Comprehensive analysis of risk factors for postoperative wound infection following radical mastectomy in breast cancer patients.

Surgical site infections (SSIs) following radical mastectomy in breast cancer patients can significantly affect patient recovery and healthcare resources. Identifying and understanding the risk factors for postoperative wound infections (PWIs) are crucial for improving surgical outcomes. This retrospective study was conducted from June 2020 to June 2023, including 23 breast cancer patients who developed PWIs post-radical mastectomy and a control group of 46 patients without such infections. Comprehensive patient data, including variables such as intraoperative blood loss, hospital stay duration, body mass index (BMI), operation time, anaemia, drainage time, diabetes mellitus, cancer stage, white blood cell (WBC) count, serum albumin levels and preoperative neoadjuvant chemotherapy, were meticulously gathered. Statistical analyses, including univariate and multivariate logistic regression, were performed using SPSS software (Version 27.0). The univariate analysis identified several factors significantly associated with an increased risk of PWIs, including preoperative neoadjuvant chemotherapy, low serum albumin levels, advanced cancer stage, diabetes mellitus and reduced WBC count. Multivariate logistic regression highlighted anaemia, prolonged drainage time, diabetes mellitus, advanced cancer stage, reduced WBC count, hypoalbuminemia and preoperative neoadjuvant chemotherapy as significant contributors to the increased risk of PWIs. Anaemia, extended drainage time, diabetes mellitus, advanced cancer stage, low WBC count, hypoalbuminemia and preoperative neoadjuvant chemotherapy are key risk factors for SSIs post-radical mastectomy. Early identification and proactive management of these factors are imperative to reduce the incidence of postoperative infections and enhance recovery outcomes in breast cancer patients.

Incidence, associated factors, and outcomes of acute kidney injury following placement of antibiotic bone cement spacers in two-stage exchange for periprosthetic joint infection: a comprehensive study.

Background: Two-stage exchange with placement of antibiotic cement spacer (ACS) is the gold standard for the treatment of chronic periprosthetic joint infection (PJI), but it could cause a high prevalence of acute kidney injury (AKI). However, the results of the current evidence on this topic are too mixed to effectively guide clinical practice. Methods: We retrospectively identified 340 chronic PJI patients who underwent the first-stage exchange with placement of ACS. The Kidney Disease Improving Global Outcomes guideline was used to define postoperative AKI. Multivariate logistic analysis was performed to determine the potential factors associated with AKI. Furthermore, a systematic review and meta-analysis on this topic were conducted to summarize the knowledge in the current literature further. Results: In our cohort, the incidence of AKI following first-stage exchange was 12.1%. Older age (per 10 years, OR= 1.509) and preoperative hypoalbuminemia (OR= 3.593) were independent predictors for postoperative AKI. Eight AKI patients progressed to chronic kidney disease after 90 days. A meta-analysis including a total of 2525 PJI patients showed the incidence of AKI was 16.6%, and AKI requiring acute dialysis was 1.4%. Besides, host characteristics, poor baseline liver function, factors contributing to acute renal blood flow injury, and the use of nephrotoxic drugs may be associated with the development of AKI. However, only a few studies supported an association between antibiotic dose and AKI. Conclusion: AKI occurs in approximately one out of every six PJI patients undergoing first-stage exchange. The pathogenesis of AKI is multifactorial, with hypoalbuminemia could be an overlooked associated factor. Although the need for acute dialysis is uncommon, the fact that some AKI patients will develop CKD still needs to be taken into consideration.

Hypoalbuminemia increases the risk of failure following one-stage septic revision for periprosthetic joint infection.

