Tumours of the retrorectal space: management and outcome of a heterogeneous group of diseases

Aim  Retrorectal tumours are a rare and complex entity in adults and children. They present a varied symptomatology and their treatment is very different according to their histology. We aimed to evaluate our experience of tumours of the retrorectal space. Method  Forty patients with retrorectal tumours were divided into two groups according to age. The variables analysed were sex, signs and symptoms, complementary examinations, surgical approaches, adjuvant therapies, pathological analyses, recurrence and survival. Results  Symptoms across the 30 adults varied – back pain (18) was the most common. Surgical intervention was performed on 20 patients; the rest were candidates for other treatments: five metastatic disease, two lymphomas and two Ewing tumour. The most common surgical approach was posterior, with 10 cases (50%). In all, 70% of adult tumours were malignant, with chordoma (30%) and metastases (20%) being the most common lesions. The most frequent benign lesion was hamartoma (10%). The 1‐ and 5‐year mortality rates were 23.8% and 38.1%, respectively. In the paediatric group, three patients were diagnosed in utero. The symptoms among children varied and all were operated upon. The most frequent tumour was teratoma. Overall mortality was 20%. Conclusions  Given their complexity, these tumours should be addressed by experts and all treatment options must be contemplated. They continue to present a challenge, above all in malignant tumours where the tumour cannot be controlled at a locoregional level.     

Vein of Galen aneurysmal malformations

Summary The authors report a series of 36 vein of Galen aneurysmal malformations (VGM) diagnosed in the paediatric (78%) and adult (22%) populations that were referred to them for therapeutic management between 1982 and 1988. The clinical signs leading to the diagnosis were variable: 36% of systemic manifestations, 22% of neurological symptoms, 17% of hydrocephaly and 11% of intracranial haemorrhage.30 angioarchitectural analyses could be obtained and allowed to classify these VGMs into 5 different types: 44% parenchymatous AVMs, 20% mural AVFs, 30% choroidal arteriovenous fistulas, 3% dural AVFs, 7% vein of Galen varices. This series demonstrates that the paediatric population is most sensitive to shunt effect whatever its type. Systemic manifestations and hydrocephaly are the most common signs encoutered in the newborn and infants; whereas neurological signs and symptoms and haemorrhage belong mostly to the adult symptomatology. Because of the poor outcome of VGMs, all authors believe that these malformations have to be treated aggressively. However, we found contra-indications to be represented by pretherapeutic demonstration of cerebral tissue damage, or uncontrolable systemic failure, thus treatment is indicated to compensate for cardiac failure previously responding (even partially) to medical treatment. Secondly, appearance of sub-cortical calcifications, resistance to medication or clinical deterioration will also lead to urgent treatment.The endovascular method represents at present the best treatment with an overall low mortality (13%) and a 0% technical morbidity in children compared to the surgical one of (91% mortality in newborns and 38% in infants). The results achieved by embolization in this series were as follows: 27% satisfactory results with complete or almost complete occlusion of AV Shunt, 53% significant clinical improvement, 7% of patients were unchanged. The authors believe fundamentally that these patients (specially those belonging to the paediatric population) have to be treated in a centre where a paediatric intensive care unit, neurological, neurosurgical and surgical neuro-angiographic departments coexist, in order to assure the best possible management of these children.     

POSSUM: a re-evaluation in patients undergoing surgery for rectal cancer. The Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity

