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1.
BJOG ; 127(1): 88-97, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31544327

RESUMO

OBJECTIVE: To assess the short-term incidence of serious complications of surgery for urinary incontinence or pelvic organ prolapse. DESIGN: Prospective longitudinal cohort study using a surgical registry. SETTING: Thirteen public hospitals in France. POPULATION: A cohort of 1873 women undergoing surgery between February 2017 and August 2018. METHODS: Preliminary analysis of serious complications after a mean follow-up of 7 months (0-18 months), according to type of surgery. Surgeons reported procedures and complications, which were verified by the hospitals' information systems. MAIN OUTCOME MEASURES: Serious complication requiring discontinuation of the procedure or subsequent surgical intervention, life-threatening complication requiring resuscitation, or death. RESULTS: Fifty-two women (2.8%, 95% CI 2.1-3.6%) experienced a serious complication either during surgery, requiring the discontinuation of the procedure, or during the first months of follow-up, necessitating a subsequent reoperation. One woman also required resuscitation; no women died. Of 811 midurethral slings (MUSs), 11 were removed in part or totally (1.4%, 0.7-2.3%), as were two of 391 transvaginal meshes (0.5%, 0.1-1.6%), and four of 611 laparoscopically placed mesh implants (0.7%, 0.2-1.5%). The incidence of serious complications 6 months after the surgical procedure was estimated to be around 3.5% (2.0-5.0%) after MUS alone, 7.0% (2.8-11.3%) after MUS with prolapse surgery, 1.7% (0.0-3.8%) after vaginal native tissue repair, 2.8% (0.9-4.6%) after transvaginal mesh, and 1.0% (0.1-1.9%) after laparoscopy with mesh. CONCLUSIONS: Early serious complications are relatively rare. Monitoring must be continued and expanded to assess the long-term risk associated with mesh use and to identify its risk factors. TWEETABLE ABSTRACT: Short-term serious complications are rare after surgery for urinary incontinence or pelvic organ prolapse, even with mesh.


Assuntos
Diafragma da Pelve/cirurgia , Prolapso de Órgão Pélvico/cirurgia , Telas Cirúrgicas/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Colposcopia/efeitos adversos , Colposcopia/mortalidade , Colposcopia/estatística & dados numéricos , Feminino , França/epidemiologia , Humanos , Incidência , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/mortalidade , Pessoa de Meia-Idade , Prolapso de Órgão Pélvico/mortalidade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Estudos Prospectivos , Sistema de Registros , Slings Suburetrais/efeitos adversos , Slings Suburetrais/estatística & dados numéricos , Telas Cirúrgicas/estatística & dados numéricos , Centros Cirúrgicos/estatística & dados numéricos , Adulto Jovem
2.
Anesth Analg ; 130(3): 627-634, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31651456

RESUMO

BACKGROUND: A new billable code for intraoperative cardiac arrest was introduced with the International Classification of Diseases, Tenth Revision, classification system. Using a national administrative database, we performed a retrospective analysis of intraoperative cardiac arrest in the United States. METHODS: Hospital admissions involving patients ≥18 years of age who underwent operating room procedures in 2016 were identified using the National Inpatient Sample. The primary outcome was the incidence of intraoperative cardiac arrest. Secondary outcomes included total cost of admission, in-hospital mortality, length of stay, and identification of risk factors associated with intraoperative cardiac arrest. Clinical risk factors were evaluated with multivariable logistic regression models using sampling weights and adjustment for clustering by strata. RESULTS: Of 35,675,421 admissions in 2016 in the United States, 9,244,861 admissions were identified in patients ≥18 years of age who underwent at least one operating room procedure. An estimated 5230 hospital admissions involved intraoperative cardiac arrest, yielding an estimated incidence of 5.7 (95% confidence interval [CI], 5.3-6.0) per 10,000 hospital admissions. Admissions involving an intraoperative cardiac arrest had a 35.7% in-hospital mortality, compared with 1.3% for admissions without intraoperative cardiac arrest. Intraoperative cardiac arrest was associated with a 15.44-fold (95% CI, 12.74-18.70; P < .001) increase in the risk-adjusted odds of in-hospital mortality and an additional $13,184 (95% CI, 9600-16,769; P < .001) of total admission costs. Selected factors independently associated with increased risk-adjusted odds of intraoperative cardiac arrest included: black or missing race; cardiac, thoracic, or vascular surgery; congestive heart failure; pulmonary circulation disorders; peripheral vascular disease; end-stage renal disease; and fluid and electrolyte disorders. CONCLUSIONS: In this population-based study of intraoperative cardiac arrest in the United States, admissions involving an intraoperative cardiac arrest were rare but were associated with high in-hospital mortality.


