Preoperative blood glucose concentrations and postoperative outcomes after elective non-cardiac surgery: an observational study.

BACKGROUND: The association between preoperative blood glucose (BG) concentration and outcomes after non-cardiac surgery and the impact of the diabetes diagnosis status remain unclear. We tested two hypotheses: that preoperative BG is related to surgical outcomes; and that this relationship depends on the diabetes diagnosis status of the patient. METHODS: We retrospectively analysed data on 61 536 consecutive elective non-cardiac surgery patients treated at our tertiary care facility. Logistic regression models were used to test the hypotheses before and after adjustment for baseline patient characteristics. Our primary outcome was a composite of in-hospital serious complications and mortality. A second primary outcome was 1 yr mortality. RESULTS: The crude incidence of the composite in-hospital outcome was significantly related to preoperative BG (P<0.001), but not after covariable adjustment (P=0.40). This relationship did not significantly differ between patients with and without diagnosed diabetes (P=0.09). One year mortality was significantly related to preoperative BG, both univariably (P<0.001) and after covariable-adjustment (P<0.001). Patients with diagnosed diabetes and preoperative euglycaemia generally had worse 1 yr mortality than those without diabetes at the same BG {e.g. odds ratio (OR) [95% confidence interval (CI)] of 1.27 (1.06, 1.53) at 6 mmol litre(-1) (108 mg dl(-1)), P=0.003}. Conversely, hyperglycaemic patients with diagnosed diabetes displayed a significantly lower 1 yr mortality than hyperglycaemic patients without diabetes [OR (95% CI) of 0.58 (0.44, 0.77) at 12 mmol litre(-1) (216 mg dl(-1)), P<0.001]. CONCLUSIONS: For elective non-cardiac surgery, preoperative hyperglycaemia should be given greater consideration in patients without diabetes than in those with diagnosed diabetes.

Laparoscopic augmentation cystoplasty. Surgical technique.

Laparoscopic enterocystoplasty is technically feasible and successfully emulates the established principles of open enterocystoplasty while minimizing operative morbidity. As is true in open surgery, various bowel segments can be fashioned and anastomosed to the bladder laparoscopically. The increased costs associated with laparoscopy and with minimally invasive surgery in general have been a significant disadvantage; however, a previous report on the costs of laparoscopic procedures concluded that increased surgical experience reduces the surgical time and length of hospital stay, thereby decreasing costs. Furthermore, the increased use of reusable instruments results in considerable economic benefits. Implementation of appropriate cost-saving strategies ultimately will result in decreased expenses associated with laparoscopy. Although laparoscopic enterocystoplasty is currently a lengthy procedure lasting twice as long as open surgery, further technical modifications and increasing experience will continue to reduce the surgical time involved. For patients with complex comorbid illness who desire the improved quality of life associated with traditional augmentation cystoplasty, the reduced morbidity observed in the authors' series of patients undergoing a laparoscopic procedure makes this approach an attractive option to consider. The authors' initial experience suggests that laparoscopic enterocystoplasty has the potential to become a viable alternative to open enterocystoplasty.

Tension-free vaginal tape and percutaneous vaginal tape sling procedures.

PURPOSE: Midurethral synthetic sling procedures for treatment of stress urinary incontinence (SUI) are gaining increased attention from surgeons specializing in female pelvic reconstructive techniques seeking successful patient outcomes through reproducible simplicity. This report describes the procedural steps and methods used to maximize the potential for successful outcomes using techniques of midurethral synthetic sling placement. Reported complications and surgical outcomes are reviewed with respect to patient selection and minimizing the potential for morbidity and mortality as long-term clinical experience is accumulated. MATERIALS AND METHODS: Tension-free vaginal or transvaginal tape (TVT) and the recently introduced percutaneous vaginal tape (PVT) are two new procedural choices for placement of synthetic sling material at the midurethra. Both procedures use sling material composed of polypropylene mesh, a nonabsorbable synthetic material, placed at the level of the midurethra via an antegrade (PVT, using a percutaneous ligature carrier) suprapubic approach or retrograde (TVT, using vaginal trocars) vaginal approach. Patient selection, procedural techniques, and methods described are based on observations obtained or reported from clinical experience. Outcomes and complications for TVT are derived from a literature review of all published articles in Index Medicus from 1996 to 2000. RESULTS: The experience with TVT for the last 5 years is encouraging. At 3-year follow-up for TVT, reported cure rates for SUI range from 80% to 95%. A multitude of worldwide reports on PVT with shorter follow-up support the findings of the TVT experience. Reproducible findings with midurethral synthetic slings are the short operative times recorded for the sling procedure, ease of technical performance, minimal patient discomfort, and a high rate of early return of normal voiding function. The rate of complications such as obstructive voiding or de novo instability (0-15%) and urinary retention necessitating a secondary procedure (2-4%) appear to be equal to the rates of contemporary competing technologies and procedures for treatment of SUI. CONCLUSIONS: Preliminary reports and the experience at our institution suggest that the techniques of midurethral synthetic sling placement of TVT and PVT are reproducible, easy to master, and minimally invasive with respect to tissue handling. Although complications with all anti-incontinence procedures exist, understanding the anatomical considerations and methodology of these unique procedures should minimize patient morbidity, avoid patient mortality, and produce a high rate of durable success.

Bone anchor infections in female pelvic reconstructive procedures: a literature review of series and case reports.

PURPOSE: We determined the reported prevalence of infectious osseous complications due to the use of bone anchors for suture fixation in female pelvic reconstructive procedures. In addition, the type and method of bone anchors as well as the reported pathogens associated with osseous infections were reviewed. MATERIALS AND METHODS: Primary reported series of female pelvic reconstructive procedures involving bone anchor suture fixation referenced in Index Medicus from January 1990 to July 2000 were extracted using the MEDLINE bibliographic database on English language articles involving humans. All case reports of infectious osseous complications due to bone anchor use in female reconstructive procedures were also reviewed during this period. RESULTS: Since the inception of bone anchor suture fixation for female pelvic reconstructive procedures 10 years ago, the overall prevalence of related infectious complications has been 6 cases in 1,018 procedures (0.6%). This type of adverse event developed between followup weeks 1 and 24. The prevalence of suprapubic bone anchors has been 6 cases in 698 procedures (0.86%). For transvaginal bone anchor procedures no infectious cases have been reported in the combined series of 314 procedures and the same is true for 1 reported case of sacral bone anchor placement in 6 procedures. No statistical difference was noted in regard to the prevalence of infection in procedures involving suprapubic bone anchors and transvaginal bone anchor combined with sacral bone anchor placement (Fisher's exact test p = 0.19). The organisms reported in case reports suggest a coliform, skin or hematogenous source for contamination of the bone anchor site. CONCLUSIONS: An infectious bone anchor complication in female pelvic reconstructive procedures is an uncommon event with a reported prevalence of 0.6%. Currently there is no evidence of differences in the prevalence of osseous complications after transvaginal versus suprapubic bone anchor fixation. Preoperative broad-spectrum antibiotics are recommended to decrease the potential of infectious bone anchor complications.