Vascular complications of orthopaedic surgery: an update on diagnosis and management

Abstract Vascular complications in orthopaedic surgery are not frequent, but they can be severe and occasionally life-threatening. Present technologies make it easier to detect and successfully manage them, provided a high level of clinical suspicion is kept. Spontaneous complication is deep venous thrombosis (DVT), which occurs in 2.5% of patients undergoing hip or knee arthroplasty and can be treated by prophylactic doses of low molecular weight heparin (LMWH). D-Dimer blood test and duplex scanning are the pillars of diagnosis. LMWH (6000 U twice daily) is standard therapy but in selected cases thrombolysis or surgical venous thrombectomy can be used. Iatrogenic complications come from surgical manoeuvres and instruments; risk factors are preexisting atheromatous lesions and reinterventions, both orthopaedic and vascular. These lesions can cause bleeding, ischaemia, embolism, pseudoaneurysms or arteriovenous fistula, and are classified accordingly. Diagnosis is done by duplex scanning, computed tomography or angiography (particularly intraoperative angiography) and should be timely in order to allow the earliest possible management. This is crucial for a successful result, which may avoid damage to the patient and medicolegal problems. District-specific complications and treatment are reviewed. Presented at the Failure in Orthopaedics meeting, Rome, 27–29, October 2005.     

Tracheo-innominate artery fistula after percutaneous tracheostomy: three case reports and a clinical review

Tracheo-innominate artery fistula (TIF) is an uncommon yet lifethreatening complication after a tracheostomy. Rates of 0.1–1%after surgical tracheostomy have been reported, with a peakincidence at 7–14 days post procedure. It is usually fatalunless treatment is instituted immediately. Initial case reportsof TIF resulted from surgically performed tracheostomies. Wepresent three fatalities attributable to TIF, confirmed by histopathology,after percutaneous dilatational tracheostomy (PDT). The useof PDT has resulted in tracheostomies being performed by specialistsfrom different backgrounds and the incidence of this complicationmay be increasing. Pressure necrosis from high cuff pressure,mucosal trauma from malpositioned cannula tip, low trachealincision, radiotherapy and prolonged intubation are all implicatedin TIF formation. Massive haemorrhage occurring 3 days to 6weeks after tracheostomy is a result of TIF until proven otherwise.We present a simple algorithm for management of this situation.The manoeuvres outlined will control bleeding in more than 80%of patients by a direct tamponade effect. Surgical stasis isobtained by debriding the innominate artery proximally, thentransecting and closing the lumen. Neurological sequelae arefew. Post-mortem diagnosis of TIF may be difficult, but specificpathology request should be made to assess innominate arteryabnormalities.     

Influence of Helicobacter pylori infection on gastrointestinal symptoms and complications in bariatric surgery patients: a review and meta-analysis

Background

Numerous papers have discussed the importance of preoperative detection and eradication of Helicobacter pylori (HP) in bariatric patients.

Role of routine chest radiography after percutaneous dilatational tracheostomy

Background: The role of routine chest radiography (CXR) after percutaneousdilatational tracheostomy (PDT) has been questioned. Methods: We performed a prospective observational study, on a mixed medical/surgicalcritical care unit in a university teaching hospital. We studiedall patients undergoing PDT as part of their critical care managementfrom November 1, 2003 until July 31, 2007. All PDTs were performedunder bronchoscopic guidance. After PDT, we reviewed the immediatepost-procedural films to assess the utility of routine postoperativeCXR. For the purposes of CXR review, we considered a procedureto be either uncomplicated or technically difficult. Clinicallyrelevant CXR findings were new barotrauma (pneumothorax, pneumomediastinum)or a significant change in consolidation from the pre-procedurefilm. Results: A total of 384 patients underwent PDT during the study period.Of these, 345 had immediate post-procedural CXRs available forreview. There were 252 PDTs (73%) documented as uncomplicated.There were 93 (27%) technically difficult procedures, with 107adverse events recorded. In 82 (24%) procedures, these difficultieswere described as minor procedural complications [multiple attemptsat needle insertion (3), minor bleeding or tracheal ring fracture].Significant complications (mal-placement in the anterior mediastinumand major bleeding) were documented in 12 (3.5%) patients. Newabnormalities were noted on 8 (2.3%) immediate post-proceduralCXRs. In only one patient was there a new CXR change in an uncomplicatedPDT. Conclusions: Immediate CXR after uncomplicated PDT performed under bronchoscopicguidance rarely reveals unexpected radiological abnormalities.The role of CXR after PDT appears to be restricted to thosepatients undergoing technically difficult and complicated procedures.A change in practice to this effect will lead to reductionsin both medical costs and exposure of staff and patients toionizing radiation.     

