Postoperative mortality and complications

Resident shortages and their impact on surgical care, defensive medicine, and patient management: a retrospective study in South Korea

PURPOSE

This study aimed to evaluate the impact of declining surgical residency program enrollment on patient care and outcomes in colorectal cancer surgeries.

METHODS

This retrospective observational study included 676 patients (410 males; median age: 69 years) who underwent colorectal cancer surgery at Pusan National University Hospital between January 2018 and June 2024. Patients were divided into Group A (before December 31, 2023; with residents) and Group B (after January 1, 2024; without residents). All surgeries were performed by a single attending surgeon.

RESULTS

Preoperative variables were comparable between groups. Group A had more emergency and open surgeries, and a higher proportion of advanced-stage cancers. Overall complication rates were similar, but Group B had a longer hospital stay (9.72 days vs. 11.95 days). Specific complications such as anastomotic leakage and surgical site infections differed significantly. The overall number of surgical procedures declined markedly in 2024 compared to 2018 (77.1% vs. 49.9%).

CONCLUSION

The absence of residents did not increase overall complication rates but was associated with longer hospital stays and shifts in clinical practice. Greater reliance on attending surgeons contributed to more defensive decision-making and conservative patient management. Addressing these issues requires systemic reforms, including multidisciplinary collaboration and legal protections to improve surgical care.

Frailty Predicts Failure to Rescue Following Malignant Brain Tumor Resection: A National Surgical Quality Improvement Program Analysis of 14,721 Patients/ (2012-2020)

OBJECTIVE

Failure to rescue (FTR) is defined as mortality within 30 days following a major complication. While FTR has been studied in various brain tumor resections, its predictors in malignant brain tumor resection (mBTR) remain unexplored. This study aims to identify FTR predictors in mBTR resection patients using a frailty-driven model.

METHODS

Patients undergoing craniotomy for mBTR were identified from the American College of Surgeons-National Surgical Quality Improvement Program database (2012-2020), with frailty measured by the Risk Analysis Index (RAI).

RESULTS

Of 14,721 mBTR patients, 1275 (8.66%) developed major postoperative complications and 166 (13.01%) experienced FTR. The cohort's median age was 59 years (interquartile range: 47-68). Multivariate analysis revealed nonelective surgery (odds ratio [OR]: 1.48, 95% confidence interval [CI]: 1.02-2.16, P < 0.05) as an independent risk factor for FTR. Frailty was a significant independent predictor of FTR with mBTR, with both frail (N = 110) and very frail (N = 22) patients having a 5.34-fold and 8.10-fold higher odds of FTR, respectively (P < 0.001). Expectedly, major postoperative complications were predictive of FTR, including unplanned intubation (OR: 2.56, CI: 1.66-3.95, P < 0.001), prolonged ventilation (OR: 2.00, CI: 1.37-3.14, P < 0.01), cardiac arrest (OR: 16.64, CI: 8.20-33.74, P < 0.001), and septic shock (OR: 2.08, CI: 1.10-3.91, P < 0.05). The RAI-driven frailty model demonstrated excellent discriminatory accuracy for predicting FTR patients undergoing mBTR (c-statistic: 0.82, 95% CI: 0.79-0.85).

CONCLUSIONS

Preoperative RAI-measured frailty, alongside nonelective surgery, and major postoperative complications were significant predictors of FTR in mBTR patients. Identifying mBTR patients at risk for FTR using frailty strata may aid in preoperative neurosurgical risk stratification to optimize patients prior to surgery.

Understanding the dynamics of post-surgical recovery and its predictors in resource-limited settings: a prospective cohort study

INTRODUCTION

Post-surgical recovery time is influenced by various factors, including patient demographics, surgical details, pre-existing conditions, post-operative care, and socioeconomic status. Understanding these dynamics is crucial for improving patient outcomes. This study aims to identify significant predictors of post-surgical recovery time in a resource-limited Ethiopian hospital setting and to evaluate the variability attributable to individual patient differences and surgical team variations.

METHODS

A linear mixed model was employed to analyze data from 490 patients who underwent various surgical procedures. The analysis considered multiple predictors, including age, gender, BMI, type and duration of surgery, comorbidities (diabetes and hypertension), ASA scores, postoperative complications, pain management strategies, physiotherapy, smoking status, alcohol consumption, and socioeconomic status. Random effects were included to account for variability at the patient and surgical team levels.