Background: The problem of directly comparing morbidity and mortality rates between institutions without some sort of adjustment for case mix is well documented. Scoring systems have been developed to allow comparisons to be made. The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) is one such system. It was designed to predict operative mortality and morbidity in differing settings and to be independent of case mix. The present study examines the use of POSSUM in colorectal practice in Saudi Arabia. Methods: Patients referred to King Faisal Specialist Hospital between 1990 and 1998 for primary management of an histologically proven rectal cancer were identified. POSSUM mortality and morbidity scores and Portsmouth‐Physiological and Operative Severity Score (P‐POSSUM) mortality scores were calculated separately for each patient, and predicted rates were compared with observed rates in the patients studied. Results: There were 70 men (mean age: 55.6 years; range: 25?87) and 75 women (mean age: 52.8 years; range: 26?84). One hundred and six patients underwent ‘curative’ surgery. Abdominoperineal resection was the most frequently performed procedure. Major anastomotic leakage following anterior resection occurred in two of fifty patients. One patient developed a pulmonary embolism but no patient developed postoperative myocardial infarction. Two patients died. The median and mean physiological and operative severity scores were 13 (range: 12?37) and 17 (range: 8?37) and 14.68 and 18.36, respectively. The overall POSSUM‐predicted (using median scores) morbidity and mortality rates were 35.4% and 6.7%. The P‐POSSUM‐predicted (using mean scores) mortality rate was 3.5%. Observed morbidity and mortality rates were 54.5% and 1.4%. Conclusion: POSSUM failed to predict outcomes accurately in patients undergoing surgery for rectal cancer in Saudi Arabia. P‐POSSUM also overpredicted mortality but to a lesser extent. Patient's ‘wellness’ and the previously identified inability of POSSUM to accurately predict death in low‐risk populations may explain these findings. Care must be exercised in using the POSSUM formulae for risk adjustment in different settings.     

Incidence and risk factors of perioperative respiratory adverse events in children undergoing elective surgery

BACKGROUND: Adverse respiratory events remain one of the major causes of morbidity during anaesthesia, especially in children. The purpose of this prospective study was to determine the incidence of perioperative respiratory adverse events (PRAE) during elective paediatric surgery and to identify the risk factors for these events. METHODS: Potential risk factors (atopy, eczema, rhinitis, food allergy, previous allergic tests, pollens or animal allergy, passive smoking, obstructive sleep disorders) were assessed using the International Society on Allergy and Asthma (ISAAC) questionnaire, which was submitted to the parents during preoperative anaesthetic assessment. Anaesthetic and surgical conditions were systematically recorded. A multivariate logistic regression explaining PRAE was developed in 800 children. RESULTS: The intraoperative incidence of respiratory adverse events was 21% and the incidence in the postanesthetic care unit was 13%. According to the multivariate analysis, children not anaesthetized by a specialist paediatric anaesthesiologist have 1.7 increased risk to present PRAE (95% CI = 1.13-2.57). Children anaesthetized for ear, nose, throat (ENT) surgery had a 1.57-fold higher risk of PRAE compared with other procedures (95% CI = 1.01-2.44). Furthermore, there was a synergistic interaction when two risk factors: residents and ENT surgery, were concomitant: the odds ratio (OR) of PRAE during non-ENT surgical procedures was 1.43 (95% CI = 0.91-2.24), but increased to 2.74-fold (95% CI = 1.15-4.32) for ENT surgery. The risk of PRAE was significantly lower when the anaesthetic technique included tracheal intubation with relaxants (OR = 0.6, 95% CI = 0.45-0.95) and decreased by 8% with each increasing year of age. CONCLUSIONS: This study demonstrates a high incidence of PRAE in paediatric surgical patients without respiratory tract infections, which appears to be primarily determined by the age of the child and the anaesthetic care rather than by the child's medical history.     

Major invasive surgery for urologic cancer in octogenarians with comorbid medical conditions