Assuntos
Parada Cardíaca/epidemiologia , Pacientes Internados , Complicações Intraoperatórias/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Parada Cardíaca/diagnóstico , Parada Cardíaca/mortalidade , Mortalidade Hospitalar , Humanos , Incidência , Complicações Intraoperatórias/diagnóstico , Complicações Intraoperatórias/mortalidade , Masculino , Pessoa de Meia-Idade , Admissão do Paciente , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Estados Unidos/epidemiologia , Adulto Jovem
3.
Br J Surg ; 107(1): 121-130, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31802481

RESUMO

BACKGROUND: Transanal total mesorectal excision (TaTME) for rectal cancer has emerged as an alternative to the traditional abdominal approach. However, concerns have been raised about local recurrence. The aim of this study was to evaluate local recurrence after TaTME. Secondary aims included postoperative mortality, anastomotic leak and stoma rates. METHODS: Data on all patients who underwent TaTME were recorded and compared with those from national cohorts in the Norwegian Colorectal Cancer Registry (NCCR) and the Norwegian Registry for Gastrointestinal Surgery (NoRGast). Kaplan-Meier estimates were used to compare local recurrence. RESULTS: In Norway, 157 patients underwent TaTME for rectal cancer between October 2014 and October 2018. Three of seven hospitals abandoned TaTME after a total of five procedures. The local recurrence rate was 12 of 157 (7·6 per cent); eight local recurrences were multifocal or extensive. The estimated local recurrence rate at 2·4 years was 11·6 (95 per cent c.i. 6·6 to 19·9) per cent after TaTME compared with 2·4 (1·4 to 4·3) per cent in the NCCR (P < 0·001). The adjusted hazard ratio was 6·71 (95 per cent c.i. 2·94 to 15·32). Anastomotic leaks resulting in reoperation occurred in 8·4 per cent of patients in the TaTME cohort compared with 4·5 per cent in NoRGast (P = 0·047). Fifty-six patients (35·7 per cent) had a stoma at latest follow-up; 39 (24·8 per cent) were permanent. CONCLUSION: Anastomotic leak rates after TaTME were higher than national rates; local recurrence rates and growth patterns were unfavourable.


Assuntos
Recidiva Local de Neoplasia/mortalidade , Neoplasias Retais/cirurgia , Cirurgia Endoscópica Transanal/efeitos adversos , Idoso , Fístula Anastomótica/etiologia , Fístula Anastomótica/mortalidade , Enterostomia/mortalidade , Enterostomia/estatística & dados numéricos , Feminino , Humanos , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/mortalidade , Masculino , Pessoa de Meia-Idade , Noruega/epidemiologia , Segurança do Paciente , Protectomia/mortalidade , Protectomia/estatística & dados numéricos , Neoplasias Retais/mortalidade , Sistema de Registros , Cirurgia Endoscópica Transanal/mortalidade
4.
Acta Orthop ; 91(2): 152-158, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31833434

RESUMO

Background and purpose - There are reports on perioperative deaths in cemented total hip arthroplasty (THA), and THA revisions are associated with increased mortality. We compared perioperative (intraoperatively or within 3 days of surgery), short-term and long-term mortality after all-cemented, all-uncemented, reverse hybrid (cemented cup and uncemented stem), and hybrid (uncemented cup and cemented stem) THAs.Patients and methods - We studied THA patients in the Norwegian Arthroplasty Register from 2005 to 2018, and performed Kaplan-Meier and Cox survival analyses with time of death as end-point. Mortality was calculated for all patients, and in 3 defined risk groups: high-risk patients (age ≥ 75 years and ASA > 2), intermediate-risk patients (age ≥ 75 years or ASA > 2), low-risk patients (age < 75 years and ASA ≤ 2). We also calculated mortality in patients with THA due to a hip fracture, and in patients with commonly used, contemporary, well-documented THAs. Adjustement was made for age, sex, ASA class, indication, and year of surgery.Results - Among the 79,557 included primary THA patients, 11,693 (15%) died after 5.8 (0-14) years' follow-up. Perioperative deaths were rare (30/105) and found in all fixation groups. Perioperative mortality after THA was 4/105 in low-risk patients, 34/105 in intermediate-risk patients, and 190/105 in high-risk patients. High-risk patients had 9 (CI 1.3-58) times adjusted risk of perioperative death compared with low-risk patients. All 4 modes of fixation had similar adjusted 3-day, 30-day, 90-day, 3-30 day, 30-90 day, 90-day-10-year, and 10-year mortality risk.Interpretation - Perioperative, short-term, and long-term mortality after primary THA were similar, regardless of fixation type. Perioperative deaths were rare and associated with age and comorbidity, and not type of fixation.


Assuntos
Artroplastia de Quadril/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Artroplastia de Quadril/efeitos adversos , Artroplastia de Quadril/métodos , Cimentação/efeitos adversos , Cimentação/mortalidade , Comorbidade , Feminino , Seguimentos , Prótese de Quadril/efeitos adversos , Mortalidade Hospitalar , Humanos , Complicações Intraoperatórias/mortalidade , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Noruega/epidemiologia , Osteoartrite do Quadril/mortalidade , Osteoartrite do Quadril/cirurgia , Complicações Pós-Operatórias/mortalidade , Sistema de Registros , Medição de Risco/métodos , Fatores de Risco
5.
Neurol India ; 67(6): 1423-1428, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31857527

RESUMO

Background: Carotid artery stenosis (CAS) is being recognized as an effective alternative for carotid endarterectomy (CEA). CAS is especially preferred over CEA in high-risk surgical patients with severe carotid stenosis. However, CAS carries an increased risk of stroke and transient ischemic attack (TIA). Objective: To assess the association between periprocedural stroke/TIA and 30-day mortality in carotid stenosis patients undergoing CAS. Methods: We searched PubMed, Embase, and World Science for relevant publications. Studies reporting on perioperative neurologic status (stroke/TIA) and 30-day mortality in patients undergoing CAS were included. Sensitivity, specificity, pooled odds ratio (OR), and relative risk (RR) of perioperative stroke in predicting 30-day mortality following CAS were calculated. Results: 146 studies with 156,854 patients were included in the meta-analysis. The mean patient age was 70.7 years, and 57.6% were males. Only 26.5% of the CAS cohort were symptomatic and 15.2% had bilateral carotid disease. The incidence of perioperative TIA and stroke were 2.4 and 2.7 per 100 CAS procedure, respectively. Around 11.8% of stroke-events were fatal. The pooled OR of 30-day mortality after perioperative stroke was 24.58 (95% CI, 19.92-30.32) and the pooled RR was 21.65 (95% CI, 17.87-26.22). Perioperative stroke had a sensitivity of 42.0% (95% CI 37.8-46.4%) and specificity of 97.0% (95% CI 96.7-97.3%) in predicting 30-day mortality. Conclusions: Perioperative stroke drastically increases the risk of 30-day mortality. The occurrence of perioperative stroke exhibited high specificity but modest sensitivity in predicting 30-day mortality following CAS. This highlights the importance of neurophysiologic monitoring to detect intraoperative cerebral ischemia and perform timely interventions.


