Twenty-Three-Hour-Stay Colectomy Without Increased Readmissions: An Analysis of 1905 Cases from the National Surgical Quality Improvement Program

Background

Isolated case series from highly specialized centers suggest the feasibility of a 23-h hospital stay after colectomy. We sought to determine preoperative variables associated with discharge within 23 h after colectomy to identify patients best suited for a short-stay model.

Methods

The American College of Surgeons NSQIP Colectomy-Targeted database was used to identify patients who underwent elective colectomy from 2012 to 2017. All cases with missing length of stay or inpatient death were excluded. Patients with a postoperative hospital stay ≤1 day were identified. Univariate and multivariate analyses were conducted to identify factors associated with early discharge.

Results

A total of 1905 patients were discharged within 23 h after surgery (1.6%). These patients were noted to be younger (59 versus 61 years, p < 0.001) and less likely to have insulin-dependent diabetes (3.0 versus 4.4%, p < 0.001), preoperative dyspnea (2.2 versus 6.0%, p < 0.001), COPD (3.0 versus 4.2%, p = 0.011), and hypertension (40.7 versus 46.9%, p < 0.001) than patients who stayed longer. Shorter operative time (OR 0.986, 95% CI 0.985–0.987, p < 0.001), minimally invasive techniques (OR 2.969, 95% CI 2.686–3.282, p < 0.001), lack of ostomy (OR 0.614, 95% CI 0.478–0.788, p < 0.001), and lack of ureteral stenting (OR 0.641, 95% CI 0.500–0.821, p < 0.001) were associated with early discharge in multivariable analysis. There was no increased incidence of readmission in patients discharged within 23 h.

Conclusions

Twenty-three-hour-stay colectomy is feasible on a national level and does not result in an increased incidence of readmission. Patients undergoing elective procedures without significant medical comorbidities may be eligible for early discharge. Preoperative factors may be used to select patients best suited for this short-stay model.

     

Risk Factors for and Prediction Model of Skip Metastasis to Lateral Lymph Nodes in Papillary Thyroid Carcinoma

Background

Cervical lymph node metastasis is a prognostic factor of papillary thyroid carcinoma (PTC). Skip metastasis (central lymph node negative and lateral lymph node positive) of PTC is not uncommon. This study aimed to retrospectively investigate the risk factors for skip metastasis in PTC and develop a prediction model for skip metastasis.

Methods

A total of 745 PTC patients underwent total thyroidectomy and central plus lateral lymph node dissection at the First Affiliated Hospital of Chongqing Medical University from January 2012 to December 2017. Clinicopathological characteristics were collected and analyzed. Univariate and multivariate analyses were performed to detect the risk factors for skip metastasis. A prediction model was established based on the results of multivariate analyses.

Results

The skip metastasis rate was 9.7% (72/745). Age > 55 years (OR 2.63, 95% CI 1.34–5.04, p = 0.004), tumor located in the upper portion (OR 4.15, 95% CI 2.30–7.63, p = 0.001), and unilaterality (OR 2.76, 95% CI 1.14–8.23, p = 0.040) were independent risk factors for skip metastasis. Clinically lymph node-negative (cN0) patients with tumor in the upper portion (24.6%, 43/175) had higher possibility of skip metastasis than those of clinically lateral lymph node-positive (cN1b) patients (5.9%, 10/169) (p = 0.001). The area under the receiver operating characteristic curve of prediction model was 0.734 and 0.740 in derivation group and validation group, respectively. However, skip metastasis was not associated with tumor-free survival rate of PTC patients (p = 0.274).

Conclusion

Age > 55 years, tumor located in the upper portion, and unilaterality may increase the risk of skip metastasis. We developed the first prediction model for skip metastasis based on clinicopathological parameters in PTC patients.

     

Correlation between kidney function and mortality in pyogenic spondylodiscitis: the glomerular filtration rate (GFR) as new predictive parameter?

Objective

Pyogenic spondylodiscitis is a severe medical condition, often requiring surgical intervention. Numerous risk factors are known, such as obesity, neurological impairment and old age. In-hospital mortality remains high, therefore other factors may be contributing to the increased mortality. To evaluate kidney function as a risk factor for increased morbidity of pyogenic spondylodiscitis, the glomerular filtration rate (GFR) was correlated with the patients' clinical course.

Materials and methods

We retrospectively reviewed the cases of 366 patients and 255 were included for analysis. Clinical, laboratory and surgical data were recorded with a minimum follow-up of three months. For clinical outcome measurement, mortality, length of stay and perioperative complications were analysed.

