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Preoperative cardiac and respiratory investigations do not predict cardio‐respiratory complications after pancreatectomy
Abstract
Background
The process of undergoing a pancreatic resection places a patient under notable physiologic strain throughout the perioperative journey, with well recognized risks of postoperative cardiopulmonary complications. Preoperative preparations and screening often incorporate a barrage of testing, including electrocardiograms, transthoracic echocardiography, chest X‐rays and spirometric evaluations. However, the current literature does not demonstrate whether these common tests provide any predictive correlation with postoperative cardiopulmonary complications. This retrospective study is structured to identify complications in post‐pancreatic resection patients and assess for a predictive correlation with preoperative test results.
Methods
A retrospective analysis of all patients having undergone a pancreatic resection at a single tertiary centre, between 2014 and 2016. The inpatient medical records were reviewed for 30‐day postoperative complications, including acute myocardial infarction, cardiac dysrhythmia, pulmonary embolism, pneumonia or pleural effusions. The results of routine preoperative diagnostic tests and complication rates were analysed.
Results
A total of 244 patients, median age of 66 years (range 18–88 years) were included in the study. Of these, 11 patients experienced a cardiac complication and 16 patients experienced a respiratory complication. Among those who experienced cardiac events, only two patients had abnormalities in their preoperative electrocardiograms. Patients who sustained a cardiac or respiratory event did not have any evidence of abnormality in their preoperative transthoracic echocardiography or respiratory investigations, respectively.
Conclusion
Despite the recommendation that high‐risk procedures such as pancreatic resections warrant thorough, routine, preoperative cardiac and respiratory investigation, a more functional preoperative assessment should be considered to stratify and predict postoperative outcomes.
... Clinical guidelines state that annual chest CT screening for lung cancer is recommended for people over 50 years of age [23]. In order to better assess the risk of surgery in middle-aged and elderly patients, clinicians tend to use chest CT to assess the cardiorespiratory function of these patients [24,25]. Therefore, this study made secondary use of these CT images to build a CNN model to screen out patients with osteoporosis in advance, and timely antiosteoporosis intervention was conducted for these patients to prevent the occurrence of osteoporotic fractures. ...
Introduction
A large number of middle-aged and elderly patients have an insufficient understanding of osteoporosis and its harm. This study aimed to establish and validate a convolutional neural network (CNN) model based on unenhanced chest computed tomography (CT) images of the vertebral body and skeletal muscle for opportunistic screening in patients with osteoporosis.
Materials and methods
Our team retrospectively collected clinical information from participants who underwent unenhanced chest CT and dual-energy X-ray absorptiometry (DXA) examinations between January 1, 2022, and December 31, 2022, at four hospitals. These participants were divided into a training set ( n = 581), an external test set 1 ( n = 229), an external test set 2 ( n = 198) and an external test set 3 ( n = 118). Five CNN models were constructed based on chest CT images to screen patients with osteoporosis and compared with the SMI model to predict the performance of osteoporosis patients.
Results
All CNN models have good performance in predicting osteoporosis patients. The average F1 score of Densenet121 in the three external test sets was 0.865. The area under the curve (AUC) of Desenet121 in external test set 1, external test set 2, and external test set 3 were 0.827, 0.859, and 0.865, respectively. Furthermore, the Densenet121 model demonstrated a notably superior performance compared to the SMI model in predicting osteoporosis patients.
Conclusions
The CNN model based on unenhanced chest CT vertebral and skeletal muscle images can opportunistically screen patients with osteoporosis. Clinicians can use the CNN model to intervene in patients with osteoporosis and promptly avoid fragility fractures.
Critical relevance statement
The CNN model based on unenhanced chest CT vertebral and skeletal muscle images can opportunistically screen patients with osteoporosis. Clinicians can use the CNN model to intervene in patients with osteoporosis and promptly avoid fragility fractures.
Key Points
The application of unenhanced chest CT is increasing.
Most people do not consciously use DXA to screen themselves for osteoporosis.
A deep learning model was constructed based on CT images from four institutions.
Graphical Abstract
... Although the postoperative mortality of PD has decreased in recent decades [4], the postoperative morbidity rate remains high at 30% to 55% [5][6][7]. Moreover, many patients require perioperative blood transfusion (PBT) during PD due to the sophisticated surgical procedure [8,9]. ...
Background:
The effect of perioperative blood transfusion (PBT) on the prognosis of ampullary carcinoma (AC) is still debated.
Aim:
To explore the impact of PBT on short-term safety and long-term survival in AC patients who underwent pancreaticoduodenectomy.
Methods:
A total of 257 patients with AC who underwent pancreaticoduodenectomy between 1998 and 2020 in the Cancer Hospital, Chinese Academy of Medical Sciences, were retrospectively analyzed. We used Cox proportional hazard regression to identify prognostic factors of overall survival (OS) and recurrence-free survival (RFS) and the Kaplan-Meier method to analyze survival information.
Results:
A total of 144 (56%) of 257 patients received PBT. The PBT group and nonperioperative blood transfusion group showed no significant differences in demographics. Patients who received transfusion had a comparable incidence of postoperative complications with patients who did not. Univariable and multivariable Cox proportional hazard regression analyses indicated that transfusion was not an independent predictor of OS or RFS. We performed Kaplan-Meier analysis according to subgroups of T stage, and subgroup analysis indicated that PBT might be associated with worse OS (P < 0.05) but not RFS in AC of stage T1.
Conclusion:
We found that PBT might be associated with decreased OS in early AC, but more validation is needed. The reasonable use of transfusion might be helpful to improve OS.
Pancreatic cancer is the seventh leading cause of cancer-related deaths worldwide. However, its toll is higher in more developed countries. Reasons for vast differences in mortality rates of pancreatic cancer are not completely clear yet, but it may be due to lack of appropriate diagnosis, treatment and cataloging of cancer cases. Because patients seldom exhibit symptoms until an advanced stage of the disease, pancreatic cancer remains one of the most lethal malignant neoplasms that caused 432,242 new deaths in 2018 (GLOBOCAN 2018 estimates). Globally, 458,918 new cases of pancreatic cancer have been reported in 2018, and 355,317 new cases are estimated to occur until 2040. Despite advancements in the detection and management of pancreatic cancer, the 5-year survival rate still stands at 9% only. To date, the causes of pancreatic carcinoma are still insufficiently known, although certain risk factors have been identified, such as tobacco smoking, diabetes mellitus, obesity, dietary factors, alcohol abuse, age, ethnicity, family history and genetic factors, Helicobacter pylori infection, non-O blood group and chronic pancreatitis. In general population, screening of large groups is not considered useful to detect the disease at its early stage, although newer techniques and the screening of tightly targeted groups (especially of those with family history), are being evaluated. Primary prevention is considered of utmost importance. Up-to-date statistics on pancreatic cancer occurrence and outcome along with a better understanding of the etiology and identifying the causative risk factors are essential for the primary prevention of this disease.