Safety of bariatric surgery in the elderly: results from the Dutch National Registry

BackgroundThe increased human life expectancy and prevalence of obesity lead to more elderly people with obesity. As the popularity of bariatric surgery continues to grow, more elderly persons apply for bariatric surgery. However, because of the potentially higher surgical risk in elderly patients, bariatric surgery has been performed in small numbers. Moreover, the literature so far has shown controversial results.ObjectiveTo determine the safety of bariatric surgery in elderly patients in terms of 2-year morbidity and mortality.SettingDutch nationwide mandatory registry for bariatric surgery.MethodsA population-based retrospective cohort study. Elderly patients (aged ≥65 years) who received primary bariatric surgery between January 2015 and January 2020 were compared with the general bariatric surgical population (aged 18–65 years).ResultsOf 49,553 patients, 838 elderly patients (1.7%) were included. An intraoperative complication was registered in 1.2% of the elderly patients and 1.1% of the nonelderly patients (P = .814). A severe short-term complication (≤30 days) was registered in 38 elderly patients (4.5%) and 1071 nonelderly patients (2.2%) (P < .001). The short-term mortality rates were .2% and .1%, respectively (P = .173). Bleeding was the most reported short-term complication. Significantly more nonelderly patients had a follow-up visit; 560 elderly patients (66.8%) versus 34,975 nonelderly patients (71.8%) (P = .002). The severe midterm complication rate (>30 days to ≤2 years) was significantly higher in nonelderly patients (3.7% versus 1.6%; P = .008).ConclusionsBariatric surgery in elderly patients is safe in terms of perioperative outcome, mortality, and midterm complication rate. However, elderly patients experienced twice as many severe short-term complications. Bariatric surgery in elderly patients should be recommended on a case-by-case basis.     

Psychiatric Issues in Bariatric Surgery

In this study, 100 patients were evaluated prior to surgery to assess psychiatric status. The demographic anthropometric and psychological characteristics are described. Seventeen patients developed severe psychiatric complications and required hospitalization; the diagnoses which precipitated hospital admission were most commonly affective disorders (especially major depression with suicidal ideation). The only deaths in the sample of 100 occurred among the patients who required post-surgical psychiatric hospitalization. The hospitalized group was compared to a matched group drawn from the original 100 patients. Factors associated with post-surgical psychiatric hospitalization were: presurgical psychiatric hospitalization, presence of multiple pre-surgical Axis I psychiatric diagnoses, and untreated Axis I diagnosis at the time of pre-surgical assessment. Psychiatric screening criteria were revised and 31 subsequent patients were evaluated; less than half of this group were found suitable for surgery at the time of preliminary assessment.     

It’s the procedure not the patient: the operative approach is independently associated with an increased risk of complications after rectal prolapse repair

Aim This study compares 30‐day outcomes following rectal prolapse repair, examining potential surgical and patient factors associated with perioperative complications. Method Using the NSQIP database, patients with rectal prolapse were categorized by surgical approach to repair (perineal or abdominal) and abdominal cases were further subdivided by procedure (resection compared with rectopexy alone). Univariate and multivariate analyses compared major and minor complication rates between the groups. Results Of 1275 patients, the perineal group (n = 706, 55%) was older, with more comorbidity, than those undergoing an abdominal procedure. There were fewer minor (odd ratio (OR) = 0.35; 95% confidence interval (CI), 0.20–0.60; P = 0.0038) and major complications (OR = 0.46; 95% CI, 0.31–0.80; P = 0.0038) in the perineal compared with the abdominal cohort. There was a significant increase in major complications amongst patients undergoing a resection compared with rectopexy only (OR = 2.15; 95% CI, 1.10–4.41; P = 0.0299). There was no difference in major complications between abdominal rectopexy and a perineal approach, but the latter had a lower chance of minor complications (OR = 0.47; 95% CI, 0.24–0.94; P = 0.0287). Conclusion A perineal approach is safer than an abdominal approach to the treatment of rectal prolapse. Regarding an abdominal operation, rectopexy has fewer major complications than resection.     