PURPOSE: Malnutrition is a potentially modifiable risk factor of periprosthetic joint infection (PJI). The purpose of this study was to analyze the role of nutritional status as a risk factor for failure after one- stage revision hip or knee arthroplasty for PJI. METHODS: Retrospective, single-center, case-control study. Patients with PJI according to the 2018 International Consensus Meeting criteria were evaluated. Minimum follow-up was 4 years. Total lymphocyte count (TLC), albumin values, hemoglobin, C-reactive protein, white blood cell (WBC) count and glucose levels were analyzed. An analysis was also made of the index of malnutrition. Malnutrition was defined as serum albumin < 3.5 g/dL and TLC < 1500/mm3. Septic failure was defined as the presence of local or systemic symptoms of infection and the need of further surgery as a result of persistent PJI. RESULTS: No significant differences were found between increased failure rates after a one-stage revision hip or knee arthroplasty for PJI and TLC, hemoglobin level, WBC count, glucose levels, or malnutrition. Albumin and C-reactive protein values were found to have a positive and significant relationship with failure (p < 0.05). Multivariate logistic regression identified only hypoalbuminemia (serum albumin < 3.5 g/dL) (OR 5.64, 95% CI 1.26-25.18, p = 0.023) as a significant independent risk factor for failure. The receiver operating characteristic (ROC) curve for the model yielded an area under the curve of 0.67. CONCLUSION: TLC, hemoglobin; WBC count; glucose levels; and malnutrition, understood as the combination of albumin and TLC, were not found to be statically significant risk factors for failure after single-stage revision for PJI. However, albumin < 3.5 g/dL, alone was a statically significant risk factor for failure after single-stage revision for PJI. As hypoalbuminemia seems to influence the failure rate, it is advisable to measure albumin levels in preoperative workups.

Effect of Hypoalbuminemia in Patients Undergoing Parathyroidectomy for Primary Hyperparathyroidism.

OBJECTIVES: Treatment for primary hyperparathyroidism is parathyroidectomy. This study identifies the association between hypoalbuminemia (HA) and outcomes in patients undergoing parathyroidectomy for primary hyperparathyroidism. METHODS: This retrospective cohort analysis utilized the 2006-2015 National Surgical Quality Improvement Program database. Current Procedure Terminology codes were used to identify patients undergoing parathyroidectomy for primary hyperparathyroidism. Prolonged length of stay (LOS) was defined as a duration of 2 days or greater. Demographics and comorbidities were compared between HA (serum albumin <3.5 g/dL) and non-HA cohorts using chi-square analysis. The independent effect of HA on adverse outcomes was analyzed using binary logistic regression. RESULTS: A total of 7183 cases with primary hyperparathyroidism were classified into HA (n = 381) and non-HA (n = 6802) cohorts. HA patients had increased complications, including renal insufficiency (0.8% vs. 0.0%, p = 0.001), sepsis (1.0% vs. 0.1%, p = 0.003), pneumonia (0.8% vs. 0.1%, p = 0.018), acute renal failure (1.0% vs. 0.0%, p < 0.001), and unplanned intubation (1.3% vs. 0.2%, p = 0.004). HA patients had increased risk of death (1.6% vs. 0.1%, p < 0.001), prolonged LOS (40.9% vs. 6.3%, p < 0.001), and any complication (5.5% vs. 1.2%, p < 0.001). Adjusted binary logistic regression indicated HA patients experienced increased odds of progressive renal insufficiency (OR 18.396, 95% CI 1.844-183.571, p = 0.013), prolonged LOS (OR 4.892; 95% CI 3.571-6.703; p < 0.001), unplanned reoperation (OR 2.472; 95% CI 1.012-6.035; p = 0.047), and unplanned readmission (OR 3.541; 95% CI 1.858-6.748; p < 0.001). CONCLUSIONS: HA may be associated with adverse complications in patients undergoing parathyroidectomy for primary hyperparathyroidism. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:2035-2039, 2023.

Hypoalbuminemia Predicts Failure of Two-Stage Exchange for Chronic Periprosthetic Joint Infection of the Hip and Knee.

