Improvements in pelvic exenteration: Factors responsible for reducing morbidity and mortality

Background: Since pelvic exenteration for the treatment of recurrent gynecologic malignancy first was described, reported rates of morbidity and mortality have declined steadily. However, the factors responsible for this decline have never been clearly delineated. Methods: We reviewed the charts of 154 patients who underwent pelvic exenteration for gynecologic malignancy between 1954 and 1994. Charts were abstracted for details of the surgical procedure, pathologic findings, postoperative management, short- and long-term complications, time to recurrence, and overall survival. Results: Seventy-two patients (47%) experienced 95 identifiable postoperative complications, resulting in death in 22 patients (14%). The rate of infectious complications declined to a statistically significant degree between the first two decades and latter two decades of the study (odds ratio [OR] 0.28, 95% CI 0.11–0.69). The use of routine prophylactic antibiotics was associated with this decline in infectious complications (OR 0.25, 95% CI 0.07–0.83). The use of preoperative subcutaneous heparin was associated with a reduction in thrombotic complications from 5 of 100 patients to 0 of 54 patients (P=.11), as well as a significant reduction in overall risk of complications (OR 0.53, 95% CI 0.33–0.85) and risk of postoperative mortality (OR 0.19, 95% CI 0.05–0.80). There was a significant reduction in overall risk of postoperative complications with both intensive care unit monitoring postoperatively (OR 0.65, 95% CI 0.43–0.99) and routine postoperative monitoring with a pulmonary artery catheter (OR 0.61, 95% CI 0.38–0.98). Conclusions: Routine use of prophylactic antibiotics, prophylactic subcutaneous heparin, and intensive postoperative monitoring appear to have reduced morbidity from pelvic exenteration.     

Undetected injuries: a preventable cause of increased morbidity and mortality

A prospective audit of trauma patients managed at the discretion of six different general surgical units was performed over a 6-month period. Eighteen patients were identified in whom diagnostic delay or injuries undetected at operation contributed to increased morbidity and mortality. Failure to perform investigations as indicated by the nature of the trauma was the main reason for delay in diagnosis in seven patients. Incomplete exploration at laparotomy resulted in seven undetected injuries, while unexplored retroperitoneal hematomas accounted for the remaining four. Fourteen patients (78%) required management in the intensive care unit. Eight patients died (44%) as a result of ongoing sepsis and multiple organ failure. Seven of the deaths occurred in patients in whom surgical treatment was inadequate. Delays in diagnosis and undetected injuries, although uncommon, are a readily preventable cause of phase 3 trauma deaths. Strict adherence to standard surgical protocols as employed in dedicated trauma care centers does much to reduce unnecessary morbidity and mortality.     

Factors affecting morbidity and mortality in pancreatic injuries

Purpose

Difficulties in the detection of pancreatic damage result in morbidity and mortality in cases of pancreatic trauma. This study was performed to determine factors affecting morbidity and mortality in pancreatic trauma.

Methods

The records of 33 patients who underwent surgery for pancreatic trauma between January 2004 and December 2013 were analyzed retrospectively.

Results

The types of injury were penetrating injury and blunt abdominal trauma in 75.8 and 24.2 % of all cases, respectively. Injuries were classified as stage 1 in 6 cases (18.2 %), stage 2 in 18 cases (54.5 %), stage 3 in 5 cases (15.2 %), and stage 4 in 4 cases (12.1 %). The average injury severity scale (ISS) value was 25.70 ± 9:33. Six patients (18.2 %) had isolated pancreatic injury, 27 (81.2 %) had additional intraabdominal organ injuries and 10 patients (30.3 %) had extraabdominal organ injuries. The mean length of hospital stay was 13.24 ± 9 days. Various complications were observed in eight patients (24.2 %) and mortality occurred in three (9.1 %). Complications were more frequent in patients with high pancreatic damage scores (p = 0.024), additional organ injuries (p = 0.05), and blunt trauma (p = 0.026). Pancreatic injury score was associated with morbidity, while the presence of major vascular injury was associated with mortality.

Conclusions

Complications were significantly more common in injuries with higher pancreatic damage scores, additional organ injuries, and blunt abdominal trauma. Pancreatic injury score was associated with morbidity, while the presence of major vascular injury was associated with mortality.

