A morphological study of lumbar vertebral endplates: radiographic, visual and digital measurements

Purpose

Clinical observations suggest that endplate shape and size are related to complications of disc arthroplasty surgery. Yet, the morphology of the vertebral endplate has not been well defined. This study was conducted to characterize the morphology of lumbar vertebral endplates and to quantify their morphometrics using radiographic, visual and digital measures.

Methods

A total of 591 vertebral endplates from 76 lumbosacral spines of men were studied (mean age 51.3 years). The shape of the vertebral endplates was classified as concave, flat and irregular, and was evaluated from both radiographs and cadaveric samples. Each endplate was further digitized using a laser scanner to quantify diameters, surface area and concavity for the whole endplate and its components (central endplate and epiphyseal rim). The morphological characteristics and morphometrics of the vertebral endplates were depicted.

Results

In both radiographic and visual assessments, more cranial endplates (relative to the disc) were concave and more caudal endplates were flat at all disc levels (p < 0.001). On average, the mean concavity depth was 1.5 mm for the cranial endplate and 0.7 mm for the caudal endplate. From L1/2 down to L5/S1 discs, the vertebral endplate gradually changed into a more oval shape. The central endplate was approximately 70 % of the diameter of the whole endplate and the width of the epiphyseal rim varied from 3 to 7 mm.

Conclusions

There is marked morphological asymmetry between the two adjacent endplates of a lumbar intervertebral disc: the cranial endplate is more concave than the caudal endplate. The size and shape of the vertebral endplate also vary considerably between the upper and lower lumbar regions.     

Traitement de la sténose lombaire dégénérative symptomatique par mise en place percutanée d’implant interépineux. Expérience préliminaire avec l’implant Aperius

Background and purpose

Surgery for degenerative spinal stenosis classically involves decompression by laminectomy or foraminotomy. The use of interspinous process devices has been described for these indications in recent years. This study evaluates the efficacy and morbidity of a percutaneous interspinous device to define whether this technique would be a suitable alternative to classical surgery.

Method

Twenty-two patients with degenerative lumbar spinal stenosis were studied prospectively. Pre- and postoperative symptoms were assessed using the Visual Analogic Score (VAS), the Zurich Claudication Questionnaire (ZCQ), physical activity, and patient satisfaction. The implant was positioned under biplanar fluoroscopic control after progressive distraction of the interspinous space using trocars. The patients were reviewed after 7 days, 6 weeks, and 6 months.

Results

All patients showed improved gait perimeter: 90 % could walk more than 1000 m 6 months after surgery, whereas only 50 % could walk this distance preoperatively. The mean symptom severity scores of 2.71 and physical activity scores of 2.38 improved to 1.87 (p = 0.0003) and 1.53 (p < 0.0001), respectively, after 6 months. The VAS decreased 3.5 points (p = 0.0008) 6 months after surgery for leg pain. Ninety-one percent of the patients declared they were satisfied with the operation.

Conclusion

The Aperius stand-alone and percutaneous interspinous device proved to be effective and safe in treating symptomatic lumbar spinal stenosis. This could be a good alternative to classic decompression surgery, but long-term follow-up studies are needed as well as subgroup analysis to define which patients could benefit from this technique.     

Study to determine the presence of progenitor cells in the degenerated human cartilage endplates

Introduction  

Cartilage endplate (CEP) degeneration is usually accompanied by loss of cellularity, and this loss may be a crucial key factor in initiation and development of degenerative disc disease. The study of cell types in degenerated CEP could help in understanding CEP etiopathogenesis, and may help in devising new treatments, especially if the presence of progenitor cells could be demonstrated. The aim of this study was to determine if progenitor cells existed in degenerated human CEP.     

Road use pattern and risk factors for non-fatal road traffic injuries among children in urban India

Objective

We assessed the road use pattern and incidence and risk factors of non-fatal road traffic injuries (RTI) among children aged 5-14 years in Hyderabad, India.

