Predictors for persistent urodynamic stress incontinence following extensive pelvic reconstructive surgery with and without midurethral sling

Introduction and hypothesis

The objective of this study was to identify the predictors for persistent urodynamic stress incontinence (P-USI) in women following extensive pelvic reconstructive surgery (PRS) with and without midurethral sling (MUS).

Mmethods

A total of 1,017 women who underwent pelvic organ prolapse (POP) surgery from January 2005 to December 2013 in our institutions were analyzed. We included 349 USI women who had extensive PRS for POP stage III or more of whom 209 underwent concomitant MUS.

Results

Of the women who underwent extensive PRS without MUS, 64.3 % (90/140) developed P-USI compared to only 10.5 % (22/209) of those who had concomitant MUS. Those with concomitant MUS and PRS alone were at higher risk of developing P-USI if they had overt USI [odds ratio (OR) 2.2, 95 % confidence interval (CI) 1.3–4.0, p?=?0.014 and OR 4.7, 95 % CI 2.0–11.3, p?<?0.001, respectively], maximum urethral closure pressure (MUCP) of?<?60 cm H₂O (OR 5.0, 95 % CI 3.0–8.1, p?<?0.001 and OR 5.3, 95 % CI 2.7–10.4, p?<?0.001, respectively), and functional urethral length (FUL) of?<?2 cm (OR 5.4, 95 % CI 2.7–8.8, p?<?0.001 and OR 3.9, 95 % CI 2.4–6.9, p?<?0.001, respectively). Parity?≥?6 (OR 3.9, 95 % CI 1.7–5.2, p?<?0.001) and Prolift T (OR 3.1, 95 % CI 1.9–4, p?<?0.001) posed a higher risk of P-USI in those with concomitant surgery. Perigee and Avaulta A seemed to be protective against P-USI in those without MUS.

Conclusions

Overt USI with advanced POP together with low MUCP and FUL values have a higher risk of developing P-USI. Therefore, counseling these women is worthwhile while considering the type of mesh used.

     

Risk factors for obstetric anal sphincter injuries in twin deliveries: a retrospective review

Introduction and hypothesis

Risk factors for obstetric anal sphincter injuries (OASIS) have been well-established in singleton pregnancies. Considering the unique characteristics of twin deliveries, our aim was to identify risk factors for OASIS that are specific to twins.

Methods

A retrospective study of all vaginal twin deliveries in a tertiary center between 2000 and 2014. Women who experienced OASIS (the OASIS group) were compared with those whose anal sphincter was intact (controls).

Results

Overall 717 women were eligible for the study, of whom 20 (2.8 %) experienced OASIS. Women in the OASIS group were more likely to be nulliparous (95.0 % vs 53.7 %, p?<?0.001) and were characterized by a higher gestational age at delivery (36.1?±?2.5 vs 34.6?±?3.3, p?=?0.04), a higher birth weight for both twin A and twin B (2,507?±?540 g vs 2,254?±?525 g, p?=?0.03, and 25,49?±?420 g vs 2,232?±?606 g, p?=?0.004 respectively), and a higher rate of episiotomy (40.0 % vs 14.2 %, p?=?0.001), instrumental delivery for twin A (80.0 % vs 13.5 %, p?<?0.001) or twin B (80.0 % vs 18.7 %, p?<?0.001), and inter-twin delivery interval of over 30 min (20.0 % vs 7.5 %, p?=?0.04). The only factor that remained significant on multivariate analysis was instrumental delivery: forceps delivery of twin A (OR?=?8.8, 95 % CI 2.6–30.1), vacuum extraction of twin A (OR?=?9.2, 95 % CI 2.6–34.6), and forceps delivery of twin B (OR?=?15.4, 95 % CI 4.9–48.6). In women with certain combinations of risk factors the risk of OASIS was as high as 30 %.

Conclusion

The overall rate of OASIS in twins is low and instrumental delivery, especially by forceps, is a risk factor.

     

Efficacy of Bariatric Surgery in Type 2 Diabetes Mellitus Remission: the Role of Mini Gastric Bypass/One Anastomosis Gastric Bypass and Sleeve Gastrectomy at 1 Year of Follow-up. A European survey

Background

A retrospective study was undertaken to define the efficacy of both mini gastric bypass or one anastomosis gastric bypass (MGB/OAGB) and sleeve gastrectomy (SG) in type 2 diabetes mellitus (T2DM) remission in morbidly obese patients (pts).

Methods

Eight European centers were involved in this survey. T2DM was preoperatively diagnosed in 313/3252 pts (9.62 %). In 175/313 patients, 55.9 % underwent MGB/OAGB, while in 138/313 patients, 44.1 % received SG between January 2006 and December 2014.

Results

Two hundred six out of 313 (63.7 %) pts reached 1 year of follow-up. The mean body mass index (BMI) for MGB/OAGB pts was 33.1?±?6.6, and the mean BMI for SG pts was 35.9?±?5.9 (p?<?0.001). Eighty-two out of 96 (85.4 %) MGB/OAGB pts vs. 67/110 (60.9 %) SG pts are in remission (p?<?0.001). No correlation was found in the % change vs. baseline values for hemoglobin A1c (HbA1c) and fasting plasma glucose (FPG) in relation to BMI reduction, for both MGB/OAGB or SG (ΔFPG 0.7 and ΔHbA1c 0.4 for MGB/OAGB; ΔFPG 0.7 and ΔHbA1c 0.1 for SG). At multivariate analysis, high baseline HbA1c [odds ratio (OR)?=?0.623, 95 % confidence interval (CI) 0.419–0.925, p?=?0.01], preoperative consumption of insulin or oral antidiabetic agents (OR?=?0.256, 95 % CI 0.137–0.478, p?=?<0.001), and T2DM duration >10 years (OR?=?0.752, 95 % CI 0.512–0.976, p?=?0.01) were negative predictors whereas MGB/OAGB resulted as a positive predictor (OR?=?3.888, 95 % CI 1.654–9.143, p?=?0.002) of diabetes remission.

