Cardiac injury during resternotomy does not affect perioperative mortality

BACKGROUND: Cardiac injury at the time of resternotomy is a complication faced by all cardiac surgeons, although little is known about its effects on morbidity and mortality. This study was designed to address these questions. STUDY DESIGN: Resternotomies performed at the University of Virginia from 1996 to 2005 were identified. Operative notes were reviewed, and any injury during resternotomy to the heart, great vessels, or bypass grafts was recorded. Perioperative complications and mortality were recorded using the Society of Thoracic Surgeons National Database. RESULTS: In the 11-year period studied, 612 resternotomies were performed out of 7,872 total adult cardiac procedures (7.8%). Fifty-six patients (9.1%) had an injury sustained during resternotomy and initial dissection. Injury to grafts was most common (46.4%), with mammary arteries comprising 21% of the total and vein grafts, 25%. The right ventricle was the second most commonly injured structure (21.4%). There were no significant differences in overall nonadjusted mortality in the injured group compared with that in the noninjured group (8.9% versus 10.2%, p=0.66). Multivariate analysis demonstrated third-time resternotomy to be an independent risk factor for cardiac injury (p=0.04). CONCLUSIONS: Cardiac injury at the time of resternotomy is not associated with an increase in perioperative morbidity or mortality. Third-time resternotomy is an independent risk factor for cardiac injury, so vigilance and adequate preparation are paramount in these patients.     

Female gender does not protect blunt trauma patients from complications and mortality

BACKGROUND: The protective effect of gender on posttraumatic mortality or acute complications (acute respiratory distress syndrome [ARDS], pneumonia, and sepsis) is unclear. To assess potential effects, we performed a retrospective case-controlled study, matching patients for injury factors including overall severity (Injury Severity Sscore), the presence of shock (systolic blood pressure [SBP] < 90 mm Hg) at admission, and the presence of closed head injury (CHI). METHODS: All female patients admitted over a 61/2-year period were reviewed and divided into four groups: group 1, SBP > 90, no CHI; group 2, SBP < 90, no CHI; group 3, SBP > 90, with CHI; and group 4, SBP < 90, with CHI. Each cohort was matched one to one with an equivalent male counterpart. Cohorts were compared for mortality or the development of ARDS, pneumonia, and systemic sepsis using standard definitions. RESULTS: Overall, 1,229 female patients were identified for study. The average Injury Severity Score was 16.3 and overall mortality was 2.7%. Analysis of the groups described previously demonstrated no statistically significant difference in the development of ARDS, pneumonia, systemic sepsis, or overall mortality between male and female patients including patients presenting with shock, CHI, or both. CONCLUSION: We conclude that female gender offers no protection from the development of ARDS, pneumonia, sepsis, or decreased mortality after blunt trauma.     

Obesity does not adversely affect the outcome of laparoscopic antireflux surgery (LARS)

Background: Because it has been suggested that obesity adversely affects the outcome of LARS, it is unclear how surgeons should counsel obese patients referred for antireflux surgery. Methods: A prospective database of patients undergoing LARS from 1992 to 2001 was used to compare obese and nonobese patients. Patients were surveyed preoperatively and annually thereafter. Questionnaires were completed regarding global symptoms and overall satisfaction. Results: Of the 505 patients, the body mass index (BMI) was <25 (normal) in 16%, 25–29 (overweight) in 42%, and >30 (obese) in 42%. Although the operative time was longer in the obese group than in the normal weight group (137 ± 55 min vs 115 ± 42 min, p = 0.003), the time to discharge and rate of complications did not differ. At a mean follow-up of 35 ± 25 months, there were no differences in symptoms, overall improvement, or patient satisfaction. Further, the rates of anatomic failure were similar among the obese, overweight, and normal weight groups. Conclusions: Although the operative time is longer in the obese, complication and anatomic failure rates are similar to those in the nonobese at long-term follow-up. Obese patients have equivalent symptom relief and are equally satisfied postoperatively. Therefore, obesity should not be a contraindication to LARS. Presented at the annual meeting of the Association of Academic Surgeons, Boston, MA, USA, November 2002     

