Postoperative complications of patients during the COVID-19 pandemic.

Ellison RT. Surgical complications in patients with COVID-19. NEJM Journal Watch, June 2, 2020.

“During the COVID-19 pandemic, most hospitals have suspended nonemergent surgeries. However, an increasing number of patients need urgent and semiurgent procedures, and there are economic incentives to restart elective surgery. Thus, it is critically important to know how COVID-19 affects surgical outcomes. An international observational study has assessed 30-day mortality and pulmonary complications in patients with COVID-19 undergoing surgery at 235 hospitals between January 1 and March 31, 2020. The infection was identified between 7 days before and 30 days after the procedure.

Among 1128 patients identified, 835 (74%) underwent emergency surgery, and 280, elective surgery. COVID-19 was diagnosed preoperatively in 294 (26%) and was confirmed by SARS-CoV-2 RNA detection in 969 (86%). The overall 30-day mortality rate was 24%; for elective procedures, 19%. Mortality was higher in men, patients over 70 years of age, ASA grades 3–5, malignancy, and with emergency and major surgical procedures. Pulmonary complications developed in 577 patients (51%) and were associated with a higher 30-day mortality rate.”

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Laparoscopic Cholecystectomy Versus Percutaneous Catheter Drainage for Acute Cholecystitis in High Risk Patients (CHOCOLATE): Multicentre Randomised Clinical Trial

Loozen CS, et al. Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial. BMJ. 2018 Oct 8; 363:k3965.

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what this study adds

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Preoperative communication with older patients and their families about high-risk surgical outcomes

Berian JR, et al. Association of Loss of Independence With Readmission and Death After Discharge in Older Patients After Surgical Procedures. JAMA Surg. 2016 Sep 21;151(9): e161689.

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Results: Of the 5077 patients included in this study, 2736 (53.9%) were female and 3876 (76.3%) were white, with a mean (SD) age of 75 (7) years. For this cohort, LOI increased with age; LOI occurred in 1386 of 2780 patients (49.9%) aged 65 to 74 years, 1162 of 1726 (67.3%) aged 75 to 84 years, and 479 of 571 (83.9%) 85 years and older (P < .001). Readmission occurred in 517 patients (10.2%). In a risk-adjusted model, LOI was strongly associated with readmission (odds ratio, 1.7; 95% CI, 1.4-2.2) and postoperative complication (odds ratio, 6.7; 95% CI, 4.9-9.0). Death after discharge occurred in 69 patients (1.4%). After risk adjustment, LOI was the strongest factor associated with death after discharge (odds ratio, 6.7; 95% CI, 2.4-19.3). Postoperative complication was not significantly associated with death after discharge.

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Preoperative cachexia

Mason MC, et al. Preoperative cancer cachexia and short-term outcomes following surgery. J Surg Res. 2016 Oct; 205(2):398-406.

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Results: Of 253 patients, 16.6% had preoperative cachexia, and 51.8% developed ≥ 1 postoperative complications. Complications were more common in cachectic patients (64.3% versus 49.3%, P = 0.07). This association varied by BMI category, and interaction analysis was significant for those with normal or underweight BMI (BMI < 25, P = 0.03). After multivariate modeling, in patients with normal or underweight BMI, preoperative cachexia was associated with higher odds of postoperative complications (odds ratios, 5.08 [95% confidence intervals, 1.18-21.88]; P = 0.029). Additional predictors of complications included major surgery (3.19 [1.24-8.21], P = 0.01), ostomy (4.43 [1.68-11.72], P = 0.003), and poor baseline performance status (2.31 [1.05-5.08], P = 0.03).

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Article of interest: Does Atelectasis Cause Fever After Surgery? Putting a Damper on Dogma.

Crompton JG, Crompton PD, Matzinger P. Does Atelectasis Cause Fever After Surgery? Putting a Damper on Dogma. JAMA Surg. 2019 May 1;154(5):375-376.

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fever after an operationFigure. Damage-Associated Molecular Patterns (DAMPs) and Pathogen-Associated Molecular Patterns (PAMPs)

“The danger model of immunity challenges the premise of our current therapeutic approach in treating noninfectious causes of postoperative fever. The clinical benefit of interventions targeting atelectasis as a cause of postoperative fever, such as incentive spirometry, need to be reassessed. Continue reading

Stoma versus stent as a bridge to surgery for obstructive colon cancer

Veld JV, et al. Changes in Management of Left-Sided Obstructive Colon Cancer: National Practice and Guideline Implementation. J Natl Compr Canc Netw. 2019 Dec;17(12):1512-1520.

Free full-text. 