Results

The study included 255 patients (173 men, 82 women; mean age 66.3 years). Patients with a GFR < 59 mL/min spent an average of 5 days longer in the hospital than those with a GFR ≥ 60 mL/min (p = 0.071). The mortality rate increased significantly with a decrease in GFR: A GFR of 30–59 mL/min had a mortality rate of 17.6%, whereas a GFR of < 29 mL/min had one of 30.4% (p = 0.003). Patients with impaired GFR showed an increased rate of postoperative complications (OR 4.7 p = 0.002) and higher rate of intensive care unit (ICU) stay (OR 8.7 p =  < 0.001).

Discussion

Preoperative GFR values showed a significant correlation with in-hospital mortality in patients with spondylodiscitis, when graded according to the KDIGO stages. Furthermore, a GFR of < 29 ml/mL contributes to a longer ICU stay, postoperative complications and a longer total hospital stay. Therefore, the preoperative GFR could be a marker of kidney function and as a valuable predictive risk factor regarding the clinical in-hospital course of patients suffering from pyogenic spondylodiscitis.

     

The effect of prophylactic mesh implantation on the development of incisional hernias in patients with elevated BMI: a systematic review and meta-analysis

Background

Incisional hernia is a common complication after midline laparotomy. In certain risk profiles incidences can reach up to 70%. Large RCTs showed a positive effect of prophylactic mesh reinforcement (PMR) in high-risk populations.

Objectives

The aim was to evaluate the effect of prophylactic mesh reinforcement on incisional hernia reduction in obese patients after midline laparotomies.

Methods

Following the PRISMA guidelines, a systematic literature search in Medline, Web of Science and CENTRAL was conducted. RCTs investigating PMR in patients with a BMI ≥ 27 reporting incisional hernia as primary outcome were included. Study quality was assessed using the Cochrane risk-of-bias tool and certainty of evidence was rated according to the GRADE Working Group grading of evidence. A random-effects model was used for the meta-analysis. Secondary outcomes included postoperative complications.

Results

Out of 2298 articles found by a systematic literature search, five RCTs with 1136 patients were included. There was no significant difference in the incidence of incisional hernia when comparing PMR with primary suture (odds ratio (OR) 0.59, 95% CI 0.34–1.01, p = 0.06, GRADE: low). Meta-analyses of seroma formation (OR 1.62, 95% CI 0.72–3.65; p = 0.24, GRADE: low) and surgical site infections (OR 1.52, 95% CI 0.72–3.22, p = 0.28, GRADE: moderate) showed no significant differences as well as subgroup analyses for BMI ≥ 40 and length of stay.

Conclusions

We did not observe a significant reduction of the incidence of incisional hernia with prophylactic mesh reinforcement used in patients with elevated BMI. These results stand in contrast to the current recommendation for hernia prevention in obese patients.

     

Factors contributing to a longer length of stay in adults admitted to a quaternary spinal care center

Background

Longer hospital length of stay (LOS) has been associated with worse outcomes and increased resource utilization. However, diagnostic and patient-level factors associated with LOS have not been well studied on a large scale. The goal was to identify patient, surgical and organizational factors associated with longer patient LOS for adult patients at a high-volume quaternary spinal care center.

Methods

We performed a retrospective analysis of 13,493 admissions from January 2006 to December 2019. Factors analyzed included age, sex, admission status (emergent vs scheduled), ASIA grade, operative vs non-operative management, mean blood loss, operative time, and adverse events. Specific adverse events included surgical site infection (SSI), other infection (systemic or UTI), neuropathic pain, delirium, dural tear, pneumonia, and dysphagia. Diagnostic categories included trauma, oncology, deformity, degenerative, and “other”. A multivariable linear regression model was fit to log-transformed LOS to determine independent factors associated with patient LOS, with effects expressed as multipliers on mean LOS.

Results

Mean LOS for the population (SD) was 15.8 (34.0) days. Factors significantly (p < 0.05) associated with longer LOS were advanced patient age [multiplier on mean LOS 1.011/year (95% CI: 1.007–1.015)], emergency admission [multiplier on mean LOS 1.615 (95% CI: 1.337–1.951)], ASIA grade [multiplier on mean LOS 1.125/grade (95% CI: 1.051–1.205)], operative management [multiplier on mean LOS 1.211 (95% CI: 1.006–1.459)], and the occurrence of one or more AEs [multiplier on mean LOS 2.613 (95% CI: 2.188–3.121)]. Significant AEs included postoperative SSI [multiplier on mean LOS 1.749 (95% CI: 1.250–2.449)], other infections (systemic infections and UTI combined) [multiplier on mean LOS 1.650 (95% CI: 1.359–2.004)], delirium [multiplier on mean LOS 1.404 (95% CI: 1.103–1.787)], and pneumonia [multiplier on mean LOS 1.883 (95% CI: 1.447–2.451)]. Among the diagnostic categories explored, degenerative patients experienced significantly shorter LOS [multiplier on mean LOS 0.672 (95%CI: 0.535–0.844), p < 0.001] compared to non-degenerative categories.

