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Classification of Surgical Complications
Abstract
Objective:
Although quality assessment is gaining increasing attention, there is still no consensus on how to define and grade postoperative complications. This shortcoming hampers comparison of outcome data among different centers and therapies and over time.
Patients and methods:
A classification of complications published by one of the authors in 1992 was critically re-evaluated and modified to increase its accuracy and its acceptability in the surgical community. Modifications mainly focused on the manner of reporting life-threatening and permanently disabling complications. The new grading system still mostly relies on the therapy used to treat the complication. The classification was tested in a cohort of 6336 patients who underwent elective general surgery at our institution. The reproducibility and personal judgment of the classification were evaluated through an international survey with 2 questionnaires sent to 10 surgical centers worldwide.
Results:
The new ranking system significantly correlated with complexity of surgery (P < 0.0001) as well as with the length of the hospital stay (P < 0.0001). A total of 144 surgeons from 10 different centers around the world and at different levels of training returned the survey. Ninety percent of the case presentations were correctly graded. The classification was considered to be simple (92% of the respondents), reproducible (91%), logical (92%), useful (90%), and comprehensive (89%). The answers of both questionnaires were not dependent on the origin of the reply and the level of training of the surgeons.
Conclusions:
The new complication classification appears reliable and may represent a compelling tool for quality assessment in surgery in all parts of the world.
... Do roku 2007 neexistoval v urologické literatuře akceptovaný standard zabývající se kvalitativní klasifikací pooperačních komplikací a využívána byla celá řada různých systémů (7). Až Dindo et al. publikovali klasifikační systém (Clavien-Dindo systém -CDS) založený na jasně definovaných kritériích, který se široce etabloval ve všech chirurgických oborech (8). Tento systém umožňuje systematicky porovnávat komplikace jednotlivých výkonů mezi sebou a v neposlední řadě i pracoviště mezi sebou. ...
... Současně jsme se snažili zhodnotit souvislost předoperační hodnoty BMI (body mass index) a míry komplikací. U šesti pacientů jsme stanovili stav výživy jako normální (BMI 18, [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24]9). U osmi pacientů jsme identifikovali nadváhu (BMI 25-29) a čtyři pacienti byli obézní (BMI nad 30). ...
... Other areas of interest were measured, including total operative time (time taken for patient to be in and out of the operating room), mean length of hospital stay, duration of catheterization, the number of bladder perforations (if any), number of readmissions and incidence of complications. Surgery complications were defined based on the Clavien-Dindo Classification system [12]. ...
... Secondary outcomes include self-reported stress levels of operating team members as measured using the raw NASA Task Load Index (TLX) [21,22] and frequency plus severity of postoperative complications according to the Clavien-Dindo classification [23]. ...
Introduction
Surgical process models (SPM) are simplified representations of operations and their visualization by surgical workflow management systems (SWMS), and offer a solution to enhance communication and workflow.
Methods
A 1:1 randomized controlled trial was conducted. A SPM consisting of six surgical steps was defined to represent the surgical procedure. The primary outcome, termed “deviation” measured the difference between actual and planned surgery duration. Secondary outcomes included stress levels of the operating team and complications. Analyses employed Welch t-tests and linear regression models.
Results
18 procedures were performed with a SWMS and 18 without. The deviation showed no significant difference between the intervention and control group. Stress levels (TLX score) of the team remained largely unaffected. Duration of operation steps defined by SPM allows a classification of all liver procedures into three phases: The Start Phase (low IQR of operation time), the Main Phase (high IQR of operation time) and the End Phase (low IQR of operation time).
Conclusion
This study presents a novel SPM for open liver resections visualized by a SWMS. No significant reduction of deviations from planned operation time was observed with system use. Stress levels of the operation team were not influenced by the SWMS.
... Exclusion criteria were the inability to obtain information about nutritional history and lack of informed consent. The patients were followed until hospital discharge and/or 30 days after surgery to document in-hospital mortality and 30-day major complications (classified grade III or greater by the Clavien-Dindo system) 15 . Follow-up appointments at the clinic were provided when required for postoperative assessments. ...
Background
Malnutrition is a risk factor for postoperative morbidity but the optimal tool for the assessment of malnutrition is unclear.
Methods
This is a prospective multicentre cohort study. Consecutive patients undergoing elective or emergency major abdominal surgery for benign or malignant disease in 12 Greek hospitals between January 2022 and December 2023 were included. Patients unable to provide nutrition history and/or informed consent were excluded. Subjective global assessment (SGA) was used as a reference standard for malnutrition diagnosis. GLIM (global leadership initiative on malnutrition), MNA-SF (mini nutrition assessment short form), MST (malnutrition screening tool), MUST (malnutrition universal screening tool), NRI (nutritional risk index), NRS-2002 (nutrition risk scale 2002), PONS (perioperative nutrition screen) and SNAQ (short nutrition assessment questionnaire) tools were applied for malnutrition risk assessments. Indicators of diagnostic accuracy (sensitivity, specificity, diagnostic odds ratio, areas under the receiver operating characteristic curve—AUC), construct validity (convergent associations with relevant variables) and prognostic validity (logistic regression) were appraised.
Results
1649 patients were included (58% colorectal, 21% upper gastrointestinal, 14% hepatobiliary operations). SGA defined 562 (34.1%) patients as malnourished with excellent construct and prognostic validity. Malnutrition risk assessments varied from 24.0% using NRS-2002 to 58.6% with the MNA-SF. On their ordinal scales, MNA-SF (AUC = 0.83, 95% c.i. 0.81 to 0.85) and MUST (AUC = 0.79, 95% c.i. 0.77 to 0.82) had the best discriminatory abilities with minimal between-centre heterogeneity. As binary classifiers, MNA-SF (OR = 30.2; 95% c.i. 20.2 to 45.1) and MUST (OR = 16.1; 95% c.i. 12.4 to 21.1) had the highest diagnostic ORs but only MUST had sensitivity and specificity close to 80%. MUST performed well in construct and prognostic validity appraisals.
Conclusion
This study supports the use of the MUST as it is the most valid nutritional screening tool in patients after major abdominal surgery.
... Postoperative complications were graded according to the modified Clavien-Dindo classification [13,14]. ...
Purpose
Evaluate a modification of the original modified Dunn technique, for unstable slipped capital femoral epiphysis (SCFE), where the proximal femoral epiphysis is not dislocated from the acetabulum.
Methods
We compared two cohorts of patients with unstable SCFE: one operated with dislocation of the femoral epiphysis (DG) and the other without (NDG). Groups were compared demographically and radiographically. Femoral head bleeding was determined after reduction of the slip. Operative time, development of AVN and other complications were registered. The influence of surgical technique and covariates on the slip correction was modeled by a generalized linear mixed model. The risk of necrosis was modeled by logistic regression.
Results
The groups (20 patients each) were similar regarding age (p = 0.8), time until operation (p = 0.8), gender (p = 1), laterality (p = 1) and race (p = 0.45). Operative time was longer in DG (p = 0.07). Not dislocating the head reduced Southwick angle correction by 3.74 degrees (p = 0.04). Femoral head bleeding was associated with an 85.14% reduction in AVN odds (p = 0.04). Shorter operative time (< 200 min) decreased AVN rate by 44% (p = 0.37). Both surgical techniques had similar complication rates, including 20% AVN (p > 0.05).
Conclusion
Not dislocating the femoral head in the modified Dunn technique presents similar AVN rates when compared to the original operation, shortens the operative time but provides a lower degree of Southwick angle correction. Femoral head bleeding following slip reduction is a good prognostic indicator for AVN occurrence.
Level of evidence
Level III—Retrospective comparative study.
... Postoperative Ooutcomes Postoperatively, the Clavien--Dindo classification of surgical complications was used, with grade III or greater morbidity considered clinically-significant [29]. These were further subclassified into early (occurring within 30 days of surgery), intermediate (from 31 to 90 days) and late (beyond 90 days postoperatively). ...
Background
Robotic surgery has been associated with superior short‐term outcomes in patients undergoing total mesorectal excision (TME) for organ‐confined rectal cancer. However, whether this approach offers an additional benefit over laparoscopy when performing lateral pelvic lymph node dissection (LPLND) with TME or extended TME (e‐TME) in locally advanced rectal cancer (LARC) is not known.
Aims
This study was conducted to evaluate the outcomes of robotic and laparoscopic LPLND in patients with lateral pelvic node‐positive LARC with reference to intraoperative safety, postoperative morbidity, pathological indices including nodal yield and node positivity rates, lateral pelvic recurrence rates, and short term event‐free and overall survival.
Methods and Results
In this retrospective single‐center study, consecutive patients with non‐metastatic histologically proven LARC and clinically significant lateral pelvic lymphadenopathy who had undergone laparoscopic or robotic LPLND with TME or e‐TME between 2014 and 2023 were included, all procedures having been performed by minimal‐access colorectal surgeons who were beyond the learning curve for either surgical approach. Of the 115 patients evaluated, 98.3% received neoadjuvant chemoradiotherapy, following which 27 (23.5%) underwent robotic and 88 (76.5%) laparoscopic LPLND with TME or e‐TME. The baseline clinicodemographic features, treatment‐related characteristics, and proportion of patients undergoing extended resections for persistent circumferential resection margin‐positive rectal cancer (22.7% vs. 18.5%, respectively) were statistically similar in both groups. When comparing robotic with laparoscopic resections, no significant difference was observed in intraoperative parameters including procedure‐associated blood loss (median 250 mL vs. 400 mL) and on‐table adverse events or conversion rates (none in either group), postoperative outcomes comprising clinically significant early (14.8% vs. 9.1%), intermediate (5.3% vs. 1.9%) and late (5.3% vs. 2.0%) surgical morbidity, re‐exploration rates (7.4% vs. 3.4%) and duration of hospital stay (median 6 days in both groups), or the pathological quality indices of margin involvement (7.4% vs. 2.3%), nodal yield (median 4 vs. 7 nodes) and lateral node positivity (22.2% vs. 26.1%), respectively. At a median 11 months follow‐up, oncological outcomes in terms of lateral pelvic recurrence rates (3.7% vs. 4.5%), 2‐year event‐free survival (78.7% vs. 79.3%) and 2‐year overall survival (83.1% vs. 93.8%) were also comparable.
Conclusion
Surgical competence in laparoscopy may offset the potential benefits extended by robotic platforms. In a high‐volume setup with experienced minimal‐access surgeons, the clinical, pathological, and short‐term oncological outcomes associated with both approaches may be considered equivalent.
... Postoperative complications were analysed according to Clavien dindo grades. 7 Statistical analysis was performed using Medcalc 19.1.3. Continuous data was represented in median (interquartile range -IQR). ...
Background: Most widely accepted classification for choledochal cyst was Todani classification. In which, Distal extent of choledochal cyst and its resection was not clearly defined. So, this distal classification may be supplementary in guiding distal extent of cyst and its resection in various types of choledochal cysts. Methods: This was a prospective observational study done in surgical gastroenterology at Nizams Institute of Medical Sciences, Hyderabad. All patients radiologically diagnosed as choledochal cysts were included. Patients with malignant distal bile duct stricture, refused to participate were excluded. Distal arrangement of all patients were interpreted in magnetic resonance cholangiopancreatography (MRCP) and classified distally. Results: In the present study of 44 patients, median age was 39 years with female preponderance. Median cyst diameter was 20.5 mm. Most common types were Todani I and distal I followed by other subtypes. Conclusions: Distal type I was the most common arrangement. So, extensive intrapancreatic dissection may be avoided to prevent dreadful complications like pancreatic fistula. Studies with larger sample and correlation with postoperative pancreatic complications should be done further.
... In the absence of surgical (classified according to the Clavien-Dindo classification) [25] and neurological complications, the patient was discharged after chest tube removal. Operative mortality was defined as death within 30 days after surgery or during the same period of hospitalization. ...
Background: While the safety and feasibility of robotic thymectomy have been well documented through several studies, the surgical and long-term neurological outcomes in patients with thymomatous myasthenia gravis (MG), particularly in advanced stages, remain scarce. This study aims to evaluate the surgical outcomes in patients undergoing robotic-assisted thymectomy (RATS) for thymoma and to analyze neurological outcomes in patients with myasthenia. Material and Methods: Out of 128 robotic thymectomies performed at our institution between October 2013 and January 2022, clinical and pathological data from 55 patients diagnosed with thymoma were reviewed. Of these, thirty (54.5%) patients had concomitant acetylcholine-receptor-antibody-associated MG. Neurological outcomes were assessed using the Myasthenia Gravis Foundation of America post-intervention score (MGFA-PIS). Results: Thirty-nine (70.9%) procedures were performed using the left-sided approach. The mean operative time was 196.9 ± 79.9 min in patients with MG compared to 175.8 ± 61.6 min in non-MG patients (p = 0.285). Additionally, patients with MG had a longer in-hospital stay (4.8 ± 2.6 vs. 3.3 ± 2.2 days, p = 0.01) and a significantly higher need for intensive care unit admission (p < 0.01). No deaths were reported. The rates of conversions (3.3% vs. 4.0%, p = 0.895) and complications (p = 0.813) were comparable between the myasthenic and non-myasthenic thymomas. A multivariable analysis identified lung involvement (p = 0.023), vascular involvement (p = 0.04), and extended resection (p = 0.019) as significant risk factors for conversion and complications. The mean age of surgery for patients with MG was 54.5 ± 15.9 years. After a mean follow-up period of 35.6 ± 25.7 months, 18 (60%) patients with myasthenia showed clinical improvement of their condition. Specifically, 2 patients (6.6%) achieved complete stable remission (CSR), 2 (6.6%) experienced pharmacological remission (PR), 12 (40.0%) demonstrated minimal manifestation (MM), and 4 (13.3%) exhibited a combination of PR and MM. Twelve patients (40%) exhibited no changes, maintaining a stable clinical condition. No clinical worsening was observed. The overall improvement rates at 2 years and 5 years were 38% and 83%, respectively. Conclusions: RATS thymectomy is a safe and feasible approach for patients with thymoma. Patients with coexisting MG may benefit through a good rate of neurological improvement.
