Prospective analysis of anatomic features predisposing patients to intraoperative floppy iris syndrome.

PURPOSE: To aid preoperative risk assessment by identifying anatomic parameters corresponding with a higher risk of intraoperative floppy iris syndrome (IFIS) during cataract surgery. METHODS: Prospective cohort study of 55 patients with α1-adrenergic receptor antagonist (α1-ARA) treatment and 55 controls undergoing cataract surgery. Anterior segment optical coherence tomography (AS-OCT), video pupilometer, and biometry measurements were performed preoperatively and analyzed regarding anatomic parameters that corresponded with a higher rate of IFIS. Those statistically significant parameters were evaluated with logistic regression analysis and receiver operating characteristic (ROC) curve. RESULTS: Pupil diameter was significantly smaller in patients who developed IFIS compared to those who did not develop IFIS (AS-OCT 3.29 ± 0.85 vs. 3.63 ± 0.68, p = 0.03; Pupilometer 3.56 ± 0,87 vs. 3.95 ± 0.67, p = 0.02). Biometric evaluation revealed shallower anterior chambers in the IFIS group (ACD 3.12 ± 0.40 vs. 3.32 ± 0.42, p = 0.02). Cutoff values for 50% IFIS probability (p = 0.5) were PD = 3.18 mm for pupil diameter and ACD = 2.93 mm for anterior chamber depth. ROC curves of combined parameters were calculated for α1-ARA medication with pupil diameter and anterior chamber depth, which yielded an AUC of 0.75 for all IFIS grades. CONCLUSION: The combination of biometric parameters with history of α1-ARA medication can improve assessment of risk stratification for IFIS incidence during cataract surgery.

Enhanced safety in central venous catheterization performed by Japanese board-certified pediatric surgeons: a retrospective single-center study.

PURPOSE: Board certification by the Japanese Society of Pediatric Surgeons is awarded to pediatric surgeons with substantial surgical experience and academic achievement. However, to date, the surgical performance or outcomes of certified surgeons have not been reported. This study examined the relationship between board certification and surgical outcomes of central venous catheterization. METHODS: This retrospective single-center study was conducted between April 2017 and May 2024. Patients were classified based on whether their procedures were performed by board-certified or non-certified surgeons, and their backgrounds and surgical outcomes were compared. In addition, multivariate analysis was performed to identify the factors associated with prolonged operative time. RESULTS: This study included 112 procedures: 26 performed by board-certified surgeons and 86 performed by non-certified surgeons. There were no significant differences in the age, sex, weight, or primary diagnosis between the groups; however, surgery-associated complications were significantly more common in the non-certified surgeon group than in the board-certified surgeon group (15.1% vs. 0%, P = 0.036). In addition, factors independently associated with a prolonged operative time included weight < 10 kg, left-sided approach, implantable port device use, and < 7 years of postgraduate experience for the surgeon. CONCLUSION: Board certification was associated with a significant reduction in surgery-associated complications during central venous catheterization.

Reporting perioperative complications of radical cystectomy: the influence of using standard methodology based on ICARUS and EAU quality criteria.

PURPOSE: We aimed to evaluate perioperative complications of radical cystectomy (RC) by using standardized methodology. Additionally, we identified independent risk factors associated with perioperative complications. MATERIALS AND METHODS: We retrospectively analyzed 30-day and 90-day perioperative complications of 211 consecutive RC patients. The intraoperative and postoperative complications were defined according to Clavien-Dindo classification (CDC) and reported based on the ICARUS criteria, Martin, and EAU quality criteria. Age-adjusted Charlson comorbidity index (ACCI), systemic inflammatory response index (SIRI), body mass index (BMI) ≥ 25 kg/m2, and neoadjuvant chemotherapy (NAC) were also evaluated. Multivariable regression models according to severe (CDC ≥ IIIb grade) complications were tested. RESULTS: Overall, 88.6% (187/211) patients experienced at least one intraoperative complication. Bleeding during cystectomy was the most common complication observed (81.5% [172/211]). Severe intraoperative complications (EAUiaiC grade > 2) were recorded in 8 patients. Overall, 521 postoperative complications were recorded. Overall, 69.6% of the patients experienced complications. Thirty-nine patients suffered from most severe (CDC ≥ IIIb grade) complications. ACCI (OR: 1.492 [1.144-1.947], p = 0.003), SIRI (OR: 1.279 [1.029-1.575], p = 0.031), BMI (OR: 3.62 [1.58-8.29], p = 0.002), and NAC (OR: 0.342 [0.133-0.880], p = 0.025) were significant independent predictive factors for 90-day most severe complications (CDC ≥ IIIb grade). CONCLUSIONS: RC complications were reported within a standardized manner, concordant with the ICARUS and Martin criteria and EAU guideline recommendations. Complication reporting seems to be improved with the use of standard methodology. Our results showed that ACCI, SIRI, and BMI ≥ 25 kg/m2 and the absence of NAC were significant predictive factors for most severe complications.

