BackgroundThere is currently conflicting evidence surrounding the effects of obesity on postoperative outcomes. Previous studies have found obesity to be associated with adverse events, but others have found no association. The aim of this study was to determine whether increasing body mass index (BMI) is an independent risk factor for development of major postoperative complications.MethodsThis was a multicentre prospective cohort study across the UK and Republic of Ireland. Consecutive patients undergoing elective or emergency gastrointestinal surgery over a 4‐month interval (October–December 2014) were eligible for inclusion. The primary outcome was the 30‐day major complication rate (Clavien–Dindo grade III–V). BMI was grouped according to the World Health Organization classification. Multilevel logistic regression models were used to adjust for patient, operative and hospital‐level effects, creating odds ratios (ORs) and 95 per cent confidence intervals (c.i.).ResultsOf 7965 patients, 2545 (32·0 per cent) were of normal weight, 2673 (33·6 per cent) were overweight and 2747 (34·5 per cent) were obese. Overall, 4925 (61·8 per cent) underwent elective and 3038 (38·1 per cent) emergency operations. The 30‐day major complication rate was 11·4 per cent (908 of 7965). In adjusted models, a significant interaction was found between BMI and diagnosis, with an association seen between BMI and major complications for patients with malignancy (overweight: OR 1·59, 95 per cent c.i. 1·12 to 2·29, P = 0·008; obese: OR 1·91, 1·31 to 2·83, P = 0·002; compared with normal weight) but not benign disease (overweight: OR 0·89, 0·71 to 1·12, P = 0·329; obese: OR 0·84, 0·66 to 1·06, P = 0·147).ConclusionOverweight and obese patients undergoing surgery for gastrointestinal malignancy are at increased risk of major postoperative complications compared with those of normal weight.
Background In patients with colorectal cancer liver metastases (CRLM), right portal vein embolisation (RPVE) is used to increase the volume of the future remnant liver (FRL) before major hepatic resection. It is not established whether embolisation of segment 4 in addition RPVE (RPVE + 4) induces greater hypertrophy of the FRL. Limitations of prior studies include heterogenous populations and use of hypertrophy metrics sensitive to baseline variables. Methods From 2010 to 2015, consecutive patients undergoing RPVE or RPVE + 4 for CRLM, who had not undergone prior major hepatic resection and in whom imaging was available, were included in a retrospective study. Data were extracted from hospital electronic records. Volumetric assessments of segments 2–3 were made on cross-sectional imaging before and after embolisation and corrected for standardised liver volume. Results Ninety-nine patients underwent PVE, and 60 met the inclusion criteria. Thirty-eight patients underwent RPVE, and 22 underwent RPVE + 4. Forty-five patients had undergone median 6 cycles of prior chemotherapy. Eighteen patients had FRL metastases at PVE, and 16 had undergone subsegmental metastasectomy in the FRL. Assessments of the degree of hypertrophy (DH) of segments 2/3 were made at median 35 (interquartile range 30–49) days after PVE. RPVE + 4 resulted in a significantly greater increase in DH than RPVE (7.7 ± 1.8% vs 11.3 ± 2.6%, p = 0.011). No confounding association between baseline variables and the decision to undertake RPVE or RPVE + 4 was identified. Median survival was 2.4 years and was not influenced by segment 4 embolisation. Conclusion RPVE + 4 results in greater DH of segments 2/3 than RPVE in people with CLRM.
Objectives & BackgroundApproximately 4,000 children under the age of 15 are injured falling from windows in the UK. Ten of the children die and an unknown number suffer serious injuries. This study highlights a number of temporal, demographic and socio-economic risk factors for this mechanism of injury. The study also identifies potential strategies to reduce the number of falls from windows.MethodsThis retrospective study of paediatric patients utilised the Barts Health Trust Paediatric Trauma database. Initially, all patients under 16 years of age, who presented with a fall from a height (window, roof or balcony) between 2010 and 2015 were included. This was followed by a short phone survey that was conducted to find out more about safety measures at the location and housing circumstances.Results93 patients presented with falls from a height during the study period. Two (2.15%) of these children died. Boys were twice as likely as girls to fall and 88 (94.6%) were accidents. There was a seasonal pattern with 61% of falls occurring in the summer months. 78 (83.87%) of children with falls from buildings required admission to hospital, with a mean length of stay of 3.37 days. 10.5% of children required admission to the Paediatric Critical Care Unit and 11% required emergency surgery. 53% of patients sustained limb fractures and 42% head injuries. 12% of those patients contacted by telephone survey were experiencing long term health problems. The majority (72.5%) of falls occurred in neighbourhoods ranked within the 30% most deprived in the country. Only 12% of the households represented in this study had functioning safety locks. 12% of those children who fell from windows had a pre-existing diagnosis of autism.ConclusionThis study quantifies the impact the falling from windows had on individual children, their families and the broader healthcare system. This study also suggest that window locks are extremely effective at reducing falls and should be evaluated as a public health intervention. Furthermore, the disproportionately high number of autistic child that falls from windows should prompt an urgent review to ensure these vulnerable children are living in a safe environment.
Background: Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery. Methods: This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and intercentre variation in critical care admission after emergency laparotomy. Results: Of 4529 patients included, 37.8% (n¼1713) underwent planned critical care admissions from theatre. Some 3.1% (n¼86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n¼133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51e19.97) than planned admissions (OR: 2.32, 95% CI: 1.43e3.85). Some 26.7% of patients (n¼1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8e51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n¼10/145) of centres outside the 95% CI. Conclusions: After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.
Introduction: Right portal vein embolization [RPVE] may be used to increase the volume of the future liver remnant [FRL] before major hepatic resection. It is not established whether embolization of segment 4 in addition RPVE [RPVE+4] induces greater hypertrophy of the FRL. Limitations of prior studies include heterogenous populations and absence of correction for patient size. Methods: From 2010 to 2015, consecutive patients undergoing RPVE or RPVE+4 for colorectal liver metastases [CRLM], who had not undergone prior major hepatic resection, were included in this retrospective study. