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Sample records for risk surgical patients

  1. Risk Factors for Urinary Tract Infections in Cardiac Surgical Patients

    PubMed Central

    Gillen, Jacob R.; Isbell, James M.; Michaels, Alex D.; Lau, Christine L.

    2015-01-01

    Abstract Background: Risk factors for catheter-associated urinary tract infections (CAUTIs) in patients undergoing non-cardiac surgical procedures have been well documented. However, the variables associated with CAUTIs in the cardiac surgical population have not been clearly defined. Therefore, the purpose of this study was to investigate risk factors associated with CAUTIs in patients undergoing cardiac procedures. Methods: All patients undergoing cardiac surgery at a single institution from 2006 through 2012 (4,883 patients) were reviewed. Patients with U.S. Centers for Disease Control (CDC) criteria for CAUTI were identified from the hospital's Quality Assessment database. Pre-operative, operative, and post-operative patient factors were evaluated. Univariate and multivariable analyses were used to identify significant correlations between perioperative characteristics and CAUTIs. Results: There were 55 (1.1%) documented CAUTIs in the study population. On univariate analysis, older age, female gender, diabetes mellitus, cardiogenic shock, urgent or emergent operation, packed red blood cell (PRBC) units transfused, and intensive care unit length of stay (ICU LOS) were all significantly associated with CAUTI [p<0.05]. On multivariable logistic regression, older age, female gender, diabetes mellitus, and ICU LOS remained significantly associated with CAUTI. Additionally, there was a significant association between CAUTI and 30-d mortality on univariate analysis. However, when controlling for common predictors of operative mortality on multivariable analysis, CAUTI was no longer associated with mortality. Conclusions: There are several identifiable risk factors for CAUTI in patients undergoing cardiac procedures. CAUTI is not independently associated with increased mortality, but it does serve as a marker of sicker patients more likely to die from other comorbidities or complications. Therefore, awareness of the high-risk nature of these patients should lead to

  2. Risk Factors for Urinary Tract Infections in Cardiac Surgical Patients.

    PubMed

    Gillen, Jacob R; Isbell, James M; Michaels, Alex D; Lau, Christine L; Sawyer, Robert G

    2015-10-01

    Risk factors for catheter-associated urinary tract infections (CAUTIs) in patients undergoing non-cardiac surgical procedures have been well documented. However, the variables associated with CAUTIs in the cardiac surgical population have not been clearly defined. Therefore, the purpose of this study was to investigate risk factors associated with CAUTIs in patients undergoing cardiac procedures. All patients undergoing cardiac surgery at a single institution from 2006 through 2012 (4,883 patients) were reviewed. Patients with U.S. Centers for Disease Control (CDC) criteria for CAUTI were identified from the hospital's Quality Assessment database. Pre-operative, operative, and post-operative patient factors were evaluated. Univariate and multivariable analyses were used to identify significant correlations between perioperative characteristics and CAUTIs. There were 55 (1.1%) documented CAUTIs in the study population. On univariate analysis, older age, female gender, diabetes mellitus, cardiogenic shock, urgent or emergent operation, packed red blood cell (PRBC) units transfused, and intensive care unit length of stay (ICU LOS) were all significantly associated with CAUTI [p<0.05]. On multivariable logistic regression, older age, female gender, diabetes mellitus, and ICU LOS remained significantly associated with CAUTI. Additionally, there was a significant association between CAUTI and 30-d mortality on univariate analysis. However, when controlling for common predictors of operative mortality on multivariable analysis, CAUTI was no longer associated with mortality. There are several identifiable risk factors for CAUTI in patients undergoing cardiac procedures. CAUTI is not independently associated with increased mortality, but it does serve as a marker of sicker patients more likely to die from other comorbidities or complications. Therefore, awareness of the high-risk nature of these patients should lead to increased diligence and may help to improve peri

  3. [Risk factors for surgical site infections in patients undergoing craniotomy].

    PubMed

    Cha, Kyeong-Sook; Cho, Ok-Hee; Yoo, So-Yeon

    2010-04-01

    The objectives of this study were to determine the prevalence, incidence, and risk factors for postoperative surgical site infections (SSIs) after craniotomy. This study was a retrospective case-control study of 103 patients who had craniotomies between March 2007 and December 2008. A retrospective review of prospectively collected databases of consecutive patients who underwent craniotomy was done. SSIs were defined by using the Centers for Disease Control criteria. Twenty-six cases (infection) and 77 controls (no infection) were matched for age, gender and time of surgery. Descriptive analysis, t-test, X(2)-test and logistic regression analyses were used for data analysis. The statistical difference between cases and controls was significant for hospital length of stay (>14 days), intensive care unit stay more than 15 days, Glasgrow Coma Scale (GCS) score (< or = 7 days), extra-ventricular drainage and coexistent infection. Risk factors were identified by logistic regression and included hospital length of stay of more than 14 days (odds ratio [OR]=23.39, 95% confidence interval [CI]=2.53-216.11) and GCS score (< or = 7 scores) (OR=4.71, 95% CI=1.64-13.50). The results of this study show that patients are at high risk for infection when they have a low level of consciousness or their length hospital stay is long term. Nurses have to take an active and continuous approach to infection control to help with patients having these risk factors.

  4. Nutritional risk and status of surgical patients; the relevance of nutrition training of medical students.

    PubMed

    Ferreira, C; Lavinhas, C; Fernandes, L; Camilo, Ma; Ravasco, P

    2012-01-01

    The prevalence of undernutrition among surgical patients is thought to be high, and negatively influencing outcomes. However, recent evidence shows the increase of overweight/obesity in hospitalised patients. A pilot cross-sectional study was conducted in 50 patients of a Surgical Department of the University Hospital of Santa Maria (CHLN) that aimed: 1) to assess nutritional risk and status through validated methods; 2) to explore the presence of overweight/obesity; 3) to evaluate the prevalence of metabolic risk associated with obesity. Nutritional risk was assessed by Malnutrition Universal Screening Tool (MUST), nutritional status by Body Mass Index (BMI), waist circumference (WC), & Subjective Global Assessment (SGA). Statistical significance was set for p < 0.05. 58% of patients were overweight/obese and 54% had high cardio-metabolic risk, according to waist circumference; 30% of patients had significantly lost weight (≥ 5%), whereas 28% gained weight. By MUST, 46% of patients were at low risk and 34% at high risk. By SGA, 58% patients were well nourished and 40% had moderate/severe undernutrition. A longer length of stay was associated with moderate/high risk by MUST, and undernutrition by SGA (p = 0.01). Undernutrition or obesity pose surgical risks. The lack of nutrition discipline in the medical curricula, limits the multiprofessional management and a better understanding of the more adequate approaches to these patients. Further, the change in the clinical scenario argues for more studies to clarify the prevalence and consequences of sarcopenic obesity in surgical patients.

  5. Surgical or Transcatheter Aortic-Valve Replacement in Intermediate-Risk Patients.

    PubMed

    Reardon, Michael J; Van Mieghem, Nicolas M; Popma, Jeffrey J; Kleiman, Neal S; Søndergaard, Lars; Mumtaz, Mubashir; Adams, David H; Deeb, G Michael; Maini, Brijeshwar; Gada, Hemal; Chetcuti, Stanley; Gleason, Thomas; Heiser, John; Lange, Rüdiger; Merhi, William; Oh, Jae K; Olsen, Peter S; Piazza, Nicolo; Williams, Mathew; Windecker, Stephan; Yakubov, Steven J; Grube, Eberhard; Makkar, Raj; Lee, Joon S; Conte, John; Vang, Eric; Nguyen, Hang; Chang, Yanping; Mugglin, Andrew S; Serruys, Patrick W J C; Kappetein, Arie P

    2017-04-06

    Although transcatheter aortic-valve replacement (TAVR) is an accepted alternative to surgery in patients with severe aortic stenosis who are at high surgical risk, less is known about comparative outcomes among patients with aortic stenosis who are at intermediate surgical risk. We evaluated the clinical outcomes in intermediate-risk patients with severe, symptomatic aortic stenosis in a randomized trial comparing TAVR (performed with the use of a self-expanding prosthesis) with surgical aortic-valve replacement. The primary end point was a composite of death from any cause or disabling stroke at 24 months in patients undergoing attempted aortic-valve replacement. We used Bayesian analytical methods (with a margin of 0.07) to evaluate the noninferiority of TAVR as compared with surgical valve replacement. A total of 1746 patients underwent randomization at 87 centers. Of these patients, 1660 underwent an attempted TAVR or surgical procedure. The mean (±SD) age of the patients was 79.8±6.2 years, and all were at intermediate risk for surgery (Society of Thoracic Surgeons Predicted Risk of Mortality, 4.5±1.6%). At 24 months, the estimated incidence of the primary end point was 12.6% in the TAVR group and 14.0% in the surgery group (95% credible interval [Bayesian analysis] for difference, -5.2 to 2.3%; posterior probability of noninferiority, >0.999). Surgery was associated with higher rates of acute kidney injury, atrial fibrillation, and transfusion requirements, whereas TAVR had higher rates of residual aortic regurgitation and need for pacemaker implantation. TAVR resulted in lower mean gradients and larger aortic-valve areas than surgery. Structural valve deterioration at 24 months did not occur in either group. TAVR was a noninferior alternative to surgery in patients with severe aortic stenosis at intermediate surgical risk, with a different pattern of adverse events associated with each procedure. (Funded by Medtronic; SURTAVI ClinicalTrials.gov number

  6. Different perception of surgical risks between physicians and patients undergoing laparoscopic cholecystectomy.

    PubMed

    Tuveri, Massimiliano; Caocci, Giovanni; Efficace, Fabio; Medas, Fabio; Collins, Gary S; Pisu, Salvatore

    2009-08-01

    Data on the quality of communication during informed consent for surgery is sparse; we investigated this issue in a cohort of patients undergoing laparoscopic cholecystectomy (LC). Two hundred and seven consecutive patients with benign biliary disease who had undergone LC completed 2 questionnaires. We investigated the patient choice to undergo the surgical procedure along with perceptions of risk complications presented by the surgeon. Nineteen attending surgeons also completed a questionnaire giving information on their recall perception on the information they provided. Multiple logistic regression analyses determined the predictors of perceived communication factors during the informed consent process. One hundred eighty-one patients (87.4%) returned questionnaires. Younger patients (<50 y) with lower education perceived higher level of risk complications compared with older and higher educated patients (P=0.04 and P<0.001). Younger patients felt psychologic support was necessary (P<0.001) and that quality of life issues related to the interventions were under addressed (P=0.018). Differences were observed between patients' recalled risk of complications and the risk to convert LC to open laparotomy and physicians' perception of information provided to patients regarding these aspects (P<0.01). Although informed consent for surgical procedures requires that the procedures are explained and that the patient understands the procedures and risks, our data suggest different perceptions of the quality of information provided during this process between patients and physicians. Physicians should be aware that surgical risks might be perceived differently by patients and this perception might be influenced, for example, by patients' age and education. Major efforts should be directed to improve communications skills in surgical laparoscopy.

  7. Optimizing ACS NSQIP modeling for evaluation of surgical quality and risk: patient risk adjustment, procedure mix adjustment, shrinkage adjustment, and surgical focus.

    PubMed

    Cohen, Mark E; Ko, Clifford Y; Bilimoria, Karl Y; Zhou, Lynn; Huffman, Kristopher; Wang, Xue; Liu, Yaoming; Kraemer, Kari; Meng, Xiangju; Merkow, Ryan; Chow, Warren; Matel, Brian; Richards, Karen; Hart, Amy J; Dimick, Justin B; Hall, Bruce L

    2013-08-01

    The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) collects detailed clinical data from participating hospitals using standardized data definitions, analyzes these data, and provides participating hospitals with reports that permit risk-adjusted comparisons with a surgical quality standard. Since its inception, the ACS NSQIP has worked to refine surgical outcomes measurements and enhance statistical methods to improve the reliability and validity of this hospital profiling. From an original focus on controlling for between-hospital differences in patient risk factors with logistic regression, ACS NSQIP has added a variable to better adjust for the complexity and risk profile of surgical procedures (procedure mix adjustment) and stabilized estimates derived from small samples by using a hierarchical model with shrinkage adjustment. New models have been developed focusing on specific surgical procedures (eg, "Procedure Targeted" models), which provide opportunities to incorporate indication and other procedure-specific variables and outcomes to improve risk adjustment. In addition, comparative benchmark reports given to participating hospitals have been expanded considerably to allow more detailed evaluations of performance. Finally, procedures have been developed to estimate surgical risk for individual patients. This article describes the development of, and justification for, these new statistical methods and reporting strategies in ACS NSQIP. Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

  8. Risk factors for gallbladder contractility after cholecystolithotomy in elderly high-risk surgical patients

    PubMed Central

    Wang, Tao; Luo, Hao; Yan, Hong-tao; Zhang, Guo-hu; Liu, Wei-hui; Tang, Li-jun

    2017-01-01

    Objective Cholecystolithiasis is a common disease in the elderly patient. The routine therapy is open or laparoscopic cholecystectomy. In the previous study, we designed a minimally invasive cholecystolithotomy based on percutaneous cholecystostomy combined with a choledochoscope (PCCLC) under local anesthesia. Methods To investigate the effect of PCCLC on the gallbladder contractility function, PCCLC and laparoscope combined with a choledochoscope were compared in this study. Results The preoperational age and American Society of Anesthesiologists (ASA) scores, as well as postoperational lithotrity rate and common biliary duct stone rate in the PCCLC group, were significantly higher than the choledochoscope group. However, the pre- and postoperational gallbladder ejection fraction was not significantly different. Univariable and multivariable logistic regression analyses indicated that the preoperational thickness of gallbladder wall (odds ratio [OR]: 0.540; 95% confidence interval [CI]: 0.317–0.920; P=0.023) and lithotrity (OR: 0.150; 95% CI: 0.023–0.965; P=0.046) were risk factors for postoperational gallbladder ejection fraction. The area under receiver operating characteristics curve was 0.714 (P=0.016; 95% CI: 0.553–0.854). Conclusion PCCLC strategy should be carried out cautiously. First, restricted by the diameter of the drainage tube, the PCCLC should be used only for small gallstones in high-risk surgical patients. Second, the usage of lithotrity should be strictly limited to avoid undermining the gallbladder contractility and increasing the risk of secondary common bile duct stones. PMID:28138229

  9. Risk factors for venous thromboembolic events in pediatric surgical patients: Defining indications for prophylaxis.

    PubMed

    Cairo, Sarah B; Lautz, Timothy B; Schaefer, Beverly A; Yu, Guan; Naseem, Hibbut-Ur-Rauf; Rothstein, David H

    2017-12-27

    Venous thromboembolism (VTE) in pediatric surgical patients is a rare event. The risk factors for VTE in pediatric general surgery patients undergoing abdominopelvic procedures are unknown. The American College of Surgeon's National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database (2012-2015) was queried for patients with VTE after abdominopelvic general surgery procedures. Patient and operative variables were assessed to identify risk factors associated with VTE and develop a pediatric risk score. From 2012-2015, 68 of 34,813 (0.20%) patients who underwent abdominopelvic general surgery procedures were diagnosed with VTE. On multivariate analysis, there was no increased risk of VTE based on concomitant malignancy, chemotherapy, inflammatory bowel disease, or laparoscopic surgical approach, while a higher rate of VTE was identified among female patients. The odds of experiencing VTE were increased on stepwise regression for patients older than 15 years and those with preexisting renal failure or a diagnosis of septic shock, patients with American Society of Anesthesia (ASA) classification ≥ 2, and for anesthesia time longer than 2 h. The combination of age > 15 years, ASA classification ≥ 2, anesthesia time > 2 h, renal failure, and septic shock was included in a model for predicting risk of VTE (AUC = 0.907, sensitivity 84.4%, specificity 88.2%). VTE is rare in pediatric patients, but prediction modeling may help identify those patients at heightened risk. Additional studies are needed to validate the factors identified in this study in a risk assessment model as well as to assess the efficacy and cost-effectiveness of prophylaxis methods. Level III, retrospective comparative study. Copyright © 2018. Published by Elsevier Inc.

  10. Clinical risk stratification in patients with surgically resectable micropapillary bladder cancer.

    PubMed

    Fernández, Mario I; Williams, Stephen B; Willis, Daniel L; Slack, Rebecca S; Dickstein, Rian J; Parikh, Sahil; Chiong, Edmund; Siefker-Radtke, Arlene O; Guo, Charles C; Czerniak, Bogdan A; McConkey, David J; Shah, Jay B; Pisters, Louis L; Grossman, H Barton; Dinney, Colin P N; Kamat, Ashish M

    2017-05-01

    To analyse survival in patients with clinically localised, surgically resectable micropapillary bladder cancer (MPBC) undergoing radical cystectomy (RC) with and without neoadjuvant chemotherapy (NAC) and develop risk strata based on outcome data. A review of our database identified 103 patients with surgically resectable (≤cT4acN0 cM0) MPBC who underwent RC. Survival estimates were calculated using Kaplan-Meier method and compared using log-rank tests. Classification and regression tree (CART) analysis was performed to identify risk groups for survival. For the entire cohort, estimated 5-year overall survival and disease-specific survival (DSS) rates were 52% and 58%, respectively. CART analysis identified three risk subgroups: low-risk: cT1, no hydronephrosis; high-risk: ≥cT2, no hydronephrosis; and highest-risk: cTany with tumour-associated hydronephrosis. The 5-year DSS for the low-, high-, and highest-risk groups were 92%, 51%, and 17%, respectively (P < 0.001). Patients down-staged at RC patients with surgically resectable MPBC, NAC appears to confer benefit to patients with muscle-invasive disease without hydronephrosis, while patients with cT1 disease can proceed to upfront RC. Patients with hydronephrosis do not appear to respond well to NAC and have poor prognosis regardless of treatment paradigm. However, further external validation studies are needed to support the proposed risk stratification before treatment recommendations can be made. © 2016 The Authors BJU International © 2016 BJU International Published by John Wiley & Sons Ltd.

  11. Risk factors in surgical management of thoracic empyema in elderly patients.

    PubMed

    Hsieh, Ming-Ju; Liu, Yun-Hen; Chao, Yin-Kai; Lu, Ming-Shian; Liu, Hui-Ping; Wu, Yi-Cheng; Lu, Hung-I; Chu, Yen

    2008-06-01

    Although elderly patients with thoracic disease were considered to be poor candidates for thoracotomy before, recent advances in preoperative and postoperative care as well as surgical techniques have improved outcomes of thoracotomies in this patient group. The aim of this study was to investigate surgical risk factors and results in elderly patients (aged > or =70 years) with thoracic empyema. Seventy-one elderly patients with empyema thoracis were enrolled and evaluated from July 2000 to April 2003. The following characteristics and clinical data were analysed: age, sex, aetiology of empyema, comorbid diseases, preoperative conditions, postoperative days of intubation, length of hospital stay after surgery, complications and mortality. Surgical intervention, including total pneumonolysis and evacuation of the pleura empyema cavity, was carried out in all patients. Possible influent risk factors on the outcome were analysed. The sample group included 54 men and 17 women with an average age of 76.8 years. The causes of empyema included parapneumonic effusion (n = 43), lung abscess (n = 8), necrotizing pneumonitis (n = 8), malignancy (n = 5), cirrhosis (n = 2), oesophageal perforation (n = 2), post-traumatic empyema (n = 2) and post-thoracotomy complication (n = 1). The 30-day mortality rate was 11.3% and the in-hospital mortality rate was 18.3% (13 of 71). Mean follow up was 9.4 months and mean duration of postoperative hospitalization was 35.8 days. Analysis of risk factors showed that patients with necrotizing pneumonitis or abscess had the highest mortality rate (10 of 18, 62.6%). The second highest risk factor was preoperative intubation or ventilator-dependency (8 of 18, 44.4%). This study presents the clinical features and outcomes of 71 elderly patients with empyema thoracis who underwent surgical treatment. The 30-day surgical mortality rate was 11.3%. Significant risk factors in elderly patients with empyema thoracis were necrotizing pneumonitis, abscess

  12. Surgical errors and risks – the head and neck cancer patient

    PubMed Central

    Harréus, Ulrich

    2013-01-01

    Head and neck surgery is one of the basic principles of head and neck cancer therapy. Surgical errors and malpractice can have fatal consequences for the treated patients. It can lead to functional impairment and has impact in future chances for disease related survival. There are many risks for head and neck surgeons that can cause errors and malpractice. To avoid surgical mistakes, thorough preoperative management of patients is mandatory. As there are ensuring operability, cautious evaluation of preoperative diagnostics and operative planning. Moreover knowledge of anatomical structures of the head and neck, of the medical studies and data as well as qualification in modern surgical techniques and the surgeons ability for critical self assessment are basic and important prerequisites for head and neck surgeons in order to make out risks and to prevent from mistakes. Additionally it is important to have profound knowledge in nutrition management of cancer patients, wound healing and to realize and to be able to deal with complications, when they occur. Despite all precaution and surgical care, errors and mistakes cannot always be avoided. For that it is important to be able to deal with mistakes and to establish an appropriate and clear communication and management for such events. The manuscript comments on recognition and prevention of risks and mistakes in the preoperative, operative and postoperative phase of head and neck cancer surgery. PMID:24403972

  13. Risk factors for reinsertion of urinary catheter after early removal in thoracic surgical patients.

    PubMed

    Young, John; Geraci, Travis; Milman, Steven; Maslow, Andrew; Jones, Richard N; Ng, Thomas

    2018-03-08

    To reduce the incidence of urinary tract infection, Surgical Care Improvement Project 9 mandates the removal of urinary catheters within 48 hours postoperatively. In patients with thoracic epidural anesthesia, we sought to determine the rate of catheter reinsertion, the complications of reinsertion, and the factors associated with reinsertion. We conducted a prospective observational study of consecutive patients undergoing major pulmonary or esophageal resection with thoracic epidural analgesia over a 2-year period. As per Surgical Care Improvement Project 9, all urinary catheters were removed within 48 hours postoperatively. Excluded were patients with chronic indwelling catheter, patients with urostomy, and patients requiring continued strict urine output monitoring. Multivariable logistic regression analysis was used to identify independent risk factors for urinary catheter reinsertion. Thirteen patients met exclusion criteria. Of the 275 patients evaluated, 60 (21.8%) required reinsertion of urinary catheter. There was no difference in the urinary tract infection rate between patients requiring reinsertion (1/60 [1.7%]) versus patients not requiring reinsertion (1/215 [0.5%], P = .389). Urethral trauma during reinsertion was seen in 1 of 60 patients (1.7%). After reinsertion, discharge with urinary catheter was required in 4 of 60 patients (6.7%). Multivariable logistic regression analysis found esophagectomy, lower body mass index, and benign prostatic hypertrophy to be independent risk factors associated with catheter reinsertion after early removal in the presence of thoracic epidural analgesia. When applying Surgical Care Improvement Project 9 to patients undergoing thoracic procedures with thoracic epidural analgesia, consideration to delayed removal of urinary catheter may be warranted in patients with multiple risk factors for reinsertion. Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

  14. Usefulness of administrative databases for risk adjustment of adverse events in surgical patients.

    PubMed

    Rodrigo-Rincón, Isabel; Martin-Vizcaíno, Marta P; Tirapu-León, Belén; Zabalza-López, Pedro; Abad-Vicente, Francisco J; Merino-Peralta, Asunción; Oteiza-Martínez, Fabiola

    2016-03-01

    The aim of this study was to assess the usefulness of clinical-administrative databases for the development of risk adjustment in the assessment of adverse events in surgical patients. The study was conducted at the Hospital of Navarra, a tertiary teaching hospital in northern Spain. We studied 1602 hospitalizations of surgical patients from 2008 to 2010. We analysed 40 comorbidity variables included in the National Surgical Quality Improvement (NSQIP) Program of the American College of Surgeons using 2 sources of information: The clinical and administrative database (CADB) and the data extracted from the complete clinical records (CR), which was considered the gold standard. Variables were catalogued according to compliance with the established criteria: sensitivity, positive predictive value and kappa coefficient >0.6. The average number of comorbidities per study participant was 1.6 using the CR and 0.95 based on CADB (p<.0001). Thirteen types of comorbidities (accounting for 8% of the comorbidities detected in the CR) were not identified when the CADB was the source of information. Five of the 27 remaining comorbidities complied with the 3 established criteria; 2 pathologies fulfilled 2 criteria, whereas 11 fulfilled 1, and 9 did not fulfil any criterion. CADB detected prevalent comorbidities such as comorbid hypertension and diabetes. However, the CABD did not provide enough information to assess the variables needed to perform the risk adjustment proposed by the NSQIP for the assessment of adverse events in surgical patients. Copyright © 2015. Publicado por Elsevier España, S.L.U.

  15. Image-defined Risk Factors Correlate with Surgical Radicality and Local Recurrence in Patients with Neuroblastoma.

    PubMed

    Pohl, A; Erichsen, M; Stehr, M; Hubertus, J; Bergmann, F; Kammer, B; von Schweinitz, D

    2016-04-01

    Neuroblastoma is the second most common solid pediatric tumor and the most common cancer to be detected in children younger than 12 months of age. To date, 2 different staging systems describe the extent of the disease: the International Neuroblastoma Staging System (INSS) and the International Neuroblastoma Risk Group Staging System (INRGSS). The INRGSS-system is characterized by the presence or absence of so called image-defined risk factors (IDRFs), which are described as surgical risk factors. We hypothesized that IDRFs correlate with surgical complications, surgical radicality, local recurrence and overall survival (OS). Between 2003 and 2010, 102 patients had neuroblastoma surgery performed in our department. We analyzed medical records for IDRF-status and above named data. 16 patients were IDRF-negative, whereas 86 patients showed one or more IDRF. Intra- or postoperative complications have been reported in 21 patients (21%). 19 of them showed one or more IDRF and 2 patients were IDRF-negative (p=n.s.). Patients who suffered from intra- or postoperative complications demonstrated a decreased OS (p=0.011). Statistical analysis revealed an inverse correlation between the extent of macroscopical removal and IDRF-status (p=0.001). Furthermore, the number of IDRFs were associated with a decreased likelihood of radical tumor resection (p<0.001). 19 patients had local recurrence; all of them were IDRF-positive (p=0.037). Pediatric surgeons should consider IDRFs as a useful tool for risk assessment and therefore planning for neuroblastoma surgery. © Georg Thieme Verlag KG Stuttgart · New York.

  16. Patients with anomalous aortic origin of the coronary artery remain at risk after surgical repair.

    PubMed

    Nees, Shannon N; Flyer, Jonathan N; Chelliah, Anjali; Dayton, Jeffrey D; Touchette, Lorraine; Kalfa, David; Chai, Paul J; Bacha, Emile A; Anderson, Brett R

    2018-02-08

    Anomalous aortic origin of a coronary artery (AAOCA) from the opposite sinus of Valsalva is a rare cardiac anomaly associated with sudden cardiac death (SCD). Single-center studies describe surgical repair as safe, although medium- and long-term effects on symptoms and risk of SCD remain unknown. We sought to describe outcomes of surgical repair of AAOCA. We reviewed institutional records for patients who underwent AAOCA repair, from 2001 to 2016, at 2 affiliated institutions. Patients with associated heart disease were excluded. In total, 60 patients underwent AAOCA repair. Half of the patients (n = 30) had an anomalous left coronary artery arising from the right sinus of Valsalva and half had an anomalous right. Median age at surgery was 15.4 years (interquartile range, 11.9-17.9 years; range, 4 months to 68 years). The most common presenting symptoms were chest pain (n = 38; 63%) and shortness of breath (n = 17; 28%); aborted SCD was the presenting symptom in 4 patients (7%). Follow-up data were available for 54 patients (90%) over a median of 1.6 years. Of 53 patients with symptoms at presentation, 34 (64%) had complete resolution postoperatively. Postoperative mild or greater aortic insufficiency was present in 8 patients (17%) and moderate supravalvar aortic stenosis in 1 (2%). One patient required aortic valve replacement for aortic insufficiency. Two patients required reoperation for coronary stenosis at 3 months and 6 years postoperatively. Surgical repair of AAOCA is generally safe and adverse events are rare. Restenosis, and even sudden cardiac events, can occur and long-term surveillance is critical. Multi-institutional collaboration is vital to identify at-risk subpopulations and refine current recommendations for long-term management. Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

  17. Identification of the high risk emergency surgical patient: Which risk prediction model should be used?

    PubMed

    Stonelake, Stephen; Thomson, Peter; Suggett, Nigel

    2015-09-01

    National guidance states that all patients having emergency surgery should have a mortality risk assessment calculated on admission so that the 'high risk' patient can receive the appropriate seniority and level of care. We aimed to assess if peri-operative risk scoring tools could accurately calculate mortality and morbidity risk. Mortality risk scores for 86 consecutive emergency laparotomies, were calculated using pre-operative (ASA, Lee index) and post-operative (POSSUM, P-POSSUM and CR-POSSUM) risk calculation tools. Morbidity risk scores were calculated using the POSSUM predicted morbidity and compared against actual morbidity according to the Clavien-Dindo classification. The actual mortality was 10.5%. The average predicted risk scores for all laparotomies were: ASA 26.5%, Lee Index 2.5%, POSSUM 29.5%, P-POSSUM 18.5%, CR-POSSUM 10.5%. Complications occurred following 67 laparotomies (78%). The majority (51%) of complications were classified as Clavien-Dindo grade 2-3 (non-life-threatening). Patients having a POSSUM morbidity risk of greater than 50% developed significantly more life-threatening complications (CD 4-5) compared with those who predicted less than or equal to 50% morbidity risk (P = 0.01). Pre-operative risk stratification remains a challenge because the Lee Index under-predicts and ASA over-predicts mortality risk. Post-operative risk scoring using the CR-POSSUM is more accurate and we suggest can be used to identify patients who require intensive care post-operatively. In the absence of accurate risk scoring tools that can be used on admission to hospital it is not possible to reliably audit the achievement of national standards of care for the 'high-risk' patient.

  18. Identification of the high risk emergency surgical patient: Which risk prediction model should be used?

    PubMed Central

    Stonelake, Stephen; Thomson, Peter; Suggett, Nigel

    2015-01-01

    Introduction National guidance states that all patients having emergency surgery should have a mortality risk assessment calculated on admission so that the ‘high risk’ patient can receive the appropriate seniority and level of care. We aimed to assess if peri-operative risk scoring tools could accurately calculate mortality and morbidity risk. Methods Mortality risk scores for 86 consecutive emergency laparotomies, were calculated using pre-operative (ASA, Lee index) and post-operative (POSSUM, P-POSSUM and CR-POSSUM) risk calculation tools. Morbidity risk scores were calculated using the POSSUM predicted morbidity and compared against actual morbidity according to the Clavien–Dindo classification. Results The actual mortality was 10.5%. The average predicted risk scores for all laparotomies were: ASA 26.5%, Lee Index 2.5%, POSSUM 29.5%, P-POSSUM 18.5%, CR-POSSUM 10.5%. Complications occurred following 67 laparotomies (78%). The majority (51%) of complications were classified as Clavien–Dindo grade 2–3 (non-life-threatening). Patients having a POSSUM morbidity risk of greater than 50% developed significantly more life-threatening complications (CD 4–5) compared with those who predicted less than or equal to 50% morbidity risk (P = 0.01). Discussion Pre-operative risk stratification remains a challenge because the Lee Index under-predicts and ASA over-predicts mortality risk. Post-operative risk scoring using the CR-POSSUM is more accurate and we suggest can be used to identify patients who require intensive care post-operatively. Conclusions In the absence of accurate risk scoring tools that can be used on admission to hospital it is not possible to reliably audit the achievement of national standards of care for the ‘high-risk’ patient. PMID:26468369

  19. TOTAL LYMPHOCYTE COUNT AND SERUM ALBUMIN AS PREDICTORS OF NUTRITIONAL RISK IN SURGICAL PATIENTS

    PubMed Central

    ROCHA, Naruna Pereira; FORTES, Renata Costa

    2015-01-01

    Background: Early detection of changes in nutritional status is important for a better approach to the surgical patient. There are several nutritional measures in clinical practice, but there is not a complete method for determining the nutritional status, so, health professionals should only choose the best method to use. Aim: To evaluate the total lymphocyte count and albumin as predictors of identification of nutritional risk in surgical patients. Methods: Prospective longitudinal study was conducted with 69 patients undergoing surgery of the gastrointestinal tract. The assessment of nutritional status was evaluated by objective methods (anthropometry and biochemical tests) and subjective methods (subjective global assessment). Results: All parameters used in the nutritional assessment detected a high prevalence of malnutrition, with the exception of BMI which detected only 7.2% (n=5). The albumin (p=0.01), the total lymphocytes count (p=0.02), the percentage of adequacy of skinfolds (p<0.002) and the subjective global assessment (p<0.001) proved to be useful as predictors of risk of postoperative complications, since the smaller the values of albumin and lymphocyte count and higher the score the subjective global assessment were higher risks of surgical complications. Conclusions: A high prevalence of malnutrition was found, except for BMI. The use of albumin and total lymphocyte count were good predictor for the risk of postoperative complications and when used with other methods of assessing the nutritional status, such as the subjective global assessment and the percentage of adequacy of skinfolds, can be useful for identification of nutritional risk and postoperative complications. PMID:26537145

  20. Umbilical Hernia in Peritoneal Dialysis Patients: Surgical Treatment and Risk Factors.

    PubMed

    Banshodani, Masataka; Kawanishi, Hideki; Moriishi, Misaki; Shintaku, Sadanori; Ago, Rika; Hashimoto, Shinji; Nishihara, Masahiro; Tsuchiya, Shinichiro

    2015-12-01

    No previous reports have focused on surgical treatments and risk factors of umbilical hernia alone in peritoneal dialysis (PD) patients. Herein, we evaluated the treatments and risk factors. A total of 411 PD patients were enrolled. Of the 15 patients with umbilical hernia (3.6%), six underwent hernioplasty. There was no recurrence in five patients treated with tension-free hernioplasty. The mean PD vintage after onset of hernia in the hernioplasty group tended to be longer than that in the non-hernioplasty group. An incarcerated hernia occurred in one non-hernioplasty patient. Although the incidence was significantly higher among women (P = 0.02), female sex was not a risk factor for umbilical hernia (P = 0.08). Our findings suggest that umbilical hernias should be repaired for continuing PD. Furthermore, there were no significant risk factors for umbilical hernia in PD patients. Future studies with larger sample groups are required to elucidate these risk factors. © 2015 International Society for Apheresis, Japanese Society for Apheresis, and Japanese Society for Dialysis Therapy.

  1. Costs of transcatheter versus surgical aortic valve replacement in intermediate-risk patients.

    PubMed

    Osnabrugge, Ruben L J; Head, Stuart J; Genders, Tessa S S; Van Mieghem, Nicolas M; De Jaegere, Peter P T; van der Boon, Robert M A; Kerkvliet, J Marco; Kalesan, Bindu; Bogers, Ad J J C; Kappetein, A Pieter; Hunink, M G Myriam

    2012-12-01

    Transcatheter aortic valve replacement (TAVR) offers a new treatment option for patients with aortic stenosis, but costs may play a decisive role in decision making. Current studies are evaluating TAVR in an intermediate-risk population. We assessed the in-hospital and 1-year follow-up costs of patients undergoing TAVR and surgical aortic valve replacement (SAVR) at intermediate operative risk and identified important cost components. We prospectively collected clinical data on 141 patients undergoing TAVR and 405 undergoing SAVR. Propensity score matching yielded 42 matched pairs at intermediate risk. Costs were assessed using a detailed resource-use approach and compared using bootstrap methods. In-hospital costs were higher in TAVR patients than in SAVR patients (€40802 vs €33354, respectively; p=0.010). The total costs at 1 year were €46217 vs €35511, respectively (p=0.009). The TAVR was less costly with regard to blood products, operating room use, and length-of-stay. For intermediate-risk patients with severe aortic stenosis the costs at 1 year are higher for TAVR than for SAVR. The difference was mainly caused by the higher costs of the transcatheter valve and was not compensated by the lower costs for blood products and hospital stay in TAVR patients. Therefore, SAVR remains a clinically and economically attractive treatment option. Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

  2. Risk factors for indications of intraoperative blood transfusion among patients undergoing surgical treatment for colorectal adenocarcinoma.

    PubMed

    Gonçalves, Iara; Linhares, Marcelo; Bordin, Jose; Matos, Delcio

    2009-01-01

    Identification of risk factors for requiring transfusions during surgery for colorectal cancer may lead to preventive actions or alternative measures, towards decreasing the use of blood components in these procedures, and also rationalization of resources use in hemotherapy services. This was a retrospective case-control study using data from 383 patients who were treated surgically for colorectal adenocarcinoma at 'Fundação Pio XII', in Barretos-SP, Brazil, between 1999 and 2003. To recognize significant risk factors for requiring intraoperative blood transfusion in colorectal cancer surgical procedures. Univariate analyses were performed using Fisher's exact test or the chi-squared test for dichotomous variables and Student's t test for continuous variables, followed by multivariate analysis using multiple logistic regression. In the univariate analyses, height (P = 0.06), glycemia (P = 0.05), previous abdominal or pelvic surgery (P = 0.031), abdominoperineal surgery (P<0.001), extended surgery (P<0.001) and intervention with radical intent (P<0.001) were considered significant. In the multivariate analysis using logistic regression, intervention with radical intent (OR = 10.249, P<0.001, 95% CI = 3.071-34.212) and abdominoperineal amputation (OR = 3.096, P = 0.04, 95% CI = 1.445-6.623) were considered to be independently significant. This investigation allows the conclusion that radical intervention and the abdominoperineal procedure in the surgical treatment of colorectal adenocarcinoma are risk factors for requiring intraoperative blood transfusion.

  3. Transcatheter or Surgical Aortic-Valve Replacement in Intermediate-Risk Patients.

    PubMed

    Leon, Martin B; Smith, Craig R; Mack, Michael J; Makkar, Raj R; Svensson, Lars G; Kodali, Susheel K; Thourani, Vinod H; Tuzcu, E Murat; Miller, D Craig; Herrmann, Howard C; Doshi, Darshan; Cohen, David J; Pichard, Augusto D; Kapadia, Samir; Dewey, Todd; Babaliaros, Vasilis; Szeto, Wilson Y; Williams, Mathew R; Kereiakes, Dean; Zajarias, Alan; Greason, Kevin L; Whisenant, Brian K; Hodson, Robert W; Moses, Jeffrey W; Trento, Alfredo; Brown, David L; Fearon, William F; Pibarot, Philippe; Hahn, Rebecca T; Jaber, Wael A; Anderson, William N; Alu, Maria C; Webb, John G

    2016-04-28

    Previous trials have shown that among high-risk patients with aortic stenosis, survival rates are similar with transcatheter aortic-valve replacement (TAVR) and surgical aortic-valve replacement. We evaluated the two procedures in a randomized trial involving intermediate-risk patients. We randomly assigned 2032 intermediate-risk patients with severe aortic stenosis, at 57 centers, to undergo either TAVR or surgical replacement. The primary end point was death from any cause or disabling stroke at 2 years. The primary hypothesis was that TAVR would not be inferior to surgical replacement. Before randomization, patients were entered into one of two cohorts on the basis of clinical and imaging findings; 76.3% of the patients were included in the transfemoral-access cohort and 23.7% in the transthoracic-access cohort. The rate of death from any cause or disabling stroke was similar in the TAVR group and the surgery group (P=0.001 for noninferiority). At 2 years, the Kaplan-Meier event rates were 19.3% in the TAVR group and 21.1% in the surgery group (hazard ratio in the TAVR group, 0.89; 95% confidence interval [CI], 0.73 to 1.09; P=0.25). In the transfemoral-access cohort, TAVR resulted in a lower rate of death or disabling stroke than surgery (hazard ratio, 0.79; 95% CI, 0.62 to 1.00; P=0.05), whereas in the transthoracic-access cohort, outcomes were similar in the two groups. TAVR resulted in larger aortic-valve areas than did surgery and also resulted in lower rates of acute kidney injury, severe bleeding, and new-onset atrial fibrillation; surgery resulted in fewer major vascular complications and less paravalvular aortic regurgitation. In intermediate-risk patients, TAVR was similar to surgical aortic-valve replacement with respect to the primary end point of death or disabling stroke. (Funded by Edwards Lifesciences; PARTNER 2 ClinicalTrials.gov number, NCT01314313.).

  4. Failure of anticoagulant thromboprophylaxis: risk factors in medical-surgical critically ill patients*.

    PubMed

    Lim, Wendy; Meade, Maureen; Lauzier, Francois; Zarychanski, Ryan; Mehta, Sangeeta; Lamontagne, Francois; Dodek, Peter; McIntyre, Lauralyn; Hall, Richard; Heels-Ansdell, Diane; Fowler, Robert; Pai, Menaka; Guyatt, Gordon; Crowther, Mark A; Warkentin, Theodore E; Devereaux, P J; Walter, Stephen D; Muscedere, John; Herridge, Margaret; Turgeon, Alexis F; Geerts, William; Finfer, Simon; Jacka, Michael; Berwanger, Otavio; Ostermann, Marlies; Qushmaq, Ismael; Friedrich, Jan O; Cook, Deborah J

    2015-02-01

    To identify risk factors for failure of anticoagulant thromboprophylaxis in critically ill patients in the ICU. Multivariable regression analysis of thrombosis predictors from a randomized thromboprophylaxis trial. Sixty-seven medical-surgical ICUs in six countries. Three thousand seven hundred forty-six medical-surgical critically ill patients. All patients received anticoagulant thromboprophylaxis with low-molecular-weight heparin or unfractionated heparin at standard doses. Independent predictors for venous thromboembolism, proximal leg deep vein thrombosis, and pulmonary embolism developing during critical illness were assessed. A total of 289 patients (7.7%) developed venous thromboembolism. Predictors of thromboprophylaxis failure as measured by development of venous thromboembolism included a personal or family history of venous thromboembolism (hazard ratio, 1.64; 95% CI, 1.03-2.59; p = 0.04) and body mass index (hazard ratio, 1.18 per 10-point increase; 95% CI, 1.04-1.35; p = 0.01). Increasing body mass index was also a predictor for developing proximal leg deep vein thrombosis (hazard ratio, 1.25; 95% CI, 1.06-1.46; p = 0.007), which occurred in 182 patients (4.9%). Pulmonary embolism occurred in 47 patients (1.3%) and was associated with body mass index (hazard ratio, 1.37; 95% CI, 1.02-1.83; p = 0.035) and vasopressor use (hazard ratio, 1.84; 95% CI, 1.01-3.35; p = 0.046). Low-molecular-weight heparin (in comparison to unfractionated heparin) thromboprophylaxis lowered pulmonary embolism risk (hazard ratio, 0.51; 95% CI, 0.27-0.95; p = 0.034) while statin use in the preceding week lowered the risk of proximal leg deep vein thrombosis (hazard ratio, 0.46; 95% CI, 0.27-0.77; p = 0.004). Failure of standard thromboprophylaxis using low-molecular-weight heparin or unfractionated heparin is more likely in ICU patients with elevated body mass index, those with a personal or family history of venous thromboembolism, and those receiving vasopressors. Alternate

  5. Minimally invasive mitral valve surgery expands the surgical options for high-risks patients.

    PubMed

    Petracek, Michael R; Leacche, Marzia; Solenkova, Natalia; Umakanthan, Ramanan; Ahmad, Rashid M; Ball, Stephen K; Hoff, Steven J; Absi, Tarek S; Balaguer, Jorge M; Byrne, John G

    2011-10-01

    A simplified minimally invasive mitral valve surgery (MIMVS) approach avoiding cross-clamping and cardioplegic myocardial arrest using a small (5 cm) right antero-lateral incision was developed. We hypothesized that, in high-risk patients and in patients with prior sternotomy, this approach would yield superior results compared to those predicted by the Society of Thoracic Surgeons (STS) algorithm for standard median sternotomy mitral valve surgery. Five hundred and four consecutive patients (249 males/255 females), median age 65 years (range 20-92 years) underwent MIMVS between 1/06 and 8/09. Median preoperative New York Heart Association function class was 3 (range 1-4). Eighty-two (16%) patients had an ejection fraction ≤35%. Forty-seven (9%) had a STS predicted mortality ≥10%. Under cold fibrillatory arrest (median temperature 28°C) without aortic cross-clamp, mitral valve repair (224/504, 44%) or replacement (280/504, 56%) was performed. Thirty-day mortality for the entire cohort was 2.2% (11/504). In patients with a STS predicted mortality ≥ 10% (range 10%-67%), the observed 30-day mortality was 4% (2/47), lower than the mean STS predicted mortality of 20%. Morbidity in this high-risk group was equally low: 1 of 47 (2%) patients underwent reexploration for bleeding, 1 of 47 (2%) patients suffered a permanent neurologic deficit, none had wound infection. The median length of stay was 8 days (range 1-68 days). This study demonstrates that MIMVS without aortic cross-clamp is reproducible with low mortality and morbidity rates. This approach expands the surgical options for high-risk patients and yields to superior results than the conventional median sternotomy approach.

  6. Percutaneous imaging-guided interventions for acute biliary disorders in high surgical risk patients

    PubMed Central

    Donkol, Ragab Hani; Latif, Nahed Abdel; Moghazy, Khaled

    2010-01-01

    AIM: To evaluate the efficacy of percutaneous imaging-guided biliary interventions in the management of acute biliary disorders in high surgical risk patients. METHODS: One hundred and twenty two patients underwent 139 percutaneous imaging-guided biliary interventions during the period between January 2007 to December 2009. The patients included 73 women and 49 men with a mean age of 61 years (range 35-90 years). Fifty nine patients had acute biliary obstruction, 26 patients had acute biliary infection and 37 patients had abnormal collections. The procedures were performed under computed tomography (CT)- (73 patients), sonographic- (41 patients), and fluoroscopic-guidance (25 patients). Success rates and complications were determined. The χ2 test with Yates’ correction for continuity was applied to compare between these procedures. A P value < 0.05 was considered significant. RESULTS: The success rates for draining acute biliary obstruction under CT- , fluoroscopy- or ultrasound-guidance were 93.3%, 62.5% and 46.1%, respectively with significant P values (P = 0.026 and 0.002, respectively). In acute biliary infection, successful drainage was achieved in 22 patients (84.6%). The success rates in patients drained under ultrasound- and CT-guidance were 46.1% and 88.8%, respectively and drainage under CT-guidance was significantly higher (P = 0.0293). In 13 patients with bilomas, percutaneous drainage was successful in 11 patients (84.6%). Ten out of 12 cases with hepatic abscesses were drained with a success rate of 83.3%. In addition, the success rate of drainage in 12 cases with pancreatic pseudocysts was 83.3%. The reported complications were two deaths, four major and seven minor complications. CONCLUSION: Percutaneous imaging-guided biliary interventions help to promptly diagnose and effectively treat acute biliary disorders. They either cure the disorders or relieve sepsis and jaundice before operations. PMID:21160698

  7. Outcomes in 937 Intermediate-Risk Patients Undergoing Surgical Aortic Valve Replacement in PARTNER-2A.

    PubMed

    Thourani, Vinod H; Forcillo, Jessica; Szeto, Wilson Y; Kodali, Susheel K; Blackstone, Eugene H; Lowry, Ashley M; Semple, Marie; Rajeswaran, Jeevanantham; Makkar, Raj R; Williams, Mathew R; Bavaria, Joseph E; Herrmann, Howard C; Maniar, Hersh S; Babaliaros, Vasilis C; Smith, Craig R; Trento, Alfredo; Corso, Paul J; Pichard, Augusto D; Miller, D Craig; Svensson, Lars G; Kapadia, Samir; Ailawadi, Gorav; Suri, Rakesh M; Greason, Kevin L; Hahn, Rebecca T; Jaber, Wael A; Alu, Maria C; Leon, Martin B; Mack, Michael J

    2018-05-01

    The Placement of Aortic Transcatheter Valves 2A (PARTNER-2A) randomized trial compared outcomes of transfemoral transcatheter and surgical aortic valve replacement (SAVR) in intermediate-risk patients with severe aortic stenosis. The purpose of the present study was to perform an in-depth analysis of outcomes after SAVR in the PARTNER-2A trial. From January 2012 to January 2014, 937 patients underwent SAVR at 57 centers. Mean age was 82 ± 6.7 years and 55% were men. Less-invasive operations were performed in 140 patients (15%) and concomitant procedures in 198 patients (21%). Major outcomes and echocardiograms were adjudicated by an independent events committee. Follow-up was 94% complete to 2 years. Operative mortality was 4.1% (n = 38, Society of Thoracic Surgeons predicted risk of mortality: 5.2% ± 2.3%), observed to expected ratio (O/E) was 0.8, and in-hospital stroke was 5.4% (n = 51), twice expected. Aortic clamp and bypass times were 75 ± 30 minutes and 104 ± 46 minutes, respectively. Patients having severe prosthesis-patient mismatch (n = 260, 33%) had similar survival to patients without (p > 0.9), as did patients undergoing less-invasive SAVR (p = 0.3). Risk factors for death included cachexia (p = 0.004), tricuspid regurgitation (p = 0.01), coronary artery disease (p = 0.02), preoperative atrial fibrillation (p = 0.001), higher white blood cell count (p < 0.0001), and lower hemoglobin (p = 0.0002). In this adjudicated prospective study, SAVR in intermediate-risk patients had excellent results at 2 years. However, there were more in-hospital strokes than expected, most likely attributable to mandatory neurologic assessment after the procedure. No pronounced structural valve deterioration was found during 2-year follow-up. Continued long-term surveillance remains important. Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

  8. Comparison of xenon-based anaesthesia compared with total intravenous anaesthesia in high risk surgical patients.

    PubMed

    Bein, B; Turowski, P; Renner, J; Hanss, R; Steinfath, M; Scholz, J; Tonner, P H

    2005-10-01

    Xenon, a noble gas with anaesthetic and analgesic properties, has gained renewed interest due to its favourable physical properties which allow a rapid emergence from anaesthesia. However, high costs limit its use to a subset of patients who may benefit from xenon, thereby offsetting its costs. To date, there are only limited data available on the performance of xenon in high risk patients. We studied 39 patients with ASA physical status III undergoing aortic surgery. The patients were randomly assigned to either a xenon (Xe, n = 20) or a TIVA (T, n = 19) group. Global cardiac performance and myocardial contractility were assessed using transoesophageal echocardiography, and myocardial cell damage with troponin T and CK-MB. Echocardiographic measurements were made prior to xenon administration, following xenon administration, and after clamping of the abdominal aorta, after declamping and at corresponding time points in the TIVA group. Laboratory values were determined repeatedly for up to 72 h. Data were analysed using two-way anova factoring for time and anaesthetic agent or with ancova comparing linear regression lines. No significant differences were found in global myocardial performance, myocardial contractility or laboratory values at any time during the study period. Mean (SEM) duration of stay on the ICU (xenon: 38 +/- 46 vs. TIVA 25 +/- 15 h) or in hospital (xenon: 14 +/- 12 vs. TIVA 10 +/- 6 days) did not differ significantly between the groups. Although xenon has previously been shown to exert superior haemodynamic stability, we were unable to demonstrate an advantage of xenon-based anaesthesia compared to TIVA in high risk surgical patients.

  9. The Prevalence of Malnutrition and Effectiveness of STRONGkids Tool in the Identification of Malnutrition Risks among Pediatric Surgical Patients

    PubMed Central

    Durakbaşa, Çiğdem Ulukaya; Fettahoğlu, Selma; Bayar, Ahu; Mutus, Murat; Okur, Hamit

    2014-01-01

    Background: High prevalence of malnutrition along with the risk for the development of malnutrition in hospitalised children has been reported. However, this problem remains largely unrecognised by healthcare workers. Aims: To determine the prevalence of malnutrition and effectiveness of STRONGkids nutritional risk screening (NRS) tool in the identification of malnutrition risk among pediatric surgical patients. Study Design: Cross-sectional study. Methods: A total of 494 pediatric surgical patients (median age 59 months, 75.8% males) were included in this prospective study conducted over 3 months. SD-scores <−2 for Body Mass Index (BMI) for age or weight-for-height (WFH) and height-for-age (HFA) were considered to indicate acute and chronic malnutrition, respectively. The STRONGkids NRS tool was used to determine risk for malnutrition. Results: Malnutrition was detected in 13.4% in this group of pediatric surgical patients. Acute malnutrition was identified in 10.1% of patients and more commonly in patients aged ≤60 months than aged >60 months (13.4 vs. 6.6%, p=0.012). Chronic malnutrition was identified in 23 (4.6%) of patients with no significant difference between age groups. There were 7 (1.4%) children with coexistent acute and chronic malnutrition. The STRONGkids tool revealed that 35.7% of patients were either in the moderate or high risk group for malnutrition. Malnutrition, as revealed by anthropometric measurements, was more likely in the presence of gastrointestinal (26.9%, p=0.004) and inguinoscrotal/penile surgery (4.0%, p=0.031), co-morbidities affecting nutritional status (p<0.001) and inpatient admissions (p=0.014). Among patients categorized as low risk for malnutrition, there were more outpatients than inpatients (89.3 vs. 10.7%, p<0.001) and more elective surgery cases than emergency surgery cases (93.4 vs. 6.6%, p<0.001). Conclusion: Providing data on the prevalence of malnutrition and risk of malnutrition in a prospectively recruited group

  10. Use of a surgical helmet system to minimize splash injury during percutaneous renal surgery in high-risk patients.

    PubMed

    Eandi, Jonathan A; Nanigian, Dana K; Smith, William H; Low, Roger K

    2008-12-01

    The transmission risk to surgeons performing percutaneous renal surgery on patients who are infected with human immunodeficiency virus/acquired immunodeficiency syndrome, hepatitis B, or hepatitis C is unknown. A recent study found 55% of surgeons' masks contain evidence of blood splash contamination after percutaneous nephrolithotomy. While the risk of infectious disease transmission to the surgeon after mucocutaneous exposure is unknown, the incapacitating disease these pathogens cause can have a devastating and permanent effect on a surgeon's career. We describe our use of a surgical helmet system when performing percutaneous renal surgery on high-risk patients to minimize risk of splash injury and transmission of blood-borne pathogens.

  11. Transcatheter vs Surgical Aortic Valve Replacement for Aortic Stenosis in Low-Intermediate Risk Patients: A Meta-analysis.

    PubMed

    Tam, Derrick Y; Vo, Thin Xuan; Wijeysundera, Harindra C; Ko, Dennis T; Rocha, Rodolfo Vigil; Friedrich, Jan; Fremes, Stephen E

    2017-09-01

    Transcatheter aortic valve replacement (TAVR) has emerged as the treatment of choice for patients with severe aortic stenosis at high surgical risk; the role of TAVR compared with surgical aortic valve replacement (SAVR) in the low-intermediate surgical risk population remains uncertain. Our primary objective was to determine differences in 30-day and late mortality in patients treated with TAVR compared with SAVR at low-intermediate risk (Society of Thoracic Surgeons Predicted Risk of Mortality < 10%). Medline and Embase were searched from 2010 to March 2017 for studies that compared TAVR with SAVR in the low-intermediate surgical risk population, restricted to randomized clinical trials and matched observational studies. Two investigators independently abstracted the data and a random effects meta-analysis was performed. Four randomized clinical trials (n = 4042) and 9 propensity score-matched observational studies (n = 4192) were included in the meta-analysis (n = 8234). There was no difference in 30-day mortality between TAVR and SAVR (3.2% vs 3.1%, pooled risk ratio: 1.02; 95% confidence interval, 0.80-1.30; P = 0.89; I 2  = 0%) or mortality at a median of 1.5-year follow-up (incident rate ratio: 1.01; 95% confidence interval, 0.90-1.15; P = 0.83; I 2  = 0%). There was a higher risk of pacemaker implantation and greater than trace aortic insufficiency in the TAVR group whereas the risk of early stroke, atrial fibrillation, acute kidney injury, cardiogenic shock, and major bleeding was higher in the SAVR group. Although there was no difference in 30-day and late mortality, the rate of complications differed between TAVR and SAVR in the low-intermediate surgical risk population. Copyright © 2017 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

  12. Risk of bleeding in surgical patients treated with topical bovine thrombin sealants: a review of the literature

    PubMed Central

    Reynolds, Matthew W; Clark, John; Crean, Sheila; Samudrala, Srinath

    2008-01-01

    Background One of the most anticipated, but potentially serious complications during or after surgery are bleeding events. Among the many potential factors associated with bleeding complications in surgery, the use of bovine thrombin has been anecdotally identified as a possible cause of increased bleeding risk. Most of these reports of bleeding events in association with the use of topical bovine thrombin have been limited to case reports lacking clear cause and effect relationship determination. Recent studies have failed to establish significant differences in the rates of bleeding events between those treated with bovine thrombin and those treated with either human or recombinant thrombin. Methods We conducted a search of MEDLINE for the most recent past 10 years (1997–2007) and identified all published studies that reported a study of surgical patients with a clear objective to examine the risk of bleeding events in surgical patients. We also specifically noted the reporting of any topical bovine thrombin used during surgical procedures. We aimed to examine whether there were any differences in the risk of bleeds in general surgical populations as compared to those studies that reported exposure to topical bovine thrombin. Results We identified 21 clinical studies that addressed the risk of bleeding in surgery. Of these, 5 studies analyzed the use of bovine thrombin sealants in surgical patients. There were no standardized definitions for bleeding events employed across these studies. The rates of bleeds in the general surgery studies ranged from 0.1%–20.2%, with most studies reporting rates between 2.6%–4%. The rates of bleeding events ranged from 0.0%–13% in the bovine thrombin studies with most studies reporting between a 2%–3% rate. Conclusion The risk of bleeds was not clearly different in those studies reporting use of bovine thrombin in all patients compared to the other surgical populations studied. A well-designed and well-controlled study

  13. Incidence of bisphosphonate-related osteonecrosis of the jaw in high-risk patients undergoing surgical tooth extraction.

    PubMed

    Bodem, Jens Philipp; Kargus, Steffen; Eckstein, Stefanie; Saure, Daniel; Engel, Michael; Hoffmann, Jürgen; Freudlsperger, Christian

    2015-05-01

    As the most suitable approach for preventing bisphosphonate-related osteonecrosis of the jaw (BRONJ) in patients undergoing surgical tooth extraction is still under discussion, the present study evaluates the incidence of BRONJ after surgical tooth extraction using a standardized surgical protocol in combination with an adjuvant perioperative treatment setting in patients who are at high-risk for developing BRONJ. High-risk patients were defined as patients who received intravenous bisphosphonate (BP) due to a malignant disease. All teeth were removed using a standardized surgical protocol. The perioperative adjuvant treatment included intravenous antibiotic prophylaxis starting at least 24 h before surgery, a gastric feeding tube and mouth rinses with chlorhexidine (0.12%) three times a day. In the follow-up period patients were examined every 4 weeks for the development of BRONJ. Minimum follow-up was 12 weeks. In 61 patients a total number of 184 teeth were removed from 102 separate extraction sites. In eight patients (13.1%) BRONJ developed during the follow-up. A higher risk for developing BRONJ was found in patients where an additional osteotomy was necessary (21.4% vs. 8.0%; p = 0.0577), especially for an osteotomy of the mandible (33.3% vs. 7.3%; p = 0.0268). Parameters including duration of intravenous antibiotic prophylaxis, the use of a gastric feeding tube and the duration of intravenous BP therapy showed no statistical impact on the development of BRONJ. Furthermore, patients currently undergoing intravenous BP therapy showed no higher risk for BRONJ compared with patients who have paused or completed their intravenous BP therapy (p = 0.4232). This study presents a protocol for surgical tooth extraction in high-risk BP patients in combination with a perioperative adjuvant treatment setting, which reduced the risk for postoperative BRONJ to a minimum. However, the risk for BRONJ increases significantly if an additional osteotomy is necessary

  14. A multicentre randomized-controlled trial of inhaled milrinone in high-risk cardiac surgical patients.

    PubMed

    Denault, André Y; Bussières, Jean S; Arellano, Ramiro; Finegan, Barry; Gavra, Paul; Haddad, François; Nguyen, Anne Q N; Varin, France; Fortier, Annik; Levesque, Sylvie; Shi, Yanfen; Elmi-Sarabi, Mahsa; Tardif, Jean-Claude; Perrault, Louis P; Lambert, Jean

    2016-10-01

    Inhaled milrinone (iMil) has been used for the treatment of pulmonary hypertension (PH) but its efficacy, safety, and prophylactic effects in facilitating separation from cardiopulmonary bypass (CPB) and preventing right ventricular (RV) dysfunction have not yet been evaluated in a clinical trial. The purpose of this study was to investigate if iMil administered before CPB would be superior to placebo in facilitating separation from CPB. High-risk cardiac surgical patients with PH were randomized to receive iMil or placebo after the induction of anesthesia and before CPB. Hemodynamic parameters and RV function were evaluated by means of pulmonary artery catheterization and transesophageal echocardiography. The groups were compared for the primary outcome of the level of difficulty in weaning from CPB. Among the secondary outcomes examined were the reduction in the severity of PH, the incidence of RV failure, and mortality. Of the 124 patients randomized, the mean (standard deviation [SD]) EuroSCORE II was 8.0 (2.6), and the baseline mean (SD) systolic pulmonary artery pressure (SPAP) was 53 (9) mmHg. The use of iMil was associated with increases in cardiac output (P = 0.03) and a reduction in SPAP (P = 0.04) with no systemic hypotension. Nevertheless, there was no difference in the combined incidence of difficult or complex separation from CPB between the iMil and control groups (30% vs 28%, respectively; absolute difference, 2%; 95% confidence interval [CI], -14 to 18; P = 0.78). There was also no difference in RV failure between the iMil and control groups (15% vs 14%, respectively; difference, 1%; 95% CI, -13 to 12; P = 0.94). Mortality was increased in patients with RV failure vs those without (22% vs 2%, respectively; P < 0.001). In high-risk cardiac surgery patients with PH, the prophylactic use of iMil was associated with favourable hemodynamic effects that did not translate into improvement of clinically relevant endpoints. This trial was registered at

  15. Transapical Implantation of a 2nd-Generation JenaValve Device in Patient with Extremely High Surgical Risk

    PubMed Central

    Mieres, Juan; Menéndez, Marcelo; Fernández-Pereira, Carlos; Rubio, Miguel; Rodríguez, Alfredo E.

    2015-01-01

    Transcatheter Aortic Valve Replacement (TAVR) is performed in patients who are poor surgical candidates. Many patients have inadequate femoral access, and alternative access sites have been used such as the transapical approach discussed in this paper. We present an elderly and fragile patient not suitable for surgery for unacceptable high risk, including poor ventricular function, previous myocardial infarction with percutaneous coronary intervention, pericardial effusion, and previous cardiac surgery with replacement of mechanical mitral valve. Transapical aortic valve replacement with a second-generation self-expanding JenaValve is performed. The JenaValve is a second-generation transapical TAVR valve consisting of a porcine root valve mounted on a low-profile nitinol stent. The valve is fully retrievable and repositionable. We discuss transapical access, implantation technique, and feasibility of valve implantation in this extremely high surgical risk patient. PMID:26346128

  16. Transapical Implantation of a 2nd-Generation JenaValve Device in Patient with Extremely High Surgical Risk.

    PubMed

    Mieres, Juan; Menéndez, Marcelo; Fernández-Pereira, Carlos; Rubio, Miguel; Rodríguez, Alfredo E

    2015-01-01

    Transcatheter Aortic Valve Replacement (TAVR) is performed in patients who are poor surgical candidates. Many patients have inadequate femoral access, and alternative access sites have been used such as the transapical approach discussed in this paper. We present an elderly and fragile patient not suitable for surgery for unacceptable high risk, including poor ventricular function, previous myocardial infarction with percutaneous coronary intervention, pericardial effusion, and previous cardiac surgery with replacement of mechanical mitral valve. Transapical aortic valve replacement with a second-generation self-expanding JenaValve is performed. The JenaValve is a second-generation transapical TAVR valve consisting of a porcine root valve mounted on a low-profile nitinol stent. The valve is fully retrievable and repositionable. We discuss transapical access, implantation technique, and feasibility of valve implantation in this extremely high surgical risk patient.

  17. Risk factors for complex regional pain syndrome in patients with surgically treated traumatic injuries attending hand therapy.

    PubMed

    Savaş, Serpil; İnal, Esra Erkol; Yavuz, Dudu Dilek; Uslusoy, Fuat; Altuntaş, Selman Hakkı; Aydın, Mustafa Asım

    Prospective cohort study. Identification of risk factors for CRPS development in patients with surgically treated traumatic injuries attending hand therapy allows to watch at-risk patients more closely for early diagnosis and to take precautionary measures as required. The aim of this study was to evaluate the risk factors for the development of complex regional pain syndrome (CRPS) after surgical treatment of traumatic hand injuries. In this prospective cohort, 291 patients with traumatic hand injuries were evaluated 3 days after surgery and monitored for 3 months for the development of CRPS. The factors assessed for the development of CRPS were age, sex, manual work, postoperative pain within 3 days measured on a Pain Numerical Rating Scale (0-10), and injury type (crush injury, blunt trauma, and cut laceration injury). CRPS was diagnosed in 68 patients (26.2 %) with a duration of 40.10 ± 17.01 days between the surgery and CRPS diagnosis. The mean postoperative pain score was greater in patients with CRPS than in those without CRPS (P < .001). Patients with pain scores ≥ 5 had a high risk of developing CRPS compared with patients with pain scores <5 (odds ratio: 3.61, confidence interval = 1.94-6.70). Patients with crush injuries were more likely to develop CRPS (odds ratio: 4.74, confidence interval = 2.29-9.80). The patients with a pain score of ≥5 in the first 3 days after surgery and the patients with crush injury were at high risk for CRPS development after surgical treatment of traumatic hand injuries. II b. Copyright © 2017 Hanley & Belfus. Published by Elsevier Inc. All rights reserved.

  18. Applying the National Surgical Quality Improvement Program risk calculator to patients undergoing colorectal surgery: theory vs reality.

    PubMed

    Adegboyega, Titilayo O; Borgert, Andrew J; Lambert, Pamela J; Jarman, Benjamin T

    2017-01-01

    Discussing potential morbidity and mortality is essential to informed decision-making and consent. The American College of Surgery National Surgical Quality Improvement Program developed an online risk calculator (RC) using patient-specific information to determine operative risk. Colorectal procedures at our independent academic medical center from 2010 to 2011 were evaluated. The RC's predicted outcomes were compared with observed outcomes. Statistical analysis included Brier score, Wilcoxon sign rank test, and standardized event ratio. There were 324 patients included. The RC's Brier score was .24 (.015-.219) for predicting mortality and morbidity, respectively. The observed event rate for surgical site infection and any complication was higher than the RC predicted (standardized event ratio 1.9 CI [1.49 to 2.39] and 1.39 CI [1.14 to 1.68], respectively). The observed length of stay was longer than predicted (5.6 vs 6.6 days, P < .001). The RC underestimated the surgical site infection and overall complication rates. The RC is a valuable tool in predicting risk for adverse outcomes; however, institution-specific trends may influence actual risk. Surgeons and institutions must recognize areas where they are outliers from estimated risks and tailor risk discussions accordingly. Copyright © 2016 Elsevier Inc. All rights reserved.

  19. Surgical Resection of Brain Metastases and the Risk of Leptomeningeal Recurrence in Patients Treated With Stereotactic Radiosurgery

    SciTech Connect

    Johnson, Matthew D., E-mail: Matthewjohnson@beaumont.edu; Avkshtol, Vladimir; Baschnagel, Andrew M.

    Purpose: Recent prospective data have shown that patients with solitary or oligometastatic disease to the brain may be treated with upfront stereotactic radiosurgery (SRS) with deferral of whole-brain radiation therapy (WBRT). This has been extrapolated to the treatment of patients with resected lesions. The aim of this study was to assess the risk of leptomeningeal disease (LMD) in patients treated with SRS to the postsurgical resection cavity for brain metastases compared with patients treated with SRS to intact metastases. Methods and Materials: Four hundred sixty-five patients treated with SRS without upfront WBRT at a single institution were identified; 330 ofmore » these with at least 3 months' follow-up were included in this analysis. One hundred twelve patients had undergone surgical resection of at least 1 lesion before SRS compared with 218 treated for intact metastases. Time to LMD and overall survival (OS) time were estimated from date of radiosurgery, and LMD was analyzed by the use of cumulative incidence method with death as a competing risk. Univariate and multivariate analyses were performed with competing risk regression to determine whether various clinical factors predicted for LMD. Results: With a median follow-up time of 9.0 months, 39 patients (12%) experienced LMD at a median of 6.0 months after SRS. At 1 year, the cumulative incidence of LMD, with death as a competing risk, was 5.2% for the patients without surgical resection versus 16.9% for those treated with surgery (Gray test, P<.01). On multivariate analysis, prior surgical resection (P<.01) and breast cancer primary (P=.03) were significant predictors of LMD development. The median OS times for patients undergoing surgery compared with SRS alone were 12.9 and 10.6 months, respectively (log-rank P=.06). Conclusions: In patients undergoing SRS with deferral of upfront WBRT for intracranial metastatic disease, prior surgical resection and breast cancer primary are associated with

  20. Evaluation of positive surgical margins in patients undergoing robot-assisted and open radical prostatectomy according to preoperative risk groups.

    PubMed

    Suardi, Nazareno; Dell'Oglio, Paolo; Gallina, Andrea; Gandaglia, Giorgio; Buffi, Nicolò; Moschini, Marco; Fossati, Nicola; Lughezzani, Giovanni; Karakiewicz, Pierre I; Freschi, Massimo; Lucianò, Roberta; Shariat, Shahrokh F; Guazzoni, Giorgio; Gaboardi, Franco; Montorsi, Francesco; Briganti, Alberto

    2016-02-01

    Recent studies showed that robot-assisted radical prostatectomy (RARP) represents an oncologically safe procedure in patients with prostate cancer (PCa), where the rate of positive surgical margins (PSMs) might be lower in patients treated with RARP as compared with that of those undergoing the open approach (open RP [ORP]). The aim of this study is to analyze the rate of PSMs according to preoperative risk groups in a large cohort of patients treated with RARP and ORP in a single institution with standardized surgical technique and pathological examination. We evaluated 6,194 consecutive patients with PCa undergoing either ORP (71.1%) or RARP (28.9%) between 1992 and 2014. Logistic regression analyses were used to test the association between type of surgery and PSMs in each preoperative risk group (low vs. intermediate vs. high) after adjusting for confounders. Overall, 21.6% patients had PSMs. RARP was associated with a lower rate of PSMs in low-risk (11.5 vs. 15.4%, P = 0.01), intermediate-risk (18.9 vs. 23.5%, P = 0.008), and high-risk patients (19.7 vs. 30.1%, P<0.001). In multivariable analyses, after stratification according to risk group categories, no difference in PSMs between RARP and ORP was observed for low-risk (odds ratio [OR] = 0.87, P = 0.46) and intermediate-risk patients (OR = 0.84, P = 0.19). Conversely, RARP was associated with lower odds of PSMs in high-risk patients (OR = 0.69, P = 0.04). Similar results were observed when our analyses were repeated after accounting for pathological characteristics, in patients treated between 2006 and 2014 and in a cohort of men treated by high-volume surgeons (all P≤ 0.03). The introduction of RARP at our institution led to a significant reduction in the risk of PSMs in patients with PCa with high-risk disease. Copyright © 2016 Elsevier Inc. All rights reserved.

  1. Risk of epilepsy in surgical patients undergoing general or neuraxial anaesthesia.

    PubMed

    Chang, H C; Liao, C C; Chang, C C; Huang, S Y; Yeh, C C; Hu, C J; Cherng, Y G; Chen, T L

    2018-03-01

    Limited information is available on the risks of epilepsy after surgery in patients receiving general or neuraxial anaesthesia. Using Taiwan's National Health Insurance Research Database, we identified 1,478,977 patients aged ≥ 20 years who underwent surgery (required general or neuraxial anaesthesia with hospitalisation for more than one day) between 2004 and 2011. We selected 235,066 patients with general anaesthesia and 235,066 patients with neuraxial anaesthesia using a frequency-matching procedure for age and sex. We did not study those with co-existing epilepsy-related risk factors. The adjusted rate ratios (RRs) and 95% confidence intervals (CIs) of newly diagnosed epilepsy 1 year after surgery associated with general anaesthesia were analysed in the multivariate Poisson regression model. The one-year incidence of postoperative epilepsy for patients with general anaesthesia and neuraxial anaesthesia were 0.41 and 0.32 per 1000 persons, respectively, and the corresponding RR was 1.27 (95%CI 1.15-1.41). The association between general anaesthesia and postoperative epilepsy was significant in men (RR = 1.22; 95%CI 1.06-1.40), women (RR = 1.33; 95%CI 1.15-1.55) and 20-39-year-old patients. The risk of postoperative epilepsy increased in patients with general anaesthesia who had co-existing medical conditions and postoperative complications. © 2017 The Association of Anaesthetists of Great Britain and Ireland.

  2. Complete surgical resection improves outcome in INRG high-risk patients with localized neuroblastoma older than 18 months.

    PubMed

    Fischer, Janina; Pohl, Alexandra; Volland, Ruth; Hero, Barbara; Dübbers, Martin; Cernaianu, Grigore; Berthold, Frank; von Schweinitz, Dietrich; Simon, Thorsten

    2017-08-04

    Although several studies have been conducted on the role of surgery in localized neuroblastoma, the impact of surgical timing and extent of primary tumor resection on outcome in high-risk patients remains controversial. Patients from the German neuroblastoma trial NB97 with localized neuroblastoma INSS stage 1-3 age > 18 months were included for retrospective analysis. Imaging reports were reviewed by two independent physicians for Image Defined Risk Factors (IDRF). Operation notes and corresponding imaging reports were analyzed for surgical radicality. The extent of tumor resection was classified as complete resection (95-100%), gross total resection (90-95%), incomplete resection (50-90%), and biopsy (<50%) and correlated with local control rate and outcome. Patients were stratified according to the International Neuroblastoma Risk Group (INRG) staging system. Survival curves were estimated according to the method of Kaplan and Meier and compared by the log-rank test. A total of 179 patients were included in this study. 77 patients underwent more than one primary tumor operation. After best surgery, 68.7% of patients achieved complete resection of the primary tumor, 16.8% gross total resection, 14.0% incomplete surgery, and 0.5% biopsy only. The cumulative complication rate was 20.3% and the surgery associated mortality rate was 1.1%. Image defined risk factors (IDRF) predicted the extent of resection. Patients with complete resection had a better local-progression-free survival (LPFS), event-free survival (EFS) and OS (overall survival) than the other groups. Subgroup analyses showed better EFS, LPFS and OS for patients with complete resection in INRG high-risk patients. Multivariable analyses revealed resection (complete vs. other), and MYCN (non-amplified vs. amplified) as independent prognostic factors for EFS, LPFS and OS. In patients with localized neuroblastoma age 18 months or older, especially in INRG high-risk patients harboring MYCN amplification

  3. Health Status Benefits of Transcatheter vs Surgical Aortic Valve Replacement in Patients With Severe Aortic Stenosis at Intermediate Surgical Risk: Results From the PARTNER 2 Randomized Clinical Trial.

