Frailty adversely affects outcomes of patients undergoing spine surgery: a systematic review

BackgroundWith an aging population, there are an increasing number of elderly patients undergoing spine surgery. Recent literature in other surgical specialties suggest frailty to be an important predictor of outcomes.PurposeThe aim of this review was to examine the association between frailty and outcomes after spine surgery.Study DesignA systematic review was performed.Patient SampleElectronic databases from 1946 to 2020 were searched to identify articles on frailty and spine surgery.Outcome MeasuresThe primary outcome was adverse events. Secondary outcomes included other measures of morbidity, mortality, and patient outcomes.MethodsSample size, mean age, age limitation, data source, study design, primary pathology, surgical procedure performed, follow-up period, assessment of frailty used, surgical outcomes, and impact of frailty on outcomes were extracted from eligible studies. Quality and bias were assessed using the PRISMA 27-point item checklist and the QUADAS-2 tool.ResultsThirty-two studies were selected for review, with a total of 127,813 patients. There were eight different frailty indices/measures. Regardless of how frailty was measured, frailty was associated with an increased risk of adverse events, mortality, extended length of stay, readmission, and nonhome discharge.ConclusionThere is strong evidence that frailty is associated with an increased risk of morbidity and mortality in patients who received spine surgery. However, it remains inconclusive whether frailty impacts patient outcomes and quality of life after surgery.     

Preoperative Multivariate Prediction of Morbidity After Gastrectomy for Adenocarcinoma

Background: Gastrectomy remains the only curative treatment for gastric cancer. However,surgical morbidity and mortality remains high. Our aim was to identify the risk factors thatdetermine operative morbidity and mortality and to describe a simple method for preoperativestratification of morbidity outcome.Methods: Retrospective review of patients who underwent gastrectomy for gastric cancer.Multivariate analysis was used to define risk factors for surgical morbidity and mortality.Results: A total of 208 cases were included. Fifty-one episodes of operative morbidity and 19surgery-related deaths were found. Operative blood loss (risk ratio [RR], 1.0012), serum albumin(RR, 0.42), extent of gastrectomy (RR, 2.8), lymphocyte count (RR, 0.999), and splenectomy (RR,1.51) were the most important risk factors for morbidity. However, location of the tumor, serumalbumin level, and lymphocyte count were the most important preoperative risk factors thatdetermine the appearance of surgical complications. Receiver operating characteristic analysis ofthis model allowed definition of three risk groups in terms of surgical morbidity (11.8%, 28.5%, and52.4%, respectively).Conclusions: A new method for preoperative calculation of the probability of surgical complicationswas developed. It must be validated prospectively and in different settings to be used inpreoperative interventions designed to reduce that risk.     

Critical appraisal of the impact of surgical repair of type II–IV paraoesophageal hernia (POH) on pulmonary improvement: A systematic review and meta-analysis

BackgroundParaoesophageal hernia (POH) comprising type II–IV hiatal hernia often presents with pulmonary symptoms such as shortness of breath. However, impact of surgical repair on improvement in pulmonary symptoms is unclear.ObjectiveThis systematic review and meta-analysis aimed at characterising impact of POH repair on patient reported improvement in pulmonary symptoms.MethodsThis systematic review identified studies reported pulmonary symptoms in patients with undergoing surgical repair for Type II–IV POH from 1st January 2001 to 1st December 2018. Primary outcome was improvement in pulmonary symptoms. Secondary outcomes were improvement in other patient-reported outcomes such as heartburn, regurgitation, chest pain, and dysphagia and intraoperative and postoperative outcomes.ResultsThis systematic review identified 27 studies (n = 4428 patients) reporting assessment of pulmonary symptoms. However, only 21 studies (n = 2902 patients) reported preoperative and postoperative pulmonary symptoms and hence these were included in the final meta-analysis. There was significant improvement in pulmonary symptoms following POH repair (OR: 8.40, CI_95%: 4.91–14.35, p < 0.001), with improvement in all types of POH. Rates of overall and major complications were 16% and 5%, respectively. Rates of conversion, 30-day mortality, reoperation and recurrence were 2%, 1% 4% and 12% respectively.ConclusionThis review demonstrates that POH repair is associated with improvement in pulmonary symptoms with acceptable low laparoscopic conversion rates, morbidity, mortality and recurrence rates.     

