Robotic or laparoscopic sacrohysteropexy versus open sacrohysteropexy for uterus preservation in pelvic organ prolapse

Introduction and hypothesis

The aim of this study was to compare robotic or laparoscopic sacrohysteropexy (RLSH) and open sacrohysteropexy (OSH) as a surgical treatment for pelvic organ prolapse (POP).

Methods

Among 111 consecutive patients who had undergone sacrohysteropexy for POP, surgical outcomes and postoperative symptoms were compared between the RLSH (n?=?54; robotic 14 cases and laparoscopic 40 cases) and OSH (n?=?57). groups The medical records of enrolled patients were reviewed retrospectively.

Results

Compared with the OSH group, the RLSH group had shorter operating time (120.2 vs 187.5 min, p?<?0.0001), less operative bleeding (median estimated blood loss 50 vs 150 ml; p?<?0.0001; mean hemoglobin drop 1.4 vs 2.0 g/dl; p?<?0.0001), and fewer postoperative symptoms (13 vs 45.6 %; p?<?0.0001). Patients’ overall satisfaction (94.4 vs 91.2 %; p?=?0.717) and required reoperation due to postoperative complications (3.7 vs 1.8 %; p?=?0.611) did not differ between groups.

Conclusions

RLSH could be a feasible and safe procedure in patients with POP and should be considered as a surgical option that allows preservation of the uterus. Prospective randomized trials will permit the evaluation of potential benefits of RLSH as a minimally invasive surgical approach.

     

Prognostic Significance of Acute Kidney Injury Following Emergency Laparotomy: A Prospective Observational Cohort Study

Aims

Post-operative acute kidney injury (AKI) is a common and independent mortality risk factor carrying high clinical and economic cost. This study aimed to establish the incidence of AKI in patients undergoing emergency laparotomy (EL), to determine patients’ risk profile and consequent mortality.

Methods

Consecutive 239 patients of median age 68 (IQR 51–76) years, undergoing EL in a UK tertiary hospital, were studied. Primary outcome measure was AKI and in-hospital operative mortality.

Results

Ninety-five patients (39.7%) developed AKI, which was associated with in-hospital mortality in 32 patients (33.7%) compared with 7 patients (4.9%) without AKI. AKI occurred in 81.1% of all mortalities, but none occurred when AKI resolved within 48 h of EL. AKI was associated with chronic kidney disease, age, serum lactate, white cell count, pre-EL systolic blood pressure and tachycardia (p?<?0.010). Median length of hospital stay in AKI survivors was 15 days compared with 11 days in the absence of AKI (p?<?0.001). On multivariable analysis, only AKI at 48 h post-EL was significantly and independently associated with mortality [HR 10.895, 95% CI 3.152–37.659, p?<?0.001].

Conclusion

Peri-operative AKI after EL was common and associated with a more than sixfold significant greater mortality. Pre-operative risk profile assessment and prompt protocol-driven intervention should minimise AKI and reduce EL mortality.

     

Analyzing the Impact of Compliance with National Guidelines for Pancreatic Cancer Care Using the National Cancer Database

Importance

Management of pancreatic cancer is complex, requiring coordination of multiple providers. National Comprehensive Cancer Network guidelines, developed for standardization and quality improvement, recommend a multimodal approach.

Objective

This study analyzed national rates of compliance with National Comprehensive Cancer Network recommendations, assessed factors affecting compliance, and evaluated whether compliance with evidence-based guidelines improved overall survival.

Design

This is a retrospective review of adults diagnosed with pancreatic cancer entered into the National Cancer Database. Patients included had stage I and II pancreatic cancer, and complete data in the database. Patients were classified as compliant if they underwent both surgery and a second treatment modality (chemotherapy, radiation, or chemoradiation). Clinico-pathologic variables were analyzed using univariate and multivariate models to predict overall survival.

Setting

Hospital-based national study population.

Participants

Patients with stage I or II pancreatic cancer.

Main Outcomes and Measures

Compliance with National Comprehensive Cancer Network recommendations, factors affecting compliance, and overall survival based on compliance.

