A study on assessment of postoperative complications among major abdominal surgeries using Clavien-Dindo classification

Background: Surgical team always tries to provide consistently low incidence of major complications for patient undergoing any operation. Clavien-Dindo (CD) classification is the simplest way of reporting all complications. The main aim of this study was to test the usefulness of Clavien-Dindo classification in patients undergoing the abdominal surgery. In this study Clavien-Dindo classification has been used for assessment of postsurgical complications after major abdominal surgery.Methods: A total of 50 patients admitted to surgical wards for major abdominal surgery were evaluated through history, co-morbid condition and thorough clinical examination based on inclusion and exclusion criteria along with necessary investigations. Post-operative complications and management were recorded, and then postsurgical complication was classified based on Clavien-Dindo classification and assessed.Results: Most of the patients who developed complications were in the age group of 40-50 years. Most of the patients (32%) belonged to grade 2 complications. Serum creatinine, blood urea and post-operative stay were found to have direct relation with Clavien-Dindo grade of complications.Conclusions: The Clavien-Dindo classification represents an objective and simple way of reporting all complications in patients undergoing major abdominal surgeries and comparing the various complications between different surgeries. However, a definite statement on the clinical value of this classification system is not yet possible due to the small case number in this study, but the promising results should encourage further evaluation in larger cohort with the goal to possibly establish its validity as a standard clinical practice.

Validación prospectiva multicéntrica del EuroSCORE II en Argentina / Multicenter prospective validation of the EuroSCORE II in Argentina

Resumen Objetivo: Validar, en forma prospectiva y en múltiples centros, la precisión y utilidad clínica del European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) para predecir la mortalidad operatoria de la cirugía cardíaca en centros de Argentina Método: Entre enero de 2012 y febrero de 2018 se incluyeron en forma prospectiva 2,000 pacientes consecutivos que fueron sometidos a cirugía cardíaca en diferentes centros de Argentina. El punto final fue mortalidad hospitalaria por cualquier causa. La discriminación, calibración, precisión y utilidad clínica del EuroSCORE II se evaluaron en la cohorte global y en los diferentes tipos de cirugías, basándose en las curvas Receiver Operating Characteristics (ROC), bondad de ajuste de Hosmer-Lemeshow, razón de mortalidad observada/esperada, índice de Shannon y curvas de decisión. Resultados: El área ROC del EuroSCORE II estuvo entre 0.73 y 0.80 para todo tipo de cirugía, y el valor más bajo fue para la cirugía coronaria. La mortalidad observada y esperada fue 4.3 y 3.0%, respectivamente (p = 0.034). El análisis de la curva de decisión demostró un beneficio neto positivo para los umbrales por debajo de 0.24 para todo tipo de cirugía. Conclusiones: El EuroSCORE II tuvo un desempeño adecuado en términos de discriminación y calibración para todos los tipos de cirugía, aunque algo inferior para la cirugía coronaria. Si bien en términos generales subestimó el riesgo en los grupos de riesgo intermedio, el comportamiento global fue aceptable. El EuroSCORE II podría considerarse una opción de modelo genérico y actualizado de estratificación del riesgo operatorio para predecir la mortalidad hospitalaria de la cirugía cardíaca en nuestro contexto.

Abstract Objective: To validate prospectively in multiple centers, the accuracy and clinical utility of the European System for Cardiac Operative Risk Evaluation (EuroSCORE II) to predict the operative mortality of cardiac surgery in Argentina. Methods: Between January 2012 and February 2018, 2,000 consecutive adult patients who underwent cardiac surgery in different centers in Argentina were prospectively included. The end-point was in-hospital all-cause mortality. Discrimination, calibration, precision and clinical utility of the EuroSCORE II were evaluated in the global cohort and in the different types of surgeries, based on ROC (Receiver Operating Characteristics) curves, Hosmer-Lemeshow goodness-of-fit test, observed/expected mortality ratio, Shannon index and decision curves analysis. Results: ROC area of the EuroSCORE II was between 0.73 and 0.80 for all types of surgery, being the lowest value for coronary surgery. The observed and expected mortality was 4.3% and 3.0%, respectively (p = 0.034). The decision curve analysis showed a positive net benefit for all thresholds below 0.24, considering all type of surgeries. Conclusion: The EuroSCORE II showed an adequate performance in terms of discrimination and calibration for all types of surgery, although somewhat inferior for coronary surgery. Though in general terms this model underestimated the risk in intermediate risk groups, its overall performance was acceptable. The EuroSCORE II could be considered an optional updated generic model of operative risk stratification to predict in-hospital mortality after cardiac surgery in our context.