RESULTS

Significant predictors of prolonged recovery time included higher BMI, longer surgery duration, the presence of diabetes and hypertension, higher ASA scores, and major post-operative complications. Opioid pain management was associated with increased recovery time, while inpatient physiotherapy reduced recovery duration. Socioeconomic status also significantly influenced recovery time. The model fit statistics indicated a robust model, with the unstructured covariance structure providing the best fit.

CONCLUSION

The findings highlight the importance of individualized patient care and the effective management of modifiable factors such as BMI, surgery duration, and postoperative complications. Socioeconomic status emerged as a novel factor warranting further investigation. This study underscores the value of considering patient and surgical team variability in post-surgical recovery analysis, and calls for future research to explore additional predictors and alternative modeling techniques to enhance our understanding of the recovery process.

Association of preoperative cognitive frailty with postoperative complications in older patients under general anesthesia: a prospective cohort study

BACKGROUND

Cognitive frailty (CF) is characterized by the coexistence of physical frailty and cognitive impairment, and it is associated with adverse health outcomes. Older adults are particularly vulnerable to CF due to factors such as age-related brain changes and the presence of comorbidities.

OBJECTIVE

To investigate the effect of preoperative CF on postoperative complications in older patients.

METHODS

This prospective cohort study was conducted among 253 patients aged 60-85 years, who underwent elective orthopedic and abdominal surgery (with a postoperative hospital stay of ≥ 3 days) at the Second Affiliated Hospital of Guangzhou University of Chinese Medicine from May 2023 to November 2023. CF was assessed using the Montreal Cognitive Assessment (MoCA) for the cognitive status and the Fried criteria for five frailty scales. Participants were split into four groups: Group A (neither frailty nor cognitive impairment), Group B (frailty without cognitive impairment), Group C (cognitive impairment without frailty), and Group D (cognitive frailty). The primary outcome was postoperative complications, while secondary outcomes included mobility disability, prolonged hospital stay (PLOS), re-operation and 90-day readmission.

RESULTS

The median age (interquartile range) of participants was 69 (65-73) years, of which 40.3% were male. The prevalence of CF was 17.8%. The incidence of postoperative complications was 18.2% in Group A, 50.0% in Group B, 37.4% in Group C, and 75.6% in Group D. Multivariate analysis revealed that, compared to the control group (without cognitive impairment or frailty), patients with CF had a significantly higher risk of postoperative complications (OR, 12.86; 95%CI, 4.23-39.08). "Patients with frailty without cognitive impairment" had an increased risk (OR, 6.53; 95%CI, 2.04-20.9), while "those with cognitive impairment without frailty" also showed a higher risk (OR, 3.46; 95%CI, 1.57-7.64).

CONCLUSIONS

Cognitive frailty is significantly associated with an increased risk of postoperative adverse outcomes in older patients undergoing orthopedic and abdominal surgeries with general anesthesia. It indicates that clinicians should pay much attention to these older adults with CF.

Frailty is an independent predictor of postoperative rescue medication use after endoscopic sinus surgery

INTRODUCTION

The modified five-item frailty index (mFI-5) is a validated risk stratification tool with the ability to predict adverse outcomes following surgery. In this study, we sought to use mFI-5 to assess the potential relationship between unhealthy aging and postoperative endoscopic sinus surgery (ESS) outcomes.

METHODS

Patients who underwent sinus surgery at Vanderbilt between 2014 and 2018 were identified and assessed using the mFI-5, which is calculated based on the presence of five comorbidities: diabetes mellitus, hypertension requiring medication, chronic obstructive pulmonary disease, congestive heart failure, and non-independent functional status. Multivariate regression analyses were performed to quantify the association of mFI-5 score on need for rescue oral antibiotics, oral steroids, and antibiotic irrigations within 1 year following ESS, adjusting for relevant potential confounders.

RESULTS

Four hundred and three patients met inclusion criteria.  Within 6 months of surgery, 312 (77%) required rescue antibiotics, 243 (60%) required oral corticosteroids (OCS), and 31 (8%) initiated antibiotic irrigations. Increasing mFI-5 scores were significantly associated with higher postoperative use of rescue antibiotics (p < 0.0001), OCS (p = 0.032), and antibiotic irrigation (p < 0.0001). Frailty scores remained as an independent predictor of these outcomes after adjustment for age, polyp status, preoperative sinonasal outcomes test (SNOT-22) score, and revision surgery status.