     

Factors affecting morbidity and mortality in biliary tract surgery

Thirty-six clinical and laboratory parameters in 770 consecutive patients undergoing biliary tract surgery over a 3 year period were analyzed in an effort to define the patients at greatest risk. Twelve parameters had a significant correlation with hospital mortality, while multivariate analysis revealed that septic shock, malignant obstruction, serum albumin <3.0 gm%, history of hypertension, and plasma urea nitrogen >20 mg % had an independent significance in predicting postoperative mortality. The presence of more than 2 of these risk factors identified a group of patients with an 18% mortality rate. It is for this group of patients that adequate pre-operative preparation such as fluid resuscitation, prophylactic antibiotics, and nutritional support are essential. The controversial preoperative biliary drainage might be only indicated in this group of patients.

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Resumen Se analizaron 36 parámetros clínicos y de laboratorio en 770 pacientes consecutivos sometidos a cirugía sobre el arbol biliar en el curso de un período de tres años con el propósito de identificar los pacientes de mayor riesgo. Doce parámetros demostraron correlación significativa en la mortalidad hospitalaria, en tanto que el análisis multivariable reveló que el shock séptico, la obstrucción maligna, un nivel sérico de albúmina menor de 3.0 g%, la historia de hipertensión y un nivel plasmático de nitrógeno ureico mayor de 20 mg% poseen significancia independiente en la predicción de la mortalidad postoperatoria. La presencia de más de dos de estos factores de riesgo identifica un grupo de pacientes con tasa de mortalidad de 18%. Es en este grupo de pacientes que es esencial una adecuada preparación preoperatoria tal como resucitación con líquidos parenterales, antibióticos profilácticos y soporte nutricional; el controvertido drenaje biliar preoperatorio puede estar indicado sólo en este grupo de pacientes.

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Résumé Afin de définir une population à risque, 36 paramètres cliniques et biologiques ont été analysés chez 770 patients consécutifs opérés des voies biliaires pendant trois ans. Douze facteurs étaient significativement correlés à une mortalité hospitalière plus élevée, en analyse monofactorielle. En analyse multifactorielle, un choc septique, une obstruction d'origine maligne, une albuminémie inférieure à 3.0 gm%, des antécédents d'hypertension, et une urée sanguine supérieure à 20 mg% avaient une valeur prédictive significative de mortalité postopératoire. La présence de plus de deux de ces facteurs a correctement identifié une population pour laquelle la mortalité était de 18%. C'est donc dans cette population que les auteurs suggerent une préparation préopératoire suffisante comportant une rééquilibration hydro-électrolytique, une antibiothérapie prophylactique et une assistance nutritive. De même, le drainage biliaire préopératoire, quoique discuté, pourrait être indiqué dans ce group de patients.

     

Factors influencing morbidity and mortality after liver injury

The factors influencing morbidiy and mortality after liver injury were monitored prospectively in 637 patients. Death correlated with the number of associated injuries, severity of injury, presence of great vessel injury, active bleeding from liver at laparotomy, and severe shock on admission. Morbidity correlated most with presence of a colon injury, and the use of choledochostomy drainage. The first priority in treating liver injury is to stop bleeding. The simplest technique for this is multiple liver suture. Drainage is most safely achieved with soft rubber drains placed to the site of injury. Although several patients having no drainage may do well postoperatively, at least two patients in this series died because no drains were used. The use of choledochostomy drainage for decompression of the liver is associated with increased morbidity and mortality and is, therefore, contraindicated.     

Factors influencing mortality and morbidity following oesophageal resection

Operative mortality and morbidity following oesophageal resection has fallen in recent years. We have attempted to identify the factors responsible for this improvement by reviewing the results of surgery at this hospital over the last 6 years. Two hundred and two oesophageal resections were performed between January 1981 and June 1987 for carcinoma. Of these, 21 patients (10.4%) died before leaving hospital. Fourteen patients died of multisystem failure, 1 died of pure respiratory failure and 2 died of renal failure. Two died of surgical causes (other than anastomotic leak), 1 died of pulmonary embolus and 1 from a cerebro-vascular accident. No patient died of purely cardiac causes. The most significant risk factors in those dying (Chi-square test) were: postoperative respiratory failure, defined as reventilation after initial successful extubation, (P less than or equal to 0.001), reoperation as an emergency in the early postoperative period (P less than or equal to 0.001), anastomotic leak (P less than or equal to 0.01) and age over 70 (P less than or equal to 0.005). Less significant risk factors were chyle leak and histologically undifferentiated tumour. Of the 181 survivors, 103 left hospital with no complications of any kind. The mean stay in hospital for survivors was 15 days. Respiratory infection occurred in 22% of patients, prolonged gastric stasis in 8%, wound infection in 5% and empyema in 1%. As long as high risk groups are accepted for radical surgery, operation will carry a significant mortality in those groups. In others, we believe that perioperative monitoring and early aggressive treatment of complications can further reduce mortality and morbidity.     

