Perioperative outcome, long-term mortality and time trends in elderly patients undergoing low-, intermediate- or major non-cardiac surgery.

BACKGROUND: Decision-making whether older patients benefit from surgery can be a difficult task. This report investigates characteristics and outcomes of a large cohort of inpatients, aged 80 years and over, undergoing non-cardiac surgery. METHODS: This observational study was performed at a tertiary university medical centre in the Netherlands. Patients of 80 years or older undergoing elective or urgent surgery from January 2004 to June 2017 were included. Outcomes were length of stay, discharge destination, 30-day and long-term mortality. Patients were divided into low-, intermediate and high-risk surgery subgroups. Univariable and multivariable logistic regression were used to evaluate the association of risk factors and outcomes. Secondary outcomes were time trends, assessed with Mantel-Haenszel chi-square test. RESULTS: Data of 8251 patients, undergoing 19,027 surgical interventions were collected from the patients' medical record. 7032 primary procedures were suitable for analyses. Median LOS was 3 days in the low-risk group, compared to six in the intermediate- and ten in the high-risk group. Median LOS of the total cohort decreased from 5.8 days (IQR 1.9-14.5) in 2004-2007 to 4.6 days (IQR 1.9-9.0) in 2016-2017. Three quarters of patients were discharged to their home. Postoperative 30-day mortality in the low-risk group was 2.3%. In the overall population 30-day mortality was high and constant during the study period (6.7%, ranging from 4.2 to 8.4%). CONCLUSION: Patients should not be withheld surgery solely based on their age. However, even for low-risk surgery, the mortality rate of more than 2% is substantial. Deciding whether older patients benefit from surgery should be based on the understanding of individual risks, patients' wishes and a patient-centred plan.

Liposomal bupivacaine for ultrasound-guided rectus sheath blocks after midline laparotomy.

Optimal pain management after open abdominal surgery is essential but can be difficult to achieve. The effects of inadequate analgesia go beyond the first few postoperative days; severe acute postoperative pain may contribute to the development of chronic postsurgical pain. Thoracic epidural analgesia is a traditional approach to the management of acute pain after open abdominal surgery but has multiple possible contraindications and can be technically challenging. In our hospital, we typically offer ultrasound-guided rectus sheath blocks with catheters when epidural analgesia is not feasible. However, the recent registration of long-acting liposomal bupivacaine in the Netherlands as well as logistical and equipment-related issues have led us to consider liposomal bupivacaine as an alternative to the use of catheters. Here, we present a short case series to describe our first clinical experiences with the use of liposomal bupivacaine in ultrasound-guided rectus sheath blocks after midline laparotomy for three patients in whom epidural insertion was contraindicated.

In-depth assessment of health-related quality of life after in-hospital cardiac arrest.

INTRODUCTION: Evidence on physical and psychological well-being of in-hospital cardiac arrest (IHCA) survivors is scarce. The aim of this study is to describe long-term health-related quality of life (HRQoL), functional independence and psychological distress 3 and 12 months post-IHCA. METHODS: A multicenter prospective cohort study in 25 hospitals between January 2017 - May 2018. Adult IHCA survivors were included. HRQoL (EQ-5D-5L, SF-12), psychological distress (HADS, CSI) and functional independence (mRS) were assessed at 3 and 12 months post-IHCA. RESULTS: At 3-month follow-up 136 of 212 survivors responded to the questionnaire and at 12 months 110 of 198 responded. The median (IQR) EQ-utility Index score was 0.77 (0.65-0.87) at 3 months and 0.81 (0.70-0.91) at 12 months. At 3 months, patients reported a median SF-12 (IQR) physical component scale (PCS) of 38.9 (32.8-46.5) and mental component scale (MCS) of 43.5 (34.0-39.7) and at 12 months a PCS of 43.1 (34.6-52.3) and MCS 46.9 (38.5-54.5). DISCUSSION: Using various tools most IHCA survivors report an acceptable HRQoL and a substantial part experiences lower HRQoL compared to population norms. Our data suggest that younger (male) patients and those with poor functional status prior to admission are at highest risk of impaired HRQoL.

Between-centre differences in care for in-hospital cardiac arrest: a prospective cohort study.

