Preoperative Hypoalbuminemia Predicts Early Mortality Following Open Abdominal Surgery in Patients Above 60 Years of Age.

BACKGROUND: Major abdominal surgery in older and frail patients is associated with considerable morbidity and mortality. Plasma albumin is routinely measured in the clinic and has been proposed as an indicator of frailty. This study aimed to investigate if plasma albumin is a predictor of mortality in older patients undergoing open abdominal surgery. MATERIALS AND METHODS: We conducted a single-center, register-based retrospective study of patients, aged ⩾60 years who underwent one of 81 open abdominal surgical procedures. Patients operated on during the period from January 1st, 2000 to May 31st, 2013 were consecutively identified in the Danish National Patient Registry. Plasma albumin was measured within 30 days prior to surgery and the primary endpoint was 30-day postoperative mortality. RESULTS: 3,639 patients were included of whom 68.2% underwent emergency surgery. The rate of severe hypoalbuminemia (plasma albumin < 28 g/L) was 43.4%. Preoperative plasma albumin was lower in patients with a fatal 30-day outcome (mean 20.6 g/L vs 30.1 g/L in survivors, p < 0.0001). Other independent predictive parameters of 30-day mortality were age, male sex, and emergency surgery. We present an algorithm including these four variables for the prediction of 30-day mortality for patients aged ⩾60 years undergoing open abdominal surgery. CONCLUSION: Preoperative plasma albumin is a predictor of 30-day mortality in patients above 60 years of age following open abdominal surgery. Assessment of plasma albumin in conjunction with other risk factors such as age, sex, and surgical priority may improve preoperative decision-making.

Determinants for symptomatic gallstone disease readmissions - results from a cohort with screen-detected gallstone disease.

AIM OF THE STUDY: Selection of patients for cholecystectomy is hampered by lack of objective criteria. The objectives of this cohort study were to identify if patient, symptoms, or gallstone disease characteristics determined readmission in an unselected cohort with screen-detected gallstone disease and who had experienced a first admission with symptomatic gallstone disease. METHODS: Data from three random sampled population-based cohorts were used. At baseline, participants were screened with ultrasound and 664 had gallstones of which 84 had a first admission without cholecystectomy performed. A cohort study was performed with follow-up up for hospital readmissions beyond 30 days through central registers. Age adjusted Cox regression analyses were performed. RESULTS: Readmissions occurred in 60.8% and cholecystectomy was eventually performed in 47.7% of patients. Early readmissions were determined by abdominal pain in the epigastrium (Hazard ratio (HR) 3.63, 95% confidence interval (CI) [1.62;8.12]) and of moderate intensity (HR 2.71, 95% CI [1.20;6.16]). Late readmissions were determined by larger gallstone size, especially when above 10mm (HR 4.11, 95% CI [1.18;14.3]) and inversely determined by age (HR 0.97, 95% CI [0.95;0.998]). In patients with initially uncomplicated gallstone disease, cholecystectomy was inversely determined by age (HR 0.96, 95% CI [0.93;0.98]). CONCLUSION: Once gallstones have become symptomatic and caused hospital admission, a persisting high risk for future readmission exists and half of patients end up having cholecystectomy. Pain in the epigastrium, larger gallstones, and younger age determine readmission. These determinants should be tested in future clinical treatment algorithms for gallstone disease.

Are incident gallstones associated to sex-dependent changes with age? A cohort study.

Age and female sex have repeatedly been identified as gallstone determinants but the underlying mechanisms are not clarified. The objectives of this study were to determine if changes with age in physiology, lifestyle, or reproductive hormones were associated with incident gallstones. A cohort study of a general population random sample (N = 2366) aged 30-60 years was performed. Participants were ultrasound screened for gallstones in 1982-84 and again in 1993-94. Lifestyle data and blood samples were obtained and re-analyzed in 2004. Changes with age in physiology (body mass index, blood pressure, blood lipids, self-rated health), lifestyle (smoking, alcohol and coffee consumption, dietary habits, physical activity level), and indices of reproductive function (number of births, oral contraceptive use, hormone replacement therapy, male reproductive hormones) were explored in females and males separately. Adjusted logistic regression analyses were performed. Incident gallstones (gallstones and cholecystectomy) at ultrasound examination in participants initially free of gallstones at baseline occurred in 9.9% of the study population. In females, increasing alcohol consumption (odds ratio (OR) 0.94, 95% confidence interval (CI) [0.90; 0.98]) and the cessation of hormone replacement therapy (OR 0.29, 95% CI [0.10; 0.83]) inversely determined incident gallstones. In males, increasing levels of SHBG (OR 0.97, 95% CI [0.94; 0.998]) inversely determined incident gallstones. Other changes with age in physiology, lifestyle, or reproductive hormones were not associated. High baseline free testosterone determined incident gallstones in males (OR 1.15, 95% CI [1.02; 1.30]). To conclude, changes with age in alcohol consumption in females and in reproductive hormones determined incident gallstones. Male reproductive hormones seem to have an impact on incident gallstones. Sex differences should be explored further in future studies.

