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PubMed1994

Complications of neonatal extracorporeal membrane oxygenation. Collective experience from the Extracorporeal Life Support Organization.

Since 1973, 7667 neonates have been treated with extracorporeal membrane oxygenation for severe respiratory failure and their cases reported to the Extracorporeal Life Support Organization Registry. The overall survival was 81% in these neonates, who were thought to have a survival of 20% without extracorporeal membrane oxygenation. A total of 4322 mechanical complications (0.56 +/- 0.84 per case) and 13,827 patient complications (1.80 +/- 2.12 per case) were reported overall. The most common mechanical complications included clots in the circuit (19%), cannula placement (9%), oxygenator failure (4%), and others (9%). Common patient complications included cardiopulmonary (43%), neurologic (35%), bleeding (35%), metabolic (32%), renal (25%), and renal (25%), and infectious (9%). From the initial experience to 1988 the average number of mechanical complications per case was 0.27 per case and this significantly increased during 1990 to 1992 to 0.75 per case (p < 0.05). Likewise, from 1973-1985 to 1988 the average patient complications per case were 1.44 per case and this significantly increased during 1990 to 1992 to 2.10 per case. During the same periods, patient survival significantly decreased from 84% (1973-1985 to 1988, n = 2463) to 80% (1990 to 1992, n = 4005). Venovenous double-lumen single cannula extracorporeal membrane oxygenation had a higher survival than venoarterial extracorporeal membrane oxygenation (91% versus 81%) and a lower rate of major neurologic complications. The incidence and survival with seizures (6% and 89% venovenous versus 13% and 61% venoarterial) or cerebral infarction (9% and 69% venovenous versus 14% and 46% venoarterial) was significantly lower with the venovenous method and appeared to have a substantial impact on overall survival. The correlation of patient complication rate and total complication rate with survival was highly significant, however, causality cannot be established. Explanations for the increase in complications, relative to a decrease in survival, despite a growing nationwide experience include (1) increased complexity of cases as many programs expand entry criteria (more premature infants, infants with grade 1 or 2 intracranial hemorrhage, and complex congenital diaphragmatic hernia), (2) a growing number of programs with fewer cases per program, yet greater accessibility, (3) less reluctance to report complications encountered during extracorporeal membrane oxygenation as group experience grows, and (4) changes in the Extracorporeal Life Support Organization data form to be more inclusive of more minor complications.

Equipment Failure↗

PubMed1998

Renal complications in acute leukemias.

BACKGROUND AND OBJECTIVE: Renal failure is a known complication of acute leukemias both at diagnosis and following cytostatic treatment. No recent studies give data on the incidence and risk factors of renal complications and their prognostic impact. DESIGN AND METHODS: Two hundred and twenty consecutive adult patients with newly diagnosed acute leukemia treated at a major university medical center were evaluated for renal complications before, during, and after treatment; 166 patients were treated by chemotherapy only and 54 patients were treated with chemotherapy and later transplanted with allogeneic or autologous bone marrow. Renal complications were subdivided into 3 entities: acute renal failure, major and minor complications, based on clinical and laboratory parameters. Renal failure occurring as a consequence of terminal multi-organ failure was excluded from the present study. RESULTS: Approximately 30% of patients in the chemotherapy group had a renal complication either before or after chemotherapy. Patients undergoing transplantation had a 50% risk of renal complications. Risk factors for complications were male sex, age, previous kidney disease, white cell count, and refractory leukemia (chemotherapy group) and allogeneic versus autologous transplant (transplant group). In the chemotherapy group, early but not delayed renal complications had a poor prognostic impact. In the transplant group renal complications had no impact on prognosis. In all patient groups, acute renal failure was prognostically unfavorable. INTERPRETATION AND CONCLUSIONS: We conclude from our study that renal complications are frequent in acute leukemias and that the treatment and prevention of renal complications is important for the management of acute leukemias.