Conclusion

This large-scale study taking into account diagnostic categories identified several factors associated with patient LOS. Future interventions should target modifiable factors to minimize LOS and guide hospital resource allocation thereby improving patient outcomes and quality of care and decreasing healthcare-associated costs.

     

Trends in the Incidence,Treatment and Outcomes of Patients with Intrahepatic Cholangiocarcinoma in the USA: Facility Type is Associated with Margin Status,Use of Lymphadenectomy and Overall Survival

Introduction

Intrahepatic cholangiocarcinoma (ICC) remains an uncommon disease with a rising incidence worldwide. We sought to identify trends in therapeutic approaches and differences in patient outcomes based on facility types.

Methods

Between January 1, 2004, and December 31, 2015, a total of 27,120 patients with histologic diagnosis of ICC were identified in the National Cancer Database and were enrolled in this study.

Results

The incidence of ICC patients increased from 1194 in 2004 to 3821 in 2015 with an average annual increase of 4.16% (p < 0.001). Median survival of the cohort improved over the last 6 years of the study period (2004–2009: 8.05 months vs. 2010–2015: 9.49 months; p < 0.001). Among surgical patients (n = 5943, 21.9%), the incidence of R0 resection, lymphadenectomy and harvest of ≥6 lymph nodes increased over time (p < 0.001). Positive surgical margins (referent R0: R1, HR 1.49, 95% CI 1.24–1.79, p < 0.001) and treatment at community cancer centers (referent academic centers; HR 1.24, 95% CI 1.04–1.49, p = 0.023) were associated with a worse prognosis. Patients treated at academic centers had higher rates of R0 resection (72.4% vs. 67.7%; p = 0.006) and lymphadenectomy (55.6% vs. 49.5%, p = 0.009) versus community cancer centers. Overall survival was also better at academic versus community cancer programs (median OS: 11 months versus 6 months, respectively; p < 0.001).

Conclusions

The incidence of ICC has increased over the last 12 years in the USA with a moderate improvement in survival over time. Treatment at academic cancer centers was associated with higher R0 resection and lymphadenectomy rates, as well as improved OS for patients with ICC.

     

Recurrence Patterns After Resection of Colorectal Liver Metastasis are Modified by Perioperative Systemic Chemotherapy

Background

This study investigated the impact of perioperative systemic chemotherapy on the recurrence rate and pattern following resection of colorectal liver metastases.

Methods

A retrospective cohort study was conducted in two centers. Rates and patterns of recurrence and overall survival (OS) were compared between patients treated with and without perioperative systemic chemotherapy. The clinical risk score (CRS) was used to stratify patients in low risk (CRS 0–2) and high risk (CRS 3–5) of recurrence.

Results

A total of 2020 patients were included, of whom 1442 (71%) received perioperative systemic chemotherapy. The median follow-up was 88 months, and 1289 patients (64%) developed a recurrence. The recurrence pattern was independent of chemotherapy in low-risk patients: intrahepatic recurrences (30% vs. 30%, p = 0.97) and extrahepatic recurrences (38% vs. 39%, p = 0.52). In high-risk patients, no difference in intrahepatic recurrences was found (48% vs. 50%, p = 0.59). However, a lower rate of extrahepatic recurrences (43% vs. 55%, p = 0.007) was observed with perioperative systemic chemotherapy, mainly due to a reduction in pulmonary recurrences (25% vs. 35%, p = 0.007). In competing risk analysis, the cumulative incidence of extrahepatic recurrence was significantly lower with perioperative systemic chemotherapy in high-risk patients only (5-year cumulative incidence 44% vs. 59%, p < 0.001). Perioperative chemotherapy was associated with improved OS in high-risk patients (adjusted HR 0.73, 95% CI 0.57–0.94, p = 0.02), but not in low-risk patients (adjusted HR 0.99, 95% CI 0.82–1.19, p = 0.90).

Conclusions

Perioperative systemic chemotherapy had no association with intrahepatic recurrence, but was associated with fewer pulmonary recurrences and superior OS in high-risk patients only.

     

Prediction of outcomes for symptomatic spinal cavernous malformation surgery: a multicenter prospective clinical study

Purpose

Clinical outcome of spinal cavernous malformation (SCM) varies because of its unclear natural history, and reliable prognostic prediction model for SCM patients is limited. The aim of the present study was to investigate potential factors that predict one-year neurological status in postoperative patients with SCM.