BACKGROUND: Survival after in-hospital cardiac arrest is poor, but current literature shows substantial heterogeneity in reported survival rates. This study aims to evaluate care for patients suffering in-hospital cardiac arrest (IHCA) in the Netherlands by assessing between-hospital heterogeneity in outcomes and to explain this heterogeneity stemming from differences in case-mix or differences in quality of care. METHODS: A prospective multicentre study was conducted comprising 14 centres. All IHCA patients were included. The adjusted variation in structure and process indicators of quality of care and outcomes (in-hospital mortality and cerebral performance category [CPC] scale) was assessed with mixed effects regression with centre as random intercept. Variation was quantified using the median odds ratio (MOR), representing the expected odds ratio for poor outcome between two randomly picked centres. RESULTS: After excluding centres with less than 10 inclusions (2 centres), 701 patients were included of whom, 218 (32%) survived to hospital discharge. The unadjusted and case-mix adjusted MOR for mortality was 1.19 and 1.05, respectively. The unadjusted and adjusted MOR for CPC score was 1.24 and 1.19, respectively. In hospitals where personnel received cardiopulmonary resuscitation (CPR) training twice per year, 183 (64.7%) versus 290 (71.4%) patients died or were in a vegetative state, and 59 (20.8%) versus 68 (16.7%) patients showed full recovery (p < 0.001). CONCLUSION: In the Netherlands, survival after IHCA is relatively high and between-centre differences in outcomes are small. The existing differences in survival are mainly attributable to differences in case-mix. Variation in neurological outcome is less attributable to case-mix.

Long-term survival and health-related quality of life after in-hospital cardiac arrest.

INTRODUCTION: In-hospital cardiac arrest (IHCA) is an adverse event associated with high mortality. Because of the impact of IHCA more data is needed on incidence, outcomes and associated factors that are present prior to cardiac arrest. The aim was to assess one-year survival, patient-centred outcomes after IHCA and their associated pre-arrest factors. METHODS: A multicentre prospective cohort study in 25 hospitals between January 1st 2017 and May 31st 2018. Patients ≥ 18 years receiving cardiopulmonary resuscitation (CPR) for IHCA were included. Data were collected using Utstein and COSCA-criteria, supplemented by pre-arrest Modified Rankin Scale (MRS, functional status) and morbidity through the Charlson Comorbidity Index (CCI). Main outcomes were survival, health-related quality of life (HRQoL, EuroQoL) and functional status (MRS) after one-year. RESULTS: A total of 713 patients were included, 64.5% was male, median age was 63 years (IQR 52-72) and 72.8% had a non-shockable rhythm, 394 (55.3%) achieved ROSC, 231 (32.4%) survived to hospital discharge and 198 (27.8%) survived one year after cardiac arrest. Higher pre-arrest MRS, age and CCI were associated with mortality. At one year, patients rated HRQoL 72/100 points on the EQ-VAS and 69.7% was functionally independent. CONCLUSION: One-year survival after IHCA in this study is 27.8%, which is relatively high compared to previous studies. Survival is associated with a patient's pre-arrest functional status and morbidity. HRQoL appears acceptable, however functional rehabilitation warrants attention. These findings provide a comprehensive insight in in-hospital cardiac arrest prognosis.

A cross-sectional investigation of communication in Do-Not-Resuscitate orders in Dutch hospitals.

BACKGROUND: The decision to attempt or refrain from resuscitation is preferably based on prognostic factors for outcome and subsequently communicated with patients. Both patients and physicians consider good communication important, however little is known about patient involvement in and understanding of cardiopulmonary resuscitation (CPR) directives. AIM: To determine the prevalence of Do Not Resuscitate (DNR)-orders, to describe recollection of CPR-directive conversations and factors associated with patient recollection and understanding. METHODS: This was a two-week nationwide multicentre cross-sectional observational study using a study-specific survey. The study population consisted of patients admitted to non-monitored wards in 13 hospitals. Data were collected from the electronic medical record (EMR) concerning CPR-directive, comorbidity and at-home medication. Patients reported their perception and expectations about CPR-counselling through a questionnaire. RESULTS: A total of 1136 patients completed the questionnaire. Patients' CPR-directives were documented in the EMR as follows: 63.7% full code, 27.5% DNR and in 8.8% no directive was documented. DNR was most often documented for patients >80 years (66.4%) and in patients using >10 medications (45.3%). Overall, 55.8% of patients recalled having had a conversation about their CPR-directive and 48.1% patients reported the same CPR-directive as the EMR. Most patients had a good experience with the CPR-directive conversation in general (66.1%), as well as its timing (84%) and location (94%) specifically. CONCLUSIONS: The average DNR-prevalence is 27.5%. Correct understanding of their CPR-directive is lowest in patients aged ≥80 years and multimorbid patients. CPR-directive counselling should focus more on patient involvement and their correct understanding.