Correlation between mandibular anatomy and bad split occurrence during bilateral sagittal split osteotomy: a three-dimensional study.

OBJECTIVES: This study aimed to find out the correlation between different anatomical parameters of the mandible and the occurrence of a bad split in patients who had undergone bilateral split sagittal ramus osteotomy (BSSRO). MATERIALS AND METHOD: At both the distal roots of the first molar (1) and the retromolar area (2), we measured the distance from the buccal margin of the inferior dental canal (IDC) to the buccal margin of the cortical bone (MCBC), the thickness of both buccal cortical (WBCB) and cancellous bone (WBCA), distance from the superior border of IDC to the alveolar crest (MCAC), buccolingual thickness (BLT), and thickness of cancellous bone (WCA). At the ramus, the distances between the sigmoid notch to the upper part of the lingula (SL) and the inferior border of the mandible (SIBM), the thickness of the ramus at the level of the lingula (BLTR), and the anteroposterior width of the ramus (APWR) were measured. The paired and independent t-tests were used when applicable, and a P-value < 0.05 was considered significant. RESULTS: MCBC1 showed a significant difference between bad and non-bad split sides (P = 0.037). Both WBCA1 and WBCA2 show the same significant difference (P = 0.023, 0.024). Similarly, WCA1 and WCA2 showed a statistical difference between the bad and non-bad split sides (P = 0.027, 0.036). There were no statistically significant differences between the compared sides of WBCB1, WBCB2, MCAC1, MCAC2, SIBM, APWR, SL, and BLTR. CONCLUSION: Narrow space between IDC and the buccal cortical margin, along with the decrease in the thickness of both buccal cancellous bone and total cancellous bone at the inferior border of the mandible along the course of SSRO, has been implicated in the occurrence of bad split intraoperatively.

Intraoperative Deaths: Who, Why, and Can We Prevent Them?

INTRODUCTION: Intraoperative deaths (IODs) are rare but catastrophic. We systematically analyzed IODs to identify clinical and patient safety patterns. METHODS: IODs in a large academic center between 2015 and 2019 were included. Perioperative details were systematically reviewed, focusing on (1) identifying phenotypes of IOD, (2) describing emerging themes immediately preceding cardiac arrest, and (3) suggesting interventions to mitigate IOD in each phenotype. RESULTS: Forty-one patients were included. Three IOD phenotypes were identified: trauma (T), nontrauma emergency (NT), and elective (EL) surgery patients, each with 2 sub-phenotypes (e.g., ELm and ELv for elective surgery with medical arrests or vascular injury and bleeding, respectively). In phenotype T, cardiopulmonary resuscitation was initiated before incision in 42%, resuscitative thoracotomy was performed in 33%, and transient return of spontaneous circulation was achieved in 30% of patients. In phenotype NT, ruptured aortic aneurysms accounted for half the cases, and median blood product utilization was 2,694 mL. In phenotype ELm, preoperative evaluation did not include electrocardiogram in 12%, cardiac consultation in 62%, stress test in 87%, and chest x-ray in 37% of patients. In phenotype ELv, 83% had a single peripheral intravenous line, and vascular injury was almost always followed by escalation in monitoring (e.g., central/arterial line), alert to the blood bank, and call for surgical backup. CONCLUSIONS: We have created a framework for IOD that can help with intraoperative safety and quality analysis. Focusing on interventions that address appropriateness versus futility in care in phenotypes T and NT, and on prevention and mitigation of intraoperative vessel injury (e.g., intraoperative rescue team) or preoperative optimization in phenotype EL may help prevent IODs.

