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International audience; BACKGROUND: Bariatric surgery has increased the number of patients requiring medial thighplasty after massive weight loss. However, despite the various complications, the procedure improves quality of life. The authors report postoperative complications of vertical J-shaped medial thigh lift in a series of patients and identify preoperative risk factors. METHODS: For almost 5 years, the details of all J medial thighplasties performed by a single surgeon were recorded; detailed medical records were also available. Complications can be major (e.g., need for early surgical revision or readmission) or minor (delayed wound healing). RESULTS: During the study period, 94 patients were treated and only minor complications were recorded (42.5 percent). On multivariate analysis, older age (OR, 1.05; 95 percent CI, 1.01 to 1.10) and a body mass index greater than or equal to 30 kg/m2 (OR, 2.82; 95 percent CI, 1.10 to 7.22) were independent risk factors for postoperative complications. CONCLUSIONS: As with other postbariatric operations, medial thighplasty is associated with significant morbidity, but the risk thereof can be easily established and managed. Specific algorithms for determining the risk of postoperative complications based on age and body mass index are needed to guide preoperative discussions with patients and perform patient selection. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

INTRODUCTION Target vein recanalization is defined as the postoperative detection of blood flow in a venous segment previously ablated. It can be occurred after thermal-tumescent procedures, as radiofrequency (RFA) and endovenous laser (EVLA) ablation techniques. Despite several papers described and analyzed incidence and consequences of recanalization, limited data are published on risk factors for this condition. The aim of this general review is to investigate clinical and instrumental risk factors for great and small saphenous veins recanalization after RFA, indicating their impact in the follow-up period. EVIDENCE ACQUISITION Articles were obtained through a detailed search of the scientific journal databases (PubMed, Scopus, Web of Science) for those published between January 1, 2011 to December 31, 2020. The term "radiofrequency venous ablation" was combined with "risk factors", "recanalization" and "recurrence", to obtain the first article cluster. EVIDENCE SYNTHESIS Risk factors analysis for saphenous vein recanalization after ablation is not a well-studied problem. Although several studies have analyzed recanalization patterns and anatomical causes of ablation failure, few and disaggregate data are available regarding clinical preoperative risk factors. BMI and saphenous trunk diameter seem to be the only two recognized characteristics that may affect short and long-term recanalization rate, though CVI status, sex, target vein treatment length and others factors may be taken into account. CONCLUSIONS Physicians should consider risk factors for recanalization in patient selection and treatment recommendations, but also recognize that not all "ablation failures" are of clinical relevance.

Retrospective review of a prospectively collected national database.To evaluate the predictive value of hypoalbuminemia on outcomes in surgical spine oncology patients.It is well documented that patients with hypoalbuminemia (albumin3.5) have significantly higher rates of surgical morbidity and mortality than patients with normal albumin (3.5 g/dl). We evaluated outcomes for metastatic oncologic spine surgery patients based on pre-operative albumin levels.Patients who underwent surgery for metastatic spine disease were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2006 to 2016. Three groups were established: patients with normal albumin (3.5 g/dl), mild hypoalbuminemia (2.6 g/dl - 3.4 g/dl), and severe hypoalbuminemia (=2.5 g/dl). A multivariate analysis was used to assess the association between albumin levels and mortality within 30 days of surgical intervention.A total of 700 patients who underwent surgery for metastatic spinal disease and had pre-operative albumin levels available were identified; 64.0% had normal albumin (3.5 g/dl), 29.6% had mild hypoalbuminemia, and 6.4% had severe hypoalbuminemia. The overall 30-day mortality was 7.6% for patients with normal albumin, 15.9% for patients with mild hypoalbuminemia, and 44.4% for patients with severe hypoalbuminemia. On multivariate analysis, patients with mild hypoalbuminemia (OR 1.7 95% CI: 1.0-3.0 p = 0.05) and severe hypoalbuminemia (OR 6.2 95% CI: 2.8-13.5 p 0.001) were more likely to expire within 30 days compared to patients with preoperative albumin above 3.5 g/dl.In this study, albumin level was found to be an independent predictor of 30-day mortality in patients who underwent operative intervention for metastatic spinal disease. Patients with severe hypoalbuminemia had a 7-fold increased risk when compared with those who had normal albumin. While these findings need to be validated by future studies, we believe they will prove useful for preoperative risk stratification and surgical decision-making.

Numerous prediction models have been proposed to estimate the risk of complications after esophagectomy. However, these models are not commonly used in practice and surgeons generally trust on their own clinical judgment. The aim of this study is to compare the clinical judgment of the surgeons with the existing risk stratification models with regard to predicting complications after esophageal surgery. Methods Patients with resectable esophageal cancer who underwent an esophagectomy between March 2019 and January 2020 were included in this prospective study. Literature was searched to identify prediction models predicting the incidence of postoperative complications after esophagectomy. Clinical judgment of three surgeons was assessed using a standardized form where surgeons could indicate their estimated risk for postoperative complications. The best performing prediction model was compared with the judgment of the surgeons, using the Net Reclassification Improvement (NRI). A higher NRI correlates with better estimation by the surgeon and a negative NRI indicates a better prediction by the prediction model. Results Fifty-three patients were included, 36 patients (68%) developed a complication. Two risk classification models were identified in literature: Model 1 (Lagarde et al, Annals of thoracic surgery, 2008) and model 2 (Reeh et al, Medicine, 2016). Model 1 had a better discriminative ability than model 2 (Area Under the Receiver Operator Curve 0.738 versus 0.609). The NRI for the surgeons combined was −2%, meaning that model 1 outperforms the combined judgment of the surgeons. However, there was a large difference in clinical judgment between surgeons. Figure 1 shows the NRI for all three surgeons separately. Conclusion Surgeons‘assessment does not outperform prediction models in predicting the incidence of postoperative complications after esophageal surgery. However, there is a poor agreement between surgeons regarding their risk assessment based on their clinical judgment. Some surgeons might individually outperform existing risk stratification models. Surgeon’s assessment can therefore still be important when counseling patients about the risks of esophageal surgery in addition to risk stratification models.

INTRODUCTION AND OBJECTIVE:Cytoreductive radical prostatectomy (cRP) might be an option in oligometastatic prostate cancer (PCa). However, no preoperative risk tool is available to select candidate...

Summary Accurate preoperative risk prediction for perioperative complications such as acute kidney injury (AKI) may serve to better inform patients and families of risk before surgery, assist with resource requirement planning, and aid with cohort enrichment for enrolment into clinical trials. Where a specific risk factor is modifiable, it may offer a potential therapeutic target for risk reduction. The report by Wang and colleagues describes the modest incremental benefit of N-terminal pro brain natriuretic peptide levels when added to almost 20 other variables for the preoperative prediction of AKI after cardiac surgery. This is consistent with previous smaller studies, but there are important additional questions still to be answered before this biomarker might be used for this purpose in clinical practice.

Malignant ovarian neoplasms are uncommon in the pediatric and adolescent population. Imaging and tumor markers help to guide the preoperative risk/benefit analysis for planned surgical management, which is the mainstay of therapy. An interdisciplinary approach should be taken in the management of this vulnerable population from diagnosis through post-treatment surveillance. In this review, the initial evaluation, risk stratification, and management of various types of malignant ovarian masses will be addressed with a special focus on how to optimize an interdisciplinary approach to ovarian masses.