Assuntos
Estenose das Carótidas/cirurgia , Stents/efeitos adversos , Acidente Vascular Cerebral/etiologia , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Humanos , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/mortalidade , Prognóstico , Fatores de Risco , Acidente Vascular Cerebral/mortalidade , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/mortalidade
6.
Sci Rep ; 9(1): 14975, 2019 10 18.
Artigo em Inglês | MEDLINE | ID: mdl-31628390

RESUMO

Data on predictors of intraoperative cardiac arrest (ICA) outcomes are scarce in the literature. This study analysed predictors of poor outcome and their prognostic value after an ICA. Clinical and laboratory data before and 24 hours (h) after ICA were analysed as predictors for no return of spontaneous circulation (ROSC) and 24 h and 1-year mortality. Receiver operating characteristic curves for each predictor and sensitivity, specificity, positive and negative likelihood ratios, and post-test probability were calculated. A total of 167,574 anaesthetic procedures were performed, including 158 cases of ICAs. Based on the predictors for no ROSC, a threshold of 13 minutes of ICA yielded the highest area under curve (AUC) (0.867[0.80-0.93]), with a sensitivity and specificity of 78.4% [69.6-86.3%] and 89.3% [80.4-96.4%], respectively. For the 1-year mortality, the GCS without the verbal component 24 h after an ICA had the highest AUC (0.616 [0.792-0.956]), with a sensitivity of 79.3% [65.5-93.1%] and specificity of 86.1 [74.4-95.4]. ICA duration and GCS 24 h after the event had the best prognostic value for no ROSC and 1-year mortality. For 24 h mortality, no predictors had prognostic value.


Assuntos
Parada Cardíaca/epidemiologia , Parada Cardíaca/mortalidade , Complicações Intraoperatórias/epidemiologia , Complicações Intraoperatórias/mortalidade , Adulto , Idoso , Anestesia Geral , Área Sob a Curva , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Prevalência , Probabilidade , Prognóstico , Curva ROC , Estudos Retrospectivos , Fatores de Risco , Sensibilidade e Especificidade
7.
Br J Anaesth ; 123(5): 618-626, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31540668

RESUMO

BACKGROUND: Preoperative hyponatraemia is an independent risk factor for postoperative mortality in adults. To our knowledge, this has not been investigated in children. METHODS: Using data from the 2014 and 2015 data sets of the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-P), we conducted a retrospective study of children undergoing surgery. The primary outcome was 30-day all-cause mortality. The secondary outcomes of interest were postoperative seizure within 30 days and prolonged length of stay. To identify any independent association between preoperative hyponatraemia, defined as mild (serum sodium of 131-135 mEq L-1) or severe (≤130 mEq L-1), and death, postoperative seizures, or prolonged length of stay, multivariable logistic regression models were generated. RESULTS: A total of 152 894 patients were identified, and of these 35 291 were included in the final analysis. Preoperative hyponatraemia was present in 5422 patients or 15.4% of the final cohort. There were 432 (0.80%) deaths at 30 days. Compared with patients with a normal preoperative sodium concentration, those with mild (P=0.003; odds ratio [OR]: 1.59; 95% confidence interval [CI]: 1.17-2.18) and severe (P=0.002; OR: 2.16; 95% CI: 1.32-3.54) hyponatraemia had increased rates of death, after adjusting for co-morbidity and procedural complexity. Both mild (P<0.001; OR: 1.53; 95% CI: 1.42-1.65) and severe (P<0.001; OR: 1.51; 95% CI: 1.19-1.93) hyponatraemia were independently associated with prolonged length of stay, after adjusting for relevant co-variates. CONCLUSIONS: This retrospective analysis identified an association between preoperative hyponatraemia and perioperative mortality and length of stay in paediatric patients.


Assuntos
Hiponatremia/mortalidade , Complicações Intraoperatórias/mortalidade , Complicações Pós-Operatórias/mortalidade , Período Pré-Operatório , Chicago/epidemiologia , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Estudos Retrospectivos , Fatores de Risco
8.
Bone Joint J ; 101-B(9): 1129-1137, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31474142