Subtotal colectomy in ulcerative colitis—long term considerations for the rectal stump

BACKGROUNDThe initial operation of choice in many patients presenting as an emergency with ulcerative colitis is a subtotal colectomy with end ileostomy. A percentage of patients do not proceed to completion proctectomy with ileal pouch anal anastomosis.AIMTo review the existing literature in relation to the significant long-term complic-ations associated with the rectal stump, to provide an overview of options for the surgical management of remnant rectum and anal canal and to form a consolidated guideline on endoscopic screening recommendations in this cohort.METHODSA systematic review was carried out in accordance with PRISMA guidelines for papers containing recommendations for endoscopy surveillance in rectal remnants in ulcerative colitis. A secondary narrative review was carried out exploring the medical and surgical management options for the retained rectum.RESULTSFor rectal stump surveillance guidelines, 20% recommended an interval of 6 mo to a year, 50% recommended yearly surveillance 10% recommended 2 yearly surveillance and the remaining 30% recommended risk stratification of patients and different screening intervals based on this. All studies agreed surveillance should be carried out via endoscopy and biopsy. Increased vigilance is needed in endoscopy in these patients. Literature review revealed a number of options for surgical management of the remnant rectum.CONCLUSIONThe retained rectal stump needs to be surveyed endoscopically according to risk stratification. Great care must be taken to avoid rectal perforation and pelvic sepsis at time of endoscopy. If completion proctectomy is indicated the authors favour removal of the anal canal using an intersphincteric dissection technique.     

Omental patch versus gastric resection for perforated gastric ulcer: Systematic review and meta-analysis for an unresolved debate

BackgroundPerforated gastric ulcers are surgical emergencies with paucity of data on the preferred treatment modality of resection versus omental patch. We aim to compare outcomes with ulcer repair and gastric resection surgeries in perforated gastric ulcers after systematic review of literature.MethodsA systematic literature search was performed for publications in PubMed Medline, Embase, and Cochrane Central Register of Controlled Trials. We included all studies which compared ulcer repair vesus gastric resection surgeries for perforated gastric ulcers. We excluded studies which did not separate outcomes gastric and duodenal ulcer perforations.ResultsThe search included nine single-institution retrospective reviews comparing ulcer repair (449 patients) versus gastric resection surgeries (212 patients). Meta-analysis was restricted to perforated gastric ulcers and excluded perforated duodenal ulcers. The majority of these studies did not control for baseline characteristics, and surgical strategies were often chosen in a non-randomized manner. All of the studies included were at high risk of bias. The overall odds ratio of mortality in ulcer repair surgery compared to gastric resection surgery was 1.79, with 95% CI 0.72 to 4.43 and p-value 0.209.ConclusionIn this meta-analysis, there was no difference in mortality between the two surgical groups. The overall equivalence of clinical outcomes suggests that gastric resection is a potentially viable alternative to ulcer repair surgery and should not be considered a secondary strategy. We would recommend a multicenter randomized control trial to evaluate the surgical approach that yields superior outcomes.Level of evidenceSystematic review and meta-analysis, level III.     

An assessment of different scoring systems in cirrhotic patients undergoing nontransplant surgery