    PubMed

    Baron, Suzanne J; Arnold, Suzanne V; Wang, Kaijun; Magnuson, Elizabeth A; Chinnakondepali, Khaja; Makkar, Raj; Herrmann, Howard C; Kodali, Susheel; Thourani, Vinod H; Kapadia, Samir; Svensson, Lars; Brown, David L; Mack, Michael J; Smith, Craig R; Leon, Martin B; Cohen, David J

    2017-08-01

    In patients with severe aortic stenosis (AS) at intermediate surgical risk, treatment with transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) results in similar 2-year survival. The effect of TAVR vs SAVR on health status in patients at intermediate surgical risk is unknown. To compare health-related quality of life among intermediate-risk patients with severe AS treated with either TAVR or SAVR. Between December 2011 and November 2013, 2032 intermediate-risk patients with severe AS were randomized to TAVR with the Sapien XT valve or SAVR in the Placement of Aortic Transcatheter Valve 2 Trial and were followed up for 2 years. Data analysis was conducted between March 1, 2016, to April 30, 2017. Health status was assessed at baseline, 1 month, 1 year, and 2 years using the Kansas City Cardiomyopathy Questionnaire (KCCQ) (23 items covering physical function, social function, symptoms, self-efficacy and knowledge, and quality of life on a 0- to 100-point scale; higher scores indicate better quality of life), Medical Outcomes Study Short Form-36 (36 items covering 8 dimensions of health status as well as physical and mental summary scores; higher scores represent better health status), and EuroQOL-5D (assesses 5 dimensions of general health on a 3-level scale, with utility scores ranging from 0 [death] to 1 [ideal health]). Analysis of covariance was used to examine changes in health status over time, adjusting for baseline status. Of the 2032 randomized patients, baseline health status was available for 1833 individuals (950 TAVR, 883 SAVR) who formed the primary analytic cohort. A total of 1006 (54.9%) of the population were men; mean (SD) age was 81.4 (6.8) years. Over 2 years, both TAVR and SAVR were associated with significant improvements in both disease specific (16-22 points on the KCCQ-OS scale) and generic health status (3.9-5.1 points on the SF-36 physical summary scale). At 1 month, TAVR was associated with better

  4. Off-pump coronary surgery: surgical strategy for the high-risk patient.

    PubMed

    Van Belleghem, Y; Caes, F; Maene, L; Van Overbeke, H; Moerman, A; Van Nooten, G

    2003-02-01

    In a retrospective study, we compared two groups of consecutive patients operated by the same team during the year 2000 for coronary artery disease with the use of extracorporeal circulation (group 1, n=230) or on the beating heart using the Octopus II plus stabiliser (group 2, n=228). High-risk patients were identified by a EuroSCORE plus 6. EuroSCORE definitions and predicted risk models were utilized to compare the variables of the groups. There were no significant differences between the preoperative variables of the groups in age, gender, left ventricular function, diabetes and peripheral vascular and renal disease as is indicated by the Euroscore (resp. 4.7/5.1 p=0.107). Calcification of the ascending aorta and chronic obstructive lung disease were statistically significant more prevalent in the beating heart group. No differences in preoperative variables in the high-risk patients group (Euroscore 8.5/8.1 p=0.356) except for calcification of the ascending aorta. All patients underwent a full revascularisation through a midline sternotomy. Significant more distal anastomoses were performed in group 1 (3.7 per patient (1-6)) with regard to group 2 (2.9 per patient (1-6)). Anesthesia, postoperative treatment and follow up were equal for both groups. A significant lower incidence of atrial fibrillation (p=0.010), shorter ICU stay (p=0.031) and renal insufficiency (p=0.033) was reported in group 2. In the low risk group, we could not diagnose any difference between the two groups, except for atrial fibrillation. The benefits of the beating heart surgery however were more pronounced in the high-risk patient as is indicated by a significant reduction of the ICU stay by 1 day (3.5d/2.5d (p=0.028)), better preservation of the renal function (p=0.017) and a significant reduction of the length of hospital stay by more than two days (p=0.040). A lower incidence of atrial fibrillation, however not significant. In our experience, beating heart surgery is a safe

  5. Competing Risk Analysis for Evaluation of Dalteparin Versus Unfractionated Heparin for Venous Thromboembolism in Medical-Surgical Critically Ill Patients.

    PubMed

    Li, Guowei; Cook, Deborah J; Levine, Mitchell A H; Guyatt, Gordon; Crowther, Mark; Heels-Ansdell, Diane; Holbrook, Anne; Lamontagne, Francois; Walter, Stephen D; Ferguson, Niall D; Finfer, Simon; Arabi, Yaseen M; Bellomo, Rinaldo; Cooper, D Jamie; Thabane, Lehana

    2015-09-01

    Failure to recognize the presence of competing risk or to account for it may result in misleading conclusions. We aimed to perform a competing risk analysis to assess the efficacy of the low molecular weight heparin dalteparin versus unfractionated heparin (UFH) in venous thromboembolism (VTE) in medical-surgical critically ill patients, taking death as a competing risk.This was a secondary analysis of a prospective randomized study of the Prophylaxis for Thromboembolism in Critical Care Trial (PROTECT) database. A total of 3746 medical-surgical critically ill patients from 67 intensive care units (ICUs) in 6 countries receiving either subcutaneous UFH 5000 IU twice daily (n = 1873) or dalteparin 5000 IU once daily plus once-daily placebo (n = 1873) were included for analysis.A total of 205 incident proximal leg deep vein thromboses (PLDVT) were reported during follow-up, among which 96 were in the dalteparin group and 109 were in the UFH group. No significant treatment effect of dalteparin on PLDVT compared with UFH was observed in either the competing risk analysis or standard survival analysis (also known as cause-specific analysis) using multivariable models adjusted for APACHE II score, history of VTE, need for vasopressors, and end-stage renal disease: sub-hazard ratio (SHR) = 0.92, 95% confidence interval (CI): 0.70-1.21, P-value = 0.56 for the competing risk analysis; hazard ratio (HR) = 0.92, 95% CI: 0.68-1.23, P-value = 0.57 for cause-specific analysis. Dalteparin was associated with a significant reduction in risk of pulmonary embolism (PE): SHR = 0.54, 95% CI: 0.31-0.94, P-value = 0.02 for the competing risk analysis; HR = 0.51, 95% CI: 0.30-0.88, P-value = 0.01 for the cause-specific analysis. Two additional sensitivity analyses using the treatment variable as a time-dependent covariate and using as-treated and per-protocol approaches demonstrated similar findings.This competing risk analysis yields no

  6. Competing Risk Analysis for Evaluation of Dalteparin Versus Unfractionated Heparin for Venous Thromboembolism in Medical-Surgical Critically Ill Patients

    PubMed Central

    Li, Guowei; Cook, Deborah J.; Levine, Mitchell A.H.; Guyatt, Gordon; Crowther, Mark; Heels-Ansdell, Diane; Holbrook, Anne; Lamontagne, Francois; Walter, Stephen D.; Ferguson, Niall D.; Finfer, Simon; Arabi, Yaseen M.; Bellomo, Rinaldo; Cooper, D. Jamie; Thabane, Lehana

    2015-01-01

    Abstract Failure to recognize the presence of competing risk or to account for it may result in misleading conclusions. We aimed to perform a competing risk analysis to assess the efficacy of the low molecular weight heparin dalteparin versus unfractionated heparin (UFH) in venous thromboembolism (VTE) in medical-surgical critically ill patients, taking death as a competing risk. This was a secondary analysis of a prospective randomized study of the Prophylaxis for Thromboembolism in Critical Care Trial (PROTECT) database. A total of 3746 medical-surgical critically ill patients from 67 intensive care units (ICUs) in 6 countries receiving either subcutaneous UFH 5000 IU twice daily (n = 1873) or dalteparin 5000 IU once daily plus once-daily placebo (n = 1873) were included for analysis. A total of 205 incident proximal leg deep vein thromboses (PLDVT) were reported during follow-up, among which 96 were in the dalteparin group and 109 were in the UFH group. No significant treatment effect of dalteparin on PLDVT compared with UFH was observed in either the competing risk analysis or standard survival analysis (also known as cause-specific analysis) using multivariable models adjusted for APACHE II score, history of VTE, need for vasopressors, and end-stage renal disease: sub-hazard ratio (SHR) = 0.92, 95% confidence interval (CI): 0.70–1.21, P-value = 0.56 for the competing risk analysis; hazard ratio (HR) = 0.92, 95% CI: 0.68–1.23, P-value = 0.57 for cause-specific analysis. Dalteparin was associated with a significant reduction in risk of pulmonary embolism (PE): SHR = 0.54, 95% CI: 0.31–0.94, P-value = 0.02 for the competing risk analysis; HR = 0.51, 95% CI: 0.30–0.88, P-value = 0.01 for the cause-specific analysis. Two additional sensitivity analyses using the treatment variable as a time-dependent covariate and using as-treated and per-protocol approaches demonstrated similar findings. This competing risk analysis

  7. Concurrent risk-reduction surgery in patients with increased lifetime risk for breast and ovarian cancer: an analysis of the National Surgical Quality Improvement Program (NSQIP) database.

    PubMed

    Elmi, Maryam; Azin, Arash; Elnahas, Ahmad; McCready, David R; Cil, Tulin D

    2018-05-14

    Patients with genetic susceptibility to breast and ovarian cancer are eligible for risk-reduction surgery. Surgical morbidity of risk-reduction mastectomy (RRM) with concurrent bilateral salpingo-oophorectomy (BSO) is unknown. Outcomes in these patients were compared to patients undergoing RRM without BSO using a large multi-institutional database. A retrospective cohort analysis was conducted using the American College of Surgeon's National Surgical Quality Improvement Program (NSQIP) 2007-2016 datasets, comparing postoperative morbidity between patients undergoing RRM with patients undergoing RRM with concurrent BSO. Patients with genetic susceptibility to breast/ovarian cancer undergoing risk-reduction surgery were identified. The primary outcome was 30-day postoperative major morbidity. Secondary outcomes included surgical site infections, reoperations, readmissions, length of stay, and venous thromboembolic events. A multivariate analysis was performed to determine predictors of postoperative morbidity and the adjusted effect of concurrent BSO on morbidity. Of the 5470 patients undergoing RRM, 149 (2.7%) underwent concurrent BSO. The overall rate of major morbidity and postoperative infections was 4.5% and 4.6%, respectively. There was no significant difference in the rate of postoperative major morbidity (4.5% vs 4.7%, p = 0.91) or any of the secondary outcomes between patients undergoing RRM without BSO vs. those undergoing RRM with concurrent BSO. Multivariable analysis showed Body Mass Index (OR 1.05; p < 0.001) and smoking (OR 1.78; p = 0.003) to be the only predictors associated with major morbidity. Neither immediate breast reconstruction (OR 1.02; p = 0.93) nor concurrent BSO (OR 0.94; p = 0.89) were associated with increased postoperative major morbidity. This study demonstrated that RRM with concurrent BSO was not associated with significant additional morbidity when compared to RRM without BSO. Therefore, this joint approach may

  8. Carotid Stenting with Distal Protection in High-Surgical-Risk Patients: One-Year Results of the ASTI Trial

    SciTech Connect

    Bosiers, Marc, E-mail: marc.bosiers@telenet.be; Scheinert, Dierk, E-mail: dierk.scheinert@gmx.de; Mathias, Klaus, E-mail: k.mathias@asklepios.com

    2015-04-15

    PurposeThis prospective, multicenter, nonrandomized study evaluated the periprocedural and 1-year outcomes in high-surgical-risk patients with carotid artery stenosis treated with the Adapt Carotid Stent plus FilterWire EZ distal protection catheter (Boston Scientific Corporation, Natick, MA).Materials and MethodsThe study enrolled 100 patients (32 symptomatic, 63 asymptomatic, 5 unknown) at high risk for carotid endarterectomy due to prespecified anatomical criteria and/or medical comorbidities. Thirty-day and 1-year follow-up included clinical evaluation, carotid duplex ultrasound, and independent neurologic and NIH stroke scale assessments. One-year endpoints included the composite rate of major adverse events (MAE), defined as death, stroke, and myocardial infarction (MI) and themore » rates of late ipsilateral stroke (31–365 days), target lesion revascularization, and in-stent restenosis.ResultsOf the 100 enrolled patients, technical success was achieved in 90.9 % (90/99). The 30-day MAE rate (5.1 %) consisted of major stroke (2.0 %) and minor stroke (3.1 %); no deaths or MIs occurred. The 1-year MAE rate (12.2 %) consisted of death, MI, and stroke rates of 4.4, 3.3, and 8.9 %, respectively. Late ipsilateral stroke (31–365 days) rate was 1.1 %. Symptomatic patients had higher rates of death (11.1 vs. 1.7 %) and MI (7.4 vs. 1.7 %), but lower rates of major (7.4 vs. 10.0 %) and minor stroke (0.0 vs. 6.7 %), compared with asymptomatic patients.ConclusionResults through 1 year postprocedure demonstrated that carotid artery stenting with Adapt Carotid Stent and FilterWire EZ is safe and effective in high-risk-surgical patients.« less

  9. Characterization of perioperative infection risk among patients undergoing radical cystectomy: Results from the national surgical quality improvement program.

    PubMed

    Parker, William P; Tollefson, Matthew K; Heins, Courtney N; Hanson, Kristine T; Habermann, Elizabeth B; Zaid, Harras B; Frank, Igor; Thompson, R Houston; Boorjian, Stephen A

    2016-12-01

    To evaluate the incidence, risk factors, and timing of infections following radical cystectomy (RC). The American College of Surgeons National Surgical Quality Improvement Project database was queried to identify patients undergoing RC for bladder cancer from 2006 to 2013. Characteristics including year of surgery, age, sex body mass index, diabetes, smoking, renal function, steroid usage, preoperative albumin, preoperative hematocrit, perioperative blood transfusion (PBT), and operative time were assessed for association with the risk of infection within 30 days of RC using multivariable logistic regression. A total of 3,187 patients who had undergone RC were identified, of whom 766 (24.0%) were diagnosed with a postoperative infection, at a median of 13 days (interquartile ranges 8-19) after RC. Infections included surgical site infection (SSI) (404; 12.7%), sepsis/septic shock (405; 12.7%), and urinary tract infection (UTI) (309; 9.7%). On multivariable analysis, body mass index≥30kg/m 2 (odds ratios [OR] = 1.52; P<0.01), receipt of a PBT (OR = 1.27; P<0.01), and operative time≥480 minutes (OR = 1.72; P<0.01) were significantly associated with the risk of infection. When the outcomes of UTI, SSI, and sepsis were analyzed separately, operative time≥480 minutes remained independently associated with increased infection risk in each model (OR = 2.11 for UTI, OR = 1.63 for SSI, and OR = 1.80 for sepsis/septic shock; all P<0.05), whereas PBT was associated with SSI and sepsis/septic shock (OR = 1.33 and OR = 1.29, respectively; both P< 0.05). Approximately 25% of patients undergoing RC experience an infection within 30 days of surgery. Several potentially modifiable risk factors for infection were identified, specifically PBT and prolonged operative time, which may represent opportunities for future care improvement. Copyright © 2016 Elsevier Inc. All rights reserved.

  10. Incidence and Predicted Risk Factors of Pressure Ulcers in Surgical Patients: Experience at a Medical Center in Taipei, Taiwan

    PubMed Central

    Fu Shaw, Ling; Chang, Pao-Chu; Lee, Jung-Fen; Kung, Huei-Yu

    2014-01-01

    Purpose. To explore the context of incidence of and associated risk factors for pressure ulcers amongst the population of surgical patients. Methods. The initial study cohort was conducted with a total of 297 patients admitted to a teaching hospital for a surgical operation from November 14th to 27th 2006 in Taipei, Taiwan. The Braden scale, pressure ulcers record sheet, and perioperative patient outcomes free from signs and symptoms of injury related to positioning and related nursing interventions and activities were collected. Results. The incidence of immediate and thirty-minute-later pressure ulcers is 9.8% (29/297) and 5.1% (15/297), respectively. Using logistic regression model, the statistically significantly associated risk factors related to immediate and thirty-minute-later pressure ulcers include operation age, type of anesthesia, type of operation position, type of surgery, admission Braden score, and number of nursing intervention after adjustment for confounding factors. Conclusion. Admission Braden score and number of nursing intervention are well-established protected factors for the development of pressure ulcers. Our study shows that older operation age, type of anesthesia, type of operation position, and type of surgery are also associated with the development of pressure ulcers. PMID:25057484

  11. Fracture risk assessment: improved evaluation of vertebral integrity among metastatic cancer patients to aid in surgical decision-making

    NASA Astrophysics Data System (ADS)

    Augustine, Kurt E.; Camp, Jon J.; Holmes, David R.; Huddleston, Paul M.; Lu, Lichun; Yaszemski, Michael J.; Robb, Richard A.

    2012-03-01

    Failure of the spine's structural integrity from metastatic disease can lead to both pain and neurologic deficit. Fractures that require treatment occur in over 30% of bony metastases. Our objective is to use computed tomography (CT) in conjunction with analytic techniques that have been previously developed to predict fracture risk in cancer patients with metastatic disease to the spine. Current clinical practice for cancer patients with spine metastasis often requires an empirical decision regarding spinal reconstructive surgery. Early image-based software systems used for CT analysis are time consuming and poorly suited for clinical application. The Biomedical Image Resource (BIR) at Mayo Clinic, Rochester has developed an image analysis computer program that calculates from CT scans, the residual load-bearing capacity in a vertebra with metastatic cancer. The Spine Cancer Assessment (SCA) program is built on a platform designed for clinical practice, with a workflow format that allows for rapid selection of patient CT exams, followed by guided image analysis tasks, resulting in a fracture risk report. The analysis features allow the surgeon to quickly isolate a single vertebra and obtain an immediate pre-surgical multiple parallel section composite beam fracture risk analysis based on algorithms developed at Mayo Clinic. The analysis software is undergoing clinical validation studies. We expect this approach will facilitate patient management and utilization of reliable guidelines for selecting among various treatment option based on fracture risk.

  12. [Cognitive and quality of life trajectory after either surgical or transcatheter aortic valve replacement in high-risk patients].

    PubMed

    Ciuca, Cristina; Fortuna, Daniela; Ferrari, Susy; Salizzoni, Stefano; Grisoglio, Enrica; Punta, Giuseppe; Del Ponte, Stefano; Aranzulla, Tiziana Claudia; Gabbieri, Davide; Gandolfo, Caterina; Dispensa, Flavia; Vecchio Verderame, Lavinia; Tamburino, Corrado; Caruso, Cinzia; Grossi, Claudio; Mikus, Elisa; Guiducci, Vincenzo; Violini, Roberto; Rongoni, Silvia; Pandolfi, Claudia; Moretti, Carolina; De Palma, Rossana; Chattat, Rabih; Savini, Carlo; Marzocchi, Antonio; Saia, Francesco

    2016-12-01

    The impact of transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (AVR) on cognitive status and quality of life in high-risk patients has been incompletely investigated. We conducted a prospective, multicenter study including all patients treated with TAVI and high-risk patients undergoing AVR (age ≥80 years or logistic EuroSCORE ≥15%) at participating centers. Multidimensional geriatric evaluation including Mini Mental State Examination (MMSE), EuroQol 5D (EQ5D) and Minnesota Living With Heart Failure Questionnaire (MLHFQ) were performed at baseline and at 3- and 12-month follow-up. A total of 518 patients (151 AVR and 367 TAVI) were enrolled in 10 Italian institutions. Patients receiving AVR were older (82.7 ± 2.4 years), with a lower logistic EuroSCORE (12.5 ± 7.1%) as compared with TAVI patients (81.5 ± 6.2 years and 19.6 ± 14.0%, respectively, p=0.001 and p<0.001). Overall, 35.5% of patients showed some degree of cognitive impairment at baseline, with no differences between groups. No significant changes in the cognitive status were observed between baseline and follow-up and between groups at any time point. TAVI patients had a lower quality of life at baseline as compared with AVR patients. Generic and heart failure-related quality of life improved significantly after either procedure. In high-risk patients, both TAVI and AVR are associated with a significant improvement of quality of life up to 1 year without a detrimental effect on cognitive function.

  13. Percutaneous edge-to-edge mitral valve repair in high-surgical-risk patients: do we hit the target?

    PubMed

    Van den Branden, Ben J L; Swaans, Martin J; Post, Martijn C; Rensing, Benno J W M; Eefting, Frank D; Jaarsma, Wybren; Van der Heyden, Jan A S

    2012-01-01

    This study sought to assess the feasibility and safety of percutaneous edge-to-edge mitral valve (MV) repair in patients with an unacceptably high operative risk. MV repair for mitral regurgitation (MR) can be accomplished by use of a clip that approximates the free edges of the mitral leaflets. All patients were declined for surgery because of a high logistic EuroSCORE (>20%) or the presence of other specific surgical risk factors. Transthoracic echocardiography was performed before and 6 months after the procedure. Differences in New York Heart Association (NYHA) functional class, quality of life (QoL) using the Minnesota questionnaire, and 6-min walk test (6-MWT) distances were reported. Fifty-five procedures were performed in 52 patients (69.2% male, age 73.2 ± 10.1 years, logistic EuroSCORE 27.1 ± 17.0%). In 3 patients, partial clip detachment occurred; a second clip was placed successfully. One patient experienced cardiac tamponade. Two patients developed inguinal bleeding, of whom 1 needed surgery. Six patients (11.5%) died during 6-month follow-up (5 patients as a result of progressive heart failure and 1 noncardiac death). The MR grade before repair was ≥3 in 100%; after 6 months, a reduction in MR grade to ≤2 was present in 79% of the patients. Left ventricular (LV) end-diastolic diameter, LV ejection fraction, and systolic pulmonary artery pressure improved significantly. Accompanied improvements in NYHA functional class, QoL index, 6-MWT distances, and log N-terminal pro-B-type natriuretic peptide were observed. In a high-risk population, MR reduction can be achieved by percutaneous edge-to-edge valve repair, resulting in LV remodeling with improvement of functional capacity after 6 months. Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

  14. Defining the high-risk patient for carotid endarterectomy: an analysis of the prospective National Surgical Quality Improvement Program database.

    PubMed

    Stoner, Michael C; Abbott, William M; Wong, Daniel R; Hua, Hong T; Lamuraglia, Glenn M; Kwolek, Chirstopher J; Watkins, Michael T; Agnihotri, Arvind K; Henderson, William G; Khuri, Shukri; Cambria, Richard P

    2006-02-01

    Carotid endarterectomy (CEA) is the gold standard for the treatment of carotid stenosis, but carotid angioplasty and stenting has been advocated in high-risk patients. The definition of such a population has been elusive, particularly because the data are largely retrospective. Our study examined results for CEA in the National Surgical Quality Improvement Program database (both Veterans Affairs and private sector). National Surgical Quality Improvement Program data were gathered prospectively for all patients undergoing primary isolated CEA during the interval 2000 to 2003 at 123 Veterans Affairs and 14 private sector academic medical centers. Study end points included the 30-day occurrence of any stroke, death, or cardiac event. A variety of clinical, demographic, and operative variables were assessed with multivariate models to identify risk factors associated with the composite (stroke, death, or cardiac event) end point. Adjudication of end points was by trained nurse reviewers (previously validated). A total of 13,622 CEAs were performed during the study period; 95% were on male patients, and 91% of cases were conducted within the Veterans Affairs sector. The average age was 68.6 +/- 0.1 years, and 42.1% of the population had no prior neurologic event. The composite stroke, death, or cardiac event rate was 4.0%; the stroke/death rate was 3.4%. Multivariate correlates of the composite outcome were (odds ratio, P value) as follows: deciles of age (1.13, .018), insulin-requiring diabetes (1.73, <.001), oral agent-controlled diabetes (1.39, .003), decade of pack-years smoking (1.04, >.001), history of transient ischemic attack (1.41, >.001), history of stroke (1.51, >.001), creatinine >1.5 mg/dL (1.48, >.001), hypoalbuminemia (1.49, >.001), and fourth quartile of operative time (1.44, >.001). Cardiopulmonary comorbid features did not affect the composite outcome in this model. Regional anesthesia was used in 2437 (18%) cases, with a resultant relative risk

  15. Use of hand grip strength in nutrition risk screening of older patients admitted to general surgical wards.

    PubMed

    Byrnes, Angela; Mudge, Alison; Young, Adrienne; Banks, Merrilyn; Bauer, Judy

    2018-04-16

    Hand grip strength (HGS) has been proposed as an indicator of nutritional status that is objective, requires minimal assessor training and is quick to administer, making it attractive for use in the acute setting. This study aimed to determine the discriminatory ability of impaired HGS to screen for malnutrition in an older hospital population and assess the added value of combining this with existing screening tools. Measures were undertaken during acute admission in patients ≥65 years admitted to general surgical wards. Impaired HGS was defined as a mean value below the lower limit of the 95% CI of population norms and observed HGS standardised as a percentage of this value. Nutritional risk was assessed using the Malnutrition Screening Tool (MST) and malnutrition defined as Patient-Generated Subjective Global Assessment (PG-SGA) rating B or C. Discriminatory ability of impaired HGS to identify malnourished patients was tested using the area under the receiver operating characteristic curve (AUC). Seventy-five patients (mean age: 74.0 (SD 6.7) years, 60% male) were recruited. Impaired HGS did not accurately identify malnutrition (AUC (95% CI): 0.41 (0.25-0.58), P < 0.001), nor did it improve discriminatory ability of the MST (AUC (95% CI), MST: 0.83 (0.71-0.95), P = 0.32; MST/HGS combined: 0.68 (0.51-0.86), P = 0.035). HGS was not found to be suitable in screening older inpatients for malnutrition during admission to surgical wards. As such, screening for nutrition risk using an existing validated tool to identify patients for further in-depth nutritional assessment by an appropriately trained clinician remains the preferred method. © 2018 Dietitians Association of Australia.

  16. Ultrasound guided percutaneous cholecystostomy in high-risk patients for surgical intervention.

    PubMed

    Bakkaloglu, Huseyin; Yanar, Hakan; Guloglu, Recep; Taviloglu, Korhan; Tunca, Fatih; Aksoy, Murat; Ertekin, Cemalettin; Poyanli, Arzu

    2006-11-28

    To assess the efficacy and safety of ultrasound guided percutaneous cholecystostomy (PC) in the treatment of acute cholecystitis in a well-defined high risk patients under general anesthesia. The data of 27 consecutive patients who underwent percutaneous transhepatic cholecystostomy for the management of acute cholecystitis from January 1999 to June 2003 was retrospectively evaluated. All of the patients had both clinical and sonographic signs of acute cholecystitis and had comorbid diseases. Ultrasound revealed gallbladder stones in 25 patients and acalculous cholecystitis in two patients. Cholecystostomy catheters were removed 14-32 d (mean 23 d) after the procedure in cases where complete regression of all symptoms was achieved. There were statistically significant reductions in leukocytosis, (13.7 x 10(3)+/-1.3 x 10(3) microg/L vs 13 x 10(3)+/-1 x 10(3) microg/L, P < 0.05 for 24 h after PC; 13.7 x 10(3)+/-1.3 x 10(3) microg/L vs 8.3 x 10(3)+/-1.2 x 10(3) microg/L, P < 0.0001 for 72 h after PC), C -reactive protein (51.2+/-18.5 mg/L vs 27.3+/-10.4 mg/L, P < 0.05 for 24 h after PC; 51.2+/-18.5 mg/L vs 5.4+/-1.5 mg/L, P < 0.0001 for 72 h after PC), and fever (38+/-0.35 centigrade vs 37.3+/-0.32 centigrade, P < 0.05 for 24 h after PC; 38+/-0.35 centigrade vs 36.9+/-0.15 centigrade, P < 0.0001 for 72 h after PC). Sphincterotomy and stone extraction was performed successfully with endoscopic retrograde cholangio-pancreatography (ERCP) in three patients. After cholecystostomy, 5 (18%) patients underwent delayed cholecystectomy without any complications. Three out of 22 patients were admitted with recurrent acute cholecystitis during the follow-up and recovered with medical treatment. Catheter dislodgement occurred in three patients spontaneously, and two of them were managed by reinsertion of the catheter. As an alternative to surgery, percutaneous cholecystostomy seems to be a safe method in critically ill patients with acute cholecystitis and can be performed with

  17. Ultrasound guided percutaneous cholecystostomy in high-risk patients for surgical intervention

    PubMed Central

    Bakkaloglu, Huseyin; Yanar, Hakan; Guloglu, Recep; Taviloglu, Korhan; Tunca, Fatih; Aksoy, Murat; Ertekin, Cemalettin; Poyanli, Arzu

    2006-01-01

    AIM: To assess the efficacy and safety of ultrasound guided percutaneous cholecystostomy (PC) in the treatment of acute cholecystitis in a well-defined high risk patients under general anesthesia. METHODS: The data of 27 consecutive patients who underwent percutaneous transhepatic cholecystostomy for the management of acute cholecystitis from January 1999 to June 2003 was retrospectively evaluated. All of the patients had both clinical and sonographic signs of acute cholecystitis and had comorbid diseases. RESULTS: Ultrasound revealed gallbladder stones in 25 patients and acalculous cholecystitis in two patients. Cholecystostomy catheters were removed 14-32 d (mean 23 d) after the procedure in cases where complete regression of all symptoms was achieved. There were statistically significant reductions in leukocytosis, (13.7 × 103 ± 1.3 × 103 μg/L vs 13 × 103 ± 1 × 103 μg/L, P < 0.05 for 24 h after PC; 13.7 × 103 ± 1.3 × 103 μg/L vs 8.3 × 103 ± 1.2 × 103 μg/L, P < 0.0001 for 72 h after PC), C -reactive protein (51.2 ± 18.5 mg/L vs 27.3 ± 10.4 mg/L, P < 0.05 for 24 h after PC; 51.2 ± 18.5 mg/L vs 5.4 ± 1.5 mg/L, P < 0.0001 for 72 h after PC), and fever (38 ± 0.35°C vs 37.3 ± 0.32°C, P < 0.05 for 24 h after PC; 38 ± 0.35°C vs 36.9 ± 0.15°C, P < 0.0001 for 72 h after PC). Sphincterotomy and stone extraction was performed successfully with endoscopic retrograde cholangio-pancreatography (ERCP) in three patients. After cholecystostomy, 5 (18%) patients underwent delayed cholecystectomy without any complications. Three out of 22 patients were admitted with recurrent acute cholecystitis during the follow-up and recovered with medical treatment. Catheter dislodgement occurred in three patients spontaneously, and two of them were managed by reinsertion of the catheter. CONCLUSION: As an alternative to surgery, percutan-eous cholecystostomy seems to be a safe method in critically ill patients with acute cholecystitis and can be performed with low

  18. Endovascular approach to treat ascending aortic pseudoaneurysm in a patient with previous CABG and very high surgical risk.

    PubMed

    Zago, Alexandre C; Saadi, Eduardo K; Zago, Alcides J

    2011-10-01

    Pseudoaneurysm of the ascending aorta is an uncommon pathology and a challenge in high-risk patients who undergo conventional surgery because of high operative morbidity and mortality. Endovascular exclusion of an aortic pseudoaneurysm using an endoprosthesis is a less invasive approach, but few such cases have been reported. Moreover, the use of this approach poses unique therapeutic challenges because there is no specific endoprosthesis for ascending aortic repair, particularly to treat patients with previous coronary artery bypass graft (CABG). We describe the case of a 74-year-old patient who had undergone CABG and later presented with an iatrogenic ascending aortic pseudoaneurysm that occurred during an angiography. This patient was at very high risk for surgical treatment and, therefore, an endovascular approach was adopted: percutaneous coronary intervention for the left main coronary artery, left anterior descending and left circumflex native coronary arteries followed by endovascular endoprosthesis deployment in the ascending aorta to exclude the pseudoaneurysm. Both procedures were successfully performed, and the patient was discharged without complications 4 days later. At 5 months' clinical follow-up, his clinical condition was good and he had no complications. Copyright © 2011 Wiley-Liss, Inc.

  19. Risk factors and outcome of increased red blood cell transfusion in cardiac surgical patients aged 65 years and older.

    PubMed

    Isil, Canan Tulay; Yazici, Pinar; Bakir, Ihsan

    2015-02-01

    The use of blood products is not uncommon during cardiac surgery in elderly patients. We conducted this study to investigate the risk factors and adverse outcomes of increased red blood cell (RBC) transfusion in the patients aged ≥ 65 years undergoing cardiac surgery. During 1 year period, 288 patients (197 male/91 female) aged ≥ 65 years who underwent coronary and/or valvular surgery were retrospectively reviewed. Patients were stratified into groups on the basis of the number of transfusions received (< 4 and ≥ 4 U) which was classified as increased transfusion. Univariate analysis and multivariate logistic regression were used to identify risk factors for increased transfusion. The mean unit of RBC transfusion was 4.5 ± 3.1 and 55.9% (n = 161) of patients received ≥ 4 U RBC. The overall postoperative complication rate was 36% and significantly higher in those with ≥ 4 U) RBC transfusion (p < 0.01). Risk factors including age, EuroSCORE, and low body surface were significantly higher in patient with ≥ 4 U RBC transfusion. Besides, preoperative anemia, postoperative drainage volume, and fresh frozen plasma (FFP) transfusion during hospital stay were found to be significantly associated with increased transfusion requirements. No difference was observed in mortality (p = 0.13). These results suggest that improvement in blood transfusion policy in elderly patients undergoing cardiac surgery requires elimination of preoperative anemia, careful attention to surgical hemostasis, and FFP use. Georg Thieme Verlag KG Stuttgart · New York.

  20. Predicted versus observed 30-day perioperative outcomes using the ACS NSQIP surgical risk calculator in patients undergoing partial nephrectomy for renal cell carcinoma.

    PubMed

    Blair, Brian M; Lehman, Erik B; Jafri, Syed M; Kaag, Matthew G; Raman, Jay D

    2018-06-04

    The purpose of the study was to evaluate the accuracy of the American College of Surgeons NSQIP Surgical Risk Calculator for predicting risk-adjusted 30-day outcomes for patients undergoing partial nephrectomy (PN) for renal cell carcinoma (RCC). A single institution, multi-surgeon, prospectively maintained database was queried for patients undergoing PN for RCC from 1998 to 2015. 21 preoperative factors were analyzed for each patient with predicted risk for 30-day complications, mortality, and length of stay (LOS) calculated. Differences between the mean predicted risk and observed rate of surgical outcomes were determined using two-sided one-sample t test with significance at p < 0.05. Subgroup analyses of outcomes stratified by surgical approach were also performed. 470 patients undergoing PN for RCC were analyzed. Comparing NSQIP predicted to observed outcomes, clinically significant underestimations occurred with rates of overall complications (9.16 vs. 16.81%, p < 0.001), surgical site infections [SSI] (1.65 vs. 2.77%, p < 0.001), urinary tract infection [UTI] (1.41 vs. 3.40%, p < 0.001), and LOS (3.25 vs. 3.73 days, p < 0.001). On subgroup analysis, 209 open PN and 261 minimally invasive PN (MIPN) were performed. The NSQIP calculator consistently underestimated overall complications, SSI, UTI, and LOS (p < 0.001) among both surgical approaches, while overestimating MIPN severe complications (p < 0.001). Clinically important differences persisted when stratifying the MIPN group by laparoscopic (N = 111) and robotic (N = 150) approaches. The ACS NSQIP Surgical Risk Calculator had significant discrepancies among observed and predicted outcomes. Additional analyses confirmed these differences remained significant irrespective of surgical approach. These findings emphasize the need for urologic oncology-specific calculators to better predict surgical outcomes in this complex patient population.

  1. Surgical risk factors associated with lung transplantation.

    PubMed

    Paradela, M; González, D; Parente, I; Fernández, R; De La Torre, M M; Delgado, M; García, J A; Fieira, E; Bonhome, C; Maté, J M B

    2009-01-01

    Despite years of experience with lung transplantation, perioperative morbidity rates remain high. The objective of this study was to analyze our series of lung transplant recipients, seeking to identify possible intra- and postoperative risk factors associated with mortality. We performed a descriptive, retrospective study of 224 consecutive patients undergoing lung transplantation over a period of 112 months; we excluded retransplant procedures. We gathered details of the surgical procedure and postoperative period in the recovery unit. Univariate analysis using the chi-square test identified variables associated with the incidence of mortality. From 1999 to 2008, we performed 224 lung transplants, including 66% in men and 34% in women. Their overall mean age was 49.9 +/- 13.5 years. The conditions that led to transplantation were pulmonary fibrosis (38.4%); chronic obstructive pulmonary disease emphysema (29%); cystic fibrosis (10.7%); bronchiectasis (8.9%); pulmonary hypertension (3.1%); and other diseases (9.9%). A total of 124 (55.4%) patients underwent single and 100 (44.6%) received sequential bilateral lung transplantations. Surgical risk factors were identified in 51.3% of the cases, the most frequent being hemorrhage (25.3%), followed by severe pulmonary hypertension (14.7%) and cardiopulmonary bypass (12.1%). Greater perioperative mortality was detected among patients with surgical risk factors, namely, significantly related to cardiopulmonary bypass, pulmonary hypertension, and air leak. A higher frequency of surgical risk factors was observed among patients with bilateral lung transplantations and longer procedures, but they were not associated with greater perioperative mortality. Reoperation was necessary in 16 patients (7.2%), mainly owing to bleeding, it was not significantly related to mortality risk. The incidence of surgical risk factors in lung transplantation was high, especially in bilateral lung transplantations and prolonged procedures

  2. Surgical site infections: reanalysis of risk factors.

    PubMed

    Malone, Debra L; Genuit, Thomas; Tracy, J Kathleen; Gannon, Christopher; Napolitano, Lena M

    2002-03-01

    Surgical site infections (SSI) are the most common nosocomial infection in surgical patients, accounting for 38% of all such infections, and are a significant source of postoperative morbidity resulting in increased hospital length of stay and increased cost. During 1986-1996 the Center for Disease Control and Prevention's National Nosocomial Infections Surveillance system reported 15,523 SSI following 593,344 operations (2.6%). Previous studies have documented patient characteristics associated with an increased risk of SSI, including diabetes, tobacco or steroid use, obesity, malnutrition, and perioperative blood transfusion. In this study we sought to reevaluate risk factors for SSI in a large cohort of noncardiac surgical patients. Prospective data (NSQIP) were collected on 5031 noncardiac surgical patients at the Veteran's Administration Maryland Healthcare System from 1995 to 2000. All preoperative risk factors were evaluated as independent predictors of surgical site infection. The mean age of the study cohort was 61 plus minus 13. SSI occurred in 162 patients, comprising 3.2% of the study cohort. Gram-positive organisms were the most common bacterial etiology. Multiple logistic regression analysis documented that diabetes (insulin- and non-insulin-dependent), low postoperative hematocrit, weight loss (within 6 months), and ascites were significantly associated with increased SSI. Tobacco use, steroid use, and chronic obstructive pulmonary disease (COPD) were not predictors for SSI. This study confirms that diabetes and malnutrition (defined as significant weight loss 6 months prior to surgery) are significant preoperative risk factors for SSI. Postoperative anemia is a significant risk factor for SSI. In contrast to prior analyses, this study has documented that tobacco use, steroid use, and COPD are not independent predictors of SSI. Future SSI studies should target early preoperative intervention and optimization of patients with diabetes and malnutrition.

  3. Quality of life in high-risk patients: comparison of transcatheter aortic valve implantation with surgical aortic valve replacement.

    PubMed

    Amonn, Kathrin; Stortecky, Stefan; Brinks, Henriette; Gahl, Brigitta; Windecker, Stephan; Wenaweser, Peter; Carrel, Thierry; Huber, Christoph

    2013-01-01

    To compare health-related quality of life (QoL) in patients undergoing transcatheter aortic valve implantation via transapical access (TA TAVI) with patients undergoing surgical aortic valve replacement (SAVR). One hundred and forty-four high-risk patients referred for aortic valve replacement underwent TAVI screening and were assigned to either TA TAVI (n = 51, age 79.7 ± 9.2 years, logistic EuroSCORE 26.5 ± 16.1%, 51% males) or SAVR (n = 93, age 81.1 ± 5.3 years, logistic EuroSCORE 12.1 ± 9.3%, 42% males) by the interdisciplinary heart team. QoL was assessed using the Short Form 36 (SF-36) Health Survey Questionnaire and the Hospital Anxiety and Depression Scale. Furthermore, current living conditions and the degree of independence at home were evaluated. Patients undergoing TA TAVI were at higher risk as assessed by EuroSCORE (26.5 ± 16 vs. 12.1 ± 9, P < 0.001) and STS score (6.7 ± 4 vs. 4.4 ± 3, P < 0.001) compared with SAVR patients. At the 30-day follow-up, the rate of mortality was similar and amounted to 7.8% for TA TAVI and 7.5% for SAVR patients and raised to 25.5% in TA TAVI and 18.3% in SAVR patients after a follow-up period of 15 ± 10 months. Assessment of QoL revealed no differences in terms of anxiety and depression between TA TAVI and SAVR patients. The SF-36 mental health metascore was similar in both groups (65.6 ± 19 vs. 68.8 ± 22, P = 0.29), while a significant difference was observed in the physical health metascore (49.7 ± 21 vs. 62.0 ± 21, P = 0.015). After adjustment for baseline characteristics, this difference disappeared. However, every added point in the preoperative risk assessment with the STS score decreased the SF-36 physical health dimension by two raw points at the follow-up assessment. Selected high-risk patients undergoing TAVI by using a transapical access achieve similar clinical outcomes and QoL compared with patients undergoing SAVR. Increased STS scores predict worse QoL outcomes.

  4. Surgical patient selection and counseling

    PubMed Central

    Ziegelmann, Matt; Köhler, Tobias S.; Bailey, George C.; Miest, Tanner; Alom, Manaf

    2017-01-01

    The objectives of patient selection and counseling are ultimately to enhance successful outcomes. However, the definition for success is often narrowly defined in published literature (ability to complete surgery, complications, satisfaction) and fails to account for patient desires and expectations, temporal changes, natural history of underlying diseases, or independent validation. Factors associated with satisfaction and dissatisfaction are often surgery-specific, although correlation with pre-operative expectations, revisions, and complications are common with most procedures. The process of appropriate patient selection is determined by the integration of patient and surgeon factors, including psychological capacity to handle unsatisfactory results, baseline expectations, complexity of case, and surgeon volume and experience. Using this model, a high-risk scenario includes one in which a low-volume surgeon performs a complex case in a patient with limited psychological capacity and high expectations. In contrast, a high-volume surgeon performing a routine case in a male with low expectations and abundant psychiatric reserve is more likely to achieve a successful outcome. To further help identify patients who are at high risk for dissatisfaction, a previously published mnemonic is recommended: CURSED Patient (compulsive/obsessive, unrealistic, revision, surgeon shopping, entitled, denial, and psychiatric). Appropriate patient counseling includes setting appropriate expectations, reviewing the potential and anticipated risks of surgery, post-operative instruction to limit complications, and long-term follow-up. As thorough counseling is often a time-consuming endeavor, busy practices may elect to utilize various resources including educational materials, advanced practice providers, or group visits, among others. The consequences for poor patient selection and counseling may range from poor surgical outcomes and patient dissatisfaction to lawsuits, loss of

  5. Surgical patient selection and counseling.

    PubMed

    Ziegelmann, Matt; Köhler, Tobias S; Bailey, George C; Miest, Tanner; Alom, Manaf; Trost, Landon

    2017-08-01

    The objectives of patient selection and counseling are ultimately to enhance successful outcomes. However, the definition for success is often narrowly defined in published literature (ability to complete surgery, complications, satisfaction) and fails to account for patient desires and expectations, temporal changes, natural history of underlying diseases, or independent validation. Factors associated with satisfaction and dissatisfaction are often surgery-specific, although correlation with pre-operative expectations, revisions, and complications are common with most procedures. The process of appropriate patient selection is determined by the integration of patient and surgeon factors, including psychological capacity to handle unsatisfactory results, baseline expectations, complexity of case, and surgeon volume and experience. Using this model, a high-risk scenario includes one in which a low-volume surgeon performs a complex case in a patient with limited psychological capacity and high expectations. In contrast, a high-volume surgeon performing a routine case in a male with low expectations and abundant psychiatric reserve is more likely to achieve a successful outcome. To further help identify patients who are at high risk for dissatisfaction, a previously published mnemonic is recommended: CURSED Patient (compulsive/obsessive, unrealistic, revision, surgeon shopping, entitled, denial, and psychiatric). Appropriate patient counseling includes setting appropriate expectations, reviewing the potential and anticipated risks of surgery, post-operative instruction to limit complications, and long-term follow-up. As thorough counseling is often a time-consuming endeavor, busy practices may elect to utilize various resources including educational materials, advanced practice providers, or group visits, among others. The consequences for poor patient selection and counseling may range from poor surgical outcomes and patient dissatisfaction to lawsuits, loss of

  6. Chest cage angle difference and rotation of main thoracic curve are independent risk factors of postoperative shoulder imbalance in surgically treated patients with adolescent idiopathic scoliosis.

    PubMed

    Yagi, Mitsuru; Takemitsu, Masakazu; Machida, Masafumi

    2013-09-01

    Retrospective case series of surgically treated adolescent patients with scoliosis. To assess the prevalence and independent risk factors for postoperative shoulder imbalance in surgically treated adolescent patients with idiopathic scoliosis. Despite recent reports that have identified risk factors for postoperative shoulder imbalance, the relative risks remain unclear. A retrospective review of 85 consecutive patients treated with thoracic fusion with a minimum 2-year follow-up (mean, 3.1 yr) was conducted to investigate the patient radiographical measurements and demographics. Shoulder height difference (SHD) was measured as the graded height difference of the soft tissue shadows. A SHD more than 2 cm indicated an unbalanced shoulder. Patient demographics and radiographical data were studied to determine risk factors for postoperative SHD. The potential risk factors included age, sex, Risser sign, Cobb angle, flexibility, and apical vertebral rotation (AVR) of the main curve, upper-instrumented vertebra level, SHD, and clavicle chest cage angle difference (CCAD). Univariate and multivariate logistic regression analyses were performed to determine the independent risk factors for postoperative shoulder imbalance. Of the 85 patients, 21 patients presented postoperative shoulder imbalance. The univariate analysis indicated age, Risser sign, Cobb angle of the main curve, AVR of the main curve, and CCAD as risk factors, but the multivariate logistic regression analysis showed that only AVR of the main curve and CCAD were independent risk factors for postoperative shoulder imbalance (AVR, P = 0.04, odds ratio (OR): 3.54; CCAD, P = 0.01, OR: 5.10). Postoperative shoulder imbalance was observed in 25% of the surgically treated adolescent patients. The CCAD and AVR of the main thoracic curve were independent risk factors for postoperative shoulder imbalance in surgically treated patients with adolescent idiopathic scoliosis. The significant correlation between CCAD and

  7. Evaluating the use of antibiotic prophylaxis during open reduction and internal fixation surgery in patients at low risk of surgical site infection.

    PubMed

    Xu, Sheng-Gen; Mao, Zhao-Guang; Liu, Bin-Sheng; Zhu, Hui-Hua; Pan, Hui-Lin

    2015-02-01

    Widespread overuse and inappropriate use of antibiotics contribute to increasingly antibiotic-resistant pathogens and higher health care costs. It is not clear whether routine antibiotic prophylaxis can reduce the rate of surgical site infection (SSI) in low-risk patients undergoing orthopaedic surgery. We designed a simple scorecard to grade SSI risk factors and determined whether routine antibiotic prophylaxis affects SSI occurrence during open reduction and internal fixation (ORIF) orthopaedic surgeries in trauma patients at low risk of developing SSI. The SSI risk scorecard (possible total points ranged from 5 to 25) was designed to take into account a patient's general health status, the primary cause of fractures, surgical site tissue condition or wound class, types of devices implanted, and surgical duration. Patients with a low SSI risk score (≤8 points) who were undergoing clean ORIF surgery were divided into control (routine antibiotic treatment, cefuroxime) and evaluation (no antibiotic treatment) groups and followed up for 13-17 months after surgery. The infection rate was much higher in patients with high SSI risk scores (≥9 points) than in patients with low risk scores assigned to the control group (10.7% vs. 2.2%, P<0.0001). SSI occurred in 11 of 499 patients in the control group and in 13 of 534 patients in the evaluation group during the follow-up period of 13-17 months. The SSI occurrence rate did not differ significantly (2.2% vs. 2.4%, P=0.97) between the control and evaluation groups. Routine antibiotic prophylaxis does not significantly decrease the rate of SSI in ORIF surgical patients with a low risk score. Implementation of this scoring system could guide the rational use of perioperative antibiotics and ultimately reduce antibiotic resistance, health care costs, and adverse reactions to antibiotics. Copyright © 2014 Elsevier Ltd. All rights reserved.

  8. Carotid artery stenting in high surgical risk patients using the FiberNet embolic protection system: the EPIC trial results.

    PubMed

    Myla, Subbarao; Bacharach, J Michael; Ansel, Gary M; Dippel, Eric J; McCormick, Daniel J; Popma, Jeffrey J

    2010-05-01

    The multicenter EPIC (FiberNet Embolic Protection System in Carotid Artery Stenting Trial) single-arm trial evaluated the 30-day outcomes of a new design concept for embolic protection during carotid artery stenting (CAS). Embolic protection filters available for use during CAS include fixed and over-the-wire systems that rely on embolic material capture within a "basket" structure. The FiberNet Embolic Protection System (EPS), which features a very low crossing profile, consists of a three-dimensional fiber-based filter distally mounted on a 0.014 inch guidewire with integrated aspiration during filter retrieval. The trial enrolled 237 patients from 26 centers. Demographics, clinical and lesion characteristics, as well as adverse events through a 30-day follow-up were recorded. The mean age of the patients was 74 years, 64% were male and 20% had symptomatic carotid artery disease. The combined major adverse event (MAE) rate at 30 days for all death, stroke, and myocardial infarction was 3.0%. There were three major strokes (two ischemic and one hemorrhagic) and two minor strokes (both ischemic) for a 2.1% 30-day stroke rate. The procedural technical success rate was 97.5% and macroscopic evidence of debris was reported in 90.9% of the procedures. The FiberNet EPS, used with commercially available stents, produced low stroke rates following CAS in high surgical risk patients presenting with carotid artery disease. The unique filter design including aspiration during retrieval may have contributed to the low 30-day stroke rate reported during CAS in patients considered at high risk for complications following carotid endarterectomy (CEA). Copyright 2010 Wiley-Liss, Inc.

  9. Clarification of the circulatory patho-physiology of anaesthesia - implications for high-risk surgical patients.

    PubMed

    Wolff, Christopher B; Green, David W

    2014-12-01

    The paper examines the effects of anaesthesia on circulatory physiology and their implications regarding improvement in perioperative anaesthetic management. Changes to current anaesthetic practice, recommended recently, such as the use of flow monitoring in high risk patients, are already beginning to have an impact in reducing complications but not mortality [1]. Better understanding of the patho-physiology should help improve management even further. Analysis of selected individual clinical trials has been used to illustrate particular areas of patho-physiology and how changes in practice have improved outcome. There is physiological support for the importance of achieving an appropriate rate of oxygen delivery (DO2), particularly following induction of anaesthesia. It is suggested that ensuring adequate DO2 during anaesthesia will avoid development of oxygen debt and hence obviate the need to induce a high, compensatory, DO2 in the post-operative period. In contrast to the usual assumptions underlying strategies requiring a global increase in blood flow [1] by a stroke volume near maximization strategy, blood flow control actually resides entirely at the tissues not at the heart. This is important as the starting point for understanding failed circulatory control as indicated by 'volume dependency'. Local adjustments in blood flow at each individual organ - auto-regulation - normally ensure the appropriate local rate of oxygen supply, i.e. local DO2. Inadequate blood volume leads to impairment of the regulation of blood flow, particularly in the individual tissues with least capable auto-regulatory capability. As demonstrated by many studies, inadequate blood flow first occurs in the gut, brain and kidney. The inadequate blood volume which occurs with induction of anaesthesia is not due to blood volume loss, but probably results from redistribution due to veno-dilation. The increase in venous capacity renders the existing blood volume inadequate to maintain

  10. The American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator Does Not Accurately Predict Risk of 30-Day Complications Among Patients Undergoing Microvascular Head and Neck Reconstruction.

    PubMed

    Arce, Kevin; Moore, Eric J; Lohse, Christine M; Reiland, Matthew D; Yetzer, Jacob G; Ettinger, Kyle S

    2016-09-01

    The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Surgical Risk Calculator (SRC) is a novel universal risk calculator designed to aid in risk stratification of patients undergoing various types of major surgery. The purpose of this study was to assess the validity of the ACS NSQIP SRC in predicting postoperative complications in patients undergoing microvascular head and neck reconstruction. A retrospective cohort study of patients undergoing head and neck microvascular reconstruction with fibular free flaps at a single institution was completed. The NSQIP SRC was used to compute complication risk estimates and length of stay (LOS) estimates for all patients under study. Associations between complication risk estimates generated by the SRC and actual rates of observed complications were evaluated using logistic regression models. Logistic regression models also were used to evaluate the SRC estimates for LOS duration compared with the actual observed LOS after surgery. Of 153 patients under study, 46 (30%) developed a postoperative complication corresponding to those defined by NSQIP SRC. Thirty-eight patients (25%) developed a postoperative complication categorized as severe in the parameters of the NSQIP SRC. None of the SRC complication estimates showed a statistically relevant association with the corresponding observed rates of complications. The mean LOS predicted by the SRC was 8.0 days (median, 7.5 days; interquartile range [IQR], 6.5 to 9; range, 5.0 to 18.5 days). The mean observed LOS for the study group was 9.6 days (median, 7.0 days; IQR, 6 to 9; range, 5 to 67 days). Lin's (Biometrics 45:255, 1989) concordance correlation coefficient to measure agreement between observed and predicted LOS was 0.10, indicating only slight agreement between the 2 values. The ACS NSQIP SRC is not a useful risk-stratifying metric for patients undergoing major head and neck reconstruction with microvascular fibular free

  11. Application of an artificial intelligence program to therapy of high-risk surgical patients.

    PubMed

    Patil, R S; Adibi, J; Shoemaker, W C

    1996-11-01

    We developed an artificial intelligence program from a large computerized database of hemodynamic and oxygen transport measurements together with prior studies defining survivors' values, outcome predictors, and a branched-chain decision tree. The artificial intelligence program was then tested on the data of 100 survivors and 100 nonsurvivors not used for the development of the program or other analyses. Using the predictor as a surrogate outcome measure, the therapy recommended by the program improved the predicted outcome 3.16% per therapeutic intervention while the actual therapy given increased outcome 1.86% in surviving patients; the artificial intelligence-recommended therapy improved outcome 7.9% in nonsurvivors, while the actual therapy given increased predicted outcome -0.29% in nonsurvivors (p < .05). There were fewer patients whose predicted outcome decreased after recommended treatment (14%) than after the actual therapy given (37%). Review of therapy recommended by the program did not reveal instances of inappropriate or potentially harmful recommendations.

  12. Prevention of VTE in Nonorthopedic Surgical Patients

    PubMed Central

    Garcia, David A.; Wren, Sherry M.; Karanicolas, Paul J.; Arcelus, Juan I.; Heit, John A.; Samama, Charles M.

    2012-01-01

    Background: VTE is a common cause of preventable death in surgical patients. Methods: We developed recommendations for thromboprophylaxis in nonorthopedic surgical patients by using systematic methods as described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. Results: We describe several alternatives for stratifying the risk of VTE in general and abdominal-pelvic surgical patients. When the risk for VTE is very low (< 0.5%), we recommend that no specific pharmacologic (Grade 1B) or mechanical (Grade 2C) prophylaxis be used other than early ambulation. For patients at low risk for VTE (∼1.5%), we suggest mechanical prophylaxis, preferably with intermittent pneumatic compression (IPC), over no prophylaxis (Grade 2C). For patients at moderate risk for VTE (∼3%) who are not at high risk for major bleeding complications, we suggest low-molecular-weight heparin (LMWH) (Grade 2B), low-dose unfractionated heparin (Grade 2B), or mechanical prophylaxis with IPC (Grade 2C) over no prophylaxis. For patients at high risk for VTE (∼6%) who are not at high risk for major bleeding complications, we recommend pharmacologic prophylaxis with LMWH (Grade 1B) or low-dose unfractionated heparin (Grade 1B) over no prophylaxis. In these patients, we suggest adding mechanical prophylaxis with elastic stockings or IPC to pharmacologic prophylaxis (Grade 2C). For patients at high risk for VTE undergoing abdominal or pelvic surgery for cancer, we recommend extended-duration, postoperative, pharmacologic prophylaxis (4 weeks) with LMWH over limited-duration prophylaxis (Grade 1B). For patients at moderate to high risk for VTE who are at high risk for major bleeding complications or those in whom the consequences of bleeding are believed to be particularly severe, we suggest

  13. Late surgical correction of hypospadias increases the risk of complications: a series of 501 consecutive patients.

    PubMed

    Garnier, Sarah; Maillet, Olivier; Cereda, Barbara; Ollivier, Margot; Jeandel, Clement; Broussous, Sylvie; Lopez, Christophe; Paris, Francoise; Philibert, Pascal; Amouroux, Cyril; Jeandel, Claire; Coffy, Amandine; Gaspari, Laura; Daures, Jean Pierre; Sultan, Charles; Kalfa, Nicolas

    2017-06-01

    To evaluate the outcomes of hypospadias surgery according to age and to determine if some complications are age-related. This retrospective study was based on 722 boys with hypospadias undergoing primary repair. A total of 501 boys underwent urethroplasty and were included in the study. Complications requiring an additional procedure (stenosis, fistula, dehiscence, relapse of curvature, urethrocele) were included in the analysis, as well as healing problems, infections, haematomas and detrusor-sphincter dyssynergy. Logistic regression analysis was performed. Hypospadias was anterior in 63.1%, mid-penile in 20.5%, posterior in 8.4% and scrotal in 7.9% of the boys. The median (range) age was 4 (1-16) years. The overall rates of re-intervention and complications were 22.8% and 36.2%, respectively. Age >2 years was a significant predictor of complications (P = 0.002, odds ratio 1.98 [95% confidence interval 1.26-3.13]). Some periods of time appeared to be associated with a specific complication: dyssynergy was more common between the ages of 24 and 36 months (12.5 vs 3.6%; P = 0.01) and healing problems were more common in boys aged >13 years (1.5 vs 28.5%; P = 0.06). Delayed surgery may be detrimental for patients. Factors related to age may influence the rate of complications. After the age of 2 years, urethral surgery may interfere with the normal toilet-training process. During puberty, endogenous testosterone may alter healing. Even if no specific data exist for severe hypospadias, it may be prudent to continue to advocate early surgery in patients with disorders of sex development. © 2017 The Authors BJU International © 2017 BJU International Published by John Wiley & Sons Ltd.

  14. Risk factors associated with the surgical management of craniopharyngiomas in pediatric patients: analysis of 1961 patients from a national registry database.

    PubMed

    Bakhsheshian, Joshua; Jin, Diana L; Chang, Ki-Eun; Strickland, Ben A; Donoho, Dan A; Cen, Steven; Mack, William J; Attenello, Frank; Christian, Eisha A; Zada, Gabriel

    2016-12-01

    OBJECTIVE Patient demographic characteristics, hospital volume, and admission status have been shown to impact surgical outcomes of sellar region tumors in adults; however, the data available following the resection of craniopharyngiomas in the pediatric population remain limited. The authors sought to identify potential risk factors associated with outcomes following surgical management of pediatric craniopharyngiomas. METHODS The Nationwide Inpatient Sample database and Kids' Inpatient Database were analyzed to include admissions for pediatric patients (≤ 18 years) who underwent a transcranial or transsphenoidal craniotomy for resection of a craniopharyngioma. Patient-level factors, including age, race, comorbidities, and insurance type, as well as hospital factors were collected. Outcomes analyzed included mortality rate, endocrine and nonendocrine complications, hospital charges, and length of stay. A multivariate model controlling for variables analyzed was constructed to examine significant independent risk factors. RESULTS Between 2000 and 2011, 1961 pediatric patients were identified who underwent a transcranial (71.2%) or a transsphenoidal (28.8%) craniotomy for resection of a craniopharyngioma. A major predilection for age was observed with the selection of a transcranial (23.4% in < 7-year-olds, 28.1% in 7- to 12-year-olds, and 19.7% in 13- to 18-year-olds) versus transphenoidal (2.9% in < 7-year-olds, 7.4% in 7- to 12-year-olds, and 18.4% in 13- to 18-year-olds) approach. No significant outcomes were associated with a particular surgical approach, except that 7- to 12-year-old patients had a higher risk of nonendocrine complications (relative risk [RR] 2.42, 95% CI 1.04-5.65, p = 0.04) with the transsphenoidal approach when compared with 13- to 18-year-old patients. The overall inpatient mortality rate was 0.5% and the most common postoperative complication was diabetes insipidus (64.2%). There were no independent factors associated with inpatient

  15. Latest evidence on transcatheter aortic valve implantation vs. surgical aortic valve replacement for the treatment of aortic stenosis in high and intermediate-risk patients.

    PubMed

    Praz, Fabien; Siontis, George C M; Verma, Subodh; Windecker, Stephan; Jüni, Peter

    2017-03-01

    The goal of this review is to summarize the current evidence supporting the use of transcatheter aortic valve implantation (TAVI) in high and intermediate-risk patients. The focus is on the five randomized controlled trials comparing TAVI with surgical aortic valve replacement (SAVR) published to date, as well as two recent meta-analyses. TAVI has profoundly transformed the treatment of elderly patients presenting with symptomatic severe aortic stenosis. In experienced hands, the procedure has become well tolerated and the results more predictable. So far, two trials using two different devices [Placement of Aortic Transcatheter Valve (PARTNER) 1A and US CoreValve High Risk] have shown that TAVI is able to compete in terms of mortality with SAVR in high-risk patients. These findings have been extended to the intermediate-risk population in two recently published randomized controlled trials [PARTNER 2 and Nordic Aortic Valve Intervention (NOTION)]. The two meta-analyses suggested improved survival in both high and intermediate-risk patients during the first 2 years following the intervention. The survival benefit was only found in patients treated via the transfemoral access, and appeared more pronounced in women. Individual randomized trials enrolling high and intermediate-risk patients have established the noninferiority of TAVI in comparison with SAVR, whereas subsequent meta-analyses suggest superiority of transfemoral TAVI in terms of a sustained survival benefit 2 years after valve implantation irrespective of the surgical risk category. The benefit of TAVI appears more pronounced in women than in men.

  16. Preoperative quality of life and surgical outcomes in gynecologic oncology patients: A new predictor of operative risk?

    PubMed Central

    Doll, KM; Snavely, AC; Kalinowski, A; Irwin, DE; Bensen, JT; Bae-Jump, V; Boggess, JF; Soper, JT; Brewster, WR; Gehrig, PA

    2014-01-01

    Objective Quality of life (QoL) for women with gynecologic malignancies is predictive of chemotherapy related toxicity and overall survival but has not been studied in relation to surgical outcomes and hospital readmissions. Our goal was to evaluate the association between baseline, pre-operative QoL measures and 30-day post-operative morbidity and health resource utilization by gynecologic oncology patients. Methods We analyzed prospectively collected survey data from an institution-wide cohort study. Patients were enrolled from 8/2012 – 6/2013 and medical records data was abstracted (demographics, comorbid conditions, and operative outcomes). Responses from several validated health-related QoL instruments were collected. Bivariate tests and multivariable linear and logistic regression models were used to evaluate factors associated with QoL scores. Results Of 182 women with suspected gynecologic malignancies, 152 (84%) were surveyed pre-operatively and 148 (81%) underwent surgery. Uterine (94; 63.5%), ovarian (26; 17.5%), cervical (15; 10%), vulvar/vaginal (8; 5.4%), and other (5; 3.4%) cancers were represented. There were 37 (25%) cases of postoperative morbidity (PM), 18 (12%) unplanned ER visits, 9(6%) unplanned clinic visits, and 17 (11.5%) hospital readmissions(HR) within 30 days of surgery. On adjusted analysis, lower functional well-being scores resulted in increased odds of PM (OR 1.07, 95%CI 1.01-.1.21) and HR (OR 1.11, 95%CI 1.03-1.19). A subjective global assessment score was also strongly associated with HR (OR 1.89, 95%CI 1.14, 3.16). Conclusion Lower pre-operative QoL scores are significantly associated with post-operative morbidity and hospital readmission in gynecologic cancer patients. This relationship may be a novel indicator of operative risk. PMID:24726615

  17. Preoperative quality of life and surgical outcomes in gynecologic oncology patients: a new predictor of operative risk?

    PubMed

    Doll, K M; Snavely, A C; Kalinowski, A; Irwin, D E; Bensen, J T; Bae-Jump, V; Boggess, J F; Soper, J T; Brewster, W R; Gehrig, P A

    2014-06-01

    Quality of life (QoL) for women with gynecologic malignancies is predictive of chemotherapy related toxicity and overall survival but has not been studied in relation to surgical outcomes and hospital readmissions. Our goal was to evaluate the association between baseline, pre-operative QoL measures and 30-day post-operative morbidity and health resource utilization by gynecologic oncology patients. We analyzed prospectively collected survey data from an institution-wide cohort study. Patients were enrolled from 8/2012 to 6/2013 and medical record data was abstracted (demographics, comorbid conditions, and operative outcomes). Responses from several validated health-related QoL instruments were collected. Bivariate tests and multivariable linear and logistic regression models were used to evaluate factors associated with QoL scores. Of 182 women with suspected gynecologic malignancies, 152 (84%) were surveyed pre-operatively and 148 (81%) underwent surgery. Uterine (94; 63.5%), ovarian (26; 17.5%), cervical (15; 10%), vulvar/vaginal (8; 5.4%), and other (5; 3.4%) cancers were represented. There were 37 (25%) cases of postoperative morbidity (PM), 18 (12%) unplanned ER visits, 9(6%) unplanned clinic visits, and 17 (11.5%) hospital readmissions (HR) within 30days of surgery. On adjusted analysis, lower functional well-being scores resulted in increased odds of PM (OR 1.07, 95%CI 1.01-.1.21) and HR (OR 1.11, 95%CI 1.03-1.19). A subjective global assessment score was also strongly associated with HR (OR 1.89, 95%CI 1.14, 3.16). Lower pre-operative QoL scores are significantly associated with post-operative morbidity and hospital readmission in gynecologic cancer patients. This relationship may be a novel indicator of operative risk. Copyright © 2014 Elsevier Inc. All rights reserved.

  18. Can the ACS-NSQIP surgical risk calculator predict post-operative complications in patients undergoing flap reconstruction following soft tissue sarcoma resection?

    PubMed

    Slump, Jelena; Ferguson, Peter C; Wunder, Jay S; Griffin, Anthony; Hoekstra, Harald J; Bagher, Shaghayegh; Zhong, Toni; Hofer, Stefan O P; O'Neill, Anne C

    2016-10-01

    The ACS-NSQIP surgical risk calculator is an open-access on-line tool that estimates the risk of adverse post-operative outcomes for a wide range of surgical procedures. Wide surgical resection of soft tissue sarcoma (STS) often requires complex reconstructive procedures that can be associated with relatively high rates of complications. This study evaluates the ability of this calculator to identify patients with STS at risk for post-operative complications following flap reconstruction. Clinical details of 265 patients who underwent flap reconstruction following STS resection were entered into the online calculator. The predicted rates of complications were compared to the observed rates. The calculator model was validated using measures of prediction and discrimination. The mean predicted rate of any complication was 15.35 ± 5.6% which differed significantly from the observed rate of 32.5% (P = 0.009). The c-statistic was relatively low at 0.626 indicating poor discrimination between patients who are at risk of complications and those who are not. The Brier's score of 0.242 was significantly different from 0 (P < 0.001) indicating poor correlation between the predicted and actual probability of complications. The ACS-NSQIP universal risk calculator did not maintain its predictive value in patients undergoing flap reconstruction following STS resection. J. Surg. Oncol. 2016;114:570-575. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

  19. Surgical risks associated with winter sport tourism.

    PubMed

    Sanchez, Stéphane; Payet, Cécile; Lifante, Jean-Christophe; Polazzi, Stéphanie; Chollet, François; Carty, Matthew J; Duclos, Antoine

    2015-01-01

    Mass tourism during winter in mountain areas may cause significant clustering of body injuries leading to increasing emergency admissions at hospital. We aimed at assessing if surgical safety and efficiency was maintained in this particular context. We selected all emergency admissions of open surgery performed in French hospitals between 2010 and 2012. After identifying mountain areas with increasing volume of surgical stays during winter, we considered seasonal variations in surgical outcomes using a difference-in-differences study design. We computed multilevel regressions to evaluate whether significant increase in emergency cases had an effect on surgical mortality, complications and length of stay. Clustering effect of patients within hospitals was integrated in analysis and surgical outcomes were adjusted for both patient and hospital characteristics. A total of 381 hospitals had 559,052 inpatient stays related to emergency open surgery over 3 years. Compared to other geographical areas, a significant peak of activity was noted during winter in mountainous hospitals (Alps, Pyrenees, Vosges), ranging 6-77% volume increase. Peak was mainly explained by tourists' influx (+124.5%, 4,351/3,496) and increased need for orthopaedic procedures (+36.8%, 4,731/12,873). After controlling for potential confounders, patients did not experience increased risk for postoperative death (ratio of OR 1.01, 95%CI 0.89-1.14, p = 0.891), thromboembolism (0.95, 0.77-1.17, p = 0.621) or sepsis (0.98, 0.85-1.12, p = 0.748). Length of stay was unaltered (1.00, 0.99-1.02, p = 0.716). Surgical outcomes are not compromised during winter in French mountain areas despite a substantial influx of major emergencies.

  20. Surgical Risks Associated with Winter Sport Tourism

    PubMed Central

    Sanchez, Stéphane; Payet, Cécile; Lifante, Jean-Christophe; Polazzi, Stéphanie; Chollet, François; Carty, Matthew J; Duclos, Antoine

    2015-01-01

    Background Mass tourism during winter in mountain areas may cause significant clustering of body injuries leading to increasing emergency admissions at hospital. We aimed at assessing if surgical safety and efficiency was maintained in this particular context. Methods We selected all emergency admissions of open surgery performed in French hospitals between 2010 and 2012. After identifying mountain areas with increasing volume of surgical stays during winter, we considered seasonal variations in surgical outcomes using a difference-in-differences study design. We computed multilevel regressions to evaluate whether significant increase in emergency cases had an effect on surgical mortality, complications and length of stay. Clustering effect of patients within hospitals was integrated in analysis and surgical outcomes were adjusted for both patient and hospital characteristics. Results A total of 381 hospitals had 559,052 inpatient stays related to emergency open surgery over 3 years. Compared to other geographical areas, a significant peak of activity was noted during winter in mountainous hospitals (Alps, Pyrenees, Vosges), ranging 6-77% volume increase. Peak was mainly explained by tourists’ influx (+124.5%, 4,351/3,496) and increased need for orthopaedic procedures (+36.8%, 4,731/12,873). After controlling for potential confounders, patients did not experience increased risk for postoperative death (ratio of OR 1.01, 95%CI 0.89-1.14, p = 0.891), thromboembolism (0.95, 0.77-1.17, p = 0.621) or sepsis (0.98, 0.85-1.12, p = 0.748). Length of stay was unaltered (1.00, 0.99-1.02, p = 0.716). Conclusion Surgical outcomes are not compromised during winter in French mountain areas despite a substantial influx of major emergencies. PMID:25970625

  1. Methicillin-resistant Staphylococcus aureus in surgical patients: identification of high-risk populations for the development of targeted screening programmes

    PubMed Central

    Fraser, Stephanie; Brady, Richard R; Graham, Catriona; Paterson-Brown, Simon; Gibb, Alan P

    2010-01-01

    INTRODUCTION Methicillin-resistant Staphylococcus aureus (MRSA)-related hospital-acquired infection (HAI) in surgical patients is associated with high morbidity, mortality and financial cost. The identification and characterisation of populations of patients who are at high risk of developing MRSA infection or colonisation could inform the design of more effective strategies to prevent HAIs and reduce transmission of MRSA. PATIENTS AND METHODS An analysis of historical discharge data for the whole of 2005 (7145 surgical in-patients) was performed, for all patients admitted to general surgery at the Royal Infirmary of Edinburgh. Analysis specifically focused on MRSA laboratory data and coding data for patient demographics, medical co-morbidities, and progress of in-patient stay. RESULTS A total of 134 (1.88%) individual patients with colonisation or infection by MRSA were identified from indicated laboratory testing. Univariate analysis identified a significant association of concurrent MRSA-positive status with patients aged over 60 years (P < 0.01), a duration of inpatient stay > 7 days (P < 0.01), presence of a malignant neoplasm (P < 0.01), circulatory disease (P < 0.01), respiratory disease (P < 0.01), central nervous system disease (P < 0.01), renal failure (P < 0.01), and concurrent admission to ITU/HDU (P < 0.01). Multivariate analysis suggested MRSA colonisation or infection was strongest in those with co-morbid malignancy (P < 0.0001) or admission to ITU/HDU (P < 0.0001). CONCLUSIONS This large observational study has identified cancer patients as a UK surgical patient subpopulation which is at significantly higher risk of colonisation by MRSA. These data could inform the development of focused hospital in-patient screening protocols and provide a means to stratify patient risk. PMID:20385046

  2. Analysis of risk factors for loss of lumbar lordosis in patients who had surgical treatment with segmental instrumentation for adolescent idiopathic scoliosis.

    PubMed

    Trobisch, Per D; Samdani, Amer F; Betz, Randal R; Bastrom, Tracey; Pahys, Joshua M; Cahill, Patrick J

    2013-06-01

    Iatrogenic flattening of lumbar lordosis in patients with adolescent idiopathic scoliosis (AIS) was a major downside of first generation instrumentation. Current instrumentation systems allow a three-dimensional scoliosis correction, but flattening of lumbar lordosis remains a significant problem which is associated with decreased health-related quality of life. This study sought to identify risk factors for loss of lumbar lordosis in patients who had surgical correction of AIS with the use of segmental instrumentation. Patients were included if they had surgical correction for AIS with segmental pedicle screw instrumentation Lenke type 1 or 2 and if they had a minimum follow-up of 24 months. Two groups were created, based on the average loss of lumbar lordosis. The two groups were then compared and multivariate analysis was performed to identify parameters that correlated to loss of lumbar lordosis. Four hundred and seventeen patients were analyzed for this study. The average loss of lumbar lordosis at 24 months follow-up was an increase of 10° lordosis for group 1 and a decrease of 15° for group 2. Risk factors for loss of lumbar lordosis included a high preoperative lumbar lordosis, surgical decrease of thoracic kyphosis, and the particular operating surgeon. The lowest instrumented vertebra or spinopelvic parameters were two of many parameters that did not seem to influence loss of lumbar lordosis. This study identified important risk factors for decrease of lumbar lordosis in patients who had surgical treatment for AIS with segmental pedicle screw instrumentation, including a high preoperative lumbar lordosis, surgical decrease of thoracic kyphosis, and factors attributable to a particular operating surgeon that were not quantified in this study.

  3. Patient-specific risk factors are predictive for postoperative adverse events in colorectal surgery: an American College of Surgeons National Surgical Quality Improvement Program-based analysis.

    PubMed

    Kohut, Adrian Y; Liu, James J; Stein, David E; Sensenig, Richard; Poggio, Juan L

    2015-02-01

    Pay-for-performance measures incorporate surgical site infection rates into reimbursement algorithms without accounting for patient-specific risk factors predictive for surgical site infections and other adverse postoperative outcomes. Using American College of Surgeons National Surgical Quality Improvement Program data of 67,445 colorectal patients, multivariable logistic regression was performed to determine independent risk factors associated with various measures of adverse postoperative outcomes. Notable patient-specific factors included (number of models containing predictor variable; range of odds ratios [ORs] from all models): American Society of Anesthesiologists class 3, 4, or 5 (7 of 7 models; OR 1.25 to 1.74), open procedures (7 of 7 models; OR .51 to 4.37), increased body mass index (6 of 7 models; OR 1.15 to 2.19), history of COPD (6 of 7 models; OR 1.19 to 1.64), smoking (6 of 7 models; OR 1.15 to 1.61), wound class 3 or 4 (6 of 7 models; OR 1.22 to 1.56), sepsis (6 of 7 models; OR 1.14 to 1.89), corticosteroid administration (5 of 7 models; OR 1.11 to 2.24), and operation duration more than 3 hours (5 of 7 models; OR 1.41 to 1.76). These findings may be used to pre-emptively identify colorectal surgery patients at increased risk of experiencing adverse outcomes. Copyright © 2015 Elsevier Inc. All rights reserved.