BACKGROUND: Nutritionally compromized patients, with preoperative serum albumin (SAB) < 3.5g/dL, are at higher risk for periprosthetic joint infection (PJI) in total joint arthroplasty. The relationship between nutritional and PJI treatment success is unknown. The purpose of this study was to examine the relationship between preresection nutrition and success after first-stage resection in planned two-stage exchange for PJI. METHODS: A retrospective review was performed on 418 patients who had first-stage resection of a planned two-stage exchange for chronic hip or knee PJI between 2014 and 2018. A total of 157 patients (58 hips and 99 knees) were included who completed first stage, had available preop SAB and had a 2-year follow-up. Failure was defined as persistent infection or repeat surgery for infection after resection. Demographic and surgical data were abstracted and analyzed. RESULTS: Among knee patients with preop SAB >3.5 g/dL, the failure rate was 32% (15 of 47) versus a 48% (25 of 40) failure rate when SAB <3.5 g/dL (P = .10). Similarly, the failure rate among hip patients with preop SAB >3.5 g/dL versus 12.5% (3 of 24) versus 44% (15 of 34) for hip patients with SAB <3.5 g/dL (P = .01). Multivariable regression results indicated that patients with SAB< 3.5 g/dL (P = .0143) and Musculoskeletal Infection Society host type C (P = .0316) were at an increased risk of failure. CONCLUSION: Low preoperative SAB and Musculoskeletal Infection Societyhost type-C are independent risk factors for failure following first-stage resection in planned two-stage exchange for PJI. Efforts to nutritionally optimize PJI patients, when possible, may improve the outcome of two-stage exchange.

A case of familial adenomatous polyposis with protein-losing enteropathy treated by laparoscopic total colorectal resection: A literature review.

Familial adenomatous polyposis (FAP) with protein-losing enteropathy is a rare disorder and is difficult to treat medically. A 74-year-old female patient was referred to our hospital with a chief complaint of anorexia. Lower gastrointestinal endoscopy showed multiple adenomas from the ascending colon to the rectum and adenocarcinoma in the sigmoid colon and descending colon. Laboratory findings showed hypoalbuminemia (albumin 1.6 mg/dl). Protein leak scintigraphy using 99mTc-HSAD found a protein leak from the colon. Although hypercaloric infusion was administered, the nutritional status was not improved and albumin transfusion was required. The patient underwent laparoscopic total proctocolectomy, ileal pouch-anal anastomosis, and temporary ileostomy. She had a good postoperative course and the hypoalbuminemia normalized in a few weeks. The patient underwent temporary ileostomy reversal. Here we report a case of FAP with protein-losing enteropathy who underwent laparoscopic total proctocolectomy, which resulted in improvement of the protein leak as well as cancer treatment.

Prognostic Value of Sarcopenia and Albumin in the Surgical Management of Localized Renal Cell Carcinoma.

INTRODUCTION: A universally accepted model for preoperative surgical risk stratification in localized RCC patients undergoing nephrectomy is currently lacking. Both the evaluation of body composition and nutritional status has demonstrated prognostic value for patients with cancer. This study aims to investigate the potential associations between sarcopenia and hypoalbuminemia and survival outcomes in patients with localized kidney cancer treated with partial or radical nephrectomy. MATERIALS AND METHODS: We retrospectively analyzed 473 patients with localized RCC managed with radical and partial nephrectomy. Skeletal muscle index (SMI) was measured from preoperative CT and MRI. Sarcopenic criteria were created using BMI- and sex-stratified thresholds. Relationships between sarcopenia and hypoalbuminemia (Albumin <3.5 g/dL) with overall (OS), recurrence-free (RFS), and cancer-specific survival (CSS) were determined using multivariable and Kaplan-Meier analysis. RESULTS: Of the 473 patients, 42.5% were sarcopenic and 24.5% had hypoalbuminemia. Sarcopenia was significantly associated with shorter OS (HR=1.51, 95% CI 1.07-2.13), however, was nonsignificant in the RFS (HR = 1.33, 95% CI 0.88-2.03) and CSS (HR=1.66, 95% CI 0.96-2.87) models. Hypoalbuminemia predicted shorter OS (HR=1.76, 95% CI 1.22-2.55), RFS (HR=1.86, 95% CI 1.19-2.89), and CSS (HR=1.82, 95% CI 1.03-3.22). Patients were then stratified into low, medium, and high-risk groups based on the severity of sarcopenia and hypoalbuminemia. Risk groups demonstrated an increasing association with shorter OS (all p<0.05). Reduced RFS was observed in the medium risk-hypoalbuminemia (HR=2.18, 95% CI 1.16-4.09) and high-risk groups (HR=2.42, 95% CI 1.34-4.39). Shorter CSS was observed in the medium risk-hypoalbuminemia (HR=2.31, 95% CI 1.00-5.30) and high-risk groups (HR=2.98, 95% CI 1.34-6.61). CONCLUSION: Localized RCC patients with combined preoperative sarcopenia and hypoalbuminemia displayed a two to a three-fold reduction in OS, RFS, and CSS after nephrectomy. These data have implications for guiding prognostication and treatment election in localized RCC patients undergoing extirpative surgery.