Conclusions

A significant BMI decrease and T2DM remission unrelated from weight loss were recorded for both procedures if compared to baseline values. At univariate and multivariate analyses, MGB/OAGB seems to outperform significantly SG. Four independent variables able to influence T2DM remission at 12 months have been identified.

     

Postoperative Peritonitis After Digestive Tract Surgery: Surgical Management and Risk Factors for Morbidity and Mortality,a Cohort of 191 Patients

Background

Postoperative peritonitis (POP) following gastrointestinal surgery is associated with significant morbidity and mortality, with no clear management option proposed. The aim of this study was to report our surgical management of POP and identify pre- and perioperative risk factors for morbidity and mortality.

Methods

All patients with POP undergoing relaparotomy in our department between January 2004 and December 2013 were included. Pre- and perioperative data were analyzed to identify predictors of morbidity and mortality.

Results

A total of 191 patients required relaparotomy for POP, of which 16.8% required >1 reinterventions. The commonest cause of POP was anastomotic leakage (66.5%) followed by perforation (20.9%). POP was mostly treated by anastomotic takedown (51.8%), suture with derivative stoma (11.5%), enteral resection and stoma (12%), drainage of the leak (8.9%), stoma on perforation (8.4%), duodenal intubation (7.3%) or intubation of the leak (3.1%). The overall mortality rate was 14%, of which 40% died within the first 48 h. Major complications (Dindo–Clavien >?2) were seen in 47% of the cohort. Stoma formation occurred in 81.6% of patients following relaparotomy. Independent risk factors for mortality were: ASA?>?2 (OR?=?2.75, 95% CI?=?1.07–7.62, p?=?0.037), multiorgan failure (MOF) (OR?=?5.22, 95% CI?=?2.11–13.5, p?=?0.0037), perioperative transfusion (OR?=?2.7, 95% CI?=?1.05–7.47, p?=?0.04) and upper GI origin (OR?=?3.55, 95% CI?=?1.32–9.56, p?=?0.013). Independent risk factors for morbidity were: MOF (OR?=?2.74, 95% CI?=?1.26–6.19, p?=?0.013), upper GI origin (OR?=?3.74, 95% CI?=?1.59–9.44, p?=?0.0034) and delayed extubation (OR?=?0.27, 95% CI?=?0.14–0.55, p?=?0.0027).

Conclusion

Mortality following POP remains a significant issue; however, it is decreasing due to effective and aggressive surgical intervention. Predictors of poor outcomes will help tailor management options.

     

Prognostic Significance of Post-Operative Morbidity Severity Score After Potentially Curative D2 Gastrectomy for Carcinoma

Background

Survival and relapse after gastric cancer surgery are largely attributed to tumor biology and surgical radicality; yet, other prognostic factors have been reported, including respiratory sepsis and anastomotic leakage, but not global morbidity severity score (MSS). The hypothesis tested was that MSS would be associated with both disease-free (DFS) and overall survival (OS).

Methods

Consecutive 373 patients undergoing potentially curative surgery for gastric adenocarcinoma between 2004 and 2016 in a UK cancer network were studied. Complications were defined prospectively as any deviation from a pre-determined post-operative course within 30 days of surgery and classified according to the Clavien-Dindo severity classification (CDSC). Primary outcome measures were DFS and OS.

Results

Post-operative complications were identified in 127 (34.0%) patients, which was associated with 9 (2.4%) post-operative deaths. Five-year DFS and OS were 35.9 and 38.5% for patients with a post-operative complication compared with 59.5 and 61.5% in controls (p?<?0.001, p?=?0.001, respectively). On multivariable DFS analysis, post-operative morbidity [hazard ratio (HR) 1.63, 95% confidence interval (CI) 1.06–2.50, p?=?0.026] was independently associated with poor survival. On multivariable OS analysis, post-operative morbidity HR 2.25 (95% CI 1.04–4.85, p?=?0.039) and CDSC HR 1.76 (95% CI 1.35–2.29, p?<?0.001) were independently associated with poor survival. These associations were also observed in patients with TNM stage I and II disease with morbidity HR 7.06 (95% CI 1.89–26.38, p?=?0.004) and CDSC HR 2.93 (95% CI 1.89–4.55, p?<?0.001) offering independent prognostic value.

Conclusion

Post-operative CDSC was an important independent prognostic factor after potentially curative gastrectomy for carcinoma associated with both DFS and OS. Prehabilitation strategies to minimize complications are warranted.

     

Predictive Value of Preoperative Sarcopenia in Patients with Gastric Cancer: a Meta-analysis and Systematic Review

Purpose

The impact of preoperative sarcopenia on postoperative complications and overall survival has been recently debated. Our meta-analysis aims to ascertain whether preoperative sarcopenia increases the risk of poor outcomes and to attempt to provide new ideas for the prognosis of outcomes for patients with gastric cancer.