Methods

In a cross-sectional population-based survey, data were collected on 2809 participants aged 5-14 years (98.4% participation) selected using multi-stage cluster sampling. Participants recalled non-fatal RTI during the previous 3 and 12 months. RTI was defined as an injury resulting from a road traffic crash irrespective of severity and outcome.

Results

Boys (11.5) had a higher mean number of road trips per day than girls (9.6), and the latter were more likely to walk and less likely to use a cycle (p < 0.001). With increasing household income quartile, the proportion of trips using cycles or motorised two-wheeled vehicles increased while trips as pedestrians decreased (p < 0.001). Based on the 3-month recall period, the age-sex-adjusted annual rate of RTI requiring recovery period of >7 days was 5.8% (95% CI 4.9-6.6). Boys and girls had similar RTI rates as pedestrians but boys had a three times higher rate as cyclists. Considering the most recent RTI in the last 12 months, children of the highest household income quartile were significantly less likely to sustain pedestrian RTI (0.26, 95% CI 0.08-0.86). The odds of overall RTI were significantly higher for those who rode a cycle (2.45, 95% CI 1.75-3.42) and who currently drove a motorised two-wheeled vehicle (2.83, 95% CI 1.60-5.00).

Conclusion

These findings can assist in planning appropriate road safety initiatives to reduce cycle and pedestrian RTI among children to reduce RTI burden in India.     

Stromal progenitor cells promote leukocyte migration through production of stromal-derived growth factor 1alpha: a potential mechanism for stromal progenitor cell-mediated enhancement of cellular recruitment to wounds

Background/Purpose

Stromal progenitor cells (SPC) enhance tissue repair in a variety of injury models. However, the mechanisms by which SPCs facilitate tissue repair remain poorly understood. We hypothesized that SPC-enhanced tissue repair is, in part, because of SPC-mediated recruitment of circulating cells to areas of tissue injury. To test this, we examined the migration of leukocytes in response to SPC in vitro.

Methods

Leukocyte migration was assessed in response to SPC, SPC + transforming growth factor (TGF)-β1, or SPC + AMD3100 using a Transwell assay system (Corning, distributed by Fisher Scientific, Pittsburgh, PA). Supernatants were collected from lower chambers and analyzed for leukocyte content, leukocyte viability, and stromal-derived growth factor (SDF)-1α concentration.

Results

Stromal progenitor cells increased leukocyte migration compared to media alone (450 ± 70 vs 112 ± 17 cells/μL; P < .05). SPC treatment with TGF-β1 resulted in a 36% increase in leukocyte migration and correlated with an increase in SDF-1α production. Treatment with AMD3100 resulted in inhibition of leukocyte migration.

Conclusions

Stromal progenitor cells promote leukocyte migration, and this appears to be mediated through SDF-1α production. The SPC production of SDF-1α may be modulated by other cytokines present in the microenvironment during wound healing. Together, these observations provide a potential mechanism by which SPC may augment healing through enhanced recruitment of inflammatory cells and tissue progenitor cells to areas of tissue injury.     

Mechanism of bar displacement and corresponding bar fixation techniques in minimally invasive repair of pectus excavatum

Purpose

Bar displacement is a major complication in repair of pectus excavatum with the Nuss technique. Mechanisms of bar displacement have been elucidated by case-by-case analysis, and specific bar fixation techniques have been developed to deal with each mechanism. The efficacy of our bar fixation techniques is appraised.

Methods

Data from 725 consecutive patients between 1999 and 2006 who were repaired with our modifications to the Nuss procedure were retrospectively analyzed.