Results

A total of 52,450 patients were included; 19,272 patients (37%) were compliant. Patients were found to be most compliant in the 50–59-year-old range (49% complaint), with decreased compliance at the extremes of age. Male patients were more compliant than female patients (39 vs 34%, p?<?0.0001). Caucasians were more compliant (39%) than African Americans (32%) or other races (32%, p?<?0.0001). Patients treated at academic/research centers were more compliant than patients treated at other facilities (39% compliant, p?<?0.0001). Patients with stage II disease were more compliant compared with stage I disease (43 vs 18%, p?<?0.0001). Compliance was shown to improve overall survival (p?<?0.0001).

Conclusion

Adherence to National Comprehensive Cancer Network guidelines for pancreatic cancer patients improves survival. Compliance nationwide is low, especially for older patients and minorities and those treated outside academic centers. More studies will need to be performed to identify factors that hinder compliance.

     

Two-way Interaction Effects of Perioperative Complications on 30-Day Mortality in General Surgery

Background

Multiple perioperative complications increase mortality risk, and certain complications synergistically increase this risk to a greater degree than might be expected if the complications were independent, but these effects are not well established.

Methods

This is a retrospective cohort study of 422,827 intraabdominal general surgery patients (American College of Surgeons National Surgical Quality Improvement Program 2005–2011). Eight complications were evaluated: acute respiratory failure (ARF), acute kidney injury (AKI), sepsis/septic shock, stroke, cardiac arrest (CA), myocardial infarction (MI), deep vein thrombosis/pulmonary embolus, and transfusion. Each combination of two complications (28 total) was modeled using a Cox model for 30-day mortality, with adjustment for preoperative comorbidities and risk factors. Additive interaction was determined with the relative excess risk due to interaction (RERI). A positive RERI indicates that the mortality risk with both complications is greater than the sum of the individual mortality risks. Bonferroni correction was applied (α = 0.05/28 = 0.0018).

Results

Seven combinations demonstrated positive interaction: sepsis-CA (RERI 88.1; p < 0.0001), ARF–AKI (RERI 50.5; p < 0.0001), AKI–sepsis (RERI 33.9; p < 0.0001), sepsis–stroke (RERI 33.9; p < 0.0001), ARF–stroke (RERI 32.3; p < 0.0001), AKI–MI (RERI 24.5; p = 0.0013), and ARF–sepsis (RERI 19.2; p < 0.0001). Two combinations demonstrated negative interaction: ARF–CA (RERI ?65.1; p = 0.0017) and CA-transfusion (RERI ?52.0, p < 0.0001).

Conclusions

Interaction effects exist between certain complications to increase the risk of short-term mortality. ARF, AKI, sepsis, and stroke were most likely to be involved in positive interactions. Further research into the mechanisms for these effects will be necessary to develop strategies to minimize the compounding effects of multiple complications in the perioperative period.

     

Comparative analysis of overall cost and rate of healthcare utilization among apical prolapse procedures

Introduction and hypothesis

The annual cost of prolapse surgeries is expected to grow at twice the rate of population growth. Understanding the economic impact of apical prolapse procedures, including sacrospinous fixation (SSF), abdominal sacrocolpopexy (ASC), and laparoscopic sacrocolpopexy (LSC), is crucial. We aimed to compare overall cost of SSF versus ASC and LSC, as well as health resource utilization, up to 90-day follow-up.

Methods

Truven Marketscan Commercial Claims and Encounter databases 2008–2012 were used to calculate index and 90-day follow-up costs for SSF, ASC, and LSC with/without hysterectomy. Rates of inpatient readmissions, outpatient visits, and emergency room (ER) visits were also calculated during the follow-up period. Statistical analyses were performed using SAS 9.3.

Results

There were 17,549 SSF, 6126 ASC, and 10,708 LSC procedures. Mean index cost was lower for SSF (US$10,993) than ASC ($12,763, p?<?0.0001) and LSC ($13,647, p?<?0.0001). Concurrent hysterectomy impacted costs. Follow-up costs were likewise lower for SSF ($13,916) than ASC ($15,716, p?<?0.0001) and LSC ($16,838, p?<?0.0001). Lower rates of readmission were reported in SSF (4.22%) than ASC (5.40%, p?=?0.0001) and LSC (4.64%, p?=?0.0411). The rate of at least one ER visit was also lower for SSF (10.9%) than for ASC (12.0%, p?=?0.0170) and comparable with LSC (10.6%, p?=?0.0302).

