Background To examine the rates and predictors of deep periprosthetic infections after primary total shoulder arthroplasty (TSA). Methods We used prospectively collected data on all primary TSA ...patients from 1976-2008 at Mayo Clinic Medical Center. We estimated survival free of deep periprosthetic infections after primary TSA using Kaplan-Meier survival. Univariate and multivariable Cox regression was used to assess the association of patient-related factors (age, gender, body mass index), comorbidity (Deyo-Charlson index), American Society of Anesthesiologists class, implant fixation, and underlying diagnosis with risk of infection. Results A total of 2,207 patients, with a mean age of 65 years (SD, 12 years), 53% of whom were women, underwent 2,588 primary TSAs. Mean follow-up was 7 years (SD, 6 years), and the mean body mass index was 30 kg/m2 (SD, 6 kg/m2 ). The American Society of Anesthesiologists class was 1 or 2 in 61% of cases. Thirty-two confirmed deep periprosthetic infections occurred during follow-up. In earlier years, Staphylococcus predominated; in recent years, Propionibacterium acnes was almost as common. The 5-, 10-, and 20-year prosthetic infection–free rates were 99.3% (95% confidence interval CI, 98.9-99.6), 98.5% (95% CI, 97.8-99.1), and 97.2% (95% CI, 96.0-98.4), respectively. On multivariable analysis, a male patient had a significantly higher risk of deep periprosthetic infection (hazard ratio, 2.67 95% CI, 1.22-5.87; P = .01) and older age was associated with lower risk (hazard ratio, 0.97 95% CI, 0.95-1.00 per year; P = .05). Conclusions The periprosthetic infection rate was low at 20-year follow-up. Male gender and younger age were significant risk factors for deep periprosthetic infections after TSA. Future studies should investigate whether differences in bone morphology, medical comorbidity, or other factors are underlying these associations.
Little consensus exists and varying outcomes are reported when the 4 most common esophagogastric anastomotic techniques are compared: circular stapled (CS), hand sewn (HS), linear stapled (LS) ...(longitudinally stapled anastomosis), and modified Collard (MC) (combined linear and transverse stapled anastomosis). This report analyzes outcomes of these anastomotic techniques.
From July 2004 through December 2008, all intrathoracic and cervical esophagogastric anastomoses at our institution were reviewed.
There were 432 patients (358 men, 74 women) who underwent primary esophagogastric operations. Median age was 64 years (range, 23-90 years). The approach was an Ivor Lewis esophagectomy in 254 patients (59%), transhiatal esophagectomy in 115 patients (27%), McKeown (3-hole) esophagectomy in 49 (11%) patients, minimally invasive esophagectomy in 9 (2.1%) patients, and thoracoabdominal esophagectomy in 6 (1.4%) patients. There were 268 intrathoracic (62%) and 164 cervical (38%) anastomoses. Anastomotic techniques included LS in 260 (60%) patients MC in 67 (16%) patients, HS in 57 (13%) patients, and CS in 48 (11%) patients. Operative mortality was 3.7%. Anastomotic leak occurred in 50 patients (11%). Grade III or IV leaks occurred in 21 patients (4.9%), including 13 in the chest (4.8%) and 8 in the neck (4.9%). Grade III or IV leaks occurred in 12 patients (4.6%) with LS anastomoses, in 4 (7.0%) patients with HS anastomoses, in 3 (6.2%) patients with CS anastomoses, and in 2 (3.0%) patients with MC anastomoses. HS anastomoses had the highest odds of leakage (p=0.01) and LS anastomoses had the lowest risk of stricture (p=0.006).
When performing an esophagogastric anastomosis, clinically significant leaks occur with similar frequency in both cervical and intrathoracic locations. The HS technique has the highest leak rate and the LS technique had the lowest rate of stricture formation.
Background Total proctocolectomy and ileal pouch anal anastomosis (IPAA) is the preferred operation for patients with chronic ulcerative colitis (CUC) refractory to medical therapy. Infliximab (IFX), ...an antitumor necrosis factor−α antibody, has demonstrated efficacy in medical management of CUC. The aim of this study is to determine if IFX before IPAA impacts short-term outcomes. Study Design A prospective institutional database was retrospectively reviewed for short-term complications after IPAA for CUC. Postoperative outcomes were compared between patients who received pre-IPAA IFX and those who did not. Results Between 2002 and 2005, 47 patients received IFX before IPAA, and 254 patients received none. There were no gender (p = 0.16) or body mass index (p = 0.07) differences between groups. IFX patients were younger than non-IFX patients (mean age 28.1 to 39.3 years) (p < 0.001). In IFX patients, 70% were receiving preoperative IFX, azathioprine, and corticosteroids. Mortality was nil. Overall surgical morbidity was similar: 61.7% and 48.8%, IFX and non-IFX, respectively (p = 0.10). Anastomotic leaks (p = 0.02), pouch-specific (p = 0.01) and infectious (p < 0.01) complications were more common in IFX patients. Multivariable analysis revealed IFX as the only factor independently associated with infectious complications (odds ratio OR = 3.5; CI, 1.6−7.5). In a separate analysis, incorporating age, high-dose corticosteroids, azathioprine, and severity of colitis, IFX remained significantly associated with infectious complications (OR = 2.7; CI, 1.1−6.7). Conclusions CUC patients treated with IFX before IPAA have substantially increased the odds of postoperative pouch-related and infectious complications. Additional prospective studies are required to determine if IFX alone or other factors contribute to the observed increases in infectious complications.