Acute Disease↗

PubMed2003

Complications in transoral CO2 laser surgery for carcinoma of the larynx and hypopharynx.

BACKGROUND: Because of the increase in indications for laser surgery to treat malignant tumors of the larynx and hypopharynx, a higher number of complications may be expected. We prospectively evaluated the frequency and characteristics of intraoperative and postoperative complications of early and advanced tumors of the larynx and hypopharynx treated with CO(2) laser surgery and the potential influence of the surgical learning curve on the complication rate. METHODS: Two hundred seventy-five patients operated in a tertiary referral center. Complications were classified either as major, requiring intensive medical treatment, blood transfusion, surgery, or ICU admission, or minor, resolving spontaneously or with conventional ambulatory treatment without sequelae. The surgical learning curve was analyzed by dividing the patients into two groups according to the date of surgery and then comparing the number of complications. RESULTS: Complications occurred in 18.9% of patients; 9.8% were considered major and 9.1% minor. Complications included local infection (0.7%), emphysema (1%), cutaneous fistula (0.3%), postoperative bleeding (8%), airway ignition (0.3%), dyspnea (because of edema or stenosis) (1.8%), and swallowing difficulties or aspiration pneumonia (6.1%). The complication rate correlated significantly with tumor extension (p <.0001), the presence of diabetes mellitus (p =.01), and less surgical experience (p <.0001). Complications with severe sequelae occurred in two patients (p =.7). CONCLUSIONS: Complications after transoral laser surgery of larynx and hypopharynx carcinomas are relatively frequent (18.9%), but serious sequelae and mortality rate are low. Complications are associated with tumor extension, limited surgical experience, and diabetes mellitus.

Adult↗

PubMed2006

Oral health in women with pregnancy and delivery complications.

Oral health was retrospectively studied in 207 women (mean age 30 years) in the Helsinki Womens' Hospital with the hypothesis that women with pregnancy complications and/or delivery complications would present poorer dental status than women without complications. Computerized dental records of the City of Helsinki Health Department were used with decayed, missing, filled index (DMF) and community periodontal index (CPI) scoring systems and a summary dental health index (DHI) was constructed for statistics. In 72%, the delivery was uncomplicated, while 18% had Caesarean section. Of the women, 8% had gestational diabetes, 7.1% had gestational hypertension, and 1.8% had preeclampsia. Fifteen (6.6%) preterm babies were born; eight (3.5%) babies weighed <2.500 g, seven (3.2%) received a 1-min Apgar point <7 indicating less than satisfactory state of the newborn. DMF was 12.9+/-6.6 in women without complications compared to 15.3+/-6.7 in women with complications (n.s.). CPI values did not differ between the groups. The mean DHI values were 2.07 in women with normal pregnancy complications and no delivery complications, 2.23 in those with pregnancy complications, and 2.13 in those with delivery complications, respectively. In logistic regression analysis, no oral health parameters associated with any complications. Thus, this study failed to show an association between poor dental health and pregnancy or delivery complications.

Adolescent↗

PubMed2005

Risk factors for perineal wound complications following abdominoperineal resection.

PURPOSE: Perineal wound complications are common following abdominoperineal resection. This study investigates the factors contributing to these complications. METHODS: Patients undergoing abdominoperineal resection at our institution from June 1997 to May 2003 were reviewed. Significant predictors associated with minor (separation <2 cm, stitch abscesses, or sinus tracts) or major (>2 cm of separation, reoperation required, or readmission) wound complications were ascertained. RESULTS: Of 153 patients, there were 22 major (14 percent) and 32 minor (24 percent) wound complications. Patients with anal cancer had a higher rate of major complications than those with rectal cancer or inflammatory bowel disease. Minor wound complications were more common in patients with anal cancer and inflammatory bowel disease than those with rectal cancer. Factors associated with a higher rate of major wound complications included flap closure, tumor size, body mass index, diabetes, and indication for the procedure. When the subset of patients with rectal cancer was considered, higher rates of major wounds were associated with increased body mass index, diabetes, and stage. Minor complications were associated with a two-team approach and increasing body mass index. CONCLUSIONS: This is currently the largest review of perineal wound complications following abdominoperineal resection. Patients with anal cancer and inflammatory bowel disease were at higher risk for perineal wound complications than those with rectal cancer. Preoperative radiation and primary closure were not associated with increased complications following abdominoperineal resection for rectal cancer.