Background The purpose of this study is to evaluate risk factors for pneumonia following THA and TKA. Methods Patients were identified from the American College of Surgeons National Quality Improvement Database (NSQIP) who experienced postoperative pneumonia after undergoing primary THA and TKA. Results Many characteristics including old age, anemia, diabetes, cardiac comorbidities, dialysis, and smoking were independent risk factors for postoperative pneumonia after THA or TKA. Conclusion This analysis offers new evidence on risk factors associated with the development of pneumonia after THA and TKA. These risk factors can help guide clinicians in preventing postoperative pneumonia after THA and TKA.

The most commonly used preoperative assessment tools include the American College of Surgeons National Surgical Quality Improvement Program and the Revised Cardiac Risk Index. These tools seek to predict the risk of an individual experiencing postoperative complications, including but not limited to mortality, myocardial infarction, pneumonia, stroke, venous thromboembolism, and pneumonia. Many published studies have sought to objectively quantify the utility of the preoperative risk calculations by retrospectively compiling data for patients who underwent the same or comparable surgeries to compare actual complications to predicted complications. Therefore, we searched these studies to review the literature to draw more general conclusions and recommend which risk calculator is best for different types of surgeries.

An accurate assessment of preoperative risk may improve use of hospital resources and reduce morbidity and mortality in high-risk surgical patients. This study aims at implementing an automated surgical risk calculator based on Artificial Neural Network technology to identify patients at risk for postoperative complications. We developed the new SUMPOT based on risk factors previously used in other scoring systems and tested it in a cohort of 560 surgical patients undergoing elective or emergency procedures and subsequently admitted to intensive care units, high-dependency units or standard wards. The whole dataset was divided into a training set, to train the predictive model, and a testing set, to assess generalization performance. The effectiveness of the Artificial Neural Network is a measure of the accuracy in detecting those patients who will develop postoperative complications. A total of 560 surgical patients entered the analysis. Among them, 77 patients (13.7%) suffered from one or more postoperative complications (PoCs), while 483 patients (86.3%) did not. The trained Artificial Neural Network returned an average classification accuracy of 90% in the testing set. Specifically, classification accuracy was 90.2% in the control group (46 patients out of 51 were correctly classified) and 88.9% in the PoC group (8 patients out of 9 were correctly classified). The Artificial Neural Network showed good performance in predicting presence/absence of postoperative complications, suggesting its potential value for perioperative management of surgical patients. Further clinical studies are required to confirm its applicability in routine clinical practice.

Background: The number of patients requiring reoperation has increased as the volume of hip arthroscopy for femoroacetabular impingement syndrome (FAIS) has increased. The factors most important in determining patients who are likely to require reoperation remain elusive. Purpose: To leverage machine learning to better characterize the complex relationship across various preoperative factors (patient characteristics, radiographic parameters, patient-reported outcome measures [PROMs]) for patients undergoing primary hip arthroscopy for FAIS to determine which features predict the need for future ipsilateral hip reoperation, namely, revision hip arthroscopy, total hip arthroplasty (THA), hip resurfacing arthroplasty (HRA), or periacetabular osteotomy (PAO). Study Design: Cohort study; Level of evidence, 3. Methods: A cohort of 3147 patients undergoing 3748 primary hip arthroscopy procedures were included from an institutional hip preservation registry. Preoperative computed tomography of the hip was obtained for each patient, from which the following parameters were calculated: the alpha angle; the coronal center-edge angle; the neck-shaft angle; the acetabular version angle at 1, 2, and 3 o’clock; and the femoral version angle. Preoperative PROMs included the modified Harris Hip Score (mHHS), the Hip Outcome Score (HOS)–Activities of Daily Living subscale (HOS-ADL) and the Sport Specific subscale, and the international Hip Outcome Tool (iHOT-33). Random forest models were created for revision hip arthroscopy, the THA, the HRA, and the PAO. Area under the curve (AUC) for the receiver operating characteristic curve and accuracy were calculated to evaluate each model. Results: A total of 171 patients (4.6%) underwent subsequent hip surgery after primary hip arthroscopy for FAIS. The AUC and accuracy, respectively, were 0.77 (fair) and 76% for revision hip arthroscopy (mean, 26.4-month follow-up); 0.80 (good) and 81% for THA (mean, 32.5-month follow-up); 0.62 (poor) and 69% for HRA (mean, 45.4-month follow-up); and 0.76 (fair) and 74% for PAO (mean, 30.4-month follow-up). The most important factors in predicting reoperation after primary hip arthroscopy were higher body mass index (BMI) and lower preoperative HOS-ADL for revision hip arthroscopy, greater age and lower preoperative iHOT-33 for THA, increased BMI for HRA, and larger neck-shaft angle and lower preoperative mHHS for PAO. Conclusion: Despite the low failure rate of hip arthroscopy for FAIS, our study demonstrated that machine learning has the capability to identify key preoperative risk factors that may predict subsequent ipsilateral hip surgery before the index hip arthroscopy. Knowledge of these demographic, radiographic, and patient-reported outcome data may aid in preoperative counseling and expectation management to better optimize hip preservation.

Aim We have routinely performed emergent laparoscopic cholecystectomy (LC) as soon as we diagnosed acute cholecystitis (AC), if patients could tolerate surgery. This study was conducted to identify the preoperative risk factors that predict the technical difficulty of emergent LC for AC. Methods A retrospective review of patients with AC who underwent emergent LC between 2012 and 2019 was conducted. Technical difficulty was defined as the presence of the following conditions: open conversion, operative time ≥120 min, or blood loss ≥500 ml. Results In all, 327 patients were included and divided into difficult LC (DLC, n = 61) and nondifficult LC (non-DLC, n = 266). Multivariate logistic analysis revealed that symptom duration ≥72 h was the only independent risk factor for DLC. Comparison of late LC (beyond 72 h, LLC) and early LC (within 72 h, ELC) showed a lower rate of creation of the critical view of safety and a longer hospital stay, as well as a longer operative time, a larger amount of bleeding, and a higher open conversion rate in LLC. However, the postoperative complication rates were equivalent. Conclusion LC for AC with symptom duration ≥72 h tends to be technically difficult. However, it is acceptable regarding operative outcomes.

Background. Despite good results of total knee arthroplasty (TKA) as a treatment of idiopathic osteoarthritis (OA) of the knee, significant number of patients (16-33%) complain of persistent pain of unknown origin. This phenomenon is the major cause of patient’s dissatisfaction. It has been theorized that certain preoperative factors may increase the risk of persistent pain; hence, their identification should enable proper preoperative education and development of realistic expectations regarding results of TKA. This study is aimed at identifying the preoperative chronic pain predictors in patients undergoing TKA. Methods. In this prospective cohort study, patients scheduled for TKA were examined one day prior to surgery. Demographics, comorbidities, pressure pain thresholds, pain intensity and duration, radiographic OA grade, and range of motion were recorded. Questionnaires such as Beck Depression Inventory (BDI) and Knee Injury and Osteoarthritis Outcome Score (KOOS) were collected. Study cohort was evaluated approximately 6 months following surgery. Patients were assigned to group A if they had no pain and to group B if they complained of any pain. Collected data was analyzed by biostatistician. Results. 64 patients were included in final analysis, 49 (76,6%) females and 15 (23,4%) males. Mean age was 67,6 yrs (48-84, ±7,42). Group A consisted of 21 patients (33%) while group B consisted of 43 patients (67%). There were no statistically significant differences regarding preoperative factors except for duration of preoperative pain, which was shorter in group A (36 (12-180) vs. 72 (24-180), p = 0,011 ). Every 12 months of preoperative pain were found to increase risk of persistent pain by 1,27 ( p = 0,009 ). Conclusions. Preoperative duration of pain is a risk factor for chronic pain following TKA. Therefore, patients should be operated on as soon as indications arise. Should the surgical treatment of knee arthritis be postponed, intensive and individualized pain management is highly recommended.

