Obesity and spine surgery: reassessment based on a prospective evaluation of perioperative complications in elective degenerative thoracolumbar procedures

Background ContextThe correlation between obesity and incidence of complications in spine surgery is unclear, with some reports suggesting linear relationships between body mass index (BMI) and complication incidence and others noting no relationship.PurposeThe purpose of this article was to assess the relationship between obesity and occurrence of perioperative complications in an elective thoracolumbar surgery cohort.Study Design/SettingProspective observational cohort study at a tertiary care facility.Patient SampleCohort of 87 consecutive patients undergoing elective surgery for degenerative thoracolumbar pathologies over a 6-month period (May to December 2008).Outcome MeasuresIncidence of perioperative complications (those occurring within 30 days of surgery).MethodsA prospective assessment of perioperative spine surgery complications was completed, and data were prospectively entered into a central database. Two independent auditors assessed for the presence and severity of perioperative complications. Previously validated binary definitions of major and minor complications were used. Patient data and early complications (those occurring within 30 days of index surgery) were analyzed using multivariate regression.ResultsMean BMI in this cohort was 31.3; 40.8% of patients were obese (BMI>30) and 10 patients (11.5%) were morbidly obese (BMI>40). The overall complication incidence was 67%. Minor complications occurred in 50% of patients, and major complications occurred in 17.8% of patients. No positioning palsies occurred in this series. Age correlated with an increase in complication risk (p=.006) as did hypertension (p=.004) and performance of a fusion (p<.0001). BMI did not correlate with the incidence of minor, major, or any complications (p=.58).ConclusionsThis prospective assessment of perioperative complications in elective degenerative thoracolumbar procedures shows no relationship between patient BMI and the incidence of perioperative minor or major complications. Specific care in perioperative positioning may limit the risk of perioperative positioning palsies in obese patients.     

Elective spine surgery with continuation of clopidogrel anti-platelet therapy: Experiences from the community

PurposeThis retrospective study aimed to assess the feasibility of continuing clopidogrel therapy during the perioperative period in elective cervical and thoracolumbar surgery.MethodsAfter IRB approval, medical records of patients requiring one or two-level surgery over a two-year period (2015–2017) while receiving clopidogrel were reviewed for relevant outcomes. Over the same period, a control group of patients not receiving clopidogrel perioperatively was formed.ResultIn total, 136 patients were included: 37 clopidogrel and 99 control, with a mean age of 64.8 years. Between clopidogrel and control respectively, operative time was 86.7 min and 86.7 min (p = 0.620); blood loss was 127.0 cc and 117.5 cc (p = 0.480); drain output was 171.2 cc and 190.7 cc (p = 0.354); length of stay was 1.8 days and 1.5 days (p = 0.103). Two clopidogrel patients and 1 control patient had complications. Two clopidogrel patients and 1 control patient were readmitted within 30 days.ConclusionsRemaining on clopidogrel therapy during elective spine surgery results in no difference in operative time, blood loss, drain output, length of stay, or readmission. Precaution should be taken in cervical procedures as the drain output in clopidogrel patients was increased and complications in this region can be severe.     

Dural injury following elective spine surgery – A prospective analysis of risk factors,management and complications

Incidental dural tears being a familiar complication in spine surgery could result in dreaded postoperative outcomes. Though the literature pertaining to their incidence and management is vast, it is limited by the retrospective study designs and smaller case series. Hence, we performed a prospective study in our institute to determine the incidence, surgical risk factors, complications and surgical outcomes in patients with unintended durotomy during spine surgery over a period of one year. The overall incidence in our study was 2.3% (44/1912). Revision spine surgeries in particular had a higher incidence of 16.6%. The average age of the study population was 51.6 years. The most common intraoperative surgical step associated with dural tear was removal of the lamina, and 50% of the injuries were during usage of kerrison rongeur. The most common location of the tear was paramedian location (20 patients) and the most common size of the tear was about 1 mm-5mm (31 patients). We observed that the dural repair techniques, placement of drain and prolonged post-operative bed rest didnot significantly affect the post-operative outcomes. One patient in our study developed persistent CSF leak, which was treated by subarachnoid lumbar drain placement. No patients developed pseudomeningocele or post-operative neurological worsening or re-exploration for dural repair. Wound complications were noted in 4 patients and treated by debridement and antibiotics. Based on our study, we have proposed a treatment algorithm for the management of dural tears in spine surgery.     

