Comparison of Preoperative Surgical Risk Estimated by Thoracic Surgeons vs a Standardized Surgical Risk Prediction Tool

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Risk of AKI with Gentamicin as Surgical Prophylaxis

In 2009, the Scottish government issued a target to reduce Clostridium difficile infection by 30% in 2 years. Consequently, Scottish hospitals changed from cephalosporins to gentamicin for surgical antibiotic prophylaxis. This study examined rates of postoperative AKI before and after this policy change. The study population comprised 12,482 adults undergoing surgery (orthopedic, urology, vascular, gastrointestinal, and gynecology) with antibiotic prophylaxis between October 1, 2006, and September 30, 2010 in the Tayside region of Scotland. Postoperative AKI was defined by the Kidney Disease Improving Global Outcomes criteria. The study design was an interrupted time series with segmented regression analysis. In orthopedic patients, change in policy from cefuroxime to flucloxacillin (two doses of 1 g) and single-dose gentamicin (4 mg/kg) was associated with a 94% increase in AKI (P=0.04; 95% confidence interval, 93.8% to 94.3%). Most patients who developed AKI after prophylactic gentamicin had stage 1 AKI, but some patients developed persistent stage 2 or stage 3 AKI. The antibiotic policy change was not associated with a significant increase in AKI in the other groups. Regardless of antibiotic regimen, however, rates of AKI were high (24%) after vascular surgery, and increased steadily after gastrointestinal surgery. Rates could only be ascertained in 52% of urology patients and 47% of gynecology patients because of a lack of creatinine testing. These results suggest that gentamicin should be avoided in orthopedic patients in the perioperative period. Our findings also raise concerns about the increasing prevalence of postoperative AKI and failures to consistently measure postoperative renal function.Reported rates of postoperative AKI vary because of the heterogeneity of the populations studied. Uncomplicated AKI is associated with a mortality of 10%, rising to 50% in the context of multiorgan failure and up to 80% if RRT is required.^1,2 It was thought that the presence of AKI was a marker of coexisting pathology that increased mortality risk, but recent reports demonstrate AKI as an independent risk factor for mortality.^3,4 The increasing incidence of AKI and its long-term consequences have significant socioeconomic and public health effects globally.⁵Clostridium difficile infection (CDI) is an important healthcare-associated infection. Antibiotic use increases the risk of CDI for at least 3 months⁶ and short courses of perioperative antibiotic prophylaxis have also been associated with an increased risk of CDI, particularly in the context of an established outbreak.⁷In 2009, the Scottish government issued a new target for all health boards to reduce CDI by at least 30% over 2 years.⁸ The Scottish Antimicrobial Prescribing Group also produced recommendations for all National Health Service (NHS) boards to restrict the use of antibiotics associated with a high risk of CDI.⁹ As part of a widespread antibiotic policy change at NHS Tayside, orthopedic antibiotic prophylaxis was changed from cefuroxime to gentamicin and flucloxacillin. After concerns raised by nephrologists and a small uncontrolled study in the Dumfries and Galloway region of Scotland that described an increased rate of AKI in patients after orthopedic surgery after this policy change,¹⁰ it was felt that further investigation was required.This study aimed to use robust methodology, in a larger, population-based study of adult patients undergoing orthopedic implant surgery, to evaluate the effect of the policy change on postoperative AKI. It is noteworthy that patients who underwent repair of a neck of femur (NOF) fracture received coamoxiclav as antibiotic prophylaxis after the policy change because of concerns raised by orthopedic surgeons with regard to administering gentamicin in this particular patient group. This analysis was then extended to evaluate postoperative AKI in other surgical specialties (urology, vascular, gastrointestinal, and gynecology) that had changed to a gentamicin-based regimen.     

Risk Factor of Surgical Site Infection After Pancreaticoduodenectomy

Background

Although surgical site infection (SSI) following pancreaticoduodenectomy is a common complication, the risk factors remain unclear.