CONCLUSIONS

Modified frailty scores may be a useful clinical tool to predict the need for postoperative rescue medication use after ESS.

Surveillance of high-risk early postsurgical patients for real-time detection of complications using wireless monitoring (SHEPHERD study): results of a randomized multicenter stepped wedge cluster trial

Background

Vital signs measurements on the ward are performed intermittently. This could lead to failure to rapidly detect patients with deteriorating vital signs and worsens long-term outcome. The aim of this study was to test the hypothesis that continuous wireless monitoring of vital signs on the postsurgical ward improves patient outcome.

Methods

In this prospective, multicenter, stepped-wedge cluster randomized study, patients in the control group received standard monitoring. The intervention group received continuous wireless monitoring of heart rate, respiratory rate and temperature on top of standard care. Automated alerts indicating vital signs deviation from baseline were sent to ward nurses, triggering the calculation of a full early warning score followed. The primary outcome was the occurrence of new disability three months after surgery.

Results

The study was terminated early (at 57% inclusion) due to COVID-19 restrictions. Therefore, only descriptive statistics are presented. A total of 747 patients were enrolled in this study and eligible for statistical analyses, 517 patients in the control group and 230 patients in the intervention group, the latter only from one hospital. New disability at three months after surgery occurred in 43.7% in the control group and in 39.1% in the intervention group (absolute difference 4.6%).

Conclusion

This is the largest randomized controlled trial investigating continuous wireless monitoring in postoperative patients. While patients in the intervention group seemed to experience less (new) disability than patients in the control group, results remain inconclusive with regard to postoperative patient outcome due to premature study termination.

Clinical trial registration

ClinicalTrials.gov, ID: NCT02957825.

Laparoscopic versus open surgical management in elderly patients with rectal cancer aged 70 and older

Background

This retrospective study aimed to compare the short- and long-term surgical outcomes of laparoscopic surgery versus open surgery in elderly patients with rectal cancer.

Patients and Methods

Elderly patients (≥70 years old) with rectal cancer who received radical surgery were retrospectively analysed. Patients were matched (1:1 ratio) using propensity score matching (PSM), with age, sex, body mass index, American Society of Anesthesiologists score and tumour-node-metastasis staging included as covariates. Baseline characteristics, post-operative complications, short- and long-term surgical outcomes and overall survival (OS) were compared between the two matched groups.

Results

Sixty-one pairs were selected after PSM. Patients with laparoscopic surgery had a longer duration of operation time, lower estimated blood loss, shorter duration of post-operative analgesics administered, time to first flatus, time to first oral diet and post-operative hospitalisation stay than those observed in patients with open surgery (All P < 0.05). The incidence of post-operative complications in the open surgery group was numerically higher than that occurred in the laparoscopic surgery group (30.6% vs. 17.7%). Median OS was 67.0 months (95% confidence interval [CI], 62.2-71.8) in the laparoscopic surgery group and 65.0 months (95% CI, 59.9-70.1) in the open surgery group, however, Kaplan-Meier curves indicated that no significant differences in OS (Log-rank test, P = 0.535) were noted between the two matched groups.

Conclusions

Compared with the open surgery, laparoscopic surgery had the advantages of less trauma and faster recovery, and provided similar long-term prognostic outcome in elderly patients with rectal cancer.

Impact of Intraoperative Data on Risk Prediction for Mortality After Intra-Abdominal Surgery

BACKGROUND

Risk prediction models for postoperative mortality after intra-abdominal surgery have typically been developed using preoperative variables. It is unclear if intraoperative data add significant value to these risk prediction models.

METHODS

With IRB approval, an institutional retrospective cohort of intra-abdominal surgery patients in the 2005 to 2015 American College of Surgeons National Surgical Quality Improvement Program was identified. Intraoperative data were obtained from the electronic health record. The primary outcome was 30-day mortality. We evaluated the performance of machine learning algorithms to predict 30-day mortality using: 1) baseline variables and 2) baseline + intraoperative variables. Algorithms evaluated were: 1) logistic regression with elastic net selection, 2) random forest (RF), 3) gradient boosting machine (GBM), 4) support vector machine (SVM), and 5) convolutional neural networks (CNNs). Model performance was evaluated using the area under the receiver operator characteristic curve (AUROC). The sample was randomly divided into a training/testing split with 80%/20% probabilities. Repeated 10-fold cross-validation identified the optimal model hyperparameters in the training dataset for each model, which were then applied to the entire training dataset to train the model. Trained models were applied to the test cohort to evaluate model performance. Statistical significance was evaluated using P < .05.