Whether preoperative spirometry in non-thoracic surgery can predict postoperative pulmonary complications (PPCs) is controversial. We investigated whether preoperative spirometry results can predict the occurrence of PPCs in patients who had undergone laparoscopic abdominal surgery. This retrospective observational study analyzed the records of patients who underwent inpatient laparoscopic gastric or colorectal cancer surgery at Seoul National University Bundang Hospital between January 2010 and June 2017. Preoperative spirometry was performed for patients at a high risk of PPCs, such as elderly patients (age >60 years), patients aged <60 years with chronic pulmonary disease, and current smokers. The main outcome was the association between the results of spirometry tests performed within 1 month prior to surgery and the occurrence of PPCs, as determined by multivariable logistic regression analysis. Of the 898 included patients who underwent laparoscopic gastric (372 patients) or colorectal cancer surgery (526 patients), PPC occurred in 117 patients (gastric cancer: 74, colorectal cancer: 43). A 1% greater preoperative forced vital capacity (FVC) was associated with a 2% lower incidence of PPCs after laparoscopic gastric or colorectal cancer surgery (odds ratio: 0.98, 95% confidence interval: 0.97–0.99, P = 0.018). However, the preoperative forced expiratory volume in 1 second (FEV1) (%) and FEV1/FVC (%) were not significantly associated with PPCs (P = 0.059 and P = 0.147, respectively). In conclusion, lower preoperative spirometry FVC, but not FEV1 or FEV1/FVC, may predict PPCs in high-risk patients undergoing laparoscopic abdominal surgery.
Background
Oesophagectomy has a high risk of postoperative morbidity. The impact of postoperative complications on overall survival of oesophageal cancer remains unclear. This meta‐analysis addressed the impact of complications on long‐term survival following oesophagectomy.
Methods
A search of PubMed and Cochrane Library databases was undertaken for systematic review of papers published between January 1995 and August 2016 that analysed the relation between postoperative complications and long‐term survival. In the meta‐analysis, data were pooled. The main outcome was overall survival (OS). Secondary endpoints included disease‐free (DFS) and cancer‐specific (CSS) survival.
Results
A total of 357 citations was reviewed; 21 studies comprising 11 368 patients were included in the analyses. Overall, postoperative complications were associated with significantly decreased 5‐year OS (hazard ratio (HR) 1·16, 95 per cent c.i. 1·06 to 1·26; P = 0·001) and 5‐year CSS (HR 1·27, 1·09 to 1·47; P = 0·002). Pulmonary complications were associated with decreased 5‐year OS (HR 1·37, 1·16 to 1·62; P < 0·001), CSS (HR 1·60, 1·35 to 1·89; P < 0·001) and 5‐year DFS (HR 1·16, 1·00 to 1·33; P = 0·05). Patients with anastomotic leakage had significantly decreased 5‐year OS (HR 1·20, 1·10 to 1·30; P < 0·001), 5‐year CSS (HR 1·81, 1·11 to 2·95; P = 0·02) and 5‐year DFS (HR 1·13, 1·02 to 1·25; P = 0·01).
Conclusion
Postoperative complications after oesophagectomy, including pulmonary complications and anastomotic leakage, decreased long‐term survival.
Postoperative pancreatic fistula (POPF) remains the major cause of morbidity after pancreatic resection, affecting up to 41% of cases. With the recent development of a consensus definition of POPF, there has been a large number of reports examining various risk factors, prediction models, and mitigation strategies for this costly complication. Despite these strategies, the rates of POPF have not significantly diminished. Here, we review the literature and evidence regarding both traditional and emerging concepts in POPF prediction, prevention, and management. In particular, we review the evidence for the association between postoperative pancreatitis and POPF, and present a novel proposed mechanism for the development of POPF.
Transthoracic echocardiography has become increasingly popular in clinical practice. It is used for the functional evaluation of patients with various cardiovascular diseases. Its use has been extended further in routine screening for cardiovascular health and in preoperative risk assessment before non-cardiac surgery because it is non-invasive, easy to perform, reproducible, and cost-effective. When the results of preoperative echocardiography contain abnormalities, the findings must be interpreted to determine clinical relevance. However, when the results of preoperative echocardiography are apparently normal, many physicians and surgeons readily think that the patient will not have any cardiovascular events in the future, or at least in the perioperative period. In this review, we will cover 1) current guidelines for preoperative echocardiographic assessment, 2) specific cardiac conditions for which the non-cardiac surgery should be delayed, 3) commonly encountered echocardiographic findings before non-cardiac surgeries, 4) application of stress echocardiography, and 5) clinical perspectives of focused transthoracic echocardiography before non-cardiac surgery.
Patient- and procedure-related factors associated with postoperative pulmonary complications (PPCs) have changed over the last decade. Therefore, we sought to identify independent risk factors of PPCs and to develop a clinically applicable scoring system. We retrospectively analyzed clinical data from 2,059 patients who received preoperative evaluations from respiratory physicians between June 2011 and October 2012. A new scoring system for estimating PPCs was developed using beta coefficients of the final multiple regression models. Of the 2,059 patients studied, 140 (6.8%) had PPCs. A multiple logistic regression model revealed seven independent risk factors (with scores in parentheses): age ≥70 years (2 points), current smoker (1 point), the presence of airflow limitation (1 point), American Society of Anesthesiologists class ≥2 (1 point), serum albumin <4 g/dL (1 point), emergency surgery (2 points), and non-laparoscopic abdominal/cardiac/aortic aneurysm repair surgery (4 points). The area under the curve was 0.79 (95% CI, 0.75-0.83) with the newly developed model. The new risk stratification including laparoscopic surgery has a good discriminative ability for estimating PPCs in our study cohort. Further research is needed to validate this new prediction rule.