Abdomen↗

PubMed2006

Contributing factors to mandibulotomy complications: a retrospective study.

OBJECTIVE: The purpose of this article is to investigate the complications associated with mandibulotomies and analyze contributing factors. STUDY DESIGN: A total of 103 patients, who had undergone a mandibulotomy for tumors of the oral cavity or oropharynx, were identified and their hospital records, clinical charts, and radiographs retrospectively reviewed. Variables associated with mandibulotomy complications (osteotomy type, osteotomy site, tooth extraction, fixation method, radiation, and chemotherapy) were classified and statistically analyzed. RESULTS: Various complications were encountered in 19 (18.4%) patients, and were classified into 2 categories: intraoperative and postoperative complications. Paramedian (42.7%) stair-step (86.4%) osteotomies had been frequently used. Rigid fixation using one monocortical plate, one bicortical plate, and screws (MCP + BCP [46.6%]) was the main fixation method and showed statistical significance in the complications of mandibulotomy (P < .05). Five (71.4%) out of 7 patients who received preoperative radiotherapy developed postoperative complications, and 3 (60%) out of 5 patients who received preoperative chemotherapy developed complications. Among the complications, nonunion was observed in 7 (6.7%) patients and osteoradionecrosis in 5 (4.9%). CONCLUSION: Paramedian stair-step osteotomy is recommended and the reapproximation is improved with minimal bone loss using a thin saw blade. Rigid monocortical and bicortical plate fixation (MCP + BCP) is advantageous to preventing postoperative complications. Perioperative radiation therapy contributes to those complications, therefore it is necessary to establish the precise position of the portals and the adequate dose of radiotherapy through consultation with a radiation oncologist preoperatively, and consider a proper surgical approach. Because infection is an important contributing factor, it is necessary to actively control the infection to decrease the incidence of complications.

Adult↗

PubMed2000

Complications of hysteroscopy: a prospective, multicenter study.

OBJECTIVE: To estimate the incidence of complications of diagnostic and operative hysteroscopic procedures in the Netherlands and describe their nature. METHODS: Data on complications were recorded by 82 hospitals in 1997. Participating hospitals had a 100% response rate. Any unexpected events that required intraoperative or postoperative intervention were defined as complications in two groups: approach (entry-related) and technique-related (caused by surgical instruments). RESULTS: Thirty-eight complications occurred among 13,600 hysteroscopic procedures (rate 0.28%). Diagnostic hysteroscopic procedures had a significantly lower complication rate (0.13%) than operative procedures (rate 0.95%; P <.01). Fluid overloads of distention medium were recorded five times (rate 0.20%). The most frequent surgical complication was perforation of the uterine cavity (rate 0.76%). Approximately half the perforations (18 of 33) were entry-related. Bleeding caused by perforation was seen in 0.16% of cases. Incidences of complications were: intrauterine adhesiolysis 4.48%, endometrium resection 0.81%, myomectomy 0.75%, and removal of a polyp 0.38%. CONCLUSION: Diagnostic hysteroscopic procedures had very low complication rates, so are safe procedures with which to evaluate intrauterine pathology. Operative hysteroscopic procedures were more risky, but the removal of polyps had a very low complication rate (12 times lower than synechiolysis). Half the complications were entry-related, so attention has to be paid to the method of entry with the hysteroscope (ie, no unnecessary dilation of cervix and introduction of the scope under direct vision). The other half of complications were related to surgeons' experience and type of procedure.