Methods

We searched for all relevant articles on PubMed, the EMBASE database, and Web of Science (up to September 1, 2017). Data synthesis and statistical analysis were carried out using RevMan 5.3 software.

Results

Thirteen studies involving 4262 patients who underwent gastrectomy for gastric cancer were analyzed (sarcopenia group?=?1234; non-sarcopenia group?=?3028). The results showed that preoperative sarcopenia significantly associated with poor pathological staging (high pT: OR?=?1.86, 95% CI?=?1.49–2.31; P?<?0.01; pN+: OR?=?1.61, 95% CI?=?1.33–1.94; P?<?0.01; high TNM category: OR?=?1.84, 95% CI?=?1.53–2.22; P?<?0.01). Patients with preoperative sarcopenia had an increased risk of total postoperative complications (OR?=?2.17, 95% CI?=?1.53–3.08; P?<?0.01), severe complications (OR?=?1.65, 95% CI?=?1.09–2.50; P?=?0.02), and poorer OS (HR?=?1.70, 95% CI?=?1.45–1.99; P?<?0.01). The results of subgroup analyses revealed that patients with preoperative sarcopenia over 65 years old and those from Asian populations had higher risks for total postoperative complications and severe complications.

Conclusion

This meta-analysis reveals that preoperative sarcopenia may be used as a new indicator of poor pathological staging, impaired overall survival, and increased postoperative complications. Notably, patients with gastric cancer who are over 65 years old and from Asia should be routinely screened for sarcopenia before surgery to adequately assess the risk of postoperative complications in clinical practice.

     

Risk factors of microtia: A systematic review and meta-analysis

Background

The pathogenesis of microtia is still unclear. Various risk factors have been studied but they remain inconclusive. We conducted the first ever systematic review and meta-analysis to look for the association between microtia and various environmental risk factors.

Methods

Relevant case-control studies published between January 2000 to October 2014 were identified through a systematic search in PubMed and EMBASE. Reference lists from relevant review articles were also searched. Studies were included if they meet our selection criteria. Out of 1706 potential articles, 12 were included in the systematic review and 8 in the meta-analysis.

Results

Risk factors which showed significant positive association with microtia were: cold-like syndrome during pregnancy (OR?=?2.15; 95 % CI?=?1.36, 3.41, P?=?0.001); multiple gestation (OR?=?1.55; 95 % CI?=?1.05, 2.29, P?=?0.03); and gestational diabetes (OR?=?1.48; 95 % CI?=?1.04, 2.10, P?=?0.03). Risk factors which showed positive association but statistically insignificant were: threatened abortion (OR?=?1.22; 95 % CI?=?0.69, 2.15, P?=?0.50); smoking during pregnancy (OR?=?1.05; 95 % CI?=?0.63, 1.77, P?=?0.84); alcohol during pregnancy (OR?=?1.08; 95 % CI?=?0.65,1.80 P?=?0.77); urinary tract infection (OR?=?1.04; 95 % CI?=?0.59, 1.84, P?=?0.89); essential hypertension (OR?=?1.04; 95 % CI?=?0.74, 1.47, P?=?0.82); maternal diabetes (OR?=?3.98; 95 % CI?=?0.72, 21.96, P?=?0.11); respiratory tract infection (OR?=?1.26,95 % CI?=?0.84,1.88, P?=?0.26); chronic disease during pregnancy (OR?=?1.29,95 % CI?=?0.99,1.69, P?=?0.06); severe nausea/vomiting (OR?=?1.16; 95 % CI?=?0.66, 2.04, P?=?0.61); NSAIDs during pregnancy (OR?=?1.17, 95 % CI?=?0.61,2.22, P?=?0.64); antihypertensives during pregnancy (OR?=?1.84,95 % CI?=?0.94,3.62, P?=?0.08); and illegal drugs during pregnancy (OR?=?1.69; 95 % CI?=?0.65, 4.39, P?=?0.28). Reduced risk for microtia was found with these factors: folic acid (OR?=?0.55; 95 % CI?=?0.33, 0.92, P?=?0.02); advanced maternal age (OR?=?0.94; 95 % CI?=?0.79, 1.11, P?=?0.45); ampicillin during pregnancy (OR?=?0.80,95 % CI?=?0.50, 1.28, P?=?0.35); and metronidazole during pregnancy (OR?=?0.77,95 % CI?=?0.40, 1.48 P?=?0.44).

Conclusions

Our study indicates cold-like syndrome, multiple gestation, and gestational diabetes as significant risk factors for microtia; whereas folic acid consumption during pregnancy is shown to be a protective factor. Studies on risk factors for microtia are still very limited to establish the definitive risk factors. Further large-scale and multicentre studies are needed to clarify the role of key risk factors for the development of microtia.Level of Evidence: Level II, risk / prognostic study.

     

Risk factors affecting unplanned reoperation after laparoscopic gastrectomy for gastric cancer: experience from a high-volume center

Background

To evaluate the risk factors affecting unplanned reoperation (URO) after laparoscopic gastrectomy (LAG) for gastric cancer (GC) and establish a model to predict URO preoperatively.

Study design

Between May 2007 and December 2014, we prospectively collected and retrospectively analyzed the data of 2608 GC patients who underwent LAG. Among them, 2580 patients not requiring an URO were defined as the Non-URO group, and 28 patients requiring an URO were defined as the URO group. Univariate, multivariate, and bootstrap analyses were performed to determine the independent predictors for URO, and a nomogram was constructed to preoperatively predict the rate of URO after LAG.

