Age as a risk factor in major genitourinary surgery.

Surgery for urinary incontinence is often not considered in elderly persons (older than 65 years) because of their age. In this paper the authors examine the effect of age on the success rate and complications of abdominal correction (modified retropubic colpourethropexy with or without other major gynecologic surgery) for genuine stress incontinence. Other than age, length of hospital stay and some urodynamic values there were no statistically significant differences in success and complication rates between the elderly and younger patients. The authors conclude that in properly selected elderly patients with genuine stress incontinence, retropubic colpourethropexy is as safe and effective as in younger patients.     

Obesity as a risk factor for complications during laparoscopic surgery for renal cancer: multivariate analysis

BACKGROUND AND PURPOSE: A number of clinical variables are believed to be risk factors for complications of laparoscopic renal surgery. We reviewed our experience with laparoscopic surgery specifically for renal cancers to better clarify which clinical variables were significant risk factors. METHODS: Our laparoscopic experience with 210 cases of renal cancer from April 1999 through August 2004 was reviewed. Preoperative clinical characteristics were recorded. Complete information was available for 134 patients: 54 radical nephrectomies, 41 nephroureterectomies, 19 radiofrequency ablations, and 20 partial nephrectomies. Outcomes monitored included blood loss, length of hospital stay, conversion, blood transfusion, and intraoperative, minor postoperative, and major postoperative complications. Multivariate analysis was performed to determine whether any variable was a significant risk factor for adverse outcomes during or after laparoscopic surgery. RESULTS: The numbers of patients requiring operative conversion or blood transfusions were 6 (4.5%) and 20 (14.9%), respectively. Intraoperative, minor postoperative, and major postoperative complication occurred in 9 (6.7%), 22 (16.4%), and 11 (8.2%) patients, respectively. The year surgery was performed was inversely proportional to the incidence of minor postoperative complications, implying a protective association with the experience of the surgeon. On multivariate analysis, only body mass index (BMI) was found to be a significant risk factor for major postoperative complications with an odds ratio of 1.14 (P = 0.03). CONCLUSIONS: Laparoscopic surgery is safe, but with every unit increase in the BMI, the risk of a major complication increases by 14%.     

Donor age as a risk factor for patient survival in the liver transplant

OBJECTIVES: Our aims were to establish whether there is a relationship between donor age and patient and graft survival among liver transplant recipients and to determine the age at which this relationship emerges. PATIENTS AND METHODS: We reviewed 254 consecutive liver transplants performed at the Hospital Ramón y Cajal, Madrid in 206 patients over a 79-month period. Survival rates were determined using Kaplan-Meier curves analyzed by the log-rank method. RESULTS: The mean donors age was 42.08+/-17.89 years (range 8-79 years). The minimum and mean patient follow-up times were 6 months and 29.48+/-23.37 months. Mean patient and graft survival rates, along with their standard errors and 95% confidence intervals were 62.47+/-2.42(57.72-67.21) and 57.30+/-2.40(52.59-62.01) months, respectively. Mean survival was lower (P=.047) among patients who received a graft from a donor of 30 or more years (58.24+/-3.05[52.28-64.21] months) versus from a younger donor (66.19+/-3.55[59.23-73.15] months). Graft survival was also significantly different (P=.037) for donors older versus younger than 25 years (53.04+/-2.83[47.50-58.58] and 64.72+/-4.11[56.67-72.77] months, respectively). CONCLUSIONS: Patients undergoing liver transplant show lower survival when the donor is older than 30 and the survival of the implanted graft is also lower when the donor is over 25.     

Preoperative assessment of mortality risk in hepatic resection by clinical variables: a multivariate analysis.