The effect of intrathecal bupivacaine/morphine on quality of recovery in robot-assisted radical prostatectomy: a randomised controlled trial.

Robot-assisted radical prostatectomy causes discomfort in the immediate postoperative period. This randomised controlled trial investigated if intrathecal bupivacaine/morphine, in addition to general anaesthesia, could be beneficial for the postoperative quality of recovery. One hundred and fifty-five patients were randomly allocated to an intervention group that received intrathecal 12.5 mg bupivacaine/300 µg morphine (20% dose reduction in patients > 75 years) or a control group receiving a subcutaneous sham injection and an intravenous loading dose of 0.1 mg.kg-1 morphine. Both groups received standardised general anaesthesia and the same postoperative analgesic regimen. The primary outcome was a decrease in the Quality of Recovery-15 (QoR-15) questionnaire score on postoperative day 1. The intervention group (n = 76) had less reduction in QoR-15 on postoperative day 1; median (IQR [range]) 10% (1-8 [-60% to 50%]) vs. 13% (5-24 [-6% to 50%]), p = 0.019, and used less morphine during the admission; 2 mg (1-7 [0-41 mg]) vs. 15 mg (12-20 [8-61 mg]), p < 0.001. Furthermore, they perceived lower pain scores during exertion; numeric rating scale (NRS) 3 (1-6 [0-9]) vs. 5 (3-7 [0-9]), p = 0.001; less bladder spasms (NRS 1 (0-2 [0-10]) vs. 2 (0-5 [0-10]), p = 0.001 and less sedation; NRS 2 (0-3 [0-10]) vs. 3 (2-6 [0-10]), p = 0.005. Moreover, the intervention group used less rescue medication. Pruritus was more severe in the intervention group; NRS 4 (1-7 [0-10]) vs. 0 (0-1 [0-10]), p = 0.000. We conclude that despite a modest increase in the incidence of pruritus, multimodal pain management with intrathecal bupivacaine/morphine remains a viable option for robot-assisted radical prostatectomy.

Postoperative troponin release is associated with major adverse cardiovascular events in the first year after noncardiac surgery.

INTRODUCTION: Troponin elevations after intermediate-to-high risk noncardiac surgery are common and can predict mortality. However, the prognostic value for early and late major adverse cardiovascular events (MACE) is less well investigated. The authors evaluated the relationship between postoperative troponin release and MACE in the first year after noncardiac surgery. METHODS: This observational cohort registry comprised data of patients aged ≥60 years undergoing intermediate-to-high risk noncardiac surgery between July 2012 and 2015, at the Erasmus University Medical Center, Rotterdam, the Netherlands. High-sensitivity troponin T was measured on day 1 to 3 after surgery. Peak troponin values were divided into four categories: <14 ng·L-1, 14-49 ng·L-1, 50-149 ng·L-1 and ≥150 ng·L-1. The primary endpoint MACE was defined as the occurrence of myocardial infarction, angina, revascularization therapy or cerebrovascular accident in the first year after surgery. The incidence of MACE and all-cause mortality was calculated using Kaplan-Meier estimates. Cox regression was used to estimate risks for both endpoints. RESULTS: In total, 3085 patients were included for analyses and peak troponin elevation above 14 ng·L-1 was present in 1678 (54.4%) patients. The overall incidence for one-year MACE was 5.8% (3.4%, 6.1%, 10.4% and 40.6% per increasing troponin category) with adjusted HR (95% CI) 1.32 (0.85-2.06), 2.53 (1.42-4.53) and 10.24 (5.91-17.75) for the consecutive increasing categories. One-year mortality occurred in 14.6% and showed a similar stepwise increase with adjusted HR (95% CI) 1.25 (0.98-1.60), 2.39 (1.72-3.32) and 3.79 (2.60-5.54). CONCLUSION: Our dataset demonstrates a graded relationship between postoperative troponin release and occurrence of MACE in the first year after intermediate-to-high risk noncardiac surgery.