This comprehensive narrative literature review aims to extract studies related to frailty indices and their use in elective spine procedures, as limited studies regarding frailty exist in the spine literature. Most studies are retrospective analyses of prospectively collected databases. Evidence suggests a positive correlation between frailty level and mortality rate, postoperative complication rate, length of stay, and the possibility of discharge to a skilled nursing facility; these correlations have been illustrated across various spine procedures. The leading index is the modified frailty index, which measures 11 deficits. The development of more comprehensive frailty indices, such as the Adult Spinal Deformity Frailty Index, are promising and have high predictive value regarding postoperative complication rate in patients with spinal deformity. However, a frailty index that combines clinical, radiographic, and laboratory measures awaits development. Perhaps, the use of a frailty index in preoperative risk stratification for elective spine procedures could serve multiple purposes, including screening for high-risk patients, enhancement of operative decision making, approximation of complication rate for informed decision making, and refinement of perioperative care. Further prospective studies are warranted to determine clinically meaningful interventions in frail individuals.

Objectives Outcomes after coronary artery bypass grafting (CABG) are worse in women than in men. This study aims to investigate whether off-pump coronary artery bypass (OPCAB) surgery improves the outcomes in women by comparing different outcome measures in both genders. Methods Patients who underwent isolated CABG, either on-pump (ONCAB) or OPCAB, between January 1998 and June 2017 were included. Primary endpoints were 30-day and 120-day mortality. Logistic regression models were constructed to evaluate the effect of the CABG technique on important outcomes such as mortality and the need for blood transfusion. Results The data of 17,052 patients were analysed, 3,684 of whom were women (414 OPCAB) and 13,368 men (1,483 OPCAB). The mean number of grafts was lower in the OPCAB group of both genders (p p p p = 0.026]. The difference in 120-day mortality was not significant in men (OR = 0.787, 95% CI 0.498–1.246, p = 0.307). Conclusions Women undergoing CABG benefit more from OPCAB surgery than from ONCAB surgery in terms of 120-day mortality. This difference was not found in men in our patient population.

Objectives - to optimize the indications for radiofrequency thermal ablation in patients with synchronous multiple metastases of colorectal cancer to the liver on the basis of prognostic treatment results. Material and methods. The study group included 78 patients with colorectal cancer with synchronous multiple bilobar liver metastases, who have underwent combined treatment in the period of 2007- 2015, such as cytoreductive surgery removing the primary intestinal tumor in combination with RFA of metastases in the liver, followed by chemotherapy. Results. A computer program for preoperative risk assessment of disease progression was developed and introduced in clinical practice. It is based on the results of the analysis of the factors, predicting the risk of relapse during the first year after cytoreductive surgery with RFA of synchronous multiple CRC liver metastases. Conclusion. The index of metastatic liver damage (the product of the sum of the diameters of metastatic liver lesions by their number), the mutational status of the KRAS gene, CEA values are significant factors in predicting the progression of the disease, which can optimize indications for radiofrequency thermal ablation in the treatment of patients with stage IV CRC with synchronous metastases to the liver.

PurposeTo report the prevalence of outer retinal layer (ORL) damage after macula-off rhegmatogenous retinal detachment (RRD) surgery and to determine its associated preoperative risk factors.Methods253 eyes successfully operated for macula-off RRD were included in the study. The integrity of the external limiting membrane (ELM), ellipsoid zone (EZ) and cone interdigitation zone (CIZ) of the photoreceptors was assessed at 1 month and 6 months using spectral-domain optical coherence tomography. Risk factors were analysed using univariate and multivariate logistic regression. The correlation between ORL integrity and visual outcomes was also evaluated.ResultsCIZ, EZ and ELM defects were found in, respectively, 198 (93.4%) eyes, 100 (47.2%) eyes, 64 (30.2%) eyes at 1 month and in 160 (63.2%) eyes, 44 (17.4%) eyes and 18 (7.1%) eyes at 6 months. In multivariate analysis, duration of macular detachment was the only factor associated with ORL damage at 6 months (p=0.007). Best-corrected visual acuity significantly improved from 0.5±0.3 at 1 month to 0.3±0.3 logarithm of minimal angle of resolution at 6 months (pConclusionPrevalence of outer retinal band defects substantially decreased through the study period, confirming the ability of photoreceptors to recover over time. However, shorter interval to surgery and better visual outcomes were significantly associated with fewer defects within the ORL at 6 months. These findings suggest that earlier surgery may limit RRD-associated photoreceptor degeneration and improve the patient’s visual prognosis.

Background Certain behavioral traits and inadequate social support are known risk factors for complications after cancer surgery. Despite their importance, it is unclear whether conventional patient preoperative evaluation captures them. This study was conducted to assess concordance between documentation and patient survey of selected risk factors and to determine whether failure to document affected postoperative outcomes. Methods Adult patients at a tertiary academic medical center were surveyed before abdominal cancer surgery to assess 6 psychosocial risk factors. Risk factors were also assessed by retrospective chart review and compared with survey results through concordance measures. Thirty-day postoperative complications were abstracted by chart review. Rates of major complications for those with and without clinically missed risk factors were compared. Results Comparisons between chart review and screening survey revealed poor-to-moderate positive agreement (0%–47%) for 5 risk factors and strong negative agreement (82%–99%) among all risk factors. Kappa analysis demonstrated poor-to-fair agreement among 5 risk factors (κ = 0.112–0.423). The overall complication rate was 36%. The complication rate for patients with at least 1 clinically missed risk factor was 49% vs 24% in those without (P = .021), with a similar effect replicated for each individual risk factor. Conclusion This study shows a high level of discordance between formal screening and routine clinician documentation in a preoperative setting for psychosocial risk factors. There is a significant association between missing these risk factors and worse postoperative outcomes. Future work should examine whether structured screening of psychosocial risk factors may improve preoperative risk stratification through proactive interventions.

