Factors affecting morbidity and mortality in incarcerated abdominal wall hernias

Background Incarcerated abdominal wall hernia cases may necessitate emergency interventions, but under such circumstances morbidity and mortality rates may increase. The aim of this study was to investigate the factors that affect morbidity and mortality in patients with incarcerated abdominal wall hernias who underwent emergency surgery. Methods Urgent surgical interventions due to incarcerated abdominal wall hernias were performed in 182 patients in our clinics between January 1998 and January 2006. Factors that affect morbidity and mortality in incarcerated abdominal wall hernias were investigated retrospectively by browsing the archives. Logistic regression analysis was used to evaluate parameters that affect morbidity and mortality. Results Morbidity and mortality occurred in 43 (23.6%) and 9 (4.9%) patients, respectively. A symptomatic period of longer than 8 h, presence of accompanying disease, high American Society of Anesthesiology (ASA) score, general anesthesia, presence of strangulation, and necrosis were found to affect morbidity significantly by univariate analysis. Necrosis was the sole factor affecting morbidity significantly by multivariate analysis. Advanced age, presence of accompanying disease, high ASA score, presence of strangulation, necrosis, and hernia repair with graft were found to affect mortality significantly by univariate analysis; however, necrosis was the sole factor affecting mortality significantly by multivariate analysis. Conclusions Intestinal necrosis, which was followed by bowel resection, was the sole factor affecting morbidity and mortality using multivariate logistic regression analysis. Emergency surgery is required for incarcerated abdominal wall hernias before intestinal necrosis develops.     

Peace-time abdominal gunshot wounds

From analysis of the results of surgical treatment of gunshot injuries of the abdomen in 55 patients the authors conclude that insufficient experience of surgeons in the treatment of such injuries is the main cause of pyogenic complications (51%). They failed, as a rule, to take into account the extent of the affection and the spread of the devitalized tissues, as a consequence of which unjustified economical and non-radical debridement was performed. Eleven patients (20%) died, seven of them, from peritonitis.     

Factors affecting mortality rates in patients with abdominal vascular injuries.

BACKGROUND: Major vessel injury is seen in 5% to 25% of patients admitted to hospitals with abdominal trauma, and this is the most common cause of death in these patients. METHODS: Data on 470 patients with abdominal vascular injuries seen at a Level I trauma center were reviewed retrospectively. RESULTS: The overall mortality rate was 45%. The incidence of various types of trauma were blunt in 51 patients (11%), gunshot wounds in 329 patients (70%), shotgun wounds in 21 patients (4%), and stab wounds in 69 patients (15%). The three vessels with the highest mortality rates were aorta (at and proximal to the renals) (32 of 35 [91%]), hepatic veins and/or retrohepatic vena cava (36 of 41 [88%]), and portal vein (25 of 36 [69%]). The most significant risk factors (p < 0.001) for death were a trauma score of 9 or less, initial operating room (OR) systolic blood pressure (SBP) < 90 mm Hg, final OR core temperature < 34 degrees C, 10 or more blood transfusions in the first 24 hours, and an initial emergency department SBP < 70 mm Hg. Of 120 patients with an initial OR SBP < 70 mm Hg, 103 (86%) died. Of 29 patients with a good response to a prelaparotomy thoracotomy with thoracic aortic cross-clamping (SBP > 90 mm Hg within 5 minutes), 11 (38%) survived. Of the remaining 87 patients, only 6 (7%) survived (p = 0.01). CONCLUSION: Rapid control of bleeding sites (to keep blood transfusions to < 10 units) and urgent correction of hypothermia seem to be the main factors improving survival over which the surgeon has some control.     

Factors affecting morbidity and mortality in pancreatic injuries

Purpose

Difficulties in the detection of pancreatic damage result in morbidity and mortality in cases of pancreatic trauma. This study was performed to determine factors affecting morbidity and mortality in pancreatic trauma.

Methods

The records of 33 patients who underwent surgery for pancreatic trauma between January 2004 and December 2013 were analyzed retrospectively.

Results

The types of injury were penetrating injury and blunt abdominal trauma in 75.8 and 24.2 % of all cases, respectively. Injuries were classified as stage 1 in 6 cases (18.2 %), stage 2 in 18 cases (54.5 %), stage 3 in 5 cases (15.2 %), and stage 4 in 4 cases (12.1 %). The average injury severity scale (ISS) value was 25.70 ± 9:33. Six patients (18.2 %) had isolated pancreatic injury, 27 (81.2 %) had additional intraabdominal organ injuries and 10 patients (30.3 %) had extraabdominal organ injuries. The mean length of hospital stay was 13.24 ± 9 days. Various complications were observed in eight patients (24.2 %) and mortality occurred in three (9.1 %). Complications were more frequent in patients with high pancreatic damage scores (p = 0.024), additional organ injuries (p = 0.05), and blunt trauma (p = 0.026). Pancreatic injury score was associated with morbidity, while the presence of major vascular injury was associated with mortality.