Methods

This was a multicenter prospective observational study in consecutive patients with SCMs. SCMs treated microsurgically between January 2015 and January 2021 were included. Outcome was defined as the American Spinal Injury Association Impairment Scale (AIS) grade at one year after operation. Multivariable analyses were used to construct the best predictive model for patient outcomes.

Results

We identified 268 eligible SCM patients. Neurological outcome had worsened from preoperative baseline in 51 patients (19.0%) at one year. In the multivariable logistic regression, the best predictive model for unfavorable outcome included symptom duration ≥ 26 months (95% CI 2.80–16.96, P < 0.001), size ≤ 5 mm (95% CI 1.43–13.50, P = 0.010), complete intramedullary (95% CI 1.69–8.14, P = 0.001), subarachnoid hemorrhage (95% CI 2.92–12.57, P < 0.001), AIS B (95% CI 1.91–40.93, P = 0.005) and AIS C (95% CI 1.12–14.54, P = 0.033).

Conclusions

Admission size of the lesion, morphology, symptom duration, AIS grade and the presence of subarachnoid hemorrhage were strong outcome predictors regarding prognostication of neurological outcome in postoperative patients with SCMs. A decision to surgically remove a symptomatic SCM should be justified by systematic analysis of all factors potentially affecting outcome.

     

Mild and Moderate Traumatic Brain Injury and Gender-Based Critical Care Outcomes

Background

Traumatic brain injury (TBI) is a major contributor to death and complications. Previous studies have identified gender disparities among trauma patients. This study aims to examine the association between gender and outcomes in TBI patients.

Study design and methods

Review of our trauma registry: Patients were classified into groups according to their gender. Demographics extracted from the registry included age, injury severity score (ISS), Glasgow Coma Score (GCS), head abbreviated injury score (AIS), and the presence of an epidural hematoma (EDH). The primary outcome was mortality; secondary outcomes included ICU length of stay (ICU-LOS), craniotomy rate, ventilator-associated pneumonia (VAP), and readmission rates. Significance was defined as p < 0.05.

Results

Nine hundred and thirty-five patients with TBI were studied: 62.1% (n = 581) were male and 37.9% (n = 354) were female. There were no differences in GCS, ISS, and head AIS. Males were younger [53 (IQR 30–77) vs. 76 (IQR 49.25–84), p < 0.05] and were more likely to have an EDH (9.6% vs. 4.8%, p = 0.007). Males also had a longer median ICU-LOS [4 days (IQR 2–8) vs. 3 days (IQR 0–5), p < 0.05] and were significantly more likely to require a craniotomy (44.6% vs. 19.2%, p < 0.001). In addition, males were more likely to develop VAP (4.1% vs. 0.8%, p = 0.004). Predicted survival (79.2% vs. 72.9%) and actual mortality rates (4.5% vs. 4.5%) were similar in both genders (p > 0.05).

Conclusion

In the context of our study, male patients with TBI were significantly younger, were more likely to sustain an EDH, and were also more likely to require a craniotomy, but mortality rates between both genders were similar. The male gender was also associated with a significantly increased ICU-LOS and VAP.

     

One-Step Multichannel Percutaneous Transhepatic Cholangioscopic Lithotripsy Applied in Bilateral Hepatolithiasis

Background

The aim of this study was to compare the outcomes of one-step multichannel percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) with traditional PTCSL in the treatment of bilateral hepatolithiasis.

Methods

From February 2011 to June 2015, 156 patients with bilateral hepatolithiasis received surgical treatment in our department. Among these patients, 81 received one-step multichannel PTCSL (group A), and the remaining 75 received traditional PTCSL (group B).

Results

Compared with group B, group A was characterized by a significantly shorter operation time (83.7 ± 28.5 min vs 118.1 ± 41.5 min; P = 0.000), hospital stay (11.1 ± 3.4 d vs 17.8 ± 5.6 d; P = 0.034), and postoperative hospital stay (6.9 ± 3.1 d vs 9.6 ± 4.5 d; P = 0.026). In addition, the immediate clearance (62.9% vs 45.3%, P = 0.027) and final clearance (90.1% vs 78.7%, P = 0.048) rates were higher in group A than in group B. During the follow-up period, stone recurrence was significantly less common in group A than in group B (13.6% vs 26.7%, P = 0.041). Multivariate Cox analysis showed that the PTCSL method (HR = 2.32, 95% confidence interval [CI] = 1.09–4.90, P = 0.028), bilateral biliary stricture (HR = 4.17, 95% CI = 1.73–10.03, P = 0.001), and stones located in segments I (HR = 7.75, 95% CI = 3.67–16.38, P = 0.000) were independent predictors of recurrence.