Objectives Type II endoleak is a problem after endovascular abdominal aneurysm repair. Preoperative risk factors for Type II endoleak include anatomical factors in the lumbar artery and inferior mesenteric artery; however, preventable postoperative risk factors are unknown. Postimplantation syndrome is associated with lower incidence of Type II endoleak. Therefore, we focused on inflammation, and our aim was to investigate nonsteroidal anti-inflammatory drugs as a postoperative risk factor for Type II endoleak. Methods This was a retrospective study of patients with aortic aneurysm who underwent endovascular aneurism repair at the Department of Cardiovascular Surgery, Beppu Medical Center, Oita, Japan, from January 2011 to August 2018. Clinical characteristics were retrieved from patients’ medical records and included age, sex, body mass index, smoking history, comorbidities, treatment devices, medications, and perioperative information, including postimplantation syndrome. Postimplantation syndrome was defined as body temperature >38.5°C with 12,000/dL white blood cells or >10.0 mg/dL C-reactive protein. The primary outcome was the presence or absence of Type II endoleak assessed on the first postoperative enhanced computed tomography scan. Risk factors for Type II endoleak were assessed. Results and conclusions: Of the eligible 84 patients, 20 (24%) had Type II endoleak identified in the first enhanced computed tomographic scans after endovascular aneurism repair. Nonsteroidal anti-inflammatory drug use (odds ratio (OR): 21.2; 95% confidence interval (95% CI): 1.5–308.4; P = 0.026), cerebrovascular disease (OR: 7.27; 95% CI: 1.06–49.99; P = 0.044), and body mass index 2 (OR: 17.3; 95% CI: 2.1–141.8; P = 0.008) were independent risk factors for Type II endoleak after endovascular aneurism repair. Comparing the rate of Type II endoleak among patients who did not receive nonsteroidal anti-inflammatory drugs within 24 h after endovascular aneurism repair, patients who first used nonsteroidal anti-inflammatory drugs 12–24 h after endovascular aneurism repair, and those who received nonsteroidal anti-inflammatory drugs within 12 h after endovascular aneurism repair, we found a significant difference among the groups (4%, 18%, 45%, respectively; P = 0.001). Nonsteroidal anti-inflammatory drug use within 24 h after endovascular aneurism repair is a risk factor for Type II endoleak. We should know nonsteroidal anti-inflammatory drugs within 24 h after endovascular aneurism repair can be a risk of Type II endoleak.

PURPOSE: To build radiomic prediction models using contrast-enhanced computed tomography (CE-CT) to preoperatively predict malignant potential and mitotic count of gastrointestinal stromal tumors (GISTs). PATIENTS AND METHODS: A total of 333 GISTs patients were retrospectively included in our study. Radiomic features were extracted from the preoperative CE-CT images. According to postoperative pathology, patients were categorized by malignant potential and mitotic count, respectively. The most valuable radiomic features were chosen to build a logistic regression model to predict the malignant potential and a random forest classifier model to predict the mitotic count. The performance of radiomic models was assessed with the receiver operating characteristics curve. Our study further developed a radiomic nomogram to preoperatively predict malignant potential in a personalized way for patients with GISTs. RESULTS: The predictive model was built to discriminate high– from low–malignant potential GISTs with an area under the curve (AUC) of 0.882 (95% CI 0.823-0.942) in the training set and 0.920 (95% CI 0.870-0.971) in the validation set. Moreover, the other radiomic model was built to differentiate high– from low–mitotic count GISTs with an AUC of 0.820 (95% CI 0.753-0.887) in the training set and 0.769 (95% CI 0.654-0.883) in the validation set. CONCLUSION: The radiomic models using CE-CT showed a good predictive performance for preoperative risk stratification of GISTs and hold great potential for personalized clinical decision making.

A retrospective review of prospectively collected data.The purpose of this study is to compare and validate several preoperative scores for predicting outcomes following spine tumor resection.Preoperative risk assessment for patients undergoing spinal tumor resection remains challenging. At present, few risk assessment tools have been validated in this high-risk population.The 2008 to 2014 National Surgical Quality Improvement database was used to identify all patients undergoing surgical resection of spinal tumors, stratified as extradural, intradural extramedullary, and intramedullary based on CPT codes. American Society of Anesthesiologists (ASA) score, modified Charlson Comorbidity Index (CCI), and modified Frailty Index (mFI) were computed. A binary logistic regression model was used to explore the relationship between these variables and postoperative outcomes, including mortality, major and minor adverse events, and hospital length of stay (LOS). Other significant variables such as demographics, operative time, and tumor location were controlled for in each model.Two thousand one hundred seventy patients met the inclusion criteria. Higher CCI scores were independent predictors of mortality (OR = 1.24, 95% CI: 1.14-1.36, P 0.001), major adverse events (OR = 1.07, 95% CI: 1.01-1.31, P = 0.018), minor adverse events (OR = 1.15, 95% CI: 1.10-1.20, P 0.001), and prolonged LOS (OR = 1.14, 95% CI: 1.09-1.19, P 0.001). Patients' mFI scores were significantly associated with mortality and LOS, but not major or minor adverse events. ASA scores were not associated with any outcome metric when controlling for other variables.The CCI demonstrated superior predictive capacity compared with mFI and ASA scores and may be valuable as a preoperative risk assessment tool for patients undergoing surgical resection of spinal tumors. The validation of assessment scores is important for preoperative risk stratification and improving outcomes in this high-risk group.3.

This study examined the effects of pain and opioid intakes on subsyndromal delirium in older adults who had joint replacement surgery. Delirium assessments of 53 older adults were completed on the first, second, and third days following joint replacement surgery using the Confusion Assessment Method (CAM). Statistical relationships were analyzed using correlations and multiple regressions. Subsyndromal delirium developed in 68% ( n = 36) of participants. Pain was significantly related ( p < .05) to increased delirium symptoms after accounting for preoperative risk factors of comorbidity, cognitive status, fall history, and preoperative fasting times, whereas opioid intake was not significantly associated with increased delirium symptoms. Findings suggest older adults with increased pain levels are at higher risk for subsyndromal delirium as well as delirium after joint replacement surgery.

The aim of this study was to compare the patient profiles and outcomes of men and women undergoing isolated aortic valve replacement.Patient data were analyzed retrospectively.This single-center study was performed at Catharina Hospital in Eindhoven, the Netherlands.The study comprised 2,362 patients, of whom 1,040 (44%) were women and 1,322 were men (56%).Isolated aortic valve replacement was performed between January 1998 and December 2016.The mean follow-up was 8.3 ± 5.1 years. Women were relatively older (69.9 years v 64.6 years; p0.001); more of them were underweight, obese, and diabetic; and they had lower hemoglobin values and worse renal function than did men. However, fewer women than men experienced chronic obstructive pulmonary disease, aortic regurgitation, left ventricular dysfunction, and endocarditis. Early mortality did not differ significantly between men and women (p = 0.238). Overall survival was worse in women (p0.001). After correction for potential risk factors, female sex was not associated with worse survival. During the study period, the mean age of patients undergoing aortic valve replacement increased. In addition, the mean age at the time of death increased, following the trend of national statistics.Although women undergoing aortic valve replacement have relatively more risk factors than do men, early mortality in women is not significantly higher than in men. Overall survival is worse in women than in men; however, after adjustment for preoperative risk factors, there is no difference in overall survival between women and men.

Purpose of review The current review covers recent research examining the utility of preoperative frailty assessments to predict worse postoperative outcomes after radical cystectomy. It also discusses how to implement frailty assessments into routine clinical practice. Recent findings Frailty is associated with worse postoperative outcomes after radical cystectomy, including increased complications and nonhome discharge. Although the majority of these studies have been retrospective using a frailty index, prospective studies using a preoperative frailty assessment have also shown frailty to be associated with worse outcomes. Preoperative frailty assessments based on patients' physiologic fitness, such as the Fried Frailty Criteria or psoas muscle volume, have been the best predictors of worse outcomes on prospective cohorts. However, no study to date has directly compared a prospective frailty assessment and frailty index to determine the most effective tool for routine clinical care. National guidelines are lacking on how to assess frailty preoperatively before radical cystectomy. Summary Frailty has been consistently shown to correlate with worse postoperative outcomes after radical cystectomy. Although the most effective and efficient method for preoperative assessment has yet to be determined, assessments based on physiologic fitness are likely to be most useful. Improved guidelines will likely increase implementation of frailty assessments into routine management.