Conclusions

Complications were significantly more common in injuries with higher pancreatic damage scores, additional organ injuries, and blunt abdominal trauma. Pancreatic injury score was associated with morbidity, while the presence of major vascular injury was associated with mortality.

     

Factors affecting morbidity and mortality in biliary tract surgery

Thirty-six clinical and laboratory parameters in 770 consecutive patients undergoing biliary tract surgery over a 3 year period were analyzed in an effort to define the patients at greatest risk. Twelve parameters had a significant correlation with hospital mortality, while multivariate analysis revealed that septic shock, malignant obstruction, serum albumin <3.0 gm%, history of hypertension, and plasma urea nitrogen >20 mg % had an independent significance in predicting postoperative mortality. The presence of more than 2 of these risk factors identified a group of patients with an 18% mortality rate. It is for this group of patients that adequate pre-operative preparation such as fluid resuscitation, prophylactic antibiotics, and nutritional support are essential. The controversial preoperative biliary drainage might be only indicated in this group of patients.

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Resumen Se analizaron 36 parámetros clínicos y de laboratorio en 770 pacientes consecutivos sometidos a cirugía sobre el arbol biliar en el curso de un período de tres años con el propósito de identificar los pacientes de mayor riesgo. Doce parámetros demostraron correlación significativa en la mortalidad hospitalaria, en tanto que el análisis multivariable reveló que el shock séptico, la obstrucción maligna, un nivel sérico de albúmina menor de 3.0 g%, la historia de hipertensión y un nivel plasmático de nitrógeno ureico mayor de 20 mg% poseen significancia independiente en la predicción de la mortalidad postoperatoria. La presencia de más de dos de estos factores de riesgo identifica un grupo de pacientes con tasa de mortalidad de 18%. Es en este grupo de pacientes que es esencial una adecuada preparación preoperatoria tal como resucitación con líquidos parenterales, antibióticos profilácticos y soporte nutricional; el controvertido drenaje biliar preoperatorio puede estar indicado sólo en este grupo de pacientes.

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Résumé Afin de définir une population à risque, 36 paramètres cliniques et biologiques ont été analysés chez 770 patients consécutifs opérés des voies biliaires pendant trois ans. Douze facteurs étaient significativement correlés à une mortalité hospitalière plus élevée, en analyse monofactorielle. En analyse multifactorielle, un choc septique, une obstruction d'origine maligne, une albuminémie inférieure à 3.0 gm%, des antécédents d'hypertension, et une urée sanguine supérieure à 20 mg% avaient une valeur prédictive significative de mortalité postopératoire. La présence de plus de deux de ces facteurs a correctement identifié une population pour laquelle la mortalité était de 18%. C'est donc dans cette population que les auteurs suggerent une préparation préopératoire suffisante comportant une rééquilibration hydro-électrolytique, une antibiothérapie prophylactique et une assistance nutritive. De même, le drainage biliaire préopératoire, quoique discuté, pourrait être indiqué dans ce group de patients.

     

Factors affecting postoperative mortality in abdominal trauma.

Records of 345 patients in whom laparatomies were performed because of blunt and penetrating abdominal trauma were reviewed retrospectively with respect to factors affecting mortality. One hundred and twenty-eight patients had blunt abdominal trauma (Group I), 114 patients had gunshot wounds of the abdomen (Group II), and 103 patients had stab wounds of the abdomen (Group III). Mortality rates were 14.8%, 12.3% and 1.9% in groups I, II and III respectively. The presence of head trauma especially if accompanied by hypotension in group I, and the presence of chest trauma (hemothorax and/or pneumothorax) and hypotension (less than 90 mmHg) in group II were associated with a high mortality rate (p less than 0.05). Of the two patients who died in group III, one had septic shock due to massive intestinal necrosis and the other had hemorrhagic shock due to multiple organ injury and bleeding from an injured internal thoracic artery as the cause of death.     

Factors affecting morbidity, mortality, and survival in patients undergoing Ivor Lewis esophagogastrectomy

