Time-to-surgery paradigms: wait time and surgical outcomes in critically Ill patients who underwent emergency surgery for gastrointestinal perforation.

BACKGROUND: Waiting time for emergency abdominal surgery have been known to be linked to mortality. However, there is no clear consensus on the appropriated timing of surgery for gastrointestinal perforation. We investigated association between wait time and surgical outcomes in emergency abdominal surgery. METHODS: This single-center retrospective cohort study evaluated adult patients who underwent emergency surgery for gastrointestinal perforations between January 2003 and September 2021. Risk-adjusted restricted cubic splines modeled the probability of each mortality according to wait time. The inflection point when mortality began to increase was used to define early and late surgery. Outcomes among propensity-score matched early and late surgical patients were compared using percent absolute risk differences (RDs, with 95% CIs). RESULTS: Mortality rates began to rise after 16 h of waiting. However, early and late surgery groups showed no significant differences in 30-day mortality (11.4% vs. 5.7%), ICU stay duration (4.3 ± 7.5 vs. 4.3 ± 5.2 days), or total hospital stay (17.4 ± 17.0 vs. 24.7 ± 23.4 days). Notably, patients waiting over 16 h had a significantly higher ICU readmission rate (8.6% vs. 31.4%). The APACHE II score was a significant predictor of 30-day mortality. CONCLUSIONS: Although we were unable to reveal significant differences in mortality in the subgroup analysis, we were able to find an inflection point of 16 h through the RCS curve technique. TRIAL REGISTRATION: Formal consent was waived due to the retrospective nature of the study, and ethical approval was obtained from the institutional research committee of our institution (B-2110-714-107) on 6 October 2021.

Postoperative major bleeding risk in patients using oral antiplatelets and/or anticoagulants after laparoscopic gastric cancer surgery.

Purpose: The use of antiplatelet and/or anticoagulant therapies has become common. In rare cases, these therapies may increase the risk of dangerous postoperative bleeding. We investigated the association of antiplatelets and/or anticoagulants with postoperative major bleeding risk in laparoscopic gastric cancer surgery. Methods: We retrospectively enrolled 3,663 gastric cancer patients (antiplatelet/anticoagulant group, 518; control group, 3,145) who had undergone laparoscopic surgery between January 2012 and December 2017. To minimize selection bias, 508 patients in each group were matched using propensity score matching (PSM) method. The primary outcome was postoperative major bleeding. Secondary outcomes were intraoperative, postoperative transfusion and early complications. Results: After PSM, postoperative major bleeding occurred in 10 (2.0%) and 3 cases (0.6%) in the antiplatelets/anticoagulants and control groups, respectively (P = 0.090). Intraoperative and postoperative transfusions were not significantly different between 2 groups (2.4% vs. 1.4%, P = 0.355 and 5.5% vs. 4.3%, P = 0.469). Early complications developed in 58 (11.4%) and 43 patients (8.5%) in the antiplatelets/anticoagulants and control groups, respectively (P = 0.142). The mean amounts of intraoperative and postoperative transfusions were not significantly different between the groups (366.67 ± 238.68 mL vs. 371.43 ± 138.01 mL, P = 0.962; 728.57 ± 642.25 mL vs. 508.09 ± 468.95 mL, P = 0.185). In multivariable analysis, male (P = 0.008) and advanced stage (III, IV) (P = 0.024) were independent significant risk factors for postoperative major bleeding. Conclusion: Preoperative antiplatelets and/or anticoagulants administration did not significantly increase the risk of postoperative major bleeding after laparoscopic gastric cancer surgery.

Preoperative Statin Use and 90-Day Mortality After Noncardiac Surgery: A Hospital Registry Study.