How I do it: management of M2 tear injury caused by drilling during intradural anterior clinoidectomy for microsurgical clipping of intracranial aneurysms.

BACKGROUND: High-speed drilling is associated with potential injury to neurovascular structures, particularly during intradural drilling of the anterior clinoid process. METHOD: During an anterior clinoidectomy, a cotton patty and middle cerebral artery branches became inadvertently wrapped around the bit, causing a tear on the inferior M2 trunk. Following temporary clipping of the internal carotid artery, the tear was identified. Temporary clips were placed proximally and distally. The tear was then repaired with interrupted microsutures. CONCLUSION: Extreme care should be exercised during clinoidectomy. Should small vascular injury occur, direct microsuturing can be a good alternative to sacrificing or implantation anastomosis repair.

A novel technique for superficial complicated stomas using the Dacron vascular prosthesis.

BACKGROUND AND PURPOSE: Despite the advances achieved in surgical techniques in recent years, an intestinal stoma is still needed in many patients undergoing colorectal surgery. However, the intestinal stoma may be associated with serious complications and the need for a second surgical procedure. In extreme cases, when it is not possible to access the abdominal cavity, the management of a complicated stoma is challenging. The purpose of this study was to describe the use of a Dacron vascular prosthesis (DVP) in patients with intestinal stoma complications. METHODS: In patients with a shallow, superficial stoma or mucocutaneous separation (MCS), we sutured the prosthesis in the intestinal loop (at the edge of an intestinal fistula) to create a device to direct the fecal content to the collection bag. RESULTS: We included 9 patients in this series (colorectal cancer, n = 5; Crohn's disease, n = 2; giant abdominal hernia and morbid obesity, n = 2). The results obtained were promising since they showed good evolution in patients with severe intestinal complications and an impossibility of surgical correction of the stoma. Five patients presented complete healing, and two patients presented partial healing. There were two deaths caused by sepsis, which were not related to the surgical procedure. With this technique, there was a reduction in the leakage of intestinal contents into the peritoneal cavity and an increase in the healing of the peristomal dermatitis in most of the patients. The DVP could possibly represent a surgical alternative in selected patients with complicated stomas when surgical correction may not be a suitable option. CONCLUSIONS: The authors recommend this technique for selected complex cases of stoma complications after unsuccessful attempts to adapt collecting equipment. The placement of the DVP allowed the peristomal skin to heal and improved the contamination of the peritoneal cavity.

Influence of Intraoperative Medial Collateral Ligament Bony Avulsion Injury on the Outcome of Primary Total Knee Arthroplasty.

BACKGROUND: The purpose of this study is (1) to find the clinical and radiological outcome of intraoperative bony avulsion of medial collateral ligament (MCL) treated with screw and washer construct and (2) to predict the preoperative factors which may contribute to the avulsion-type MCL injury during primary total knee arthroplasty (TKA). METHODS: Intraoperative MCL avulsion injury occurred in 46 (0.8%) of the 4916 consecutive primary TKA from January 2011 to December 2015. After exclusion, the 41 knees were matched 1:2 with controls without MCL injury and compared for the various clinical, radiological, and functional parameters. The clinical parameters analyzed were age, gender, body mass index, preoperative diagnosis like osteoarthritis or rheumatoid arthritis, range of motion, sagittal deformity, and vitamin D levels. The radiological parameters calculated were coronal deformity, proximal tibial varus angle, distal femur valgus angle, joint line congruence angle, posterior tibial slope, "cup and saucer" morphology, presence or absence of knee subluxation, tibia vara, and femoral bowing. The preoperative and postoperative Knee Society Score and Knee Society Functional Score were analyzed. Complications or revisions, if any, were noted during the follow-up. Multivariate logistic regression analysis was used to predict the preoperative risk factors for MCL avulsion injury. RESULTS: At a mean follow-up of 58.4 ± 19.3 months, there were no radiological or physical examination findings of instability. Compared to the preoperative disability, there was a statistically significant improvement in clinical scores (Knee Society Score and Knee Society Functional Score) in the final follow-up (P < .001) in both cases and the control group. The mean preoperative coronal deformity was 170.6 ± 6.96 in the study group and 167.7 ± 4.3 in the control group (P = .021). The mean preoperative tibial slope was 10.5 ± 4.9 in the study group and 7.91 ± 4.15 in the control group (P = .003). The preoperative knee subluxation was present in 48.8% knees (P < .001) and "cup and saucer" morphology in 68.3 knees (P < .001) in the study group. The adjusted odds of MCL avulsion injury were greater for severe varus deformity (odds ratio [OR] 1.462, 95% confidence interval [CI] 1.15-1.86), knee subluxation (OR 39.78, 95% CI 3.78-418.86), and "cup and saucer" morphology (OR 33.11, 95% CI 5.69-192.66). CONCLUSION: Intraoperative MCL bony avulsion injury can be managed successfully with screw and washer construct without the need for increased prosthetic constraint in primary TKA. The presence of severe varus deformity, knee subluxation, and "cup and saucer" morphology tend to have an increased chance of MCL avulsion injury.