Results

The mechanism of bar displacement consisted of one or a combination of the following types: type 1, “bar flipping”—rotation of the bar along the axis of hinge; type 2, “lateral sliding”—horizontal slipping of the bar to one side in asymmetric pectus excavatum; and type 3, “hinge-point disruption”—a dorsal shift of the bar owing to tearing of the supporting intercostal musculature. Specific bar fixation techniques have been tailored to compensate for potential mechanisms of bar displacement according to pectus morphology: multipoint pericostal bar fixation (MPF) (n = 496) for type 1 displacement; incorporation of a stabilizer on the depressed side (n = 169) for type 2 displacement; and hinge point reinforcement and the crane technique (n = 122) for type 3 displacement. The bar displacement rate was decreased with our mechanism-based approach (4.6% before MPF vs 1.8% after MPF, P = .045). In addition, the major complication rates (6.8% before MPF vs 2.0% after MPF, P = .001) and reoperation rates (5.5% before MPF vs 1.6% after MPF, P = .019) decreased.

Conclusions

Mechanism-based bar fixation techniques, especially multipoint pericostal wire fixation, seems to be effective in preventing bar displacement following pectus excavatum repair.     

Morphological changes of the neural cells after blast injury of spinal cord and neuroprotective effects of sodium β-aescinate in rabbits

Objective

Explosive blast neurotrauma is becoming more and more common not only in the military population but also in civilian life due to the ever-present threat of terrorism and accidents. However, little attention has been offered to the studies associated with blast wave-induced spinal cord injury in the literatures. The purpose of this study is to report a rabbit model of explosive blast injury to the spinal cord, to investigate the histological changes, focusing especially on apoptosis, and to reveal whether β-aescinate (SA) has the neuroprotective effects against the blast injury.

Methods

Adult male New Zealand white rabbits were randomly divided into sham group, experimental group and SA group. All rabbits except the sham group were exposed to the detonation, produced by the blast tube containing 0.7 g cyclotrimethylene trinitramine, with the mean peak overpressure of 50.4 MP focused on the dorsal surface of T9-T10 level. After evaluation of the neurologic function, spinal cord of the rabbits was removed at 8 h, 1, 3, 7,14 or 30 days and the H&E staining, EM examination, DNA gel electrophoresis and TUNEL were progressively performed.

Results

The study demonstrated the occurrence of both necrosis and apoptosis at the lesion site. Moreover, the SA therapy could not only improve the neurologic outcomes (P < 0.05) but also reduce the loss of motoneuron and TUNEL-positive rate (P < 0.05).

Conclusions

In the rabbit model of explosive blast injury to the spinal cord, the coexistent apoptotic and necrotic changes in cells was confirmed and the SA had neuroprotective effects to the blast injury of the spinal cord in rabbits. This is the first report in which the histological characteristics and drug treatment of the blast injury to the spinal cord is demonstrated.     

Salvage radical prostatectomy for radiation-recurrent prostate cancer: a multi-institutional collaboration

Background

Oncologic outcomes in men with radiation-recurrent prostate cancer (PCa) treated with salvage radical prostatectomy (SRP) are poorly defined.

Objective

To identify predictors of biochemical recurrence (BCR), metastasis, and death following SRP to help select patients who may benefit from SRP.

Design, setting, and participants

This is a retrospective, international, multi-institutional cohort analysis. There was a median follow-up of 4.4 yr following SRP performed on 404 men with radiation-recurrent PCa from 1985 to 2009 in tertiary centers.

Intervention

Open SRP.

Measurements

BCR after SRP was defined as a serum prostate-specific antigen (PSA) ≥0.1 or ≥0.2 ng/ml (depending on the institution). Secondary end points included progression to metastasis and cancer-specific death.

Results and limitations

Median age at SRP was 65 yr of age, and median pre-SRP PSA was 4.5 ng/ml. Following SRP, 195 patients experienced BCR, 64 developed metastases, and 40 died from PCa. At 10 yr after SRP, BCR-free survival, metastasis-free survival, and cancer-specific survival (CSS) probabilities were 37% (95% confidence interval [CI], 31-43), 77% (95% CI, 71-82), and 83% (95% CI, 76-88), respectively. On preoperative multivariable analysis, pre-SRP PSA and Gleason score at postradiation prostate biopsy predicted BCR (p = 0.022; global p < 0.001) and metastasis (p = 0.022; global p < 0.001). On postoperative multivariable analysis, pre-SRP PSA and pathologic Gleason score at SRP predicted BCR (p = 0.014; global p < 0.001) and metastasis (p < 0.001; global p < 0.001). Lymph node involvement (LNI) also predicted metastasis (p = 0.017). The main limitations of this study are its retrospective design and the follow-up period.