... Short-term results that occurred within 30 days after surgery included recovery from intestinal transit, satisfactory oral tolerance, readmission, hospital stay, and postoperative surgical complications. Surgical complications were classified according to the Clavien-Dindo classification (12) and included anastomotic leakage, wound infection, incisional herniation, and bleeding. Furthermore, postoperative medical complications were also evaluated. ...
... The primary outcome was all-cause mortality, and the secondary outcomes were major complications within 30 days after surgery, recurrence, and gastric cancer-specific mortality. Postoperative complications were graded using the Clavien-Dindo classification as defined previously 17 . Major complications of grade 3 or higher were analysed for surgical outcomes. ...
This study aimed to evaluate prognostic value of resting heart rate (RHR) in patients with gastric cancer. We analyzed 1,561 patients who underwent radical gastrectomy at Severance Hospital, Korea. RHRs were measured after surgery, and detailed medical, treatment, and lifestyle information was collected. Cox regression models were used to estimate the hazard ratios (HRs) and 95% confidence interval (95% CI) for the association between postoperative RHR and prognostic outcomes. During a median of 4 years of follow-up, we identified 174 total deaths, 92 major complications (within 30 days), 186 recurrences, and 106 gastric-cancer-specific deaths. In multivariable-adjusted models, HRs (95% CI) per 10 beats per minute increase in RHR were 1.18 (1.07–1.31) for all-cause mortality, 1.45 (1.33–1.59) for major complication within 30 days, 1.13 (1.02–1.26) for recurrence, and 1.07 (0.93–1.24) for gastric cancer-specific mortality. We consistently observed that higher postoperative RHR is associated with poor prognostic outcomes regardless of demographics, lifestyle, and cancer stage in patients with gastric cancer. In conclusion, an elevated postoperative RHR was associated with an increased risk of all-cause mortality, major complications, and recurrence in patients with gastric cancer. RHR can potentially be used to predict the prognosis of patients with gastric cancer.
... For both the development and validation cohorts, the primary endpoints were overall complications and duration of hospital stay following surgery. Secondary endpoints included specific complications, complication severity, chest tube duration, unscheduled readmission AGR albumin-to-globulin ratio, ALI advanced lung cancer inflammation index, CI confidence interval, CONUT controlling nutritional status score, GNRI geriatric nutritional risk index, LMR lymphocyte-to-monocyte ratio, NLR neutrophil-to-lymphocyte ratio, NPR neutrophil-to-platelet ratio, PLR platelet-to-lymphocyte ratio, PNI [29], classified using the Clavien-Dindo classification [30], and quantified using the comprehensive complication index (CCI) [31]. Major complications were defined as those with a Clavien-Dindo classification of ≥ 2. Chest tubes were removed under conditions of no sign of leakage, normal drainage, and the drainage volume of less than 200 ml/day. ...
Background
Systemic nutrition and inflammation status is recognized for its influence on cancer survival, yet its role in perioperative outcomes remains poorly defined. This study aimed to refine the assessment of systemic nutrition and inflammation status in non-small cell lung cancer (NSCLC) patients and to elucidate its impact on perioperative outcomes.
Methods
All patients underwent video-assisted thoracoscopic lobectomy, with their nutrition and inflammation status assessed based on preoperative blood tests. The development cohort, comprising 1497 NSCLC patients from two centers, evaluated the predictive value of systemic nutrition/inflammation indicators for perioperative endpoints and formulated the systemic nutrition-inflammation index (SNII). The tertiles of SNII were used to classify the nutrition/inflammation risk as high (< 15.6), moderate (15.6–23.1), and low (> 23.1). An external validation cohort of 505 NSCLC patients was utilized to confirm the effectiveness of SNII in guiding perioperative management.
Results
In the development cohort, the SNII tool, calculated as the product of total cholesterol and total lymphocytes divided by total monocytes, demonstrated a stronger correlation with perioperative outcomes compared to 11 existing nutrition/inflammation indicators. A low SNII score, indicative of high nutrition/inflammation risk, was independently predictive of increased complication incidence and severity, as well as prolonged chest tube duration and hospital stay. These findings were corroborated in the validation cohort. Upon combining the development and validation cohorts, the superiority of the SNII in predicting perioperative outcomes was further confirmed over the existing nutrition/inflammation indicators. Additionally, comprehensive subgroup analyses revealed the moderately variable efficacy of SNII across different patient populations.
Conclusions
This study developed and validated the SNII as a tool for identifying systemic nutrition and inflammation risk, which can enhance perioperative managements in NSCLC patients. Patients identified with high risk may benefit from prehabilitation and intensive treatments, highlighting the need for further research.
Wound related and lymphatic reflow-related complications are commonly seen in penile cancer patients after inguinal lymph node dissection (ILND). However, the risk factors for them remain unclear. The objective of this study is to identify surgical-related risk factors for complications after ILND in penile squamous cell carcinoma (PSCC) patients. In this study, 192 PSCC patients aged 23–88 were enrolled between October 2008 and October 2023. Univariate analysis and logistic regression were performed to identify risk factors. Receiver operating characteristic (ROC) curves were used to analyze the relationship between certain risk factors and postoperative complications and find cut-off points for certain risk factors. Postoperative complications were observed in 87.5% of patients, with lymphatic fistula being the most common (50.0%) and wound dehiscence the least common (1.1%). Different factors were associated with each complication. Additionally, we found that the retention time of the drainage tube correlates with both lymphocele and wound infection, emphasizing the importance of optimizing drainage tube management to reduce lymphatic and wound-related complications. In conclusion, this study identified specific risk factors for complications after ILND in PSCC patients, particularly the shorter and longer retention times of the drainage tube for lymphocele and wound infection as determined by our multivariate analysis, and proposed new strategies to not only reduce the occurrence of these complications but also accelerate the postoperative healing process.
Background
En bloc resection of adjacent structures, including major vessels, is often required to achieve negative margins in retroperitoneal sarcoma (RPS). However, the effect of vascular involvement and different reconstruction techniques in patients undergoing vascular resection remains unclear. This study investigated the morbidity, mortality, and long-term survival of patients who underwent an aggressive surgical approach with vascular resection for RPS.
Methods
We analyzed a prospectively maintained database of patients who underwent surgical resection (with or without vascular resection) for RPS between 2015 and 2020. The primary endpoint was long-term overall survival (OS).
Findings
The study population comprised 252 patients. Postoperative morbidity, mortality, and OS did not differ significantly between the vascular and no vascular resection groups. Among patients with vascular involvement, those who underwent aggressive surgical approach with vascular resection had a significantly higher OS (66.3 months vs. 25.6 months) compared to those who underwent palliative resection, without an increase in mortality or complication rate. No significant differences were observed in postoperative morbidity, 30-day mortality, or estimated median OS between patients who underwent primary repair and reconstruction.
Conclusions
In patients with RPS with vascular involvement, an aggressive surgical approach with vascular resection achieved optimal clinical outcomes. Vascular reconstruction techniques had no impact on clinical outcomes.
Vesicovaginal fistula (VVF) is a devastating obstetric complication. Transvaginal, transabdominal, laparoscopic and robotic repairs have been proposed. This study was carried out to compare peri-operative and post-operative parameters of supratrigonal VVF repair to find out the best surgical approach among vaginal, abdominal and laparoscopic approaches.
A quasi-experimental study was carried out from January 2015 to January 2021. A total of 175 women suffering from VVF were screened and 150 women with supratrigonal VVF were recruited. VVF repair was performed using transvaginal, transabdominal and laparoscopic approaches (50 repairs using each approach). Parameters such as success rate, operative time, blood loss, post-operative complications and hospital stay were recorded. Statistical analysis was carried out using SPSS Version 21. Written informed consent was taken before the recruitment of subjects.
Lower (uterine) segment Caesarean section, open or laparoscopic hysterectomy and obstructed labour were the common causes. Statistical analysis showed that mean operative time was significantly lower in vaginal repair, whereas analgesic requirement, hospital stay and blood loss were significantly lower in vaginal and laparoscopic repair. Urinary tract infection was seen in all three approaches, and was resolved by administration of antibiotics post-operatively. Minor wound infection was seen only in the transabdominal repair group, which resolved with the regular application of dressings. None of the patients developed recurrence during follow-up.
Transvaginal and laparoscopic repairs are safe and effective approaches for VVF repair. However, laparoscopic repair requires a steep learning curve. Transvaginal repair has a significantly shorter operative time. Hence, in simple supratrigonal VVF, a transvaginal repair can be a preferred option.
Background
The range of surgical benign prostatic hyperplasia (BPH) treatments has hugely expanded in recent years. There is a need to keep up-to-date with ongoing innovations in BPH surgery, and critically appraise the new emerging treatments. The aim of this systematic review was to critically analyse the recent evidence for novel BPH therapies, not presently discussed in urological guidelines
Methods
An initial scoping search was conducted to identify relevant BPH treatments for inclusion: Optilume ® BPH, transperineal laser ablation (TPLA), novel implantable nitinol devices, transurethral columnar balloon dilatation (TUCBD) and transurethral ultrasound ablation (TULSA). A systematic review was conducted of these treatments, searching MEDLINE, SCOPUS and PubMed databases, limited to within 5 years.
Results
A total of 26 independent studies were included: 14 TPLA, 2 Optilume BPH, 2 TULSA, 5 TUCBD and 3 novel nitinol devices (ClearRing, Urocross Expander, Butterfly stent). For TPLA, most studies demonstrated significant improvement in efficacy outcomes in the absence of adverse events, although most trials were of small patient numbers with short follow-up. The highest quality evidence was presented by the randomised sham-controlled PINNACLE study for Optilume BPH, showing sustained significant International Prostate Symptom Score (IPSS) improvements at 2 years, and low retreatment rates. The evidence for TULSA was limited, showing unclear benefit and concerns about cost-effectiveness. The three novel nitinol device studies were of low evidence quality, with a high number of device-related events for the ClearRing and Butterfly implants. The Urocross Expander had a better safety profile, but limited efficacy data. The TUCBD studies showed contradictory outcomes, with possible confounding from combined bladder neck resection.
Conclusion
This review has identified that TPLA and Optilume BPH appear to have the strongest evidence base and show promise as future BPH treatments. Further higher quality research is required for TULSA, TUCBD and novel nitinol devices.
Level of evidence
2A
Background
Incisional hernia repairs (IHRs) are not recommended in patients with severe obesity (BMI ≥ 35 kg/m ² ). Weight loss is challenging, but new medications, such as glucagon‐like peptide‐1 receptor agonists (GLP‐1 agonists), have recently attracted increased attention for their potential weight loss advantages. The aim was to analyze the preliminary results about the safety and weight loss efficiency of the use of GLP‐1 agonists in the context of prehabilitation prior to complex IHR.
Methods
All patients planned for IHR with a BMI ≥ 35 kg/m ² and treated with preoperative GLP‐1 agonists were included in the experimental group and compared with a comparable historical surgical cohort treated with a conventional tailored nutritional preoperative management. Weight loss in the experimental group and perioperative and postoperative outcomes were compared between the two groups. The success rate of GLP1 agonists was defined as a weight loss that enables the patient to fall within the recommended limits of a BMI ≤ 35 kg/m ² before an IHR.
Results
Fifty‐two patients in the control group were compared to 24 with GLP‐1 agonists. The distribution of GLP‐1 agonists was as follows: semaglutide ( n = 12; 50%), dulaglutide ( n = 7; 29.2%), and liraglutide ( n = 5; 20.8%). The mean initial BMI was 40.1 ± 3.6 kg/m ² kg/m ² . The average percentage of weight loss was 11.3 ± 7.4% with GLP‐1 agonists (maximum weight loss was observed with semaglutide 2.4 mg/wk). The success rate of GLP1 agonists (defined as BMI ≤ 35 kg/m ² before IHR) was reached for 15/24 patients (62.5%). Postoperative total complication rate was lower in the group with GLP‐1 agonists (59.6% in the control group vs. 45.8% in GLP‐1 and p = 0.2).
Conclusion
This study demonstrated the efficacy of GLP‐1 agonists in the optimization of patients with obesity, allowing two thirds of the patients to benefit from IHR, with a tendency for lower morbidity.
Trial Registration: CPP Mediterranee, n° 21.00430.000004.
Background
To identify the predictors of local recurrence and distant metastasis after radical surgery for stage I–III colorectal cancer.
Materials and Methods
Patient and tumor characteristics, clinicopathological stages, perioperative factors, and postoperative outcomes, including local and distant recurrence, of patients who underwent primary colorectal resection were evaluated in this multicenter retrospective analysis. Univariate and multivariate regression analyses were performed to identify the risk factors for local and distant recurrences, with a focus on the intraoperative blood loss (IBL) ratio [IBL (mL)/total blood volume (mL)] and postoperative complications.
Results
The risk factors for local and distant recurrence pattern differed. The predictors for local recurrence included perioperative factors, such as the IBL ratio and anastomotic leakage, as well as tumor factors, including pT4, rectal cancer, and poorly differentiated histology, in the multivariate analysis. On the other hand, the predictors for distant recurrence included perioperative factors, such as Clavien–Dindo score ≥ 3, and absence of adjuvant chemotherapy as well as tumor factors including pT stage, pN stage, and rectal cancer. The area under the receiver operating characteristic curve (AUC) for local recurrence in the IBL ratio was 0.745, which was higher than the AUCs for other recurrence patterns in the IBL ratio. Patients with a higher IBL ratio had a higher rate of early local recurrence within 2 years postoperatively (Wilcoxon test and p = 0.028).
Conclusion
Reducing IBL and formulating perioperative strategies to prevent anastomotic leakage may help decrease the local recurrence rate and improve prognosis.