RESUMO

AIMS: The aim of this study was to investigate mortality and risk of intraoperative medical complications depending on delay to hip fracture surgery by using data from the Norwegian Hip Fracture Register (NHFR) and the Norwegian Patient Registry (NPR). PATIENTS AND METHODS: A total of 83 727 hip fractures were reported to the NHFR between 2008 and 2017. Pathological fractures, unspecified type of fractures or treatment, patients less than 50 years of age, unknown delay to surgery, and delays to surgery of greater than four days were excluded. We studied total delay (fracture to surgery, n = 38 754) and hospital delay (admission to surgery, n = 73 557). Cox regression analyses were performed to calculate relative risks (RRs) adjusted for sex, age, American Society of Anesthesiologists (ASA) classification, type of surgery, and type of fracture. Odds ratio (OR) was calculated for intraoperative medical complications. We compared delays of 12 hours or less, 13 to 24 hours, 25 to 36 hours, 37 to 48 hours, and more than 48 hours. RESULTS: Mortality remained unchanged when total delay was less than 48 hours. Total delay exceeding 48 hours was associated with increased three-day mortality (RR 1.69, 95% confidence interval (CI) 1.23 to 2.34; p = 0.001) and one-year mortality (RR 1.06, 95% CI 1.04 to 1.22; p = 0.003). More intraoperative medical complications were reported when hospital delay exceeded 24 hours. CONCLUSION: Hospitals should operate on patients within 48 hours after fracture to reduce mortality and intraoperative complications. Cite this article: Bone Joint J 2019;101-B:1129-1137.


Assuntos
Artroplastia de Quadril/mortalidade , Fixação Interna de Fraturas/mortalidade , Fraturas do Quadril/mortalidade , Fraturas do Quadril/cirurgia , Complicações Intraoperatórias/mortalidade , Tempo para o Tratamento/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Artroplastia de Quadril/estatística & dados numéricos , Feminino , Fixação Interna de Fraturas/estatística & dados numéricos , Hemiartroplastia/estatística & dados numéricos , Fraturas do Quadril/epidemiologia , Hospitalização/estatística & dados numéricos , Humanos , Complicações Intraoperatórias/epidemiologia , Complicações Intraoperatórias/etiologia , Masculino , Noruega/epidemiologia , Sistema de Registros/estatística & dados numéricos , Fatores de Risco
9.
Biomed Res Int ; 2019: 4572130, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31467891

RESUMO

Purpose: Acute kidney injury (AKI) is a major and severe complication following donation-after-circulatory-death (DCD) liver transplantation (LT) and is associated with increased postoperative morbidity and mortality. However, the risk factors and the prognosis factors of AKI still need to be further explored, and the relativity of intraoperative hepatic blood inflow (HBI) and AKI following LT has not been discussed yet. The purpose of this study was to investigate the correlation between HBI and AKI and to construct a prediction model of early acute kidney injury (EAKI) following DCD LT with the combination of HBI and other clinical parameters. Methods: Clinical data of 132 patients who underwent DCD liver transplantation at the first hospital of China Medical University from April 2005 to March 2017 were analyzed. Data of 105 patients (the first ten years of patients) were used to develop the prediction model. Then we assessed the clinical usefulness of the prediction models in the validation cohort (27 patients). EAKI according to Kidney Disease Improving Global Outcomes (KDIGO) criteria based on serum creatinine increase during 7-day of postoperative follow-up. Results: After Least Absolute Shrinkage and Selection Operator (LASSO) regression and simplification, a simplified prediction model consisting of the Child-Turcotte-Pugh (CTP) score (p=0.033), anhepatic phase (p=0.014), packed red blood cell (pRBC) transfusion (p=0.027), and the HBI indexed by height (HBI/h) (p=0.002) was established. The C-indexes of the model in the development and validation cohort were 0.823 [95% CI, 0.738-0.908] and 0.921 [95% CI, 0.816-1.000], respectively. Conclusions: In this study, we demonstrated the utility of HBI/h as a predictor for EAKI following DCD LT, as well as the clinical usefulness of the prediction model through the combination of the CTP score, anhepatic phase, pRBC transfusion and HBI/h.


Assuntos
Lesão Renal Aguda/diagnóstico , Complicações Intraoperatórias/diagnóstico , Transplante de Fígado/efeitos adversos , Fígado/irrigação sanguínea , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/mortalidade , Adulto , Creatinina/metabolismo , Feminino , Sobrevivência de Enxerto , Humanos , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/mortalidade , Fígado/patologia , Masculino , Pessoa de Meia-Idade , Medição de Risco , Fatores de Risco , Obtenção de Tecidos e Órgãos
10.
J Surg Oncol ; 120(4): 603-610, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31292970

RESUMO

BACKGROUND: Gallbladder adenocarcinoma is often incidentally identified following cholecystectomy. We hypothesized that intraoperative bile spillage would be a negative prognostic factor. METHODS: A retrospective review of patients treated at a cancer center with histologically confirmed gallbladder adenocarcinoma, 2009-2017, was performed. Patient, disease, and treatment factors were analyzed in terms of progression-free survival (PFS) and overall survival (OS). RESULTS: Sixty-six patients were identified. Tumor stage was T1 (n = 8, 12%), T2 (n = 23, 35%), T3 (n = 35, 53%). Node stage was N0 (n = 22, 33%), N1+ (n = 26, 39%), Nx (n = 18, 27%). Operations included cholecystectomy alone (n = 27, 36%), cholecystectomy and partial hepatectomy (n = 30, 45%), or hepaticojejunostomy (n = 9, 14%). Median PFS was 7 months (interquartile range [IQR], 2-19); median OS was 16 months (IQR, 10-31). Subset multivariate proportional hazards regression of 41 patients who underwent initial cholecystectomy showed decreased PFS was associated with intraoperative spillage (n = 12, 29%; hazard ratio [HR], 5.5; P = .0014); decreased OS was associated with drain placement (n = 21, 51%; HR, 8.1; P = .006). CONCLUSIONS: Intraoperative bile spillage and surgical drain placement at initial cholecystectomy are negatively associated with PFS and OS in gallbladder adenocarcinoma. Explicit documentation of spillage and drain placement rationale is critical, possibly indicating locally advanced disease and prompting stronger consideration of systemic therapy before definitive resection.