Preoperative Hypoalbuminemia as a Predictor of Severe Postoperative Complications in Patients Undergoing Whipple Pancreatoduodenectomy.

Background: Pancreaticoduodenectomy (PD) known as Whipple procedure is still one of the most complex abdominal surgeries used for treatment of periampullary tumors. PD is often followed with postoperative complications (pancreatic, biliar or intestinal fistula, haemorrhage, intraabdominal abscess, delayed gastric empting. Severe postoperative complications (SPC) can be reason for reoperation and reason of bad outcome of treatment and life treathening condition. Objective: To investigate predicitive value of preoperative hypoalbuminemia for severe postoperative complications (SPC) in patients who have undergone Whipple pancreaticoduodenetomy (PD). However, no similiar study has been ever reported from our country until now. Methods: In this retrospective-prospective study, 100 patients who have had Whipple pancreaticoduodenectomy for malignant periampullary tumors at the Department for Surgery of University Clinic Center Tuzla, Bosnia and Herzegovina were enrolled, from january of 2009 to decembre of 2021. All patients were preoperatively analysed according to serum albumine levels and presensce of hypolabuminemia (serum albumine levels <32g/l). Serum albumine biochemical test were done 1-2 days preoperatively. Clavien Dindo classification was used for determination patients with SPC. Patients who did not have SPC belonged to (I-II) Clavien Dindo group of patients while those who had SPC belonged to( III-V) Clavien Dindo group of patients. Results: Out of 100 patients who have undergone pancreaticoduodenetomy, in 55 (55%) patients postoperative complications were noticed. Mortality rate was 18 (18%) and reoperation has been done in 20 cases (20%). SPC were noticed in 19 patients and most often were: delayed gastric emptying (20%), pancreatic fistula (13%) and intraabdominal collections (9%). Hypoalbuminemic patients had a significantly higher rate of severe postoperative complications ( p<0.05). Using hypoalbuminemia-SPC correlation analaysis, there is confirmed statistically significant correlation between hypoalbuminemia and SPC (ρ= 0.236; p<0.05). Conclusion: Preoperative hypoalbuminemia can be used as predictor and prognostic factor for severe postoperative complications after Whipple pancreaticoduodenectomy. Identification and optimization of serum albumin level prior to Whipple pancreatoduodenectomy may improve surgical outcomes.

[A case of juvenile gastric polyposis with gastric cancer successfully treated by laparoscopic total gastrectomy -review of 36 reported cases in Japan].

A 43-year-old woman was suffering from epigastric pain. Her gastroscopy revealed polyposis of the stomach, and her biopsy revealed a hyperplastic polyp. During the 18-month follow-up, the polyps proliferated, and the patient was referred to our institute for further investigation and treatment. A juvenile gastric polyposis diagnosis was made. She refused to have the surgery despite the fact that it was necessary due to the anemia and hypoalbuminemia she was experiencing. Endoscopic biopsy results revealed gastric cancer at a follow-up visit 2 years and 3 months later; thus, a laparoscopic total gastrectomy was performed. Pathological examination revealed adenocarcinomas that were scattered and well-differentiated, with hyperplastic polyps in the background. No lymph node metastasis was found. Despite the fact that juvenile gastric polyposis is a pathologically benign disease, there have been numerous case reports of surgery being performed due to anemia, hypoalbuminemia, or gastric cancer associated with the disease. When gastric cancers are discovered in cases of juvenile gastric polyposis, they are usually in an early stage, making them a good candidate for laparoscopic total gastrectomy.

Free flap reconstruction of plantar weight-bearing heel defects: Long-term functional and patient-reported outcomes.