Metanálisis sobre la mortalidad hospitalaria del reemplazo valvular aórtico en pacientes con riesgo bajo e intermedio en Argentina / Single-arm Meta-analysis of Argentine Studies Reporting In-hospital Mortality After Aortic Valve Replacement in Low and Intermediate Risk Patients

RESUMEN Introducción: Actualmente, la cirugía de reemplazo valvular es la primera opción para el tratamiento de la enfermedad aórtica sintomática excepto en pacientes añosos de alto riesgo, en los cuales el implante valvular aórtico transcatéter (TAVI) sería una mejor alternativa. Objetivos: Considerando que se ha propuesto extender el uso de TAVI a otros grupos de bajo riesgo, el propósito de este estudio fue realizar un metanálisis de estudios de grupo único sobre mortalidad hospitalaria luego de la cirugía de reemplazo valvular aórtico en pacientes de riesgo bajo y moderado en Argentina, como punto de referencia para comparar con los resultados locales de TAVI. Métodos: Se realizó una revisión sistemática utilizando estudios observacionales identificados en MEDLINE, Embase, SCOPUS, y la biblioteca Cochrane hasta marzo de 2019. Resultados: De 80 estudios identificados a través de la búsqueda, 4 estudios observacionales consideraron mortalidad hospitalaria y complicaciones post-quirúrgicas luego del reemplazo valvular aórtico, divididos en pacientes de riesgo moderado y/o bajo de acuerdo al puntaje STS o EuroSCORE II. En 1.192 pacientes, la mortalidad fue de 3.1%. Las estimaciones ponderadas del conjunto de estudios fueron: accidente cerebrovascular postquirúrgico 1.3%, infarto de miocardio 0.4%, necesidad de marcapasos definitivo 2.7%, mediastinitis 1.4% y reoperación por sangrado 2.6%. Conclusiones: La eficacia de TAVI en pacientes de alto riesgo está produciendo la expansión de esta indicación a casos de menor riesgo, aunque dicho avance debería estar apoyado por evidencia significativa de su beneficio sobre la cirugía de reemplazo valvular. Este metanálisis de estudios de grupo único argentinos presenta la mortalidad hospitalaria y las complicaciones post-quirúrgicas luego del reemplazo valvular aórtico en pacientes de riesgo bajo e intermedio. La información actualizada de resultados de cirugía locales podría servir como punto de referencia para compararla con el desempeño de TAVI en nuestro medio.

ABSTRACT Background: Current evidence favors surgical valve replacement to treat symptomatic aortic disease, except in elderly patients at increased risk for surgery, in whom transcatheter aortic valve implantation (TAVI) may be eligible. Objectives: Considering that the use of TAVI has been proposed to be extended to other groups at lower risk, the purpose of this study was to perform a single-arm meta-analysis of local studies reporting in-hospital mortality after surgical aortic valve replacement in low and intermediate risk patients in Argentina, as a benchmark for comparing with local TAVI outcomes. Methods: A systematic review search strategy was performed using controlled trials and observational studies identified in MEDLINE, Embase, SCOPUS, and the Cochrane library to March 2019. Results: Among 80 studies identified through the search, 4 observational articles reported in-hospital mortality and postoperative complications after aortic valve replacement, divided into intermediate and/or low risk patients according to the STS score or the EuroSCORE II. In 1,192 patients, in-hospital mortality was 3.1%. Weighted pooled estimates were: postoperative stroke1.3%, myocardial infarction 0.4%, need for definite pacemaker 2.7%, mediastinitis 1.4%, and reoperation for bleeding 2.6%. Conclusions: The proven efficacy of TAVI in high-risk patients is leading to the expansion of its indications toward lower-risk cases; but this shift should be supported by meaningful evidence of its benefit over surgical valve replacement. This single-arm meta-analysis of Argentine studies presents in-hospital mortality and postoperative complications after aortic valve replacement in low and intermediate risk patients. The updated information on local results of surgery could serve as a benchmark for comparing with TAVI performance in our setting.