Results

Of the 2608 patients, the URO rate was 1.1% (28/2608) within the 30-day hospitalization. The mean URO time interval to first operation was 5.6?±?5.5 (0.10–18.5) days. The main causes requiring URO were intraabdominal bleeding (57.1%), anastomotic bleeding (17.9%), anastomotic leakage (7.1%), and intraabdominal infection (7.1%). Compared to the Non-URO group, the URO group had a significantly longer hospital stay (p?<?0.001) and significantly higher hospital fees (p?<?0.001). The morbidity rate was 39.2% in the URO group and 14.5% in the non-URO group (p?=?0.001), and mortality was 3.6% in the URO group and 0.2% in the non-URO group (p?=?0.063). Multivariate analysis using bootstrap method revealed that age?>70 years (odds ratio (OR)?=?2.232, 95% confidence interval (CI)?=?1.023–4.491, p?=?0.028), male gender (OR?=?32.983, 95% CI 1.405–25.343?×?10⁶, p?=?0.027), and body mass index (BMI)?>?25 kg/m² (OR?=?2.550, 95% CI 1.017–5.398, p?=?0.012) were independent risk factors for URO. A multivariable nomogram model for predicting URO exhibited a strong optimism-adjusted discrimination (concordance index, 0.687). No significant correlation was noted between the URO rate and operative period by Spearman analysis (r?=?0.012, p?=?0.548).

Conclusions

Age?>?70 years, Male, and BMI?>?25 kg/m² were independent risk factors for URO. Based on the three risk factors, we developed a simple and practical nomogram to predict URO preoperatively, which might aid surgeons in reducing the URO rate when planning to perform LAG for GC.

     

Outcomes of selective nonoperative management of civilian abdominal gunshot wounds: a systematic review and meta-analysis

Background

Although mandatory laparotomy has been standard of care for patients with abdominal gunshot wounds (GSWs) for decades, this approach is associated with non-therapeutic operations, morbidity, and long hospital stays. This systematic review and meta-analysis sought to summarize outcomes of selective nonoperative management (SNOM) of civilian abdominal GSWs.

Methods

We searched electronic databases (March 1966–April 1, 2017) and reference lists of articles included in the systematic review for studies reporting outcomes of SNOM of civilian abdominal GSWs. We meta-analyzed the associated risks of SNOM-related failure (defined as laparotomy during hospital admission), mortality, and morbidity across included studies using DerSimonian and Laird random-effects models. Between-study heterogeneity was assessed by calculating I² statistics and conducting tests of homogeneity.

Results

Of 7155 citations identified, we included 41 studies [n?=?22,847 patients with abdominal GSWs, of whom 6777 (29.7%) underwent SNOM]. The pooled risk of failure of SNOM in hemodynamically stable patients without a reduced level of consciousness or signs of peritonitis was 7.0% [95% confidence interval (CI)?=?3.9–10.1%; I² =?92.6%, homogeneity p?<?0.001] while the pooled mortality associated with use of SNOM in this patient population was 0.4% (95% CI?=?0.2–0.6%; I² =?0%, homogeneity p?>?0.99). In patients who failed SNOM, the pooled estimate of the risk of therapeutic laparotomy was 68.0% (95% CI?=?58.3–77.7%; I² =?91.5%; homogeneity p?<?0.001). Risks of failure of SNOM were lowest in studies that evaluated patients with right thoracoabdomen (3.4%; 95% CI?=?0–7.0%; I² =?0%; homogeneity p?=?0.45), flank (7.0%; 95% CI?=?3.9–10.1%), and back (3.1%; 95% CI?=?0–6.5%) GSWs and highest in those that evaluated patients with anterior abdomen (13.2%; 95% CI?=?6.3–20.1%) GSWs. In patients who underwent mandatory abdominopelvic computed tomography (CT), the pooled risk of failure was 4.1% versus 8.3% in those who underwent selective CT (p?=?0.08). The overall sample-size-weighted mean hospital length of stay among patients who underwent SNOM was 6 days versus 10 days if they failed SNOM or developed an in-hospital complication.

Conclusions

SNOM of abdominal GSWs is safe when conducted in hemodynamically stable patients without a reduced level of consciousness or signs of peritonitis. Failure of SNOM may be lower in patients with GSWs to the back, flank, or right thoracoabdomen and be decreased by mandatory use of abdominopelvic CT scans.

     

Predictive Value of CEA for Survival in Stage I Rectal Cancer: a Population-Based Propensity Score-Matched Analysis

Background

The aim of the study was to assess whether preoperative carcinoembryonic antigen (CEA) level is an independent predictor of overall- and cancer-specific survival in stage I rectal cancer.

Methods

Stage I rectal cancer patients were identified in the Surveillance, Epidemiology, and End Results database between 2004 and 2011. The impact of an elevated preoperative CEA level (C1-stage) compared with a normal CEA level (C0-stage) on overall and cancer-specific survival was assessed using risk-adjusted Cox proportional hazard regression models and propensity score methods.

Results

Overall, 1932 stage I rectal cancer patients were included, of which 328 (17 %) patients had C1-stage. The 5-year overall and cancer-specific survival for patients with C0-stage were 85.7 % (95 % CI 83.2–88.2 %) and 94.7 % (95 % CI 93.1–96.3 %), versus 76.8 % (95 % CI 70.9–83.1 %) and 88.1 % (95 % CI 83.3–93.2 %) for patients with C1-stage (P?<?0.001 and P?=?0.001). The negative impact of C1-stage on overall and cancer-specific survival was confirmed by risk-adjusted Cox proportional hazard regression analysis (hazard ratio [HR]?=?1.57, 95 % CI?=?1.15–2.16, P?=?0.007 and 2.04, 95 % CI?=?1.25–3.33, P?=?0.006), and after propensity score matching (overall survival [OS]: HR?=?1.46, 95 % CI?=?1.02–2.08, P?=?0.044 and cancer-specific survival [CSS]: HR?=?3.28, 95 % CI?=?1.78–6.03, P?<?0.001).

Conclusion

This is the first population-based investigation of a large cohort of exclusively stage I rectal cancer patients providing compelling evidence that elevated preoperative CEA level is a strong predictor of worse overall and cancer-specific survival.

     

Early Postoperative Outcomes of Primary Bariatric Surgery in Patients on Chronic Steroid or Immunosuppressive Therapy

Background

Previous research suggests that patients on chronic steroids may be at an increased risk of postoperative morbidity after major surgery. We aimed to evaluate the prognostic impact of chronic use of steroid or immunosuppression on 30-day morbidity and mortality rates after primary bariatric surgery.

Methods

From American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database, we identified patients who underwent primary bariatric surgery between 2005 and 2013. Logistic regression was used to determine the prognostic impact of chronic use of steroid or immunosuppression on the 30-day postoperative outcomes.

Results

One thousand two hundred seventy seven steroid/immunosuppressant-dependent (SD) and 112,892 non-dependent (ND) patients were analyzed. SD patients had a higher baseline risk profile compared to ND patients. Thirty-day mortality rates for SD and ND patients were 0.55 and 0.11 %, respectively (P?<?0.001) which corresponds to an adjusted odds ration (OR) of 6.85 (95 % confidence interval (CI) 1.95–24.12). SD patients had a higher 30-day major morbidity compared to ND patients (5.01 versus 2.54 %; P?<?0.001, respectively). After adjustment, this translated into an OR of 2.21 (95 % CI 1.29–3.79). Among SD patients, there was no significant difference in 30-day major morbidity after gastric bypass compared to sleeve gastrectomy (OR?=?0.36; 95 % CI 0.08–1.66).

Conclusions

Chronic and active use of steroid or immunosuppressant medications is a strong predictor of 30-day postoperative morbidity and mortality following primary bariatric surgery. Among the steroid/immunosuppressant users, complication rates were similar for gastric bypass and sleeve gastrectomy patients. Further studies are needed to help guide the management or discontinuation of such medications in the perioperative period.

     

Readmission Following Gastric Cancer Resection: Risk Factors and Survival

Background

This study utilized a multi-institutional database to evaluate risk factors for readmission in patients undergoing curative gastrectomy for gastric adenocarcinoma with the intent of describing both perioperative risk factors and the relationship of readmission to survival.

Methods

Patients who underwent curative resection of gastric adenocarcinoma from 2000 to 2012 from seven academic institutions of the US Gastric Cancer Collaborative were analyzed. In-hospital deaths and palliative surgeries were excluded, and readmission was defined as within 30 days of discharge. Univariate and multivariable logistic regression analyses were employed and survival analysis conducted.

Results

Of the 855 patients, 121 patients (14.2 %) were readmitted. Univariate analysis identified advanced age (p?<?0.0128), American Society of Anesthesiology status ≥3 (p?=?0.0045), preexisting cardiac disease (p?<?0.0001), hypertension (p?=?0.0142), history of smoking (p?=?0.0254), increased preoperative blood urea nitrogen (BUN; p?=?0.0426), concomitant pancreatectomy (p?=?0.0056), increased operation time (p?=?0.0384), estimated blood loss (p?=?0.0196), 25th percentile length of stay (<7 days, p?=?0.0166), 75th percentile length of stay (>12 days, p?=?0.0256), postoperative complication (p?<?0.0001), and total gastrectomy (p?=?0.0167) as risk factors for readmission. Multivariable analysis identified cardiac disease (odds ratio (OR) 2.4, 95 % confidence interval (CI) 1.6–3.3, p?<?0.0001), postoperative complication (OR 2.3, 95 % CI 1.6–5.4, p?<?0.0001), and pancreatectomy (OR 2.2, 95 % CI 1.1–4.1, p?=?0.0202) as independent risk factors for readmission. There was an association of decreased overall median survival in readmitted patients (39 months for readmitted vs. 103 months for non-readmitted). This was due to decreased survival in readmitted stage 1 (p?=?0.0039), while there was no difference in survival for other stages. Stage I readmitted patients had a higher incidence of cardiac disease than stage I non-readmitted patients (58 vs. 24 %, respectively, p?=?0.0002).

Conclusions

Within this multi-institutional study investigating readmission in patients undergoing curative resection for gastric cancer, cardiac disease, postoperative complication, and concomitant pancreatectomy were identified as significant risk factors for readmission. Readmission was associated with decreased overall median survival, but on further analysis, this was driven by differences in survival for stage I disease only.

