Risk factors in carotid artery surgery: an evaluation of 414 operations

Four hundred and fourteen carotid reconstructions performed on 352 patients during the years 1971-82 were analysed retrospectively. Fifty-eight percent of the patients were operated on because of hemispheric transient ischaemic attacks (TIA). Twenty-eight percent had suffered a stroke before surgery. The overall combined mortality and morbidity was 7.7%. The procedure mortality was 2.9% with a slightly higher mortality i.e. 5.9% in the stroke group although not significantly higher than among non-stroke patients with a mortality of 1.4%. Patients of more than 70-years had a significantly higher operative mortality (11.1%) than the rest of the patients (1.7%). Non-fatal strokes occurred in 20 patients (4.8%). No correlation was found with the degree of stenosis of the contralateral artery.     

Risk factors for wound infection in head and neck cancer surgery: a prospective study

BACKGROUND: The goal of this prospective study is to determine risk factors for wound infections (WI) for patients with head and neck cancer who underwent surgical procedure with opening of upper aerodigestive tract mucosa. METHODS: One hundred sixty-five consecutive surgical procedures were studied at Oscar Lambret Cancer Center within a 24-month interval. Twenty-five variables were recorded for each patient. Statistical evaluation used Chi2 test analysis (categorical data) and Mann-Whitney test (continuous variables). RESULTS: The overall rate of WI was 41.8%. Univariate analysis indicated that five variables were significantly related to the likelihood of WI: tumor stage (p =.044), previous chemotherapy (p =.008), duration of preoperative hospital stay (p = 022), permanent tracheostomy (p =.00008), and hypopharyngeal and laryngeal cancers (p =.008). CONCLUSIONS: Despite antibiotic prophylaxis, WI occurrence is high. These data inform the head and neck surgeon, when a patient is at risk for WI and may help to design future prospective studies.     

Risk factors for anastomotic leakage after surgery for colorectal cancer: results of prospective surveillance

BACKGROUND: Anastomotic leakage in operations for colorectal cancer not only results in morbidity and mortality, but also increases the risk of local recurrence and worsens prognosis. So a better understanding of risk factors for developing anastomotic leakage in colorectal cancer surgery is important to surgeons. The aim of this study was to determine the incidence and risk factors for clinical anastomotic leakage after elective surgery for colorectal cancer. STUDY DESIGN: We conducted prospective surveillance of all elective colorectal resections performed by a single surgeon in a single university hospital from November 2000 to July 2004. The outcomes of interest was clinical anastomotic leakage. Eighteen independent clinical variables were examined by univariate and multivariate analyses. RESULTS: A total of 391 patients undergoing elective operations for colorectal cancer were admitted to the program. Clinical anastomotic leakage was identified in 11(2.8%) patients. Univariate and multivariate analyses showed that preoperative steroid use (odds ratio=8.7), longer duration of operation (odds ratio=9.9), and wound contamination (odds ratio=7.8) were independently predictive of clinical anastomotic leakage. Although there were no statistical differences in leakage rates between patients with and without covering stoma, all four patients requiring reoperation for leakage were without covering stoma. CONCLUSIONS: Preoperative steroid use, longer duration of operation, and contamination of the operative field were independent risk factors for developing clinical anastomotic leakage after elective resection for colorectal cancer. Surgeons should be aware of such high-risk patients, which would help them to decide whether to create a diversion stoma during surgery.     

Bleeding peptic ulcer: A prospective evaluation of risk factors for rebleeding and mortality