Each year, an increasing number of elderly patients with cardiovascular disease undergoing non-cardiac surgery require careful perioperative management to minimize the perioperative risk. Perioperative cardiovascular complications are the strongest predictors of morbidity and mortality after major non-cardiac surgery. A Joint Task Force of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA) has recently published revised Guidelines on the perioperative cardiovascular management of patients scheduled to undergo non-cardiac surgery, which represent the official position of the ESC and ESA on various aspects of perioperative cardiac care. According to the Guidelines effective perioperative cardiac management includes preoperative risk stratification based on preoperative assessment of functional capacity, type of surgery, cardiac risk factors, and cardiovascular function. The ESC/ESA Guidelines discourage indiscriminate routine preoperative cardiac testing, because it is time- and cost-consuming, resource-limiting, and does not improve perioperative outcome. They rather emphasize the importance of individualized preoperative cardiac evaluation and the cooperation between anesthesiologists and cardiologists. We summarize the relevant changes of the 2014 Guidelines as compared to the previous ones, with particular emphasis on preoperative cardiac testing.
Background:
The value of spirometry as a routine preoperative test for bariatric surgery is debatable. The aim of this study was to assess the relationship between spirometry results and the frequency of postoperative pulmonary complications in 602 obese patients.
Methods:
Clinical files of patients undergoing bariatric surgery between 2004 and 2013 were reviewed. Demography, risk factors, respiratory symptoms, and spirometry results (forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), FEV1/FVC) were recorded, and their relationship with postoperative pulmonary complications was evaluated.
Results:
There were 256 males and 346 females with a mean age of 40.2 ± 11.6 years and a mean BMI of 42.1 ± 6.4 kg/m2. History of smoking was found in 408 patients (68 %). Preoperative respiratory symptoms were present in 328 (54.5 %). Most frequent symptoms were snoring (288), dyspnea (119), bronchospasm [6], and chronic productive cough [6]. In 153 patients, history of respiratory disease was documented. The obstructive sleep apnea syndrome (OSAS) was present in 124, 20 requiring continuous positive airway pressure (CPAP). Asthma was present in 27 and chronic obstructive pulmonary disease (COPD) in 2. Variables associated to a higher risk of pulmonary complications were OSAS (OR 2.3), an abnormal spirometry (OR 2.6), male gender (OR 1.9), and preoperative respiratory symptoms (OR 1.9). Using multivariate logistic regression, an abnormal spirometry was a significant predictor of postoperative pulmonary complications in patients with respiratory symptoms and/or OSAS. However, it lost prognostic significance when both conditions were subtracted.
Conclusions:
In obese patients undergoing bariatric surgery, abnormal preoperative spirometry predicts postoperative respiratory complications only in patients with OSAS.
Background:
Postoperative pulmonary complication (PPC) is a serious complication after liver surgery and is a major cause of mortality and morbidity in the intensive care unit (ICU). Therefore, the early identification of risk factors of PPCs may help to reduce the adverse outcomes.
Objective:
The aim of this retrospective study was to determine the predictors of PPCs in patients undergoing hepatic resection.
Design:
Retrospective, observational.
Methods:
The patients admitted after hepatic resection in the gastrosurgical ICU of our institute between October 2009 and June 2013 was identified. The ICU charts were retrieved from the database to identify patients who developed PPCs. A comparison of risk factors was made between the patients who developed PPC (PPC group) against the patients who did not (no-PPC group).
Results:
Of 117 patients with hepatic resection, 28 patients developed PPCs. Among these, pneumonia accounted for 12 (42.8%) followed by atelectasis in 8 (28.5%) and pleural effusion in 3 (10.7%). Among the patients developing PPCs, 16 patients were over a 70-year-old (57.1%), 21 patients were smokers (75%) and 8 patients (28.5%) had chronic obstructive pulmonary disease (COPD). The requirement for blood transfusion and duration of mechanical ventilation were greater in the patients developing PPC (2000 ± 340 vs. 1000 ± 210 ml; 10 ± 4.5 vs. 3 ± 1.3 days).
Conclusion:
Old age, chronic smoking, COPD, increased blood product transfusion, increased duration of mechanical ventilation and increased length of ICU stay increased the relative risk of PPC, presence of diabetes and occurrence of surgical complications (leak, dehiscence, etc.) were independent predictive variables for the development of PPC.
In patients undergoing pancreatic resection (PR), identification of subgroups at increased risk for postoperative complications can allow focused interventions that may improve outcomes.
Patients undergoing PR from 2005-2010 were selected from the American College of Surgeons National Surgical Quality Improvement Program database and categorized as having any history of cardiac disease (angina, congestive heart failure (CHF), myocardial infarction (MI), cardiac stent, or bypass) or as having acute cardiac disease (symptoms of CHF or angina within 30 days or MI within 6 months). These variables were utilized to examine the relationship between cardiac disease and outcomes after PR.
The rate of serious complications and perioperative mortality in patients with any history of cardiac disease vs. those without was 34 vs. 24 % (p < 0.001) and 4.5 vs. 2.0 % (p < 0.001), respectively, and in patients with acute cardiac disease compared to patients without was 37 vs. 25 % (p < 0.001) and 8.6 vs. 2.2 % (p < 0.001), respectively. In multivariate analysis, the two cardiac disease variables remained associated with mortality.
In patients undergoing PR, cardiac disease is a significant risk factor for adverse outcomes. These observations are critical for meaningful informed consent in patients considering pancreatectomy.
To identify predictors of postoperative pulmonary complications (PPCs) in patients aged ≥60 years who underwent laparoscopy-assisted gastrectomy (LAG), and to examine the value of preoperative spirometry to predict PPCs.
Patients with preoperative spirometric results who underwent LAG were retrospectively studied. Spirometry included four parameters: forced expiratory volume in 1 s; functional vital capacity; mean forced expiratory flow during middle of functional vital capacity; peak expiratory flow rate.
Of 213 patients, overall incidence of PPCs was 19.2%. Abnormal spirometry findings were not identified as an independent predictor of PPCs using multivariate logistic regression analysis. Age was found to be the only independent predictor of PPCs out of all variables evaluated. Separate assessment of individual spirometric parameters using receiver-operating curve analyses indicated poor diagnostic accuracy.
Preoperative spirometry was not reliably predictive of PPCs, either as combined or individual parameters, in patients aged ≥60 years who underwent LAG. These results do not support routine use of spirometry to stratify risk of PPCs in this surgical population.
Although numerous studies suggest that there is an inverse relation between hospital volume of surgical procedures and surgical mortality, the relative importance of hospital volume in various surgical procedures is disputed.