Conclusions

Overall mean costs are significantly lower for SSF than ASC/LSC, as are those for health resource utilization. Besides lower morbidity rates being associated with vaginal procedures, our results demonstrate another reason to consider the increased use of SSF over sacrocolpopexies in apical prolapse surgery.

     

Detection of patients at high risk for nonocclusive mesenteric ischemia after cardiovascular surgery

Objectives

Nonocclusive mesenteric ischemia (NOMI) is a rare but life-threatening complication after cardiovascular surgery. Early diagnosis and treatment is essential for a chance to cure. The aim of this study is to identify the independent risk factors for NOMI based on the evaluation of 12 cases of NOMI after cardiovascular surgery.

Methods

We retrospectively analyzed 12 patients with NOMI and 674 other patients without NOMI who underwent cardiovascular surgery in our hospital. We reviewed the clinical data on NOMI patients, including their characteristics and the clinical course. In addition, we performed a statistical comparison of each factor from both NOMI and non-NOMI groups to identify the independent risk factors for NOMI.

Results

The median duration between the cardiac surgery and the diagnosis of NOMI was 14.0 (10.3–20.3) days. The in-hospital mortality of NOMI patients was 75.0%. Age (p?<?0.05), peripheral arterial disease (p?<?0.001), postoperative hemodialysis (p?<?0.001), intraaortic balloon pump (p?<?0.05), norepinephrine (NOE)?>?0.10γ (p?<?0.0001), percutaneous cardiopulmonary support (p?<?0.001), sepsis (p?<?0.05), loss of sinus rhythm (p?<?0.05), prolonged ventilation (p?<?0.0001), and resternotomy for bleeding (p?<?0.05) showed significant differences between NOMI and non-NOMI groups. In the multivariate logistic regression model, prolonged ventilation [odds ratio (OR)?=?18.1, p?<?0.001] and NOE?>?0.10 μg/kg/min (OR?=?130.0, p?<?0.0001) were detected as independent risk factors for NOMI.

Conclusions

We have identified the risk factors for NOMI based on the evaluation of the 12 cases of NOMI after cardiovascular surgery. This result may be useful in predicting NOMI, which is considered difficult in clinical practice. For the patient with suspected of NOMI who has these risk factors, early CT scan and surgical exploration should be performed without delay.

     

Short- and long-term outcomes after non-severe acute kidney injury

Background

Severe acute kidney injury (AKI) is associated with chronic kidney disease (CKD), cardiovascular events and increased mortality. However, little is known about the prognosis in hospitalized population suffering from non-severe AKI episodes. The aim of this study is to determine the impact of non-severe AKI episodes in cardiovascular events, mortality and CKD, on short and long term.

Methods

Retrospective cohort study to 360 patients who met the criteria for diagnosis of AKI according ADQI guidelines with full recovery of renal function after the AKI episode, admitted between January 2000 and December 2010 in our hospital. Follow-up was 4 years after the diagnosis of AKI. Covariates included demographic variables, baseline creatinine and diagnosis of comorbidities.

Results

360 AKI survivor patients were included. Twenty five of them (6.7%) had developed CKD after 1-year follow-up. Hypertension (OR 1.62; 95% CI 1.2–2.6, p < 0.05) and serum creatinine >2.6 mg/dL in AKI (OR 1.7; 95% CI 1.2–3.7, p < 0.05) were independent risk factors. After 4-year follow-up, 40 patients (18.3%) had developed CKD; age >66 years was an independent risk factor (OR 1.03, 95% CI 1.03–1.06, p < 0.05). Mortality rate at 4 years was 25.3% and was significantly higher in CKD patients (OR 4.3, 95% CI 1.13–4.90, p < 0.05) and patients >66 years (OR 1.12, 95% CI 1.02–1.06, p < 0.05). The incidence of cardiovascular events also was higher in CKD patients than in non-CKD patients (62.7 vs. 21.7%, p < 0.05).