To identify risk factors for progression to renal replacement therapy (RRT) and all-cause mortality in patients who underwent renal artery (RA) stent placement for atherosclerotic renal artery ...stenosis (RAS).
A retrospective study from June 1996 to June 2009 identified 1,052 patients who underwent RA stent placement. Glomerular filtration rate at time of RA stent placement was estimated from serum creatinine level and divided into chronic kidney disease (CKD) stages 1-5. Univariate and multivariable Cox proportional hazards models were used to determine which factors were associated with each endpoint.
Times to progression to all-cause mortality and RRT were similar for CKD stages 1/2/3A and served as the reference group. In multivariable analysis, high-grade proteinuria (P < .001) and higher CKD stage (5 vs 1/2/3A P < .001, 4 vs 1/2/3A P < .001, 3B vs 1/2/3A P = .02) remained independently associated with increased risk of progression to RRT. Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB) use was associated with decreased risk of progression to RRT (P = .03). Higher CKD stage (5 vs 1/2/3A P < .001, 4 vs 1/2/3A P = .004), carotid artery disease (P < .001), diabetes mellitus (P = .002), and high-grade proteinuria (P < .001) remained independently associated with all-cause mortality. Statin use was associated with decreased risk of all-cause mortality (P < .001).
Patients with atherosclerotic RAS who undergo RA stent placement and have high-grade proteinuria and CKD stage 3B/4/5 have increased risk of progression to RRT. Patients with high-grade proteinuria, CKD stage 3B/4/5, carotid artery disease, or diabetes have increased risk for all-cause mortality after renal artery stent placement. Patients receiving ACEI/ARBs have a decreased risk of progression to RRT, and patients receiving statins have a decreased risk of all-cause mortality.
Background The surgical treatment of metastatic, nonfunctional pancreatic neuroendocrine carcinoma (nPNEC) is not well defined. Existing series are confounded by inclusion of patients with metastatic ...functional tumors or gastrointestinal carcinoid. Our hypothesis was that the surgical treatment of metastatic nPNEC provides favorable perioperative and oncologic outcomes. Study Design We performed a retrospective review of all patients undergoing surgical treatment of metastatic nPNEC to the liver from 1987 through 2008 at the Mayo Clinic. Data are presented as medians with ranges. Results Seventy-two patients were identified, with a median age of 57 years (range 28 to 77 years) and median body mass index (BMI) of 26 kg/m2 (range 18 to 40 kg/m2 ). Operative intent of resection was curative in 39 (54%) or palliative (≥90% tumor debulking) in 32 (44%). Median number of tumors treated and median tumor size were 8 (range 1 to 30) and 4.5 cm (range 0.3 to 20 cm), respectively. Tumor grade was 1 or 2 in 97%, and angioinvasion was identified in 55 (76%) patients. Postoperative morbidity and mortality were 50% and 0%, respectively. Among the 72 patients, overall survivals at 1, 5 and 10 years were 97.1%, 59.9%, and 45.0%, respectively. Among the 39 patients with a complete (R0) resection, the 1- and 5-year disease-free survivals were 53.7% and 10.7%, respectively. For patients undergoing debulking of ≥90% tumor burden, the 1- and 5-year survivals free of progression were 58.1% and 3.5%, respectively. Conclusions Surgical treatment of metastatic nPNEC to the liver with curative intent or for palliative ≥90% debulking provides favorable oncologic outcomes. Despite a high incidence of tumor recurrence, 5-year survival rates are encouraging and appear to justify an aggressive surgical approach in these patients.
Five-year survival of stage IV esophageal cancer is rare. The treatment of advanced esophageal cancer is typically palliative and the role of surgery remains controversial. We sought to understand ...the impact of curative surgery on survival and identify any favorable tumor or patient characteristics that might make surgical resection appropriate when treating stage IV esophageal cancer.