BackgroundDetermining surgical risk in cirrhotic patients is difficult and multiple scoring systems have sought to quantify this risk. The purpose of our study was to assess the impact of Childs-Turcotte-Pugh (CTP), Model of End-Stage Liver Disease (MELD), and MELD-Sodium (MELD-Na) scores on postoperative morbidity and mortality for cirrhotic patients undergoing nontransplant surgery.MethodsWe performed a single-center retrospective review of all cirrhotic patients who underwent nontransplant surgery under general anesthesia over a 6-year period of time to analyze outcomes using the 3 scoring systems.ResultsSixty-four cirrhotic patients (mean age, 57 y; 62 men) underwent nontransplant surgery under general anesthesia. A CTP score of ≥7.5 was associated with an 8.3-fold increased risk of 30-day morbidity, a MELD score of ≥14.5 was associated with a 5.4-fold increased risk of 3-month mortality, and a MELD-Na score ≥14.5 was associated with a 4.5-fold increased risk of 1-year mortality. Emergent surgery, the presence of ascites, and low serum sodium level were associated significantly with morbidity and 1-year mortality.ConclusionsThe major strengths of the 3 scoring systems are for CTP in estimating 30-day morbidity, MELD for estimating 3-month mortality, and MELD-Na for estimating 1-year mortality.     

Postoperative outcomes in older surgical patients with preoperative cognitive impairment: A systematic review and meta-analysis

Study objectiveTo determine the effect of cognitive impairment (CI) and dementia on adverse outcomes in older surgical patients.DesignA systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs). Various databases were searched from their inception dates to March 8, 2021.SettingPreoperative assessment.PatientsOlder patients (≥ 60 years) undergoing non-cardiac surgery.MeasurementsOutcomes included postoperative delirium, mortality, discharge to assisted care, 30-day readmissions, postoperative complications, and length of hospital stay. Effect sizes were calculated as Odds Ratio (OR) and Mean Difference (MD) based on random effect model analysis. The quality of included studies was assessed using the Cochrane Risk Bias Tool for RCTs and Newcastle-Ottawa Scale for observational cohort studies.ResultsFifty-three studies (196,491 patients) were included. Preoperative CI was associated with a significant risk of delirium in older patients after non-cardiac surgery (25.1% vs. 10.3%; OR: 3.84; 95%CI: 2.35, 6.26; I²: 76%; p < 0.00001). Cognitive impairment (26.2% vs. 13.2%; OR: 2.28; 95%CI: 1.39, 3.74; I²: 73%; p = 0.001) and dementia (41.6% vs. 25.5%; OR: 1.96; 95%CI: 1.34, 2.88; I²: 99%; p = 0.0006) significantly increased risk for 1-year mortality. In patients with CI, there was an increased risk of discharge to assisted care (44.7% vs. 38.3%; OR 1.74; 95%CI: 1.05, 2.89, p = 0.03), 30-day readmissions (14.3% vs. 10.8%; OR: 1.36; 95%CI: 1.00, 1.84, p = 0.05), and postoperative complications (40.7% vs. 18.8%; OR: 1.85; 95%CI: 1.37, 2.49; p < 0.0001).ConclusionsPreoperative CI in older surgical patients significantly increases risk of delirium, 1-year mortality, discharge to assisted care, 30-day readmission, and postoperative complications. Dementia increases the risk of 1-year mortality. Cognitive screening in the preoperative assessment for older surgical patients may be helpful for risk stratification so that appropriate management can be implemented to mitigate adverse postoperative outcomes.     

Timing and methods of frailty assessments in geriatric trauma patients: A systematic review

IntroductionThe trauma population is aging and better prognostic measures for geriatric trauma patients are required. Frailty rather than age appears to be associated with poor outcomes. This systematic review aimed to identify the optimum frailty assessment instrument and timing of assessment in patients aged over 65 years admitted to hospital after traumatic injury. The secondary aim was to evaluate outcomes associated with frailty in elderly trauma populations.MethodsThis systematic review was registered with the PROSPERO International Prospective Register of Systematic Reviews (CRD42018090620). A MEDLINE and EMBASE literature search was conducted from inception to June 2019 combining the concepts of injury, geriatric, frailty, assessment and prognosis. Included studies were in patients 65 years or older hospitalised after injury and exposed to an instrument meeting consensus definition for frailty assessment. Study quality was assessed using criteria for review of prognostic studies combined with a GRADE approach.ResultsTwenty-eight papers met inclusion criteria. Twenty-eight frailty or component instruments were reported, and assessments of pre-injury frailty were made up to 1-year post injury. Pre-injury frailty prevalence varied from 13% (13/100) to 94% (17/18), with in-hospital mortality rates from 2% (5/250) to 33% (6/18). Eleven studies found an association between frailty and mortality. Eleven studies reported an association between frailty and a composite outcome of mortality and adverse discharge destination. Generalisability and assessment of strength of associations was limited by single centre studies with inconsistent findings and overlapping cohorts.ConclusionsAssociations between frailty and adverse outcomes including mortality in geriatric trauma patients were demonstrated despite a range of frailty instruments, administering clinicians, time of assessment and data sources. Although evidence gaps remain, incorporating frailty assessment into trauma systems is likely to identify geriatric patients at risk of adverse outcomes. Consistency in frailty instruments and long-term geriatric specific outcome measures will improve research relevance.Level of evidence: Level III prognostic.     