  4. Risk of Hemorrhage Attributed to Underlying Chronic Diseases and Uninterrupted Aspirin Therapy of Patients Undergoing Minor Oral Surgical Procedures: A Retrospective Cohort Study.

    PubMed

    Rojanaworarit, Chanapong; Limsawan, Soontaree

    2017-01-01

    This study aimed to estimate the risk of bleeding following minor oral surgical procedures and uninterrupted aspirin therapy in high-risk patients or patients with existing chronic diseases compared to patients who did not use aspirin during minor oral surgery at a public hospital. This retrospective cohort study analyzed the data of 2912 patients, aged 20 years or older, who underwent 5251 minor oral surgical procedures at a district hospital in Thailand. The aspirin group was comprised of patients continuing aspirin therapy during oral surgery. The non-aspirin group (reference) included all those who did not use aspirin during surgery. Immediate and late-onset bleeding was evaluated in each procedure. The risk ratio of bleeding was estimated using a multilevel Poisson regression. The overall cumulative incidence of immediate bleeding was 1.3% of total procedures. No late-onset bleeding was found. A significantly greater incidence of bleeding was found in the aspirin group (5.8% of procedures, p<0.001). After adjusting for covariates, a multilevel Poisson regression model estimated that the bleeding risk in the aspirin group was 4.5 times higher than that of the non-aspirin group (95% confidence interval, 2.0 to 10.0; p<0.001). However, all bleeding events were controlled by simple hemostatic measures. High-risk patients or patients with existing chronic diseases who continued aspirin therapy following minor oral surgery were at a higher risk of hemorrhage than general patients who had not used aspirin. Nonetheless, bleeding complications were not life-threatening and could be promptly managed by simple hemostatic measures. The procedures could therefore be provided with an awareness of increased bleeding risk, prepared hemostatic measures, and postoperative monitoring, without the need for discontinuing aspirin, which could lead to more serious complications.

  5. Transcatheter aortic valve replacement in patients with severe aortic stenosis who are at high risk for surgical complications: summary assessment of the California Technology Assessment Forum.

    PubMed

    Tice, Jeffrey A; Sellke, Frank W; Schaff, Hartzell V

    2014-08-01

    The California Technology Assessment Forum is dedicated to assessment and public reporting of syntheses of available data on medical technologies. In this assessment, transcatheter aortic valve replacement (TAVR) was evaluated for patients with severe aortic stenosis (AS) who are at high risk for complications. In this assessment, 5 criteria were used: Regulatory approval, sufficient scientific evidence to allow conclusions on effectiveness, evidence that the technology improves net health outcomes, evidence that the technology is as beneficial as established methods, and availability of the technology outside investigational settings. In this assessment, all 5 criteria were judged to have been met. The primary benefit of TAVR is the ability to treat AS in patients who would otherwise be ineligible for surgical aortic valve replacement. It may also be useful for patients at high surgical risk by potentially reducing periprocedural complications and avoiding the morbidity and recovery from undergoing heart surgery. Potential harms include the need for conversion to an open procedure, perioperative death, myocardial infarction, stroke, bleeding, valve embolization, aortic regurgitation, heart block that requires a permanent pacemaker, renal failure, pulmonary failure, and major vascular complications such as cardiac perforation or arterial dissection. Potential long-term harms include death, stroke, valve failure or clotting, and endocarditis. As highlighted at the February 2012 California Technology Assessment Forum meeting, the dispersion of this technology to new centers across the United States must proceed with careful thought given to training and proctoring multidisciplinary teams to become new centers of excellence. TAVR is a potentially lifesaving procedure that may improve quality of life for patients at high risk for surgical AVR. However, attention needs to be paid to appropriate patient selection, their preoperative evaluation, surgical techniques, and

  6. [The risk of surgical glove perforations].

    PubMed

    Hagen, Gerd Ødegård; Arntzen, Halvard

    2007-03-29

    The increasing prevalence of blood-borne viral diseases has drawn attention to the barrier between the surgical personnel's hands and the patients body fluids during surgery. At present, the typical practice is to use double gloving in orthopaedic surgery, and single gloving in other types of surgery. The main purpose of our study was to estimate and compare the perforation risk in different categories of surgery. In a series of 655 surgical operations covering 5 main categories of surgery, all detected glove perforations were recorded and analysed. Perforations were found in 203 out of 655 operations (31%). The observed perforation frequency was 44.5% in gastrointestinal surgery, 34.7% in orthopaedic surgery, 31.1% in gynaecology, 18.6% in vascular surgery and 9.2% in general surgery. In some subcategories, the frequencies were even higher. In several categories of surgery, we found high perforation frequencies. Perforations in single gloves are often not detected during operations. This may increase the risk of transmission of blood-borne infections, particularly because the time of exposure may be long. Double indicator gloves make the intra-operative detection of perforations easier. Also double gloving is known to significantly reduce the perforation risk. The use of double indicator gloves is recommended in all categories of surgery.

  7. Evolution of surgical techniques for a progressive risk reduction.

    PubMed

    Amato, Bruno; Santoro, Mario; Izzo, Raffaele; Servillo, Giuseppe; Compagna, Rita; Di Domenico, Lorenza; Di Nardo, Veronica; Giugliano, Giuseppe

    2017-07-18

    Advanced age is a strong predictor of high perioperative mortality in surgical patients and patients aged 75 years and older have an elevated surgical risk, much higher than that of younger patients. Progressive advances in surgical techniques now make it possible to treat high-risk surgical patients with minimally invasive procedures. Endovascular techniques have revolutionized the treatment of several vascular diseases, in particular carotid stenosis, aortic pathologies, and severely incapacitating intermittent claudication or critical limb ischemia. The main advantages of the endovascular approach are the low complication rate, high rate of technical success and a good clinical outcome. Biliary stenting has improved the clinical status of severely ill patients with bile duct stricture before major surgery, and represents a good palliative therapy in the case of malignant biliary obstruction.

  8. Risk management: correct patient and specimen identification in a surgical pathology laboratory. The experience of Infermi Hospital, Rimini, Italy.

    PubMed

    Fabbretti, G

    2010-06-01

    Because of its complex nature, surgical pathology practice is prone to error. In this report, we describe our methods for reducing error as much as possible during the pre-analytical and analytical phases. This was achieved by revising procedures, and by using computer technology and automation. Most mistakes are the result of human error in the identification and matching of patient and samples. To avoid faulty data interpretation, we employed a new comprehensive computer system that acquires all patient ID information directly from the hospital's database with a remote order entry; it also provides label and request forms via-Web where clinical information is required before sending the sample. Both patient and sample are identified directly and immediately at the site where the surgical procedures are performed. Barcode technology is used to input information at every step and automation is used for sample blocks and slides to avoid errors that occur when information is recorded or transferred by hand. Quality control checks occur at every step of the process to ensure that none of the steps are left to chance and that no phase is dependent on a single operator. The system also provides statistical analysis of errors so that new strategies can be implemented to avoid repetition. In addition, the staff receives frequent training on avoiding errors and new developments. The results have been shown promising results with a very low error rate (0.27%). None of these compromised patient health and all errors were detected before the release of the diagnosis report.

  9. A pragmatic multi-centre randomised controlled trial of fluid loading and level of dependency in high-risk surgical patients undergoing major elective surgery: trial protocol

    PubMed Central

    2010-01-01

    Background Patients undergoing major elective or urgent surgery are at high risk of death or significant morbidity. Measures to reduce this morbidity and mortality include pre-operative optimisation and use of higher levels of dependency care after surgery. We propose a pragmatic multi-centre randomised controlled trial of level of dependency and pre-operative fluid therapy in high-risk surgical patients undergoing major elective surgery. Methods/Design A multi-centre randomised controlled trial with a 2 * 2 factorial design. The first randomisation is to pre-operative fluid therapy or standard regimen and the second randomisation is to routine intensive care versus high dependency care during the early post-operative period. We intend to recruit 204 patients undergoing major elective and urgent abdominal and thoraco-abdominal surgery who fulfil high-risk surgical criteria. The primary outcome for the comparison of level of care is cost-effectiveness at six months and for the comparison of fluid optimisation is the number of hospital days after surgery. Discussion We believe that the results of this study will be invaluable in determining the future care and clinical resource utilisation for this group of patients and thus will have a major impact on clinical practice. Trial Registration Trial registration number - ISRCTN32188676 PMID:20398378

  10. Acute cholecystitis in high risk surgical patients: percutaneous cholecystostomy versus laparoscopic cholecystectomy (CHOCOLATE trial): Study protocol for a randomized controlled trial

    PubMed Central

    2012-01-01

    Background Laparoscopic cholecystectomy in acute calculous cholecystitis in high risk patients can lead to significant morbidity and mortality. Percutaneous cholecystostomy may be an alternative treatment option but the current literature does not provide the surgical community with evidence based advice. Methods/Design The CHOCOLATE trial is a randomised controlled, parallel-group, superiority multicenter trial. High risk patients, defined as APACHE-II score 7-14, with acute calculous cholecystitis will be randomised to laparoscopic cholecystectomy or percutaneous cholecystostomy. During a two year period 284 patients will be enrolled from 30 high volume teaching hospitals. The primary endpoint is a composite endpoint of major complications within three months following randomization and need for re-intervention and mortality during the follow-up period of one year. Secondary endpoints include all other complications, duration of hospital admission, difficulty of procedures and total costs. Discussion The CHOCOLATE trial is designed to provide the surgical community with an evidence based guideline in the treatment of acute calculous cholecystitis in high risk patients. Trial Registration Netherlands Trial Register (NTR): NTR2666 PMID:22236534

  11. Risk factors for superficial surgical site infection after elective rectal cancer resection: a multivariate analysis of 8880 patients from the American College of Surgeons National Surgical Quality Improvement Program database.

    PubMed

    Sutton, Elie; Miyagaki, Hiromichi; Bellini, Geoffrey; Shantha Kumara, H M C; Yan, Xiaohong; Howe, Brett; Feigel, Amanda; Whelan, Richard L

    2017-01-01

    Superficial surgical site infection (sSSI) is one of the most common complications after colorectal resection. The goal of this study was to determine the comorbidities and operative characteristics that place patients at risk for sSSI in patients who underwent rectal cancer resection. The American College of Surgeons National Surgical Quality Improvement Program database was queried (via diagnosis and Current Procedural Terminology codes) for patients with rectal cancer who underwent elective resection between 2005 and 2012. Patients for whom data concerning 27 demographic factors, comorbidities, and operative characteristics were available were eligible. A univariate and multivariate analysis was performed to identify possible risk factors for sSSI. A total of 8880 patients met the entry criteria and were included. sSSIs were diagnosed in 861 (9.7%) patients. Univariate analysis found 14 patients statistically significant risk factors for sSSI. Multivariate analysis revealed the following risk factors: male gender, body mass index (BMI) >30, current smoking, history of chronic obstructive pulmonary disease (COPD), American Society of Anesthesiologists III/IV, abdominoperineal resection (APR), stoma formation, open surgery (versus laparoscopic), and operative time >217 min. The greatest difference in sSSI rates was noted in patients with COPD (18.9 versus 9.5%). Of note, 54.2% of sSSIs was noted after hospital discharge. With regard to the timing of presentation, univariate analysis revealed a statistically significant delay in sSSI presentation in patients with the following factors and/or characteristics: BMI <30, previous radiation therapy (RT), APR, minimally invasive surgery, and stoma formation. Multivariate analysis suggested that only laparoscopic surgery (versus open) and preoperative RT were risk factors for delay. Rectal cancer resections are associated with a high incidence of sSSIs, over half of which are noted after discharge. Nine patient and

  12. Influence of surgical implantation angle of left ventricular assist device outflow graft and management of aortic valve opening on the risk of stroke in heart failure patients

    NASA Astrophysics Data System (ADS)

    Chivukula, V. Keshav; McGah, Patrick; Prisco, Anthony; Beckman, Jennifer; Mokadam, Nanush; Mahr, Claudius; Aliseda, Alberto

    2016-11-01

    Flow in the aortic vasculature may impact stroke risk in patients with left ventricular assist devices (LVAD) due to severely altered hemodynamics. Patient-specific 3D models of the aortic arch and great vessels were created with an LVAD outflow graft at 45, 60 and 90° from centerline of the ascending aorta, in order to understand the effect of surgical placement on hemodynamics and thrombotic risk. Intermittent aortic valve opening (once every five cardiac cycles) was simulated and the impact of this residual native output investigated for the potential to wash out stagnant flow in the aortic root region. Unsteady CFD simulations with patient-specific boundary conditions were performed. Particle tracking for 10 cardiac cycles was used to determine platelet residence times and shear stress histories. Thrombosis risk was assessed by a combination of Eulerian and Lagrangian metrics and a newly developed thrombogenic potential metric. Results show a strong influence of LVAD outflow graft angle on hemodynamics in the ascending aorta and consequently on stroke risk, with a highly positive impact of aortic valve opening, even at low frequencies. Optimization of LVAD implantation and management strategies based on patient-specific simulations to minimize stroke risk will be presented

  13. Management of recurrent/persistent nodal disease in patients with differentiated thyroid cancer: a critical review of the risks and benefits of surgical intervention versus active surveillance.

    PubMed

    Tufano, Ralph P; Clayman, Gary; Heller, Keith S; Inabnet, William B; Kebebew, Electron; Shaha, Ashok; Steward, David L; Tuttle, R Michael

    2015-01-01

    The primary goals of this interdisciplinary consensus statement are to define the eligibility criteria for management of recurrent and persistent cervical nodal disease in patients with differentiated thyroid cancer (DTC) and to review the risks and benefits of surgical intervention versus active surveillance. A writing group was convened by the Surgical Affairs Committee of the American Thyroid Association and was tasked with identifying the important clinical elements to consider when managing recurrent/persistent nodal disease in patients with DTC based on the available evidence in the literature and the group's collective experience. The decision on how best to manage individual patients with suspected recurrent/persistent nodal disease is challenging and requires the consideration of a significant number of variables outlined by the members of the interdisciplinary team. Here we report on the consensus opinions that were reached by the writing group regarding the technical and clinical issues encountered in this patient population. Identification of recurrent/persistent disease requires a team decision-making process that includes the patient and physicians as to what, if any, intervention should be performed to best control the disease while minimizing morbidity. Several management principles and variables involved in the decision making for surgery versus active surveillance were developed that should be taken into account when deciding how best to manage a patient with DTC and suspected recurrent or persistent cervical nodal disease.

  14. An evidence-based approach to medication preparation for the surgical patient at risk for latex allergy: is it time to stop being stopper poppers?

    PubMed

    Heitz, James W; Bader, Stephen O

    2010-09-01

    The prevalence of latex allergy is increasing in surgical patient populations. Avoidance of exposure to the allergen is essential to minimizing perioperative complications in patients suspected to be at risk. Natural rubber latex has historically been ubiquitous in medical devices containing rubber. In 1998, the Food and Drug Administration (FDA) began to require the labeling of medical devices made from natural rubber latex; since that time substantial progress has been made in identifying latex-free alternatives. However, the rubber stoppers commonly found in pharmaceutical vial closures are exempt from FDA labeling requirements. Examination of the clinical and basic science literature regarding pharmaceutical vial closures supports limiting the rubber stopper to a single needle puncture as a safer practice, with the caveat that no strategy exists for the complete elimination of risk as long as stoppers made from natural rubber latex are used in pharmaceutical vials intended for human use. Copyright © 2010 Elsevier Inc. All rights reserved.

  15. Efficacy and safety of transcatheter aortic valve replacement in aortic stenosis patients at low to moderate surgical risk: a comprehensive meta-analysis.

    PubMed

    Elmaraezy, Ahmed; Ismail, Ammar; Abushouk, Abdelrahman Ibrahim; Eltoomy, Moutaz; Saad, Soha; Negida, Ahmed; Abdelaty, Osama Mahmoud; Abdallah, Ahmed Ramadan; Aboelfotoh, Ahmed Magdy; Hassan, Hossam Mahmoud; Elmaraezy, Aya Gamal; Morsi, Mahmoud; Althaher, Farah; Althaher, Moath; AlSafadi, Ammar M

    2017-08-24

    Recently, transcatheter aortic valve replacement (TAVR) has become the procedure of choice in high surgical risk patients with aortic stenosis (AS). However, its value is still debated in operable AS cases. We performed this meta-analysis to compare the safety and efficacy of TAVR to surgical aortic valve replacement (SAVR) in low-to-moderate surgical risk patients with AS. A systematic search of five authentic databases retrieved 11 eligible studies (20,056 patients). Relevant Data were pooled as risk ratios (RRs) or standardized mean differences (SMD), with their 95% confidence interval, using Comprehensive Meta-Analysis and RevMan software for windows. At one-year of follow-up, the pooled effect-estimates showed no significant difference between TAVR and SAVR groups in terms of all-cause mortality (RR 1.02, 95% CI [0.83, 1.26], stroke (RR 0.83, 95%CI [0.56, 1.21]), myocardial infarction (RR 0.82, 95% CI [0.57, 1.19]), and length of hospital stay (SMD -0.04, 95% CI [-0.34, 0.26]). The incidence of major bleeding (RR 0.45, 95% CI [0.24, 0.86]) and acute kidney injury (RR 0.52, 95% CI [0.30, 0.88]) was significantly lower in the TAVR group, compared to the SAVR group. However, TAVR was associated with a higher risk of permanent pacemaker implantation (RR 2.57, 95% CI [1.36, 4.86]), vascular-access complications at 1 year (RR 1.99, 95%CI [1.04, 3.80]), and paravalvular aortic regurgitation at 30 days (RR 3.90, 95% CI [1.25, 12.12]), compared to SAVR. Due to the comparable mortality rates in SAVR and TAVR groups and the lower risk of life-threatening complications in the TAVR group, TAVR can be an acceptable alternative to SAVR in low-to-moderate risk patients with AS. However, larger trials with longer follow-up periods are required to compare the long-term outcomes of both techniques.

  16. Interaction Effects of Acute Kidney Injury, Acute Respiratory Failure, and Sepsis on 30-Day Postoperative Mortality in Patients Undergoing High-Risk Intraabdominal General Surgical Procedures.

    PubMed

    Kim, Minjae; Brady, Joanne E; Li, Guohua

    2015-12-01

    Acute kidney injury (AKI), acute respiratory failure, and sepsis are distinct but related pathophysiologic processes. We hypothesized that these 3 processes may interact to synergistically increase the risk of short-term perioperative mortality in patients undergoing high-risk intraabdominal general surgery procedures. We performed a retrospective, observational cohort study of data (2005-2011) from the American College of Surgeons-National Surgical Quality Improvement Program, a high-quality surgical outcomes data set. High-risk procedures were those with a risk of AKI, acute respiratory failure, or sepsis greater than the average risk in all intraabdominal general surgery procedures. The effects of AKI, acute respiratory failure, and sepsis on 30-day mortality were assessed using a Cox proportional hazards model. Additive interactions were assessed with the relative excess risk due to interaction. Of 217,994 patients, AKI, acute respiratory failure, and sepsis developed in 1.3%, 3.7%, and 6.8%, respectively. The 30-day mortality risk with sepsis, acute respiratory failure, and AKI were 11.4%, 24.1%, and 25.1%, respectively, compared with 0.85% without these complications. The adjusted hazard ratios and 95% confidence intervals for a single complication (versus no complication) on mortality were 7.24 (6.46-8.11), 10.8 (8.56-13.6), and 14.2 (12.8-15.7) for sepsis, AKI, and acute respiratory failure, respectively. For 2 complications, the adjusted hazard ratios were 30.8 (28.0-33.9), 42.6 (34.3-52.9), and 65.2 (53.9-78.8) for acute respiratory failure/sepsis, AKI/sepsis, and acute respiratory failure/AKI, respectively. Finally, the adjusted hazard ratio for all 3 complications was 105 (92.8-118). Positive additive interactions, indicating synergism, were found for each combination of 2 complications. The relative excess risk due to interaction for all 3 complications was not statistically significant. In high-risk general surgery patients, the development of AKI

  17. Intra-operative cardiac monitoring by trans-oesophageal Doppler is not risk free in surgical patients.

    PubMed

    Siddiqui, Muhammad Rafay Sameen; Sajid, Muhammad Shafiq; Baig, Mirza Khurram

    2009-04-01

    The advancement of medical technology and future improvements in public health will lead to surgeons operating on high risk patients. One of these advances is to use intra-operative trans-oesophageal Doppler (TOD) to optimise fluid management. TOD is known to be the most effective technique for intraoperative cardiac monitoring. We report a case of a potentially life threatening complication from intraoperative TOD monitoring.

  18. Surgical site infections among high-risk patients in clean-contaminated head and neck reconstructive surgery: concordance with preoperative oral flora.

    PubMed

    Yang, Ching-Hsiang; Chew, Khong-Yik; Solomkin, Joseph S; Lin, Pao-Yuan; Chiang, Yuan-Cheng; Kuo, Yur-Ren

    2013-12-01

    Salivary contamination of surgical wounds in clean-contaminated head and neck surgery with free flap reconstruction remains a major cause of infection and leads to significant morbidity. This study investigates the correlation between intraoral flora and surgical site infections (SSIs) among high-risk head and neck cancer patients undergoing resection and free flap reconstruction. One hundred twenty-nine patients were identified as being at high risk for infective complications based on cancer stage, tumor size, comorbid factors, and extent of reconstruction. All patients had intraoral swab cultures before surgery. Patients with culture-confirmed SSI after surgery were chosen for analysis, using the κ index and its 95% confidence interval for concordance analysis. All patients received clindamycin and gentamicin for antibiotic prophylaxis for 5 days. Antibiotic susceptibility testing of all isolates was obtained and analyzed. Thirty-seven patients experienced SSI, or an infection rate of 28.3%, occurring at a mean of 9.3 postoperative days. The overall concordance between oral flora and SSI was fair to moderate (κ index of 0.25), but detailed analysis shows a higher concordance for known and opportunistic pathogens, such as Pseudomonas aeruginosa and Enterococcus faecalis, compared to typical oral commensals. Antibiotic susceptibility tests show rapid and significant increases in resistance to clindamycin, indicating a need for a more effective alternative. Predicting pathogens in SSI using preoperative oral swabs did not demonstrate a good concordance in general for patients undergoing clean-contaminated head and neck surgery, although concordance for certain pathogenic species seem to be higher than for typical intraoral commensals. The rapid development of resistance to clindamycin precludes its use as a prophylactic agent.

  19. Epidermal growth factor receptor gene mutation as risk factor for recurrence in patients with surgically resected lung adenocarcinoma: a matched-pair analysis.

    PubMed

    Matsumura, Yuki; Owada, Yuki; Yamaura, Takumi; Muto, Satoshi; Osugi, Jun; Hoshino, Mika; Higuchi, Mitsunori; Ohira, Tetsuya; Suzuki, Hiroyuki; Gotoh, Mitsukazu

    2016-08-01

    Epidermal growth factor receptor (EGFR) mutation is a robust prognostic factor in patients with lung adenocarcinoma (ADC). However, the role of EGFR mutation status as a recurrence-risk factor remains unknown because the presence of such mutations is associated with other background characteristics. We therefore conducted a matched-pair analysis to compare recurrence-free survival (RFS) in matched cohorts of patients with lung ADC. We enrolled 379 patients who underwent surgical resection for lung ADC between 2005 and 2012. We determined the EGFR mutation status of each tumour. Matching their age, gender, smoking history and pathological stage (pStage), we compared RFS between matched cohorts with and without EGFR mutation (n = 86 each). The median age was 67 years, there were 39 (45%) men, 39 (45%) ex- or current smokers and pStage I: 71 (83%), II: 5 (6%), III: 8 (9%), IV: 2 (2%) in each group. The 3- and 5-year RFS rates in patients with mutant and wild-type EGFR were 85 and 78%, and 74 and 60%, respectively, with significant differences between the groups (P = 0.040). Multivariate analysis identified vascular invasion and lymphatic permeation, but not EGFR mutation status, as independent risk factors for recurrence. EGFR-gene mutation might be a favourable recurrence-risk factor in patients with surgically resected lung ADC, but further studies in larger cohorts are needed to verify this hypothesis. © The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

  20. Single-port versus conventional multiport access prophylactic laparoscopic bilateral salpingo-oophorectomy in high-risk patients for ovarian cancer: a comparison of surgical outcomes

    PubMed Central

    Angioni, Stefano; Pontis, Alessandro; Sedda, Federica; Zampetoglou, Theodoros; Cela, Vito; Mereu, Liliana; Litta, Pietro

    2015-01-01

    Bilateral salpingo-oophorectomy (BSO) in carriers of BRCA1 and BRCA2 mutations is widely recommended as part of a risk-reduction strategy for ovarian or breast cancer due to an underlying genetic predisposition. BSO is also performed as a therapeutic intervention for patients with hormone-positive premenopausal breast cancer. BSO may be performed via a minimally invasive approach with the use of three to four 5 mm and/or 12 mm ports inserted through a skin incision. To further reduce the morbidity associated with the placement of multiple port sites and to improve cosmetic outcomes, single-port laparoscopy has been developed with a single access point from the umbilicus. The purpose of this study was to evaluate the surgical outcomes associated with reducing the risks of salpingo-oophorectomy performed in a single port, while comparing multiport laparoscopy in women with a high risk for ovarian cancer. Single-port laparoscopy–BSO is feasible and safe, with favorable surgical and cosmetic outcomes when compared to conventional laparoscopy. PMID:26170692

  1. Single-port versus conventional multiport access prophylactic laparoscopic bilateral salpingo-oophorectomy in high-risk patients for ovarian cancer: a comparison of surgical outcomes.

    PubMed

    Angioni, Stefano; Pontis, Alessandro; Sedda, Federica; Zampetoglou, Theodoros; Cela, Vito; Mereu, Liliana; Litta, Pietro

    2015-01-01

    Bilateral salpingo-oophorectomy (BSO) in carriers of BRCA1 and BRCA2 mutations is widely recommended as part of a risk-reduction strategy for ovarian or breast cancer due to an underlying genetic predisposition. BSO is also performed as a therapeutic intervention for patients with hormone-positive premenopausal breast cancer. BSO may be performed via a minimally invasive approach with the use of three to four 5 mm and/or 12 mm ports inserted through a skin incision. To further reduce the morbidity associated with the placement of multiple port sites and to improve cosmetic outcomes, single-port laparoscopy has been developed with a single access point from the umbilicus. The purpose of this study was to evaluate the surgical outcomes associated with reducing the risks of salpingo-oophorectomy performed in a single port, while comparing multiport laparoscopy in women with a high risk for ovarian cancer. Single-port laparoscopy-BSO is feasible and safe, with favorable surgical and cosmetic outcomes when compared to conventional laparoscopy.

  2. Is stereotactic ablative radiotherapy equivalent to sublobar resection in high-risk surgical patients with stage I non-small-cell lung cancer?

    PubMed

    Mahmood, Sarah; Bilal, Haris; Faivre-Finn, Corinne; Shah, Rajesh

    2013-11-01

    A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'Is stereotactic ablative radiotherapy equivalent to sublobar resection in high-risk surgical patients with Stage I non-small cell lung cancer?'. Altogether over 318 papers were found, of which 18 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Stereotactic ablative radiotherapy (SABR) and sublobar resection (SLR) offer clear survival benefit in the treatment of early-stage non-small-cell lung cancer (NSCLC) in high-risk patients unsuitable for lobectomy and SABR has shown good results in medically operable patients. No randomized data are available comparing SLR and SABR, and therefore, data from prospective studies were compared. Overall survival at 1 year was similar between patients treated with SABR and SLR (81-85.7 vs 92%); however, overall 3-year survival was higher following SLR (87.1 vs 45.1-57.1%). There was no statistically significant difference in local recurrence in patients treated with SABR compared with SLR (3.5-14.5 vs 4.8-20%). Both treatment modalities are associated with complications. Fatigue (31-32.6%), pneumonitis (2.1-12.5%) and chest wall pain (3.1-12%) were common following SABR; however, serious grade 3 and 4 toxicity were rare. Morbidity following SLR was reported between 7.3 and 33.7%. Thirty-day mortality following SABR was 0%, while predicted 30-day mortality following a lung resection, using the thoracoscore predictive model ranges between 1 and 2.6%. Treatment for early-stage NSCLC should be tailored to individual patients. SABR is an acceptable alternative to SLR in high-risk patients but comparative data are required.

  3. Risk factors for extended spectrum β-lactamase-producing Escherichia coli versus susceptible E. coli in surgical site infections among cancer patients in Mexico.

    PubMed

    Montes, Claudia V; Vilar-Compte, Diana; Velazquez, Consuelo; Golzarri, Maria Fernanda; Cornejo-Juarez, Patricia; Larson, Elaine L

    2014-10-01

    Extended-spectrum β-lactamase (ESBL)-producing Escherichia coli are of increasing concern as a cause of healthcare-associated infections. Using a matched case-control design, demographics, antibiotic use, and relevant surgical data were obtained for 173 cases (ESBL E. coli surgical site infections, [SSI]) and 173 controls (antibiotic-susceptible E. coli SSI) in an oncology hospital in Mexico City. Conditional logistic regression modeling was used to calculate odds ratios (OR). The mean age of patients was 53.6 years, 214 (62%) were female. Demographics and comorbidities were similar between groups. Although antibiotic prophylaxis was common among both cases and controls (84% and 89%), more than one-half of cases (53%) were given prophylaxis outside the recommended window or were exposed for more than 24 h in comparison to 29% of controls. Patients who received untimely (OR=3.13, 95% confidence interval [CI] 1.5-6.4) and discontinued inappropriately (OR 6.38, 95% CI=2.5-16.2) prophylaxis were more likely to develop an ESBL SSI. In addition, patients with an organ/space infection compared with superficial had a higher rate of a resistant infection (OR 4.2, 95% CI 1.3-13.9). Among patients not given timely or appropriately discontinued prophylaxis, post-operative cephalosporin use (OR 3.3, 95% CI 1.4-7.7) was associated with ESBL E. coli SSIs. The appropriate timing and duration of perioperative antimicrobial prophylaxis were associated with lower risk of ESBL E. coli in SSIs. Even though compliance to antimicrobial prophylaxis guidelines is of the utmost importance, reduced exposure to cephalosporins may also potentially decrease the risk of ESBL SSI.

  4. [Surgical smoke: risks and preventive measures].

    PubMed

    Carbajo-Rodríguez, Hilario; Aguayo-Albasini, José Luis; Soria-Aledo, Víctor; García-López, Concepción

    2009-05-01

    The application of the advanced technologies in medicine has led to the appearance of new risk factors for health personnel. One of these could be the surgical smoke produced by electrosurgical instruments, ultrasounds or laser. However, there is still insufficient evidence in the published population studies on the detrimental effects of chronic exposure to surgical smoke. The main concern on the possible damage to the health of operating room staff is mainly based on the components currently detected until the date and laboratory experiments. Caution must also be used when extrapolating the results of in vitro studies to daily clinical practice. The organisations responsible for protecting the health of the workers in different countries have still not issued guidelines for the treatment and removal of the surgical smoke generated in both open and laparoscopic procedures. In this article we try to present a view of the consequences that surgical smoke has on health and the preventive measures that can be adopted.

  5. The flaws in the detail of an observational study on transcatheter aortic valve implantation versus surgical aortic valve replacement in intermediate-risks patients.

    PubMed

    Barili, Fabio; Freemantle, Nick; Folliguet, Thierry; Muneretto, Claudio; De Bonis, Michele; Czerny, Martin; Obadia, Jean Francois; Al-Attar, Nawwar; Bonaros, Nikolaos; Kluin, Jolanda; Lorusso, Roberto; Punjabi, Prakash; Sadaba, Rafael; Suwalski, Piotr; Benedetto, Umberto; Böning, Andreas; Falk, Volkmar; Sousa-Uva, Miguel; Kappetein, Pieter A; Menicanti, Lorenzo

    2017-06-01

    The PARTNER group recently published a comparison between the latest generation SAPIEN 3 transcatheter aortic valve implantation (TAVI) system (Edwards Lifesciences, Irvine, CA, USA) and surgical aortic valve replacement (SAVR) in intermediate-risk patients, apparently demonstrating superiority of the TAVI and suggesting that TAVI might be the preferred treatment method in this risk class of patients. Nonetheless, assessment of the non-randomized methodology used in this comparison reveals challenges that should be addressed in order to elucidate the validity of the results. The study by Thourani and colleagues showed several major methodological concerns: suboptimal methods in propensity score analysis with evident misspecification of the propensity scores (PS; no adjustment for the most significantly different covariates: left ventricular ejection fraction, moderate-severe mitral regurgitation and associated procedures); use of PS quintiles rather than matching; inference on not-adjusted Kaplan-Meier curves, although the authors correctly claimed for the need of balancing score adjusting for confounding factors in order to have unbiased estimates of the treatment effect; evidence of poor fit; lack of data on valve-related death.These methodological flaws invalidate direct comparison between treatments and cannot support authors' conclusions that TAVI with SAPIEN 3 in intermediate-risk patients is superior to surgery and might be the preferred treatment alternative to surgery. © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

  6. The PER (Preoperative Esophagectomy Risk) Score: A Simple Risk Score to Predict Short-Term and Long-Term Outcome in Patients with Surgically Treated Esophageal Cancer.

    PubMed

    Reeh, Matthias; Metze, Johannes; Uzunoglu, Faik G; Nentwich, Michael; Ghadban, Tarik; Wellner, Ullrich; Bockhorn, Maximilian; Kluge, Stefan; Izbicki, Jakob R; Vashist, Yogesh K

    2016-02-01

    Esophageal resection in patients with esophageal cancer (EC) is still associated with high mortality and morbidity rates. We aimed to develop a simple preoperative risk score for the prediction of short-term and long-term outcomes for patients with EC treated by esophageal resection. In total, 498 patients suffering from esophageal carcinoma, who underwent esophageal resection, were included in this retrospective cohort study. Three preoperative esophagectomy risk (PER) groups were defined based on preoperative functional evaluation of different organ systems by validated tools (revised cardiac risk index, model for end-stage liver disease score, and pulmonary function test). Clinicopathological parameters, morbidity, and mortality as well as disease-free survival (DFS) and overall survival (OS) were correlated to the PER score. The PER score significantly predicted the short-term outcome of patients with EC who underwent esophageal resection. PER 2 and PER 3 patients had at least double the risk of morbidity and mortality compared to PER 1 patients. Furthermore, a higher PER score was associated with shorter DFS (P < 0.001) and OS (P < 0.001). The PER score was identified as an independent predictor of tumor recurrence (hazard ratio [HR] 2.1; P < 0.001) and OS (HR 2.2; P < 0.001). The PER score allows preoperative objective allocation of patients with EC into different risk categories for morbidity, mortality, and long-term outcomes. Thus, multicenter studies are needed for independent validation of the PER score.

  7. Surgical fires: a patient safety perspective.

    PubMed

    2006-02-01

    A surgical fire is a fire that occurs on or in a surgical patient. Such fires are rare--they occur in only an extremely small percentage of surgical cases. Nevertheless, the actual number of incidents that occur each year may surprise many healthcare professionals. ECRI estimates that 50 to 100 or more surgical fires occur each year in the United States alone. And such fires can have devastating consequences, not only for the patient, but also for the surgical staff and for the healthcare facility. Fortunately, through awareness of the hazards-and with emphasis placed on following safe practices-virtually all surgical fires can be prevented. Thus, it's important that surgical fire safety be incorporated into formal patient safety initiatives. In this article, we describe a few surgical fire patient safety initiatives that have been instituted in recent years. In addition, we describe in detail the causes of surgical fires and the preventive measures that are available for healthcare personnel to follow. In addition, we review how staff should respond in the event of a surgical fire.

  8. A pragmatic multi-centre randomised controlled trial of fluid loading in high-risk surgical patients undergoing major elective surgery--the FOCCUS study.

    PubMed

    Cuthbertson, Brian H; Campbell, Marion K; Stott, Stephen A; Elders, Andrew; Hernández, Rodolfo; Boyers, Dwayne; Norrie, John; Kinsella, John; Brittenden, Julie; Cook, Jonathan; Rae, Daniela; Cotton, Seonaidh C; Alcorn, David; Addison, Jennifer; Grant, Adrian

    2011-01-01

    Fluid strategies may impact on patient outcomes in major elective surgery. We aimed to study the effectiveness and cost-effectiveness of pre-operative fluid loading in high-risk surgical patients undergoing major elective surgery. This was a pragmatic, non-blinded, multi-centre, randomised, controlled trial. We sought to recruit 128 consecutive high-risk surgical patients undergoing major abdominal surgery. The patients underwent pre-operative fluid loading with 25 ml/kg of Ringer's solution in the six hours before surgery. The control group had no pre-operative fluid loading. The primary outcome was the number of hospital days after surgery with cost-effectiveness as a secondary outcome. A total of 111 patients were recruited within the study time frame in agreement with the funder. The median pre-operative fluid loading volume was 1,875 ml (IQR 1,375 to 2,025) in the fluid group compared to 0 (IQR 0 to 0) in controls with days in hospital after surgery 12.2 (SD 11.5) days compared to 17.4 (SD 20.0) and an adjusted mean difference of 5.5 days (median 2.2 days; 95% CI -0.44 to 11.44; P = 0.07). There was a reduction in adverse events in the fluid intervention group (P = 0.048) and no increase in fluid based complications. The intervention was less costly and more effective (adjusted average cost saving: £2,047; adjusted average gain in benefit: 0.0431 quality adjusted life year (QALY)) and has a high probability of being cost-effective. Pre-operative intravenous fluid loading leads to a non-significant reduction in hospital length of stay after high-risk major surgery and is likely to be cost-effective. Confirmatory work is required to determine whether these effects are reproducible, and to confirm whether this simple intervention could allow more cost-effective delivery of care. Prospective Clinical Trials, ISRCTN32188676.

  9. A pragmatic multi-centre randomised controlled trial of fluid loading in high-risk surgical patients undergoing major elective surgery - the FOCCUS study

    PubMed Central

    2011-01-01

    Introduction Fluid strategies may impact on patient outcomes in major elective surgery. We aimed to study the effectiveness and cost-effectiveness of pre-operative fluid loading in high-risk surgical patients undergoing major elective surgery. Methods This was a pragmatic, non-blinded, multi-centre, randomised, controlled trial. We sought to recruit 128 consecutive high-risk surgical patients undergoing major abdominal surgery. The patients underwent pre-operative fluid loading with 25 ml/kg of Ringer's solution in the six hours before surgery. The control group had no pre-operative fluid loading. The primary outcome was the number of hospital days after surgery with cost-effectiveness as a secondary outcome. Results A total of 111 patients were recruited within the study time frame in agreement with the funder. The median pre-operative fluid loading volume was 1,875 ml (IQR 1,375 to 2,025) in the fluid group compared to 0 (IQR 0 to 0) in controls with days in hospital after surgery 12.2 (SD 11.5) days compared to 17.4 (SD 20.0) and an adjusted mean difference of 5.5 days (median 2.2 days; 95% CI -0.44 to 11.44; P = 0.07). There was a reduction in adverse events in the fluid intervention group (P = 0.048) and no increase in fluid based complications. The intervention was less costly and more effective (adjusted average cost saving: £2,047; adjusted average gain in benefit: 0.0431 quality adjusted life year (QALY)) and has a high probability of being cost-effective. Conclusions Pre-operative intravenous fluid loading leads to a non-significant reduction in hospital length of stay after high-risk major surgery and is likely to be cost-effective. Confirmatory work is required to determine whether these effects are reproducible, and to confirm whether this simple intervention could allow more cost-effective delivery of care. Trial registration Prospective Clinical Trials, ISRCTN32188676 PMID:22177541

  10. Risk factors for 30-day postoperative complications and mortality after below-knee amputation: a study of 2,911 patients from the national surgical quality improvement program.

    PubMed

    Belmont, Philip J; Davey, Shaunette; Orr, Justin D; Ochoa, Leah M; Bader, Julia O; Schoenfeld, Andrew J

    2011-09-01

    This investigation sought to evaluate risk factors for morbidity and mortality from a large series of below-knee amputees prospectively entered in a national database. All patients undergoing below-knee amputations in the years 2005-2008 were identified in the database of the National Surgical Quality Improvement Program (NSQIP). Demographic data, medical comorbidities, and medical history were obtained. Mortality and postoperative complications within 30 days of the below-knee amputation were also documented. Chi-square test, univariate, and multivariate logistic regression analyses were used to assess the effect of specific risk factors on mortality, as well as the likelihood of developing major, minor, or any complications developing. Below-knee amputations were performed in 2,911 patients registered in the NSQIP database between 2005 and 2008. The average age of patients was 65.8 years old and 64.3% were male. There was a 7.0% 30-day mortality rate and 1,627 complications occurred in 1,013 patients (34.4%). Multivariate logistic regression analysis identified renal insufficiency, cardiac issues, history of sepsis, steroid use, COPD, and increased patient age as independent predictors of mortality. The most common major complications were return to the operating room (15.6%), wound infection (9.3%), and postoperative sepsis (9.3%). History of sepsis, alcohol use, steroid use, cardiac issues, renal insufficiency, and contaminated/infected wounds were independent predictors of one or more complications developing. Renal disease, cardiac issues, history of sepsis, steroid use, COPD, and increased patient age were identified as predictors of mortality after below-knee amputation. Renal disease, cardiac issues, history of sepsis, steroid use, contaminated/infected wounds, and alcohol use were also found to be predictors of postoperative complications. Published by Elsevier Inc.

  11. Transfemoral transcatheter aortic valve replacement compared with surgical replacement in patients with severe aortic stenosis and comparable risk: cost-utility and its determinants.

    PubMed

    Ribera, Aida; Slof, John; Andrea, Rut; Falces, Carlos; Gutiérrez, Enrique; Del Valle-Fernández, Raquel; Morís-de la Tassa, César; Mota, Pedro; Oteo, Juan Francisco; Cascant, Purificació; Altisent, Omar Abdul-Jawad; Sureda, Carlos; Serra, Vicente; García-Del Blanco, Bruno; Tornos, Pilar; Garcia-Dorado, David; Ferreira-González, Ignacio

    2015-03-01

    To evaluate cost-effectiveness of transfemoral TAVR vs surgical replacement (SAVR) and its determinants in patients with severe symptomatic aortic stenosis and comparable risk. Patients were prospectively recruited in 6 Spanish hospitals and followed up over one year. We estimated adjusted incremental cost-effectiveness ratio (ICER) (Euros per quality-adjusted life-year [QALY] gained) using a net-benefit approach and assessed the determinants of incremental net-benefit of TAVR vs SAVR. We analyzed data on 207 patients: 58, 87 and 62 in the Edwards SAPIEN (ES) TAVR, Medtronic-CoreValve (MC) TAVR and SAVR groups respectively. Average cost per patient of ES-TAVR was €8800 higher than SAVR and the gain in QALY was 0.036. The ICER was €148,525/QALY. The cost of MC-TAVR was €9729 higher than SAVR and the QALY difference was -0.011 (dominated). Results substantially changed in the following conditions: 1) in patients with high preoperative serum creatinine the ICERs were €18,302/QALY and €179,618/QALY for ES and MC-TAVR respectively; 2) a 30% reduction in the cost of TAVR devices decreased the ICER for ES-TAVR to €32,955/QALY; and 3) imputing hospitalization costs from other European countries leads to TAVR being dominant. In countries with relatively low health care costs TAVR is not likely to be cost-effective compared to SAVR in patients with intermediate risk for surgery, mainly because of the high cost of the valve compared to the cost of hospitalization. TAVR could be cost-effective in specific subgroups and in countries with higher hospitalization costs. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

  12. Low-Molecular-Weight Heparin and the Relative Risk of Surgical Site Bleeding Complications: Results of a Systematic Review and Meta-Analysis of Randomized Controlled Trials of Venous Thromboprophylaxis in Patients After Total Joint Arthroplasty.

    PubMed

    Suen, Kary; Westh, Roger N; Churilov, Leonid; Hardidge, Andrew J

    2017-09-01

    Venous thromboembolism causes significant morbidity and mortality in patients after total joint arthroplasty. Although network meta-analyses have demonstrated a benefit of various thromboprophylactic agents, there remains a concern in the surgical community regarding the resulting wound complications. There is currently no systematic review of the surgical site bleeding complications of thromboprophylactic agents. The aim of this study was to systematically review the surgical site bleeding outcomes of venous thromboembolism prophylaxis in this population. A systematic review and meta-analysis was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized controlled trials comparing more than one of low-molecular-weight heparin (LMWH), warfarin, rivaroxaban, apixaban, dabigatran, aspirin, or no pharmacologic treatment in patients after total hip or knee arthroplasty were selected for inclusion. Five meta-analyses were performed to compare LMWH with control, warfarin, apixaban, rivaroxaban, and dabigatran. Forty-five randomized controlled trials of 56,730 patients were included. LMWH had a significantly increased relative risk of surgical site bleeding in comparison with control (relative risk, 2.32; 95% confidence interval, 1.40-3.85) and warfarin (1.54; 1.23-1.94). The relative risk of LMWH trended higher than apixaban (1.27; 1.00-1.63) and was similar to rivaroxaban (0.95; 0.74-1.23). Only 1 study reported the risk of surgical site bleeding in LMWH vs dabigatran (5.97; 2.08-17.11). LMWH increased the risk of surgical site bleeding compared with control, warfarin. and dabigatran and trended toward an increased risk compared with apixaban. The risk of surgical site bleeding was similar with LMWH and rivaroxaban. Copyright © 2017 Elsevier Inc. All rights reserved.

  13. Reliability of wireless monitoring using a wearable patch sensor in high-risk surgical patients at a step-down unit in the Netherlands: a clinical validation study.

    PubMed

    Breteler, Martine J M; Huizinga, Erik; van Loon, Kim; Leenen, Luke P H; Dohmen, Daan A J; Kalkman, Cor J; Blokhuis, Taco J

    2018-02-27

    Intermittent vital signs measurements are the current standard on hospital wards, typically recorded once every 8 hours. Early signs of deterioration may therefore be missed. Recent innovations have resulted in 'wearable' sensors, which may capture patient deterioration at an earlier stage. The objective of this study was to determine whether a wireless 'patch' sensor is able to reliably measure respiratory and heart rate continuously in high-risk surgical patients. The secondary objective was to explore the potential of the wireless sensor to serve as a safety monitor. In an observational methods comparisons study, patients were measured with both the wireless sensor and bedside routine standard for at least 24 hours. University teaching hospital, single centre. Twenty-five postoperative surgical patients admitted to a step-down unit. Primary outcome measures were limits of agreement and bias of heart rate and respiratory rate. Secondary outcome measures were sensor reliability, defined as time until first occurrence of data loss. 1568 hours of vital signs data were analysed. Bias and 95% limits of agreement for heart rate were -1.1 (-8.8 to 6.5) beats per minute. For respiration rate, bias was -2.3 breaths per minute with wide limits of agreement (-15.8 to 11.2 breaths per minute). Median filtering over a 15 min period improved limits of agreement of both respiration and heart rate. 63% of the measurements were performed without data loss greater than 2 min. Overall data loss was limited (6% of time). The wireless sensor is capable of accurately measuring heart rate, but accuracy for respiratory rate was outside acceptable limits. Remote monitoring has the potential to contribute to early recognition of physiological decline in high-risk patients. Future studies should focus on the ability to detect patient deterioration on low care environments and at home after discharge. © Article author(s) (or their employer(s) unless otherwise stated in the text of

  14. Preoperative Hospitalization Is Independently Associated With Increased Risk for Venous Thromboembolism in Patients Undergoing Colorectal Surgery: A National Surgical Quality Improvement Program Database Study.

    PubMed

    Greaves, Spencer W; Holubar, Stefan D

    2015-08-01

    An important factor in the pathophysiology of venous thromboembolism is blood stasis, thus, preoperative hospitalization length of stay may be contributory to risk. We assessed preoperative hospital length of stay as a risk factor for venous thromboembolism. We performed a retrospective review of patients who underwent colorectal operations using univariate and multivariable propensity score analyses. This study was conducted at a tertiary referral hospital. Data on patients was obtained from the American College of Surgeons National Surgical Quality Improvement Program 2005-2011 Participant Use Data Files. Short-term (30-day) postoperative venous thromboembolism was measured. Our analysis included 242,670 patients undergoing colorectal surgery (mean age, 60 years; 52.9% women); of these, 72,219 (29.9%) were hospitalized preoperatively. The overall rate of venous thromboembolism was 2.07% (1.4% deep vein thrombosis, 0.5% pulmonary embolism, and 0.2% both). On multivariable analysis, the most predictive independent risk factors for venous thromboembolism were return to the operating room (OR, 1.62 (95% CI, 1.44-1.81); p < 0.001) and chronic steroid use (OR, 1.59 (95% CI, 1.41-1.80); p < 0.001); preoperative hospitalization also independently predicted venous thromboembolism (OR, 1.39 (95% CI, 1.28-1.51); p < 0.001), whereas the use of laparoscopy was protective (OR, 0.75 (95% CI, 0.67-0.83); p < 0.001). Propensity score stratification (capped at 7 days, 100 strata, area under the curve = 0.73) indicated that each day of preoperative hospitalization increased the odds of venous thromboembolism (OR, 1.42 (95% CI, 1.32-1.53); p < 0.001). All of the analyses showed a dose-response relationship between preoperative lengths of stay and risk of postoperative venous thromboembolism (p < 0.001). Patients who experienced venous thromboembolism had a higher 30-day mortality rate (3.7% vs 8.9%; p < 0.001). This study has limited potential generalizability and a retrospective

  15. Impact of prostate weight on probability of positive surgical margins in patients with low-risk prostate cancer after robotic-assisted laparoscopic radical prostatectomy.

    PubMed

    Marchetti, Pablo E; Shikanov, Sergey; Razmaria, Aria A; Zagaja, Gregory P; Shalhav, Arieh L

    2011-03-01

    To evaluate the impact of prostate weight (PW) on probability of positive surgical margin (PSM) in patients undergoing robotic-assisted radical prostatectomy (RARP) for low-risk prostate cancer. The cohort consisted of 690 men with low-risk prostate cancer (clinical stage T1c, prostate-specific antigen <10 ng/mL, biopsy Gleason score ≤6) who underwent RARP with bilateral nerve-sparing at our institution by 1 of 2 surgeons from 2003 to 2009. PW was obtained from the pathologic specimen. The association between probability of PSM and PW was assessed with univariate and multivariate logistic regression analysis. A PSM was identified in 105 patients (15.2%). Patients with PSM had significant higher prostate-specific antigen (P = .04), smaller prostates (P = .0001), higher Gleason score (P = .004), and higher pathologic stage (P < .0001). After logistic regression, we found a significant inverse relation between PSM and PW (OR 0.97%; 95% confidence interval [CI] 0.96, 0.99; P = .0003) in univariate analysis. This remained significant in the multivariate model (OR 0.98%; 95% CI 0.96, 0.99; P = .006) adjusting for age, body mass index, surgeon experience, pathologic Gleason score, and pathologic stage. In this multivariate model, the predicted probability of PSM for 25-, 50-, 100-, and 150-g prostates were 22% (95% CI 16%, 30%), 13% (95% CI 11%, 16%), 5% (95% CI 1%, 8%), and 1% (95% CI 0%, 3%), respectively. Lower PW is independently associated with higher probability of PSM in low-risk patients undergoing RARP with bilateral nerve-sparing. Copyright © 2011 Elsevier Inc. All rights reserved.

  16. Assessment scale of risk for surgical positioning injuries 1

    PubMed Central

    Lopes, Camila Mendonça de Moraes; Haas, Vanderlei José; Dantas, Rosana Aparecida Spadoti; de Oliveira, Cheila Gonçalves; Galvão, Cristina Maria

    2016-01-01

    ABSTRACT Objective: to build and validate a scale to assess the risk of surgical positioning injuries in adult patients. Method: methodological research, conducted in two phases: construction and face and content validation of the scale and field research, involving 115 patients. Results: the Risk Assessment Scale for the Development of Injuries due to Surgical Positioning contains seven items, each of which presents five subitems. The scale score ranges between seven and 35 points in which, the higher the score, the higher the patient's risk. The Content Validity Index of the scale corresponded to 0.88. The application of Student's t-test for equality of means revealed the concurrent criterion validity between the scores on the Braden scale and the constructed scale. To assess the predictive criterion validity, the association was tested between the presence of pain deriving from surgical positioning and the development of pressure ulcer, using the score on the Risk Assessment Scale for the Development of Injuries due to Surgical Positioning (p<0.001). The interrater reliability was verified using the intraclass correlation coefficient, equal to 0.99 (p<0.001). Conclusion: the scale is a valid and reliable tool, but further research is needed to assess its use in clinical practice. PMID:27579925

  17. Pre-surgical CT-assessment of neurogenic myositis ossificans of the hip and risk factors of recurrence: a series of 101 consecutive patients.

    PubMed

    Law-Ye, Bruno; Hangard, Chloé; Felter, Adrien; Safa, Dominique; Denormandie, Philippe; Genet, François; Carlier, Robert-Yves

    2016-10-18

    Neurogenic Myositis Ossificans (NMO) is a rare disabling pathology characterized by peri-articular heterotopic ossifications following severe peripheral or central nervous system injuries. It results in ankylosis and vessels or nerves compressions. Our study aimed to describe the pre-operative findings of patients with NMO of the hip using biphasic computerized tomography (CT). Between 2006 and 2012, we retrospectively analyzed 101 consecutive patients with hip NMO. We analyzed all CTs and surgical reports following a standardized grid depicting the osteoma and its relations with joint capsule, vessels and nerves and bone mineralization. We studied surgical complications and recurrence during follow-up. Chi2-test and Fischer's test were performed to compare qualitative values with respectively normal and non-normal distribution. Quantitative values were analyzed with a one factor analysis of variance (ANOVA) test. Agreement between pre-surgical CT and surgical observations was evaluated with Cohen's kappa test. Correlation between pre-operative CT and surgical findings was excellent regarding relationships with vessels (0,82) and was good concerning relationships with sciatic nerves (0.62) and with joint capsule (0.68). Close contact or disruption of joint capsule (p = 0.005), joint space narrowing (p = 0.007) and bone demineralization (p < 0.001) were correlated with NMO recurrence. Biphasic enhanced-CT allows pre-operative assessment of NMO with good correlation to surgical observations and helps prevent surgical complications.

  18. Shortened OR time and decreased patient risk through use of a modular surgical instrument with artificial intelligence.

    PubMed

    Miller, David J; Nelson, Carl A; Oleynikov, Dmitry

    2009-05-01

    With a limited number of access ports, minimally invasive surgery (MIS) often requires the complete removal of one tool and reinsertion of another. Modular or multifunctional tools can be used to avoid this step. In this study, soft computing techniques are used to optimally arrange a modular tool's functional tips, allowing surgeons to deliver treatment of improved quality in less time, decreasing overall cost. The investigators watched University Medical Center surgeons perform MIS procedures (e.g., cholecystectomy and Nissen fundoplication) and recorded the procedures to digital video. The video was then used to analyze the types of instruments used, the duration of each use, and the function of each instrument. These data were aggregated with fuzzy logic techniques using four membership functions to quantify the overall usefulness of each tool. This allowed subsequent optimization of the arrangement of functional tips within the modular tool to decrease overall time spent changing instruments during simulated surgical procedures based on the video recordings. Based on a prototype and a virtual model of a multifunction laparoscopic tool designed by the investigators that can interchange six different instrument tips through the tool's shaft, the range of tool change times is approximately 11-13 s. Using this figure, estimated time savings for the procedures analyzed ranged from 2.5 to over 32 min, and on average, total surgery time can be reduced by almost 17% by using the multifunction tool.

  19. Costs and cost-effectiveness of carotid stenting versus endarterectomy for patients at standard surgical risk: results from the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST).

    PubMed

    Vilain, Katherine R; Magnuson, Elizabeth A; Li, Haiyan; Clark, Wayne M; Begg, Richard J; Sam, Albert D; Sternbergh, W Charles; Weaver, Fred A; Gray, William A; Voeks, Jenifer H; Brott, Thomas G; Cohen, David J

    2012-09-01

    from this controlled clinical trial demonstrate only trivial differences in overall healthcare costs and quality-adjusted life expectancy between the 2 strategies. If the CREST results can be replicated in clinical practice, these findings suggest that factors other than cost-effectiveness should be considered when deciding between treatment options for carotid artery stenosis in patients at standard risk for surgical complications. Clinical Trial Registration- URL: http://clinicaltrials.gov. Unique Identifier: NCT00004732.

  20. Costs and Cost-Effectiveness of Carotid Stenting versus Endarterectomy for Patients at Standard Surgical Risk: Results from the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST)

    PubMed Central

    Vilain, Katherine R.; Magnuson, Elizabeth A.; Li, Haiyan; Clark, Wayne M.; Begg, Richard J.; Sam, Albert D.; Sternbergh, W. Charles; Weaver, Fred A.; Gray, William A.; Voeks, Jenifer H.; Brott, Thomas G.; Cohen, David J.

    2012-01-01

    CEA compared with CAS, projected 10-year outcomes from this controlled clinical trial demonstrate only trivial differences in overall healthcare costs and quality-adjusted life expectancy between the 2 strategies. If the CREST results can be replicated in clinical practice, these findings suggest that factors other than cost-effectiveness should be considered when deciding between treatment options for carotid artery stenosis in patients at standard risk for surgical complications. PMID:22821614

  1. Social Media in Surgical Training: Opportunities and Risks.

    PubMed

    Ovaere, Sander; Zimmerman, David D E; Brady, Richard R

    2018-05-02

    Surgeon engagement with social media is growing rapidly. Innovative applications in diverse fields of health care are increasingly available. The aim of this review is to explore the current and future applications of social media in surgical training. In addition, risks and barriers of social media engagement are analyzed, and recommendations for professional social media use amongst trainers and trainees are suggested. The published, peer-reviewed literature on social media in medicine, surgery and surgical training was reviewed. MESH terms including "social media", "education", "surgical training" and "web applications" were used. Different social media surgical applications are already widely available but limited in use in the trainee's curriculum. E-learning modalities, podcasts, live surgery platforms and microblogs are used for teaching purposes. Social media enables global research collaboratives and can play a role in patient recruitment for clinical trials. The growing importance of networking is emphasized by the increased use of LinkedIn, Facebook, Sermo and other networking platforms. Risks of social media use, such as lack of peer review and the lack of source confirmation, must be considered. Governing surgeon's and trainee's associations should consider adopting and sharing their guidelines for standards of social media use. Surgical training is changing rapidly and as such, social media presents tremendous opportunities for teaching, training, research and networking. Awareness must be raised on the risks of social media use. Copyright © 2018 Association of Program Directors in Surgery. All rights reserved.

  2. Perfecting patient flow in the surgical setting.

    PubMed

    Amato-Vealey, Elaine J; Fountain, Patricia; Coppola, Deborah

    2012-07-01

    Reduced surgical efficiency and productivity, delayed patient discharges, and prolonged use of hospital resources are the results of an OR that is unable to move patients to the postanesthesia care unit or other patient units. A primary reason for perioperative patient flow delay is the lack of hospital beds to accommodate surgical patients, which consequently causes backups of patients currently in the surgical suite. In one facility, implementing Six Sigma methodology helped to improve OR patient flow by identifying ways that frontline staff members could work more intelligently and more efficiently, and with less stress to streamline workflow and eliminate redundancy and waste in ways that did not necessitate reducing the number of employees. The results were improved employee morale, job satisfaction and safety, and an enhanced patient experience. Copyright © 2012 AORN, Inc. Published by Elsevier Inc. All rights reserved.

  3. Development and validation of the Surgical Outcome Risk Tool (SORT)

    PubMed Central

    Protopapa, K L; Simpson, J C; Smith, N C E; Moonesinghe, S R

    2014-01-01

    Background Existing risk stratification tools have limitations and clinical experience suggests they are not used routinely. The aim of this study was to develop and validate a preoperative risk stratification tool to predict 30-day mortality after non-cardiac surgery in adults by analysis of data from the observational National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Knowing the Risk study. Methods The data set was split into derivation and validation cohorts. Logistic regression was used to construct a model in the derivation cohort to create the Surgical Outcome Risk Tool (SORT), which was tested in the validation cohort. Results Prospective data for 19 097 cases in 326 hospitals were obtained from the NCEPOD study. Following exclusion of 2309, details of 16 788 patients were analysed (derivation cohort 11 219, validation cohort 5569). A model of 45 risk factors was refined on repeated regression analyses to develop a model comprising six variables: American Society of Anesthesiologists Physical Status (ASA-PS) grade, urgency of surgery (expedited, urgent, immediate), high-risk surgical specialty (gastrointestinal, thoracic, vascular), surgical severity (from minor to complex major), cancer and age 65 years or over. In the validation cohort, the SORT was well calibrated and demonstrated better discrimination than the ASA-PS and Surgical Risk Scale; areas under the receiver operating characteristic (ROC) curve were 0·91 (95 per cent c.i. 0·88 to 0·94), 0·87 (0·84 to 0·91) and 0·88 (0·84 to 0·92) respectively (P < 0·001). Conclusion The SORT allows rapid and simple data entry of six preoperative variables, and provides a percentage mortality risk for individuals undergoing surgery. PMID:25388883

  4. Three-Year Outcomes of Transcatheter Aortic Valve Implantation in Patients With Varying Levels of Surgical Risk (from the CoreValve ADVANCE Study).

    PubMed

    Barbanti, Marco; Schiltgen, Molly; Verdoliva, Sarah; Bosmans, Johan; Bleiziffer, Sabine; Gerckens, Ulrich; Wenaweser, Peter; Brecker, Stephen; Gulino, Simona; Tamburino, Corrado; Linke, Axel

    2016-03-01

    This study compared 3-year clinical outcomes of patients who underwent transcatheter aortic valve implantation with the Society of Thoracic Surgeons (STS) score ≤7% to those of patients with a score >7%. Data were drawn from the ADVANCE study, a multinational post-market clinical trial that enrolled real-world patients with severe aortic stenosis treated with the CoreValve bioprosthesis. Events were independently adjudicated using Valve Academic Research Consortium-1 definitions. A total of 996 patients were implanted: STS ≤7% (n = 697, median STS 4.3%, interquartile range 3.1% to 5.4%) and STS >7% (n = 298, median STS 9.7%, interquartile range 8.0% to 12.4%). At 3 years, the STS ≤7% group had lower rates of all-cause mortality (28.6 vs 45.9, p <0.01) and cardiovascular mortality (19.0 vs 30.2, p <0.01) than the STS >7% group. No differences were observed in cerebrovascular accidents, vascular complications, bleeding, or myocardial infarction. In patients with STS ≤7%, mortality at 3 years was higher in those with moderate or severe aortic regurgitation (AR) at discharge than in those with mild or less AR (39.9% vs 22.9%; hazard ratio 1.98; 95% confidence interval 1.37 to 2.86; p <0.01). Conversely, the severity of AR at discharge did not affect 3-year mortality in patients with STS >7% (42.9% vs 44.6%, moderate/severe vs mild/less; hazard ratio 1.04; 95% confidence interval, 0.62 to 1.75; p = 0.861; p for interaction = 0.047). In conclusion, patients with STS ≤7% had lower rates of all-cause and cardiovascular mortality at 3 years after transcatheter aortic valve implantation. Complication rates were low and stable in both groups, demonstrating the safety of this procedure for patients at various levels of surgical risk. Copyright © 2016 Elsevier Inc. All rights reserved.

  5. Rhabdomyolysis in Critically Ill Surgical Patients

    PubMed Central

    Kuzmanovska, Biljana; Cvetkovska, Emilija; Kuzmanovski, Igor; Jankulovski, Nikola; Shosholcheva, Mirjana; Kartalov, Andrijan; Spirovska, Tatjana

    2016-01-01

    Introduction: Rhabdomyolysis is a syndrome of injury of skeletal muscles associated with myoglobinuria, muscle weakness, electrolyte imbalance and often, acute kidney injury as severe complication. The aim: of this study is to detect the incidence of rhabdomyolysis in critically ill patients in the surgical intensive care unit (ICU), and to raise awareness of this medical condition and its treatment among the clinicians. Material and methods: A retrospective review of all surgical and trauma patients admitted to surgical ICU of the University Surgical Clinic “Mother Teresa” in Skopje, Macedonia, from January 1st till December 31st 2015 was performed. Patients medical records were screened for available serum creatine kinase (CK) with levels > 200 U/l, presence of myoglobin in the serum in levels > 80 ng/ml, or if they had a clinical diagnosis of rhabdomyolysis by an attending doctor. Descriptive statistical methods were used to analyze the collected data. Results: Out of totally 1084 patients hospitalized in the ICU, 93 were diagnosed with rhabdomyolysis during the course of one year. 82(88%) patients were trauma patients, while 11(12%) were surgical non trauma patients. 7(7.5%) patients diagnosed with rhabdomyolysis developed acute kidney injury (AKI) that required dialysis. Average values of serum myoglobin levels were 230 ng/ml, with highest values of > 5000 ng/ml. Patients who developed AKI had serum myoglobin levels above 2000 ng/ml. Average values of serum CK levels were 400 U/l, with highest value of 21600 U/l. Patients who developed AKI had serum CK levels above 3000 U/l. Conclusion: Regular monitoring and early detection of elevated serum CK and myoglobin levels in critically ill surgical and trauma patients is recommended in order to recognize and treat rhabdomyolysis in timely manner and thus prevent development of AKI. PMID:27703296

  6. Rhabdomyolysis in Critically Ill Surgical Patients.

    PubMed

    Kuzmanovska, Biljana; Cvetkovska, Emilija; Kuzmanovski, Igor; Jankulovski, Nikola; Shosholcheva, Mirjana; Kartalov, Andrijan; Spirovska, Tatjana

    2016-07-27

    Rhabdomyolysis is a syndrome of injury of skeletal muscles associated with myoglobinuria, muscle weakness, electrolyte imbalance and often, acute kidney injury as severe complication. of this study is to detect the incidence of rhabdomyolysis in critically ill patients in the surgical intensive care unit (ICU), and to raise awareness of this medical condition and its treatment among the clinicians. A retrospective review of all surgical and trauma patients admitted to surgical ICU of the University Surgical Clinic "Mother Teresa" in Skopje, Macedonia, from January 1 st till December 31 st 2015 was performed. Patients medical records were screened for available serum creatine kinase (CK) with levels > 200 U/l, presence of myoglobin in the serum in levels > 80 ng/ml, or if they had a clinical diagnosis of rhabdomyolysis by an attending doctor. Descriptive statistical methods were used to analyze the collected data. Out of totally 1084 patients hospitalized in the ICU, 93 were diagnosed with rhabdomyolysis during the course of one year. 82(88%) patients were trauma patients, while 11(12%) were surgical non trauma patients. 7(7.5%) patients diagnosed with rhabdomyolysis developed acute kidney injury (AKI) that required dialysis. Average values of serum myoglobin levels were 230 ng/ml, with highest values of > 5000 ng/ml. Patients who developed AKI had serum myoglobin levels above 2000 ng/ml. Average values of serum CK levels were 400 U/l, with highest value of 21600 U/l. Patients who developed AKI had serum CK levels above 3000 U/l. Regular monitoring and early detection of elevated serum CK and myoglobin levels in critically ill surgical and trauma patients is recommended in order to recognize and treat rhabdomyolysis in timely manner and thus prevent development of AKI.

  7. Surgical specimen handover from the operating theatre to laboratory-Can we improve patient safety by learning from aviation and other high-risk organisations?

    PubMed

    Brennan, Peter A; Brands, Marieke T; Caldwell, Lucy; Fonseca, Felipe Paiva; Turley, Nic; Foley, Susie; Rahimi, Siavash

    2018-02-01

    Essential communication between healthcare staff is considered one of the key requirements for both safety and quality care when patients are handed over from one clinical area to other. This is particularly important in environments such as the operating theatre and intensive care where mistakes can be devastating. Health care has learned from other high-risk organisations (HRO) such as aviation where the use of checklists and human factors awareness has virtually eliminated human error and mistakes. To our knowledge, little has been published around ways to improve pathology specimen handover following surgery, with pathology request forms often conveying the bare minimum of information to assist the laboratory staff. Furthermore, the request form might not warn staff about potential hazards. In this article, we provide a brief summary of the factors involved in human error and introduce a novel checklist that can be readily completed at the same time as the routine pathology request form. This additional measure enhances safety, can help to reduce processing and mislabelling errors and provides essential information in a structured way assisting both laboratory staff and pathologists when handling head and neck surgical specimens. © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

  8. Serial post-surgical stimulated and unstimulated highly sensitive thyroglobulin measurements in low- and intermediate-risk papillary thyroid carcinoma patients not receiving radioactive iodine.

    PubMed

    Kashat, Lawrence; Orlov, Steven; Orlov, David; Assi, Jasmeet; Salari, Farnaz; Walfish, Paul G

    2016-11-01

    μg/L, respectively. Upon exclusion of 73 patients with an initial undetectable Stim-Tg (n = 48), serial Stim-Tg measurements did not change significantly over time (all p = NS). For these patients, the estimated changes in Stim-Tg per year for rhTSH, T4 withdrawal, and T3 withdrawal were -0.09, -0.10, and 0.01 μg/L, respectively. Serial u-hsTg measurements did not significantly change over time after adjusting for TSH level (p = NS). The estimated change in u-hsTg per year was -0.003 μg/L. No patients had any clinical or imaging evidence of a recurrence during the duration of their follow-up. Among low/intermediate-risk PTC patients not treated with RAI, serial post-surgical Stim-Tg and u-hsTg measurements do not change significantly over a median follow-up of 6.5 years.

  9. Preoperative Optimization of Total Joint Arthroplasty Surgical Risk: Obesity.

    PubMed

    Fournier, Matthew N; Hallock, Justin; Mihalko, William M

    2016-08-01

    Obesity is a problem that is increasing in prevalence in the United States and in other countries, and it is a common comorbidity in patients seeking total joint arthroplasty for degenerative musculoskeletal diseases. Obesity, as well as commonly associated comorbidities such as diabetes mellitus, cardiovascular disease, and those contributing to the diagnosis of metabolic syndrome, have been shown to have detrimental effects on total joint arthroplasty outcomes. Although there are effective surgical and nonsurgical interventions which can result in weight loss in these patients, concomitant benefit on arthroplasty outcomes is not clear. Preoperative optimization of surgical risk in obese total joint arthroplasty patients is an important point of intervention to improve arthroplasty outcomes. Copyright © 2016 Elsevier Inc. All rights reserved.

  10. Travel Time Influences Readmission Risk: Geospatial Mapping of Surgical Readmissions.

    PubMed

    Turrentine, Florence E; Buckley, Patrick J; Sohn, Min-Woong; Williams, Michael D

    2017-06-01

    The University of Virginia (UVA) has recently become an Accountable Care Organization (ACO), intensifying efforts to provide better care for individuals. UVA's ACO population resides across the entire Commonwealth, with a large percentage of patients living in rural areas. To provide better health for this population, the central tenet of the ACO mission, we identified geographic risk factors influencing hospital readmission. We analyzed the relationship between the distance of patients' residence to the nearest hospital and 30-day readmission in general surgery patients. A retrospective chart review using January 1, 2011 through October 31, 2013 American College of Surgeons National Surgical Quality Improvement Program data for general surgery procedures was conducted. ArcGIS mapped street addresses provided graphical representation of distance between surgical population and the nearest hospital. We analyzed the impact on readmission, of time traveled, insurance status, and median household income. Each increase of 10 minutes in travel time from the patient's residence to the nearest hospital, not just UVA, was associated with a 9 per cent increase in the probability of readmission after adjusting for patient characteristics, preoperative comorbidities, laboratory values, and postoperative complications before or after discharge (odds ratio = 1.09; 95% confidence interval = 1.01-1.17; P = 0.019). Unlike urban hospitals, those serving rural populations may be at particular risk of postsurgical readmissions. Patients living furthest from a hospital facility are most at risk for readmission after a general surgery procedure. This vulnerable population may benefit most from comprehensive discharge planning.

  11. Patient profiling can identify patients with adult spinal deformity (ASD) at risk for conversion from nonoperative to surgical treatment: initial steps to reduce ineffective ASD management.

    PubMed

    Passias, Peter G; Jalai, Cyrus M; Line, Breton G; Poorman, Gregory W; Scheer, Justin K; Smith, Justin S; Shaffrey, Christopher I; Burton, Douglas C; Fu, Kai-Ming G; Klineberg, Eric O; Hart, Robert A; Schwab, Frank; Lafage, Virginie; Bess, Shay

    2018-02-01

    , but CROSS had larger pelvic incidence and lumbar lordosis (PI-LL) mismatch than NON (11.9° vs. 3.1°, p=.032). CROSS and OP had similar baseline PROM scores; however, CROSS had worse baseline ODI, PCS, SRS-22r (p<.05). At time of crossover, CROSS had worse ODI (35.7 vs. 27.8) and SRS Satisfaction (2.6 vs. 3.3) compared with NON (p<.05). Alignment remained similar for CROSS from baseline to conversion; however, PROMs (ODI, PCS, SRS Activity/Pain/Total) worsened (p<.05). Early and late crossover evaluation demonstrated CROSS-early (n=25) had worsening ODI, SRS Activity/Pain at time of crossover (p<.05). From time of crossover to 2-year follow-up, CROSS-early had less SRS Appearance/Mental improvement compared with OP. Both CROSS-early/late had worse baseline, but greater improvements, in ODI, PCS, SRS Pain/Total compared with NON (p<.05). Baseline alignment and disability parameters increased crossover odds-Non with Schwab T/L/D curves and ODI≥40 (odds ratio [OR]: 3.05, p=.031), and Non with high PI-LL modifier grades ("+"/'++') and ODI≥40 (OR: 5.57, p=.007) were at increased crossover risk. High baseline and increasing disability over time drives conversion from non-operative to operative ASD care. CROSS patients had similar spinal deformity but worse PROMs than NON. CROSS achieved similar 2-year outcome scores as OP. Profiling at first visit for patients at risk of crossover may optimize physician counseling and cost savings. Copyright © 2017. Published by Elsevier Inc.

  12. A comparison of propensity score-based approaches to health service evaluation: a case study of a preoperative physician-led clinic for high-risk surgical patients.

    PubMed

    Pham, Clarabelle T; Gibb, Catherine L; Mittinty, Murthy N; Fitridge, Robert A; Marshall, Villis R; Karnon, Jonathan D

    2016-10-01

    A physician-led clinic for the preoperative optimization and management of high-risk surgical patients was implemented in a South Australian public hospital in 2008. This study aimed to estimate the costs and effects of the clinic using a mixed retrospective and prospective observational study design. Alternative propensity score estimation methods were applied to retrospective routinely collected administrative and clinical data, using weighted and matched cohorts. Supplementary survey-based prospective data were collected to inform the analysis of the retrospective data and reduce potential unmeasured confounding. Using weighted cohorts, clinic patients had a significantly longer mean length of stay and higher mean cost. With the matched cohorts, reducing the calliper width resulted in a shorter mean length of stay in the clinic group, but the costs remained significantly higher. The prospective data indicated potential unmeasured confounding in all analyses other than in the most tightly matched cohorts. The application of alternative propensity-based approaches to a large sample of retrospective data, supplemented with a smaller sample of prospective data, informed a pragmatic approach to reducing potential observed and unmeasured confounding in an evaluation of a physician-led preoperative clinic. The need to generate tightly matched cohorts to reduce the potential for unmeasured confounding indicates that significant uncertainty remains around the effects of the clinic. This study illustrates the value of mixed retrospective and prospective observational study designs but also underlines the need to prospectively plan for the evaluation of costs and effects alongside the implementation of significant service innovations. © 2016 John Wiley & Sons, Ltd.