Conclusion

Even after fully recovered non-severe AKI episodes, some patients develop CKD and those have an increase in the incidence of cardiovascular events and long-term mortality.

     

Acute kidney injury associated with concomitant vancomycin and piperacillin/tazobactam administration: a systematic review and meta-analysis

Background

As a tricyclic glycopeptide antibiotic used to treat acute infections, Vancomycin (VAN) is often administered with piperacillin/tazobactam (PT) to treat various infections in clinical practice. However, whether the combination of these two drugs, compared to VAN alone, can cause an increased risk of acute kidney injury (AKI) remains controversial.

Objectives

This study aims to identify the correlation between the development of AKI and the combined use of VAN and PT.

Methods

We conducted a meta-analysis of eight observational cohort studies (a total of 10727 participants received VAN and PT versus VAN and other β-lactams). PubMed, Chinese Biological Medicine Database (CBM), China National Knowledge Infrastructure (CNKI) Database, Wan Fang Digital Periodicals Database (WFDP), and China Science Citation Database (CSCD) were searched through April 2017 using “vancomycin” and “piperacillin” and “tazobactam” as well as “acute kidney injury” or “acute renal failure” or “AKI” or “ARF” or “nephrotoxicity.” Two reviewers extracted the data and assessed the risk of bias.

Results

A correlation was found between the development of AKI and concurrent use of VAN and PT compared with concomitant VAN and β-lactams (OR 1.57; 95% CI, 1.13–2.01; I²?=?76.4%, p?<?0.001). Similar findings were obtained in an analysis of studies comparing concurrent VAN and PT use with concurrent VAN and β-lactam (cefepime) use (OR 1.50; 95% CI, 1.07–1.93; I²?=?80.5%, p?<?0.001). Exclusion of fair-quality and low-quality articles did not change the results (OR 1.49; 95% CI, 1.06–1.92; I²?=?84.1%, p?<?0.001).

Conclusions

Regarding β-lactam therapy in clinical practice, an elevated risk of AKI due to the combined use of VAN and PT should be considered.

     

Treatment Intensity Differences After Early-Stage Breast Cancer (ESBC) Diagnosis Depending on Participation in a Screening Program

Background

While population mammographic screening identifies early-stage breast cancers (ESBCs; ductal carcinoma in situ [DCIS] and invasive disease stages 1–3A), commentaries suggest that harms from overdiagnosis and overtreatment may outweigh the benefits. Apparent benefits to patients with screen-detected cancers may be due to selection bias from exclusion of interval cancers (ICs). Treatment intensity is rarely discussed, with an assumption that all ESBCs are treated similarly. We hypothesized that women diagnosed while in a screening program would receive less-intense treatment than those never or not recently screened (NRS).

Methods

This was a retrospective analysis of all women aged 50–69 years managed for ESBC (invasive or DCIS) during the period 2007–2013 within a single service, comparing treatment according to screening status. Data on demographics, detection, pathology, and treatment were derived from hospital, cancer registry, and screening service records.

Results

Overall, 622 patients were active screeners (AS) at diagnosis (569 screen-detected and 53 ICs) and 169 patients were NRS. AS cancers were smaller (17 mm vs. 26 mm, p?<?0.0001), less likely to involve nodes (26% vs. 48%, p?<?0.0001), and lower grade. For invasive cancer, NRS patients were more likely to be recommended for mastectomies [35% vs. 16%; risk ratio(RR) 2.2, p?<?0.0001], axillary dissection (43% vs. 19%; RR 2.3, p?<?0.0001), adjuvant chemotherapy (65% vs. 37%; RR 1.7, p?<?0.0001), and postmastectomy radiotherapy (58% vs. 39%; RR 1.5, p?=?0.04).

Conclusion

Participants in population screening diagnosed with ESBC receive substantially less-intense treatment than non-participants. Differences persist when potential overdiagnosis is taken into account; these differences should be factored into debates around mammographic screening.

     

Delta neutrophil index as an early predictor of acute appendicitis and acute complicated appendicitis in adults

Background

This retrospective study aimed to evaluate the ability of the delta neutrophil index (DNI) to predict histologically normal appendicitis preoperatively and to differentiate between simple and complicated appendicitis.