BACKGROUND
The degree of obstruction plays an important role in decision-making for obstructive colorectal cancer (OCRC). The existing assessment still relies on the colorectal obstruction scoring system (CROSS) which is based on a comprehensive analysis of patients’ complaints and eating conditions. The data collection relies on subjective descriptions and lacks objective parameters. Therefore, a scoring system for the evaluation of computed tomography-based obstructive degree (CTOD) is urgently required for OCRC.
AIM
To explore the relationship between CTOD and CROSS and to determine whether CTOD could affect the short-term and long-term prognosis.
METHODS
Of 173 patients were enrolled. CTOD was obtained using k-means, the ratio of proximal to distal obstruction, and the proportion of nonparenchymal areas at the site of obstruction. CTOD was integrated with the CROSS to analyze the effect of emergency intervention on complications. Short-term and long-term outcomes were compared between the groups.
RESULTS
CTOD severe obstruction (CTOD grade 3) was an independent risk factor [odds ratio (OR) = 3.390, 95% confidence interval (CI): 1.340-8.570, P = 0.010] via multivariate analysis of short-term outcomes, while CROSS grade was not. In the CTOD-CROSS grade system, for the non-severe obstructive (CTOD 1-2 to CROSS 1-4) group, the complication rate of emergency interventions was significantly higher than that of non-emergency interventions (71.4% vs 41.8%, P = 0.040). The postoperative pneumonia rate was higher in the emergency intervention group than in the non-severe obstructive group (35.7% vs 8.9%, P = 0.020). However, CTOD grade was not an independent risk factor of overall survival and progression-free survival.
CONCLUSION
CTOD was useful in preoperative decision-making to avoid unnecessary emergency interventions and complications.
Introduction
Postoperative pancreatic fistula (POPF) is the most frequent complication after partial pancreatectomy, which is by definition associated with clinical consequences requiring changes in postoperative management. Despite numerous scientific efforts, effective procedures to prevent POPF are lacking. Obsidian ASG autologous platelet-rich fibrin matrix has been effectively applied to prevent anastomotic leakage following colorectal surgery. This study is the first to investigate the feasibility of using the sealant in pancreatic surgery.
Methods and analysis
25 consecutive patients scheduled for elective formal partial pancreatectomy due to any underlying disease fulfilling the eligibility criteria will be included. Obsidian ASG sealant prepared out of 120 mL of each patient’s whole blood will be applied to the pancreatic stump or the pancreatic anastomosis, respectively. The primary endpoint is the feasibility of the procedure, for example, the proportion of patients undergoing successful trial intervention. Secondary endpoints comprise safety and surgical outcome parameters including rate and severity of POPF as well as further pancreas-specific complications as defined by the International Study Group of Pancreatic Surgery during 90 days after surgery. Patients will be matched with a historic collective in a 1:2 ratio to gain first data on efficacy.
Ethics and dissemination
This trial and the associated study protocol (V.1.1.1, date 26 March 2024) were approved by the institution’s ethics committee (reference number 2191/2023). All trial procedures are performed in accordance with the International Council for Harmonisation harmonised tripartite guideline on Good Clinical Practice and the ethical principles of the Declaration of Helsinki. After completion of the study, results will be published in due course.
Trial registration number
The trial was registered in the German Clinical Trials Register on 6 May 2024 (DRKS-ID: DRKS00034052).
Backgorund and Aim: Gastric cancer is the fifth most common cancer in the world and the third most common cause of cancer-related deaths. Its incidence is also increasing in elderly patients. A patient-based, multidisciplinary treatment approach is required in the evaluation of elderly patients. Surgical resection is the curative method in the treatment of gastric cancer. We aimed to evaluate the early surgical outcomes, mortality and morbidity of patients aged 80 years and older who were operated for gastric cancer. Materials and Methods: Patients aged 80 years and older who underwent surgery for gastric adenocarcinoma between January 2015 and June 2022 were retrospectively analyzed. Demographic, clinical, and histopathological parameters and postoperative outcomes were evaluated. Results: Twenty-three patients aged 80 years and older were included in the study. The mean age was 81.95 ± 3.11 (Range 80-96) years. 8 were female and 15 were male. 5 patients were ASA I, 11 patients were ASA II, and 7 patients were ASA III. Neoadjuvant therapy was applied to 3 patients. Total gastrectomy was performed in 11 patients, distal gastrectomy in 5 patients, and proximal gastrectomy in 7 patients. The mean number of lymph nodes removed was 19.87±12.61. The mean hospital stay length was 9.34 ± 3.45 days. The mortality rate in the first thirty days of our study was 8.69%. 2 patients had Clavien - Dindo grade 5 complications (mortality) and one patient had Clavien - Dindo grade 2 Conclusion: Octogenarians are a special patient group. The treatment plan should be individualized. If possible, all medically fit patients should undergo curative surgery.
Background
Superficial abscess of the skin is a common emergency presentation often requiring surgical management. Ambulatory Care Pathways (ACPs) are a method that can reduce the burden of this disease on hospital bed pressure by treating patients with superficial abscesses as day cases.
We conducted a prospective cohort study to assess the safety and effectiveness of an ACP for patients meeting strict criteria with a superficial abscess.
Methods
Data on a new ACP for the management of superficial abscesses was collected for 12 months from June 20th, 2021 and compared to a retrospective control cohort of patients managed on an inpatient care pathway. Primary outcomes were length of inpatient stay and cost of admission, secondary outcomes were delays to theatre, complications, hospital or theatre readmission within 30 days.
Results
In total, 151 patient presentations were assessed, 79 in the ACP and 72 in the retrospective cohort. The mean age in our retrospective cohort was 36.3 ± 14.2 years, which was similar to our ACP cohort at 33.2 ± 12.5 ( P = 0.16). Both cohorts had similar patient demographics.
Inpatient bed days were significantly shorter for ACP patients with a median of 0.30 (IQR 0.20–0.95) days, compared to 1.53 (IQR 1.06–1.70) days for the retrospective cohort ( P < 0.001). Both corhorts had similar postoperative complication rates ( P > 0.4).
Conclusion
Managing selected patients who present out of hours with a superficial abscess using an ambulatory care pathway reduced cumulative inpatient length of stay and resulted in no increase in patient morbidity.
Background
After head and neck cancer surgery with free flap reconstruction, the use of glucocorticoids is often required to alleviate inflammation and edema. However, the impact of glucocorticoid on postoperative complications and cancer progression remains unclear.
Methods
This retrospective cohort study included 711 elderly patients who underwent head and neck cancer surgery with free flap reconstruction at Shanghai Ninth People’s Hospital from January 1, 2014, to December 31, 2022. Patients were categorized based on postoperative glucocorticoid usage into a high-dose steroid group (n = 307) and a control group (n = 404). The study focused on the impact of postoperative GC use on postoperative complications and long-term oncological outcomes.
Results
Multivariate analysis indicated that compared to the control group, the high-dose steroid group had a significant increase in postoperative complications, including atelectasis (OR: 3.83, 95% CI: 1.27–14.11, P = 0.025), postoperative hyperglycemia (OR: 1.54, 95% CI: 1.14–2.08, P = 0.006), and flap complications (OR: 4.61, 95% CI: 3.31–6.47, P < 0.001). These complications often required extended hospital stays (β: 1.656, 95% CI: 1.075-2.236, P < 0.001). Additionally, the high-dose steroid group had a higher rate of unplanned readmissions within one year (OR: 5.61, 95% CI: 3.87–8.25, P < 0.001). The increased readmission rates were notably due to difficulties swallowing requiring percutaneous gastrostomy (OR: 3.62, 95% CI: 1.97–6.98, P < 0.001), recurrence (OR: 9.34, 95% CI: 5.02–19.05, P < 0.001), and metastasis (OR: 4.78, 95% CI: 2.58-9.44, P < 0.001).
Conclusion
The use of high-dose postoperative glucocorticoids is associated with increased postoperative complications, higher readmission rates, and poorer oncological outcomes in patients. The results advocate for cautious use and dosage management of perioperative glucocorticoids in head and neck surgeries to optimize patient outcomes.
Background
Retroperitoneal lymph node dissection (RPLND) plays an integral role in the curative management of metastatic testicular cancer. As a major surgery, RPLND poses a risk of significant complications, particularly in the post-chemotherapy (PC-RPLND) setting. We assessed the safety of introducing RPLND as a new service at an Australian tertiary hospital.
Methods
A strict protocol prioritising appropriate case selection, multidisciplinary surgical expertise and ready access to intensive care facilities was implemented to introduce RPLND. Prospective data was collected on patients who underwent PC-RPLND between October 2020 and October 2022 at the Northern Hospital in Melbourne. Primary and secondary endpoints were 30-day postoperative Clavien-Dindo (CD) classification complication rate and perioperative quality measures, respectively.
Results
Six patients (mean age 28.7 ± 4.3 years) underwent bilateral template open PC-RPLND. Median node count was 17 (IQR = 16) with metastatic germ cell tumour identified in all patients on histopathology. Median length of stay was 6 days (IQR = 3) with 1 day in intensive care. No blood transfusions were required, and no 30-day CD complications were encountered. Median follow-up was 22 months (IQR = 21) with no recurrences or significant delayed complications.
Conclusion
Following a strict protocol, RPLND has been safely introduced as a new service at our tertiary institution. Perioperative quality endpoints match those of high-volume international centres.
Introduction
The reoperation rate for artificial urinary sphincters (AUS) in men is about 25%, with poorer survival rates when reimplantation occurs after urethral erosion or infection. Data on the outcomes of second AUS implants are rare, and no data exist for third AUS implants. We aimed to evaluate the functional and survival outcomes of a third AUS after two previous explantations.
Methods
The records of all patients implanted with a third AUS between 2006 and 2023 in seven French university hospitals were reviewed retrospectively. Only AUS implants following two previous AUS cuff explantations or revisions were included. The primary endpoint was the reoperation‐free survival of the third AUS. Secondary endpoints included functional outcomes at 6 months and at the last follow‐up, and overall functional outcomes after possible subsequent AUS implants, as well as reoperations.
Results
A total of 75 patients were included. Early complications occurred in 16.7% of patients. Median follow‐up was 11 months (1–122), 28 explantations were required (37.3%). The 5‐year reoperation‐free survival rate was 34.8%. The only significant predictive factor for explantation was smoking. At 6 months, 66.2% of patients were socially continent (0–1 protection per day), 10.8% were improved, and 23% were unchanged or worsened. At the last follow‐up of the third AUS, these results were 40%, 5.3%, and 54.7%, respectively. However, at the last overall follow‐up (median 12 months, 1–183), social continence was 54.8%, improvement 9.6%, and failure 35.6%, with 23 patients (30.7%) receiving a fourth or fifth AUS.
Conclusion
Early functional outcomes of a third AUS are similar to primary AUS, but survival rates and late functional outcomes are inferior. Predictive factors for outcomes were related to patients, not the surgery itself. A third AUS may be suitable for motivated patients with limited therapeutic options. Further studies are needed to refine patient selection and assess the impact of reimplantation techniques on outcomes.
Introduction
Simulation‐based training (SBT) has become an essential component of surgical education. However, the definitive evidence for dissrect patient outcomes remains inconsistent. This prompted us to conduct this systematic review and meta‐analysis to evaluate Kirkpatrick Level 4 evidence on whether SBT translates into clinical benefits and improves patient outcomes.
Methods
We designed a search protocol a priori and followed PRISMA guidelines for systematic reviews. Medline (via PubMed), Cochrane Library, online clinical trial registers, and websites were reviewed from their inception until 31 st October 2024. Included studies were randomized controlled trials with patients undergoing any invasive intervention involving manual skills after SBT compared to the same intervention involving manual skills without SBT and comparing Clavien–Dindo complication grades. The methodological quality of included studies was assessed using the Cochrane's revised tool to assess the risk of bias in randomized trials. The Cochrane Collaboration's Review Manager software version 5.3 was utilized for data analysis. The grading of recommendation, assessment, development, and evaluation (GRADE) instrument was used for recommendation strength in the included studies in the meta‐analysis.
Results
Ten studies were included in the final meta‐analysis; all were rated as low risk of bias. The results favored simulation, but no statistically significant difference was observed between simulation and conventional training. The GRADE assessment reflected moderate certainty.
Discussion
We evaluated the effectiveness of simulation‐based training (SBT) in improving patient‐centric outcomes, classified by Clavien–Dindo complication grades using Kirkpatrick Level 4 evidence from randomized controlled trials, and discovered that results were comparable to traditional training. Future studies are needed to address this limitation in the current evidence base for simulation‐based training to confirm and maximize its patient‐centered benefits.
Background
Early complications increase in-hospital stay and mortality after intestinal obstruction surgery. It is important to identify the risk of postoperative early complications for patients with intestinal obstruction at a sufficiently early stage, which would allow preemptive individualized enhanced therapy to be conducted to improve the prognosis of patients with intestinal obstruction. A risk predictive model based on machine learning is helpful for early diagnosis and timely intervention.
Objective
This study aimed to construct an online risk calculator for early postoperative complications in patients after intestinal obstruction surgery based on machine learning algorithms.
Methods
A total of 396 patients undergoing intestinal obstruction surgery from April 2013 to April 2021 at an independent medical center were enrolled as the training cohort. Overall, 7 machine learning methods were used to establish prediction models, with their performance appraised via the area under the receiver operating characteristic curve (AUROC), accuracy, sensitivity, specificity, and F1-score. The best model was validated through 2 independent medical centers, a publicly available perioperative dataset the Informative Surgical Patient dataset for Innovative Research Environment (INSPIRE), and a mixed cohort consisting of the above 3 datasets, involving 50, 66, 48, and 164 cases, respectively. Shapley Additive Explanations were measured to identify risk factors.