Female↗

PubMed2000

Complications of hysteroscopic surgery: predicting patients at risk.

OBJECTIVE: To determine the frequency of operative complications and whether they can be predicted by specific patient characteristics or type of hysteroscopic procedure. METHODS: We collected demographic and medical history information on 925 women who had hysteroscopies from 1995 through 1996. We compared differences in rates of operative complications of specific hysteroscopic procedures. Operative complications were defined as uterine perforation, excessive glycine absorption (1 L or more), hyponatremia, hemorrhage (500 mL or more), bowel or bladder injury, inability to dilate the cervix, and procedure-related hospital admissions. RESULTS: Operative complications occurred in 25 (2.7%) of 925 hysteroscopies. Excessive fluid absorption was the most frequent complication. Hysteroscopic myomectomy and resection of uterine septum were associated with greater odds of complications (odds ratio [OR] 7.4, 95% confidence interval [CI] 3.3, 16.6 and OR 4.0, 95% CI 0.9, 19.6, respectively). Hysteroscopic polypectomy and endometrial ablation were associated with lower odds of complications (OR 0.1, 95% CI 0.0, 0.7 and OR 0.4, 95% CI 0.1, 3.3, respectively). Hysteroscopies done by reproductive endocrinologists and preoperative GnRH agonist therapy were associated with 4-7 times higher odds for operative complications. CONCLUSION: Complications during hysteroscopic surgery are rare. Among hysteroscopic procedures, myomectomies and resections of uterine septa have significantly higher rates of complications, especially excessive fluid absorption. Meticulous fluid management might limit the number of serious complications of these higher-risk procedures.

Adult↗

PubMed2000

Complications of interval laparoscopic tubal sterilization: findings from the United States Collaborative Review of Sterilization.

OBJECTIVE: To estimate the risk of intraoperative or postoperative complications for interval laparoscopic tubal sterilizations. METHODS: We used a prospective, multicenter cohort study of 9475 women who had interval laparoscopic tubal sterilization to calculate the rates of intraoperative or postoperative complications. The relative safety of various methods was assessed by calculating overall complication rates for each major method of tubal occlusion. Method-related complication rates also were calculated and included only complications attributable to a method of occlusion. We used logistic regression to identify independent predictors of one or more complications. RESULTS: When we used a more restrictive definition of unintended major surgery, the overall rate of complications went from 1.6 to 0.9 per 100 procedures. There was one life-threatening event and there were no deaths. Complications rates for each of the four major methods of tubal occlusion ranged from 1.17 to 1.95, with no significant differences between them. When complication rates were calculated, the spring clip method had the lowest method-related complication rate (0.47 per 100 procedures), although it was not significantly different from the others. In adjusted analysis, diabetes mellitus (adjusted odds ratio [OR] 4.5; 95% confidence interval [CI] 2.3, 8.8), general anesthesia (OR 3.2; CI 1.6, 6.6), previous abdominal or pelvic surgery (OR 2.0; CI 1.4, 2.9), and obesity (OR 1.7; CI 1.2, 2.6) were independent predictors of one or more complications. CONCLUSION: Interval laparoscopic sterilization generally is a safe procedure; serious morbidity is rare.

Adolescent↗

PubMed1998

Predicting risk of complications with gynecologic laparoscopic surgery.