Protective Approach for Anatomical Structures at Risk in Total Ankle Replacement.

Currently, total ankle replacement (TAR) is an alternative to arthrodesis in selected patients, with the anterior approach being the most widely used to carry it out. Regardless of the type of implant used, the pins for bone resection guides, chisels, and the saw for distal tibial resection can endanger the neurovascular and tendon structures that lie in intimate proximity to the posterior aspect of the ankle. Additionally, there is a documented complication rate of up to 15.3% in such surgery. We have implemented a protective posteromedial approach that complements the anterior approach to reduce this risk of intraoperative iatrogenic injury. Using this method we introduce a protective instrument that separates the posterior anatomical structures from the posterior cortex of the tibia. This article describes the surgical technique used to carry out TAR through an anterior approach in a safer way, without increasing complications or the duration of real-time surgery.

A novel preoperative scoring system to predict technical difficulty in laparoscopic splenectomy for non-traumatic diseases.

BACKGROUND: Laparoscopic splenectomy (LS) has been proven to be a safe and advantageous procedure. To ensure that resections of appropriate difficulty are selected, an objective preoperative grading of difficulty is required. We aimed to develop a predictive difficulty grading of LS based on intraoperative complications. METHODS: A total of 272 non-traumatic patients who underwent LS were identified from a regional medical center. Patients were randomized into a training cohort (n = 222) and a validation cohort (n = 50). Data on demographics, medical and surgical history, operative and pathological characteristics, and postoperative outcome details were collected. Univariate and multivariate analyses of risk factors for intraoperative complications were performed to develop a difficulty scoring system. The Spearman correlation coefficient was used to evaluate the relationship between the difficulty grading score and intraoperative outcomes. Receiver operating characteristic (ROC) curve was used to evaluate the discriminatory power of this scoring system. RESULTS: Three preoperative factors (spleen weight, esophagogastric varices, and INR) had a significant effect on operative time, bleeding, and conversion to open surgery. We created a difficulty grading score with three levels of difficulty: low (≤ 4 points), medium (5-6 points), and high (≥ 7 points), based on the three preoperative parameters. The correlation was highly significant (P < 0.01) according to Spearman's correlation. The area under the ROC curve was 0.695 (95% CI 0.630-0.755). The external validation showed significant correlations with the present model, with an AUC of 0.725 (95% CI 0.580-0.842). The comparison between our difficulty score and the previous grading system in the 272-patient cohort presented a significant difference in the AUC (0.701, 95% CI 0.643-0.755 vs. 0.644, 95% CI 0.584-0.701, P = 0.0452). CONCLUSION: The present difficulty scoring system, based on preoperative factors, has good performance in predicting the risk of intraoperative complications of LS and could be helpful for enabling appropriate case selection with respect to the current experience of a surgeon.

Reverse wedge effect following intramedullary nailing of a basicervical trochanteric fracture variant combined with a mechanically compromised greater trochanter.