OBJECTIVES: We retrospectively reviewed the records of the octogenarian patients who underwent major surgery for urologic cancer at two institutions. The aims of our study were to assess intra- and postoperative morbidity and mortality rates, and to identify potential risk factors that can predict postoperative complications and, as a consequence, surgical outcome. METHODS: Fifty-five patients (median age: 83 yr) underwent major surgery for urologic cancer. Radical nephrectomy was performed in 27 patients, radical cystectomy with urinary diversion was done in 20 patients, and nephroureterectomy was performed in the remainder. Significant comorbidity was present in 51 patients. RESULTS: The perioperative mortality rate was 9%. The overall mortality rate was 69%; cancer-specific mortality was 28%. Intraoperative complications occurred in 11% of patients. Postoperative intensive care monitoring was required in 29% of patients. The early postoperative complication rate was 33%. Only the presence of more than two comorbidities (p<0.05) and chronic obstructive lung disease (COLD) (p=0.017) resulted in independent prognostic factors for morbidity. Sixteen percent of patients developed a late postoperative complication within the first 6 mo. Median hospital stay was 14 d (range: 6-55), and hospital stays were significantly longer among patients with complications (p<0.05). The 3-yr and 5-yr overall survival rates were 36% and 26%, respectively; these rates were significantly lower in patients with COLD (p<0.01). There was no significant difference between cancer-specific and non-cancer-specific survival rates. CONCLUSIONS: Major surgery for urologic malignancies can be safely performed in selected octogenarian patients.     

Paediatric trauma at an adult trauma centre

BACKGROUND: Trauma in children remains the commonest cause of mortality. The majority of injured children who reach hospital survive, indicating that additional more sensitive outcome measures should be utilized to evaluate paediatric trauma care, including morbidity and missed injury rates. Limited contemporary data have been presented reviewing the care of injured children at an adult trauma centre (ATC). METHODS: A review was undertaken of injured children who warranted activation of the trauma team, treated within the emergency department of an ATC (Royal North Shore Hospital) situated in the Lower North Shore area of Sydney. Data were collected prospectively and patients followed through to death or discharge from the ATC or another institution to which they had been transferred. RESULTS: A total of 93 children were admitted to the ATC between January 1999 and April 2002. Mean age was 9 years 3 months (range 5 weeks-15 years 9 months) and 70% were male. The median injury severity score was 15 (range 1-75) and there were three deaths. Forty-two children were transferred to a paediatric trauma centre (PTC), including three children who had been transferred to the ATC from another hospital. There was one missed injury and one iatrogenic urethral injury. CONCLUSIONS: The majority of children with trauma were treated safely and appropriately at the ATC. The missed injury rate was < 1% and there were no adverse long-term sequelae of initial treatment. Three secondary transfers could have been avoided by more appropriate coordination of the initial referral to a PTC.     

The impact of pre‐admission morbidity level on 3‐year mortality after intensive care: a Danish cohort study

Background: Chronic diseases are common among intensive care unit (ICU) patients and may worsen their prognosis. We examined the prevalence and impact of pre‐admission/index morbidity among ICU patients compared with a general population cohort. Methods: Our study encompassed all 28,172 adult patients admitted to ICUs in northern Denmark in 2005–2007 and 281,671 age‐ and sex‐matched individuals from the general population. We used a nationwide hospital registry to obtain a 5‐year history of 19 chronic diseases and computed Charlson Comorbidity Index (CCI) for each study participant and grouped them into low (CCI=0), moderate (CCI=1–2), and high (CCI=3+) morbidity levels. We computed mortality and mortality rate ratios (MRRs) adjusted for confounders, and compared the mortality between ICU patients and the general population cohort. Results: Low, moderate, and high pre‐admission morbidity levels were present in 51.5%, 34.1%, and 14.4% of ICU patients, respectively. In these groups, 30‐day mortality was 10.8%, 18.4%, and 26.7%, respectively. Three‐year mortality was 21.3%, 43.1%, and 63.2%, respectively. The adjusted 30‐day MRR was 1.30 [95% confidence intervals (CI): 1.21–1.39] and 1.86 (95% CI: 1.71–2.01) for ICU patients with moderate and high morbidity levels, both compared with a low morbidity level. The general population had a lower morbidity level and mortality at all morbidity levels throughout the study period. Interaction between ICU admission and high morbidity level added 5.1% to the mortality during the second and third year of follow‐up. Conclusion: A high pre‐admission morbidity level was frequent among ICU patients and associated with a worsened prognosis. Morbidity had more impact on mortality among ICU patients compared with a general population cohort.     