OBJECTIVE: To determine the incidence and predictors of risk for operative complications, conversions to laparotomy, and postoperative admissions after laparoscopic procedures. METHODS: We obtained demographic information on and medical histories of a consecutive series of 843 women who underwent laparoscopic surgery for all procedures other than tubal ligation at Brigham and Women's Hospital during 1994. All major complications after surgery were recorded. Major operative complications were defined as bowel, bladder, ureter, or vascular injuries or significant abdominal wall or other internal bleeding. Categorical analysis was used to compare differences in the rates of operative complications, conversions to laparotomy, and postoperative admissions after laparoscopy. We also estimated the influence of medical history and specific laparoscopic procedures on the risk of adverse complications after surgery. RESULTS: Operative complications and conversion to laparotomy occurred in 1.9% and 4.7% of laparoscopic procedures, respectively. Complications included four bowel, two bladder, one ureteral, two vascular, and five abdominal wall injuries. There were 165 patients (19.6%) admitted postoperatively. Aside from the type of operative procedure, increasing age was the most important predictor of complications. Relative to all other operative procedures, women treated for endometriosis or ovarian cystectomy had generally low rates of operative complications, conversions to laparotomy, and postoperative admissions. In contrast, 12.5% of women undergoing laparoscopically assisted vaginal hysterectomy experienced operative injuries or abdominal bleeding and 90% were hospitalized postoperatively. CONCLUSION: Serious operative complications after gynecologic laparoscopy were rare in this patient population. The more complex laparoscopic procedures resulted in proportionately greater rates of operative complications, conversions to laparotomy, and postoperative admissions to the hospital.

Adolescent↗

PubMed1998

Incidence and management of intraoperative and early postoperative complications in 1000 consecutive laser in situ keratomileusis cases.

OBJECTIVE: To identify intraoperative and early postoperative complications of laser in situ keratomileusis (LASIK) surgery learning curve and to offer recommendations on prevention and management. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: The first 1000 consecutive myopic LASIK eyes (April 1995-February 1997) operated on by one surgeon (HVG) were examined. INTERVENTION: Myopic LASIK surgery was performed with the Chiron Corneal Shaper and NIDEK EC-5000 excimer laser. MAIN OUTCOME MEASURES: The preoperative and 6-month postoperative spherical equivalent, best-corrected visual acuity, and corneal status were recorded, as was the incidence of intraoperative and early postoperative complications. The rate of retreatments was also recorded. RESULTS: There were 32 (3.2%) intraoperative complications and surgical events recorded, including 19 (1.9%) microkeratome-related flap complications and 13 (1.3%) nonmicrokeratome-related surgical events such as inability to obtain sufficient suction. There were 18 (1.8%) postoperative complications requiring repositioning of microwrinkled or shifted flaps. Six-month spherical equivalent was -0.52 diopter [D] +/- 1.19 D for eyes with microkeratome complications, -0.56 D +/- 1.07 D for the group with nonmicrokeratome-related intraoperative events, and -0.78 D +/- 0.92 for eyes requiring postoperative flap repositioning. None of the 32 eyes with intraoperative complications and surgical events lost 2 or more lines of vision. One eye in the postoperative complications group lost two lines of vision. The rate of microkeratome complications related to surgical technique and the overall surgery times decreased over the course of the first 1000 myopic LASIK cases. CONCLUSION: The complications encountered during the early learning curve of LASIK surgery have not in this series resulted in a significant loss of best-corrected visual acuity. With increasing surgical experience, the incidence of complications, along with surgical times, has decreased.

Adult↗

PubMed2002

Minor complications arising in alveolar distraction osteogenesis.

PURPOSE: This study evaluates complications that arise during mandibular alveolar distraction osteogenesis and suggests treatments. METHODS: We monitored complications that arose during alveolar distraction osteogenesis in 5 patients who underwent a total of 7 distractions, in all cases using an intraosseous distractor (Lead System, Leibinger, Germany). We report our responses to each type of complication. RESULTS: All 7 distractions were followed by the placement of 2 implants. The restoration was ideal in 4 of the 7 cases and functional but not ideal in the remaining 3. In all 7 distractions, we observed complications, although many were minor complications readily avoided by the use of appropriate technique. The complications were, first, intraoperative complications, namely 1) fracture of the transport segment (1 of 7 cases; RESPONSE: appropriate preventative measures), 2) difficulties in finishing the osteotomy on the lingual side (7 of 7 cases; RESPONSE: use of fine chisels made from cement spatulas), and 3) excessive length of the threaded rod (1 of 7 cases; RESPONSE: cut the rod). Second, complications arose during distraction: 1) incorrect direction of distraction (2 of 7 cases; no corrective measures necessary in the present cases), 2) perforation of the mucosa by the transport segment (2 of 7 cases; response: smooth the crest of the segment with a bone rongeur), and 3) suture dehiscence (1 of 7 cases; no significant implications). Third, there were postdistraction complications, namely bone formation defects (4 of 7 cases; response: guided bone regeneration). CONCLUSIONS: A number of complications may arise during alveolar distraction osteogenesis. Most of these complications can be considered minor and are readily avoided or resolved by the use of appropriate procedures.