A retrospective review of 3,500 esophagectomies performed at our institution from 1985 to 2013 identified 52 (1.5%) patients with stage IV esophageal cancer who underwent surgical resection with intent for cure. In 46 (88.5%) patients, M1 disease was discovered at the time of surgery and 6 (11.5%) patients had known M1 disease prior to surgery.
Median age at the time of surgery was 60 years (range, 31 to 81 years). The majority of patients were men (82.7%) with adenocarcinoma (88.5%). Neoadjuvant therapy was used in 18 (34.6%) patients; all patients operated on after 1999 received neoadjuvant therapy. An Ivor Lewis esophagectomy was performed in 39 (75%) patients. Follow-up was complete in all patients for a median of 324 days (range, 4 days to 8.5 years). Overall, 1-year survival was 29% and 5-year survival was 6%. There was no significant difference in survival between patients with known preoperative versus intraoperative discovery of M1 disease. Factors associated with improved survival included neoadjuvant treatment, low T stage, and lack of alcohol use.
Few patients with stage IV esophageal cancer survive long term after surgical resection, though 5-year survival can occur. Our current recommendation is that esophagectomy should not be performed for stage IV disease.
Objective The objective was to study associations between clinical variables, demographic factors, and outcome after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA). Methods ...Data of consecutive patients who underwent EVAR between 1997 and 2011 at a tertiary center were analyzed. Comorbidity scores stratified patients into low/normal-risk (score ≤ 10) or high-risk categories (score > 10). The primary end point was mortality; secondary end points were morbidities, reinterventions, conversions, and ruptures. Results The study included 934 patients, 117 women (13%) and 817 men (87%) (mean age, 76 ± 7.3 years; range, 51-99 years). There were 870 (93%) asymptomatic, 36 (3.9%) symptomatic, and 28 (3.0%) ruptured AAAs. The 30-day mortality was 1.4% (13 of 934), 1.0% (9 of 870) for asymptomatic patients, 2.8% (1 of 36) for patients with symptomatic AAAs, and 11% (3 of 28) for patients with ruptured AAAs ( P = .004). Clinical presentation with symptoms or rupture was associated with more complications ( P = .02), reinterventions ( P = .003), and a lower 5-year survival ( P = .04). Association between surgical risk, female gender, age, and outcome was studied in 870 asymptomatic patients. Both 30-day mortality and complication rates were higher for high-risk vs low/normal-risk patients (2.3% vs 0.2%, P = .003; 15% vs 10%, P = .04); reintervention rates were equivalent (3.8% vs 4.4%; P = .67). The 30-day mortality and complication rates were similar in women and men (2.8% vs 0.8%, P = .09; 17% vs 11%, P = .11), but reintervention rate was higher in women (8.5% vs 3.5%; P = .02). Follow-up averaged 3.8 years (1 month-13.5 years). In asymptomatic patients, 5-year survival was 74% for low/normal-risk patients and 54% for high-risk patients ( P < .001); both had similar rates of freedom from complications (65% vs 63%; P = .24), reinterventions (71% vs 75%; P = .36), or rupture (99.3% vs 99.7%; P = .42). Women had more complications (47% vs 34%; P = .04) and reinterventions than men did (39% vs 26%; P = .02); freedom from rupture was the same (100% vs 99.3%; P = .30). There were eight ruptures, all in asymptomatic patients. In multivariate analysis, high surgical risk and age were associated with all-cause mortality ( P < .001); female gender was associated with complications and reinterventions ( P < .05) but not mortality. Conclusions Clinical presentation predicts early mortality and complications, age predicts both early and late mortalities after EVAR. Although women had an increased rate of complications and reinterventions, women did not have significantly higher mortality than men.
Background Management of patients with giant hemangiomas of the liver encounters persistent controversy. Although recent case series suggest a low complication rate with nonoperative management, the ...classic paradigm of preventive operative resection remains. Study Design A retrospective cohort study was conducted of 492 patients with giant hepatic hemangioma (>4 cm in size) diagnosed between 1985 and 2005 at Mayo Clinic Rochester. Long-term outcomes were assessed by patient survey, with a follow-up of 11 ± 6.4 years. Results Of 492 patients, 289 responded to the survey. In the nonoperative group (n = 233), 20% had persistent or new onset of hemangioma-associated symptoms, including potentially life-threatening complications in 2%. In the operative group (n = 56), perioperative complications occurred in 14%, including potentially life-threatening complications in 7%. None of the operative patients had persistent or new onset of hemangioma-associated symptoms after resection of the dominant hemangioma. In group comparison, the rate of adverse events was similar (20% versus 14%; p = 0.45) with an overall low risk for potentially life-threatening complications (2% versus 7%; p = 0.07). Size of hemangiomas was not associated with adverse events in either group. Subjective health status and quality of life at follow-up were similar in both groups (p > 0.54). Conclusions Clinical observation of patients with giant hemangioma of the liver has a similar rate of complications compared with operative management, but might prevent the need for invasive interventions in some patients. Clinical observation is preferred in most patients and operative treatment should be reserved for patients with severe symptoms or disease-associated complications.