     

Systematic review and meta-analysis of minimally invasive versus open approach for pancreaticoduodenectomy

Backgrounds and objective

The technique of minimally invasive pancreatic surgeries has evolved rapidly, including minimally invasive pancreaticoduodenectomy (MIPD). However, controversy on safety and feasibility remains when comparing the MIPD with the open pancreaticoduodenectomy (OPD); therefore, we aimed to compare MIPD and OPD with a systemic review and meta-analysis.

Methods

Multiple electronic databases were systematically searched to identify studies (up to February 2016) comparing MIPD with OPD. Intra-operative outcomes, oncologic data, postoperative complications and postoperative recovery were evaluated.

Results

Twenty-two retrospective studies including 6120 patients (1018 MIPDs and 5102 OPDs) were included. MIPD was associated with a reduction in estimated blood loss (WMD ?312.00 ml, 95 % CI ?436.30 to ?187.70 ml, p < 0.001), transfusion rate (OR 0.41, 95 % CI 0.30–0.55, p < 0.001), wound infection (OR 0.37, 95 % CI 0.20–0.66, p < 0.001) and length of hospital stay (WMD ?3.57 days, 95 % CI ?5.17 to ?1.98 days, p < 0.001). Meanwhile, MIPD group has a higher R0 resection rate (OR 1.47, 95 % CI 1.18–1.82, p < 0.001) and more lymph nodes harvest (WMD 1.74, 95 % CI 1.03–2.45, p < 0.001). However, it had longer operation time (WMD 83.91 min, 95 % CI 36.60–131.21 min, p < 0.001). There were no significant differences between the two procedures in morbidities (p = 0.86), postoperative pancreatic fistula (p = 0.17), delayed gastric empting (p = 0.65), vascular resection (p = 0.68), reoperation (p = 0.33) and mortality (p = 0.90).

Conclusions

MIPD can be a reasonable alternative to OPD with potential advantages. However, further large-volume, well-designed RCTs with extensive follow-ups are suggested to confirm and update the findings of our analysis.

     

LBP rs2232618 polymorphism contributes to risk of sepsis after trauma

Background

Previous study revealed that rs2232618 polymorphism (Phe436Leu) within LBP gene is a functional variant and associated with susceptibility of sepsis in traumatic patients. Our aim was to confirm the reported association by enlarging the population sample size and perform a meta-analysis to find additional evidence.

Methods

Traumatic patients from Southwest (n?=?1296) and Southeast (n?=?445) of China were enrolled in our study. After genotyping, the relationship between rs2232618 and the risk of sepsis was analyzed. Furthermore, we proceeded with a comprehensive literature search and meta-analysis to determine whether the rs2232618 polymorphism conferred susceptibility to sepsis.

Results

Significance correlation was observed between rs2232618 and risk of sepsis in Southwest patients (P?=?0.002 for the dominant model, P?=?0.006 for the recessive model). The association was confirmed in Southeast cohort (P?=?0.005 for the dominant model) and overall combined cohorts (P =?4.5?×?10^?4, P?=?0.041 for the dominant and recessive model). Multiple logistical regression analyses suggested that rs2232618 polymorphism was related to higher risk of sepsis (OR?=?1.77, 95% CI?=?1.26–2.48, P?=?0.001 in Southwest patients; OR?=?2.11, 95% CI?=?1.24–3.58, P?=?0.006 in Southeast cohort; OR?=?1.54, 95% CI?=?1.34–2.08, P?=?0.006 in overall cohort). Furthermore, meta-analysis of four studies (including the present study) confirmed that rs2232618 within LBP increased the risk of sepsis (OR?=?1.75, P?<?0.001 for the dominant model; OR?=?6.08, P?=?0.003 for the recessive model; OR?=?2.72, P?<?0.001 for the allelic model).

Conclusions

The results from our replication study and meta-analysis provided firm evidence that rs2232618T allele significantly increased the risk of sepsis.

     

Incidence and risk factors for proximal junctional kyphosis: a meta-analysis

Purpose

To analyse the incidence and risk factors associated with proximal junctional kyphosis (PJK) following spinal fusion, we collect relative statistics from the articles on PJK and perform a meta-analysis.

Methods

An extensive search of literature was performed in PubMed, Embase, and The Cochrane Library (up to April 2015). The following risk factors were extracted: age at surgery, gender, combined anterior-posterior surgery, use of pedicle screw at top of construct, hybrid instrumentation, thoracoplasty, fusion to sacrum (S1), preoperative thoracic kyphosis angle (T5–T12) >40°, bone mineral density (BMD) and preoperative to postoperative sagittal vertical axis (SVA difference) >5 cm. Data analysis was conducted with RevMan 5.3 and STATA 12.0.

Results

A total of 14 unique studies including 2215 patients were included in the final analyses. The pooled analysis showed that there were significant difference in age at surgery >55 years old (OR 2.19, 95 % CI 1.36–3.53, p = 0.001), fusion to S1 (OR 2.12, 95 % CI 1.57–2.87, p < 0.001), T5–T12 >40° (OR 2.68, 95 % CI 1.73–4.13, p < 0.001), low BMD (OR 2.37, 95 % CI 1.45–3.87, p < 0.001) and SVA difference >5 cm (OR 2.53, 95 % CI 1.24–5.18, p = 0.01). However, there was no significant difference in gender (OR 0.98, 95 % CI 0.74–1.30, p = 0.87), combined anterior-posterior surgery (OR 1.55, 95 % CI 0.98–2.46, p = 0.06), use of pedicle screw at top of construct (OR 1.55, 95 % CI 0.67–3.59, p = 0.30), hybrid instrumentation (OR 1.31, 95 % CI 0.92–1.87, p = 0.13) and thoracoplasty (OR 1.55, 95 % CI 0.89–2.72, p = 0.13). The incidence of PJK following spinal fusion was 30 % (ranged from 17 to 62 %) based on the 14 studies.

