Outcomes of basal ganglia and thalamic cavernous malformation surgery: A meta-analysis

Surgical resection of basal ganglia (BG) and thalamic cavernous malformations (CMs) has not yet become standardized in the field of neurosurgery due to the eloquent location of these lesions and the relative paucity of literature on the subject. This review presents a consolidation of the available literature on outcomes and complication rates after surgical resection of these lesions. A systematic literature review was performed via PubMed database for articles published between 1985 and 2019. Studies comprising ≥2 patients receiving surgery for BG or thalamic CMs with available follow-up data were included. Pooled data included patient demographics, CM preoperative characteristics, and surgical outcomes Twenty studies comprising 227 patients were included for analysis. Complete resection was achieved in 94.7% (fixed-effects pooled estimate [FE]: 94.9%[91.0%–97.8%]; random-effects pooled estimate [RE]: 90.0%[79.8%–96.9%]), and hemorrhage of incompletely resected CMs occurred in 50% (FE: 55.9%[25.9%–83.6%]; RE: 55.9%[25.9%–83.6%]) of patients. Early morbidity was observed in 24.0% (FE: 24.9%[17.8%–32.6%]; RE: 24.9%[17.8%–32.6%]). At final follow-up, 67.3% (FE: 67.7%[58.8%–76.0%]; RE: 67.8%[52.2%–81.6%]) and 20.6% (FE: 20.6%[13.6%–28.6%]; RE: 20.9%[9.8%–34.9%]) had improvement and stability of preoperative symptoms, respectively. Mortality rate was 1.3% (FE: 2.3%[0.6%–5.1%]; RE: 2.3%[0.6%–5.1%]). Therefore, high cure rates with low rates of postoperative morbidity can be achieved in BG or thalamic CM surgery. Most patients had improved neurological function at final follow-up. Complete resection should be attempted to reduce rates of repeat hemorrhage.     

Failure to rescue as a source of variation in hospital mortality after rectal surgery: The Italian experience

IntroductionFailure to rescue (FTR) patients from postoperative complications could contribute to the variability in surgical mortality seen among hospitals with different volumes. We sought to examine the impact of complications and FTR on mortality following rectal surgery.MethodsThe National Italian Hospital Discharge Dataset allowed to identify 75,280 patients who underwent rectal surgery between 2002 and 2014. Hospital volume was stratified into tertiles. Rates of major complications, FTR from complications and mortality following rectal surgery were compared.ResultsDuring the study period, both the incidence of complications (2002, 23.7% versus 2014, 21.2%), and FTR decreased overtime (2002, 6.9% versus 2014, 3.8%) (both P < 0.001). The complication rate was 24.4% in low-, 21.6% in intermediate- and 20.4% in high-volume hospitals (P < 0.001). Complications were less common in minimally invasive surgery (MIS) versus open cases (18.2% versus 23.2%; P < 0.001). The most frequent complications included prolonged ileus or small bowel obstruction (5.3%), and anemia requiring blood transfusions (5.3%). The rate of FTR was 5.5%, 5.6% and 3.7% for low-, intermediate- and high-volume hospitals, respectively (P < 0.001). FTR after MIS was 2.6% vs. 5.5% after open surgery (P < 0.001). After accounting for patient and hospital characteristics, patients treated at low-volume hospitals were 23% more likely to die after a complication, compared to patients at high-volume hospitals (OR 1.23, 95%CI 1.13–1.33).ConclusionsHospital volume is the strongest predictor of complication and FTR. The reduction in mortality in high-volume hospitals could be determined by the better ability to rescue patients. These findings support the centralization policy of rectal cancer treatment.     

