). We retrospectively studied 61 patients with C2 (+) OPLL who had posterior instrumented laminectomy and fusion at Ganga Hospital, Coimbatore between July 2011 and January 2021, with a minimum follow-up of 2 years. Data on demographics, clinical outcomes, radiology, and post-surgical outcomes were gathered. Among 61 patients, 56 were males and five were females. The OPLL pattern was mixed in 32 cases (52.5%), continuous in 26 cases (42.6%), segmental in two cases (3.3%), and circumscribed in one patient (1.6%). All of our patients showed signs of neurological improvement after a 24-month follow-up. The mean preoperative modified Japanese Orthopaedic Association (mJOA) score was 10.6 (range, 5-11) and the postoperative mJOA score was 15.8 (range, 12-18). The recovery rate was >75% in 27 patients (44.6%), >50% in 32 patients (52.5%), and >25% in two patients (3.3%). The average recovery rate was 71% (range, 33%-100%). The independent risk factor for predicting recovery rate is the preoperative mJOA score. In C2 (+) OPLL, posterior instrumented decompression and fusion provide a relatively safe approach and satisfactory results.

Risk factors of delayed gastric emptying in patients after pancreaticoduodenectomy: a comprehensive systematic review and meta-analysis.

Delayed gastric emptying (DGE) is a common complication after pancreaticoduodenectomy (PD) or pylorus-preserving pancreaticoduodenectomy (PPPD). However, its risk factors are still unclear. This meta-analysis aimed to identify the potential risk factors of DGE among patients undergoing PD or PPPD. We searched PubMed, EMBASE, Web of Science, Cochrane Library, Google Scholar, and ClinicalTrial.gov for studies that examined the clinical risk factors of DGE after PD or PPPD from inception through 31 July 2022. We pooled odds ratios (ORs) with 95% CIs using random-effects or fixed-effects models. We also performed heterogeneity, sensitivity, and publication bias analyses. The study included a total of 31 research studies, which involved 9205 patients. The pooled analysis indicated that out of 16 nonsurgical-related risk factors, three risk factors were found to be associated with an increased incidence of DGE. These risk factors were older age (OR 1.37, P =0.005), preoperative biliary drainage (OR 1.34, P =0.006), and soft pancreas texture (OR 1.23, P =0.04). On the other hand, patients with dilated pancreatic duct (OR 0.59, P =0.005) had a decreased risk of DGE. Among 12 operation-related risk factors, more blood loss (OR 1.33, P =0.01), postoperative pancreatic fistula (POPF) (OR 2.09, P <0.001), intra-abdominal collection (OR 3.58, P =0.001), and intra-abdominal abscess (OR 3.06, P <0.0001) were more likely to cause DGE. However, our data also revealed 20 factors did not support stimulative factors influencing DGE. Age, preoperative biliary drainage, pancreas texture, pancreatic duct size, blood loss, POPF, intra-abdominal collection, and intra-abdominal abscess are significantly associated with DGE. This meta-analysis may have utility in guiding clinical practice for improvements in screening patients with a high risk of DGE and selecting appropriate treatment measures.

Prognostic model on niche development after a first caesarean section: development and internal validation

ObjectiveTo develop and internally validate a prognostic prediction model for development of a niche in the uterine scar after a first caesarean section (CS). Study designSecondary analyses on data of a randomized controlled trial, performed in 32 hospitals in the Netherlands among women undergoing a first caesarean section. We used multivariable backward logistic regression. Missing data were handled using multiple imputation. Model performance was assessed by calibration and discrimination. Internal validation using bootstrapping techniques took place. The outcome was ‘development of a niche in the uterus’, defined as an indentation of ≥ 2 mm in the myometrium. ResultsWe developed two models to predict niche development: in the total population and after elective CS. Patient related risk factors were: gestational age, twin pregnancy and smoking, and surgery related risk factors were double-layer closure and less surgical experience. Multiparity and Vicryl suture material were protective factors. The prediction model in women undergoing elective CS revealed similar results. After internal validation, Nagelkerke R2 ranged from 0.01 to 0.05 and was considered low; median area under the curve (AUC) ranged from 0.56 to 0.62, indicating failed to poor discriminative ability. ConclusionsThe model cannot be used to accurately predict the development of a niche after a first CS. However, several factors seem to influence scar healing which indicates possibilities for future prevention such as surgical experience and suture material. The search for additional risk factors that play a role in development of a niche should be continued to improve the discriminative ability.

Iatrogenic nerve injury in primary and revision reverse total shoulder arthroplasty

IntroductionIatrogenic nerve injury in orthopedic surgery can impair functional outcomes. During the last years, a steady increase in the number of performed reverse total shoulder arthroplasties has been reported and complications associated with this procedure are continuously described. Neurological complications, however, remain underreported. The aims of this study were to calculate the incidence of iatrogenic nerve injury after primary and revision reverse total shoulder arthroplasty in a large patient cohort, as well as identify associated patient-and surgery-related risk factors.Materials and methodsA retrospective review of our institution’s internal Reverse Total Shoulder Arthroplasty (RTSA) database from September 2005 to December 2019 was undertaken and 34 patients with iatrogenic nerve injuries were identified, resulting in a neurological complication rate of 2.6%. Group comparisons between patients with nerve injuries (n = 34) and the remaining cohort without nerve injuries (n = 1275) were performed to identify patient- and surgery-related risk factors.ResultsOf the 34 cases with iatrogenic nerve injury, damage to terminal nerve branches occurred in 21 patients, whereas a brachial plexus lesion was diagnosed in the other 13. Nerve revision surgery was necessary in four patients. At final follow-up 13 patients (45%) had residual motor deficits and 17 (59%) had residual sensory deficits. Higher numbers of previous surgeries of the affected shoulder correlated with subsequent nerve injury (p = 0.035). Operative time was significantly longer in patients, who developed a neurologic deficit, showing a correlation between duration of surgery and occurrence of nerve injury (p = 0.013). Patients with neurologic complications were significantly younger than patients without nerve damage (median 68 vs. 72 years, p = 0.017).ConclusionsIn specialists’ hands reverse total shoulder arthroplasty is a rather safe procedure regarding the risk of neurologic injury. However, multiple previous surgeries of the affected shoulder increase the risk of neurological complications. Cases with post-operative neurologic compromise are rare and usually recover well, with few patients suffering long-term functional deficits from iatrogenic nerve injury.Level of evidenceLevel III, retrospective cohort study.