Frailty and functional outcomes after open and endovascular procedures for patients with peripheral arterial disease: A systematic review

BackgroundFrailty has been associated with postoperative complications and mortality across surgical specialties, including vascular surgery. However, the influence of frailty on postoperative functional outcomes is unclear. We sought to determine the influence of frailty on functional outcomes after open or endovascular vascular procedures in patients with peripheral arterial disease.MethodsThis systematic review was conducted according to the PRISMA guidelines. Eligible articles were identified through database searches of Pubmed and EMBASE in April 2017. Studies reporting on frailty and functional outcomes after vascular interventions for peripheral artery disease (PAD) were included. Outcomes of interest were dependency in activities of daily living (ADL), dependent mobility, discharge destination, disability-free survival, and quality of life. Individual studies were assessed for quality and risk of bias using the Quality in Prognosis Studies tool.ResultsEight studies met the eligibility criteria and were included. The risk of bias was low in two studies, intermediate in three studies, and high in three studies. Methods for frailty assessment were different for each study. Frailty was a predictor for discharge to a higher level of care, dependent mobility, and dependency in ADL after vascular procedures for PAD. Both frailty models and individual frailty characteristics seem to be associated with these adverse functional outcomes.ConclusionsDespite a limited amount of literature and an overall intermediate quality of the included studies, this systematic review shows an association between frailty and adverse functional outcomes after peripheral arterial procedures for PAD, including discharge to a care facility, dependent mobility, and a decline in ADL functioning.     

The Waterlow score for risk assessment in surgical patients

Introduction

Perioperative scoring systems aim to predict outcome following surgery and are used in preoperative counselling to guide management and to facilitate internal or external audit. The Waterlow score is used prospectively in many UK hospitals to stratify the risk of decubitus ulcer development. The primary aim of this study was to assess the potential value of this existing scoring system in the prediction of mortality and morbidity in a general surgical and vascular cohort.

Methods

A total of 101 consecutive moderate to high risk emergency and elective surgical patients were identified through a single institution database. The preoperative Waterlow score and outcome data pertaining to that admission were collected. The discriminatory power of the Waterlow score was compared against that of the American Society of Anesthesiologists (ASA) grade and the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM).

Results

The inpatient mortality rate was 17% and the 30-day morbidity rate was 29%. A statistically significant association was demonstrated between the preoperative Waterlow score and inpatient mortality (p<0.0001) and 30-day morbidity (p=0.0002). Using a threshold Waterlow score of 20 to dichotomise risk, accuracies of 0.84 and 0.76 for prediction of mortality and morbidity were demonstrated. In comparison with P-POSSUM, the preoperative Waterlow score performed well on receiver operating characteristic analysis. With respect to mortality, the area under the curve was 0.81 (0.80–0.85) and for morbidity it was 0.72 (0.69–0.76). The ASA grade achieved a similar level of discrimination.

Conclusions

The Waterlow score is collected routinely by nursing staff in many hospitals and might therefore be an attractive means of predicting postoperative morbidity and mortality. It might also function to stratify perioperative risk for comparison of surgical outcome data. A prospective study comparing these risk prediction scores is required to support these findings.     