OBJECTIVE: The aim of this study was to investigate the association between preadmission statin use and 90-day mortality after planned elective noncardiac surgery in adult patients. SUMMARY BACKGROUND DATA: Statin therapy is known to have pleiotropic effects, which improve the outcomes of various diseases. However, the effect of perioperative statin therapy on postoperative mortality remains controversial. METHODS: This retrospective cohort study analyzed the medical records of adult patients who were admitted to a single tertiary academic hospital for elective noncardiac surgery between January 2012 and December 2018. The primary endpoint was 90-day mortality, which was defined as any mortality within 90 days after surgery. The secondary endpoint was overall survival. RESULTS: After propensity score matching, a total of 33,514 patients (16,757 patients in each group) were included in the analysis. The logistic regression analysis of the propensity score-matched cohort indicated that the odds ratio (OR) of 90-day mortality in the statin group was 26% lower than that of the nonstatin group [OR: 0.74; 95% confidence interval (CI): 0.59 to 0.92; P = 0.009]. The sensitivity analysis indicated that the high-dose intensity statin group had a 61% lower 90-day mortality rate than the nonstatin group (OR: 0.39; 95% CI: 0.18-0.84; P = 0.016). The overall survival time was significantly longer in the statin group than in the nonstatin group after propensity score matching (P < 0.001 by log-rank test). CONCLUSIONS: Preoperative statin use was associated with lower 90-day mortality and longer overall survival for adult patients who underwent elective noncardiac surgery. This association was more evident for high-intensity statin users.

Lactate level and unplanned readmission to the surgical intensive care unit: a retrospective cohort study.

BACKGROUND: This study aimed to investigate the association between lactate levels during intensive care unit (ICU) stay and unplanned ICU readmission rates within 48 and 120 h in surgical patients. METHODS: This single-center retrospective cohort study evaluated adult patients who were discharged from the ICU between January 2012 and December 2018. The association between lactate levels (initial lactate at ICU admission, peak level during ICU stay, and last level before ICU discharge) and unplanned ICU readmission was investigated using uni- and multivariable logistic regression analyses. RESULTS: The cohort included 3,707 patients. The unplanned ICU readmission rate within 48 and 120 h was 2.1% (n=78 patients) and 4.5% (n=166 patients), respectively. In the multivariable model, 1 mg dL-1 increase in the peak lactate level during ICU stay was associated with 1.1-fold increase in unplanned ICU readmission within 48 h (odds ratio: 1.10; 95% confidence interval: 1.02 to 1.2; P=0.016). In contrast, both initial and last lactate levels during ICU stay were not significantly associated. A similar trend was observed for unplanned ICU readmission within 120 h. On receiver operating characteristic analysis, the areas under the curve (AUC) of the initial, last, and peak lactate levels were 0.61, 0.53, and 0.63, respectively. CONCLUSIONS: The peak lactate level during ICU admission is independently associated with unplanned ICU readmission within both, 48 and 120 h among surgical ICU patients. However, the lactate level has relatively poor predictive capability for unplanned ICU readmissions, and a new model is needed to predict unplanned ICU readmissions among surgical patients.

Antiplatelet Therapy in Patients Without a Coronary Stent and Mortality After Noncardiac Surgery.

BACKGROUND: This study aimed to investigate the association between perioperative antiplatelet (anti-PLT) therapy and 90-d mortality after elective noncardiac surgery. MATERIALS AND METHODS: This retrospective cohort study analyzed the medical records of adult patients aged 18 y and older who were admitted to a single tertiary academic hospital between January 1, 2012 and December 31, 2018 for planned elective noncardiac surgery. All patients with a history of coronary artery stent insertion before the day of surgery were excluded from the analysis. Propensity score matching and conditional logistic regression analysis were used for statistical analysis. RESULTS: After propensity score matching, a total of 24,710 patients (12,355 in each group) were included in the final analysis. Ninety-day mortalities in the anti-PLT and non-anti-PLT groups were 0.9% (107/12,355) and 1.2% (143/12,355), respectively. The anti-PLT group showed significantly lower odds for 90-d mortality (by 27%) than the non-anti-PLT group (odds ratio, 0.73; 95% confidence interval, 0.55-0.95; P = 0.017). In the sensitivity analysis of the anti-PLT group classified according to the drug type and combination, the aspirin and clopidogrel subgroups significantly showed 23% and 41% lower odds for 90-d mortality compared with the non-anti-PLT group, respectively. The dual anti-PLT groups showed no significant difference in 90-d mortality (P = 0.658). CONCLUSIONS: Perioperative anti-PLT therapy (aspirin, clopidogrel, or dual anti-PLT therapy) was associated with lower 90-d mortality after elective noncardiac surgery in adult surgical patients without a coronary stent. This association was most evident in patients on a monotherapy of aspirin or clopidogrel.

