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Objective: The objective of this study was to assess the complicated relationship between frailty, perioperative complications, and patient-reported outcomes (PROs) in elderly patients (≥ 75 years old) undergoing lumbar spine fusion (LSF)., Methods: Consecutive patients who underwent LSF between March 2019 and December 2021 were recruited in this study. Frail patients (modified frailty index [mFI] score ≥ 2) were propensity score matched to nonfrail patients (mFI score 0-1) on the basis of age, sex, and the number of fused levels. Perioperative complications were collected and assessed according to the comprehensive complication index. Subgroups were further subdivided on the basis of the presence of major complications. The data from SF-36, Oswestry Disability Index (ODI), and North American Spine Society Satisfaction Questionnaire (NASS) at baseline and 1- and 2-year follow-up evaluations were compared between groups. Furthermore, the minimal clinically important difference (MCID) achievement rate was also compared., Results: The final analysis included 631 patients: 344 in the frail group and 287 in the nonfrail group. Frail patients were older (79.7 ± 5.1 years vs 76.4 ± 4.8 years, p < 0.001), with a higher proportion of females (68.9% vs 57.8%, p = 0.004) and those with malnutrition (17.7% vs 11.1%, p = 0.020). After propensity score matching for age, sex, and number of fused levels, 402 patients (201 in each group) were analyzed. Frail patients were more prone to have delirium (7.5% vs 3.0%, p = 0.044), blood transfusion (43.3% vs 30.3%, p = 0.007), and surgical site infection (6.0% vs 2.0%, p = 0.041). In addition, frail patients had a higher proportion of major complications (29.4% vs 16.9%, p = 0.003). Although they had worse PROs at baseline, frail patients obtained higher mean improvements and higher rates of MCID achievement by the 1- and 2-year follow-up evaluations than their nonfrail counterparts. Major complications did not seem to affect PROs in frail and nonfrail patients., Conclusions: Despite being associated with worse baseline PROs, frail patients gained greater mean improvement in PROs and higher rates of MCID achievement by the 1- and 2-year follow-up evaluations than nonfrail patients. In addition, the presence of major complications did not affect PROs at the 1- and 2-year follow-ups. Although associated with major complications, elderly patients with frailty could benefit from LSF.

Background Context: The number of elderly patients with degenerative spinal deformity (DSD) is increasing, and posterior thoracolumbar fusion surgery is an effective treatment option, but there are often postoperative major complications, which may hinder the benefit for elderly patients. Currently, there is no consensus on the best risk assessment technique for predicting major complications in elderly patients undergoing long-segment fusion surgery., Purpose: This study constructs a risk assessment model using the Modified 5-Item Frailty Index (mFI-5) and serum albumin and evaluates its predictive value., Study Design: This is a retrospective analysis of a prospectively established database of DSD., Patient Sample: Consecutive patients (aged 65 and older) who underwent open posterior thoracolumbar fusion surgery for DSD between April 2018 and December 2023 were included., Outcome Measures: Outcome measures included postoperative major complications, length of hospital stay [LOS], readmission and reoperation within 30 days, discharge disposition, physiological function recovery., Methods: The study reviewed consecutive patients who underwent open posterior thoracolumbar fusion surgery for DSD. Patients were divided into three groups based on the presence or absence of frailty or frailty combined with malnutrition. Spearman ρ analysis was used to assess the correlation between mFI-5 and serum albumin levels. Univariate analyses and multivariate logistic regression were conducted to explore the relationship between frailty and malnutrition defined by mFI-5 and serum albumin and major postoperative complications. Finally, the Receiver Operating Characteristic (ROC) curve was used to evaluate the predictive value of this model for major complications., Results: Compared to the Normal group (n=59), both the Frailty group (n=121) and the Frailty and Malnutrition group (n=50) had higher rates of major complications (21.5% vs. 8.5%, p=.035; 28% vs. 8.5%, p=.002). Multivariate logistic regression showed that frailty and malnutrition status, higher ASA score, and more bleeding were independent predictors of major postoperative complications. The ROC curve demonstrated that frailty combined with malnutrition defined by mFI-5 and serum albumin had a larger area under the curve compared to mFI-5 or serum albumin alone (AUC: 0.676; 95% CI: 1.101-14.129; p<.001)., Conclusions: Compared to considering frailty or malnutrition alone, the combined assessment of frailty and malnutrition using mFI-5 and serum albumin is valuable in predicting major complications in elderly patients undergoing posterior thoracolumbar fusion surgery., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Transesophageal echocardiography (TEE) is mandatory before transvenous lead extraction (TLE), but its usefulness remains underestimated. This study aims to describe the broad range of TEE findings in TLE candidates, as well as their influence on procedure complexity, major complications (MCs) and long-term survival. Methods: Preoperative TEE was performed in 1191 patients undergoing TLE. Results: Lead thickening (OR = 1.536; p = 0.007), lead adhesion to heart structures (OR = 2.531; p < 0.001) and abnormally long lead loops (OR = 1.632; p = 0.006) increased the complexity of TLE. Vegetation-like masses on the lead (OR = 4.080; p = 0.44), lead thickening (OR = 2.389; p = 0.049) and lead adhesion to heart structures (OR = 6.341; p < 0.001) increased the rate of MCs. The presence of vegetations (HR = 7.254; p < 0.001) was the strongest predictor of death during a 1-year follow-up period. Conclusions: TEE before TLE provides a lot of important information for the operator. Apart from the visualization of possible vegetations, it can also detect various forms of lead-related scar tissue. Build-up of scar tissue and the presence of long lead loops are associated with increased complexity of the procedure and risk of MCs. Preoperative TEE performed outside the operating room may have an impact on the clinical decision-making process, such as transferring potentially more difficult patients to a more experienced center or having the procedure performed by the most experienced operator. Moreover, the presence of masses or vegetations on the leads significantly increases 1-year and all-cause mortality.

Objective: This study aims to evaluate the prevalence of early postoperative complications of radical cystectomy, using standardized reporting methodology to assess perioperative characteristics and determine risk factors for major complications., Materials and Methods: A retrospective study included 254 consecutive bladder cancer patients undergoing RC between 2012 and 2020 at a urological cancer referral center. Postoperative complications within 30 days were recorded and graded according to the Clavien-Dindo classification (CDC). The study examined risk factors, including novel inflammatory-nutrition biomarkers and perioperative serum chloride., Results: Total complications were observed in 135 (53 %). Of these, 47 (18.5 %) were high grade (CDC ≥ 3). Wound dehiscence was the most common complication, occurring in 14 (5.5 %) patients. Independent risk factors for major complications included an age-adjusted Charlson comorbidity index (ACCI) > 4 and thrombocytopenia (odds ratio [OR] 3.67 and OR 8.69). Preoperative platelet counts < 220,000/μL and albumin < 3 mg/dL were independent risk factors for wound dehiscence (OR 3.91 and OR 4.72). Additionally, postoperative hypochloremia was a risk factor for major complications (OR 13.71), while novel serum biomarkers such as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), systemic inflammatory response index (SIRI), and prognostic nutritional index (PNI) were not associated with early major complications., Conclusion: Patients who have multiple comorbidities are at a greater risk of developing major complications after undergoing RC. Our result suggests that preoperative platelet counts and serum albumin levels are associated with wound dehiscence., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Background: Comminuted, markedly displaced distal radius fractures can cause instability requiring advanced stabilization with dorsal bridge plating. However, published complication rates of bridge plating widely vary. We hypothesize that complications of bridge plating of distal radius fractures are more prevalent than published rates., Methods: A retrospective review was performed on all patients at an academic level I trauma center treated with a bridge plate for a distal radius fracture from 2014 to 2022., Results: Sixty-five wrists were included in the final analysis: average age 53 years, male 51%, average plate retention 4 months, and average follow-up 6 months. Carpal tunnel release (CTR) was performed at time of primary procedure in 7 (10%) cases. Radial height, radial inclination, dorsal tilt, and ulnar variance were all significantly improved ( P < .001). Grip strength, flexion, extension, and supination were significantly limited ( P < .03). Twenty-one patients (32%) developed 35 major complications requiring unplanned reoperation, including mechanical hardware-related complication (15%), deep infection (11%), nonunion/delayed union (9%), adhesions (6%), median neuropathy (6%), symptomatic arthritis (5%), and tendon rupture (2%). Plate breakage occurred in 3 patients (5%) and was always localized over the central drill holes of the bridge plate., Conclusions: Major complications for bridge plating of distal radius fractures were higher at our institution than previously published. Plate breakage should prompt reconsideration of plate design to avoid drill holes over the wrist joint. Signs and symptoms of carpal tunnel syndrome should be carefully assessed at initial presentation, and consideration for concomitant CTR should be strongly considered., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Sarcopenia is highly prevalent among patients with colorectal cancer (CRC). Computed tomography (CT)-based assessment of low skeletal muscle index (SMI) is widely used for diagnosing sarcopenia. However, there are conflicting findings on the association between low SMI and overall survival (OS) in CRC patients. The objective of this study was to investigate whether CT-determined low SMI can serve as a valuable prognostic factor in CRC., Methods: We collected data from patients with CRC who underwent radical surgery at our institution between June 2020 and November 2021. The SMI at the third lumbar vertebra was calculated using CT scans, and the cutoff values for defining low SMI were determined using receiver operating characteristic curves. Univariate and multivariate analyses were performed to assess the associations between clinical characteristics and postoperative major complications., Results: A total of 464 patients were included in the study, 229 patients (46.7%) were classified as having low SMI. Patients with low SMI were older and had a lower body mass index (BMI), a higher neutrophil to lymphocyte ratio (NLR), and higher nutritional risk screening 2002 (NRS2002) scores compared to those with normal SMI. Furthermore, patients with sarcopenia had a higher rate of major complications (10.9% vs. 1.3%; p < 0.001) and longer length of stay (9.09 ± 4.86 days vs. 8.25 ± 3.12 days; p = 0.03). Low SMI and coronary heart disease were identified as independent risk factors for postoperative major complications. Moreover, CRC patients with low SMI had significantly worse OS. Furthermore, the combination of low SMI with older age or TNM stage II + III resulted in the worst OS in each subgroup analysis., Conclusions: CT-determined low SMI is associated with poor prognosis in patients with CRC, especially when combined with older age or advanced TNM stage., (© 2024 The Author(s). Cancer Medicine published by John Wiley & Sons Ltd.)

