Association between reduced physical performance measures and short-term consequences after major emergency abdominal surgery: a prospective cohort study.

BACKGROUND: Major emergency abdominal surgery is associated with high morbidity with outcomes worse than for similar elective surgery, including complicated physical recovery, increased need for rehabilitation, and prolonged hospitalisation. PURPOSE: To investigate whether low physical performance test scores were associated with an increased risk of postoperative complications, and, furthermore, to investigate the feasibility of postoperative performance tests in patients undergoing major emergency abdominal surgery. We hypothesize that patients with low performance test scores suffer more postoperative complications. METHODS: The study is a prospective observational cohort study including all patients who underwent major abdominal surgery at the Department of Surgery at Zealand University Hospital between 1st March 2017 and 31st January 2019. Patients were evaluated with De Morton Mobility Index (DEMMI) score, hand grip strength, and 30-s chair-stand test. RESULTS: The study included 488 patients (median age 69, 50.6% male). Physiotherapeutic evaluation including physical performance tests with DEMMI and hand grip strength in the immediate postoperative period were feasible in up to 68% of patients undergoing major emergency abdominal surgery. The 30-s chair-stand test was less viable in this population; only 21% of the patients could complete the 30-s chair-stand test during the postoperative period. In logistic regression models low DEMMI score (< 40) and ASA classification and low hand grip strength (< 20 kg for women, < 30 kg for men were independent risk factors for the development of postoperative severe complications Clavien-Dindo (CD) grade ≥ 3. CONCLUSIONS: In patients undergoing major emergency surgery low performance test scores (DEMMI and hand grip strength), were independently associated with the development of significant postoperative complications CD ≥ 3.

Short and long-term readmission after major emergency abdominal surgery: a prospective Danish study.

PURPOSE: Major emergency abdominal surgery is associated with severe in-hospital complications and loss of performance. After discharge, a substantial fraction of patients are readmitted emergently; however, limited knowledge exists of the long-term consequences. The aim of this study was to examine the risks and causes of short-term (30-day) and long-term (180-day) readmission among patients undergoing major emergency abdominal surgery. METHODS: This study included 504 patients who underwent major emergency abdominal surgery at the Zealand University Hospital between March 1, 2017, and February 28, 2019. The population was followed from 0 to 180 days after discharge, and detailed readmission information was registered. A Cox proportional hazards model was used to examine the independent risk factors for readmission within 30 and 180 days. RESULTS: From 0 to 30 days after discharge, 161 (31.9%) patients were readmitted emergently, accumulating to 241 (47.8%) patients within 180 days after discharge. The main reasons for short-term readmission were related to the gastrointestinal tract and surgical wounds, whereas long-term readmissions were due to infections, cardiovascular complications, and abdominal pain. Stomal placement was an independent risk factor for short-term readmission, whereas an ASA score of 3 was a risk factor for both short-term and long-term readmission. CONCLUSION: Close to 50% of all patients who underwent major emergency abdominal surgery had one or more emergency readmission within 180 days of discharge, and these data points towards the risk factors involved.

The ARISCAT score is a promising model to predict postoperative pulmonary complications after major emergency abdominal surgery: an external validation in a Danish cohort.

PURPOSE: Postoperative pulmonary complications (PPCs) occur in up to 30% of patients undergoing surgery and are a significant contributor to the overall risk of surgery. A preoperative risk prediction tool for postoperative pulmonary complications could succour clinical identification of patients at increased risk and support clinical decision making. This original study aimed to externally validate a risk model for predicting postoperative pulmonary complications (ARISCAT) in a cohort of patients undergoing major emergency abdominal surgery at a Danish University Hospital. METHODS: ARISCAT was validated prospectively in a cohort of patients undergoing major emergency abdominal surgery between March 2017 and January 2019. Predicted PPCs by ARISCAT were compared with observed PPCs. ARISCAT was validated with calibration, discrimination and accuracy and in adherence to the TRIPOD statement. RESULTS: The study included a total of 585 patients with a median age of 70 years. The majority of patients underwent emergency laparotomy without bowel resection. The predicted PPC frequency by ARISCAT was 24.9%, while the observed frequency of PPCs in the cohort was 36.1%. The slope of the calibration plot was 0.9546, the y axis interception was 0.1269 and the plot was well fitted to a linear slope. The Hosmer Lemeshow goodness-of-fit analysis showed good calibration (p > 0.25). ARISCAT showed good discrimination with AUC 0.83 (95% CI 0.79-0.86) on a receiver-operating characteristics curve and the accuracy was also good with a Brier score of 0.19. CONCLUSIONS: ARISCAT was a promising tool to predict PPCs in a high-risk surgical population undergoing major emergency abdominal surgery.

Validation of the preoperative score to predict postoperative mortality (POSPOM) in patients undergoing major emergency abdominal surgery.