Clinical, endoscopic, and laboratory data were collected prospectively in 701 patients with bleeding peptic ulcer. The overall rebleeding rate was 16.1% and increased the risk of a fatal outcome by 17 fold (1.2% versus 20.6%,p < 0.001). Rebleeding was documented in more than 75% of the group who did not survive following initial conservative management. Rebleeding was more likely (24.1% versus 14.2%,p < 0.02) when shock was present on admission and the risk of a rebleed was doubled in patients over 60 years of age (22.1% versus 10.9%,p < 0.001). Ulcers greater than 1 cm in size carried twice the risk of rebleeding (23.9% versus 12.4%,p < 0.002). Concomitant medical illness had a significant adverse effect on outcome (p < 0.05). Shock on admission was associated with a doubling of mortality figures (9.5% versus 3.7%,p < 0.01). The identification of endoscopic stigmata of recent hemorrhage (ESRH) tripled the risk of mortality (7.5% versus 2.4%,p < 0.002), ESRH were more frequently encountered when ulcer size was larger than 1 cm (61.4% versus 39.8%,p < 0.001). Respective mortality rates for ulcers less than or equal to 1 cm and greater than 1 cm in size were 1.6% and 12.5% (p < 0.001), corresponding mortality figures for patients over 60 years of age being 4.4% and 16.4% (p < 0.002). The risk of a rebleed tripled (6.7% versus 2.6%,p < 0.02) when ESRH were evident. There was a 6-fold increase in mortality following emergency surgery when compared with conservative management of patients in whom no surgical intervention was necessary (2.6% versus 14.9%,p < 0.001). In summary, age over 60 years, previous medical illness, shock on admission, large ulcer size, and ESRH were each associated with an increased risk of rebleeding and mortality.

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Resumen Los datos endoscópicos y de laboratorio fueron recolectados en forma prospectiva en 701 pacientes con úlcera péptica sangrante. La tasa global de resangrado fue 16.1% y ésta incrementó 17 veces (1.2% versus 20.6%,p < 0.001) el riesgo de desenlace fatal. Se documentó resangrado en 75% del grupo que no sobrevivió el manejo conservador inicial. El resangrado apareció más frecuente (24.1% versus 14.2%,p < 0.02) cuando hubo shock en el momento de la admisión y el riesgo de resangrado fue del doble en pacientes >60 años (22.1% versus 10.9%,p < 0.001). Las ulceras >1 cm también exhibieron un riesgo de resangrado del doble (23.9% versus 12.4%,p < 0.002). La presencia de enfermedad médica concomitante representó) un efecto adverso significativo sobre el desenlace final (p < 0.05). La presencia de shock en el momento de la admisión apareció asociada con un doblaje de las cifras de mortalidad (9.5% versus 3.7%,p < 0.01). La identificación de estigmas de hemorragia reciente triplicó el riesgo de mortalidad (7.5% versus 2.4%,p < 0.002), y los estigmas fueron hallados con mayor frecuencia cuando el tamano de la úlcera fue >1 cm (61.4% versus 39.8%,p < 0.001). Las tasas respectivas de mortalidad para úlceras <1 cm y >1 cm fueron 1.6% y 12.5% (p < 0.001); las tasas de mortalidad correspondientes para pacientes >60 años fueron 4.4% y 16.4% (p < 0.002). El riesgo de resangrado se triplicó (6.7% versus 2.6%,p < 0.02) cuando se evidenciaron estigmas de hemorragia reciente. Se observó un incremento de 6 veces en la mortalidad después de cirugía de urgencia en comparación con el manejo conservador de pacientes en quienes no fue necesario realizar una intervención quirúrgica (2.6% versus 14.9%,p < 0.001). En resumen, la edad >60, enfermedad médica concomitante, la presencia de shock en el momento de la admisión, una úlcera de gran tamano, y la evidencia de estigmas de hemorragia reciente aparecieron asociados con un mayor riesgo de sangrado y una elevada mortalidad.