Using information from the national Medicare claims data base and the Nationwide Inpatient Sample, we examined the mortality associated with six different types of cardiovascular procedures and eight types of major cancer resections between 1994 and 1999 (total number of procedures, 2.5 million). Regression techniques were used to describe relations between hospital volume (total number of procedures performed per year) and mortality (in-hospital or within 30 days), with adjustment for characteristics of the patients.
Mortality decreased as volume increased for all 14 types of procedures, but the relative importance of volume varied markedly according to the type of procedure. Absolute differences in adjusted mortality rates between very-low-volume hospitals and very-high-volume hospitals ranged from over 12 percent (for pancreatic resection, 16.3 percent vs. 3.8 percent) to only 0.2 percent (for carotid endarterectomy, 1.7 percent vs. 1.5 percent). The absolute differences in adjusted mortality rates between very-low-volume hospitals and very-high-volume hospitals were greater than 5 percent for esophagectomy and pneumonectomy, 2 to 5 percent for gastrectomy, cystectomy, repair of a nonruptured abdominal aneurysm, and replacement of an aortic or mitral valve, and less than 2 percent for coronary-artery bypass grafting, lower-extremity bypass, colectomy, lobectomy, and nephrectomy.
In the absence of other information about the quality of surgery at the hospitals near them, Medicare patients undergoing selected cardiovascular or cancer procedures can significantly reduce their risk of operative death by selecting a high-volume hospital.
The importance of clinical risk factors for postoperative pulmonary complications and the value of preoperative testing to stratify risk are the subject of debate.
To systematically review the literature on preoperative pulmonary risk stratification before noncardiothoracic surgery.
MEDLINE search from 1 January 1980 through 30 June 2005 and hand search of the bibliographies of retrieved articles.
English-language studies that reported the effect of patient- and procedure-related risk factors and laboratory predictors on postoperative pulmonary complication rates after noncardiothoracic surgery and that met predefined inclusion criteria.
The authors used standardized abstraction instruments to extract data on study characteristics, hierarchy of research design, study quality, risk factors, and laboratory predictors.
The authors determined random-effects pooled estimate odds ratios and, when appropriate, trim-and-fill estimates for patient- and procedure-related risk factors from studies that used multivariable analyses. They assigned summary strength of evidence scores for each factor. Good evidence supports patient-related risk factors for postoperative pulmonary complications, including advanced age, American Society of Anesthesiologists class 2 or higher, functional dependence, chronic obstructive pulmonary disease, and congestive heart failure. Good evidence supports procedure-related risk factors for postoperative pulmonary complications, including aortic aneurysm repair, nonresective thoracic surgery, abdominal surgery, neurosurgery, emergency surgery, general anesthesia, head and neck surgery, vascular surgery, and prolonged surgery. Among laboratory predictors, good evidence exists only for serum albumin level less than 30 g/L. Insufficient evidence supports preoperative spirometry as a tool to stratify risk.
For certain risk factors and laboratory predictors, the literature provides only unadjusted estimates of risk. Prescreening, variable selection algorithms, and publication bias limited reporting of risk factors among studies using multivariable analysis.
Selected clinical and laboratory factors allow risk stratification for postoperative pulmonary complications after noncardiothoracic surgery.
Background:
Spirometry is a basic test that provides much information about pulmonary function; it is performed preoperatively in almost all patients undergoing colorectal cancer (CRC) surgery in our hospital. However, the value of spirometry as a preoperative test for CRC surgery remains unknown. The aim of this study was to determine whether spirometry is useful to predict postoperative complications (PCs) after CRC surgery.
Methods:
The medical records of 1236 patients who had preoperative spirometry tests and underwent CRC surgery between 2005 and 2014 were reviewed. Preoperative spirometry results, such as forced vital capacity (FVC), one-second forced expiratory volume (FEV1), %VC (FVC/predicted VC) and FEV1/FVC (%FEV1), were analyzed with regard to PCs, including pneumonia.
Results:
PCs were found in 383 (30.9%) patients, including 218 (56%) with surgical site infections, 67 (17%) with bowel obstruction, 62 (16%) with leakage and 20 (5.2%) with pneumonia. Of the spirometry results, %VC was correlated with PC according to logistic regression analysis (odds ratio, OR = 0.99, 95% confidence interval, CI = 0.98-0.99; P = 0.034). Multivariate analysis after adjusting for male sex, age, laparoscopic surgery, tumor location, operation time and blood loss showed that a lower %VC tends to be a risk factor for PC (OR = 0.99, 95% CI = 0.98-1.002; P = 0.159) and %VC was an independent risk factor for postoperative pneumonia in PCs (OR = 0.97, 95% CI = 0.94-0.99; P = 0.049).
Conclusions:
In CRC surgery, %VC may be a predictor of postoperative complications, especially pneumonia.
Postoperative pulmonary complications (PPCs) are common, costly, and increase patient mortality. Changes to the respiratory system occur immediately on induction of general anaesthesia: respiratory drive and muscle function are altered, lung volumes reduced, and atelectasis develops in>75% of patients receiving a neuromuscular blocking drug. The respiratory system may take 6 weeks to return to its preoperative state after general anaesthesia for major surgery. Risk factors for PPC development are numerous, and clinicians should be aware of non-modifiable and modifiable factors in order to recognize those at risk and optimize their care. Many validated risk prediction models are described. These have been useful for improving our understanding of PPC development, but there remains inadequate consensus for them to be useful clinically. Preventative measures include preoperative optimization of co-morbidities, smoking cessation, and correction of anaemia, in addition to intraoperative protective ventilation strategies and appropriate management of neuromuscular blocking drugs. Protective ventilation includes low tidal volumes, which must be calculated according to the patient's ideal body weight. Further evidence for the most beneficial level of PEEP is required, and on-going randomized trials will hopefully provide more information. When PEEP is used, it may be useful to precede this with a recruitment manoeuvre if atelectasis is suspected. For high-risk patients, surgical time should be minimized. After surgery, nasogastric tubes should be avoided and analgesia optimized. A postoperative mobilization, chest physiotherapy, and oral hygiene bundle reduces PPCs.
Background:
Increasingly patients undergoing non-cardiac surgery are older and have more comorbidities yet pre-operative cardiac assessment appears haphazard and unsystematic. We hypothesized that patients at high cardiac risk were not receiving adequate cardiac assessment and patients with low-cardiac risk were being over-investigated.
Methods:
We examined cardiac assessment patterns prior to elective non-cardiac surgery in a representative sample of patients. Cardiac risk was calculated using the revised cardiac risk index (RCRI).