Patients and methods

A retrospective study of 408 consecutive patients undergoing pancreaticoduodenectomy was conducted and the risk factors for SSI were assessed. The bacterial composition was also analyzed.

Results

Sixty-one patients developed incisional SSI, and 195 developed organ/space SSI. A multivariate analysis identified that length of operation >480 min (odds ratio [OR] 3.22), main pancreatic duct (MPD) ≤3 mm (OR 2.18), and abdominal wall thickness >10 mm (OR 2.16) were significant risk factors for incisional SSI. The development of pancreatic fistula (OR 7.56), use of semi-closed drainage system (OR 3.68), body mass index >23.5 kg/m² (OR 3.04), MPD ≤3 mm (OR 2.21), and length of operation >480 min (OR 1.78) were significantly associated with organ/space SSI. Bacterial isolation at the SSI foci revealed that gut-derived micro-organisms were the predominant bacterial species.

Conclusions

The presence of pancreatic fistula was the strongest risk factor for organ/space SSI. Efforts to reduce the development of pancreatic fistulas, to decrease length of operation, and to use a closed drainage system would decrease the incidence of SSI following pancreaticoduodenectomy. If SSI that requires antibacterial treatment occurs, then the treatment should target enterobacteria.     

Perioperative Risk Assessment for Gastrectomy by Surgical Apgar Score

Background

Recently, a simple and easy complication prediction system, the surgical apgar score (SAS) calculated by three intraoperative parameters (estimated blood loss, lowest mean arterial pressure, and lowest heart rate), has been proposed for general surgery. In this study, we evaluated the predictability of the original SAS (oSAS) for severe complications after gastrectomy. In addition, the predictability of a modified SAS (mSAS) was evaluated, in which the cutoff value for blood loss was slightly modified.

Methods

We investigated 328 patients who underwent gastrectomy at the Shizuoka Cancer Center in 2010. Clinical data, including intraoperative parameters, were collected retrospectively. Patients with postoperative morbidities classified as Clavien–Dindo grade IIIa or more were defined as having severe complications. Univariate and multivariate analyses were performed to elucidate factors that affected the development of severe complications.

Results

Thirty-six patients (11.0 %) had severe complications postoperatively. Univariate analyses showed that the oSAS (p = 0.007) and mSAS (p < 0.001), as well as sex, preoperative chemotherapy, cStage, type of operation, thoracotomy, surgical approach, operation time, and extent of lymph node dissection, were associated with severe complications. Multivariate analysis showed that an mSAS ≤6 was found to be an independent risk factor for severe complication, while an oSAS ≤6 was not.

Conclusions

The oSAS was not found to be a predictive factor for severe complications following gastrectomy in Japanese patients. A slightly modified SAS (i.e. the mSAS) is considered to be a useful predictor for the development of severe complications in elective surgery.     

Risk Factors for Surgical Site Infections After Elective Gastrectomy

Objective

The aim of this study was to identify the risk factors for surgical site infections (SSIs) after elective gastrectomy.

Methods

This study reviewed the medical records of 842 patients who underwent elective gastrectomy. Multivariate analyses were performed to determine the risk factors for SSIs.

Results

Superficial incisional, deep incisional, and organ/space SSIs were detected in 50 (5.9%) patients, 2 (0.2%) patients, and 90 (10.7%) patients, respectively. A multivariate analysis demonstrated that female gender (p?=?0.0332) and allogenic blood transfusion (p?=?0.0266) were independent predictors for superficial incisional SSIs, while a male gender (p?=?0.0355), corticosteroid therapy (p?=?0.037), total gastrectomy (p?p?=?0.0062) were independent predictors for organ/space SSIs. The median length of postoperative hospital stay was significantly longer in patients with organ/space SSIs in comparison to those without SSIs (p?p?p?Conclusions The risk factors both for incisional SSIs and for organ/space SSIs are strongly associated with surgical results. Meticulous surgical techniques are therefore required to prevent SSIs.     