Hepatic resection is a chance for cure for primary and secondary liver tumors and a variety of benign diseases. Despite advances in surgical technique and patient care, preoperative and postoperative morbidity in patients undergoing liver resection remains high. Because a high morbidity represents a risk factor contributing to a fatal outcome of the surgical procedure, our study aimed to investigate the contribution of different risk factors to a fatal outcome and if mortality can be predicted by the presence of certain risk factors. Two hundred fifty-seven patients undergoing hepatic resection (curative and palliative) were analyzed preoperatively, immediately after surgery, and 10 days after surgery for 60 potential risk factors. Survivors (n = 238) and nonsurvivors (n = 19) were compared univariately. The analysis identified 14 variables to differentiate between groups. These variables were processed by multivariate logistic regression analysis. Three models to estimate 30-day mortality were identified, tested for statistical accuracy, and assessed for their receiver-operated characteristics (ROCs). The variables in the multivariate models were as follows: preoperatively, age, number of comorbid factors, and presence of cirrhosis; immediately after surgery, age, number of comorbid factors, and percentage of resected liver; and 10 days after surgery, age, hours of ventilation, and number of adverse events. Goodness of fit was 0. 863, 0.912, and 0.966, respectively. Areas under the ROC curves were 83.6%, 85.7%, and 98.0%. The specificity (probability to identify survivors correctly) was greater than 90% for all models, although sensitivity (probability to identify nonsurvivors correctly) was greater than 90% only for 10 days after surgery. We conclude that logistic regression is appropriate to assess the importance of risk factors in the course of hepatic resection and to identify patient groups at high risk.     

Surgical complications requiring early relaparotomy after pancreas transplantation: a multivariate risk factor and economic impact analysis of the cyclosporine era.

OBJECTIVES: To study significant surgical complications requiring early (< or = 3 months posttransplant) relaparotomy (relap) after pancreas transplants, and to develop clinically relevant surgical and peritransplant decision-making guidelines for preventing and managing such complications. SUMMARY BACKGROUND DATA: Pancreas grafts are still associated with the highest surgical complication rate of all routinely transplanted solid organs. However, the impact of surgical complications on morbidity, hospital costs, and graft and patient survival rates has not been analyzed in detail to date. METHODS: We retrospectively studied surgical complications requiring relap in 441 consecutive cadaver, bladder-drained pancreas transplants (54% simultaneous pancreas and kidney [SPK]; 22% pancreas after kidney [PAK]; 24% pancreas transplant alone [PTA]; 37% retransplant). Outcome and hospital charges were analyzed separately for recipients with versus without reoperation. RESULTS: The overall relap rate was 32% (SPK, 36%; PAK, 25%; PTA, 16%; p = 0.04). The most common causes were intraabdominal infection and graft pancreatitis (38%), pancreas graft thrombosis (27%), and anastomotic leak (15%). Perioperative relap mortality was 9%; transplant pancreatectomy was necessary in 57% of all recipients with one or more relaps. The pancreas graft was lost in 80% of recipients with versus 41% without relap (p < 0.0001). Patient survival rates were significantly lower (p < 0.05) for recipients with versus without relap. By multivariate analysis, significant risk factors for graft loss included older donor age (SPK, PAK), retransplant (PAK), relap for infection (SPK, PAK), and relap for leak or bleeding (PAK). For death, risk factors included older recipient age (SPK, PAK),retransplant (SPK, PAK), relap for thrombosis (PAK), relap for infection or leak (SPK), and relap for bleeding (PTA). CONCLUSIONS: Posttransplant surgical complications requiring relap were frequent, resulted in a high rate of pancreas (SPK, PAK, PTA) and kidney (SPK, PAK) graft loss, and had a major economic impact (p = 0.0001). Complications were associated with substantial perioperative mortality and decreased patient survival rates. The focus must therefore shift from graft salvage to preservation of the recipient's life once a pancreas graft-related complication requiring relap occurs. Thus, the threshold for pancreatectomy should be low. In this context, acceptance of older donors and recipients must be reconsidered.     

Hyperlipidemia as a risk factor of renal allograft function impairment

In this study, the graft outcome in renal allograft recipients with [high cholesterol group (HCG), n = 30] or without [normal cholesterol group (NCG), n = 42] hypercholesterolemia and with [high triglyceride group (HTG), n = 33] or without [normal triglyceride group (NTG), n = 36] hypertriglyceridemia were prospectively compared. At 6 months post-transplantation, no significant difference was observed between the groups (NTG compared with HTG, and NCG compared with HCG) regarding age, presence of arterial hypertension, kind of donor (living related or cadaveric), immunosuppressive therapy, number of rejection episodes per patient, frequency of patients with acute cellular rejection, prevalence of patients with diabetes mellitus or proteinuria > 3 g/24 h, and mean serum creatinine. The probability of doubling serum creatinine during follow-up was statistically different between NTG and HTG (12 months: NTG = 0.03, HTG = 0.15; 36 months: NTG = 0.08, HTG = 0.33: 60 months: NTG = 0.08, HTG = 0.48; and 120 months: NTG = 0.18, HTG = 0.48), but not between NCG and HCG (12 months: NCG = 0.05, HCG = 0.13; 36 months: NCG = 0.13, HCG = 0.24; 60 months: NCG = 0.19, HCG = 0.31; 84 months: NCG = 0.27, HCG = 0.31). There was no significant difference in actuarial graft survival between HCG and NCG or between NTG and HTG. Hypertriglyceridemia, but not hypercholesterolemia, was associated with loss of graft function.     