Obesity and increased mortality in blunt trauma

To determine the effect of admission body weight on blunt trauma victims, a chart review of all patients greater than 12 years of age admitted to Sentara Norfolk General Hospital between January 1 and July 31, 1987 was undertaken. The charts of 351 patients were reviewed; 184 records contained admission height and weight. These 184 patients made up the study group and age, gender, injuries, Injury Severity Score (ISS), ventilator days (VD), complications, length of stay (LOS), and outcome were noted. Body Mass Index (BMI) (weight (kg)/(height(m))2, was calculated for each patient. The average ISS was 21.87 (range, 1-66) and the average BMI was 25.15 kg/m2 (range, 16-46 kg/m2). The overall mortality for the population was 9%. The population was grouped according to BMI: average (less than 27 kg/m2), overweight (27-31 kg/m2), and severely overweight (greater than 31 kg/m2). The mortality of 5.0% and 8.0% in the average and overweight groups was not different. The severely overweight group had a higher mortality at 42.1% compared with the other two groups (p less than 0.0001). The groups did not differ in age, ISS, LOS, nor VD. Age, BMI, and ISS were subjected to regression analysis. By this method BMI and ISS were independent determinants of outcome (p less than 0.0001). There was an increase in complications, mainly pulmonary problems, in the SO group (p less than 0.05). The three groups were subdivided into survivors and nonsurvivors. The nonsurvivors had a longer average LOS at 26.6 days compared with nonsurvivors in the overweight (5.0 days) or severely overweight (8.62 days) groups (p less than 0.007). The severely group was characterized by a rapid deterioration and demise that was unresponsive to intervention. ISS did not differ among nonsuvivors. Among survivors the severely overweight group had a lower ISS, 9.73. This was different from the overweight group (21.57) and from the average group (20.21) (p less than 0.04).     

Obesity does not necessarily affect the accuracy of acetabular cup implantation in total hip replacement

Postoperative radiographs of 111 patients who had undergone cemented total hip replacement performed or supervised by a single surgeon were analysed. All surgeries were performed via an anterolateral approach with patients in the lateral position. Patients were stratified according to Body Mass Index (BMI) into three groups (healthy, overweight and obese) and acetabular cup angles were measured. Mean values for cup abduction angle were similar for all three groups (44.5 degrees, 46.8 degrees, 44.0 degrees respectively, p = 0.335). Furthermore there were no differences in mean cup anteversion between groups (11.6 degrees, 12.2 degrees and 10.7 degrees respectively, p = 0.665). We conclude that obesity does not necessarily influence the accuracy of cup positioning in total hip replacement.     

Increasing age does not affect good outcome after lumbar disc replacement

From 1992 to 1998 fifteen Link-Charite SB III disc prostheses were implanted into 14 patients. The main indication was degenerative lumbar disc disease with segmental instability. With a mean follow-up of 48 months (18–68 months); 12 patients had a good (10) or fair (2) outcome regarding pain relief, return to employment and level of general physical activity. In contrast to previous publications we felt that age over 45 years did not appear to adversely affect the outcome.

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Résumé  De 1992 a 1998 quinze prothe`ses discales LINK-CHARITE III ont été posées chez quatorze patients avec une dégéneration lombaire. Avec un suivi post-operatoire de 48 mois (18 – 68 mois); douze patients ont bien récupéré en ce qui concerne l’analgesie ainsi que la retour au travail et aux activites physiques générales. Nous ne trouvont pas que l’age plus de 45 ans affectait les resultats.

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Accepted: 21 November 1999     

Comorbidity does not predict long-term mortality after total hip arthroplasty

Background and purpose — In-hospital death following total hip arthroplasty (THA) is related to comorbidity. The long-term effect of comorbidity on all-cause mortality is, however, unknown for this group of patients and it was investigated in this study.

Patients and methods — We used data from the Swedish Hip Arthroplasty Register, linked to the National Patient Register from the National Board of Health and Welfare, for patients operated on with THA in 1999–2012. We identified 120,836 THAs that could be included in the study. We evaluated the predictive power of the Charlson and Elixhauser comorbidity indices on mortality, using concordance indices calculated after 5, 8, and 14 years after THA.