RESULTS

The training and testing cohorts contained 4322 and 1079 patients, respectively, with 62 (1.4%) and 15 (1.4%) experiencing 30-day mortality, respectively. When using only baseline variables to predict mortality, all algorithms except SVM (area under the receiver operator characteristic curve [AUROC], 0.83 [95% confidence interval {CI}, 0.69-0.97]) had AUROC >0.9: GBM (AUROC, 0.96 [0.94-1.0]), RF (AUROC, 0.96 [0.92-1.0]), CNN (AUROC, 0.96 [0.92-0.99]), and logistic regression (AUROC, 0.95 [0.91-0.99]). AUROC significantly increased with intraoperative variables with CNN (AUROC, 0.97 [0.96-0.99]; P = .047 versus baseline), but there was no improvement with GBM (AUROC, 0.97 [0.95-0.99]; P = .3 versus baseline), RF (AUROC, 0.96 [0.93-1.0]; P = .5 versus baseline), and logistic regression (AUROC, 0.94 [0.90-0.99]; P = .6 versus baseline).

CONCLUSIONS

Postoperative mortality is predicted with excellent discrimination in intra-abdominal surgery patients using only preoperative variables in various machine learning algorithms. The addition of intraoperative data to preoperative data also resulted in models with excellent discrimination, but model performance did not improve.

Contribution of oxidative stress in the mechanisms of postoperative complications and multiple organ dysfunction syndrome

BACKGROUND

The extent of the damage following surgery has been subject of study for several years. Numerous surgical complications can impact postoperative quality of life of patients and even can cause mortality. Although these complications are generally due to multifactorial mechanisms, oxidative stress plays a key pathophysiological role. Moreover, oxidative stress could be an unavoidable effect derived even from the surgical procedure itself.

METHODS

A systematic review was performed following an electronic search of Pubmed and ScienceDirect databases. Keywords such as sepsis, oxidative stress, organ dysfunction, antioxidants, outcomes in postoperative complications, among others, were used. Review articles were preferably used between the years 2015 onwards, not excluding older ones.

RESULTS

The vast majority point to the role of oxidative stress in generating greater damage and worse prognosis in postoperative patients without the necessary care and precautions, taking importance on the use of antioxidants to prevent this problem.

DISCUSSIONS

Oxidative stress represents a common final pathway related to pathological processes such as inflammation or ischemia-reperfusion, among others. The expression of greater severity of these complications can result in multiple organ dysfunction or sepsis. The aim of this study was to present an update of the role of oxidative stress on surgical postoperative complications.

General anaesthesia related mortality in a limited resource settings region: a retrospective study in two teaching hospitals of Butembo

Background

General anaesthesia (GA) in developing countries is still a high-risk practice, especially in Africa, accompanied with high morbidity and mortality. No study has yet been conducted in Butembo in the Democratic Republic of the Congo to determine the mortality related to GA practice. The main objective of this study was to assess mortality related to GA in Butembo.

Methods

This was a retrospective descriptive and analytic study of patients who underwent surgery under GA in the 2 main teaching hospitals of Butembo from January 2011 to December 2015. Data were collected from patients files, anaesthesia registries and were analysed with SPSS 26.

Results

From a total of 921 patients, 539 (58.5%) were male and 382 (41.5%) female patients. A total of 83 (9.0%) patients died representing an overall perioperative mortality rate of 90 per 1000. Out of the 83 deaths, 38 occurred within 24 h representing GA related mortality of 41 per 1000. There was a global drop in mortality from 2011 to 2015. The risk factors of death were: being a neonate or a senior adult, emergency operation, ASA physical status > 2 and a single deranged vital sign preoperatively, presenting any complication during GA, anaesthesia duration > 120 minutes as well as visceral surgeries/laparotomies. Ketamine was the most employed anaesthetic.