BACKGROUND: To introduce an unreported intraoperative complication in intramedullary nailing (IN) of an anatomically reduced trochanteric fracture variant characterized by a basicervical fracture line and coronally disrupted greater trochanter (GT). METHODS: A total of 414 trochanteric fractures (TF) treated with intramedullary nails from 2013 to 2017 were included in this study. After analysis of intraoperative fluoroscopy data, 33 cases, including 21 females and 12 males, with a mean age of 72.5 years (33 to 96 years) were identified for internal rotation of the cephalocervical fragment and inferior opening at the basicervical fracture line caused by nailing a satisfactorily reduced TF. The morphological features of this group of patients were analyzed on computed tomography (CT) scan. On radiograph, the magnitude of the displacement and final femoral neck-shaft angle (NSA) were measured. RESULTS: CT analysis demonstrated that the basicervical fracture line and the posterolateral fragment (PLF) detached from the GT were the two dominant features of this cohort. They were classified according to the number of main fragments: a 3-fragmentary subgroup containing three consistent fragments (cephalocervical fragment, PLF and distal femoral shaft) and a 4-fragmentary subgroup embracing one additional fragment (lesser trochanter). The four subtypes were as follows: the 3-fragmentary S indicating a small PLF (6 cases), the 3-fragmentary M presenting a moderate PLF (3 cases), the 3-fragmentary L standing for the PLF involving whole lesser trochanter (LT) (4 cases) and the 4-fragmentary GL incorporating separated PLF and LT fragments (20 cases). Geological analysis demonstrated that the majority of the basicervical fracture lines (81.8%) just crossed the center of the piriformis fossa, while the others marginally involved the medial wall of the GT. Postoperatively, the mean width of the inferior opening at the basicervical region was 9.2 ± 4.6 mm. The mean NSA was 135.2 ± 7.8 degrees. The comparison between the 3- and 4-fragmentary subgroups revealed no significant differences in magnitude of displacement and NSA. CONCLUSION: This unreported intraoperative complication predominantly occurred in the intramedullary nailed basicervical trochanteric fracture variant combined with a PLF from the GT. The magnitude of the secondary displacement was substantial and resulted in a relative valgus reduction. This secondary displacement was caused by an impingement of the reamer with the superolateral cortex of the cephalocervical fragment and should be addressed during the operation. LEVEL OF EVIDENCE: Therapy IV.

A Combination of the Mayo Adhesive Probability Score and the RENAL Score to Predict Intraoperative Complications in Small Renal Masses.

INTRODUCTION: To evaluate the potential predictive value of the Mayo Adhesive Probability (MAP) score combined with the RENAL score for intraoperative outcomes in retroperitoneal laparoscopic nephron-sparing surgery (NSS) in an Eastern Asian population. METHODS: An initial of 388 patients undergoing retroperitoneal laparoscopic NSS were identified. MAP and RENAL scores were calculated according to CT and a logistic regression model was adopted as a combination of the RENAL score and the MAP score. RESULTS: A total of 293 patients were included. The overall intraoperative complication rate was 7.5% (21 cases). The MAP score was found to correlate with operation time (OT; r = 0.169), estimated blood loss (EBL; r = 0.318), and intraoperative complications (r = 0.242). The RENAL score was correlated with warm is-chemia time (r = 0.503), OT (r = 0.334), intraoperative complications (r = 0.178), and EBL (r = 0.218). The MAP score and the RENAL score were reliable predictors of overall intraoperative complications, with areas under the curve (AUC) of 0.728 and 0.759, respectively. After combination of these 2 scores, the AUC of overall intra-operative complications was improved with statistical significance (AUC = 0.847, combination vs. RENAL score: p = 0.044 < 0.05; combination vs. MAP score: p = 0.005 < 0.05). CONCLUSION: The MAP score is an important predictor of EBL, OT, and intraoperative complications in retroperitoneal laparoscopic NSS and its combination with the RENAL score showed a superior predictive value compared to a single score in overall intraoperative complications. The MAP score might be considered in preoperative radiologic aspects as regularly as the RENAL score.

Performance of femtosecond laser-assisted cataract surgery in Chinese patients with cataract: a prospective, multicenter, registry study.

BACKGROUND: This study aimed to investigate the completion rate, visual performance, and adverse outcomes of femtosecond laser-assisted cataract surgery (FLACS) in Chinese patients. METHODS: This is a prospective, single-arm, multicenter registry study of 19 cataract surgery clinics in China. Chinese patients with cataract who underwent FLACS using the Alcon LenSx® laser system in single eye (n = 1140) or both eyes (n = 201) were enrolled and data were collected between March 2015 and August 2016. Clinical characteristics were recorded before surgery, and on postoperative days 1, 7, and 30. For surgery on both eyes, the second eye was included in the analysis only if it was operated within 30 days after the first eye surgery. The primary outcome was the completion rate of circular anterior capsulotomy. Secondary outcomes for lens fragmentation, corneal incision, and intraocular lens (IOL) implantation included best corrected distance visual acuity (BCDVA) and completion rates. Adverse events (AEs) were recorded. RESULTS: The completion rates of circular anterior capsulotomy, lens fragmentation, corneal incision, and IOL implantation were 98.6% (95% CI: 97.8-99.1%), 99.5% (95% CI: 99.1-99.8%), 97.6% (95% CI: 96.7-98.3%), and 100% (95% CI: 99.8-100%), respectively. BCDVA preoperatively and at postoperative day 30 were 1.134 ± 0.831 logMAR and 0.158 ± 0.291 logMAR, respectively. The proportion of eyes with BCDVA of 20/20 or better was 1.6% at baseline and 41.3% at postoperative day 30. AE incidence was 0.32%, with posterior capsule rupture present in 0.19% of eyes. CONCLUSION: FLACS using the LenSx® laser system can achieve satisfactory results in a real-world setting.

The external validation of a difficulty scoring system for predicting the risk of intraoperative complications during laparoscopic liver resection.

BACKGROUND: This study aimed to externally validate and upgrade the recent difficulty scoring system (DSS) proposed by Halls et al. to predict intraoperative complications (IOC) during laparoscopic liver resection (LLR). METHODS: The DSS was validated in a cohort of 128 consecutive patients undergoing pure LLRs between 2008 and 2019 at a single tertiary referral center. The validated DSS includes four difficulty levels based on five risk factors (neoadjuvant chemotherapy, previous open liver resection, lesion type, lesion size and classification of resection). As established by the validated DSS, IOC was defined as excessive blood loss (> 775 mL), conversion to an open approach and unintentional damage to surrounding structures. Additionally, intra- and postoperative outcomes were compared according to the difficulty levels with usual statistic methods. The same five risk factors were used for validation done by linear and advanced nonlinear (artificial neural network) models. The study was supported by mathematical computations to obtain a mean risk curve predicting the probability of IOC for every difficulty score. RESULTS: The difficulty level of LLR was rated as low, moderate, high and extremely high in 36 (28.1%), 63 (49.2%), 27 (21.1%) and 2 (1.6%) patients, respectively. IOC was present in 23 (17.9%) patients. Blood loss of >775 mL occurred in 8 (6.2%) patients. Conversion to open approach was required in 18 (14.0%) patients. No patients suffered from unintentional damage to surrounding structures. Rates of IOC (0, 9.5, 55.5 and 100%) increased gradually with statistically significant value among difficulty levels (P < 0.001). The relations between the difficulty level, need for transfusion, operative time, hepatic pedicle clamping, and major postoperative morbidity were statistically significant (P < 0.05). Linear and nonlinear validation models showed a strong correlation (correlation coefficients 0.914 and 0.948, respectively) with the validated DSS. The Weibull cumulative distribution function was used for predicting the mean risk probability curve of IOC. CONCLUSION: This external validation proved this DSS based on patient's, tumor and surgical factors enables us to estimate the risk of intra- and postoperative complications. A surgeon should be aware of an increased risk of complications before starting with more complex procedures.

Maternal obesity and major intraoperative complications during cesarean delivery.