Assuntos
Adenocarcinoma/mortalidade , Bile , Colecistectomia/mortalidade , Neoplasias da Vesícula Biliar/mortalidade , Vesícula Biliar/lesões , Complicações Intraoperatórias/mortalidade , Adenocarcinoma/patologia , Adenocarcinoma/cirurgia , Idoso , Feminino , Seguimentos , Neoplasias da Vesícula Biliar/patologia , Neoplasias da Vesícula Biliar/cirurgia , Humanos , Achados Incidentais , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida
11.
Int J Cardiol ; 293: 80-83, 2019 10 15.
Artigo em Inglês | MEDLINE | ID: mdl-31281048

RESUMO

BACKGROUND: Despite advancements in the safety of transcatheter aortic valve replacement (TAVR) resulting in progressively wider indications, adverse periprocedural outcomes still raise concern. Real-world outcome data are thus of primary importance to evaluate the procedural risk-benefit trade-off in the continuously changing populations undergoing TAVR. METHODS: We retrospectively assessed 1348 consecutive patients undergoing TAVR between 2007 and 2017. The primary endpoint was a composite of procedural mortality and need for conversion to emergent surgery, as defined by the Valve Academic Research Consortium-2 criteria. Temporal trends in baseline characteristics and outcomes were evaluated. The independent outcomes predictors were assessed through multivariate regression analysis. RESULTS: A total of 56 (4.1%) patients experienced the primary endpoint. 47 (3.5%) patients died during hospital stay, 19 (1.4%) within 72 h from the procedure. 17 patients (1.2%) needed an emergent conversion to open surgery, of whom 7 (41.2%) did not survive. Significant temporal trends of increasing mean age (from 79.4 ±â€¯7.4 to 81 ±â€¯7.5, p = 0.007) and decreasing surgical risk (mean STS: from 9 ±â€¯9.5 to 7.1 ±â€¯9.8, p = 0.010) were observed. When dichotomized at the median procedural date (year 2014), a significant reduction in the occurrence of the primary endpoint in more recent years was observed (3.0% vs 5.2%, p = 0.041). This was the single primary endpoint independent predictor at multivariate analysis. CONCLUSION: The high-volume 10-year experience in TAVR procedures at our center shows encouraging trends in procedural mortality reduction, which anyhow still occurs at a non-negligible rate, calling for further research to detect and to blunt the determinant of early procedural events.


Assuntos
Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/cirurgia , Hospitais com Alto Volume de Atendimentos/tendências , Complicações Intraoperatórias/mortalidade , Substituição da Valva Aórtica Transcateter/mortalidade , Substituição da Valva Aórtica Transcateter/tendências , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/diagnóstico , Feminino , Mortalidade Hospitalar/tendências , Humanos , Complicações Intraoperatórias/diagnóstico , Masculino , Mortalidade/tendências , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
12.
World Neurosurg ; 129: e776-e781, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31289000

RESUMO

OBJECTIVE: To identify predictors of short-term mortality and complications after anterior odontoid screw fixation. METHODS: This was a retrospective analysis of a national database. The American College of Surgeons National Quality Improvement Database was queried using Current Procedural Terminology codes to identify patients aged ≥60 years who underwent surgery for anterior fixation of odontoid fracture admitted from 2007 to 2016. Univariate analysis and subsequent multivariate analysis were used to analyze risk factors for postoperative complications and 30-day postoperative mortality. Complications were defined as surgical-site infection, wound breakdown, pneumonia, venous thromboembolism, stroke, myocardial infarction, sepsis, renal progressive renal insufficiency/acute kidney injury, or cardiac arrest. RESULTS: A total of 198 patients were identified. Mean age was 77.7 (±8.7) years and 60.6% were female. Overall mortality rate was 7.6%, and the complication rate was 9.1%. In multivariate analysis, dependent functional status (0.012; odds ratio [OR] 5.2; 95% confidence interval [CI] 1.42-18.72) and preoperative systemic inflammatory response syndrome (P = 0.011; OR 6.2; 95% CI 1.52-25.79) predicted mortality. Emergency case status (P = 0.033; OR 3.4; 95% CI 1.10-10.70) predicted perioperative complications. Age was not significantly associated with either complications or mortality in multivariate analysis. CONCLUSIONS: Functional dependence and preoperative systemic inflammatory response syndrome predict mortality following odontoid screw placement. Although age often is considered a limiting factor in pursuing surgical intervention in patients with odontoid fracture, age did not independently increase odds of either complications or perioperative mortality in this analysis. Further studies are needed to explore these findings.