  13. Quantifying surgical complexity with machine learning: looking beyond patient factors to improve surgical models.

    PubMed

    Van Esbroeck, Alexander; Rubinfeld, Ilan; Hall, Bruce; Syed, Zeeshan

    2014-11-01

    To investigate the use of machine learning to empirically determine the risk of individual surgical procedures and to improve surgical models with this information. American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data from 2005 to 2009 were used to train support vector machine (SVM) classifiers to learn the relationship between textual constructs in current procedural terminology (CPT) descriptions and mortality, morbidity, Clavien 4 complications, and surgical-site infections (SSI) within 30 days of surgery. The procedural risk scores produced by the SVM classifiers were validated on data from 2010 in univariate and multivariate analyses. The procedural risk scores produced by the SVM classifiers achieved moderate-to-high levels of discrimination in univariate analyses (area under receiver operating characteristic curve: 0.871 for mortality, 0.789 for morbidity, 0.791 for SSI, 0.845 for Clavien 4 complications). Addition of these scores also substantially improved multivariate models comprising patient factors and previously proposed correlates of procedural risk (net reclassification improvement and integrated discrimination improvement: 0.54 and 0.001 for mortality, 0.46 and 0.011 for morbidity, 0.68 and 0.022 for SSI, 0.44 and 0.001 for Clavien 4 complications; P < .05 for all comparisons). Similar improvements were noted in discrimination and calibration for other statistical measures, and in subcohorts comprising patients with general or vascular surgery. Machine learning provides clinically useful estimates of surgical risk for individual procedures. This information can be measured in an entirely data-driven manner and substantially improves multifactorial models to predict postoperative complications. Copyright © 2014 Elsevier Inc. All rights reserved.

  14. Current Surgical Options for Patients with Epilepsy.

    PubMed

    Rasul, Fahid T; Bal, Jarnail; Pereira, Erlick A; Tisdall, Martin; Themistocleous, Marios; Haliasos, Nikolaos

    2017-01-01

    Surgery for epilepsy dates back to 1886 and has undergone significant developments. Today it is considered a key treatment modality in patients who are resistant to pharmacological intervention. It improves seizure control, cognition and quality of life. New technologies, advances in surgical technique and progress in scientific research underlie the expansion of surgery in epilepsy treatment. Effectiveness of surgical treatment depends on several factors including the type of epilepsy, the underlying pathology and the localisation of the epileptogenic zone. Timely referral to an experienced epilepsy surgery centre is important to allow the greatest chance of seizure control and to minimise associated morbidity and mortality. Following referral, patients undergo thorough presurgical investigation to evaluate their suitability for surgery. The commonest form of epilepsy treated by surgery is mesial temporal lobe sclerosis and there is Class I evidence for the medium-term efficacy of temporal lobe resection from two randomised control trials. Various other forms of epilepsy are now considered for resective and neuromodulatory surgical intervention due to favourable results. In this article, the authors review the current status of surgical treatment for epilepsy including the presurgical evaluation of patients, surgical techniques and the future directions in epilepsy surgery. Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.

  15. Estimation of physiologic ability and surgical stress (E-PASS) scoring system could provide preoperative advice on whether to undergo laparoscopic surgery for colorectal cancer patients with a high physiological risk

    PubMed Central

    Zhang, Ao; Liu, Tingting; Zheng, Kaiyuan; Liu, Ningbo; Huang, Fei; Li, Weidong; Liu, Tong; Fu, Weihua

    2017-01-01

    Abstract Laparoscopic colorectal surgery had been widely used for colorectal cancer patient and showed a favorable outcome on the postoperative morbidity rate. We attempted to evaluate physiological status of patients by mean of Estimation of physiologic ability and surgical stress (E-PASS) system and to analyze the difference variation of postoperative morbidity rate of open and laparoscopic colorectal cancer surgery in patients with different physiological status. In total 550 colorectal cancer patients who underwent surgery treatment were included. E-PASS and some conventional scoring systems were reviewed to examine their mortality prediction ability. The preoperative risk score (PRS) in the E-PASS system was used to evaluate the physiological status of patients. The difference of postoperative morbidity rate between open and laparoscopic colorectal cancer surgeries was analyzed respectively in patients with different physiological status. E-PASS had better prediction ability than other conventional scoring systems in colorectal cancer surgeries. Postoperative morbidities were developed in 143 patients. The parameters in the E-PASS system had positive correlations with postoperative morbidity. The overall postoperative morbidity rate of laparoscopic surgeries was lower than open surgeries (19.61% and 28.46%), but the postoperative morbidity rate of laparoscopic surgeries increased more significantly than in open surgery as PRS increased. When PRS was more than 0.7, the postoperative morbidity rate of laparoscopic surgeries would exceed the postoperative morbidity rate of open surgeries. The E-PASS system was capable to evaluate the physiological and surgical risk of colorectal cancer surgery. PRS could assist preoperative decision-making on the surgical method. Colorectal cancer patients who were assessed with a low physiological risk by PRS would be safe to undergo laparoscopic surgery. On the contrary, surgeons should make decisions prudently on the operation

  16. Outcome of anesthesia in elective surgical patients with comorbidities.

    PubMed

    Eyelade, Olayinka; Sanusi, Arinola; Adigun, Tinuola; Adejumo, Olufemi

    2016-01-01

    Presence of comorbidity in surgical patients may be associated with adverse perioperative events and increased the risk of morbidity and mortality. This audit was conducted to determine the frequencies of comorbidities in elective surgical patients and the outcome of anesthesia in a Tertiary Hospital in Nigeria. Observational study of a cross-section of adult patients scheduled for elective surgery over a 6-month period. A standardized questionnaire was used to document patients' demographics, the presence of comorbidity and type, surgical diagnosis, anesthetic technique, intraoperative adverse events, and outcome of anesthesia. The questionnaire was administered pre- and post-operatively to determine the effects of the comorbidities on the outcome of anesthesia. One hundred and sixty-five adult patients aged between 18 and 84 years were studied. There were 89 (53.9%) females and 76 (46.1%) males. Forty-five (27.3%) have at least one comorbidity. Hypertension was the most common (48.8%) associated illness. Other comorbidities identified include anemia (17.8%), asthma (8.9%), diabetes mellitus (6.7%), chronic renal disease (6.7%), and others. The perioperative period was uneventful in majority of patients (80.6%) despite the presence of comorbidities. Intraoperative adverse events include hypotension, hypertension, shivering, and vomiting. No mortality was reported. Hypertension was the most common comorbidity in this cohort of patients. The presence of comorbidity did not significantly affect the outcome of anesthesia in elective surgical patients.

  17. Second branchial cleft fistulae: patient characteristics and surgical outcome.

    PubMed

    Kajosaari, Lauri; Mäkitie, Antti; Salminen, Päivi; Klockars, Tuomas

    2014-09-01

    Second branchial cleft anomalies predispose to recurrent infections, and surgical resection is recommended as the treatment of choice. There is no clear consensus regarding the timing or surgical technique in the operative treatment of these anomalies. Our aim was to compare the effect of age and operative techniques to patient characteristics and treatment outcome. A retrospective study of pediatric patients treated for second branchial sinuses or fistulae during 1998-2012 at two departments in our academic tertiary care referral center. Comparison of patient characteristics, preoperative investigations, surgical techniques and postoperative sequelae. Our data is based on 68 patients, the largest series in the literature. One-fourth (24%) of patients had any infectious symptoms prior to operative treatment. Patient demographics, preoperative investigations, use of methylene blue, or tonsillectomy had no effect on the surgical outcome. There were no re-operations due to residual disease. Three complications were observed postoperatively. Our patient series of second branchial cleft sinuses/fistulae is the largest so far and enables analyses of patient characteristics and surgical outcomes more reliably than previously. Preoperative symptoms are infrequent and mild. There was no difference in clinical outcome between the observed departments. Performing ipsilateral tonsillectomy gave no outcome benefits. The operation may be delayed to an age of approximately three years when anesthesiological risks are and possible harms are best avoided. Considering postoperative pain and risk of postoperative hemorrhage a routine tonsillectomy should not be included to the operative treatment of second branchial cleft fistulae. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

  18. The extent of surgical patients' understanding.

    PubMed

    Pugliese, Omar Talhouk; Solari, Juan Lombardi; Ferreres, Alberto R

    2014-07-01

    The notion that consent to surgery must be informed implies not only that information should be provided by the surgeon but also that the information should be understood by the patient in order to give a foundation to his or her decision to accept or refuse treatment and thus, achieve autonomy for the patient. Nonetheless, this seems to be an idyllic situation, since most patients do not fully understand the facts offered and thus the process of surgical informed consent, as well as the patient's autonomy, may be jeopardized. Informed consent does not always mean rational consent.

  19. [Patient readmission for surgical site infection: integrative review].

    PubMed

    Machado, Lilian; Turrini, Ruth N T; Siqueira, Ana L

    2013-02-01

    Surgical site infections (SSI) represent an inherent risk after surgical procedures associated both to the surgical procedure and to the patient clinical conditions. To analyze in an integrative review the studies related to patient readmission due to SSI. The review was carried out by LILACS, CINHAL, MEDLINE and COCHRANE databases and articles published from 1966 to 2010 were selected. It was analyzed 13 studies classified as transversal (7), cohort (4) and longitudinal (2). Few studies analyzed only the readmissions related to the SSI. Time to define the readmission ranged from 28 to 90 days after surgery and studies related to orthopedic procedures were more frequent. The ISS readmission rates were lower than 5%. The main aetiological agents isolated from ISS were Staphylococcus aureus and coagulase-negative staphylococci. Monitoring readmissions due to SSI could contribute to dimension the occurrence of ISS post-discharge, once about half of the SSI post-discharge was diagnosed at the readmission moment.

  20. Optimizing the patient for surgical treatment of the wound.

    PubMed

    Myers, Wesley T; Leong, Mimi; Phillips, Linda G

    2007-10-01

    Plastic surgeons are consulted often to close wounds that fail or are difficult to heal. Optimizing the patient's medical condition before surgical closure of a wound can mean the difference between a successful outcome and an undesirable one. It is imperative that plastic surgeons have an extensive knowledge of the modifiable risk factors affecting the wound-healing process and their subsequent complications. This knowledge allows the surgeon to tailor the treatment options and intervene when appropriate to optimize outcomes for successful surgical closure of a wound. Whether the impairments to wound healing and closure are local or systemic, they must be addressed appropriately.

  1. Surgical wound dehiscence: a conceptual framework for patient assessment.

    PubMed

    Sandy-Hodgetts, Kylie; Carville, Keryln; Leslie, Gavin D

    2018-03-02

    This paper presents a conceptual framework which outlines the risk factors associated with surgical wound dehiscence (SWD) as identified in the literature. The purpose for the development of the conceptual framework was to derive an evidence-based, informed understanding of factors associated with SWD, in order to inform a programme of research on the aetiology and potential risk factors of SWD. Incorporated within the patient-centric conceptual framework are patient related comorbidities, intraoperative and postoperative risk factors related to SWD. These are categorised as either 'mechanical' or 'physiological mechanisms' posited to influence these relationships. The use of the conceptual model for assessment of patients has particular clinical relevance for identification of risk and the management of patients in the pre-, intra- and postoperative period.

  2. Risk factors for surgical site infections after pediatric spine operations.

    PubMed

    Croft, Lindsay D; Pottinger, Jean M; Chiang, Hsiu-Yin; Ziebold, Christine S; Weinstein, Stuart L; Herwaldt, Loreen A

    2015-01-15

    Matched case-control study. To identify modifiable risk factors for surgical site infections (SSIs) after pediatric spinal fusion. The number of SSIs after pediatric spinal fusions increased. Between July 2001 and July 2010, 22 of 598 pediatric patients who underwent spinal fusion at a university hospital acquired SSIs. Each patient with an SSI was matched with 2 controls by procedure date. Bivariable and multivariable analyses were used to identify risk factors for SSIs and outcomes of SSIs. Gram-negative organisms caused more than 50% of the SSIs. By multivariable analysis, neuromuscular scoliosis (odds ratio [OR] = 20.8; 95% confidence interval [CI], 3.1-889.5; P < 0.0001) and weight-for-age at the 95th percentile or higher (OR = 8.6; 95% CI, 1.2-124.9; P = 0.02) were preoperative factors associated with SSIs. Blood loss (OR = 1.0; 95% CI, 1.0-1.0; P = 0.039) and allografts and allografts in combination with other grafts were operative risk factors for SSIs. The final overall risk model for SSIs was weight-for-age at the 95th percentile or higher (OR = 4.0; 95% CI, 1.4-∞; P = 0.037), American Society of Anesthesiologists score 3 or more (OR = 3.8; 95% CI, 1.6-∞; P = 0.01), and prolonged operation duration (OR = 1.0/min increase; 95% CI, 1.0-1.0; P = 0.004). SSIs were associated with 2.8 days of additional postoperative length of stay (P = 0.02). Neuromuscular scoliosis was the only factor significantly associated with hospital readmission (OR = 23.6; 95% CI, 3.8-147.3; P = 0.0007). Our results suggest that pediatric patients undergoing spinal fusion might benefit from antimicrobial prophylaxis that covers gram-negative organisms. Surgical duration, graft implantation, and blood loss are potentially modifiable operative risk factors. Neuromuscular scoliosis, high weight-for-age, and American Society of Anesthesiologists scores 3 or more may help surgical teams identify patients at high risk for SSI.

  3. Adolescent clavicle nonunions: potential risk factors and surgical management.

    PubMed

    Pennock, Andrew T; Edmonds, Eric W; Bae, Donald S; Kocher, Mininder S; Li, Ying; Farley, Frances A; Ellis, Henry B; Wilson, Philip L; Nepple, Jeffrey; Gordon, J Eric; Willimon, Samuel C; Busch, Michael T; Spence, David D; Kelly, Derek M; Pandya, Nirav K; Sabatini, Coleen S; Shea, Kevin G; Heyworth, Benton E

    2018-01-01

    Clavicle nonunions in adolescent patients are exceedingly rare. The purpose of this study was to evaluate a series of clavicle nonunions from a pediatric multicenter study group to assess potential risk factors and treatment outcomes. A retrospective review of all clavicle nonunions in patients younger than 19 years was performed at 9 pediatric hospitals between 2006 and 2016. Demographic and surgical data were documented. Radiographs were evaluated for initial fracture classification, displacement, shortening, angulation, and nonunion type. Clinical outcomes were evaluated, including rate of healing, time to union, return to sports, and complications. Risk factors for nonunion were assessed by comparing the study cohort with a separate cohort of age-matched patients with a diaphyseal clavicle fracture. There were 25 nonunions (mean age, 14.5 years; range, 10.0-18.9 years) identified, all of which underwent surgical fixation. Most fractures were completely displaced (68%) initially, but 21% were partially displaced and 11% were nondisplaced. Bone grafting was performed in 24 of 25 cases, typically using the hypertrophic callus. Radiographic healing was achieved in 96% of cases. One patient (4%) required 2 additional procedures to achieve union. The primary risk factor for development of a nonunion was a previous history of an ipsilateral clavicle fracture. Clavicle nonunions can occur in the adolescent population but are an uncommon clinical entity. The majority occur in male patients with displaced fractures, many of whom have sustained previous fractures of the same clavicle. High rates of union were achieved with plate fixation and the use of bone graft. Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

  4. Advantages of a multi-state approach in surgical research: how intermediate events and risk factor profile affect the prognosis of a patient with locally advanced rectal cancer.

    PubMed

    Manzini, G; Ettrich, T J; Kremer, M; Kornmann, M; Henne-Bruns, D; Eikema, D A; Schlattmann, P; de Wreede, L C

    2018-02-13

    Standard survival analysis fails to give insight into what happens to a patient after a first outcome event (like first relapse of a disease). Multi-state models are a useful tool for analyzing survival data when different treatments and results (intermediate events) can occur. Aim of this study was to implement a multi-state model on data of patients with rectal cancer to illustrate the advantages of multi-state analysis in comparison to standard survival analysis. We re-analyzed data from the RCT FOGT-2 study by using a multi-state model. Based on the results we defined a high and low risk reference patient. Using dynamic prediction, we estimated how the survival probability changes as more information about the clinical history of the patient becomes available. A patient with stage UICC IIIc (vs UICC II) has a higher risk to develop distant metastasis (DM) or both DM and local recurrence (LR) if he/she discontinues chemotherapy within 6 months or between 6 and 12 months, as well as after the completion of 12 months CTx with HR 3.55 (p = 0.026), 5.33 (p = 0.001) and 3.37 (p < 0.001), respectively. He/she also has a higher risk to die after the development of DM (HR 1.72, p = 0.023). Anterior resection vs. abdominoperineal amputation means 63% risk reduction to develop DM or both DM and LR (HR 0.37, p = 0.003) after discontinuation of chemotherapy between 6 and 12 months. After development of LR, a woman has a 4.62 times higher risk to die (p = 0.006). A high risk reference patient has an estimated 43% 5-year survival probability at start of CTx, whereas for a low risk patient this is 79%. After the development of DM 1 year later, the high risk patient has an estimated 5-year survival probability of 11% and the low risk patient one of 21%. Multi-state models help to gain additional insight into the complex events after start of treatment. Dynamic prediction shows how survival probabilities change by progression of the clinical history.

  5. Surgical approaches for varicocele in pediatric patient

    PubMed Central

    Parrilli, Alejandra; Escolino, Maria; Esposito, Ciro

    2016-01-01

    Background Varicocele represents one of the most common surgically correctible urologic anomalies in adolescent males. The best procedure for the treatment of adolescent varicocele has not been established, but with recent advances in minimal access surgery, there have been many reports praising the safety and efficacy of laparoscopy and retroperitoneoscopy for the surgical correction of varicocele in adolescent. The aim of this review is to compare the results of Palomo’s technique, with retroperitoneoscopic and transperitoneoscopic approaches in adolescent, analyzing recurrence, testicular growth and complications. Methods A literature search on PubMed and Cochrane Database was conducted with regard to management of varicocele in adolescent population. Twenty two English language studies that compared outcome of different minimally invasive treatments or outcome of minimally invasive and traditional surgical treatments for adolescent diagnosed with varicocele were included. Results Intraoperative complications of minimally invasive approaches occur in early cases, but in pediatric urology these procedures would become more efficient with experience and these approaches continue to increase in number. Postoperative hydrocele is the most postoperative compliance of Palom technique, and reports have shown a wide range of variability for his incidence, depending on the technique used for surgical treatment. Literature showed an increase of testicular volume for real growth of testis after surgery, and an intratesticular improvement in sperm quality after minimally invasive approach. In laparoscopic approach reports have showed very low recurrence because allows better vision of collateral veins, and a lymphatic sparing technique permit to identify lymphatic vessels in 100% of cases. Conclusions The literature has shown that laparoscopic varicocelectomy is the surgical approach most commonly reported in adolescent patients, and that its use is increasing for better

  6. Essential fatty acid deficiency in surgical patients.

    PubMed Central

    O'Neill, J A; Caldwell, M D; Meng, H C

    1977-01-01

    Parenteral nutrition may protect patients unable to eat from malnutrition almost indefinitely. If fat is not also given EFAD will occur. This outlines a prospective study of 28 surgical patients on total intravenous fat-free nutrition to determine the developmental course of EFAD and the response to therapy. Twenty-eight patients ranging from newborn to 66 years receiving parenteral nutrition without fat had regular determinations of the composition of total plasma fatty acids and the triene/tetraene ratio using gas liquid chromatography. Physical signs of EFAD were looked for also. Patients found to have evidence of EFAD were treated with 10% Intralipid. Topical safflower oil was used in three infants. Total plasma fatty acid composition was restudied following therapy. In general, infants on fat-free intravenous nutrition developed biochemical EFAD within two weeks, but dermatitis took longer to become evident. Older individuals took over four weeks to develop a diagnostic triene/tetraene ratio (greater than 0.4; range 0.4 to 3.75). Therapeutic correction of biochemical EFAD took 7 to 10 days but dermatitis took longer to correct. Cutaneous application of safflower oil alleviated the cutaneous manifestations but did not correct the triene/tetraene ratio of total plasma fatty acids. These studies indicate that surgical patients who are unable to eat for two to four weeks, depending upon age and expected fat stores, should receive fat as a part of their intravenous regimen. Images Fig. 7. PMID:404973

  7. Feasibility of Electronic Nicotine Delivery Systems in Surgical Patients

    PubMed Central

    Nolan, Margaret; Leischow, Scott; Croghan, Ivana; Kadimpati, Sandeep; Hanson, Andrew; Schroeder, Darrell

    2016-01-01

    Abstract Introduction: Cigarette smoking is a known risk factor for postoperative complications. Quitting or cutting down on cigarettes around the time of surgery may reduce these risks. This study aimed to determine the feasibility of using electronic nicotine delivery systems (ENDS) to help patients achieve this goal, regardless of their intent to attempt long-term abstinence. Methods: An open-label observational study was performed of cigarette smoking adults scheduled for elective surgery at Mayo Clinic Rochester and seen in the pre-operative evaluation clinic between December 2014 and June 2015. Subjects were given a supply of ENDS to use prior to and 2 weeks after surgery. They were encouraged to use them whenever they craved a cigarette. Daily use of ENDS was recorded, and patients were asked about smoking behavior and ENDS use at baseline, 14 days and 30 days. Results: Of the 105 patients approached, 80 (76%) agreed to participate; five of these were later excluded. Among the 75, 67 (87%) tried ENDS during the study period. At 30-day follow-up, 34 (51%) who had used ENDS planned to continue using them. Average cigarette consumption decreased from 15.6 per person/d to 7.6 over the study period ( P < .001). At 30 days, 11/67 (17%) reported abstinence from cigarettes. Conclusion: ENDS use is feasible in adult smokers scheduled for elective surgery and is associated with a reduction in perioperative cigarette consumption. These results support further exploration of ENDS as a means to help surgical patients reduce or eliminate their cigarette consumption around the time of surgery. Implications: Smoking in the perioperative period increases patients’ risk for surgical complications and healing difficulties, but new strategies are needed to help patients quit or cut down during this stressful time. These pilot data suggest that ENDS use is feasible and well-accepted in surgical patients, and worthy of exploration as a harm reduction strategy in these patients

  8. Evaluation and Enhancement of Calibration in the American College of Surgeons NSQIP Surgical Risk Calculator.

    PubMed

    Liu, Yaoming; Cohen, Mark E; Hall, Bruce L; Ko, Clifford Y; Bilimoria, Karl Y

    2016-08-01

    The American College of Surgeon (ACS) NSQIP Surgical Risk Calculator has been widely adopted as a decision aid and informed consent tool by surgeons and patients. Previous evaluations showed excellent discrimination and combined discrimination and calibration, but model calibration alone, and potential benefits of recalibration, were not explored. Because lack of calibration can lead to systematic errors in assessing surgical risk, our objective was to assess calibration and determine whether spline-based adjustments could improve it. We evaluated Surgical Risk Calculator model calibration, as well as discrimination, for each of 11 outcomes modeled from nearly 3 million patients (2010 to 2014). Using independent random subsets of data, we evaluated model performance for the Development (60% of records), Validation (20%), and Test (20%) datasets, where prediction equations from the Development dataset were recalibrated using restricted cubic splines estimated from the Validation dataset. We also evaluated performance on data subsets composed of higher-risk operations. The nonrecalibrated Surgical Risk Calculator performed well, but there was a slight tendency for predicted risk to be overestimated for lowest- and highest-risk patients and underestimated for moderate-risk patients. After recalibration, this distortion was eliminated, and p values for miscalibration were most often nonsignificant. Calibration was also excellent for subsets of higher-risk operations, though observed calibration was reduced due to instability associated with smaller sample sizes. Performance of NSQIP Surgical Risk Calculator models was shown to be excellent and improved with recalibration. Surgeons and patients can rely on the calculator to provide accurate estimates of surgical risk. Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

  9. Management of Postoperative Fever in Adult Cardiac Surgical Patients.

    PubMed

    O'Mara, Susan K

    Postoperative fever after cardiac surgery is a common occurrence. Most fevers are benign and self-limiting resulting from inflammation caused by surgical trauma and blood contact with cardiopulmonary bypass circuit resulting in the release of cytokines. Only a small percentage of time is postoperative fever due to an infection complicating surgery. The presence of fever frequently triggers a battery of diagnostic tests that are costly, could expose the patient to unnecessary risks, and can produce misleading or inconclusive results. It is therefore important that fever be evaluated in a systematic, prudent, clinically appropriate, and cost-effective manner. This article focuses on the current evidence regarding pathophysiology, incidence, causes, evaluation, and management of fever in postoperative adult cardiac surgical patients.

  10. Surgical complications associated with robotic urologic procedures in elderly patients.

    PubMed

    Cusano, Antonio; Haddock, Peter; Staff, Ilene; Jackson, Max; Abarzua-Cabezas, Fernando; Dorin, Ryan; Meraney, Anoop; Wagner, Joseph; Shichman, Steven; Kesler, Stuart

    2015-02-01

    Urologic malignancies are often diagnosed at an older age, and are increasingly managed utilizing robotic-assisted surgical techniques. As such, we assessed and compared peri-postoperative complication rates following robotic urologic surgery in elderly and younger patients. A retrospective analysis of IRB-approved databases and electronic medical records identified patients who underwent robotic-assisted urologic surgery between December 2003-September 2013. Patients were grouped according to surgical procedure (partial nephrectomy, radical cystectomy, radical prostatectomy) and age at surgery (≤ 74 or ≥ 75 years old). Associations between age, comorbidities, Charlson comorbidity index (CCI), and patient outcomes were evaluated within each surgery type. 97.5% and 2.5% of patients were ≤ 74 or ≥ 75 years old, respectively. Cystectomies, partial nephrectomies and prostatectomies accounted for 3.5%, 9.5% and 87.1% of surgeries, respectively. Within cystectomy, nephrectomy and prostatectomy groups, 24.4%, 12.5% and 0.6% patients were ≥ 75 years old. Within each surgical type, elderly patients had significantly elevated CCI scores. Length of stay was significantly prolonged in elderly patients undergoing partial nephrectomy or prostatectomy. In elderly cystectomy, partial nephrectomy and prostatectomy patients, 36.7%, 14.3% and 5.9% suffered ≥ 1 Clavien grade 3-5 complication, respectively. Major complications were not significantly different between age groups. A qualitatively similar pattern was observed regarding Clavien grade 1-2 complications. The risks of robotic-assisted urologic surgery in elderly patients are not significantly elevated compared to younger patients.

  11. Herbal medications for surgical patients: a systematic review protocol.

    PubMed

    Arruda, Ana Paula Nappi; Ayala, Ana Patricia; Lopes, Luciane C; Bergamaschi, Cristiane C; Guimarães, Caio; Grossi, Mariana Del; Righesso, Leonardo A R; Agarwal, Arnav; El Dib, Regina

    2017-07-26

    Postoperative nausea and vomiting (PONV) affect approximately 80% of surgical patients and is associated with increased length of hospital stay and systemic costs. Preoperative and postoperative pain, anxiety and depression are also commonly reported. Recent evidence regarding their safety and effectiveness has not been synthesised. The aim of this systematic review is to evaluate the efficacy and safety of herbal medications for the treatment and prevention of anxiety, depression, pain and PONV in patients undergoing laparoscopic, obstetrical/gynaecological and cardiovascular surgical procedures. The following electronic databases will be searched up to 1 October 2016 without language or publication status restrictions: CENTRAL, MEDLINE, EMBASE, CINAHL, Web of Science and LILACS. Randomised clinical trials enrolling adult surgical patients undergoing laparoscopic, obstetrical/gynaecological and cardiovascular surgeries and managed with herbal medication versus a control group (placebo, no intervention or active control) prophylactically or therapeutically will be considered eligible. Outcomes of interest will include the following: anxiety, depression, pain, nausea and vomiting. A team of reviewers will complete title and abstract screening and full-text screening for identified hits independently and in duplicate. Data extraction, risk of bias assessments and evaluation of the overall quality of evidence for each relevant outcome reported will be conducted independently and in duplicate using the Grading of Recommendations Assessment Development and Evaluation classification system. Dichotomous data will be summarised as risk ratios; continuous data will be summarised as standard average differences with 95% CIs. This is one of the first efforts to systematically summarise existing evidence evaluating the use of herbal medications in laparoscopic, obstetrical/gynaecological and cardiovascular surgical patients. The findings of this review will be disseminated

  12. Risk Factors for Surgical Site Infection After Cholecystectomy

    PubMed Central

    Nickel, Katelin B.; Wallace, Anna E.; Mines, Daniel; Tian, Fang; Symons, William J.; Fraser, Victoria J.; Olsen, Margaret A.

    2017-01-01

    Abstract Background. There are limited data on risk factors for surgical site infection (SSI) after open or laparoscopic cholecystectomy. Methods. A retrospective cohort of commercially insured persons aged 18–64 years was assembled using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure or Current Procedural Terminology, 4th edition codes for cholecystectomy from December 31, 2004 to December 31, 2010. Complex procedures and patients (eg, cancer, end-stage renal disease) and procedures with pre-existing infection were excluded. Surgical site infections within 90 days after cholecystectomy were identified by ICD-9-CM diagnosis codes. A Cox proportional hazards model was used to identify independent risk factors for SSI. Results. Surgical site infections were identified after 472 of 66566 (0.71%) cholecystectomies; incidence was higher after open (n = 51, 4.93%) versus laparoscopic procedures (n = 421, 0.64%; P < .001). Independent risk factors for SSI included male gender, preoperative chronic anemia, diabetes, drug abuse, malnutrition/weight loss, obesity, smoking-related diseases, previous Staphylococcus aureus infection, laparoscopic approach with acute cholecystitis/obstruction (hazards ratio [HR], 1.58; 95% confidence interval [CI], 1.27–1.96), open approach with (HR, 4.29; 95% CI, 2.45–7.52) or without acute cholecystitis/obstruction (HR, 4.04; 95% CI, 1.96–8.34), conversion to open approach with (HR, 4.71; 95% CI, 2.74–8.10) or without acute cholecystitis/obstruction (HR, 7.11; 95% CI, 3.87–13.08), bile duct exploration, postoperative chronic anemia, and postoperative pneumonia or urinary tract infection. Conclusions. Acute cholecystitis or obstruction was associated with significantly increased risk of SSI with laparoscopic but not open cholecystectomy. The risk of SSI was similar for planned open and converted procedures. These findings suggest that stratification by operative factors is

  13. Effect of reversal of neuromuscular blockade with sugammadex versus usual care on bleeding risk in a randomized study of surgical patients.

    PubMed

    Rahe-Meyer, Niels; Fennema, Hein; Schulman, Sam; Klimscha, Walter; Przemeck, Michael; Blobner, Manfred; Wulf, Hinnerk; Speek, Marcel; McCrary Sisk, Christine; Williams-Herman, Debora; Woo, Tiffany; Szegedi, Armin

    2014-11-01

    Previous studies show a prolongation of activated partial thromboplastin time and prothrombin time in healthy volunteers after treatment with sugammadex. The authors investigated the effect of sugammadex on postsurgical bleeding and coagulation variables. This randomized, double-blind trial enrolled patients receiving thromboprophylaxis and undergoing hip or knee joint replacement or hip fracture surgery. Patients received sugammadex 4 mg/kg or usual care (neostigmine or spontaneous recovery) for reversal of rocuronium- or vecuronium-induced neuromuscular blockade. The Cochran-Mantel-Haenszel method, stratified by thromboprophylaxis and renal status, was used to estimate relative risk and 95% confidence interval (CI) of bleeding events with sugammadex versus usual care. Safety was further evaluated by prespecified endpoints and adverse event reporting. Of 1,198 patients randomized, 1,184 were treated (sugammadex n = 596, usual care n = 588). Bleeding events within 24 h (classified by an independent, blinded Adjudication Committee) were reported in 17 (2.9%) sugammadex and 24 (4.1%) usual care patients (relative risk [95% CI], 0.70 [0.38 to 1.29]). Compared with usual care, increases of 5.5% in activated partial thromboplastin time (P < 0.001) and 3.0% in prothrombin time (P < 0.001) from baseline with sugammadex occurred 10 min after administration and resolved within 60 min. There were no significant differences between sugammadex and usual care for other blood loss measures (transfusion, 24-h drain volume, drop in hemoglobin, and anemia), or risk of venous thromboembolism, and no cases of anaphylaxis. Sugammadex produced limited, transient (<1 h) increases in activated partial thromboplastin time and prothrombin time but was not associated with increased risk of bleeding versus usual care.

  14. Surgical treatment for infective endocarditis in elderly patients.

    PubMed

    Ramírez-Duque, N; García-Cabrera, E; Ivanova-Georgieva, R; Noureddine, M; Lomas, J M; Hidalgo-Tenorio, C; Plata, A; Gálvez-Acebal, J; Ruíz-Morales, J; de la Torre-Lima, J; Reguera, J M; Martínez-Marcos, F J; de Alarcón, A

    2011-08-01

    We evaluate the clinical, echographic and prognostic characteristics of infective endocarditis (IE) in a large population of elderly patients, and the results of surgical approach. Multicentric, prospective, observational cohort study with 961 consecutive left-sided IE: 356 patients aged ≥65 years were compared with 605 younger. Indications for cardiac surgery, potential surgical risk, time and outcome, were compared. Hospital-acquired endocarditis, comorbidity, renal failure and septic shock were more frequent in elderly, but embolisms were less. Intracardiac destruction and ventricular failure were similar in both groups, but significantly fewer elderly patients underwent cardiac surgery (36% vs 51%; p < 0.01), and this group showed a worse outcome (43.2% of mortality vs 27% in younger; p < 0.01), resulting age as an independent predictor of mortality (OR: 1.02 CI95%: 1.01-1.03). Compared with medical treatment, surgery showed lower percentages of mortality compared with medical treatment (23.3% vs 31.3%; p = 0.03) in younger group, but a high mortality was observed with both procedures (47.6% vs 40.3%; p = 0.1) in the elderly. Although similar percentages of heart failure and intracardiac complications, increasing age is associated with higher mortality in IE. Lower rates of surgical treatment and a worse outcome after operation are common features in elderly patients. Copyright © 2011 The British Infection Association. Published by Elsevier Ltd. All rights reserved.

  15. Oral potassium supplementation in surgical patients.

    PubMed

    Hainsworth, Alison J; Gatenby, Piers A

    2008-08-01

    Hospital inpatients are frequently hypokalaemic. Low plasma potassium levels may cause life threatening complications, such as cardiac arrhythmias. Potassium supplementation may be administered parenterally or enterally. Oral potassium supplements have been associated with oesophageal ulceration, strictures and gastritis. An alternative to potassium salt tablets or solution is dietary modification with potassium rich food stuffs, which has been proven to be a safe and effective method for potassium supplementation. The potassium content of one medium banana is equivalent to a 12 mmol potassium salt tablet. Potassium supplementation by dietary modification has been shown to be equally efficacious to oral potassium salt supplementation and is preferred by the majority of patients. Subsequently, it is our practice to replace potassium using dietary modification, particularly in surgical patients having undergone oesophagogastrectomy or in those with peptic ulcer disease.

  16. Remodeling characteristics and collagen distribution in synthetic mesh materials explanted from human subjects after abdominal wall reconstruction: an analysis of remodeling characteristics by patient risk factors and surgical site classifications

    PubMed Central

    Cavallo, Jaime A.; Roma, Andres A.; Jasielec, Mateusz S.; Ousley, Jenny; Creamer, Jennifer; Pichert, Matthew D.; Baalman, Sara; Frisella, Margaret M.; Matthews, Brent D.

    2014-01-01

    Background The purpose of this study was to evaluate the associations between patient characteristics or surgical site classifications and the histologic remodeling scores of synthetic meshes biopsied from their abdominal wall repair sites in the first attempt to generate a multivariable risk prediction model of non-constructive remodeling. Methods Biopsies of the synthetic meshes were obtained from the abdominal wall repair sites of 51 patients during a subsequent abdominal re-exploration. Biopsies were stained with hematoxylin and eosin, and evaluated according to a semi-quantitative scoring system for remodeling characteristics (cell infiltration, cell types, extracellular matrix deposition, inflammation, fibrous encapsulation, and neovascularization) and a mean composite score (CR). Biopsies were also stained with Sirius Red and Fast Green, and analyzed to determine the collagen I:III ratio. Based on univariate analyses between subject clinical characteristics or surgical site classification and the histologic remodeling scores, cohort variables were selected for multivariable regression models using a threshold p value of ≤0.200. Results The model selection process for the extracellular matrix score yielded two variables: subject age at time of mesh implantation, and mesh classification (c-statistic = 0.842). For CR score, the model selection process yielded two variables: subject age at time of mesh implantation and mesh classification (r2 = 0.464). The model selection process for the collagen III area yielded a model with two variables: subject body mass index at time of mesh explantation and pack-year history (r2 = 0.244). Conclusion Host characteristics and surgical site assessments may predict degree of remodeling for synthetic meshes used to reinforce abdominal wall repair sites. These preliminary results constitute the first steps in generating a risk prediction model that predicts the patients and clinical circumstances for which non

  17. [Nutritional support response in critically ill patients; differences between medical and surgical patients].

    PubMed

    Zamora Elson, M; Serón Arbeloa, C; Labarta Monzón, L; Garrido Ramírez de Arellano, I; Lander Azcona, A; Marquina Lacueva, M I; López Claver, J C; Escós Orta, J

    2012-01-01

    To assess the nutritional response of a group of critically ill patients, as well as the differences in the response to nutritional support between medical and surgical patients. One-year long retrospective study including critically ill patients on artificial nutrition for 7 days. Throughout the first week, three nutritional biochemical controls were done that included albumin, prealbumin, transferrin, cholesterol, and electrolytes. Other data gathered were: nutritional risk index, age, gender, weight, height, APACHE, delay of onset of nutritional support, access route, predicted and real caloric intake, medical or surgical patient, hospital stay, duration of the central venous catheter, urinary tube, and/or mechanical ventilation, incidence and density of incidence of nosocomial infections. Sixty-three patients were studied, 30 (47%) medical and 33 (53%) surgical/trauma patients, with a usage of EN higher among medical patients (16/30, 53% vs. 5/33, 15%), PN higher among surgical patients (25/33, 76%), and mixed nutrition similar in both groups (5 medical and 3 surgical patients) (p = 0.001). There were no differences between medical and surgical patients regarding: both predicted and real caloric and nitrogenous intake, APACHE, delay of onset of nutrition, phosphorus, magnesium or glucose levels, mortality and incidence of nosocomial infections. There were no differences either in hospital stay or use of mechanical ventilation, although these tended to be lower in surgical patients. The baseline biochemical parameters did not show differences between both groups, although they were worse among surgical patients. These patients presented during the study period steady albumin levels with improvement in the remaining parameters, whereas medical patients showed a decrease in albumin and transferrin levels, steady prealbumin levels, and slightly improvement in cholesterol levels. We have observed higher usage of PN among surgical patients, which showed worse

  18. Management of Early Stage, High-Risk Endometrial Carcinoma: Preoperative and Surgical Considerations

    PubMed Central

    Pettigrew, Gaetan

    2013-01-01

    Endometrial cancer is the most common gynecologic malignancy in the developed world. Most cases are diagnosed at an early stage and have low-grade histology, portending an overall excellent prognosis. There exists a subgroup of patients with early, high-risk disease, whose management remains controversial, as current data is clouded by inclusion of early stage tumors with different high-risk features for recurrence, unstandardized protocols for surgical staging, and an evolving staging system by which we are grouping these patients. Here, we present preoperative and intraoperative considerations that should be taken into account when planning surgical management for this population of patients. PMID:23878545

  19. Beyond adding years to life: health-related quality-of-life and functional outcomes in patients with severe aortic valve stenosis at high surgical risk undergoing transcatheter aortic valve replacement.

    PubMed

    Deutsch, Marcus-Andre; Bleiziffer, Sabine; Elhmidi, Yacine; Piazza, Nicolo; Voss, Bernhard; Lange, Ruediger; Krane, Markus

    2013-11-01

    Aortic valve stenosis (AVS) is the most frequent acquired valvular heart disease in western industrialized countries and its prevalence considerably increases with age. Once becoming symptomatic severe AVS has a very poor prognosis. Progressive and rapid symptom deterioration leads to an impairment of functional status and compromised healthrelated quality-of-life (HrQoL) simultaneously. Until recently, surgical aortic valve replacement (SAVR) has been the only effective treatment option for improving symptoms and prolonging survival. Transcatheter aortic valve replacement (TAVR) emerged as an alternative treatment modality for those patients with severe symptomatic AVS in whom the risk for SAVR is considered prohibitive or too high. TAVR has gained clinical acceptance with almost startling rapidity and has even quickly become the standard of care for the treatment of appropriately selected individuals with inoperable AVS during recent years. Typically, patients currently referred for and treated by TAVR are elderly with a concomitant variable spectrum of multiple comorbidities, disabilities and limited life expectancy. Beyond mortality and morbidity, the assessment of HrQoL is of paramount importance not only to guide patient-centered clinical decision-making but also to judge this new treatment modality. As per current evidence, TAVR significantly improves HrQoL in high-surgical risk patients with severe AVS with sustained effects up to two years when compared with optimal medical care and demonstrates comparable benefits relative to SAVR. Along with a provision of a detailed overview of the current literature regarding functional and HrQoL outcomes in patients undergoing TAVR, this review article addresses specific considerations of the HrQoL aspect in the elderly patient and finally outlines the implications of HrQoL outcomes for medico-economic deliberations.

  20. Abdominal Aortic Aneurysms in “High-Risk” Surgical Patients

    PubMed Central

    Jordan, William D.; Alcocer, Francisco; Wirthlin, Douglas J.; Westfall, Andrew O.; Whitley, David

    2003-01-01

    Objective To evaluate the early results of endovascular grafting for high-risk surgical candidates in the treatment of abdominal aortic aneurysms (AAA). Summary Background Data Since the approval of endoluminal grafts for treatment of AAA, endovascular repair of AAA (EVAR) has expanded to include patients originally considered too ill for open AAA repair. However, some concern has been expressed regarding technical failure and the durability of endovascular grafts. Methods The University of Alabama at Birmingham (UAB) Computerized Vascular Registry identified all patients who underwent abdominal aneurysm repair between January 1, 2000, and June 12, 2002. Patients were stratified by type of repair (open AAA vs. EVAR) and were classified as low risk or high risk. Patients with at least one of the following classifications were classified as high risk: age more than 80 years, chronic renal failure (creatinine > 2.0), compromised cardiac function (diminished ventricular function or severe coronary artery disease), poor pulmonary function, reoperative aortic procedure, a “hostile” abdomen, or an emergency operation. Death, systemic complications, and length of stay were tabulated for each group. Results During this 28-month period, 404 patients underwent AAA repair at UAB. Eighteen patients (4.5%) died within 30 days of their repair or during the same hospitalization. Two hundred seventeen patients (53%) were classified as high risk. Two hundred fifty-nine patients (64%) underwent EVAR repair, and 130 (50%) of these were considered high-risk patients (including four emergency procedures). One hundred forty-five patients (36%) underwent open AAA repair, including 15 emergency operations. All deaths occurred in the high-risk group: 12 (8.3%) died after open AAA repair and 6 (2.3%) died after EVAR repair. Postoperative length of stay was shorter for EVAR repair compared to open AAA. Conclusions High-risk and low-risk patients can undergo EVAR repair with a lower rate

  1. Surgical correction of gynecomastia in thin patients.

    PubMed

    Cigna, Emanuele; Tarallo, Mauro; Fino, Pasquale; De Santo, Liliana; Scuderi, Nicolò

    2011-08-01

    Gynecomastia refers to a benign enlargement of the male breast. This article describes the authors' method of using power-assisted liposuction and gland removal through a subareolar incision for thin patients. Power-assisted liposuction is performed for removal of fatty breast tissue in the chest area to allow skin retraction. The subareolar incision is used to remove glandular tissue from a male subject considered to be within a normal weight range but who has bilateral grade 1 or 2 gynecomastia. Gynecomastia correction was successfully performed for all the patients. The average volume of aspirated fat breast was 100-200 ml on each side. Each breast had 5-80 g of breast tissue removed. At the 3-month, 6-month, and 1-year follow-up assessments, all the treated patients were satisfied with their aesthetic results. Liposuction has the advantages of reducing the fat tissue where necessary to allow skin retraction and of reducing the traces left by surgery. The combination of surgical excision and power-assisted lipoplasty also is a valid choice for the treatment of thin patients.

  2. A surgical approach in the management of mucormycosis in a trauma patient.

    PubMed

    Zahoor, B A; Piercey, J E; Wall, D R; Tetsworth, K D

    2016-11-01

    Mucormycosis as a consequence of trauma is a devastating complication; these infections are challenging to control, with a fatality rate approaching 96% in immunocompromised patients. We present a case where a proactive approach was successfully employed to treat mucormycosis following complex polytrauma. Aggressive repeated surgical debridement, in combination with appropriate antifungal therapy, proved successful in this instance. In our opinion, mucormycosis in trauma mandates an aggressive surgical approach. This prevents ascending dissemination of mucormycosis and certainly reduces the risk of patient mortality as a direct result. Anti-fungal therapy should be used secondarily as an adjunct together with surgical debridement, or as an alternative when surgical intervention is not feasible.

  3. Evaluation of the National Surgical Quality Improvement Program Universal Surgical Risk Calculator for a gynecologic oncology service.

    PubMed

    Szender, J Brian; Frederick, Peter J; Eng, Kevin H; Akers, Stacey N; Lele, Shashikant B; Odunsi, Kunle

    2015-03-01

    The National Surgical Quality Improvement Program is aimed at preventing perioperative complications. An online calculator was recently published, but the primary studies used limited gynecologic surgery data. The purpose of this study was to evaluate the performance of the National Surgical Quality Improvement Program Universal Surgical Risk Calculator (URC) on the patients of a gynecologic oncology service. We reviewed 628 consecutive surgeries performed by our gynecologic oncology service between July 2012 and June 2013. Demographic data including diagnosis and cancer stage, if applicable, were collected. Charts were reviewed to determine complication rates. Specific complications were as follows: death, pneumonia, cardiac complications, surgical site infection (SSI) or urinary tract infection, renal failure, or venous thromboembolic event. Data were compared with modeled outcomes using Brier scores and receiver operating characteristic curves. Significance was declared based on P < 0.05. The model accurately predicated death and venous thromboembolic event, with Brier scores of 0.004 and 0.003, respectively. Predicted risk was 50% greater than experienced for urinary tract infection; the experienced SSI and pneumonia rates were 43% and 36% greater than predicted. For any complication, the Brier score 0.023 indicates poor performance of the model. In this study of gynecologic surgeries, we could not verify the predictive value of the URC for cardiac complications, SSI, and pneumonia. One disadvantage of applying a URC to multiple subspecialties is that with some categories, complications are not accurately estimated. Our data demonstrate that some predicted risks reported by the calculator need to be interpreted with reservation.

  4. Acute suppurative parotitis: a dreadful complication in elderly surgical patients.

    PubMed

    Lampropoulos, Pavlos; Rizos, Spyros; Marinis, Athanasios

    2012-08-01

    Acute suppurative parotitis (ASP) is a severe infection seen particularly in elderly surgical patients. Factors that increase the risk of ASP include post-operative dehydration, debilitating conditions, and immunosuppressed states. Case report and literature review. An 82-year-old female patient was admitted because of paralytic ileus, dehydration, and poor oral hygiene, and was in distress. After two days of hospitalization, the patient developed a progressive painful swelling of her right parotid gland and fever up to 39.0°C. Computed tomography scanning showed an abscess in the parotid gland. Because of her progressive clinical deterioration, the patient underwent operative drainage of the abscess and removal of the necrotic material. Unfortunately, she suffered multiple organ dysfunction syndrome and died. Acute suppurative parotitis requires prompt aggressive treatment that nevertheless may fail.

  5. Can Image-Defined Risk Factors Predict Surgical Complications in Localized Neuroblastoma?

    PubMed

    Yoneda, Akihiro; Nishikawa, Masanori; Uehara, Shuichiro; Oue, Takaharu; Usui, Noriaki; Inoue, Masami; Fukuzawa, Masahiro; Okuyama, Hiroomi

    2016-02-01

    Image-defined risk factors (IDRFs) have been propounded for predicting the surgical risks associated with localized neuroblastoma (NB) since 2009. In 2011, a new guideline (NG) for assessing IDRFs was published. According to the NG, the situation in which "the tumor is only in contact with renal vessels," should be considered to be "IDRF-present." Previously, this situation was diagnosed as "IDRF absent." In this study, we evaluated the IDRFs in localized NB patients to clarify the predictive capability of IDRFs for surgical complications, as well as the usefulness of the NG. Materials and A total of 107 localized patients with NB were included in this study. The enhanced computed tomography and magnetic resonance images from the time of their diagnoses were evaluated by a single radiologist. We also analyzed the association of clinical factors, including the IDRFs (before and after applying the NG), with surgical complications. Of the 107 patients, 33 and 74 patients were diagnosed as IDRF-present (OP group), and IDRF-absent (ON group) before the NG, respectively. According to the NG, there were 76 and 31 patients who were classified as IDRF-present (NP group) and IDRF absent (NN group), respectively. Thus, 43 (40%) patients in the ON group were reassigned to the NP group after the NG. Surgical complications were observed in 17 of 82 patients who underwent surgical resection. Of the patients who underwent secondary operations, surgical complication rates were 55% in the OP group and 44% in the NP group. According to a univariate analysis, non-INSS 1, IDRFs before and after the NG and secondary operations were significantly associated with surgical complications. In a multivariate analysis, non-INSS 1 status and IDRFs after the NG were significantly associated with surgical complications. Georg Thieme Verlag KG Stuttgart · New York.

  6. Risk factors for acute surgical site infections after lumbar surgery: a retrospective study.

    PubMed

    Lai, Qi; Song, Quanwei; Guo, Runsheng; Bi, Haidi; Liu, Xuqiang; Yu, Xiaolong; Zhu, Jianghao; Dai, Min; Zhang, Bin

    2017-07-19

    Currently, many scholars are concerned about the treatment of postoperative infection; however, few have completed multivariate analyses to determine factors that contribute to the risk of infection. Therefore, we conducted a multivariate analysis of a retrospectively collected database to analyze the risk factors for acute surgical site infection following lumbar surgery, including fracture fixation, lumbar fusion, and minimally invasive lumbar surgery. We retrospectively reviewed data from patients who underwent lumbar surgery between 2014 and 2016, including lumbar fusion, internal fracture fixation, and minimally invasive surgery in our hospital's spinal surgery unit. Patient demographics, procedures, and wound infection rates were analyzed using descriptive statistics, and risk factors were analyzed using logistic regression analyses. Twenty-six patients (2.81%) experienced acute surgical site infection following lumbar surgery in our study. The patients' mean body mass index, smoking history, operative time, blood loss, draining time, and drainage volume in the acute surgical site infection group were significantly different from those in the non-acute surgical site infection group (p < 0.05). Additionally, diabetes mellitus, chronic obstructive pulmonary disease, osteoporosis, preoperative antibiotics, type of disease, and operative type in the acute surgical site infection group were significantly different than those in the non-acute surgical site infection group (p < 0.05). Using binary logistic regression analyses, body mass index, smoking, diabetes mellitus, osteoporosis, preoperative antibiotics, fracture, operative type, operative time, blood loss, and drainage time were independent predictors of acute surgical site infection following lumbar surgery. In order to reduce the risk of infection following lumbar surgery, patients should be evaluated for the risk factors noted above.

  7. Educational levels of hospital nurses and surgical patient mortality.

    PubMed

    Aiken, Linda H; Clarke, Sean P; Cheung, Robyn B; Sloane, Douglas M; Silber, Jeffrey H

    2003-09-24

    Growing evidence suggests that nurse staffing affects the quality of care in hospitals, but little is known about whether the educational composition of registered nurses (RNs) in hospitals is related to patient outcomes. To examine whether the proportion of hospital RNs educated at the baccalaureate level or higher is associated with risk-adjusted mortality and failure to rescue (deaths in surgical patients with serious complications). Cross-sectional analyses of outcomes data for 232 342 general, orthopedic, and vascular surgery patients discharged from 168 nonfederal adult general Pennsylvania hospitals between April 1, 1998, and November 30, 1999, linked to administrative and survey data providing information on educational composition, staffing, and other characteristics. Risk-adjusted patient mortality and failure to rescue within 30 days of admission associated with nurse educational level. The proportion of hospital RNs holding a bachelor's degree or higher ranged from 0% to 77% across the hospitals. After adjusting for patient characteristics and hospital structural characteristics (size, teaching status, level of technology), as well as for nurse staffing, nurse experience, and whether the patient's surgeon was board certified, a 10% increase in the proportion of nurses holding a bachelor's degree was associated with a 5% decrease in both the likelihood of patients dying within 30 days of admission and the odds of failure to rescue (odds ratio, 0.95; 95% confidence interval, 0.91-0.99 in both cases). In hospitals with higher proportions of nurses educated at the baccalaureate level or higher, surgical patients experienced lower mortality and failure-to-rescue rates.

  8. Generating patient-specific pulmonary vascular models for surgical planning

    NASA Astrophysics Data System (ADS)

    Murff, Daniel; Co-Vu, Jennifer; O'Dell, Walter G.

    2015-03-01

    Each year in the U.S., 7.4 million surgical procedures involving the major vessels are performed. Many of our patients require multiple surgeries, and many of the procedures include "surgical exploration". Procedures of this kind come with a significant amount of risk, carrying up to a 17.4% predicted mortality rate. This is especially concerning for our target population of pediatric patients with congenital abnormalities of the heart and major pulmonary vessels. This paper offers a novel approach to surgical planning which includes studying virtual and physical models of pulmonary vasculature of an individual patient before operation obtained from conventional 3D X-ray computed tomography (CT) scans of the chest. These models would provide clinicians with a non-invasive, intricately detailed representation of patient anatomy, and could reduce the need for invasive planning procedures such as exploratory surgery. Researchers involved in the AirPROM project have already demonstrated the utility of virtual and physical models in treatment planning of the airways of the chest. Clinicians have acknowledged the potential benefit from such a technology. A method for creating patient-derived physical models is demonstrated on pulmonary vasculature extracted from a CT scan with contrast of an adult human. Using a modified version of the NIH ImageJ program, a series of image processing functions are used to extract and mathematically reconstruct the vasculature tree structures of interest. An auto-generated STL file is sent to a 3D printer to create a physical model of the major pulmonary vasculature generated from 3D CT scans of patients.

  9. Feasibility of Electronic Nicotine Delivery Systems in Surgical Patients.

    PubMed

    Nolan, Margaret; Leischow, Scott; Croghan, Ivana; Kadimpati, Sandeep; Hanson, Andrew; Schroeder, Darrell; Warner, David O

    2016-08-01

    Cigarette smoking is a known risk factor for postoperative complications. Quitting or cutting down on cigarettes around the time of surgery may reduce these risks. This study aimed to determine the feasibility of using electronic nicotine delivery systems (ENDS) to help patients achieve this goal, regardless of their intent to attempt long-term abstinence. An open-label observational study was performed of cigarette smoking adults scheduled for elective surgery at Mayo Clinic Rochester and seen in the pre-operative evaluation clinic between December 2014 and June 2015. Subjects were given a supply of ENDS to use prior to and 2 weeks after surgery. They were encouraged to use them whenever they craved a cigarette. Daily use of ENDS was recorded, and patients were asked about smoking behavior and ENDS use at baseline, 14 days and 30 days. Of the 105 patients approached, 80 (76%) agreed to participate; five of these were later excluded. Among the 75, 67 (87%) tried ENDS during the study period. At 30-day follow-up, 34 (51%) who had used ENDS planned to continue using them. Average cigarette consumption decreased from 15.6 per person/d to 7.6 over the study period (P < .001). At 30 days, 11/67 (17%) reported abstinence from cigarettes. ENDS use is feasible in adult smokers scheduled for elective surgery and is associated with a reduction in perioperative cigarette consumption. These results support further exploration of ENDS as a means to help surgical patients reduce or eliminate their cigarette consumption around the time of surgery. Smoking in the perioperative period increases patients' risk for surgical complications and healing difficulties, but new strategies are needed to help patients quit or cut down during this stressful time. These pilot data suggest that ENDS use is feasible and well-accepted in surgical patients, and worthy of exploration as a harm reduction strategy in these patients. © The Author 2016. Published by Oxford University Press on behalf of

  10. Perioperative patient safety indicators and hospital surgical volumes.

    PubMed

    Kitazawa, Takefumi; Matsumoto, Kunichika; Fujita, Shigeru; Yoshida, Ai; Iida, Shuhei; Nishizawa, Hirotoshi; Hasegawa, Tomonori

    2014-02-28

    Since the late 1990s, patient safety has been an important policy issue in developed countries. To evaluate the effectiveness of the activities of patient safety, it is necessary to quantitatively assess the incidence of adverse events by types of failure mode using tangible data. The purpose of this study is to calculate patient safety indicators (PSIs) using the Japanese Diagnosis Procedure Combination/per-diem payment system (DPC/PDPS) reimbursement data and to elucidate the relationship between perioperative PSIs and hospital surgical volume. DPC/PDPS data of the Medi-Target project managed by the All Japan Hospital Association were used. An observational study was conducted where PSIs were calculated using an algorithm proposed by the US Agency for Healthcare Research and Quality. We analyzed data of 1,383,872 patients from 188 hospitals who were discharged from January 2008 to December 2010. Among 20 provider level PSIs, four PSIs (three perioperative PSIs and decubitus ulcer) and mortality rates of postoperative patients were related to surgical volume. Low-volume hospitals (less than 33rd percentiles surgical volume per month) had higher mortality rates (5.7%, 95% confidence interval (CI), 3.9% to 7.4%) than mid- (2.9%, 95% CI, 2.6% to 3.3%) or high-volume hospitals (2.7%, 95% CI, 2.5% to 2.9%). Low-volume hospitals had more deaths among surgical inpatients with serious treatable complications (38.5%, 95% CI, 33.7% to 43.2%) than high-volume hospitals (21.4%, 95% CI, 19.0% to 23.9%). Also Low-volume hospitals had lower proportion of difficult surgeries (54.9%, 95% CI, 50.1% to 59.8%) compared with high-volume hospitals (63.4%, 95% CI, 62.3% to 64.6%). In low-volume hospitals, limited experience may have led to insufficient care for postoperative complications. We demonstrated that PSIs can be calculated using DPC/PDPS data and perioperative PSIs were related to hospital surgical volume. Further investigations focusing on identifying risk factors for poor

  11. Development and Evaluation of the American College of Surgeons NSQIP Pediatric Surgical Risk Calculator.

    PubMed

    Kraemer, Kari; Cohen, Mark E; Liu, Yaoming; Barnhart, Douglas C; Rangel, Shawn J; Saito, Jacqueline M; Bilimoria, Karl Y; Ko, Clifford Y; Hall, Bruce L

    2016-11-01

    There is an increased desire among patients and families to be involved in the surgical decision-making process. A surgeon's ability to provide patients and families with patient-specific estimates of postoperative complications is critical for shared decision making and informed consent. Surgeons can also use patient-specific risk estimates to decide whether or not to operate and what options to offer patients. Our objective was to develop and evaluate a publicly available risk estimation tool that would cover many common pediatric surgical procedures across all specialties. American College of Surgeons NSQIP Pediatric standardized data from 67 hospitals were used to develop a risk estimation tool. Surgeons enter 18 preoperative variables (demographics, comorbidities, procedure) that are used in a logistic regression model to predict 9 postoperative outcomes. A surgeon adjustment score is also incorporated to adjust for any additional risk not accounted for in the 18 risk factors. A pediatric surgical risk calculator was developed based on 181,353 cases covering 382 CPT codes across all specialties. It had excellent discrimination for mortality (c-statistic = 0.98), morbidity (c-statistic = 0.81), and 7 additional complications (c-statistic > 0.77). The Hosmer-Lemeshow statistic and graphic representations also showed excellent calibration. The ACS NSQIP Pediatric Surgical Risk Calculator was developed using standardized and audited multi-institutional data from the ACS NSQIP Pediatric, and it provides empirically derived, patient-specific postoperative risks. It can be used as a tool in the shared decision-making process by providing clinicians, families, and patients with useful information for many of the most common operations performed on pediatric patients in the US. Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

  12. Derivation and Validation of the Surgical Site Infections Risk Model Using Health Administrative Data.

    PubMed

    van Walraven, Carl; Jackson, Timothy D; Daneman, Nick

    2016-04-01

    OBJECTIVE Surgical site infections (SSIs) are common hospital-acquired infections. Tracking SSIs is important to monitor their incidence, and this process requires primary data collection. In this study, we derived and validated a method using health administrative data to predict the probability that a person who had surgery would develop an SSI within 30 days. METHODS All patients enrolled in the National Surgical Quality Improvement Program (NSQIP) from 2 sites were linked to population-based administrative datasets in Ontario, Canada. We derived a multivariate model, stratified by surgical specialty, to determine the independent association of SSI status with patient and hospitalization covariates as well as physician claim codes. This SSI risk model was validated in 2 cohorts. RESULTS The derivation cohort included 5,359 patients with a 30-day SSI incidence of 6.0% (n=118). The SSI risk model predicted the probability that a person had an SSI based on 7 covariates: index hospitalization diagnostic score; physician claims score; emergency visit diagnostic score; operation duration; surgical service; and potential SSI codes. More than 90% of patients had predicted SSI risks lower than 10%. In the derivation group, model discrimination and calibration was excellent (C statistic, 0.912; Hosmer-Lemeshow [H-L] statistic, P=.47). In the 2 validation groups, performance decreased slightly (C statistics, 0.853 and 0.812; H-L statistics, 26.4 [P=.0009] and 8.0 [P=.42]), but low-risk patients were accurately identified. CONCLUSION Health administrative data can effectively identify postoperative patients with a very low risk of surgical site infection within 30 days of their procedure. Records of higher-risk patients can be reviewed to confirm SSI status.

  13. From policy to patients and back: surgical treatment decision making for patients with breast cancer.

    PubMed

    Katz, Steven J; Hawley, Sarah T

    2007-01-01

    Persistent use of mastectomy for breast cancer has motivated concerns about overtreatment by surgeons and lack of patient involvement in decisions. However, recent studies suggest that patients perceive substantial involvement and that some patients prefer more invasive surgery, while other research suggests that surgical treatment choices might be poorly informed. Decision-making quality can be improved by increasing patients' knowledge about treatments' risks and benefits and by optimizing their involvement. The mastectomy story underscores the limitations of utilization measures as quality indicators. Strategies to improve patient outcomes should focus on tools to improve the quality of decision making and innovations in multispecialty practice.

  14. Transforming Patient Value: Comparison of Hospital, Surgical, and General Surgery Patients.

    PubMed

    Pitt, Henry A; Tsypenyuk, Ella; Freeman, Susan L; Carson, Steven R; Shinefeld, Jonathan A; Hinkle, Sally M; Powers, Benjamin D; Goldberg, Amy J; DiSesa, Verdi J; Kaiser, Larry R

    2016-04-01

    Patient value (V) is enhanced when quality (Q) is increased and cost (C) is diminished (V = Q/C). However, calculating value has been inhibited by a lack of risk-adjusted cost data. The aim of this analysis was to measure patient value before and after implementation of quality improvement and cost reduction programs. Multidisciplinary efforts to improve patient value were initiated at a safety-net hospital in 2012. Quality improvement focused on adoption of multiple best practices, and minimizing practice variation was the strategy to control cost. University HealthSystem Consortium (UHC) risk-adjusted quality (patient mortality + safety + satisfaction + effectiveness) and cost (length of stay + direct cost) data were used to calculate patient value over 3 fiscal years. Normalized ranks in the UHC Quality and Accountability Scorecard were used in the value equation. For all hospital patients, quality scores improved from 50.3 to 66.5, with most of the change occurring in decreased mortality. Similar trends were observed for all surgery patients (42.6 to 48.4) and for general surgery patients (30.9 to 64.6). For all hospital patients, cost scores improved from 71.0 to 2.9. Similar changes were noted for all surgical (71.6 to 27.1) and general surgery (85.7 to 23.0) patients. Therefore, value increased more than 30-fold for all patients, 3-fold for all surgical patients, and almost 8-fold for general surgery patients. Multidisciplinary quality and cost efforts resulted in significant improvements in value for all hospitalized patients as well as general surgery patients. Mortality improved the most in general surgery patients, and satisfaction was highest among surgical patients. Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

  15. TextWithSurgeryPatients - A Research Hypothesis in Enhancing Education and Physical Assessment for Abdominal Surgical Patients.

    PubMed

    Hansen, Margaret

    2016-01-01

    Medical surgical nurses may not have the time or resources to provide effective pre- and post-operative instructions for patients in today's healthcare system. And, making timely physical assessments following discharge from the hospital is not always straightforward. Therefore, the risk for readmission associated with post-surgical complications is a concern. At present, mobile healthcare technologies and patient care are precipitously evolving and may serve as a resource to enhance communication between the healthcare provider and patient. A mobile telephone text message (short message service [SMS]) intervention for abdominal surgical patients may foster effective education (communication) and timely self-reported physical assessment in the home environment hence preventing deleterious outcomes. The aim of this research proposal is to identify the feasibility of using a SMS intervention via smart phones to improve health outcomes via timely communication, reach large numbers of at-risk surgical patients and, establish and sustain uniform protocols in a cost-efficient manner.

  16. Patients Awaiting Surgical Repair for Large Abdominal Aortic Aneurysms Can Exercise at Moderate to Hard Intensities with a Low Risk of Adverse Events

    PubMed Central

    Weston, Matthew; Batterham, Alan M.; Tew, Garry A.; Kothmann, Elke; Kerr, Karen; Nawaz, Shah; Yates, David; Danjoux, Gerard

    2017-01-01

    power output increased 23% across the 4-week HIT intervention. One participant experienced an adverse event but were still able to complete their remaining exercise sessions. Conclusions: Despite an inconsistent and lower than prescribed intensity, it is possible to exercise this high-risk patient population at moderate to hard intensities with a low risk of adverse events. Clinical Trial Registration: http://www.isrctn.com/, registration number ISRCTN09433624. PMID:28119627

  17. The efficacy of mobile application use on recall of surgical risks in nasal bone fracture reduction surgery

    PubMed Central

    Kim, Choong Hyeon; Cheon, Ji Seon; Choi, Woo Young; Son, Kyung Min

    2018-01-01

    Background The number of surgical risks recalled by a patient after surgery can be used as a parameter for assessing how well the patient has understood the informed consent process. No study has investigated the usefulness of a self-developed mobile application in the traditional informed consent process in patients with a nasal bone fracture. This study aimed to investigate whether delivery of information, such as surgical risks, through a mobile application is more effective than delivery of information through only verbal means and a paper. Methods This prospective, randomized study included 60 patients with a nasal bone fracture. The experimental group (n=30) received preoperative explanation with the traditional informed consent process in addition to a mobile application, while the control group (n=30) received preoperative explanation with only the traditional informed consent process. Four weeks after surgery, the number of recalled surgical risks was compared for analysis. The following six surgical risks were explained: pain, bleeding, nasal deformity, numbness, nasal obstruction, and nasal cartilage necrosis. Results The mean number of recalled surgical risks among all patients was 1.58±0.56. The most frequently recalled surgical risk was nasal deformity in both groups. The mean number of recalled surgical risks was 1.72±0.52 in the experimental group and 1.49±0.57 in the control group. There was a significant association between mobile application use and the mean number of recalled surgical risks (p=0.047). Age, sex, and the level of education were not significantly associated with the mean number of recalled surgical risks. Conclusion This study found that a mobile application could contribute to the efficient delivery of information during the informed consent process. With further improvement, it could be used in other plastic surgeries and other surgeries, and such an application can potentially be used for explaining risks as well as

  18. The efficacy of mobile application use on recall of surgical risks in nasal bone fracture reduction surgery.

    PubMed

    Kim, Choong Hyeon; Cheon, Ji Seon; Choi, Woo Young; Son, Kyung Min

    2018-03-01

    The number of surgical risks recalled by a patient after surgery can be used as a parameter for assessing how well the patient has understood the informed consent process. No study has investigated the usefulness of a self-developed mobile application in the traditional informed consent process in patients with a nasal bone fracture. This study aimed to investigate whether delivery of information, such as surgical risks, through a mobile application is more effective than delivery of information through only verbal means and a paper. This prospective, randomized study included 60 patients with a nasal bone fracture. The experimental group (n=30) received preoperative explanation with the traditional informed consent process in addition to a mobile application, while the control group (n=30) received preoperative explanation with only the traditional informed consent process. Four weeks after surgery, the number of recalled surgical risks was compared for analysis. The following six surgical risks were explained: pain, bleeding, nasal deformity, numbness, nasal obstruction, and nasal cartilage necrosis. The mean number of recalled surgical risks among all patients was 1.58±0.56. The most frequently recalled surgical risk was nasal deformity in both groups. The mean number of recalled surgical risks was 1.72±0.52 in the experimental group and 1.49±0.57 in the control group. There was a significant association between mobile application use and the mean number of recalled surgical risks ( p =0.047). Age, sex, and the level of education were not significantly associated with the mean number of recalled surgical risks. This study found that a mobile application could contribute to the efficient delivery of information during the informed consent process. With further improvement, it could be used in other plastic surgeries and other surgeries, and such an application can potentially be used for explaining risks as well as delivering other types of information.

  19. Risk factors of erectile dysfunction and penile vascular changes after surgical repair of penile fracture.

    PubMed

    El-Assmy, A; El-Tholoth, H S; Abou-El-Ghar, M E; Mohsen, T; Ibrahiem, E H I

    2012-01-01

    This study was conducted to determine the preoperative and intraoperative risk factors of ED and the underlying penile vascular abnormalities among patients with penile fracture treated surgically. In all, 180 patients with penile fracture were treated surgically and followed up in one center. None of our patients had ED before the penile trauma and only two of them had risk factors for systemic vascular diseases, such as diabetes mellitus (one patient) and hypertension (one patient). After a mean follow-up of 106 months, 11 patients (6.6%) developed ED, 7 had mild ED and 4 had moderate ED. The main risk factors for subsequent ED were aging, >50 years, and bilateral corporal involvement. Among the 11 patients with ED, color Doppler ultrasonography (CDU) showed normal Doppler indices in 4 (36.4%), veno-occlusive dysfunction in 4 (36.4%) and arterial insufficiency in the remaining 3 (27.2%) patients. CDU assessments from the injured and intact sides were comparable. ED of either a psychological or vascular origin can be encountered as a long-term sequel of surgical treatment of penile fracture. Aging, >50 years, at presentation and bilateral corporal involvement is the main risk factors for subsequent development of ED.

  20. [Management of patients with bronchial asthma received general anesthesia and surgical intervention].

    PubMed

    To, Masako; Tajima, Makoto; Ogawa, Cyuhei; Otomo, Mamoru; Suzuki, Naohito; Sano, Yasuyuki

    2002-01-01

    Stimulation to bronchial mucosa is one of the major risk factor of asthma attack. When patients receive surgical intervention and general anesthesia, they are always exposed to stimulation to bronchial mucosa. Prevention method of bronchial asthma attack during surgical intervention is not established yet. We investigated that clinical course of patients with bronchial asthma who received general anesthesia and surgical intervention. Seventy-six patients with bronchial asthma were received general anesthesia and surgical intervention from 1993 to 1998. Twenty-four patients were mild asthmatic patients, 39 were moderate asthmatic patients and 13 were severe asthmatic patients. Preoperative treatment for preventing asthma attack was as follows; Eight patients were given intravenous infusion of aminophylline before operation. Fifty-two patients were given intravenous infusion of aminophylline and hydrocortisone before operation. Three patients were given intravenous infusion of hydrocortisone for consecutive 3 days before operation. Thirteen patients were given no treatment for preventing asthma attack. One patient was suffered from asthma attack during operation. She was given no preventing treatment for asthma attack before operation. Three patients were suffered from asthma attack after operation. No wound dehiscence was observed in all patients. To prevent asthma attack during operation, intravenous infusion of steroid before operation is recommended, when patients with asthma receive general anesthesia and surgical intervention.

  1. Incidence and risk factors for surgical site infection in general surgeries 1

    PubMed Central

    de Carvalho, Rafael Lima Rodrigues; Campos, Camila Cláudia; Franco, Lúcia Maciel de Castro; Rocha, Adelaide De Mattia; Ercole, Flávia Falci

    2017-01-01

    ABSTRACT Objective: to estimate the incidence of surgical site infection in general surgeries at a large Brazilian hospital while identifying risk factors and prevalent microorganisms. Method: non-concurrent cohort study with 16,882 information of patients undergoing general surgery from 2008 to 2011. Data were analyzed by descriptive, bivariate and multivariate analysis. Results: the incidence of surgical site infection was 3.4%. The risk factors associated with surgical site infection were: length of preoperative hospital stay more than 24 hours; duration of surgery in hours; wound class clean-contaminated, contaminated and dirty/infected; and ASA index classified into ASA II, III and IV/V. Staphyloccocus aureus and Escherichia coli were identified. Conclusion: the incidence was lower than that found in the national studies on general surgeries. These risk factors corroborate those presented by the National Nosocomial Infection Surveillance System Risk Index, by the addition of the length of preoperative hospital stay. The identification of the actual incidence of surgical site infection in general surgeries and associated risk factors may support the actions of the health team in order to minimize the complications caused by surgical site infection. PMID:29211190

  2. Perioperative Care of the Obese Cardiac Surgical Patient.

    PubMed

    Chacon, M Megan; Cheruku, Sreekanth R; Neuburger, Peter J; Lester, Laeben; Shillcutt, Sasha K

    2017-12-13

    Morbid obesity is associated with impairment of cardiovascular, pulmonary, gastrointestinal, and renal physiology with significant perioperative consequences and has been linked with higher morbidity and mortality after cardiac surgery. Cardiac surgery patients have a higher incidence of difficult airway and difficult laryngoscopy than general surgery patients do, and obesity is associated with difficult mask ventilation and direct laryngoscopy. Positioning injuries occur more frequently because obese patients are at greater risk of pressure injury, such as rhabdomyolysis and compartment syndrome. Despite the association between obesity and several chronic disease states, the effects of obesity on perioperative outcomes are conflicting. Studies examining outcomes of overweight and obese patients in cardiac surgery have reported varying results. An "obesity paradox" has been described, in which the mortality for overweight and obese patients is lower compared with patients of normal weight. This review describes the physiologic abnormalities and clinical implications of obesity in cardiac surgery and summarizes recommendations for anesthesiologists to optimize perioperative care of the obese cardiac surgical patient. Copyright © 2017 Elsevier Inc. All rights reserved.