Risk Factors for Surgical Complications in Ventral Hernia Repair

Background

The aim of this study was to identify risk factors for an adverse event, i.e. early surgical complication, need for ICU care and readmission, following ventral hernia repair. Our hypothesis was that there is an association between an increased complication rate following ventral hernia repair and specific factors, including hernia size, BMI?>?35, concomitant bowel surgery, ASA-class, age, gender and method of hernia repair.

Methods

Data from a hernia database with prospectively entered data on 408 patients operated for ventral hernia between 2007 and 2014 at two Swedish university hospitals were analysed. A 3-month follow-up of complications, need for intensive care and readmission, was performed by reviewing the medical records.

Results

Eighty-one of 408 patients (20%) had a registered complication. Fifty-eight (14%) of these were classed as Clavien I–IIIa, and in 19 cases a Clavien IIIb–IV complication was reported. Large hernia size was associated with increased risk for early complication. A Kendall Tau test analysis revealed a proportional relationship between hernia size and modified Clavien outcome class (p?<?0.001). Morbid obesity, ASA-class, method, hernia recurrence, age and concomitant bowel surgery were not statistically significant predictors of adverse events.

Conclusions

Assessment of hernia aperture size is of great importance in the preoperative evaluation of ventral hernia patients to consider risk for post-operative complications. These results suggest a careful attitude when applying watchful waiting concepts and when postponing hernia surgery to achieve weight loss. A delaying attitude may result in increased risk of complications caused by increasing hernia size.

     

Risk Factors in Surgical Patients with Verified Preoperative Myocardial Infarction

A series of 89 surgical patients (111 operations) with preoperative myocardial infarction (MI) was analysed for factors predisposing to the development of a postoperative reinfarction. Six of them suffered postoperative MI, and three of these patients died. In the statistical analysis the following risk factors emerged: age over 60 years, anaemia, hypertension, and the fact that the previous MI had been posterior. Abdominal operations were more dangerous concerning reinfarction than other operations. In the other series of 11 deceased patients with postoperative reinfarction collected from the autopsy material, about the same risk factors were found. The most important factor seemed to be hypotension, which complicated the surgery. All 11 patients had arrhythmias in their preoperative electrocardiogram. Previously treated heart failure was present in five of these patients. Postoperative symptoms analysed in the first series suggest that if a patient with preoperative MI has arrhythmias, hypotension, dyspnoea, diffuse unlocalized pain or chest pain after sugery, he is very likely to have a reinfarction.     

Risk Factor Documentation in Elective and Emergency Vascular Surgical Admissions

OBJECTIVES: this study investigates current practice of risk factor documentation in a vascular unit and compares variations in risk factor assessment between elective and emergency admissions. METHODS: one hundred and forty-four patients who underwent vascular surgical intervention for atherosclerotic disease during the year 2000 were retrospectively identified from computerised database. Case note review collated demographic details, data on risk factor assessment and the nature of surgery. Data were analysed using SPSS statistical software. RESULTS: the male to female ratio was 2.3:1 with a median (range) age of 73 (31-95) years. For 55 (38%) emergency admissions the following risk factors were not documented; ischaemic heart disease (8), diabetes mellitus (10), hypertension (10), smoking habit (13) and antiplatelet therapy (18). For 89 (62%) elective admissions the following risk factors were not documented; ischaemic heart disease (11), diabetes mellitus (9), hypertension (4), smoking habit (5) and antiplatelet therapy (19). Sixty-six (72.5%) routine admissions and 11 (20.8%) emergency admissions had estimations of serum cholesterol documented (chi(2) p < 0.001). There were no statistically significant differences in the documentation of other risk factors between the 2 groups. CONCLUSION: risk factors are not documented consistently for emergency vascular surgical admissions. Staff education should aim to improve risk factor assessment for elective and emergency admissions to reduce cardiovascular events and possibly improve surgical outcome in patients with atherosclerotic disease.     