Predictors of 30-day postoperative systemic complications in geriatric patients undergoing elective brain tumor surgery

Little evidence exists to guide the preoperative selection of elderly brain tumor patients who are fit for surgery. We aimed to evaluate the safety of brain tumor resection in geriatric patients and identify predictors of postoperative 30-day systemic complications. We conducted a retrospective cohort study of 212 consecutive patients at or above the age of 60 years who underwent elective brain tumor resection between 2007 and 2017. The primary outcome measures analyzed were perioperative systemic complications within 30 days after the operation. A total of 212 geriatric brain tumor patients were included. Fifty-two (24.5%) had a 30-day systemic complication. Among them, 29 (13.7%) had systemic infections, 13 (6.1%) had perioperative seizures, 10 (4.7%) had syndrome of inappropriate antidiuretic hormone secretion (SIADH), five (2.4%) had deep venous thrombosis (DVT), four (1.9%) had perioperative stroke, three (1.4%) had acute myocardial infarction (AMI) and three (1.4%) had central nervous system (CNS) infections. One patient (0.5%) died. Perioperative stroke was predicted by previous stroke (p = 0.040), chronic liver disease (p < 0.001) and vestibular schwannoma (p = 0.002 with reference to meningiomas). Perioperative AMI was predicted by co-existing ischemic heart disease (p = 0.031). Systemic infection was predicted by female gender (p = 0.007) and preoperative Karnofsky Performance Scale (KPS) score < 70 (p = 0.019). DVT was predicted by GBM (p = 0.014). In conclusion, brain tumor surgery can be safe in carefully-selected geriatric patients. The risk factors identified in this study would be helpful to select suitable candidates for surgery.     

Sepsis after elective neurosurgery: Incidence,outcomes, and predictive factors

Sepsis is a life-threatening condition resulting from systemic infection, with mortality rates approaching 30%. Most neurological surgeries are now performed electively, which permits medical optimization preoperatively. We performed a retrospective cohort analysis of 122,466 adult elective neurosurgical patients from 2012 to 2018 in the National Surgical Quality Improvement Program database. To select for a medically optimized population, patients were included if they arrived from home on the day of surgery, were not pregnant or puerperium, and had no documented evidence of preexisting infection. We analyzed demographic, comorbidity, and operative information; performed multivariate logistic regression to explore factors predictive of postoperative sepsis; and evaluated outcomes for patients who developed sepsis. Overall, 0.87% of patients developed postoperative sepsis (n = 1,067). The rate of sepsis was higher in the cranial subpopulation (1.21%; n = 330) and lower in the spinal subpopulation (0.77%; n = 733). The overall sepsis cohort was older, had more males, was more functionally dependent, had longer operation durations, and had higher rates of medical comorbidities. Minority race and smoking were not associated with sepsis. The sepsis cohort fared worse than the control cohort across all outcome measures, including prolonged length-of-stay (≥90^th percentile), discharge anywhere but home, 30-day readmission, 30-day reoperation, and 30-day mortality. Results for the cranial and spine subpopulations follow similar trends. In summary, sepsis in the elective neurosurgical population is an uncommon but devastating cause of excess morbidity and mortality.     

A diabetes risk index for small areas in England

UK and international studies point to significant area variation in diabetes risk, and summary indices of diabetic risk are potentially of value in effective targeting of health interventions and healthcare resources. This paper aims to develop a summary measure of the diabetic risk environment which can act as an index for targeting health care resources. The diabetes risk index is for 6791 English small areas (which provide entire coverage of England) and has advantages in incorporating evidence from both diabetes outcomes and area risk factors, and in including spatial correlation in its construction. The analysis underlying the risk index shows that area socio-economic status, social fragmentation and south Asian ethnic concentration are all positive risk factors for diabetes risk. However, urban-rural and regional differences in risk intersect with these socio-demographic influences.     

Factors Affecting Morbidity and Mortality in Patients Who Underwent Emergency Operation for Incarcerated Abdominal Wall Hernia

Patients with incarcerated abdominal wall hernias (AWHs) are often encountered in emergency care units. Despite advances in anesthesia, antisepsis, antibiotic therapy, and fluid therapy, the morbidity and mortality rates for these patients remain high. Between 2006 and 2011, we retrospectively analyzed the cases of 131 patients who underwent emergency surgery for incarcerated abdominal wall hernias. Of these, there were 70 women (53.4%) and 61 men (46.6%) with an average age of 63.3 ± 17.4 years (range, 17–91 years). Morbidity was observed in 28 patients (21.4%), and the mortality rate was 2.3%. Intestinal resection, presence of concomitant disease, and general anesthesia were the independent variants that affected morbidity of patients with incarcerated abdominal wall hernias.     