  3. Surgical treatment of chronic pancreatitis in young patients.

    PubMed

    Zhou, Feng; Gou, Shan-Miao; Xiong, Jiong-Xin; Wu, He-Shui; Wang, Chun-You; Liu, Tao

    2014-10-01

    The main treatment strategies for chronic pancreatitis in young patients include therapeutic endoscopic retrograde cholangio-pancreatography (ERCP) intervention and surgical intervention. Therapeutic ERCP intervention is performed much more extensively for its minimally invasive nature, but a part of patients are referred to surgery at last. Historical and follow-up data of 21 young patients with chronic pancreatitis undergoing duodenum-preserving total pancreatic head resection were analyzed to evaluate the outcomes of therapeutic ERCP intervention and surgical intervention in this study. The surgical complications of repeated therapeutic ERCP intervention and surgical intervention were 38% and 19% respectively. During the first therapeutic ERCP intervention to surgical intervention, 2 patients developed diabetes, 5 patients developed steatorrhea, and 5 patients developed pancreatic type B pain. During the follow-up of surgical intervention, 1 new case of diabetes occurred, 1 case of steatorrhea recovered, and 4 cases of pancreatic type B pain were completely relieved. In a part of young patients with chronic pancreatitis, surgical intervention was more effective than therapeutic ERCP intervention on delaying the progression of the disease and relieving the symptoms.

  4. Adhering to a national surgical care bundle reduces the risk of surgical site infections

    PubMed Central

    Hopmans, Titia E. M.; Soetens, Loes C.; Wille, Jan C.; Geerlings, Suzanne E.; Vos, Margreet C.; van Benthem, Birgit H. B.; de Greeff, Sabine C.

    2017-01-01

    Background In 2008, a bundle of care to prevent Surgical Site Infections (SSIs) was introduced in the Netherlands. The bundle consisted of four elements: antibiotic prophylaxis according to local guidelines, no hair removal, normothermia and ‘hygiene discipline’ in the operating room (i.e. number of door movements). Dutch hospitals were advised to implement the bundle and to measure the outcome. This study’s goal was to assess how effective the bundle was in reducing SSI risk. Methods Hospitals assessed whether their staff complied with each of the bundle elements and voluntary reported compliance data to the national SSI surveillance network (PREZIES). From PREZIES data, we selected data from 2009 to 2014 relating to 13 types of surgical procedures. We excluded surgeries with missing (non)compliance data, and calculated for each remaining surgery with reported (non)compliance data the level of compliance with the bundle (that is, being compliant with 0, 1, 2, 3, or 4 of the elements). Subsequently, we used this level of compliance to assess the effect of bundle compliance on the SSI risk, using multilevel logistic regression techniques. Results 217 489 surgeries were included, of which 62 486 surgeries (29%) had complete bundle reporting. Within this group, the SSI risk was significantly lower for surgeries with complete bundle compliance compared to surgeries with lower compliance levels. Odds ratios ranged from 0.63 to 0.86 (risk reduction of 14% to 37%), while a 13% risk reduction was demonstrated for each point increase in compliance-level. Sensitivity analysis indicated that due to analysing reported bundles only, we probably underestimated the total effect of implementing the bundle. Conclusions This study demonstrated that adhering to a surgical care bundle significantly reduced the risk of SSIs. Reporting of and compliance with the bundle compliance can, however, still be improved. Therefore an even greater effect might be achieved. PMID:28877223

  5. Surgical innovation-enhanced quality and the processes that assure patient/provider safety: A surgical conundrum.

    PubMed

    Bruny, Jennifer; Ziegler, Moritz

    2015-12-01

    Innovation is a crucial part of surgical history that has led to enhancements in the quality of surgical care. This comprises both changes which are incremental and those which are frankly disruptive in nature. There are situations where innovation is absolutely required in order to achieve quality improvement or process improvement. Alternatively, there are innovations that do not necessarily arise from some need, but simply are a new idea that might be better. All change must assure a significant commitment to patient safety and beneficence. Innovation would ideally enhance patient care quality and disease outcomes, as well stimulate and facilitate further innovation. The tensions between innovative advancement and patient safety, risk and reward, and demonstrated effectiveness versus speculative added value have created a contemporary "surgical conundrum" that must be resolved by a delicate balance assuring optimal patient/provider outcomes. This article will explore this delicate balance and the rules that govern it. Recommendations are made to facilitate surgical innovation through clinical research. In addition, we propose options that investigators and institutions may use to address competing priorities. Copyright © 2015 Elsevier Inc. All rights reserved.

  6. Surgical Management of the Pediatric Cochlear Implant Patient.

    ERIC Educational Resources Information Center

    Cohen, Seth M.; Haynes, David S.

    2003-01-01

    This article discusses the surgical management of children receiving cochlear implants. It identifies preoperative considerations to select patients likely to benefit, contraindications, some new surgical techniques, complications, special considerations (otitis media, meningitis, head growth, inner ear malformations, and cochlear obstruction).…

  7. Assessment scale of risk for surgical positioning injuries.

    PubMed

    Lopes, Camila Mendonça de Moraes; Haas, Vanderlei José; Dantas, Rosana Aparecida Spadoti; Oliveira, Cheila Gonçalves de; Galvão, Cristina Maria

    2016-08-29

    to build and validate a scale to assess the risk of surgical positioning injuries in adult patients. methodological research, conducted in two phases: construction and face and content validation of the scale and field research, involving 115 patients. the Risk Assessment Scale for the Development of Injuries due to Surgical Positioning contains seven items, each of which presents five subitems. The scale score ranges between seven and 35 points in which, the higher the score, the higher the patient's risk. The Content Validity Index of the scale corresponded to 0.88. The application of Student's t-test for equality of means revealed the concurrent criterion validity between the scores on the Braden scale and the constructed scale. To assess the predictive criterion validity, the association was tested between the presence of pain deriving from surgical positioning and the development of pressure ulcer, using the score on the Risk Assessment Scale for the Development of Injuries due to Surgical Positioning (p<0.001). The interrater reliability was verified using the intraclass correlation coefficient, equal to 0.99 (p<0.001). the scale is a valid and reliable tool, but further research is needed to assess its use in clinical practice. construir e validar escala de avaliação de risco para lesões decorrentes do posicionamento cirúrgico em pacientes adultos. pesquisa metodológica, conduzida em duas etapas: construção e validação de face e de conteúdo da escala e pesquisa de campo, com a participação de 115 pacientes. a Escala de Avaliação de Risco para o Desenvolvimento de Lesões Decorrentes do Posicionamento Cirúrgico contém sete itens, sendo que cada um apresenta cinco subitens. A pontuação dessa escala varia de sete a 35 pontos, quanto maior o escore maior o risco do paciente. O Índice de Validade de Conteúdo da escala foi de 0,88. Por meio da aplicação do teste t de Student, para igualdade de médias, constatou-se validade de crit

  8. The epidemiology of upper airway injury in patients undergoing major surgical procedures.

    PubMed

    Hua, May; Brady, Joanne; Li, Guohua

    2012-01-01

    Airway injury is a potentially serious and costly adverse event of anesthesia care. The epidemiologic characteristics of airway injury have not been well documented. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) is a multicenter, prospective, outcome-oriented database for patients undergoing major surgical procedures. Using the NSQIP data for the years 2005 to 2008, we examined the incidence of, and risk factors for, airway injury. Of the 563,190 patients studied, 1202 (0.2%) sustained airway injury. The most common airway injury was lip laceration/hematoma (61.4%), followed by tooth injury (26.1%), tongue laceration (5.7%), pharyngeal laceration (4.7%), and laryngeal laceration (2.1%). Multivariable logistic modeling revealed an increased risk of airway injury in patients with Mallampati class III (adjusted odds ratio [OR], 1.69; 99% confidence interval [CI], 1.36-2.11, relative to patients with Mallampati classes I and II) or class IV (adjusted OR, 2.6; 99% CI, 1.52-4.02), and in patients aged 80 years or older (adjusted OR, 1.50; 99% CI, 1.02-2.19, relative to patients aged 40 to 49 years). The risk of airway injury for patients undergoing major surgical procedures is approximately 1 in 500. Patients with difficult airways as indicated by Mallampati classes III and IV are at significantly increased risk of sustaining airway injury during anesthesia for major surgical procedures.

  9. Patient views on financial relationships between surgeons and surgical device manufacturers.

    PubMed

    Camp, Mark W; Gross, Allan E; McKneally, Martin F

    2015-10-01

    Over the past decade, revelations of inappropriate financial relationships between surgeons and surgical device manufacturers have challenged the presumption that surgeons can collaborate with surgical device manufacturers without damaging public trust in the surgical profession. We explored postoperative Canadian patients' knowledge and opinions about financial relationships between surgeons and surgical device manufacturers. This complex issue was explored using qualitative methods. We conducted semistructured face-to-face interviews with postoperative patients in follow-up arthroplasty clinics at an academic hospital in Toronto, Canada. Interviews were audiotaped, transcribed and analyzed. Patient-derived concepts and themes were uncovered. We interviewed 33 patients. Five major themes emerged: 1) many patients are unaware of the existence of financial relationships between surgeons and surgical device manufacturers; 2) patients approve of financial relationships that support innovation and research but are opposed to relationships that involve financial incentives that benefit only the surgeon and the manufacturer; 3) patients do not support disclosure of financial relationships during the consent process as it may shift focus away from the more important risks; 4) patients support oversight at the professional level but reject the idea of government involvement in oversight; and 5) patients entrust their surgeons to make appropriate patient-centred choices. This qualitative study deepens our understanding of financial relationships between surgeons and industry. Patients support relationships with industry that provide potential benefit to current or future patients. They trust our ability to self-regulate. Disclosure combined with appropriate oversight will strengthen public trust in professional collaboration with industry.

  10. Surgical smoke.

    PubMed

    Fan, Joe King-Man; Chan, Fion Siu-Yin; Chu, Kent-Man

    2009-10-01

    Surgical smoke is the gaseous by-product formed during surgical procedures. Most surgeons, operating theatre staff and administrators are unaware of its potential health risks. Surgical smoke is produced by various surgical instruments including those used in electrocautery, lasers, ultrasonic scalpels, high speed drills, burrs and saws. The potential risks include carbon monoxide toxicity to the patient undergoing a laparoscopic operation, pulmonary fibrosis induced by non-viable particles, and transmission of infectious diseases like human papilloma virus. Cytotoxicity and mutagenicity are other concerns. Minimisation of the production of surgical smoke and modification of any evacuation systems are possible solutions. In general, a surgical mask can provide more than 90% protection to exposure to surgical smoke; however, in most circumstances it cannot provide air-tight protection to the user. An at least N95 grade or equivalent respirator offers the best protection against surgical smoke, but whether such protection is necessary is currently unknown.

  11. Providing care for critically ill surgical patients: challenges and recommendations.

    PubMed

    Tisherman, Samuel A; Kaplan, Lewis; Gracias, Vicente H; Beilman, Gregory J; Toevs, Christine; Byrnes, Matthew C; Coopersmith, Craig M

    2013-07-01

    Providing optimal care for critically ill and injured surgical patients will become more challenging with staff shortages for surgeons and intensivists. This white paper addresses the historical issues behind the present situation, the need for all intensivists to engage in dedicated critical care per the intensivist model, and the recognition that intensivists from all specialties can provide optimal care for the critically ill surgical patient, particularly with continuing involvement by the surgeon of record. The new acute care surgery training paradigm (including trauma, surgical critical care, and emergency general surgery) has been developed to increase interest in trauma and surgical critical care, but the number of interested trainees remains too few. Recommendations are made for broadening the multidisciplinary training and practice opportunities in surgical critical care for intensivists from all base specialties and for maintaining the intensivist model within acute care surgery practice. Support from academic and administrative leadership, as well as national organizations, will be needed.

  12. Supplemental perioperative oxygen and the risk of surgical wound infection: a randomized controlled trial.

    PubMed

    Belda, F Javier; Aguilera, Luciano; García de la Asunción, José; Alberti, Javier; Vicente, Rosario; Ferrándiz, Lucía; Rodríguez, Rafael; Company, Roque; Sessler, Daniel I; Aguilar, Gerardo; Botello, Stephanie García; Ortí, Rafael

    2005-10-26

    Supplemental perioperative oxygen has been variously reported to halve or double the risk of surgical wound infection. To test the hypothesis that supplemental oxygen reduces infection risk in patients following colorectal surgery. A double-blind, randomized controlled trial of 300 patients aged 18 to 80 years who underwent elective colorectal surgery in 14 Spanish hospitals from March 1, 2003, to October 31, 2004. Wound infections were diagnosed by blinded investigators using Centers for Disease Control and Prevention criteria. Baseline patient characteristics, anesthetic treatment, and potential confounding factors were recorded. Patients were randomly assigned to either 30% or 80% fraction of inspired oxygen (FIO2) intraoperatively and for 6 hours after surgery. Anesthetic treatment and antibiotic administration were standardized. Any surgical site infection (SSI); secondary outcomes included return of bowel function and ability to tolerate solid food, ambulation, suture removal, and duration of hospitalization. A total of 143 patients received 30% perioperative oxygen and 148 received 80% perioperative oxygen. Surgical site infection occurred in 35 patients (24.4%) administered 30% FIO2 and in 22 patients (14.9%) administered 80% FIO2 (P=.04). The risk of SSI was 39% lower in the 80% FIO2 group (relative risk [RR], 0.61; 95% confidence interval [CI], 0.38-0.98) vs the 30% FIO2 group. After adjustment for important covariates, the RR of infection in patients administered supplemental oxygen was 0.46 (95% CI, 0.22-0.95; P = .04). None of the secondary outcomes varied significantly between the 2 treatment groups. Patients receiving supplemental inspired oxygen had a significant reduction in the risk of wound infection. Supplemental oxygen appears to be an effective intervention to reduce SSI in patients undergoing colon or rectal surgery. Trial Registration ClinicalTrials.gov Identifier: NCT00235456.

  13. Characteristics of Pseudoaneurysms in Northern India; Risk Analysis, Clinical Profile, Surgical Management and Outcome.

    PubMed

    Lone, Hafeezulla; Ganaie, Farooq Ahmad; Lone, Ghulam Nabi; Dar, Abdul Majeed; Bhat, Mohammad Akbar; Singh, Shyam; Parra, Khursheed Ahmad

    2015-04-01

    To determine the risk factors, clinical characteristics, surgical management and outcome of pseudoaneurysm secondary to iatrogenic or traumatic vascular injury. This was a cross-sectional study being performed in department of cardiovascular and thoracic surgery skims soura during a 4-year period. We included all the patients referring to our center with primary diagnosis of pseudoaneurysm. The pseudoaneurysm was diagnosed with angiography and color Doppler sonography. The clinical and demographic characteristics were recorded and the risk factors were identified accordingly. Patients with small swelling (less than 5-cm) and without any complication were managed conservatively. They were followed for progression and development of complications in relation to swelling. Others underwent surgical repair and excision. The outcome of the patients was also recorded. Overall we included 20 patients with pseudoaneurysm. The mean age of the patients was 42.1±0.6 years. Among them there were 11 (55%) men and 9 (45%) women. Nine (45%) patients with end stage renal disease developed pseudoaneurysm after inadvertent femoral artery puncture for hemodialysis; two patients after interventional cardiology procedure; one after femoral embolectomy; one developed after fire arm splinter injury and one formed femoral artery related pseudoaneurysm after drainage of right inguinal abscess. The most common site of pseudoaneurysm was femoral artery followed by brachial artery. Overall surgical intervention was performed in 17 (85%) patients and 3 (15%) were managed conservatively. End stage renal disease is a major risk factor for pseudoaneurysm formation. Coagulopathy, either therapeutic or pathological is also an important risk factor. Patients with these risk factors need cannulation of venous structures for hemodialysis under ultrasound guide to prevent inadvertent arterial injury. Patients with end stage renal disease who sustain inadvertent arterial puncture during cannulation for

  14. The American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator Has a Role in Predicting Discharge to Post-Acute Care in Total Joint Arthroplasty.

    PubMed

    Goltz, Daniel E; Baumgartner, Billy T; Politzer, Cary S; DiLallo, Marcus; Bolognesi, Michael P; Seyler, Thorsten M

    2018-01-01

    Patient demand and increasing cost awareness have led to the creation of surgical risk calculators that attempt to predict the likelihood of adverse events and to facilitate risk mitigation. The American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator is an online tool available for a wide variety of surgical procedures, and has not yet been fully evaluated in total joint arthroplasty. A single-center, retrospective review was performed on 909 patients receiving a unilateral primary total knee (496) or hip (413) arthroplasty between January 2012 and December 2014. Patient characteristics were entered into the risk calculator, and predicted outcomes were compared with observed results. Discrimination was evaluated using the receiver-operator area under the curve (AUC) for 90-day readmission, return to operating room (OR), discharge to skilled nursing facility (SNF)/rehab, deep venous thrombosis (DVT), and periprosthetic joint infection (PJI). The risk calculator demonstrated adequate performance in predicting discharge to SNF/rehab (AUC 0.72). Discrimination was relatively limited for DVT (AUC 0.70, P = .2), 90-day readmission (AUC 0.63), PJI (AUC 0.67), and return to OR (AUC 0.59). Risk score differences between those who did and did not experience discharge to SNF/rehab, 90-day readmission, and PJI reached significance (P < .01). Predicted length of stay performed adequately, only overestimating by 0.2 days on average (rho = 0.25, P < .001). The American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator has fair utility in predicting discharge to SNF/rehab, but limited usefulness for 90-day readmission, return to OR, DVT, and PJI. Although length of stay predictions are similar to actual outcomes, statistical correlation remains relatively weak. Copyright © 2017 Elsevier Inc. All rights reserved.

  15. Review of information technology for surgical patient care.

    PubMed

    Robinson, Jamie R; Huth, Hannah; Jackson, Gretchen P

    2016-06-01

    Electronic health records (EHRs), computerized provider order entry (CPOE), and patient portals have experienced increased adoption by health care systems. The objective of this study was to review evidence regarding the impact of such health information technologies (HIT) on surgical practice. A search of Medline, EMBASE, CINAHL, and the Cochrane Library was performed to identify data-driven, nonsurvey studies about the effects of HIT on surgical care. Domain experts were queried for relevant articles. Two authors independently reviewed abstracts for inclusion criteria and analyzed full text of eligible articles. A total of 2890 citations were identified. Of them, 32 observational studies and two randomized controlled trials met eligibility criteria. EHR or CPOE improved appropriate antibiotic administration for surgical procedures in 13 comparative observational studies. Five comparative observational studies indicated that electronically generated operative notes had increased accuracy, completeness, and availability in the medical record. The Internet as an information resource about surgical procedures was generally inadequate. Surgical patients and providers demonstrated rapid adoption of patient portals, with increasing proportions of online versus inperson outpatient surgical encounters. The overall quality of evidence about the effects of HIT in surgical practice was low. Current data suggest an improvement in appropriate perioperative antibiotic administration and accuracy of operative reports from CPOE and EHR applications. Online consumer health educational resources and patient portals are popular among patients and families, but their impact has not been studied well in surgical populations. With increasing adoption of HIT, further research is needed to optimize the efficacy of such tools in surgical care. Copyright © 2016 Elsevier Inc. All rights reserved.

  16. Surgical or non-surgical periodontal treatment: factors affecting patient decision making.

    PubMed

    Patel, Amit M; Richards, Philip S; Wang, Hom-Lay; Inglehart, Marita R

    2006-04-01

    This study explored which factors affected patients' decisions to pursue either surgical or non-surgical periodontal treatment. Data were collected from 74 patients at a regularly scheduled periodontal appointment, at which each patient was told that periodontal treatment was needed, and 2 weeks following the actual treatment. The surveys assessed the patients' decisions and potential determinants of these decisions. The dental anxiety scale-revised, the state-trait anxiety inventory, and the Iowa dental control index were used to measure psychosocial factors. Patients who decided to have surgery did not differ from patients who decided against surgery in sociodemographic variables such as gender, age, education, and socioeconomic status, nor in their desire for control over the treatment decision. However, they had less dental fear and less general anxiety than the non-surgery patients. Although the two patient groups did not differ in their responses concerning how well the dentists had informed them about the procedure, they differed in the degree of trust and rapport with their dentists. The less dentally fearful and anxious patients were in general and the more they trusted their provider and felt they had good rapport, the more likely they were to accept surgical periodontal treatment. These results stress the importance of good patient-provider communication.

  17. Chronic Opioid Usage in Surgical Patients in a Large Academic Center

    PubMed Central

    Jiang, Xueying; Orton, Margaret; Feng, Rui; Hossain, Erik; Malhotra, Neil R.; Zager, Eric L.; Liu, Renyu

    2017-01-01

    Objective The objective of this study is to investigate the prevalence and disparity of chronic opioid usage in surgical patients and the potential risk factors associated with chronic opioid usage. Background Chronic opioid usage is common in surgical patients; however, the characteristics of opioid usage in surgical patients is unclear. In this study, we hypothesize that the prevalence of chronic opioid usage in surgical patients is high, and that significant disparities may exist among different surgical populations. Methods Data of opioid usage in outpatients among different surgical services were extracted from the electronic medical record database. Patient demographics, clinical characteristics of sex, age, race, body mass index (BMI), specialty visited, duration of opioid use, and opioid type were collected. Chronic opioid users were defined as patients who had been recorded as taking opioids for at least 90 days determined by the first and last visit dates under opioid usage during the investigation. Results There were 79,123 patients included in this study. The average prevalence is 9.2%, ranging from 4.4% to 23.8% among various specialties. The prevalence in orthopedics (23.8%), neurosurgery (18.7%), and gastrointestinal surgery (14.4%) ranked in the top three subspecialties. Major factors influencing chronic opioid use include age, Ethnicitiy, Subspecialtiy, and multiple specialty visits. Approximately 75% of chronic users took opioids that belong to the category II Drug Enforcement Administration classification. Conclusions Overall prevalence of chronic opioid usage in surgical patients is high with widespread disparity among different sex, age, ethnicity, BMI, and subspecialty groups. Information obtained from this study provides clues to reduce chronic opioid usage in surgical patients. PMID:27163960

  18. Surgical procedures in liver transplant patients: A monocentric retrospective cohort study.

    PubMed

    Sommacale, Daniele; Nagarajan, Ganesh; Lhuaire, Martin; Dondero, Federica; Pessaux, Patrick; Piardi, Tullio; Sauvanet, Alain; Kianmanesh, Reza; Belghiti, Jacques

    2017-05-01

    Pre-existing chronic liver diseases and the complexity of the transplant surgery procedures lead to a greater risk of further surgery in transplanted patients compared to the general population. The aim of this monocentric retrospective cohort study was to assess the epidemiology of surgical complications in liver transplanted patients who require further surgical procedures and to characterize their post-operative risk of complications to enhance their medical care. From January 1997 to December 2011, 1211 patients underwent orthotropic liver transplantation in our center. A retrospective analysis of prospectively collected data was performed considering patients who underwent surgical procedures more than three months after transplantation. We recorded liver transplantation technique, type of surgery, post-operative complications, time since the liver transplant and immunosuppressive regimens. Among these, 161 patients (15%) underwent a further 183 surgical procedures for conditions both related and unrelated to the transplant. The most common surgical procedure was for an incisional hernia repair (n = 101), followed by bilioenteric anastomosis (n = 44), intestinal surgery (n = 23), liver surgery (n = 8) and other surgical procedures (n = 7). Emergency surgery was required in 19 procedures (10%), while 162 procedures (90%) were performed electively. Post-operative mortality and morbidity were 1% and 30%, respectively. According to the Dindo-Clavien classification, the most common grade of morbidity was grade III (46%), followed by grade II (40%). Surgical procedures on liver transplanted patients are associated with a significantly high risk of complications, irrespective of the time elapsed since transplantation. Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

  19. Sodium bicarbonate use and the risk of hypernatremia in thoracic aortic surgical patients with metabolic acidosis following deep hypothermic circulatory arrest

    PubMed Central

    Ghadimi, Kamrouz; Gutsche, Jacob T.; Ramakrishna, Harish; Setegne, Samuel L.; Jackson, Kirk R.; Augoustides, John G.; Ochroch, E. Andrew; Weiss, Stuart J.; Bavaria, Joseph E.; Cheung, Albert T.

    2016-01-01

    Objective: Metabolic acidosis after deep hypothermic circulatory arrest (DHCA) for thoracic aortic operations is commonly managed with sodium bicarbonate (NaHCO3). The purpose of this study was to determine the relationships between total NaHCO3 dose and the severity of metabolic acidosis, duration of mechanical ventilation, duration of vasoactive infusions, and Intensive Care Unit (ICU) or hospital length of stay (LOS). Methods: In a single center, retrospective study, 87 consecutive elective thoracic aortic operations utilizing DHCA, were studied. Linear regression analysis was used to test for the relationships between the total NaHCO3 dose administered through postoperative day 2, clinical variables, arterial blood gas values, and short-term clinical outcomes. Results: Seventy-five patients (86%) received NaHCO3. Total NaHCO3 dose averaged 136 ± 112 mEq (range: 0.0–535 mEq) per patient. Total NaHCO3 dose correlated with minimum pH (r = 0.41, P < 0.0001), minimum serum bicarbonate (r = −0.40, P < 0.001), maximum serum lactate (r = 0.46, P = 0.007), duration of metabolic acidosis (r = 0.33, P = 0.002), and maximum serum sodium concentrations (r = 0.29, P = 0.007). Postoperative hypernatremia was present in 67% of patients and peaked at 12 h following DHCA. Eight percent of patients had a serum sodium ≥ 150 mEq/L. Total NaHCO3 dose did not correlate with anion gap, serum chloride, not the duration of mechanical ventilator support, vasoactive infusions, ICU or hospital LOS. Conclusion: Routine administration of NaHCO3 was common for the management of metabolic acidosis after DHCA. Total dose of NaHCO3 was a function of the severity and duration of metabolic acidosis. NaHCO3 administration contributed to postoperative hypernatremia that was often severe. The total NaHCO3 dose administered was unrelated to short-term clinical outcomes. PMID:27397449

  20. Surgical menopause and nonvertebral fracture risk among older US women.

    PubMed

    Vesco, Kimberly K; Marshall, Lynn M; Nelson, Heidi D; Humphrey, Linda; Rizzo, Joanne; Pedula, Kathryn L; Cauley, Jane A; Ensrud, Kristine E; Hochberg, Marc C; Antoniucci, Diana; Hillier, Teresa A

    2012-05-01

    The aim of this study was to determine whether older postmenopausal women with a history of bilateral oophorectomy before natural menopause (surgical menopause) have a higher risk of nonvertebral postmenopausal fracture than women with natural menopause. We used 21 years of prospectively collected incident fracture data from the ongoing Study of Osteoporotic Fractures, a cohort study of community-dwelling women without previous bilateral hip fracture who were 65 years or older at enrollment, to determine the risk of hip, wrist, and any nonvertebral fracture. χ(2) and t tests were used to compare the two groups on important characteristics. Multivariable Cox proportional hazards regression models stratified by baseline oral estrogen use status were used to estimate the risk of fracture. Baseline characteristics differed significantly among the 6,616 women within the Study of Osteoporotic Fractures who underwent either surgical (1,157) or natural (5,459) menopause, including mean age at menopause (44.3 ± 7.4 vs 48.9 ± 4.9 y, P < 0.001) and current use of oral estrogen (30.2% vs 6.5%, P < 0.001). Fracture rates were not significantly increased for surgical versus natural menopause, even among women who had never used oral estrogen (hip fracture: hazard ratio [HR], 0.87; 95% CI, 0.63-1.21; wrist fracture: HR, 1.10; 95% CI, 0.78-1.57; any nonvertebral fracture: HR, 1.11; 95% CI, 0.93-1.32). These data provide some reassurance that the long-term risk of nonvertebral fracture is not substantially increased for postmenopausal women who experienced premenopausal bilateral oophorectomy, compared with postmenopausal women with intact ovaries, even in the absence of postmenopausal estrogen therapy.

  1. Operating Room Traffic as a Modifiable Risk Factor for Surgical Site Infection.

    PubMed

    Wanta, Brendan T; Glasgow, Amy E; Habermann, Elizabeth B; Kor, Daryl J; Cima, Robert R; Berbari, Elie F; Curry, Timothy B; Brown, Michael J; Hyder, Joseph A

    2016-12-01

    Surgical site infections (SSI) contribute to surgical patients' morbidity and costs. Operating room traffic may be a modifiable risk factor for SSI. We investigated the impact of additional operating room personnel on the risk of superficial SSI (sSSI). In this matched case-control study, cases included patients in whom sSSI developed in clean surgical incisions after elective, daytime operations. Control subjects were matched by age, gender, and procedure. Operating room personnel were classified as (1) surgical scrubbed, (2) surgical non-scrubbed, or (3) anesthesia. We used conditional logistic regression to test the extent to which additional personnel overall and from each work group were associated with infection. In total, 474 patients and 803 control subjects were identified. Each additional person among total personnel and personnel from each work group was significantly associated with greater odds of infection (all personnel, odds ratio [OR] = 1.082, 95% confidence interval [CI] 1.031-1.134, p = 0.0013; surgical scrubbed OR = 1.132, 95% CI 1.029-1.245, p = 0.0105; surgical non-scrubbed OR = 1.123, 95% CI 1.008-1.251, p = 0.0357; anesthesia OR = 1.153, 95% CI 1.031-1.290, p = 0.0127). After adjusting for operative duration, body mass index, diabetes mellitus, and vascular disease, additional personnel and sSSI were no longer associated overall or for any work groups (total personnel OR = 1.033, 95% CI 0.974-1.095, p = 0.2746; surgical scrubbed OR = 1.060, 95% CI 0.952-1.179, p = 0.2893; surgical non-scrubbed OR = 1.023 95% CI 0.907-1.154, p = 0.7129; anesthesia OR = 1.051, 95% CI 0.926-1.193, p = 0.4442). The presence of additional operating room personnel was not independently associated with increased odds of sSSI. Efforts dedicated to sSSI reduction should focus on other modifiable risk factors.

  2. Patient Preferences Regarding Surgical Interventions for Knee Osteoarthritis

    PubMed Central

    Moorman, Claude T; Kirwan, Tom; Share, Jennifer; Vannabouathong, Christopher

    2017-01-01

    Surgical interventions for knee osteoarthritis (OA) have markedly different procedure attributes and may have dramatic differences in patient desirability. A total of 323 patients with knee OA were included in a dual response, choice-based conjoint analysis to identify the relative preference of 9 different procedure attributes. A model was also developed to simulate how patients might respond if presented with the real-world knee OA procedures, based on conservative assumptions regarding their attributes. The “amount of cutting and removal of the existing bone” required for a procedure had the highest preference score, indicating that these patients considered it the most important attribute. More specifically, a procedure that requires the least amount of bone cutting or removal would be expected to be the most preferred surgical alternative. The model also suggested that patients who are younger and report the highest pain levels and greatest functional limitations would be more likely to opt for surgical intervention. PMID:28974919

  3. Results of surgical excision of urethral prolapse in symptomatic patients.

    PubMed

    Hall, Mary E; Oyesanya, Tola; Cameron, Anne P

    2017-11-01

    Here, we present the clinical presentation and surgical outcomes of women with symptomatic urethral prolapse presenting to our institution over 20 years, and seek to provide treatment recommendations for management of symptomatic urethral prolapse and caruncle. A retrospective review of medical records from female patients who underwent surgery for symptomatic urethral prolapse from June 1995 to August 2015 was performed. Surgical technique consisted of a four-quadrant excisional approach for repair of urethral prolapse. A total of 26 patients were identified with a mean age of 38.8 years (range 3-81). The most common presentations were vaginal bleeding, hematuria, pain, and dysuria. All patients underwent surgical excision of urethral prolapse via a standard approach. Follow-up data was available in 24 patients. Six patients experienced temporary postoperative bleeding, and one patient required placement of a Foley catheter for tamponade. One patient experienced temporary postoperative urinary retention requiring Foley catheter placement. Three patients had visible recurrence of urethral prolapse, for which one later underwent re-excision. Surgical excision of urethral prolapse is a reasonable treatment option in patients who have tried conservative management without relief, as well as in those who present with severe symptoms. Possible complications following excision include postoperative bleeding and recurrence, and patients must be counseled accordingly. In this work, we propose a treatment algorithm for symptomatic urethral prolapse. © 2017 Wiley Periodicals, Inc.

  4. Impact of surgical innovation on tissue repair in the surgical patient.

    PubMed

    Tevlin, R; Atashroo, D; Duscher, D; Mc Ardle, A; Gurtner, G C; Wan, D C; Longaker, M T

    2015-01-01

    Throughout history, surgeons have been prolific innovators, which is hardly surprising as most surgeons innovate daily, tailoring their intervention to the intrinsic uniqueness of each operation, each patient and each disease. Innovation can be defined as the application of better solutions that meet new requirements, unarticulated needs or existing market needs. In the past two decades, surgical innovation has significantly improved patient outcomes, complication rates and length of hospital stay. There is one key area that has great potential to change the face of surgical practice and which is still in its infancy: the realm of regenerative medicine and tissue engineering. A literature review was performed using PubMed; peer-reviewed publications were screened for relevance in order to identify key surgical innovations influencing regenerative medicine, with a focus on osseous, cutaneous and soft tissue reconstruction. This review describes recent advances in regenerative medicine, documenting key innovations in osseous, cutaneous and soft tissue regeneration that have brought regenerative medicine to the forefront of the surgical imagination. Surgical innovation in the emerging field of regenerative medicine has the ability to make a major impact on surgery on a daily basis. © 2015 BJS Society Ltd. Published by John Wiley & Sons Ltd.

  5. Risk factors associated with intestinal necrosis in children with failed non-surgical reduction for intussusception.

    PubMed

    Huang, Hui-Ya; Huang, Xiao-Zhong; Han, Yi-Jiang; Zhu, Li-Bin; Huang, Kai-Yu; Lin, Jing; Li, Zhong-Rong

    2017-05-01

    Intestinal necrosis is the most serious complication of intussusception. The risk factors associated with intestinal necrosis in pediatric patients with intussusception have not been well characterized. This study aimed to investigate the risk factors associated with intestinal necrosis in pediatric patients with failed non-surgical reduction for intussusception. Hospitalized patients who failed the air-enema reduction for intussusception in the outpatient department and subsequently underwent surgery were retrospectively reviewed. All cases were categorized into two groups: intestinal necrosis group and non-intestinal necrosis group based on the surgical findings. Demographic and clinical features including the findings from the surgery were recorded and analyzed. Factors associated with intestinal necrosis were analyzed using univariate and multivariate unconditional logistic regression analyses. A total of 728 cases were included. Among them, 171 had intestinal necrosis at the time of surgery. The group with intestinal necrosis had a longer duration of symptom or length of illness (P = 0.000), and younger (P = 0.000) than the non-intestinal necrosis group. Complex/compound type of intussusceptions is more likely to have intestinal necrosis. Multivariate analysis showed that the presence of grossly bloody stool (OR = 2.12; 95% CI 1.19-3.76, P = 0.010) and duration of symptom (OR = 1.07; 95% CI 1.06-1.08, P = 0.000) were independent risk factors for intestinal necrosis in patients hospitalized for surgical reduction for intussusceptions. At time of admission, the presence of bloody stools and duration of symptom are the important risk factors for developing intestinal necrosis for those patients who failed non-surgical reduction. The length of illness has the highest sensitivity and specificity to correlate with intestinal necrosis. This finding may suggest that we should take the intussusception cases that have the longer duration of

  6. The surgical management of upper tract stone disease among spinal cord-injured patients.

    PubMed

    Welk, B; Shariff, S; Ordon, M; Catharine Craven, B; Herschorn, S; Garg, A X

    2013-06-01

    Retrospective cohort study, using linked, population-based health-care data. To describe the incidence, management and outcomes of surgically treated kidney stones after spinal cord injury (SCI). To evaluate the impact of a past history of kidney stones on the occurrence of kidney stones. Ontario, Canada. A total of 5121 patients were followed a median of 4 years after an incident SCI (occurring between 2002 and 2011). The primary outcome was surgical intervention for upper tract kidney stones. In follow-up, 66 patients (1.3%) had 89 episodes of surgically treated kidney stones. Treatments included: ureteroscopic lithotripsy (34%), ureteral stent/percutaneous nephrostomy (30%), shockwave lithotripsy (19%) or percutaneous nephrolithotripsy (17%). Following stone treatment, the 30-day mortality rate was low, and the 30-day admission rate to an intensive care unit was 12%. A history of surgically treated kidney stones before SCI (compared with no such history) was associated with a higher risk of kidney stones after SCI (27 vs 3 per 1000 person-years; adjusted hazard ratio 14.74, 95% confidence interval 5.69-38.22). During intermediate follow-up after SCI, surgically treated upper tract kidney stones occur in 1.3% of patients. Ureteroscopy with lithotripsy is the most common treatment. A history of surgically managed kidney stones before SCI portends a higher risk of stones after SCI.

  7. Incidence of surgical-site infections and the validity of the National Nosocomial Infections Surveillance System risk index in a general surgical ward in Santa Cruz, Bolivia.

    PubMed

    Soleto, Lorena; Pirard, Marianne; Boelaert, Marleen; Peredo, Remberto; Vargas, Reinerio; Gianella, Alberto; Van der Stuyft, Patrick

    2003-01-01

    To estimate the frequency of and risk factors for surgical-site infections (SSIs) in Bolivia, and to study the performance of the National Nosocomial Infections Surveillance (NNIS) System risk index in a developing country. A prospective study with patient follow-up until the 30th postoperative day. A general surgical ward of a public hospital in Santa Cruz, Bolivia. Patients admitted to the ward between July 1998 and June 1999 on whom surgical procedures were performed. Follow-up was complete for 91.5% of 376 surgical procedures. The overall SSI rate was 12%. Thirty-four (75.6%) of the 45 SSIs were culture positive. A logistic regression model retained an American Society of Anesthesiologists score of more than 1 (odds ratio [OR], 1.87), a not-clean wound class (OR, 2.28), a procedure duration of more than 1 hour (OR, 1.81), and drain (OR, 1.98) as independent risk factors for SSI. There was no significant association between the NNIS System risk index and SSI rates. However, a "local" risk index constructed with the above cutoff points showed a linear trend with SSI (P < .001) and a relative risk of 3.18 for risk class 3 versus a class of less than 3. SSIs cause considerable morbidity in Santa Cruz. Appropriate nosocomial infection surveillance and control should be introduced. The NNIS System risk index did not discriminate between patients at low and high risk for SSI in this hospital setting, but a risk score based on local cutoff points performed substantially better.

  8. Management of antithrombotic therapy in patients with coronary artery disease or atrial fibrillation who underwent abdominal surgical operations.

    PubMed

    Schizas, Dimitrios; Kariori, Maria; Boudoulas, Konstantinos Dean; Siasos, Gerasimos; Patelis, Nikolaos; Kalantzis, Charalampos; Carmen-Maria, Moldovan; Vavuranakis, Manolis

    2018-04-02

    Patients treated with antithrombotic therapy that require abdominal surgical procedures has progressively increased overtime. The management of antithrombotics during both the peri- and post- operative period is of crucial importance. The goal of this review is to present current data concerning the management of antiplatelets in patients with coronary artery disease and of anticoagulants in patients with atrial fibrillation who had to undergo abdominal surgical operations. For this purpose, incidence of major adverse cardiovascular events (MACE) and risk of antithrombotic use during surgical procedures, as well as the recommendations based on recent guidelines were reported. A thorough search of PubMed, Scopus and the Cochrane Databases was conducted to identify randomized controlled trials, observational studies, novel current reviews, and ESC and ACC/AHA guidelines on the subject. Antithrombotic use in daily clinical practice results to two different pathways: reduction of thromboembolic risk, but a simultaneous increase of bleeding risk. This may cause a therapeutic dilemma during the perioperative period. Nevertheless, careless cessation of antithrombotics can increase MACE and thromboembolic events, however, maintenance of antithrombotic therapy may increase bleeding complications. Studies and current guidelines can assist clinicians in making decisions for the treatment of patients that undergo abdominal surgical operations while on antithrombotic therapy. Aspirin should not be stopped perioperatively in the majority of surgical operations. Determining whether to discontinue the use of anticoagulants before surgery depends on the surgical procedure. In surgical operations with a low risk for bleeding, oral anticoagulants should not be discontinued. Bridging therapy should only be considered in patients with a high risk of thromboembolism. Finally, patients with an intermediate risk for thromboembolism, management should be individualized according to patient

  9. Antibiotic prophylaxis for surgical site infections as a risk factor for infection with Clostridium difficile.

    PubMed

    Balch, Aubrey; Wendelboe, Aaron M; Vesely, Sara K; Bratzler, Dale W

    2017-01-01

    We aimed to measure the association between 2013 guideline concordant prophylactic antibiotic use prior to surgery and infection with Clostridium difficile. We conducted a retrospective case-control study by selecting patients who underwent a surgical procedure between January 1, 2012 and December 31, 2013. Large urban community hospital. Cases and controls were patients age 18+ years who underwent an eligible surgery (i.e., colorectal, neurosurgery, vascular/cardiac/thoracic, hysterectomy, abdominal/pelvic and orthopedic surgical procedures) within six months prior to infection diagnosis. Cases were diagnosed with C. difficile infection while controls were not. The primary exposure was receiving (vs. not receiving) the recommended prophylactic antibiotic regimen, based on type and duration. Potential confounders included age, sex, length of hospital stay, comorbidities, type of surgery, and prior antibiotic use. Crude and adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated using logistic regression. We enrolled 68 cases and 220 controls. The adjusted OR among surgical patients between developing C. difficile infection and not receiving the recommended prophylactic antibiotic regimen (usually receiving antimicrobial prophylaxis for more than 24 hours) was 6.7 (95% CI: 2.9-15.5). Independent risk factors for developing C. difficile infection included having severe comorbidities, receiving antibiotics within the previous 6 months, and undergoing orthopedic surgery. Adherence to the recommended prophylactic antibiotics among surgical patients likely reduces the probability of being case of C. difficile. Antibiotic stewardship should be a priority in strategies to decrease the morbidity, mortality, and costs associated with C. difficile infection.

  10. Kyphectomy in meningomyelocele children: surgical technique, risk analysis, and improvement of kyphosis.

    PubMed

    de Amoreira Gepp, Ricardo; Quiroga, Marco Rolando Sainz; Gomes, Cícero Ricardo; de Araújo, Hugo José

    2013-07-01

    Kyphosis is a major complication of spina bifida, causing skin ulcers and osteomyelitis. This study examined the clinical and surgical characteristics of eight patients who underwent surgery, as well as improvement of their postoperative kyphosis angulations. The authors reviewed eight cases submitted to surgery between 2006 and 2010. Surgical intervention was indicated for osteomyelitis and recurrent ulcers at the curvature apex. Osteotomies and spine stabilization were performed. The patients' clinical characteristics were analyzed, as were the surgical techniques employed, variables of surgical complications, and angle range of the kyphosis deformity postcorrection. There were no deaths. The average age at the time of surgery was 11 years old. The level of neurological injury was T10 in four patients and T12 in four. Average amount of bleeding during surgery was 1,442 ml, (range, 340 to 3,200 ml). Improvement of kyphosis angle was evident in all patients. The average difference between preoperative and postoperative kyphosis angle was 63.2. Surgery performed by a multidisciplinary team minimizes risks. Despite the high number of complications published in the literature, the results found in this study were excellent with regards to improving kyphosis angle, as well as facilitating rehabilitation and daily care of children.

  11. Prevalence of Recent Antimicrobial Exposure among Elective Surgical Patients.

    PubMed

    Guidry, Christopher A; Sawyer, Robert G

    2017-10-01

    The annual prevalence of antimicrobial exposure is high in the outpatient setting and should be a common exposure for surgical patients. Antimicrobials have negative side effects and may be associated with poor outcomes. Logically, one would expect surgical patients to be particularly susceptible to any negative effects of recent antimicrobial exposure. Despite these observations, however, the prevalence of recent antimicrobial exposure among surgical patients remains undefined. The purpose of this study is to define the prevalence of antimicrobial exposure in patients undergoing elective surgical procedures. Patients presenting for elective operations between August 4, 2015 and August 3, 2016 at our institution were asked prospectively about any antimicrobial exposure in the previous three months. Answers were recorded as either Yes, No, or Unsure. Patients were grouped according to age, American Society of Anesthesiologists (ASA) score, primary operative service, and post-operative destination. Descriptive statistics were employed using simple percentages and chi-square analysis when appropriate. Cochrane-Armitage test was used to evaluate temporal trends. There were 21,473 elective surgical procedures performed during the study period across 13 operative services. Answers were recorded for 91.2% cases. The overall prevalence of exposure during this period was 28.6%. Exposure varied with age, ASA score, and surgical specialty. Vascular and transplant operations had the highest prevalence of exposure while ophthalmology and pediatric orthopedic procedures had the lowest. Patients with recent antimicrobial exposure were less likely to be discharged home on the same day and more likely to be admitted to an intensive care or intermediate care unit than those who denied recent exposure. In this descriptive analysis, the prevalence of recent antimicrobial exposure is overall approximately 28.6% and is higher than anticipated. Further work is needed to determine to what

  12. Incidence, prevalence and risk factors for post-surgical hypocalcaemia and hypoparathyroidism

    PubMed Central

    Edafe, Ovie

    2017-01-01

    Hypocalcaemia following thyroid surgery is common and is associated with significant short and long term morbidity. Damage to or devascularisation of parathyroid glands is the predominant underlying mechanism; although other factors such as hungry bone syndrome may occasionally contribute to it in the immediate post-operative period. The reported incidence of post-surgical hypocalcaemia and/or hypoparathyroidism (PoSH) varies significantly in the literature; the variation thought to be at least partly due to differences in the definitions used. Figures on the prevalence of chronic or long term post-surgical hypocalcaemia in the population are unclear. Risk factors for PoSH have been extensively studied in recent years and may be classified into patient, disease and surgery related factors. Some risk factors are modifiable; but both modifiable and non-modifiable factors help in generating a risk profile that may be used to select patients for preventative measures and/or changes in surgical strategy. This narrative review discusses recent literature on the incidence, prevalence and risk factors for PoSH. PMID:29322023

  13. Surgical management of patients with primary brain tumors.

    PubMed

    Bohan, Eileen; Glass-Macenka, Deanna

    2004-11-01

    To provide an overview of the diagnostic work-up, intraoperative technologies, postoperative treatment options, and investigational new therapies in patients with malignant brain tumors. Published textbooks and articles and other reference materials. Recent improvements in diagnostic and surgical equipment have influenced outcomes and overall quality of life for patients with central nervous system tumors. The ability to more accurately target and more safely remove brain tumors has enhanced the postoperative period and decreased hospital stays. However, malignant neoplasms continue to be refractory to current treatments, necessitating innovative surgical approaches at the time of initial diagnosis and at tumor recurrence. Nurses with an understanding of current diagnostic and surgical treatment modalities for brain tumors are able to provide accurate patient education and comprehensive care, enhancing the overall hospital and outpatient experience.

  14. Participation of family members and quality of patient care - the perspective of adult surgical patients.

    PubMed

    Leino-Kilpi, Helena; Gröndahl, Weronica; Katajisto, Jouko; Nurminen, Matti; Suhonen, Riitta

    2016-08-01

    The aim of this study is to describe the participation of family members in the care of Finnish adult surgical patients and the connection of the participation with the quality of patient care as perceived by surgical patients. The family members of adult surgical patients are important. Earlier studies vary concerning the nature of participation, its meaning and the connection of participation with patient-centred quality of care. In this study, we aim to produce new knowledge about adult surgical patients whose family members have participated in their care. This was a cross-sectional descriptive survey study. The data were collected among adult surgical patients (N = 481) before being discharged home from hospital with two instruments: the Good Nursing Care scale and the Received Knowledge of Hospital Patients. Based on the results, most adult surgical patients report that family members participate in their care. Participation was connected with received knowledge and preconditions of care, which are components of the quality of patient care. In future, testing of different solutions for improving the participation of surgical patients' family members in patient care should be implemented. Furthermore, the preconditions of family members' participation in care and the concept of participation should be analysed to emphasise the active role of family members. The results emphasised the importance of family members for the patients in surgical care. Family members' participation is connected with the quality of patient care. © 2016 John Wiley & Sons Ltd.

  15. Risk of surgical glove perforation in oral and maxillofacial surgery.

    PubMed

    Kuroyanagi, N; Nagao, T; Sakuma, H; Miyachi, H; Ochiai, S; Kimura, Y; Fukano, H; Shimozato, K

    2012-08-01

    Oral and maxillofacial surgery, which involves several sharp instruments and fixation materials, is consistently at a high risk for cross-contamination due to perforated gloves, but it is unclear how often such perforations occur. This study aimed to address this issue. The frequency of the perforation of surgical gloves (n=1436) in 150 oral and maxillofacial surgeries including orthognathic surgery (n=45) was assessed by the hydroinsufflation technique. Orthognathic surgery had the highest perforation rate in at least 1 glove in 1 operation (91.1%), followed by cleft lip and palate surgery (55.0%), excision of oral soft tumour (54.5%) and dental implantation (50.0%). The perforation rate in scrub nurses was 63.4%, followed by 44.4% in surgeons and first assistants, and 16.3% in second assistants. The odds ratio for the perforation rate in orthognathic surgery versus other surgeries was 16.0 (95% confidence interval: 5.3-48.0). The protection rate offered by double gloving in orthognathic surgery was 95.2%. These results suggest that, regardless of the surgical duration and blood loss in all fields of surgery, orthognathic surgery must be categorized in the highest risk group for glove perforation, following gynaecological and open lung surgery, due to the involvement of sharp objects. Copyright © 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

  16. Surgical outcome in patients with epilepsy and dual pathology.

    PubMed

    Li, L M; Cendes, F; Andermann, F; Watson, C; Fish, D R; Cook, M J; Dubeau, F; Duncan, J S; Shorvon, S D; Berkovic, S F; Free, S; Olivier, A; Harkness, W; Arnold, D L

    1999-05-01

    High-resolution MRI can detect dual pathology (an extrahippocampal lesion plus hippocampal atrophy) in about 5-20% of patients with refractory partial epilepsy referred for surgical evaluation. We report the results of 41 surgical interventions in 38 adults (mean age 31 years, range 14-63 years) with dual pathology. Three patients had two operations. The mean postoperative follow-up was 37 months (range 12-180 months). The extrahippocampal lesions were cortical dysgenesis in 15, tumour in 10, contusion/infarct in eight and vascular malformation in five patients. The surgical approach aimed to remove what was considered to be the most epileptogenic lesion, and the 41 operations were classified into lesionectomy (removal of an extrahippocampal lesion); mesial temporal resection (removal of an atrophic hippocampus); and lesionectomy plus mesial temporal resection (removal of both the lesion and the atrophic hippocampus). Lesionectomy plus mesial temporal resection resulted in complete freedom from seizures in 11/15 (73%) patients, while only 2/10 (20%) patients who had mesial temporal resection alone and 2/16 (12.5%) who had a lesionectomy alone were seizure-free (P < 0.001). When classes I and II were considered together results improved to 86, 30 and 31%, respectively. Our findings indicate that in patients with dual pathology removal of both the lesion and the atrophic hippocampus is the best surgical approach and should be considered whenever possible.

  17. Prolonged Operative Duration Increases Risk of Surgical Site Infections: A Systematic Review

    PubMed Central

    Chen, Brian Po-Han; Soleas, Ireena M.; Ferko, Nicole C.; Cameron, Chris G.; Hinoul, Piet

    2017-01-01

    Abstract Background: The incidence of surgical site infection (SSI) across surgical procedures, specialties, and conditions is reported to vary from 0.1% to 50%. Operative duration is often cited as an independent and potentially modifiable risk factor for SSI. The objective of this systematic review was to provide an in-depth understanding of the relation between operating time and SSI. Patients and Methods: This review included 81 prospective and retrospective studies. Along with study design, likelihood of SSI, mean operative times, time thresholds, effect measures, confidence intervals, and p values were extracted. Three meta-analyses were conducted, whereby odds ratios were pooled by hourly operative time thresholds, increments of increasing operative time, and surgical specialty. Results: Pooled analyses demonstrated that the association between extended operative time and SSI typically remained statistically significant, with close to twice the likelihood of SSI observed across various time thresholds. The likelihood of SSI increased with increasing time increments; for example, a 13%, 17%, and 37% increased likelihood for every 15 min, 30 min, and 60 min of surgery, respectively. On average, across various procedures, the mean operative time was approximately 30 min longer in patients with SSIs compared with those patients without. Conclusions: Prolonged operative time can increase the risk of SSI. Given the importance of SSIs on patient outcomes and health care economics, hospitals should focus efforts to reduce operative time. PMID:28832271

  18. [Surgical technique in patients with chronic pancreatitis].

    PubMed

    Pronin, N A; Natalskiy, A A; Tarasenko, S V; Pavlov, A V; Fedoseev, V A

    To justify ligation of vascular branches of anterior pancreateroduodenal arterial arch or gastroduodenal artery prior to bifurcation. This method was tested on sufficient clinical material: 147 patients with recurrent chronic pancreatitis. The interventions are presented by Frey, Beger procedures and its Berne variant. Comparative analysis showed reliable advantages of vascular ligation during pancreatectomy.

  19. Is there a Relationship between Patient Satisfaction and Favorable Surgical Outcomes?

    PubMed Central

    Tevis, Sarah E.; Kennedy, Gregory D.; Kent, K. Craig

    2015-01-01

    Summary Satisfaction of patients with their health care is gaining importance as a measure of hospital quality due to public reporting of these values and an increasing connection between hospital reimbursement and scores on the current tool to measure satisfaction, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. We found that high hospital and surgical volume and low rates of risk-adjusted mortality are associated with high patient satisfaction. However, other favorable patient outcomes are not consistently associated with positive satisfaction scores on HCAHPS. Contributors to patients' perceptions of their care are likely multifactorial and not related just to outcomes traditionally assessed by surgeons or hospitals. Moving in a direction of patient centered care, with a focus on increased understanding and involvement of patients in the care process, will likely strengthen the relationship between surgical outcomes and patient satisfaction. PMID:26299501

  20. Surgical Face Masks Worn by Patients with Multidrug-Resistant Tuberculosis

    PubMed Central

    Mphahlele, Matsie; Stoltz, Anton; Venter, Kobus; Mathebula, Rirhandzu; Masotla, Thabiso; Lubbe, Willem; Pagano, Marcello; First, Melvin; Jensen, Paul A.; van der Walt, Martie; Nardell, Edward A.

    2012-01-01

    Rationale: Drug-resistant tuberculosis transmission in hospitals threatens staff and patient health. Surgical face masks used by patients with tuberculosis (TB) are believed to reduce transmission but have not been rigorously tested. Objectives: We sought to quantify the efficacy of surgical face masks when worn by patients with multidrug-resistant TB (MDR-TB). Methods: Over 3 months, 17 patients with pulmonary MDR-TB occupied an MDR-TB ward in South Africa and wore face masks on alternate days. Ward air was exhausted to two identical chambers, each housing 90 pathogen-free guinea pigs that breathed ward air either when patients wore surgical face masks (intervention group) or when patients did not wear masks (control group). Efficacy was based on differences in guinea pig infections in each chamber. Measurements and Main Results: Sixty-nine of 90 control guinea pigs (76.6%; 95% confidence interval [CI], 68–85%) became infected, compared with 36 of 90 intervention guinea pigs (40%; 95% CI, 31–51%), representing a 56% (95% CI, 33–70.5%) decreased risk of TB transmission when patients used masks. Conclusions: Surgical face masks on patients with MDR-TB significantly reduced transmission and offer an adjunct measure for reducing TB transmission from infectious patients. PMID:22323300

  1. A Comparison of Costs Between Medical and Surgical Patients in an Academic Pediatric Intensive Care Unit.

    PubMed

    Hsu, Benson S; Brazelton, Thomas B

    2015-12-01

    To estimate the impact of patient type on costs incurred during a pediatric intensive care unit (PICU) hospitalization. Retrospective cohort study at an academic PICU located in the United States that examined 850 patients admitted to the PICU from January 1 to December 31, 2009. Forty-eight patients were excluded due to lack of financial data. Primary service was defined by the attending physician of record. Outcome measures were total and daily pediatric intensive care costs (2009 US dollars). Of 802 patients in the sample, there were 361 medical and 441 surgical patients. Comparing medical to surgical patients, severity of illness as defined by Pediatric Risk of Mortality (PRISM) III scores was 4.53 vs 2.08 (P < 0.001), length of stay was 7.37 vs 5.00 days (P < 0.001), total pediatric intensive care hospital costs were $34,786 vs $30,598 (P < 0.001), and mean daily pediatric intensive care hospital costs were $3985 vs $6616 (P < 0.001). Medical patients had higher severity of illness and length of stay resulting in higher total pediatric intensive care costs when compared to surgical patients. Interestingly, when accounting the length of stay, surgical patients had higher daily pediatric intensive care costs despite lower severity of illness.

  2. Factors that increase diagnostic yield of surgical lung biopsy in pediatric oncology patients.

    PubMed

    Acker, Shannon N; Gonzales, Danielle; Ross, James T; Dishop, Megan K; Deterding, Robin R; Partrick, David A

    2015-09-01

    Recent data demonstrate that surgical lung biopsy in immunocompromised children, including oncology patients, alters therapy in only 50% of cases. We hypothesized that there are factors identifiable preoperatively which can predict the patients who will or will not benefit from surgical biopsy. We reviewed the medical records of all children with malignancy who underwent surgical lung biopsy between 2004 and 2013 at a single institution, excluding those children who had previously undergone a solid organ or bone marrow transplant. Eighty lung wedge biopsies were performed (median age 13 years, IQR 5.25-16; 63% male, n=50) 53 (66%) of which led to a change in patient management. The majority of biopsies were performed to diagnose a new mass or differentiate infection from metastases (mass group) (n=68, 85%), and 12 biopsies (15%) were performed to diagnose a known infection for antibiotic guidance (infection group). Children in the infection group were more likely to be febrile preoperatively, were more likely to be an inpatient preoperatively, and had a lower absolute neutrophil count at the time of biopsy. Patients in the infection group had higher postoperative mortality rates and higher rates of major complications. In pediatric oncology patients, surgical lung biopsy has a lower diagnostic yield and higher complication rate when performed for antibiotic guidance. Prior to proceeding with biopsy in this high-risk patient population, surgeons and oncologists should carefully weigh the potential risks and benefits. Copyright © 2015 Elsevier Inc. All rights reserved.

  3. Surgical risk factors for recurrence of inverted papilloma.

    PubMed

    Healy, David Y; Chhabra, Nipun; Metson, Ralph; Holbrook, Eric H; Gray, Stacey T

    2016-04-01

    To identify variations in surgical technique that impact the recurrence of inverted papilloma following endoscopic excision. Retrospective cohort. Data from 127 consecutive patients who underwent endoscopic excision of inverted papilloma and oncocytic papilloma at a tertiary care medical center from 1998 to 2011 were reviewed. Patient demographics, comorbidities, tumor stage, and intraoperative details, including tumor location and management of the base, were evaluated to identify factors associated with tumor recurrence. Recurrence of papilloma occurred in 16 patients (12.6%). Mean time to recurrence was 31.0 months (range, 5.2-110.0 months). Mucosal stripping alone was associated with a recurrence rate of 52.2% (12/23 patients), compared to 4.9% (3/61 patients) when the tumor base was drilled, 4.7% (1/21 patients) when it was cauterized, and 0.0% (0/22 patients) when it was completely excised (P = .001). Increased recurrence rate was associated with tumors located in the maxillary sinus (P = .03), as well as the performance of endoscopic medial maxillectomy (P = .001) and external frontal approaches (P = .02). Drilling, cauterizing, or completely excising the bone underlying the tumor base during endoscopic resection reduces the recurrence rate of inverted and oncocytic papilloma, when compared to mucosal stripping alone. Surgeons who perform endoscopic resection of these tumors should consider utilization of these techniques when possible. 4. © 2015 The American Laryngological, Rhinological and Otological Society, Inc.

  4. Surgical Outcomes in Vedolizumab-Treated Patients with Ulcerative Colitis.

    PubMed

    Lightner, Amy L; McKenna, Nicholas P; Moncrief, Sara; Pemberton, John H; Raffals, Laura E; Mathis, Kellie L

    2017-12-01

    Surgical outcomes and pouch outcomes in the setting of vedolizumab remains poorly understood. We sought to determine the rate of 30-day postoperative surgical infectious complications and pouch-specific complications among patients with ulcerative colitis (UC) who received vedolizumab within 12 weeks of surgery. A retrospective chart review between 5/1/2014 and 12/31/2016 of all adult patients with UC who underwent an abdominal operation was performed. Patients with UC who received vedolizumab within 12 weeks of their abdominal operation were compared with patients with UC on anti-TNFα treatment. Eighty-eight patients received vedolizumab and 62 received anti-TNFα within 12 weeks of surgery. More vedolizumab-treated patients had superficial surgical site infections (P = 0.047) and mucocutaneous separation at the ileostomy (P = 0.047), but there was no difference in the overall surgical infectious complication rate, deep space SSI, 30-day hospital readmission or return to the operating room. On univariate analysis of SSI among patients with UC, exposure to vedolizumab was not a significant predictor of SSI (P = 0.27), but steroids were predictive of SSI on univariate (P = 0.02) and multivariable analysis (P = 0.02). After ileal pouch anal anastomosis, there was a higher rate of intra-abdominal abscesses (31.3% versus 5.9%) and mucocutaneous separation (18.8% versus 0%) in the vedolizumab group compared with the anti-TNFα group, but statistical significance was not reached. Vedolizumab patients had significantly increased rates of superficial SSI, but not overall infectious complications. Among ileal pouch anal anastomosis patients, peripouch abscess rates were increased among vedolizumab-treated patients, but this did not reach statistical significance. Vedolizumab seems safe in the perioperative period for patients with UC.

  5. Endovascular Versus Open Surgical Intervention in Patients with Takayasu's Arteritis: A Meta-analysis.

    PubMed

    Jung, Jae Hyun; Lee, Young Ho; Song, Gwan Gyu; Jeong, Han Saem; Kim, Jae-Hoon; Choi, Sung Jae

    2018-06-01

    Although medical treatment has advanced, surgical treatment is needed to control symptoms of Takayasu's arteritis (TA), such as angina, stroke, hypertension, or claudication. Endovascular or open surgical intervention is performed; however, there are few comparative studies on these methods. This meta-analysis and systematic review aimed to examine the outcome of surgical treatment of TA. A meta-analysis comparing outcomes of endovascular and open surgical intervention was performed using MEDLINE and Embase. This meta-analysis included only observational studies, and the evidence level was low to moderate. Data were pooled and analysed using a fixed or random effects model with the I 2 statistic. The included studies involved a total of 770 patients and 1363 lesions, with 389 patients treated endovascularly and 420 treated by surgical revascularization. Restenosis was more common with endovascular than open surgical intervention (odds ratio [OR] 5.18, 95% confidence interval [CI] 2.78-9.62; p < .001). In subgroup analysis according to the involved lesions, endovascular intervention patients showed more restenosis than open surgical intervention patients in the coronary artery, supra-aortic branches, and renal artery. In both the active and inactive stages, restenosis was more common in those treated endovascularly than in those treated by open surgery. However, stroke occurred less often with endovascular intervention than with open surgical intervention (OR 0.33, 95% CI 0.12-0.90; p = .003). Mortality and complications other than stroke and mortality did not differ between endovascular and open surgical intervention. This meta-analysis has shown a lower risk of restenosis with open surgical intervention than with endovascular intervention. Stroke was generally more common with open surgical intervention than with endovascular intervention. However, there were differences according to the location of the lesion, and the risk of stroke in open surgery is higher

  6. An Online Tool for Global Benchmarking of Risk-Adjusted Surgical Outcomes.

    PubMed

    Spence, Richard T; Chang, David C; Chu, Kathryn; Panieri, Eugenio; Mueller, Jessica L; Hutter, Matthew M

    2017-01-01

    Increasing evidence demonstrates significant variation in adverse outcomes following surgery between countries. In order to better quantify these variations, we hypothesize that freely available online risk calculators can be used as a tool to generate global benchmarking of risk-adjusted surgical outcomes. This is a prospective cohort study conducted at an academic teaching hospital in South Africa (GSH). Consecutive adult patients undergoing major general or vascular surgery who met the ACS-NSQIP inclusion criteria for a 3-month period were included. Data variables required by the ACS risk calculator were prospectively collected, and patients were followed for 30 days post-surgery for the occurrence of endpoints. Calculating observed-to-expected ratios for ten outcome measures of interest generated risk-adjusted outcomes benchmarked against the ACS-NSQIP consortium. A total of 373 major general and vascular surgery procedures met the inclusion criteria. The GSH operative cohort varied significantly compared to the 2012 ACS-NSQIP database. The risk-adjusted O/E ratios were significant for any complication O/E 1.91 (95 % CI 1.57-2.31), surgical site infections O/E 4.76 (95 % CI 3.71-6.01), renal failure O/E 3.29 (95 % CI 1.50-6.24), death O/E 3.43 (95 % CI 2.19-5.11), and total length of stay (LOS) O/E 3.43 (95 % CI 2.19-5.11). Freely available online risk calculators can be utilized as tools for global benchmarking of risk-adjusted surgical outcomes.

  7. Information Needs of Hepato-Pancreato-Biliary Surgical Oncology Patients.

    PubMed

    Gillespie, Jacqueline; Kacikanis, Anna; Nyhof-Young, Joyce; Gallinger, Steven; Ruthig, Elke

    2017-09-01

    A marked knowledge gap exists concerning the information needs of hepato-pancreato-biliary (HPB) surgical oncology patients. We investigated the comprehensive information needs of this patient population, including the type and amount of information desired, as well as the preferred method of receiving information. A questionnaire was administered to patients being treated surgically for cancers of the liver, pancreas, gallbladder, or bile ducts at Toronto General Hospital, part of the University Health Network, in Toronto, Canada. The questionnaire examined patients' information needs across six domains of information: medical, practical, physical, emotional, social, and spiritual. Among 36 respondents, the importance of information and amount of information desired differed significantly by domain (both p < 0.001). This group of patients rated information in the medical and physical domains as most important, though they also desired specific items of information from the emotional, practical, and social domains. Patients' overwhelming preference was to receive information via a one-on-one consultation with a healthcare provider. It is important for healthcare providers working with HPB surgical oncology patients to be comprehensive when providing information related to patients' cancer diagnosis, prognosis, associated symptoms, and side effects of treatment. Certain emotional, practical, and social issues (e.g., fears of cancer recurrence, drug coverage options, relationship changes) should be addressed as well. Face-to-face interactions should be the primary mode of delivering information to patients. Our findings are being used to guide the training of healthcare providers and the development of educational resources specific to HPB surgical oncology patients.

  8. The power of the National Surgical Quality Improvement Program--achieving a zero pneumonia rate in general surgery patients.

    PubMed

    Fuchshuber, Pascal R; Greif, William; Tidwell, Chantal R; Klemm, Michael S; Frydel, Cheryl; Wali, Abdul; Rosas, Efren; Clopp, Molly P

    2012-01-01

    The National Surgical Quality Improvement Program (NSQIP) of the American College of Surgeons provides risk-adjusted surgical outcome measures for participating hospitals that can be used for performance improvement of surgical mortality and morbidity. A surgical clinical nurse reviewer collects 135 clinical variables including preoperative risk factors, intraoperative variables, and 30-day postoperative mortality and morbidity outcomes for patients undergoing major surgical procedures. A report on mortality and complications is prepared twice a year. This article summarizes briefly the history of NSQIP and how its report on surgical outcomes can be used for performance improvement within a hospital system. In particular, it describes how to drive performance improvement with NSQIP data using the example of postoperative respiratory complications--a major factor of postoperative mortality. In addition, this article explains the benefit of a collaborative of several participating NSQIP hospitals and describes how to develop a "playbook" on the basis of an outcome improvement project.

  9. Failure to Redose Antibiotic Prophylaxis in Long Surgery Increases Risk of Surgical Site Infection.

    PubMed

    Kasatpibal, Nongyao; Whitney, Joanne D; Dellinger, E Patchen; Nair, Bala G; Pike, Kenneth C

    Antibiotic prophylaxis is a key component of the prevention of surgical site infection (SSI). Failure to manage antibiotic prophylaxis effectively may increase the risk of SSI. This study aimed to examine the effects of antibiotic prophylaxis on SSI risk. A retrospective cohort study was conducted among patients having general surgery between May 2012 and June 2015 at the University of Washington Medical Center. Peri-operative data extracted from hospital databases included patient and operation characteristics, intra-operative medication and fluid administration, and survival outcome. The effects of antibiotic prophylaxis and potential factors on SSI risk were estimated using multiple logistic regression and were expressed as risk ratios (RRs). A total of 4,078 patients were eligible for analysis. Of these, 180 had an SSI. Mortality rates within and after 30 days were 0.8% and 0.3%, respectively. Improper antibiotic redosing increased the risk of SSI (RR 4.61; 95% confidence interval [CI] 1.33-15.91). Other risk factors were in-patient status (RR 4.05; 95% CI 1.69-9.66), smoking (RR 1.63; 95% CI 1.03-2.55), emergency surgery (RR 1.97; 95% CI 1.26-3.08), colectomy (RR 3.31; 95% CI 1.19-9.23), pancreatectomy (RR 4.52; 95% CI 1.53-13.39), proctectomy (RR 5.02; 95% CI 1.72-14.67), small bowel surgery (RR 6.16; 95% CI 2.13-17.79), intra-operative blood transfusion >500 mL (RR 2.76; 95% CI 1.45-5.26), and multiple procedures (RR 1.40; 95% CI 1.01-1.95). These data demonstrate that failure to redose prophylactic antibiotic during long operations increases the risk of SSI. Strengthening a collaborative surgical quality improvement program may help to eradicate this risk.

  10. Combining the ASA Physical Classification System and Continuous Intraoperative Surgical Apgar Score Measurement in Predicting Postoperative Risk.

    PubMed

    Jering, Monika Zdenka; Marolen, Khensani N; Shotwell, Matthew S; Denton, Jason N; Sandberg, Warren S; Ehrenfeld, Jesse Menachem

    2015-11-01

    The surgical Apgar score predicts major 30-day postoperative complications using data assessed at the end of surgery. We hypothesized that evaluating the surgical Apgar score continuously during surgery may identify patients at high risk for postoperative complications. We retrospectively identified general, vascular, and general oncology patients at Vanderbilt University Medical Center. Logistic regression methods were used to construct a series of predictive models in order to continuously estimate the risk of major postoperative complications, and to alert care providers during surgery should the risk exceed a given threshold. Area under the receiver operating characteristic curve (AUROC) was used to evaluate the discriminative ability of a model utilizing a continuously measured surgical Apgar score relative to models that use only preoperative clinical factors or continuously monitored individual constituents of the surgical Apgar score (i.e. heart rate, blood pressure, and blood loss). AUROC estimates were validated internally using a bootstrap method. 4,728 patients were included. Combining the ASA PS classification with continuously measured surgical Apgar score demonstrated improved discriminative ability (AUROC 0.80) in the pooled cohort compared to ASA (0.73) and the surgical Apgar score alone (0.74). To optimize the tradeoff between inadequate and excessive alerting with future real-time notifications, we recommend a threshold probability of 0.24. Continuous assessment of the surgical Apgar score is predictive for major postoperative complications. In the future, real-time notifications might allow for detection and mitigation of changes in a patient's accumulating risk of complications during a surgical procedure.

  11. Surgical myocardial revascularization in patients with reduced systolic left ventricular function.

    PubMed

    Bruno, Piergiorgio; Iafrancesco, Mauro; Massetti, Massimo

    2018-04-20

    Surgical myocardial revascularization in patients with reduced left ventricular function has been a matter of debate for decades. Recently published 10-years extension follow-up of the STICH trial have conclusively demonstrated benefit of surgical myocardial revascularization in patients with significant coronary artery disease and low left ventricular ejection fraction. However, selection of patients for surgery remains challenging as well as decision to perform percutaneous rather than surgical revascularization in this class of patients. New evidence helped to clarify the role of preoperative patients' characteristics as risk factors for surgery and to identify those patients who may benefit the most from surgery. Focus of this review is to review epidemiology, aetiology and pathophysiology of coronary artery disease in patients with reduced left ventricular function, role of viability and results of observational and investigational studies on revascularization in patients with reduced left ventricular function with a particular emphasis on relative indication of coronary artery bypass grafting and percutaneous coronary intervention and the surgical implications of development of ischemic mitral regurgitation or ischemic left ventricular aneurysm.

  12. Anesthetic issues and perioperative blood pressure management in patients who have cerebrovascular diseases undergoing surgical procedures.

    PubMed

    Jellish, W Scott

    2006-11-01

    Patients who have cerebrovascular disease and vascular insufficiency routinely have neurosurgical and nonneurosurgical procedures. Anesthetic priorities must provide a still bloodless operative field while maintaining cardiovascular stability and renal function. Patients who have symptoms or a history of cerebrovascular disease are at increased risk for stroke, cerebral hypoperfusion, and cerebral anoxia. Type of surgery and cardiovascular status are key concerns when considering neuroprotective strategies. Optimization of current condition is important for a good outcome; risks must be weighed against perceived benefits in protecting neurons. Anesthetic use and physiologic manipulations can reduce neurologic injury and assure safe and effective surgical care when cerebral hypoperfusion is a real and significant risk.

  13. Rates and risk factors of unplanned 30-day readmission following general and thoracic pediatric surgical procedures.

    PubMed

    Polites, Stephanie F; Potter, Donald D; Glasgow, Amy E; Klinkner, Denise B; Moir, Christopher R; Ishitani, Michael B; Habermann, Elizabeth B

    2017-08-01

    Postoperative unplanned readmissions are costly and decrease patient satisfaction; however, little is known about this complication in pediatric surgery. The purpose of this study was to determine rates and predictors of unplanned readmission in a multi-institutional cohort of pediatric surgical patients. Unplanned 30-day readmissions following general and thoracic surgical procedures in children <18 were identified from the 2012-2014 National Surgical Quality Improvement Program- Pediatric. Time-dependent rates of readmission per 30 person-days were determined to account for varied postoperative length of stay (pLOS). Patients were randomly divided into 70% derivation and 30% validation cohorts which were used for creation and validation of a risk model for readmission. Readmission occurred in 1948 (3.6%) of 54,870 children for a rate of 4.3% per 30 person-days. Adjusted predictors of readmission included hepatobiliary procedures, increased wound class, operative duration, complications, and pLOS. The predictive model discriminated well in the derivation and validation cohorts (AUROC 0.710 and 0.701) with good calibration between observed and expected readmission events in both cohorts (p>.05). Unplanned readmission occurs less frequently in pediatric surgery than what is described in adults, calling into question its use as a quality indicator in this population. Factors that predict readmission including type of procedure, complications, and pLOS can be used to identify at-risk children and develop prevention strategies. III. Copyright © 2017 Elsevier Inc. All rights reserved.

  14. [Cervical spine instability in the surgical patient].

    PubMed

    Barbeito, A; Guerri-Guttenberg, R A

    2014-03-01

    Many congenital and acquired diseases, including trauma, may result in cervical spine instability. Given that airway management is closely related to the movement of the cervical spine, it is important that the anesthesiologist has detailed knowledge of the anatomy, the mechanisms of cervical spine instability, and of the effects that the different airway maneuvers have on the cervical spine. We first review the normal anatomy and biomechanics of the cervical spine in the context of airway management and the concept of cervical spine instability. In the second part, we review the protocols for the management of cervical spine instability in trauma victims and some of the airway management options for these patients. Copyright © 2013 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. All rights reserved.