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Résumé Les données cliniques, endoscopiques, et biochimiques chez 701 patients ayant un ulcère gastroduodénal hémorragique ont été analysés prospectivement. Le taux global de récidive hémorragique était de 16.1%; le risque fatal était augmenté de 17 fois (1.2% vs 20.6%,p < 0.001). Parmi ceux qui n'ont pas survécu au traitment conservateur initial, plus de 75% avaient resaigné. La récidive hémorragique s'avérait plus probable (24.1% vs 14.2%,p < 0.02) lorsque le patient était en état de choc à l'admission. Le risque de récidive hémorragique était doublé chez le patient de plus de 60 ans (22.1% vs 10.9%,p < 0.001).Les maladies associées ont influencé l'évolution de façon significative (p < 0.01) selon que le patient était en état de choc ou pas. Lorsque l'endoscopie mettait en évidence des signes d'hémorragie récente, le risque de mortalité triplait (2.4% vs 7.5%,p < 0.002). Ces signes endoscopiques ont été plus fréquemment rencontrés lorsque la taille de l'ulcère dépassait 1 cm (61.4% vs 39.8%,p < 0.001). Les taux de mortalité respectifs lorsque la taille de l'ulcère étaient ou > de 1 cm était de 1.6% et 12.5% (p < 0.001). Les taux correspondants chez les patients de plus de 60 ans étaient de 4.4% et 16.2% (p < 0.002). Le risque de récidive hémorragique triplait lorsque les signes d'hémorragie récente était présents. La mortalité augmentait de 6 fois lorsqu'une intervention a dû être pratiquée en urgence après échec du traitement nonopératoire (2.6% vs 14.9%,p < 0.001). Les risques de récidive hémorragique et de mortalité augmentent chez le patient agé de plus de 60 ans, ayant une pathologie associée, un état de choc à l'admission, un ulcère de taille importante, et des signes d'hémorrragie récente.

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This study was supported by grants 335/048/0047, 337/049/0001 (Committee on Research and Conference Grants), 362/030/3368/4F (Medical Faculty Research Grant Fund), and 377/030/7828/4F (Lee Wing Tat Medical Research Fund).     

Risk factors for persistent pain after breast cancer surgery: a multicentre prospective cohort study

Identifying factors associated with persistent pain after breast cancer surgery may facilitate risk stratification and individualised management. Single-population studies have limited generalisability as socio-economic and genetic factors contribute to persistent pain development. Therefore, this prospective multicentre cohort study aimed to develop a predictive model from a sample of Asian and American women. We enrolled women undergoing elective breast cancer surgery at KK Women's and Children's Hospital and Duke University Medical Center. Pre-operative patient and clinical characteristics and EQ-5D-3L health status were recorded. Pain catastrophising scale; central sensitisation inventory; coping strategies questionnaire-revised; brief symptom inventory-18; perceived stress scale; mechanical temporal summation; and pressure-pain threshold assessments were performed. Persistent pain was defined as pain score ≥ 3 or pain affecting activities of daily living 4 months after surgery. Univariate associations were generated using generalised estimating equations. Enrolment site was forced into the multivariable model, and risk factors with p < 0.2 in univariate analyses were considered for backwards selection. Of 210 patients, 135 (64.3%) developed persistent pain. The multivariable model attained AUC = 0.807, with five independent associations: age (OR 0.85 95%CI 0.74–0.98 per 5 years); diabetes (OR 4.68, 95%CI 1.03–21.22); pre-operative pain score at sites other than the breast (OR 1.48, 95%CI 1.11–1.96); previous mastitis (OR 4.90, 95%CI 1.31–18.34); and perceived stress scale (OR 1.35, 95%CI 1.01–1.80 per 5 points), after adjusting for: enrolment site; pre-operative pain score at the breast; pre-operative overall pain score at rest; postoperative non-steroidal anti-inflammatory drug use; and pain catastrophising scale. Future research should validate this model and evaluate pre-emptive interventions to reduce persistent pain risk.     

Elective colon and rectal surgery differ in risk factors for wound infection: results of prospective surveillance

OBJECTIVE: The objective of this study was to clarify the incidence and risk factors for developing incisional surgical site infection (SSI) in both elective colon and rectal surgery. SUMMARY BACKGROUND DATA: SSI is a frequent complication after elective colorectal resection. The National Nosocomial Infection Surveillance system surveys all colorectal surgeries together, without differentiating the type of colorectal surgery performed. However, rectal surgery may have a higher risk for SSI, and identifying risk factors that are more specific to each procedure would be more predictive. METHODS: We conducted prospective SSI surveillance of all elective colorectal resections performed by a single surgeon in a single institution from November 2000 to July 2004. The data for colon and rectal surgeries were collected separately. The outcome of interest was incisional SSI. Univariate and multivariate analyses were performed to determine the predictive significance of variables in each type of surgery. RESULTS: A total of 556 colorectal resections, consisting of 339 colon and 217 rectal surgeries, were admitted to the program. The incisional SSI rates in colon and rectal surgeries were 9.4% and 18.0%, respectively (P = 0.0033). Risk factors for developing incisional SSI in colon surgery were ostomy closure (OR = 7.3) and lack of oral antibiotics (OR = 3.3), while in rectal surgery, risk factors were preoperative steroids (OR = 3.7), preoperative radiation (OR = 2.8), and ostomy creation (OR = 4.9). CONCLUSIONS: Colon and rectal surgeries differ with regard to incidence and risk factors for developing incisional SSI. SSI surveillance for such surgeries should be performed separately, as this should lead to more efficient identification of risk factors and a reduction in SSI.     