Increasing evidence supports immediate colectomy in acute fulminant ulcerative colitis in comparison with ongoing medical management. Prior studies have been limited to inpatient-only administrative data sets or single-institution experiences.The purpose of this study was to compare outcomes of early versus delayed emergency colectomy in patients admitted with ulcerative colitis flares while controlling for known preoperative risks and acuity.This is a cohort study of patients undergoing emergent total abdominal colectomies for ulcerative colitis compared by the timing of surgery.Adult patients undergoing an emergent total abdominal colectomy for ulcerative colitis, 2005 to 2015, were identified in the American College of Surgeons National Surgical Quality Improvement Program database.Patients undergoing total abdominal colectomy with an operative indication of ulcerative colitis admitted on a nonelective basis were selected.The primary outcomes measured were 30-day National Surgical Quality Improvement Program-reported mortality and postoperative complications, and early operation within 2 days of admission.We identified 573 total abdominal colectomies after propensity score matching. Median time to surgery was 1 hospital day in the early group versus 6 hospital days in the delayed group (p0.001). Early operation was associated with a lower mortality rate (4.9% versus 20.3% in matched groups, p0.001) and lower complication rate (64.5% versus 72.0%, p = 0.052). Multivariable logistic regression with propensity weighting of mortality on preoperative risk factors demonstrated that early surgery is associated with an 82% decrease in the odds of death compared with delayed surgery (p0.001). Regression of morbidity on preoperative risk factors demonstrated that early surgery is associated with a 35% decrease in the odds of a complication with delayed surgery (p = 0.034).Quality improvement data were used for clinical research questions.Patients undergoing immediate surgical intervention for acute ulcerative colitis have decreased postoperative complications and mortality rates. Rapid and early transitioning from medical to surgical management may benefit those expected to require surgery on the same admission. See Video Abstract at http://links.lww.com/DCR/A800.

Despite a significant number of patients being discharged to inpatient care facilities after anterior lumbar interbody fusion (ALIF), the current literature remains limited regarding the predictors associated with a nonhome discharge and the impact of continued inpatient care in a facility on postdischarge outcomes.The 2013-2016 American College of Surgeons National Surgical Quality Improvement Program was queried using Current Procedural Terminology (CPT) codes for ALIF (CPT-22558) and additional level fusions (CPT-22585). Discharge to inpatient care facilities included discharge to skilled care facilities and/or inpatient rehabilitation units.Independent predictors of an inpatient care facility discharge were age older than 45 years (P0.001), female sex (P0.001), more than 10% body weight loss in the last 6 months prior to surgery (P=0.012), American Society of Anesthesiologists grade greater than II (P=0.005), undergoing a 2-level (P0.001) or more than 2-level fusion (P=0.017), a length of stay greater than 3 days (P0.001), and the occurrence of any predischarge complication (P0.001). After adjustment for differences in clinical and baseline characteristics between the 2 groups, discharge to an inpatient care facility after ALIF was independently associated with higher odds of any postdischarge complication (P=0.010), postdischarge wound complication (P=0.005), and postdischarge septic complications (P=0.011). No significant impact was seen on 30-day readmissions (P=0.943), 30-day reoperations (P=0.228), and 30-day mortality (P=0.913).With an increasing focus toward minimizing costs associated with postacute care, providers should understand the need of appropriate preoperative risk stratification and construction of care pathways aimed at a home discharge to reduce the occurrence and/or risk of experiencing postdischarge complications.

Previous reports of early extubation after cardiac surgical procedures vary in the definition of "early" and may limit findings to patients with less preoperative risk. This study sought to determine whether an eight-tier multidisciplinary early extubation protocol with the goal of extubating within 6 hours postoperatively would be successful without increasing adverse events in patients with increased preoperative risk.Postoperative adult cardiac surgical patients in a tertiary care intensive care unit (n = 459) were analyzed 6 months before and 6 months after implementation of the protocol. The Society of Thoracic Surgeons (STS) risk scores were used as surrogate markers of risk. Patients with STS scores (n = 333) were stratified into four equal groups from lowest to highest score. A composite of acute renal failure, reintubation, stroke, and mortality was the primary outcome. Secondary outcomes included intensive care unit and hospital lengths of stay, reoperation, and sternal wound infection.In all patients, ventilation times were significantly decreased from a median of 7.4 hours to 5.7 hours after protocol implementation. When stratified by STS scores, higher-risk patients (groups 3 and 4) had the largest reduction in ventilation times from a median of 9.2 hours to 5.7 hours (p0.0001) without a significant increase in adverse events. The highest-risk patients (STS score40%; n = 14) all had extubation times shorter than 6 hours after the protocol with no significant increase found in adverse events (p = 0.138).A prudent and diligent multifaceted early extubation protocol may be successful in high-risk cardiac surgical patients without an increase in adverse outcomes. A larger study is needed in the future to confirm the finding.

Retrospective review.Develop a simplified frailty index for cervical deformity (CD) patients.To improve preoperative risk stratification for surgical CD patients, a CD frailty index (CD-FI) incorporating 40 health deficits was developed. While novel, the CD-FI is clinically impractical due to the large number of factors needed for its calculation. To increase clinical utility, a simpler, modified CD-FI (mCD-FI) is necessary.CD patients (C2-C7 Cobb10°, CL10°, cSVA4 cm, or CBVA25°)18 year with preoperative CD-FI component factors. Pearson bivariate correlation assessed relationships between component deficits of the CD-FI and overall CD-FI score. Top deficits contributing to CD-FI score were included in multiple stepwise regression models. Deficits from model with largest R were dichotomized, and the mean score of all deficits calculated, resulting in mCD-FI score from 0 to 1. Patients were stratified by mCD-FI: Not Frail (NF,0.3), Frail (0.3-0.5), Severely Frail (SF,0.5). Means comparison tests established correlations between frailty category and clinical outcomes.Included: 121 CD patients (61 ± 11 yr, 60%F). Multiple stepwise regression models identified 15 deficits as responsible for 86% of the variation in CD-FI; these factors were used to construct the mCD-FI. Overall, mean mCD-FI was 0.31 ± 0.14. Breakdown of patients by mCD-FI category: NF: 47.9%, Frail: 46.3%, SF: 5.8%. Compared with NF and Frail, SF patients had the longest inpatient hospital stays (P = 0.042), as well as greater baseline neck pain (P = 0.033), inferior Neck Disability Index scores (P0.001) and inferior EQ-5D scores (P 0.001). Frail patients had higher odds of superficial infection (OR:1.1[1.0-1.2]), and SF patients had increased odds of mortality (OR:8.3[1.3-53.9]).Increased frailty, assessed by mCD-FI, correlated with increased length of stay, neck pain, and decreased health-related quality of life. Frail patients were at greater risk for infection, and severely frail patients had greater odds of mortality. This relationship between frailty and clinical outcomes suggests that mCD-FI offers clinical utility as a preoperative risk stratification tool.3.