  15. Characteristics of antibiotic prophylaxis and risk of surgical site infections in open colectomies

    PubMed Central

    Poeran, Jashvant; Wasserman, Isaac; Zubizarreta, Nicole; Mazumdar, Madhu

    2016-01-01

    Background Despite numerous trials assessing optimal antibiotic prophylaxis strategies for colorectal surgery, few studies have assessed real-world practice on a national scale with respect to risk of surgical site infections. Objective Using a large, national claims database we aimed to describe 1) current use of prophylactic antibiotics (type and duration) and 2) associations with surgical site infection after open colectomies. Design Retrospective study using the Premier Perspective database. Setting Patient hospitalizations nationwide from January 2006 to December 2013. Patients 90,725 patients that underwent an open colectomy in 445 different hospitals. Main Outcome Measures Multilevel multivariable logistic regressions measured associations between surgical site infection and 1) type of antibiotic used and 2) duration (day of surgery only, day of surgery and the day after, >1 day after surgery). Results Overall surgical site infection prevalence was 5.2% (n=4,750). Most patients (41.8%) received cefoxitin for prophylaxis; other choices were ertapenem (18.2%), cefotetan (10.3%), metronidazole+cefazolin (9.9%), ampicillin+sulbactam (7.6%), while 12.2% received other antibiotics. Distribution of prophylaxis duration was: 51.6%, 28.5%, and 19.9% for days 0, 0+1, and 1+, respectively. Compared to cefoxitin, lower odds for surgical site infection were observed for ampicillin+sulbactam (odds ratio 0.71; 95% confidence interval 0.63–0.82), ertapenem (odds ratio 0.65; 95% confidence interval 0.58–0.71) and metronidazole+cefazolin (odds ratio 0.56; 95% confidence interval 0.49–0.64), and “other” (odds ratio 0.81; 95% confidence interval 0.73–0.90); duration was not significantly associated with altered odds for surgical site infection. Sensitivity analyses supported the main findings. Limitations Lack of detailed clinical information in the billing dataset used. Conclusions In this national study assessing real-world use of prophylactic antibiotics in open

  16. Gross Instability After Hip Arthroscopy: An Analysis of Case Reports Evaluating Surgical and Patient Factors.

    PubMed

    Yeung, Marco; Memon, Muzammil; Simunovic, Nicole; Belzile, Etienne; Philippon, Marc J; Ayeni, Olufemi R

    2016-06-01

    Gross hip instability is a rare complication after hip arthroscopy, and there is limited literature surrounding this topic. This systematic review investigates cases of gross hip instability after arthroscopy and discusses the risk factors associated with this complication. A systematic search was performed in duplicate for studies investigating gross hip instability after hip arthroscopy up to October 2015. Study parameters including sample size, mechanism and type of dislocation, surgical procedure details, patient characteristics, postoperative rehabilitation protocol, and level of evidence were analyzed. The systematic review identified 9 case reports investigating gross hip instability after hip arthroscopy (10 patients). Anterior dislocation occurred in 66.7% of patients, and most injuries occurred with a low-energy mechanism. Common surgical factors cited included unrepaired capsulotomy (77.8%) and iliopsoas release (33.3%), whereas patient factors included female gender (77.8%), acetabular dysplasia (22.2%), and general ligamentous laxity (11.1%). Postoperative restrictions and protocols were variable and inconsistently reported, and their relation to post-arthroscopy instability was difficult to ascertain. This systematic review discussed various patient, surgical, and postoperative risk factors of gross hip instability after arthroscopy. Patient characteristics such as female gender, hip dysplasia, and ligamentous laxity may be risk factors for post-arthroscopy dislocation. Similarly, surgical risk factors for iatrogenic hip instability may include unrepaired capsulotomies and iliopsoas debridement, although the role of capsular closure in iatrogenic instability is not clear. The influences of postoperative restrictions and protocols on dislocation are also unclear in the current literature. Surgeons should be cognizant of these risk factors when performing hip arthroscopy and be mindful that these factors appear to occur in combination. Level IV

  17. East meets West: the influence of racial, ethnic and cultural risk factors on cardiac surgical risk model performance.

    PubMed

    Soo-Hoo, Sarah; Nemeth, Samantha; Baser, Onur; Argenziano, Michael; Kurlansky, Paul

    2018-01-01

    To explore the impact of racial and ethnic diversity on the performance of cardiac surgical risk models, the Chinese SinoSCORE was compared with the Society of Thoracic Surgeons (STS) risk model in a diverse American population. The SinoSCORE risk model was applied to 13 969 consecutive coronary artery bypass surgery patients from twelve American institutions. SinoSCORE risk factors were entered into a logistic regression to create a 'derived' SinoSCORE whose performance was compared with that of the STS risk model. Observed mortality was 1.51% (66% of that predicted by STS model). The SinoSCORE 'low-risk' group had a mortality of 0.15%±0.04%, while the medium-risk and high-risk groups had mortalities of 0.35%±0.06% and 2.13%±0.14%, respectively. The derived SinoSCORE model had a relatively good discrimination (area under of the curve (AUC)=0.785) compared with that of the STS risk score (AUC=0.811; P=0.18 comparing the two). However, specific factors that were significant in the original SinoSCORE but that lacked significance in our derived model included body mass index, preoperative atrial fibrillation and chronic obstructive pulmonary disease. SinoSCORE demonstrated limited discrimination when applied to an American population. The derived SinoSCORE had a discrimination comparable with that of the STS, suggesting underlying similarities of physiological substrate undergoing surgery. However, differential influence of various risk factors suggests that there may be varying degrees of importance and interactions between risk factors. Clinicians should exercise caution when applying risk models across varying populations due to potential differences that racial, ethnic and geographic factors may play in cardiac disease and surgical outcomes.

  18. Risk factors of surgical failure following sacrospinous colpopexy for the treatment of uterovaginal prolapse.

    PubMed

    Qatawneh, Ayman; Thekrallah, Fida; Bata, Majed; Al-Kazaleh, Fawaz; Almustafa, Mahmoud; Abu-Kader, Ilham

    2013-06-01

    Trans-vaginal sacrospinous colpopexy is one of the surgical procedures used to repair varying degrees of vaginal vault and uterovaginal prolapse. The purpose of this study is to analyse the potential risk factors of surgical failure following sacrospinous colpopexy. A retrospective study of 114 women who underwent unilateral sacrospinous colpopexy at Jordan University Hospital from January 2005 to January 2008 were included. Patient demographics, clinical characteristics and concomitant pelvic organ prolapse surgery were assessed. The patients were evaluated at 6 weeks, and every 6 months thereafter. Twelve (11 %) had recurrent apical (vaginal cuff) prolapse, 26 (23 %) had recurrent prolapse at any compartment were compared with those who had successful surgery. Univariate and logistic regression analyses were used to assess the independent prognostic values of the variables associated with surgical failure. After a mean follow-up of 40 months, the statistically significant predictors of surgical failure included the presence of advanced pre-operative stages of prolapse (stages III and IV), the more distally located points Ba, Bp and C and a lack of mesh augmentation of the anterior vaginal wall during surgery (P = 0.01, 0.027, 0.024, 0.034 and 0.006, respectively). However, a history of prior vaginal repair, the more distally located point Ba and a lack of anterior vaginal wall mesh augmentation were defined as independent predictive variables based on logistic regression analyses (P = 0.04, 0.005 and 0.046, respectively). The presence of advanced anterior vaginal wall prolapse, prior vaginal repair and a lack of mesh augmentation of the anterior compartment are significant risk factors for the surgical failure of sacrospinous suspension surgery.

  19. Refining Risk Adjustment for the Proposed CMS Surgical Hip and Femur Fracture Treatment Bundled Payment Program.

    PubMed

    Cairns, Mark A; Ostrum, Robert F; Clement, R Carter

    2018-02-21

    The U.S. Centers for Medicare & Medicaid Services (CMS) has been considering the implementation of a mandatory bundled payment program, the Surgical Hip and Femur Fracture Treatment (SHFFT) model. However, bundled payments without appropriate risk adjustment may be inequitable to providers and may restrict access to care for certain patients. The SHFFT proposal includes adjustment using the Diagnosis-Related Group (DRG) and geographic location. The goal of the current study was to identify and quantify patient factors that could improve risk adjustment for SHFFT bundled payments. We retrospectively reviewed a 5% random sample of Medicare data from 2008 to 2012. A total of 27,898 patients were identified who met SHFFT inclusion criteria (DRG 480, 481, and 482). Reimbursement was determined for each patient over the bundle period (the surgical hospitalization and 90 days of post-discharge care). Multivariable regression was performed to test demographic factors, comorbidities, geographic location, and specific surgical procedures for associations with reimbursement. The average reimbursement was $23,632 ± $17,587. On average, reimbursements for male patients were $1,213 higher than for female patients (p < 0.01). Younger age was also associated with higher payments; e.g., reimbursement for those ≥85 years of age averaged $2,282 ± $389 less than for those aged 65 to 69 (p < 0.01). Most comorbidities were associated with higher reimbursement, but dementia was associated with lower payments, by an average of $2,354 ± $243 (p < 0.01). Twenty-two procedure codes are included in the bundle, and patients with the 3 most common codes accounted for 98% of the cases, with average reimbursement ranging from $22,527 to $24,033. Less common procedures varied by >$20,000 in average reimbursement (p < 0.01). DRGs also showed significant differences in reimbursement (p < 0.01); e.g., DRG 480 was reimbursed by an average of $10,421 ± $543 more than DRG 482. Payments varied

  20. [Surgical risk of transfusion in a French Universitary Hospital].

    PubMed

    Puel, C; Ducharne, T; Mialon, A; Augey, L; Repellin, L; Corond, P; Magaud, J-P; Piriou, V

    2012-02-01

    Immunohaematology examinations are usually prescribed preoperatively according to more or less standardized protocols. We wanted to assess the relevance of these protocols on the basis of factual data: an overview of the rate of transfusions carried out as part of surgery within the HCL in 2009. The list of patients operated in 2009 in the HCL (IPOP by Cristalnet) has been combined with the list of patients transfused in the same time period (CTS server, Inlog). The percentage of patients transfused during the stay, and the percentage of patients transfused on the day of the intervention itself were determined for each type of surgery. The study focused on 13,571 patients affected by 44 surgeries. Six hundred and thirty-three patients were transfused, 45% of them the day of the intervention. The risk of needing to carry out a transfusion depends on the risk to the patient and surgery. For example, the total hip arthroplasty transfusion risk is 11.9% when it's programmed against 37.8% in emergency surgery. The transfusion risk of knee arthroscopies, osteosynthesis of wrist fracture, carpal canal surgeries and of appendectomies, thyroidectomies, herna repair surgeries are below 0.5%. The transfusion risk of colectomy is 18.1%. Thus, new recommendations for good clinical practices on the relevance of settled surgery-preoperative immunohematologic exams can be established. The emergency degree of the transfusion must be taken into account for such recommendation. Each hospital should perform its own cartography to justify its own protocols. Copyright © 2011 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.

  1. Patient views on financial relationships between surgeons and surgical device manufacturers

    PubMed Central

    Camp, Mark W.; Gross, Allan E.; McKneally, Martin F.

    2015-01-01

    Background Over the past decade, revelations of inappropriate financial relationships between surgeons and surgical device manufacturers have challenged the presumption that surgeons can collaborate with surgical device manufacturers without damaging public trust in the surgical profession. We explored postoperative Canadian patients’ knowledge and opinions about financial relationships between surgeons and surgical device manufacturers. Methods This complex issue was explored using qualitative methods. We conducted semistructured face-to-face interviews with postoperative patients in follow-up arthroplasty clinics at an academic hospital in Toronto, Canada. Interviews were audiotaped, transcribed and analyzed. Patient-derived concepts and themes were uncovered. Results We interviewed 33 patients. Five major themes emerged: 1) many patients are unaware of the existence of financial relationships between surgeons and surgical device manufacturers; 2) patients approve of financial relationships that support innovation and research but are opposed to relationships that involve financial incentives that benefit only the surgeon and the manufacturer; 3) patients do not support disclosure of financial relationships during the consent process as it may shift focus away from the more important risks; 4) patients support oversight at the professional level but reject the idea of government involvement in oversight; and 5) patients entrust their surgeons to make appropriate patient-centred choices. Conclusion This qualitative study deepens our understanding of financial relationships between surgeons and industry. Patients support relationships with industry that provide potential benefit to current or future patients. They trust our ability to self-regulate. Disclosure combined with appropriate oversight will strengthen public trust in professional collaboration with industry. PMID:26384147

  2. Regret in Surgical Decision Making: A Systematic Review of Patient and Physician Perspectives.

    PubMed

    Wilson, Ana; Ronnekleiv-Kelly, Sean M; Pawlik, Timothy M

    2017-06-01

    Regret is a powerful motivating factor in medical decision making among patients and surgeons. Regret can be particularly important for surgical decisions, which often carry significant risk and may have uncertain outcomes. We performed a systematic review of the literature focused on patient and physician regret in the surgical setting. A search of the English literature between 1986 and 2016 that examined patient and physician self-reported decisional regret was carried out using the MEDLINE/PubMed and Web of Science databases. Clinical studies performed in patients and physicians participating in elective surgical treatment were included. Of 889 studies identified, 73 patient studies and 6 physician studies met inclusion criteria. Among the 73 patient studies, 57.5% examined patients with a cancer diagnosis, with breast (26.0%) and prostate (28.8%) cancers being most common. Interestingly, self-reported patient regret was relatively uncommon with an average prevalence across studies of 14.4%. Factors most often associated with regret included type of surgery, disease-specific quality of life, and shared decision making. Only 6 studies were identified that focused on physician regret; 2 pertained to surgical decision making. These studies primarily measured regret of omission and commission using hypothetical case scenarios and used the results to develop decision curve analysis tools. Self-reported decisional regret was present in about 1 in 7 surgical patients. Factors associated with regret were both patient- and procedure related. While most studies focused on patient regret, little data exist on how physician regret affects shared decision making.

  3. Electronic patient data confidentiality practices among surgical trainees: questionnaire study.

    PubMed

    Mole, Damian J; Fox, Colin; Napolitano, Giulio

    2006-10-01

    The objective of this work was to evaluate the safeguards implemented by surgical trainees to protect the confidentiality of electronic patient data through a structured questionnaire sent to Northern Ireland surgical trainees. A group of 32 basic and higher surgical trainees attending a meeting of the Northern Ireland Association of Surgeons-in-Training were invited to complete a questionnaire regarding their computer use, UK Data Protection Act, 1988 registration and electronic data confidentiality practices. Of these 32 trainees, 29 returned completed questionnaires of whom 26 trainees regularly stored sensitive patient data for audit or research purposes on a computer. Only one person was registered under the Data Protection Act, 1988. Of the computers used to store and analyse sensitive data, only 3 of 14 desktops, 8 of 19 laptops and 3 of 14 hand-held computers forced a password logon. Of the 29 trainees, 16 used the same password for all machines, and 25 of 27 passwords were less than 8 characters long. Two respondents declined to reveal details of their secure passwords. Half of all trainees had never adjusted their internet security settings, despite all 14 desktops, 16 of 19 laptops and 5 of 14 hand-helds being routinely connected to the internet. Of the 29 trainees, 28 never encrypted their sensitive data files. Ten trainees had sent unencrypted sensitive patient data over the internet, using a non-secure server. Electronic data confidentiality practices amongst Northern Ireland surgical trainees are unsafe. Simple practical measures to safeguard confidentiality are recommended.

  4. Surgical care of the pediatric Crohn's disease patient.

    PubMed

    Stewart, Dylan

    2017-12-01

    Despite the significant advances in the medical management of inflammatory bowel disease over the last decade, surgery continues to play a major role in the management of pediatric Crohn's disease (CD). While adult and pediatric Crohn's disease may share many clinical characteristics, pediatric Crohn's patients often have a more aggressive phenotype, and the operative care given by the pediatric surgeon to the newly diagnosed Crohn's patient is very different in nature to the surgical needs of adult patients after decades of disease progression. Children also have the unique surgical indication of growth failure to consider in the overall clinical decision making. While surgery is never curative in CD, it has the ability to transform the disease process in children, and appropriately timed operations may have tremendous impact on a child's physical and mental maturation. This monograph aims to address the surgical care of Crohn's disease in general, with a specific emphasis on the surgical treatment of small intestinal and ileocecal involvement. Copyright © 2017 Elsevier Inc. All rights reserved.

  5. Surgical revision after percutaneous mitral valve repair by edge-to-edge device: when the strategy fails in the highest risk surgical population.

    PubMed

    Alozie, Anthony; Westphal, Bernd; Kische, Stephan; Kaminski, Alexander; Paranskaya, Liliya; Bozdag-Turan, Ilkay; Ortak, Jasmin; Schubert, Jochen; Steinhoff, Gustav; Ince, Hüseyin

    2014-07-01

    Percutaneous edge-to-edge devices for non-surgical repair of mitral valve regurgitation are under clinical evaluation in high-risk patients deemed not suitable for conventional surgery. To address guidelines for initial therapy decision, we here report on 13 cases of surgery after failed percutaneous edge-to-edge mitral valve repair or attempted repair, and discuss methodology and prognostic factors for operative outcome in this high-risk situation. Thirteen patients referred to our cardiothoracic unit after failed percutaneous mitral valve repair or attempted repair using the edge-to-edge technique, were treated surgically for mitral valve failure between June 2010 and December 2012. Pathology of mitral valve before and after interventional mitral valve repair (especially prevalent mode of failure) was evaluated and classified for each individual patient by echocardiography and intraoperative direct visualization. Number of implanted edge-to-edge devices were identified. Preoperative risk scores were matched with intraoperative observations and histopathological findings of valve tissue. Postoperative morbidity and mortality were analysed with respect to mitral valve and patient-related data. Three of 10 patients were referred with severe mitral valve regurgitation/stenosis after initially successful percutaneous edge-to-edge therapy or attempted therapy. In 3 patients, ≥ 2 edge-to-edge devices were implanted leading to very tight edge-to-edge leaflet connection and fibrosis. All patients underwent successful surgical mitral valve replacement and concomitant complete cardiac surgery (CABG, aortic or tricuspid valve surgery, ASD closure and pulmonary vein isolation for atrial fibrillation). The likelihood of repair was reduced with respect to multiple edge-to-edge technology. One device could not be harvested surgically because of embolization. One patient died on the second postoperative day due to sepsis with multiple organ failure. The remaining 12 patients

  6. Umbilical hernia in patients with liver cirrhosis: A surgical challenge

    PubMed Central

    Coelho, Julio C U; Claus, Christiano M P; Campos, Antonio C L; Costa, Marco A R; Blum, Caroline

    2016-01-01

    Umbilical hernia occurs in 20% of the patients with liver cirrhosis complicated with ascites. Due to the enormous intraabdominal pressure secondary to the ascites, umbilical hernia in these patients has a tendency to enlarge rapidly and to complicate. The treatment of umbilical hernia in these patients is a surgical challenge. Ascites control is the mainstay to reduce hernia recurrence and postoperative complications, such as wound infection, evisceration, ascites drainage, and peritonitis. Intermittent paracentesis, temporary peritoneal dialysis catheter or transjugular intrahepatic portosystemic shunt may be necessary to control ascites. Hernia repair is indicated in patients in whom medical treatment is effective in controlling ascites. Patients who have a good perspective to be transplanted within 3-6 mo, herniorrhaphy should be performed during transplantation. Hernia repair with mesh is associated with lower recurrence rate, but with higher surgical site infection when compared to hernia correction with conventional fascial suture. There is no consensus on the best abdominal wall layer in which the mesh should be placed: Onlay, sublay, or underlay. Many studies have demonstrated several advantages of the laparoscopic umbilical herniorrhaphy in cirrhotic patients compared with open surgical treatment. PMID:27462389

  7. Umbilical hernia in patients with liver cirrhosis: A surgical challenge.

    PubMed

    Coelho, Julio C U; Claus, Christiano M P; Campos, Antonio C L; Costa, Marco A R; Blum, Caroline

    2016-07-27

    Umbilical hernia occurs in 20% of the patients with liver cirrhosis complicated with ascites. Due to the enormous intraabdominal pressure secondary to the ascites, umbilical hernia in these patients has a tendency to enlarge rapidly and to complicate. The treatment of umbilical hernia in these patients is a surgical challenge. Ascites control is the mainstay to reduce hernia recurrence and postoperative complications, such as wound infection, evisceration, ascites drainage, and peritonitis. Intermittent paracentesis, temporary peritoneal dialysis catheter or transjugular intrahepatic portosystemic shunt may be necessary to control ascites. Hernia repair is indicated in patients in whom medical treatment is effective in controlling ascites. Patients who have a good perspective to be transplanted within 3-6 mo, herniorrhaphy should be performed during transplantation. Hernia repair with mesh is associated with lower recurrence rate, but with higher surgical site infection when compared to hernia correction with conventional fascial suture. There is no consensus on the best abdominal wall layer in which the mesh should be placed: Onlay, sublay, or underlay. Many studies have demonstrated several advantages of the laparoscopic umbilical herniorrhaphy in cirrhotic patients compared with open surgical treatment.

  8. [Risk factors of rupture of internal carotid artery during surgical resection of carotid body tumor].

    PubMed

    Li, Y H; Wang, J S; Yao, C; Chang, G Q; Yin, H H; Li, S Q; Lü, W M; Hu, Z J; Wang, S M

    2017-06-13

    Objective: To investigate risk factors of rupture of internal carotid artery resection during carotid body tumor resection and to summarize our treatment experience. Methods: During the period from 1991 to 2016, rupture of internal carotid artery occurred in 27 patients (28 tumors) during surgical resection of carotid body tumor in the First Affiliated Hospital of Sun Yat-sen University. Their clinical and follow-up data were retrospectively collected and analyzed. For all patients underwent surgical resection during this period, Logistic regression analysis was used to investigate the risk factors of intraoperative rupture of internal carotid artery. Results: Of these 28 tumors, there were 15 (53.6%) tumors with diameter≥5 cm and 20 (71.4%) Shamblin Ⅲ tumors. Intraoperatively, shunt was applied for 8 (28.6%) cases. Thirteen (46.4%) patients underwent ligation of external carotid artery, while 2 (7.1%) patients accepted resection of cranial nerves. Direct closure/patchplasty, autologous vessels or graft reconstruction was used in 16, 10 and 2 cases, respectively. Postoperatively, stroke occurred in 4(14.3%) cases and cranial nerve deficit in 15 (53.6%) cases. During a median length of 36 (14-125) months, cranial nerve deficit persisted in 5 cases. Follow-up radiologic examination indicated 3 (10.7%) cases of targeted vessel occlusion. However, no new-onset stroke was identified. Among all patients underwent surgical resection of carotid body tumor, female ( OR =3.650, P =0.012), age≤25 years old ( OR =3.710, P =0.013) and Shamblin Ⅲ tumor ( OR =4.631, P =0.008) increase the risks of intraoperative carotid artery rupture. Conclusions: Shamblin Ⅲ tumor is the predictor of rupture of internal carotid artery. Intraoperative, properly increased blood pressure, intraoperative heparinization and use of shunt for those cases without well-compensated cranial collateral arteries are likely to decreasing the incidence of stroke.

  9. Risk of surgical site infection in paediatric herniotomies without any prophylactic antibiotics: A preliminary experience.

    PubMed

    Vaze, Dhananjay; Samujh, Ram; Narasimha Rao, Katragadda Lakshmi

    2014-01-01

    Different studies underline the use of pre-operative antibiotic prophylaxis in clean surgeries like herniotomy and inguinal orchiopexy. But, the meta-analyses do not recommend nor discard the use of prophylactic pre-operative antibiotics. The scarcity of controlled clinical trials in paediatric population further vitiates the matter. This study assessed the difference in the rate of early post-operative wound infection cases in children who received single dose of pre-operative antibiotics and children who did not receive antibiotics after inguinal herniotomy and orchiopexy. This randomised prospective study was conducted in Paediatric Surgery department of PGIMER Chandigarh. Out of 251 patients, 112 patients were randomised to the case group and 139 were ascribed to the control group. The patients in control group were given a standard regimen of single dose of intravenous antibiotic at the time of induction followed by 3-4 days of oral antibiotic. Case group patients underwent the surgical procedure in similar manner with no antibiotic either at the time of induction or post-operatively. The incidence of surgical site infection in case group was 3.73 % and that in control group was 2.22%. The observed difference in the incidence of surgical site infection was statistically insignificant (P value = 0.7027). The overall infection rate in case and control group was 2.89%. Our preliminary experience suggests that there is no statistically significant difference in the proportion of early post-operative wound infection between the patients who received single dose of pre-operative antibiotics and the patients who received no antibiotics after inguinal herniotomy and orchiopexy. The risk of surgical site infection in paediatric heriotomies does not increase even if the child's weight is less than his/her expected weight for age.

  10. [Lung-preserving surgical treatment of patients with bronchial carcinoid].

    PubMed

    Pikin, O V; Trakhtenberg, A Kh; Sokolov, V V; Ryabov, A B; Telegina, L V; Kolbanov, K I; Amiraliyev, A M; Glushko, V A

    2015-01-01

    Isolated bronchus resection for central cancer was performed in 25 patients including preoperative bronchoscopic removal of exophytic tumor in 20 (80%) observations in thoracic department of P. Gertsen Moscow Research Cancer Institute. According to morphological study typical carcinoid was diagnosed in 23 (92%) patients, atypical - in 2 (8%) cases. All patients underwent conventional mediastinal lymphadenectomy. Postoperative complications after bronchus resection developed in 6 (33.3%) patients. There were no deaths. Overall 5- and 10-year survival was 100% and 96% respectively. The authors consider that by strict indications combination of endoscopic removal with isolated bronchus resection preserves all pulmonary parenchyma without prejudice for surgical radicalism.

  11. Risk factors for postoperative anxiety and depression after surgical treatment for lung cancer†.

    PubMed

    Park, Samina; Kang, Chang Hyun; Hwang, Yoohwa; Seong, Yong Won; Lee, Hyun Joo; Park, In Kyu; Kim, Young Tae

    2016-01-01

    Psychological distress associated with cancer treatment is an emerging issue in the management of cancer patients. The aim of this study was to identify the prevalence of postoperative anxiety and depression after surgical treatment for lung cancer, and to assess the risk factors associated with these phenomena. Patients who underwent curative surgical resection for primary lung cancer were included in this study. Patients with complex treatment histories (recurrent or metastatic lung cancer or neoadjuvant treatment) and those taking psychiatric medication were excluded. We prospectively evaluated the degrees of pre- and postoperative anxiety and depression using a Hospital Anxiety Depression Scale questionnaire. The relationships between clinical and patient factors and anxiety and depression after surgical treatment for lung cancer were assessed. A total of 278 patients were enrolled. The mean age was 62 years. Thoracoscopic resection was performed in 246 patients (89%). The prevalence rates of preoperative anxiety and depression were 8% (n = 22) and 12% (n = 32), and changed to 9% (n = 26) and 19% (n = 54) postoperatively (P = 0.37 and <0.001, respectively). Gender, age, marital status, advanced clinical stage, alcohol abuse, smoking status, length of hospital stay, pulmonary function and preoperative comorbidities were not associated with postoperative anxiety and depression. Multivariate analysis revealed that thoracotomy was a risk factor for postoperative anxiety after adjusting for preoperative anxiety (odds ratio [OR] = 4.5, P = 0.002). Thoracotomy (OR = 3.4, P = 0.009), postoperative dyspnoea (OR = 4.8, P < 0.001), severe pain (OR = 3.9, P = 0.001) and diabetes mellitus (OR = 3.0, P = 0.012) were identified as risk factors for postoperative depression after adjusting for preoperative depression. Twenty-four patients were referred to mental health professionals and provided with supportive psychotherapy or pharmacological intervention. Of these, 14

  12. Surgical and survival outcomes of lung cancer patients with intratumoral lung abscesses.

    PubMed

    Yamanashi, Keiji; Okumura, Norihito; Takahashi, Ayuko; Nakashima, Takashi; Matsuoka, Tomoaki

    2017-05-26

    Intratumoral lung abscess is a secondary lung abscess that is considered to be fatal. Therefore, surgical procedures, although high-risk, have sometimes been performed for intratumoral lung abscesses. However, no studies have examined the surgical outcomes of non-small cell lung cancer patients with intratumoral lung abscesses. The aim of this study was to investigate the surgical and survival outcomes of non-small cell lung cancer patients with intratumoral lung abscesses. Eleven consecutive non-small cell lung cancer patients with intratumoral lung abscesses, who had undergone pulmonary resection at our institution between January 2007 and December 2015, were retrospectively analysed. The post-operative prognoses were investigated and prognostic factors were evaluated. Ten of 11 patients were male and one patient was female. The median age was 64 (range, 52-80) years. Histopathologically, 4 patients had Stage IIA, 2 patients had Stage IIB, 2 patients had Stage IIIA, and 3 patients had Stage IV tumors. The median operative time was 346 min and the median amount of bleeding was 1327 mL. The post-operative morbidity and mortality rates were 63.6% and 0.0%, respectively. Recurrence of respiratory infections, including lung abscesses, was not observed in all patients. The median post-operative observation period was 16.1 (range, 1.3-114.5) months. The 5-year overall survival rate was 43.3%. No pre-operative, intra-operative, or post-operative prognostic factors were identified in the univariate analyses. Surgical procedures for advanced-stage non-small cell lung cancer patients with intratumoral lung abscesses, although high-risk, led to satisfactory post-operative mortality rates and acceptable prognoses.

  13. Assessment of Telemedicine in Surgical Education and Patient Care

    PubMed Central

    Demartines, Nicolas; Mutter, Didier; Vix, Michel; Leroy, Joël; Glatz, Dieter; Rösel, Fritz; Harder, Felix; Marescaux, Jacques

    2000-01-01

    Objective To analyze the value of teleconferencing for patient care and surgical education by assessing the activity of an international academic network. Summary Background Data The uses of telemedicine include teleeducation, training, and consulting, and surgical teams are now involved, sharing diagnostic information and opinions without the need for travel. However, the value of telematics in surgery remains to be assessed. Methods During a 2-year period, weekly surgical teleconferences were held among six university hospitals in four European countries. To assess the accuracy of telediagnosis for surgical cases, 60 randomly selected cases were analyzed by a panel of surgeons. Participants’ opinions were analyzed by questionnaire. Results Seventy teleconferences (50 lectures and 271 case presentations) were held. Ninety-five of the 114 participants (83.3%) completed the final questionnaire. Eighty-six percent rated the surgical activity as good or excellent, 75.7% rated the scientific level as good or excellent, 55.8% rated the daily clinical activity as good or excellent, and 28.4% rated the manual surgical technique as good or excellent. The target organ was identified in all the cases; the organ structure and pathology were considered well defined in 93.3%, and the fine structure was considered well defined in 58.3%. Diagnosis was accurate in 17 cases (28.3%), probable in 25 (41.7%), possible but uncertain in 16 (26.7%), and not possible in 2 cases (3.3%). Discussion among the remote sites increased the rate of valuable therapeutic advice from 55% of cases before the discussion to 95% after the discussion. Eighty-six percent of the surgeons expressed satisfaction with telematics for medical education and patient care. Conclusions Participant satisfaction was high, transmission of clinical documents was accurate, and the opportunity to discuss case documentation and management significantly improved diagnostic potential, resulting in an accuracy rate of up

  14. [The unnecessary application of central venous catheterization in surgical patients].

    PubMed

    Uemura, Keiko; Inoue, Satoki; Kawaguchi, Masahiko

    2018-04-06

    Perioperative physicians occasionally encounter situations where central venous catheters placed preoperatively turn out to be unnecessary. The purpose of this retrospective study is to identify the unnecessary application of central venous catheter placement and determine the factors associated with the unnecessary application of central venous catheter placement. Using data from institutional perioperative central venous catheter surveillance, we analysed data from 1,141 patients who underwent central venous catheter placement. We reviewed the central venous catheter registry and medical charts and allocated registered patients into those with the proper or with unnecessary application of central venous catheter according to standard indications. Multivariate analysis was used to identify factors associated with the unnecessary application of central venous catheter placement. In 107 patients, representing 9.38% of the overall population, we identified the unnecessary application of central venous catheter placement. Multivariate analysis identified emergencies at night or on holidays (odds ratio [OR] 2.109, 95% confidence interval [95% CI] 1.021-4.359), low surgical risk (OR=1.729, 95% CI 1.038-2.881), short duration of anesthesia (OR=0.961/10min increase, 95% CI 0.945-0.979), and postoperative care outside of the intensive care unit (OR=2.197, 95% CI 1.402-3.441) all to be independently associated with the unnecessary application of catheterization. Complications related to central venous catheter placement when the procedure consequently turned out to be unnecessary were frequently observed (9/107) compared with when the procedure was necessary (40/1034) (p=0.032, OR=2.282, 95% CI 1.076-4.842). However, the subsequent multivariate logistic model did not hold this significant difference (p=0.0536, OR=2.115, 95% CI 0.988-4.526). More careful consideration for the application of central venous catheter is required in cases of emergency surgery at night or on

  15. Incidence and risk factors of surgical site infection in general surgery in a developing country.

    PubMed

    Alp, Emine; Elmali, Ferhan; Ersoy, Safiye; Kucuk, Can; Doganay, Mehmet

    2014-04-01

    To investigate the incidence of surgical site infections (SSIs) according to risk factors, etiological agents, antimicrobial resistance rates of pathogens, and antimicrobial prophylaxis (AMP) in a developing country. Prospective surveillance of SSIs was carried out in general surgery (GS) units between May 2005 and April 2009. SSI was diagnosed in 415 (10.8%) patients. Cefazolin was used as AMP in 780 (49%) operations, whereas broad-spectrum antibiotics were used in the remaining operations. AMP was administered for >24 h in 69 and 64% of the GS patients. The most significant risk factors for SSI after GS were total parenteral nutrition, transfusion, and a drainage catheter. The most common pathogen was Escherichia coli, but all the isolated pathogens were multiresistant. AMP is effective for reducing the risk of SSI; however, the prolonged use of AMP and broad-spectrum antibiotics may be associated with the emergence of resistant bacterial strains.

  16. The importance and provision of oral hygiene in surgical patients.

    PubMed

    Ford, Samuel J

    2008-10-01

    The provision of mouth care on the general surgical ward and intensive care setting has recently gained momentum as an important aspect of patient care. Oropharyngeal morbidity can cause pain and disordered swallowing leading to reluctance in commencing or maintaining an adequate dietary intake. On the intensive care unit, aside from patient discomfort and general well-being, oral hygiene is integral to the prevention of ventilator-associated pneumonia. Chlorhexidine (0.2%) is widely used to decrease oral bacterial loading, dental bacterial plaque and gingivitis. Pineapple juice has gained favour as a salivary stimulant in those with a dry mouth or coated tongue. Tooth brushing is the ideal method of promoting oral hygiene. Brushing is feasible in the vast majority, although access is problematic in ventilated patients. Surgical patients undergoing palliative treatment are particularly prone to oral morbidity that may require specific but simple remedies. Neglect of basic aspects of patient care, typified by poor oral hygiene, can be detrimental to surgical outcome.

  17. A positive association between nutritional risk and the incidence of surgical site infections: A hospital-based register study.

    PubMed

    Skeie, Eli; Koch, Anne Mette; Harthug, Stig; Fosse, Unni; Sygnestveit, Kari; Nilsen, Roy Miodini; Tangvik, Randi J

    2018-01-01

    Surgical site infections (SSI) are amongst the most common health care-associated infections and have adverse effects for patient health and for hospital resources. Although surgery guidelines recognize poor nutritional status to be a risk factor for SSI, they do not tell how to identify this condition. The screening tool Nutritional Risk Screening 2002 is commonly used at hospitals to identify patients at nutritional risk. We investigated the association between nutritional risk and the incidence of SSI among 1194 surgical patients at Haukeland University Hospital (Bergen, Norway). This current study combines data from two mandatory hospital-based registers: a) the incidence of SSI within 30 days after surgery, and b) the point-prevalence of patients at nutritional risk. Patients with more than 30 days between surgery and nutritional risk screening were excluded. Associations were assessed using logistic regression, and the adjusted odds ratio included age (continuous), gender (male/female), type of surgery (acute/elective) and score from The American Society of Anesthesiologists Physical Status Classification System. There was a significant higher incidence of SSI among patients at nutritional risk (11.8%), as compared to those who were not (7.0%) (p = 0.047). Moreover, the incidence of SSI was positively associated with the prevalence of nutritional risk in both simple (OR 1.76 (95% CI: 1.04, 2.98)) and adjusted (OR 1.81 (95% CI: 1.04, 3.16)) models. Answering "yes" to the screening questions regarding reduced dietary intake and weight loss was significantly associated with the incidence of SSI (respectively OR 2.66 (95% CI: 1.59, 4.45) and OR 2.15 (95% CI: 1.23, 3.76)). In conclusion, we demonstrate SSI to occur more often among patients at nutritional risk as compared to those who are not at nutritional risk. Future studies should investigate interventions to prevent both SSI and nutritional risk among surgical patients.

  18. Antibiotic prophylaxis for surgical site infections as a risk factor for infection with Clostridium difficile

    PubMed Central

    Balch, Aubrey; Vesely, Sara K.; Bratzler, Dale W.

    2017-01-01

    Objective We aimed to measure the association between 2013 guideline concordant prophylactic antibiotic use prior to surgery and infection with Clostridium difficile. Design We conducted a retrospective case-control study by selecting patients who underwent a surgical procedure between January 1, 2012 and December 31, 2013. Setting Large urban community hospital. Patients Cases and controls were patients age 18+ years who underwent an eligible surgery (i.e., colorectal, neurosurgery, vascular/cardiac/thoracic, hysterectomy, abdominal/pelvic and orthopedic surgical procedures) within six months prior to infection diagnosis. Cases were diagnosed with C. difficile infection while controls were not. Methods The primary exposure was receiving (vs. not receiving) the recommended prophylactic antibiotic regimen, based on type and duration. Potential confounders included age, sex, length of hospital stay, comorbidities, type of surgery, and prior antibiotic use. Crude and adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated using logistic regression. Results We enrolled 68 cases and 220 controls. The adjusted OR among surgical patients between developing C. difficile infection and not receiving the recommended prophylactic antibiotic regimen (usually receiving antimicrobial prophylaxis for more than 24 hours) was 6.7 (95% CI: 2.9–15.5). Independent risk factors for developing C. difficile infection included having severe comorbidities, receiving antibiotics within the previous 6 months, and undergoing orthopedic surgery. Conclusions Adherence to the recommended prophylactic antibiotics among surgical patients likely reduces the probability of being case of C. difficile. Antibiotic stewardship should be a priority in strategies to decrease the morbidity, mortality, and costs associated with C. difficile infection. PMID:28622340

  19. Incidence and risk factors for surgically acquired pressure ulcers: a prospective cohort study investigators.

    PubMed

    Webster, Joan; Lister, Carolyn; Corry, Jean; Holland, Michelle; Coleman, Kerrie; Marquart, Louise

    2015-01-01

    To assess the incidence of hospital-acquired, surgery-related pressure injury (ulcers) and identify risk factors for these injuries. We used a prospective cohort study to investigate the research question. The study was conducted at a major metropolitan hospital in Brisbane, Australia. Five hundred thirty-four adult patients booked for any surgical procedure expected to last more than 30 minutes were eligible for inclusion. Patients who provided informed consent for study participation were assessed for pressure ulcers, using the European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel Guidelines, before entering the operating room and again in the post-anesthetic care unit (PACU). Research nurses and all PACU nurses were trained in skin assessment and in pressure ulcer staging. Patients were not assessed again after their discharge from the PACU. Seven patients (1.3%) had existing pressure injuries (ulcers) and a further 6 (1.3%) developed a surgery-related pressure ulcer. Risk factors associated with surgery-related pressure injuries were similar to non-surgically related risks and included older age, skin condition, and being admitted from a location other than one's own home. Length of surgery was not associated with pressure ulcer development in this cohort. Perioperative nurses play an important role in identifying existing or new pressure injuries. However, many of these nurses are unfamiliar with pressure ulcer classification, so education in this area is essential. Although the incidence of surgically acquired pressure ulcers was low in this cohort, careful skin inspection before and after surgery provides an opportunity for early treatment and may prevent existing lesions progressing to higher stages.

  20. Is surgical plume developing during routine LEEPs contaminated with high-risk HPV? A pilot series of experiments.

    PubMed

    Neumann, Kay; Cavalar, Markus; Rody, Achim; Friemert, Luisa; Beyer, Daniel A

    2018-02-01

    Growing evidence shows a causal role of high-risk humane papillomavirus (HPV) infections in the development of head and neck cancer. A recent case report shows two patients suffering from tonsillar cancer without any risk factors apart from their work as gynecologists doing laser ablations and loop electrosurgical excision procedures (LEEP). The aim of the present investigation is to evaluate whether surgical plume resulting from routine LEEPs of HSIL of the cervix uteri might be contaminated with the DNA of high-risk HPV. The prospective pilot study is done at the Department of Gynecology and Obstetrics of the University of Lübeck, Germany. The primary outcome was defined as HPV subtype in resected cone and in surgical plume resulting from LEEPs of HSIL of the cervix uteri. Plume resulting from LEEPs was analyzed using a Whatman FTA Elute Indicating Card which was placed in the tube of an exhaust suction device used to remove the resulting aerosols. For detection of HPV and analysis of its subtype, the novel EUROArray HPV test was performed. Resected cones of LEEPs were evaluated separately for HPV subtypes. Four samples of surgical plume resulting from routine LEEPs indicated contamination with high-risk HPV and showed the same HPV subtype as identified in the resected cones. Surgical plume resulting from routine LEEPs for HSIL of the cervix uteri has the risk of contamination with high-risk HPV. Further investigations of infectiousness of surgical plume are necessary for evaluation of potential hazards to involved healthcare professionals.

  1. [Complications of surgical stage of treatment in patients with cancer of cervix uteri stage IIB].

    PubMed

    Kryzhanivs'ka, A Ie

    2013-11-01

    The results of treatment of 127 patients, suffering cervix uteri cancer stage IIB in period of 1998 - 2012 yrs, were analyzed. Complications of surgical stage of the combined treatment have had occurred in 40.9% patients, including 40.5% patients, to whom neoadjuvant chemotherapy was conducted and in 41.5%--radiation therapy (RTH). The main postoperative complications--retroperitoneal lymphatic cysts--were revealed in 35.4% patients. The factors, raising the risk of postoperative complications occurrence, are following: the primary tumor spreading, metastatic affection of lymphatic nodes of pelvic cavity, preoperative conduction of RTH or chemotherapy.

  2. Management of patients with risk factors

    PubMed Central

    Waldfahrer, Frank

    2013-01-01

    This review addresses concomitant diseases and risk factors in patients treated for diseases of the ears, nose and throat in outpatient and hospital services. Besides heart disease, lung disease, liver disease and kidney disease, this article also covers disorders of coagulation (including therapy with new oral anticoagulants) and electrolyte imbalance. Special attention is paid to the prophylaxis, diagnosis and treatment of perioperative delirium. It is also intended to help optimise the preparation for surgical procedures and pharmacotherapy during the hospital stay. PMID:24403970

  3. Endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy

    PubMed Central

    Wang, Fei; Xu, Boming; Li, Quanpeng; Zhang, Xiuhua; Jiang, Guobing; Ge, Xianxiu; Nie, Junjie; Zhang, Xiuyun; Wu, Ping; Ji, Jie; Miao, Lin

    2016-01-01

    Abstract Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy is challenging. Results of ERCP in those patients varied. The aim of our study was to evaluate the safety and effectiveness of various endoscopes-assisted ERCP in patients with surgically altered anatomy. Fifty-two patients with Billroth II reconstruction (group A), 20 patients with subtotal or total gastrectomy with Roux-en-Y anastomosis (group B), 25 patients with pancreatoduodenectomy or Roux-en-Y hepaticojejunostomy reconstruction (group C) were included. Gastroscope, duodenoscope, colonoscope, and double-balloon enteroscope were used. The endoscope insertion success rate of groups A, B, C was 96.2% (50/52), 85.0% (17/20), 80% (20/25), respectively. χ2 test showed that there was no significant difference between the 3 groups (P = 0.068). The mean insertion time was 36.7, 68.4, and 84.0 minutes, respectively. One-way ANOVA showed that the insertion time of group C was significantly longer than that of groups B and C (both P <0.001). The endoscopic cannulation success rates of groups A, B, C were 90%, 82.4%, and 100%, respectively. χ2 test showed that there was no significant difference between the 3 groups (P = 0.144). The mean cannulation time was 19.4, 28.1, and 20.4 minutes, respectively. One-way ANOVA showed that the cannulation time of group B was longer than that of groups A and C (P <0.001, P = 0.001, respectively). In total, 74 patients with successful biliary cannulation achieved the therapeutic goal; thus, the clinical success rate was 76.3% (74/97). Our study showed that ERCP in patients with surgically altered anatomy was safe and feasible. PMID:28033284

  4. Diabetes and Risk of Surgical Site Infection: A systematic review and meta-analysis

    PubMed Central

    Kaye, Keith S.; Knott, Caitlin; Nguyen, Huong; Santarossa, Maressa; Evans, Richard; Bertran, Elizabeth; Jaber, Linda

    2016-01-01

    Objective To determine the independent association between diabetes and SSI across multiple surgical procedures. Design Systematic review and meta-analysis. Methods Studies indexed in PubMed published between December 1985 and through July 2015 were identified through the search terms “risk factors” or “glucose” and “surgical site infection”. A total of 3,631 abstracts were identified through the initial search terms. Full texts were reviewed for 522 articles. Of these, 94 articles met the criteria for inclusion. Standardized data collection forms were used to extract study-specific estimates for diabetes, blood glucose levels, and body mass index (BMI). Random-effects meta-analysis was used to generate pooled estimates and meta-regression was used to evaluate specific hypothesized sources of heterogeneity. Results The primary outcome was SSI, as defined by the Centers for Disease Control and Prevention surveillance criteria. The overall effect size for the association between diabetes and SSI was OR=1.53 (95% Predictive Interval 1.11, 2.12, I2: 57.2%). SSI class, study design, or patient BMI did not significantly impact study results in a meta-regression model. The association was higher for cardiac surgery 2.03 (95% Predictive Interval 1.13, 4.05) compared to surgeries of other types (p=0.001). Conclusion These results support the consideration of diabetes as an independent risk factor for SSIs for multiple surgical procedure types. Continued efforts are needed to improve surgical outcomes for diabetic patients. PMID:26503187

  5. Surgical procedures in patients with haemophilic arthropathy of the ankle.

    PubMed

    Barg, A; Morris, S C; Schneider, S W; Phisitkul, P; Saltzman, C L

    2016-05-01

    In haemophilia, the ankle joint is one of the most common and earliest joints affected by recurrent bleeding, commonly resulting in end-stage ankle osteoarthritis during early adulthood. The surgical treatment of haemophilic ankle arthropathy is challenging. This review aims to highlight the literature addressing clinical outcomes following the most common approaches for different stages of haemophilia-induced ankle osteoarthritis: arthroscopic debridement, joint distraction arthroplasty, supramalleolar osteotomies, total ankle replacement, and ankle arthrodesis. A systematic literature review was performed using established medical literature databases. The following information was retrieved from the literature: patients' demographics, surgical technique, duration of follow-up, clinical outcome including pain relief and complication rate. A total of 42 clinical studies published between 1978 and 2015 were included in the systematic literature review. Eight and 34 studies had prospective and retrospective design, respectively. The most common studies were level IV studies (64.3%). The orthopaedic treatment of patients with haemophilic ankle osteoarthritis is often challenging and requires complete and careful preoperative assessment. In general, both joint-preserving and joint non-preserving procedure types can be performed. All specific relative and absolute contraindications should be considered to achieve appropriate postoperative outcomes. The current literature demonstrated that orthopaedic surgeries, with appropriate indication, in patients with haemophilic ankle arthropathy result in good postoperative results comparable to those observed in non-haemophiliacs. The surgical treatment should be performed in a setting with the ability to have multidisciplinary management, including expertise in haematology. © 2016 John Wiley & Sons Ltd.

  6. [Unnecessary routine laboratory tests in patients referred for surgical services].

    PubMed

    Mata-Miranda, María del Pilar; Cano-Matus, Norberto; Rodriguez-Murrieta, Margarita; Guarneros-Zapata, Idalia; Ortiz, Mario

    2016-01-01

    To question the usefulness of the lab analysis considered routine testing for the identification of abnormalities in the surgical care. To determine the percentage of unnecessary laboratory tests in the preoperative assessment as well as to estimate the unnecessary expenses. A descriptive, cross-sectional study of patients referred for surgical evaluation between January 1st and March 31st 2013. The database of laboratory testing and electronic files were reviewed. Reference criteria from surgical services were compared with the tests requested by the family doctor. In 65% of the patients (n=175) unnecessary examinations were requested, 25% (n=68) were not requested the tests that they required, and only 10% of the patients were requested laboratory tests in accordance with the reference criteria (n=27). The estimated cost in unnecessary examinations was $1,129,552 in a year. The results were similar to others related to this theme, however, they had not been revised from the perspective of the first level of attention regarding the importance of adherence to the reference criteria which could prevent major expenditures. It is a priority for leaders and operational consultants in medical units to establish strategies and lines of action that ensure compliance with institutional policies so as to contain spending on comprehensive services, and which in turn can improve the medical care. Copyright © 2015 Academia Mexicana de Cirugía A.C. Published by Masson Doyma México S.A. All rights reserved.

  7. Patient engagement with surgical site infection prevention: an expert panel perspective.

    PubMed

    Tartari, E; Weterings, V; Gastmeier, P; Rodríguez Baño, J; Widmer, A; Kluytmans, J; Voss, A

    2017-01-01

    Despite remarkable developments in the use of surgical techniques, ergonomic advancements in the operating room, and implementation of bundles, surgical site infections (SSIs) remain a substantial burden, associated with increased morbidity, mortality and healthcare costs. National and international recommendations to prevent SSIs have been published, including recent guidelines by the World Health Organization, but implementation into clinical practice remains an unresolved issue. SSI improvement programs require an integrative approach with measures taken during the pre-, intra- and postoperative care from the numerous stakeholders involved. The current SSI prevention strategies have focused mainly on the role of healthcare workers (HCWs) and procedure related risk factors. The importance and influence of patient participation is becoming an increasingly important concept and advocated as a means to improve patient safety. Novel interventions supporting an active participative role within SSI prevention programs have not been assessed. Empowering patients with information they require to engage in the process of SSI prevention could play a major role for the implementation of recommendations. Based on available scientific evidence, a panel of experts evaluated options for patient involvement in order to provide pragmatic recommendations for pre-, intra- and postoperative activities for the prevention of SSIs. Recommendations were based on existing guidelines and expert opinion. As a result, 9 recommendations for the surgical patient are presented here, including a practice brief in the form of a patient information leaflet. HCWs can use this information to educate patients and allow patient engagement.

  8. Health literacy assessment and patient satisfaction in surgical practice.

    PubMed

    Komenaka, Ian K; Nodora, Jesse N; Machado, Lorenzo; Hsu, Chiu-Hsieh; Klemens, Anne E; Martinez, Maria Elena; Bouton, Marcia E; Wilhelmson, Krista L; Weiss, Barry D

    2014-03-01

    Individuals with limited health literacy have barriers to patient-physician communication. Problems in communication are known to contribute to malpractice litigation. Concern exists, however, about the feasibility and patient acceptance of a health literacy assessment. This study was performed to determine the feasibility of health literacy assessment in surgical practice and its effect on patient satisfaction. Every patient seen in a Breast Surgery Clinic during a 2-year period was asked to undergo a health literacy assessment with the Newest Vital Sign (NVS) as part of the routine history and physical examination. During the year before routine NVS assessments and during the 2-year study period, all patients were asked to rate their "overall satisfaction with clinic visit" on a 5-point scale. A total of 2,026 of 2,097 patients (96.6%) seen during the study were eligible for the health literacy assessment. Of those, no patients refused assessment, and only one patient was missed. Therefore, 2,025 of 2,026 eligible patients (99.9%) underwent the assessment. The average time for NVS assessment was 2:02 minutes. Only 19% of patients had adequate health literacy. Patient satisfaction ratings were slightly greater during the first year of the health literacy assessment (3.8 vs 3.7, P = .049) compared with the year prior to health literacy assessment and greater during the second year of health literacy assessment (4.1 vs 3.7, P < .0001). Routine health literacy assessment is feasible in surgical practice and results in no decrease in patient satisfaction. In fact, satisfaction was greater during the years when health literacy assessments were performed. Copyright © 2014 Mosby, Inc. All rights reserved.

  9. Preoperative Surgical Discussion and Information Retention by Patients.

    PubMed

    Feiner, David E; Rayan, Ghazi M

    2016-10-01

    To assess how much information communicated to patients is understood and retained after preoperative discussion of upper extremity procedures. A prospective study was designed by recruiting patients prior to undergoing upper extremity surgical procedures after a detailed discussion of their operative technique, postoperative care and treatment outcomes. Patients were given the same 20-item questionnaire to fill out twice, at two pre operative visits. An independent evaluator filled out a third questionnaire as a control. Various discussion points of the survey were compared among the 3 questionnaires and retained information and perceived comprehension were evaluated. The average patients' age was 50.3 (27-75) years The average time between the two surveys preoperative 1 and preoperative 2 was 40.7 (7-75) days,. The average patient had approximately 2 years of college or an associate's degree. Patients initially retained 73% (52-90%) of discussion points presented during preoperative 1 and 61% (36-85%) of the information at preoperative 2 p = .002. 50% of patients felt they understood 100% of the discussion, this dropped to only 10% at their preoperative 2 visit. 15% of our patients did not know what type of anesthesia they were having at preoperative 2. A communication barrier between patients and physicians exists when patients are informed about their preoperative surgical discussion. The retention of information presented is worsened with elapsing time from the initial preoperative discussion to the second preoperative visit immediately prior to surgery. Methods to enhance patients' retention of information prior to surgery must be sought and implemented which will improve patients' treatment outcome.

  10. Constipation Risk in Patients Undergoing Abdominal Surgery

    PubMed Central

    Celik, Sevim; Atar, Nurdan Yalcin; Ozturk, Nilgun; Mendes, Guler; Kuytak, Figen; Bakar, Esra; Dalgiran, Duygu; Ergin, Sumeyra

    2015-01-01

    Background: Problems regarding bowel elimination are quite common in patients undergoing abdominal surgery. Objectives: To determine constipation risk before the surgery, bowel elimination during postoperative period, and the factors affecting bowel elimination. Patients and Methods: This is a cross-sectional study. It was conducted in a general surgery ward of a university hospital in Zonguldak, Turkey between January 2013 and May 2013. A total of 107 patients were included in the study, who were selected by convenience sampling. Constipation Risk Assessment Scale (CRAS), patient information form, medical and nursing records were used in the study. Results: The mean age of the patients was found to be 55.97 ± 15.74 (year). Most of the patients have undergone colon (37.4%) and stomach surgeries (21.5%). Open surgical intervention (83.2%) was performed on almost all patients (96.3%) under general anesthesia. Patients were at moderate risk for constipation with average scores of 11.71 before the surgery. A total of 77 patients (72%) did not have bowel elimination problem during postoperative period. The type of the surgery (P < 0.05), starting time for oral feeding after the surgery (P < 0.05), and mobilization (P < 0.05) were effective on postoperative bowel elimination. Conclusions: There is a risk for constipation after abdominal surgery. Postoperative practices are effective on the risk of constipation. PMID:26380107

  11. Improved implementation of the risk-adjusted Bernoulli CUSUM chart to monitor surgical outcome quality.

    PubMed

    Keefe, Matthew J; Loda, Justin B; Elhabashy, Ahmad E; Woodall, William H

    2017-06-01

    The traditional implementation of the risk-adjusted Bernoulli cumulative sum (CUSUM) chart for monitoring surgical outcome quality requires waiting a pre-specified period of time after surgery before incorporating patient outcome information. We propose a simple but powerful implementation of the risk-adjusted Bernoulli CUSUM chart that incorporates outcome information as soon as it is available, rather than waiting a pre-specified period of time after surgery. A simulation study is presented that compares the performance of the traditional implementation of the risk-adjusted Bernoulli CUSUM chart to our improved implementation. We show that incorporating patient outcome information as soon as it is available leads to quicker detection of process deterioration. Deterioration of surgical performance could be detected much sooner using our proposed implementation, which could lead to the earlier identification of problems. © The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

  12. Pressure Ulcer Prevalence and Risk Factors among Prolonged Surgical Procedures in the OR

    PubMed Central

    Primiano, Mike; Friend, Michael; McClure, Connie; Nardi, Scott; Fix, Lisa; Schafer, Marianne; Savochka, Kathlyn; McNett, Molly

    2015-01-01

    Pressure ulcer formation related to positioning in the OR increases length of hospital stay and hospital costs, but there is little evidence documenting how positioning devices used in the OR influence pressure ulcer development when examined with traditional risk factors. The aim of this prospective cohort study was to identify prevalence of and risk factors associated with pressure ulcer development among patients undergoing surgical procedures lasting longer than three hours. Participants included all adult same-day admit patients scheduled for a three-hour surgical procedure during an eight-month period (N = 258). Data were gathered preoperatively, intraoperatively, and postoperatively on pressure ulcer risk factors. Bivariate analyses indicated that the type of positioning (ie, heels elevated) (χ2 = 7.897, P = .048), OR bed surface (ie, foam table pad) (χ2 15.848, P = .000), skin assessment in the postanesthesia care unit (χ2 = 41.652, P = .000), and male gender (χ2 = 6.984, P = .030) were associated with pressure ulcer development. Logistic regression analyses indicated that use of foam pad (B = 2.691, P = .024) and a lower day-one Braden score (B = .244, P = .003) were predictive of pressure ulcers. PMID:22118201

  13. Fast-track cardiac care for adult cardiac surgical patients.

    PubMed

    Zhu, Fang; Lee, Anna; Chee, Yee Eot

    2012-10-17

    Fast-track cardiac care is a complex intervention involving several components of care during cardiac anaesthesia and in the postoperative period, all with the ultimate aim of early extubation after surgery, to reduce the length of stay in the intensive care unit and in the hospital. Safe and effective fast-track cardiac care may reduce hospital costs. This is an update of a Cochrane review published in 2003. To update the evidence on the safety and effectiveness of fast-track cardiac care compared to conventional (not fast-track) care in adult patients undergoing cardiac surgery. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 3), MEDLINE (January 1966 to April 2012), EMBASE (January 1980 to April 2012), CINAHL (January 1982 to April 2012), and ISI Web of Science (January 2003 to April 2012). We searched reference lists of articles and contacted experts in the field. All randomized controlled trials of adult cardiac surgical patients (coronary artery bypass grafts, aortic valve replacement, mitral valve replacement) that compared fast-track cardiac care and conventional (not fast-track) care groups were included. We focused on the following fast-track interventions that were designed for early extubation after surgery, administration of low-dose opioid based general anaesthesia during cardiac surgery and the use of a time-directed extubation protocol after surgery. The primary outcome was the risk of mortality. Secondary outcomes included postoperative complications, reintubation within 24 hours of surgery, time to extubation, length of stay in the intensive care unit and in the hospital, quality of life after surgery and hospital costs. Two review authors independently assessed trial quality and extracted the data. Study authors were contacted for additional information. We used a random-effects model and reported relative risk (RR), mean difference (MD) and 95% confidence intervals (95% CI). Twenty-five trials involving 4118

  14. Electronic Patient Data Confidentiality Practices Among Surgical Trainees: Questionnaire Study

    PubMed Central

    Mole, Damian J; Fox, Colin; Napolitano, Giulio

    2006-01-01

    INTRODUCTION The objective of this work was to evaluate the safeguards implemented by surgical trainees to protect the confidentiality of electronic patient data through a structured questionnaire sent to Northern Ireland surgical trainees. PARTICIPANTS AND METHODS A group of 32 basic and higher surgical trainees attending a meeting of the Northern Ireland Association of Surgeons-in-Training were invited to complete a questionnaire regarding their computer use, UK Data Protection Act, 1988 registration and electronic data confidentiality practices. RESULTS Of these 32 trainees, 29 returned completed questionnaires of whom 26 trainees regularly stored sensitive patient data for audit or research purposes on a computer. Only one person was registered under the Data Protection Act, 1988. Of the computers used to store and analyse sensitive data, only 3 of 14 desktops, 8 of 19 laptops and 3 of 14 hand-held computers forced a password logon. Of the 29 trainees, 16 used the same password for all machines, and 25 of 27 passwords were less than 8 characters long. Two respondents declined to reveal details of their secure passwords. Half of all trainees had never adjusted their internet security settings, despite all 14 desktops, 16 of 19 laptops and 5 of 14 hand-helds being routinely connected to the internet. Of the 29 trainees, 28 never encrypted their sensitive data files. Ten trainees had sent unencrypted sensitive patient data over the internet, using a non-secure server. CONCLUSIONS Electronic data confidentiality practices amongst Northern Ireland surgical trainees are unsafe. Simple practical measures to safeguard confidentiality are recommended. PMID:17059715

  15. Outcomes of surgery in patients aged ≥90 years in the general surgical setting.

    PubMed

    Sudlow, A; Tuffaha, H; Stearns, A T; Shaikh, I A

    2018-03-01

    Introduction An increasing proportion of the population is living into their nineties and beyond. These high risk patients are now presenting more frequently to both elective and emergency surgical services. There is limited research looking at outcomes of general surgical procedures in nonagenarians and centenarians to guide surgeons assessing these cases. Methods A retrospective analysis was conducted of all patients aged ≥90 years undergoing elective and emergency general surgical procedures at a tertiary care facility between 2009 and 2015. Vascular, breast and endocrine procedures were excluded. Patient demographics and characteristics were collated. Primary outcomes were 30-day and 90-day mortality rates. The impact of ASA (American Society of Anesthesiologists) grade, operation severity and emergency presentation was assessed using multivariate analysis. Results Overall, 161 patients (58 elective, 103 emergency) were identified for inclusion in the study. The mean patient age was 92.8 years (range: 90-106 years). The 90-day mortality rates were 5.2% and 19.4% for elective and emergency procedures respectively (p=0.013). The median survival was 29 and 19 months respectively (p=0.001). Emergency and major gastrointestinal operations were associated with a significant increase in mortality. Patients undergoing emergency major colonic or upper gastrointestinal surgery had a 90-day mortality rate of 53.8%. Conclusions The risk for patients aged over 90 years having an elective procedure differs significantly in the short term from those having emergency surgery. In selected cases, elective surgery carries an acceptable mortality risk. Emergency surgery is associated with a significantly increased risk of death, particularly after major gastrointestinal resections.

  16. [Surgical treatment of patients with exudative otitis media].

    PubMed

    Dmitriev, N S; Mileshina, N A

    2003-01-01

    The article concerns peculiarities of surgery for chronic exudative otitis media (CEOM). The significance of miringotomy, tympanostomy, tympanotomy and tympanoantrotomy is demonstrated. The experience of the authors in surgical treatment and postoperative management of CEOM is reviewed. Of primary importance is valid selection of patients for each operation and choice of ventilatory tubes depending on the disease stage. Incidence rate and causes of recurrences in respect to the patients' age are presented and the role of follow-up in prevention of CEOM recurrences is shown. Use of temporal bone computed tomography in CEOM is specified. Key words: exudative otitis media, tympanostomy, ventilation tubes, CT of the temporal bone.

  17. [Failure of surgical treatment in patients with laryngeal cancer].

    PubMed

    Semczuk, B; Klonowski, S; Szmeja, Z; Janczewski, G; Olszewski, E; Kruk-Zagajewska, A; Horoch, A

    1995-01-01

    In 4 ENT Clinics of Medical Akademies in Poznań, Warszawa, Kraków, Lublin 2620 laryngeal cancer patients were operated upon during the years 1980-1987. The treatment failure occurred in 760 cases (29%). The following possible to discover factors were probably responsible for unsuccessful results: prolonged diagnostic procedure, upper laryngeal localization of tumors, advanced extents T3 and T4 (83%), advanced clinical stages of cancer (III degree and IV degree 85%), lack of surgical radicality especially in neck dissection. The early recurrencies in these places in apart of patients spoke for the presence of the neoplasmatic cells in this region.

  18. Travelling for earlier surgical treatment: the patient's view.

    PubMed Central

    Stewart, M; Donaldson, L J

    1991-01-01

    As part of the northern region's programme within the national waiting list initiative, schemes have been funded to test the feasibility and acceptability of offering patients the opportunity to travel further afield in order to receive earlier treatment. A total of 484 patients experiencing a long wait for routine surgical operations in the northern region were offered the opportunity to receive earlier treatment outside their local health district; 74% of the patients accepted the offer. The initiative was well received by the participating patients and the majority stated that if the need arose on a future occasion they would prefer to travel for treatment rather than have to wait for lengthy periods for treatment at their local hospital. These findings, interpreted in the light of the National Health Service reforms introduced in April 1991, suggest that for some types of care, patients would welcome greater flexibility in the placing of contracts, not merely reinforcement of historical patterns of referral. PMID:1823553

  19. Pancytopenia in a surgical patient, a rare presentation of hyperthyroidism.

    PubMed

    Jha, Prabhat; Singh, Yogendra Prasad; Ghimire, Bikal; Jha, Binit Kumar

    2014-12-15

    Pancytopenia is a rare complication of hyperthyroidism. Various mechanisms have been described such as immunological, bone marrow suppression. The possibility of hyperthyroidism should be considered in patients with unexplained pancytopenia. There are many case reports showing the association between hyperthyroidism and pancytopenia. All of these reports show association between Graves disease and pancytopenia but our case shows association between Multinodular goitre and pancytopenia. Besides it is uncommon to find such association in a surgical patient. This case report describes a 62 yr old hindu female with splenic injury and pancytopenia. On further investigations the patient was found to have hyperthyroidism. Though the definite mechanism regarding the association of pancytopenia with hyperthyroidism isn't clear, various cases have been described in the literature. This case shows the diagnostic dilemma that can occur in patients with pancytopenia. Any patient with unexplained pancytopenia should undergo thyroid function tests to rule out hyperthyroidism.

  20. Surgical repositioning of the premaxilla with bone graft in 50 bilateral cleft lip and palate patients.

    PubMed

    Carlini, João L; Biron, Cassia; Gomes, Kelston Ulbricht; Da Silva, Rafael M

    2009-04-01

    The aim of this study was to evaluate a modified surgical technique for premaxilla repositioning with concomitant autogenous bone grafting in bilateral trans-foramen cleft lip and palate patients. The study included 50 bilateral trans-foramen cleft lip and palate patients. Bone graft was harvested from the mandibular symphysis in 24 patients. Whenever more grafting was necessary, the iliac crest bone was used as the donor site (26 patients). The premaxilla was displaced by rupturing the bone and the palatine mucosa, and repositioned in a more adequate position using a surgical guide. The premaxilla and the grafts were fixed with miniplates and screws or screws only. The surgical guide was kept in place for 2 months, whereas the miniplates and screws were removed after 6 months, together with the complete bilateral lip and nose repair. Follow-up examinations were performed at 3, 6, and 12 months by means of periapical and occlusal radiographs, and by clinical examination. Thereafter, the patients were referred for completion of the orthodontic treatment. Overall, in 48 cases (96%) the treatment achieved total graft integration, with complete closure of the bucconasal and palatal fistulas, and premaxilla stability (either at first surgery or after reoperation). In the remaining 2 patients (4%), the treatment failed, due to necrosis of the premaxilla. The procedure is complex and involves risk. However, the patient's social inclusion, especially at the addressed age group, is the best benefit achieved.

  1. Aspergillus infections in transplant and non-transplant surgical patients.

    PubMed

    Davies, Stephen; Guidry, Christopher; Politano, Amani; Rosenberger, Laura; McLeod, Matthew; Hranjec, Tjasa; Sawyer, Robert

    2014-06-01

    Aspergillus infections are associated commonly with immunocompromised states, such as transplantation and hematologic malignant disease. Although Aspergillus infections among patients having surgery occur primarily in transplant recipients, they are found in non-recipients of transplants, and have a mortality rate similar to that seen among transplant recipients. We conducted a retrospective analysis of a prospective data base collected from 1996 to 2010, in which we identified patients with Aspergillus infections. We compared demographic data, co-morbidities, and outcomes in non-transplant patients with those in abdominal transplant recipients. Continuous data were evaluated with the Student t-test, and categorical data were evaluated through χ(2) analysis. Twenty-three patients (11 transplant patients and 12 non-transplant patients) were identified as having had Aspergillus infections. The two groups were similar with regard to their demographics and co-morbidities, with the exceptions of their scores on the Acute Physiology and Chronic Health Evaluation II (APACHE II), of 23.6±8.1 points for transplant patients vs. 16.8±6.1 points for non-transplant patients (p=0.03); Simplified Acute Physiology Score (SAPS) of 16.6±8.3 points vs. 9.2±4.1 points, respectively (p=0.02); steroid use 91.0% vs. 25.0%, respectively (p=0.003); and percentage of infections acquired in the intensive care unit (ICU) 27.3% vs. 83.3%, respectively (p=0.01). The most common site of infection in both patient groups was the lung. The two groups showed no significant difference in the number of days from admission to treatment, hospital length of stay following treatment, or mortality. Although Aspergillus infections among surgical patients have been associated historically with solid-organ transplantation, our data suggest that other patients may also be susceptible to such infections, especially those in an ICU who are deemed to be critically ill. This supports the idea that critically

  2. Aspergillus Infections in Transplant and Non-Transplant Surgical Patients

    PubMed Central

    Guidry, Christopher; Politano, Amani; Rosenberger, Laura; McLeod, Matthew; Hranjec, Tjasa; Sawyer, Robert

    2014-01-01

    Background: Aspergillus infections are associated commonly with immunocompromised states, such as transplantation and hematologic malignant disease. Although Aspergillus infections among patients having surgery occur primarily in transplant recipients, they are found in non-recipients of transplants, and have a mortality rate similar to that seen among transplant recipients. Methods: We conducted a retrospective analysis of a prospective data base collected from 1996 to 2010, in which we identified patients with Aspergillus infections. We compared demographic data, co-morbidities, and outcomes in non-transplant patients with those in abdominal transplant recipients. Continuous data were evaluated with the Student t-test, and categorical data were evaluated through χ2 analysis. Results: Twenty-three patients (11 transplant patients and 12 non-transplant patients) were identified as having had Aspergillus infections. The two groups were similar with regard to their demographics and co-morbidities, with the exceptions of their scores on the Acute Physiology and Chronic Health Evaluation II (APACHE II), of 23.6±8.1 points for transplant patients vs. 16.8±6.1 points for non-transplant patients (p=0.03); Simplified Acute Physiology Score (SAPS) of 16.6±8.3 points vs. 9.2±4.1 points, respectively (p=0.02); steroid use 91.0% vs. 25.0%, respectively (p=0.003); and percentage of infections acquired in the intensive care unit (ICU) 27.3% vs. 83.3%, respectively (p=0.01). The most common site of infection in both patient groups was the lung. The two groups showed no significant difference in the number of days from admission to treatment, hospital length of stay following treatment, or mortality. Conclusions: Although Aspergillus infections among surgical patients have been associated historically with solid-organ transplantation, our data suggest that other patients may also be susceptible to such infections, especially those in an ICU who are deemed to be critically ill

  3. Successful surgical management of ruptured umbilical hernias in cirrhotic patients

    PubMed Central

    Chatzizacharias, Nikolaos A; Bradley, J Andrew; Harper, Simon; Butler, Andrew; Jah, Asif; Huguet, Emmanuel; Praseedom, Raaj K; Allison, Michael; Gibbs, Paul

    2015-01-01

    Acute umbilical hernia rupture in patients with hepatic cirrhosis and ascites is an unusual, but potentially life-threatening complication, with postoperative morbidity about 70% and mortality between 60%-80% after supportive care and 6%-20% after urgent surgical repair. Management options include primary surgical repair with or without concomitant portal venous system decompression for the control of the ascites. We present a retrospective analysis of our centre’s experience over the last 6 years. Our cohort consisted of 11 consecutive patients (median age: 53 years, range: 36-63 years) with advanced hepatic cirrhosis and refractory ascites. Appropriate patient resuscitation and optimisation with intravenous fluids, prophylactic antibiotics and local measures was instituted. One failed attempt for conservative management was followed by a successful primary repair. In all cases, with one exception, a primary repair with non-absorbable Nylon, interrupted sutures, without mesh, was performed. The perioperative complication rate was 25% and the recurrence rate 8.3%. No mortality was recorded. Median length of hospital stay was 14 d (range: 4-31 d). Based on our experience, the management of ruptured umbilical hernias in patients with advanced hepatic cirrhosis and refractory ascites is feasible without the use of transjugular intrahepatic portosystemic shunt routinely in the preoperative period, provided that meticulous patient optimisation is performed. PMID:25780312

  4. [Class III surgical patients facilitated by accelerated osteogenic orthodontic treatment].

    PubMed

    Wu, Jia-qi; Xu, Li; Liang, Cheng; Zou, Wei; Bai, Yun-yang; Jiang, Jiu-hui

    2013-10-01

    To evaluate the treatment time and the anterior and posterior teeth movement pattern as closing extraction space for the Class III surgical patients facilitated by accelerated osteogenic orthodontic treatment. There were 10 skeletal Class III patients in accelerated osteogenic orthodontic group (AOO) and 10 patients in control group. Upper first premolars were extracted in all patients. After leveling and alignment (T2), corticotomy was performed in the area of maxillary anterior teeth to accelerate space closing.Study models of upper dentition were taken before orthodontic treatment (T1) and after space closing (T3). All the casts were laser scanned, and the distances of the movement of incisors and molars were digitally measured. The distances of tooth movement in two groups were recorded and analyzed. The alignment time between two groups was not statistically significant. The treatment time in AOO group from T2 to T3 was less than that in the control group (less than 9.1 ± 4.1 months). The treatment time in AOO group from T1 to T3 was less than that in the control group (less than 6.3 ± 4.8 months), and the differences were significant (P < 0.01). Average distances of upper incisor movement (D1) in AOO group and control group were (2.89 ± 1.48) and (3.10 ± 0.95) mm, respectively. Average distances of upper first molar movement (D2) in AOO group and control group were (2.17 ± 1.13) and (2.45 ± 1.04) mm, respectively.No statistically significant difference was found between the two groups (P > 0.05). Accelerated osteogenic orthodontic treatment could accelerate space closing in Class III surgical patients and shorten preoperative orthodontic time. There were no influence on the movement pattern of anterior and posterior teeth during pre-surgical orthodontic treatment.

  5. Vascular risk reduction during anterior surgical approach sacroiliac joint plating.

    PubMed

    Alla, Sreenivasa R; Roberts, Craig S; Ojike, Nwakile I

    2013-02-01

    Open reduction and internal fixation of sacroiliac (SI) joint is often performed through an anterior approach. However, there were no studies to our knowledge which described the "at risk area" for injury to the nutrient artery as it relates to open reduction and internal fixation of the SI joint. The purpose of this study was to determine the "at risk area" for the nutrient artery during anterior surgical approaches to the SI joint and to define the safe location of the plate for SI joint fixation. Six right and five left hemipelvises (three male and three female cadavers) were dissected with a mean age of 72 years (range, 51-90 years). Three bony landmarks including the pelvic brim, anterior SI joint line, and the anterior superior iliac spine (ASIS) were identified to quantify the measurements. Three different measurements were taken: from the nutrient foramen to the anterior SI joint line; from the nutrient foramen to the nearest point on the pelvic brim; from the nutrient foramen to ASIS using a flexible ruler with a 1mm base. The nutrient artery courses across the SI joint to enter into the nutrient foramen. Whilst exposing the internal surface of the SI joint, the nutrient foramen was identified at a mean distance of 88.1mm medial to ASIS, 20.1mm above the pelvic brim, and 20.1mm lateral to SI joint. The variability of the location of the nutrient foramen was identified and was located from 80mm to 95mm medial to the ASIS, 12mm to 25mm lateral to the SI joint, and 16mm to 30mm above the pelvic brim. Familiarity of the vasculature of the internal pelvis is of utmost importance for the surgeon when considering operative fixation of the anterior SI joint. We were able to identify the relation of the nutrient artery to the anatomic landmarks of the internal pelvis and to define the "at risk area" for the nutrient artery. We believe increased understanding of the anatomy of the nutrient artery will aid in the avoidance of vascular complications during internal

  6. A cost-utility analysis of transcatheter versus surgical aortic valve replacement for the treatment of aortic stenosis in the population with intermediate surgical risk.