Association of body mass index with short-term outcomes after cardiac surgery: retrospective study and meta-analysis

The relationship between higher body mass index (BMI), decreased morbidity and mortality is known as the "obesity paradox", and has been described in cohorts of patients with hypertension, diabetes, heart failure, coronary and peripheral artery diseases, non-cardiac surgery, and end-stage renal disease. Here we investigated the relationship between BMI and short-term outcomes after adult cardiac surgery to explore the existence of an obesity paradoxical effect. A secondary objective was to perform an updated systematic review to further analyze the association between BMI and 30-day in-hospital mortality after cardiac surgery. A retrospective analysis was performed from a consecutive series of 1823 adult patients who underwent cardiac surgery, that were assigned to five BMI groups: normal weight (18.5-24.9 kg/m²), overweight (25-29.9 kg/m²), class I obese (30-34.9 kg/m²), class II obese (35-39.9 kg/m²), and class III obese or morbidly obese (40-49.9 kg/m²). A systematic review search was performed including controlled trials and observational studies identified in MEDLINE, Embase, SCOPUS, and the Cochrane library (to the end of June 2017). In the present series, overweight and obese patients had similar or slightly lower in-hospital mortality rates after cardiac surgery compared with normal-weight individuals. Conversely, postoperative complication rates increased with higher BMI levels. Most studies included in the review showed that overweight and obese patients had at least the same mortality rate as normal-weight patients, or even a lower death risk. Pooled-data of the meta-analysis provided evidence on the association between higher BMI levels and a lower all-cause in-hospital mortality rate after cardiac surgery.

La relación entre mayor índice de masa corporal (IMC) y menor morbilidad y mortalidad se conoce como "paradoja de la obesidad". Se ha descrito en cohortes de pacientes con hipertensión, diabetes, insuficiencia cardíaca, enfermedad coronaria y arterial periférica, cirugías no cardíacas y enfermedad renal en etapa terminal. Aquí se investigó la relación entre IMC y resultados a corto plazo después de cirugía cardíaca en adultos, y la manifestación de la paradoja de la obesidad. También se realizó una revisión sistemática sobre asociación entre IMC y mortalidad a 30 días de la cirugía cardíaca. Se hizo un análisis retrospectivo de una serie consecutiva de 1823 adultos con cirugía cardíaca, asignados a cinco grupos de IMC: peso normal (18.5-24.9 kg/m²), sobrepeso (25- 29.9 kg/m²), obesidad clase I (30-34.9 kg/m²), clase II (35-39.9 kg/m²), y clase III (40-49.9 kg/m²), y una búsqueda sistemática de ensayos controlados y estudios observacionales en MEDLINE, Embase, SCOPUS y Cochrane (hasta 30/6/2017). En la serie, las tasas de mortalidad hospitalaria fueron similares o ligeramente menores en pacientes con sobrepeso y obesidad comparados con aquellos de peso normal. Pero también las tasas de complicaciones postoperatorias aumentaron con el IMC. La mayoría de los estudios observacionales revisados mostraron que los pacientes con sobrepeso y obesidad tenían al menos similar tasa de mortalidad que aquellos con peso normal, o menor riesgo de muerte. Los datos combinados del metaanálisis evidenciaron asociación entre los niveles de IMC mayores y tasa de mortalidad hospitalaria más baja después de cirugía cardíaca.