Assuntos
Fixação Interna de Fraturas/efeitos adversos , Complicações Intraoperatórias/mortalidade , Processo Odontoide/cirurgia , Complicações Pós-Operatórias/mortalidade , Idoso , Idoso de 80 Anos ou mais , Parafusos Ósseos/efeitos adversos , Bases de Dados Factuais , Feminino , Fixação Interna de Fraturas/mortalidade , Humanos , Complicações Intraoperatórias/etiologia , Masculino , Processo Odontoide/lesões , Complicações Pós-Operatórias/etiologia , Fraturas da Coluna Vertebral/cirurgia
13.
Anesth Analg ; 128(6): 1286-1291, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31094801

RESUMO

BACKGROUND: Surgical care is essential to improving population health, but metrics to monitor and evaluate the continuum of surgical care delivery have rarely been applied in low-resource settings, and improved efforts at benchmarking progress are needed. The objective of this study was to measure the intraoperative mortality at a Central Referral Hospital in Malawi, evaluate whether there have been changes in intraoperative mortality between 2 time periods, and assess factors associated with intraoperative mortality. METHODS: This was a retrospective cohort study of patients undergoing surgery at Kamuzu Central Hospital in Lilongwe, Malawi. Data describing daily consecutive operative cases were collected prospectively during 2 time periods: 2004-2006 (early cohort) and 2015-2016 (late cohort). The primary outcome was intraoperative mortality. Inverse probability of treatment weighting was used to analyze the association of intraoperative mortality with time using logistic regression models. Multivariable logistic models were performed to evaluate factors associated with intraoperative mortality. RESULTS: There were 21,090 surgeries performed during the 2 time periods, with 15,846 (75%) and 5244 (25%) completed from 2004 to 2006 and 2015 to 2016, respectively. Intraoperative mortality in the early cohort was 57 deaths per 100,000 surgeries (95% confidence interval [CI], 26-108) and in the late cohort was 133 per 100,000 surgeries (95% CI, 56-286), with 76 per 100,000 surgeries (95% CI, 44-124) overall. After applying inverse probability of treatment weighting, there was no evidence of an association between time periods and intraoperative mortality (odds ratio [OR], 1.6; 95% CI, 0.9-2.8; P = .08). Factors associated with intraoperative mortality, adjusting for demographics, included American Society of Anesthesiology physical status III or IV versus I or II (OR, 4.4; 95% CI, 1.5-12.5; P = .006) and emergency versus elective surgery (OR, 7.7; 95% CI, 2.5-23.6; P < .001). CONCLUSIONS: Intraoperative mortality in the study hospital in Malawi is high and has not improved over time. These data demonstrate an urgent need to improve the safety and quality of perioperative care in developing countries and integrate perioperative care into global health efforts.


Assuntos
Anestesia/efeitos adversos , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Tratamento de Emergência/efeitos adversos , Mortalidade Hospitalar , Complicações Intraoperatórias/mortalidade , Assistência Perioperatória , Tempo para o Tratamento/estatística & dados numéricos , Adolescente , Adulto , Idoso , Benchmarking , Criança , Pré-Escolar , Feminino , Hospitais , Humanos , Lactente , Modelos Logísticos , Malaui , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Estudos Prospectivos , Estudos Retrospectivos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Resultado do Tratamento , Adulto Jovem
14.
World J Surg ; 43(8): 1880-1889, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30953195

RESUMO

BACKGROUND: Approximately 5 billion people do not have access to safe, timely, and affordable surgical and anesthesia care, with this number disproportionately affecting those from low-middle-income countries (LMICs). Perioperative mortality rates (POMRs) have been identified by the World Health Organization as a potential health metric to monitor quality of surgical care provided. The purpose of this systematic review was to evaluate published reports of POMR and suggest recommendations for its appropriate use as a health metric. METHODS: The protocol was registered a priori with PROSPERO. A peer-reviewed search strategy was developed adhering with the PRISMA guidelines. Relevant articles were identified through Medline, Embase, CENTRAL, CDSR, LILACS, PubMed, BIOSIS, Global Health, Africa-Wide Information, Scopus, and Web of Science databases. Two independent reviewers performed a primary screening analysis based on titles and abstracts, followed by a full-text screen. Studies describing POMRs of adult emergency abdominal surgeries in LMICs were included. RESULTS: A total of 7787 articles were screened of which 7466 were excluded based on title and abstract. Three hundred and twenty-one articles entered full-text screen of which 70 articles met the inclusion criteria. Variables including timing of POMR reporting, intraoperative mortality, length of hospital stay, complication rates, and disease severity score were collected. Complication rates were reported in 83% of studies and postoperative stay in 46% of studies. 40% of papers did not report the specific timing of POMR collection. 7% of papers reported on intraoperative death. Additionally, 46% of papers used a POMR timing specific to the duration of their study. Vital signs were discussed in 24% of articles, with disease severity score only mentioned in 20% of studies. CONCLUSION: POMR is an important health metric for quantifications of quality of care of surgical systems. Further validation and standardization are necessary to effectively use this health metric.


Assuntos
Abdome Agudo/cirurgia , Período Perioperatório/mortalidade , Indicadores de Qualidade em Assistência à Saúde , Abdome Agudo/mortalidade , Anestesia/normas , Acesso aos Serviços de Saúde/normas , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Renda , Complicações Intraoperatórias/mortalidade , Tempo de Internação/estatística & dados numéricos , Complicações Pós-Operatórias/mortalidade , Procedimentos Cirúrgicos Operatórios/mortalidade , Procedimentos Cirúrgicos Operatórios/normas
15.
J Am Acad Orthop Surg ; 27(7): 256-263, 2019 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-30897607