PURPOSE: Patients undergoing major emergency abdominal surgery have a high mortality rate. Preoperative risk prediction tools of in-hospital mortality could assist clinical identification of patients at increased risk and thereby aid clinical decision-making and postoperative pathways. The aim of this study was to validate the preoperative score to predict mortality (POSPOM) in a population of patients undergoing major emergency abdominal surgery. METHODS: POSPOM was investigated in a retrospectively collected cohort of patients undergoing major emergency abdominal surgery at a Danish University Hospital from 2010 to 2016. Predicted in-hospital mortality by POSPOM was compared to observed in-hospital mortality. Calibration was assessed by Hosmer-Lemeshow goodness-of-fit and calibration plot. Discrimination was assessed by area under the receiver operating characteristic curve and accuracy was assessed with Brier score. RESULTS: The study included 979 patients (513 females) with a median age of 64 (IQR 55-77) years. The majority of patients underwent open surgery (94.5%). The observed in-hospital mortality rate was 10.9%. The estimated mean in-hospital mortality rate by POSPOM was 6.7%. POSPOM showed a good discrimination [AUC 0.82 (95% CI 0.78-0.85)] and an excellent accuracy [Brier score 0.09 (95% CI 0.07-0.10)]. However, a poor calibration was found (p < 0.01) as POSPOM underestimated in-hospital mortality. CONCLUSIONS: POSPOM is not an ideal prediction model for in-hospital mortality in patients undergoing major emergency abdominal surgery due a poor calibration.

The effect of postoperative respiratory and mobilization interventions on postoperative complications following abdominal surgery: a systematic review and meta-analysis.

PURPOSE: Up to 30% of patients undergoing abdominal surgery suffer from postoperative pulmonary complications. The purpose of this systematic review and meta-analyses was to investigate whether postoperative respiratory interventions and mobilization interventions compared with usual care can prevent postoperative complications following abdominal surgery. METHODS: The review was conducted in line with PRISMA and GRADE guidelines. MEDLINE, Embase, and PEDRO were searched for randomized controlled trials and observational studies comparing postoperative respiratory interventions and mobilization interventions with usual care in patients undergoing abdominal surgery. Meta-analyses with trial sequential analysis on the outcome pulmonary complications were performed. Review registration: PROSPERO (identifier: CRD42019133629) RESULTS: Pulmonary complications were addressed in 25 studies containing 2068 patients. Twenty-three studies were included in the meta-analyses. Patients predominantly underwent open elective upper abdominal surgery. Postoperative respiratory interventions consisted of expiratory resistance modalities (CPAP, EPAP, BiPAP, NIV), assisted inspiratory flow modalities (IPPB, IPAP), patient-operated ventilation modalities (spirometry, PEP), and structured breathing exercises. Meta-analyses found that ventilation with high expiratory resistance (CPAP, EPAP, BiPAP, NIV) reduced the risk of pulmonary complications with OR 0.42 (95% CI 0.18-0.97, p = 0.04, I2 = 0%) compared with usual care, however, the trial sequential analysis revealed that the required information size was not met. Neither postoperative assisted inspiratory flow therapy, patient-operated ventilation modalities, nor breathing exercises reduced the risk of pulmonary complications. CONCLUSION: The use of postoperative expiratory resistance modalities (CPAP, EPAP, BiPAP, NIV) after abdominal surgery might prevent pulmonary complications and it seems the preventive abilities were largely driven by postoperative treatment with CPAP.

Effect of High Inspiratory Oxygen Fraction on Endothelial Function in Healthy Volunteers: A Randomized Controlled Crossover Pilot Study.

It has been suggested that high inspiratory oxygen concentrations during anesthesia may be associated with higher postoperative mortality due to endothelial dysfunction. A randomized controlled crossover study was conducted with 25 healthy male volunteers. They inhaled an oxygen concentration of 30% and 80%. The endothelial function was assessed using noninvasive digital pulse amplitude tonometry (EndoPAT) supported by endothelial biomarkers. The difference in endothelial function between the 2 treatments was 0.05 (95% confidence interval, -0.36 to 0.27; P = .77). Endothelial biomarkers were unaffected. Inhalation of a high oxygen fraction in healthy volunteers did not result in a significant reduction of endothelial function.

Systemic inflammatory response after hernia repair: a systematic review.

PURPOSE: All surgical procedures elicit a complex systemic inflammatory response effectuated and modulated by cytokines. The purpose of this systematic review was to present an overview of the inflammatory response and the serum markers associated with hernia repair and to compare the response between patients treated with and without mesh. METHODS: The review was conducted in line with PRISMA guidelines. The outcomes of interest were serum concentration of leukocytes, cytokines, and acute phase proteins before and after hernia repair with or without mesh reinforcement. The risk of bias was assessed using the Cochrane ROBINS-I tool for non-randomized studies of intervention. RESULTS: A total of 31 studies were included in the systematic review including 1326 patients with a mean age ranging from 33 to 67 years. The studies predominantly included males (95.0% males, 5.0% female) with inguinal hernias (98.5% inguinal hernias, 1.5% incisional hernias). The inflammatory response after hernia repair was characterized by an increase in CRP, IL-6, leukocytes, neutrophils, IL-1, IL-10, fibrinogen, and α1-antitrypsin and a decrease in lymphocytes and albumin within the first 24 postoperative hours. The systemic inflammatory response was normalized before or on the seventh postoperative day. A higher CRP and IL-6 serum concentration was found in patients treated with mesh compared with sutured repairs. CONCLUSIONS: Hernia repair elicits a systemic inflammatory response characterized by an increase in CRP, IL-6, leukocytes, neutrophils, IL-1, IL-10, fibrinogen, and α1-antitrypsin and a decrease in lymphocytes and albumin. A higher inflammatory response was found after mesh repair compared with non-mesh repair and after open mesh repair compared with laparoscopic mesh repair.