Results
The incidence of postoperative complications in the training cohort was 47.44% (176/371), while the incidences in 4 external validation cohorts were 34% (17/50), 56.06% (37/66), 52.08% (25/48), and 48.17% (79/164), respectively. Postoperative complications were associated with 8-item features: Physiological Severity Score for the Enumeration of Mortality and Morbidity (POSSUM physiological score), the amount of colloid infusion, shock index before anesthesia induction, ASA (American Society of Anesthesiologists) classification, the percentage of neutrophils, shock index at the end of surgery, age, and total protein. The random forest model showed the best overall performance, with an AUROC of 0.788 (95% CI 0.709-0.869), accuracy of 0.756, sensitivity of 0.695, specificity of 0.810, and F1-score of 0.727 in the training cohort. The random forest model also achieved a comparable AUROC of 0.755 (95% CI 0.652-0.839) in validation cohort 1, a greater AUROC of 0.817 (95% CI 0.695-0.913) in validation cohort 2, a similar AUROC of 0.786 (95% CI 0.628-0.902) in validation cohort 3, and the comparable AUROC of 0.720 (95% CI 0.671-0.768) in validation cohort 4. We visualized the random forest model and created a web-based online risk calculator.
Conclusions
We have developed and validated a generalizable random forest model to predict postoperative early complications in patients undergoing intestinal obstruction surgery, enabling clinicians to screen high-risk patients and implement early individualized interventions. An online risk calculator for early postoperative complications was developed to make the random forest model accessible to clinicians around the world.
Background
The role of preoperative inflammatory markers in predicting postoperative outcomes has been investigated in different types of cancer. However, little is known about retroperitoneal sarcoma (RPS). This study aimed to evaluate the association between preoperative inflammatory status and major postoperative morbidity in patients undergoing RPS surgery.
Methods
Data on patients undergoing surgery for primary RPS between 2008 and 2022 at three specialist sarcoma centers were analyzed. The preoperative inflammatory status was evaluated, assessing the C‐reactive protein (CRP) value, the neutrophil/lymphocyte ratio (NLR), and the platelet/lymphocyte ratio (PLR). The primary outcome was 90‐day major postoperative morbidity. The best‐balanced cutoff values to apply in the uni‐ and multivariable analysis were calculated using a receiver operating characteristic (ROC) curve analysis.
Results
Data were available for 239 patients. Major postoperative complications occurred in 52 of 235 patients (22.1%). Increased median values of CRP, NLR, and PLR were significantly higher in patients with dedifferentiated liposarcoma (DDLPS) (p < 0.001). As such, further analysis focused only on this specific histotype. On multivariable analysis, after adjusting for potential confounders, the association between increasing CRP and NLR with 90‐day major postoperative morbidity remained significant, with an OR of 2.96 (95% CI: 1.03–8.49, p = 0.044) for CRP > 61 mg/L, and with an OR of 4.69 (1.55–14.20, p = 0.006) for NLR > 4.85.
Conclusion
Elevated preoperative levels of CRP and NLR are independently associated with major postoperative morbidity in patients affected by primary retroperitoneal DDLPS. These findings may help decision‐making and optimize perioperative management in these patients.
Objectives
Fall severely affects the quality of life of Parkinson's disease (PD) patients. Subthalamic nucleus (STN) deep brain stimulation (DBS) is an effective treatment for PD motor symptoms (MS), but DBS increased the risk of falls in some studies and has mixed effects on nonmotor symptoms (NMS). However, the link between NMS and falls, and how DBS influences this relationship, remain unclear. This study investigated changes in NMS and falls before and after STN‐DBS, and the longitudinal association between NMS and falls.
Methods
The study included 136 PD patients undergoing STN‐DBS between April 2020 and February 2022. Data were collected preoperatively, at 6 months, and at 12 months postoperatively. Assessments included MS via the Unified Parkinson's Disease Rating Scale‐III (UPDRS‐III) and NMS via the Nonmotor Symptoms Scale (NMSS). We used the Friedman and chi‐square tests to assess changes in NMS and falls. Specific circumstances of falls were assessed through structured interviews. Generalized estimating equations (GEE) were used to explore the longitudinal associations between NMS and fall occurrence, as well as the interaction effects between MS and NMS on fall occurrence.
Results
Significant improvements (p < 0.01) were observed in all NMSS domains except gastrointestinal, with no change in fall occurrence. However, there were significant changes in both the locations where falls occurred and whether freezing of gait was present among falling patients (p < 0.01). GEE analysis revealed significant associations between falls and mood/cognition (p = 0.044), gastrointestinal (p = 0.027), and urinary symptoms (p = 0.007), as well as interactions between motor and these NMS domains (p < 0.05).
Conclusions
NMS, particularly mood/cognition, gastrointestinal, and urinary symptoms, and their interactions with MS, are associated with falls, underscoring the need for targeted fall prevention strategies.
Aim: Fournier gangrene disease (FGD) is a condition that requires emergent surgery due to
its high risk of mortality. The use of biomarkers to predict outcomes after surgery for
patients with FGD may be critical, as they assist in tailoring treatment approaches to indi-
vidual needs. Our aim in our study is to investigate the presence of simple and easily acces-
sible biochemical markers that can be used to predict early mortality.
Methods: The medical records of 100 patients diagnosed with FGD at our hospital between
January 2015 and December 2023 were retrospectively reviewed. Clinical and laboratory
variables were assessed, and predictive factors for mortality were analyzed using multivari-
ate logistic regression.
Results: Demographics and perioperative clinical data of the whole study group, and sub-
groups according to the mortality status are evaluated. CRP was found to be independent
predictor for 30-day mortality in FGD. In ROC curve analysis provided a cutoff value of
121.3 mg/L for CRP which was signi cantly associated with 30-day mortality for FGD.
Conclusion: Preoperative CRP ≥ 121.3 mg/L value could be predict 30-day mortality in
patients diagnosed with FGD.
BACKGROUND
Gastric ulcer perforation is a critical condition that can lead to significant morbidity and mortality if not promptly addressed. It is often the result of chronic peptic ulcer disease, which is characterized by a breach in the gastric wall due to ulceration. Surgical intervention is essential for managing this life-threatening complication. However, the optimal surgical technique remains debatable among clinicians. Various methods have been employed, including simple closure, omental patch repair, and partial gastrectomy, each with distinct advantages and disadvantages. Understanding the comparative efficacy and postoperative outcomes of these techniques is crucial for improving patient care and surgical decision-making. This study addresses the need for a comprehensive analysis in this area.
AIM
To compare the efficacy and postoperative complications of different surgical methods for the treatment of gastric ulcer perforation.
METHODS
A retrospective analysis was conducted on 120 patients who underwent surgery for gastric ulcer perforation between September 2020 and June 2023. The patients were divided into three groups based on the surgical method: Simple closure, omental patch repair, and partial gastrectomy. The primary outcomes were the operative success rate and incidence of postoperative complications. Secondary outcomes included the length of hospital stay, recovery time, and long-term quality of life.
RESULTS
The operative success rates for simple closure, omental patch repair, and partial gastrectomy were 92.5%, 95%, and 97.5%, respectively. Postoperative complications occurred in 20%, 15%, and 17.5% of patients in each group, respectively. The partial gastrectomy group showed a significantly longer operative time (P < 0.001) but the lowest rate of ulcer recurrence (2.5%, P < 0.05). The omental patch repair group demonstrated the shortest hospital stay (mean 7.2 days, P < 0.05) and fastest recovery time.
CONCLUSION
While all three surgical methods showed high success rates, omental patch repair demonstrated the best overall outcomes, with a balance of high efficacy, low complication rates, and shorter recovery time. However, the choice of the surgical method should be tailored to individual patient factors and the surgeon’s expertise.
Introduction
Laparoscopic left lateral sectionectomy (LLLS) is often performed as an introduction to laparoscopic liver resection (LLR). However, laparoscopic anatomical liver resection (LALR) of the left lateral segment is a challenging procedure. There are few reports on LALR of the left lateral segment. Robot liver resection (RLR) has the benefits of a stable blur‐free visual field and mobility with multi‐joint forceps, so robot anatomical liver resection (RALR) of the left lateral segment can be carried out safely.
Method
LLR and RLR were retrospectively investigated from January 2017 to August 2024. The procedure of RALR of the left lateral segment was demonstrated, and the safety of RALR of the left lateral segment was evaluated by comparing the perioperative outcomes to LLR.
Results
This study comprised 13 LLLS cases, 5 LALR cases, and 10 RALR cases. In LLR, it was more likely that LLLS was performed for the lesion of Segment 2 (11 cases) and LALR was performed for the lesion of Segment 3 (4 cases). LALR had a significantly longer operation time than LLLS. On the other hand, the difference in operation time between RALR and LLLS was not statistically significant. The amount of blood loss was not significantly different between LLLS and RALR. Other perioperative outcomes, such as length of stay or postoperative complications, did not show any differences.
Conclusion
RALR of the left lateral segment is regarded as a safe approach in the treatment of liver tumors.
Background
Peptic ulcer perforation is a potentially life‐threatening complication of peptic ulcer disease. Several scoring systems have been developed to predict outcomes in these patients. The red cell distribution width‐to‐albumin ratio (RAR) has shown promise as a prognostic marker in various conditions, yet its role in peptic ulcer perforation remains unclear. This study aimed to evaluate the predictive value of RAR in patients with peptic ulcer perforation.
Methods
This retrospective study was conducted between 2016 and 2024 on patients who underwent surgery for peptic ulcer perforation. Patient demographics, clinical features, laboratory values, and surgical outcomes were analyzed. The main outcomes were major postoperative complications and 30‐day mortality. Multivariate regression analysis was used to identify independent predictors of these outcomes. The ability of RAR to predict outcomes was also assessed.
Results
The study included 187 patients with a median age of 49.7 years, of whom 78.6% were males. Major complications occurred in 18.1% of the patients and the 30‐day mortality rate was 9.6%. Multivariate analysis identified age, surgical delay, elevated C‐reactive protein and RAR as independent predictors of major complications. For 30‐day mortality, only age and RAR remained significant in the multivariate model. Receiver operating characteristic curve analysis showed that RAR had high diagnostic accuracy for predicting both major complications (AUC = 0.883) and mortality (AUC = 0.944).
Conclusion
With its high sensitivity and specificity for predicting major complications and mortality in patients with peptic ulcer perforation, RAR has significant potential as a prognostic marker in conjunction with traditional risk factors in clinical practice.
Percutaneous transhepatic gallbladder drainage (PTGBD) is an alternative to percutaneous transhepatic biliary drainage (PTBD) for cases with obstructive jaundice in which the bile duct obstruction is below the confluence of the cystic ducts. This retrospective study aimed to evaluate the usefulness of PTGBD and PTBD in patients with obstructive jaundice. We recruited patients who had undergone percutaneous biliary drainage for acute cholangitis and obstructive jaundice at two institutions between January 2017 and March 2024. In principle, PTBD was the first choice. PTGBD was selected for cases where the intrahepatic bile duct diameter was ≤ 5 mm or ≥ 6 mm with significant respiratory-related variability of the positioning of the bile ducts. In other cases, PTBD was chosen. Fifty-five patients were included in this analysis. However, patients with intrahepatic or hilar bile duct stenosis, post choledocholithiasis, complex cholecystitis, total bilirubin levels of < 2.0 mg/dL, and uncorrectable bleeding tendency and those who had undergone the procedure and later discontinued without puncture were excluded. The technical success rates, clinical success rates, and complication rates of the procedure were evaluated. The technical success rates were 96.3% (26/27) and 82.1% (23/28) in the PTGBD and PTBD groups, respectively. The clinical success rates were 85.2% (23/27) and 67.9% (19/28) in the PTGBD and PTBD groups, respectively. The complication rates were 18.5% (5/27) and 25.0% (7/28) in the PTGBD and PTBD groups, respectively. No serious complications were observed in either group. Hence, the two groups did not significantly differ in any of the endpoints. The outcomes of PTGBD were comparable to those of PTBD in patients with obstructive jaundice. Hence, PTGBD is a reasonable treatment option for cases of obstructive jaundice in which PTBD is not feasible.
Background
Pneumonia is one of the most common complications after lung resection. However, there are currently no reports of postoperative pneumonia in patients with bronchiectasis.
Objectives
Our study aims to construct a new nomogram to predict the risk of postoperative pneumonia in patients with localized bronchiectasis.
Design
The clinical data of patients with localized bronchiectasis from April 2012 to August 2022 were retrospectively analyzed.
Methods
Independent risk factors were identified through simple linear regression and multiple linear regression analysis, and a new nomogram was constructed based on independent risk factors. The validity of the nomogram was evaluated using the consistency index (C-index), receiver operating characteristic curve, calibration chart, and decision curve analysis chart.
Results
The new nomogram prediction model included five independent risk factors: tuberculosis history, smoking history, platelet–lymphocyte ratio (PLR), diffusing capacity of the lung for carbon monoxide, and controlled nutritional status score. The area under the curve of the prediction model is 0.870 (95% CI: 0.750–0.892), showing good discrimination ability, and the probability threshold was set at 0.2013. In addition, the calibration curve shows that the nomogram has good calibration. In the decision curve, the nomogram model showed good clinical net benefit.
Conclusion
This study is the first to construct a nomogram prediction model for postoperative pneumonia of localized bronchiectasis, which can more accurately and directly assess the risk probability of postoperative pneumonia, and provide certain help for clinicians in prevention and treatment decisions.
Background and Aims
Remote ischemic conditioning (RIC) has shown promise in preclinical and clinical studies, but its effectiveness in reducing hepatic ischemia–reperfusion injuries (HIRIs) and enhancing postoperative recovery after hepatectomy remains uncertain. In this study, we aimed to evaluate the impact of perioperative RIC (PRIC) on postoperative recovery in patients undergoing hepatectomy.