Prognostic value of postoperative high-sensitivity troponin T in patients with different stages of kidney disease undergoing noncardiac surgery.

BACKGROUND: Emerging evidence suggests that postoperative troponin release is a strong and independent predictor of short-term mortality. However, evaluating elevated troponins in patients with chronic kidney disease (CKD) is still controversial and is often disregarded. This study examines morbidity along with short- and long-term mortality risk associated with elevated high-sensitivity troponin T (hsTnT) in patients with different stages CKD undergoing noncardiac surgery. METHODS: This observational cohort comprised 3262 patients aged ≥60 yr who underwent noncardiac surgery. Postoperative hsTnT concentrations were divided into normal [<14 ng l-1 (reference)], low (14-49 ng l-1), moderate (50-149 ng l-1), and high (≥150 ng l-1) groups. A threshold of 50 ng l-1 was used to dichotomize hsTnT. The study endpoints were 30-day and long-term all-cause mortality, and postoperative myocardial infarction. RESULTS: Postoperative hsTnT was associated with a stepwise increase in 30-day and long-term mortality risk: low hsTnT adjusted hazard ratio (HR) 1.4 [95% confidence interval (CI): 1.1-1.7], moderate hsTnT adjusted HR 3.1 (95% CI: 2.3-4.3), high hsTnT adjusted HR 5.5 (95% CI: 3.6-8.4). Postoperative hsTnT ≥50 ng l-1 was associated with 30-day and long-term mortality risk for each stage of CKD. Elevated troponin concentrations in severe CKD (estimated glomerular filtration rate <30 mL min-1 1.73 m-2), however, did not predict short-term death. CONCLUSIONS: Elevated postoperative hsTnT is associated with a dose-dependent increase in 30-day and long-term mortality risk in each stage of CKD with an estimated glomerular filtration rate ≥30 ml min-1 1.73 m-2.

Association between postoperative mean arterial blood pressure and myocardial injury after noncardiac surgery.

BACKGROUND: Myocardial injury after noncardiac surgery is common, although the exact pathophysiology is unknown. It is plausible that hypotension after surgery is relevant for the development of myocardial injury. The authors evaluated whether low mean arterial pressures (MAPs) after surgery are related to an increased incidence in postoperative cardiac-troponin elevation. METHODS: A prospective cohort of 2211 patients aged ≥60 yr, undergoing major or moderate noncardiac surgery in The Netherlands, was retrospectively analysed for the occurrence of postoperative cardiac-troponin elevation [high-sensitive troponin T (hsTnT) >14 ng L-1]. Blood pressures after surgery were recorded and divided into quartiles based on the lowest MAP prior to peak troponin recording. The association between MAP and extent of postoperative cardiac-troponin elevation was analysed. RESULTS: The patients were divided into quartiles based on their lowest MAP in the period preceding the peak hsTnT, ranging from a median of 62 in the lowest quartile to 94 in the highest quartile. Postoperative hsTnT elevation was present in 53.2% of the population. An association between MAP quartile and postoperative peak hsTnT was predominantly observed in the lowest quartile (P<0.001): median hsTnT 17.6 (10.3-37.3), 14.9 (9.4-24.6), 13.8 (9.1-22.5), and 14.0 (9.2-22.4). The multivariable logistic-regression analysis showed an increased risk for postoperative cardiac-troponin elevation with decreasing MAP thresholds. CONCLUSIONS: Lower postoperative blood pressure is associated with an increased incidence of postoperative cardiac hsTnT elevation, irrespective of pre- and intraoperative variables.

Awake craniotomy versus craniotomy under general anesthesia for the surgical treatment of insular glioma: choices and outcomes.