Outcomes of reoperation for total arch replacement combined with frozen elephant trunk after previous cardiovascular surgery

BackgroundAortic arch replacement(TAR) combined with frozen elephant trunk (FET) technique is a high-risk operation after previous cardiovascular surgery. The aim of the study was to review our strategy and outcomes in this cohort.MethodData were reviewed for patients who underwent TAR combined with FET after previous cardiovascular surgery from January 2010 to December 2020. The patients were divided into elective group and non-selective group.Results63 eligible patients were divided into elective(n = 44) and non-elective(n = 19) groups. The interval between two operations was shorter in non-elective group than elective groups (P = 0.001). The indication for reoperation was different in two groups (P = 0.000), however, the type of reoperations has no differences. Cardiopulmonary bypass time was shorter in elective group than non-elective group (P = 0.000). The over-all 30-day mortality rate was 17.5%, and it was higher in non-elective group (P = 0.013). The 24h drainage increased in non-elective group (P = 0.001) as well as re-explore rate for bleeding (P = 0.022). Postoperative hospital stay prolonged in non-elective group (P = 0.002). However, rates of survival without further aortic events were 72.3 ± 7.1% in elective group, 72.9 ± 13.5% in non-elective group at 5 years, respectively (P = 0. 955).ConclusionReduced 30-day mortality and shortened post-operative hospital stay was observed in elective group, however, long-term survival rate without reintervention were not affected.     

Incidence of surgical site infection following adult spinal deformity surgery: an analysis of patient risk

Surgical site infection (SSI) following spinal surgery is a frequent complication and results in higher morbidity, mortality and healthcare costs. Patients undergoing surgery for spinal deformity (scoliosis/kyphosis) have longer surgeries, involving more spinal levels and larger blood losses than typical spinal procedures. Previous research has identified risk factors for SSI in spinal surgery, but few studies have looked at adult deformity surgeries. We retrospectively performed a large case cohort analysis of all adult patients who underwent surgery for kyphosis or scoliosis, between June 1996 and December 2005, by our adult spine division in an academic institution to asses the incidence and identify risk factors for SSI. We reviewed the electronic patient records of 830 adult patients. SSI was classified as deep or superficial to the fascia. 46 (5.5%) patients were found to have a SSI with 29 patients (3.5%) having deep infections. Obesity was found to be an independent risk factor for all SSI and superficial SSI (P = 0.014 and P = 0.013). As well, a history of prior SSI was also found to be a risk factor for SSI (P = 0.041). Patient obesity and history of prior SSI lead to increased risk of infection. Since obesity was related to an increased risk of both superficial and deep SSI, counseling and treatment for obesity should be considered before elective deformity surgery.     

Comparison of perioperative complications in anterior decompression with fusion and posterior decompression with fusion for thoracic ossification of the posterior longitudinal ligament -a retrospective cohort study using a nationwide inpatient database

BackgroundThoracic ossification of the posterior longitudinal ligament (T-OPLL) is a rare disease, which can cause spinal cord compression leading to various neurological symptoms. There are limited treatment options for T-OPLL, surgery is generally considered the only effective treatment. However, few studies have investigated surgical complications in patients with T-OPLL, and there are no data regarding surgical risks in anterior decompression with fusion (ADF) when compared with posterior decompression with fusion (PDF) for T-OPLL.MethodsPatients who were diagnosed as T-OPLL and underwent ADF via the anterior approach and PDF via the posterior approach from April 1, 2012 to March 31, 2018, were extracted from the Diagnosis Procedure Combination (DPC) database. We analyzed perioperative systemic and local complication rates after ADF and PDF and compared them using propensity score matching (PSM) method. In each of the two groups, we investigated the details of length of stay, costs, mortality, and discharge destination.ResultsIn total 1344 patients (ADF: 88 patients, PDF: 1256 patients), 176 patients were investigated after PSM (88 pairs). While the incidence of overall systemic complication was significantly higher in the ADF group (ADF/PDF: 25.0%/8.0%, P = 0.002), there was no significant difference in the overall local complication rate (15.9%/19.3%, P = 0.55). Specifically, respiratory complications were more frequently observed in the ADF group (9.1%/0%, P = 0.004), however, other systemic and local complications did not differ significantly between the two groups. The length of stay was 1.7 times longer (P < 0.001) and the medical costs were 1.4 times higher (P < 0.001) in patients with perioperative complications, compared to those without perioperative complications.ConclusionWe demonstrated the perioperative complications of ADF and PDF in patients with T-OPLL using a large national database. ADF showed a higher incidence of respiratory complications. Development of perioperative complications was associated with longer hospital stay and higher medical costs.     