Lack of association between inguinal hernia and abdominal aortic aneurysm in a population-based male cohort.

BACKGROUND: Previous studies have reported a higher prevalence of inguinal hernia in patients with abdominal aortic aneurysm (AAA). The aim of this study was to explore the association between inguinal hernia and AAA in a large population-based cohort of men who had screening for AAA. METHODS: A total of 18,331 men aged 65-76 years had ultrasound screening for AAA in the Central Region of Denmark from 2008 to 2010. The Danish National Patient Registry was interrogated, and screened men registered with an inguinal hernia from 1977 to 2011 were identified. The association between inguinal hernia and AAA was assessed by multiple logistic regression analysis. RESULTS: The prevalence of AAA was 3.3 per cent (601 of 18,331). A total of 2936 (16.0 per cent) of the 18,331 patients were registered with a diagnosis of inguinal hernia or hernia repair. Inguinal hernia was not associated with AAA: crude odds ratio (OR) 0.86 (95 per cent confidence interval 0.68 to 1.09) and adjusted OR 0.94 (0.75 to 1.20). CONCLUSION: In contrast to smaller patient-based studies, this large population-based study found no association between inguinal hernia and AAA.

Connective tissue alteration in abdominal wall hernia.

BACKGROUND: The aetiology and pathogenesis of abdominal wall hernia formation is complex. Optimal treatment of hernias depends on a full understanding of the pathophysiological mechanisms involved in their formation. The aim of this study was to review the literature on specific collagen alterations in abdominal wall hernia formation. METHODS: A computer-assisted search of the medical databases PubMed and Embase was performed, together with a cross-reference search of eligible papers. RESULTS: Fifty-two papers were included. Collagen alteration depended on the type of hernia; there were more pronounced changes in patients with a direct inguinal hernia than in those with an indirect inguinal hernia, recurrent inguinal hernia or incisional hernia. A consistent finding was a significant increase in immature type III collagen relative to the stronger type I collagen in patients with a hernia. This resulted in thinner collagen fibres with a correspondingly diminished biomechanical strength. It has been suggested that these alterations are due to variation in the synthesis, maturation or degradation of collagen by matrix metalloproteinases, in combination or alone. CONCLUSION: Hernia formation and recurrence is associated with altered collagen metabolism manifested by a decreased type I:III collagen ratio.

Smoking and skin disease.

Tobacco smoking is a serious and preventable health hazard that can cause or exacerbate a number of diseases and shorten life expectancy, but the role of smoking as an etiologic factor in the development of skin disease is largely unknown. Although epidemiological evidence is sparse, findings suggest that tobacco smoking is a contributing factor in systemic lupus erythematosus, psoriasis, palmoplantar pustulosis, cutaneous squamous cell carcinoma, hidradenitis suppurativa, and genital warts. In contrast, smoking may confer some protective effects and mitigate other skin diseases, notably pemphigus vulgaris, pyoderma gangrenosum, aphthous ulcers, and Behçet's disease. Various degenerative dermatologic conditions are also impacted by smoking, such as skin wrinkling and dysregulated wound healing, which can result in post-surgical complications and delayed or even arrested healing of chronic wounds. Most likely, alteration of inflammatory cell function and extracellular matrix turnover caused by smoking-induced oxidative stress are involved in the pathophysiologic mechanisms.

Strategies of smoking cessation intervention before hernia surgery--effect on perioperative smoking behavior.