BACKGROUND We assessed the differences in postoperative feeding outcomes when comparing early and traditional diet advancement in patients who had an ostomy creation. METHODS At a U.S. tertiary care hospital, data from patients who underwent an ileostomy or colostomy creation from June 1, 2013, to April 30, 2017 were extracted from an institutional database. Patients who received early diet advancement (postoperative days 0 and 1) were compared with traditional diet advancement (postoperative day 2 and later) for demographics, preoperative risk factors, and operative features. The postoperative feeding outcomes included time to first flatus and ostomy output. Mann-Whitney U tests determined bivariate differences in postoperative feeding outcomes between groups. Poisson regression was used to adjust for unequal baseline characteristics. RESULTS Data from 255 patients were included; 204 (80.0%) received early diet advancement, and 51 (20.0%) had traditional diet advancement. Time to first flatus and time to first ostomy output were significantly shorter in the early compared with traditional diet advancement group (median difference of 1 day for both flatus and ostomy output, P < 0.001). Adjusting for baseline group differences (American Society for Anesthesiology Physical Status Classification System, surgical approach, resection and ostomy type) maintained the significant findings for both time to first flatus (β = 1.32, P = 0.01) and time to first ostomy output (β = 1.41, P < 0.001). CONCLUSIONS Early diet advancement is associated with earlier return of flatus and first ostomy output compared with traditional diet advancement after the creation of an ileostomy or colostomy.

Preoperative fitness training has been listed as a top ten research priority in anesthesia. We aimed to capture the current practice patterns and perspectives of anesthetists and colorectal surgeons in Australia and New Zealand regarding preoperative risk stratification and prehabilitation to provide a basis for implementation research.During 2016, we separately surveyed fellows of the Australian and New Zealand College of Anaesthetists (ANZCA) and members of the Colorectal Society of Surgeons in Australia and New Zealand (CSSANZ). Our outcome measures investigated the responders' demographics, practice patterns, and perspectives. Practice patterns examined preoperative assessment and prehabilitation utilizing exercise, hematinic, and nutrition optimization.We received 155 responses from anesthetists and 71 responses from colorectal surgeons. We found that both specialty groups recognized that functional capacity was linked to postoperative outcome; however, fewer agreed that robust evidence exists for prehabilitation. Prehabilitation in routine practice remains low, with significant potential for expansion. The majority of anesthetists do not believe their patients are adequately risk stratified before surgery, and most of their colorectal colleagues are amenable to delaying surgery for at least an additional two weeks. Two-thirds of anesthetists did not use cardiopulmonary exercise testing as they lacked access. Hematinic and nutritional assessment and optimization is less frequently performed by anesthetists compared with their colorectal colleagues.An unrecognized potential window for prehabilitation exists in the two to four weeks following cancer diagnosis. Early referral, larger multi-centre studies focusing on long-term outcomes, and further implementation research are required.RéSUMé: OBJECTIF: Le conditionnement physique préopératoire a été cité dans les dix priorités de recherche les plus importantes en anesthésie. Notre objectif était de déterminer quels étaient les habitudes actuelles de pratique ainsi que les perspectives des anesthésistes et des chirurgiens colorectaux en Australie et en Nouvelle-Zélande concernant la stratification préopératoire du risque et la préhabilitation afin de proposer un point de départ pour la recherche sur sa mise en œuvre. MéTHODE: Au cours de l’année 2016, nous avons soumis un questionnaire séparé aux membres du Collège australien et néozélandais des anesthésistes (ANZCA - Australian and New Zealand College of Anaesthetists) et aux membres de la Société colorectale des chirurgiens australiens et néozélandais (CSSANZ - Colorectal Society of Surgeons in Australia and New Zealand). Nos critères d’évaluation portaient sur les données démographiques, les habitudes de pratique et les perspectives des répondants. Les questions sur les habitudes de pratique touchaient à l’évaluation préopératoire et la préhabilitation fondée sur l’exercice physique et l’optimisation antianémique et nutritionnelle. RéSULTATS: Nous avons reçu 155 réponses d’anesthésistes et 71 réponses de chirurgiens colorectaux. Notre questionnaire a révélé que les deux spécialités reconnaissaient que la capacité fonctionnelle est liée au pronostic postopératoire; toutefois, moins de répondants étaient d’avis qu’il existe des données probantes fiables concernant la préhabilitation. Dans la pratique de routine, la préhabilitation demeure peu courante mais a le potentiel de prendre plus d’ampleur. La plupart des anesthésistes estiment que leurs patients ne sont pas stratifiés adéquatement en fonction de leur risque avant leur chirurgie, et la plupart de leurs collègues colorectaux sont ouverts à l’idée de retarder la chirurgie d’au moins deux semaines supplémentaires. Deux tiers des anesthésiologistes n’ont pas eu recours à un test d’effort cardiopulmonaire par manque d’accès à ce type d’examen. L’évaluation et l’optimisation antianémique et nutritionnelle sont moins fréquemment réalisées par les anesthésistes comparativement à leurs collègues colorectaux. CONCLUSION: Il existe une fenêtre potentielle mais non reconnue pour la mise en œuvre d’une préhabilitation au cours des deux à quatre semaines suivant l’annonce d’un diagnostic de cancer. Une prise en charge précoce par des spécialistes, des études multicentriques plus importantes s’intéressant aux pronostics à long terme et des travaux de recherche supplémentaires sur la mise en œuvre sont nécessaires.

Background: There is high prevalence of diabetes mellitus in patients of end stage liver disease and it has been implicated for complications in post-transplant patients. Glycated hemoglobin is now targeted as a modifiable preoperative risk factors for postoperative complications. Data describing the course and severity of postoperative liver transplant complication and their relation with pre-operative glycated hemoglobin level is sparse. In this study, we looked for co-relation between the preoperative HbA1c level and post-operative mortality and morbidity in patients scheduled for liver transplant. Materials and Methods: Retrospective data in 400 adult patients operated for liver transplant were retrieved. After exclusion, data were analyzed for 224 patients. Patients were divided into two groups on the basis of glycated hemoglobin levels (Group 1 (HbA1C ≥6.5) and Group 2 (HbA1C

Background Several risk models target the issue of posttransplant survival, but none of them have been validated in a large European cohort. This aspect is important, in a time of the planned change of the Eurotransplant allocation system to a scoring system. Material and Methods Data of 761 heart transplant recipients from the Eurotransplant region with a total follow up of 5027 patient-years were analyzed. We assessed 30-day to 10-year freedom from graft failure. Existing post-transplant mortality risk models, IMPACT, Meld-XI and Columbia Risk Stratification Score were (RSS) were evaluated. A new risk model was created and the predictive accuracy was compared with the existing risk scores, with a focus on LVAD patients. Results Thirty-day, 1-year, 5-year and 10-year rates of freedom from graft failure were 78.3±1.5%, 68.8±1.71%, 59.1±1.8% and 44.1±1.9. The 1-year incidence of graft failure varied from 14.1% to 50% (RSS), from 22.9% to 57.1 (IMPACT) and from 24.9% to 42.6% using MELD-XI. Our newly adjusted risk score showed an improved area under the curve (AUC) of 0.69 (95% CI 0.64-0.72) with better discrimination in the intermediate to moderate risk cohort (CABDES Score). Conclusion IMPACT, Meld-XI and RSS were suitable to predict posttransplant graft failure only in a high and low risk cohort. CABDES Score, might be an alternative scoring system, with donor age and eGFR beeing the strongest predictors. Implementation of the IMPACT score within the new Eurotransplant Cardiac Allocation Score for patient prioritization for heart transplantation, should be reevaluated.