OBJECTIVE: To investigate differences in outcomes in patients who underwent surgery for insular glioma using an awake craniotomy (AC) vs. a craniotomy under general anesthesia (GA). METHODS: Data from patients treated at our hospital between 2005 and 2015 were analyzed retrospectively. The preoperative, intraoperative, postoperative, and longer term follow-up characteristics and outcomes of patients who underwent surgery for primary insular glioma using either an AC or GA were compared. RESULTS: Of the 52 identified patients, 24 had surgery using an AC and 28 had surgery under GA. The extent of resection was similar for the two anesthesia techniques: the median extent of resection was 61.4% (IQR: 37.8-74.3%) in the WHO grade <4 AC group vs. 50.5% (IQR: 35.0-71.2%) in the grade <4 GA group and 73.4% (IQR: 54.8-87.2%) in the grade 4 AC group vs. 88.6% (IQR: 61.2-93.0%) in the grade 4 GA group. Consistent with literature, there were more early neurological deficits after an AC, while the GA group showed more new late neurological deficits; however, these trends were not significant. Survival was similar between the two groups, with 100% 1- and 2-year survival in the grade <4 groups. CONCLUSION: Our results showed that the extent of resection, neurological outcomes, and survival were similar using the two anesthesia techniques. Since AC is more challenging for the patient and for his or her caregiver after surgery, this finding has implications for clinical decision-making.

Pediatric out-of-hospital cardiopulmonary resuscitation by helicopter emergency medical service, does it has added value compared to regular emergency medical service?

PURPOSE: To determine the outcome of out-of-hospital (OOH) cardiopulmonary resuscitation (CPR) and the advanced life support (ALS) procedures provided in pediatrics by the Rotterdam Helicopter Emergency Medical Service (HEMS) METHODS: Retrospective evaluation of all pediatric (0-17 years) OOH cardiopulmonary arrests within a 6-year period and attended by the Rotterdam HEMS team. RESULTS: There were 201 OOH CPRs from October 2008 until October 2014. Endotracheal intubation was performed in 164 cases and done by HEMS in 104 patients (63%), intraosseous/intravenous cannulation 43/27 times, and additional medication given by HEMS in 70 patients (35%). The overall survival rate for OOH CPR was 15%, but in trauma was low. Twenty-seven of the 29 pediatric patients who survived until discharge are neurological well. Although the Dutch nationwide ambulance protocol states intubation, intravenous, or intraosseal excess and medication, in many patients, only HEMS provided additional ALS care. CONCLUSION: The HEMS brings essential medical expertise in the field not provided by regular emergency medical service. HEMS provide a significant quantity of procedures, obviously needed by the OOH CPR of a pediatric patient.

Higher 30 Day Mortality in Patients with Familial Abdominal Aortic Aneurysm after EVAR.

OBJECTIVES: To determine the influence of a positive family history for aneurysms on clinical success and mortality after endovascular aneurysm repair (EVAR). METHODS: From 2009 to 2011, 1262 patients with abdominal aortic aneurysms (AAA) treated by EVAR were enrolled in a prospective, industry sponsored clinical registry ENGAGE. Patients were classified into familial and sporadic AAA patients according to baseline clinical reports. Clinical characteristics, aneurysm morphology, and follow-up were registered. The primary endpoint was clinical success after EVAR, a composite of technical success and freedom from the following complications: AAA increase >5 mm, type I and III endoleak, rupture, conversion, secondary procedures, migration, and occlusion. Secondary endpoints were the individual components of clinical success, 30 day mortality, and aneurysm related and all cause mortality. RESULTS: Of the 1262 AAA patients (89.5% male and mean age 73.1 years), 86 patients (6.8%) reported a positive family history and were classified as familial AAA. Duration of follow-up was 4.4 ± 1.7 years. Patients with familial AAA were more often female (18.6% vs. 9.9%, p = .012). No difference was observed in aneurysm morphology. There was no significant difference in clinical success between patients with familial and sporadic AAA (72.1% vs. 79.3%, p=.116). Familial AAA patients had a higher 30 day mortality after EVAR (4.7% vs. 1.0%, adjusted HR 5.7, 1.8-17.9, p = .003) as well as aneurysm related mortality (5.8% vs. 1.3%, adjusted HR 5.4, 1.9-14.9, p = .001), while no difference was observed in all cause mortality (19.8% vs. 24.3%, adjusted HR 0.8, 0.5-1.4, p = .501). CONCLUSIONS: The current study shows a higher 30 day mortality after EVAR in familial AAA patients. Future studies should determine the role of family history in AAA treatment, suitability for endovascular or open repair, and on adaptation of post-operative surveillance. For the time being, patients with familial forms of AAA should be considered at higher risk for EVAR and warrant extra vigilance.