Results:
Of 671 patients, 589 (88%) were low risk and 82 (12%) were high risk. We found nearly 14% of low risk and 45% of high risk patients had investigations for coronary ischaemia prior to surgery. Vascular surgery had the highest rate of investigation (38%), thoracic patients the lowest rate (14%). Whilst 78% of high risk patients had coronary disease, only 46% were on beta-blockers, 49% on aspirin and 77% on statins. For current smokers (17.3% of cohort, n = 98), 60% were advised to quit pre-op.
Conclusions:
Practice patterns varied across surgical sub-types with low-risk patients tending to be over-investigated and high-risk patients under-investigated. A more systemized approach to this large group of patients could improve clinical outcomes, and more judicious use of investigations could lower health care costs and increase efficiency in managing this cohort.
Objective: The aim of this study was to evaluate the safety of pancreatic resections in patients 80 years or older. Methods: A systematic search of the literature was carried out that compared perioperative outcomes after pancreatic resection in patients 80 years or older with patients younger than 80 years. The primary end points were postoperative mortality and morbidity. The secondary end points were incidence of postoperative pancreatic fistula, delayed gastric emptying, bile leak, pneumonia, postoperative infection, cardiologic complications, reoperation, and length of hospital stay. Results: Nine studies were found to be suitable for the meta-analysis. The postoperative mortality and morbidity were significantly higher in the group 80 years or older (P < 0.00001 and P = 0.003, respectively) except for patients in whom there were no differences in preoperative comorbidities (P = 0.56 and P = 0.36, respectively). Postoperative cardiac complications were significantly more frequent in patients 80 years or older (P < 0.0001), and the length of hospital stay was significantly longer in octogenarian patients (P = 0.008). Conclusions: Patients 80 years or older have an increased incidence of postoperative mortality, morbidity, and cardiac complications and a longer length of hospital stay than do younger patients. Thus, pancreatic resection can be recommended only in a selected group of patients 80 years or older.
Background: The importance of clinical risk factors for postoperative pulmonary complications and the value of preoperative testing to stratify risk are the subject of debate. Purpose: To systematically review the literature on preoperative pulmonary risk stratification before noncardiothoracic surgery. Data Sources: MEDLINE search from 1 January 1980 through 30 June 2005 and hand search of the bibliographies of retrieved articles. Study Selection: English-language studies that reported the effect of patient- and procedure-related risk factors and laboratory predictors on postoperative pulmonary complication rates after noncardiothoracic surgery and that met predefined inclusion criteria. Data Extraction: The authors used standardized abstraction instruments to extract data on study characteristics, hierarchy of research design, study quality, risk factors, and laboratory predictors. Data Synthesis: The authors determined random-effects pooled estimate odds ratios and, when appropriate, trim-and-fill estimates for patient- and procedure-related risk factors from studies that used multivariable analyses. They assigned summary strength of evidence scores for each factor. Good evidence supports patient-related risk factors for postoperative pulmonary complications, including advanced age, American Society of Anesthesiologists class 2 or higher, functional dependence, chronic obstructive pulmonary disease, and congestive heart failure. Good evidence supports procedure-related risk factors for postoperative pulmonary complications, including aortic aneurysm repair, nonresective thoracic surgery, abdominal surgery, neurosurgery, emergency surgery, general anesthesia, head and neck surgery, vascular surgery, and prolonged surgery. Among laboratory predictors, good evidence exists only for serum albumin level less than 30 g/L. Insufficient evidence supports preoperative spirometry as a tool to stratify risk. Limitations: For certain risk factors and laboratory predictors, the literature provides only unadjusted estimates of risk. Prescreening, variable selection algorithms, and publication bias limited reporting of risk factors among studies using multivariable analysis. Conclusions: Selected clinical and laboratory factors allow risk stratification for postoperative pulmonary complications after noncardiothoracic surgery.
Objective:
The aim of this study was to evaluate the safety of pancreatic resections in patients 80 years or older.
Methods:
A systematic search of the literature was carried out that compared perioperative outcomes after pancreatic resection in patients 80 years or older with patients younger than 80 years. The primary end points were postoperative mortality and morbidity. The secondary end points were incidence of postoperative pancreatic fistula, delayed gastric emptying, bile leak, pneumonia, postoperative infection, cardiologic complications, reoperation, and length of hospital stay.
Results:
Nine studies were found to be suitable for the meta-analysis. The postoperative mortality and morbidity were significantly higher in the group 80 years or older (P < 0.00001 and P = 0.003, respectively) except for patients in whom there were no differences in preoperative comorbidities (P = 0.56 and P = 0.36, respectively). Postoperative cardiac complications were significantly more frequent in patients 80 years or older (P < 0.0001), and the length of hospital stay was significantly longer in octogenarian patients (P = 0.008).
Conclusions:
Patients 80 years or older have an increased incidence of postoperative mortality, morbidity, and cardiac complications and a longer length of hospital stay than do younger patients. Thus, pancreatic resection can be recommended only in a selected group of patients 80 years or older.
Pancreaticoduodenectomy is the standard of care for tumors confined to the head of pancreas and can be undertaken with low operative mortality. The procedure has a high morbidity, particularly in older patient populations with preexisting comorbidities. This study evaluated the role of cardiopulmonary exercise testing to predict postoperative morbidity and outcome in high-risk patients undergoing pancreaticoduodenectomy.
In a prospective cohort of consecutive patients undergoing pancreaticoduodenectomy, those aged over 65 years (or younger with comorbidity) were categorized as high risk and underwent preoperative assessment by cardiopulmonary exercise testing (CPET) according to a predefined protocol. Data were collected on functional status, postoperative complications, and survival.
A total of 143 patients underwent preoperative assessment, 50 of whom were deemed to be at low risk for surgery per study protocol. Of 93 high-risk patients, 64 proceeded to surgery after preoperative CPET. Neither anaerobic threshold (AT) nor maximal oxygen consumption ([Formula: see text] O 2 MAX) predicted patient mortality or morbidity. However, ventilatory equivalent of carbon dioxide ([Formula: see text] E/[Formula: see text] CO 2) at AT was a predictive marker of postoperative mortality, with an area under the curve (AUC) of 0.84 (95 % confidence interval [CI] 0.63-1.00, p = 0.020); a threshold of 41 was 75 % sensitive and 95 % specific (positive predictive value 50 %, negative predictive value 98 %). Above this threshold, raised [Formula: see text] E/[Formula: see text] CO 2 predicted poor long-term survival (hazard ratio 2.05, 95 % CI 1.09-3.86, p = 0.026).