Estudio prospectivo de los factores asociados al delirium en el postoperatorio de la cirugía abdominal urgente

IntroductionDelirium is a frequent complication in elderly patients after urgent abdominal surgery.MethodsProspective study of consecutive patients aged ≥ 65 years who had undergone urgent abdominal surgery from 2017-2019. The following variables were recorded: age, sex, ASA, physiological state, cognitive impairment, frailty (FRAIL Scale), functional dependence (Barthel Scale), quality of life (Euroqol-5D-VAS), nutritional status (MNA-SF), preoperative diagnosis, type of surgery (BUPA Classification), approach and diagnosis of postoperative delirium (Confusion Assessment Method). Univariate and multivariate analyses were performed to analyze the correlation of these variables with delirium.ResultsThe study includes 446 patients with a median age of 78 years, 63.6% were ASA ≥ III and 8% had prior cognitive impairment. 13.2% were frail and 5.4% of the patients had a severe or total degree of dependence. 13.6% developed delirium in the postoperative period. In the univariate analysis, all the variables were statistically significant except for sex, type of surgery (BUPA) and duration. In the multivariate analysis the associated factors were: age (P < .001; OR: 1,08; 95% CI: 1,038-1,139), ASA (P = .026; OR: 3.15; 95% CI: 1.149-8.668), physiological state (P < .001; OR: 5.8; 95% CI: 2.176-15.457), diagnosis (P = .006) and cognitive impairment (P < .001; OR: 5.8; 95% CI: 2.391-14.069).ConclusionThe factors associated with delirium are age, ASA, physiological state in the emergency room, preoperative diagnosis and prior cognitive impairment.     

Update on Post‐mastectomy Lymphedema Management

Lymphedema is a chronic, progressive condition caused by an imbalance of lymphatic flow. Upper extremity lymphedema has been reported in 16–40% of breast cancer patients following axillary lymph node dissection. Furthermore, lymphedema following sentinel lymph node biopsy alone has been reported in 3.5% of patients. While the disease process is not new, there has been significant progress in the surgical care of lymphedema that can offer alternatives and improvements in management. The purpose of this review is to provide a comprehensive update and overview of the current advances and surgical treatment options for upper extremity lymphedema.     

Postoperative care of adult cardiac surgery patients

Over 35,000 cardiac operations are performed in the UK each year, with the majority requiring cardiopulmonary bypass (CPB). CPB replaces the heart and lung function temporarily by providing non-pulsatile oxygenated blood flow in order to facilitate arrested heart surgery. The use of an extracorporeal circuit and cardioplegia causes the release of pro-inflammatory cytokines inducing a systemic inflammatory response, coagulation cascade activation, haemodilution and transient myocardial depression among other effects. These manifest as a series of typical pathophysiological derangements, which require the adoption of a standard management strategy. The aim of this article is to provide an overview of the key issues including cardiac, respiratory, neurological, renal and haemostatic complications, which may arise while managing the postoperative cardiac surgical patient.     

前列腺增生住院患者10年回顾(附1345例报告)

目的探讨前列腺增生（BPH）的临床特点和治疗情况。方法回顾分析近10年我科收住的1345例BPH患者的临床特点和治疗情况。结果1345例BPH患者中，表现有尿频1188例（88．3％），尿痛183例（13．6％），血尿254例（18．9％），排尿困难1213例（90．2％），有尿潴留671例（49．9％）；合并肾积水89例（6．6％），膀胱结石97例（7．2％），膀胱憩室29例（2．2％）。454例（33．8％）患者尿常规提示有炎症存在；635例（47．2％）患者接受了PSA检测，结果为0．1～150μg/L，平均9．55μg/L；611例（45．4％）B超测得的前列腺体积为20～193ml，平均58．76ml；730例（54．3％）残余尿量为0～1200ml，平均99．1ml。前列腺体积随年龄增加而增大（F=2．82，P〈0．01），PSA随体积增大而升高（F=8．19。P〈0．01）。450例（33．5％）患者接受了前列腺开放切除，553例（41．1％）接受了TURP，TURP组患者的并发症及住院时间明显低于前者（P1=0．02，P2〈0．01）。结论BPH的症状和并发症严重影响患者的生活质量，及时有效’的治疗是防止并发症发生、发展的关键。TURP是治疗BPH的标准方法。     