Effectiveness of a mucolythic agent as a local adjuvant in revision lumbar spine surgery

Aim of this prospective randomized trial was to analyze the effectiveness of MESNA in chemical dissection of peridural fibrosis in patients who underwent revision lumbar spine surgery. Between January 2003 and October 2006, 30 patients who underwent revision lumbar spine surgery were enrolled in the study. Patients were randomly assigned to one of two groups: a study group (A) and a control group (B). Once peridural fibrosis was exposed, MESNA (Uromixetan MESNA, 50 mg/ml) was intraoperatively applied on the fibrous tissue (Group A) to ease tissue dissection and enter the canal. In patients of Group B, saline solution was used. Surgical time, preoperative and 1 week postoperative hemoglobin (Hb), length of hospitalization (days), and incidence of perioperative complications were evaluated. The blinded surgeon assigned the surgeries to one of four categories as none, minimal, moderate, and severe basing on intraoperative difficulty in dissecting the fibrous tissue and intraoperative bleeding. Statistical analysis used chi-square analysis to evaluate the difference in surgery difficulty and the incidence of intraoperative complications between the two groups. The analysis of surgical time and hemoglobin levels was performed using a one-sample Wilcoxon test and Mann–Whitney U test. Patients in whom MESNA was used intraoperatively (Group A) presented better intraoperative and perioperative parameters with respect to the control group. Average surgical time and decrease in Hb postoperatively were more in the saline group (B) respect to MESNA (A) (P = 0.004 and P = 0.001, respectively), while no difference in average hospital stay was reported between the two groups. Surgeon-blinded intraoperative report on surgical difficulty showed a significant difference between the two groups (P < 0.05). Postoperatively, no complications directly attributable to the use of MESNA were experienced. The incidence of dural tears and intraoperative bleeding from epidural veins were significantly less in Group A with respect to the control group. MESNA contributed significantly to reduce the operative complications, with a diminution of the surgical time and the grade of difficult for the surgeon, confirming its ability as chemical dissector also for epidural fibrosis in revision lumbar spine surgery.     

Sonographic predictors of aggressive behavior in medullary thyroid carcinomas

ObjectiveTo identify the clinical and sonographic risk factors for aggressive behavior of Medullary Thyroid Carcinomas (MTCs).Material and methodsThis is a retrospective analysis. The informed consents were waived. Totally, 127 patients were selected from the database. Two radiologists were invited to review the clinical records and ultrasonic images and scored all the cases according to ACR TI-RADS, retrospectively. Kappa test was used to evaluate the consistency between the two reviewers. Logistic regression analysis was carried to identify the risk factors for aggressive behaviors of MTCs. Comparison of survival proportions between different groups were calculated by Kaplan–Meier method and log-rank test.ResultsFemale patients with MTCs were more commonly seen than male (1.7:1), male sex was a risk factor for both metastasis (OR: 4.471, P = 0.001) and perithyroidal invasion (OR = 4.674, P = 0.004). Consistency between the two reviewers were quite high (K value, 0.797–0.988). On sonograms, typical MTCs manifest as hypoechoic (96.9%) solid nodules (94.5%). Sex of patients (P = 0.001), margin (P = 0.003) and focality (P = 0.01) of the nodule were independent risk factors for metastasis, whereas sex of the patients (P = 0.004) and margin (P = 0.000) were independent risk factors for perithyroidal invasion. By Kaplan–Meier analysis, survival proportions different between groups with/without perithyroidal extension (P = 0.000) but not between groups with/without metastasis (P = 0.473).ConclusionHigh frequency ultrasound and TI-RADS were effective methods for preoperative diagnosis of MTC. Sex of the patients and margin of the nodule are common risk factors for both metastasis and perithyroidal invasion. Focality of the tumor is another independent risk factor for metastasis.     