Methods

The data from 650 patients were divided into positive and negative appendectomy groups (histologically normal appendicitis). The patients in the acute appendicitis group were further sub-divided into simple and complicated appendicitis groups.

Results

The DNI was significantly higher in the positive group than in the negative appendectomy group (0.4 vs. ?0.4, p?<?0.001) as well as in the complicated group compared with that in the simple appendicitis group (1.2 vs. 0.3, p?<?0.001). The DNI independently predicted a positive appendectomy and an acute complicated appendicitis in multivariate logistic regression analysis [odds ratio (OR) 2.62, 95% confidence interval (CI) (1.11~6.16), p?=?0.028 and odds ratio (OR) 4.10, 95% confidence interval (CI) (2.94~5.80), p?<?0.001]. The optimum cut-off for a positive appendectomy and acute complicated appendicitis were 0.2 [area under curve (AUC) 0.709] and 0.6 (AUC 0.727).

Conclusions

We suggest that obtaining a preoperative DNI is a useful parameter to aid in the diagnosis of histologically normal appendicitis and to differentiate between simple and complicated appendicitis.

     

Evaluation of right atrial function using right atrial speckle tracking analysis in patients with pulmonary artery hypertension

Background

In patients with pulmonary artery hypertension (PAH), right ventricular pressure overload eventually causes right heart failure (RHF), leading to a poor prognosis. Right atrial (RA) overload and RA dysfunction occur in patients with PAH-complicated RHF.

Objectives

We evaluated RA function using right atrial longitudinal strain (RALS) by two-dimensional speckle tracking echocardiography (2D-STE) and investigated the association between RALS and the severity of RHF in patients with pulmonary artery hypertension (PAH) noninvasively.

Methods

We performed 2D-STE in 56 PAH patients and 20 normal control subjects. The peak global RALS and peak global RA longitudinal strain rate (RALSR) were analyzed by 2D-STE. Simultaneous right heart catheterization was performed to determine the right atrial pressure (RAP) and cardiac index (CI).

Results

Peak global RALS (34.6 ± 14.1 vs. 58.3 ± 9.9 %, p < 0.0001) and peak global RALSR (2.5 ± 1.3 vs. 3.1 ± 1.2 s^?1, p < 0.0001) were significantly lower in PAH patients compared with normal controls. There was a significant negative correlation between peak global RALS and RAP (r = ?0.8037, p < 0.0001). There was a significant positive correlation between peak global RALS and CI (r = 0.8179, p < 0.0001). Peak global RALSR was also correlated with RAP (r = ?0.7308, p < 0.0001) and CI (r = 0.7596, p < 0.0001).

Conclusions

RALS and RALSR by 2D-STE were useful for noninvasive evaluation of RA dysfunction and the severity of RHF in patients with PAH.

     

Serum NGAL and copeptin levels as predictors of acute kidney injury in asphyxiated neonates

Background

Acute kidney injury (AKI) is the most common complication of perinatal asphyxia. Recent research indicates that serum neutrophil gelatinase-associated lipocalin (NGAL) is an early marker for AKI, but there are the lacks of data about its use in term neonates with perinatal asphyxia.

Methods

A prospective cohort study was conducted on 43 term neonates. Umbilical cord blood and 24 h after birth serum NGAL, copeptin, creatinine, and molality were measured in all asphyxiated and controls neonates.

Results

During the study period, 8 of asphyxiated nenates (18.6 %) suffered from AKI, while 35 newborns have no signs of AKI and 30 healthy infants. We did not observe any differences in creatinine and copeptin levels, as well as serum osmolality in all three investigated groups (AKI, no-AKI, and controls) in cord blood, and 24 h after birth. Serum NGAL levels in umbilical cord blood were significantly higher in the AKI group (174.3 ng/mL) compared with no-AKI (88.5 ng/mL, p = 0.01) and control groups (28.5 ng/mL, p < 0.001), and 24 h after birth (respectively, AKI 152.5 ng/mL vs no-AKI 74.9 ng/mL, p = 0.02 vs controls 39.1 ng/mL, p < 0.001). NGAL concentration showed a strong negative correlation to umbilical artery pH (Rho = ?0.42, p = 0.04), base excess (Rho = ?0.31, p = 0.03), and Apgar score in 1st min (Rho = ?0.41, p = 0.02) and 5th min of life (Rho = ?0.20, p = 0.001). ROC curve analysis demonstrated a good predictive value for NGAL levels (>140.7 ng/mL) which allows to diagnose AKI in asphyxiated patients with 88.9 % sensitivity (95 % CI 75–95 %) and 95.0 % specificity (95 % CI 76–99 %).