Association Between Use of Preoperative Antihypertensive Medication and 90-Day Mortality After Noncardiac Surgery: A Retrospective Cohort Study.

BACKGROUND: This study aimed to determine whether use of preoperative antihypertensive medication is associated with postoperative 90-day mortality in the hypertensive adult population that underwent elective noncardiac surgery. METHODS: In this retrospective cohort study, medical records of preoperative hypertensive patients who underwent noncardiac surgery at a single tertiary academic hospital from 2012 to 2018 were reviewed. Among the hypertensive patients, those prescribed to take antihypertensive medication continuously for more than 1 month before admission were defined as the HTN MED group; others were defined as the non-HTN MED group. Multiple imputation, propensity score (PS) matching, and logistic regression analysis were used for statistical analysis. RESULTS: Overall, 35,589 preoperative hypertensive adult patients (HTN MED group: 26,154 patients, non-HTN MED group: 9,435 patients) were included in the analysis. After PS matching, each group comprised 6,205 patients; thus, 12,410 patients were included in the final analysis. The odds for 90-day mortality of the HTN MED group in the PS-matched cohort were 41% lower (odds ratio: 0.59, 95% confidence interval: 0.41-0.85; P = 0.005) than those of the non-HTN MED group. Comparable results were obtained in the multivariable logistic regression analysis of the entire cohort (odds ratio: 0.54, 95% confidence interval: 0.41-0.72; P < 0.001). CONCLUSIONS: This study showed that the use of preoperative antihypertensive medication was associated with lower 90-day mortality among hypertensive patients who underwent noncardiac surgery. Therefore, preoperative screening and treatment with appropriate antihypertensive medication are important for hypertensive patients.

Preadmission Exposure to Air Pollution and 90-Day Mortality in Critically ill Patients: A Retrospective Study.

OBJECTIVE: We investigated the association between preadmission exposure to air pollutants and 90-day mortality in critically ill patients. METHODS: This retrospective cohort study analyzed the medical records of adult patients (more than or equal to 18 years) admitted to the intensive care unit of a tertiary academic hospital from 2015 to 2016. RESULTS: Four air pollutants were not significantly associated with 90-day mortality and pulmonary disease-related 90-day mortality (P > 0.05). In patients with preadmission chronic obstructive lung disease (COPD), a 1 ppm increase in ozone (O3) and carbon monoxide (CO) was associated with a 1.04-fold and 5.99-fold increase in pulmonary disease-related 90-day mortality, respectively. CONCLUSIONS: Preadmission exposure to air pollution was not associated with 90-day mortality in critically ill patients. However, a higher concentration of CO and O3 was associated with an increase in pulmonary disease-related 90-day mortality in patients with preadmission COPD.

Validation of difficulty scoring system for laparoscopic liver resection in patients who underwent laparoscopic left lateral sectionectomy.