Background: Delayed gastric emptying (DGE) commonly occurs after pancreaticoduodenectomy (PD). Risk factors for DGE have been reported in open PD but are rarely reported in laparoscopic PD (LPD). This study was designed to evaluate the perioperative risk factors for DGE and secondary DGE after LPD in a single center., Methods: This retrospective cohort study included patients who underwent LPD between October 2014 and April 2023. Demographic data, preoperative, intraoperative, and postoperative data were collected. The risk factors for DGE and secondary DGE were analyzed., Results: A total of 827 consecutive patients underwent LPD. One hundred and forty-two patients (17.2%) developed DGE of any type. Sixty-five patients (7.9%) had type A, 62 (7.5%) had type B, and the remaining 15 (1.8%) had type C DGE. Preoperative biliary drainage (p = 0.032), blood loss (p = 0.014), and 90-day any major complication with Dindo-Clavien score ≥ III (p < 0.001) were independent significant risk factors for DGE. Seventy-six (53.5%) patients were diagnosed with primary DGE, whereas 66 (46.5%) patients had DGE secondary to concomitant complications. Higher body mass index, soft pancreatic texture, and perioperative transfusion were independent risk factors for secondary DGE. Hospital stay and drainage tube removal time were significantly longer in the DGE and secondary DGE groups., Conclusion: Identifying patients at an increased risk of DGE and secondary DGE can be used to intervene earlier, avoid potential risk factors, and make more informed clinical decisions to shorten the duration of perioperative management., (© 2024. The Author(s).)

Background: Total ankle arthroplasty (TAA) is an effective treatment for various ankle pathologies, but some concern remains for the high associated complication and failure rates relative to major joint arthroplasty of the hip and knee. Patient body mass index (BMI) is a modifiable and potentially important preoperative variable when evaluating postoperative complications. The purpose of this study is to evaluate the effect of BMI, age and sex on the acute postoperative complication rate after TAA., Methods: We retrospectively reviewed adult patients who underwent TAA between 2006 and 2021 from the NSQIP database. Using overweight patients as the reference BMI group, we utilized log-binomial models to estimate risk ratios on outcomes while adjusting for sex and age to investigate whether there were significant adjusted differences in complication rates among the BMI groups., Results: We found that, relative to overweight patients, there were no statistically significant differences in the risk of acute complications for underweight (BMI < 18.5) (P = .118), healthy weight (18.5≤BMI < 25) (P = .544), obese (30≤BMI < 40) (P = .930), or morbidly obese (BMI < 40) (P = .602) patients who underwent TAA. There were also no statistically significant differences in the risk of acute complications based on age category (P = .482,.824) or sex (P = .440) for TAA. Additionally, there were no significant differences between the BMI groups for either major complications (P = .980) or minor complications (P = .168)., Conclusion: Ultimately, we found that BMI, age, and sex did not lead to statistically significant differences in the risk of complications within 30 days postoperatively for TAA, even when stratified by major vs minor complications., Level of Evidence: Level III., Competing Interests: Declaration of Competing Interest There was no conflicts of interest for any of the authors. No funding was received for this study. AI was not used for this article., (Copyright © 2023 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is the standard of care for selected cases of peritoneal surface malignancy. However, due to its morbidity and learning curve, it is only delivered in six centres in Australia and Aotearoa New Zealand (AoNZ). In this study, we report peri-operative morbidity and mortality following CRS/HIPEC at Waikato and Braemar Hospitals, which have treated patients from all regions of AoNZ since 2008., Methods: We retrospectively reviewed a database of all patients undergoing CRS and HIPEC from 01/01/2008 to 01/11/2020 at Waikato and Braemar Hospitals., Results: Two-hundred and forty procedures were performed for 221 patients with a mean age of 55, including 22 (9.2%) re-do procedures. One hundred and eighty-six cases were European, 32 were Māori, and 16 were Pasifika. There were 152 pseudomyxoma peritonei, 39 colorectal adenocarcinomas, 29 appendiceal cancers, 8 ovarian cancers, 6 peritoneal mesothelioma, and 6 other tumour types. The median PCI was 16. HIPEC was administered to 196 out of 196 CC0/1 cases (100%) and 3 out of 44 CC2/3 cases (6.8%). Fifty-six cases (23.3%) had at least one major complication. There were two mortalities (0.8%) within 30 days. The median length of stay was 11 days. Operative duration was identified as an independent risk factor for major complications. There was considerable variation in the number of referrals from different regions of AoNZ. Over time, a decline in major complication rate is seen with increased case volume., Conclusion: The Waikato region has achieved favourable short-term outcomes following CRS/HIPEC., (© 2024 Royal Australasian College of Surgeons.)

Background: Postoperative complications after cranial or spine surgery are prevalent, and frailty can be a key contributing patient factor. Therefore, we evaluated frailty's impact on 30-day mortality. We compared the discrimination for risk analysis index (RAI), modified frailty index-5 (mFI-5) and increasing patient age for predicting 30-day mortality., Methods: Patients with major complications following neurosurgery procedures between 2012- 2020 in the ACS-NSQIP database were included. We employed receiver operating characteristic (ROC) curve and examined discrimination thresholds for RAI, mFI-5, and increasing patient age for 30-day mortality. Independent relationships were examined using multivariable analysis., Results: There were 19,096 patients included in the study and in the ROC analysis for 30-day mortality, RAI showed superior discriminant validity threshold C-statistic 0.655 (95% CI: 0.644-0.666), compared to mFI-5 C-statistic 0.570 (95% CI 0.559-0.581), and increasing patient age C-statistic 0.607 (95% CI 0.595-0.619). When the patient population was divided into subsets based on the procedures type (spinal, cranial or other), spine procedures had the highest discriminant validity threshold for RAI (Cstatistic 0.717). Furthermore, there was a frailty risk tier dose response relationship with 30-day mortalityy (p<0.001)., Conclusion: When a major complication arises after neurosurgical procedures, frail patients have a higher likelihood of dying within 30 days than their non-frail counterparts. The RAI demonstrated a higher discriminant validity threshold than mFI-5 and increasing patient age, making it a more clinically relevant tool for identifying and stratifying patients by frailty risk tiers. These findings highlight the importance of initiatives geared toward optimizing frail patients, to mitigate long-term disability., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Objectives: To investigate the incidence of preoperative abnormal iron status and its association with packed red blood cell (PRBC) transfusion, postoperative major complications, and new onset of clinically significant disability in patients undergoing elective cardiac surgery., Design: A prospective, observational multicenter cohort study., Setting: Three cardiac surgical centers in the Netherlands between 2019 and 2021. Recruitment was on hold between March and May 2020 due to COVID-19., Patients: A total of 427 patients aged 60 years and older who underwent elective on-pump cardiac surgery., Measurements and Main Results: The primary endpoint was a 30-day PRBC transfusion. Secondary endpoints were postoperative major complications within 30 days (eg, acute kidney injury, sepsis), and new onset of clinically significant disability within 120 days of surgery. Iron status was evaluated before surgery. Abnormal iron status was present in 45.2% of patients (n = 193), and most frequently the result of iron deficiency (27.4%, n = 117). An abnormal iron status was not associated with PRBC transfusion (adjusted relative risk [ARR] 1.2; 95% CI 0.9-1.8: p = 0.227) or new onset of clinically significant disability (ARR 2.0; 95% CI 0.9-4.6: p = 0.098). However, the risk of postoperative major complications was increased in patients with an abnormal iron status (ARR 1.7; 95% CI 1.1-2.5: p = 0.012)., Conclusions: An abnormal iron status before elective cardiac surgery was associated with an increased risk of postoperative major complications but not with PRBC transfusion or a new onset of clinically significant disability., Competing Interests: Declaration of competing interest Dr Thijs C.D. Rettig and Dr Peter G. Noordzij have held lectures on perioperative biomarkers, for which they have received an honorarium from Roche Diagnostics. Dr Thijs C.D. Rettig and Dr Peter G. Noordzij are principal investigators of studies sponsored by Roche Diagnostics and Pharmacocosmos A/S. The other authors declare no competing interests., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Study Design/setting: Retrospective cohort study., Objective: Assess the extent to which defined risk factors of adverse events are drivers of cost-utility in spinal deformity (ASD) surgery., Methods: ASD patients with 2-year (2Y) data were included. Tertiles were used to define high degrees of frailty, sagittal deformity, blood loss, and surgical time. Cost was calculated using the Pearl Diver registry and cost-utility at 2Y was compared between cohorts based on the number of risk factors present. Statistically significant differences in cost-utility by number of baseline risk factors were determined using ANOVA, followed by a generalized linear model, adjusting for clinical site and surgeon, to assess the effects of increasing risk score on overall cost-utility., Results: By 2 years, 31% experienced a major complication and 23% underwent reoperation. Patients with ≤2 risk factors had significantly less major complications. Patients with 2 risk factors improved the most from baseline to 2Y in ODI. Average cost increased by $8234 per risk factor (R 2 = .981). Cost-per-QALY at 2Y increased by $122,650 per risk factor (R 2 = .794). Adjusted generalized linear model demonstrated a significant trend between increasing risk score and increasing cost-utility (r 2 = .408, P < .001)., Conclusions: The number of defined patient-specific and surgical risk factors, especially those with greater than two, were associated with increased index surgical costs and diminished cost-utility. Efforts to optimize patient physiology and minimize surgical risk would likely reduce healthcare expenditures and improve the overall cost-utility profile for ASD interventions. Level of evidence: III., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Peter Gust Passias, MDAllosource: Other financial or material support Cervical Scoliosis Research Society: Research support Globus Medical: Paid presenter or speaker Medtronic: Paid consultant Royal Biologics: Paid consultant Spine: Editorial or governing board SpineWave: Paid consultant Terumo: Paid consultant Zimmer: Paid presenter or speaker. Virginie Lafage, PhD DePuy, A Johnson & Johnson Company: Paid presenter or speaker European Spine Journal: Editorial or governing board Globus Medical: Paid consultant International Spine Study Group: Board or committee member Nuvasive: IP royalties Scoliosis Research Society: Board or committee member The Permanente Medical Group: Paid presenter or speaker. Ferran Pellise, MDAOSpine Deformity Knowledge Forum: Board or committee member DePuy, A Johnson & Johnson Company: Research support European Spine Journal: Editorial or governing board EuroSpine, The Spine Society of Europe: Board or committee member Medtronic: Paid consultant; Research support Scoliosis Research Society: Board or committee member Spanish Spine Society, GEER: Board or committee member Stryker: Paid consultant. Renaud Lafage, MS Nemaris: Stock or stock Options. Munish C Gupta, MD. AO Spine Faculty, travel: Board or committee memberDePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Paid presenter or speaker European Spine Journal-Advisory Board: Editorial or governing board Global Spine Journal-Reviewer: Editorial or governing board Globus Medical: IP royalties; Paid consultant honorarium for faculty: Board or committee member Innomed: IP royalties Johnson & Johnson: Stock or stock Options Medtronic: Paid consultant Spine Deformity, Reviewer: Editorial or governing board SRS-Board of Directors: Board or committee member SRS-IMAST & Education committee: Board or committee member travel: Board or committee member Wolters Kluwer Health - Lippincott Williams & Wilkins: Publishing royalties, financial or material support. Michael Patrick Kelly, MD, MSc, AO Spine: Board or committee memberCervical Spine Research Society: Board or committee member Scoliosis Research Society: Board or committee member Spine: Editorial or governing board. 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Background: We conducted a prospective study of surgical inpatients at a teaching hospital to assess the incidence and potential risk factors for major complications of caudal anesthesia in anorectal surgery., Methods: A total of 973 patients undergoing anorectal surgery under caudal block were included in this prospective, observer-blinded trial after providing consent. Demographic information, detailed perioperative information, anesthesia-related complications and postoperative follow-up information were recorded. Meanwhile, the incidence and risk factors for major caudal anesthesia-related complications were analyzed., Results: A total of 973 patients underwent caudal block. The effective rate was 95.38 % (928 cases). However, there were still 38 (3.91 %) cases with insufficient block and 7 (0.72 %) cases with no block. The major anesthesia-related complications were local anesthetic systemic toxicity (9, 0.92 %), cauda equine syndrome (1, 0.10 %), transient neurological symptoms (3, 0.31 %) and localized pain at the caudal insertion site (30, 3.08 %). The identified risk factor for local anesthetic systemic toxicity was multiple attempts locating the caudal space (OR = 5.30; 1.21-23.29). The identified risk factor for localized pain at the caudal insertion site was multiple attempts locating the caudal space (OR = 10.57; 4.89-22.86)., Conclusion: The main complications of caudal block in adult patients are transient neurological symptoms, cauda equine syndrome, serious local anesthetic systemic toxicity and localized pain at the caudal insertion site. Overall, the incidence of complications is low and symptoms are mild. Caudal block is still a safe and reliable method for anesthesia in adult anorectal surgery., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors. Published by Elsevier Ltd.)

