Association between Complications and Death within 30 days after General Surgery: A Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) substudy.

OBJECTIVE: To determine the epidemiology of post-operative complications among general surgery patients, inform their relationships with 30-day mortality, and determine the attributable fraction of death of each postoperative complication. BACKGROUND: The contemporary causes of post-operative mortality among general surgery patients are not well characterized. METHODS: VISION is a prospective cohort study of adult non-cardiac surgery patients across 28 centres in 14 countries, who were followed for 30 days after surgery. For the subset of general surgery patients, a cox proportional hazards model was used to determine associations between various surgical complications and post-operative mortality. The analyses were adjusted for preoperative and surgical variables. Results were reported in adjusted hazard ratios (HR) with 95% confidence intervals (CI). RESULTS: Among 7950 patients included in the study, 240 (3.0%) patients died within 30 days of surgery. Five post-operative complications (myocardial injury after non-cardiac surgery [MINS], major bleeding, sepsis, stroke, and acute kidney injury resulting in dialysis) were independently associated with death. Complications associated with the largest attributable fraction (AF) of post-operative mortality (i.e., percentage of deaths in the cohort that can be attributed to each complication, if causality were established) were major bleeding (n=1454, 18.3%, HR 2.49 95%CI 1.87-3.33, P<0.001, AF 21.2%), sepsis (n=783, 9.9%, HR 6.52, 95%CI 4.72-9.01, P<0.001, AF 15.6%), and MINS (n=980, 12.3%, HR 2.00, 95%CI 1.50-2.67, P<0.001, AF 14.4%). CONCLUSION: The complications most associated with 30-day mortality following general surgery are major bleeding, sepsis, and MINS. These findings may guide the development of mitigating strategies, including prophylaxis for perioperative bleeding.

Impact of the acute care surgery model on resident operative experience in emergency general surgery.

Background: The acute care surgery (ACS) model has been shown to improve patient, hospital and surgeon-specific outcomes. To date, however, little has been published on its impact on residency training. Our study compared the emergency general surgery (EGS) operative experiences of residents assigned to ACS versus elective surgical rotations. Methods: Resident-reported EGS case logs were prospectively collected over a 9-month period across 3 teaching hospitals. Descriptive statistics were tabulated and group comparisons were made using χ2 statistics for categorical data and t tests for continuous data. Results: Overall, 1061 cases were reported. Resident participation exceeded 90%). Appendiceal and biliary disease accounted for 49.7% of EGS cases. Residents on ACS rotations reported participating in twice as many EGS cases per block as residents on elective rotations (12.64 v. 6.30 cases, p < 0.01). Most cases occurred after hours while residents were on call rather than during daytime ACS hours (78.8% v. 21.1%, p < 0.01). Senior residents were more likely than junior residents to report having a primary operator role (71.3% v. 32.0%, p < 0.01). Although the timing of cases made no difference in the operative role of senior residents, junior residents assumed the primary operator role more often during the daytime than after hours (50.0% v. 33.1%, p = 0.01). Conclusion: Despite implementation of the ACS model, residents in our program obtained most of their EGS operative experience after hours while on call. Although further research is needed, our study suggests that improved daytime access to the operating room may represent an opportunity to improve the quantity and quality of the EGS operative experience at our academic network.

Contexte: Il a été prouvé que le modèle de chirurgie en soins actifs (CSA) améliore les résultats pour le patient, l'hôpital et le chirurgien. Pour le moment, peu de publications s'intéressent aux effets de ce modèle sur les résidents. Notre étude compare l'expérience des chirurgies générales d'urgence (CGU) chez les résidents effectuant un stage en CSA et chez les résidents effectuant un stage optionnel en chirurgie. Méthodes: Les cas de CGU rapportés par les résidents ont été recueillis de manière prospective pendant 9 mois dans 3 hôpitaux universitaires. Les statistiques descriptives ont été compilées, et les 2 groupes ont été comparés à l'aide du test du χ2 pour les variables catégorielles et du test t pour les variables continues. Résultats: En tout, 1061 cas ont été rapportés (la participation des résidents était de plus de 90 %). Les atteintes de l'appendice et de la vésicule biliaire représentaient 49,7 % des CGU. Les résidents en CSA ont indiqué participer à 2 fois plus de CGU que les résidents en stage optionnel (12,64 c. 6,30 cas, p < 0,01). La plupart des CGU se sont produites en dehors des heures normales, alors que les résidents étaient de garde, plutôt que pendant les heures de CSA (78,8 % c. 21,1 %, p < 0,01). Les médecins résidents finissants étaient plus susceptibles d'indiquer avoir tenu le rôle de chirurgien principal que les résidents en début de parcours (71,3 % c. 32,0 %, p < 0,01). Le moment des chirurgies ne faisait aucune différence pour ce qui est du rôle des résidents finissants, mais les résidents en début de parcours ont davantage assumé le rôle de chirurgien principal pendant les heures de CSA que pendant les périodes de garde (50,0 % c. 33,1 %, p < 0,01). Conclusion: Malgré l'adoption du modèle de CSA, les résidents de notre programme ont acquis la majorité de leur expérience en CGU en dehors des heures normales, alors qu'ils étaient de garde. Bien que d'autres études soient nécessaires, notre étude laisse croire qu'un meilleur accès aux salles d'opération pendant le jour pourrait augmenter la quantité et la qualité de l'expérience en CGU dans le réseau universitaire.

The ace of spades: reverse takotsubo cardiomyopathy in the context of angiographic embolization of recurrent metastatic serotonin-positive neuroendocrine tumour of the pancreas.

A 62-year-old woman undergoing embolization of recurrent neuroendocrine tumor, positive for serotonin, developed chest pain and bradycardia with lateral ST-segment depression. Cardiac biomarkers were elevated, and echocardiography revealed akinesis of all basal segments with a normally contracting apex. The absence of flow-limiting coronary disease on angiography confirmed the presence of reverse Takotsubo cardiomyopathy. After optimal medical therapy for six weeks, left ventricular function returned to normal. Takotsubo cardiomyopathy has been described across a wide variety of hyperadrenergic states; the description of the reverse-type Takotsubo cardiomyopathy in the setting of embolization of recurrent neuroendocrine with serotonergic positivity tumour is novel.