Sex-specific comparison of clinical characteristics and prognosis in Crohn's disease: A retrospective cohort study of 611 patients in China.

Background: Real-world data on the impact of sex on the disease progression and prognosis of Crohn’s disease (CD) from large-scale Chinese cohorts are lacking. Aims: This study aimed to evaluate sex disparities in the clinical characteristics of, disease progression behaviours of and surgery-related risk factors for CD. Methods: A retrospective cohort study comprising 611 patients consecutively diagnosed with CD at Peking Union Medical College Hospital from January 2000 to December 2020 was conducted. Multivariate Cox regression and survival analyses was performed to assess the risk factors for disease progression and CD-related surgery in sex subgroups. Results: Male sex was an independent protective factor against multisystemic extraintestinal manifestations [EIMs] (HR: 0.52, p = 0.03) and a risk factor for intestinal perforation (HR: 1.85, p = 0.01). Male patients had longer EIM-free survival (p = 0.024) and shorter intestinal perforation-free survival (PFS) than females (p = 0.012). Of the 397 patients with the A2 classification, male patients had a higher risk of CD-related surgery (HR: 1.80, p = 0.028) and shorter surgery-free survival (SFS) than female patients (p = 0.04). Conclusion: Sex disparities in disease progression and outcomes of CD were revealed in a single Chinese centre. Male sex was independently associated with worse disease progression and prognosis including multisystemic EIMs and perforation, which suggests the need for individualized management according to risk classification.

Failure to Rescue After Severe Acute Kidney Injury in Patients Undergoing Non–Cardiac Surgery

IntroductionMany deaths after surgery can be attributed to “failure to rescue,” which may be a better surgical quality indicator than the occurrence of a postoperative complication. Acute kidney injury (AKI) is one such postoperative complication associated with high mortality. The purpose of this study is to identify perioperative risk factors associated with failure to rescue among patients who develop postoperative AKI. MethodsWe identified adult patients who underwent non–cardiac surgery between 2012 and 2018 and experienced postoperative severe AKI (an increase in blood creatinine concentration of >2 mg/dL above baseline or requiring hemodialysis) from the American College of Surgeons National Surgical Quality Improvement Program database. Multivariable logistic regression was used to identify risk factors for failure to rescue among patients who developed severe AKI. ResultsAmong 5,765,904 patients who met inclusion criteria, 26,705 (0.46%) patients developed postoperative severe AKI, of which 6834 (25.6%) experienced failure to rescue. Risk factors with the strongest association (adjusted odds ratio >1.5) with failure to rescue in patients with AKI included advanced age, higher American Society of Anesthesiologists class, presence of preoperative ascites, disseminated cancer, septic shock, and blood transfusion within 72 h of surgery start time. ConclusionsAbout one-fourth of patients who develop severe AKI after non–cardiac surgery die within 30 d of surgery. Both patient- and surgery-related risk factors are associated with this failure to rescue. Further studies are needed to identify early and effective interventions in high-risk patients who develop postoperative severe AKI to prevent the antecedent mortality.

Risk Factors for Postoperative Cerebrospinal Fluid Leakage After Intradural Spine Surgery

Well-defined risk factors for cerebrospinal fluid leakage (CSFL) after intradural spine surgery are scarce in the literature. The aim of the present study was to identify patient- and surgery-related risk factors and the incidence of CSFL. For the present retrospective cohort study, we identified consecutive patients who had undergone intradural spine surgery between 2009 and 2021 at our department. The primary endpoint was the incidence of clinically or radiologically proven CSFL. The effects of the clinical and surgical factors on the occurrence of CSFL were analyzed. A total of 375 patients (60.3% women; mean age, 54 ± 16.5 years) were included. Of the 375 patients, 30 (8%) had experienced postoperative CSFL and, thus, a significantly greater risk of wound healing disorders (odds ratio [OR], 24.9; 95% confidence interval [CI], 9.3-66.7) and surgical site infections (OR, 8.4; 95% CI, 2.6-27.7; P < 0.01 for each). No patient-related factors were associated with the development of CSFL. Previous surgery at the index level correlated significantly with the occurrence of postoperative CSFL (OR, 2.76; 95% CI, 1.1-6.8; P= 0.03) on multivariate analysis. Furthermore, patients with intradural tumors tended to have a greater risk of CSFL (OR, 2.3; 95% CI, 0.9-5.8; P= 0.07). Surgery-related factors did not influence the occurrence of CSFL. Surgery on the thoracic spine had resulted in a significantly lower postoperative CSFL rate compared with surgery on the cervical or lumbar spine (OR,-2.5; 95% CI, 1.3-4.9; P= 0.02). Our study found no modifiable risk factors for preventing CSFL after intradural spine surgery. Patients with previous surgery at the index level had a greater risk of CSFL. The occurrence of CSFL resulted in significantly more wound healing disorders and surgical site infections, necessitating further therapy.