Conclusions

In a select group of patients who underwent SRP for radiation-recurrent PCa, freedom from clinical metastasis was observed in >75% of patients 10 yr after surgery. Patients with lower pre-SRP PSA levels and lower postradiation prostate biopsy Gleason score have the highest probability of cure from SRP.     

Effect of endplate reduction on endplate healing morphology and intervertebral disc degeneration in patients with thoracolumbar vertebral fracture

Objective

To determine the effect of endplate reduction on the final healing morphology and degenerative changes in intervertebral discs.

Methods

Forty-eight patients with single-level thoracolumbar fractures with endplate injury were included. All patients underwent posterior reduction and pedicle screw fixation, and postoperative imaging was used to determine whether endplate reduction was successful. The healing morphology of the endplate was divided into three types: increased endplate curvature, irregular healing and traumatic Schmorl node. MRI was performed at baseline and at the last follow-up evaluation to observe changes in disc degeneration (disc height and nucleus pulposus signal) and Modic changes.

Results

The reduction rate in the central area was significantly lower than that in the peripheral area (P = 0.017). In patients with successful reduction, 90.9% (20/22) of the endplates healed with increased curvature. In patients with an unsuccessful endplate reduction, 63.4% (26/41) of the endplates healed irregularly, and 34.1% (14/41) of the endplates formed traumatic Schmorl nodes. Endplate reduction was closely related to the final healing morphology of the endplate (P < 0.001), which had a significant protective effect on the degeneration of the intervertebral disc. At the last follow-up evaluation, there was no statistically significant correlation between different endplate healing morphologies and new Modic changes.

Conclusions

The reduction rate in the central area is significantly lower than that in the peripheral area. Although all of the intervertebral discs corresponding to fractured endplates had degenerated to different degrees, successful endplate fracture reduction can obviously delay the degeneration of intervertebral discs.

     

Tranexamic acid reduces haematomas but not pain after total knee arthroplasty

Aim

Tranexamic acid (TxA) reduces total blood losses (TBL) and allogenic transfusion (TH) after total knee arthroplasty (TKA). TBL can be external (surgical field, drains), or hidden (haematomas). Haematomas induce pain and limit postoperative rehabilitation. The aim of the study was to evaluate if TxA reduces haematomas and pain after TKA.

Study design

Prospective non-randomized study.

Method

After ethical committee approvement and written informed consent, the patients planned for a primary TKA were included (control group followed by a TxA group, 15 mg/kg before incision and at skin closure). General anaesthesia and analgesia were standardized (sciatic block, continuous femoral block, ketamine, ketoprofene, paracetamol, PCA with morphine). Volume of haematomas = TBL (calculated based on haemograms performed the day before surgery, and at postoperative day 5, and on transfusions) - measured external bleeding. Patients were followed up for 8 days, and at postoperative day 180 (by phone). Fifty patients per group allowed the detection of a 50% morphine sparing at day 8 (α = 0.05 and β = 0.2), and a 25% reduction of haematoma volumes at day 5.

Results

Perioperative data, pain scores and functional parameters (until day 180) were not different between control group patients (n = 52) and TxA group patients (n = 55): morphine consumption at day 8 was respectively 35 ± 32 and 42 ± 38 mg (P = 0.29). Yet, TxA reduced hematoma volumes (526 ± 202 versus 337 ± 165 mL of red blood cells, P < 0.0001) and clinically apparent hematomas. Morphine consumptions at day 8 and haematoma volumes were not correlated.

Conclusion

After TKA, TxA reduces the volume of hematomas, without any improvement in analgesia and rehabilitation until the sixth postoperative month.     

Anatomic renal artery branch microdissection to facilitate zero-ischemia partial nephrectomy

Background

Robot-assisted and laparoscopic partial nephrectomies (PNs) for medial tumors are technically challenging even with the hilum clamped and, until now, were impossible to perform with the hilum unclamped.