Risk of Surgical Mitral Valve Repair for Primary Mitral Regurgitation

BackgroundRisk estimation for surgical intervention is an essential component of heart team shared decision-making. However, current mitral valve (MV) surgery risk models used in practice lack etiologic or procedural specificity. The purpose of this study was to establish a comprehensive method for assessment of operative risk of MV repair of primary mitral regurgitation (MR).MethodsA novel etiology and procedure-specific algorithm identified 53,462 consecutive (July 2014 to June 2020) intention-to-treat MV repair patients with primary MR from The Society of Thoracic Surgeons Adult Cardiac Surgery Database. Risk models were fit for 30-day operative mortality, mortality and/or major morbidity, and conversion-to-replacement (CONV). As-treated mortality and morbidity models were derived separately.ResultsEvent rates for mortality (n = 619; 1.16%), mortality plus morbidity (n = 4746; 8.88%), and CONV (n = 3399; 6.36%) were low. Mortality was higher in CONV patients vs repair (3.18% vs 1.02%). All event rates were lower with increasing program volumes. The mortality risk model had excellent discrimination (AUC: 0.807) and calibration and confirmed very low mortality risk for isolated MV repair for primary MR, with mean mortality risk of 1.16% and median of 0.55% (interquartile range: 0.30%-1.17%) with 90th and 95th percentiles 2.48% and 3.99%, respectively. The mortality risk was <0.5% in patients <65 years of age, with 97% of the total population across age groups having a risk of <3%. Only 1 in 4 patients age 75 or older had >3% estimated risk of mortality.ConclusionsThis etiologic and procedure-specific risk model establishes that the contemporary mortality risk of MV repair for primary MR is <1% for the vast majority of patients.     

Risk Assessment Tool for Pressure Ulcer Development in Indian Surgical Wards

The aims of this paper were to compare the predictive validity of three pressure ulcer (PU) risk scales—the Norton scale, the Braden scale, and the Waterlow scale—and to choose the most appropriate calculator for predicting PU risk in surgical wards of India. This is an observational prospective cohort study in a tertiary educational hospital in New Delhi among 100 surgical ward patients from April to July 2011. The main outcomes measured included sensitivity, specificity, positive predictive value (PVP) and negative predictive value (PVN), and the area under the curve of the receiver operating characteristic (ROC) curve of the three PU risk assessment scales. Based on the cutoff points found most appropriate in this study, the sensitivity, specificity, PVP, and PVN were as follows: the Norton scale (cutoff, 16) had the values of 95.6, 93.5, 44.8, and 98.6, respectively; the Braden scale (cutoff, 17) had values of 100, 89.6, 42.5, and 100, respectively; and the Waterlow scale (cutoff, 11) had 91.3, 84.4, 38.8, and 97, respectively. According to the ROC curve, the Norton scale is the most appropriate tool. Factors such as physical condition, activity, mobility, body mass index (BMI), nutrition, friction, and shear are extremely significant in determining risk of PU development (p < 0.0001). The Norton scale is most effective in predicting PU risk in Indian surgical wards. BMI, mobility, activity, nutrition, friction, and shear are the most significant factors in Indian surgical ward settings with necessity for future comparison with established scales.     

血管外科手术病人中的血小板基因多态性和心脏风险评估

背景 :目前围术期心脏风险评估工具是沿用外科手术影响因素对病人进行分级。血小板糖蛋白I IIa(GPIIIa)及GPIbα和非外科手术情况下的心肌缺血相关 ,但他们与围术期心肌缺血的关系并不清楚。作者提出假说血小板基因型和临床因素结合起来可成为围术期心肌缺血的预测指标。方法 :196例行下肢动脉、腹主动脉 ,胸主动脉血管手术的病人以临床和基因型因素预测术后心肌缺血的发生发展情况。基因组DNA由GPIIIa的Leu33Pro基因和GPIbα的Thr14 5Met基因构成。心肌缺血后果通过心脏死亡的医疗记录回顾或心肌梗死和肌钙蛋白I监测、持续自动 …