减少Duckett手术治疗尿道下裂并发症发生的体会

目的 探讨提高Duckett术式治疗尿道下裂手术成功率的技术要点.方法 2000至2008年采用Duckett手术1期治疗尿道下裂共57例病例.分A组(2000年至2005年手术的)和B组(2006年至2008年手术的)进行手术成功率、尿瘘及尿道狭窄发生率的分析比较.结果 B组手术成功率高于A组,尿瘘和尿道狭窄等并发症发生率更低(P<0.05).结论 Duckett手术要注意带血管蒂皮瓣的分离层面以及尿道管的缝合技术.血管蒂筋膜覆盖尿道管可以减少尿瘘发生.术中要注意消灭创面死腔.尿道吻合口和尿道外口缝合要宽敞.熟练掌握并灵活运用Duckett术式可以减少尿道F裂并发症的发生.     

Hydrothorax: an unexpected complication after laparoscopic myomectomy

We report a case of hydrothorax as a complication of laparoscopicmyomectomy in an otherwise healthy woman. The most likely causeof the patient’s hydrothorax was irrigation fluid movingfrom the peritoneal cavity into the pleural space via defectsin the diaphragm. Anaesthestists and surgeons should considerhydrothorax as a potential complication in any patient undergoinglaparoscopy. Br J Anaesth 2001; 87: 507–9     

An institutional experience with laparoscopic gastric bypass complications seen in the first year compared with open gastric bypass complications during the same period

BACKGROUND: Complication rates for laparoscopic bariatric surgery remain in evolution. METHODS: Single institution review of the initial year's experience with laparoscopic gastric bypass compared with open gastric bypass complications for the same period. RESULTS: There were 20 laparoscopic and 52 open gastric bypass procedures. Five laparoscopic patients had major complications. There were 4 anastomotic leaks. Nine open bypass patients had major complications, with 2 leaks. Leak rate was 20% for the laparoscopic group and 4% for the open group. All leaks in both groups led to substantial morbidity. There were two deaths, one in each group. The laparoscopic death was from postleak sepsis. CONCLUSIONS: Gastric bypass, whether done open or laparoscopically, has significant surgical risk. Complication profiles differed between the two groups. Anastomotic leaks were significantly more frequent in the laparoscopic group, probably related to the learning curve. There is a continued need for open surgery in many bariatric patients.     

Redo Gastric Restriction: A Higher Risk Procedure

Twenty-one patients have undergone redo gastric restrictive procedures, three after gastric bypass, 18 after gastroplasty. Weight at the time of the redo procedure was 101 kg ± 32.4 SD (222 lb ± 71.2) (178% IBW ± 33.8), down from 137 kg ± 65.5) (217% IBW ± 33.9) at the time of initial procedure. Sixteen of 21 (76%) initial procedures failed because of staple-line dehiscence, at least in part. Redo procedures were vertical banded gastroplasty (VBG) in ten, gastric bypass (GB) in ten, and silico ring banded gastroplasty in one. Early complications were three gastric leaks, one enterocutaneous fistula, one gastroplasty outlet obstruction, and one wound infection occurring in three of ten VBG and three of ten GB. All three leaks and one fistula were not seen on gastrograffin/barium swallow done 2-4 days after the redo procedure. Late complications were failure of seven redo procedures, one small bowel obstruction, and one recurrent enterocutaneous fistula, with two lost to followup. We conclude that redo gastric restriction procedures carry relatively high perioperative risks. Radiologic contrast studies done in the early postoperative period do not necessarily detect leaks, which are presumably due to gastric ischemia and subsequent infarction. Ischemia is thought to be due to devascularization from the initial procedure. Late failure is unfortunately common, possibly reflecting behaviours which lead to the initial staple line dehiscence and failure. Higher risk of perioperative complications and late failure must be considered prior to revisional surgery.