Conclusions

Compared with traditional PTCSL, one-step multichannel PTCSL was more efficient and effective in the treatment of bilateral hepatolithiasis.

     

Risk factors for thirty-day morbidity and mortality after spinal trauma

Background

Traumatic Spinal Injuries (TSI) often follow high velocity injuries and frequently accompanied by polytrauma. While most studies have focussed on outcomes of spinal cord injuries, the incidence and risk factors that predict morbidity and mortality after TSI has not been well-defined.

Methods

Data of consecutive patients of TSI (n = 2065) treated over a 5-year-period were evaluated for demographics, injury mechanisms, neurological status, associated injuries, timing of surgery and co-morbidities. The thirty-day incidence and risk factors for complications, length of stay and mortality were analysed.

Results

The incidence of spinal trauma was 6.2%. Associated injuries were seen in 49.7% (n = 1028), and 33.5% (n = 692) patients had comorbidities. The 30-day mortality was 0.73% (n = 15). Associated chest injuries (p = 0.0001), cervical spine injury (p = 0.0001), ASIA-A neurology (p < 0.01) and ankylosing spondylitis (p = 0.01) correlated with higher mortality. Peri-operative morbidity was noted in 571 patients (27.7%) and were significantly associated with age > 60 (p = 0.043), ASIA-A neurology (p < 0.05), chest injuries (p = 0.042), cervical and thoracic spine injury (p < 0.0001). The mean length of stay in hospital was 8.87 days. Cervical spine injury (p < 0.0001), delay in surgery > 48 h (p = 0.011), Diabetes mellitus (p = 0.01), Ankylosing spondylitis (p = 0.009), associated injuries of chest, head, pelvis and face (p < 0.05) were independent risk factors for longer hospital stay.

Conclusion

Key predictors of mortality after spinal trauma were cervical spine injury, complete neurological deficit, chest injuries and ankylosing spondylitis, while additionally higher age and thoracic injuries contributed to higher morbidity and prolonged hospitalisation. Notably multi-level injuries, higher age, co-morbidities and timing of surgery did not influence the mortality.

     

Open Abdomen in Obese Patients: Pay Attention! New Evidences from IROA,the International Register of Open Abdomen

Background

Open abdomen is the cornerstone of damage control strategies in acute care and trauma surgery. The role of BMI has not been well investigated. The aim of the study was to assess the role of BMI in determining outcomes after open abdomen.

Methods

This is an analysis of patients recorded into the International Register of Open Abdomen; patients were classified in two groups according to BMI using a cutoff of 30 kg/m². The primary outcome was in-hospital mortality; secondary outcomes were primary fascia closure rate, length of treatment, complication rate, entero-atmospheric fistula rate and length of ICU stay.

Results

A total of 591 patients were enrolled from 57 centers, and obese patients were 127 (21.5%). There was no difference in mortality between the two groups; complications developed during the open treatment were higher in obese patients (63.8% vs. 53.4%, p = 0.038) while post-closure complications rate was similar. Obese patients had a significantly longer duration of the open treatment (9.1 ± 11.5 days vs. 6.3 ± 7.5 days; p = 0,002) and lower primary fascia closure rate (75.5% vs. 89.5%; p < 0,001). No differences in fistula rate were found. There was a linear correlation between the duration of open abdomen and the BMI (Pearson’s linear correlation coefficient = 0,201; p < 0,001).

Conclusions

Open abdomen in obese patients seems to be safe as in non-obese patients with similar mortality; however, in obese patients the length of open abdomen is significantly higher with higher complication rate, longer ICU length of stay and lower primary fascia closure rate.

Trial registration number

ClinicalTrials.gov, Identifier: NCT02382770.

     

Critical Appraisal of the Impact of Oesophageal Stents in the Management of Oesophageal Anastomotic Leaks and Benign Oesophageal Perforations: An Updated Systematic Review

Introduction

Endoscopic placement of oesophageal stents may be used in benign oesophageal perforation and oesophageal anastomotic leakage to control sepsis and reduce mortality and morbidity by avoiding thoracotomy. This updated systematic review aimed to assess the safety and effectiveness of oesophageal stents in these two scenarios.

Methods

A systematic literature search of all published studies reporting use of metallic and plastic stents in the management of post-operative anastomotic leaks, spontaneous and iatrogenic oesophageal perforations were identified. Primary outcomes were technical (deploying ≥ 1 stent to occlude site of leakage with no evidence of leakage of contrast within 24–48 h) and clinical success (complete healing of perforation or leakage by placement of single or multiple stents irrespective of whether the stent was left in situ or was removed). Secondary outcomes were stent migration, perforation and erosion, and mortality rates. Subgroup analysis was performed for plastic versus metallic stents and anastomotic leaks versus perforations separately.