Paediatric surgery carried out by general surgeons: a rural New Zealand experience

Background: There are increasing moves towards centralization in paediatric surgery. With only four paediatric tertiary centres in New Zealand, many general surgeons still routinely carry out paediatric surgery. We present an audit of paediatric surgical patients admitted to our general surgical unit. Methods: Data were prospectively recorded using a standardized pro forma on all children aged 15 years and below, who presented to general surgery between 11 December 2005 and 11 December 2006. Results: There were 209 admissions (194 children); the median age was 8 years (range 6 weeks to 15 years) with 153 (73%) acutes. Male : female ratio was 3:2 and 37 children (18%) were less than 2 years of age. Procedures (n = 119) comprised appendicectomy (35), inguinal herniotomy (30), skin procedures (29), endoscopy (10), testicular (10) and others (5). The commonest acute and elective operations were appendicectomy and inguinal herniotomy, respectively, with 51% of all operations carried out acutely. There were 10 tertiary hospital transfers (5%) for burns (4), pyloric stenosis (3), intussusception (1), neonatal inguinal hernia (1) and pyoderma gangrenosum (1). Median age of transfers was 11 months (range 6 weeks to 14 years). Complications were wound infection (1), postoperative ileus (2) and infarcted ovary (1). Conclusion: A large number of children presented to our surgical department. Approximately half required surgery and half of the operations were acute. There is still a significant need for general paediatric surgery in the provinces and hence close collaboration with specialist paediatric surgeons.     

Invasive pneumococcal pneumonia is the major cause of paediatric haemolytic-uraemic syndrome in Taiwan

Aim: Streptococcus pneumoniae‐associated haemolytic uraemic syndrome (SP‐HUS) is a major concern of paediatric acute renal failure in Taiwan; it leads to significant morbidity and mortality during the acute phase and to long‐term morbidity after an acute episode. Methods: Twenty children diagnosed with HUS between 1 May 1995, and 31 December 2008 was enrolled. Clinical variables related to laboratory data, organ involved, and outcomes were examined between patients with and without SP‐HUS. Results: Thirteen of the 20 (13/20, 65%) patients required dialysis, nine (9/20, 45.0%) developed hepatic dysfunction, disseminated intravascular coagulation (DIC), gastrointestinal bleeding, and hypertension, respectively. They were the second most common extrarenal complication except empyema (11/20, 55%). Two (10%) died and seven (35%) of the survivors developed long‐term renal morbidity. Twelve of the 20 patients (60%) were diagnosed with SP‐HUS. Younger age, female children, higher white blood cell count, higher alanine transaminase, higher lactate dehydrogenase and high incidence of DIC were significantly common in SP‐HUS cases. All SP‐HUS cases were complicated with pleural effusion, empyema, or both. Positive Thomsen‐Freidenreich antigen (T‐Ag) activation was 83% sensitive and 100% specific for SP‐HUS, and a positive direct Coombs' test was 58% sensitive and 100% specific. Conclusion: Invasive pneumococcal infection is the most common cause of HUS in Taiwan. Positive T‐Ag activation and a direct Coombs' test are rapid predictors of SP‐HUS in children with invasive pneumonia.     

Surgical management of bronchiectasis in childhood.