Conclusion

NGAL seems to be a promising marker, even in subclinical AKI in neonates, due to its high specificity, but copeptin did not meet expectations.

     

Evaluating the impact of a minimally invasive pediatric surgeon on hospital practice: comparison of two children’s hospitals

Purpose

Widespread adoption of minimally invasive surgery (MIS) techniques in pediatric surgery has progressed slowly, and the shift in practice patterns has been variable among surgeons. We hypothesized that a pediatric surgeon committed to MIS could effectively change surgical practice by creating an emphasis on MIS.

Methods

Annual case volumes from 2000 to 2009 at two tertiary care pediatric hospitals, one with a dedicated minimally invasive pediatric surgeon, were evaluated for trends in MIS for ten different operations. Univariate analyses of the differences between hospitals in the use of the open versus laparoscopic approach were performed. The Breslow–Day test was used to examine differences in use of laparoscopic procedures across hospitals in early versus middle and middle versus late time periods.

Results

Between the two hospitals, for 9 of the 10 types of surgery, the number of laparoscopic and open procedures differed significantly (p values ranged from <0.0001 to 0.003). Over the 10-year period, the hospital with a dedicated MIS surgeon had a larger proportion of procedures done laparoscopically for all years. This difference reached statistical significance for appendectomy (p < 0.0001), congenital diaphragmatic hernia (p < 0.0002), chest wall reconstruction (p < 0.0001), cholecystectomy (p = <0.0001), gastrostomy (p < 0.0001), nissen fundoplication (p < 0.0001) oophorectomy (p < 0.0001), pyloromyotomy (p < 0.0001) and splenectomy (p = 0.0006). After grouping the years into early (2000–2003), middle (2004–2006) and late (2007–2009) categories, the hospital with a dedicated MIS surgeon had a significantly higher rate of increase in use of laparoscopic surgery between the early and middle years for four procedures: diaphragmatic hernia repair (p = 0.003), chest wall reconstruction (p = 0.0086), cholecystectomy (0.0083) and endorectal pull-through (p = 0.025).

Conclusion

The presence of a dedicated minimally invasive pediatric surgeon led to a significant change in surgical practice with an overall trend of increasing MIS several years in advance of a hospital that did not have a dedicated MIS surgeon. This has implications for resident training in academic medical centers and potential patient care outcomes.

     

Hospital cost savings and other advantages of sutureless vs stented aortic valves for intermediate-risk elderly patients

Purpose

To evaluate and compare the clinical outcomes and hospital costs of using sutureless aortic valves vs conventional stented aortic valves.

Methods

Between 2007 and 2011, 52 elderly patients undergoing aortic valve replacement for aortic stenosis in our center had a sutureless valve inserted. From among 180 patients who had a stented valve inserted during the same period, 52 patients were matched to the sutureless group, based on age, gender, and operation type. We compared clinical outcomes and hospital costs between the two groups.

Results

The sutureless group had a higher Euroscore (logistic Euroscore I) risk (12.8 vs 9.7; p?=?0.02), with significantly shorter aortic cross-clamp (ACC) time (p?<?0.01), cardiopulmonary bypass (CPB) time (p?<?0.01), intensive care unit stay (p?<?0.01), intubation time (p?<?0.01), and overall hospital stay (p?=?0.05). The sutureless group also revealed a significant hospital cost saving of approximately 8200€ (p?=?0.01).