PURPOSE: Non-healing plantar weight-bearing heel ulcers are a challenging problem to treat. Free tissue transfer (FTT) reconstruction of the heel is an opportunity for limb salvage to preserve gait and ambulation. The aim of this study is to describe surgical and functional outcomes in patients who underwent FTT to treat chronic heel ulcers. METHODS: A retrospective review of patients who underwent FTT for plantar heel ulcers from 2011 to 2021 was conducted. Patient demographics, comorbidities, perioperative data, postoperative complications, and long-term outcomes were recorded. Primary outcomes included flap success, complications, postoperative ambulation, patient-reported outcome measures and limb salvage, with patients stratified into limb salvage or eventual amputation groups. RESULTS: Forty-four patients underwent 45 heel reconstructions. Average age and BMI were 57.3 years and 30.1 kg/m2 , respectively. Thirty-eight patients (86.4%) had calcaneal osteomyelitis, 35 patients (79.5%) had diabetes, and 18 patients (40.9%) had peripheral vascular disease (PVD). Immediate microsurgical success rate was 95.6%. At mean follow-up of 19.6 ± 20.9 months, overall limb salvage rate was 73.3% (n = 33). Preoperative albumin levels were higher in limb salvage group compared to the amputation group (3.0 vs. 2.4 g/dl, p = .018). Prior stroke history and hypoalbuminemia were significantly higher in the amputation group compared to limb salvage group (p = .012 and p = .018, respectively). Risk for eventual amputation was associated with PVD (OR 4.0, p = .053), hypoalbuminemia (OR 4.9, p = .020), and postoperative infection (OR 6.3, p = .013). Of the 12 amputations that occurred, the most common indication for amputation was infection (n = 8, 66.7%), which most often occurred at the original wound location (62.5%). At most recent follow-up, 90.7% of patients (n = 39) were ambulatory. CONCLUSION: FTT is an effective alternative to amputation in patients with chronic heel ulcers. Proper patient selection, preoperative optimization, and postoperative care are imperative to the success of this limb salvage procedure.

Risk factors analysis and nomogram construction for blood transfusion in elderly patients with femoral neck fractures undergoing hemiarthroplasty.

INTRODUCTION: Elderly patients with femoral neck fractures (FNFs) undergoing hemiarthroplasty usually have poor physical condition. The main aim of this study was to identify risk factors for blood transfusion in these patients and construct a nomogram to intuitively predict the requirement of transfusion. The secondary purpose was to examine the relationship between blood transfusion and complications within 30 days post-operatively. Our hypothesis was that chronic kidney disease (CKD) and hypoalbuminemia may increase the requirement of transfusion. METHODS: Data of 414 elderly patients undergoing hemiarthroplasty for FNFs were retrospectively collected. Univariate and multiple regression analysis were performed to identify independent risk factors for blood transfusion, which were used to construct a nomogram subsequently. The discrimination and calibration of the nomogram model were assessed with concordance index (C-index), the area under receiver operating characteristic curve (AUC), and calibration curve. Furthermore, the complications of blood transfusion within 30 days post-operatively were also analyzed. RESULTS: Out of 414 patients, 127 (30.7%) received a blood transfusion. Independent risk factors for blood transfusion included CKD, hypoalbuminemia, pre-operative anaemia, general anaesthesia, higher American Society of Anesthesiologists score, more intraoperative blood loss, and longer surgical time. Increased hidden blood loss, deep vein thrombosis, superficial wound infection, and prolonged hospital stays were more common in transfused patients. The C-index of the nomogram model was 0.848 (95% CI = 0.811-0.885), and the AUC value was 0.859. The calibration curve showed a good consistency between the actual transfusion and the predicted probability. DISCUSSION: We observed a transfusion rate of 30.7% in elderly FNF patients undergoing hemiarthroplasty. CKD and hypoalbuminemia were firstly identified as independent risk for blood transfusion. In addition, blood transfusion can increase the occurrence of early post-operative complications. CONCLUSION: Targeted pre-operative intervention, such as optimizing CKD and correcting hypoalbuminemia is essential and highly regarded.

Menetrier's disease exacerbating ulcerative colitis and relieved by gastrectomy.