The purpose of this study was to analyze the components of inpatient costs for coronary artery bypass graft (CABG) according to preoperative risk stratification and to provide evidence for improvement of diagnosis-related groups (DRGs) payment. All patients (n=458) receiving an isolated CABG between January 2014 and December 2016 in a tertiary referral center, in southwest China, were analyzed. Hospital mortality was predicted by the EuroSCORE II for each patient. The patients were subdivided into two groups according to the observed mortality (1.97%, 9/458): a high-risk group (group H, predicted mortality ≥1.97%) and a low-risk group (group L, predicted mortality

Mohammed Hakim,1 Shabana Zainab Shafy,1 Rebecca Miller,1 Kris R Jatana,2 Mark Splaingard,3 Dmitry Tumin,1 Joseph D Tobias,1,4 Vidya T Raman1,4 1Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA; 2Department of Pediatric Otorhinolaryngology, Nationwide Children’s Hospital, Columbus, OH, USA; 3Department of Sleep Disorders Centre, Nationwide Children’s Hospital, Columbus, OH, USA; 4Department of Anesthesiology & Pain Medicine, Ohio State University, Columbus, OH, USA Background: The incidence of obstructive sleep apnea (OSA) and sleep-disordered breathing (SDB) in children exceeds the availability of polysomnography (PSG) to definitively diagnose OSA and identify children at higher risk of perioperative complications. As sleep deficits are associated with slower reaction times (RTs), measuring RT may be a cost-effective approach to objectively identify SDB symptoms. Aim: The aim of this study is to compare RT on a standard 10-minute psychomotor vigilance test (PVT) based on children’s history of OSA/SDB. Methods : Children, 6–11 years of age, were enrolled from two different clinical groups. The SDB group included children undergoing adenotonsillectomy with a clinical history of SDB, OSA, or snoring. The control group included children with no history of SDB, OSA, or snoring who were scheduled for surgery other than adenotonsillectomy. RT was measured via 10-minute PVT (Ambulatory Monitoring Inc., Ardsley, NY, USA). Median RT was calculated for each patient based on all responses to stimuli during the PVT assessment and was compared to published age-sex-specific norms. The proportion of children exceeding RT norms was compared between study groups. Results: The study included 72 patients (36/36 male/female, median age 7 years), 46 with SDB and 26 without SDB. There was no difference in the RT between the two groups. Fifty-four percent of patients with SDB exceeded norms for median RT vs 42% of control patients (95% CI of difference: – 12, 36; P=0.326). Conclusion: Approximately half of the patients in both groups exceeded published norms for median RT on PVT. Despite its convenience, measurement of RT did not distinguish between patients with probable SDB/OSA for preoperative risk stratification. Keywords: psychomotor vigilance test, obstructive sleep apnea, anesthesia, polysomnography, sleep-disordered breathing

The Risk Analysis Index (RAI) for frailty is a rapid survey for comorbidities and performance status, which predicts mortality after general surgery. We aimed to validate the RAI in predicting outcomes after hepatopancreatobiliary surgery.Associations of RAI, determined in 162 patients prior to undergoing hepatopancreatobiliary surgery, with prospectively collected 30-day post-operative outcomes were analyzed with multivariate logistic and linear regression.Patients (age 62 ± 14, 51% female) had a median RAI of 7, range 0-25. With every unit increase in RAI, length of stay increased by 5% (95% CI: 2-7%), odds of ICU admission increased by 10% (0-20%), ICU length of stay increased by 21% (9-34%), and odds of discharge to a nursing facility increased by 8% (0-17%) (all P 0.05). Particularly in patients who suffered a first post-operative complication, RAI was associated with additional complications (1.6 unit increase in Comprehensive Complication Index per unit increase in RAI, P = 0.002). In a direct comparison in a subset of 74 patients, RAI and the ACS-NSQIP Risk Calculator performed comparably in predicting outcomes.While RAI and ACS-NSQIP Risk Calculator comparatively predicted short-term outcomes after HPB surgery, RAI has been specifically designed to identify frail patients who can potentially benefit from preoperative prehabilitation interventions.

Increasingly the relationship between the hip and spine has become recognized as a risk factor for postoperative instability following total hip arthroplasty. Thorough understanding of the relationship between the spine and pelvis, spinopelvic parameters, and normal and pathologic spinopelvic motion is critical to surgical planning and prevention of instability after total hip arthroplasty. This review details spinopelvic motion and postural changes that predispose patients to instability, guides readers through a preoperative risk assessment tool and our stepwise protocol to classify spinopelvic motion and prevent instability.

Aims It has been shown that the preoperative modification of risk factors associated with obesity may reduce complications after total knee arthroplasty (TKA). However, the optimal method of doing so remains unclear. The aim of this study was to investigate whether a preoperative Risk Stratification Tool (RST) devised in our institution could reduce unexpected intensive care unit (ICU) transfers and 90-day emergency department (ED) visits, readmissions, and reoperations after TKA in obese patients. Methods We retrospectively reviewed 1,614 consecutive patients undergoing primary unilateral TKA. Their mean age was 65.1 years (17.9 to 87.7) and the mean BMI was 34.2 kg/m2 (SD 7.7). All patients underwent perioperative optimization and monitoring using the RST, which is a validated calculation tool that provides a recommendation for postoperative ICU care or increased nursing support. Patients were divided into three groups: non-obese (BMI < 30 kg/m2, n = 512); obese (BMI 30 kg/m2 to 39.9 kg/m2, n = 748); and morbidly obese (BMI > 40 kg/m2, n = 354). Logistic regression analysis was used to evaluate the outcomes among the groups adjusted for age, sex, smoking, and diabetes. Results Obese patients had a significantly increased rate of discharge to a rehabilitation facility compared with non-obese patients (38.7% (426/1,102) vs 26.0% (133/512), respectively; p < 0.001). When stratified by BMI, discharge to a rehabilitation facility remained significantly higher compared with non-obese (26.0% (133)) in both obese (34.2% (256), odds ratio (OR) 1.6) and morbidly obese (48.0% (170), OR 3.1) patients (p < 0.001). However, there was no significant difference in unexpected ICU transfer (0.4% (two) non-obese vs 0.9% (seven) obese (OR 2.5) vs 1.7% (six) morbidly obese (OR 5.4); p = 0.054), visits to the ED (8.6% (44) vs 10.3% (77) (OR 1.3) vs 10.5% (37) (OR 1.2); p = 0.379), readmissions (4.5% (23) vs 4.0% (30) (OR 1.0) vs 5.1% (18) (OR 1.4); p = 0.322), or reoperations (2.5% (13) vs 3.3% (25) (OR 1.2) vs 3.1% (11) (OR 0.9); p = 0.939). Conclusion With the use of a preoperative RST, morbidly obese patients had similar rates of short-term postoperative adverse outcomes after primary TKA as non-obese patients. This supports the assertion that morbidly obese patients can safely undergo TKA with appropriate perioperative optimization and monitoring. Cite this article: Bone Joint J 2021;103-B(6 Supple A):45–50.