Risk factors for dysphagia after anterior cervical spine surgery: a two-year prospective cohort study.

BACKGROUND CONTEXT: Severe and disabling dysphagia is a relatively uncommon complication of anterior cervical spine surgery. However, the incidence of dysphagia ranges widely (2% to 60%). Furthermore, risk factors that contribute to the development of dysphagia have not been well identified. PURPOSE: The purpose of this study was to evaluate the prevalence of dysphagia after anterior cervical spine surgery, and to identify any risk factors associated with increased dysphagia. STUDY DESIGN: This study is a prospective cohort study designed to evaluate the prevalence of dysphagia at 1, 2, 6, 12, and 24 months. Patients were prospectively interviewed at 1, 2, 6, 12, and 24 months regarding the presence and subjective severity of dysphagia. PATIENT SAMPLE: Between the period of 1999 and 2002, 348 cervical spine surgeries were performed using the anterior Smith Robinson approach. 310 of these patients were available for 2-year follow-up. OUTCOMES MEASURE: Using the dysphagia grading system defined by Bazaz et al. (Spine 2002), we prospectively evaluated patients' postoperative dysphagia. METHODS: The presence and severity of dysphagia were reported during the telephone interviews performed at 1, 2, 6, 12, and 24 months after the procedure. Proportion analysis (chi-square or a Fisher Exact Test), prevalence ratios, and 95% confidence intervals were used to compare the prevalence of dysphagia with age, gender, type of surgery (eg, discectomy vs. corpectomy, primary vs. revision), use of instrumentation, number and location of surgical levels. RESULTS: The overall prevalences for dysphagia at 1, 2, 6, 12, and 24 months were 54.0%, 33.6%, 18.6%, 15.2%, and 13.6%. The prevalence of dysphagia was found to be significantly higher in women (18.3%) than men (9.9%) 2 years after the surgery. Revision surgery patients (27.7%) also had a significantly higher prevalence of dysphagia than primary surgery (11.3%) patients 2 years after the surgery. Patients who underwent more than two-level surgery (19.3%) also had significantly higher rates of dysphagia 2 years after their procedures than patients who had two or less levels (9.7%) operated on. CONCLUSION: Overall the incidence of dysphagia 2 years after anterior cervical spine surgery was 13.6%. Risk factors for long-term dysphagia after anterior cervical spine surgery include gender, revision surgeries, and multilevel surgeries. The use of instrumentation, higher levels, or corpectomy versus discectomy did not significantly increase the prevalence of dysphagia.     

Urolithiasis in infants: evaluation of risk factors

Objective

Urolithiasis in infants is not a very rare situation in Turkey, and the incidence has been increasing in recent years. The purpose of this paper was to investigate the clinical characteristics, metabolic and anatomic risk factors for urolithiasis and microlithiasis in infants.

Methods

The cases of 178 infants (63 girls, 115 boys), who were referred to our department between 1999 and 2009 with urolithiasis, were evaluated.

Results

The mean age at diagnosis of stone disease was 11.5 months (range, 10 days–24 months). The mean follow-up duration was 33.6 months (1.2–110 months). The major clinical symptoms of our patients were restlessness in 24 children (13.5%) and vomiting in 23 (13%). Thirty-five infants (19.7%) had a urinary tract abnormality; vesico-ureteral reflux was the most common abnormality (12.9%). Hypercalciuria and hyperuricosuria were detected in 46 and 56%, respectively. Stone analysis was performed in 56 infants, and calcium oxalate was determined in 36 patients (64.3%). A family history of urolithiasis, presenting symptoms and underlying metabolic abnormalities were similar for patients with microlithiasis and those with larger stones. However, infants with microlithiasis had higher ratios for history of vitamin D administration and feeding with formula. Surgical treatment was performed in 42 infants and extracorporeal shock wave lithotripsy in 30 infants.