Methods
A randomised controlled trial was performed. A total of 135 eligible patients were randomised to either a control group (sham RIC), a PRIC‐1 group (RIC once daily for 3 days starting on the day of surgery) or a PRIC‐2 group (RIC twice daily). The primary outcome was the time to 2 times the upper limit of normal (2ULN) alanine transaminase (ALT) levels post‐hepatectomy. Secondary outcomes included time to reach 2ULN for aspartate transaminase (AST) levels, the area under the concentration–time curve on postoperative Day 7 (AUC‐POD7) for ALT, AST, total bilirubin and lactic acid, as well as assessments of gastrointestinal function and postoperative complications.
Results
Median time to 2ULN ALT was shorter in the PRIC‐1 and PRIC‐2 groups than in the control group (PRIC‐1: 5.0 [3.5, 6.0] vs. control: 7.0 [7.0, 10.0] days, p < 0.001; PRIC‐2: 5.0 [4.0, 8.0] vs. control: 7.0 [7.0, 10.0] days, p < 0.001). The AUC‐POD7 for ALT and AST, time to 2ULN AST, time to gastrointestinal tolerance and postoperative complications were significantly improved in the PRIC groups compared with thecontrols.
Conclusions
PRIC is safe and effective in reducing HIRIs and enhancing recovery post‐hepatectomy. Once‐daily PRIC offers similar benefits to twice‐daily PRIC.
Trial Registration
NCT06130436 ( ClinicalTrials.gov )
Objectives
To evaluate and compare surgical techniques for robot‐assisted reconstruction of recurrent bladder neck stenosis (BNS). BNS following a simple prostatectomy represents a rare but challenging condition in operative urology. Various robotic reconstructive techniques have been described, showing differing success rates. This monocentric case series reports on three distinct robotic surgical approaches for managing recurrent BNS.
Patients and methods
A retrospective analysis was conducted on patients undergoing robot‐assisted surgical repair for recurrent BNS at our institution. Clinical data, including patient history, comorbidities (Charlson Comorbidity Index), surgical treatment, complications (Clavien‐Dindo classification) and follow‐up outcomes, were analysed.
Results
A total of 27 patients underwent robotic bladder neck reconstruction for recurrent BNS. Twelve patients were treated with YV plasty, 12 with stricture resection and end‐to‐end anastomosis and 3 with reconstruction using a buccal mucosa graft (BMG). At a median follow‐up of 18 months, therapy failure occurred in 9 patients (33.3%), with failure rates of 25.0% for YV plasty, 33.3% for stricture resection and 66.7% for BMG plasty. Nine patients (33.3%) experienced surgery‐related complications, including 7 minor complications (5 in the stricture resection group, 1 in the YV plasty group and 1 in the BMG group) and 2 major complications (1 in the stricture resection group and 1 in the YV plasty group). De novo incontinence occurred in five patients (19.2%), all of whom had undergone stricture resection with end‐to‐end anastomosis.
Conclusions
Recurrent BNS poses a significant surgical challenge. Based on our experience, BMG reconstruction demonstrated suboptimal outcomes, while stricture resection was associated with the highest complication rate and the most frequent occurrence of de novo incontinence. YV plasty, with its relatively low morbidity and minimally invasive nature, has become the preferred technique in our institution for managing this condition. Prospective studies with larger cohorts are warranted to confirm these findings and further refine surgical approaches.
A 36-item short-form (SF-36) was constructed to survey health status in the Medical Outcomes Study. The SF-36 was designed for use in clinical practice and research, health policy evaluations, and general population surveys. The SF-36 includes one multi-item scale that assesses eight health concepts: 1) limitations in physical activities because of health problems; 2) limitations in social activities because of physical or emotional problems; 3) limitations in usual role activities because of physical health problems; 4) bodily pain; 5) general mental health (psychological distress and well-being); 6) limitations in usual role activities because of emotional problems; 7) vitality (energy and fatigue); and 8) general health perceptions. The survey was constructed for self-administration by persons 14 years of age and older, and for administration by a trained interviewer in person or by telephone. The history of the development of the SF-36, the origin of specific items, and the logic underlying their selection are summarized. The content and features of the SF-36 are compared with the 20-item Medical Outcomes Study short-form.
A 36-item short-form (SF-36) was constructed to survey health status in the Medical Outcomes Study. The SF-36 was designed for use in clinical practice and research, health policy evaluations, and general population surveys. The SF-36 includes one multi-item scale that assesses eight health concepts: 1) limitations in physical activities because of health problems; 2) limitations in social activities because of physical or emotional problems; 3) limitations in usual role activities because of physical health problems; 4) bodily pain; 5) general mental health (psychological distress and well-being); 6) limitations in usual role activities because of emotional problems; 7) vitality (energy and fatigue); and 8) general health perceptions. The survey was constructed for self-administration by persons 14 years of age and older, and for administration by a trained interviewer in person or by telephone. The history of the development of the SF-36, the origin of specific items, and the logic underlying their selection are summarized. The content and features of the SF-36 are compared with the 20-item Medical Outcomes Study short-form.
To construct a scoring system for the prediction of early mortality in cardiac surgical patients in Europe on the basis of objective risk factors.
The EuroSCORE database was divided into developmental and validation subsets. In the former, risk factors deemed to be objective, credible, obtainable and difficult to falsify were weighted on the basis of regression analysis. An additive score of predicted mortality was constructed. Its calibration and discrimination characteristics were assessed in the validation dataset. Thresholds were defined to distinguish low, moderate and high risk groups.
The developmental dataset had 13,302 patients, calibration by Hosmer Lemeshow Chi square was (8) = 8.26 (P < 0.40) and discrimination by area under ROC curve was 0.79. The validation dataset had 1479 patients, calibration Chi square (10) = 7.5, P < 0.68 and the area under the ROC curve was 0.76. The scoring system identified three groups of risk factors with their weights (additive % predicted mortality) in brackets. Patient-related factors were age over 60 (one per 5 years or part thereof), female (1), chronic pulmonary disease (1), extracardiac arteriopathy (2), neurological dysfunction (2), previous cardiac surgery (3), serum creatinine >200 micromol/l (2), active endocarditis (3) and critical preoperative state (3). Cardiac factors were unstable angina on intravenous nitrates (2), reduced left ventricular ejection fraction (30-50%: 1, <30%: 3), recent (<90 days) myocardial infarction (2) and pulmonary systolic pressure >60 mmHg (2). Operation-related factors were emergency (2), other than isolated coronary surgery (2), thoracic aorta surgery (3) and surgery for postinfarct septal rupture (4). The scoring system was then applied to three risk groups. The low risk group (EuroSCORE 1-2) had 4529 patients with 36 deaths (0.8%), 95% confidence limits for observed mortality (0.56-1.10) and for expected mortality (1.27-1.29). The medium risk group (EuroSCORE 3-5) had 5977 patients with 182 deaths (3%), observed mortality (2.62-3.51), predicted (2.90-2.94). The high risk group (EuroSCORE 6 plus) had 4293 patients with 480 deaths (11.2%) observed mortality (10.25-12.16), predicted (10.93-11.54). Overall, there were 698 deaths in 14,799 patients (4.7%), observed mortality (4.37-5.06), predicted (4.72-4.95).
EuroSCORE is a simple, objective and up-to-date system for assessing heart surgery, soundly based on one of the largest, most complete and accurate databases in European cardiac surgical history. We recommend its widespread use.
Anastomotic leak after gastrointestinal surgery is an important postoperative event that leads to significant morbidity and mortality. Postoperative leak rates are frequently used as an indicator of the quality of surgical care provided. Comparison of rates between and within institutions depends on the use of standard definitions and methods of measurement of anastomotic leak. The aim of this study was to review the definition and measurement of anastomotic leak after oesophagogastric, hepatopancreaticobiliary and lower gastrointestinal surgery.
A systematic review was undertaken of the published literature. Searches were carried out on five bibliographical databases (Medline, Embase, The Cochrane Library, Cumulative Index for Nursing and Allied Health Literature and HealthSTAR) for English language articles published between 1993 and 1999. Articles were critically appraised by two independent reviewers and data on definition and measurement of anastomotic leak were extracted.
Ninety-seven studies were reviewed and a total of 56 separate definitions of anastomotic leak were identified at three sites: upper gastrointestinal (13 definitions), hepatopancreaticobiliary (14) and lower gastrointestinal (29). The majority of studies used a combination of clinical features and radiological investigations to define and detect anastomotic leak.
There is no universally accepted definition of anastomotic leak at any site. The definitions and values used to measure anastomotic failure vary extensively and preclude accurate comparison of rates between studies and institutions.
To analyze the risk factors for pancreatic leakage after pancreaticoduodenectomy (PD) and to evaluate whether duct-to-mucosa pancreaticojejunostomy could reduce the risk of pancreatic leakage.
Sixty-two patients who underwent PD at our hospital between January 2000 and November 2003 were reviewed retrospectively. The primary diseases of the patients included pancreas cancer, ampullary cancer, bile duct cancer, islet cell cancer, duodenal cancer, chronic pancreatitis, pancreatic cystadenoma, and gastric cancer. Standard PD was performed for 25 cases, PD with extended lymphadenectomy for 27 cases, pylorus-preserving PD for 10 cases. A duct-to-mucosa pancreaticojejunostomy was performed for patients with a hard pancreas and a dilated pancreatic duct, and a traditional end-to-end invagination pancreaticojejunostomy for patients with a soft pancreas and a non-dilated duct. Patients were divided into two groups according to the incidence of postoperative pancreaticojejunal anastomotic leakage: 10 cases with leakage and 52 cases without leakage. Seven preoperative and six intraoperative risk factors with the potential to affect the incidence of pancreatic leakage were analyzed with SPSS10.0 software. Logistic regression was then used to determine the effect of multiple factors on pancreatic leakage.
Of the 62 patients, 10 (16.13%) were identified as having pancreatic leakage after operation. Other major postoperative complications included delayed gastric emptying (eight patients), abdominal bleeding (four patients), abdominal abscess (three patients) and wound infection (two patients). The overall surgical morbidity was 43.5% (27/62). The hospital mortality in this series was 4.84% (3/62), and the mortality associated with pancreatic fistula was 10% (1/10). Sixteen cases underwent duct-to-mucosa pancreaticojejunostomy and 1 case (1/16, 6.25%) developed postoperative pancreatic leakage, 46 cases underwent invagination pancreaticojejunostomy and 9 cases (9/46, 19.6%) developed postoperative pancreatic leakage. General risk factors including patient age, gender, history of jaundice, preoperative nutrition, pathological diagnosis and the length of postoperative stay were similar in the two groups. There was no statistical difference in the incidence of pancreatic leakage between the patients who received the prophylactic use of octreotide after surgery and the patients who did not undergo somatostatin therapy. Moreover, multivariate logistic regression analysis showed that none of the above factors seemed to be associated with pancreatic fistula. Two intraoperative risk factors, pancreatic duct size and texture of the remnant pancreas, were found to be significantly associated with pancreatic leakage. The incidence of pancreatic leakage was 4.88% in patients with a pancreatic duct size greater than or equal to 3 mm and was 38.1% in those with ducts smaller than 3 mm (P = 0.002). The pancreatic leakage rate was 2.94% in patients with a hard pancreas and was 32.1% in those with a soft pancreas (P = 0.004). Operative time, blood loss and type of resection were similar in the two patient groups. The incidence of pancreatic leakage was 6.25% (1/16) in patients with duct-to-mucosa anastomosis, and was 19.6% (9/46) in those with traditional invagination anastomosis. Although the difference of pancreatic leakage between the two groups was obvious, no statistical significance was found. This may be due to the small number of patients with duct-to-mucosa anastomosis. By further analyzing with multivariate logistic regression, both pancreatic duct size and texture of the remnant pancreas were demonstrated to be independent risk factors (P = 0.007 and 0.017, OR = 11.87 and 15.45). Although anastomotic technique was not a significant factor, pancreatic leakage rate was much less in cases that underwent duct-to-mucosa pancreaticojejunostomy.
Pancreatic duct size and texture of the remnant pancreas are risk factors influencing pancreatic leakage after PD. Duct-to-mucosa pancreaticojejunostomy, as a safe and useful anastomotic technique, can reduce pancreatic leakage rate after PD.
• Fifteen patients who had a general or gynecologic abdominal operation were operated on a second time for a complication of the first operation. There were three deaths. Extra costs attributable to the complications amounted to $211,503, of which one third was uncollectible. One half of the extra hospital days for surviving patients were spent in the intensive care unit.
(Arch Surg 1984;119:1065-1066)
The influence of postoperative complications on employment and health status following orthotopic liver transplantation (OLT) remains elusive. Postoperative complications were scored prospectively using a standardized medical outcome classification in each patient transplanted at Duke University from October 1992 to January 1995. Functional status was evaluated by using the Karnofsky score. Between 12 and 18 months following transplantation, patients were asked to complete mailed questionnaires to assess employment and health status (SF-36). The response rate was 86% (42 of 49 eligible patients). The mean patient age was 48 yr. Sixteen of 42 patients (38%) exhibited minimal or no postoperative complications, and 62% exhibited moderate to severe postoperative complications. Age, gender, education, UNOS status for severity of disease, insurance status, and Karnofsky score did not correlate with postoperative complications. Postoperative complications did not predict employment post-transplantation. Paradoxically, patients with minimal or no postoperative complications perceived that their health status was significantly impaired post-transplantation, as evidenced by a median score of 0 in the role-physical subscale of the SF-36, in contrast to those patients with moderate or severe postoperative complications who exhibited a median score of 25 (p < 0.01). Similarly, patients with minimal or no postoperative complications had significantly lower scores on the mental health subscale than those with moderate or severe complications, with median score of 60 vs. 78 (p < 0.03). The physical functioning subscale was not affected by postoperative complications. Thirteen of 42 (31%) respondents returned to full employment post-transplantation. Health perceptions differed with respect to employment status post-transplantation. Patients unemployed post-transplantation exhibited a median score of 55 in the physical functioning subscale, a value much lower than the median score of 80 in the patients who were employed post-transplantation (p < 0.02). No differences in the role physical or mental health subscales were noted with respect to employment status post-transplantation. Employment status was unaffected by Karnofsky status, indicating that functional status does not predict employment. In conclusion, patients exhibited very poor health perceptions post-transplantation, irrespective of postoperative complications. Prospective evaluation of patients undergoing liver transplantation revealed that medical complications did not affect employment post-transplantation.