Results

A total of 66 studies (n = 1752 patients) were included. Technical and clinical success rates were 96% and 87%, respectively. Plastic stents had significantly higher migration rates (24% vs 16%, p = 0.001) and repositioning (11% vs 3%, p < 0.001) and lower technical success (91% vs 95%, p = 0.032) than metallic stents. In patients with anastomotic leaks, plastic stents were associated with higher stent migration (26% vs 15%, p = 0.034), perforation (2% vs 0%, p = 0.013), repositioning (10% vs 0%, p < 0.001), and lower technical success (95% vs 100%, p = p = 0.002). In patients with perforations only, plastic stents were associated with significantly lower technical success (85% vs 99%, p < 0.001).

Conclusions

Covered metallic oesophageal stents appear to be more effective than plastic stents in the management of oesophageal perforation and anastomotic leakage. However, quality of evidence of generally poor and high-quality randomised trial is needed to further evaluate best management option for oesophageal perforation and anastomotic leakage.

     

Increased Morbidity and Mortality of Emergency Laparotomy in Elderly Patients

Background

There is an increasing incidence of elderly patients requiring emergency laparotomy. Our study compares the outcomes of elderly patients undergoing emergency laparotomy against the outcomes of non-elderly patients.

Methodology

Patients who underwent emergency laparotomy between 2015 and 2017 from the National University Hospital, Singapore, were included. Apart from demographic data, indication of surgery and surgical procedure performed were collected. Prospectively collected nutritional scores were evaluated. Outcome measures included duration of surgery, length of ICU and total hospital stay, post-operative complications, and mortality indices. We performed multivariate Cox regression analysis to determine the contribution of various risk factors towards overall survival following emergency laparotomy.

Results

A total of 170 emergency laparotomies were performed. Compared to non-elderly patients, elderly patients had a significantly longer mean stay in hospital (31.5 vs. 18.6 days, p = 0.006) and mean stay in ICU (13.1 vs. 5.3 days, p = 0.003). More elderly patients suffered from post-laparotomy complications compared with non-elderly patients (65.8% vs. 37.4%, p < 0.001). 30-day mortality (31.5% vs. 8.8%, p = 0.019) and 1-year mortality (27.9% vs. 14.3%, p = 0.023) were higher in elderly patients compared with non-elderly patients. Interestingly, there was no statistically significant difference between elderly and non-elderly groups in both the global 3-MinNS as well as the global SGA nutritional scores. ASA status (HR 2.61, 95% CI 1.05–6.45, p = 0.038) was an independent risk factor for decreased survival following emergency laparotomy. Notably, while age ≥ 65 demonstrated a significant correlation with survival on univariate analysis (HR 1.03 (1.01–1.05), p = 0.003), this effect was lost following multivariate regression (HR 1.01 (0.453–2.23), p = 0.989).

Conclusion

Elderly patients suffer worse morbidity and mortality following emergency laparotomy. This is likely contributed by comorbidities resulting in higher ASA status.

     

The Effect of Perioperative Iron Therapy in Acute Major Non-cardiac Surgery on Allogenic Blood Transfusion and Postoperative Haemoglobin Levels: A Systematic Review and Meta-analysis

Background

Perioperative anaemia in relation to surgery is associated with adverse clinical outcomes. In an elective surgical setting, it is possible to optimize patients prior to surgery, often by iron supplementation with correction of anaemia. Possibilities for optimization prior to and during acute surgical procedures are limited. This review investigates whether iron treatment initiated perioperatively improves outcomes in patients undergoing major acute non-cardiac surgery.

Method

This systematic review was performed using PubMed, EMBASE (Ovid) and Scopus to identify current evidence on iron supplementation in acute surgery. Primary outcomes were allogenic blood transfusion (ABT) rate and changes in haemoglobin. Secondary outcomes were postoperative mortality, length of stay (LOS), and postoperative complications. Iron was administered at latest within 24 h after end of surgery.

Results

Of the 5413 studies screened, four randomized controlled trials and nine observational cohort studies were included. Ten studies included patients with hip fractures. A meta-analysis of seven studies showed a risk reduction of transfusion (OR = 0.35 CI 95% (0.20–0.63), p = 0.0004, I² = 66%). No influence on plasma haemoglobin was found. Postoperative mortality was reduced in the iron therapy group in a meta-analysis of four observational studies (OR 0.50 (CI 95% 0.26–0.96) p = 0.04). No effect was found on LOS, but a reduction in postoperative infection was seen in four studies.