Conclusions

The results of our meta-analysis suggest that age at surgery >55 years, fusion to S1, T5–T12 >40°, low BMD and SVA difference >5 cm are risk factors for PJK. However, gender, combined anterior–posterior surgery, use of pedicle screw at top of construct, hybrid instrumentation and thoracoplasty are not associated with PJK.

     

A Challenge between Trainee Education and Patient Safety: Does Fellow Participation Impact Postoperative Outcomes Following Bariatric Surgery?

Background

Surgical training may potentially influence patient care. A safe, high-quality bariatric and metabolic surgery practice requires dedicated and specialized training commonly acquired during a fellowship. This study evaluates the impact of fellow participation on early postoperative outcomes in bariatric surgery.

Methods

From the American College of Surgeons (ACS-NSQIP) database, we identified all obese patients who had undergone primary laparoscopic Roux-en-Y gastric bypass (LRYGB) and sleeve gastrectomy (LSG) between 2010 and 2012. Logistic regression was used to prognosticate the surgical fellow (PGY-6, 7, or 8) participation in bariatric surgeries on perioperative outcomes, as compared to surgeries with no trainee participation.

Results

The study cohort consisted of 10,838 patients (8819 LRYGB, 2019 LSG, 32 % fellow participation). Fellows participated in higher-risk surgeries. Fellow involvement was associated with increased operative time in LRYGB (difference 42.4?±?1.2 min, p?<?0.001) and in LSG (difference 38.8?±?2.5 min, p?<?0.001). Multivariate regression revealed that fellow involvement in LSG did not significantly alter postoperative adverse events. Conversely, in the LRYGB group, fellow participation was independently associated with higher rates of overall complications (OR?=?1.37, 95 % CI 1.16–1.63), serious complications (OR?=?1.23, 95 % CI 1.00–1.52), surgical complications (OR?=?1.42; 95 % CI 1.17–1.73), and reoperation (OR?=?1.43, 95 % CI 1.10–1.87). On adjusted analysis, while readmission was higher with fellow involvement in both procedures, mortality rates were comparable.

Conclusions

Fellow involvement resulted in a clinically appreciable increase in operative times. Fellow participation in the operating room was also independently associated with worse early postoperative outcomes following LRYGB, but was not the case for LSG. Promoting proficiency in surgical simulation laboratories and a gradual participation of fellows from LSG to LRYGB during fellowship may be associated with a reduction in postoperative complications.

     

ORIF versus arthroplasty for open proximal humerus fractures: Nationwide Inpatient Sample data between 1998 and 2013

Background

Limited data exists in analyzing open reduction and internal fixation (ORIF) and arthroplasty in the management of open proximal humerus fractures. We analyzed differences in hospital course between these procedures, patient demographics, complication rate, length of stay, hospital charges, and mortality rate.

Materials and methods

This is a retrospective review of the Nationwide Inpatient Sample database. ICD-9 codes identified patients hospitalized for open proximal humerus fractures from 1998 to 2013 who underwent ORIF or shoulder arthroplasty (hemi-, total, or reverse). Demographics and in-hospital complications were compared. Logistic regression controlling for age, gender, and Deyo index tested the impact of ORIF vs ARTH on any complications.

Results

Seven hundred thirty patients were included (ORIF, n?=?662 vs ARTH, n?=?68). ORIF patients were younger (p?<?0.001), more likely to be males (p?<?0.001), and had a lower Deyo score (p?=?0.012). Both groups had comparable complication rates (21.4% vs 18.0%, p?=?0.535), lengths of stay (7.86 days vs 7.44 days, p?=?0.833), hospital charges ($76,998 vs $64,133, p?=?0.360), and mortality rates (0.2% vs 0%, p?=?0.761). Type of surgery was not a predictor of any complications (OR?=?0.67 [95% CI 0.33–1.35], p?=?0.266), extended length of stay (OR?=?1.01 [95% CI 0.58–1.78], p?=?0.967), or high hospital charges (OR?=?1.39 [95% CI 0.68–2.86], p?=?0.366).

Conclusion

We revealed no differences in hospital course between ORIF and arthroplasty for management of open proximal humerus fractures. Although differences in demographics existed, no differences in complication rates, length of stay, hospital charges and mortality rates were noted. Future studies can evaluate the long-term outcomes of these procedures.

Level of evidence

Level III.

     

Zonal NephRo Score: external validation for predicting complications after open partial nephrectomy

Purpose

The aim of the study was to externally validate the Zonal NePhRO Score (ZNS) published in 2014 as latest and superior nephrometry score in terms of prediction of perioperative complications and outcome of open partial nephrectomies (OPNs).

Methods

We identified 200 consecutive patients who underwent OPN. Analysis of preoperative CT or MRI scans and retrospective analysis of the patients’ clinical records were performed. Tumour complexity was stratified according to the ZNS into three categories: low (4–6), moderate (7–9) and high (10–12) complexity. Predictors for perioperative complications and surgical parameters were identified using univariate and multivariate logistic regression.