Because of concern about increasing health care costs, we undertook a study to find patient risk factors associated with increased hospital costs and to evaluate the relationship between increased cost and in-hospital mortality and serious morbidity.
More than 100 patient variables were screened in 1221 patients undergoing cardiac procedures. Simultaneously, patient hospital costs were computed from the cost-to-charge ratio. Univariate and multivariate statistics were used to explore the relationship between hospital cost and patient outcomes, including operative death, in-hospital morbidity, and length of stay.
The greatest costs were for 31 patients who did not survive operation (27,102 to 60,335, 95% confidence interval 130,897, p = 0.02) and those for 1070 patients who survived operation without complication (21,944 to $49,849, p = 0.001). Breakdown of the components of hospital costs in fatalities and in cases with nonfatal complications revealed that the greatest contributions were in anesthesia and operating room costs. Significant (by stepwise linear regression analysis) independent risks for increased hospital cost were as follows (in order of decreasing importance): (1) preoperative congestive heart failure, (2) serum creatinine level greater than 2.5 mg/dl, (3) New York state predicted mortality risk, (4), type of operation (coronary artery bypass grafting, valve, valve plus coronary artery bypass grafting, or other), (5) preoperative hematocrit, (6) need for reoperative procedure, (7) operative priority, and (8) sex. These risks were different than those for in-hospitality death or increased length of stay. Hospital cost correlated with length of stay (r = 0.63, p < 0.001), but there were many outliers at the high end of the hospital cost spectrum.
We conclude that operative death is the most costly outcome; length of stay is an unreliable indicator of hospital cost, especially at the high end of the cost spectrum; risks of increased hospital cost are different than those for perioperative mortality or increased length of stay; and ventricular dysfunction in elderly patients undergoing urgent operations for other than coronary disease is associated with increased cost. Certain patient factors, such as preoperative anemia and congestive heart failure, are amenable to preoperative intervention to reduce costs, and a high-risk patient profile can serve as a target for cost-reduction strategies.
Results of elective open cholecystectomy in 1252 patients treated in a North American and a European center were examined using a recent standardized classification of complications. Although there were significant differences between centers in population age, rate of concomitant disorders, and numbers of operators, the frequency and severity of complications were comparable. There were no deaths, but 12% and 14% of the patients developed complications in the two centers. About 6% of the patients developed grade I complications. Grade II complications were noted in 6% and 8%, and grade III in 0% and 0.3%. Using univariate and multivariate analysis, individual risk factors for developing complications were found to be different in the two centers. Two preoperative scoring systems, ASA and a simplified APACHE II, were predictive for complications in both centers, but did not account for all risk in these patients. Data from the two centers could not be combined because of significant interaction between risk factors and center. Elective open cholecystectomy is a safe procedure, particularly in terms of highly morbid complications and death. Generalization of risk factors identified in a particular center may be misleading because local conditions may significantly affect risk factors for complications. The data also demonstrate the advantages of a uniform way of reporting surgical complications, which may permit meaningful comparisons among centers.
Lack of uniform reporting of negative outcomes makes interpretation of surgical literature difficult. We attempt to define and classify negative outcomes by differentiating complications, sequelae, and failures. Complications and sequelae result from procedures, adding new problems to the underlying disease. However, complications are unexpected events not intrinsic to the procedure, whereas sequelae are inherent to the procedure. Failures are events in which the purpose of the procedure is not fulfilled. We propose a classification of complications based on four grades: Grade I complications are alterations from the ideal postoperative course, non-life-threatening, and with no lasting disability. Complications of this grade necessitate only bedside procedures and do not significantly extend hospital stay. Grade II complications are potentially life-threatening but without residual disability. Within grade II complications a subdivision is made according to the requirement for invasive procedures. Grade III complications are those with residual disability, including organ resection or persistence of life-threatening conditions. Finally, grade IV complications are deaths as a result of complications. To illustrate the relevance of the classification, we reviewed 650 cases of elective cholecystectomy. Risk factors for development of complications were determined, and the classification was also used to analyze the value of a modified APACHE II as a preoperative prognostic score. Both supported the relevance of the proposed classification. The advantages of such a classification are (1) increased uniformity in reporting results, (2) the ability to compare results of two distinct time periods in a single center, (3) the ability to compare results of surgery between different centers, (4) the ability to compare results of surgical versus nonsurgical measures, (5) the ability to perform adequate metaanalysis, (6) the ability to identify objective preoperative risk factors, and (7) the ability to establish preoperative prognostic scores.
Fifteen patients who had a general or gynecologic abdominal operation were operated on a second time for a complication of the first operation. There were three deaths. Extra costs attributable to the complications amounted to +211,503, of which one third was uncollectible. One half of the extra hospital days for surviving patients were spent in the intensive care unit.
The authors determined the effect of complications on length of stay (LOS) in surgical patients.
From 1987 to 1990, in the Professional General Surgical Unit of Royal Victoria Hospital, a retrospective survey was conducted on 5128 consecutively admitted patients with 396 different diagnosis; 228 different operations were examined.
Patient LOS during a 3-year period in a general surgical ward was analyzed from hospital activity analysis, case notes, ward audit notes, and sepsis audit notes. Readmission rates for complications in patients with a short LOS were examined. Comparison were made between LOS and age, type of surgery, and complication type.
Pressure on beds resulting from an increased demand on surgical care decreases patient's hospital LOS; increasing age increases LOS. In general, complications double the average LOS. The authors calculated that a surgical complication can be given a numerical ratio that directly reflects the severity of the complication and increases the patient's LOS. The ration of the infective complication corresponds with the clinical severity of the complication. However, a short LOS may lead to readmission of patients for further treatment. For patients readmitted with complications, 41% had been discharged earlier than the average LOS for their diagnosis.
Length of stay is increased by complications and can be used to implement discharge planning in general surgical patients. Furthermore, a complication of their treatment can be given a numerical ratio that corresponds to the clinical severity of the complication and the increased LOS in hospital.
This study defined negative outcomes of solid organ transplantation, proposed a new classification of complications by severity, and applied the classification to evaluate the results of orthotopic liver transplantation (OLT).
The lack of uniform reporting of negative outcomes has made reports of transplantation procedures difficult to interpret and compare. In fact, only mortality is well reported; morbidity rates and severity of complications have been poorly described.
Based on previous definition and classification of complications for general surgery, a new classification for transplantation in four grades is proposed. Results including risk factors of the first 215 OLTs performed at the University of Toronto have been evaluated using the classification.
All but two patients (99%) had at least one complication of any kind, 92% of patients surviving more than 3 months had grade 1 (minor) complications, 74% had grade 2 (life-threatening) complications, and 30% had grade 3 (residual disability or cancer) complications. Twenty-nine per cent of patients had grade 4 complications (retransplantation or death). The most common grade 1 complications were steroid responsive rejection (69% of patients) and infection that did not require antibiotics or invasive procedures (23%). Grade 2 complications primarily were infection requiring antibiotics or invasive procedures (64%), postoperative bleeding requiring > 3 units of packed red cells (35%), primary dysfunction (26%), and biliary disease treated with antibiotics or requiring invasive procedures (18%). The most frequent grade 3 complication was renal failure, which is defined as a permanent rise in serum creatinine levels > or = twice the pretransplantation values (11%). Grade 4 complications (retransplantation or death) mainly were infection (14%) and primary dysfunction (11%). Comparison between the first and last 50 OLTs of the series indicates a significant decrease in the mean number of grade 1 and 2 complications. This was partially a result of better medical status of patients at the time of transplantation. Using univariate and multivariate analyses of risk factors, the best predictor of grade 1 complications was donor obesity; for grade 2 complications, the best predictor was a donor liver rewarming time of > 90 minutes, and for grade 3 and 4 complications, the best predictor was the APACHE II scoring system and donor cardiac arrest.
Standardized definitions and classifications of complications of transplantation will allow us to better evaluate and compare results of transplantation among centers and over time, and better compare effectiveness of new therapies. Orthotopic liver transplantation still is a procedure with high morbidity that requires careful analysis of risk factors to optimize selection of patients and organ sharing.
The rapid approach of capitated reimbursement mandates that providers examine their practice patterns associated with all surgical procedures. Documentation of (1) the complications associated with these procedures and (2) the additional hospital costs associated with the management of these complications is critical for comprehensive fiscal accountability. This study analyzed (1) the feasibility of obtaining accurate hospital cost data specific for complications and (2) the outcome in terms of fully loaded hospital costs generated in the management of the most common surgical complications associated with pacemaker and nonthoracotomy implantable defibrillator therapies. Between July 1989 and September 1994, a total of 1031 pacemaker and 105 implantable defibrillator procedures were performed by a cardiac surgeon in a tertiary-level teaching hospital setting. The additional fully loaded hospital costs were determined by (1) correlating clinical data from the complete medical record with complete hospital charge data for the admission(s) related to the complication, (2) carving out complication-related charges based on the clinical data, (3) converting complication-related charges to fully loaded costs based on conversion factors in effect at the time of service, and (4) correlating cost with hospital net reimbursement and payor source. The feasibility study determined that accurate and reliable cost data specific to complications can be obtained, although the process was cumbersome and difficult. The outcomes study determined that mean fully loaded complication costs were 1540 for pacemaker lead revision and 3167 for implantable defibrillator lead dislodgement, 14,585 for pacemaker infection, and 12,505 for defibrillator generator system malfunction. The one infected defibrillator cost $57,213 to treat. Costs exceeded reimbursement for almost all Medicare patients with complications in this study, suggesting that similar shortfalls would occur under a capitation scheme. This information is critical to a complete understanding of the financial impact of interventional procedures in a capitated reimbursement environment.
Despite improved surgical techniques there is still a risk of mortality in elective general surgery. In a prospective study preoperative data from 3250 patients were collected and compared with postoperative systemic complications, using univariate chi 2 analysis. Highly significant (P < 0.00001) variables were subjected to stepwise logistic regression analysis. The severity of operative procedure, higher American Society of Anesthesiologists (ASA) grade, symptoms of respiratory disease and malignancy were found to be significant risk factors predicting postoperative morbidity (P < 0.05). Using these four variables, a simple preoperative risk scoring system has been defined. Class A (up to 5 points) was defined as a low-risk group (systemic complication rate 5.0 per cent), class B (5-7 points) was intermediate risk (systemic complication rate 17.9 per cent) and class C (8-10 points) was high risk (systemic complication rate 33.3 per cent). Patients at high risk for perioperative and postoperative complications are more likely to be identified by this analysis than by using the ASA classification alone.
After pylorus-preserving Whipple (PPW), delayed gastric emptying (DGE) is reported in up to 50% of these patients. We analyzed gastric emptying and hormonal adaptation of cholecystokinin (CCK), pancreatic polypeptide (PP), and gastrin following two surgical procedures for chronic pancreatitis (CP): the PPW and the duodenum-preserving pancreatic head resection (DPPHR).
Ten patients underwent DPPHR and 10 underwent PPW for CP. Preoperatively and 10 days and 6 months postoperatively, gastric emptying (paracetamol absorption test) and CCK, gastrin, and PP were measured using a test meal stimulation.
The area under the serum paracetamol time curve for 0 to 120 minutes (AUC) showed no preoperative difference. Ten days postoperatively, the AUC was significantly reduced (P <0.05) after PPW but not after DPPHR. Six months postoperatively, AUC was comparable with the preoperative findings in DPPHR and PPW. The integrated 180-minute PP release was significantly reduced 10 days and 6 months postoperatively in both groups. The integrated 180-minute CCK release was decreased 10 days after PPW, but failed to be significant (P = 0.053). Gastrin levels were postoperatively unchanged.
Following DPPHR we found no delay in gastric emptying. In contrast, DGE occurs early after PPW. Our data may help explain the slower recovery in PPW patients with regard to weight gain and relief from pain, which may be due to the functional alteration of gastric emptying and motility after this type of surgery.
Purpose:
Surgical outcome data are generally reported as raw morbidity and mortality rates, which do not necessarily reflect quality of surgical care. The Society for Vascular Surgery has led this area with recommendations by the Ad Hoc Committee on Reporting Standards to establish standardized methods of outcome assessment in vascular surgery. The purpose of this study was to evaluate a new method for evaluating the overall quality of surgical care, which includes surgeon, nursing, and hospital system performance. The goal of the method is to identify problem areas in surgical practice that can be targeted for focused improvement to improve outcome.
Methods:
A database of more than 9000 general and vascular surgical cases was compiled over a 3-year period. Every postoperative complication was tabulated prospectively by a surgical nurse on a daily basis. Fifty clinically significant complication types specific for vascular surgery patients were identified from a list of 151 postoperative events by a panel of vascular surgeons and were grouped into nine broad categories (vascular, cardiac, pulmonary, etc.). These complications reflect the entire continuum of postoperative care, including surgeon, nursing, and hospital system performance. Each complication type was further stratified into four grades (mild, moderate, severe, death) and assigned a SCOUT severity score from 0 to 100 (0, no complication; 100, death) by the panel of surgeons. For case of data collection and monitoring of outcome, a software program was developed to run on a laptop computer and includes medical history, risk factors, pertinent laboratory data, and the preassigned SCOUT severity scores for measuring outcome. In this study, 170 major vascular procedures performed over the previous 12-month period were prospectively evaluated usig the SCOUT method in an attempt to more easily identify problem areas of practice. In-hospital morbidity and 30-day mortality results were examined.