Conclusions

This review examined perioperative iron therapy in acute major non-cardiac surgery. IV iron showed a lower 30-day mortality, a reduction in postoperative infections and a reduction in ABT largely due to the observational studies. The review primarily consisted of small observational studies and does not have the power to formally recommend this practice.

     

Obesity is Associated with Worse Outcomes Among Abdominal Trauma Patients Undergoing Laparotomy: A Propensity-Matched Nationwide Cohort Study

Introduction

Obesity is associated with increased morbidity and mortality in abdominal trauma patients. The characteristics of abdominal trauma patients with poor outcomes related to obesity require evaluation. We hypothesize that obesity is related to increased mortality and length of stay (LOS) among abdominal trauma patients undergoing laparotomies.

Methods

Abdominal trauma patients were identified from the National Trauma Data Bank between 2013 and 2015. Patients who received laparotomies were analyzed using propensity score matching (PSM) to evaluate the mortality rate and LOS between obese and non-obese patients. Patients without laparotomies were analyzed as a control group using PSM cohort analysis.

Results

A total of 33,798 abdominal trauma patients were evaluated, 10,987 of them received laparotomies. Of these patients, the proportion of obesity in deceased patients was significantly higher when compared to the survivors (33.1% vs. 26.2%, p < 0.001). Elevation of one kg/m² of body mass index independently resulted in 2.5% increased odds of mortality. After a well-balanced PSM, obese patients undergoing laparotomies had significantly higher mortality rates [3.7% vs. 2.4%, standardized difference (SD) = 0.241], longer hospital LOS (11.1 vs. 9.6 days, SD = 0.135), and longer intensive care unit LOS (3.5 vs. 2.3 days, SD = 0.171) than non-obese patients undergoing laparotomies.

Conclusions

Obesity is associated with increased mortality in abdominal trauma patients who received laparotomies versus those who did not. Obesity requires a careful evaluation of alternatives to laparotomy in injured patients.

     

Single- Versus Double-Anastomosis Duodenal Switch: Outcomes Stratified by Preoperative BMI

Purpose

Describe and analyze the safety and weight loss performance of biliopancreatic diversion and duodenal switch (BPD-DS) and single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S), verifying any possible superiority according to preoperative BMI.

Methods

Retrospective review of patients who underwent primary SADI-S or BPD-DS in three bariatric centers. Study groups were further stratified according to preoperative BMI (subgroup 1: BMI < 50; subgroup 2: 50 ≤ BMI < 55; subgroup 3: BMI ≥ 55).

Results

Four hundred and sixty patients underwent BPD-DS (n = 220) or SADI-S (n = 240). The mean LOS was 3.48 ± 3.7 and 3.13 ± 2.3 days for BPD-DS and SADI-S respectively (p = 0.235). The mean operative time was shorter in the SADI-S group (167.25 ± 33.6 vs 140.85 ± 56.7 min) (p < 0.00). The mean %EWL was 44.2, 62.4, and 69.4 for the BPD-DS group and 48.4, 64.5, and 67.1 for the SADI-S group at 6, 12, and 24 months respectively. The mean %TBWL was 25, 35.9, and 40.3 for the BPD-DS group, and 26.2, 35, and 36.9 for the SADI-S group at 6, 12, and 24 months respectively. Overall complication rates were comparable between BPD-DS and SADI-S groups (14% vs 18%) (p = 0.219). SADI-S showed greater emergency department visits (17% vs 7%) (p = 0.005); similar readmission rates (6% vs 7%) (p = 0.80); similar reoperation rates (3% vs 7%) (p = 0.102); and similar mortality rate (0.9% vs 0.4%), after BPD-DS and SADI-S respectively.

Conclusion

BPD-DS achieved greater %TBWL at 2 years, but no superiority was perceived among study subgroups. SADI-S and BPD-DS showed similar overall complication rates.

Graphical abstract

     

Analysis of the Factors Contributing to Bariatric Success After Laparoscopic Redo Bariatric Procedures: Results from Multicenter Polish Revision Obesity Surgery Study (PROSS)

Introduction

With continuously growing number of redo bariatric surgeries (RBS), it is necessary to look for factors determining success of redo-surgeries.

Patients and methods

A retrospective cohort study analyzed consecutive patients who underwent RBS in 12 referral bariatric centers in Poland from 2010 to 2020. The study included 529 patients. The efficacy endpoints were percentage of excessive weight loss (%EWL) and remission of hypertension (HT) and/or type 2 diabetes (T2D).