BACKGROUND: Multiple studies have demonstrated an association between maternal obesity and postoperative complications, but there is a dearth of information about the impact of obesity on intraoperative complications. OBJECTIVE: To estimate the association between maternal obesity at delivery and major intraoperative complications during cesarean delivery (CD). METHODS: This is a secondary analysis of the deidentified Maternal-Fetal Medicine Unit Cesarean Registry of women with singleton pregnancies. Maternal body mass index (BMI) at delivery was categorized as BMI 18.5 to 29.9 kg/m2, BMI 30 to 39.9 kg/m2, BMI 40 to 49.9 kg/m2, and BMI ≥ 50 kg/m2. The primary outcome, any intraoperative complication, was defined as having at least 1 major intraoperative complication, including perioperative blood transfusion, intraoperative injury (bowel, bladder, ureteral injury; broad ligament hematoma), atony requiring surgical intervention, repeat laparotomy, and hysterectomy. Log-binomial models were used to estimate risk ratios of intraoperative complication in 2 models: model 1 adjusting for maternal race, and preterm delivery <37 weeks; and model 2 adjusting for confounders in Model 1 as well as emergency CD, and type of skin incision. RESULTS: A total of 51,218 women underwent CD; 38% had BMI 18.5 to 29.9 kg/m2, 47% BMI 30 to 39.9 kg/m2, 12% BMI 40 to 49.9 kg/m2 and 3% BMI ≥ 50 kg/m2. Having at least 1 intraoperative complication was uncommon (3.4%): 3.8% for BMI 18.5 to 29.9 kg/m2, 3.2% BMI 30 to 39.9 kg/m2, 2.6% BMI 40 to 49.9 kg/m2 and 4.3% BMI ≥ 50 kg/m2 (P < .001). In the fully adjusted model 2, women with BMI 40 to 49.9 kg/m2 had a lower risk of any intraoperative complication (adjusted risk ratio [ARR], 0.76; 95% confidence interval [CI], 0.64 to 0.89) compared with women with BMI 18.5 to 29.9 kg/m2. Women with BMI 30 to 39.9 kg/m2 (ARR, 0.93; 95% CI, 0.84 to 1.03) had a similar risk of any intraoperative complication compared with nonobese women. Among super obese women, there was evidence of effect modification by emergency CD. Compared with nonobese women, neither super obese women undergoing nonemergency CD (ARR, 1.13; 95% CI, 0.84 to 1.52) nor those undergoing emergency CD (ARR, 0.59; 95% CI, 0.32 to 1.10) had an increased risk of intraoperative complication. CONCLUSION: In contrast to the risk for postcesarean complications, the risk of intraoperative complication does not appear to be increased in obese women, even among those with super obesity.

Right versus left laparoscopic colectomy for colon cancer: does side make any difference?

PURPOSE: To compare the intraoperative and postoperative outcomes between right laparoscopic colectomy (RLC) and left laparoscopic colectomy (LLC) for colon cancer. METHOD: Patients who underwent elective RLC or LLC for colon cancer between January 2004 and December 2014 were identified and elected for a retrospective analysis. Primary outcomes were technical difficulty (including operative time, intraoperative complications, and conversion rate) and postoperative outcome (including postoperative complications, length of hospital stay, reinterventions, readmissions, and mortality). RESULTS: A total of 547 patients (mean age: 68.5 years old; 48.4% males) were analyzed. The RLC group had a higher mean age (71 vs 65; p < 0.001), ASA 3/4 grade (36 vs 26%; p = 0.02), and comorbidity rate (61 vs 48%, p = 0.003). Regarding technical difficulty, no difference was found between the groups in intraoperative complications (4.1 vs 5.9%; p = 0.34) or conversion rate (6.2 vs 3.9%, p = 0.24). Mean operative time was significantly shorter for RLC (162 vs 185 min, p < 0.001). Regarding postoperative outcome, the RLC group had a higher overall morbidity (20.5 vs 13.3%, p = 0.03), ileus (10.6 vs 2.4%, p < 0.001), and a longer hospital stay (4.7 vs 3.9 days, p = 0.003), with no differences regarding reoperations, readmissions, or mortality. The multivariate analysis showed that RLC were independently associated with a longer operative time and postoperative ileus. CONCLUSIONS: RLC for colon cancer was independently associated with a shorter operative time, an increased risk of ileus, and a longer hospital stay than left laparoscopic colectomy in high-volume centers.

Incidence of adhesions and maternal and neonatal morbidity after repeat cesarean section.