Results:
One hundred sixteen postoperative complications were identified in the 170 patients, with an overall morbidity rate of 51% and a 30-day mortality rate of 1.8%. Fifty-three percent of the complications were "mild" and required minimal intervention or observation only. Abdominal aortic aneurysm repair was associated with the highest morbidity rate (mean SCOUT score, 384.35), whereas distal extremity bypass grafting had the lowest morbidity rate (mean SCOUT score, 114.4). However, subgroup analysis demonstrated that cardiac events accounted for 52% of the morbidity associated with distal extremity bypass but only 34.7% of the morbidity associated with abdominal aortic aneurysm repair (p < 0.05).
Conclusions:
The SCOUT score is a new technical quality of care measure that can objectively quantify surgeon and other hospital system-related performance. The SCOUT score allows the surgeon to identify problem areas that can then be targeted for improvement to positively affect outcome.
This study was undertaken to compare the incidence of adverse postoperative outcomes recorded in a prospective general surgery database with that identified through weekly morbidity and mortality (M&M) rounds and to measure the impact of feedback of information to the providers of care.
Data were collected on patients admitted to one general surgery service between October 1, 1995, and May 15, 1996, and recorded in a computer database. Postoperative complications were graded in severity from I (minor) to IV (mortality).
Of 479 admissions entered into the database during the study period, 325 (311 patients) led to operations and were further analyzed. Admissions resulting in complications were associated with longer hospital stays, regardless of complication grade, compared to uncomplicated admissions (p < 0.01). A total of 29 of 106 patients with postoperative complications were presented at M&Ms (27.4%). Whereas 15.4% of database patients with grade I complications were presented at M&Ms, this proportion increased to 22.2% for grade IIa, 34.8% for grade IIb, 33.3% for grade III, and 87.5% for grade IV. (p < 0.05 for grade I, IIa, and IIb compared to grade IV). A total of 58 of 142 patients in the first part of the study period developed complications (40.8%), compared to 53 of 183 patients in the second part of the study (29%, p = 0.034).
Although most severe complications are recorded at M&M rounds, a large proportion of complications remain unreported. Monitoring of outcomes may contribute to improvements in quality of care.
The long-term effect on survival of treatment in stroke units is still under debate. The hypothesis that a stroke unit with short length of stay increases 1-year and 18-month survival rates was tested in this study.
A quasi-randomized, controlled study was undertaken among 802 patients > or =60 years old admitted to the Central Hospital of Akershus in Norway with a diagnosis of stroke between January 1, 1993, and February 1, 1995. All patients with onset of symptoms <24 hours before admittance were included and enrolled and were followed until death or to the end of the observation 18 months after stroke. Patients were allocated to a stroke unit (n=364) or a general medical ward (n=438).
Case fatality within the first 10 days was 8.2% among patients in the stroke unit and 15.1% among patients in the general medical ward (P=.0019). One-year survival among patients treated in the stroke unit was 70.6% and in the general medical wards 64.6% (P=.026); 18-month survival rates were 65.1% and 58.0%, respectively (P=.021). Among patients with cerebral hemorrhage, 10-day case fatality was 24.5% and 51.6% (P=.004) in favor of the stroke unit.
Stroke units increase survival rates among stroke patients compared with general medical wards. The effect on survival occurs early after the stroke and sustains during at least 18 months of observation.
To provide reliable risk-adjusted morbidity and mortality rates after major surgery to the 123 Veterans Affairs Medical Centers (VAMCs) performing major surgery, and to use risk-adjusted outcomes in the monitoring and improvement of the quality of surgical care to all veterans.
Outcome-based comparative measures of the quality of surgical care among surgical services and surgical subspecialties have been elusive.
This study included prospective assessment of presurgical risk factors, process of care during surgery, and outcomes 30 days after surgery on veterans undergoing major surgery in 123 medical centers; development of multivariable risk-adjustment models; identification of high and low outlier facilities by observed-to-expected outcome ratios; and generation of annual reports of comparative outcomes to all surgical services in the Veterans Health Administration (VHA).
The National VA Surgical Quality Improvement Program (NSQIP) data base includes 417,944 major surgical procedures performed between October 1, 1991, and September 30, 1997. In FY97, 11 VAMCs were low outliers for risk-adjusted observed-to-expected mortality ratios; 13 VAMCs were high outliers for risk-adjusted observed-to-expected mortality ratios. Identification of high and low outliers by unadjusted mortality rates would have ascribed an outlier status incorrectly to 25 of 39 hospitals, an error rate of 64%. Since 1994, the 30-day mortality and morbidity rates for major surgery have fallen 9% and 30%, respectively.
Reliable, valid information on patient presurgical risk factors, process of care during surgery, and 30-day morbidity and mortality rates is available for all major surgical procedures in the 123 VAMCs performing surgery in the VHA. With this information, the VHA has established the first prospective outcome-based program for comparative assessment and enhancement of the quality of surgical care among multiple institutions for several surgical subspecialties. Key features to the success of the NSQIP are the support of the surgeons who practice in the VHA, consistent clinical definitions and data collection by dedicated nurses, a uniform nationwide informatics system, and the support of VHA administration and managerial staff.
To evaluate the risk factors for pancreatic fistula after pancreatic head resection.
Retrospective review.
University hospital, in the 71-month period from January 1992 through November 1997.
Sixty-two patients who underwent pancreatic head resection with pancreatojejunostomy. We performed an extensive analysis of preoperative and perioperative risk factors for pancreatic fistula.
Pancreatic fistula was defined as high amylase level (> 1000 U/L) in the drainage fluid collected from the peripancreatic drains and/or anastomotic disruption demonstrated radiographically.
Nine (15%) of the 62 patients developed pancreatic fistula, and 1 (1.6%) died of intra-abdominal hemorrhage related to the pancreatic fistula. A preoperative normal N-benzoyl-L-tyrosyl-p-aminobenzoic acid test result (P=.01), soft or intermediate pancreatic consistency (P=.04), duodenum-preserving pancreatic head resection for the normal exocrine pancreas (P=.002), and a larger amount of postoperative pancreatic juice output (P=.02) were significant risk factors for pancreatic fistula formation.
Careful attention should be paid to the preoperative exocrine pancreatic function, pancreatic consistency at surgery, and postoperative pancreatic juice output to predict and prevent pancreatic fistula after pancreatic head resection.
To document the incidence and outcome of complications in the department of surgery.
Retrospective study.
District hospital, The Netherlands.
7455 patients operated on between 1 January 1993 and 31 December 1995.
Documentation and outcome of complications (defined as "every unwanted development in the illness of the patient or in the treatment of the patient's illness that occurs in the clinic").
1078 complications were recorded after 8130 operations (13%), 337 (33%) of which had no long term effects. 175/1078 (16%) required reoperation, and in 134 of these (77%) an error in management or surgical technique was responsible for the complication. 6 patients were irreversibly harmed and of the 141 patients who died, 11 had evidence of some sort of error.
Audit of complications is necessary to improve practice in a surgical department, and weekly morbidity and mortality meetings are a good opportunity for learning about them.
Despite more than three decades of research on iatrogenesis, surgical adverse events have not been subjected to detailed study to identify their characteristics. This information could be invaluable, however, for guiding quality assurance and research efforts aimed at reducing the occurrence of surgical adverse events. Thus we conducted a retrospective chart review of 15,000 randomly selected admissions to Colorado and Utah hospitals during 1992 to identify and analyze these events.
We selected a representative sample of hospitals from Utah and Colorado and then randomly sampled 15,000 nonpsychiatric discharges from 1992. With use of a 2-stage record-review process modeled on previous adverse event studies, we estimated the incidence, morbidity, and preventability of surgical adverse events that caused death, disability at the time of discharge, or prolonged hospital stay. We characterized their distribution by type of injury and by physician specialty and determined incidence rates by procedure.
Adverse events were no more likely in surgical care than in nonsurgical care. Nonetheless, 66% of all adverse events were surgical, and the annual incidence among hospitalized patients who underwent an operation or child delivery was 3.0% (confidence interval 2.7% to 3.4%). Among surgical adverse events 54% (confidence interval 48.9% to 58.9%) were preventable. We identified 12 common operations with significantly elevated adverse event incidence rates that ranged from 4.4% for hysterectomy (confidence interval 2.9% to 6.8%) to 18.9% for abdominal aortic aneurysm repair (confidence interval 8.3% to 37.5%). Eight operations also carried a significantly higher risk of a preventable adverse event: lower extremity bypass graft (11.0%), abdominal aortic aneurysm repair (8.1%), colon resection (5.9%), coronary artery bypass graft/cardiac valve surgery (4.7%), transurethral resection of the prostate or of a bladder tumor (3.9%), cholecystectomy (3.0%), hysterectomy (2.8%), and appendectomy (1.5%). Among all surgical adverse events, 5.6% (confidence interval 3.7% to 8.3%) resulted in death, accounting for 12.2% (confidence interval 6.9% to 21.4%) of all hospital deaths in Utah and Colorado. Technique-related complications, wound infections, and postoperative bleeding produced nearly half of all surgical adverse events.
These findings provide direction for research to identify the causes of surgical adverse events and for targeted quality improvement efforts.
Length of stay (LOS) is an important outcome as a marker of resource consumption. Determining which factors increase LOS may provide information on reducing costs and improving the delivery of care. The purpose of this study was to determine the independent association of intraoperative process of care and postoperative events with prolonged LOS after adjusting for preoperative severity of illness in patients undergoing major elective surgery.
Cases representing 11 elective operations from the National VA Surgical Quality Improvement Program were analyzed using multivariate logistic regression analysis. The outcome, prolonged LOS, was defined as an LOS greater than or equal to the 75th percentile (in days) for each operation. Hierarchical modeling was used to assess the independent association of groups of variables (preoperative patient characteristics, intraoperative process of care, and postoperative adverse events) with prolonged LOS.
For the 11 operations explored, there were 23,919 cases. Common preoperative variables associated with prolonged LOS were functional status, American Society of Anesthesiology class, and age. The most predictive intraoperative and postoperative variables included intraoperative blood transfusion, operative time, return to the operating room, and the number of complications after surgery.
Prolonged LOS is associated with preoperative, intraoperative, and postoperative factors. Although preoperative factors were independently associated with a prolonged LOS, the factors generating the highest risks for a prolonged LOS were the intraoperative process of care and postoperative adverse events. To reduce costs, efforts should be made to improve the intraoperative process of care and to minimize postoperative complications.
Although currently available surgical scoring systems have good outcome predictive power, their use is often limited by complexity and their non-dynamic nature. The aim of this study was to develop and test a risk adjustment for general surgical audit which is both simple and dynamic, while preserving a high predictive power for surgical morbidity.
Twelve easily measured, well defined prognostic variables for morbidity were identified from the Otago Surgical Audit data collection form and stratified into suitable categories. Logistic regression was used to adjust for confounding between factors, identifying risk factors with the strongest prognostic value for the outcome of severe and intermediate complications. The resulting model was tested by back-validation and validation.
The derived risk adjustment included all 12 variables. Adjusted odds ratios for all variables were markedly lower than unadjusted values. After logistic regression, the strongest predictors of postoperative morbidity were duration of operation, operation category, inpatient status and organ system in which the procedure was carried out. The area under the receiver operating characteristic curve was 0.86.
A simple dynamic model for surgical morbidity has been developed which is comparable to previously published surgical scoring systems in terms of predictive power. This risk adjustment tool can be incorporated into the existing audit system, enabling comparison of surgical unit performance.
Analysis of the type and characteristics of complications after laparoscopic splenectomy may permit the identification of clinical factors with predictive value for the development of complications.
Univariate and multivariate analysis of factors related to complications in a prospective series of laparoscopic splenectomies.
A large tertiary referral university-teaching general hospital.
One hundred twenty-two nonselected consecutive patients, in whom laparoscopic splenectomy was attempted between February 1993 and July 1999.
Laparoscopic splenectomy.
Immediate complications classified according to the Clavien score. Univariate and multivariate analyses were performed of complications related to age, sex, body mass index, and malignant nature of the hematologic disease; preoperative hematocrit and platelet count; operative time; operative position; need of accessory incision; transfusion status; learning curve; and existence of comorbid diseases.
One hundred thirteen laparoscopic splenectomies were completed (conversion rate, 7.4%). Twenty patients (18%) developed 23 complications. All were Clavien type I or II, without mortality. One complication was intraoperative (diaphragmatic perforation), and 22 were postoperative: 6 pulmonary (26%), 3 fever (13%), 8 hemorrhagic (35%) (5 episodes of postoperative bleeding and 3 abdominal wall hematomas), and 6 others (26%). Ten (43%) of the 23 were technically related. Univariate analysis showed that complications were only related to age (mean +/- SD, 55 +/- 15 vs 39 +/- 17 years; P<.008) or transfusion (50% vs 11%; P<.001). Multivariate analysis showed that the learning curve (P<.005; 95% confidence interval, 2.46), age (P<.001; 95% confidence interval, 1. 04), spleen weight (P<.009; 95% confidence interval, 1.00), and malignant neoplasm diagnosis (P<.007; 95% confidence interval, 3.82) were independent predictors of complications.
Laparoscopic splenectomy is feasible, and the incidence of severe complications is reduced. However, a high proportion of these complications are technique related. Laparoscopic splenectomy requires great technical care but offers major clinical advantages, even in less favorable situations, such as in patients with splenomegaly or with malignant neoplasms.
Measures of risk-adjusted outcome are particularly suited for the assessment of the quality of surgical care. The reliability of measures of quality that use surgical outcomes is enhanced by prospective data acquisition and should be adjusted for the preoperative severity of illness. Such measures should be based only on reliable and validated data, and they should apply state-of-the-art analytical methods. The risk-adjusted postoperative mortality rate is useful as a quality measure only in specialties and operations expected to have a high rate of postoperative deaths. Risk-adjusted complications are more common but are limited as a comparative measure of quality by a lack of uniform definitions and data collection mechanisms. In specialties in which the expected postoperative mortality is low, risk-adjusted functional outcomes are promising measures for the assessment of the quality of surgical care. Measures of cost and patient satisfaction should also be incorporated in systems designed to measure the quality and cost-effectiveness of surgical care.