Ménétrier's disease (MD) is a rare gastropathy characterised by giant rugal folds which can present with nausea, vomiting, abdominal pain and protein losing gastropathy. We report a 21-year-old woman with comorbid MD and ulcerative colitis (UC). Management was complicated by limited treatment options for MD, significant symptom burden, worsening nutrition and difficulty determining which disease was the predominant cause of symptoms. Since age 18 the patient experienced recurrent UC flares characterised by diarrhoea, persistent vomiting and corticosteroid dependence. Endoscopic assessment demonstrated concurrent MD and active UC. Octreotide and cetuximab were trialled given persistent hypoalbuminaemia and suspicion for MD associated protein-losing gastropathy. UC management comprised dose-optimised infliximab and methotrexate. Repeat endoscopic assessment demonstrated improvement in UC without corresponding improvement in symptoms or hypoalbuminaemia. Nasojejunal feeding and parenteral nutrition failed to significantly improve nutritional status and accordingly the patient proceeded to radical total gastrectomy. Postoperatively, MD-associated symptoms and hypoalbuminemia resolved completely.

Hypoalbuminemia and Bandemia Predict Failure of Infliximab Rescue Therapy in Acute Severe Ulcerative Colitis.

BACKGROUND AND AIMS: Infliximab rescue therapy is effective in patients with corticosteroid refractory acute severe ulcerative colitis, but predictors of response remain poorly understood. We aimed to identify predictors of colectomy in this high-risk patient population. METHODS: Patients hospitalized with acute severe ulcerative colitis who received infliximab after failing intravenous corticosteroid therapy between July 2012 and June 2017 were retrospectively identified. Stepwise regression with backward elimination was used to identify predictors of colectomy at 90 days and 1 year. Ninety-day and 1-year colectomy rates were compared between the patients who received 5 mg/kg and 10 mg/kg IFX rescue dose. RESULTS: Sixty-three patients met the eligibility criteria. Twenty-nine patients received 5 mg/kg, and 34 received 10 mg/kg infliximab dose. Serum albumin on admission (OR 0.10; p = 0.04) and band neutrophil percentage at the time of infliximab administration (OR 1.21; p = 0.02) were independent predictors of 90-day colectomy. A combination of serum albumin ≤ 2.5 g/dl and band neutrophil count ≥ 13% had a 100% positive predictive value for 90-day colectomy. Unadjusted 90-day and 1-year colectomy rates were similar in the 5 mg/kg and 10 mg/kg infliximab groups. After adjusting for confounding factors, 10 mg/kg infliximab dose was potentially protective for 90-day (OR 0.07; p = 0.06) but not for 1-year colectomy (OR 0.19; p = 0.16). CONCLUSIONS: Bandemia and low serum albumin are independent predictors of failure of infliximab rescue therapy in acute severe ulcerative colitis. Serum albumin ≤ 2.5 g/dl and band neutrophil count ≥ 13% had a 100% positive predictive value for 90-day colectomy.

Hypoalbuminemia Is Associated With Septic Revisions After Primary Surgery and Postoperative Infection After Revision Surgery.

STUDY DESIGN: Retrospective database review. OBJECTIVE: To determine (1) the relationship between hypoalbuminemia and body mass index (BMI); (2) the association between malnutrition and revision spine surgery for septic reasons; and (3) the association between malnutrition and infection after aseptic revision spine surgery. SUMMARY OF BACKGROUND DATA: Although malnutrition has been suggested to increase the risk of infection after spine surgery, evidence supporting this hypothesis is conflicting. METHODS: Patients undergoing revision spine surgery were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) from 2006 to 2014. Hypoalbuminemia (albumin < 3.5 g/dL) was used as a surrogate marker of malnutrition. Multivariate analysis was used to assess the association of hypoalbuminemia with septic versus aseptic revision spine surgery. The association between hypoalbuminemia and deep infection postoperatively within 30 days of aseptic revision surgeries was also assessed. RESULTS: A total of 3136 patients who underwent revision spine surgery were identified; 2922 (93.2%) underwent surgery for aseptic reasons, and 214 (6.8%) for septic reasons. Hypoalbuminemia was present in all BMI groups including obese patients, though it was highest in underweight patients (22.4%). Patients who underwent surgery for septic reasons had a higher rate of hypoalbuminemia than those undergoing surgery for aseptic reasons (49.1% vs. 8.5%, P < 0.001) with nine times the odds of having hypoalbuminemia (adjusted odds ratio, OR = 9.17, P < 0.001). Of the 2922 patients undergoing revision spine surgery for aseptic reasons, hypoalbuminemia was independently associated with acute deep infection within 30 days of surgery (adjusted OR = 2.85, P = 0.019). CONCLUSION: Malnutrition is more common in revision spine surgery for septic reasons when compared with aseptic revision surgery. Acute postoperative infection following aseptic revision surgery is also more common in patients with malnutrition. Further study, in the form of prospective trials, will help to increase our understanding of the effects of malnutrition in spine surgery. LEVEL OF EVIDENCE: 3.