The preoperative cardiology consultation: indications and risk modification.

BACKGROUND: The cardiologist is regularly consulted preoperatively by anaesthesiologists. However, insights into the efficiency and usefulness of these consultations are unclear. METHODS: This is a retrospective study of 24,174 preoperatively screened patients ≥18 years scheduled for elective non-cardiac surgery, which resulted in 273 (1%) referrals to the cardiologist for further preoperative evaluation. Medical charts were reviewed for patient characteristics, main reason for referring, requested diagnostic tests, interventions, adjustment in medical therapy, 30-day mortality and major adverse cardiac events. RESULTS: The most common reason for consultation was the evaluation of a cardiac murmur (95 patients, 35%). In 167 (61%) patients, no change in therapy was initiated by the cardiologist. Six consultations (2%) led to invasive interventions (electrical cardioversion, percutaneous coronary intervention or coronary artery bypass surgery). On average, consultation delayed clearance for surgery by two weeks. CONCLUSION: In most patients referred to the cardiologist after being screened at an outpatient anaesthesiology clinic, echocardiography is performed for ruling out specific conditions and to be sure that no further improvement can be made in the patient's health. In the majority, no change in therapy was initiated by the cardiologist. A more careful consideration about the potential benefits of consulting must be made for every patient.

[High-risk obstetrics in tertiary centres: anaesthetist, hybrid operating suite and obstetric critical care unit]. / Hoogcomplexe verloskunde in derdelijnscentra.

The frequency of pregnancy-related morbidity has increased over recent decades, as has the number of patients with complex congenital cardiac anomalies reaching fertile age, resulting in an increasing number of high-risk pregnancies. In order to optimalise maternal and foetal outcome in these patients, not only is the availability of optimal in-hospital facilities (e.g. obstetric critical care unit, hybrid operating suite) important, but also a multidisciplinary approach which is mandatory for successful maternal and foetal outcome. The role of a dedicated obstetric anaesthetist in this multidisciplinary team is essential. In contrast with other Western countries, in the Netherlands this has so far been underestimated. Obstetric anaesthetists should also be part of multidisciplinary obstetric care in high-risk patients during pregnancy, thus optimalising conditions for successful delivery and maternal and foetal outcome.

Iliac Seal Zone Dynamics and Clinical Consequences After Endovascular Aneurysm Repair.

OBJECTIVE: To evaluate the dynamics of the iliac attachment zone after EVAR, and the association with clinical events. METHODS: A tertiary institution's prospective EVAR database was searched to identify common iliac arteries at risk. Internally validated measurements were made, using centre lumen line reconstructions. Iliac dilatation and endograft limb retraction were the main endpoints. Associations between dilatation, retraction, oversizing, and distal seal length were investigated. Association with clinical events (sealing or occlusion) was also explored. RESULTS: Of 452 primary EVAR patients treated from 2004 to 2012, 341 were included (mean age 72 years, 12% female, 597 common iliac arteries). Median follow-up was 4.7 years. At 30 days, the mean iliac diameter increased from 14 mm to 15 mm (p < .001). Over follow-up, it increased to 18 mm (p < .001). Iliac dilatation ≥20% occurred in 295 cases (49.4%) and exceeded the implanted endograft diameter in 170 (28.7%). Limb retraction ≥5 mm was identified in 54 patients (9.1%) and was associated with iliac seal complications (p < 0.001). Iliac endograft extension diameter ≥24 mm (OR 3.3, 95% CI 1.7-6.4) and iliac artery dilatation beyond the endograft (OR 2.1, 95% CI 1.2-3.8) were independent risk factors. Overall, there were 34 (5.7%) iliac seal complications. Retraction of the iliac endograft (OR 1.17 per mm, 95% CI 1.10-1.24) and baseline AAA diameter (1.04 per mm, 95% CI 1.01-1.07) were independent risk factors for seal related complications. Greater initial post-operative iliac seal length was protective (OR 0.94 per mm, 95% CI 0.90-0.97). CONCLUSIONS: Iliac dilatation and endograft retraction are common findings during follow-up, potentially leading to adverse clinical events. Optimisation of the iliac seal zone providing a long distal seal length and added attention to patients with large aneurysms or receiving ≥24 mm diameter iliac extensions are recommended. Also, long-term surveillance including CTA is advised to reveal and correct loss of seal at the iliac attachments before adverse clinical events occur.