Factors affecting morbidity and mortality in incarcerated abdominal wall hernias

Background Incarcerated abdominal wall hernia cases may necessitate emergency interventions, but under such circumstances morbidity and mortality rates may increase. The aim of this study was to investigate the factors that affect morbidity and mortality in patients with incarcerated abdominal wall hernias who underwent emergency surgery. Methods Urgent surgical interventions due to incarcerated abdominal wall hernias were performed in 182 patients in our clinics between January 1998 and January 2006. Factors that affect morbidity and mortality in incarcerated abdominal wall hernias were investigated retrospectively by browsing the archives. Logistic regression analysis was used to evaluate parameters that affect morbidity and mortality. Results Morbidity and mortality occurred in 43 (23.6%) and 9 (4.9%) patients, respectively. A symptomatic period of longer than 8 h, presence of accompanying disease, high American Society of Anesthesiology (ASA) score, general anesthesia, presence of strangulation, and necrosis were found to affect morbidity significantly by univariate analysis. Necrosis was the sole factor affecting morbidity significantly by multivariate analysis. Advanced age, presence of accompanying disease, high ASA score, presence of strangulation, necrosis, and hernia repair with graft were found to affect mortality significantly by univariate analysis; however, necrosis was the sole factor affecting mortality significantly by multivariate analysis. Conclusions Intestinal necrosis, which was followed by bowel resection, was the sole factor affecting morbidity and mortality using multivariate logistic regression analysis. Emergency surgery is required for incarcerated abdominal wall hernias before intestinal necrosis develops.     

Factors affecting mortality and morbidity in patients with abdominal gunshot wounds

Risk factors that may independently predict mortality and morbidity in patients with abdominal gunshot wounds have not been fully elucidated. We prospectively studied the effects of 12 potential risk factors on mortality and morbidity in 82 patients with abdominal gunshot wounds who required laparotomy. Univariate analysis of these factors revealed that shock on admission, presence of penetrating colon injury and number of intra-abdominal organs injured (NOI)>2 were associated with greater than threefold increased incidence of death (p<0.05). Penetrating abdominal trauma index (PATI) score>15 was associated with twentyfold increased incidence of death (P<0.0001). Multivariate analysis showed that only PATI (P=0.001), number of postoperative complications per patient (N(comp)) (P=0.023) and presence of shock on admission (P=0. 028) were independently significant in predicting mortality. PATI was the only risk factor that independently predicted the development of postoperative infectious complications and N(comp) (P<0.0001). The type of gun used was not a significant risk factor (P>0.05). The 15 (18.3%) non-survivors were significantly older than survivors (P=0.02), had longer operations (P=0.004) and their NOI, PATI and N(comp) were significantly higher (P<0.001). The uniformly prolonged injury to surgery time in all patients contributed to the high incidence of infectious complications (62.2%) and mortality. PATI score was the most important factor found to be independently associated with mortality and morbidity in our subset of patients with prolonged injury to surgery time and high rate of colon injury.     

Vascular repair after firearm injury is associated with increased morbidity and mortality