Hepatic steatosis as a potential risk factor for major hepatic resection

Hepatic steatosis is a recognized risk factor for primary nonfunction of hepatic allografts, but the effect of steatosis on postoperative recovery after major liver resection is unknown. Our aim was to determine if hepatic steatosis is associated with increased perioperative morbidity and mortality in patients undergoing major resection. A retrospective review of medical records of 13 5 patients who had undergone major hepatic resection from 1990 to 1993 was performed. Histopathology of the hepatic parenchyma at the resection margin was reviewed for the presence of macroor microvesicular steatosis. The extent of steatosis was graded as none (group l), mild with less than 30% hepatocytes involved (group 2), or moderate-to-severe with 30% or more hepatocytes involved (group 3). Outcome of patients was correlated with extent of steatosis. Patients with moderate-to-severe steatosis were obese (body mass index = 25.8 +-2 0.5 vs. 26.5 t 1.0+-. 33.4 +2.9; P <0.05 groups 1,2, and 3, respectively) and had an increased serum bilirubin concentration preoperatively. Hepatectomy required a longer operative time for group 3 (290 +-2 9 minutes vs. 287 +13 minutes vs. 35.5 +24 minutes; P <0.05 groups 1,2, and 3, respectively). Likelihood of blood transfusion was 5 1% in group l,S2 % in group 2, and 7 1% in group 3. Mortality was 14% in group 3 vs. 3% in group 1, and 7% in group 2; and liver failure occurred in 14% of patients in group 3 compared to 4% and 9% in groups 1 and 2, respectively. Patients in group 3 also had increased post-operative bilirubin levels compared to preoperative values. Moderate-to-severe hepatic steatosis may be associated with increased perioperative morbidity and mortality, and preoperative identification of steatosis warrants caution prior to major resection. Presented at the Thirty-Eighth Annual Meeting of The Society for Surgery of the Alimentary Tract, Washington, D.C., May 11–14, 1997.     

DNA ploidy is a major prognostic factor in advanced gastric carcinoma--univariate and multivariate analysis

DNA ploidy was determined by cytofluorometric analysis of paraffin-embedded malignant tissue from 96 Japanese patients in whom gastric carcinoma had invaded the serosa. Aneuploidy was found in gastric carcinoma tissue from 63 patients (66%). The postoperative 5-year survival rate of patients with aneuploid malignancy was significantly lower (13%) than those with diploid malignancy (36%) (p less than 0.05). A multivariate analysis of various clinical and pathologic factors showed that tumor size, lymph node metastasis, vascular invasion, and DNA ploidy were significant and independent factors, which correlated with prognosis.     

Mixed allogeneic chimerism as a reliable model for composite tissue allograft tolerance induction across major and minor histocompatibility barriers