Results

Tumour complexity was graded in 19.8 % of the cases as low, in 50.3 % as moderate and in 29.9 % as high. In the multivariate analysis, ZNS was significantly associated with a higher complication rate (OR 1.25, 95 % CI 1.04–1.49, p = 0.014), longer ischaemia time (IT) (β = 1.19, 95 % CI 0.33–2.05, p = 0.007), postoperative drop of estimated glomerular filtration rate (eGFR) (β = ?1.86, 95 % CI ?3.71 to ?0.01, p = 0.049) and opening of the collecting system (CS) (OR 1.72, 95 % CI 1.40–2.10, p < 0.001). In addition, age and body mass index were identified as independent predictors for complications (OR 1.03, 95 % CI 1.00–1.06, p = 0.043 and OR 1.08, 95 % CI 1.00–1.15, p = 0.031).

Conclusion

The present study is the first external validation of the ZNS as a predictor of perioperative complications in patients undergoing OPN. A higher ZNS score was associated with a longer IT, a higher rate of opening the CS and drop of eGFR.

     

Novel effects of sarcopenic osteoarthritis on metabolic syndrome,insulin resistance,osteoporosis, and bone fracture: the national survey

Summary

This study compared the effects sarcopenic osteoarthritis on metabolic syndrome, insulin resistance, osteoporosis, and bone fracture. By using national survey data, we suggest that the relationship between sarcopenia and metabolic syndrome or insulin resistance is potentiated by the severity of osteoarthritis and is independent of body weight.

Introduction

Sarcopenia and osteoarthritis are known risk factors for metabolic syndrome. However, their combined effects on metabolic syndrome, insulin resistance and osteoporosis remain uncertain.

Methods

We used data from the fifth Korean National Health and Nutrition Examination Survey using a total of 3158 adults (age >50 years). Sarcopenia was defined as a skeletal muscle index score (appendicular skeletal muscle mass/body weight) within the fifth percentile of sex-matched younger reference participants. Radiographic knee osteoarthritis was defined as a Kellgren-Lawrence (K-L) grade of 2 or greater. Metabolic syndrome was diagnosed using the National Cholesterol Education Program criteria. Insulin resistance was evaluated using the homeostasis model assessment-estimated insulin resistance index (HOMA-IR). Osteoporosis was defined using the World Health Organization T-score criteria.

Results

In multivariable logistic regression analysis, the sarcopenic osteoarthritis group had a higher odds ratio (OR) for metabolic syndrome (OR?=?11.00, 95 % confidential interval (CI)?=?2.12–56.99, p?=?0.013) than the non-sarcopenic osteoarthritis (OR?=?1.02, 95 % CI?=?0.65–1.62, p?=?0.972) and sarcopenic non-osteoarthritis groups (OR?=?7.15, 95 % CI?=?1.57–32.53, p?=?0.027). Similarly, sarcopenic osteoarthritis had a greater OR of highest HOMA-IR quartiles (OR?=?8.19, 95 % CI?=?2.03–33.05, p?=?0.003) than the other groups. Overall, the association between the K-L grade and body mass index was significant; however, this significance was lower in individuals with sarcopenia and was lost in those with sarcopenic osteoarthritis. Additionally, osteoporosis and bone fracture were not associated to sarcopenic osteoarthritis (p?>?0.05).

Conclusions

These results suggest that the relationship between sarcopenia and metabolic syndrome or insulin resistance is potentiated by the severity of osteoarthritis and is independent of body weight.

     

Differences in Characteristics and Outcome of Patients with Penetrating Injuries in the USA and the Netherlands: A Multi-institutional Comparison

Introduction

The incidence and nature of penetrating injuries differ between countries. The aim of this study was to analyze characteristics and clinical outcomes of patients with penetrating injuries treated at urban Level-1 trauma centers in the USA (USTC) and the Netherlands (NLTC).

Methods

In this retrospective cohort study, 1331 adult patients (470 from five NLTC and 861 from three USTC) with truncal penetrating injuries admitted between July 2011 and December 2014 were included. In-hospital mortality was the primary outcome. Outcome comparisons were adjusted for differences in population characteristics in multivariable analyses.

Results

In USTC, gunshot wound injuries (36.1 vs. 17.4%, p?<?0.001) and assaults were more frequent (91.2 vs. 77.7%, p?<?0.001). ISS was higher in USTC, but the Revised Trauma Score (RTS) was comparable. In-hospital mortality was similar (5.0 vs. 3.6% in NLTC, p?=?0.25). The adjusted odds ratio for mortality in USTC compared to NLTC was 0.95 (95% confidence interval 0.35–2.54). Hospital stay length of stay was shorter in USTC (difference 0.17 days, 95% CI ?0.29 to ?0.05, p?=?0.005), ICU admission rate was comparable (OR 0.96, 95% CI 0.71–1.31, p?=?0.80), and ICU length of stay was longer in USTC (difference of 0.39 days, 95% CI 0.18–0.60, p?<?0.0001). More USTC patients were discharged to home (86.9 vs. 80.6%, p?<?0.001). Readmission rates were similar (5.6 vs. 3.8%, p?=?0.17).

Conclusion

Despite the higher incidence of penetrating trauma, particularly firearm-related injuries, and higher hospital volumes in the USTC compared to the NLTC, the in-hospital mortality was similar. In this study, outcome of care was not significantly influenced by differences in incidence of firearm-related injuries.