Dental Implantation, Endosseous↗

PubMed2006

Surgical complications of posterior lumbar interbody fusion with total facetectomy in 251 patients.

OBJECT: Previous studies of surgical complications associated with posterior lumbar interbody fusion (PLIF) are of limited value due to intrastudy variation in instrumentation and fusion techniques. The purpose of the present study was to examine rates of intraoperative and postoperative complications of PLIF using a large number of cases with uniform instrumentation and a uniform fusion technique. METHODS: The authors reviewed the hospital records of 251 patients who underwent PLIF for degenerative lumbar disorders between 1996 and 2002 and who could be followed for at least 2 years. Intraoperative, early postoperative, and late postoperative complications were investigated. Intraoperative complications occurred in 26 patients: dural tearing in 19 patients and pedicle screw malposition in seven patients. Intraoperative complications did not affect the postoperative clinical results. Early postoperative complications occurred in 19 patients: brain infarction occurred in one, infection in one, and neurological complications in 17. Of the 17 patients with neurological complications, nine showed severe motor loss such as foot drop; the remaining eight patients showed slight motor loss or radicular pain alone, and their symptoms improved within 6 weeks. Late postoperative complications occurred in 17 patients: hardware failure in three, nonunion in three, and adjacent-segment degeneration in 11. Postoperative progression of symptomatic adjacent-segment degeneration was defined as a condition that required additional surgery to treat neurological deterioration. CONCLUSIONS: The most serious complications of PLIF were postoperative severe neurological deficits and adjacent-segment degeneration. Prevention and management of such complications are necessary to attain good long-term clinical results.

Adolescent↗

PubMed1997

Prevalence of perioperative complications after anterior spinal fusion for patients with idiopathic scoliosis.

Anterior spinal fusion (ASF) has been proven to improve curve correction, save motion segments, and decrease the rate of pseudarthrosis when compared with posterior spinal fusion alone. However, in patients with idiopathic scoliosis, the complication rate of the anterior approach to the spine using current techniques has only been scantly defined in the literature. This is a retrospective review of consecutive patients who underwent primary ASF for idiopathic scoliosis to determine the prevalence and types of complications specifically related to the anterior approach. All patients who underwent primary ASFs for idiopathic scoliosis done by one of two orthopaedic surgeons between October 1986 and July 1992 were reviewed. Adequate records were available for 98 of 103 patients. The average age at time of surgery was 22 years (range, 10-60 years). Complications were divided into three groups: major (resulting in permanent sequelae or necessitating a second major operation); minor (resulting in a prolonged hospital stay, necessitating a minor operation, and/or resulting in a significant temporary hardship or persistent minor problem); and insignificant (anything less than minor). One of 98 patients had a major complication (a pelvic deep venous thrombosis that required operative thrombectomy). Twenty-five of 98 patients had 28 complications classified as minor, and 28 of 98 patients had 30 complications classified as insignificant. Smoking was a significant risk factor for the development of minor complications. There was no statistically significant relationship between the development of complications and the degree of curve, the approach used, the procedure performed, or the performance of rib resections. The anterior approach to the spine in patients with idiopathic scoliosis in this series was very safe, with only one major complication in 98 patients. However, minor and insignificant complications were quite common, occurring in 45 of 98 patients (46%). Smoking was a significant risk factor for minor complications.