Results

Group 1: weight regain

Two hundred thirty-eight of 352 patients (67.6%) exceeded 50% EWL after RBS. The difference in body mass index (BMI) pre-RBS and lowest after primary procedure < 10.6 kg/m2 (OR 2.33, 95% CI: 1.43–3.80, p = 0.001) was independent factor contributing to bariatric success after RBS, i.e., > 50% EWL.

Group 2: insufficient weight loss

One hundred thirty of 177 patients (73.4%) exceeded 50% EWL after RBS. The difference in BMI pre-RBS and lowest after primary procedure (OR 0.76, 95% CI: 0.64–0.89, p = 0.001) was independent factors lowering odds for bariatric success.

Group 3: insufficient control of obesity-related diseases

Forty-three of 87 patients (49.4%) achieved remission of hypertension and/or type 2 diabetes. One Anastomosis Gastric Bypass (OAGB) as RBS was independent factor contributing to bariatric success (OR 7.23, 95% CI: 1.67–31.33, p = 0.008), i.e., complete remission of HT and/or T2D.

Conclusions

RBS is an effective method of treatment for obesity-related morbidity. Greater weight regain before RBS was minimizing odds for bariatric success in patients operated due to weight regain or insufficient weight loss. OAGB was associated with greater chance of complete remission of hypertension and/or diabetes.

Graphical abstract

     

Surgical Complications in Children with CDH: A Multivariate Analysis

Introduction

Several medical and surgical improvements in the treatment of congenital diaphragmatic hernia (CDH) patients have led to a higher survival rate. However, some of these improvements also lead to an increased morbidity rate. This study aims to determine the contribution different medical and surgical treatments have had on the development of surgical complications.

Method

All CDH patients treated in a single centre between 2000 and 2015 were retrospectively evaluated. Multivariate logistic regression was used to estimate the independent effects of several treatment options that could influence the surgical outcome by adjustment for multiple risk factors.

Results

Sixty of the 197 surgically repaired CDH patients had surgical complications. There were more haemorrhagic complications in the ECMO compared to non-ECMO group (27% vs. 2%, p < 0.001). The use of inhaled nitric oxide was also significantly related to haemorrhage (OR = 13.0 (95% CI 1.1–159)). After adjustment for other risk factors, chylothorax was neither significantly associated with ECMO treatment (OR = 1.6 (95% CI 0.5–5.2) nor with patch repair (OR = 2.1: 95% CI 0.7–6.1). A recurrence occurred more often in patients with pulmonary hypertension (OR = 10.0 (95% CI 1.5–65.8) and after treatment with an abdominal patch (OR = 11.3: 95% CI 1.5–84.4).

Conclusion

ECMO treatment and the inhalation of nitric oxide are used in the most severe CDH patients but are associated with a higher risk on surgical haemorrhage. The recurrence rate is associated with both the use of an abdominal patch and the presence of pulmonary hypertension, regardless of medical treatment.

     

Patient-controlled sublingual sufentanil tablet system versus intravenous opioid analgesia for postoperative pain management after lumbar spinal fusion surgery

Purpose

This retrospective cohort study investigated the efficacy of a sublingual sufentanil tablet system (SSTS) in comparison to intravenous patient-controlled analgesia (IV-PCA) with piritramide for the management of postoperative pain following lumbar spinal fusion surgery.

Methods

This was a retrospective analysis of patients undergoing single- or two-level lumbar spinal fusion surgery and receiving the SSTS or IV-PCA for postoperative pain relief as part of multimodal pain management that included IV paracetamol and oral metamizole. The following variables were collected: postoperative pain intensity and frequency scores using the numerical rating scale (NRS), hospital anxiety and depression scale (HADS), occurrence of nausea, postoperative mobilization, and patient satisfaction (MacNab criteria).

Results

Sixty-four patients were included. Those receiving the SSTS (n = 30) had significantly lower pain intensities on the operative day (NRS: 4.0, CI: 3.6–4.3 vs. 4.5, CI: 4.2–4.9; p < 0.05) and one day postoperatively (NRS: 3.4, CI: 3.1–3.8 vs. 3.9 CI: 3.6–4.3; p < 0.05) compared to patients receiving IV-PCA (n = 34). No differences were observed on postoperative days 2 to 5. SSTS patients experienced more nausea than IV-PCA patients (p = 0.027). Moreover, SSTS patients had a higher percentage of early mobilization following surgery than IV-PCA patients (p = 0.040). Regarding patient satisfaction, no significant differences were seen between the groups.

Conclusion

The SSTS is a potentially advantageous alternative to opioid IV-PCA for use within a multimodal approach to managing postoperative pain after lumbar fusion surgery. Furthermore, the potentially higher emetic effect of SSTS should be considered, and the patient should be able to perform the application.