Conclusion

GA related mortality is very high in Butembo. Improved GA services and outcomes can be obtained by training more anaesthesia providers, proper patients monitoring, improved infrastructure, better equipment and drugs procurement and considering regional anaesthesia whenever possible.

Evaluation of Internal Medicine Physician or Multidisciplinary Team Comanagement of Surgical Patients and Clinical Outcomes: A Systematic Review and Meta-analysis

Importance

Older patients who undergo surgery may benefit from geriatrician comanagement. It is unclear whether other internal medicine (IM) physician involvement improves outcomes for adults who undergo surgery.

Objective

To evaluate the association of IM physician involvement with clinical and health system outcomes compared with usual surgical care among adults who undergo surgery.

Data Sources

MEDLINE, Embase, CINAHL, and CENTRAL databases were searched for studies published in English from database inception to April 2, 2019.

Study Selection

Prospective randomized or nonrandomized clinical studies comparing IM physician consultation or comanagement with usual surgical care were selected by consensus of 2 reviewers.

Data Extraction and Synthesis

Data were extracted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline by 2 authors independently. Intervention characteristics were described using existing indicators. Risk of bias was assessed using Risk of Bias 2.0 and Risk of Bias in Nonrandomized Studies of Interventions tools. Studies were pooled when appropriate in meta-analysis using random-effects models. Prespecified subgroups included IM physician-only vs multidisciplinary team interventions and patients undergoing elective vs emergency procedures.

Main Outcomes and Measures

The prespecified primary outcome was length of stay; other outcomes included 30-day readmissions, inpatient mortality, medical complications, functional outcomes, and costs.

Results

Of 6027 records screened, 14 studies (with 1 randomized clinical trial) involving 35 800 patients (13 142 [36.7%] in intervention groups) were eligible for inclusion. Interventions varied substantially among studies and settings; most interventions described comanagement by a hospitalist or internist; 7 (50%) included a multidisciplinary team, and 9 (64%) studied predominantly patients who had elective procedures. Risk of bias in 10 studies (71%) was serious. Meta-analysis showed no significant association with length of stay (mean difference, -1.02 days; 95% CI, -2.09 to 0.04 days; P = .06) or mortality (odds ratio, 0.79; 95% CI, 0.56 to 1.11; P = .18), but multidisciplinary team involvement was associated with significant reduction in length of stay (mean difference, -2.03 days; 95% CI, -4.05 to -0.01 days; P = .05) and mortality (odds ratio, 0.67; 95% CI, 0.51 to 0.88; P = .004). There was no difference in 30-day readmissions (odds ratio, 0.89; 95% CI, 0.68 to 1.16; P = .39). Data could not be pooled for complications or costs. Only 1 study (7%) reported functional outcomes.

Conclusions and Relevance

The findings of this study suggest that IM physician comanagement that includes multidisciplinary team involvement may be associated with reduced length of stay and mortality in adults undergoing surgery. Evidence was low quality, and well-designed prospective studies are still needed.

Remote wireless vital signs monitoring on the ward for early detection of deteriorating patients: A case series

INTRODUCTION

Remote wireless monitoring is a new technology that allows the continuous recording of ward patients' vital signs, supporting nurses by measuring vital signs frequently and accurately. A case series is presented to illustrate how these systems might contribute to improved patient surveillance.

METHODS AND RESULTS

Five hospitals in three European countries installed a remote wireless vital signs monitoring system on medical or surgical wards. Heart rate, respiratory rate and temperature were measured by the system every 2 min. Four cases of (paroxysmal) atrial fibrillation are presented, two cases of sepsis and one case each of pyrexia, cardiogenic pulmonary edema and pulmonary embolisms. All cases show that the remote monitoring system revealed the first signs of ventilatory and circulatory deterioration before a change in the trends of the respective values became obvious by manual vital signs measurement.

DISCUSSION

This case series illustrates that a wireless remote vital signs monitoring system on medical and surgical wards has the potential to reduce time to detect deteriorating patients.

The Colostomy of Duret for the High Risk Patient

Background: Heitzer and Duret described the surgical creation of colostomy in the 1700s, more than a century before the introduction of anesthesia. With the ever increasing degree of frailty in patients of advanced age who require surgical intervention, a simplified methodology for the creation of a colostomy based on their original reports is described and the advantages for use in high risk patients and the critical care setting is discussed. Methods: Eleven patients underwent simplified colostomy under local anesthesia, without complication. Results: All colostomies functioned normally within hours. There were no bleeding or infectious complications, nor peri-operative adverse events. Conclusions: Colostomy formation can be safely performed under local anesthesia when the patient is considered too high risk to undergo general anesthesia.