OBJECTIVE: Though there is a gradual decrease in the prevalence of bronchiectasis, it is still a cause of mortality and morbidity among children in developing countries such as Turkey. We reviewed the morbidity and mortality rates and the outcome of surgical treatment for childhood bronchiectasis. PATIENTS AND METHODS: Age, sex, etiological factors, symptoms, radiological examinations, surgical procedures, postoperative morbidity and mortality in patients aged 16 years and younger, operated for bronchiectasis between January 1991 and April 2006 in the Thoracic Surgery Clinic of Atatürk Training and Research Hospital for Chest Disease and Chest Surgery were reviewed retrospectively. RESULTS: Between January 1991 and April 2006, 176 cases aged 16 and younger were operated for bronchiectasis. There were 95 females (54%) and 81 males (46%), with a mean age of 12.3 years (range: 3.4-16 years). The most common cause of bronchiectasis was lung infection (n: 87, 49.4%). Main symptoms were coughing (n: 167, 94.9%), sputum (n: 139, 79%), hemoptysis (n: 78, 44.3%), and fever (n: 77, 43.7%). Mean duration of the symptoms in patients who were operated was 3.8 years (range: 0-7.6 years). Cases underwent a total of 201 operations: 19 cases had bilateral surgical resection and 6 cases had completion pneumonectomy. Majority of cases had complete resection (n: 165, 93.75%) while only 11 cases (6.25%) had incomplete resection. Mean duration of hospitalization was 8.9 days (range: 5-39 days). The outcome, based on the responses of patients postoperatively, was 'perfect' in 129 cases (73.3%), 'improved' in 41 cases (23.3%), and 'no changes' in 6 cases (3.4%). The mean follow-up after surgery was 4.3 years (range: 14 months to 7.2 years), mortality was 0% and morbidity was 13% (n: 23). CONCLUSION: With acceptable mortality and morbidity rates and high chance of cure after complete resection, surgical treatment is a successful and reliable method of treatment in childhood bronchiectasis that yields marked improvement in the quality of life.     

Higher Age Predicts Adverse Outcome and Readmission after Coronary Artery Bypass Grafting

The present prospective clinical study was carried out to investigate the effect of age on mortality, morbidity, and readmission rates after coronary artery bypass grafting (CABG). Data on 1131 consecutive CABG patients were collected in a surgical center and in all 18 secondary referral hospitals up to 3 months after discharge. Analysis was based on three age groups: 64 years or less (510 patients), 65 to 74 years (448 patients), and 75 years or more (173 patients). Thirty-day mortality rates were 1.6% for the youngest, 5.4% for the middle age group, and 6.9% for the oldest. Major complications occurred in 10.8%, 21.2%, and 24.9% of these patients, respectively. Higher age was associated with more readmissions to health care facilities: The oldest patients had a rate twice as high as those in the youngest group (34.5% vs. 18.6%). Atrial fibrillation (15.4%), chest pain (10.6%), and congestive heart failure (8.5%) were the most common reasons for readmission. In conclusion, elderly patients, who are often suboptimal candidates for CABG, have higher 30-day mortality, higher morbidity, longer length of stay in health care facilities, and an increased risk of readmission within 3 months after CABG; age was an independent predictor of 30-day mortality and postdischarge readmission. Despite the higher risk of adverse events after surgery, three out of four elderly patients recover uneventfully.     

Children in Sweden admitted to intensive care after trauma

OBJECTIVE: The aims of this study were to describe the demographics, injuries, mechanisms and severity of injury, prehospital and hospital care during the first 24h, and patient outcome, in the most severely injured children cared for following trauma at a paediatric intensive care unit in Sweden. METHODS: The medical records of 131 traumatised children (0-16 years of age), admitted to the paediatric intensive care unit in Gothenburg from January 1990 to October 2000, were retrospectively examined. Nine internationally recognised scoring systems were used to calculate severity of injury, in order to predict the chances of patient survival. RESULTS: Paediatric trauma was more common in boys (68%). The mean age at injury was 7.9 years (S.D. 4.7 years). Traffic-related accidents (40%) and falls (34%) were the leading causes of injury. Injuries to the head were the most frequent, forming 24% of all injuries. Severity of injury was recorded as an Injury Severity Score median of 14, Trauma Score Injury Severity Score median of 99% and Paediatric Risk of Mortality Score median of 0.69%. The mortality rate was 3%. CONCLUSION: Trauma with admission to a paediatric intensive care unit is rare in a Swedish paediatric population. When cared for at a centre with the necessary facilities and trained personnel, these children have a good chance of survival.     