Background: Percutaneous radiologic gastrostomy (PRG) is the method of choice for patients incapable of ingesting nutrition orally. The complications related to PRG are classified into major and minor complications. This article presents the prevalence of major and minor complications of PRG among adult patients admitted to King Abdulaziz Medical City (KAMC) in Riyadh, Saudi Arabia between 2017 and 2018., Methods: This was a retrospective cross-sectional study, which included adult patients who underwent a new PRG intubation between 2017 and 2018 in KAMC in Riyadh, Saudi Arabia. The variables reviewed were the demographics, comorbidities, indications of tube insertion, major and minor complications, and mortality rates., Results: A total of 105 patients who underwent PRG were covered in this study with a mean age of 69.2 + 20.4 years. The most common indications were neurogenic pharyngeal dysphagia (31%) and dementia (29%). Most of the complications reported were minor (40%) and major complications were found in 2%. The percentage of patients with both minor and major complications was 37%. The patients who had no complications made up 21%. Major skin complication was reported in 19 patients (18%), while leakage was the most occurring minor complication found in 49 patients (47%). The 30-day mortality was observed in five patients (5%) and one-year mortality was observed in 21 patients (20%), and none of them were related to the PRG tube., Conclusion: This study found that the PRG procedure had low rates of complications in KAMC. The majority were minor complications, and the mortality rate was low with none being related to the tube itself. So PRG may be considered to be a relatively safe procedure., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Alrasheed et al.)

Background: The literature on predictors for postoperative complications after Frey procedure (FP) is sparse. The aim of this study is to report our experience with 90-day complications of FP and predictors for complications., Methods: All patients with chronic pancreatitis (CP), who underwent a FP between August 2007 and July 2021, were retrospectively reviewed. Univariate and multivariate analysis were used to identify predictors of 90-day morbidity and mortality., Results: Of the total 270 patients, 84 (31%) patients developed at least one postoperative complication. Major complications occurred in 32 (12%) patients. Most common complication was wound infection and it was significantly more common in stented patients (p = 0.017). Pancreatic fistula and post pancreatectomy hemorrhage (PPH) developed in 7.4% of patients. Thirteen patients (4.8%) required early re-operation and the most common cause of re-exploration was PPH. 90-day mortality was 1% (n = 3) and all 3 patients required re-exploration for PPH. Median postoperative hospital stay was 9 (5-51) days. Perioperative blood transfusions was the only independent predictor of postoperative complications after FP., Conclusions: Frey procedure is an acceptable treatment modality with low rates of mortality and reasonable perioperative morbidities. Minimizing blood transfusions may further improve 90-day outcomes., Competing Interests: Declaration of competing interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The known risks and benefits of native kidney biopsies are mainly based on the findings of retrospective studies. The aim of this multicentre prospective study was to evaluate the safety of percutaneous renal biopsies and quantify biopsy-related complication rates in Italy., Methods: The study examined the results of native kidney biopsies performed in 54 Italian nephrology centres between 2012 and 2020. The primary outcome was the rate of major complications 1 day after the procedure, or for longer if it was necessary to evaluate the evolution of a complication. Centre and patient risk predictors were analysed using multivariate logistic regression., Results: Analysis of 5304 biopsies of patients with a median age of 53.2 years revealed 400 major complication events in 273 patients (5.1%): the most frequent was a ≥2 g/dL decrease in haemoglobin levels (2.2%), followed by macrohaematuria (1.2%), blood transfusion (1.1%), gross haematoma (0.9%), artero-venous fistula (0.7%), invasive intervention (0.5%), pain (0.5%), symptomatic hypotension (0.3%), a rapid increase in serum creatinine levels (0.1%) and death (0.02%). The risk factors for major complications were higher plasma creatinine levels [odds ratio (OR) 1.12 for each mg/dL increase, 95% confidence interval (95% CI) 1.08-1.17], liver disease (OR 2.27, 95% CI 1.21-4.25) and a higher number of needle passes (OR for each pass 1.22, 95% CI 1.07-1.39), whereas higher proteinuria levels (OR for each g/day increase 0.95, 95% CI 0.92-0.99) were protective., Conclusions: This is the first multicentre prospective study showing that percutaneous native kidney biopsies are associated with a 5% risk of a major post-biopsy complication. Predictors of increased risk include higher plasma creatinine levels, liver disease and a higher number of needle passes., (© The Author(s) 2022. Published by Oxford University Press on behalf of the ERA.)

Background: Previous studies have suggested that higher surgeon volume leads to improved perioperative outcomes for oncologic surgery; however, the effect of surgeon volumes on surgical outcomes might differ according to the surgical approach used. This paper attempts to evaluate the effect of surgeon volume on complications or cervical cancer in an abdominal radical hysterectomy (ARH) cohort and laparoscopic radical hysterectomy (LRH) cohort., Methods: We conducted a population-based retrospective study using the Major Surgical Complications of Cervical Cancer in China (MSCCCC) database to analyse patients who underwent radical hysterectomy (RH) from 2004 to 2016 at 42 hospitals. We estimated the annualized surgeon volumes in the ARH cohort and in the LRH cohort separately. The effect of the surgeon volume of ARH or LRH on surgical complications was examined using multivariable logistic regression models., Results: In total, 22,684 patients who underwent RH for cervical cancer were identified. In the abdominal surgery cohort, the mean surgeon case volume increased from 2004 to 2013 (3.5 to 8.7 cases) and then decreased from 2013 to 2016 (8.7 to 4.9 cases). The mean surgeon case volume number of surgeons performing LRH increased from 1 to 12.1 cases between 2004 and 2016 (P < 0.01). In the abdominal surgery cohort, patients treated by intermediate-volume surgeons were more likely to experience postoperative complications (OR = 1.55, 95% CI = 1.11-2.15) than those treated by high-volume surgeons. In the laparoscopic surgery cohort, surgeon volume did not appear to influence the incidence of intraoperative or postoperative complications (P = 0.46; P = 0.13)., Conclusions: The performance of ARH by intermediate-volume surgeons is associated with an increased risk of postoperative complications. However, surgeon volume may have no effect on intraoperative or postoperative complications after LRH., (© 2023. The Author(s).)

Background: Postoperative complications and mortality following laparotomy have remained high worldwide. Early postoperative risk stratification is essential to improve outcomes and clinical care. The surgical Apgar score (SAS) is a simple and objective bedside prediction tool that can guide a surgeon's postoperative decision making. The objective of this study was to evaluate the performance of SAS in predicting outcomes in patients undergoing laparotomy at Mulago hospital., Method: A prospective observational study was conducted among eligible adult patients undergoing laparotomy at Mulago hospital and followed up for 4 months. We collected data on the patient's preoperative and intraoperative characteristics. Using the data generated, SAS was calculated, and patients were classified into 3 groups namely: low (8-10), medium (5-7), and high (0-4). Primary outcomes were in-hospital major complications and mortality. Data was presented as proportions or mean (standard deviation) or median (interquartile range) as appropriate. We used inferential statistics to determine the association between the SAS and the primary outcomes while the SAS discriminatory ability was determined from the receiver-operating curve (ROC) analysis., Results: Of the 151 participants recruited, 103 (68.2%) were male and the mean age was 40.6 ± 15. Overall postoperative in-hospital major complications and mortality rates were 24.2% and 10.6%, respectively. The participants with a high SAS category had an18.4 times risk (95% CI, 1.9-177, p = 0.012) of developing major complications, while those in medium SAS category had 3.9 times risk (95% CI, 1.01-15.26, p = 0.048) of dying. SAS had a fair discriminatory ability for in-hospital major complications and mortality with the area under the curve of 0.75 and 0.77, respectively. The sensitivity and specificity of SAS ≤ 6 for major complications were 60.5% and 81.14% respectively, and for death 54.8% and 81.3%, respectively., Conclusion: SAS of ≤ 6 is associated with an increased risk of major complications and/or mortality. SAS has a high specificity with an overall fair discriminatory ability of predicting the risk of developing in-hospital major complications and/or death following laparotomy., (© 2022. The Author(s).)