Perioperative Complications are Associated With Adverse Long-Term Prognosis and Affect the Cause of Death After General Surgery.

BACKGROUND: It is unclear how mortality and causes of death vary between patients and surgical procedures and how occurrence of postoperative complications is associated with prognosis. This study describes long-term mortality rates and causes of death in a general surgical population. Furthermore, we explore the effect of postoperative complications on mortality. METHODS: A single-centre analysis of postoperative complications, with mortality as primary endpoint, was conducted in 4479 patients undergoing surgery. We applied univariate and multivariable regression models to analyse the effect of risk factors, including surgical risk and postoperative complications, on mortality. Causes of death were also explored. RESULTS: 75 patients (1.7 %) died within 30 days after surgery and 730 patients (16.3 %) died during a median follow-up of 6.3 years (IQR 5.8-6.8). Significant differences in long-term mortality were observed with worst outcome for patients undergoing high-risk vascular surgery (HR 1.5; 95 % CI 1.2-1.9). When looking at causes of death, high-risk surgery was associated with a twofold higher risk of cardiovascular death (HR 1.9; 95 % CI 1.2-3.1), whereas the intermediate-risk group had a higher risk of dying from cancer-related causes (HR 1.5; 95 % CI 1.1-2.0). Occurrence of complications-particularly of cardiovascular nature- was associated with worse survival (HR 1.9; 95 % CI 1.3-2.7). CONCLUSION: High-risk vascular surgery and occurrence of postoperative complications are important predictors of late mortality. Further focus on these groups of patients can contribute to reduced morbidity. Improvement in quality of care should be aimed at preventing postoperative complications and thus a better outcome in a general surgical population.

Low Socioeconomic Status is an Independent Risk Factor for Survival After Abdominal Aortic Aneurysm Repair and Open Surgery for Peripheral Artery Disease.

OBJECTIVE/BACKGROUND: The association between socioeconomic status (SES), presentation, and outcome after vascular surgery is largely unknown. This study aimed to determine the influence of SES on post-operative survival and severity of disease at presentation among vascular surgery patients in the Dutch setting of equal access to and provision of care. METHODS: Patients undergoing surgical treatment for peripheral artery disease (PAD), abdominal aortic aneurysm (AAA), or carotid artery stenosis between January 2003 and December 2011 were retrospectively included. The association between SES, quantified by household income, disease severity at presentation, and survival was studied using logistic and Cox regression analysis adjusted for demographics, and medical and behavioral risk factors. RESULTS: A total of 1,178 patients were included. Low income was associated with worse post-operative survival in the PAD cohort (n = 324, hazard ratio 1.05, 95% confidence interval [CI] 1.00-1.10, per 5,000 Euro decrease) and the AAA cohort (n = 440, quadratic relation, p = .01). AAA patients in the lowest income quartile were more likely to present with a ruptured aneurysm (odds ratio [OR] 2.12, 95% CI 1.08-4.17). Lowest income quartile PAD patients presented more frequently with symptoms of critical limb ischemia, although no significant association could be established (OR 2.02, 95% CI 0.96-4.26). CONCLUSIONS: The increased health hazards observed in this study are caused by patient related factors rather than differences in medical care, considering the equality of care provided by the study setting. Although the exact mechanism driving the association between SES and worse outcome remains elusive, consideration of SES as a risk factor in pre-operative decision making and focus on treatment of known SES related behavioral and psychosocial risk factors may improve the outcome of patients with vascular disease.