A POPULATION‐BASED STUDY OF THE INCIDENCE,MORTALITY AND OUTCOMES IN PATIENTS FOLLOWING SURGERY FOR COLORECTAL CANCER IN WESTERN AUSTRALIA

Background : The literature contains many reports on the management of colorectal cancer from single institutions or groups of specialist surgeons. But there are few data on community‐wide patterns of treatment or the outcomes of colorectal surgery. The aim of the present study was to use a population‐based linked database to assess the trends in colorectal cancer incidence and mortality in Western Australia (WA) in the period 1982–95, and to evaluate the outcomes following surgical care. Methods : A population‐based linked database was used to relate the cancer registry, hospitalization and mortality records of all patients with a diagnosis of colorectal cancer in WA during 1982–95. Data on surgical treatment and postoperative morbidity and mortality in this group of patients were available only in 1988–95. Patient records were selected using the international classification for diagnosis and procedure codes pertaining to colorectal cancer and surgery. Incidence and mortality trends in colon and rectal cancers were estimated by Poisson regression of age‐standardized rates, and relative survival analysis was used to compare patient survival with the general population. Results : During the 14‐year period, 9673 patients presented with a diagnosis of colorectal cancer. The sex distribution of patients with colon cancer was evenly divided, but rectal cancer was more common in men (ratio 1:4). The mean age at diagnosis was 67.8 years (SD: 12.7). During the study period there was a significant increase in the standardized incidence rate of rectal cancer in men, and in the mortality rates from colon cancer in women. The overall crude 5‐year survival was 57%. Large bowel resections were performed on 71% of patients with an in‐hospital postoperative mortality of 4.2%. Conclusion : Colorectal cancer is a continuing major cause of morbidity and mortality in WA. The present study demonstrated increases in the incidence rate of rectal cancer in men and in the mortality rate from colon cancer in women in the period 1982–95.     

Survival and transplantation outcomes of children less than 2 years of age with end-stage renal disease

Background

Young children with end-stage renal disease (ESRD) requiring renal replacement therapy (RRT) have traditionally experienced high rates of morbidity and mortality; however, detailed long-term follow-up data is limited.

Methods

Using a population-based retrospective cohort with data from a national organ failure registry and administrative data from Canada’s universal health care system, we analysed the outcomes of 87 children starting RRT (before age 2 years) and followed them until death or date of last contact [median follow-up 4.7 years, interquartile range (IQR) 1.4–9.8). We assessed secular trends in survival and the influence of: (1) age at start of RRT and (2) etiology of ESRD with survival and time to transplantation.

Results

Patients were mostly male (69.0 %) with ESRD predominantly due to renal malformations (54.0 %). Peritoneal dialysis was the most common initial RRT (83.9 %). Fifty-seven (65.5 %) children received a renal transplant (median age at first transplant: 2.7 years, IQR 2.0–3.3). During 490 patient-years of follow-up, there were 23 (26.4 %) deaths, of which 22 occurred in patients who had not received a transplant. Mortality was greater for patients commencing dialysis between 1992 and 1999 and among the youngest children starting RRT (0–3 months). Children with ESRD secondary to renal malformations had better survival than those with ESRD due to other causes. Among the transplanted patients, all but one survived to the end of the observation period.

Conclusion

Children who start RRT before 3 months of age have a high risk of mortality. Among our paediatric patient cohort, mortality rates were much lower among children who had received a renal transplant.     

The Surgical Treatment of Breast Cancer in the Elderly: A Single Institution Comparative Review of 5235 Patients with 1028 Patients ≥70 years