Long-term Recurrence and Complications Associated With Elective Incisional Hernia Repair.

Importance: Prosthetic mesh is frequently used to reinforce the repair of abdominal wall incisional hernias. The benefits of mesh for reducing the risk of hernia recurrence or the long-term risks of mesh-related complications are not known. Objective: To investigate the risks of long-term recurrence and mesh-related complications following elective abdominal wall hernia repair in a population with complete follow-up. Design, Setting, and Participants: Registry-based nationwide cohort study including all elective incisional hernia repairs in Denmark from January 1, 2007, to December 31, 2010. A total of 3242 patients with incisional repair were included. Follow-up until November 1, 2014, was obtained by merging data with prospective registrations from the Danish National Patient Registry supplemented with a retrospective manual review of patient records. A 100% follow-up rate was obtained. Exposures: Hernia repair using mesh performed by either open or laparoscopic techniques vs open repair without use of mesh. Main Outcomes and Measures: Five-year risk of reoperation for recurrence and 5-year risk of all mesh-related complications requiring subsequent surgery. Results: Among the 3242 patients (mean age, 58.5 [SD, 13.5] years; 1720 women [53.1%]), 1119 underwent open mesh repair (34.5%), 366 had open nonmesh repair (11.3%), and 1757 had laparoscopic mesh repair (54.2%). The median follow-up after open mesh repair was 59 (interquartile range [IQR], 44-80) months, after nonmesh open repair was 62 (IQR, 44-79) months, and after laparoscopic mesh repair was 61 (IQR, 48-78) months. The risk of the need for repair for recurrent hernia following these initial hernia operations was lower for patients with open mesh repair (12.3% [95% CI, 10.4%-14.3%]; risk difference, -4.8% [95% CI, -9.1% to -0.5%]) and for patients with laparoscopic mesh repair (10.6% [95% CI, 9.2%-12.1%]; risk difference, -6.5% [95% CI, -10.6% to -2.4%]) compared with nonmesh repair (17.1% [95% CI, 13.2%-20.9%]). For the entirety of the follow-up duration, there was a progressively increasing number of mesh-related complications for both open and laparoscopic procedures. At 5 years of follow-up, the cumulative incidence of mesh-related complications was 5.6% (95% CI, 4.2%-6.9%) for patients who underwent open mesh hernia repair and 3.7% (95% CI, 2.8%-4.6%) for patients who underwent laparoscopic mesh repair. The long-term repair-related complication rate for patients with an initial nonmesh repair was 0.8% (open nonmesh repair vs open mesh repair: risk difference, 5.3% [95% CI, 4.4%-6.2%]; open nonmesh repair vs laparoscopic mesh repair: risk difference, 3.4% [95% CI, 2.7%-4.1%]). Conclusions and Relevance: Among patients undergoing incisional repair, sutured repair was associated with a higher risk of reoperation for recurrence over 5 years compared with open mesh and laparoscopic mesh repair. With long-term follow-up, the benefits attributable to mesh are offset in part by mesh-related complications.

[Transscrotal and transurethral cholecystectomy: a meta-analysis]. / Transskrotal og transuretral kolecystektomi: en metaanalyse

INTRODUCTION: Patients treated with transvaginal cholecystectomy have less post-operative pain and improved cosmesis compared to patients treated with conventional laparoscopic cholecystectomy. No systematic review or meta-analysis has been conducted focusing on similar beneficial surgeries for men. The aim of this meta-analysis was to compare transscrotal and transurethral cholecystectomy with conventional laparoscopic cholecystectomy. METHODS: PubMed and Embase were systematically searched for observational and randomized controlled trials comparing transscrotal and transurethral cholecystectomy with conventional laparoscopic cholecystectomy. The primary outcome was post-operative complications. Cosmetic satisfaction and whether the patient would recommend the surgery to others were assessed as secondary outcome. RESULTS: No observational or randomized controlled trials comparing transscrotal and transurethral cholecystectomy with conventional laparoscopic cholecystectomy was found. CONCLUSIONS: Sufficient evidence to illustrate the advantages of transscrotal and transurethral cholecystectomy compared with conventional laparoscopic cholecystectomy cannot be provided currently. There is an urgent need for qualified data in this surgical field. Large randomized controlled trials assessing this topic would be appreciated. FUNDING: none. TRIAL REGISTRATION: none.