Morbidity of childhood onset narcolepsy: a controlled national study

Narcolepsy is associated with significant morbidities. We evaluated the morbidities and mortality in a national group of child and adolescent patients after a first diagnosis of narcolepsy.MethodsIdentified from the Danish National Patient Registry (NPR), 243 patients (128 boys) aged 0–19 years diagnosed with narcolepsy between 1998 and 2012 with follow-up until 2014 were compared with 970 controls who were randomly chosen from the Danish Civil Registration System Statistics and matched by age, gender and geography. Comorbidities were calculated three years before and after diagnoses.ResultsIn addition to the more frequent health contacts due to neurological diseases, patients showed elevated odds ratios before and after diagnosis of endocrine and metabolic conditions (4.4 (95% CI, 1.9–10.4); 3.8 (1.7–8.4)), nervous disorders (16.6 (8.0–34.4); 198 (49.0–804)), psychiatric illnesses (4.5 (2.3–9.1)/5.8 (2.8–12.1)), pulmonary diseases, and other diseases (3.1 (2.0–4.9); 3.1 (2.0–4.9)). Congenital abnormalities (2.5 (1.1–5.5)), respiratory (2.9 (1.5-5-5)) and eye (5.7 (2.2–15.0)) diseases were more common before diagnosis. Injuries were also more common after diagnosis (1.5 (1.0–2.1)). Narcoleptic children presented significantly more diagnoses of multiple comorbidities than controls before and after diagnosis.ConclusionBefore and after a diagnosis of narcolepsy in children, morbidity is more frequent in several domains, including metabolic, psychiatric, neurological and other diseases.     

Complications and operative spine fusion construct length in Parkinson’s disease: A nationwide population-based analysis

There remains a dearth of information regarding the surgical complications following multilevel spine surgery in Parkinson’s disease (PD) patients. This retrospective cohort study was performed to address this issue on a nationwide level using the Nationwide Inpatient Sample from 2001 to 2012. More than 25 postoperative variables were analyzed to assess the impact of fusion construct length on each variable. Subsequently, the same analysis was performed on admissions without PD. 4301 PD patients with spine fusion were identified, of whom 934 (21.7%) underwent fusion of at least three levels; the remaining 3367 underwent fusion of 1–2 levels. Patients with 3+ level fusions were more likely to suffer paraplegia (P = .001; OR = 3.0; 95%CI = 1.5–6.1), hematoma/seroma (P = .009; OR = 1.9; 95%CI = 1.2–3.2), IVC filter placement (P = .018; OR = 2.1; 95%CI = 1.1–3.9), RBC transfusion (P < .001; OR = 3.2; 95%CI = 2.7–3.8), PE (P = .027; OR = 4.5; 95%CI = 1.2–16.9), postoperative shock (P = .023; OR = 7.3; 95%CI = 1.3–39.6), ARDS (P < .001; OR = 4.1; 95%CI = 2.7–6.3), VTE (P = .006; OR = 2.6; 95%CI = 1.3–5.4), acute posthemorrhagic anemia (P < .001; OR = 2.0; 95%CI = 1.7–2.4), device-related complications (P < .001; OR = 3.1; 95%CI = 2.3–4.2), and in-hospital mortality (P = .005; OR = 3.4; 95%CI = 1.5–7.4). 3+ level fusions were also more likely to have LOS > 1 week (P < .001; OR = 2.1; 95%CI = 1.8–2.5), and a nonroutine discharge (P = .005; OR = 1.9; 95%CI = 1.4–2.4). 692,173 non-PD patients with spine fusion were identified; 123,964 (17.9%) underwent 3+ level fusion. Differences between 3+ versus 1–2 level fusions were similar to those in PD patient, but unlike PD patients, postoperative infection was significant while in-hospital mortality, PE and VTE were not. Fusion of at least three levels increased morbidity, mortality, and adverse discharge disposition compared with 1–2 level fusions. Nearly 80% of all spine fusions performed in the United States are fewer than three levels. These findings are worth considering during operative decision-making in both PD and non-PD patients.