Liver biopsy can be performed percutaneously, or via a transjugular approach. Transjugular liver biopsy (TJLB) is usually used in patients who are suffering from severe coagulation disorders (prolonged prothrombin time or low platelets), ascites, severe obesity, or failure of a previous non-targeted percutaneous liver biopsy. In TJLB, the biopsy needle is inserted into the liver parenchyma via the hepatic vein, avoiding transgression of the hepatic capsule and peritoneum. Unlike a percutaneous biopsy, a transjugular approach reduces the risk of bleeding as any bleeding from the biopsy site should be returned into the venous system. It is a safe, well-tolerated procedure, with a major complication rate of less than 0.6%. This case report describes the rare occurrence of a severe intraperitoneal haemorrhage post-TJLB, and describes and discusses the technique, complication profile, and learning points from this complication., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Teodorescu-Arghezi et al.)

Background: Current diagnostic criteria for cancer cachexia are inconsistent, and arguments still exist about the impact of cachexia on the survival of patients with colorectal cancer. In this study, we aim to investigate the prognostic value of a novel cachexia indicator, the cachexia index (CXI), in patients with colorectal cancer., Methods: The CXI was calculated as skeletal muscle index (SMI) × serum albumin/neutrophil-lymphocyte ratio. The cut-off value of CXI was determined by the receiver operating characteristic (ROC) curves and Youden's index. The major outcomes were major complications, overall survival (OS), and recurrence-free survival (RFS)., Results: A total of 379 patients (234 men and 145 women) were included. The ROC curves indicated that CXI had a significantly diagnostic capacity for the detection of major complications. Based on Youden's index, there were 231 and 148 patients in the low and high CXI groups, respectively. Patients in the low CXI group had significantly older age, lower BMI, and a higher percentage of cachexia and TNM stage II+III. Besides, Patients in low CXI group were associated with a significantly higher rate of major complications, blood transfusion, and longer length of stay. Logistic regression analysis indicated that low CXI, cachexia, and coronary heart disease were independent risk factors for the major complications. Kaplan Meier survival curves indicated that patients with high CXI had a significantly more favorable OS than those with low CXI, while no significant difference was found in RFS between the two groups. Besides, there were no significant differences in OS or RFS between patients with and without cachexia. The univariate and multivariate Cox regression analysis indicated that older age, low CXI, and coronary heart disease instead of cachexia were associated with a decreased OS., Conclusion: CXI was better than cachexia in predicting OS and could be a useful prognostic indicator in patients with colorectal cancer, and greater attention should be paid to patients with low CXI., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Wan, Yuan, Zhao, Shen, Chen, Li and Song.)

Objectives: This study aimed to assess trends by evaluating the types and complications of hysterectomies performed for benign gynecological reasons at our clinic, which is one of the largest hospitals in Turkey., Materials and Methods: Hysterectomies performed for benign reasons at our gynecology and obstetrics clinic between January 1, 2015 and December 31, 2020 were retrospectively reviewed and included in the analysis. Of the 4288 patients who had undergone hysterectomy, 888 patients were excluded some reasons. The data of the remaining 3400 patients were analyzed., Results: For the 3400 patients, the hysterectomy methods performed were as follows: Total Abdominal Hysterectomy (TAH (60%, n = 2055), Total Laparoscopic Hysterectomy (TLH), (27%, n = 948), Vaginal Hysterectomy (VH), (8.9%, n = 302), Conversion from laparoscopy to laparotomy (L / S > LT). (1.4%, n = 49), Robotic hysterectomy (RH), (1%, n = 33), and Subtotal hysterectomy (SH), (0.4%, n = 13). The length of hospital stay was statistically significantly lower in the TLH group than in the TAH group ( P < 0.05). A statistically significant and moderate correlation was noted between the length of hospital stay and the duration of operation (r: 0.68 P = 0.00)., Conclusion: The ratio of TLH group among hysterectomy modalities has increased over the years. There are many factors that affect the surgeon's decision in determining the hysterectomy method. TLH is the first option in patients who are not suitable for vaginal hysterectomy., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Gynecology and Minimally Invasive Therapy.)

Background: To assess the frequency of major complications after thermal ablation of liver tumours and to determine risk factors for adverse events., Methods: A retrospective study was conducted between January 2015 and January 2021. A total of 2,084 thermal ablation sessions in 1,592 patients with primary and metastatic liver tumours were evaluated. The frequency of major complications was evaluated according to the Society of Interventional Radiology Standards, and putative predictors of adverse events were analysed using simple and multivariate logistic regression., Results: Thermal ablation-related mortality was 0.1% (2/2,084), with an overall major complication rate of 5.6% (117/2,084). The most frequent major complication was symptomatic pleural effusion (2.9%, 60/2,084). Multivariate logistic regression analysis revealed that a total maximum diameter of lesions >3 cm, microwave ablation (MWA) and MWA combined with radiofrequency ablation, intrahepatic cholangiocarcinoma and postoperative systemic inflammatory response syndrome were independent prognostic factors for major complications., Conclusions: Thermal ablation of liver tumours is a safe procedure with an acceptable incidence of major complications. The risk factors identified in this study will help to stratify high-risk patients., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2022 Huang, Pang, Zeng, He, Zheng, Ge and Li.)

Aim: Although major complication rates following percutaneous liver biopsy (PLB) have been reported to be higher in children than in adults, scarce data are available regarding pediatric patients stratified by native and transplanted liver. We aimed to assess the factors associated with major complications after percutaneous biopsy of native or transplanted liver using a nationwide inpatient database., Methods: Using the Japanese Diagnosis Procedure Combination database, we retrospectively identified pediatric patients who underwent PLB between 2010 and 2018. We described major complication rates and analyzed factors associated with major complications following PLB, stratified by native and transplanted liver., Results: We identified 3584 pediatric PLBs among 1732 patients from 239 hospitals throughout Japan during the study period, including 1310 in the native liver and 2274 in the transplanted liver. Major complications following PLB were observed in 0.5% (n = 18) of the total cases; PLB in the transplanted liver had major complications less frequently than those in the native liver (0.2% vs. 1.0%, p = 0.002). The occurrence of major complications was associated with younger age, liver cancers, unscheduled admission, anemia or coagulation disorders in cases with native liver, while it was associated with younger age alone in cases with transplanted liver., Conclusions: The present study, using a nationwide database, found that major complications occurred more frequently in pediatric cases with native liver and identified several factors associated with its major complications., (© 2022. The Author(s).)

Background: Although many studies reported the effectiveness of transarterial chemoembolization (TACE) combined with radiofrequency ablation (RFA) or surgical resection (SR) in the treatment of hepatocellular carcinoma (HCC), the efficacy of these two strategies remains controversial. Therefore, this meta-analysis aimed to evaluate and compare the efficacy of sequential use of TACE plus RFA (TACE + RFA) and SR alone in treating HCC., Methods: Relevant studies with unmatched and propensity score-matched patients were identified by comprehensive search of MEDLINE, PubMed, EMBASE, Web of Science, and Cochrane electronic databases. Meta-analysis was conducted using Review Manager (RevMan) software version 5.4.1. Finally, 12 eligible studies were included in this study, including 11 case-control studies and 1 randomized controlled trial. The primary outcome of interest for this study was to compare the 1-, 3-, and 5-year overall survival (OS) and disease-free survival (DFS), major complications, 5-year OS in different tumor diameters between the two treatment strategies, and hospital stay time., Results: HCC patients who received TACE + RFA had a lower incidence of complication rates and shorter hospital stay time than those who received SR alone. Among these studies using propensity score-matched cohorts, SR had better 3- and 5-year OS than TACE + RFA, whereas there were no significant differences between TACE + RFA and SR regarding the 1-, 3-, and 5-year DFS. When the tumor diameter is longer than 3 cm, the 5-year OS rate is better when SR is selected., Conclusion: There was no significant difference in the short-term survival outcomes between TACE + RFA and SR in HCC patients. Moreover, SR is superior to TACE + RFA in terms of long-term beneficial effects but may result in a higher risk of major complications and a longer hospital stay time., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Dan, Meng, Li, Chen, Lyu and Yu.)

Background and Objective: Transjugular intrahepatic portosystemic shunt (TIPS) is a well-established procedure for treating complications of portal hypertension. Due to the complexity of anatomy and difficulty of the puncture technique, the procedure itself might brought potential complications, such as puncture failure, bleeding, infection, and, rarely, death. The aim of this study is to explore the incidence, management, and outcome of TIPS procedure-related major complications using covered stents., Methods: Patients who underwent TIPS implantation from January 2015 to December 2020 were recruited retrospectively. Major complications after TIPS were screened and analyzed., Results: Nine hundred and forty-eight patients underwent the TIPS procedure with 95.1% (n = 902) technical success in our department. TIPS procedure-related major complications occurred in 30 (3.2%) patients, including hemobilia ( n = 13; 1.37%), hemoperitoneum ( n = 7; 0.74%), accelerated liver failure ( n = 6; 0.63%), and rapidly progressive organ failure ( n = 4; 0.42%). Among them, 8 patients died because of hemobilia ( n = 1), accelerated liver failure ( n = 4), and rapidly progressive organ failure ( n = 3)., Conclusion: The incidence of major complications related to TIPS procedure is relatively low, and some of them could recover through effective medical intervention. In our cohort, the overall incidence is about 3%, which causes 0.84% death. The most fatal complication is organ failure and hemobilia., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Yin, Gu, Zhang, Yin, Xiao, Wang, Zou, Zhang and Zhuge.)