PURPOSE OF INVESTIGATION: We investigated the effect of repeat cesarean sections (CSs) and intra-abdominal adhesions on neonatal and maternal morbidity. MATERIALS AND METHODS: We analyzed intra-abdominal adhesions of 672 patients. RESULTS: Among the patients, 173, 206, 151, and 142 underwent CS for the first, second, third, and fourth time or more, respectively. There were adhesions in 393 (58.5 %) patients. Among first CSs, there were no adhesions, the rate of maternal morbidity [Morales et al. (Am J Obstet Gynecol 196(5):461, 2007)] was 26 %, and the rate of neonatal morbidity (NM) was 35 %. Among women who have history of two CSs, the adhesion rate was 66.3 %, the adhesion score was 2.05, MM was 14 %, and NM was 21 %. Among third CSs, these values were 82.1, 2.82, 23, and 14 %, respectively. Among women who have history of four or more CSs, these values were 92.2, 4.72, 31.7, and 18 %, respectively. Adhesion sites and dense fibrous adhesions increased parallel to the number of subsequent CSs. Increased adhesion score was associated with 1.175-fold higher odds of NM and 1.29-fold higher odds of MM. The rate of NM was eightfold higher in emergency-delivered newborns (emergency: 39.4, 40 %; elective: 4.9 %). MM was 20 and 26 % for elective and emergency CSs, respectively. CONCLUSIONS: Emergency operations and adhesions increased complications.

Minor Anesthesia-Related Events During Radiofrequency Ablation for Barrett's Esophagus Are Associated with an Increased Number of Treatment Sessions.

BACKGROUND: There is limited data regarding the prevalence and clinical impact of sedation-related adverse events (SRAEs) during radiofrequency ablation (RFA) for dysplastic Barrett's esophagus (BE). AIM: Our primary aim was to measure SRAE during RFA. Secondary aims were to identify risk factors for adverse events, and to determine whether SRAEs impacted the number of RFA treatments to achieve complete eradication of dysplasia (CE-D). METHODS: We conducted a retrospective analysis of 120 consecutive patients undergoing initial RFA for dysplastic BE between 2008 and 2014. The main outcome measures were SRAEs and the number of RFA sessions required to achieve CE-D. RESULTS: Of 120 initial RFA procedures, 83 % were performed with MAC and 17 % with GET. SRAEs occurred in 32 %, including 25 % of MAC patients (25/100) and 65 % (12/20) GET patients. The most frequent SRAE was hypotension (23 %, n = 27/120), followed by hypoxia (n = 9/120), arrhythmia (n = 4/120), and one unplanned intubation. There were no premature procedure terminations. After adjusting for length of BE mucosa and ASA score, the occurrence of a SRAE was associated with requiring more (>4) RFA sessions to achieve CE-D, OR 3.45 (95 % CI 1.49-7.99). Mean RFA sessions required to achieve CE-D was 5 ± 1 in patients with SRAE, compared to 3 ± 0.7 in patients without SRAE during the first treatment session (p < 0.001). CONCLUSIONS: SRAE during RFA for dysplastic BE occurs at a rate typical of other advanced endoscopic procedures. Patients who experience minor events related to anesthesia during the first RFA are likely to require more RFA treatment sessions to achieve CE-D.

[Risk of rectal perforation during intention to treat laser photovaporization of prostate with transrectal ultrasound guidance: a report of 4 cases]. / Risque de perforation rectale liée à l'utilisation de l'échographie endorectale au cours de la photovaporisation prostatique au laser en intention de traiter : à propos de 4 cas.

CONTEXT: Transrectal ultrasound guidance (TUG) during prostate endoscopic surgery can optimize the procedure by reducing the risk of capsular perforation and ascertain the treatment completeness. TUG is proposed during photoselective vaporisation of prostate (PVP). OBJECTIVE: To report four cases of rectal perforations during PVP with TUG and assess their occurrence. MATERIALS AND METHODS: This is a retrospective study including prostate endoscopic surgeries with TUG, performed in two centers between November 2011 and May 2013. Rectal perforations were identified. Surgical data, treatment modalities and postoperative outcomes of rectal perforations were analysed. RESULTS: Four rectal perforations were identified among 450 surgical procedures. Median age and prostate volume were 80 years old [62-91] and 40mL [13-150], respectively. Two perforations occurred during PVP with Greenlight(®) XPS 180W. Two perforations occurred during transurethral resection of prostate or cervicoprostatic incision. Patients were treated by systematic urinary drainage associated with colostomy or direct suture. Two patients died from this complication and two patients have satisfying functional outcomes at one year. CONCLUSION: TUG during prostate endoscopic surgery could lead to rectal perforation by protusion of the prostate and therefore should be used cautiously. LEVEL OF EVIDENCE: 5.