CPET is a useful adjunctive test for predicting postoperative outcome in patients being assessed for pancreaticoduodenectomy. Raised CPET-derived [Formula: see text] E/[Formula: see text] CO 2 predicts early postoperative death and poor long-term survival.
The aim of this study was to evaluate the incidence, clinical impact and outcome of perioperative myocardial infarction (PMI) in patients undergoing pancreatic surgery.
A data of 1,625 patients undergoing pancreatic resection were prospectively collected and analysed with regard to PMI. Demographic aspects, co-morbidities and clinical course were evaluated. Cardiac risk factors (ASA and NYHA), postoperative complications and mortality were compared in a match-pair analysis (1:3) with patients without PMI.
Twenty-nine patients with PMI after pancreatic surgery were identified. PMI occurred after all types of pancreatic operations and was observed most frequently (72.2 %) within the first postoperative week. In a total of 90 %, PMI fulfilled the criteria of non-STEMI. Nearly half of the patients (48 %) were clinically asymptomatic. Both ASA III and heart failure were more frequent in patients with PMI. The in-hospital mortality was significantly increased after PMI (p < 0.002), with post-pancreatectomy haemorrhage (PPH) as the most relevant underlying risk factor.
PMI is a rare but severe complication after pancreatic operations, contributing significantly to in-hospital mortality. Clinical management mainly includes an anti-coagulant approach. This may be related with an increased risk for PPH. Therefore, the use of anti-coagulant drugs in the early postoperative period-especially in asymptomatic patients-should be critically evaluated.
Background
Surgery followed by chemotherapy is the primary modality of cure for patients with resectable pancreatic cancer but is associated with significant morbidity. The aim of the present study was to evaluate the role of cardiopulmonary exercise testing (CPET) in predicting post-operative adverse events and fitness for chemotherapy after major pancreatic surgery. Methods
Patients who underwent a pancreaticoduodenectomy or total pancreatectomy for pancreatic head lesions and had undergone pre-operative CPET were included in this retrospective study. Data on patient demographics, comorbidity and results of pre-operative evaluation were collected. Post-operative adverse events, hospital stay and receipt of adjuvant therapy were outcome measures. ResultsOne hundred patients were included. Patients with an anaerobic threshold less than 10ml/kg/min had a significantly greater incidence of a post-operative pancreatic fistula [International Study Group for Pancreatic Surgery (ISGPS) Grades A-C, 35.4% versus 16%, P = 0.028] and major intra-abdominal abscesses [Clavien-Dindo (CD) Grades III-V, 22.4% versus 7.8%, P = 0.042] and were less likely to receive adjuvant therapy [hazard ratio (HR) 6.30, 95% confidence interval (CI) 1.25-31.75, P = 0.026]. A low anaerobic threshold was also associated with a prolonged hospital stay (median 20 versus 14 days, P = 0.005) but not with other adverse events. DiscussionCPET predicts a post-operative pancreatic fistula, major intra-abdominal abscesses as well as length of hospital stay after major pancreatic surgery. Patients with a low anaerobic threshold are less likely to receive adjuvant therapy.
This study evaluated whether coronary artery calcium scores (CACS) and the degree of stenosis that were measured with computed tomography coronary angiography (CTCA) predicted post-operative cardiovascular events in patients who were undergoing intermediate-risk noncardiac surgery.
Cardiovascular complications are important causes of mortality and morbidity in patients undergoing major noncardiac surgeries.
A total of 239 patients underwent CTCA before intermediate-risk noncardiac surgeries. We measured CACS and the degree of stenosis with CTCA and assessed clinical risk factors according to the revised cardiac risk index (RCRI) scores. Post-operative cardiovascular events were defined as cardiac death, acute coronary syndrome, pulmonary edema, ventricular arrhythmia with hemodynamic compromise, and complete heart block.
Nineteen patients (8%) had post-operative cardiac events. The variables that correlated with the occurrence of cardiac events were RCRI (p < 0.001), CACS (p < 0.001), the presence of significant coronary artery stenosis (diameter stenosis ≥50%) (p = 0.01), and multivessel coronary artery disease (p < 0.001). In the receiver-operating characteristic (ROC) curve analysis of CACS for prediction of cardiac events, the cutoff value was 113 (sensitivity, 0.79; specificity, 0.61; area under the curve, 0.762). When comparing ROC curves of the combination models of RCRI, high CACS (≥113), and the presence of multivessel disease, RCRI plus high CACS, RCRI plus multivessel disease, and RCRI plus high CACS plus multivessel disease were significantly more predictable of post-operative cardiovascular events than RCRI alone.
In the pre-operative risk stratification of patients who were undergoing intermediate-risk noncardiac surgeries, CTCA evaluations showed additive value to RCRI.
Our objective was to revise the definition of acute respiratory distress syndrome (ARDS) using a conceptual model incorporating reliability and validity, and a novel iterative approach with formal evaluation of the definition.
The European Society of Intensive Care Medicine identified three chairs with broad expertise in ARDS who selected the participants and created the agenda. After 2 days of consensus discussions a draft definition was developed, which then underwent empiric evaluation followed by consensus revision.
The Berlin Definition of ARDS maintains a link to prior definitions with diagnostic criteria of timing, chest imaging, origin of edema, and hypoxemia. Patients may have ARDS if the onset is within 1 week of a known clinical insult or new/worsening respiratory symptoms. For the bilateral opacities on chest radiograph criterion, a reference set of chest radiographs has been developed to enhance inter-observer reliability. The pulmonary artery wedge pressure criterion for hydrostatic edema was removed, and illustrative vignettes were created to guide judgments about the primary cause of respiratory failure. If no risk factor for ARDS is apparent, however, objective evaluation (e.g., echocardiography) is required to help rule out hydrostatic edema. A minimum level of positive end-expiratory pressure and mutually exclusive PaO(2)/FiO(2) thresholds were chosen for the different levels of ARDS severity (mild, moderate, severe) to better categorize patients with different outcomes and potential responses to therapy.
This panel addressed some of the limitations of the prior ARDS definition by incorporating current data, physiologic concepts, and clinical trials results to develop the Berlin definition, which should facilitate case recognition and better match treatment options to severity in both research trials and clinical practice.