Introduction: Open abdominal aortic aneurysm (AAA) surgery is associated with significant morbidity, mortality and high length of stay (LOS). Enhanced recovery is now commonplace and has been shown to decrease these in other non-vascular surgery settings. This systematic review and meta-analysis aimed to assess the benefits of enhanced recovery (ERAS) in aortic surgery. Method: Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were used to undertake a systematic review via Ovid MEDLINE and Embase on 10.07.2021. The search terms were "aortic aneurysm" and "fast track" or "enhanced recovery". Data was obtained on major complications, 30-day mortality and LOS. Results: 107 papers were identified and 10 papers included for meta-analysis. Complication rates were significantly reduced with ERAS compared to non-ERAS protocols (ERAS n = 709, non-ERAS n = 930) (odds ratio .38, .22 to .65: P = .0005). LOS was also significantly reduced with an ERAS protocol (ERAS n = 708, non-ERAS n = 956) with a mean reduction of 3 .18 days (-5.01 to -1.35 days) ( P = .0007: I 2 = 97%). There was no significant difference however in 30-day mortality ( P = .92). Conclusion: This meta-analysis demonstrates significant benefits to an enhanced recovery programme in open AAA surgery. There is a need for a multi-centre randomized controlled trial to assess this further.

Objective: To investigate the relationship of pulmonary artery diameter (PAD) measured by computed tomography (CT) with outcomes following lobectomy., Methods: Records of patients undergoing pulmonary lobectomy for lung cancer between 2011 and 2018 were reviewed. Baseline characteristics and postoperative outcome data were derived from the institutional Society of Thoracic Surgeons database. Luminal diameter of the central pulmonary arteries and ascending aorta were measured on preoperative CTs. Logistic regression analyses were performed to test the association of PAD with complications., Results: A total of 736 lobectomy patients were included, who had a preoperative CT scan (25% with contrast, 75% noncontrast) available for review. A total of 141 (19.2%) patients had an enlarged main PAD ≥30 mm, and 58 (7.9%) patients had a main PAD that was larger than the ascending aorta (PA/ascending aorta ratio > 1). The right or left PAD on the surgical side was associated with major complication (odds ratio per mm, 1.12; 95% confidence interval, 1.05-1.18; P < .001), unexpected intensive care unit admission (odds ratio per millimeter, 1.11; 95% confidence interval, 1.04-1.19; P = .002), and 30-day mortality (odds ratio per millimeter, 1.25; 95% confidence interval, 1.06-1.46; P = .007). On multivariable analysis, adjusted for cardiovascular comorbidities, pulmonary function, and the operative approach, surgical side PAD remained an independent factor associated with major complication., Conclusions: CT-based measurements of the PAD on the operative side may inform of the about the risk of major complications after lobectomy. Review of PA size on preoperative CT scans may help identify patients who would benefit from formal evaluation of PA pressures to improve the operative risk assessment., (Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The aim of this study was to assess the impact of baseline health related quality of life (HRQOL) on the occurrence of postoperative complications and death in patients with resectable esophageal cancer., Methods: Existing data from a prospective, multicenter, open label, randomized, controlled phase III trial comparing hybrid versus open esophagectomy in patients with resectable esophageal cancer from 2009 to 2012 in France were used. A Cox regression model was used to assess the prognostic value of the baseline HRQOL score on the occurrence of major complications (MC), and major pulmonary complications (MPC) at 30 days post-surgery, as well as on 1-year postoperative overall survival (OS)., Results: Every 10-point increase in the baseline role functioning score was associated with a 14% reduction in the risk of MC, while every 10-point increase in fatigue or pain score was associated with an 18% increase in the risk of MC. Similarly, higher scores on fatigue and pain were associated with a higher risk of MPC. Compared with the hybrid procedure, patients undergoing open esophagectomy had a significantly higher risk of MC and MPC. Patients diagnosed with esophageal adenocarcinoma were at significantly lower risk of MC or MPC compared to patients with esophageal squamous cell carcinoma. Higher pain (HR = 1.23, p = 0.035) and insomnia (HR = 1.16, P = 0.031) scores were associated with increased 1-year OS., Conclusion: Fatigue, pain, insomnia, and squamous cell pathology were indicators of poor prognosis, and that the presence of these findings might possibly change the management plan towards other forms of treatment and warrant close attention., (Copyright © 2021. Published by Elsevier Ltd.)

Total thyroidectomy (TT) in patients with Graves' disease is challenging even for an experienced thyroid surgeon. This study aimed to investigate the accumulation of experience and applying newly developed devices on major complications and voice outcomes after surgery of a single surgeon over 30 years. This study retrospectively reviewed 90 patients with Graves' disease who received TT. Forty-six patients received surgery during 1990-1999 (Group A), and 44 patients received surgery during 2010-2019 (Group B). Major complications rates were compared between Group A/B, and objective voice parameters were compared between the usage of energy-based devices (EBDs) within Group B. Compared to Group B, Group A patients had higher rates of recurrent laryngeal nerve palsy (13.0%/1.1%, p = 0.001), postoperative hypocalcemia (47.8%/18.2%, p = 0.002), and postoperative hematoma (10.9%/2.3%, p = 0.108). Additionally, Group A had one permanent vocal cord palsy, four permanent hypocalcemia, and one thyroid storm, whereas none of Group B had these complications. Group B patients with EBDs had a significantly better pitch range ( p = 0.015) and jitter ( p = 0.035) than those without EBDs. To reduce the major complications rate, inexperienced thyroid surgeons should remain vigilant when performing TT for Graves' disease. Updates on surgical concepts and the effective use of operative adjuncts are necessary to improve patient safety and voice outcome.

The effect of post-operative adverse events (AEs) on patient outcomes such as length of stay (LOS) and readmissions to hospital is not completely understood. This study examined the severity of AEs from a high-volume thoracic surgery center and its effect on the patient postoperative LOS and readmissions to hospital. This study includes patients who underwent an elective lung resection between September 2018 and January 2020. The AEs were grouped as no AEs, 1 or more minor AEs, and 1 or more major AEs. The effects of the AEs on patient LOS and readmissions were examined using a survival analysis and logistic regression, respectively, while adjusting for the other demographic or clinical variables. Among 488 patients who underwent lung surgery, (Wedge resection [n = 100], Segmentectomy [n = 51], Lobectomy [n = 310], Bilobectomy [n = 10], or Pneumonectomy [n = 17]) for either primary (n = 440) or secondary (n = 48) lung cancers, 179 (36.7%) patients had no AEs, 264 (54.1%) patients had 1 or more minor AEs, and 45 (9.2%) patients had 1 or more major AEs. Overall, the median of LOS was 3 days which varied significantly between AE groups; 2, 4, and 8 days among the no, minor, and major AE groups, respectively. In addition, type of surgery, renal disease (urinary tract infection [UTI], urinary retention, or acute kidney injury), and ASA (American Society of Anesthesiology) score were significant predictors of LOS. Finally, 58 (11.9%) patients were readmitted. Readmission was significantly associated with AE group ( P  = 0.016). No other variable could significantly predict patient readmission. Overall, postoperative AEs significantly affect the postoperative LOS and readmission rates., Competing Interests: Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2022.)

Skeletal muscle mass (SMM) depletion has been validated in many surgical fields as independent predictor of complications through cross-sectional imaging. We evaluated SMM depletion in a stage III-IV head and neck cancer cohort, comparing the accuracy of CT/MRI at C3 level with ultrasound (US) of rectus femoris muscle (RF) in terms of prediction of major complications. Patients submitted to surgery were recruited from 2016 to 2021. SMM was estimated on CT/MRI by calculating the sum of the cross-sectional area (CSA) of the sternocleidomastoid and paravertebral muscles at C3 level and its height-indexed value (cervical skeletal muscle index, CSMI) and on US by computing the CSA of RF. Specific thresholds were defined for both US and CT/MRI according to ROC curve in terms of best prediction of 30-day major complications to detect sarcopenic subjects (40-53%). Sixty-five patients completed the study. At univariate analysis, major complications were associated to lower RF CSA, lower CSA at C3 level and lower CSMI, together with previous radiotherapy, higher ASA score and higher modified frailty index (mFI). At multivariate analysis RF CSA (OR 7.07, p = 0.004), CSA at C3 level (OR 6.74, p = 0.005) and CSMI (OR 4.02, p = 0.025) were confirmed as independent predictors in three different models including radiotherapy, ASA score and mFI. This analysis proved the value of SMM depletion as predictor of major complications in a head and neck cancer cohort, either defined on cross-sectional imaging at C3 or on US of RF.