Laboratory alerts to guide early intensive care team review in surgical patients: A feasibility, safety, and efficacy pilot randomized controlled trial

AIM

Common blood tests can help identify patients at risk of death, unplanned intensive care unit (ICU) admission, or rapid response team (RRT) call. We aimed to test whether early ICU-team review triggered by such laboratory tests (lab alert) is feasible, safe, and can alter physiological variables, clinical management, and clinical outcomes.

METHODS

In prospective pilot randomized controlled trial in surgical wards of a tertiary hospital, we studied patients admitted for >24 h. We applied a previously validated risk assessment tool to each set of common laboratory tests to identify patients at risk and generate a "lab-alert". We randomly allocated such lab-alert patients to receive early ICU-team review (intervention) or usual care (control).

RESULTS

We studied 205 patients (males 54.1%; average age 79 years; 103 randomized to intervention and 102 to usual care). Intervention patients were more likely to trigger RRT activation during their first lab-alert (10.7 vs. 2.0%; P < 0.001) but less likely to receive an allied health referral (18.0% vs. 24.5%; p = 0.007). They were less likely to trigger RRT activation in the 24-h before subsequent alerts (18.4 vs. 22.4%; p = 0.008) and less likely to generate further alerts (204 vs. 320; p < 0.001), but more likely to receive a not for resuscitation or endotracheal intubation status in the 24-h before subsequent alerts (26.6 vs. 17.3%; p = 0.05). Mortality at 24 h was 1.9% for the intervention group vs. 2.9% in the control group (p = 0.63). Finally, overall mortality was 19.4% for intervention patients vs. 23.5% for control patients (p = 0.50).

CONCLUSION

Among surgical patients, lab alerts identify patients with a high mortality. Lab alert-triggered interventions are associated with more first alert-associated RRT activations; more changes in resuscitation status toward a more conservative approach; fewer subsequent alert-associated RRT activations; fewer subsequent alerts, and decreased allied health interventions (ANZCTRN12615000146594).

Frailty and anesthesia - risks during and post-surgery

Frailty is a state of decreased physiologic reserve and resistance to stressors. Its prevalence increases with age and is estimated to be 26% in those aged above 85 years. As the population ages, frailty will be increasingly seen in surgical patients receiving anesthesia. Here, we evaluate the instruments which have been developed and validated for measuring frailty in surgical patients and summarize frailty tools used in 110 studies linking frailty status with adverse outcomes post-surgery. Frail older people are vulnerable to geriatric syndromes, and complications such as postoperative cognitive dysfunction and delirium are explored. This review also considers how frailty, with its decline of organ function, affects the metabolism of anesthetic agents and may influence the choice of anesthetic technique in an older person. Optimal perioperative care includes the identification of frailty, a multisystem and multidisciplinary evaluation preoperatively, and discussion of treatment goals and expectations. We conclude with an overview of the emerging evidence that Comprehensive Geriatric Assessment can improve postoperative outcomes and a discussion of the models of care that have been developed to improve preoperative assessment and enhance the postoperative recovery of older surgical patients.

Perceptions of quality and safety and experience of adverse events in 27 European Union healthcare systems, 2009-2013

Objective

To assess trends in the perception of quality and safety between 2009 and 2013 in the European Union (EU).

Design

We analysed data from waves 72.2 and 80.2 of the Eurobarometer survey. Multilevel logistic regression models adjusted for sociodemographic factors and country-level health expenditure were fitted to assess changes between 2009 and 2013 in each of the assessed outcomes.

Setting

Twenty-seven EU member states.

Participants

A total of n = 26 663 (2009) and n = 26 917 (2013) individuals aged ≥15 years.

Main outcome measure(s)

Outcomes included the perception of being harmed in hospital and non-hospital care; rating of the overall quality of the healthcare system; and personal or family experience of adverse events.