Results — All comorbidity indices performed poorly as predictors, in fact worse than a base model with age and sex only. Elixhauser was, however, the least bad choice and it predicted mortality with concordance indices 0.59, 0.58, and 0.56 for 5, 8, and 14 years after THA.

Interpretation — Comorbidity indices are poor predictors of long-term mortality after THA.     

On-site coagulation monitoring does not affect hemostatic outcome after cardiac surgery

BACKGROUND: Rapid coagulation tests are now available for monitoring of bleeding patients after cardiac surgery. As inappropriate blood use in these patients may be due to lack of timely coagulation data, we studied the effect of an algorithm with on-line coagulation monitoring on transfusions in these patients. METHODS: Prospectively, patients bleeding (>1.5 ml kg(-1) 15 min(-1)) after cardiac surgery were randomly assigned to two groups: in group A (n=28), hemostatic treatment during the immediate recovery period (1 h after surgery) was based on an algorithm with on-site hemostasis monitoring, whereas during the same period group B patients (n=30) were managed solely according to the clinician's judgement; laboratory tests other than activated clotting time after heparin neutralization were prohibited. RESULTS: Cumulative chest tube drainage up to 16 h and total transfusion requirements did not differ between the groups. Using a platelet transfusion trigger of 100x10(9)/l, significantly more patients received platelets during the immediate recovery period in the algorithm group than in the control group (14 vs. 3 patients, P=0.001). Desmopressin acetate was administered more often in group A than in group B (8 vs. 2 patients, P=0.04). CONCLUSIONS: Algorithm-based therapy increased utilization of hemostatic interventions during the immediate recovery period without any obvious benefit to the hemostatic outcome. Re-evaluation of the platelet transfusion trigger seems warranted.     

Subclinical thyroid dysfunction does not affect one-year mortality in elderly patients after hip fracture: A prospective longitudinal study

Mortality after hip fractures in the elderly is one of the most important patient outcome measures. Subclinical thyroid dysfunction is common in the elderly population. This is a prospective study of 131 elderly patients with a mean (SD) age of 82.0 (8.9) years (range: 61-94) admitted consecutively to our trauma unit. The aim of the study was to determine the prevalence of subclinical thyroid dysfunction in an elderly cohort of patients with hip fracture and to determine if this affects the one-year mortality.There were three times more women (n = 100) than men (n = 31) in this cohort. All patients underwent surgical treatment for the hip fracture. The prevalence of subclinical hypothyroidism (TSH > 5.5 mU/L) was 15% (n = 20) and of subclinical hyperthyroidism (TSH < 0.35 mU/L) was 3% (n = 4). Overall 18% (n = 24) of patients had a subclinical thyroid dysfunction. The twelve-month mortality was 27% (n = 36).Age, gender, heart rate at admission, pre-existing coronary heart disease, ASA grade and presence of overt or subclinical thyroid dysfunction were analysed for association with twelve-month mortality using a forward stepwise logistic regression analysis. Only ASA grade was found to significantly affect mortality at twelve months (χ² = 3.98, df = 1, p = 0.046). Independently the presence of subclinical hypo- or hyperthyroidism was not associated with a higher mortality (p = 0.477). We conclude that subclinical thyroid dysfunction does not affect the one-year mortality in elderly patients treated surgically for hip fracture.     

Obesity does not impact outcomes for appendicitis

Obesity has long been considered a risk factor for surgery. The purpose of this study was to evaluate the impact of obesity on outcomes after appendectomy. A retrospective study was performed using discharge abstract data obtained from patients with documented body mass index (BMI) undergoing appendectomy for appendicitis (n = 2919). Complications and length of stay for different BMI categories were compared. Obese patients (BMI > 30 kg/m(2)) had similar rates of perforation (20%) and were as likely to undergo a laparoscopic approach (85%) as nonobese patients. On multivariable and univariate analysis, no significant differences were observed when comparing obese and nonobese patients for the outcomes of length of stay, infectious complications, and need for readmission. On multivariate analysis, laparoscopy predicted lower complication rates and decreased length of stay. In this study, obesity did not significantly impact rates of perforation, operative approach, length of stay, infectious complications, or readmission.