Objective

Evaluate whether targeted vascular microdissection (VMD) of renal artery branches allows zero-ischemia PN to be performed even for challenging medial tumors.

Design, setting, and participants

A prospective cohort evaluation of 44 patients with renal masses who underwent robot-assisted or laparoscopic zero-ischemia PN either with anatomic VMD (group 1; n = 22) or without anatomic VMD (group 2; n = 22) performed by a single surgeon from April 2010 to January 2011.

Intervention

Zero-ischemia PN with VMD incorporates four maneuvers: (1) preoperative computed tomographic reconstruction of renal arterial branch anatomy, (2) anatomic dissection of targeted, tumor-specific tertiary or higher-order renal arterial branches, (3) neurosurgical aneurysm microsurgical bulldog clamp(s) for superselective tumor devascularization, and (4) transient, controlled reduction of blood pressure, if necessary.

Measurements

Baseline, perioperative, and postoperative data were collected prospectively.

Results and limitations

Group 1 tumors were larger (4.3 vs 2.6 cm; p = 0.011), were more often hilar (41% vs 9%; p = 0.09), were medial (59% and 23%; p = 0.017), were closer to the hilum (1.46 vs 3.26 cm; p = 0.0002), and had a lower C index score (2.1 vs 3.9; p = 0.004) and higher RENAL nephrometry scores (7.7 vs 6.2; p = 0.013). Despite greater complexity, no group 1 tumor required hilar clamping, and perioperative outcomes were similar to those of group 2: operating room time (4.7 and 4.1 h), median blood loss (200 and 100 ml), surgical margins for cancer (all negative), major complications (0% and 9%), and minor complications (18% and 14%). The median serum creatinine level was similar 2 mo postoperatively (1.2 and 1.3 mg/dl). The study was limited by the relatively small sample size.

Conclusions

Anatomic targeted dissection and superselective control of tumor-specific renal arterial branches facilitate zero-ischemia PN. Even challenging medial and hilar tumors can be excised without hilar clamping. Global surgical renal ischemia has been eliminated for most patients undergoing PN at our institution.     

The effect of clopidogrel and aspirin on blood loss in hip fracture surgery

Introduction

Anti-platelet drugs are commonly used for primary and secondary prevention of thrombo-embolic events and following invasive coronary interventions. Their effect on surgery-related blood loss and perioperative complications is unclear, and the management of trauma patients treated by anti-platelets is controversial. The anti-platelet effect is over in nearly 10 days. Notably, delay of surgical intervention for hip fracture repair for >48 h has been reported to increase perioperative complications and mortality.

Patients and methods

Intra-operative and perioperative blood loss, the amount of transfused blood and surgery-related complications of 44 patients on uninterrupted clopidogrel treatment were compared with 44 matched controls not on clopidogrel (either on aspirin alone or not on any anti-platelets).

Results

The mean perioperative blood loss was 899 ± 496 ml for patients not on clopidogrel, 1091 ± 654 ml for patients on clopidogrel (p = 0.005) and 1312 ± 686 ml for those on combined clopidogrel and aspirin (p = 0.0003 vs. all others). Increased blood loss was also associated with a shorter time to operation (p = 0.0012) and prolonged surgical time (p = 0.0002). There were no cases of mortality in the early postoperative period.

Conclusions

Patients receiving anti-platelet drugs can safely undergo hip fracture surgery without delay, regardless of greater perioperative blood loss and possible thrombo-embolic/postoperative bleeding events.     

Is the red-yellow-black scheme suitable to classify donor site wounds? An inter-observer analysis

Background

The red-yellow-black-scheme (RYB) is a well-known and validated scheme to classify chronic and acute wounds, based on wound color and moistness. We investigated whether this RYB-scheme is also useful to classify donor site wounds uniformly (DSW).