Results

Respondents in 2013 were more likely to think that it was likely to be harmed in hospital (Odds Ratio [OR] = 1.09; 95% Confidence Interval [CI]: 1.05-1.13; P < 0.001) and non-hospital care (OR = 1.11; 95% CI: 1.07-1.15; P < 0.001), compared to 2009. However, they were more likely to rate the quality of their country's healthcare system as good (OR = 1.26; 95% CI: 1.21-1.32; P < 0.001) and no significant change over time was identified in reported experience of adverse events (OR = 1.00; 95% CI: 0.95-1.05; P = 0.929). Lower health expenditure and decrease in health expenditure between the two waves were associated with worse outcomes in overall quality and perceptions of harm. There was significant variation between and within countries in all indicators.

Conclusions

The public's perception of safety in European healthcare systems declined in recent years, which highlights that there are safety issues that could be addressed.

Melatonin attenuates carbon tetrachloride-induced liver fibrosis via inhibition of necroptosis

We investigated the protective mechanisms of melatonin (MLT) associated with necroptosis signaling and damage-associated molecular patterns, which are mediated by the activation of pattern recognition receptors in liver fibrosis. Rats were given an intraperitoneal injection of carbon tetrachloride (CCl4) dissolved in olive oil (1:3, vol/vol) twice a week (0.5 mL/kg) for 8 weeks. During this period, MLT was administered orally at 2.5, 5, and 10 mg/kg once a day. Chronic CCl4 administration increased hepatic hydroxyproline content and hepatocellular damage. MLT attenuated these increases. The expression levels of transforming growth factor β1 and α-smooth muscle actin that were increased by chronic CCl4 exposure were attenuated by MLT. CCl4 significantly increased receptor-interacting protein 1 (RIP1) expression, the formation of the RIP1 and RIP3 necrosome complex, and the level of mixed lineage kinase domain-like protein in liver tissue, which were attenuated by MLT. MLT also attenuated CCl4-induced increases in serum high-mobility group box 1 (HMGB1) and interleukin 1α, as well as the interaction between HMGB1 receptors for advanced glycation end products (RAGE). The increases in toll-like receptor 4 expression, p38, c-Jun N-terminal kinases phosphorylation, and nuclear factor κB translocation were suppressed by MLT. MLT attenuated the overexpression of RAGE, increased level of early growth response protein 1, and increased messenger RNA level of macrophage inflammatory protein 2. Our findings suggest MLT may prevent liver fibrosis by inhibiting necroptosis-associated inflammatory signaling.

A cross-sectional retrospective analysis of the regionalization of complex surgery

Background

The Veterans Health Administration (VHA) system has assigned a surgical complexity level to each of its medical centers by specifying requirements to perform standard, intermediate or complex surgical procedures. No study to similarly describe the patterns of relative surgical complexity among a population of United States (U.S) civilian hospitals has been completed.

Methods

Design: single year, retrospective, cross-sectional.

Setting/Participants: the study used Florida Inpatient Discharge Data from short-term acute hospitals for calendar year 2009. Two hundred hospitals with 2,542,920 discharges were organized into four quartiles (Q 1, 2, 3, 4) based on the number of complex procedures per hospital. The VHA surgical complexity matrix was applied to assign relative complexity to each procedure. The Clinical Classification Software (CCS) system assigned complex procedures to clinically meaningful groups. For outcome comparisons, propensity score matching methods adjusted for the surgical procedure, age, gender, race, comorbidities, mechanical ventilator use and type of admission.

Main Outcome Measures: in-hospital mortality and length-of-stay (LOS).

Results

Only 5.2% of all inpatient discharges involve a complex procedure. The highest volume complex procedure hospitals (Q4) have 49.8% of all discharges but 70.1% of all complex procedures. In the 133,436 discharges with a primary complex procedure, 374 separate specific procedures are identified, only about one third of which are performed in the lowest volume complex procedure (Q1) hospitals. Complex operations of the digestive, respiratory, integumentary and musculoskeletal systems are the least concentrated and proportionately more likely to occur in the lower volume hospitals. Operations of the cardiovascular system and certain technology dependent miscellaneous diagnostic and therapeutic procedures are the most concentrated in high volume hospitals. Organ transplants are only done in Q4 hospitals. There were no significant differences in in-hospital mortality rates and the longest lengths of stay were found in higher volume hospitals.