Validation of age, creatinine and ejection fraction (ACEF) and Cockcroft-Gault ACEF scores in elective cardiac surgery

The objective of this study was to evaluate the efficacy of age, creatinine and ejection fraction (ACEF) score and the modified ACEFCG model, incorporating creatinine clearance, to predict immediate operative mortality risk of patients undergoing elective cardiac surgery. A retrospective analysis was performed of prospectively collected data between 2012 and 2015, from a series of 1190 adult patients who underwent elective cardiac surgery. Operative risk mortality was assessed with ACEF, ACEFCG and EuroSCORE II. Overall mortality rate was 4.0% (48 cases), while mean mortality rates predicted by ACEF, ACEFCG, and EuroSCORE II were 2.3% (p = 0.014), 6.4% (p = 0.010) and 2.5% (p = 0.038), respectively. Overall observed/predicted mortality ratio was 1.8 for ACEF score, 0.6 for ACEFCG score and 1.6 for EuroSCORE II. The ACEF score demonstrated an adequate overall performance for the low- and intermediate-risk groups, but underestimated mortality for the high risk group. The ACEFCG score discriminatory power systematically improved the area under the ROC curve (AUC) obtained with the ACEF score; however, EuroSCORE II showed the best AUC. Overall accuracy was 56.1% for the ACEF score, 51.2% for the ACEFCG score and 75.9% for EuroSCORE II. For clinical use, the ACEF score seems to be adequate to predict mortality in low- and intermediate-risk patients. Though the ACEFCG score had a better discriminatory power and calibration, it tended to overestimate the expected risk. Since ideally, a simpler risk stratification score should be desirable for bedside clinical use, the ACEF model reasonably met the expected performance in our population.

El objetivo fue evaluar la eficacia de la escala de riesgo de edad, creatinina y fracción de eyección (ACEF) y también ACEFCG, que incorpora la depuración de creatinina, para predecir el riesgo de mortalidad operatoria inmediata tras una cirugía cardiaca electiva. Se realizó un análisis retrospectivo de datos recolectados prospectivamente entre 2012 y 2015, de 1190 adultos sometidos a cirugía cardíaca electiva. El riesgo de mortalidad operatoria se evaluó con ACEF, ACEFCG y EuroSCORE II. La tasa de mortalidad global fue 4.0% (48 casos), mientras que las tasas de mortalidad predichas por ACEF, ACEFCG y EuroSCORE II fueron 2.3% (p = 0.014), 6.4% (p = 0.010) y 2.5% (p = 0.038), respectivamente. La razón mortalidad observada/esperada fue 1.8 para el ACEF, 0.6 para el ACEFCG y 1.6 para el EuroSCORE II. La puntuación de ACEF demostró un desempeño adecuado para los grupos de riesgo bajo y medio, pero subestimó la mortalidad del grupo de alto riesgo. La discriminación del ACEFCG mejoró sistemáticamente el área ROC del ACEF; sin embargo, el EuroSCORE II mostró la mejor área ROC. La precisión global fue 56.1% para el ACEF, 51.2% para el ACEFCG y 75.9% para el EuroSCORE II. Para uso clínico, el modelo ACEF parece ser adecuado para predecir la mortalidad en pacientes de riesgo bajo y medio. Aunque el puntaje de ACEFCG tuvo un mejor poder discriminatorio y calibración, tendió a sobrestimar el riesgo esperado. Considerando que sería ideal contar con un método de estratificación de riesgo más simple para uso clínico al lado de la cama, el modelo ACEF tuvo un desempeño razonable en nuestra población.

Pérdidas económicas para las compañías aseguradoras derivadas de personas lesionadas en accidentes de tránsito: aplicación de un modelo de pérdidas agregadas / Economic Losses for Insurers Arising from Injured in Traffic Accidents: Applying a Loss Distribution Aggregated Model / As perdas económicas para as seguradoras decorrentes de feridos em acidentes de trânsito: aplicação de um modelo de perdas agregadas

Los accidentes de tránsito, por las graves secuelas sobre las personas y los altos costos económicos asociados, se catalogan como un problema social y de salud pública mundial. Este trabajo cuantificó las pérdidas económicas para las compañías de seguro, por personas lesionadas en accidentes de motocicletas en el periodo 2012-2013 en un hospital de nivel III. Es un estudio cuantitativo-explicativo, donde se aplicó un modelo de distribución de pérdidas agregadas (dpa). La base informativa fue primaria, con 2518 pacientes que representan el 9,08% de los accidentes reportados en la ciudad de Medellín. El 72,18% del total de urgencias corresponde a eventos con motociclistas. El día domingo es el de mayor accidentalidad, con un promedio de 122 pacientes. Las pérdidas promedio-día ascienden a $36 373 000. El VaR operacional -máxima pérdida al 95 % de confianza- es de $112 400 000 y representa la máxima pérdida probable por día para las aseguradoras. Las cifras y variables permiten desarrollar políticas de movilidad y aumento de controles en los días y sitios vulnerables con un mayor número de accidentes de tránsito.