Conclusion

Our results showed that urolithiasis in infants may present nonspecific symptoms and may even be asymptomatic and that a positive family history for urolithiasis, urologic abnormalities, metabolic disorders, urinary tract infections, vitamin D administration and feeding with formula may increase the occurrence of urolithiasis in infants.     

A prospective study of risk factors and cardiopulmonary complications associated with anaesthesia and surgery: risk indicators of cardiopulmonary morbidity

The aims of this study were: 1) to describe the frequency and type of cardiopulmonary complications, 2) to identify factors significantly associated with cardiovascular and pulmonary complications associated with anaesthesia and surgery, and 3) to estimate the total risk of cardiopulmonary complications for an anaesthetic when a combination of risk factors is present. Seven thousand three hundred and six anaesthetized patients undergoing gastrointestinal, urological, gynaecological, and orthopaedic surgery were included in the study; 6.3% (1:16) had one or more cardiovascular complications requiring intervention associated with anaesthesia and surgery, and 4.8% (1:21) had pulmonary complications. The total incidence of patients with one or more complications associated with anaesthesia and surgery was 9.4% (1:11). Based on logistic regression analyses, our data indicate that the following patient categories constitute high risk patients with regard to cardiovascular complications: patients aged greater than or equal to 70 years, patients with a history of ischaemic heart disease (IHD) with previous myocardial infarction less than 1 year, a history of chronic heart failure (CHF), and in patients admitted to major surgery. The extent of pulmonary complications following anaesthesia and surgery was significantly correlated to patients aged greater than or equal to 70 years, preoperative chronic obstructive lung disease (COLD), major surgery, and to general anaesthesia involving muscle relaxants. Attempts to estimate the cardiopulmonary complications which may accompany anaesthesia and surgery provided important information about the anaesthetic course and outcome. With our model it seems possible to distinguish between very different levels of cardiopulmonary risk in the anaesthetic patient.     

Fluorescein sodium-guided surgery in glioblastoma multiforme: a prospective evaluation

We have evaluated the influence of fluorescein-guided resection on gross total resection (GTR) and survival in a series of patients with GBM. Group 1 consisted of 47 patients given fluorescein and group 2 comprised 33 patients, on whom fluorescein was not used. Median survival time was 43.9 weeks in the patients given fluorescein and was 41.8 weeks in the non-fluorescein group. There was no statistically significant difference in survival between the two groups. However, the extent of resection had a powerful influence on the median survival time. Survival was 34.3 weeks after partial resection and 46.5 after GTR. Our data shows that the use of fluorescein injection is a simple procedure, which allows a significant increase in the number of patients having GTR (83 vs. 55%). Our findings are similar to a recently published multicentre Phase III randomized trial in which 5-aminolevulinic acid was used to facilitate resection of malignant glioma.     

Incidence and risk factors of surgical site infection after intertrochanteric fracture surgery: A prospective cohort study

Surgical site infection (SSI) is a challenging complication after intertrochanteric fracture surgery but without a large‐sample size study to investigate the incidence and risk factors of it. The present study was to investigate the incidence and risk factors of SSI after intertrochanteric fracture surgery. A total of 1941 patients underwent intertrochanteric fracture surgery between October 2014 and December 2018 were included. Demographic data, surgical variables, and preoperative laboratory indexes were obtained from a prospective database and reviewed by hospital records. The optimum cut‐off value for quantitative data was detected by receiver operating characteristic analysis. The univariate analysis and multivariable analysis were conducted to analyse the risk factors. In total, 25 patients (1.3%) developed SSI, including 22(1.1%) superficial infection and 3(0.2%) deep infection. After adjustment of multiple variables, gender (odds ratio[OR] 2.64, P = .024), time to surgery>4 days (OR 2.41, P = .046), implant (intramedullary or extramedullary devices) (OR 2.96, P = .036), ALB<35 g/L (OR 2.88, P = .031) remained significant factors. In conclusion, the incidence of SSI after intertrochanteric fractures surgery was 1.3%, with 1.1% for superficial and 0.2% for deep infection. Gender, time to surgery>4 days, the implant (intramedullary or extramedullary devices), and ALB<35 g/L were independent risk factors for the rate of SSI.     