Have advances in surgical implants and techniques in hemiarthroplasty for intracapsular hip fractures improved patient outcomes compared to THA? A systematic review and meta-analysis of the evidence

IntroductionHip fractures are common orthopaedic hospital admissions and result in considerable morbidity and mortality in the patients affected. The aim of this study is to review how advances in surgical implants and techniques have impacted on outcomes of Hemiarthroplasty (HA) vs Total Hip Arthroplasty (THA) for displaced intracapsular neck of femur fractures.MethodsA systematic review and meta-analysis of randomised controlled trials was performed and reported in accordance with the Preferred Reporting Items for Systematic Reviews & Meta-analyses (PRISMA) statement. We included all studies that were prospective randomised controlled trials comparing the outcomes THA versus HA in patients with displaced intracapsular neck of femur fractures.Results13 randomised controlled trial met the eligibility criteria; the overall pooled sample size was 3050 patients. The evidence suggests that the short-term functional outcomes favour THA, without strong evidence of a clinically significant benefit. More recent larger RCTs suggest limited functional improvement conferred by THA vs. HA, whilst the risks of complications may outweigh these small gains. Overall, THA is associated with higher dislocation rates without a significant need for re-operation, but no increase in infection or need for transfusion over HA. Consultant or equivalent supervision has a positive effect on outcomes in both groups.ConclusionThe literature supports a change in direction, this meta-analysis confirms HA surgery has equivalent clinical outcomes and possibly a lower mortality in octogenarians and provides further evidence for the stratification of THA treatment in displaced intracapsular neck of femur fractures is urgently required.Level of evidence1.     

Outcomes following pelvic ring fractures in the paediatric population: A systematic review

BackgroundPelvic fractures represent a small proportion of all paediatric fractures, but are likely to be associated with a high-energy mechanism, multiple injuries, and significant morbidity and mortality. Operative fixation of unstable pelvic fractures is accepted. However, there remains a paucity of data on functional outcomes and complications following pelvic fractures in the skeletally immature.MethodsA PRISMA-compliant systematic review was performed, searching Medline, Embase, and Cochrane central review. The primary outcome was functional outcome after pelvic fractures in the paediatric population following operative or non-operative treatment. Secondary outcomes included mechanism of injury, associated injuries, mortality rate, and method of surgical fixation if required. Where possible, weighted totals of the data set were performed.ResultsIn total, 23 studies were included in this review. Only eight studies reported functional outcomes, with limb length discrepancy and limp being the most common complication. Only 8.8% of all pelvic fractures underwent surgical fixation. Motor vehicle collision was the most common cause of injury, and extremity fracture was the most common associated injury.ConclusionPaediatric pelvic fractures are caused by high-energy mechanisms and have significant morbidity and mortality. There remains a paucity of information on functional outcomes after these injuries.     

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.

     

Children with heart disease: Risk stratification for non-cardiac surgery

Study objectiveChildren with congenital or acquired heart disease have an increased risk of anesthesia related morbidity and mortality. The child's anesthetic risk is related to the severity of their underlying cardiac disease, associated comorbidities, and surgical procedure. The goal of this project was to determine the ease of use of a preoperative risk stratification tool for assigning pediatric cardiac staff and to determine the relative frequency that children with low, moderate, and high risk cardiac disease present for non-cardiac surgery at a tertiary pediatric hospital.DesignA risk-stratification tool was prospectively applied to children with congenital heart disease who presented for non-cardiac surgery.SettingPerioperative.PatientsWe identified a subset of 100 children with congenital heart disease out of 2200 children who required general anesthesia for surgical or radiological procedures over a 6 week period.InterventionsA risk stratification tool was utilized to place the patient into low, moderate, or high risk categories to help predict anticipated anesthetic risk. Each grouping specified assignment of staff caring for the patient, clarified preoperative expectations for cardiac assessment, and determined if patient care could be performed at our freestanding ambulatory surgical center.MeasurementsElectronic perioperative records were reviewed to obtain demographic information, the underlying heart disease, prior cardiac surgery, associated conditions, anesthetic management, complications, and provider type.Main resultsApproximately 4.5% of children presented with cardiac disease over a 6 week period. In 100 consecutive children with cardiac disease, 23 of the children were classified as low risk, 66 patients were classified as moderate risk, and 11 of the patients were classified as high risk. Pediatric cardiac anesthesiologists provided care to all high risk patients. There were no serious adverse events.ConclusionsWe found this risk stratification method an effective method to differentiate children into low, moderate, and high risk categories for anesthesia planning and management.     