Study Objective: The potential of perioperative goal-directed therapy (PGDT) to improve outcome after high-risk abdominal surgery remains subject of debate. In particular, there is a need for large, multicenter trials focusing on relevant patient outcomes to confirm the evidence found in small, single center studies including minor complications in their composite endpoints. The present study therefore aims to investigate the effect of an arterial waveform analysis based PGDT algorithm on the incidence of major complications including mortality after high-risk abdominal surgery., Design: Prospective randomized controlled multicenter trial., Setting: Operating theatres and Post-Anesthesia/Intensive Care units (PACU/ICU) of four tertiary hospitals in The Netherlands., Patients: A total number of 482 patients undergoing elective, abdominal surgery that is considered high-risk due to the extent of the procedure and/or patient comorbidities., Interventions: Hemodynamic therapy using an age-specific PGDT algorithm including cardiac index (CI) and stroke volume variation (SVV) measurements during a 24-h perioperative period starting at induction of anesthesia., Measurements: The average number of major complications (including mortality) within 30 days after surgery, the number of minor complications, hospital and PACU/ICU length of stay (LOS), amounts of fluids and vasoactive medications used. Complications were graded using the Accordion severity grading system., Results: The average number of major complications per patient was 0.79 (PGDT group) versus 0.69 (control group) (p = 0.195). There were no statistically significant differences in the number of minor complications, hospital LOS, PACU/ICU LOS, or grading of complications. Patients in the PGDT group received more fluids intraoperatively, more dobutamine intra- and postoperatively, while patients in the control group received more phenylephrine during the operation., Conclusions: PGDT based on a CI and SVV driven algorithm did not result in improved outcomes after high-risk abdominal surgery., Clinical Trial Registration: Netherlands Trial Registry: NTR3380., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: Sarcopenia has drawn considerable attention as a predictor of postoperative risk, although the relationship between sarcopenia and postoperative risk is contentious. This meta-analysis was conducted to evaluate this relationship., Methods: A systematic literature search up to May 2020 was carried out and 43 studies were identified (with 16,716 patients) reporting on the relationship between sarcopenia and postoperative risk. In order to evaluate this relationship, odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using the dichotomous and continuous method with a random or fixed effects model., Results: Compared with non-sarcopenic patients, those with sarcopenia have a higher major complications rate (OR: 4.03, 95% CI: 2.49-5.57, p <0.001), a higher total complications rate (OR: 1.77, 95% CI: 1.40-2.24, p <0.001), a higher 30-day mortality rate (OR: 2.38, 95% CI: 1.56-3.63, p <0.001) and a longer hospital stay (mean difference: 4.54 days, 95% CI: 2.49-6.59 days, p <0.001)., Conclusions: Sarcopenia significantly increases the risk of major complications, total complications, 30-day mortality and length of hospital stay. For this reason, it is recommended that sarcopenia is added to preoperative risk evaluation to avoid any possible negative outcomes following gastrointestinal oncological surgery.

Objective: To compare the oncological outcomes and major complications of laparoscopic radical hysterectomy (LRH) and abdominal radical hysterectomy (ARH) for stage IB1 cervical cancer (FIGO 2009) with a tumour size less than 2 cm., Methods: We retrospectively compared the oncological outcomes and major complications of 1207 stage IB1 cervical cancer patients with a tumour size less than 2 cm who received LRH (n = 546) or ARH (n = 661) in 37 hospitals., Results: (1) There was no significant difference in 3-year overall survival (OS; 97.3% vs. 98.5%, P = 0.288) or 3-year disease-free survival (DFS; 95.1% vs. 95.4%, P = 0.792) between LRH (n = 546) and ARH (n = 661).(2) The rate of any 1 complication refers to the incidence of one or more complications in a patient, which was higher with LRH than ARH (OR = 4.047, 95% CI = 2.035-8.048, P < 0.001). Additionally, intraoperative complications occurred with LRH (OR = 12.313, 95% confidence intervals [CI] = 1.571-96.493, P = 0.017), and postoperative complications (OR = 3.652, 95% CI = 1.763-7.562, P < 0.001) were higher with LRH than ARH. The ureteral injury rate was higher with LRH than with ARH (1.50% vs. 0.20%, OR = 9.814, 95% CI = 1.224-78.712, P = 0.032). The ureterovaginal fistula rate was higher with LRH than ARH. The rates of obturator nerve injury, bladder injury, vesicovaginal fistula, rectovaginal fistula, venous thromboembolism, bowel obstruction, chylous leakage, pelvic haematoma, and haemorrhage were similar between the groups., Conclusions: The oncological outcomes of LRH and ARH for stage IB1 cervical cancer patients with a tumour size less than 2 cm do not differ significantly. However, incidences of any 1 complication, intraoperative complications, and postoperative complications were higher with LRH than ARH, with complications manifesting mainly as ureteral injury and uterovaginal fistula., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Background and Aim: Percutaneous endoscopic gastrostomy (PEG) has been used in patients with dysphagia and inadequate food intake via an oral route. Despite being a procedure with a high success rate, complications and death have been reported. The aim was to identify the factors related to major complications and mortality, as well as PEG removal prognostic factors due to improvement of their general condition., Methods: Patient characteristics, comorbidities, laboratory data, concomitant medication, sedation, and indication for PEG placement were collected. Major complications, mortality, and PEG removal factors were assessed., Results: A total of 388 patients were enrolled. There were 15 (3.9%) cases of major complications, with major bleeding being the most frequent in 6 (1.5%) patients. Corticosteroids were the independent variable associated with major complications (odds ratio [OR] 5.85; 95% confidence interval [CI] 1.71-20; P  = <0.01). Advanced cancer (hazard ratio [HR] 0.5; 95% CI 0.3-1; P  = 0.05), albumin (HR 0.6; 95% CI 0.4-0.9; P  = <0.01), and C-reactive protein (CRP) (HR 1.1; CI 1-1.2; P  = 0.01) were considered risk factors for mortality. Previous pneumonia (HR 0.4; CI 0.2-0.9; P  = 0.02) was a factor for permanent use of a PEG; however, oncological indication (HR 8.2; CI 3.2-21; P  = <0.01) was factors for PEG withdrawal., Conclusions: Chronic corticosteroid users potentially present with major complications. Low albumin levels and elevated CRP were associated with death. Previous aspiration pneumonia was a factor associated with permanent use of PEG; however, patients with oncological indication were the most benefited., (© 2021 The Authors. JGH Open published by Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background: There is a national shift toward laparoscopic hysterectomy as the predominant form of minimally invasive hysterectomy. Previous research suggests that vaginal hysterectomy is associated with lower operative time and improved outcomes; however, this has not been validated in a modern cohort of women., Objective: This analysis aims to evaluate whether total vaginal hysterectomy remains associated with lower operative times and fewer postoperative complications than total laparoscopic hysterectomy or laparoscopic-assisted vaginal hysterectomy, given recent shifts in clinical practice patterns and training experience., Study Design: A secondary analysis of the National Surgical Quality Improvement Program database was performed. Three primary outcomes were defined for the analysis: operative time, rate of major complications, and rate of minor complications. Secondary outcomes included changes in route of surgery over time. Descriptive analyses were performed for all outcomes of interest. Operative time, rate of major complications, and rate of minor complications were compared for each of the 3 forms of minimally invasive hysterectomy: total laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, and total vaginal hysterectomy. Bivariate analyses were performed using analysis of variance, Kruskal-Wallis, Pearson chi-square, or Fisher exact tests where appropriate. Multivariable ordinary least squares and logistic regression were used to assess for overall differences in outcomes and trends over time, controlling for sociodemographic factors and medical comorbidities. Sensitivity analyses were performed using a propensity score-matched cohort created to balance groups across time., Results: A total of 161,626 women met criteria for inclusion. Rates of total vaginal hysterectomy dropped from 51% to 13% between 2008 and 2018, whereas rates of total laparoscopic hysterectomy increased from 12% to 68% (P<.001). In multivariable analyses, total laparoscopic hysterectomy and laparoscopic-assisted vaginal hysterectomy were associated with lower odds of major complications (adjusted odds ratio [95% confidence interval]: 0.813 [0.750-0.881] and 0.873 [0.797-0.957], respectively) and minor complications (adjusted odds ratio [95% confidence interval]: 0.723 [0.676-0.772] and 0.896 [0.832-0.964], respectively) than total vaginal hysterectomy. Temporal trends show an increase in total vaginal hysterectomy operative time and decreases in total laparoscopic hysterectomy and laparoscopic-assisted vaginal hysterectomy operative times over the 11-year analysis period (P<.001), although total vaginal hysterectomy continues to have the shortest median operative time overall. No temporal trends were observed in rates of complications., Conclusion: This analysis highlights recent shifts in rates of minimally invasive hysterectomy. Alongside this change in practice pattern, this study also brings to light a resultant shift in the complication rates associated with each surgical approach, as laparoscopic hysterectomy has lower rates of complications than vaginal hysterectomy despite longer operative times., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: The diagnosis of ankyloglossia, or tongue-tie, and the number of frenotomies performed has increased over 10-fold from 1997 to 2012 in the United States. The sharpest increase has been in neonates. For parents considering frenotomy for their breastfeeding newborn, there is controversy surrounding the evaluation of tongue-tie and the benefit of a frenotomy. Complications from tongue-tie procedures are thought to be low, though it is not well reported nor studied., Objectives: The aim of this study is to describe a case of a sublingual mucocele after laser frenotomy in a neonate with tongue-tie and to investigate major complications reported after tongue-tie release in pediatric patients through a systematic review of the literature., Case Report: We present a 6-week-old female who underwent a laser frenotomy procedure performed by a dentist who presented with a new cyst under her tongue., Material and Methods: A systematic literature search of articles published from 1965 to April 2020 was conducted in Ovid MEDLINE(R), Ovid EMBASE, and Scopus. Citations were uploaded into a systematic review software program (DistillerSR, Ottawa, ON, Canada), followed by full text screening., Results: 47 major complications were reported in 34 patients, including our patient. Most of the cases were located in the United States and Europe. The most frequent indications for the procedure were breastfeeding problems (n = 18) and speech impediment (n = 4). The procedure was performed by dentists (n = 6), lactation consultants (n = 5), and otolaryngologists (n = 4). The bulk of the major complications after frenotomy included poor feeding (n = 7), hypovolemic shock (n = 4), apnea (n = 4), acute airway obstruction (n = 4), and Ludwig angina (n = 2)., Conclusions: Reporting of complications after frenotomy is lacking. Risks to neonates may be different than risks to older children and adults. Practitioners across different specialties should be monitoring and studying this more rigorously to better guide patients and families on the risks and benefits of this procedure., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: The optimal timing of operative stabilization of patients with traumatic spinal fractures without spinal cord injury (SCI) has not been established. The challenges of early operative intervention, which may require prone positioning in a patient with multisystem injuries, must be balanced with the disadvantages of prolonged immobilization. The authors set out to define the optimal timing of surgical repair of traumatic spinal fractures in patients without SCI and the effect of delayed repair on the incidence of major complications., Methods: A retrospective cohort study was conducted using data derived from the American College of Surgeons Trauma Quality Improvement Program. Adult trauma patients who underwent operative fixation of a spinal fracture within 7 days of admission were included. Patients with SCI were excluded. The primary outcome was the occurrence of a major complication. Secondary outcomes included death and length of stay. Restricted cubic splines were used to model the nonlinear effects of time to spinal fixation and determine a threshold beyond which stabilization was associated with a higher rate of major complications. Logistic regression and propensity score matching were then used to derive estimates for the association between delayed fixation and major complications., Results: The authors identified 19,310 patients treated at 389 centers who met the inclusion criteria. Modeling identified fixation beyond 24 hours as a risk for major complications. Adjusting for potential confounders using multivariable logistic regression showed that late fixation was associated with a 1.30 (95% CI 1.15-1.46) times increased odds of developing a major complication. After propensity score matching, late fixation remained associated with a 1.25 (95% CI 1.13-1.39) times increased risk of experiencing a major complication., Conclusions: In the absence of clear contraindications, surgeons should strive to stabilize traumatic spinal fractures without SCI within 24 hours. Early fixation can be expected to reduce major complications by 25%-30%.