Roux-en-Y gastric bypass for the treatment of severe complications after omega-loop gastric bypass.

BACKGROUND: Omega-loop gastric bypass (OLGB) may be associated with severe complications, including anastomotic leak, refractory ulcer or stenosis, undernutrition, and disabling digestive disorders (chronic diarrhea, steatorrhea, bile reflux, and vomiting). OLGB conversion to Roux-en-Y gastric bypass (RYGB) was suggested to treat these complications. OBJECTIVES: To evaluate the efficacy and risk of severe complications after OLGB conversion to RYGB. SETTING: University hospital. METHODS: Retrospective analysis between October 2011 and June 2016. RESULTS: Seventeen patients underwent OLGB conversion to RYGB. Fourteen patients (82%) presented at least 1 disabling digestive disorder. Before conversion, 10 patients (58.8%) received nutritional support for undernutrition. There was no postoperative mortality. Seven patients (41.1%) developed major adverse events (<90 d). At conversion, the average weight, body mass index, and percent of excess weight loss for the population without undernutrition (n = 7) were 103.7±24 kg, 38.7±6.8 kg/m², and 37%±33%, respectively. These values were 85±18.3 kg, 30.6±4.7 kg/m², and 73.3%±21.5%, respectively, at 2 years. In patients with undernutrition (n = 10), the average weight, body mass index, and percent of excess weight loss were 52.2±16.5 kg, 18.7±5.9 kg/m², and 149.3%±46.5%, respectively, before nutritional support and 58.9±14.7 kg, 21.1±5.2 kg/m², and 132.7%±39.1%, respectively, at revisional surgery. At 2 years the values were 71±5.6 kg, 24.3±2.2 kg/m², and 104.6%±15.2%, respectively. The patients experienced significant improvements in hypoalbuminemia, anemia, and vitamin/trace element deficiencies. The disabling digestive disorders resolved in 85% of patients. CONCLUSION: The conversion of OLGB to RYGB for severe complications allows for weight correction in patients with undernutrition, reduces disabling digestive disorders, and improves the nutritional status of patients. However, the conversion is associated with high morbidity.

Poor Prognosis in Critical Limb Ischemia Without Pre-Onset Intermittent Claudication.

BACKGROUND: Some patients with critical limb ischemia (CLI) lack symptoms of intermittent claudication (IC) before the onset of CLI. We studied the outcome of such patients, because this is currently unknown. METHODS AND RESULTS: For retrospective exploratory analysis, we divided 225 patients (265 limbs) with CLI into 2 groups: 142 patients (172 limbs) without a history of IC (non-IC group) and 83 patients (93 limbs) with IC (IC group). We examined comorbid factors and found that a higher proportion of patients in the non-IC group failed to undergo arterial revascularization (49% vs. 20%, P<0.0001) due to progressed limb ischemia and infection. We then analyzed 140 patients (161 limbs) with revascularization. Patients in the non-IC group were more likely to have diabetes mellitus (P=0.03), hypoalbuminemia (P=0.02), advanced Rutherford's classification (P=0.0007), worse ambulatory function (P=0.009), and longer postoperative stay (P=0.04). Amputation-free survival was lower in the non-IC group (P=0.005). On Cox regression analysis, hemodialysis (P=0.002), coronary artery disease (P=0.04), cerebrovascular disease (P=0.02), non-ambulatory status (P=0.02), and non-IC (P=0.01) were independent risk factors for lower amputation-free survival. CONCLUSIONS: Patients without IC before CLI onset have several unique features, and non-IC is an independent risk factor for poor outcome.