ObjectiveFirearm injuries have high morbidity and mortality. Presentation of injuries requiring concurrent vascular repair and its outcomes are unclear. Our study's objective was to characterize the injury details and to assess the associated mortality and morbidity after vascular repair.MethodsThe National Inpatient Sample was queried from 1993 to 2014 for all firearm injuries. International Classification of Diseases, Ninth Revision codes were used to identify firearm injuries and those who also underwent a vascular repair. Multivariable analysis was used to assess the effect of a concurrent vascular repair on outcomes.ResultsThere were 648,662 firearm injuries identified; 63,973 (9.9%) involved a vascular repair. Overall, 88.7% of patients were male, and Medicaid was the most common insurance (40.2%). Intents were assault or legal intervention (60%), unintentional (24.2%), and suicide (8.6%). Patients undergoing vascular repair were younger, more often of black race and male sex, and on Medicaid insurance, with a lower household income and assault/legal intent (P < .005). Patients who underwent vascular repair had a higher frequency of abdomen/pelvis and extremity injuries as well as an elevated New Injury Severity Score (P < .005). Patients with vascular repair were more frequently treated at urban, teaching, and large hospitals (P < .005). Overall mortality rate was 2.2%; patients who underwent vascular repair had a higher mortality compared with those without (5.51% vs 1.98%; P < .001). Patients with vascular repair had higher rates of acute renal failure (3.1% vs 0.8%), venous thromboembolic events (0.5% vs 0.3%), pulmonary-related events (0.6% vs 0.28%), cardiac-related events (0.8% vs 0.2%), sepsis (1.4% vs 0.5%), and any complication (5.7% vs 2%; all P < .0001). Vascular repair was independently associated with mortality (odds ratio [OR], 2.68; 95% confidence interval [CI], 2.43-2.95; P < .0001). Age older than 46 years (OR, 2.01; 95% CI, 1.71-2.35; P < .0001), male sex (OR, 1.15; 95% CI, 1.05-1.25; P = .003), self-pay/no insurance (OR, 1.6; 95% CI, 1.47-1.75; P < .0001), suicide intent (OR, 3.73; 95% CI, 3.36-4.13; P < .0001), unintentional intent (OR, 1.12; 95% CI, 1.03-1.22; P < .0001), head/neck location (OR, 13.9; 95% CI, 12.5-15.6; P < .0001), Northeast region, and New Injury Severity Score >4 were independently associated with in-hospital mortality. Vascular repair was also independently associated with any complication (OR, 2.12; 95% CI, 1.98-2.28; P < .0001).ConclusionsFirearm injuries with vascular repair were independently associated with higher injury severity score and mortality. A majority of vascular repairs were performed for injury to the abdomen/pelvis and extremity with assault/legal intent, whereas head and neck injury and suicide intent were the least frequent.     

C-reactive protein elevation is associated with increased morbidity and mortality in elderly burned patients

BackgroundC-reactive protein (CRP) is an acute-phase protein produced in response to inflammation after traumatic injury. We posit that C-reactive protein (CRP) is reliable in predicting morbidity and mortality following severe burn. In this study, we explored the relationship between serum CRP values and clinical outcomes in the severely burned.MethodsUsing the Research Network within the TriNetX database, we queried de-identified burn patient data across the United States and enrolled 36,556 burn patients with reported CRP values from 2006 to 2020.ResultsCirculating CRP levels were elevated significantly in patients ≥60 years as well as in males and African Americans (p < 0.05). CRP levels reached the zenith on the first day after burn, and were highest when burn size reached 60% total body surface area (TBSA). After bisecting the data at 10 mg/L of CRP, we compared clinical findings between patient groups (n = 16,284/18,647 in high/low CRP levels). The risk of patient death doubled in the high CRP group from 4.687% to 9.313%, with higher incidences of sepsis, skin infection, and myocardial infarction (p < 0.05). Moreover, mortality increased from 0.9% to 1.926% in those younger than 20 years when comparing the low and high CRP groups, whereas mortality significantly increased from 8.84% to 15.818% in those ≥60 years old (p < 0.05). Both elderly and paediatric groups had significant increases in the diagnosis of sepsis-associated with increased CRP expression. However, incidences of skin infection, pneumonia, and acute kidney injury increased significantly only in the elderly group (p < 0.05).ConclusionElevated CRP expression is common in burn patients. The factor of age influenced the association of CRP expression to clinical outcomes.     

Hyperglycemia is associated with increased morbidity and mortality rates in neonates with necrotizing enterocolitis

Background purpose

An association between hyperglycaemia and poor outcome has been reported in critically ill adults and children. The authors investigated the incidence of hyperglycemia in infants with necrotizing enterocolitis (NEC) and the relationship between glucose levels and outcome in these infants.

Methods

All glucose measurements (n = 6508) in 95 neonates with confirmed NEC admitted to the surgical intensive care unit (ICU) were reviewed. Maximum glucose concentration during admission (G_max) was determined for each infant and correlated with outcome. Eleven infants in whom treatment was withdrawn within 24 hours owing to unsalvageable panintestinal NEC were excluded from the analysis.

Results

Glucose levels ranged from 0.5 to 35.0 mmol/L and 69% of infants became hyperglycemic (>8 mmol/L) during their admission. Thirty-two infants died. Mortality rate tended to be higher in infants with G_max greater than 11.9 mmol/L compared with those with G_max less than 11.9 mmol/L, and late (>10 days admission) mortality rate was significantly higher in these infants (29% v, 2%; P = .0009). Median length of stay was 9.3 days. Linear regression analysis indicated that G_max was significantly related to length of stay (P < .0001).

Conclusions

Hyperglycemia is common in infants with NEC admitted to the ICU and is associated with an increase in late mortality and longer intensive care stay. Aggressive glycemic control may improve outcome in this group of infants.