Objective The objective of this study was to compare outcomes after open repair (OR) vs endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysms (AAAs). Methods Clinical data of ...consecutive patients treated for asymptomatic AAA between 2000 and 2011 were reviewed. Patients were stratified into low/normal-risk (comorbidity score ≤ 10) and high-risk (score > 10) categories. The primary end point was all-cause mortality; secondary end points were complications, reinterventions, conversions, and ruptures. Propensity score-based matching was performed to compare outcomes. Results There were 1534 patients, of whom 207 were women (13%); 641 (42%) were treated with OR and 893 (58%) with EVAR. After propensity score matching, we selected 558 pairs of OR and EVAR (mean age, 73 ± 7.6 years); 158 were women (14%). The 30-day mortality rate was 1.3% after OR and 0.9% after EVAR ( P = .56). In multivariable analysis, only high risk was an independent predictor of early mortality (odds ratio, 4.65; 95% confidence interval CI, 1.20-18; P = .03). The early complication rate was lower for EVAR (13%; odds ratio, 0.5; 95% CI, 0.4-0.8; P < .001) than for OR (24%). Median follow-up was 7.6 years (31 days-13.1 years). The cumulative 5-year survival rate was 72% after EVAR and 81% after OR (hazard ratio, 1.44; 95% CI, 1.19-1.73; P < .001). The 5-year survival was not significantly different in matched cohorts operated on after 2005 (77% vs 81%; P = .57). High risk, advanced age, cancer history, AAA size, and EVAR predicted all-cause mortality. Freedom from reintervention was 74% after EVAR and 88% after OR (hazard ratio, 2.60; 95% CI, 1.92-3.51; P < .001). Freedom from rupture was 99.2% after EVAR and 99.8% after OR ( P = .04). In multivariable models, female gender was associated with complications; EVAR was associated with reinterventions ( P < .05). Conclusions In this retrospective propensity score-matched study, early mortality was similarly low after both EVAR and OR, significantly different from all except one large randomized controlled trial. EVAR had fewer early complications, but it was associated with late all-cause mortality and reinterventions and had a small but definite risk of late rupture. Significantly increased mortality at 5 years was no longer observed when operations were performed after 2005. High risk, advanced age, cancer history, and AAA size predicted late all-cause mortality. This study failed to confirm early or late survival benefit for EVAR vs OR. Improved surveillance, longer follow-up, and analysis of factors affecting late death in prospective studies are warranted.
Abstract Objective The purpose of this study was to evaluate whether maximal aortic diameter affects outcome after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA). Methods ...Clinical data of patients undergoing EVAR between 1997 and 2011 for nonruptured asymptomatic AAAs in a tertiary center were reviewed. Patients were classified according to diameter of AAA: group 1, <5.0 cm; group 2, 5.0 to 5.4 cm; group 3, 5.5 to 5.9 cm; and group 4, ≥6.0 cm. The primary end point was all-cause mortality; secondary end points were complications, reinterventions, and ruptures. Results There were 874 patients studied (female, 108 12%; group 1, 119; group 2, 246; group 3, 243; group 4, 266); mean age was 76 ± 7.2 years. The 30-day mortality rate was 1.0%, not significantly different between groups ( P = .22); complication and reintervention rates were 13% and 4.1%, respectively, similar between groups ( P < .05). Five-year survival was 68%; freedom from complications and reinterventions was 65% and 74%, respectively; rupture rate was 0.5%. Multivariate analysis revealed that factors associated with all-cause mortality included maximal aortic diameter, age, gender, surgical risk, cancer history, and endograft type ( P < .05). Group 4 had increased risks of mortality (hazard ratio HR, 2.0; 95% confidence interval CI, 1.38-2.85; P = .002) and complications (HR, 1.6; 95% CI, 1.2-2.7; P = .009) relative to group 1. Reinterventions were more frequent for aneurysms ≥6.0 cm (HR, 2.0; 95% CI, 1.2-3.3; P = .01). Late rupture rate after EVAR was not different between groups. Conclusions Maximal aortic diameter is associated with long-term outcomes after elective EVAR. Patients with large AAAs (≥6.0 cm) have higher all-cause mortality, complication, and reintervention rates after EVAR than those with smaller aneurysms. We continue to recommend that AAAs be repaired when they reach 5.5 cm as recommended by the guidelines of the Society for Vascular Surgery. On the basis of our data, EVAR should be considered even in high-risk patients with a maximal aortic diameter between 5.5 and 6.0 cm because surgical risk with aneurysm size above 6.0 cm will increase significantly.
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