Age is often the sole criterion for determining the need for preoperative electrocardiograms. However, screening electrocardiograms have not been shown to add value above clinical information. This study was designed to determine whether it is possible to target electrocardiograms ordering to patients most likely to have an abnormality that would affect management and if age alone is predictive of significant electrocardiograms abnormalities.
A list was developed of electrocardiograms abnormalities considered significant enough to impact management, as well as a list of patient factors believed to increase cardiovascular risk. electrocardiograms in all patients over 50 yr of age presenting for preoperative evaluation during a 2-month period were reviewed.
A total of 1,149 electrocardiograms were reviewed, with 89 patients (7.8%) having at least one significant abnormality. These patients were compared with a group of 195 patients who had electrocardiograms that did not contain significant abnormalities. Patients at higher risk of having a significantly abnormal electrocardiograms that would potentially affect management were those older than 65 yr of age or who had a history of heart failure, high cholesterol, angina, myocardial infarction, or severe valvular disease. Five patients (0.44%) had an abnormal electrocardiograms in the absence of risk factors. The sensitivity of the model is 87.6%.
Age greater than 65 yr remains an independent predictor for significant preoperative electrocardiograms abnormalities. The specific clinical risk factors that were found have a high sensitivity and identified all but 0.44% of patients with electrocardiograms abnormalities that may affect preoperative management.
A multicentre retrospective study was carried out to analyse short- and long-term results of 787 pancreatic resections performed for cancer between 1982 and 1988. The postoperative mortality rate was 10 per cent and the morbidity rate 35 per cent. Age above 70 years and systemic organ failure independently influenced operative mortality. In patients surviving more than 30 days the median survival was 12.3 months and the actuarial survival rate at 5 years 12 per cent. The 5-year survival rate was lower for patients with lymph node involvement than for those without (4 versus 20 per cent, P = 0.001). The operative mortality rate was higher after total pancreatectomy than pancreatoduodenectomy (17 versus 8 per cent, P = 0.015). The median survival time and 5-year survival rate after total pancreatectomy and pancreatoduodenectomy were 11 versus 14 months and 3 versus 15 per cent respectively. Of the clinical and pathological factors studied, location of the tumour in the left pancreas was most strongly related to survival, with no survivors at 4 years. These results suggest that resection should be avoided in patients over 70 years old with systemic organ failure. Pancreatoduodenectomy remains the best procedure for resection, total pancreatectomy being performed only in patients with multifocal carcinoma or those in whom a safe pancreatic anastomosis cannot be constructed.
Intra-abdominal operations are relatively high risk for pulmonary complications. Previous research has more intensely investigated cardiac operative risk, but recent work suggests that significant pulmonary complications may be more common than cardiac complications and associated with longer length of stay. This study identified risk indicators for pulmonary complications after elective abdominal operations.
Nested case-control.
University affiliated Veterans Affairs hospital.
We used a computerized registry of all 2,291 patients undergoing elective abdominal operations from 1982 to 1991. Ascertainment and verification of pulmonary and cardiac complications were systematic and explicit. Charts of all 116 patients identified by the registry as having complications and 412 (19%) randomly selected from 2,175 remaining patients were reviewed to verify complications, using explicit criteria and independent abstraction of preoperative and postoperative components of charts. From 528 validated subjects (23% of the cohort), 82 cases and 82 control subjects were closely matched by operation type and age, +/- 10 years.
The primary outcome measure was postoperative pulmonary complications. Among 82 cases with pulmonary complications, 27 (33%) also had cardiac complications. Preoperative variables independently associated with pulmonary complications by multivariable analysis (p < or = 0.05) included the following: Charlson comorbidity index (per point odds ratio [OR], 1.6; 95% confidence interval [CI], 1.004 to 2.6), Goldman cardiac risk index (per point OR, 2.04; 95% CI, 1.17 to 3.6), abnormal chest radiograph (OR, 3.2; 95% CI, 1.07 to 9.4), and abnormal findings on lung examination (OR, 5.8; 95% CI, 1.04 to 32). Equal proportions of cases and control subjects had preoperative diagnostic spirometry. No component of spirometry predicted complications, including severity of obstructive lung disease.
For pulmonary operative risk, abnormal results of lung examination and chest radiography plus cardiac and overall comorbidity were important. Spirometry was not helpful. Because 33% of cases had both cardiac and pulmonary complications, future studies should prospectively examine comparative incidence, outcomes, and predictors of both type of complications.
To examine the effect of preoperative smoking behavior on postoperative pulmonary complications.
Prospective cohort study.
The Veterans Administration Medical Center, Syracuse, NY.
Patients scheduled for noncardiac elective surgery (n=410).
Smoking status was determined by self-report. Postoperative pulmonary complications were determined by systematic extraction of medical record data. Postoperative pulmonary complications occurred in 31 of 141 (22.0%) current smokers, 24 of 187 (12.8%) past smokers, and 4 of 82 (4.9%) never smokers. The odds ratio (OR) for developing a postoperative pulmonary complication for current smokers vs never smokers was 5.5 (95% confidence interval [CI], 1.9 to 16.2) and 4.2 (95% CI, 1.2 to 14.8) after adjustment for type of surgery, type of anesthesia, abnormal chest radiograph, chronic cough, history of pulmonary disease, history of cardiac disease, history of COPD, education level, pulmonary function, body mass index, and age. Current smokers who reported reducing cigarette consumption prior to surgery were more likely to develop a complication compared with those who did not (adjusted OR=6.7, 95% CI, 2.6 to 17.1).
Current smoking was associated with a nearly sixfold increase in risk for a postoperative pulmonary complication. Reduction in smoking within 1 month of surgery was not associated with a decreased risk of postoperative pulmonary complications.
Most evidence guiding perioperative medical risk management of patients undergoing hip fracture repair focuses on cardiac and thromboembolic risk. Little is known of the relative clinical importance of other complications.
To systematically map incidence and outcomes of a broad spectrum of medical complications after hip fracture repair.
Retrospective cohort study of patients 60 years or older in 20 academic, community, and Veterans Affairs hospitals. Data on complications and mortality were abstracted from medical records by trained abstractors using standardized, pretested forms or the National Death Index.