Surgical Treatment of Mesenteric Lymphatic Malformations in Children: An Observational Cohort study

BackgroundFew studies have analyzed the cyst characteristics and complications of mesenteric lymphatic malformations (ML). This study aimed to compare ML's cyst characteristics and preoperative complications at different locations and suggest a modified ML classification for patients requiring surgery.MethodsIn total, 157 ML patients underwent surgery at Beijing Children's Hospital between January 2010 and December 2021. The cyst characteristics and preoperative complications were reviewed. The surgical methods for ML were analyzed according to the modified ML classification (Type I, n = 87, involving the intestinal wall; Type II, n = 45, located in the mesenteric boundaries; Type III, n = 16, involving the root of the mesentery; Type IV, n = 7, multicentric ML; Type V, n = 2, involving the upper rectum).ResultsOverall, 111 (70.7%) ML were located at the intestinal mesentery and 44 (28.0%) at the mesocolon. Type I and type II ML mainly involved intestinal mesentery (64.9%) and mesocolon (56.8%), respectively (P < 0.001). Microcystic-type ML and ML with chylous fluid were only located in the intestinal mesentery. Intestinal volvulus was only found in patients with ML in the intestinal mesentery (P < 0.001), whereas ML in the mesocolon were more prone to hemorrhage (P = 0.002) and infection (P = 0.005). ML in the jejunal mesentery was an independent risk factor for intestinal volvulus (OR = 3.5, 95% CI 1.5–8.3, P = 0.003). The surgical methods significantly differed between Type I and type II ML (P < 0.001).ConclusionsML at different locations have different characteristics. For patients requiring surgery, the new ML classification can be used to select an appropriate surgical method.Level of EvidenceLevel III.     

Risk predictors of perioperative complications for the palliative surgical treatment of spinal metastasis

BackgroundThe complication rate for palliative surgery in spinal metastasis is relatively high, and major complications can impair the patient's activities of daily living. However, surgical indications are determined based primarily on the prognosis of the cancer, with the risk of complications not truly considered. We aimed to identify the risk predictors for perioperative complications in palliative surgery for spinal metastasis.MethodsA multicentered, retrospective review of 195 consecutive patients with spinal metastasis who underwent palliative surgeries with posterior procedures from 2001 to 2016 was performed. We evaluated the type and incidence of perioperative complications within 14 days after surgery. Patients were categorized into either the complication group (C) or no-complication group (NC). Univariate and multivariate analyses were used to identify potential predictors for perioperative complications.ResultsThirty patients (15%) experienced one or more complications within 14 days of surgery. The most frequent complications were surgical site infection (4%) and motor weakness (3%). A history of diabetes mellitus (C; 37%, NC; 9%: p < 0.01) and surgical time over 300 min (C; 27%, NC; 12%: p < 0.05) were significantly associated with complications according to univariate analysis. Increased blood loss and non-ambulatory status were determined to be potential risk factors. Of these factors, multivariate logistic regression revealed that a history of diabetes mellitus (OR: 6.6, p < 0.001) and blood loss over 1 L (OR: 2.7, p < 0.05) were the independent risk factors for perioperative complications. There was no difference in glycated hemoglobin A1c between the diabetes patients with and without perioperative complications.ConclusionsDiabetes mellitus should be used for the risk stratification of surgical candidates regardless of the treatment status, and strict prevention of bleeding is needed in palliative surgeries with posterior procedures to mitigate the risk of perioperative complications.     