Conclusions

The clinical and hemodynamic outcomes of using the sutureless bioprosthesis were excellent. The reduced ACC and CPB times had a favorable effect on the duration of intubation and intensive care stay, resulting not only in faster recovery and discharge home, but also in a significant hospital cost reduction.

     

Influence of Insulin Resistance Status on the Development of Gallstones Following Roux-En-Y Gastric Bypass: a Prospective Cohort Study

Background

The occurrence of gallstones following Roux-en-Y gastric bypass (RYGB) has been extensively reported. As RYGB promotes improvement in insulin resistance (IR), which is one of the factors enrolled in the pathophysiology of gallstones, this study aims to determine the influence of IR and its post-RYGB course on the development of gallstones.

Methods

This is a prospective cohort study that enrolled 108 morbidly obese subjects free of gallstones which underwent RYGB and were followed up for 24 months, through clinical, laboratory, and ultrasound examinations. IR was assessed through the surrogate marker homeostasis model assessment (HOMA).

Results

Of the individuals evaluated, 29 (26.8 %) developed gallstones following RYGB. In the univariate analysis, postsurgical gallstones were associated with preoperative HOMA (p?<?0.0001), preoperative fasting glucose (p?=?0.0019), preoperative fasting insulin (p?=?0.0001), and preoperative triglycerides (p?=?0.0001). Multivariate analysis revealed that preoperative HOMA was the only factor independently associated with gallstones (p?<?0.0001). The incidence of gallstones among individuals with IR was 46.8 %; in the non-IR subjects, the incidence was 7.4 % (p?<?0.0001). Preoperative IR led to a relative risk of 6.02 (95 % CI?=?2.1–17.3; p?=?0.0009) of gallstones.

Conclusions

As gallstones often occur following RYGB, there is controversy regarding their management. Some authors propose systematic cholecystectomy along with RYGB, while others suggest that the aggregate risk of the concomitant approach is significantly higher. As IR was a significant risk factor in this study, an individualized approach for this population may be proposed. Further research is needed to confirm these findings.

     

Comparison of different definitions of acute kidney injury in extremely low birth weight infants

Background

The definition of acute kidney injury (AKI) has evolved over the years, and three definitions have been adapted including pediatric risk injury failure, loss of kidney function (pRIFLE), Acute Kidney Injury Network (AKIN), and Neonatal Modified Kidney Disease Improving Global Outcomes (KDIGO). We sought to report the prevalence and outcome of (AKI) according to the three existing definitions in extremely low birth weight (ELBW) infants.

Methods

In a retrospective cohort study, medical records of all ELBW infants (<1000 g) admitted to our neonatal intensive care unit (NICU) between Jan 2002 and Dec 2011 were reviewed. Infants’ demographics, anthropometric measurements, and clinical characteristics were collected at the time of birth and at discharge from the NICU. Infants were staged according to the three different definitions.

Results

During the study period, 483 ELBW infants met our inclusion criteria. The incidence of AKI was 56, 59, and 60% according to pRIFLE, AKIN, and KDIGO, respectively. Mortality, NICU length of stay, and serum creatinine (SCr) at NICU discharge were higher in infants with advanced AKI stages regardless of the definition. In addition, discharge NICU weight and length z scores were lower in infants with advanced AKI stages. SCr at 72 h of life and SCr peak were predictable of NICU mortality [AUC 0.667 (95% CI 0.604–0.731), p < 0.001 and AUC 0.747 (95% CI 0.693–0.801), p < 0.001, respectively].

Conclusion

Regardless of the definition, advanced AKI is associated with increased mortality, prolonged NICU length of stay, and poor growth in ELBW infants. SCr at 72 h of life and SCr peak may be predictable of NICU mortality.

     

Postoperative atrial fibrillation is less frequent in pulmonary segmentectomy compared with lobectomy

Objective

The aim of this study was to elucidate the characteristics and predictors of postoperative atrial fibrillation (POAF) from the standpoint of surgical mode.

Methods

Retrospective analysis was carried out on 607 patients who underwent lobectomy or segmentectomy for clinical stage IA lung cancer. We investigated the clinical factors to determine the predictors of the development of POAF.