Os acidentes de trânsito, devido às graves consequências que têm sobre as pessoas e os altos custos econômicos associados a eles, são considerados um problema social e de saúde pública mundial. Este trabalho avalia perdas económicas devido a acidentes de moto entre 2012 e 2013 em um hospital de nível 3. Este é um estudo quantitativo-explicativo, onde um modelo de perda agregada é aplicada. Uma entrada de 2.518 pacientes é utilizado o que representa 9,08% dos acidentes Medellin's relatados. O 72,18 % de todos os eventos de emergência vieram de acidentes de moto. Domingo foi o dia com maior número de acidentes com um 122 pacientes médios perdas médias por quantidade dia a cop 36.373 milhões. O VaR operacional - perda máxima por dia a 95 % de confiança - é cop 112.400 milhões, e representa a provável perda máxima por dia. Os números e variáveis permitem desenvolver políticas de mobilidade e aumento dos controles em dias e locais vulneráveis com o maior número de acidentes de trânsito.

Traffic accidents, due to the serious consequences they have on people, and the high economic costs associated with them, are considered a worldwide social and public health problem. This paper assesses economic loss due to motorcycle accidents between 2012 and 2013 in a level 3 hospital. This is a quantitative-explanatory study, where an aggregate loss model is applied. An input of 2,518 patients is used which represents 9.08% of the Medellin's accidents reported. The 72.18% of all emergency events came from motorcycle accidents. Sunday was the day with highest accidents number with a 122 average patients. Average losses per day amount to cop 36,373 million. The operational VaR -maximum loss per day at 95 % confidence- is cop 112,400 million, and represents the probable maximum loss per day. The numbers and variables allow developing mobility policies and increased controls on days and vulnerable places with the highest traffic accidents number.

Validation of the European System for Cardiac Operative Risk Evaluation-II model in an urban Indian population and comparison with three other risk scoring systems.

Aims and Objectives: The aims were to compare the European System for Cardiac Operative Risk Evaluation (EuroSCORE)‑II system against three established risk scoring systems for predictive accuracy in an urban Indian population and suggest improvements or amendments in the existing scoring system for adaptation in Indian population. Materials and Methods: EuroSCORE‑II, Parsonnet score, System‑97 score, and Cleveland score were obtained preoperatively for 1098 consecutive patients. EuroSCORE‑II system was analyzed in comparison to each of the above three scoring systems in an urban Indian population. Calibrations of scoring systems were assessed using Hosmer–Lemeshow test. Areas under receiver operating characteristics (ROC) curves were compared according to the statistical approach suggested by Hanley and McNeil. Results: All EuroSCORE‑II subgroups had highly significant P values stating good predictive mortality, except high‑risk group (P = 0.175). The analysis of ROC curves of different scoring systems showed that the highest predictive value for mortality was calculated for the System‑97 score followed by the Cleveland score. System‑97 revealed extremely high predictive accuracies across all subgroups (curve area >80%). This difference in predictive accuracy was found to be statistically significant (P < 0.001). Conclusions: The present study suggests that the EuroSCORE‑II model in its present form is not validated for use in the Indian population. An interesting observation was significantly accurate predictive abilities of the System‑97 score

30-day mortality after coronary artery bypass grafting and valve surgery has greatly improved over the last decade, but the 1-year mortality remains constant.