OBJECTIVES: To examine the safety of transthoracic esophagogastrectomy (TTE) in a multidisciplinary cancer center and to determine which clinical parameters influenced survival and the rates of death and complications. SUMMARY BACKGROUND DATA: Although the incidence of cancer at the gastroesophageal junction has been rising rapidly in the United States, controversy still exists about the safety of surgical procedures designed to remove the distal esophagus and proximal stomach. Alternatives to TTE have been proposed because of the reportedly high rates of death and complications associated with the procedure. METHODS: Data from 143 patients treated by TTE by one author (1989-1999) were entered into a computerized database. Preoperative clinical parameters were tested for effect on death, complications, and survival. RESULTS: The patient population consisted of 127 men and 16 women. One hundred twenty-one patients had a history of tobacco abuse, and 118 reported the regular ingestion of alcohol. One hundred fifteen patients had adenocarcinoma, 16 had squamous cell cancer, 6 had another form of esophageal tumor, and 6 had high-grade dysplasia associated with Barrett epithelia. Fifty-six patients had adenocarcinomas arising in Barrett epithelium. Twenty-eight patients were treated with neoadjuvant chemoradiation before surgery. Three patients died within 30 days of surgery (mortality rate 2.1%). Five patients (3.5%) had a documented anastomotic leak; three died). Overall, 42 patients had complications (29%). Twenty-six had pulmonary complications (19%). The mean length of stay in the intensive care unit was 3.35 days; the mean hospital length of stay was 13.54 days. The overall 3-year survival rate was 29.6%. CONCLUSIONS: A high ASA score and the development of complications predicted an increased length of stay. The presence of diabetes predicted the development of complication and an increased length of stay. None of the other parameters tested predicted perioperative death or complications. Only disease stage, diabetes, and blood transfusion affected overall survival. From these results with a large series of patients with gastroesophageal junction cancers, TTE can be performed with a low death rate (2.1%), a low leak rate (3. 5%), and an acceptable complication rate (29%).     

Specifics of intensive therapy in abdominal gunshot wounds

Among the wounded admitted to the departments of anesthesiology, resuscitation and intensive therapy there were from 57.8 to 77.6% of gunshot injuries of the abdomen. Successful treatment of such patients is dependent not only on the timeliness and quality of surgical interventions but also on the correct choice of intensive therapy before and during operation and in the postoperative period. The temporizing strategy providing for expanding the list of the methods used as late as the symptoms of the unfavorable course of the postoperative period can not be considered sufficiently effective. Complex intensive therapy with a forestalling action on different links of the wound disease pathogenesis in most cases allows not only the elimination of organic and systemic impairments resulting from the wound but also is more effective for defensive compensatory mechanisms. Differentiation of the programs of treatment depending not only on the severity of the patient's state but also on the character of injuries of organs of the abdominal and retroperitoneal areas is of the leading significance.     

Treatment of peace-time thoracic and abdominal gunshot wounds]

The article analyses the results of treatment of gunshot injuries to the chest and abdomen suffered by 59 males in peace time. Their ages ranged from 17 to 51 years. It was found that gunshot injuries to the chest and abdomen suffered in peace time are characterized by a severe clinical course, multiple damages of polyorganic localization, they are often attended by shock and are marked by a great number of pyoseptic complications and a high mortality rate, particularly in concurrent and combined injuries to the organs of both cavities.     

Laparoscopic evaluation of tangential abdominal gunshot wounds.

The use of laparoscopy in abdominal trauma has been proposed for several decades; however, it has not been widely used. With the advent of laparoscopic cholecystectomy, general surgeons are realizing the potential of this technique. This should result in an expanded role for laparoscopy, including the evaluation of abdominal trauma. We present a series in which laparoscopy was used in the evaluation of tangential gunshot wounds to the abdomen. Laparoscopy enabled us to demonstrate whether the missile had violated the peritoneal cavity and to avoid laparotomy in cases without peritoneal penetration.     

Factors affecting postoperative morbidity and mortality in isolated coronary artery bypass graft surgery

Purpose  This study was conducted to investigate predictors of mortality before and after isolated coronary artery bypass grafting (CABG). Methods  Single-institutional data on risk factors and mortality were collected for 8890 patients who underwent isolated CABG by the same group of surgeons. The relationship between risk factors and outcome was assessed using univariate and multivariate analyses in two risk models: a preoperative model (model 1) and then a pre-, intra-, and postoperative model (model 2). Results  The mean age of the patients (25.4% women and 74.6% men) was 58.5 ± 9.7 years. Fifty-five (0.6%) patients died after surgery. Hypercholesterolemia was the most common comorbidity factor (61.1%), followed by hypertension, a smoking habit, recent myocardial infarction (MI) <21 days, and diabetes. Postoperative tamponade, graft occlusion, and MI (0.01%) were the least common complications. The patients spent 39.7 ± 33.9 h in the intensive care unit (ICU) postoperatively. Patients were followed up for a minimum of 30 days. The multivariate analysis of our preoperative risk model revealed that the best predictors of operative mortality were a history of diabetes, hypertension, previous CABG, the presence of angina, arrhythmia, Canadian Cardiovascular Society Classification (CCS) of grade III or IV, ejection fraction (EF) ≤30%, three-vessel disease, and left main disease. Conclusion  After surgery, and with the inclusion of all the pre-, intra-, and postoperative variables into model two, the following were revealed to be prognostic factors for in-hospital mortality: a history of diabetes, hypertension, the presence of angina, CCS grades III or IV, EF −30%, absence of internal mammary artery (IMA) use, prolonged cardiopulmonary bypass (CPB) time, and prolonged ICU stay.