Results

Of the 607 patients, 443 underwent lobectomy, and 164 underwent segmentectomy. POAF developed in 37 patients. Of these, 34 (7.7%) were in the lobectomy group, and 3 (1.8%) in the segmentectomy group. In the univariate analysis for predictors of POAF, age (p?<?0.01), history of ischemic heart disease (p?=?0.03), FEV1.0% (p?<?0.01) and surgical mode (p?=?0.01) showed significant differences between the groups. The multivariate analysis revealed that increasing age (p?<?0.01, HR 1.059, CI 1.015–1.106), surgical mode (p?=?0.02, HR 5.734, CI 1.350–24.361) and FEV1.0%?<?70% (p?=?0.03, HR 2.182, CI 1.067–4.461) were independent predictors of POAF.

Conclusion

POAF was significantly less following segmentectomy compared with lobectomy.

     

Acute Pancreatitis After Laparoscopic Transcystic Common Bile Duct Exploration: An Analysis of Predisposing Factors in 447 Patients

Introduction

In laparoscopic transcystic common bile duct exploration (LTCBDE), the risk of acute pancreatitis (AP) is well recognized. The present study assesses the incidence, risk factors, and clinical impact of AP in patients with choledocholithiasis treated with LTCBDE.

Methods

A retrospective database was completed including patients who underwent LTCBDE between 2007 and 2017. Univariate and multivariate analyses were performed by logistic regression.

Results

After exclusion criteria, 447 patients were identified. There were 70 patients (15.7%) who showed post-procedure hyperamylasemia, including 20 patients (4.5%) who developed post-LTCBDE AP. Of these, 19 were edematous and one was a necrotizing pancreatitis. Patients with post-LTCBDE AP were statistically more likely to have leukocytosis (p?<?0.004) and jaundice (p?=?0.019) before surgery and longer operative times (OT, p?<?0.001); they were less likely to have incidental intraoperative diagnosis (p?=?0.031) or to have biliary colic as the reason for surgery (p?=?0.031). In the final multivariate model, leukocytosis (p?=?0.013) and OT (p?<?0.001) remained significant predictors for AP. Mean postoperative hospital stay (HS) was significantly longer in AP group (p?<?0.001).

Conclusion

The risk of AP is moderate and should be considered in patients with preoperative leukocytosis and jaundice and exposed to longer OT. AP has a strong impact on postoperative HS.

     

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

Purpose

The purpose of the study was to evaluate the accuracy of the American College of Surgeons NSQIP Surgical Risk Calculator for predicting risk-adjusted 30-day outcomes for patients undergoing partial nephrectomy (PN) for renal cell carcinoma (RCC).

Methods

A single institution, multi-surgeon, prospectively maintained database was queried for patients undergoing PN for RCC from 1998 to 2015. 21 preoperative factors were analyzed for each patient with predicted risk for 30-day complications, mortality, and length of stay (LOS) calculated. Differences between the mean predicted risk and observed rate of surgical outcomes were determined using two-sided one-sample t test with significance at p?<?0.05. Subgroup analyses of outcomes stratified by surgical approach were also performed.

Results

470 patients undergoing PN for RCC were analyzed. Comparing NSQIP predicted to observed outcomes, clinically significant underestimations occurred with rates of overall complications (9.16 vs. 16.81%, p?<?0.001), surgical site infections [SSI] (1.65 vs. 2.77%, p?<?0.001), urinary tract infection [UTI] (1.41 vs. 3.40%, p?<?0.001), and LOS (3.25 vs. 3.73 days, p?<?0.001). On subgroup analysis, 209 open PN and 261 minimally invasive PN (MIPN) were performed. The NSQIP calculator consistently underestimated overall complications, SSI, UTI, and LOS (p?<?0.001) among both surgical approaches, while overestimating MIPN severe complications (p?<?0.001). Clinically important differences persisted when stratifying the MIPN group by laparoscopic (N?=?111) and robotic (N?=?150) approaches.

Conclusions

The ACS NSQIP Surgical Risk Calculator had significant discrepancies among observed and predicted outcomes. Additional analyses confirmed these differences remained significant irrespective of surgical approach. These findings emphasize the need for urologic oncology-specific calculators to better predict surgical outcomes in this complex patient population.