Introduction: European system for cardiac operative risk evaluation (EuroSCORE) is a valuable tool in control of the quality of cardiac surgery. However, the validity of the risk score for the individual patient may be questioned. The present study was carried out to investigate whether the continued fall in short‑term mortality reflects an actual improvement in late mortality, and subsequently, to investigate EuroSCORE as predictor of 1‑year mortality. Methods: A population‑based cohort study of 25,602 patients from a 12‑year period from three public university hospitals undergoing coronary artery bypass grafting (CABG) or valve surgery. Analysis was carried out based on EuroSCORE, age and co‑morbidity factors (residual EuroSCORE). Results: During the period the average age increased from 65.1 ± 10.0 years to 68.9 ± 10.7 years (P < 0.001, one‑way ANOVA), and the number of females increased from 26.0% to 28.2% (P = 0.0012, Chi‑square test). The total EuroSCORE increased from 4.67 to 5.68 while the residual EuroSCORE decreased from 2.64 to 1.83. Thirty‑day mortality decreased from 4.07% in 1999–2000 to 2.44% in 2011–2012 (P = 0.0056; Chi‑square test), while 1‑year mortality was unchanged (6.50% in 1999–2000 vs. 6.25% in 2011–2012 [P = 0.8086; Chi‑square test]). Discussion: The study demonstrates that both co‑morbidity and age has a great impact on 30‑day mortality. However, with time the impact of co‑morbidity seems less. Thus, age is more important than co‑morbidity in late mortality. The various developments in short and long‑term mortality are not readily explained. Conclusion: Although 30‑day mortality of CABG and valve surgery patients has decreased during the 12‑year period, the 1‑year mortality remains the same.

The application of European system for cardiac operative risk evaluation II (EuroSCORE II) and Society of Thoracic Surgeons (STS) risk-score for risk stratification in Indian patients undergoing cardiac surgery.

Aims and Objectives: To validate European system for cardiac operative risk evaluation II (EuroSCORE II) and Society of Thoracic Surgeons (STS) risk-score for predicting mortality and STS risk-score for predicting morbidity in Indian patients after cardiac surgery. Materials and Methods: EuroSCORE II and STS risk-scores were obtained pre-operatively for 498 consecutive patients. The patients were followed for mortality and various morbidities. The calibration of the scoring systems was assessed using Hosmer-Lemeshow test. The discriminative capacity was estimated by area under receiver operating characteristic (ROC) curves. Results: The mortality was 1.6%. For EuroSCORE II and STS risk-score C-statics of 5.43 and 6.11 were obtained indicating satisfactory model fit for both the scores. Area under ROC was 0.69 and 0.65 for EuroSCORE II and STS risk-score with P values of 0.068 and 0.15, respectively, indicating poor discriminatory power. Good fit and discrimination was obtained for renal failure, long-stay in hospital, prolonged ventilator support and deep sternal wound infection but the scores failed in predicting risk of reoperation and stroke. Mortality risk was correctly estimated in low (< 2%) and moderate (2-5%) risk patients, but over-estimated in high-risk (> 5%) patients by both scoring systems. Conclusions: EuroSCORE II and STS risk-scores have satisfactory calibration power in Indian patients but their discriminatory power is poor. Mortality risk was over-estimated by both the scoring systems in high-risk patients. The present study highlights the need for forming a national database and formulating risk stratification tools to provide better quality care to cardiac surgical patients in India.

The classification of ureter disease by the level of difficulty and risk during rigid ureteroscopic surgery / 中华泌尿外科杂志

Objective To summarize the common types and clinical characteristics of ureter disease;which can increase manipulation difficulties and adverse events during rigid ureteroscopic procedures. Methods From Jan 2001 to Dec 2010,our team performed 317 rigid ureteroscopic Drocedures for ureteroscopic examination or treatment;including 60 difficult procedures(34 male and 26 female).The mean age of the patients was 37 years (range,18 to 71).The ureteral diseases were classifted into five types according to the pathological characteristics:Type Ⅰ calculous stenosis,Type Ⅱ neoplastic stenosis;Type Ⅲ non-congenital stenosis,Type Ⅳ congenital stenosis,Type Ⅴ expansion of tortuous ureters.The operative time,complications,and conversion to open surgery were evaluated,and the therapeutic methods were analyzed. Results Of the 60 difficuhly-manipulated procedures,the mean manipulated time was 75 min (range,31 to 200).Intra-operative complications occurred in 9 procedures,including 4 cases of mucosal bleeding,2 cases of submucosaI false passage and 3 cases of ureteral perforation.Eleven procedures were converted to open surgery. In five procedures only a double J tube was inserted for drainage due to the difficulty of entering the ureter.Fiftyfive patients were followed up for 17 months (range,3 to 110);48 patients were cured,5 patients improved and 2 patients were unchanged. Conclusions The five types of ureteral disease can increase operative difficulties and risks of rigid ureteroscopic procedures.We should be cautious during surgery and should stop manipulation or convert to other surgeries if necessary.