Abstract: As the wave of the baby boomers shifts the age demographic of patients, the current surgical management of breast cancer in elderly women (≥70 years of age) becomes relevant because deviation from standard treatment often occurs in this group. The purpose of this study was to determine the operative mortality when treated with standard surgical procedures and to investigate trends in the surgical management of breast cancer in the elderly. A total of 5,235 patients undergoing either mastectomy or breast conservation surgery (BCS) for invasive and ductal carcinoma in situ (DCIS) were identified in a retrospective review of a prospectively accrued data base between the years of 1994 and 2007 at the Moffitt Cancer Center. Of the 5,235 patients, 1,028 (20%) patients were ≥70 years of age. The 30‐day and 90‐day mortality in the elderly group (age ≥70 years) was 0.2% (95% CI 0.02–0.7%) and 0.7% (95% CI 0.3–1.4%), respectively. The 30‐day and 90‐day mortality among patients <70 years was 0 and 0.05% (2 of 4,207 patients) (95% CI 0.005–0.2), respectively. BCS rates for invasive carcinomas were the highest for patients between 40 and 70 years of age, whereas the mastectomy rates were higher among patients <40 years of age (53%). Elderly women were as likely as women <40 years to have BCS for invasive carcinoma (OR 1.1, 95% CI 0.8–1.5), but more likely to have BCS for DCIS (OR 1.9, 95% CI 1.1–3.3). Surgical mortality in elderly women treated for breast cancer was extremely low and was related to the extent of surgery performed. Breast cancer treatment differed by age groups.     

Anesthetic and perioperative risk in the patient with Ataxia-Telangiectasia

Objectives/Aim: To report our relatively large experience with perioperative care for patients with Ataxia‐Telangiectasia (A‐T) and to identify the nature and frequency of complications. Background: Ataxia‐Telangiectasia is a rare autosomal recessive genetic disorder resulting in progressive multisystem degeneration and characteristic findings including complex neurodegeneration, immunodeficiency, increased risk of malignancy, and lung disease. Anecdotal reports have suggested high perioperative morbidity in patients with A‐T, but few data exist. Methods/Materials: The Ataxia‐Telangiectasia Clinical Center database was cross‐referenced with operative records between 1995 and 2009 to identify patients with perioperative A‐T, and medical records were reviewed for preoperative history, management techniques, and complications. Results: Twenty‐one patients with A‐T underwent 34 anesthetics during the study period. The median age was 12.5 years (range 6–33 years). Common comorbidities included neurologic (100%), pulmonary (68%), immunologic (50%), oncologic (47%), and gastroenterologic (35%) disorders. Supplemental oxygen was required on postanesthesia care unit discharge for 24% of patients with a maximal duration of 24 h. Although mild postoperative hypothermia was relatively common (44% of anesthetics), there were no major complications, no unplanned admissions, and no mortality in this series. Conclusions: Although limited by its retrospective nature, this is the first series describing perioperative risk for patients with A‐T. Our results indicate that general anesthesia, airway manipulation, and perioperative mechanical ventilation may be tolerated with only minor postoperative anesthetic concerns. Perioperative providers should be aware of the complex multisystem medical concerns that may arise in these patients.     

Outcome of surgery for colonoscopic perforation

Aim The aetiology of colonoscopic perforation and factors related to poor outcome of surgical treatment were studied. Method A single‐centre review was conducted of all patients who underwent surgical treatment of a colonoscopic perforation, identified from a prospective registry of 21 981 consecutive colonoscopies carried out between 1993 and 2009. Results There were 29 (eight women) patients of mean age 73 years including 10 who had a nonelective colonoscopy. The perforation was not immediately recognized in 12 patients and in the remaining 17, seven were initially managed conservatively. The causes of perforation were barotrauma (11), mechanical force (14) and polypectomy‐related (3). Barotrauma was more frequent in emergency colonoscopy and mechanical force in elective colonoscopy. The outcome of surgery was as follows: mortality 10%, complications 34.5%, reoperation 14%, secondary surgery 23% and permanent colostomy 3%. The only factor related to in‐hospital mortality was an increased American Society of Anesthesiologists (ASA) score. Conclusion Colonoscopic perforation requiring surgery is a catastrophic event with high mortality, morbidity and reoperation rates.     