Outcomes following pelvic ring fractures in the paediatric population: A systematic review

BackgroundPelvic fractures represent a small proportion of all paediatric fractures, but are likely to be associated with a high-energy mechanism, multiple injuries, and significant morbidity and mortality. Operative fixation of unstable pelvic fractures is accepted. However, there remains a paucity of data on functional outcomes and complications following pelvic fractures in the skeletally immature.MethodsA PRISMA-compliant systematic review was performed, searching Medline, Embase, and Cochrane central review. The primary outcome was functional outcome after pelvic fractures in the paediatric population following operative or non-operative treatment. Secondary outcomes included mechanism of injury, associated injuries, mortality rate, and method of surgical fixation if required. Where possible, weighted totals of the data set were performed.ResultsIn total, 23 studies were included in this review. Only eight studies reported functional outcomes, with limb length discrepancy and limp being the most common complication. Only 8.8% of all pelvic fractures underwent surgical fixation. Motor vehicle collision was the most common cause of injury, and extremity fracture was the most common associated injury.ConclusionPaediatric pelvic fractures are caused by high-energy mechanisms and have significant morbidity and mortality. There remains a paucity of information on functional outcomes after these injuries.     

Transfusion guidelines in adult spine surgery: a systematic review and critical summary of currently available evidence

Background ContextRed blood cell transfusion can be associated with complications in medical and surgical patients. Acute anemia in ambulatory patients undergoing surgery can also impede wound healing and independent self-care. Current transfusion threshold guidelines are still based on evidence derived from critically-ill intensive care unit medical patients and may not apply to spine surgery candidates.PurposeWe aimed to provide the reader with a synthesis of the best available evidence to recommend transfusion trigger thresholds and guidelines in adult patients undergoing spine surgery.Study Design/SettingThis is a systematic review.Outcome measuresPhysiological measure: Blood transfusion thresholds and associated posttransfusion complications (morbidity, mortality, length of stay, infections, etc) of the published articles.Patient SampleAdult spine surgery patients.MethodsA systematic review of the literature using the PubMed, Google Scholar, and Web of Science electronic databases was made according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Focus was set on papers discussing thresholds for blood transfusion in adult surgical spine patients, as well as complications associated with transfusion after acute surgical blood loss in the operating room or postoperative period. Publications discussing pediatric cases, blood type analyses, blood loss prevention strategies and protocols, systematic reviews and letters to the editor were excluded.ResultsA total of 22 articles fitting our search criteria were reviewed. Patients who received blood transfusion in these studies were older, of female gender, had more severe comorbidities except for smoking, and had prolonged surgical time. Blood transfusion was associated with multiple adverse postoperative complications, including a higher rate of superficial or deep surgical site infections, sepsis, urinary and pulmonary infections, cardiovascular complications, return to the operating room, and increased postoperative length of stay and 30 day readmission.Analysis of transfusion thresholds from these studies showed that a pre-operative hemoglobin (Hb) of > 13 g/dL, and an intraoperative and post-operative Hb nadir above 9 and 8 g/dL, respectively, were associated with better outcomes and fewer wound infections than lower thresholds (Level B Class III). Additionally, it was generally recommended to transfuse autologous blood that was < 28 days old, if possible, with a limit of 2 to 3 units to minimize patient morbidity and mortality.ConclusionsBlood transfusion thresholds in surgical patients may be specialty-specific and different than those used for critically-ill medical patients. For adult spine surgery patients, red blood cell transfusion should be avoided if Hb numbers remain > 9 and 8 g/dL in the intraoperative and direct post-operative periods, respectively.     