Adolescent↗

PubMed2000

Complications of laparoscopic splenectomy.

HYPOTHESIS: Analysis of the type and characteristics of complications after laparoscopic splenectomy may permit the identification of clinical factors with predictive value for the development of complications. DESIGN: Univariate and multivariate analysis of factors related to complications in a prospective series of laparoscopic splenectomies. SETTING: A large tertiary referral university-teaching general hospital. PATIENTS: One hundred twenty-two nonselected consecutive patients, in whom laparoscopic splenectomy was attempted between February 1993 and July 1999. INTERVENTION: Laparoscopic splenectomy. MAIN OUTCOME MEASURES: Immediate complications classified according to the Clavien score. Univariate and multivariate analyses were performed of complications related to age, sex, body mass index, and malignant nature of the hematologic disease; preoperative hematocrit and platelet count; operative time; operative position; need of accessory incision; transfusion status; learning curve; and existence of comorbid diseases. RESULTS: One hundred thirteen laparoscopic splenectomies were completed (conversion rate, 7.4%). Twenty patients (18%) developed 23 complications. All were Clavien type I or II, without mortality. One complication was intraoperative (diaphragmatic perforation), and 22 were postoperative: 6 pulmonary (26%), 3 fever (13%), 8 hemorrhagic (35%) (5 episodes of postoperative bleeding and 3 abdominal wall hematomas), and 6 others (26%). Ten (43%) of the 23 were technically related. Univariate analysis showed that complications were only related to age (mean +/- SD, 55 +/- 15 vs 39 +/- 17 years; P<.008) or transfusion (50% vs 11%; P<.001). Multivariate analysis showed that the learning curve (P<.005; 95% confidence interval, 2.46), age (P<.001; 95% confidence interval, 1. 04), spleen weight (P<.009; 95% confidence interval, 1.00), and malignant neoplasm diagnosis (P<.007; 95% confidence interval, 3.82) were independent predictors of complications. CONCLUSIONS: Laparoscopic splenectomy is feasible, and the incidence of severe complications is reduced. However, a high proportion of these complications are technique related. Laparoscopic splenectomy requires great technical care but offers major clinical advantages, even in less favorable situations, such as in patients with splenomegaly or with malignant neoplasms.

Adult↗

PubMed1997

The impact of surgical complications after liver transplantation on resource utilization.

OBJECTIVE: To evaluate the impact of surgical complications on length of stay and hospital charges after liver transplantation. DESIGN: A retrospective economic evaluation of the outcomes during initial hospitalization after liver transplantation. SETTING: University hospital treating referred patients. PATIENTS: The study population was 109 patients undergoing 111 liver transplantations during fiscal year 1993. MAIN OUTCOME MEASURES: Hospital charges and length of stay during the initial hospitalization after liver transplantation. Multivariate regression methods were used to analyze the impact of surgical complications on costs. RESULTS: Of the 111 transplantations, 30 (27%) had a surgical complication that required a return to the operating room during the initial hospitalization. The effect of a surgical complication was to increase the mean hospital charges (excluding physician charges) from $150,092 to $347,728 (difference of mean, $197,636; confidence interval of difference, $114,153 to $319,326). The median length of stay was 16 days for patients without complications and 45 days for those with complications. Univariate and multivariate models suggested that surgical complications had the greatest effect on length of stay and hospital charges among the factors studied. Complications tended to occur more frequently among patients with United Network for Organ Sharing (UNOS) status 1 (42% vs 22%), but this did not reach statistical significance (P = .09). CONCLUSIONS: Surgical complications after liver transplantation have a marked impact on the cost of the procedure. The magnitude of this effect is greater than that of UNOS status, presence of rejection, or other demographic or clinical factors studied. Complications tend to occur in the most ill patients. Identifying strategies to reduce the risk of complications, particularly in patients with UNOS status 1, likely can reduce the cost of transplantation.