A small minority of patients undergoing gastroenterological surgery are at high risk for postoperative complications, which may lead to prolonged hospital stay, disproportionate use of resources and increased mortality. The nature and frequency of, and predictive factors for, postoperative complications were studied and the impact of complications on resource utilization was assessed.
A prospective observational study was undertaken of 503 patients undergoing gastroenterological surgery in a tertiary care centre. The incidence of cardiorespiratory, infective and surgical complications was assessed. The need for reoperation, intensive care and length of hospital stay, readmission, death at 6 months and costs were evaluated.
Some 235 patients (47 per cent) had at least one complication, most commonly delayed oral intake (n = 70). Complications were associated with cardiovascular disease, prolonged operation, high Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity, and increased number of Shoemaker's criteria. The length of hospital stay of patients with complications was longer than that of those without complications (11 versus 6 days). Morbidity resulted in a twofold increase in median costs.
High-risk patients could be identified by simple clinical criteria, although the commonly used risk criteria were not very sensitive. A reduction in postoperative complication rates would result in marked cost savings.
The purpose was to assess the current variation in complication rates and evaluate the association between specific types of complications and in-hospital mortality and total hospital charges for patients having abdominal aortic surgery.
We studied 2987 patients for abdominal aortic surgery in Maryland from 1994 to 1996 and used discharge diagnoses and procedure codes to identify diagnoses that most likely represent major surgery complications. We evaluated how in-hospital mortality and total hospital charges related to specific complications, adjusting for patient demographics, severity of illness, comorbidity, and hospital and surgeon volumes. Discharge data was obtained from the hospital marketing departments.
Complication rates varied widely among hospitals. Complications independently associated with increased risk of in-hospital death include cardiac arrest with an odds ratio (OR) of 90 and a 95% confidence interval (CI) of 32-251, septicemia (OR 6.1, CI 3.3-11.3), acute myocardial infarction (OR 5.7, CI 2.3-14.3), acute renal failure (OR 5.0, CI 2.3-11.0), surgical complications after a procedure (OR 3.1, CI 2.0-4.9), and reoperation for bleeding (OR 2.2, CI 1.1-4.8). The population-attributable risk for in-hospital mortality was 47% for cardiac arrest and 27% for acute renal failure.
In abdominal aortic surgery on patients in Maryland, the rates of some complications vary widely and are independently associated with increased in-hospital mortality and hospital charges (charges differ from costs). Efforts to reduce these complications should help to decrease both levels.
To identify 10 critical elements of accurate and comprehensive reports of surgical complications.
Despite a venerable tradition of weekly morbidity and mortality conferences, inconsistent complication reporting is common in the surgical literature.
An analysis of articles reporting short-term outcomes after pancreatectomy, esophagectomy, and hepatectomy was performed. Randomized clinical trials (RCTs) published from 1975 to 2001 and retrospective series of more than 100 patients published from 1990 to 2001 were reviewed.
A total of 119 articles reporting outcomes in 22,530 patients were analyzed. This included 42 RCTs and 77 retrospective series. Of the 10 criteria developed, no articles met all criteria; 2% met 9 criteria, 38% 7 or 8, 34% 5 or 6, 40% 3 or 4, and 12% 1 or 2. Outpatient information (22% of articles), definitions of complications provided (34% of articles), severity grade used (20% of articles), and risk factors included in analysis (29% of articles) were the most commonly unmet quality reporting criteria. Type of study (RCT vs. retrospective), site of institution (U.S. vs. non-U.S.) and journal (U.S. vs. non-U.S.) did not influence the quality of complication reporting.
Short-term surgical outcomes are routinely included in the data reported in the surgical literature. This is often used to show improvements over time or to assess the impact of therapeutic changes on patient outcome. The inconsistency of reporting and the lack of accepted principles of accrual, display, and analysis of complication data argue strongly for the creation and generalized use of standards for reporting this information.
To identify predictors of requirement for readmission to the intensive care unit (ICU) for patients undergoing cardiac surgery.
The setting was a 17-bedded ICU in a tertiary level institute for specialist adult cardiorespiratory disease. The case notes and ICU charts of 65 ICU readmissions and 65 controls, matched for day of initial ICU discharge, were analysed. Patient variables assessed included preoperative risk stratification, ICU admission APACHE III score and intensive therapy interventions, complications and indication for readmission if readmitted.
Twenty of 65 patients (31%) readmitted to the cardiac ICU died, compared with no mortality among the control group. Significant univariate determinants of ICU readmission (odds ratio, 95% confidence interval) included worse angina (1.38, 0.99-1.91) and dyspnoea (1.70, 1.10-2.61) classes and corresponding non-elective surgery (2.04, 1.31-3.19), higher Parsonnet score (1.06, 1.01-1.11) or EuroSCORE (1.14, 1.01-1.28), APACHE III score (1.03, 1.00-1.05), body mass index>27 (4.25, 1.43-12.63), non-usage of beta-blockers (1.53, 1.03-2.26), emergency resternotomy (5.00, 1.10-22.79), and lower haemoglobin (0.75, 0.58-0.96), higher required inspiratory oxygen (1.05, 1.02-1.08), and higher respiratory rate upon ICU discharge (1.09, 1.01-1.18). Renal failure, respiratory failure and cardiac arrest were the most common indications for ICU readmission. Thirty-five of 65 patients readmitted to the ICU required ventilation for a mean of 7.1 days. The mean ICU readmission duration for all 65 cases was 5.7 days.
Readmission of cardiac surgical patients to the ICU is associated with high morbidity and mortality, and substantial resource consumption. Parsonnet or EuroSCORE risk stratification models in combination with obesity, operative urgency, resternotomy and respiratory indices at time of intended ICU discharge are strongly associated with readmission to ICU.
To review the current status of pancreatoduodenectomy for pancreatic cancer and chronic pancreatitis using evidence-based methodology.
Despite improved results of pancreatoduodenectomy over the recent years, the reputation of the Whipple procedure and its main modifications has remained poor. In addition, the current status of newer modifications of standard pancreatoduodenectomy is still under debate.
Medline search and manual cross-referencing were performed to identify all relevant articles for classification and analysis according to their quality of evidence. The search was limited to articles published between 1990 and 2001.
The mortality rate of pancreatoduodenectomy has declined to less than 5% for chronic pancreatitis and 3% to 8% for pancreatic cancer. In contrast, overall morbidity rates remain high, ranging between 20% and 70%. Delayed gastric emptying represents almost half of all complications. The overall 5-year survival rate for patients with pancreatic cancer remains poor, ranging between 5% and 15%, with a median survival of 13 to 17 months. Mortality and morbidity are not related to the type of pancreatoduodenectomy; however, patients with pancreatic cancer tend to be at increased risk for complications. Extended lymph node dissection and portal vein resection can be performed with similar mortality and morbidity rates as standard procedures, but without apparent survival benefits in the long term. Major relief of pain is achieved in 70% to 100% of patients with chronic pancreatitis.
Pancreatoduodenectomy and its main modifications are safe and effective treatment modalities, especially in experienced centers with a high patient volume. For chronic pancreatitis, surgical resection provides major relief of pain and thus increased quality of life. Overall survival for patients with pancreatic cancer is determined predominantly by the pathology within the resected specimen.
Severe donor organ shortage has provided the impetus for adult living donor liver transplantation (ALDLT). Despite rapid implementation and expansion of the procedure, outcome analysis of ALDLT is still incomplete. This study analyzed both donor and recipient outcomes after ALDLT at a single center. ALDLT performed at UCLA between August 1999 and November 2001 were reviewed retrospectively. Twenty recipients (14 men and 6 women) with a mean age of 48.8 +/- 9.7 (29 to 66) years underwent right lobe ALDLT. By computed tomograpy (CT), graft/recipient weight ratio (GRWR) was 1.3 +/- 0.3 (1 to 2.2). Overall 1-year patient and graft survival rates were 95% and 85%, respectively. One recipient died of heart failure with normal liver function 5 months after transplantation. Three grafts (14%) were lost and all three patients underwent successful cadaveric retransplantation. Complications were classified according to the Clavien grading system with all but 3 recipients encountering at least one complication. Nine (45%) had grade 1 (minor), 10 (50%) had grade 2 (potentially life threatening without residual disease/disability), 3 (14%) had grade 4A (retransplantation) and one grade 4B (death). Right lobectomy for living donation was performed in 20 patients (12 men, 8 women). Residual left lobe volumes were 36 +/- 5.3 (23.9 to 47.9)% of total donor liver volume. No donor required intensive care unit admission and median hospital stay was 7.5 (6 to 14) days. One donor was aborted after intraoperative biopsy showed > 50% macrovesicular steatosis. No donor mortality or long-term complications were encountered. Five grade 1 minor complications, by Clavien Classification, occurred in 4 of 20 (20%) donors. ALDLT using right lobe grafts is an effective procedure to expand a severely depleted donor, but is associated with a high complication rate despite good survival outcomes. Continuous standardized reporting of ALDLT outcomes is required to allow successful and safe implementation of the procedure.
Obese patients are generally believed to be at a higher risk for surgery than those who are not obese, although convincing data are lacking.
We prospectively investigated a cohort of 6336 patients undergoing general elective surgery at our institution to assess whether obesity affects the outcome of surgery. Exclusion criteria were emergency, vascular, thoracic, and bariatric operations; transplantation procedures; patients under immunosuppression; and operations done under local anaesthesia. Postoperative morbidity was analysed for non-obese and obese patients (body-mass index <30 kg/m(2) vs >or=30 kg/m(2)). Obesity was further stratified into mild obesity (30.0-34.9 kg/m(2)) and severe obesity (>or=35 kg/m(2)). Risk factors were analysed with univariate and multivariate models.
The cohort consisted of 6336 patients, of whom 808 (13%) were obese, 569 (9%) were mildly obese, and 239 (4%) had severe obesity. The morbidity rates in patients who were obese compared with those who were not were much the same (122 [15.1%] of 808 vs 901 [16.3%] of 5528; p=0.26), with the exception of an increased incidence of wound infections after open surgery in patients who were obese (17 [4%] of 431 vs 92 [3%] of 3555, p=0.03). Incidence of complications did not differ between patients who were mildly obese (91 [16.0%] of 569), severely obese (36 [15.1%] of 239), and non-obese (901 [16.3%] of 5528; p=0.19). In multivariate regression analyses, obesity was not a risk factor for development of postoperative complications. Of note, the additional medical resource use as estimated by a new classification of complications showed no differences between patients who were and were not obese.
Obesity alone is not a risk factor for postoperative complications. The regressive attitude towards general surgery in obese patients is no longer justified.
Patients undergoing pylorus-preserving pancreatoduodenenectomy (PPPD) have a risk of up to 50% for developing delayed gastric emptying (DGE) in the early postoperative course. From 1994 to August 2002, a total of 204 patients underwent PPPD for pancreatic or periampullary cancer (50%), chronic pancreatitis (42%), and other indications (8%). Retrocolic end-to-side duodenojejunostomy was performed below the mesocolon. DGE was defined by the inability to tolerate a regular diet after day 10 (DGE10) or day 14 (DGE14) postoperatively, as well as the need for a nasogastric tube at or beyond day 10 (DGE10GT). Postoperative morbidity was 38%, 30-day mortality was 2.9%, and median postoperative length of stay was 15 days. DGE occurred in 14.7% (DGE10), 5.9% (DGE14), and 6.4% (DGE10GT), respectively. After further exclusion of 21 patients (10.3%) with major complications and no possible oral intake (because of death, reoperation, or mechanical ventilation), the frequencies of DGE10, DGE14, and DGE10GT in the remaining group of 183 patients were 9%, 2%, and 2%, respectively. Multivariate analysis revealed postoperative complications (P<0.001), the presence of portalvenous hypertension (P<0.01), and tumors as indications for surgery (P<0.01) as independent risk factors for DGE10. The overall incidence of DGE was low after PPPD. In those patients experiencing DGE, however, other postoperative complications were the most important factor associated with its occurrence.
Pancreatic fistula (PF) is still regarded as a serious complication both in terms of frequency and sequelae. The incidence varies greatly in different reports because of the different definitions used. The aim of this study was to compare several definitions of PF encountered in the current literature and to demonstrate that the PF rate in the same group of patients treated in a high volume center is dependent upon the definition applied.
A Medline search of the last 10 years was performed as regards the definition of PF. A score was assigned to the reproducible definitions based upon two basic parameters: daily output (cm3) and duration of the fistula represented by the number of days between the postoperative day of onset and the duration of the complication. Four definitions were formulated and were then applied to a group of 242 patients that underwent pancreatic head or intermediate resections with pancreatico-jejunal anastomosis in our Pancreatic Unit between November 1996 and December 2000. Statistical analysis was carried out using the Yates correct chi2 test with statistical significance set at p < 0.05.
Among 26 different definitions identified, 14 were found suitable for the applied score. We formulated four final definitions summarizing the current concepts of PF. The incidence of PF ranged between 9.9 and 28.5% according to the different definitions applied with highly statistical differences between them.
The PF rate after pancreatic resections is strictly dependent upon the definition used. An overall general agreement for an internationally accepted definition is urgently needed to correctly compare different experiences.
The additional hospital costs generated in the management of complications of pacemaker and defibrillator implantations
- T J Ferguson
- C Ferguson
- K Crites
Ferguson TJ, Ferguson C, Crites K, et al. The additional hospital
costs generated in the management of complications of pacemaker
and defibrillator implantations. J Thorac Cardiovasc Surg. 1996;111:
742-751.
The additional hospital costs generated in the management of complications of pacemaker and defibrillator implantations.
- Ferguson