Proximal aortic repair in dialysis patients: A national database analysis

ObjectivesDialysis is a well-established risk factor for morbidity and mortality after cardiovascular procedures. However, little is known regarding the outcomes of proximal aortic surgery in this high-risk cohort.MethodsPerioperative (in-hospital or 30-day mortality) and 10-year outcomes were analyzed for all the patients who underwent open proximal aortic repair with the diagnosis of nonruptured thoracic aortic aneurysm (aneurysm, n = 325) or type A aortic dissection (dissection, n = 461) from 1987 to 2015 using the US Renal Data System database.ResultsIn patients with aneurysm, perioperative mortality was 12.6%. The 10-year mortality was 81% ± 3%. Age 65 years or more (hazard ratio [HR], 1.35; 95% confidence interval [CI], 1.03 to 1.78; P = .03), chronic obstructive pulmonary disease (HR, 1.68; 95% CI, 1.01-2.82; P = .047), and Black race (HR, 1.46; 95% CI, 1.09-1.97; P = .01) were independently associated with worse 10-year mortality. In patients with dissection, perioperative mortality was 24.3% and 10-year mortality was 87.9% ± 2.2%. Age 65 years or more (HR, 1.49; 95% CI, 1.19-1.86; P < .001), congestive heart failure (HR, 1.39; 95% CI, 1.11-2.57; P = .004), and diabetes mellitus as the cause of dialysis (HR, 1.75; 95% CI, 1.2-2.57; P = .004) were independently associated with worse 10-year mortality. Black race (HR, 0.74; 95% CI, 0.6-0.92; P = .008) was associated with a better outcome.ConclusionsWe described challenging perioperative and 10-year outcomes for dialysis patients undergoing proximal aortic repair. The present study suggests the need for careful patient selection in the elective repair of proximal aortic aneurysm for dialysis-dependent patients, whereas it affirms the feasibility of emergency surgery for acute type A aortic dissections.     

Cranial fat dissemination following fat grafting for lumbar dural tear: First case report in the literature

Introduction and importanceDural tear and cerebrospinal fluid (CSF) leak is among the most common complications in lumbar spine surgery. Although primary dural suturing is the preferred method for repair, this is not always achievable specially with ventrolateral tears. Autologous fat grafting is one of the oldest and effective methods for dural repair which can also be used along with other methods of repair. This case report highlights a unique post spinal surgery complication with comment on how to avoid it. To our knowledge, this has not been previously reported in the literature.Case presentationThe authors report a sixty-seven-year-old male with lumbar pseudomeningocele and cranial fat dissemination following fat grafting for non suturable lumbar dural tear. This was demonstrated on magnetic resonance imaging (MRI) after her presented with low-pressure headache.Clinical discussionIntraoperative dural tear is one of the most common complications in spinal surgery. Methods for optimal dural repair including fat grafting have been described but the choice still heavily dependent on the surgeon’s preference and experience. Fat graft can migrate leading to potential undesirable further complications like hydrocephalus and aseptic meningitis.ConclusionCranial fat dissemination following fat grafting for lumbar dural tear should be recognized as a post-operative complication in lumbar spine surgery. It should be considered in case of hydrocephalus or aseptic meningitis post dural fat grafting. Surgeons should utilize adjunct methods to minimize its incidence.     

Systematic review and meta-analysis comparing perioperative outcomes of emergency appendectomy performed by trainee vs trained surgeon

BackgroundAppendectomy is a benchmark operation for trainee progression, but this should be weighed against patient safety and perioperative outcomes.MethodsSystematic literature review and meta-analysis comparing outcomes of appendectomy performed by trainees versus trained surgeons.ResultsOf 2086 articles screened, 29 studies reporting on 135,358 participants were analyzed. There was no difference in mortality (Odds ratio [OR] 1.08, P = 0.830), overall complications (OR 0.93, P = 0.51), or major complications (OR 0.56, P = 0.16). There was no difference in conversion from laparoscopic to open surgery (OR 0.81, P = 0.12) and in intraoperative blood loss (Mean Difference [MD] 5.58 mL, P = 0.25). Trainees had longer operating time (MD 7.61 min, P < 0.0001). Appendectomy by trainees resulted in shorter duration of hospital stay (MD 0.16 days, P = 0.005) and decreased reoperation rate (OR 0.78, P = 0.05).ConclusionsAppendectomy performed by trainees does not compromise patient safety. Due to statistical heterogeneity, further randomized controlled trials, with standardized reported outcomes, are required.     