BACKGROUND: Although prolonged composite tissue allograft (CTA) survival is achievable in animals using immunosuppressive drugs, long-term immunosuppression of CTAs in the clinical setting may be unacceptable for most patients. The purpose of this study was to develop a model for reliable CTA tolerance induction in the adult rat across a major MHC mismatch without the need for long-term immunosuppression. METHODS: Mixed allogeneic chimeras were prepared by using rat strains with strong MHC incompatibility [WF (RT1Au), ACI (RT1Aa)] WF + ACI-->WF, n=23. The bone marrow (BM) of recipient animals was pretreated with low-dose irradiation (500-700 cGy), followed by reconstitution with a mixture of T cell-depleted syngeneic (WF) and allogeneic (ACI) cells. Additionally, the recipient animals received a single dose of anti-lymphocyte serum (10 mg) 5 days before bone marrow transplantation (BMT) and tacrolimus (1 mg/kg/day) from the day before BMT to 10 days post-BMT. Hindlimb transplants were performed 12 months after BMT. Five animals received a limb allograft irradiated (1000 cGy) just before transplantation. Rat chimeras were characterized (percentage of donor cells present within the bloodstream) by flow cytometry at 3 and 12 months after BM reconstitution and after hindlimb transplantation. RESULTS: Peripheral blood lymphocyte chimerism (WF/ACI) remained stable >12 months after BM reconstitution in 18/23 animals. Multi-lineage chimerism of both lymphoid and myeloid lineages was present, suggesting that engraftment of the pluripotent rat stem cell had occurred. In animals with donor chimerism >60% (n=18) no sign of limb rejection was present for the duration of the study. All animals with chimerism <20% (n=5) developed moderate signs of rejection clinically and histologically. Gross motor and sensory reinnervation (weight bearing, toe spread) developed at >60 days in 14/21 rats. Postoperative flow cytometry studies demonstrated stable chimerism in all animals studied (n=10). Five out of five animals with irradiated limb transplants showed no sign of GVHD at >100 days. CONCLUSIONS: Stable mixed allogeneic chimerism can be achieved in a rat hindlimb model of composite tissue allotransplantation. Hindlimb allografts to mixed allogeneic chimeras exhibit prolonged, rejection-free survival. Partial functional return should be expected. The BM transplanted as part of the hindlimb allograft plays a role in the etiology of GVHD. Manipulating that BM before transplantation may influence the incidence of GVHD. This represents the first reliable rat hindlimb model demonstrating rejection-free CTA survival in an adult animal across a major MHC mismatch without the long-term need for immunosuppressive agents.     

Acute thrombosis of prosthetic valves: a multivariate analysis of the risk factors for a lifethreatening event.

In 3231 prosthetic valves implanted between January 1975 and November 1990, we observed 61 cases of prosthetic obstruction of biological origin with clinical and laboratory findings of severe functional impairment which required surgery as emergency treatment. The hospital mortality was 19.67% (12/61). The obstruction was due to a primary thrombosis in all 5 bioprostheses which were not anticoagulated and in 11/56 (19.64%) mechanical prostheses of which 3 were not anticoagulated and 4 were not properly anticoagulated. The obstruction was due to fibrous tissue overgrowth in the other 45 mechanical prostheses (80.35%) with secondary thrombosis in 34 cases (60.71%) and no thrombosis in 11 (19.64%); 71.11% of these prostheses were adequately anticoagulated. Of the 61 obstructed prostheses, 53 were mitral and 8 were aortic. No tricuspid obstruction was observed. A statistical assessment by multiple correspondence, cluster and chi square analysis was performed in two groups of patients with different models of mechanical mitral prostheses. The 5-year actuarial incidence of obstruction was 6.08%. Significant risk factors were: tilting disc prostheses, prostheses without pyrocarbon coating, large prostheses, tilting disc prostheses with a small orifice posteriorly oriented, atrial fibrillation, enlarged left atrium, time from implant greater than 4 years, age between 40 and 50 years. In our opinion, prosthetic obstruction may be referred to a primary thrombosis only in cases where it may be prevented by adequate anticoagulation. In most cases, the obstruction is produced by periprosthetic fibroblastic proliferation which may develop in spite of adequate anticoagulation in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)     

肝内胆管空肠吻合手术严重并发症和病死率的多因素分析

目的探讨肝内胆管空肠吻合术的术后严重并发症及其危险因素。方法回顾性分析1990年1月至2004年8月暨南大学附属广州市红十字会医院163例行肝内胆管空肠吻合术病人的手术死亡和术后严重并发症的情况，并通过单因素分析和多因素分析评价其危险因素。结果住院期间病死率为11．7％（19／163），与手术相关的严重并发症发生率为23．9％（39／163）。Logistic回归分析显示，发生并发症危险因素依次是低蛋白血症、胆肠吻合口过多、病人有心肺合并症或糖尿病和恶性病变，而影响手术死亡率的危险因素是恶性病变、低蛋白血症和心肺合并症或糖尿病。结论术前肝功能不良是肝内胆管空肠吻合术术后并发症最主要的危险因素。手术医生正确掌握相关危险因素，提高手术技能是减少术后并发症的关键。