BACKGROUND: A difficulty scoring system (DSS) based on the extent of liver resection, tumor location, liver function, tumor size, and tumor proximity to major vessels was recently developed to assess the difficulty of various laparoscopic liver resection procedures. We validated DSS in patients who underwent laparoscopic left lateral sectionectomy (LLS). METHODS: We reviewed the clinical data of 124 patients who underwent laparoscopic LLS between July 2003 and November 2015 and validated the DSS in 90 patients who underwent laparoscopic LLS for tumor according to their surgical outcomes. We also developed and evaluated the modified DSS in 34 patients who underwent LLS for intrahepatic duct (IHD) stones. RESULTS: The DSS score ranged from 3 to 6 in laparoscopic LLS for tumors. The median blood loss (P = 0.002) was significantly different among patients divided into subgroups by DSS score. We made modified DSS for IHD stones using factors influencing longer operation time, including stone location (P = 0.002), atrophy of liver parenchyma (P = 0.012), ductal stricture <1 cm from the bifurcation (P = 0.047), and combined choledochoscopic examination for remnant IHD (P < 0.001). The modified DSS score for IHD stones ranged from 3 to 7. Blood loss (P = 0.02) and operation time (P < 0.001) were significantly different among subgroups of patients divided by their difficulty scores. The median hospital stay (P = 0.004) and operation time (P = 0.039) were significantly longer and the complication rate (P = 0.025) and complication grade (P = 0.021) were significantly greater in patients with IHD stones than in patients with tumors. CONCLUSIONS: The surgical difficulty varies among patients undergoing the same laparoscopic LLS procedure. The modified DSS developed here can also be applied to patients with IHD stones.

Laparoscopic left lateral sectionectomy in patients with histologically confirmed cirrhosis.

BACKGROUND: Laparoscopic left lateral sectionectomy (LLS) is now considered as a standard practice. However, the safety of laparoscopic LLS in cirrhotic patients is unclear. This is the retrospective study of comparing the outcomes of laparoscopic LLS between cirrhotic and non-cirrhotic patients. METHODS: We reviewed the clinical data for 107 patients who underwent laparoscopic LLS between July 2003 and July 2013. The patients were divided into cirrhotic group (n = 31) and non-cirrhotic group (n = 76) with histologically confirmed F4 or F3 fibrosis. RESULTS: There were no differences between the two groups in terms of the operation time (P = 0.807), blood loss (P = 0.115), transfusion rate (P = 0.716), postoperative complication rate (P = 0.601) and duration of hospital stay (P = 0.261). Open conversion occurred in one non-cirrhotic patient (P = 1.000). The postoperative peak total bilirubin level was higher in cirrhotic patients than in non-cirrhotic patients (P < 0.001). Among patients with hepatocellular carcinoma, the disease-free survival (P = 0.249) and overall survival (P = 0.768) rates were not significantly different between cirrhotic patients (n = 28) and non-cirrhotic patients (n = 12). There were no significant differences in the complication rate (P = 0.085), operation time (P = 0.159), blood loss (P = 0.306), transfusion rate (P = 1.00), and hospital day (P = 0.408) between laparoscopic LLS and cases of open LLS performed in the same study period (n = 10). CONCLUSIONS: Laparoscopic LLS is safe and reproducible, even in cirrhotic patients.

Spontaneous Renal Artery Dissection Complicated by Renal Infarction: Three Case Reports.

Spontaneous renal artery dissection (SRAD) is a rare disease entity. The diagnosis is usually delayed because clinical presentation is non-specific. We report three cases of symptomatic SRAD complicated by renal infarction which occurred in previously healthy middle-aged male patients. They visited the hospital due to acute abdominal or flank pain. They had no specific underlying disease or trauma history. The laboratory tests and physical examination were normal. They were not suspected of having SRAD initially, but computed tomography (CT) revealed dissection of the renal artery with distal hypoperfusion leading to renal infarction. They were treated conservatively with anticoagulation and/or antiplatelets for 6 months. They had a 6-month regular follow-up with CT, where resolution was confirmed in one patient and all patients remained asymptomatic. These cases emphasize the importance of clinical suspicion of SRAD in previously healthy patients who complain of abdominal pain without specific findings on initial investigation.