Completely laparoscopic versus open radical nephrectomy and infrahepatic tumor thrombectomy: Comparison of surgical complexity and prognosis

ObjectiveTo compare the operation complexity and prognosis of completely laparoscopic versus open radical nephrectomy and infrahepatic tumor thrombectomy.MethodsWe reviewed and analyzed the clinical data of 87 patients with infrahepatic tumor thrombus from January 2015 to April 2019 retrospectively. Completely laparoscopic infrahepatic tumor thrombectomy was completed in 41 cases, and open surgery was completed in 46 cases.ResultsAll 41 patients successfully completed laparoscopic operation, and there were no cases of death during the operation. The completely laparoscopic group were older, had smaller renal tumor diameter, shorter median operation time, lower median intraoperative hemorrhage volume, and lower median transfusion volume of suspended red blood cells compared with open surgeries. The proportion of low-level tumor thrombus (Mayo I) in the completely laparoscopic group was higher (63.4%), while the proportion of low-level tumor thrombus in the open surgery group was lower (30.4%) (P = 0.002). The postoperative complications incidence of laparoscopic surgery was 19.5%, which was lower than that of open surgery (47.8%) (P = 0.004). The mean cancer-specific survival time of the laparoscopic surgery group was 36.6 ± 2.5 months, while that of the open surgery group was 32.3 ± 2.7 months (P = 0.277). There was no statistical difference between the two groups.ConclusionAlthough completely laparoscopic radical nephrectomy and infrahepatic tumor thrombectomy is a challenging operation, it could be feasible and safely performed, especially in the hands of highly-experienced laparoscopic urologists for well selected cases.     

The effectiveness of positive airway pressure therapy in reducing postoperative adverse outcomes in surgical patients with obstructive sleep apnea: A systematic review and meta-analysis

ImportanceObstructive sleep apnea (OSA) is prevalent in surgical patients and is associated with an increased risk of adverse perioperative events.Study objectiveTo determine the effectiveness of positive airway pressure (PAP) therapy in reducing the risk of postoperative complications in patients with OSA undergoing surgery.DesignSystematic review and meta-analysis searching Medline and other databases from inception to October 17, 2021. The search terms included: “positive airway pressure,” “surgery,” “post-operative,” and “obstructive sleep apnea.” The inclusion criteria were: 1) adult patients with OSA undergoing surgery; (2) patients using preoperative and/or postoperative PAP; (3) at least one postoperative outcome reported; (4) control group (patients with OSA undergoing surgery without preoperative and/or postoperative PAP therapy); and (5) English language articles.PatientsTwenty-seven studies included 30,514 OSA patients undergoing non-cardiac surgery and 837 OSA patients undergoing cardiac surgery.InterventionPAP therapyMain resultsIn patients with OSA undergoing non-cardiac surgery, PAP therapy was associated with a decreased risk of postoperative respiratory complications (2.3% vs 3.6%; RR: 0.72, 95% CI: 0.51–1.00, asymptotic P = 0.05) and unplanned ICU admission (0.12% vs 4.1%; RR: 0.44, 95% CI: 0.19–0.99, asymptotic P = 0.05). No significant differences were found for all-cause complications (11.6% vs 14.4%; RR: 0.89, 95% CI: 0.74–1.06, P = 0.18), postoperative cardiac and neurological complications, in-hospital length of stay, and in-hospital mortality between the two groups. In patients with OSA undergoing cardiac surgery, PAP therapy was associated with decreased postoperative cardiac complications (33.7% vs 50%; RR: 0.63, 95% CI: 0.51–0.77, P < 0.0001), and postoperative atrial fibrillation (40.1% vs 66.7%; RR: 0.59, 95% CI 0.45–0.77, P < 0.0001).ConclusionIn patients with OSA undergoing non-cardiac surgery, PAP therapy was associated with a 28% reduction in the risk of postoperative respiratory complications and 56% reduction in unplanned ICU admission. In patients with OSA undergoing cardiac surgery, PAP therapy decreased the risk of postoperative cardiac complications and atrial fibrillation by 37% and 41%, respectively.     