Methods

Twenty-three digital photographs of DSWs in various stages of wound healing were presented to internationally renowned wound scientists (n = 11), surgical doctors (n = 31), specialized wound nurses (n = 55), and surgical nurses (n = 28). These observers classified the color and moistness of the wound according to the RYB-scheme, yielding seven wound categories. Inter-observer agreement (IOA) was expressed as a kappa (κ) value.

Results

IOA's among specialized wound nurses were moderate when based on wound color and moistness (κ = 0.41; 95% CI 0.33-0.49), wound color only (κ = 0.41; 95% CI 0.29-0.53), or moistness only (κ = 0.54; 95% CI 0.45-0.64). However, these IOA's tended to be better than those among the scientists, doctors and nurses. Scientists showed the lowest agreement (k-values between 0.17 and 0.25). Doctors scored slightly better than nurses.

Conclusion

Clinicians and scientists have difficulty with classifying DSWs by means of the RYB-scheme. Therefore, this scheme does not appear useful to classify donor site wounds in a uniform manner.     

Estimating the usage of allograft in the treatment of major burns

Aim

To assess the amount of allograft used in the past treatment of major burns and calculate a figure to guide estimation of the quantity of allograft required to treat future patients and aid resource planning.

Methods

A retrospective observational study. Records of 143 patients treated with major burns at a regional centre, from January 2004 to November 2008 were accessed with biometric data and quantity of allograft used being recorded. This data was used to calculate an allograft index (cm² allograft used/burn surface area (cm²)) (AI) for each patient.

Results

112 of the 143 patients had complete sets of data, of the 112, 89 patients survived the initial stay in hospital. For all data average AI = 1.077 ± 0.090. AI varied according to burn % area with burns <40% requiring 0.490 cm² allo/cm² burn, increasing in a logarithmic fashion (R² = 0.995) for burn areas >40%.

Conclusions

The ability to estimate deceased donor skin requirements based on % body surface area affected is important in the care planning for patients with major burns. Our findings of 0.5 cm² allograft/cm² burn for injuries less than 40% TBSA, increasing to 1.82 cm² allograft/cm² burn for injuries up to 80% TBSA can be used for planning purposes for individual services and for burn disaster planning.     

Evaluation of the methylation status of tumour suppressor genes for predicting bacillus Calmette-Guérin response in patients with T1G3 high-risk bladder tumours

Background

Bacillus Calmette-Guérin (BCG) is a standard treatment for reducing tumour recurrence and delaying progression of high-risk non-muscle-invasive bladder tumours. However, it is not clear yet which patients are more likely to respond to BCG.

Objective

To evaluate the role of the methylation of 25 tumour suppressor genes (TSG) as clinical outcome predictive biomarkers in T1G3 bladder tumours treated with BCG.

Design, setting, and participants

A retrospective design included 91 paraffin-embedded tumours of patients with T1G3 primary non-muscle-invasive disease undergoing nonmaintenance BCG treatment.

Measurements

The methylation status of 25 TSGs was measured using a methylation-specific multiplex ligation-dependent probe amplification (MS-MLPA) assay. Recurrence, progression into muscle-invasive tumours, and disease-specific survival (DSS) rates were analysed using univariate and multivariate tests.

Results and limitations

The genes most frequently methylated included STK11 (94.5%), MSH6 (81.3%), BRCA1 (72.5%), PAX5A (68.1%), MGMT (67.0%), CDH13 (62.6%), and IGSF4 (61.5%). Methylation was newly identified in T1G3 tumours for TP73, MSH6, ESR1, PAX5A, WT1, CD44, ATM, IGSF4, CHFR, BRCA2, THBS1, PYCARD, STK11, and GATA5. Methylation for several TSGs was significantly associated with multifocality and tumour size. Patients with different methylation statuses of TSGs showed differential recurrence rates (PAX6: p = 0.025), progression rates (MSH6: p = 0.040; RB1: p = 0.042; THBS1: p = 0.041; PYCARD: p = 0.048; TP73: p = 0.048; ESR1: p = 0.036; and GATA5: p = 0.019), and DSS rates (GATA5: p = 0.037). Several combinations improved prediction for progression. Multivariate analyses indicated that among the combinations remaining as independent predictors, two genes—MSH6 and THBS1—already provided the most significant predictive assessment for progression (p = 0.004). The major limitation of this study is related to its retrospective design.