Background: Radical nephroureterectomy (RNU) is the referent standard for managing bulky, invasive, or high grade upper-tract urothelial carcinoma (UTUC). The UTUC patient population, however, generally harbor medical comorbidities thereby placing them at risk of surgical complications. This study reviews a large international cohort of RNU patients to define the risk of major complications and preoperative factors associated with their occurrence., Methods: Patients undergoing RNU at 14 academic medical centers between 2002 and 2015 were retrospectively reviewed. Preoperative clinical, demographic, operative, and comorbidity indices were recorded. The modified Clavien-Dindo index was used to grade complications occurring within 30 days of surgery. The association between preoperative variables and major complications occurring after RNU was determined by multivariable logistic regression., Results: One thousand two hundred and sixty-six patients (707 men; 559 women) with a median age of 70 years and BMI of 27 kg/m 2 were included. Over three-quarters of the cohort was white, 50.1% had baseline chronic kidney disease (CKD) ≥ stage III, 22.4% had a Charlson comorbidity index (CCI) score >5, and 17.1% had an Eastern Cooperative Oncology Group (ECOG) performance status ≥2. Overall, 413 (32.6%) experienced a complication including 103 (8.1%) with a major event. Specific distribution of major complications included 49 Clavien III, 44 Clavien IV, and 10 Clavien V. On univariate analysis, patient age (P=0.006), hypertension (P=0.002), diabetes mellitus (P=0.023), CKD stage (P<0.001), American Society of Anesthesiologists (ASA) score (P=0.022), ECOG (P<0.001), and CCI (P<0.001) all were associated with major complications. On multivariate analysis, ECOG ≥2 (OR 2.38, 95% CI, 1.46-3.90), P=0.001), CCI >5 (OR 3.45, 95% CI, 1.41-8.33, P=0.007), and CKD stage ≥3 (OR 3.64, P=0.008) were independently associated with major complications., Conclusions: Major complications following RNU occurred in almost 10% of patients. Impaired preoperative performance status and baseline CKD are preoperative variables associated with these major post-surgical adverse event. These easily measurable indices warrant consideration and discussion prior to proceeding with RNU., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/tau.2020.01.22). The series “Upper-Tract Urothelial Carcinoma: Current State and Future Directions” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare., (2020 Translational Andrology and Urology. All rights reserved.)

Background: Esophagectomy is a highly invasive procedure with a high incidence of complications. The objectives of this study were to create risk prediction models for postoperative morbidity associated with esophagectomy and to test their performance using a population-based large database., Methods: A total of 10 862 patients who underwent esophagectomy between January 2011 and December 2012 derived from the Japanese national clinical database (NCD) were included. Based on the 148 preoperative clinical variables collected, risk prediction models for eight major postoperative morbidities were created using 80% (8715 patients) of the study population and validated using the remaining 20% (2147 patients) of the patients., Results: The mortality rate was 3.1% and postoperative morbidity was observed in 42.6% of the patients. The c-statistics of the eight risk models established by the training set were surgical site infection (0.564), anastomotic leakage (0.531), need for transfusion (0.636), blood loss >1000 mL (0.644), pneumonia (0.632), unplanned intubation (0.607), prolonged mechanical ventilation over 48 hours (0.614), and sepsis (0.618) in the validation analysis., Conclusions: Risk prediction models for postoperative morbidity after esophagectomy using the population-based large database showed relatively fair performance. The current models may offer baseline information for risk stratification in clinical decision makings and help select more suitable surgical and nonsurgical treatment options and future clinical studies., (© 2019 Wiley Periodicals, Inc.)

Background: There is a paucity of robust clinical data on major postoperative complications following robotic-assisted resection for primary lung cancer. This study assessed the incidence and outcomes of patients who experienced major complications after robotic anatomic pulmonary resection., Methods: This was a multicenter, retrospective review of patients who underwent robotic anatomic pulmonary resection between 2002 and 2018. Major complications were defined as grade III or higher complications according to the Clavien-Dindo classification. Statistical analysis was performed based on patient-, surgeon-, and treatment-related factors., Results: During the study period, 1264 patients underwent robotic anatomic pulmonary resections, and 64 major complications occurred in 54 patients (4.3%). Univariate analysis identified male sex, forced expiratory volume in 1 second, diffusion capacity of the lung for carbon monoxide, neoadjuvant therapy, and extent of resection as associated with increased likelihood of a major postoperative complication. Patient age, performance status, body mass index, reoperation status, and surgeon experience did not have a significant impact on major complications. Patients who experienced at least 1 major complication were at higher risk for an intensive care unit stay of >24 hours (17.0% vs 1.4%; P < .001) and prolonged hospitalization (8.5 days vs 4 days; P < .001). Patients who experienced a major postoperative complication had a 14.8% risk of postoperative death., Conclusions: In this series, the major complication rate during the postoperative period was 4.3%. A number of identified patient- and treatment-related factors were associated with an increased risk of major complications. Major complications had a significant impact on mortality and duration of stay., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: To report the trends in surgical approaches and compare the major surgical complication rates of laparoscopic and abdominal radical hysterectomy for cervical cancer., Methods: From the major surgical complications of cervical cancer in China (MSCCCC) database, we obtained the demographic, clinical, treatment hospital and complication data of patients with cervical cancer who underwent radical hysterectomy from 2004 to 2015 at 37 hospitals. The patients were assigned to the laparoscopic and abdominal surgery groups. The differences in the complication rates were analyzed using univariate and multivariable logistic regression models., Results: We identified a total of 18447 patients; 5491 (29.8%) underwent laparoscopic surgery and 12956 (70.2%) underwent abdominal surgery. The proportion of laparoscopic surgery rose from 0.35% in 2004 to 49.31% in 2015. In the multivariate analysis, the laparoscopic group had increased odds of intraoperative and postoperative complications (OR = 3.88, 95% CI = 2.47-6.11; OR = 1.42, 95% CI = 1.11-1.82). A more detailed analysis showed that laparoscopic surgery was associated with increased rates of intraoperative ureteral injury (OR = 3.83, 95% CI = 2.11-6.95), bowel injury (OR = 14.83, 95% CI = 1.32-167.25), vascular injury (OR = 3.37, 95% CI = 1.18-9.62), postoperative vesicovaginal fistula (OR = 4.16, 95% CI = 2.08-8.32), ureterovaginal fistula (OR = 4.16, 95% CI = 2.08-8.32), rectovaginal fistula (OR = 8.04, 95% CI = 1.63-39.53), and chylous leakage (OR = 10.65, 95% CI = 1.18-95.97), while abdominal surgery was more likely to cause bowel obstruction (OR = 0.55, 95% CI = 0.35-0.87). The two groups had similar rates of bladder injury, obturator nerve injury, pelvic hematoma, rectovaginal fistula and venous thromboembolism (P > 0.05)., Conclusion: Laparoscopic surgery was associated with more major surgical complications, especially intraoperative ureteral injury and postoperative fistula, than abdominal surgery among women with cervical cancer., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Renal biopsies are essential in nephrology but they are invasive and complications can occur. The aim of this study was to explore clinical parameters that can be used as predictors for biopsy complications., Methods: Clinical parameters such as demographics, biopsy indications, serology, comorbidities and clinical chemistry were retrieved from a regional biopsy registry between 2006 and 2015 and from a nationwide registry between 2015 and 2017. Clinical data before biopsy were compared with data on major biopsy complications. Fisher's exact and χ 2 tests were used and odds ratios (ORs) with 95% confidence intervals (CIs) were presented. Univariate and multiple binary logistic regression analyses were performed with complications as outcome. A two-sided P-value <0.05 was considered significant., Results: In total, 2835 consecutive native kidney biopsies were analysed (39% women and 61% men, median age 57 years). No death and nephrectomy due to biopsy complications were registered. The frequency of major biopsy complications was 5.65%. In the multiple logistic regression, the risk for complications increased in women [OR 1.51 (95% CI 1.08-2.11)] and decreased with age: 45-64 years age group [OR 0.66 (95% CI 0.44-0.99)] and >74 years age group [OR 0.51 (95% CI 0.27-0.96)]. Among comorbidities, patients with diabetes mellitus type 2 [OR 2.07 (95% CI 1.15-3.72)] and non-ischaemic heart disease [OR 3.20 (95% CI 1.64-6.25)] had a higher risk for major biopsy complications., Conclusions: Female gender, younger age (≤44 years), diabetes mellitus type 2 and non-ischaemic heart disease were found as risk factors for major biopsy complications., (© The Author(s) 2019. Published by Oxford University Press on behalf of ERA-EDTA.)

Aims: We aimed at describing outcomes and predictors of cardiac avulsion or tear (CA/T) with tamponade and vascular avulsion or tear (VA/T) after transvenous lead extraction (TLE) in the ESC-EHRA European Lead Extraction ConTRolled (ELECTRa) registry., Methods and Results: A total of 3555 consecutive patients of whom 3510 underwent TLE at 73 centres in 19 European countries were enrolled. Among 58 patients (1.7%) with procedure-related major complications, 49 (84.5%) patients (30 CA/T and 19 VA/T) presented cardiovascular complications requiring pericardiocentesis, chest tube positioning and/or surgical repair. The mortality was 20% in patients with tamponade due to CA/T and 31.6% in patients with VA/T. Pericardiocentesis as first manoeuvre followed by rescue surgical repair was highly effective in case of CA/T (93.8%). At multivariate analysis, CA/T with tamponade was more common in RIATA lead extraction, female patients, leads with a mean dwelling time more than 10 years, and when ≥3 leads were extracted or multiple sheaths required. Occlusion or critical stenosis of superior venous access and the leads mean dwelling time more than 10 years were independent predictors for VA/T, while mechanical dilatation was an independent predictor of a lower incidence of this complication as compared to the use of powered sheaths., Conclusions: In the ELECTRa registry, RIATA lead extraction and superior venous access occlusion/thrombosis are two new independent predictors for cardiac tamponade and major vascular complications, respectively. The use of mechanical sheaths seems to be associated with a lower incidence of VA/T. A strategy of pericardiocentesis followed by a rescue surgical approach seems to be reasonable in order to treat a CA/T with tamponade., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2018. For permissions, please email: journals.permissions@oup.com.)