Adolescent↗

PubMed2001

Results of laparoscopic vs. conventional appendectomy in complicated appendicitis.

BACKGROUND: Although many trials show some advantages of laparoscopic appendectomy over open appendectomy, the value of laparoscopic appendectomy is still controversial. Specifically the question of whether there are benefits of laparoscopic appendectomy over open appendectomy in complicated appendicitis remains to be answered. METHODS: Of 1,106 consecutive appendectomies (717 laparoscopic appendectomies, 330 open appendectomies, and 59 conversions) between 1989 and 1999, the results of 299 patients with complicated appendicitis (defined by perforation, abscess, or peritonitis) were analyzed retrospectively to compare the complications of laparoscopic appendectomy and conversion (intention-to-treat group) with those of open appendectomy. RESULTS: Complicated appendicitis (n = 299) was treated by laparoscopic appendectomy in 171 patients, by open appendectomy in 82 patients, and by conversion in 46 patients. Laparoscopic appendectomy and conversion showed fewer abdominal wall complications than open appendectomy (13/217; 6 percent vs. 15/82; 18.3 percent; P < 0.003), which led to a decrease of the total complication rate in the intention-to-treat group (21/217; 9.7 percent vs. 19/82; 23.1 percent; P = 0.004). The rate of intra-abdominal abscess formation was nearly the same after laparoscopic appendectomy (4.1 percent) and open appendectomy (4.9 percent). The total complication rate was higher in complicated appendicitis than in acute appendicitis (P < 0.005) but was independent of the laparoscopic technique. The conversion rate was higher in complicated appendicitis than in acute appendicitis (21.2 vs. 2.3 percent; P < 0.001). CONCLUSION: In comparison with open appendectomy, laparoscopic appendectomy (by itself and in an intention-to-treat view) leads to a significant reduction of early postoperative complications in complicated appendicitis and therefore should be considered as the procedure of choice.

Abscess↗

PubMed1998

Functional results after perineal complications of ileal pouch-anal anastomosis.

PURPOSE: This study investigated the functional significance of perineal complications after ileal pouch-anal anastomosis. METHODS: Review of a prospective registry of 628 patients was undertaken. Bowel function was assessed by detailed functional questionnaire. Statistical analyses were performed using chi-squared and Fisher's exact probability tests. RESULTS: Of 628 patients, 153 (24.4 percent) had 171 perineal complications. The 277 control patients had no complications. Complications included 66 (10.5 percent) anastomotic strictures, 28 (4.5 percent) anastomotic separations, 36 (5.7 percent) pouch fistulas, 41 (6.5 percent) episodes of pelvic sepsis, and 18 (2.9 percent) patients with multiple complications. After these complications were addressed, the pouch failure rate was low (10 percent); in 90 percent of patients, the pouch could be salvaged. Most pouch failures were the result of pouch fistulas, and most occurred in patients ultimately diagnosed with Crohn's disease. Functional results after cure of these perineal complications revealed no significant functional differences between control patients and those cured of anastomotic separations, anastomotic strictures, and pouch fistulas. Only a few minor differences were demonstrated in function after an episode of pelvic sepsis. The major deterioration in function occurred after treatment for multiple perineal complications. CONCLUSIONS: An appreciable number of perineal complications occur after ileal pouch-anal anastomosis. Pouch-perineal fistulas are associated with the highest pouch failure rate. The majority of these fistulas occur in patients ultimately diagnosed with Crohn's disease or indeterminate colitis. Although there is no substitute for good technique and sound clinical judgment in the success of ileal pouch-anal anastomosis, if perineal complications are successfully treated, functional outcome is equivalent to that in patients without perineal complications.

Anastomosis, Surgical↗