Perioperative outcomes and risk factors in gastric surgery for morbid obesity: a 9-year experience

OBJECTIVE: Surgical treatment of severe obesity is the most rapidly growing specialty area of surgery. The rapid expansion of bariatric surgery has raised questions and concerns regarding possible increased surgical mortality and morbidity rates in both academic and community settings. The purpose of this study was to evaluate postoperative outcomes and risk factors for bariatric gastric surgery for severe obesity. METHODS: A community experience of 1009 consecutive patients who underwent open surgical treatment of morbid obesity during a 9-year period was reviewed from a prospective database. The series included 858 primary gastric bypass operations and 151 revision operations. Perioperative outcomes, late complications, and weight loss results were recorded. Morbidity and mortality rates were analyzed according to patient age, body mass index (BMI), and gender. RESULTS: The mortality rate in the series was 0.6%, and the morbidity rate was 20%. The major complication rate was 6.6%. There were no deaths in the 151 revision patients. The gastrointestinal leak rate was 0.8%, and the thromboembolism rate was 1%. Statistical analysis indicates that BMI is a risk factor for surgical complications. CONCLUSION: Open gastric surgery for morbid obesity can be carried out in the community setting with low mortality and morbidity rates. BMI is a proven surgical risk factor.     

Survival analysis of pediatric dialysis patients in Taiwan

Aim: The long‐term survival of Taiwanese children with end‐stage renal disease (ESRD) has not been reported before. This study aimed to determine the long‐term survival, mortality hazards and causes of death in paediatric patients receiving dialysis. Methods: Paediatric patients (aged 19 years and younger) with incident ESRD who were reported to the Taiwan Renal Registry from 1995 to 2004 were included. A total of 319 haemodialysis (HD) and 156 peritoneal dialysis (PD) patients formed the database. After stratification by dialysis modality, multivariate Cox proportional‐hazards model was constructed with age, sex and co‐morbidity as predictive variables. Results: The annual paediatric ESRD incidence rate was 8.12 per million of age‐related populations. The overall 1‐, 5‐, and 10‐year survival rates for PD patients were 98.1%, 88.0% and 68.4%, respectively, and were 96.9%, 87.3% and 78.5% for HD patients. The survival analysis showed no significant difference between HD and PD (P = 0.4878). Using ‘15–19 years’ as a reference group, the relative risk (RR) of the youngest group (0–4 years) was 6.60 (95% CI: 2.50–17.38) for HD, and 5.03 (95% CI: 1.23–20.67) for PD. The death rate was 24.66 per 1000 dialysis patient‐years. The three major causes of death were infection (23.4%), cardiovascular disease (13.0%) and cerebrovascular disease (10.4%). Hemorrhagic stroke (87.5%) was the main type of foetal cerebrovascular accident. Conclusion: We conclude that there was no significant difference of paediatric ESRD patient survival between HD and PD treatment in Taiwan. The older paediatric ESRD patients had better survival than younger patients.     

Surgery in the nineties

The population of the United States is aging, and by 2020 it is estimated that 16 per cent of U.S. citizens will be over 65 years of age. Little has been published about the results of surgery in nonagenarians but mortality rates of 45 per cent are reported. Given recent improvements in perioperative care we reviewed the experience with major general surgical operative procedures in nonagenarians. We reviewed the charts of patients greater than or equal to 90 years of age who underwent general surgical procedures at UCLA Medical Center since 1986. No patients were excluded. Thirty-two patients were identified. Most (87.5%) patients had significant premorbid conditions. The most common diagnoses were cancer (12), incarcerated hernia (seven), trauma (three), colonic volvulus (two), and cholecystitis (two). Overall perioperative mortality was 9.4 per cent (3 of 32). Twenty-two surgeries (69%) were performed on an emergency basis, and all three deaths were in this group (13.6%). Overall morbidity rate was 57 per cent. Mean intensive care unit stay was 4.8 days. Most patients were discharged home. Our findings support the perioperative safety of elective general surgery in nonagenarians (0% mortality and 20% morbidity). We also found an acceptable risk (13.6% mortality and 68% morbidity) for emergency procedures despite significant comorbid conditions. Most of the patients had acceptable functional outcomes.