    PubMed

    Tam, Derrick Y; Hughes, Avery; Fremes, Stephen E; Youn, Saerom; Hancock-Howard, Rebecca L; Coyte, Peter C; Wijeysundera, Harindra C

    2018-05-01

    Although transcatheter aortic valve implantation has been shown to be noninferior to surgical aortic valve replacement in patients with severe aortic stenosis at intermediate surgical risk, the cost-effectiveness of this strategy in this population is unknown. Our objective was to conduct a cost-utility analysis comparing transcatheter aortic valve implantation with surgical aortic valve replacement in the population with intermediate risk severe aortic stenosis. A fully probabilistic Markov model with 30-day cycles was constructed from the Canadian third-party payer's perspective to estimate the difference in cost and effectiveness (measured as quality-adjusted life years) of transcatheter aortic valve implantation versus surgical aortic valve replacement for intermediate-risk patients over a lifetime time horizon, discounted at 1.5% per annum. Clinical trial data from The Placement of Aortic Transcatheter Valve 2 informed the efficacy inputs. Costs (adjusted to 2016 Canadian dollars) were obtained from the Canadian Institute of Health Information and the Ontario Schedule of Benefits. Incremental cost-effectiveness ratios were calculated. In the base-case analysis, total lifetime costs for transcatheter aortic valve implantation were $10,548 higher than surgical aortic valve replacement but added 0.23 quality-adjusted life years, for an incremental cost-effectiveness ratio of $46,083/quality-adjusted life-years gained. Deterministic 1-way analyses showed that the incremental cost-effectiveness ratio was sensitive to rates of complications and cost of the transcatheter aortic valve implantation prosthesis. There was moderate-to-high parameter uncertainty; transcatheter aortic valve implantation was the preferred option in only 52.7% and 55.4% of the simulations at a $50,000 and $100,000 per quality-adjusted life years willingness-to-pay thresholds, respectively. On the basis of current evidence, transcatheter aortic valve implantation may be cost-effective for the

  7. Overweight is a risk factor for surgical site infection following distal gastrectomy for gastric cancer.

    PubMed

    Hirao, Motohiro; Tsujinaka, Toshimasa; Imamura, Hiroshi; Kurokawa, Yukinori; Inoue, Kentaro; Kimura, Yutaka; Shimokawa, Toshio; Furukawa, Hiroshi

    2013-04-01

    Our objective was to assess the risk factors for surgical site infections (SSIs) in gastric surgery using the results of the Osaka Gastrointestinal Cancer Chemotherapy Study Group (OGSG) 0501 phase 3 trial. The OGSG 0501 trial was conducted to compare standard prophylactic antibiotic administration versus extended prophylactic antibiotic administration in 355 patients who underwent open distal gastrectomy for gastric cancer. Various risk factors associated with the incidence of SSI following gastrectomy were analyzed from the results of this multi-institutional randomized controlled trial. Among the 355 patients, there were 24 SSIs, for an overall SSI rate of 7 %. Multivariate analysis using eight baseline factors (administration of antibiotics, age, sex, body mass index [BMI], prognostic nutritional index, tumor stage, lymph node dissection, reconstructive method) identified that BMI ≥ 25 kg/m(2) was an independent risk factor for the occurrence of SSI (odds ratio 2.82; 95 % confidence interval [CI] 1.05-7.52; P = 0.049). BMI also showed significant relationships with the volume of blood loss and the operation time (P = 0.001 and P < 0.001, respectively). Compared with patients of normal weight, overweight patients had a significantly higher risk of SSI after distal gastrectomy for cancer.

  8. [The impact of preoperative biliary drainage on surgical morbidity in hilar cholangiocarcinoma patients].

    PubMed

    Li, Shao-qiang; Chen, Dong; Liang, Li-jian; Peng, Bao-gang; Yin, Xiao-yu

    2009-08-01

    To evaluate the impact of preoperative biliary drainage on surgical morbidity in hilar cholangiocarcinoma patients underwent surgery. One hundred and eleven consecutive patients with hilar cholangiocarcinoma whose serum total bilirubin (TBIL) level > 85 micromol/L and underwent surgery in the period from June 1998 to August 2007 were enrolled. There were 67 male and 44 female patients, aged from 26 to 82 years old with a mean of 56 years old. Fifty-five patients underwent preoperative biliary drainage with a mean of 11.4 d of drainage period (drainage group), the other (n = 56) were the non-drainage group. The preoperative TBIL level of drainage group was (154 +/- 69) micromol/L, which was significantly lower than the value of pre-drainage (256 +/- 136) micromol/L (P = 0.000) and the value of non-drainage group (268 +/- 174) micromol/L (P = 0.005). ALT and GGT levels could be lowered by preoperative biliary drainage. The postoperative complications of these two groups were comparable (36.3% vs. 28.6%, P = 0.381). Four patients in drainage group and 5 patients in non-drainage group died of liver failure. Multivariate logistic regression indicated that hepatectomy (OR = 0.284, P = 0.003) was the independent risk factor associated with postoperative morbidity. Bismuth-Corlette classification (OR = 0.211, P = 0.028) was the independent risk factor linked to postoperative mortality. Preoperative biliary drainage could alleviate liver injury due to hyperbilirubin, but it could not decrease the surgical morbidity and postoperative mortality. Concomitant hepatectomy and Bismuth-Corlette classification were independent risk factors linked to surgical risks.

  9. Surgical site infections after elective neurosurgery: a survey of 1747 patients.

    PubMed

    Valentini, Laura G; Casali, Cecilia; Chatenoud, Liliane; Chiaffarino, Francesca; Uberti-Foppa, Caterina; Broggi, Giovanni

    2008-01-01

    To evaluate the incidence and risk factors of postsurgical site infections (SSIs) in elective neurosurgical procedures in patients treated with an ultrashort antibiotic protocol. In this consecutive series of 1747 patients treated with elective neurosurgery and ultrashort prophylactic antibiotic therapy at the Fondazione Istituto Nazionale Neurologico "Carlo Besta" in Milan, the rate of SSIs was 0.7% (13 patients). When only clean neurosurgery was considered, there were 11 such SSIs (1.52%) in 726 craniotomies and one SSI (0.15) in 663 spinal operations. The antibiotic protocol was prolonged in every case of external communication as cerebrospinal fluid leaks or external drainages. The infection rate of the whole series was low (0.72%), and a risk factor identified for SSIs in clean neurosurgery was longer surgery duration. The relative risk estimate was 12.6 for surgeries lasting 2 hours and 24.3 for surgeries lasting 3 or more hours. Patients aged older than 50 years had a lower risk of developing SSI with a relative risk of 0.23 when compared with patients aged younger than 50 years. The present series reports a low incidence of SSIs for elective neurosurgery, even for high-risk complex craniotomies performed for tumor removal. Given that an antibiotic protocol prolongation was used to pretreat any early signs of infection and external communication, the protocol was appropriate for the case mix. The two identified risk factors (surgical duration > 2 hours and middle-aged patients [16-50 yr]) may be indicators of other factors, such as the level of surgical complexity and poor neurological outcome.

  10. [Propensity score comparison of the various radical surgical techniques for high-risk prostate cancer].

    PubMed

    Busch, J; Gonzalgo, M; Leva, N; Ferrari, M; Friedersdorff, F; Hinz, S; Kempkensteffen, C; Miller, K; Magheli, A

    2015-01-01

    The optimal surgical treatment of patients with a high risk prostate cancer (PCa) in terms of radical prostatectomy (RP) is still controversial: open retropubic RP (RRP), laparoscopic RP (LRP), or robot-assisted (RARP). We aimed to investigate the influence of the different surgical techniques on pathologic outcome and biochemical recurrence. A total of 805 patients with a high risk PCa (PSA >20 ng/mL, Gleason Score ≥8, or clinical stage ≥cT2c) were included. A comparison of 407 RRP patients with 398 minimally invasive cases (LRP+RARP) revealed significant confounders. Therefore all 110 RARP cases were propensity score (PS) matched 1:1 with LRP and RRP patients. PS included age, clinical stage, preoperative PSA, biopsy Gleason score, surgeon's experience and application of a nerve sparing technique. Comparison of overall survival (OS) and recurrence-free survival (RFS) was done with the log rank test. Predictors of RFS were analyzed by means of Cox regression models. Within the post-matching cohort of 330 patients a pathologic Gleason score < 7, = 7 and > 7 was found in 1.8, 55.5 and 42.7% for RARP, in 8.2, 36.4, 55.5% for LRP and in 0, 60.9 and 39.1% for RRP (p=0.004 for RARP vs. LRP and p=0.398 for RARP vs. RRP). Differences in histopathologic stages were not statistically significant. The overall positive surgical margin rate (PSM) as well as PSM for ≥ pT3 were not different. PSM among patients with pT2 was found in 15.7, 14.0 and 20.0% for RARP, LRP and RRP (statistically not significant). The respective mean 3-year RFS rates were 41.4, 77.9, 54.1% (p<0.0001 for RARP vs. LRP and p=0.686 for RARP vs. RRP). The mean 3-year OS was calculated as 95.4, 98.1 and 100% respectively (statistically not significant). RARP for patients with a high risk PCa reveals similar pathologic and oncologic outcomes compared with LRP and RRP. © Georg Thieme Verlag KG Stuttgart · New York.

  11. Critical roles of orthopaedic surgeon leadership in healthcare systems to improve orthopaedic surgical patient safety.

    PubMed

    Kuo, Calvin C; Robb, William J

    2013-06-01

    The prevention of medical and surgical harm remains an important public health problem despite increased awareness and implementation of safety programs. Successful introduction and maintenance of surgical safety programs require both surgeon leadership and collaborative surgeon-hospital alignment. Documentation of success of such surgical safety programs in orthopaedic practice is limited. We describe the scope of orthopaedic surgical patient safety issues, define critical elements of orthopaedic surgical safety, and outline leadership roles for orthopaedic surgeons needed to establish and sustain a culture of safety in contemporary healthcare systems. We identified the most common causes of preventable surgical harm based on adverse and sentinel surgical events reported to The Joint Commission. A comprehensive literature review through a MEDLINE(®) database search (January 1982 through April 2012) to identify pertinent orthopaedic surgical safety articles found 14 articles. Where gaps in orthopaedic literature were identified, the review was supplemented by 22 nonorthopaedic surgical references. Our final review included 36 articles. Six important surgical safety program elements needed to eliminate preventable surgical harm were identified: (1) effective surgical team communication, (2) proper informed consent, (3) implementation and regular use of surgical checklists, (4) proper surgical site/procedure identification, (5) reduction of surgical team distractions, and (6) routine surgical data collection and analysis to improve the safety and quality of surgical patient care. Successful surgical safety programs require a culture of safety supported by all six key surgical safety program elements, active surgeon champions, and collaborative hospital and/or administrative support designed to enhance surgical safety and improve surgical patient outcomes. Further research measuring improvements from such surgical safety systems in orthopaedic care is needed.

  12. Pancreatic duct stones in patients with chronic pancreatitis: surgical outcomes.

    PubMed

    Liu, Bo-Nan; Zhang, Tai-Ping; Zhao, Yu-Pei; Liao, Quan; Dai, Meng-Hua; Zhan, Han-Xiang

    2010-08-01

    Pancreatic duct stone (PDS) is a common complication of chronic pancreatitis. Surgery is a common therapeutic option for PDS. In this study we assessed the surgical procedures for PDS in patients with chronic pancreatitis at our hospital. Between January 2004 and September 2009, medical records from 35 patients diagnosed with PDS associated with chronic pancreatitis were retrospectively reviewed and the patients were followed up for up to 67 months. The 35 patients underwent ultrasonography, computed tomography, or both, with an overall accuracy rate of 85.7%. Of these patients, 31 underwent the modified Puestow procedure, 2 underwent the Whipple procedure, 1 underwent simple stone removal by duct incision, and 1 underwent pancreatic abscess drainage. Of the 35 patients, 28 were followed up for 4-67 months. There was no postoperative death before discharge or during follow-up. After the modified Puestow procedure, abdominal pain was reduced in patients with complete or incomplete stone clearance (P>0.05). Steatorrhea and diabetes mellitus developed in several patients during a long-term follow-up. Surgery, especially the modified Puestow procedure, is effective and safe for patients with PDS associated with chronic pancreatitis. Decompression of intraductal pressure rather than complete clearance of all stones predicts postoperative outcome.

  13. Surgical Adverse Events, Risk Management, and Malpractice Outcome: Morbidity and Mortality Review Is Not Enough

    PubMed Central

    Morris, John A.; Carrillo, Ysela; Jenkins, Judith M.; Smith, Philip W.; Bledsoe, Sandy; Pichert, James; White, Andrew

    2003-01-01

    Objective To review all admissions (age > 13) to three surgical patient care centers at a single academic medical center between January 1, 1995, and December 6, 1999, for significant surgical adverse events. Summary Background Data Little data exist on the interrelationships between surgical adverse events, risk management, malpractice claims, and resulting indemnity payments to plaintiffs. The authors hypothesized that examination of this process would identify performance improvement opportunities overlooked by standard medical peer review; the risk of litigation would be constant across the three homogeneous patient care centers; and the risk management process would exceed the performance improvement process. Methods Data collected included patient demographics (age, gender, and employment status), hospital financials (hospital charges, costs, and financial class), and outcome. Outcome categories were medical (disability: <1 month, 1–6 months, permanent/death), legal (no legal action, settlement, summary judgment), financial (indemnity payments, legal fees, write-offs), and cause and effect analysis. Cause and effect analysis attempts to identify system failures contributing to adverse outcomes. This was determined by two independent analysts using the 17 Harvard criteria and subdividing these into subsystem causative factors. Results The study group consisted of 130 patients with surgical adverse events resulting in total liabilities of $8.2 million. The incidence of adverse events per 1,000 admissions across the three patient care centers was similar, but indemnity payments per 1,000 admissions varied (cardiothoracic = $30, women’s health = $90, trauma = $520). Patient demographics were not predictive of high-risk subgroups for adverse events or litigation. In terms of medical outcome, 51 patients had permanent disability or death, accounting for 98% of the indemnity payments. In terms of legal outcome, 103 patients received no indemnity payments, 15

  14. Ethnicity and patient's perception of risk in joint replacement surgery.

    PubMed

    Gandhi, Rajiv; Razak, Fahad; Davey, J Roderick; Mahomed, Nizar N

    2008-08-01

    Despite much evidence showing racial disparities in the use of surgical procedures, it is unknown whether ethnicity affects perception of surgical risk. We surveyed 1609 patients undergoing primary hip or knee replacement surgery. Relevant covariates including demographic data, body mass index (BMI), sex, comorbidities, education, and ethnicity were recorded. Pain and joint functional status were assessed at baseline and at 1-year followup with the Western Ontario McMaster University Osteoarthritis Index (WOMAC) pain and function scores. Risk perception was assessed with 3 survey questions. Non-European patients had greater functional disability and pain prior to surgery and demonstrated significantly greater perception of risk than European patients (p < 0.001). Independent of other covariates, non-European ethnicity was an independent predictor of a greater perception of risk (p < 0.05). Patient ethnicity is an important factor to consider in understanding a patient's perception of risk in joint replacement surgery.

  15. Early- and Middle-Term Surgical Outcomes in Patients with Heterotaxy Syndrome.

    PubMed

    Chen, Weidan; Ma, Li; Cui, Hujun; Yang, Shengchun; Xia, Yuansheng; Zou, Minghui; Chen, Xinxin

    2016-01-01

    Heterotaxy syndrome is a recognized risk factor for surgical cardiac interventions. We evaluated the early- and middle-term results of a surgical intervention for patients with heterotaxy syndrome. A total of 42 patients with heterotaxy syndrome were enrolled (September 2008 to March 2015). Left and right atrial isomerism were identified in 26% (11 out of 42) and 74% of patients (31 out of 42), respectively. The median age of the patients at the time of surgery was 6.8 months (range: 5 days to 22.3 years). Biventricular repair was completed in 3 patients with left atrial isomerism. Seventeen out of 39 patients who were scheduled for single ventricular repair completed a modified Fontan procedure. The hospital mortality rate was 4.7% (2 out of 42). Another 5 deaths occurred in the remaining survivors following hospital discharge with a follow-up duration of 45.8 ± 23.6 months (range: 13-111 months). The 1-year and 5-year survival rates were 88.1% (37/42) and 83.3% (35/42), respectively. Univariate analysis and multivariate analysis identified pulmonary venous obstruction and atrioventricular valve replacement as additional risk factors for mortality. Right ventricular bypass surgery remains the preferred palliative procedure for patients with heterotaxy syndrome. Based on the current results, the early- and middle-term outcomes are satisfactory. © 2015 S. Karger AG, Basel.

  16. Surgical management of cleft lip in pedo-patients.

    PubMed

    Taware, C P; Kulkarni, S R

    1991-01-01

    The Present article describes in short etiology of cleft lip and cleft palate. With this in-born defect, patient develops crucial problems with feeding, phonation, overall growth and development of affected and allied soft and hard tissue structures. This in turn results in deformity and asymmetry which is going to affect functional requirements as well as aesthetic outlook. Hence it really becomes mandatory to correct this defect surgically as early as possible, at stipulated timings so as to avoid present and future anticipated problems.

  17. Surgical, medical and developmental outcomes in patients with Down syndrome and cataracts.

    PubMed

    Santoro, Stephanie L; Atoum, Dema; Hufnagel, Robert B; Motley, William W

    2017-01-01

    Individuals with Down syndrome have an increased risk for congenital cataracts, but descriptions of surgical, medical and developmental outcomes are sparse. Retrospective review of medical charts of patients with Down syndrome with visits to Cincinnati Children's Hospital from 1988 to 2013 was performed. A case series of five patients with Down syndrome and cataracts is presented. A total of 47 patients with Down syndrome without cataracts were used as a developmental control. Developmental quotients were compared using an independent-sample, unequal variance t-test. Post-operative cataract complication rates ranged from 20% to 60%. Visual outcomes were varied; significant associations between complication rate and visual outcome were not found. Developmental quotients did not show an association with number of complications, but were lower for children with Down syndrome with cataracts requiring surgery compared to children with Down syndrome without cataracts. In children with Down syndrome and congenital cataract, surgical intervention has risk for post-operative complications. Further investigation is needed to determine if there is an association between surgical complications and visual or developmental outcomes.

  18. Effects of the Smartphone Application "Safe Patients" on Knowledge of Patient Safety Issues Among Surgical Patients.

    PubMed

    Cho, Sumi; Lee, Eunjoo

    2017-12-01

    Recently, the patient's role in preventing adverse events has been emphasized. Patients who are more knowledgeable about safety issues are more likely to engage in safety initiatives. Therefore, nurses need to develop techniques and tools that increase patients' knowledge in preventing adverse events. For this reason, an educational smartphone application for patient safety called "Safe Patients" was developed through an iterative process involving a literature review, expert consultations, and pilot testing of the application. To determine the effect of "Safe Patients," it was implemented for patients in surgical units in a tertiary hospital in South Korea. The change in patients' knowledge about patient safety was measured using seven true/false questions developed in this study. A one-group pretest and posttest design was used, and a total of 123 of 190 possible participants were tested. The percentage of correct answers significantly increased from 64.5% to 75.8% (P < .001) after implementation of the "Safe Patients" application. This study demonstrated that the application "Safe Patients" could effectively improve patients' knowledge of safety issues. This will ultimately empower patients to engage in safe practices and prevent adverse events related to surgery.

  19. Derivation, Validation and Application of a Pragmatic Risk Prediction Index for Benchmarking of Surgical Outcomes.

    PubMed

    Spence, Richard T; Chang, David C; Kaafarani, Haytham M A; Panieri, Eugenio; Anderson, Geoffrey A; Hutter, Matthew M

    2018-02-01

    Despite the existence of multiple validated risk assessment and quality benchmarking tools in surgery, their utility outside of high-income countries is limited. We sought to derive, validate and apply a scoring system that is both (1) feasible, and (2) reliably predicts mortality in a middle-income country (MIC) context. A 5-step methodology was used: (1) development of a de novo surgical outcomes database modeled around the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) in South Africa (SA dataset), (2) use of the resultant data to identify all predictors of in-hospital death with more than 90% capture indicating feasibility of collection, (3) use these predictors to derive and validate an integer-based score that reliably predicts in-hospital death in the 2012 ACS-NSQIP, (4) apply the score in the original SA dataset and demonstrate its performance, (5) identify threshold cutoffs of the score to prompt action and drive quality improvement. Following step one-three above, the 13 point Codman's score was derived and validated on 211,737 and 109,079 patients, respectively, and includes: age 65 (1), partially or completely dependent functional status (1), preoperative transfusions ≥4 units (1), emergency operation (2), sepsis or septic shock (2) American Society of Anesthesia score ≥3 (3) and operative procedure (1-3). Application of the score to 373 patients in the SA dataset showed good discrimination and calibration to predict an in-hospital death. A Codman Score of 8 is an optimal cutoff point for defining expected and unexpected deaths. We have designed a novel risk prediction score specific for a MIC context. The Codman Score can prove useful for both (1) preoperative decision-making and (2) benchmarking the quality of surgical care in MIC's.

  20. Outcomes following surgical management of femoral neck fractures in elderly dialysis-dependent patients.

    PubMed

    Puvanesarajah, Varun; Amin, Raj; Qureshi, Rabia; Shafiq, Babar; Stein, Ben; Hassanzadeh, Hamid; Yarboro, Seth

    2018-06-01

    Proximal femur fractures are one of the most common fractures observed in dialysis-dependent patients. Given the large comorbidity burden present in this patient population, more information is needed regarding post-operative outcomes. The goal of this study was to assess morbidity and mortality following operative fixation of femoral neck fractures in the dialysis-dependent elderly. The full set of medicare data from 2005 to 2014 was retrospectively analyzed. Elderly patients with femoral neck fractures were selected. Patients were stratified based on dialysis dependence. Post-operative morbidity and mortality outcomes were compared between the two populations. Adjusted odds were calculated to determine the effect of dialysis dependence on outcomes. A total of 320,629 patients met the inclusion criteria. Of dialysis-dependent patients, 1504 patients underwent internal fixation and 2662 underwent arthroplasty. For both surgical cohorts, dialysis dependence was found to be associated with at least 1.9 times greater odds of mortality within 1 and 2 years post-operatively. Blood transfusions within 90 days and infections within 2 years were significantly increased in the dialysis-dependent study cohort. Dialysis dependence alone did not contribute to increased mechanical failure or major medical complications. Regardless of the surgery performed, dialysis dependence is a significant risk factor for major post-surgical morbidity and mortality after operative treatment of femoral neck fractures in this population. Increased mechanical failure in the internal fixation group was not observed. The increased risk associated with caring for this population should be understood when considering surgical intervention and counseling patients.

  1. Thinking in three's: changing surgical patient safety practices in the complex modern operating room.

    PubMed

    Gibbs, Verna C

    2012-12-14

    The three surgical patient safety events, wrong site surgery, retained surgical items (RSI) and surgical fires are rare occurrences and thus their effects on the complex modern operating room (OR) are difficult to study. The likelihood of occurrence and the magnitude of risk for each of these surgical safety events are undefined. Many providers may never have a personal experience with one of these events and training and education on these topics are sparse. These circumstances lead to faulty thinking that a provider won't ever have an event or if one does occur the provider will intuitively know what to do. Surgeons are not preoccupied with failure and tend to usually consider good outcomes, which leads them to ignore or diminish the importance of implementing and following simple safety practices. These circumstances contribute to the persistent low level occurrence of these three events and to the difficulty in generating sufficient interest to resource solutions. Individual facilities rarely have the time or talent to understand these events and develop lasting solutions. More often than not, even the most well meaning internal review results in a new line to a policy and some rigorous enforcement mandate. This approach routinely fails and is another reason why these problems are so persistent. Vigilance actions alone have been unsuccessful so hospitals now have to take a systematic approach to implementing safer processes and providing the resources for surgeons and other stakeholders to optimize the OR environment. This article discusses standardized processes of care for mitigation of injury or outright prevention of wrong site surgery, RSI and surgical fires in an action-oriented framework illustrating the strategic elements important in each event and focusing on the responsibilities for each of the three major OR agents-anesthesiologists, surgeons and nurses. A Surgical Patient Safety Checklist is discussed that incorporates the necessary elements to

  2. Relationship Between Hospital Performance on a Patient Satisfaction Survey and Surgical Quality.

    PubMed

    Sacks, Greg D; Lawson, Elise H; Dawes, Aaron J; Russell, Marcia M; Maggard-Gibbons, Melinda; Zingmond, David S; Ko, Clifford Y

    2015-09-01

    The Centers for Medicare and Medicaid Services include patient experience as a core component of its Value-Based Purchasing program, which ties financial incentives to hospital performance on a range of quality measures. However, it remains unclear whether patient satisfaction is an accurate marker of high-quality surgical care. To determine whether hospital performance on a patient satisfaction survey is associated with objective measures of surgical quality. Retrospective observational study of participating American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) hospitals. We used data from a linked database of Medicare inpatient claims, ACS NSQIP, the American Hospital Association annual survey, and Hospital Compare from December 2, 2004, through December 31, 2008. A total of 103 866 patients older than 65 years undergoing inpatient surgery were included. Hospitals were grouped by quartile based on their performance on the Hospital Consumer Assessment of Healthcare Providers and Systems survey. Controlling for preoperative risk factors, we created hierarchical logistic regression models to predict the occurrence of adverse postoperative outcomes based on a hospital's patient satisfaction scores. Thirty-day postoperative mortality, major and minor complications, failure to rescue, and hospital readmission. Of the 180 hospitals, the overall mean patient satisfaction score was 68.0% (first quartile mean, 58.7%; fourth quartile mean, 76.7%). Compared with patients treated at hospitals in the lowest quartile, those at the highest quartile had significantly lower risk-adjusted odds of death (odds ratio = 0.85; 95% CI, 0.73-0.99), failure to rescue (odds ratio = 0.82; 95% CI, 0.70-0.96), and minor complication (odds ratio = 0.87; 95% CI, 0.75-0.99). This translated to relative risk reductions of 11.1% (P = .04), 12.6% (P = .02), and 11.5% (P = .04), respectively. No significant relationship was noted between patient satisfaction

  3. Towards reducing thrombogenicity of LVAD therapy: optimizing surgical and patient management strategies

    NASA Astrophysics Data System (ADS)

    Chivukula, Venkat Keshav; Lafzi, Ali; Mokadam, Nahush; Beckman, Jennifer; Mahr, Claudius; Aliseda, Alberto

    2017-11-01

    Unfavourable hemodynamics in heart failure patients implanted with left ventricular assist devices (LVAD), due to non-optimal surgical configurations and patient management, strongly influence thrombogenicity. This is consistent with the increase in devastating thromboembolic complications (specifically thrombosis and stroke) in patients, even as the risk of thrombosis inside the device decreases with modern designs. Inflow cannula and outflow graft surgical configurations have been optimized via patient-specific modeling that computes the thrombogenic potential with a combination of Eulerian (endothelial) wall shear stress and Lagrangian (platelet shear history) tracking. Using this view of hemodynamics, the benefits of intermittent aortic valve opening (promoting washout and reducing stagnant flow in the aortic valve region) have been assessed in managing the patient's residual native cardiac output. The use of this methodology to understand the contribution of the hemodynamics in the flow surrounding the LVAD itself to thrombogenesis show promise in developing holistic patient-specific management strategies to minimize stroke risk and enhance efficacy of LVAD therapy. Funded in part by an AHA postdoctoral fellowship 16POST30520004.

  4. Risk adjusted surgical audit in gynaecological oncology: P-POSSUM does not predict outcome.

    PubMed

    Das, N; Talaat, A S; Naik, R; Lopes, A D; Godfrey, K A; Hatem, M H; Edmondson, R J

    2006-12-01

    To assess the Physiological and Operative Severity Score for the enumeration of mortality and morbidity (POSSUM) and its validity for use in gynaecological oncology surgery. All patients undergoing gynaecological oncology surgery at the Northern Gynaecological Oncology Centre (NGOC) Gateshead, UK over a period of 12months (2002-2003) were assessed prospectively. Mortality and morbidity predictions using the Portsmouth modification of the POSSUM algorithm (P-POSSUM) were compared to the actual outcomes. Performance of the model was also evaluated using the Hosmer and Lemeshow Chi square statistic (testing the goodness of fit). During this period 468 patients were assessed. The P-POSSUM appeared to over predict mortality rates for our patients. It predicted a 7% mortality rate for our patients compared to an observed rate of 2% (35 predicted deaths in comparison to 10 observed deaths), a difference that was statistically significant (H&L chi(2)=542.9, d.f. 8, p<0.05). The P-POSSUM algorithm overestimates the risk of mortality for gynaecological oncology patients undergoing surgery. The P-POSSUM algorithm will require further adjustments prior to adoption for gynaecological cancer surgery as a risk adjusted surgical audit tool.

  5. [Surgical therapeutic strategy in vital risk polytrauma with multiple organ injuries, case report].

    PubMed

    Munteanu, Iulia; Stefan, S; Isloi, Anca; Coca, I C; Baroi, Genoveva; Radu, L; Lăpuşneanu, A; Tamaş, Camelia

    2008-01-01

    The medical interest for trauma pathology is incresing, due to the gravity of the given injuries. The surgical therapeutic strategy used is directly related to the localization and to the type of the trauma. The supplementary lesions and their vital risk also matter. The multidisciplinary team approach is the key to resolve this type of lesions with a good outcome. We recently observed an increasing tendency toward the rise of number and variety of patients with trauma, due to the great diversity of the etiopathogenic agents. The most important factor, during the assessment of a politraumatised patient is to diagnose correctly the functional deficits of vital organs and establish the vital prognosis. It is necessary to adopt the best and fast therapeutic strategy in order to obtain rapid life-saving decisions.

  6. Should Perioperative Supplemental Oxygen Be Routinely Recommended for Surgical Patients? A Bayesian Meta-analysis

    PubMed Central

    Kao, Lillian S.; Millas, Stefanos G.; Pedroza, Claudia; Tyson, Jon E.; Lally, Kevin P.

    2012-01-01

    Objective The purpose of this study is to use updated data and Bayesian methods to evaluate the effectiveness of hyperoxia to reduce surgical site infections (SSIs) and/or mortality in both colorectal and all surgical patients. Because few trials assessed potential harms of hyperoxia, hazards were not included. Background Use of hyperoxia to reduce SSIs is controversial. Three recent meta-analyses have had conflicting conclusions. Methods A systematic literature search and review were performed. Traditional fixed-effect and random-effects meta-analyses and Bayesian meta-analysis were performed to evaluate SSIs and mortality. Results Traditional meta-analysis yielded a relative risk of an SSI with hyperoxia among all surgery patients of 0.84 (95% confidence interval, CI, 0.73–0.97) and 0.84 (95% CI 0.61–1.16) for the fixed-effect and random effects models respectively. The probabilities of any risk reduction in SSIs among all surgery patients were 77%, 81%, and 83% for skeptical, neutral, and enthusiastic priors. Subset analysis of colorectal surgery patients increased the probabilities to 86%, 89%, and 92%. The probabilities of at least a 10% reduction were 57%, 62%, and 68% for all surgical patients and 71%, 75%, and 80% among the colorectal surgery subset. Conclusions There is a moderately high probability of a benefit to hyperoxia in reducing SSIs in colorectal surgery patients; however, the magnitude of benefit is relatively small and might not exceed treatment hazards. Further studies should focus on generalizability to other patient populations or on treatment hazards and other outcomes. PMID:23160100

  7. [Perioperative fluid therapy for surgical patients with chronic kidney disease].

    PubMed

    Iijima, Takehiko

    2013-11-01

    Chronic kidney disease (CKD) often accompanies cardiovascular complications, causing postoperative morbidity and even mortality. Since fluid and electrolyte homeostasis is deregulated in CKD patients, fluid therapy itself may cause postoperative morbidity. Recent studies have shown that forced diuresis through fluid overload offers no renoprotective effect and instead has harmful consequences. Fluid overload should be avoided, and the volume load should be used as the rationale for controlling hemodynamics. The emerging concept of a "zero-fluid balance policy" may be beneficial even for CKD patients. Hydroxyethylstarch might not be preferentially used for CKD patients. Hydroxyethylstarch is not contraindicated for CKD patients except in cases with long-term accumulation caused by increased vascular permeability, such as cases with sepsis, as long as an efficient volume expansion is beneficial to the patient. The regulation of renal function through the endocrine system (i.e., renin-angiotensin-aldosterone and vasopressin) is a key target for protecting the kidney in CKD. The recent development of a receptor blocker targeting these endocrine systems may be beneficial for correcting the fluid balance caused by excess intraoperative fluid therapy. The main issue for fluid therapy in surgical CKD patients may not be the quantity of fluid, but rational intervention affecting the endocrine system.

  8. Gender and racial differences in surgical outcomes among adult patients with acute heart failure.

    PubMed

    Arslanian-Engoren, Cynthia; Sferra, Joseph J; Engoren, Milo

    Approximately three million U.S. adult women have heart failure (HF), increasing their risk of adverse perioperative outcomes. While gender and racial differences are reported in surgical outcomes, less is known about 30-day perioperative outcomes in HF patients. To characterize and compare gender and racial differences in 30-day perioperative outcomes in adults with new or acute/worsening HF. The 2012-2013 American College of Surgeons National Surgical Quality Improvement Program database of surgical patients (n = 9458) with HF was analyzed. Logistic regression was used to adjust for gender and racial differences in baseline covariates. No gender difference in mortality (odds ratio = 0.922, 95% confidence interval = 0.0792-1.073, p = 0.294) was noted. Whites were more likely than Blacks to die 30 days after surgery (14% vs 9%, p < 0.001); after adjustment, Blacks were more likely to experience complications and be readmitted compared to Whites. There was no gender difference in mortality. White patients with HF were more likely to die after surgery than Black patients. Copyright © 2017 Elsevier Inc. All rights reserved.

  9. Hyperkalemia in both surgically and medically treated patients with primary aldosteronism.

    PubMed

    Wada, N; Shibayama, Y; Umakoshi, H; Ichijo, T; Fujii, Y; Kamemura, K; Kai, T; Sakamoto, R; Ogo, A; Matsuda, Y; Fukuoka, T; Tsuiki, M; Suzuki, T; Naruse, M

    2017-10-01

    Hyperkalemia is an important complication of adrenalectomy for patients with primary aldosteronism (PA). The frequency of hyperkalemia after medication using mineralocorticoid receptor antagonists (MRAs) for PA is unclear. The aim of this study is to investigate the frequency and the risk factors of hyperkalemia after surgery and medication for PA. The data of 376 patients with PA registered in a multicentre-collaborative study in Japan, including surgically treated patients (group A; n=142) and medically treated patients with MRAs (group B; n=234) were studied. The prevalence of hyperkalemic patients (serum potassium >5.0 mEq l -1 ) after treatment was higher in group A than group B (9.9 vs 3.8%, P<0.01). At diagnosis, the hyperkalemic patients were older and had a poorer renal function than the non-hyperkalemic patients in both groups (P<0.05). The hyperkalemic patients had severer PA in group A and milder PA in group B. The independent risk factor by a logistic regression analysis was only age in both groups. After treatment, the percentages of patients withdrawing antihypertensive drugs and the normalization of aldosterone renin ratio were not different between hyperkalemic and non-hyperkalemic patients in group A. The type and dose of MRAs and the combination of other antihypertensive drugs were not different between hyperkalemic and non-hyperkalemic patients in group B. In conclusion, the potential occurrence of hyperkalemia should be considered after medical as well as surgical treatment for PA, especially in patients with older age (>60 years) and impaired renal function (estimated glomerular filtration rate <70 ml min -1 per 1.73 m 2 ) at diagnosis.

  10. Aprotinin may increase mortality in low and intermediate risk but not in high risk cardiac surgical patients compared to tranexamic acid and ε-aminocaproic acid -- a meta-analysis of randomised and observational trials of over 30.000 patients.

    PubMed

    Meybohm, Patrick; Herrmann, Eva; Nierhoff, Julia; Zacharowski, Kai

    2013-01-01

    To compare the effect of aprotinin with the effect of lysine analogues (tranexamic acid and ε-aminocaproic acid) on early mortality in three subgroups of patients: low, intermediate and high risk of cardiac surgery. We performed a meta-analysis of randomised controlled trials and observational with the following data sources: Medline, Cochrane Library, and reference lists of identified articles. The primary outcome measure was early (in-hospital/30-day) mortality. The secondary outcome measures were any transfusion of packed red blood cells within 24 hours after surgery, any re-operation for bleeding or massive bleeding, and acute renal dysfunction or failure within the selected cited publications, respectively. Out of 328 search results, 31 studies (15 trials and 16 observational studies) included 33,501 patients. Early mortality was significantly increased after aprotinin vs. lysine analogues with a pooled risk ratio (95% CI) of 1.58 (1.13-2.21), p<0.001 in the low (n = 14,297) and in the intermediate risk subgroup (1.42 (1.09-1.84), p<0.001; n = 14,427), respectively. Contrarily, in the subgroup of high risk patients (n = 4,777), the risk for mortality did not differ significantly between aprotinin and lysine analogues (1.03 (0.67-1.58), p = 0.90). Aprotinin may be associated with an increased risk of mortality in low and intermediate risk cardiac surgery, but presumably may has no effect on early mortality in a subgroup of high risk cardiac surgery compared to lysine analogues. Thus, decisions to re-license aprotinin in lower risk patients should critically be debated. In contrast, aprotinin might probably be beneficial in high risk cardiac surgery as it reduces risk of transfusion and bleeding complications.

  11. Aprotinin May Increase Mortality in Low and Intermediate Risk but Not in High Risk Cardiac Surgical Patients Compared to Tranexamic Acid and ε-Aminocaproic Acid – A Meta-Analysis of Randomised and Observational Trials of over 30.000 Patients

    PubMed Central

    Meybohm, Patrick; Herrmann, Eva; Nierhoff, Julia; Zacharowski, Kai

    2013-01-01

    Background To compare the effect of aprotinin with the effect of lysine analogues (tranexamic acid and ε-aminocaproic acid) on early mortality in three subgroups of patients: low, intermediate and high risk of cardiac surgery. Methods and Findings We performed a meta-analysis of randomised controlled trials and observational with the following data sources: Medline, Cochrane Library, and reference lists of identified articles. The primary outcome measure was early (in-hospital/30-day) mortality. The secondary outcome measures were any transfusion of packed red blood cells within 24 hours after surgery, any re-operation for bleeding or massive bleeding, and acute renal dysfunction or failure within the selected cited publications, respectively. Out of 328 search results, 31 studies (15 trials and 16 observational studies) included 33,501 patients. Early mortality was significantly increased after aprotinin vs. lysine analogues with a pooled risk ratio (95% CI) of 1.58 (1.13–2.21), p<0.001 in the low (n = 14,297) and in the intermediate risk subgroup (1.42 (1.09–1.84), p<0.001; n = 14,427), respectively. Contrarily, in the subgroup of high risk patients (n = 4,777), the risk for mortality did not differ significantly between aprotinin and lysine analogues (1.03 (0.67–1.58), p = 0.90). Conclusion Aprotinin may be associated with an increased risk of mortality in low and intermediate risk cardiac surgery, but presumably may has no effect on early mortality in a subgroup of high risk cardiac surgery compared to lysine analogues. Thus, decisions to re-license aprotinin in lower risk patients should critically be debated. In contrast, aprotinin might probably be beneficial in high risk cardiac surgery as it reduces risk of transfusion and bleeding complications. PMID:23483965

  12. Spinal epidural abscesses: risk factors, medical versus surgical management, a retrospective review of 128 cases.

    PubMed

    Patel, Amit R; Alton, Timothy B; Bransford, Richard J; Lee, Michael J; Bellabarba, Carlo B; Chapman, Jens R

    2014-02-01

    Spinal epidural abscess (SEA) is a rare, serious and increasingly frequent diagnosis. Ideal management (medical vs. surgical) remains controversial. The purpose of this study is to assess the impact of risk factors, organisms, location and extent of SEA on neurologic outcome after medical management or surgery in combination with medical management. Retrospective electronic medical record (EMR) review. We included 128 consecutive, spontaneous SEA from a single tertiary medical center, from January 2005 to September 11. There were 79 male and 49 female with a mean age of 52.9 years (range, 22-83). Patient demographics, presenting complaints, radiographic features, pre/post-treatment neurologic status (ASIA motor score [MS] 0-100), treatment (medical vs. surgical) and clinical follow-up were recorded. Neurologic status was determined before treatment and at last available clinical encounter. Imaging studies reviewed location/extent of pathology. Inclusion criteria were a diagnosis of a bacterial SEA based on radiographs and/or intraoperative findings, age greater than 18 years, and adequate EMR. Exclusion criteria were postinterventional infections, Pott's disease, isolated discitis/osteomyelitis, treatment initiated at an outside facility, and imaging suggestive of a SEA but negative intraoperative findings/cultures. The mean follow-up was 241 days. The presenting chief complaint was site-specific pain (100%), subjective fevers (50%), and weakness (47%). In this cohort, 54.7% had lumbar, 39.1% thoracic, 35.9% cervical, and 23.4% sacral involvement spanning an average of 3.85 disc levels. There were 36% ventral, 41% dorsal, and 23% circumferential infections. Risk factors included a history of IV drug abuse (39.1%), diabetes mellitus (21.9%), and no risk factors (22.7%). Pathogens were methicillin-sensitive Staphylococcus aureus (40%) and methicillin-resistance S aureus (30%). Location, SEA extent, and pathogen did not impact MS recovery. Fifty-one patients were

  13. Diffusion of surgical innovation among patients with kidney cancer

    PubMed Central

    Miller, David C.; Saigal, Christopher S.; Banerjee, Mousumi; Hanley, Jan; Litwin, Mark S.

    2009-01-01

    Background Despite their potential benefits to patients with kidney cancer, the adoption of partial nephrectomy and laparoscopy has been gradual and asymmetric. To clarify whether this trend reflects differences in kidney cancer patients or differences in surgeon practice styles, we compared the magnitude of surgeon-attributable variance in the use of partial nephrectomy and laparoscopic radical nephrectomy with that attributable to patient and tumor characteristics. Methods Using linked Surveillance, Epidemiology, and End Results-Medicare data, we identified a cohort of 5,483 Medicare beneficiaries treated surgically for kidney cancer between 1997 and 2002. We defined two primary outcomes: (1) use of partial nephrectomy, and (2) use of laparoscopy among patients undergoing radical nephrectomy. Using multilevel models, we estimated surgeon- and patient-level contributions to observed variations in the use of partial nephrectomy and laparoscopic radical nephrectomy. Results Of the 5,483 cases identified, 611(11.1%) underwent partial nephrectomy (43 performed laparoscopically), and 4,872 (88.9%) underwent radical nephrectomy (515 performed laparoscopically). After adjusting for patient demographics, comorbidity, tumor size and surgeon volume, the surgeon-attributable variance was 18.1% for partial nephrectomy and 37.4% for laparoscopy. For both outcomes, the percentage of total variance attributable to surgeon factors was consistently higher than that attributable to patient characteristics. Conclusions For many patients with kidney cancer, the surgery provided depends more on their surgeon’s practice style than on the characteristics of the patient and his or her disease. Consequently, dismantling barriers to surgeon adoption of partial nephrectomy and laparoscopy is an important step toward improving the quality of care for patients with early-stage kidney cancer. PMID:18330868

  14. Surgical "buy-in": the contractual relationship between surgeons and patients that influences decisions regarding life-supporting therapy.

    PubMed

    Schwarze, Margaret L; Bradley, Ciaran T; Brasel, Karen J

    2010-03-01

    There is a general consensus by intensivists and nonsurgical providers that surgeons hesitate to withdraw life-sustaining therapy on their operative patients despite a patient's or surrogate's request to do so. The objective of this study was to examine the culture and practice of surgeons to assess attitudes and concerns regarding advance directives for their patients who have high-risk surgical procedures. A qualitative investigation using one-on-one, in-person interviews with open-ended questions about the use of advance directives during perioperative planning. Consensus coding was performed using a grounded theory approach. Data accrual continued until theoretical saturation was achieved. Modeling identified themes and trends, ensuring maximal fit and faithful data representation. Surgical practices in Madison and Milwaukee, WI. Physicians involved in the performance of high-risk surgical procedures. None. We describe the concept of surgical "buy-in," a complex process by which surgeons negotiate with patients a commitment to postoperative care before undertaking high-risk surgical procedures. Surgeons describe seeking a commitment from the patient to abide by prescribed postoperative care, "This is a package deal, this is what this operation entails," or a specific number of postoperative days, "I will contract with them and say, 'look, if we are going to do this, I am going to need 30 days to get you through this operation.'" "Buy-in" is grounded in a surgeon's strong sense of responsibility for surgical outcomes and can lead to surgeon unwillingness to operate or surgeon reticence to withdraw life-sustaining therapy postoperatively. If negotiations regarding life-sustaining interventions result in treatment limitation, a surgeon may shift responsibility for unanticipated outcomes to the patient. A complicated relationship exists between the surgeon and patient that begins in the preoperative setting. It reflects a bidirectional contract that is assumed by

  15. Scoliosis in patients with Prader Willi Syndrome - comparisons of conservative and surgical treatment.

    PubMed

    Weiss, Hans-Rudolf; Goodall, Deborah

    2009-05-06

    In children with Prader Willi syndrome (PWS), besides growth hormone (GH) therapy, control of the food environment and regular exercise, surgical treatment of scoliosis deformities seems the treatment of choice, even though the risks of spinal surgery in this specific population is very high. Therefore the question arises as to whether the risks of spinal surgery outweigh the benefits in a condition, which bears significant risks per se. The purpose of this systematic review of the Pub Med literature was to find mid or long-term results of spinal fusion surgery in patients with PWS, and to present the conservative treatment in a case study of nine patients with this condition. Types of studies included; all kinds of studies; retrospective and prospective ones, which reported upon the outcome of scoliosis surgery in patients with PWS.Types of participants included: patients with scoliosis and PWS.Type of intervention: surgery.Search strategy for identification of the studies; Pub Med; limited to English language and bibliographies of all reviewed articles.Nine patients with PWS from our data-base treated conservatively have been found, being 19 years or over at the time this study has been performed. The results of conservative management are described and related to the natural history and treatment results found in the Pub Med review. From 2210 titles displayed in the Pub Med database with the key word being "Prader Willi syndrome", 5 different papers were displayed at the date of the search containing some information on the outcome of surgery and none appeared to contain a mid or long-term follow-up. The PWS patients treated conservatively from our series all stayed below 70 degrees and some of which improved. If the curve of scoliosis patients with PWS can be kept within certain limits (usually below 70 degrees) conservatively, this treatment seems to have fewer complications than surgical treatments. The results of our retrospective study of nine patients

  16. Scoliosis in patients with Prader Willi Syndrome – comparisons of conservative and surgical treatment

    PubMed Central

    Weiss, Hans-Rudolf; Goodall, Deborah

    2009-01-01

    In children with Prader Willi syndrome (PWS), besides growth hormone (GH) therapy, control of the food environment and regular exercise, surgical treatment of scoliosis deformities seems the treatment of choice, even though the risks of spinal surgery in this specific population is very high. Therefore the question arises as to whether the risks of spinal surgery outweigh the benefits in a condition, which bears significant risks per se. The purpose of this systematic review of the Pub Med literature was to find mid or long-term results of spinal fusion surgery in patients with PWS, and to present the conservative treatment in a case study of nine patients with this condition. Types of studies included; all kinds of studies; retrospective and prospective ones, which reported upon the outcome of scoliosis surgery in patients with PWS. Types of participants included: patients with scoliosis and PWS. Type of intervention: surgery. Search strategy for identification of the studies; Pub Med; limited to English language and bibliographies of all reviewed articles. Nine patients with PWS from our data-base treated conservatively have been found, being 19 years or over at the time this study has been performed. The results of conservative management are described and related to the natural history and treatment results found in the Pub Med review. From 2210 titles displayed in the Pub Med database with the key word being "Prader Willi syndrome", 5 different papers were displayed at the date of the search containing some information on the outcome of surgery and none appeared to contain a mid or long-term follow-up. The PWS patients treated conservatively from our series all stayed below 70° and some of which improved. If the curve of scoliosis patients with PWS can be kept within certain limits (usually below 70 degrees) conservatively, this treatment seems to have fewer complications than surgical treatments. The results of our retrospective study of nine patients

  17. Relationships of obesity and diabetes mellitus to other primary cancers in surgically treated gastric cancer patients.

    PubMed

    Takeuchi, Daisuke; Koide, Naohiko; Komatsu, Daisuke; Okumura, Motohiro; Suzuki, Akira; Miyagawa, Shinichi

    2014-01-01

    Other primary cancers (OPC) have been reported in gastric cancer (GC) patients. Recent studies have shown relationships of obesity and diabetes mellitus to cancer development in several organs. The purpose of this study was to investigate the relationships of obesity and diabetes mellitus (DM) to the prevalence of OPC in GC patients. We reviewed 435 GC patients who were treated surgically and followed their outcomes after surgery. Patients with body mass index (BMI) ≥ 25 kg/m(2) were defined as obese. Fasting plasma glucose (FPG) and HbA1c levels were examined before surgery. OPC was observed in 109 GC patients (25.1%): 40 (9.2%) with synchronous OPC and 76 (18.2%) with metachronous OPC. The most common OPC was colorectal cancer (22.8%). OPC was frequently observed in patients with DM (p = 0.0022), and DM was an independent risk factor for the occurrence of OPC (odds ratio, 2.215; 95% confidence interval, 1.2007-4.0850; p = 0.011). Synchronous OPC was frequently observed in patients with obesity (p = 0.025), and obesity was an independent risk factor for the occurrence of synchronous OPC (odds ratio, 2.354; 95% confidence interval, 1.1246-4.9279; p = 0.023). Metachronous OPC was frequently observed in patients with DM (p = 0.0071), and DM was an independent risk factor for the occurrence of OPC (odds ratio, 2.680; 95% confidence interval, 1.0291-6.9780; p = 0.044). There is a need to be aware of the possibility of OPC in GC patients with DM/obesity. They should undergo intensive screening for OPC before and after gastrectomy. Copyright © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

  18. Recurrent tricuspid insufficiency: is the surgical repair technique a risk factor?

    PubMed

    Kara, Ibrahim; Koksal, Cengiz; Cakalagaoglu, Canturk; Sahin, Muslum; Yanartas, Mehmet; Ay, Yasin; Demir, Serdar

    2013-01-01

    This study compares the medium-term results of De Vega, modified De Vega, and ring annuloplasty techniques for the correction of tricuspid insufficiency and investigates the risk factors for recurrent grades 3 and 4 tricuspid insufficiency after repair. In our clinic, 93 patients with functional tricuspid insufficiency underwent surgical tricuspid repair from May 2007 through October 2010. The study was retrospective, and all the data pertaining to the patients were retrieved from hospital records. Functional capacity, recurrent tricuspid insufficiency, and risk factors aggravating the insufficiency were analyzed for each patient. In the medium term (25.4 ± 10.3 mo), the rates of grades 3 and 4 tricuspid insufficiency in the De Vega, modified De Vega, and ring annuloplasty groups were 31%, 23.1%, and 6.1%, respectively. Logistic regression analysis revealed that chronic obstructive pulmonary disease, left ventricular dysfunction (ejection fraction, < 0.50), pulmonary artery pressure ≥60 mmHg, and the De Vega annuloplasty technique were risk factors for medium-term recurrent grades 3 and 4 tricuspid insufficiency. Medium-term survival was 90.6% for the De Vega group, 96.3% for the modified De Vega group, and 97.1% for the ring annuloplasty group. Ring annuloplasty provided the best relief from recurrent tricuspid insufficiency when compared with DeVega annuloplasty. Modified De Vega annuloplasty might be a suitable alternative to ring annuloplasty when rings are not available.

  19. The Effect of Written Information on Recall of Surgical Risks of Carpal Tunnel Release Surgery: A Randomized Controlled Study.

    PubMed

    Wong, Alison L; Martin, Janet; Tang, David; LeBlanc, Martin; Morris, Steven F; Paletz, Justin; Stein, John; Wong, Michael J; Bezuhly, Michael

    2016-12-01

    Written information has been thought to help patients recall surgical risks discussed during the informed consent process, but has not been assessed for carpal tunnel release, a procedure with the rare but serious risk of complex regional pain syndrome. The authors' objective was to determine whether providing a pamphlet would improve patients' ability to remember the risks of surgery. Sixty patients seen for carpal tunnel release were included in this prospective, single-blind, randomized study. Patients received either a written pamphlet of the risks of surgery or no additional information following a standardized consultation. Two weeks after the initial consultation, patients were contacted to assess their risk recall and whether they had read about the operation from any source. There was no difference in terms of the number of risks recalled between pamphlet (1.33 ± 1.21) or control groups (1.45 ± 1.22; p = 0.73). Recall of infection was better in the pamphlet group (p < 0.05). No patients remembered complex regional pain syndrome. There was no difference in the proportion of people who read additional information about carpal tunnel release surgery between the pamphlet (34.8 percent) and control groups (21.4 percent; p = 0.39), but reading about carpal tunnel release surgery was associated with improved recall (2.45 ± 1.13 versus 0.77 ± 0.91; p < 0.01). Reading about surgery improved risk recall, but providing this information in the form of a pamphlet did not, nor did it affect patients' ability to recall the risk of complex regional pain syndrome. These results demonstrate that surgeons should implement additional measures to improve comprehension of surgical risks. Therapeutic, I.

  20. Risk factors for unavoidable removal of instrumentation after surgical site infection of spine surgery

    PubMed Central

    Tominaga, Hiroyuki; Setoguchi, Takao; Kawamura, Hideki; Kawamura, Ichiro; Nagano, Satoshi; Abematsu, Masahiko; Tanabe, Fumito; Ishidou, Yasuhiro; Yamamoto, Takuya; Komiya, Setsuro

    2016-01-01

    Abstract Surgical site infection (SSI) after spine instrumentation is difficult to treat, and often requires removal of instrumentation. The removal of instrumentation after spine surgery is a severe complication that can lead to the deterioration of activities of daily living and poor prognosis. Although there are many reports on SSI after spine surgery, few reports have investigated the risk factors for the removal of instrumentation after spine surgery SSI. This study aimed to identify the risk factors for unavoidable removal of instrumentation after SSI of spine surgery. We retrospectively reviewed 511 patients who underwent spine surgery with instrumentation at Kagoshima University Hospital from January 2006 to December 2014. Risk factors associated with SSI were analyzed via multiple logistic regression analysis. Parameters of the group that needed instrumentation removal were compared with the group that did not require instrumentation removal using the Mann–Whitney U and Fisher's exact tests. The posterior approach was used in most cases (453 of 511 cases, 88.6%). SSI occurred in 16 of 511 cases (3.14%) of spine surgery with instrumentation. Multivariate logistic regression analysis identified 2 significant risk factors for SSI: operation time, and American Society of Anesthesiologists physical status classification ≥ 3. Twelve of the 16 patients with SSI (75%) were able to keep the instrumentation after SSI. Pseudarthrosis occurred in 2 of 4 cases (50%) after instrumentation removal. Risk factors identified for instrumentation removal after spine SSI were a greater number of past surgeries, low preoperative hemoglobin, high preoperative creatinine, high postoperative infection treatment score for the spine, and the presence of methicillin-resistant Staphylococcus aureus. In these high risk cases, attempts should be made to decrease the risk factors preoperatively, and careful postoperative monitoring should be conducted. PMID:27787365

  1. Surgical treatment of pain in patients with chronic pancreatitis.

    PubMed

    Prochorov, Alexandermiddle Victorovich; Oldhafer, Karl-Jurgen; Tretyak, Stanislaw Ivanovich; Rashchynski, Siarhei Markovich; Donati, Marcello; Rashchynskaya, Nina Timofeevna; Audzevich, Dzmitry Anatolyevich

    2012-06-01

    The objectives of the research were to compare the outcomes of pancreatoduodenectomy (PD) (Kausch-Whipple or Traverso-Longmire) and resection with drainage operations (RDO) (Frey or Partingtone-Rochelle) in patients suffering from chronic pancreatitis (CP), in management of pain syndrome and quality of life provided by these kinds of surgical procedures. From 2002 to 2008 sixteen patients suffering from CP underwent PD and 16 underwent RDO. Treatment results for the two groups were analyzed with respect to postoperative complications and results of the questionnaire MOS SF-36 v.2(TM). In the immediate postoperative period more complications were observed in the PD group (a<0.05). In both groups a positive effect on removing the painful syndrome and improvement of the quality of life (p<0.01) were observed. In the PD group there were the best results of management by General Health difference criterion (a<0.01). A greater improvement of Physical Functiong value (a<0.01) was noticed in patients who underwent RDO. Both PD and RDO adequately remove pain syndrome and improve the quality of life in patients suffering from CP. Under equal conditions the preference should be given to RDO, as improvement in life quality of operated patients is greater.

  2. The Surgical Mortality Probability Model: derivation and validation of a simple risk prediction rule for noncardiac surgery.

    PubMed

    Glance, Laurent G; Lustik, Stewart J; Hannan, Edward L; Osler, Turner M; Mukamel, Dana B; Qian, Feng; Dick, Andrew W

    2012-04-01

    To develop a 30-day mortality risk index for noncardiac surgery that can be used to communicate risk information to patients and guide clinical management at the "point-of-care," and that can be used by surgeons and hospitals to internally audit their quality of care. Clinicians rely on the Revised Cardiac Risk Index to quantify the risk of cardiac complications in patients undergoing noncardiac surgery. Because mortality from noncardiac causes accounts for many perioperative deaths, there is also a need for a simple bedside risk index to predict 30-day all-cause mortality after noncardiac surgery. Retrospective cohort study of 298,772 patients undergoing noncardiac surgery during 2005 to 2007 using the American College of Surgeons National Surgical Quality Improvement Program database. The 9-point S-MPM (Surgical Mortality Probability Model) 30-day mortality risk index was derived empirically and includes three risk factors: ASA (American Society of Anesthesiologists) physical status, emergency status, and surgery risk class. Patients with ASA physical status I, II, III, IV or V were assigned either 0, 2, 4, 5, or 6 points, respectively; intermediate- or high-risk procedures were assigned 1 or 2 points, respectively; and emergency procedures were assigned 1 point. Patients with risk scores less than 5 had a predicted risk of mortality less than 0.50%, whereas patients with a risk score of 5 to 6 had a risk of mortality between 1.5% and 4.0%. Patients with a risk score greater than 6 had risk of mortality more than 10%. S-MPM exhibited excellent discrimination (C statistic, 0.897) and acceptable calibration (Hosmer-Lemeshow statistic 13.0, P = 0.023) in the validation data set. Thirty-day mortality after noncardiac surgery can be accurately predicted using a simple and accurate risk score based on information readily available at the bedside. This risk index may play a useful role in facilitating shared decision making, developing and implementing risk

  3. Pediatric hospitalist comanagement of surgical patients: structural, quality, and financial considerations.

    PubMed

    Rappaport, David I; Rosenberg, Rebecca E; Shaughnessy, Erin E; Schaffzin, Joshua K; O'Connor, Katherine M; Melwani, Anjna; McLeod, Lisa M

    2014-11-01

    Comanagement of surgical patients is occurring more commonly among adult and pediatric patients. These systems of care can vary according to institution type, comanagement structure, and type of patient. Comanagement can impact quality, safety, and costs of care. We review these implications for pediatric surgical patients. © 2014 Society of Hospital Medicine.

  4. Surgical Outcome of Ahmed Valve Implantation in Mexican Patients with Neovascular Glaucoma.

    PubMed

    Hernandez-Oteyza, Alejandra; Lazcano-Gomez, Gabriel; Jimenez-Roman, Jesus; Hernandez-Garciadiego, Carlos

    2014-01-01

    To describe clinical results of Ahmed glaucoma valve implantation in Mexican patients with neovascular glaucoma (NVG). We reviewed records of 60 eyes of 60 patients with NVG who underwent Ahmed valve implantation, with a follow-up period of 1 year. We identified successful and failed cases and compared baseline and follow-up characteristics to identify possible differences between both groups. We classified 36 eyes (60%) as successful and 24 (40%) as failed cases. We found a significant difference in success rate in patients who had a hypertensive phase at any time during the follow-up period (OR = 5.15, CI = 1.49-20.15, p = 0.004). Patients in the success group showed a statistically significant decrease in the number of glaucoma medications 1 year after surgery (p <0.0001). We found a statistically significant difference in success rate in patients who had preoperative best corrected visual acuity (BCVA) better than logmar 0.70 (odds ratio 4.31, CI = 1.1-19.3, p = 0.03086). A hypertensive postoperative phase and a preoperative BCVA worse or equal to 20/100 seem to be risk factors for Ahmed valve surgical failure in patients with NVG. How to cite this article: Hernandez-Oteyza A, Lazcano-Gomez G, Jimenez-Roman J, Hernandez-Garciadiego C. Surgical Outcome of Ahmed Valve Implantation in Mexican Patients with Neovascular Glaucoma. J Curr Glaucoma Pract 2014;8(3):86-90.

  5. Surgical transposition of the ovaries: imaging findings in 14 patients.

    PubMed

    Kier, R; Chambers, S K

    1989-11-01

    Pelvic radiation therapy for cervical or vaginal cancer often leads to ovarian failure. To remove the ovaries from the radiation portal and preserve their function, they can be transposed to the lateral abdomen. Serial imaging studies in 14 patients who had undergone ovarian transposition (five bilateral, nine unilateral) were reviewed. Images obtained included 32 CT scans, 20 sonograms, and one MR image. Most transposed ovaries were located along the paracolic gutters near the iliac crests, creating an extrinsic mass effect on adjacent bowel. Detection of surgical clips on the ovary on CT scans allowed confident recognition of all 19 transposed ovaries. Cysts in the transposed ovaries, noted on most imaging studies, did not correlate with complications of pain or hormonal dysfunction. In one case, a large physiologic cyst in a transposed ovary distorted the cecum and was mistaken for a mucocele of the appendix. In another case, a large ovarian cyst was thought to be tumor recurrence or a lymphocele. These findings indicate that although the transposed ovaries can be recognized on CT scans by the surgical clips attached to the ovaries, the appearance of the ovary does not predict reliably the development of complications.

  6. The introduction of an acute physiological support service for surgical patients is an effective error reduction strategy.

    PubMed

    Clarke, D L; Kong, V Y; Naidoo, L C; Furlong, H; Aldous, C

    2013-01-01

    Acute surgical patients are particularly vulnerable to human error. The Acute Physiological Support Team (APST) was created with the twin objectives of identifying high-risk acute surgical patients in the general wards and reducing both the incidence of error and impact of error on these patients. A number of error taxonomies were used to understand the causes of human error and a simple risk stratification system was adopted to identify patients who are particularly at risk of error. During the period November 2012-January 2013 a total of 101 surgical patients were cared for by the APST at Edendale Hospital. The average age was forty years. There were 36 females and 65 males. There were 66 general surgical patients and 35 trauma patients. Fifty-six patients were referred on the day of their admission. The average length of stay in the APST was four days. Eleven patients were haemo-dynamically unstable on presentation and twelve were clinically septic. The reasons for referral were sepsis,(4) respiratory distress,(3) acute kidney injury AKI (38), post-operative monitoring (39), pancreatitis,(3) ICU down-referral,(7) hypoxia,(5) low GCS,(1) coagulopathy.(1) The mortality rate was 13%. A total of thirty-six patients experienced 56 errors. A total of 143 interventions were initiated by the APST. These included institution or adjustment of intravenous fluids (101), blood transfusion,(12) antibiotics,(9) the management of neutropenic sepsis,(1) central line insertion,(3) optimization of oxygen therapy,(7) correction of electrolyte abnormality,(8) correction of coagulopathy.(2) CONCLUSION: Our intervention combined current taxonomies of error with a simple risk stratification system and is a variant of the defence in depth strategy of error reduction. We effectively identified and corrected a significant number of human errors in high-risk acute surgical patients. This audit has helped understand the common sources of error in the general surgical wards and will inform

  7. Mortality differences by surgical volume among patients with stomach cancer: a threshold for a favorable volume-outcome relationship.

    PubMed

    Choi, Hyeok; Yang, Seong-Yoon; Cho, Hee-Seung; Kim, Woorim; Park, Eun-Cheol; Han, Kyu-Tae

    2017-07-17

    Many studies have assessed the volume-outcome relationship in cancer patients, but most focused on better outcomes in higher volume groups rather than identifying a specific threshold that could assist in clinical decision-making for achieving the best outcomes. The current study suggests an optimal volume for achieving good outcome, as an extension of previous studies on the volume-outcome relationship in stomach cancer patients. We used National Health Insurance Service (NHIS) Sampling Cohort data during 2004-2013, comprising healthcare claims for 2550 patients with newly diagnosed stomach cancer. We conducted survival analyses adopting the Cox proportional hazard model to investigate the association of three threshold values for surgical volume of stomach cancer patients for cancer-specific mortality using the Youden index. Overall, 17.10% of patients died due to cancer during the study period. The risk of mortality among patients who received surgical treatment gradually decreased with increasing surgical volume at the hospital, while the risk of mortality increased again in "high" surgical volume hospitals, resulting in a j-shaped curve (mid-low = hazard ratio (HR) 0.773, 95% confidence interval (CI) 0.608-0.983; mid-high = HR 0.541, 95% CI 0.372-0.788; high = HR 0.659, 95% CI 0.473-0.917; ref = low). These associations were especially significant in regions with unsubstantial surgical volumes and less severe cases. The optimal surgical volume threshold was about 727.3 surgical cases for stomach cancer per hospital over the 1-year study period in South Korea. However, such positive effects decreased after exceeding a certain volume of surgeries.

  8. Predictors of At-Home Arterial Oxygen Desaturation Events in Ambulatory Surgical Patients.

    PubMed

    Biddle, Chuck; Elam, Charles; Lahaye, Laura; Kerr, Gordon; Chubb, Laura; Verhulst, Brad

    2016-11-02

    Little is known about the early recovery phase occurring at-home after anesthesia and surgery in ambulatory surgical patients. We studied quantitative oximetry and quality-of-life metrics in the first 48 hours after same-day orthopedic surgery examining the association between the recovery metrics and specific patient and procedural factors. We used the STOP-Bang score to quantify patient risk for obstructive sleep apnea in 50 adult patients at 2 centers using continuous portable oximetry and patient journaling. Parametric statistical procedures were used to assess relationships among patient and procedural factors and desaturation events. Higher STOP-Bang scores were predictive of the number and duration of desaturation events below mild and severe thresholds for arterial oxygen saturation during their first 48 hours after discharge from ambulatory surgery. Older patients and patients with higher BMI in particular were at an increased risk of mild and severe arterial oxygen desaturation. Using a home CPAP reduced the number of desaturation events. Of interest, taking opiate analgesics decreased the number of desaturation events. Given the absence of systematic research of early ambulatory anesthesia/surgery recovery at home and concerns of postoperative respiratory events, our results have clear implications for patient safety. Our results imply that screening based on noninvasive STOP-Bang scores may allow for suggestions for recovery from ambulatory surgery, such as encouraging patients with high scores to use home CPAP and aggressive education regarding use of opiates.

  9. The value of patient registries in advancing pediatric surgical care.

    PubMed

    Skarsgard, Erik D

    2018-05-01

    Pediatric surgeons treat a variety of conditions that are distinguished by their low occurrence rate, complexity, and need for integrated multidisciplinary care. Although randomized controlled trials (RCTs) are considered the gold standard for generating evidence to inform best practice, they are poorly suited to rare diseases based on the variability of illness severity, unpredictability in clinical course, and the impact limitations of studying a single intervention at a time. An alternative to RCTs for comparative effectiveness research for rare diseases in pediatric surgery is the patient registry, which collects detailed and condition-specific patient level data related to illness severity, treatment, and outcome, and allows a large, disease-specific database to be created for the dual purposes of collaborative research and quality improvement across participating sites. This review discusses the various functions of a patient registry in fulfilling its mandate of evidence-based practice and outcome improvement using examples from a variety of existing pediatric surgical registries. The value proposition of patient registries as sources of knowledge, facilitators of practice standardization, and enablers of continuous quality improvement is discussed. Copyright © 2018 Elsevier Inc. All rights reserved.

  10. Satisfaction of orthognathic surgical patients in a Malaysian population.

    PubMed

    Siow, K K; Ong, S T; Lian, C B; Ngeow, W C

    2002-12-01

    Thirty-one patients treated at the Faculty of Dentistry, University of Malaya, were assessed for their satisfaction following orthognathic surgery. The female to male ratio was 22:9 with an age range of 17 to 36. Almost all patients (97%) listed appearance as one of their rationales for surgery. More males (78%) than females (59%) wanted functional improvement, while more females (91%) than males (33%) hoped for improvement in self-confidence. All patients reported esthetic improvement while 68% each reported improvement in mastication and self-confidence. Slightly more than half (52%) chose esthetic improvement as the single most important factor resulting in satisfaction. Almost ninety percent of male patients claimed satisfaction with functional improvement, while 68% of those who found satisfaction in improved self-confidence were females. Eighty-seven percent rated their post-surgical changes as being well accepted by their family. The impact of these findings on the success of the surgery and the need to reinforce verbal communication with printed pamphlets are emphasized.

  11. Past history of skin infection and risk of surgical site infection after elective surgery.

    PubMed

    Faraday, Nauder; Rock, Peter; Lin, Elaina E; Perl, Trish M; Carroll, Karen; Stierer, Tracey; Robarts, Polly; McFillin, Angela; Ross, Tracy; Shah, Ashish S; Riley, Lee H; Tamargo, Rafael J; Black, James H; Blasco-Colmenares, Elena; Guallar, Eliseo

    2013-01-01

    To identify baseline patient characteristics associated with increased susceptibility to surgical site infection (SSI) after elective surgery. The Center for Medicare and Medicaid Services considers SSI to be preventable through adherence to current infection control practices; however, the etiology of wound infection is incompletely understood. Prospective cohort study involving patients undergoing cardiac, vascular, craniotomy, and spinal surgery at 2 academic medical centers in Baltimore, MD. A comprehensive medical history was obtained at baseline, and participants were followed for 6 months using active inpatient and outpatient surveillance for deep SSI and infectious death. Infection control best practices were monitored perioperatively. The relative risk of SSI/infectious death was determined comparing those with versus those without a past medical history of skin infection using Cox proportional hazards models. Of 613 patients (mean [SD] = 62.3 [11.5] years; 42.1% women), 22.0% reported a history of skin infection. The cumulative incidence of deep SSI/infectious death was 6.7% versus 3.1% for those with and without a history of skin infection, respectively (unadjusted hazard ratio (HR) = 2.25; 95% confidence interval (95% CI), 0.98-5.14; P = 0.055). Risk estimates increased after adjustments for demographic and socioeconomic variables (HR = 2.82; 95% CI, 1.18-6.74; P = 0.019) and after propensity score adjustment for all potential confounders (HR = 3.41; 95% CI, 1.36-8.59; P = 0.009). Adjustments for intraoperative infection risk factors and adherence to infection control best practice metrics had no impact on risk estimates. A history of skin infection identified a state of enhanced susceptibility to SSI at baseline that is independent of traditional SSI risk factors and adherence to current infection control practices.

  12. Association between surgical indications, operative risk, and clinical outcome in infective endocarditis: a prospective study from the International Collaboration on Endocarditis.

    PubMed

    Chu, Vivian H; Park, Lawrence P; Athan, Eugene; Delahaye, Francois; Freiberger, Tomas; Lamas, Cristiane; Miro, Jose M; Mudrick, Daniel W; Strahilevitz, Jacob; Tribouilloy, Christophe; Durante-Mangoni, Emanuele; Pericas, Juan M; Fernández-Hidalgo, Nuria; Nacinovich, Francisco; Rizk, Hussien; Krajinovic, Vladimir; Giannitsioti, Efthymia; Hurley, John P; Hannan, Margaret M; Wang, Andrew

    2015-01-13

    Use of surgery for the treatment of infective endocarditis (IE) as related to surgical indications and operative risk for mortality has not been well defined. The International Collaboration on Endocarditis-PLUS (ICE-PLUS) is a prospective cohort of consecutively enrolled patients with definite IE from 29 centers in 16 countries. We included patients from ICE-PLUS with definite left-sided, non-cardiac device-related IE who were enrolled between September 1, 2008, and December 31, 2012. A total of 1296 patients with left-sided IE were included. Surgical treatment was performed in 57% of the overall cohort and in 76% of patients with a surgical indication. Reasons for nonsurgical treatment included poor prognosis (33.7%), hemodynamic instability (19.8%), death before surgery (23.3%), stroke (22.7%), and sepsis (21%). Among patients with a surgical indication, surgical treatment was independently associated with the presence of severe aortic regurgitation, abscess, embolization before surgical treatment, and transfer from an outside hospital. Variables associated with nonsurgical treatment were a history of moderate/severe liver disease, stroke before surgical decision, and Staphyloccus aureus etiology. The integration of surgical indication, Society of Thoracic Surgeons IE score, and use of surgery was associated with 6-month survival in IE. Surgical decision making in IE is largely consistent with established guidelines, although nearly one quarter of patients with surgical indications do not undergo surgery. Operative risk assessment by Society of Thoracic Surgeons IE score provides prognostic information for survival beyond the operative period. S aureus IE was significantly associated with nonsurgical management. © 2014 American Heart Association, Inc.