Conclusions

Complex surgery in Florida is effectively regionalized so that small volume hospitals operating within the range of complex procedures appropriate to their capabilities provide no increased risk of post surgical mortality.

Hospital and geographic variability in two colorectal cancer surgery outcomes: complications and mortality after complications

BACKGROUND

The purpose of this study was to describe hospital and geographic variation in 30-day risk of surgical complications and death among colorectal cancer (CRC) patients and the extent to which patient-, hospital-, and census-tract-level characteristics increased risk of these outcomes.

METHODS

We included patients at least 66 years old with first primary stage I-III CRC from the 2000-2005 National Cancer Institute's Surveillance, Epidemiology, and End Results data linked with 1999-2005 Medicare claims. A multilevel, cross-classified logistic model was used to account for nesting of patients within hospitals and within residential census tracts. Outcomes were risk of complications and death after a complication within 30 days of surgery.

RESULTS

Data were analyzed for 35,946 patients undergoing surgery at 1,222 hospitals and residing in 12,187 census tracts; 27.2 % of patients developed complications, and of these 13.4 % died. Risk-adjusted variability in complications across hospitals and census tracts was similar. Variability in mortality was larger than variability in complications, across hospitals and across census tracts. Specific characteristics increased risk of complications (e.g., census-tract-poverty rate, emergency surgery, and being African-American). No hospital characteristics increased complication risk. Specific characteristics increased risk of death (e.g. census-tract-poverty rate, being diagnosed with colon (versus rectal) cancer, and emergency surgery), while hospitals with at least 500 beds showed reduced death risk.

CONCLUSIONS

Large, unexplained variations exist in mortality after surgical complications in CRC across hospitals and geographic areas. The potential exists for quality improvement efforts targeted at the hospital and/or census-tract levels to prevent complications and augment hospitals' ability to reduce mortality risk.

Living status in patients over 85 years of age after TUVRP

INTRODUCTION

To evaluate surgical risk and post-operative quality of living status in patients over 85 years of age after transurethral vaporization resection of the prostate (TUVRP).

METHODS

Sixty patients over 85 years of age underwent TUVRP were compared with 228 patients less than the age of 80 years. Group A was 60 patients greater than 85 years of age, Group B was 137 patients from 71 to 79 years of age, and Group C was 91 patients from 60 to 70 years of age.

RESULTS

In Group A, pre-operative ASA grade was higher than the other two groups, compared with Group C, p < 0.01. Operating time was 40.03 ± 18.90 min, compared in the three groups, p > 0.05. Follow-up was obtained in 49 (81.67%) patients; of them 10 patients were deaths with a survival time of 22.90 ± 11.14 months. In the 39 survivors, post-operative IPSS score was 11.17 ± 6.9, compared with Group B, p > 0.05 and Group C, p < 0.01. Quality of Life (QOL) index was 1.11 ± 0.80, compared with Group B, p < 0.001 and Group C, p < 0.01. Barthel Index score in 16 patients was >60 and the score was 82.81 ± 8.56 pre-operatively. The patients with >60 were increased to 19 cases and the score was improved to 90.93 ± 7.58 (p < 0.001) in follow-up.

CONCLUSION

Surgical risk in patients over 85 years of age was higher than patients less than the age of 80 years. A safety TUVRP could improve their voiding function and activities of daily living.

[Do anesthetic techniques influence postoperative outcomes? Part I]

The influence of anesthetic technique on postoperative outcomes has opened a wide field of research in recent years. High-risk patients undergoing non-cardiac surgery are those who have higher incidence of postoperative complications and mortality. A proper definition of this group of patients should focus maximal efforts and resources to improve the results. In view of the significant reduction in postoperative mortality and morbidity in last 20 years, perioperative research should take into account new indicators to investigate the role of anesthetic techniques on postoperative outcomes. Studies focused on the evaluation of intermediate outcomes would probably discriminate better effectiveness differences between anesthetic techniques. We review some of the major controversies arising in the literature about the impact of anesthetic techniques on postoperative outcomes. We have grouped the impact of these techniques into 9 major investigation areas: mortality, cardiovascular complications, respiratory complications, postoperative cognitive dysfunction, chronic postoperative pain, cancer recurrence, postoperative nausea/vomiting, surgical outcomes and resources utilization. In this first part of the review, we discuss the basis on postoperative outcomes research, mortality, cardiovascular and respiratory complications.