Of 8930 patients, 1737 (19%) had postoperative medical complications. Cardiac and pulmonary complications were most frequent (8% and 4% of patients, respectively). Similar numbers of patients had serious cardiac or pulmonary complications (2% and 3%, respectively). Other complications were gastrointestinal tract bleeding (2%), combined cardiopulmonary complications (1%), venous thromboembolism (1%), and transient ischemic attack or stroke (1%). Renal failure and septic shock were rare. After the index complication, 416 patients had 587 additional complications. Mortality was similar for serious cardiac or pulmonary complications (30 day: 22% and 17%, respectively; 1 year: 36% and 44%, respectively) and highest for patients with multiple complications (30 day: 29%-38%; 1 year: 43%-62%). Complications and death occurred significantly earlier for serious cardiac than for serious pulmonary complications (1 vs 4 days, 2 vs 8 days, P<.001); length of stay for patients surviving these complications was similar.
Most patients had no medical complications after hip fracture repair. Serious cardiac and pulmonary complications were equally important in frequency, mortality, and survivors' length of stay. Patients with multiple complications had especially poor prognosis.
Elderly patients undergoing pancreatic resection present unique challenges in postoperative care. Although mortality rates among elderly patients after pancreatectomy at high-volume centers is known to be low, the anticipated decline in functional status and nutritional parameters has received little attention. Functional decline is an unrecognized but critically important consequence of pancreatic resection in older patients.
This study is a retrospective review, validation cohort, of older and younger patients undergoing major pancreatic resection. The setting is the state of California (database of all hospitals in the state) and The University of California, San Francisco (UCSF; a tertiary care referral center). The study population is a consecutive sample of older (greater than or equal to 75 years) and younger (16 to 74 years) patients from California (January 1990 to December 1996; n = 3,113) and UCSF (January 1993 to November 2000; n = 218), who underwent radical pancreaticoduodenectomy, distal pancreatectomy, or total pancreatectomy for neoplasia. The main outcomes measures were length of stay, complications, mortality, discharge disposition, supplemental nutrition requirement, and readmissions.
Elderly patients had higher mortality rates than the young statewide (10% versus 7%, p = 0.006). Although the 3% mortality at UCSF was the same for both groups, older patients were more often admitted to the ICU (47% versus 20%, p = 0.003), treated for major cardiac events (13% versus 0.5%, p < 0.001), discharged with enteral tube feedings (48% versus 16%, p < 0.001), or malnourished on readmission (17% versus 2%, p < 0.005). Older patients were more frequently discharged to skilled nursing facilities (17% versus 1% at UCSF; 24% versus 7% in California; p < 0.001, both groups).
Older patients are more likely than younger patients to require an ICU stay, suffer a cardiac complication, and experience compromised nutritional and functional status after major pancreatic resection.
To define a simple and reproducible classification of complications following pancreaticoduodenectomy (PD) based on a therapy-oriented severity grading system.
While mortality is rare after PD, morbidity rates remain high. The lack of standardization in evaluating morbidity after PD has severely hampered meaningful comparisons over time and among centers. We adapted a novel classification of complication to stratify morbidity by severity after PD, to test whether the incidence of pancreatic fistula has changed over time, and to identify risk factors in a single North American center.
The classification was applied to a consecutive series of 633 patients undergoing PD between February 2003 and August 2005. Another series of 141 patients treated between 1987 and 1990 was also analyzed to identify changes in the incidence and severity of fistula. Univariate and multivariate analyses were performed to link respective complications with preoperative and intraoperative parameters, length of hospital stay, and long-term survival.
A total of 263 (41.5%) patients did not develop any complication, while 370 (58.5%) had at least one complication; 62 (10.0%) patients had only grade I complications (no need for specific intervention), 192 patients (30.0%) had grade II (need for drug therapy such as antibiotics), 85 patients (13.5%) had grade III (need for invasive therapy), and 19 patients (3.0%) had grade IV complications (organ dysfunction with ICU stay). Grade V (death) occurred in 12 patients (2.0%). A total of 57 patients (9.0%) developed pancreatic fistula, of which 33 (58.0%) were classified as grade II, 17 (30.0%) as grade III, 5 (9.0%) as grade IV, and 2 (3.5%) as grade V. Delayed gastric emptying was documented in 80 patients (12.7%); half of them were scored as grade II and the other half as grade III. A significant decrease in the incidence of fistula was observed between the 2 periods analyzed (14.0% vs. 9.0%, P < 0.001), mostly due to a decrease in grade II fistula. Cardiovascular disease was a risk factor for overall morbidity and complication severity, while texture of the gland and cardiovascular disease were risk factors for pancreatic fistula.
This study demonstrates the applicability and utility of a new classification in grading complications following pancreatic surgery. This novel approach may provide a standardized, objective, and reproducible assessment of pancreas surgery enabling meaningful comparison among centers and over time.
Postoperative hemorrhage is one of the most severe complications after pancreatic surgery. Due to the lack of an internationally accepted, universal definition of postpancreatectomy hemorrhage (PPH), the incidences reported in the literature vary considerably, even in reports from randomized controlled trials. Because of these variations in the definition of what constitutes a PPH, the incidences of its occurrence are not comparable.
The International Study Group of Pancreatic Surgery (ISGPS) developed an objective, generally applicable definition of PPH based on a literature review and consensus clinical experience.
Postpancreatectomy hemorrhage is defined by 3 parameters: onset, location, and severity. The onset is either early (< or =24 hours after the end of the index operation) or late (>24 hours). The location is either intraluminal or extraluminal. The severity of bleeding may be either mild or severe. Three different grades of PPH (grades A, B, and C) are defined according to the time of onset, site of bleeding, severity, and clinical impact.
An objective, universally accepted definition and clinical grading of PPH is important for the appropriate management and use of interventions in PPH. Such a definition also would allow comparisons of results from future clinical trials. Such standardized definitions are necessary to compare, in a nonpartisan manner, the outcomes of studies and the evaluation of novel operative treatment modalities in pancreatic surgery.
Pancreatic resection is the only treatment option that can lead to a meaningful prolonged survival in pancreatic cancer and, in some instances, perhaps a potential chance for cure. With the advent of organ and function preserving procedures, its use in the treatment of chronic pancreatitis and other less common benign diseases of the pancreas is increasing. Furthermore, over the past two decades, with technical advances and centralization of care, pancreatic surgery has evolved into a safe procedure with mortality rates of <5%. However, postoperative morbidity rates are still substantial. This article reviews the more common procedure-related complications, their prevention and their treatment.
Perioperative management and anaesthetic considerations for pancreatic resection surgery
- Pais Hughest
Results of resection for cancer of the exocrine pancreas: a study from the French Association of Surgery
- Baumel H
Pancreatic resection in patients 80 years or older: a meta‐analysis and systematic review
- Casadei R