The impact of the level of anxiety and temperament in asymptomatic or mildly symptomatic patients requesting implant removal surgery after tibia intramedullary nailing

BackroundImplant removal (IR) surgery is one of the most frequent procedures in orthopedic practice. Many of the IR surgeries result from patient request rather than a medical necessity. The purpose of the study was to investigate the association between the level of anxiety, type of temperament and psychopathological status, and the willingness to receive IR surgery in asymptomatic or mildly symptomatic patients. We also aimed to compare pre- and postoperative pain scores and document the complication rates after IR surgery.MethodsThe patients who received tibia intramedullary nailing after tibia diaphyseal fracture with a minimum of 18 months follow-up were included in the study. A total of 246 asymptomatic or mildly symptomatic patients were evaluated, and all patients received detailed oral and written information about the risks of IR surgery. The patients who wished to receive IR surgery were called Group 1 (N = 104), and the patients who did not wish to have surgery were called Group 2 (N = 146). All patients were referred to a psychologist to complete the Beck anxiety inventory (BAI), Symptom checklist-90-R (SCL-R-90), and the Temperament Evaluation of Memphis, Pisa, and San Diego Autoquestionnaire (TEMPS-A).ResultsThe mean age of the patients was 32.31 ± 9.56. One hundred thirteen (45.9%) of the patients were male, and 133 were female (54%). Mean BAI and SCL-90-R were higher in Group 1 than Group 2 (P = 0.001). Anxious and irritable temperament was higher in Group 1 (P = 0.045 and P = 0.035 respectively), and non-dominant and hyperthymic temperament was higher in Group 2 (P = 0.02 and P = 0.04 respectively).ConclusionsThe level of anxiety and type of temperament is associated with the willingness to receive implant removal surgery in asymptomatic or mildly symptomatic patients. Measures to reduce anxiety levels may reduce the rate of unnecessary implant removal surgeries, associated patient care costs, and potential complications.     

The impact of long-term corticosteroid use on acute postoperative complications following lumbar decompression surgery

BackgroundCorticosteroids have a negative impact on the human immune system’s ability to function at an optimal level. Studies have shown that patients on long-term corticosteroids have higher infection rates. However, the rates of infection and other complications following lumbar decompression surgery remains under-investigated. The aim of our study was to determine the impact of preoperative long-term corticosteroid usage on acute, 30-day postoperative complications in a subset of patients undergoing lumbar spine decompression surgery, without fusion or instrumentation. We hypothesize that patients on long-term corticosteroids will have higher rates of infection and other postoperative complications after undergoing lumbar decompression surgery of the spine.MethodsA retrospective cohort study was conducted using data collected from the National Surgical Quality Improvement Program database data from 2005 to 2016. Lumbar decompression surgeries, including discectomies, laminectomies, and others were identified using CPT codes. Chi-square analysis was used to evaluate differences among the corticosteroid and non-corticosteroid groups for demographics, preoperative comorbidities, and postoperative complications. Logistic regression analysis was done to determine if long-term corticosteroid use predicts incidence of postoperative infections following adjustment.Results26,734 subjects met inclusion criteria. A total of 1044 patients (3.9%) were on long-term corticosteroids prior to surgical intervention, and 25,690 patients (96.1%) were not on long-term corticosteroids. Patients on long-term corticosteroids were more likely to be older (p < 0.001), female (p < 0.001), nonsmokers (p < 0.001), and have a higher American Society of Anesthesiologist class (p < 0.001). Multivariate analysis demonstrated that long-term corticosteroid usage was associated with increased overall complications (odds ratio [OR]: 1.543; p < 0.001), and an independent risk factor for the development of minor complications (OR: 1.808; p < 0.001), urinary tract infection (OR: 2.033; p = 0.002), extended length of stay (OR: 1.244; p = 0.039), thromboembolic complications (OR: 1.919; p = 0.023), and sepsis complications (OR: 2.032; p = 0.024).ConclusionLong-term corticosteroid usage is associated with a significant increased risk of acute postoperative complication development, including urinary tract infection, sepsis and septic shock, thromboembolic complications, and extended length of hospital stay, but not with superficial or deep infection in patients undergoing lumbar decompression procedures. Spine surgeons should remain vigilant regarding postoperative complications in patients on long-term corticosteroids, especially as it relates to UTI and propensity to decompensate into sepsis or septic shock. Thromboembolic risk attenuation is also imperative in this patient group during the postoperative period and the surgeon should weigh the risks and benefits of more intensive anticoagulation measures.     