Development and application of a virtual hepatic surgical planning system / 中华肝胆外科杂志

Objective To develop a hepatic surgical planning software for hepatic operation on deciding the rational operational scheme, simulating procedures before the operation to accomplish the precise operation and decrease the operative risk. Methods The software was used in clinical practice to analyze the surgical anatomy of human liver, calculate the liver volume and vascular territory, disclose the hepatic structures and simulate the operation before operation. Results The surgical planning software is very convenient in analyzing the surgical anatomy of human liver, calculating the liver volume or vascular territory and simulating the operation before operation. Conclusion The developed surgical planning software is very helpful in clearly disclosing hepatic structures, rationally deciding operation scheme and virtually simulating the operation.

Preliminary Application of Colorectal Cancer Model of ACPGBI / 中国普外基础与临床杂志

Objective To validate the accuracy of the colorectal cancer model of the Association of Coloproctology of Great Britain and Ireland(ACPGBI-CCM),and to find out the relationship between clinical risk factors and the predictive value produced by ACPGBI-CCM.Methods The patients diagnosed definitely as colorectal cancer in the department of anal-colorectal surgery,West China hospital from April 2007 to July 2007 were analyzed retrospectively.And the predictive value of mortality for each patient was calculated by ACPGBI-CCM,then the difference of risk factors was compared by classifying the patients into lower risk group and higher risk group by making the median predictive mortality as a cut point.Results From April 2007 to July 2007,a total of 99 patients diagnosed definitely as colorectal cancer accepted treatment,and among which 67 patients included in this study were admitted whose average age was 60.09 years.And there were 34 male and 33 female patients;15 right hemicolon cancer,9 left hemicolon cancer,43 rectal cancer;Dukes staging:A 0 case,B 37 cases,C 24 cases,D 6 cases.The observed mortality 30 days after operation was 0,whereas the predictive mortality was 0.77%-25.75% with a median value of 3.36%.Then the patients whose predictive mortality were ≤3.36% were grouped as lower risk group(34 cases),the others higher risk group(33 cases),and there was strikingly different predictive mortality between two groups 〔(8.86?4.51)% vs(1.76?0.68)%,P0.05).Furthermore,stratification analysis was made for risk factors,and it came out that there were great differences of predictive mortality for different age groups and ASA grading,having internal medicine complications or not,having chemotherapy or not,and for cancer resected or not,and the differences were statistically significant(P0.05).Conclusion The clinical applicability of the ACPGBI-CCM is ascertained in such a large volume single medical centre,but the ACPGBI-CCM overpredicts the mortality in this study which may be attributed to the different areas,nations,or the different cultures.The complications and the neo-adjuvant or adjuvant therapy are further found out that they may be independent predictive factors of survival,and more research will be needed to prove this.

Surgical Treatment of Lumbar Spinal Stenosis in Geriatric Population: Is It Risky?

OBJECTIVE: Lumbar spinal stenosis is increasingly recognized as a common cause of low back pain in elderly patients. Conservative treatment has been initially applied to elderly patients, however, surgical treatment is sometimes indispensable to relieve severe pain. We retrospectively examine the age-related effects on the surgical risk, and results following general anesthesia and operative procedure in geriatric patients for two different age groups of at least 65years old. METHODS: Consecutive 51patients (> or = 65years), who underwent open surgical procedure for degenerative lumbar spinal stenosis, were selected in the study. Patients were divided into two groups. Group A included all patients who were between 65 and 69years of age at the time of surgery. Group B included all patients who were at least 70years of age at the time of surgery. We reviewed medical history including preoperative American Society of Anesthesiologists(ASA) classification of physical status, anesthetic risk factor, operative time, estimated blood loss, transfusion requirements, hospital stay, operated level, and clinical outcome to look for comparisons between two age groups (65~69 and over 70years). RESULTS: In preoperative evaulation, mean anesthetic risk factor of patients was numerically similar between the groups. The American Society of Anesthesiologists classification of physical status was similar between two groups. There was no difference in operated level, operative time, estimated blood loss, hospital stay, and anesthetic risk factor between the two groups. The clinical successful outcome showed 82.7% for Group A and 81.8% for group B. The overall postoperative complication rates were similar for both group A and B. CONCLUSION: We conclude that advanced age per se, did not increase the associated morbidity and mortality in surgical decompression for spinal stenosis.