  13. Prognostic significance of surgical extranodal extension in head and neck squamous cell carcinoma patients.

    PubMed

    Matsumoto, Fumihiko; Mori, Taisuke; Matsumura, Satoko; Matsumoto, Yoshifumi; Fukasawa, Masahiko; Teshima, Masanori; Kobayashi, Kenya; Yoshimoto, Seiichi

    2017-08-01

    Lymph node metastasis with extranodal extension represents one of the most important adverse prognostic factors for survival in patients with head and neck squamous cell carcinoma. We propose that extranodal extension occurs to differing extents. The aim of this study was to determine the prognostic significance of extranodal extension in patients with head and neck squamous cell carcinoma. Two hundred and ninety-eight patients with head and neck squamous cell carcinoma who underwent surgical resection and neck dissection were included. Cervical lymph nodes were classified into four categories: (i) pathological N negative, (ii) extranodal extension negative, (iii) non-surgical extranodal extension and (iv) surgical extranodal extension. Lymph node metastases were detected in 67.1% of laryngeal/hypopharyngeal cancer patients and 52.7% of oral cancer patients. The 3-year disease-specific survival rates for patients in the pathological N negative, extranodal extension negative, non-surgical extranodal extension and surgical extranodal extension groups were 90.9%, 79.6%, 63.8% and 48.3%, respectively. In laryngeal/hypopharyngeal cancer patients, surgical extranodal extension was associated with a significantly poorer disease-specific survival than a pathological N negative, extranodal extension negative or non-surgical extranodal extension status. In oral cancer patients, no significant differences were observed between the non-surgical and surgical extranodal extension groups. However, non-surgical extranodal extension was associated with a poorer disease-specific survival than a pathological N negative or extranodal extension negative status. Surgical extranodal extension was a poor prognostic factor in patients with head and neck squamous cell carcinoma. The prognostic significance of surgical extranodal extension differed between laryngeal/hypopharyngeal and oral cancer patients. The clinical significance of surgical extranodal extension was much greater for

  14. Impact of medical therapy on patients with Crohn’s disease requiring surgical resection

    PubMed Central

    Fu, YT Nancy; Hong, Thomas; Round, Andrew; Bressler, Brian

    2014-01-01

    AIM: To evaluate the impact of medical therapy on Crohn’s disease patients undergoing their first surgical resection. METHODS: We retrospectively evaluated all patients with Crohn’s disease undergoing their first surgical resection between years 1995 to 2000 and 2005 to 2010 at a tertiary academic hospital (St. Paul’s Hospital, Vancouver, Canada). Patients were identified from hospital administrative database using the International Classification of Diseases 9 codes. Patients’ hospital and available outpatient clinic records were independently reviewed and pertinent data were extracted. We explored relationships among time from disease diagnosis to surgery, patient phenotypes, medication usage, length of small bowel resected, surgical complications, and duration of hospital stay. RESULTS: Total of 199 patients were included; 85 from years 1995 to 2000 (cohort A) and 114 from years 2005 to 2010 (cohort B). Compared to cohort A, cohort B had more patients on immunomodulators (cohort A vs cohort B: 21.4% vs 56.1%, P < 0.0001) and less patients on 5-aminosalysilic acid (53.6% vs 29.8%, P = 0.001). There was a shift from inflammatory to stricturing and penetrating phenotypes (B1/B2/B3 38.8% vs 12.3%, 31.8% vs 45.6%, 29.4% vs 42.1%, P < 0.0001). Both groups had similar median time to surgery. Within cohort B, 38 patients (33.3%) received anti-tumor necrosis factor (TNF) agent. No patient in cohort A was exposed to anti-TNF agent. Compared to patients not on anti-TNF agent, ones exposed were younger at diagnosis (anti-TNF vs without anti-TNF: A1/A2/A3 39.5% vs 11.8%, 50% vs 73.7%, 10.5% vs 14.5%, P = 0.003) and had longer median time to surgery (90 mo vs 48 mo, P = 0.02). Combination therapy further extended median time to surgery. Using time-dependent multivariate Cox proportional hazard model, patients who were treated with anti-TNF agents had a significantly higher risk to surgery (adjusted hazard ratio 3.57, 95%CI: 1.98-6.44, P < 0.0001) compared to those

  15. Short Operative Duration and Surgical Site Infection Risk in Hip and Knee Arthroplasty Procedures

    PubMed Central

    Dicks, Kristen V.; Baker, Arthur W.; Durkin, Michael J.; Anderson, Deverick J.; Moehring, Rebekah W.; Chen, Luke F.; Sexton, Daniel J.; Weber, David J.; Lewis, Sarah S.

    2016-01-01

    OBJECTIVE To determine the association (1) between shorter operative duration and surgical site infection (SSI) and (2) between surgeon median operative duration and SSI risk among first-time hip and knee arthroplasties. DESIGN Retrospective cohort study SETTING A total of 43 community hospitals located in the southeastern United States. PATIENTS Adults who developed SSIs according to National Healthcare Safety Network criteria within 365 days of first-time knee or hip arthroplasties performed between January 1, 2008 and December 31, 2012. METHODS Log-binomial regression models estimated the association (1) between operative duration and SSI outcome and (2) between surgeon median operative duration and SSI outcome. Hip and knee arthroplasties were evaluated in separate models. Each model was adjusted for American Society of Anesthesiology score and patient age. RESULTS A total of 25,531 hip arthroplasties and 42,187 knee arthroplasties were included in the study. The risk of SSI in knee arthroplasties with an operative duration shorter than the 25th percentile was 0.40 times the risk of SSI in knee arthroplasties with an operative duration between the 25th and 75th percentile (risk ratio [RR], 0.40; 95% confidence interval [CI], 0.38–0.56; P <.01). Short operative duration did not demonstrate significant association with SSI for hip arthroplasties (RR, 1.04; 95% CI, 0.79–1.37; P =.36). Knee arthroplasty surgeons with shorter median operative durations had a lower risk of SSI than surgeons with typical median operative durations (RR, 0.52; 95% CI, 0.43–0.64; P <.01). CONCLUSIONS Short operative durations were not associated with a higher SSI risk for knee or hip arthroplasty procedures in our analysis. PMID:26391277

  16. Surgical correction of scoliosis in children with spastic quadriplegia: benefits, adverse effects, and patient selection.

    PubMed

    Legg, Julian; Davies, Evan; Raich, Annie L; Dettori, Joseph R; Sherry, Ned

    2014-04-01

    Cerebral palsy (CP) is a group of nonprogressive syndromes of posture and motor impairment associated with lesions of the immature brain. Spastic quadriplegia is the most severe form with a high incidence of scoliosis, back pain, respiratory compromise, pelvic obliquity, and poor sitting balance. Surgical stabilization of the spine is an effective technique for correcting deformity and restoring sitting posture. The decision to operate in this group of patients is challenging. The aim of this study is to determine the benefits of surgical correction of scoliosis in children with spastic quadriplegia, the adverse effects of this treatment, and what preoperative factors affect patient outcome after surgical correction. A systematic review was undertaken to identify studies describing benefits and adverse effects of surgery in spastic quadriplegia. Factors affecting patient outcome following surgical correction of scoliosis were assessed. Studies involving adults and nonspastic quadriplegia were excluded. A total of 10 case series and 1 prospective and 3 retrospective cohort studies met inclusion criteria. There was significant variation in the overall risk of complications (range, 10.9-70.9%), mortality (range, 2.8-19%), respiratory/pulmonary complications (range, 26.9-57.1%), and infection (range, 2.5-56.8%). Factors associated with a worse outcome were a significant degree of thoracic kyphosis, days in the intensive care unit, and poor nutritional status. Caregivers report a high degree of satisfaction with scoliosis surgery for children with spastic quadriplegia. There is limited evidence of preoperative factors that can predict patient outcome after scoliosis. There is a need for well-designed prospective studies of scoliosis surgery in spastic quadriplegia.

  17. The Pulmonary Thromboembolism as a Risk of Surgical Treatments and the Role of Anticoagulant Prophylaxiss

    PubMed Central

    Cukic, Vesna

    2014-01-01

    Objective: Our objective is to show the number of patients with postoperative pulmonary thromboembolism (PPTE) treated in Intensive care unit of Clinic for pulmonary diseases an TB “Podhrastovi” in three-year period : from June 1, 2011 - June 1, 2014 and to indicate the importance of various surgical operations in the development of pulmonary thromboembolism (PTE). Material and methods: This is the retrospective study which shows the number of patients with PPTE treated in Intensive care unit of Clinic for pulmonary diseases an TB “Podhrastovi” in three-year period : from 01.06.2011.-01.06.2014. It represents the number of these patients, per cent of patients with PPTE of total patients with PTE, age and sex of patients, type of surgery, period expressed in days from surgery to diagnosis of PTE, presence of deep venous thrombosis (DVT) of lower extremities, massiveness of PPTE e.g. level of pulmonary artery with embolus. Results: In three-year period 232 patients with PTE were treated in Intensive care unit of Clinic “Podhrastovi”. 60 of them or 25.86% were patients with 24 males or 40% middle-aged 58.5 years, and 36 females or 60% middle-aged 56.3 years. PPTE developed in 15 patients with abdominal, 11 with urologic, 8 with gynecologic, 15 with orthopedic, 4 with cardiologic, 2 with vascular, 3 with neurosurgical, 1 with glandular and 1 with orl operations. The average period from operation to diagnosis of PPTE was 10.5 days for women, and 13.8 days for men. Only two patients had acute DVT after operation (one man and one woman), and five had amnesias of previous DVT or PTE. The level or the site of pulmonary embolus was different from segmental to main branches of pulmonary artery. Conclusion: Different surgical operations are the big risk factor for the development of PTE. There is great significance of anticoagulant prophylaxis before surgery even in patients with no anamnesis of previous DVT or PTE. PMID:25568626

  18. [Surgery in aged patients: a study on 476 surgical cases].

    PubMed

    Guglielminetti, D; Angelini, L; Pasi, L; Carosi, V

    1990-06-01

    The Authors report their experience from 1984 to 1989 with surgery in the elderly. Patients aged 75 years were considered as geriatric and entered the study. Mortality and morbidity rates were analysed in 476 cases operated. Pre-existent diseases were related to postoperative complications. The Authors conclude underlining the feasibility of geriatric surgery as well as the acceptable risk rate.

  19. Intrawound Vancomycin Decreases the Risk of Surgical Site Infection After Posterior Spine Surgery: A Multicenter Analysis.

    PubMed

    Devin, Clinton J; Chotai, Silky; McGirt, Matthew J; Vaccaro, Alexander R; Youssef, Jim A; Orndorff, Douglas G; Arnold, Paul M; Frempong-Boadu, Anthony K; Lieberman, Isador H; Branch, Charles; Hedayat, Hirad S; Liu, Ann; Wang, Jeffrey C; Isaacs, Robert E; Radcliff, Kris E; Patt, Joshua C; Archer, Kristin R

    2018-01-01

    Secondary analysis of data from a prospective multicenter observational study. The aim of this study was to evaluate the occurrence of surgical site infection (SSI) in patients with and without intrawound vancomycin application controlling for confounding factors associated with higher SSI after elective spine surgery. SSI is a morbid and expensive complication associated with spine surgery. The application of intrawound vancomycin is rapidly emerging as a solution to reduce SSI following spine surgery. The impact of intrawound vancomycin has not been systematically studied in a well-designed multicenter study. Patients undergoing elective spine surgery over a period of 4 years at seven spine surgery centers across the United States were included in the study. Patients were dichotomized on the basis of whether intrawound vancomycin was applied. Outcomes were occurrence of SSI within postoperative 30 days and SSI that required return to the operating room (OR). Multivariable random-effect log-binomial regression analyses were conducted to determine the relative risk of having an SSI and an SSI with return to OR. .: A total of 2056 patients were included in the analysis. Intrawound vancomycin was utilized in 47% (n = 966) of patients. The prevalence of SSI was higher in patients with no vancomycin use (5.1%) than those with use of intrawound vancomycin (2.2%). The risk of SSI was higher in patients in whom intrawound vancomycin was not used (relative risk (RR) -2.5, P < 0.001), increased number of levels exposed (RR -1.1, P = 0.01), and those admitted postoperatively to intensive care unit (ICU) (RR -2.1, P = 0.005). Patients in whom intrawound vancomycin was not used (RR -5.9, P < 0.001), increased number of levels were exposed (RR-1.1, P = 0.001), and postoperative ICU admission (RR -3.3, P < 0.001) were significant risk factors for SSI requiring a return to the OR. The intrawound application of vancomycin after posterior approach spine

  20. Impact of Laterality on Surgical Outcome of Glioblastoma Patients: A Retrospective Single-Center Study.

    PubMed

    Coluccia, Daniel; Roth, Tabitha; Marbacher, Serge; Fandino, Javier

    2018-06-01

    Resection of left hemisphere (LH) tumors is often complicated by the risks of causing language dysfunction. Although neurosurgeons' concerns when operating on the presumed dominant hemisphere are well known, literature evaluating laterality as a predictive surgical parameter in glioblastoma (GB) patients is sparse. We evaluated whether tumor laterality correlated with surgical performance, functional outcome, and survival. All patients with GB treated at our institution between 2006 and 2016 were reviewed. Analysis comprised clinical characteristics, extent of resection (EOR), neurologic outcome, and survival in relation to tumor lateralization. Two hundred thirty-five patients were included. Right hemisphere (RH) tumors were larger and more frequently extended into the frontal lobe. Preoperatively, limb paresis was more frequent in RH, whereas language deficits were more frequent in LH tumors (P = 0.0009 and P < 0.0001, respectively). At 6 months after resection, LH patients presented lower Karnofsky Performance Status (KPS) score (P = 0.036). More patients with LH tumors experienced dysphasia (P < 0.0001), and no difference was seen for paresis. Average EOR was comparable, but complete resection was achieved less often in LH tumors (37.7 vs. 64.8%; P = 0.0028). Although overall survival did not differ between groups, progression-free survival was shorter in LH tumors (7.4 vs. 10.1 months; P = 0.0225). Patients with LH tumors had a pronounced KPS score decline and shorter progression-free survival without effects on overall survival. This observation might partially be attributed to a more conservative surgical resection. Further investigation is needed to assess whether systematic use of awake surgery and intraoperative mapping results in increased EOR and improved quality survival of patients with GB. Copyright © 2018 Elsevier Inc. All rights reserved.

  1. Risk factors for worsened muscle strength after the surgical treatment of arteriovenous malformations of the eloquent motor area.

    PubMed

    Lin, Fuxin; Zhao, Bing; Wu, Jun; Wang, Lijun; Jin, Zhen; Cao, Yong; Wang, Shuo

    2016-08-01

    OBJECT Case selection for the surgical treatment of arteriovenous malformations (AVMs) of the eloquent motor area remains challenging. The aim of this study was to determine the risk factors for worsened muscle strength after surgery in patients with this disorder. METHODS At their hospital the authors retrospectively studied 48 consecutive patients with AVMs involving motor cortex and/or the descending pathway. All patients had undergone preoperative functional MRI (fMRI) and diffusion tensor imaging (DTI), followed by resection. Both functional and angioarchitectural factors were analyzed with respect to the change in muscle strength. Functional factors included lesion-to-corticospinal tract distance (LCD) on DTI and lesion-to-activation area distance (LAD) and cortical reorganization on fMRI. Based on preoperative muscle strength, the changes in muscle strength at 1 week and 6 months after surgery were defined as short-term and long-term surgical outcomes, respectively. Statistical analysis was performed using the statistical package SPSS (version 20.0.0, IBM Corp.). RESULTS Twenty-one patients (43.8%) had worsened muscle strength 1 week after surgery. However, only 10 patients (20.8%) suffered from muscle strength worsening 6 months after surgery. The LCD was significantly correlated with short-term (p < 0.001) and long-term (p < 0.001) surgical outcomes. For long-term outcomes, patients in the 5 mm ≥ LCD > 0 mm (p = 0.009) and LCD > 5 mm (p < 0.001) categories were significantly associated with a lower risk of permanent motor worsening in comparison with patients in the LCD = 0 mm group. No significant difference was found between patients in the 5 mm ≥ LCD > 0 mm group and LCD > 5 mm group (p = 0.116). Nidus size was the other significant predictor of short-term (p = 0.021) and long-term (p = 0.016) outcomes. For long-term outcomes, the area under the ROC curve (AUC) was 0.728, and the cutoff point was 3.6 cm. Spetzler-Martin grade was not associated with

  2. Surgical treatment for elderly patients with secondary spontaneous pneumothorax.

    PubMed

    Igai, Hitoshi; Kamiyoshihara, Mitsuhiro; Ibe, Takashi; Kawatani, Natsuko; Shimizu, Kimihiro

    2016-05-01

    Our objective was to evaluate the validity of surgery for secondary spontaneous pneumothorax (SSP) by comparison with other treatments or with perioperative results for primary spontaneous pneumothorax (PSP). Between January 2009 and March 2015, 144 patients with SSP, aged 60 years or over, were treated in our institution. We reviewed the patients' characteristics, perioperative results, and relapse rate. Treatment to arrest air-leakage included surgery (n = 79), drainage only (n = 30), and pleurodesis (n = 35), and the pneumothorax relapse rate or mortality before discharge was compared for each. Additionally, we compared the perioperative results or relapse rate between SSP (n = 70) and PSP (n = 70) in patients who underwent 3-port thoracoscopic surgery. There was a significant difference in the relapse rate between the surgery and non-surgery groups (5.3 vs. 27.4 %, p = 0.0006). However, no significant difference in mortality before discharge was determined (p = 0.66). Significant differences were identified between the SSP and PSP groups for operation time, duration of chest drainage, and the length of postoperative hospitalization, and the postoperative morbidity were greater in the SSP group (p < 0.0001 for all). However, there was no significant difference in postoperative 30-day mortality or the relapse rate (p = 0.5, p = 0.68, respectively). Surgical treatment under general anesthesia for SSP is effective for arresting persistent air leaks or avoiding pneumothorax relapse, compared with drainage or pleurodesis, and is feasible if the appropriate perioperative management is performed.

  3. Futility and the Care of Surgical Patients: Ethical Dilemmas

    PubMed Central

    Grant, Scott B.; Modi, Parth K.

    2016-01-01

    Futility has been a contentious topic in medicine for several decades. Surgery in critical or end-of-life situations often raises difficult questions about futility. In this article, we discuss the definition of futility, methods for resolving futility disputes, and some ways to reframe the futility debate to a more fruitful discussion about the goals of care, better communication between surgeon and patient/surrogate, and palliative surgical care. Many definitions of futile therapy have been discussed. The most controversial of these is “qualitative futility” which describes a situation in which the treatment provided is likely to result in an unacceptable quality of life. This is an area of continued controversy because it has been impossible to identify universally held beliefs about acceptable quality of life. Many authors have described methods for resolving futility disputes, including community standards and legalistic multi-step due process protocols. Others, however, have abandoned the concept of futility altogether as an unhelpful term. Reframing the issue of futility as one of inadequate physician–patient communication, these authors have advocated for methods of improving communication and strengthening the patient–physician relationship. Finally, we discuss the utilization of consultants who may be of use in resolving futility disputes: ethics committees, palliative care specialists, pastoral care teams, and dedicated patient advocates. Involving these specialists in a futility conflict can help improve communication and provide invaluable assistance in arriving at the appropriate treatment decision. PMID:24849199

  4. Anesthesia and perioperative management of colorectal surgical patients - A clinical review (Part 1).

    PubMed

    Patel, Santosh; Lutz, Jan M; Panchagnula, Umakanth; Bansal, Sujesh

    2012-04-01

    Colorectal surgery is commonly performed for colorectal cancer and other pathology such as diverticular and inflammatory bowel disease. Despite significant advances, such as laparoscopic techniques and multidisciplinary recovery programs, morbidity and mortality remain high and vary among surgical centers. The use of scoring systems and assessment of functional capacity may help in identifying high-risk patients and predicting complications. An understanding of perioperative factors affecting colon blood flow and oxygenation, suppression of stress response, optimal fluid therapy, and multimodal pain management are essential. These fundamental principles are more important than any specific choice of anesthetic agents. Anesthesiologists can significantly contribute to enhance recovery and improve the quality of perioperative care.

  5. Stratification of risk to the surgical team in removal of small arms ammunition implanted in the craniofacial region: case report.

    PubMed

    Forbes, Jonathan A; Laughlin, Ian; Newberry, Shane; Ryhn, Michael; Pasley, Jason; Newberry, Travis

    2016-09-01

    In cases of penetrating injury with implantation of small arms ammunition, it can often be difficult to tell the difference between simple ballistics and ballistics associated with unexploded ordnances (UXOs). In the operative environment, where highly flammable substances are often close to the surgical site, detonation of UXOs could have catastrophic consequences for both the patient and surgical team. There is a paucity of information in the literature regarding how to evaluate whether an implanted munition contains explosive material. This report describes a patient who presented during Operation Enduring Freedom with an implanted munition suspicious for a UXO and the subsequent workup organized by Explosive Ordnance Disposal (EOD) Company prior to surgical removal. Clinical risk factors for UXOs include assassination attempts and/or wartime settings. Specific radiological features suggestive of a UXO include projectile size greater than 7.62-mm caliber, alterations in density of the tip, as well as radiological evidence of a hollowed-out core. If an implanted UXO is suspected, risks to the surgical and anesthesia teams can be minimized by notifying the nearest military installation with EOD capabilities and following clinical practice guidelines set forth by the Joint Theater Trauma System.

  6. Interventions to improve patient comprehension in informed consent for medical and surgical procedures: a systematic review.

    PubMed

    Schenker, Yael; Fernandez, Alicia; Sudore, Rebecca; Schillinger, Dean

    2011-01-01

    Patient understanding in clinical informed consent is often poor. Little is known about the effectiveness of interventions to improve comprehension or the extent to which such interventions address different elements of understanding in informed consent. . To systematically review communication interventions to improve patient comprehension in informed consent for medical and surgical procedures. Data Sources. A systematic literature search of English-language articles in MEDLINE (1949-2008) and EMBASE (1974-2008) was performed. In addition, a published bibliography of empirical research on informed consent and the reference lists of all eligible studies were reviewed. Study Selection. Randomized controlled trials and controlled trials with nonrandom allocation were included if they compared comprehension in informed consent for a medical or surgical procedure. Only studies that used a quantitative, objective measure of understanding were included. All studies addressed informed consent for a needed or recommended procedure in actual patients. Data Extraction. Reviewers independently extracted data using a standardized form. All results were compared, and disagreements were resolved by consensus. Data Synthesis. Forty-four studies were eligible. Intervention categories included written information, audiovisual/multimedia, extended discussions, and test/feedback techniques. The majority of studies assessed patient understanding of procedural risks; other elements included benefits, alternatives, and general knowledge about the procedure. Only 6 of 44 studies assessed all 4 elements of understanding. Interventions were generally effective in improving patient comprehension, especially regarding risks and general knowledge. Limitations. Many studies failed to include adequate description of the study population, and outcome measures varied widely. . A wide range of communication interventions improve comprehension in clinical informed consent. Decisions to enhance

  7. Interventions to Improve Patient Comprehension in Informed Consent for Medical and Surgical Procedures: A Systematic Review

    PubMed Central

    Schenker, Yael; Fernandez, Alicia; Sudore, Rebecca; Schillinger, Dean

    2017-01-01

    Background Patient understanding in clinical informed consent is often poor. Little is known about the effectiveness of interventions to improve comprehension or the extent to which such interventions address different elements of understanding in informed consent. Purpose To systematically review communication interventions to improve patient comprehension in informed consent for medical and surgical procedures. Data Sources A systematic literature search of English-language articles in MEDLINE (1949–2008) and EMBASE (1974–2008) was performed. In addition, a published bibliography of empirical research on informed consent and the reference lists of all eligible studies were reviewed. Study Selection Randomized controlled trials and controlled trials with non-random allocation were included if they compared comprehension in informed consent for a medical or surgical procedure. Only studies that used a quantitative, objective measure of understanding were included. All studies addressed informed consent for a needed or recommended procedure in actual patients. Data Extraction Reviewers independently extracted data using a standardized form. All results were compared, and disagreements were resolved by consensus. Data Synthesis Forty-four studies were eligible. Intervention categories included written information, audiovisual/multimedia, extended discussions, and test/feedback techniques. The majority of studies assessed patient understanding of procedural risks; other elements included benefits, alternatives, and general knowledge about the procedure. Only 6 of 44 studies assessed all 4 elements of understanding. Interventions were generally effective in improving patient comprehension, especially regarding risks and general knowledge. Limitations Many studies failed to include adequate description of the study population, and outcome measures varied widely. Conclusions A wide range of communication interventions improve comprehension in clinical informed

  8. Surgical face masks worn by patients with multidrug-resistant tuberculosis: impact on infectivity of air on a hospital ward.

    PubMed

    Dharmadhikari, Ashwin S; Mphahlele, Matsie; Stoltz, Anton; Venter, Kobus; Mathebula, Rirhandzu; Masotla, Thabiso; Lubbe, Willem; Pagano, Marcello; First, Melvin; Jensen, Paul A; van der Walt, Martie; Nardell, Edward A

    2012-05-15

    Drug-resistant tuberculosis transmission in hospitals threatens staff and patient health. Surgical face masks used by patients with tuberculosis (TB) are believed to reduce transmission but have not been rigorously tested. We sought to quantify the efficacy of surgical face masks when worn by patients with multidrug-resistant TB (MDR-TB). Over 3 months, 17 patients with pulmonary MDR-TB occupied an MDR-TB ward in South Africa and wore face masks on alternate days. Ward air was exhausted to two identical chambers, each housing 90 pathogen-free guinea pigs that breathed ward air either when patients wore surgical face masks (intervention group) or when patients did not wear masks (control group). Efficacy was based on differences in guinea pig infections in each chamber. Sixty-nine of 90 control guinea pigs (76.6%; 95% confidence interval [CI], 68-85%) became infected, compared with 36 of 90 intervention guinea pigs (40%; 95% CI, 31-51%), representing a 56% (95% CI, 33-70.5%) decreased risk of TB transmission when patients used masks. Surgical face masks on patients with MDR-TB significantly reduced transmission and offer an adjunct measure for reducing TB transmission from infectious patients.

  9. Evaluation of the Effect of Diagnostic Molecular Testing on the Surgical Decision-Making Process for Patients With Thyroid Nodules.

    PubMed

    Noureldine, Salem I; Najafian, Alireza; Aragon Han, Patricia; Olson, Matthew T; Genther, Dane J; Schneider, Eric B; Prescott, Jason D; Agrawal, Nishant; Mathur, Aarti; Zeiger, Martha A; Tufano, Ralph P

    2016-07-01

    Diagnostic molecular testing is used in the workup of thyroid nodules. While these tests appear to be promising in more definitively assigning a risk of malignancy, their effect on surgical decision making has yet to be demonstrated. To investigate the effect of diagnostic molecular profiling of thyroid nodules on the surgical decision-making process. A surgical management algorithm was developed and published after peer review that incorporated individual Bethesda System for Reporting Thyroid Cytopathology classifications with clinical, laboratory, and radiological results. This algorithm was created to formalize the decision-making process selected herein in managing patients with thyroid nodules. Between April 1, 2014, and March 31, 2015, a prospective study of patients who had undergone diagnostic molecular testing of a thyroid nodule before being seen for surgical consultation was performed. The recommended management undertaken by the surgeon was then prospectively compared with the corresponding one in the algorithm. Patients with thyroid nodules who did not undergo molecular testing and were seen for surgical consultation during the same period served as a control group. All pertinent treatment options were presented to each patient, and any deviation from the algorithm was recorded prospectively. To evaluate the appropriateness of any change (deviation) in management, the surgical histopathology diagnosis was correlated with the surgery performed. The study cohort comprised 140 patients who underwent molecular testing. Their mean (SD) age was 50.3 (14.6) years, and 75.0% (105 of 140) were female. Over a 1-year period, 20.3% (140 of 688) had undergone diagnostic molecular testing before surgical consultation, and 79.7% (548 of 688) had not undergone molecular testing. The surgical management deviated from the treatment algorithm in 12.9% (18 of 140) with molecular testing and in 10.2% (56 of 548) without molecular testing (P = .37). In the group with

  10. Hospital costs associated with surgical site infections in general and vascular surgery patients.

    PubMed

    Boltz, Melissa M; Hollenbeak, Christopher S; Julian, Kathleen G; Ortenzi, Gail; Dillon, Peter W

    2011-11-01

    Although much has been written about excess cost and duration of stay (DOS) associated with surgical site infections (SSIs) after cardiothoracic surgery, less has been reported after vascular and general surgery. We used data from the National Surgical Quality Improvement Program (NSQIP) to estimate the total cost and DOS associated with SSIs in patients undergoing general and vascular surgery. Using standard NSQIP practices, data were collected on patients undergoing general and vascular surgery at a single academic center between 2007 and 2009 and were merged with fully loaded operating costs obtained from the hospital accounting database. Logistic regression was used to determine which patient and preoperative variables influenced the occurrence of SSIs. After adjusting for patient characteristics, costs and DOS were fit to linear regression models to determine the effect of SSIs. Of the 2,250 general and vascular surgery patients sampled, SSIs were observed in 186 inpatients. Predisposing factors of SSIs were male sex, insulin-dependent diabetes, steroid use, wound classification, and operative time (P < .05). After adjusting for those characteristics, the total excess cost and DOS attributable to SSIs were $10,497 (P < .0001) and 4.3 days (P < .0001), respectively. SSIs complicating general and vascular surgical procedures share many risk factors with SSIs after cardiothoracic surgery. Although the excess costs and DOS associated with SSIs after general and vascular surgery are somewhat less, they still represent substantial financial and opportunity costs to hospitals and suggest, along with the implications for patient care, a continuing need for cost-effective quality improvement and programs of infection prevention. Copyright © 2011 Mosby, Inc. All rights reserved.

  11. Ovarian masses in pediatric patients: a multicenter study of 98 surgical cases in Tunisia.

    PubMed

    Abid, I; Zouari, M; Jallouli, M; Sahli, S; Bouden, A; Ben Abdallah, R; Trabelsi, F; Jabloun, A; Charieg, A; Mrad, C; Marzouki, M; Mosbahi, S; Ezzi, A; Mootamri, R; Hamzaoui, M; Kaabar, N; Jlidi, S; Nouri, A; Mhiri, R

    2018-03-01

    Ovarian masses requiring surgical intervention are uncommon in the pediatric population. Our aim is to report results of a multicentric Tunisian study concerning the clinical practice and the management of pediatric ovarian masses and to identify the factors that are associated with ovarian preservation. Between January 2000 and December 2015, 98 pediatric patients (<14 years) were surgically treated for ovarian masses at the five pediatric surgery departments in Tunisia. Ninety-eight patients were included in this study. The mean age of the patients at time of surgery was 8.46 ± 4.87 years. Sixty-three ovarian masses (64.3%) were non-neoplastic lesions, 24 (24.5%) were benign tumors, and 11 (11.2%) were malignant neoplasms. Conservative surgery (ovarian-preserving surgery) was successfully performed in 72.4% of the benign lesions, whereas only three patients (27.3%) with malignant tumors underwent ovary-sparing tumor resection (p < .001). The mean diameter of the tumors in the patients who underwent oophorectomy was significantly larger than that in the patients who underwent conservative surgery (7.8 ± 3.9 cm vs. 5.7 ± 2.9 cm, respectively, p = .001). In our study, the risk factors for oophorectomy were a malignant pathology and large tumor size. In accordance with the Gynecologic Cancer Intergroup consensus, we recommend that surgical management of ovarian masses in children should be based on ovarian-preserving surgery.

  12. Change in Use of Allogeneic Red Blood Cell Transfusions among Surgical Patients Over Time

    PubMed Central

    Pham, Julius Cuong; Catlett, Christina L.; Berenholtz, Sean M.; Haut, Elliott R.

    2008-01-01

    Background Although red blood cell (RBC) transfusions can be life-saving, recent evidence suggests that their use is associated with added morbidity/mortality and that a lower transfusion threshold is safe. It is unclear if this new evidence has translated into decreased RBC use among surgical patients. The purpose of this study is to measure the change in use of RBCs over the last decade. Study Design We performed a cross-sectional cohort study of all patients who underwent inpatient surgery in the 52 hospitals in Maryland in 1997–1998 and 2004–2005. The primary outcome was whether or not the patient received an allogeneic RBC transfusion. We controlled for confounders related to RBC transfusion, including age, sex, race, type of admission, comorbid conditions, and surgeon case volume. Results Patients receiving RBCs were older (63 vs. 52 yrs), were more likely to be admitted through the ED (37% vs 24%) or as a readmission (12% vs. 6.9%), had more Romano-Charlson index comorbidities, and had a higher unadjusted mortality (6.5% vs. 1.1%). Comparing 1997–1998 to 2004–2005, RBC use in surgical patients increased (8.9% vs 14%) while unadjusted mortality decreased (2.0% vs 1.5%). Factors associated with higher adjusted relative risk of transfusion include age >65 (RR 2.45), unscheduled admissions (ED RR 1.32, readmission RR 1.62), Romano-Charlson comorbidities (RR 1.04–2.71), third quartile of surgeon volume (RR 1.10), death (RR 1.24), and having surgery in 2004–2005 (RR 1.42). Conclusions Despite evidence supporting more restrictive use of RBC transfusions, RBC use among surgical patients has increased over the last decade. PMID:18722940

  13. Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.

    PubMed

    Biccard, Bruce M; Madiba, Thandinkosi E; Kluyts, Hyla-Louise; Munlemvo, Dolly M; Madzimbamuto, Farai D; Basenero, Apollo; Gordon, Christina S; Youssouf, Coulibaly; Rakotoarison, Sylvia R; Gobin, Veekash; Samateh, Ahmadou L; Sani, Chaibou M; Omigbodun, Akinyinka O; Amanor-Boadu, Simbo D; Tumukunde, Janat T; Esterhuizen, Tonya M; Manach, Yannick Le; Forget, Patrice; Elkhogia, Abdulaziz M; Mehyaoui, Ryad M; Zoumeno, Eugene; Ndayisaba, Gabriel; Ndasi, Henry; Ndonga, Andrew K N; Ngumi, Zipporah W W; Patel, Ushmah P; Ashebir, Daniel Zemenfes; Antwi-Kusi, Akwasi A K; Mbwele, Bernard; Sama, Hamza Doles; Elfiky, Mahmoud; Fawzy, Maher A; Pearse, Rupert M

    2018-04-21

    There is a need to increase access to surgical treatments in African countries, but perioperative complications represent a major global health-care burden. There are few studies describing surgical outcomes in Africa. We did a 7-day, international, prospective, observational cohort study of patients aged 18 years and older undergoing any inpatient surgery in 25 countries in Africa (the African Surgical Outcomes Study). We aimed to recruit as many hospitals as possible using a convenience sampling survey, and required data from at least ten hospitals per country (or half the surgical centres if there were fewer than ten hospitals) and data for at least 90% of eligible patients from each site. Each country selected one recruitment week between February and May, 2016. The primary outcome was in-hospital postoperative complications, assessed according to predefined criteria and graded as mild, moderate, or severe. Data were presented as median (IQR), mean (SD), or n (%), and compared using t tests. This study is registered on the South African National Health Research Database (KZ_2015RP7_22) and ClinicalTrials.gov (NCT03044899). We recruited 11 422 patients (median 29 [IQR 10-70]) from 247 hospitals during the national cohort weeks. Hospitals served a median population of 810 000 people (IQR 200 000-2 000 000), with a combined number of specialist surgeons, obstetricians, and anaesthetists totalling 0·7 (0·2-1·9) per 100 000 population. Hospitals did a median of 212 (IQR 65-578) surgical procedures per 100 000 population each year. Patients were younger (mean age 38·5 years [SD 16·1]), with a lower risk profile (American Society of Anesthesiologists median score 1 [IQR 1-2]) than reported in high-income countries. 1253 (11%) patients were infected with HIV, 6504 procedures (57%) were urgent or emergent, and the most common procedure was caesarean delivery (3792 patients, 33%). Postoperative complications occurred in 1977 (18·2%, 95% CI 17·4-18·9

  14. Quality of Life in Patients with Knee Osteoarthritis: A Commentary on Nonsurgical and Surgical Treatments

    PubMed Central

    Farr II, Jack; Miller, Larry E.; Block, Jon E.

    2013-01-01

    Knee osteoarthritis (OA) has a significant negative impact on health-related quality of life (HRQoL). Identification of therapies that improve HRQoL in patients with knee OA may mitigate the clinical, economic, and social burden of this disease. The purpose of this commentary is to report the impact of knee OA on HRQoL, describe the change in HRQoL attributable to common knee OA interventions, and summarize findings from clinical trials of a promising therapy. Nonsurgical therapies do not reliably modify HRQoL in knee OA patients given their general inability to alleviate physical manifestations of OA. Surgical knee OA interventions generally result in good to excellent patient outcomes. However, there are significant barriers to considering surgery, which limits clinical utility. Therapies that most effectively control OA-related pain with a low risk: benefit ratio will likely have the greatest benefit on HRQoL with greater rates of patient adoption. Initial clinical trial findings suggest that less invasive joint unloading implants hold promise in bridging the therapeutic gap between nonsurgical and surgical treatments for the knee OA patient. PMID:24285987

  15. An updated meta-analysis on the effectiveness of preoperative prophylactic antibiotics in patients undergoing breast surgical procedures.

    PubMed

    Sajid, Muhammad S; Hutson, Kristian; Akhter, Naved; Kalra, Lorain; Rapisarda, Ignacio F; Bonomi, Ricardo

    2012-01-01

    To systematically analyze published randomized trials on the effectiveness of preoperative prophylactic antibiotics in patients undergoing breast surgical procedures. Trials on the effectiveness of preoperative prophylactic antibiotics in patients undergoing breast surgery were selected and analyzed to generate summated data (expressed as risk ratio [RR]) by using RevMan 5.0. Nine randomized controlled trials encompassing 3720 patients undergoing breast surgery were retrieved from the electronic databases. The antibiotics group comprised a total of 1857 patients and non-antibiotics group, 1863 patients. There was no heterogeneity [χ(2) = 7.61, d.f. = 7, p < 0.37; I(2) = 8%] amongst trials. Therefore, in the fixed-effects model (RR, 0.64; 95% CI, 0.50-0.83; z = 3.48; p < 0.0005), the use of preoperative prophylactic antibiotics in patients undergoing breast surgical procedures was statistically significant in reducing the incidence of surgical site infection (SSI). Furthermore, in the fixed-effects model (RR, 1.30; 95% CI, 0.89-1.90; z = 1.37; p < 0.17), adverse reactions secondary to the use of prophylactic antibiotics was not statistically significant between the two groups. Preoperative prophylactic antibiotics significantly reduce the risk of SSI after breast surgical procedures. The risk of adverse reactions from prophylactic antibiotic administration is not significant in these patients. Therefore, preoperative prophylactic antibiotics in breast surgery patients may be routinely administered. Further research is required, however, on risk stratification for SSI, timing and duration of prophylaxis, and the need for prophylaxis in patients undergoing breast reconstruction versus no reconstruction. © 2012 Wiley Periodicals, Inc.

  16. Determinants of Malnutrition and Post-operative Complications in Hospitalized Surgical Patients

    PubMed Central

    de Aquino, José Luiz Braga

    2014-01-01

    ABSTRACT The study aimed to determine the nutritional status (NS) of hospitalized surgical patients and investigate a possible association between NS and type of disease, type of surgery and post-operative complications. The gender, age, disease, surgery, complications, length of hospital stay, number of medications, laboratory test results, and energy intake of 388 hospitalized surgical patients were recorded. NS was determined by classical anthropometry. The inclusion criteria were: nutritional status assessment done within the first 24 hours of admission, age ≥20 years, and complete medical history. Univariate and multiple Cox's regression analyses were employed to determine which variables were possible risk factors of malnutrition and complications. Malnutrition was more common in males (p=0.017), individuals aged 70 to 79 years (p=0.000), and individuals with neoplasms and digestive tract diseases (p=0.000). Malnourished individuals had longer hospital stays (p=0.013) and required more medications (p=0.001). The risk of malnutrition was associated with age and disease. Individuals aged 70 years or more had a two-fold increased risk of malnutrition (p=0.014; RR=2.207; 95% CI 1.169-4.165); those with neoplasms (p=0.008; RR=14.950; 95% CI 2.011-111.151) and those having digestive tract diseases (p=0.009; RR=14.826; 95% CI 1.939-113.362) had a 14-fold increased risk of malnutrition. Complications prevailed in older individuals (p=0.016), individuals with longer hospital stays (p=0.007), and individuals who died (p=0.002). The risk of complications was associated with age and BMI. In the present study, the risk of malnutrition was associated with age and type of disease; old age and low BMI may increase complications. PMID:25395903

  17. Economic evaluations of comprehensive geriatric assessment in surgical patients: a systematic review.

    PubMed

    Eamer, Gilgamesh; Saravana-Bawan, Bianka; van der Westhuizen, Brenden; Chambers, Thane; Ohinmaa, Arto; Khadaroo, Rachel G

    2017-10-01

    Seniors presenting with surgical disease face increased risk of postoperative morbidity and mortality and have increased treatment costs. Comprehensive Geriatric Assessment (CGA) is proposed to reduce morbidity, mortality, and the cost after surgery. A systematic review of CGA in emergency surgical patients was conducted. The primary outcome was cost-effectiveness; secondary outcomes were length of stay, return of function, and mortality. Inclusion and exclusion criteria were predefined. Systematic searches of MEDLINE, Embase, Cochrane, and National Health Service Economic Evaluation Database were performed. Text screening, bias assessment, and data extraction were performed by two authors. There were 560 articles identified; abstract review excluded 499 articles and full-text review excluded 53 articles. Eight studies were included; one nonorthopedic trauma and seven orthopedic trauma studies. Bias assessment revealed moderate to high risk of bias for all studies. Economic evaluation assessment identified two high-quality studies and six moderate or low quality studies. Pooled analysis from four studies assessed loss of function; loss of function decreased in the experimental arm (odds ratio 0.92, 95% confidence interval [CI]: 0.88-0.97). Pooled results for length of stay from five studies found a significant decrease (mean difference: -1.17, 95% CI: -1.63 to -0.71) after excluding the nonorthopedic trauma study. Pooled mortality was significantly decreased in seven studies (risk ratio: 0.78, 95% CI: 0.67-0.90). All studies decreased cost and improved health outcomes in a cost-effective manner. CGA improved return of function and mortality with reduced cost or improved utility. Our review suggests that CGA is economically dominant and the most cost-effective care model for orthogeriatric patients. Further research should examine other surgical fields. Copyright © 2017 Elsevier Inc. All rights reserved.

  18. Safety of Seasonal Influenza Vaccination in Hospitalized Surgical Patients: A Cohort Study.

    PubMed

    Tartof, Sara Y; Qian, Lei; Rieg, Gunter K; Yu, Kalvin C; Sy, Lina S; Tseng, Hung Fu; Hechter, Rulin C; Jacobsen, Steven J

    2016-05-03

    Despite recommendations to vaccinate surgical inpatients against influenza, vaccination rates remain low in this population, due in part to concerns about potential negative effects on postsurgical care. To evaluate whether influenza vaccination in the perioperative period increases health care utilization and evaluations for postsurgical infection after discharge. Retrospective cohort study. Members of Kaiser Permanente Southern California. Patients aged 6 months or older who had inpatient surgery with admission and discharge between 1 September and 31 March from 2010 to 2013. All influenza vaccinations administered between 1 August and 30 April in the 2010-2011, 2011-2012, and 2012-2013 influenza seasons. Outcomes included rates of outpatient visits, readmission, emergency department (ED) visits, fever (temperature ≥38.0 °C), and clinical laboratory evaluations for infection (urine culture, complete blood count, blood culture, and wound culture) in the 7 days after discharge. Of the 42 777 surgeries included in adjusted analyses, vaccine was administered during hospitalization in 6420. No differences were detected between the vaccinated and unvaccinated groups in risk for inpatient visits (rate ratio [RR], 1.12 [95% CI, 0.96 to 1.32]), ED visits (RR, 1.07 [CI, 0.96 to 1.20]), postdischarge fever (RR, 1.00 [CI, 0.76 to 1.31]), or clinical evaluations for infection (RR, 1.06 [CI, 0.99 to 1.13]). A marginal increase in risk for outpatient visits (RR, 1.05 [CI, 1.00 to 1.10]; P = 0.032) was found. The study did not distinguish between planned and unplanned readmissions or outpatient visits. No strong evidence of increased risk for adverse outcomes was found in comparisons of patients who received influenza vaccine during a surgical hospitalization and those who did not. The data support the recommendation to vaccinate surgical inpatients against influenza. Centers for Disease Control and Prevention.

  19. Management of critically ill surgical patients Case reports.

    PubMed

    Mangiante, Gerardo; Padoan, Roberto; Mengardo, Valentina; Bencivenga, Maria; de Manzoni, Giovanni

    2016-01-01

    The acute abdomen (AA) still remains a challenging situation for surgeons. New pathological conditions have been imposed to our attention in this field in recent years. The definition of abdominal compartmental syndrome (ACS) in surgical practice and the introduction of new biological matrices, with the concepts of tension-free (TS) repair of incisional hernias, prompted us to set up new therapeutic strategies for the treatment of patients with AA. Thus we reviewed the cases of AA that we observed in recent years in which we performed a laparostomy in order to prevent or to treat an ACS. They are all cases of acute abdomen (AA), but from different origin, including chronic diseases, as in the course of inflammatory bowel disease (IBD), and acute pancreatitis. In all the cases, the open abdominal cavity was covered with a polyethylene sheet. The edges of the wound were sutured to the plastic sheet, and a traction exerted by a device that causes a negative pressure was added. This method was adopted in several cases without randomization, and resulted in excellent patient's outcomes. Abdominal compartmental syndrome, Acute abdomen, Laparostomy.

  20. Administrative data measured surgical site infection probability within 30 days of surgery in elderly patients.

    PubMed

    van Walraven, Carl; Jackson, Timothy D; Daneman, Nick

    2016-09-01

    Elderly patients are inordinately affected by surgical site infections (SSIs). This study derived and internally validated a model that used routinely collected health administrative data to measure the probability of SSI in elderly patients within 30 days of surgery. All people exceeding 65 years undergoing surgery from two hospitals with known SSI status were linked to population-based administrative data sets in Ontario, Canada. We used bootstrap methods to create a multivariate model that used health administrative data to predict the probability of SSI. Of 3,436 patients, 177 (5.1%) had an SSI. The Elderly SSI Risk Model included six covariates: number of distinct physician fee codes within 30 days of surgery; presence or absence of a postdischarge prescription for an antibiotic; presence or absence of three diagnostic codes; and a previously derived score that gauged SSI risk based on procedure codes. The model was highly explanatory (Nagelkerke's R 2 , 0.458), strongly discriminative (C statistic, 0.918), and well calibrated (calibration slope, 1). Health administrative data can effectively determine 30-day risk of SSI risk in elderly patients undergoing a broad assortment of surgeries. External validation is necessary before this can be routinely used to monitor SSIs in the elderly. Copyright © 2016 Elsevier Inc. All rights reserved.

  1. [Vitamin A and zinc levels in gastroenterological surgical patients: Relation with inflammation and postoperative complications].

    PubMed

    Zago, L B; Danguise, E; González Infantino, C A; Río, M E; Callegari, M

    2011-01-01

    It is accepted that even mild nutrient depletion may affect the evolution of the surgical patient. To evaluate the influence of preoperative levels of plasma retinol and zinc on postoperative evolution of surgical patients; to evaluate the influence of inflammation on both level markers. Plasma retinol and zinc were determined in 50 patients before programmed gastroenterological surgeries. To detect global malnutrition BMI and weight loss percentage (WL%) were included. C-reactive protein (CRP) was included as inflammation marker. During follow up postoperative complications were recorded. The present analysis was carried out in 43 patients with complete information. Low retinol values (< 20 μg/dl) were founded in 3 cases and low Zn values (< 85 μg/dl) in 20 cases, being 9 of them indicative of severe deficiency (< 70 μg/dl). Postoperative complications were recorded in 17 patients; patients with complications presented lower values of plasma Zn (78.4 ± 25.8 vs. 87.8 ± 25.7 μg/dl) and retinol (36.9 ± 14.5 vs. 49.7 ± 20.6; P = 0.0318) than those with no complications; the number of patients with complications decreased when retinol and Zn ranges increased. No relation between BMI or WL% and appearance of complications was founded; patients with higher WL% were those with higher usual weight. Inflammation affected both markers: retinol dropped from 50.1 ± 17.2 to 44.0 ±20.8 and to 23.7 ± 4.0 μg/dl for CRP ranges of < 0.5, 0.5-3.9 and ≥ 4 mg/dl, respectively (p = 0.0193); levels of zinc fell from 90.1 ± 17.8 to 85.2 ± 29.9 and to 55.0 ± 25.9 μg/dl for the same CRP ranges (P = 0.0195). Zn level influenced retinol level, dropping to 33.1 ± 11.7 μg/dl of retinol in the Zn severe deficiency group (P = 0.0386). The obtained results confirm the influence of vitamin A and zinc on postoperative evolution of the surgical patient, while alert about the interrelationships among vitamin A, zinc and inflammation, which lead to difficulty to establish the real

  2. Complications leading to surgical revision in implantable cardioverter defibrillator patients: comparison of patients with single-chamber, dual-chamber, and biventricular devices.

    PubMed

    Duray, Gabor Z; Schmitt, Joern; Cicek-Hartvig, Sule; Hohnloser, Stefan H; Israel, Carsten W

    2009-03-01

    Implantable cardioverter defibrillator (ICD) technology has become more complex, particularly with respect to biventricular resynchronization devices. The incidence of hardware-related complications in single (SC)-, dual (DC)-, and triple (BiV)-chamber devices requiring surgical revision has not been investigated systematically. We analysed data from consecutive ICD recipients implanted between January 2000 and December 2007 with respect to the need of surgical re-intervention for device- or lead-related complications. Generator exchanges due to normal battery depletion were not considered. From 816 patients (81% male, 69% ischaemic cardiomyopathy, 48% secondary prevention ICDs) followed for 31 +/- 24 months (2118 cumulative patient-years), 98 patients underwent 110 revisions (5.2% per patient-year). Complications included lead-related revision procedures in 81 cases and generator-related problems in 29 cases. The annual incidence of surgical revision due to complications was 11.8% in BiV compared with 4.9% in SC and 4.1% in DC patients (P = 0.002). This higher revision rate was mainly caused by lead-related complications. Implantation of a BiV system was an independent risk factor of the need for surgical revision (relative risk 2.37, 95% confidence interval 1.38-4.04). Even with long-lasting operator experience, complications requiring surgical revision remain a clinically important problem of ICD therapy. The incidence of complications is significantly higher in BiV resynchronization devices than in SC and DC systems.

  3. Clinical and Surgical Factors Associated With Increased Epilepsy Risk in Children With Hydrocephalus.

    PubMed

    Tully, Hannah M; Kukull, Walter A; Mueller, Beth A

    2016-06-01

    Children with hydrocephalus are at risk for epilepsy both due to their underlying condition and as a consequence of surgical treatment; however, the relative contributions of these factors remain unknown. The authors sought to characterize epilepsy among children with infancy-onset hydrocephalus and to examine the risks of epilepsy associated with hydrocephalus subtype and with factors related to surgical treatment. We conducted a longitudinal cohort study of all children with infancy-onset hydrocephalus treated at a major regional children's hospital during 2002 to 2012, with follow-up to ascertain risk factors and epilepsy outcome through April 2015. Poisson regression was used to calculate adjusted risk ratios and 95% confidence intervals for associations. Among 379 children with hydrocephalus, 86 (23%) developed epilepsy (mean onset age = 2.7 years), almost one fifth of whom had a history of infantile spasms. Relative to spina bifida-associated hydrocephalus, children with other major hydrocephalus subtypes had fourfold higher risks of developing epilepsy. Among children who underwent surgery, surgical infection doubled the risk of epilepsy (risk ratio = 2.0, 95% confidence interval = 1.4 to 3.0). Epilepsy was associated with surgical failure for intracranial reasons but not extracranial reasons (risk ratio = 1.7, 95% confidence interval = 1.1 to 2.7; risk ratio = 1.1, 95% confidence interval = 0.7 to 1.9, respectively). Epilepsy is common among children with hydrocephalus. Compared with children with spina bifida-associated hydrocephalus, children with other major hydrocephalus subtypes have a markedly increased risk of epilepsy. Surgical infection doubles the risk of epilepsy. Copyright © 2016 Elsevier Inc. All rights reserved.

  4. Trends in diagnosis and surgical management of patients with perforated peptic ulcer.

    PubMed

    Thorsen, Kenneth; Glomsaker, Tom B; von Meer, Andreas; Søreide, Kjetil; Søreide, Jon Arne

    2011-08-01

    While the laparoscopic treatment of perforated peptic ulcers (PPU) has been shown to be feasible and safe, its implementation into routine clinical practice has been slow. Only a few studies have evaluated its overall utility. The aim of this study was to investigate changes in surgical management of PPU and associated outcomes. The study was a retrospective, single institution, population-based review of all patients undergoing surgery for PPU between 2003 and 2009. Patient demographics, diagnostic evaluation, management, and outcomes were evaluated. Included were 114 patients with a median age of 67 years (range, 20-100). Women comprised 59% and were older (p < 0.001), had more comorbidities (p = 0.002), and had a higher Boey risk score (p = 0.036) compared to men. Perforation location was gastric/pyloric in 72% and duodenal in 28% of patients. Pneumoperitoneum was diagnosed by plain abdominal x-ray in 30 of 41 patients (75%) and by abdominal computerized tomography (CT) in 76 of 77 patients (98%; p < 0.001).Laparoscopic treatment was initiated in 48 patients (42%) and completed in 36 patients (75% of attempted cases). Laparoscopic treatment rate increased from 7% to 46% during the study period (p = 0.02). Median operation time was shorter in patients treated via laparotomy (70 min) compared to laparoscopy (82 min) and those converted from laparoscopy to laparotomy (105 min; p = 0.017). Postoperative complications occurred in 56 patients (49%). Overall 30-day postoperative mortality was 16%. No statistically significant differences were found in morbidity and mortality between open versus laparoscopic repair. This study demonstrates an increased use of CT as the primary diagnostic tool for PPU and of laparoscopic repair in its surgical treatment. These changes in management are not associated with altered outcomes.

  5. Recommendations for Best Communication Practices to Facilitate Goal-concordant Care for Seriously Ill Older Patients With Emergency Surgical Conditions.

    PubMed

    Cooper, Zara; Koritsanszky, Luca A; Cauley, Christy E; Frydman, Julia L; Bernacki, Rachelle E; Mosenthal, Anne C; Gawande, Atul A; Block, Susan D

    2016-01-01

    To address the need for improved communication practices to facilitate goal-concordant care in seriously ill, older patients with surgical emergencies. Improved communication is increasingly recognized as a central element in providing goal-concordant care and reducing health care utilization and costs among seriously ill older patients. Given high rates of surgery in the last weeks of life, high risk of poor outcomes after emergency operations in these patients, and barriers to quality communication in the acute setting, we sought to create a framework to support surgeons in communicating with seriously ill, older patients with surgical emergencies. An interdisciplinary panel of 23 national leaders was convened for a 1-day conference at Harvard Medical School to provide input on concept, content, format, and usability of a communication framework. A prototype framework was created. Participants supported the concept of a structured approach to communication in these scenarios, and delineated 9 key elements of a framework: (1) formulating prognosis, (2) creating a personal connection, (3) disclosing information regarding the acute problem in the context of the underlying illness, (4) establishing a shared understanding of the patient's condition, (5) allowing silence and dealing with emotion, (6) describing surgical and palliative treatment options, (7) eliciting patient's goals and priorities, (8) making a treatment recommendation, and (9) affirming ongoing support for the patient and family. Communication with seriously ill patients in the acute setting is difficult. The proposed communication framework may assist surgeons in delivering goal-concordant care for high-risk patients.

  6. The readability of psychosocial wellness patient resources: improving surgical outcomes.

    PubMed

    Kugar, Meredith A; Cohen, Adam C; Wooden, William; Tholpady, Sunil S; Chu, Michael W

    2017-10-01

    .0093, P = 0.0054, and P = 0.0093). The overall average readability consensus for mental health information on all websites analyzed was 9.52. Online resources for mental health disorders are more complex than recommended by the NIH and AMA. Efforts to improve readability of mental health and psychosocial wellness resources could benefit patient understanding and outcomes, especially in patients with lower literacy. Surgical outcomes are correlated with patient mental health and psychosocial wellness and thus can be improved with more appropriate levels of readability of psychosocial wellness resources. Copyright © 2017 Elsevier Inc. All rights reserved.

  7. Preoperative pain as a risk factor for chronic post-surgical pain - six month follow-up after radical prostatectomy.

    PubMed

    Gerbershagen, Hans J; Ozgür, Enver; Dagtekin, Oguzhan; Straub, Karin; Hahn, Moritz; Heidenreich, Axel; Sabatowski, Rainer; Petzke, Frank

    2009-11-01

    Chronic post-surgical pain (CPSP) by definition develops for the first time after surgery and is not related to any preoperative pain. Preoperative pain is assumed to be a major risk factor for CPSP. Prospective studies to endorse this assumption are missing. In order to assess the incidence and the risk factors for CPSP multidimensional pain and health characteristics and psychological aspects were studied in patients prior to radical prostatectomy. Follow-up questionnaires were completed three and six months after surgery. CPSP incidences in 84 patients after three and six months were 14.3% and 1.2%. Preoperatively, CPSP patients were assigned to higher pain chronicity stages measured with the Mainz Pain Staging System (MPSS) (p=0.003) and higher pain severity grades (Chronic Pain Grading Questionnaire) (p=0.016) than non-CPSP patients. CPSP patients reported more pain sites (p=0.001), frequent pain in urological body areas (p=0.047), previous occurrence of CPSP (p=0.008), more psychosomatic symptoms (Symptom Check List) (p=0.031), and worse mental functioning (Short Form-12) (p=0.019). Three months after surgery all CPSP patients suffered from moderate to high-risk chronic pain (MPSS stages II and III) compared to 66.7% at baseline and 82.3% had high disability pain (CPGQ grades III and IV) compared to 41.7% before surgery. CPSP patients scored significantly less favorably in physical and mental health, habitual well-being, and psychosomatic dysfunction three months after surgery. All patients with CPSP reported on preoperative chronic pain. Patients with preoperative pain, related or not related to the surgical site were significantly at risk to develop CPSP. High preoperative pain chronicity stages and pain severity grades were associated with CPSP. CPSP patients reported poorer mental health related quality of life and more severe psychosomatic dysfunction before and 3 months after surgery.

  8. Risk adjustment models for short-term outcomes after surgical resection for oesophagogastric cancer.

    PubMed

    Fischer, C; Lingsma, H; Hardwick, R; Cromwell, D A; Steyerberg, E; Groene, O

    2016-01-01

    Outcomes for oesophagogastric cancer surgery are compared with the aim of benchmarking quality of care. Adjusting for patient characteristics is crucial to avoid biased comparisons between providers. The study objective was to develop a case-mix adjustment model for comparing 30- and 90-day mortality and anastomotic leakage rates after oesophagogastric cancer resections. The study reviewed existing models, considered expert opinion and examined audit data in order to select predictors that were consequently used to develop a case-mix adjustment model for the National Oesophago-Gastric Cancer Audit, covering England and Wales. Models were developed on patients undergoing surgical resection between April 2011 and March 2013 using logistic regression. Model calibration and discrimination was quantified using a bootstrap procedure. Most existing risk models for oesophagogastric resections were methodologically weak, outdated or based on detailed laboratory data that are not generally available. In 4882 patients with oesophagogastric cancer used for model development, 30- and 90-day mortality rates were 2·3 and 4·4 per cent respectively, and 6·2 per cent of patients developed an anastomotic leak. The internally validated models, based on predictors selected from the literature, showed moderate discrimination (area under the receiver operating characteristic (ROC) curve 0·646 for 30-day mortality, 0·664 for 90-day mortality and 0·587 for anastomotic leakage) and good calibration. Based on available data, three case-mix adjustment models for postoperative outcomes in patients undergoing curative surgery for oesophagogastric cancer were developed. These models should be used for risk adjustment when assessing hospital performance in the National Health Service, and tested in other large health systems. © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd.

  9. Surgical site infection in patients submitted to heart transplantation.

    PubMed

    Rodrigues, Jussara Aparecida Souza do Nascimento; Ferretti-Rebustini, Renata Eloah de Lucena; Poveda, Vanessa de Brito

    2016-08-29

    to analyze the occurrence and predisposing factors for surgical site infection in patients submitted to heart transplantation, evaluating the relationship between cases of infections and the variables related to the patient and the surgical procedure. retrospective cohort study, with review of the medical records of patients older than 18 years submitted to heart transplantation. The correlation between variables was evaluated by using Fisher's exact test and Mann-Whitney-Wilcoxon test. the sample consisted of 86 patients, predominantly men, with severe systemic disease, submitted to extensive preoperative hospitalizations. Signs of surgical site infection were observed in 9.3% of transplanted patients, with five (62.5%) superficial incisional, two (25%) deep and one (12.5%) case of organ/space infection. There was no statistically significant association between the variables related to the patient and the surgery. there was no association between the studied variables and the cases of surgical site infection, possibly due to the small number of cases of infection observed in the sample investigated. analisar a ocorrência e os fatores predisponentes para infecção de sítio cirúrgico em pacientes submetidos a transplante cardíaco e verificar a relação entre os casos de infecção e as variáveis referentes ao paciente e ao procedimento cirúrgico. estudo de coorte retrospectivo, com exame dos prontuários médicos de pacientes maiores de 18 anos, submetidos a transplante cardíaco. A correlação entre variáveis foi realizada por meio dos testes exato de Fischer e de Mann-Whitney-Wilcoxon. a amostra foi constituída por 86 pacientes, predominantemente homens, com doença sistêmica grave, submetidos a internações pré-operatórias extensas. Apresentaram sinais de infecção do sítio cirúrgico 9,3% dos transplantados, sendo cinco (62,5%) incisionais superficiais, duas (25%) profundas e um (12,5%) caso de infecção de órgão/espaço. Não houve associa

  10. Patient survival and surgical re-intervention predictors for intracapsular hip fractures.

    PubMed

    González Quevedo, David; Mariño, Iskandar Tamimi; Sánchez Siles, Juan Manuel; Escribano, Esther Romero; Granero Molina, Esther Judith; Enrique, David Bautista; Smoljanović, Tomislav; Pareja, Francisco Villanueva

    2017-08-01

    Choosing between total hip replacement (THR) and partial hip replacement (PHR) for patients with intracapsular hip fractures is often based on subjective factors. Predicting the survival of these patients and risk of surgical re-intervention is essential to select the most adequate implant. We conducted a retrospective cohort study on mortality of patients over 70 years with intracapsular hip fractures who were treated between January 2010 and December 2013, with either PHR or THR. Patients' information was withdrawn from our local computerized database. The age-adjusted Charlson comorbidity index (ACCI) and American Society of Anesthesiologists (ASA) score were calculated for all patients. The patients were followed for 2 years after surgery. Survival and surgical re-intervention rates were compared between the two groups using a Multivariate Cox proportional hazard model. A total of 356 individuals were included in this study. At 2 years of follow-up, 221 (74.4%) of the patients with ACCI score≤7 were still alive, in contrast to only 20 (29.0%) of those with ACCI score>7. In addition, 201 (76.2%) of the patients with ASA score≤3 were still alive after 2 years, compared to 30 (32.6%) of individuals with ASA >3. Patients with the ACCI score>7, and ASA score>3 had a significant increase in all-cause 2-year mortality (adjusted hazard ratio of 3.2, 95% CI 2.2-4.6; and 3.12, 95% CI 2.2-4.5, respectively). Patients with an ASA score>3 had a quasi-significant increase in the re-intervention risk (adjusted hazard ratio 2.2, 95% CI 1.0-5.1). The sensitivity, specificity, positive predictive value and negative predictive values of ACCI in predicting 2-year mortality were 39.2%, 91.1%, 71%, and 74.4%, respectively. On the other hand, the sensitivity, specificity, positive predictive value and negative predictive values of ASA score in predicting 2-year mortality were 49.6%, 79.1%, 67.4%, and 76.1%, respectively. Both ACCI and ASA scales were able to predict the 2-year

  11. Single-centre experience of radiation exposure in acute surgical patients: assessment of therapeutic impact and future recommendations.

    PubMed

    Fitzmaurice, Gerard J; Brown, Robin; Cranley, Brian; Conlon, Enda F; Todd, R Alan J; O'Donnell, Mark E

    2010-09-01

    Radiological investigations have become a key adjunct in patient management and consequently radiation exposure to patients is increasing. The study objectives were to examine the use of radiological investigations in the management of acute surgical patients and to assess whether a guideline-based radiation exposure risk/benefit analysis can aid in the choice of radiological investigation used. A prospective observational study was completed over a 12-week period from April to July 2008 for all acute surgical admissions. Data recorded included demographics, clinical presentation, differential diagnosis, investigations, surgical interventions, and final clinical outcome. The use of radiological investigative modalities as an adjunct to clinical assessment was then evaluated against The Royal College of Radiologists (RCR) guidelines. A total of 380 acute surgical admissions (M = 174, F = 185, children = 21) were assessed during the study period. Seven hundred thirty-four radiological investigations were performed with a mean of 1.93 investigations per patient. Based on the RCR guidelines, 680 (92.6%) radiological investigations were warranted and included 142 CT scans (19.3%), 129 chest X-rays (17.6%), and 85 abdominal X-rays (11.6%). Clinically, radiological imaging complemented surgical management in 326 patients (85.8%) and the management plan remained unchanged for the remaining 54 patients (14.2%). This accounted for an average radiation dose of 4.18 millisievert (mSv) per patient or 626 days of background radiation exposure. CT imaging was responsible for the majority of the radiation exposure, with a total of 1310 mSv (82.6%) of the total radiation exposure being attributed to CT imaging in 20.8% of acute admissions. Subgroup analysis demonstrated that 92.8% of the CT scans performed were appropriate. Radiation exposure was generally low for the majority of acute surgical admissions. However, it is recommended that CT imaging requests be evaluated carefully

  12. Surgical complications associated with primary closure in patients with diabetic foot osteomyelitis

    PubMed Central

    García-Morales, Esther; Lázaro-Martínez, José Luis; Aragón-Sánchez, Javier; Cecilia-Matilla, Almudena; García-Álvarez, Yolanda; Beneit-Montesinos, Juan Vicente

    2012-01-01

    Background The aim of this study was to determine the incidence of complications associated with primary closure in surgical procedures performed for diabetic foot osteomyelitis compared to those healed by secondary intention. In addition, further evaluation of the surgical digital debridement for osteomyelitis with primary closure as an alternative to patients with digital amputation was also examined in our study. Methods Comparative study that included 46 patients with diabetic foot ulcerations. Surgical debridement of the infected bone was performed on all patients. Depending on the surgical technique used, primary surgical closure was performed on 34 patients (73.9%, Group 1) while the rest of the 12 patients were allowed to heal by secondary intention (26.1%, Group 2). During surgical intervention, bone samples were collected for both microbiological and histopathological analyses. Post-surgical complications were recorded in both groups during the recovery period. Results The average healing time was 9.9±SD 8.4 weeks in Group 1 and 19.1±SD 16.9 weeks in Group 2 (p=0.008). The percentage of complications was 61.8% in Group 1 and 58.3% in Group 2 (p=0.834). In all patients with digital ulcerations that were necessary for an amputation, a primary surgical closure was performed with successful outcomes. Discussion Primary surgical closure was not associated with a greater number of complications. Patients who received primary surgical closure had faster healing rates and experienced a lower percentage of exudation (p=0.05), edema (p<0.001) and reinfection, factors that determine the delay in wound healing and affect the prognosis of the surgical outcome. Further research with a greater number of patients is required to better define the cases for which primary surgical closure may be indicated at different levels of the diabetic foot. PMID:23050062

  13. Patient-specific system for prognosis of surgical treatment outcomes of human cardiovascular system

    NASA Astrophysics Data System (ADS)

    Golyadkina, Anastasiya A.; Kalinin, Aleksey A.; Kirillova, Irina V.; Kossovich, Elena L.; Kossovich, Leonid Y.; Menishova, Liyana R.; Polienko, Asel V.

    2015-03-01

    Object of study: Improvement of life quality of patients with high stroke risk ia the main goal for development of system for patient-specific modeling of cardiovascular system. This work is dedicated at increase of safety outcomes for surgical treatment of brain blood supply alterations. The objects of study are common carotid artery, internal and external carotid arteries and bulb. Methods: We estimated mechanical properties of carotid arteries tissues and patching materials utilized at angioplasty. We studied angioarchitecture features of arteries. We developed and clinically adapted computer biomechanical models, which are characterized by geometrical, physical and mechanical similarity with carotid artery in norm and with pathology (atherosclerosis, pathological tortuosity, and their combination). Results: Collaboration of practicing cardiovascular surgeons and specialists in the area of Mathematics and Mechanics allowed to successfully conduct finite-element modeling of surgical treatment taking into account various features of operation techniques and patching materials for a specific patient. Numerical experiment allowed to reveal factors leading to brain blood supply decrease and atherosclerosis development. Modeling of carotid artery reconstruction surgery for a specific patient on the basis of the constructed biomechanical model demonstrated the possibility of its application in clinical practice at approximation of numerical experiment to the real conditions.

  14. [Healing status of surgical incisions in human immunodeficiency virus-positive patients with fractures].

    PubMed

    Li, Xin; Zhang, Qiang; Zhao, Changsong; Sun, Sheng; Cai, Juan

    2014-09-09

    To observe the healing status of surgical incisions in human immunodeficiency virus (HIV)-positive patients with fractures and explore the factors related with poor wound healing, treatment and preventive measures. Retrospective analyses were performed for the clinical data of 61 HIV-positive patients with fractures. And the influencing factors, treatment and outcomes of poor wound healing were analyzed. Among them, the healing status was good (n = 50) and poor (n = 11). And the outcomes included redness (n = 10), oozing (n = 8), split (n = 3), infection (n = 2), hematoma (n = 1), fat liquefaction (n = 2) and delayed healing (n = 2). All healed well after treatment. There was no infection or death during the follow-up period. Compared with HIV-negative patients, it was not statistically significant in wound infection. However, poor healing rates were significantly different (P < 0.05). The risk factors included advanced age, low body mass index, low albumin, low hemoglobin, low total lymphocyte count, low CD4⁺ T lymphocyte count, high HIV infection clinical stage, long operative duration, emergency surgery and incision contamination. In HIV-positive patients with fractures, the healing of surgical incision is generally good. However few have poor wound healing due to multiple factors. If poor healing is identified early and handled timely and correctly, good healing ensues.

  15. Cerebral oximetry values in dialyzed surgical patients: a comparison between hemodialysis and peritoneal dialysis.

    PubMed

    Papadopoulos, Georgios; Dounousi, Evangelia; Papathanasiou, Athanasios; Papathanakos, Georgios; Tzimas, Petros

    2013-07-01

    Cerebral tissue regional oxygen saturation (rSO2) through near-infrared spectroscopy (NIRS) is a method for non-invasive monitoring of cerebral tissue oxygenation. However, nowadays there is limited information on the level of cerebral tissue oxygenation in dialyzed end-stage renal disease (ESRD) surgical patients. The aim of this observational study was to evaluate the baseline cerebral rSO2 values, to compare values between hemodialysis (HD) and peritoneal dialysis (PD) patients and identify risk factors that could predict cerebral tissue oxygenation in these patients. Thirty-two ESRD patients (≥18 years old), scheduled to undergo elective minor or major surgery, were enrolled. Patients were allocated in two groups according to dialysis modality. Twenty-three patients were treated with HD and nine were treated with PD. Demographic and clinical characteristics, comorbidities and arterial hemoglobin oxygen saturation (SpO2) of the study population were recorded. Patients who were treated with HD had significant lower baseline rSO2 values compared with PD patients [median, 50% (28-63) vs. 63% (45-69), p = 0.002]. Hierarchical linear regression model analysis showed that preoperative Hb and SpO2 were positive predictive variables (B = 0.353, p = 0.01 and B = 0.375, p = 0.009, respectively) for rSO2. Moreover, dialysis modality was independent predictor for baseline rSO2. The modality of dialysis remained an independent predictor for rSO2 after controlling for the other significant variables (B = 0.291, p = 0.032) and PD was associated with higher baseline values of rSO2. In conclusion, ESRD surgical patients undergoing PD treatment appear to have significantly higher baseline cerebral tissue saturation values compared with HD.

  16. Analyzing the risk factors influencing surgical site infections: the site of environmental factors.

    PubMed

    Alfonso-Sanchez, Jose L; Martinez, Isabel M; Martín-Moreno, Jose M; González, Ricardo S; Botía, Francisco

    2017-06-01

    Addressing surgical site infection (SSI) is accomplished, in part, through studies that attempt to clarify the nature of many essential factors in the control of SSI. We sought to examine the link between multiple risk factors, including environmental factors, and SSI for prevention management. We conducted a longitudinal prospective study to identify SSIs in all patients who underwent interventions in 2014 in 8 selected hospitals on the Mediterranean coast of Spain. Risk factors related to the operating theatre included level of fungi and bacterial contamination, temperature and humidity, air renewal and differential air pressure. Patient-related variables included age, sex, comorbidity, nutrition level and transfusion. Other factors were antibiotic prophylaxis, electric versus manual shaving, American Society of Anaesthesiologists physical status classification, type of intervention, duration of the intervention and preoperative stay. Superficial SSI was most often associated with environmental factors, such as environmental contamination by fungi (from 2 colony-forming units) and bacteria as well as surface contamination. When there was no contamination in the operating room, no SSI was detected. Factors that determined deep and organ/space SSI were more often associated with patient characteristics (age, sex, transfusion, nasogastric feeding and nutrition, as measured by the level of albumin in the blood), type of intervention and preoperative stay. Antibiotic prophylaxis and shaving with electric razor were protective factors for both types of infection, whereas the duration of the intervention and the classification of the intervention as "dirty" were shared risk factors. Our results suggest the importance of environmental and surface contamination control to prevent SSI.

  17. Risk profiles for aortic dissection and ruptured or surgically treated aneurysms: a prospective cohort study.

    PubMed

    Landenhed, Maya; Engström, Gunnar; Gottsäter, Anders; Caulfield, Michael P; Hedblad, Bo; Newton-Cheh, Christopher; Melander, Olle; Smith, J Gustav

    2015-01-21

    Community screening to guide preventive interventions for acute aortic disease has been recommended in high-risk individuals. We sought to prospectively assess risk factors in the general population for aortic dissection (AD) and severe aneurysmal disease in the thoracic and abdominal aorta. We studied the incidence of AD and ruptured or surgically treated aneurysms in the abdominal (AAA) or thoracic aorta (TAA) in 30 412 individuals without diagnosis of aortic disease at baseline from a contemporary, prospective cohort of middle-aged individuals, the Malmö Diet and Cancer study. During up to 20 years of follow-up (median 16 years), the incidence rate per 100 000 patient-years at risk was 15 (95% CI 11.7 to 18.9) for AD, 27 (95% CI 22.5 to 32.1) for AAA, and 9 (95% CI 6.8 to 12.6) for TAA. The acute and in-hospital mortality was 39% for AD, 34% for ruptured AAA, and 41% for ruptured TAA. Hypertension was present in 86% of individuals who subsequently developed AD, was strongly associated with incident AD (hazard ratio [HR] 2.64, 95% CI 1.33 to 5.25), and conferred a population-attributable risk of 54%. Hypertension was also a risk factor for AAA with a smaller effect. Smoking (HR 5.07, 95% CI 3.52 to 7.29) and high apolipoprotein B/A1 ratio (HR 2.48, 95% CI 1.73 to 3.54) were strongly associated with AAA and conferred a population-attributable risk of 47% and 25%, respectively. Smoking was also a risk factor for AD and TAA with smaller effects. This large prospective study identified distinct risk factor profiles for different aortic diseases in the general population. Hypertension accounted for more than half of the population risk for AD, and smoking for half of the population risk of AAA. © 2015 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

  18. Is There Room for Prevention? Examining the Effect of Outpatient Facility Type on the Risk of Surgical Site Infection.

    PubMed

    Parikh, Rishi; Pollock, Daniel; Sharma, Jyotirmay; Edwards, Jonathan

    2016-10-01

    OBJECTIVE We compared risk for surgical site infection (SSI) following surgical breast procedures among 2 patient groups: those whose procedures were performed in ambulatory surgery centers (ASCs) and those whose procedures were performed in hospital-based outpatient facilities. DESIGN Cohort study using National Healthcare Safety Network (NHSN) SSI data for breast procedures performed from 2010 to 2014. METHODS Unconditional multivariate logistic regression was used to examine the association between facility type and breast SSI, adjusting for American Society of Anesthesiologists (ASA) Physical Status Classification, patient age, and duration of procedure. Other potential adjustment factors examined were wound classification, anesthesia use, and gender. RESULTS Among 124,021 total outpatient breast procedures performed between 2010 and 2014, 110,987 procedure reports submitted to the NHSN provided complete covariate data and were included in the analysis. Breast procedures performed in ASCs carried a lower risk of SSI compared with those performed in hospital-based outpatient settings. For patients aged ≤51 years, the adjusted risk ratio was 0.36 (95% CI, 0.25-0.50) and for patients >51 years old, the adjusted risk ratio was 0.32 (95% CI, 0.21-0.49). CONCLUSIONS SSI risk following breast procedures was significantly lower among ASC patients than among hospital-based outpatients. These findings should be placed in the context of study limitations, including the possibil