Urgent versus elective laparoscopic cholecystectomy following percutaneous transhepatic gallbladder drainage for high-risk grade II acute cholecystitis

BackgroundThe aim of this study was to evaluate the safety of urgent laparoscopic cholecystectomy (Lap-C) for grade II acute cholecystitis (AC) in high-risk patients who were defined by Tokyo Guideline 18 as having age-adjusted Charlson comorbidity index ≥6 or American Society of Anesthesiologists physical status classification (ASA-PS) ≥ 3, compared with elective Lap-C following percutaneous transhepatic gallbladder drainage (PTGBD).MethodsIn 73 grade II AC patients who underwent Lap-C from January 2012 to March 2021, 35 were identified as high-risk; 22 underwent urgent Lap-C (urgent group) and 13 PTGBD followed by elective Lap-C (elective group). Surgical and perioperative outcomes were analyzed.ResultsThere was no significant difference in operation time (median: 101 min vs 125 min; P = 0.371), blood loss (25 ml vs 7 ml; P = 0.853), morbidity rate (31.8% vs 38.5%; P = 0.726), or the incidence of total perioperative major complications (13.6% vs 15.4%; P = 1.000) between the two groups. The total duration of treatment was significantly shorter in the urgent group than the elective group (11 days vs 71 days; P < 0.001). Multivariate analysis revealed that blood loss ≥45 ml [odds ratio (OS): 12.14, 95% confidence interval (CI): 2.03–72.42, P = 0.006], and age ≥75 years with ASA-PS ≥ 3 (OS: 9.85, 95%CI: 1.26–77.26, P = 0.03) were the independent risk factors for total perioperative major complications.ConclusionIn well-selected high-risk patients with grade II AC, urgent Lap-C can be performed with comparable safety to elective Lap-C following PTGBD.     

Is it Safe to Continue Clopidogrel in Elective Hip and Knee Arthroplasty?

BackgroundNo evidence-based guidelines exist for the perioperative use of clopidogrel in elective hip and knee arthroplasty patients. This study compares the preoperative, intraoperative, and postoperative outcomes of total hip and knee arthroplasty in patients maintained on clopidogrel and with patients whose clopidogrel was held before surgery.MethodsWe retrospectively identified 158 patients taking clopidogrel before undergoing elective total hip or knee arthroplasty. Patients were stratified for having clopidogrel held or continued, based on the interval between latest dose and date of surgery. The primary end points were receipt of transfusion and readmission within 90 days of surgery. Secondary end points were the incidence of complications such as bleeding, infection, re-operation, and major cardiac or neurologic events such as myocardial infarction or stroke during the 90-day postoperative period.ResultsThe two cohorts had similar demographics. Patients who continued clopidogrel were more likely to receive a blood transfusion postoperatively (9.1% vs 0%, P = .005), but there was no difference in wound drainage (P = .65), wound infection (P = .24), readmission (P = .74), major complications (P = .64), length of stay (P = .70), or mortality (P = .42). Patients who continued clopidogrel before surgery were more likely to have received general anesthesia (P < .001) per anesthesia protocol, however, three such patients did receive spinal anesthesia without any complications. With cementless implants, blood loss was not different between clopidogrel groups.ConclusionPatients undergoing elective total hip and knee arthroplasty may be safely maintained on clopidogrel without an increased risk of wound complications, infections, length of stay, readmission, reoperation, major medical complications, or mortality. Further prospective research is warranted to confirm the effects of continuing clopidogrel in patients undergoing elective hip and knee arthroplasty.