Safe treatment of geriatric fractures / 中华创伤骨科杂志

The coming of an aged society in China will surely greatly affect the chief concerns of health care. The Chinese orthopaedists should be prepared for the tasks imposed by the new situation. Once a fracture happens due to osteoporosis in a senile person, a series of problems will follow. This paper discusses the diagnosis and prevention of osteoporosis, preoperative assessment of the patient, proper application of internal fixation and combined treatment of fracture and osteoporosis. The critical point is how to improve the therapeutic effects and to reduce the operative risks.

Surgical Treatment of Aortoiliac Occlusive Disease

BACKGROUND: The infrarenal abdominal aorta and the iliac arteries are the most common sites of chronic atherosclerosis in patients with symptomatic occlusive disease of the lower extremities. Direct anatomic reconstruction is the standard surgical treatment for a patient with aortoiliac occlusive disease, but extraanatomic bypass is used in patients with high cardiac or other risks. The purpose of this study was to compare the operative results of direct anatomic reconstruction with those an extraanatomic bypass and to select the optimal surgical treatment according to the preoperative risk. METHOD: The cases of 40 patients who received vascular reconstruction for aortoiliac occlusive disease between January 1995 and October 1997 were reviewed. The patients were classified in two groups: a direct anatomic reconstruction group and an extraanatomic bypass group. Operative risks were analyzed by the scoring system recommended by the Subcommittee on Reporting Standards for Lower Extremity Ischemia of International Society for Cardiovascular Surgery (ISCVS). Graft patency, operative mortality, and morbidity were also analyzed for the two groups. RESULT: There was no significant difference in operative risk (p>0.05) between the two groups, but the result of graft patency was better and the postoperative morbidity was less in direct anatomic reconstruction group. There was no postoperative mortality in either group. CONCLUSION: According to this study, direct anatomical reconstruction was superior to extraanatomic bypass inspite of same operative risks.

Mitral Valve Replacement / 대한흉부외과학회지

From July 1983 to December 1993, total 112 consecutive mitral valve replacement in 107 patients were performed in patient with mitral valvular abnormalites. To estimate the risk factor related to operative death, all patient's perioperative data were reviewed retrospectively. Except 20 patients received concomitant aortic valve replacement and 2 patients had incomplete data, 85 patients were included in this study. Mean age was 37.3+/-13.1 years ranging from 13 to 72 years. Thirty-seven patients were male and fourty-eight patients were female. Mean follow-up durations were 51.1+/-33.8 months ranging from 6 months to 11 years. Patients in this study showed improvement in mean NYHA functional clssification, from 3.02+/-0.73 to 1.78+/-0.55, and also in cardiothoracic ratio, from 0.61+/-0.09 to 0.58+/-0.08 at 6 months follow-up after operation. Operative complications were detected in 23 patients(27.1%) and common postoperative complications were rhythm disturbance in 7 cases, pulmonary complications in 6 cases and low cardiac output syndrome in 6 cases. Early mortality was 10.6% ( n=9 ) and most common cause of death was congestive heart failure due to low cardiac output syndrome. Main cause of our higher operative mortality than other study was that operative mortality in the initial period of our mitral surgery was high (5 operative deaths among 19 mitral valve replacement from July 1983 to December 1985 ). Actuarial survival was 80.8% at 5 years, 71.8% at 11 years including operative deaths. Actuarial freedom from anticoagulant-related bleeding was 85.3% at 5 years, 78.3% at 11 years. 95.1% at 5 years and 88.8% at 11 years among the patient in this study were free from thromboembolism, and 97.5% at 5 years and 75.1% at 11 years were free from reoperation. Preoperative cardiothoracic ratio and patient's age were statistically significant operative risk factors.