Clinical characteristics and risk factors of postoperative pneumonia after hip fracture surgery: a prospective cohort study

Summary

In this study, we attempt to determine the clinical characteristic and risk factors of postoperative pneumonia (POP) after hip fracture surgery in a well-defined hip fracture cohort. We find that intrinsic factors as well as major clinical interventions were all important risk factors of POP.

Introduction

Postoperative pneumonia (POP) is one of the major complications following hip fractures surgery. However, the risk factors of POP are not well studied in hip fracture cohorts. We attempt to determine the clinical characteristic and risk factors of POP after hip fracture surgery in a well-defined hip fracture cohort.

Methods

Datasets from a prospective hip fracture cohort study with a 2-year follow-up period, from 2000 to 2011, were reanalyzed for characteristics of POP. Multivariate Cox proportional regression was used to evaluate the association between the incidence of POP and all-cause mortality. Multivariate logistic regression was used to screen for potential risk factors of POP by analyzing demographic factors, comorbidities, major clinical interventions, and hematological parameters.

Results

In 1429 patients who underwent hip surgery, the incidence of POP was 4.9 % (n?=?70). All-cause mortality of patients with POP was significantly higher than that of patients without POP at 30 days (hazard ratio (HR) 3.05, 95 % confidence intervals (CI) 1.88–4.94), 1 year (HR 1.87, 95 % CI 1.41–2.48), and 2 years (HR 1.57, 95 % CI 1.23–1.99) postoperatively. Multivariate logistic regression showed that intrinsic factors (advanced age, anemia, diabetes, prior stroke, number of comorbidities, ASA score ≥III, and some laboratory biomarkers) as well as major clinical interventions were all significant risk factors for POP.

Conclusion

Intrinsic factors and major clinical interventions were all important risk factors of POP in patients after hip fracture surgery. Targeted preventive measures to mitigate the above risk factors may help in reducing the incidence of POP.

     

Preoperative evaluation in geriatric surgery: comorbidity, functional status and pharmacological history

The demand for elective and emergency surgery by older patients is increasing. This review examines the current practice of preoperative evaluation in geriatric anesthesia and provides an overview of new insights in this field. Preoperative anesthesia consultation is essential to examine the patient, evaluate the operative risk and plan preventive perioperative actions. Chronological age probably represents an independent risk factor. Age should not be considered an exclusion criterion from surgery per se. More than 50% of patients over 70 years old suffer from one infirmity, and 30% suffer from two or more infirmities. Hypertension is the most common disease, followed by coronary artery disease, diabetes and chronic obstructive pulmonary disease. Aging processes, illnesses, malnutrition, difficulties in communication and comprehension, psychological alterations and social needs may coexist and overlap. Changes in pharmacodynamics and pharmacokinetics induced by aging make elderly patients very sensitive to drugs, especially those administered perioperatively. Drug underuse, misuse and abuse are described, together with criteria to manage perioperative medications. Disability, dementia and frailty are risk factors for adverse outcomes and delirium after surgery. Traditional anesthesia consultation captures only a small portion of the necessary information, especially about functional status and frailty. Although the association between older age and surgical complications is well known, most anesthetists and surgeons do not measure physical and cognitive function preoperatively. Extending anesthesia consultation to functional status provides useful information for preoperative counseling and planning of postoperative care. A strong joint action with the surgical team is essential. Currently, while many resources are employed to assess preoperative cardiac risk and despite the dramatic increase in the number of elderly surgical patients, the association between older age itself and surgical complications has not been fully investigated, and preoperative evaluation of functional status is not yet a part of routine preoperative practice. Creating a new culture and developing appropriate clinical, scientific and relational approaches to these patients represent the core of the challenge.