Hyponatremia as a marker of complicated appendicitis: A systematic review

BackgroundAcute appendicitis, the most common cause of acute surgical abdomen, is associated with intra-abdominal complications, such as perforation, that increase morbidity and mortality. Early and accurate preoperative diagnosis of complicated appendicitis mandates the identification of new diagnostic markers. This systematic review summarizes current literature on the adoption of hyponatremia as an early diagnostic and predictive marker of complicated appendicitis.MethodsPubmed, Cochrane Library, Scopus, Google Scholar, WHO Global Health Library, System for Information on Grey Literature, ISI Web of Science, EBSCOHost and Virtual Health Library were searched in accordance with the PRISMA guidelines in order to identify original human studies investigating the association between hyponatremia and the presence or development of complicated appendicitis.ResultsA total of 7 studies conducted in 6 different countries were identified. A prospective diagnostic accuracy study reported a strong association between hyponatremia and complicated appendicitis in children. The largest sample size study performed in adults reported a significant association between hyponatremia and perforated or gangrenous appendicitis.ConclusionsThe admission serum sodium level measurement, a routinely performed, low-cost test, should be taken into account in patients with clinical presentation compatible with acute appendicitis and suspicion of underlying complications. Future well-designed prospective diagnostic accuracy studies are required to further establish the association between hyponatremia and perforated appendicitis.     

POSSUM and p-POSSUM overestimate morbidity and mortality in laparoscopic bariatric surgery

BackgroundDespite their wide use in surgical audit, the application of the Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) and the Portsmouth predictor of mortality (p-POSSUM) in bariatric surgery has been limited. The aim of this study was to evaluate the usefulness of POSSUM and p-POSSUM in bariatric comparative audit.MethodsData were retrospectively collected on consecutive patients who underwent laparoscopic gastric by-pass (LRYGB) and sleeve gastrectomy (SG) at a teaching institute. POSSUM and p-POSSUM equations were applied. The observed to expected ratios for morbidity and mortality were calculated. A Student’s t test was performed to assess if a relationship could be found between the observed and the predicted outcomes.ResultsBetween 2008 and 2013, 504 patients (370 female) with a mean (range) age of 46 (17–69) years underwent LRYGB (n = 383) and SG (n = 121). The operative morbidity was 10.9% and mortality was .2%. POSSUM overpredicted morbidity (30.56%), and no relationship between morbidity risk and the development of complications was found (P = .152). There was a grouping of patients in the low-risk mortality groups for both POSSUM and p-POSSUM. Both equations overpredicted mortality (5.95% and 1.62%, respectively).ConclusionBoth POSSUM and p-POSSUM equations overpredicted morbidity and mortality in this only study in the literature of modern bariatric practice that employed a large representative patient sample receiving the commonest procedures. A multicenter study is needed to address the low incidence of events and enable modification of those equations for use in bariatric surgical audit.     

The obesity paradox in the surgical population

BackgroundDespite the medical hazards of obesity, recent reports examining body mass index (BMI) show an inverse relationship with morbidity and mortality in the surgical patient. This phenomenon is known as the ‘obesity paradox’. The aim of this review is to summarize both the literature concerned with the obesity paradox in the surgical setting, as well as the theories explaining its causation.MethodsPubMed was searched to identify available literature. Search criteria included obesity paradox and BMI paradox, and studies in which BMI was used as a measure of body fat were potentially eligible for inclusion in this review.ResultsThe obesity paradox has been demonstrated in cardiac and in non-cardiac surgery patients. Underweight and morbidly obese patients displayed the worse outcomes, both postoperatively as well as at long-term follow-up. Hypotheses to explain the obesity paradox include increased lean body mass, (protective) peripheral body fat, reduced inflammatory response, genetics and a decline in cardiovascular disease risk factors, but probably unknown factors contribute too.ConclusionsPatients at the extremes of BMI, both the underweight and the morbid obese, seem to have the highest postoperative morbidity and mortality hazard, which even persists at long-term. The cause of the obesity paradox is probably multi-factorial. This offers potential for future research in order to improve outcomes for persons on both sides of the ‘optimum BMI’.