Results: A total of 2,587 patients were included (2,013 ER, 345 DS, and 229 SEMS). A trend was observed in reversal of ER (decrease from 86.2% to 69.6%) and SEMS (increase from 1.3% to 7.8%) after 2014, with an ongoing increase in DS (from 5.2% in 2009 to 22.7% in 2016). DS after 2014 was associated with more laparoscopic resections (66.0% vs 35.5%; P<.001) and more 2-stage procedures (41.5% vs 28.6%; P=.01) with fewer permanent stomas (14.7% vs 29.5%; P=.005). Overall, more laparoscopic resections (25.4% vs 13.2%; P<.001) and shorter total hospital stays (14 vs 15 days; P<.001) were observed after 2014. However, similar rates of primary anastomosis (48.7% vs 48.6%; P=.961), 90-day complications (40.4% vs 37.9%; P=.254), and 90-day mortality (6.5% vs 7.0%; P=.635) were observed.

CONCLUSIONS: Guideline revision resulted in a notable change from ER to BTS for LSOCC. This was accompanied by an increased rate of laparoscopic resections, more 2-stage procedures with a decreased permanent stoma rate in patients receiving DS as BTS, and a shorter total hospital stay. However, overall 90-day complication and mortality rates remained relatively high.

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CME & Education: VTE Prevention in the Hospital: New Approaches and Expert Perspectives

This continuing education offering is part of Medscape‘s series, Contemporary Topics in Antithrombotic Therapy. (You’ll need a Medscape account to view and/or accrue CME credit.)

Authors: Gary E. Raskob, PhD; Steven B. Deitelzweig, MD; Alex C. Spyropoulos, MD

CME Released: 12/22/2019; Valid for credit through: 12/22/2020

“…[W]e are going to talk about VTE, its importance in the hospital population of patients admitted with medical illness, and how we can work to reduce the burden of disease from this important condition.

About half of all hospitalizations in the United States are for medical illnesses, such as heart failure, pneumonia, stroke, and so on. Of these patients, about half of them are at risk for VTE and about 25% are at high risk for VTE.

Those who develop VTE tend to have pretty severe consequences, and these consequences persist beyond hospitalization.”

Open Mesh Vs. Lap Mesh Repair of Inguinal Hernia

Bullen NL, Massey LH, Antoniou SA, Smart NJ, Fortelny RH. Open versus laparoscopic mesh repair of primary unilateral uncomplicated inguinal hernia: a systematic review with meta-analysis and trial sequential analysis. Hernia. 2019; 23(3):461–472.

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RESULTS: This study included 12 randomised controlled trials with 3966 patients randomised to Lichtenstein repair (n = 1926) or laparoscopic repair (n = 2040). There were no significant differences in recurrence rates between the laparoscopic and open groups (odds ratio (OR) 1.14, 95% CI 0.51-2.55, p = 0.76). Laparoscopic repair was associated with reduced rate of acute pain compared to open repair (mean difference 1.19, CI - 1.86, - 0.51, p ≤ 0.0006) and reduced odds of chronic pain compared to open (OR 0.41, CI 0.30-0.56, p ≤ 0.00001). The included trials were, however, of variable methodological quality. Trial sequential analysis reported that further studies are unlikely to demonstrate a statistically significant difference between the two techniques.

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True or False: Atelectasis as cause of postoperative fever.

One discussion this week included atelectasis as a potential cause of postoperative fever.


Reference: Crompton JG, Crompton PD, Matzinger P. Does atelectasis cause fever after surgery? Putting a damper on dogma. JAMA Surgery. 2019 Mar 6:154(5):375-376. doi:10.1001/jamasurg.2018.5645.

Summary: Fever and atelectasis are common after surgery, and in the absence of infectious causative mechanisms, atelectasis is commonly thought to be a cause of fever. The therapeutic implication of atelectasis as a putative cause of postoperative fever has been the widespread adoption of incentive spirometry to reduce atelectasis.

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Air cholangiogram as effective measure for postoperative biliary complications

One discussion this week involved air cholangiograms.


Reference: Zimmitti G, et al. Systematic use of an intraoperative air leak test at the time of major liver resection reduces the rate of postoperative biliary complications. Journal of the American College of Surgeons. 2013 Dec;217(6):1028-1037. doi: 10.1016/j.jamcollsurg.2013.07.392.

Summary: Advances in surgical technique and better understanding of liver anatomy and physiology have facilitated a decrease in postoperative hepatic insufficiency rates and in perioperative blood transfusion needs. However, these improvements have not been paralleled by a decrease in the rate of postoperative bile leak, which remains the Achilles’ heel of liver resection. While in many cases a postoperative bile leak can be managed successfully with drainage and antibiotics, it almost always entails longer length of stay and increased hospital costs.

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