Objetivo Identificar factores de riesgo asociados a complicaciones mayores en pacientes con pielonefritis xantogranulomatosa sometidos a nefrectomia. Metodo Analisis retrospectivo de expedientes clinicos de pacientes con pielonefritis xantogranulomatosa sometidos a nefrectomia. Se analizaron el sexo, el indice de masa corporal, el indice de comorbilidad de Charlson, la clasificacion del estado fisico de la American Society of Anesthesiologists, la etapa de Malek, el conteo leucocitario y los valores de creatinina. Las complicaciones se estratificaron en menores y mayores segun la clasificacion de Clavien-Dindo. Se realizo analisis univariado y bivariado usando las pruebas exacta de Fisher y ji al cuadrado de Pearson, y se establecieron medidas de riesgo utilizando la odds ratio (OR). Resultados Se analizaron 72 pacientes con una edad media de 50 anos, el 83% mujeres, el 58.3% con urocultivo positivo y el 66% con litiasis renal. El 32% tuvieron alguna complicacion mayor y el 15% requirieron admision a la unidad de cuidados intensivos. Los valores elevados de creatinina (OR: 3.8; intervalo de confianza del 95% [IC95%]: 1.1-13; p = 0.02) y la etapa Malek II-III (OR: 4.5; IC95%: 1.2-17.5; p = 0.02) se asociaron con complicaciones mayores. Conclusion El estadio de Malek y los valores elevados de creatinina incrementan el riesgo de desarrollar complicaciones mayores en los pacientes con pielonefritis xantogranulomatosa sometidos a nefrectomia. Objective To identify preoperative risk factors associated with major complications in patients with xanthogranulomatous pyelonephritis undergoing total nephrectomy. Method Retrospective analysis of patient’s charts with xanthogranulomatous pyelonephritis who underwent nephrectomy. Risk factors included for analysis were gender, body mass index, Charlson comorbidity index, American Society of Anesthesiologists physical status classification, Malek’s stage, leukocyte count and creatinine levels. Postoperative complications were stratified in minor and major according to Clavien-Dindo’s classification. Univariate and bivariate analysis using Fisher’s exact test, Pearson’s chi-squared and odds ratio (OR) was performed. Results 72 patients were analyzed, 83% women, mean age of 50 years, 58.3% positive urine cultures and 66% kidney stones. Major complications were present in 32% of cases, and 15% were admitted to the intensive care unit. Elevated creatinine (OR: 3.8; 95% confidence interval [95%CI]: 1.1-13; p = 0.02) and Malek’s stage II to III (OR: 4.5; 95%CI: 1.2-17.5; p = 0.02) were associated with major complications. Conclusion The Malek Stage and elevated creatinine increases the risk of major complications in patients undergoing nephrectomy due to xanthogranulomatous pyelonephritis.

Purpose: Pediatric patients diagnosed with brainstem malignant gliomas (BSMGs) have a poor prognosis. Our study aimed to construct and validate a prognostic nomogram to predict the cancer‐specific survival preoperatively (CSS) rates and then a risk-stratification given to these patients.Methods: From 1998 to 2016, we extracted patients' data from Surveillance Epidemiology and End Results (SEER) database. A total of 1160 patients were enrolled and randomly divided into training and validating groups. Subsequently, the Cox regression analysis was used to screen variables. Then, the nomogram was constructed. Lastly, we calculated C-indexes and plotted calibration curves and the utility of decision curve analyses (DCAs) to assess our survival model's benefits.Result: Here, after multivariate cox regression analysis, we established four variables for constructing nomogram for CSS rates. Subsequently, the C-index, the area under the receiver operating characteristic curve, and calibration curves were used to confirm the nomogram's good performance. DCAs of the nomogram indicated that both groups obtained good 1-, 3-, and 5-year net benefits. Conclusion: The nomogram model for preoperatively predicting CSS provided a convenient and practical tool to assess pediatric patients' prognosis with BSMG.

Background Holmium laser enucleation of the prostate (HoLEP) is considered a challenging procedure with a non-negligible risk of complications limiting its widespread adoption. We investigated rates and pre-operative predictors of complications in a high volume center with long-time experience. Methods Data from 284 patients treated with HoLEP between 2015 and 2017 were analysed. Postoperative complications occurring up to 12 months after surgery were collected following the EAU guidelines recommendations. Procedure-specific complications were defined and graded by using the Clavien-Dindo (CD) system. Logistic regression analysis tested preoperative risk factors for postoperative complications. Results Baseline prostate volume was (median, IQR) 87 (60, 120) ml. As a whole, in-hospital and after discharge complications were 19% and 11.6%, respectively, with a 28.6% overall rate at 12 months from surgery. Complications were graded as CD 1 [8% (22)], 2 [18.2% (52)] and 3 [1.8% (5)], respectively. Fever was the most frequently reported (11% of cases), followed by acute urinary retention (8%). At logistic regression analysis, older age (OR: 1.07; 95%CI: 1.01-1.12; p=0.01) and having an indwelling catheter before surgery (OR: 4.03; 95%CI 1.64-9.9; p=0.002) emerged as significant risk factors for post-HoLEP complications, after accounting for surgeon experience and baseline parameters. Conclusions HoLEP is a safe procedure in a high volume center with less than 2% high-grade complications. Older patients with indwelling catheter deserve to be carefully managed due to a higher risk of postoperative complications.

Preoperative risk stratification in cancer surgery is important to improve treatment and outcome. Sarcopenia is defined by progressive and generalized loss of skeletal muscle mass and strength and is now getting attention as a poor prognostic factor. The purpose of this review was to explore the impact of sarcopenia on short and long-term outcomes in patients undergoing surgical resection of gastrointestinal tumors. Recent studies suggest that sarcopenia contributes to postoperative complications and overall survival. The relatively simple evaluability, as well as its modifiable nature, provides an intriguing potential for sarcopenia to be included in standard preoperative clinical evaluation. Such evaluations can provide physicians with important information to target high-risk individuals with prophylactic measures and eventually improve surgical outcomes.

Background Our aim is to determine the relationships among patient demographics, patient history, surgical experience, and conversion rate (CR) during elective laparoscopic cholecystectomies (LCs). Methods We analyzed data from patients who underwent LC surgery between 2005 and 2014 based on patient charts and electronic documentation. CR (%) was evaluated in 4013 patients who underwent elective LC surgery. The relationships between certain predictive factors (patient demographics, endoscopic retrograde cholangiopancreatography (ERCP), acute cholecystitis (AC), abdominal surgery in the patient history, as well as surgical experience) and CR were examined by univariate analysis and logistic regression. Results In our sample (N = 4013), the CR was 4.2%. The CR was twice as frequent among males than among females (6.8 vs. 3.2%, p p p p Conclusions Patient demographics (male gender and age > 65 years), previous ERCP, and upper abdominal surgery or history of AC affected the likelihood of conversion. More surgical experience and high surgery volume were not associated with a lower CR prevalence.

Background Stent implantation for vascular stenosis associated with congenital heart diseases is commonly performed as an off-label procedure in Japan because there is no officially approved stent for any congenital heart disease.Methods and Results:We analyzed data from the Japanese Society of Congenital Interventional Cardiology Registry collected from January 2016 to December 2018. Patients who underwent stent implantation were enrolled in the present analysis. During the study period, there were 470 procedures, 443 sessions, and 391 cases. Of 443 sessions, 427 (96.4%) succeeded procedurally. There were no differences in the procedural success rates among age groups. In all, 416 sessions (367 patients; 94%) resulted in survival to 30 days after catheter intervention. Of 392 admissions, 357 patients (91%) survived to discharge. Only 4 deaths were directly related to stent implantation. Some in-hospital complications were observed during 55 of 443 sessions. Both hospital deaths and serious complications were significantly more frequent in the group with various preoperative risk factors. Conclusions Although not officially approved for congenital heart diseases in Japan, stent implantation in congenital heart diseases has been widely and routinely performed for many years with safety and efficacy. The aim of stenting was variable and broad because of many different applications and morphological variations. These data may facilitate approval of such an important device in Japan.