Conclusions

The methylation status of TSGs was associated with the clinical outcome of patients with T1G3 tumours undergoing BCG treatment under three clinical end points: recurrence, progression, and DSS. The methylation status of TSGs distinguished patients responding to BCG from those who may require a more aggressive therapeutic intervention.     

Unexpectedly increased rate of surgical site infections following implant surgery for hip fractures: problem solution with the bundle approach

Introduction

Surgical site infections (SSIs) are the most common nosocomial infections after surgery. However, clinical guidance on how to handle any suspicious clusters of SSI in orthopaedic surgery is missing. We report on problem analysis and solution finding following the observation of an increased rate of SSI in trauma implant surgery.

Setting

Trauma unit of a university hospital.

Methods

Over a 2-year observation period, all patients (n = 370) following surgical stabilisation of proximal femur fractures in a trauma unit of a university hospital were consecutively followed using a standardised case report form. First, a retrospective cohort of 217 patients was collected for whom an increased SSI rate was detected. Based on risk analysis, new standard perioperative procedures were developed and implemented. The impact was evaluated in a prospective cohort of 153 comparable patients. Uni- and multivariable analysis of factors associated with the risk for SSI was undertaken.

Results

The intervention bundle resulted in a significant reduction of an initially increased SSI incidence of 6.9 (down) to 2.0% (p = 0.029). Multivariable analysis revealed four risk factors significantly associated with a higher risk of SSI caused by different bacteria: duration of surgery (p = 0.002), hemiarthroplasty (p = 0.002), haematoma (p = 0.004) and the presence of two operating room staff members (p < 0.001 and 0.035).

Conclusions

A standardised prospective SSI protocol and detection system offering the simultaneous use of data should guarantee every institution immediate alarm registration to avoid comparable problem situations. Detailed interdisciplinary analysis followed by the implementation of coherent interventions, based on a best-evidence structured bundle approach, may adequately resolve similar critical incidence episodes.     

Safety of presurgical targeted therapy in the setting of metastatic renal cell carcinoma

Background

In patients with metastatic renal cell carcinoma (mRCC), the timing of systemic targeted therapy in relation to cytoreductive nephrectomy (CN) is under investigation.

Objective

To evaluate postoperative complications after the use of presurgical targeted therapy prior to CN.

Design, setting, and participants

A retrospective review of all patients who underwent a CN at The University of Texas M.D. Anderson Cancer Center from 2004 to 2010 was performed. Inclusion in this study required documented evidence of mRCC, with treatment incorporating CN.

Interventions

Patients receiving presurgical systemic targeted therapy prior to CN were compared to those undergoing immediate CN.

Measurements

Complications were assessed using the modified Clavien system for a period of 12 mo postoperatively.

Results and limitations

Presurgical therapy was administered to 70 patients prior to CN (presurgical), while 103 patients had an immediate CN (immediate). A total of 232 complications occurred in 57% of patients (99 of 173). Use of presurgical systemic targeted therapy was predictive of having a complication > 90 d postoperatively (p = 0.002) and having multiple complications (p = 0.013), and it was predictive of having a wound complication (p < 0.001). Despite these specific complications, presurgical systemic targeted therapy was not associated with an increased overall complication risk on univariable or multivariate analysis (p = 0.064 and p = 0.237) and was not predictive for severe (Clavien ≥3) complications (p = 0.625). This study is limited by its retrospective nature. As is inherent to any retrospective study reporting on complications, we are limited by reporting bias and the potential for misclassification of specific complications.

Conclusions

Despite an increased risk for specific wound-related complications, overall surgical complications and the risk of severe complications (Clavien ≥3) are not greater after presurgical targeted therapy in comparison to upfront cytoreductive surgery.