Background: Computed tomography (CT)-assessed sarcopenia indexes have been reported to predict postoperative morbidity and mortality; however conclusions drawn from different indexes and studies remain controversial., Aim: The purpose of this meta-analysis was to evaluate various CT-assessed sarcopenia indexes as predictors of risk for major complications in patients undergoing hepatopancreatobiliary surgery for malignancy., Methods: Medline/PubMed, Web of Science, and Embase databases were systematically searched to identify relevant studies published before June 2018. PRISMA guidelines for systematic reviews were followed. The pooled risk ratio (RR) for major postoperative complications (Clavien-Dindo ≥III) was estimated in patients with sarcopenia versus patients without sarcopenia. Data extracted were meta-analyzed using Review Manager (version 5.3)., Results: Twenty-eight studies comprising 6,656 patients were included in this study. CT-assessed sarcopenia indexes, such as skeletal muscle index (SMI, RR 1.36; 95% CI 1.14-1.63; p = 0.0008; I2 = 24%), psoas muscle index (PMI, RR 1.35; 95% CI 1.15-1.58; p = 0.0002; I2 = 0%), muscle attenuation (MA, RR 1.40; 95% CI 1.14-1.73; p = 0.002; I2 = 4%), and intramuscular adipose tissue content (IMAC, RR 1.63; 95% CI 1.28-2.09; p < 0.0001; I2 = 0%) were all predictors of postoperative major complications, although moderate heterogeneity existed and cutoffs for these indexes to define sarcopenia varied., Conclusions: All commonly used CT-assessed sarcopenia indexes, such as SMI, PMI, MA, and IMAC can predict the risk of major postoperative complications; however, a consensus on the cutoffs for these indexes to define sarcopenia is still lacking., (© 2018 S. Karger AG, Basel.)

Background: There is little population-level data evaluating risk factors for postoperative complications after total laryngectomy., Methods: We conducted a retrospective review of the American College of Surgeons National Quality Improvement Program identifying patients who underwent total laryngectomy as a primary procedure from 2005 to 2014. Multivariate analysis was performed to identify variables that were independently associated with overall and major complications., Results: Eight hundred seventy-one cases met inclusion criteria. Three hundred twenty-eight patients (37.7%) had complications, with operative time (hours; P < .0001), class III (P < .001) wound status, and patient age (decade; P = .003) associated with overall complications. Two hundred one patients had major complications that were associated with steroid use (P = .01) and class III (P = .0083) wound classification. Preoperative hematocrit was correlated with a reduction of all and major complications on multivariate analysis (P < .0001 and P = .036)., Conclusion: Identifying and optimizing risk factors may improve outcomes in total laryngectomy., (© 2018 Wiley Periodicals, Inc.)

Purpose: To analyze major and minor complications following surgery for deeply infiltrating endometriosis including long-term impairment of intestinal, bladder, and sexual function., Methods: Patients who had undergone resection for deeply infiltrating endometriosis without anterior rectal resection between 2001 and 2011 were included (n = 134). Clinical and surgical data, as well as minor and major complications, were recorded. A questionnaire was sent to the patients and to a healthy control group (n = 100)., Results: Major complications occurred in 3.7% and minor complications in 12.7% of the patients. Surgical revision was necessary in five cases. The questionnaire response rate was 66.4%, with a mean follow-up period of 75.6 months. Weak urinary flow was reported by 26.4% of the patients; a feeling of residual urine by 16.1%; constipation by 13.5%; more than one bowel movement/day by 16.9%; insufficient lubrication during intercourse by 30.3%. The findings for weak urinary flow, feeling of residual urine, and insufficient lubrication differed significantly from the control group. Subgroup analysis did not identify any statistical associations between questionnaire responses and dyspareunia or dysmenorrhea as reasons for surgery, or previous endometriosis surgery in the patient's history., Conclusions: The major and minor complication rates were consistent with or lower than the literature data. Few studies have investigated complication rates associated with treatment for endometriosis in the sacrouterine ligaments and/or the rectovaginal septum. The high rates of impaired bladder function and sexual function after endometriosis surgery, as well as inadequate data, make further prospective studies on this topic necessary.

Introduction: The Revised Trauma Score (RTS) accurately identifies trauma patients at high risk of adverse events or death. Less is known about its usefulness in the general population and non-trauma recipients of Helicopter Emergency Medical Service (HEMS). The RTS is a simple tool and omits a lot of other data obtained during clinical evaluation. The aim was to assess the role of the RTS to identify patients at risk of major complications (death, cardiopulmonary resuscitation, defibrillation, intubation) in the general population of HEMS patients. Clinical factors beyond the RTS were analyzed to identify additional prognostic factors for predicting major complications., Material and Methods: A retrospective analysis of medical records of adult patients routinely collected during HEMS missions in the years 2011-2014 was performed., Results: The analysis included 19 554 HEMS missions. Patients were 55 ±20 years old and 68% were male. The most common indication for HEMS was diseases of the circulatory system - 41%. Major complications occurred in 2072 (10.6%) cases. In the general population of HEMS patients, the RTS accurately identified individuals at risk of major complications at a cut-off value of 10.5 and area under the curve (AUC) of 93.5%. In multivariate analysis, additional clinical data derived from clinical examination (ECG; skin, pupil and breathing examination) significantly but marginally improved the accuracy of RTS assessment: AUC 95.6% ( p < 0.001 for the difference)., Conclusions: The Revised Trauma Score accurately identifies individuals at risk of major complications during HEMS missions regardless of the indication. Additional clinical data significantly but marginally improved the accuracy of RTS in the general population of HEMS patients.

Background Context: Several studies have suggested that laboratory results have minimal impact on clinical decision making in surgery. Despite the widespread use of preoperative testing in spine surgery and the large volume of posterolateral lumbar fusions (PLFs) being performed each year, no study has assessed the ability of preoperative laboratories to predict adverse events following PLF., Purpose: The purpose of this study was to explore the relationship between commonly obtained preoperative laboratory results and postoperative complications following one- to two-level PLF., Study Design: This is a retrospective study of prospectively collected data., Patient Sample: The 2006-2013 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was employed to identify all patients who underwent one- to two-level PLF., Outcome Measures: The outcome variables of interest were 30-day postoperative complications, which were assessed as major complications, minor adverse events, and total complications., Materials and Methods: Demographics, comorbidities, and perioperative characteristics were collected for each patient. Preoperative laboratories included sodium, blood urea nitrogen, creatinine, albumin, bilirubin, serum glutamic oxaloacetic transaminase, alkaline phosphatase, white blood cell count, hematocrit, platelet count, prothrombin time, international normalized ratio, and partial thromboplastin time. Bivariate analysis and multivariate logistic regression modeling were used to explore the relationship between abnormal preoperative laboratories and the incidence of postoperative complications., Results: After controlling for age, ASA score, length of surgery, and all significant comorbidities, abnormal sodium (odds ratio [OR]=2.47, 95% confidence interval [CI]: 1.45-4.19, p=.001) and abnormal INR (OR=2.33, 95% CI: 1.09-4.98, p=.029) were significantly associated with the development of any complication. Sodium (OR=1.61, 95% CI: 1.01-2.54, p=.04) and platelets (OR=1.58, 95% CI: 1.02-2.44, p=.04) were associated with minor complications. Meanwhile, creatinine (OR=1.74, 95% CI: 1.02-2.99, p=.04) and platelets (OR=1.71, 95% CI: 1.02-2.89, p=.04) were significant predictors of major adverse events., Conclusions: This study represents the first attempt to assess the utility of preoperative laboratories in predicting postoperative complications in PLF. Although the majority of laboratories were not significantly associated with adverse events, abnormal sodium values, INR, creatinine, and platelets were shown to be predictive of various complications., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: To identify predictive factors for critical care unit-level complications (CCU complication) after long-segment fusion procedures for adult spinal deformity (ASD)., Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database [2010-2014] was reviewed. Only adult patients who underwent fusion of 7 or more spinal levels for ASD were included. CCU complications included intraoperative arrest/infarction, ventilation >48 hours, pulmonary embolism, renal failure requiring dialysis, cardiac arrest, myocardial infarction, unplanned intubation, septic shock, stroke, coma, or new neurological deficit. A stepwise multivariate regression was used to identify independent predictors of CCU complications., Results: Among 826 patients, the rate of CCU complications was 6.4%. On multivariate regression analysis, dependent functional status (P=0.004), combined approach (P=0.023), age (P=0.044), diabetes (P=0.048), and surgery for over 8 hours (P=0.080) were significantly associated with complication development. A simple scoring system was developed to predict complications with 0 points for patients aged <50, 1 point for patients between 50-70, 2 points for patients 70 or over, 1 point for diabetes, 2 points dependent functional status, 1 point for combined approach, and 1 point for surgery over 8 hours. The rate of CCU complications was 0.7%, 3.2%, 9.0%, and 12.6% for patients with 0, 1, 2, and 3+ points, respectively (P<0.001)., Conclusions: The findings in this study suggest that older patients, patients with diabetes, patients who depend on others for activities of daily living, and patients who undergo combined approaches or surgery for over 8 hours may be at a significantly increased risk of developing a CCU-level complication after ASD surgery., Competing Interests: Conflicts of Interest: The abstract of this manuscript was presented as an electronic poster in Congress of Neurological Surgeon’s Annual Meeting 2017 in Boston Massachusetts, October 7–11, 2017.