RESUMO

INTRODUCTION: Large cohort studies evaluating cardiac complications in patients undergoing spine surgery are lacking. The purpose of this study was to determine the incidence, timing, risk factors, and effect of cardiac complications in spine surgery by using a national database, the American College of Surgeons National Surgical Quality Improvement Program. METHODS: Patients who underwent spine surgery in the 2005 to 2012 National Surgical Quality Improvement Program database were identified. The primary outcome was an occurrence of cardiac arrest or myocardial infarction during the operation or the 30-day postoperative period. Risk factors for development of cardiac complications were identified using multivariate regression. The postoperative length of stay, 30-day readmission, and mortality were compared between patients who did and did not experience a cardiac complication. RESULTS: A total of 30,339 patients who underwent spine surgery were identified. The incidence of cardiac complications was 0.34% (95% confidence interval [CI], 0.27% to 0.40%). Of the cases in which a cardiac complication developed, 30% were diagnosed after discharge. Risk factors for the development of cardiac complications were greater age (most notably ≥80 years, relative risk [RR] = 5.53; 95% CI = 2.28 to 13.43; P < 0.001), insulin-dependent diabetes (RR = 2.58; 95% CI = 1.51 to 4.41; P = 0.002), preoperative anemia (RR = 2.46; 95% CI = 1.62 to 3.76; P < 0.001), and history of cardiac disorders and treatments (RR = 1.88; 95% CI = 1.16 to 3.07; P = 0.011). Development of a cardiac complication before discharge was associated with a greater length of stay (7.9 versus 2.6 days; P < 0.001), and a cardiac complication after discharge was associated with increased 30-day readmission (RR = 12.32; 95% CI = 8.17 to 18.59; P < 0.001). Development of a cardiac complication any time during the operation or 30-day postoperative period was associated with increased mortality (RR = 113.83; 95% CI = 58.72 to 220.68; P < 0.001). DISCUSSION: Perioperative cardiac complications were diagnosed in approximately 1 in 300 patients undergoing spine surgery. High-risk patients should be medically optimized and closely monitored through the perioperative period. LEVEL OF EVIDENCE: Level III.


Assuntos
Parada Cardíaca/epidemiologia , Complicações Intraoperatórias/epidemiologia , Infarto do Miocárdio/epidemiologia , Procedimentos Ortopédicos , Complicações Pós-Operatórias/epidemiologia , Coluna Vertebral/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Parada Cardíaca/mortalidade , Parada Cardíaca/prevenção & controle , Humanos , Incidência , Complicações Intraoperatórias/mortalidade , Complicações Intraoperatórias/prevenção & controle , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica , Análise Multivariada , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/prevenção & controle , Procedimentos Ortopédicos/mortalidade , Procedimentos Ortopédicos/estatística & dados numéricos , Readmissão do Paciente , Período Perioperatório , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/prevenção & controle , Fatores de Risco , Fatores de Tempo , Adulto Jovem
16.
J Pediatr Surg ; 54(10): 2112-2116, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30765156

RESUMO

BACKGROUND/OBJECTIVES: Variations in vascular anatomy (VIVAs) of the retroperitoneal great vessels are uncommon but can potentially complicate surgical procedures and negatively affect treatment outcomes, yet their incidence and clinical impact are poorly studied. We sought to assess the incidence and clinical impact of VIVAs of retroperitoneal great vessels in patients with retroperitoneal tumors. METHODS: We retrospectively analyzed imaging, surgical, treatment and survival data of all pediatric patients with retroperitoneal tumors who underwent resection between January 2007 and October 2016, comparing preoperative scans with corresponding intraoperative observations, and subsequent surgical outcomes. RESULTS: Among 66 children with renal, adrenal and paravertebral tumors, 6 (9%) had retroperitoneal VIVAs. Retroperitoneal VIVAs were present only with right-sided tumors and significantly associated with more frequent intraoperative complications (P = 0.013). While the presence of retroperitoneal VIVAs was not directly associated with survival outcomes, relapse was more frequent in patients with VIVAs (33%) than those without (18.3%, P = 0.378), and relapse was also associated with lower overall and event-free survival (P < 0.001). CONCLUSIONS: VIVAs of retroperitoneal great vessels occurred in 9% of our patients with retroperitoneal tumors. Retroperitoneal VIVAs were associated with higher rates of intraoperative complications and disease relapse but was not directly related to survival outcomes. TYPE OF STUDY: Retrospective review study. LEVEL OF EVIDENCE: Level III Retrospective comparative study.


Assuntos
Neoplasias Retroperitoneais/cirurgia , Espaço Retroperitoneal/irrigação sanguínea , Malformações Vasculares/patologia , Adolescente , Neoplasias das Glândulas Suprarrenais/mortalidade , Neoplasias das Glândulas Suprarrenais/patologia , Neoplasias das Glândulas Suprarrenais/secundário , Criança , Pré-Escolar , Intervalo Livre de Doença , Feminino , Humanos , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/mortalidade , Complicações Intraoperatórias/patologia , Neoplasias Renais/mortalidade , Neoplasias Renais/patologia , Neoplasias Renais/cirurgia , Masculino , Recidiva Local de Neoplasia/mortalidade , Recidiva Local de Neoplasia/patologia , Neoplasias Retroperitoneais/mortalidade , Neoplasias Retroperitoneais/patologia , Estudos Retrospectivos , Neoplasias da Coluna Vertebral/mortalidade , Neoplasias da Coluna Vertebral/patologia , Neoplasias da Coluna Vertebral/cirurgia , Resultado do Tratamento , Malformações Vasculares/mortalidade
17.
Clin Transl Oncol ; 21(9): 1197-1206, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30689183