BACKGROUND: Although it is now generally accepted that patients should be advised to quit smoking before surgery, the effect of low-intensive smoking cessation intervention, both on preoperative smoking behavior and on risk reduction, remains unclear. Our objective was to study the effect on perioperative smoking behavior and on postoperative wound infection of different types of low-intensive intervention before herniotomy. METHODS: Between October 1998 and October 2000, 180 consecutive smokers scheduled for elective herniotomy were advised to quit smoking perioperatively and subsequently allocated randomly to three low-intensive smoking cessation groups: a standard (control) group, a telephone group, which was reminded by telephone, and an out-patient group, which was reminded by means of an out-patient talk and demonstration of nicotine replacement drugs. Spontaneous perioperative smoking behavior was recorded for 64 consecutive non-advised smokers. Postoperative wound infection was evaluated by independent assessors. RESULTS: Of the advised patients, 19% (29/149) stopped smoking before surgery compared with 2% (1/64) in the non-advised cohort (P < 0.01). In the standard group 13% (6/48) quit smoking compared with 23% (23/101) in the pooled telephone and outpatient group (NS). In the last group 64% (65/101) reduced or stopped smoking compared with 42% (20/48) in the standard group (P < 0.05). Predictors of failed perioperative cessation of smoking were a CO breath-test at inclusion above 20 ppm (OR: 0.11; 0.02-0-57) and low motivation to quit smoking (OR: 0.25; 0.09-0.70). Wound infection occurred in 6% (13/213) and there was no difference between the groups. CONCLUSION: Low-intensive smoking cessation intervention helps approximately one fifth of patients to stop smoking perioperatively. Patients who are reminded in addition to preoperative advice are more likely to stop or reduce smoking. Failure to stop smoking is greater if the patients are not motivated and if the CO breath test is high at the time of the preoperative advice.

Evaluation of the quality of venous leg ulcer care given in a multidisciplinary specialist centre.

OBJECTIVE: To determine the quality of venous leg ulcer care given in a multidisciplinary, specialist wound-healing centre and to identify problem areas that might affect it. METHOD: The case records of 90 consecutive patients with venous leg ulcers, diagnosed and treated at the Copenhagen Wound Healing Centre, Denmark, were retrospectively audited by a Scandinavian cross-sectional and multidisciplinary expert panel. Quality of care was audited in each case using implicit criteria. The experts then formulated key recommendations for good clinical practice for patients with venous leg ulcers. RESULTS: Quality of care was satisfactory in 74 patients (82%). The one-year healing rate was 77% (69/90), with a three-month recurrence rate of 12% (11/90). Identified problem areas included the lack of systematic assessment of patients' suitability for surgery; lack of systematic, duplex-verified diagnoses of venous aetiology; and the lack of systematic examination of distal arterial pressure. The recommendations include the need for venous diagnosis, differential diagnosis, compression therapy, surgery, systemic treatment, access to venous leg ulcer care and better communication. CONCLUSION: The quality of venous leg ulcer care given in this multidisciplinary centre was satisfactory.

Smoking as a risk factor for wound healing and infection in breast cancer surgery.

AIM: Clinical studies suggest that smoking is associated with wound necrosis after breast cancer surgery. However, the significance of smoking as a risk factor for wound infection, skin flap necrosis, and epidermolysis when adjusting for other potential risk factors remains to be studied. METHODS: From June 1994 through August 1996, 425 patients underwent breast cancer surgery as simple mastectomy, modified radical mastectomy, or breast conserving surgery. The patients were evaluated postoperatively for wound infection, skin flap necrosis, and epidermolysis. Association between these complications and 17 patient, operative, and postoperative variables were analysed by three separate multiple logistic regression analyses. RESULTS: When compared to non-smoking, smoking was significantly associated with wound infection after all types of surgery (light smoking (1-14 grams per day): [odds ratio (OR)=2.95, 95% confidence interval (95% CI)=1.07-8.16], and heavy smoking (>/=15 grams per day): OR=3.46 (1.52-7.85). A similar significant association was found as regards skin flap necrosis and epidermolysis after simple mastectomy and modified radical mastectomy: both light and heavy smoking were predictive for skin flap necrosis: light smoking: OR=6.85 (1.96-23.90), heavy smoking: OR=9.22 (2.91-29.25) and for epidermolysis: light smoking: OR=3.98 (1.52-10.43) and heavy smoking: OR=4.28 (1.81-10.13). No significant dose-response relation was disclosed. Other risk factors and confounders associated with complicated wound healing were adjusted for in the analysis: diabetes, obesity, alcohol, NSAIDs, duration of surgery, and surgical experience. CONCLUSION: Independent of other risk factors, smoking is predictive for post-mastectomy wound infection, skin flap necrosis, and epidermolysis.

Increased collagen deposition in an uncomplicated surgical wound compared to a minimal subcutaneous test wound.