RESUMO

BACKGROUND: Whether intraoperative blood loss (IBL) was independently associated with poor prognosis of gastric cancer (GC) patients remains controversial. In the present study, we evaluated the impact of IBL on the disease-free survival (DFS) of GC patients. METHODS: A total of 1669 patients who underwent curative gastrectomy for GC were reviewed retrospectively. All patients were classified as IBL < 400 mL and IBL ≥ 400 mL group according to the amount of IBL. The prognostic difference between two patient groups was compared and clinicopathologic factors associated with the prognosis of GC patients were analyzed. RESULTS: The 5-year DFS rate of the patients with IBL < 400 mL and those with IBL ≥ 400 mL was 52.1% and 41.5%, respectively (P < 0.001). The 5-year DFS rate of the patients who did and did not receive intraoperative blood transfusion was 36.9% and 53.2%, respectively (P < 0.001). However, the similar survival outcomes were not observed in the subgroup analysis based on the TNM stage. The multivariate analysis indicated that IBL (HR 1.021, 95% CI 0.875-1.191, P > 0.05) and intraoperative blood transfusion (HR 1.111, 95% CI 0.943-1.309, P > 0.05) were not independent prognostic factors for GC patients. In addition, the patients with IBL ≥ 400 mL had a higher risk of postoperative complications than those with IBL < 400 mL, especially for intraabdominal infection and wound infection. The tumor located in upper 1/3 stomach, total gastrectomy, combined organ resection and advanced tumor stage (stage III) were independent risk factors for intraoperative massive hemorrhage. CONCLUSION: Intraoperative blood loss was significantly associated with tumor-related and surgery-related factors. Intraoperative blood loss itself could not independently affect survival outcome of GC patients after curative gastrectomy.


Assuntos
Perda Sanguínea Cirúrgica/mortalidade , Transfusão de Sangue/métodos , Gastrectomia/mortalidade , Complicações Intraoperatórias/mortalidade , Neoplasias Gástricas/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Perda Sanguínea Cirúrgica/prevenção & controle , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Neoplasias Gástricas/patologia , Neoplasias Gástricas/cirurgia , Taxa de Sobrevida , Adulto Jovem
19.
J Am Acad Orthop Surg ; 27(10): 375-380, 2019 May 15.
Artigo em Inglês | MEDLINE | ID: mdl-30461519

RESUMO

INTRODUCTION: We determined mortality rates after intraoperative and postoperative periprosthetic femur fractures in primary and revision total hip arthroplasty (THA). METHODS: The study population comprised 522 intraoperative and 480 postoperative femur fractures in 26,250 primary THA patients and 590 intraoperative and 224 postoperative femur fractures in 4,532 revision THA patients. The risk of death was examined using Cox regression models. RESULTS: In primary THA, intraoperative periprosthetic femur fractures were not associated with excess risk of death (hazard ratio, 1.03; 95% confidence interval, 0.86 to 1.22). The risk of death was slightly elevated among primary THA patients with postoperative femur fractures (hazard ratio, 1.19; 95% confidence interval, 1.08 to 1.43), but the excess risk was only confined to patients with comorbid orthopaedic conditions. In revision THA, neither intraoperative nor postoperative periprosthetic femur fractures were associated with excess risk of death. CONCLUSION: Periprosthetic femur fractures are not associated with excess mortality among primary osteoarthritis patients. LEVEL OF EVIDENCE: Level III.


Assuntos
Artroplastia de Quadril/efeitos adversos , Fraturas do Fêmur/etiologia , Fraturas do Fêmur/mortalidade , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/mortalidade , Fraturas Periprotéticas/etiologia , Fraturas Periprotéticas/mortalidade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Reoperação/efeitos adversos , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Risco
20.
Anesthesiology ; 130(1): 72-82, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30312182

RESUMO

BACKGROUND: Triple-low events (mean arterial pressure less than 75 mmHg, Bispectral Index less than 45, and minimum alveolar fraction less than 0.8) are associated with mortality but may not be causal. This study tested the hypothesis that providing triple-low alerts to clinicians reduces 90-day mortality. METHODS: Adults having noncardiac surgery with volatile anesthesia and Bispectral Index monitoring were electronically screened for triple-low events. Patients having triple-low events were randomized in real time, with clinicians either receiving an alert, "consider hemodynamic support," or not. Patients were blinded to treatment. Helpful responses to triple-low events were defined by administration of a vasopressor within 5 min or a 20% reduction in end-tidal volatile anesthetic concentration within 15 min. RESULTS: Of the qualifying patients, 7,569 of 36,670 (20%) had triple-low events and were randomized. All 7,569 were included in the primary analysis. Ninety-day mortality was 8.3% in the alert group and 7.3% in the nonalert group. The hazard ratio (95% CI) for alert versus nonalert was 1.14 (0.96, 1.35); P = 0.12, crossing a prespecified futility boundary. Clinical responses were helpful in about half the patients in each group, with 51% of alert patients and 47% of nonalert patients receiving vasopressors or having anesthetics lowered after start of triple low (P < 0.001). There was no relationship between the response to triple-low events and adjusted 90-day mortality. CONCLUSIONS: Real-time alerts to triple-low events did not lead to a reduction in 90-day mortality, and there were fewer responses to alerts than expected. However, similar mortality with and without responses suggests that there is no strong relationship between responses to triple-low events and mortality.


Assuntos
Pressão Arterial/fisiologia , Monitores de Consciência/estatística & dados numéricos , Hipotensão/diagnóstico , Hipotensão/mortalidade , Complicações Intraoperatórias/diagnóstico , Complicações Intraoperatórias/mortalidade , Monitorização Intraoperatória/métodos , Feminino , Humanos , Hipotensão/fisiopatologia , Complicações Intraoperatórias/fisiopatologia , Masculino , Pessoa de Meia-Idade
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