Little information is currently available concerning the relationship between results obtained in humans from surgical test wounds and results from wound models. Therefore, to evaluate human wound healing parameters, tubings of expanded polytetrafluoroethylene were implanted in a subcutaneous test wound in the arm of 47 volunteers and 20 patients undergoing hernia repair. The surgical patients also had implants left in the surgical wound cavity. After 10 days the deposition of collagen in the tubings as expressed by hydroxyproline content was 30% higher in the surgical wound than in the test wound, p < 0.05. The amount of collagen deposited in the tubing within the surgical wound did not correlate with measurements in the test wound, whereas a significant correlation of proline levels was found between the two sites, p < 0.05. Deposition of proline and total protein in the model was equivalent. In both wound types age negatively correlated with levels of protein, but not collagen. The variability of the results was 40% lower in the subcutaneous test wound than in the surgical wound. There was no significant difference in hydroxyproline deposition between the volunteers and the patients undergoing hernia repair. In patients undergoing minor surgery without signs of compromised healing the expanded polytetrafluoroethylene test wound in the arm reflects the deposition of non-collagenous protein, but not collagen, within the surgical wound.

[The effect of patient-specialist-continuity in a surgical department. Evaluation of seven years of experiences]. / Effekten af patient-specialist-kontinuitet i en kirurgisk sygehusafdeling. Evaluering af syv års kvalitetsudvikling.

From 1990 through 1997 the working schedules for staff surgeons underwent gradual changes. The aim was to comply with patient demands to receive care from few surgeons during hospital care. To evaluate the effect, four controlled or cross sectional studies were conducted. Quality of care was assessed by surgical audit. Patient and surgeon satisfaction was examined with questionnaires and interviews. Changes in costs were evaluated by administrative data. The number of different specialists providing care was reduced by 50%, initially during inpatient care and later also during outpatient care. The patients experienced this change as very satisfying. Hospital stay was reduced, as was time used by specialists on out-of-hours duty. The quality of care did not change neither did the use of diagnostic tests. The specialists appraised the increased individual responsibility in patient care as satisfying. Initiatives should be taken to examine whether other ways of organising work for hospital employed doctors have similar effect.

Smoking and alcohol abuse are major risk factors for anastomotic leakage in colorectal surgery.

BACKGROUND: Several studies have examined the association between anastomotic leakage and intraoperative risk factors in colorectal surgery, but only a few have taken patients' lifestyle into account. The aim of this study was to assess the association between anastomotic leakage and lifestyle factors such as smoking habits and alcohol consumption. METHODS: Between January 1993 and October 1996, 333 unselected consecutive patients in one surgical department underwent colonic or rectal resection with anastomosis. The association between clinical anastomotic leakage and 24 variables related to patient history, diagnosis and surgery was assessed retrospectively and analysed by logistic regression. RESULTS: The rate of clinical anastomotic leakage was 15.9 per cent (53 of 333 patients). Multiple regression analysis showed that smokers, compared with non-smokers, had an increased risk of anastomotic leakage (relative risk (RR) 3.18 (95 per cent confidence interval (c. i.) 1.44-7.00)), as did alcohol abusers compared with abstainers (RR 7.18 (95 per cent c.i. 1.20-43.01)). In the analysis, well known risk factors for anastomotic leakage such as site of anastomosis, age and stage of training of the surgeon were taken into account. CONCLUSION: Smoking and alcohol abuse are important predictive factors for anastomotic leakage after colonic and rectal resection.

[A single physician or a group of specialists in the surgical ward. I: Impact on quality of the care provided by specialists]. / Samme versus forskellige speciallaeger på stuegang. I: Indvirkning på kvaliteten af det laegefaglige arbejde.

The impact on quality of ward care provided by surgeons within two continuity schedules was assessed by explicit and implicit audit. In one schedule one surgeon provided care and in another a staff of surgeons provided care. The study included 214 consecutive inpatients. The study demonstrated that quality of ward care was unaffected by continuity schedule. In the single surgeon continuity schedule, however, nearly twice as many discharge letters were posted within four days (p < 0.001). Likewise, twice as many contained information that the patients had been informed about the diagnosis (p < 0.05). In both continuity schedules about 20% of the patients received inadequate care. Analysis of this finding demonstrated that more patients had been subject to inadequate follow-up in the single surgeon continuity schedule, whereas more patients had been subject to inadequate postoperative observation in the staff continuity schedule. In both schedules an equal number of patients had been subject to incomplete diagnoses and inadequate medical care.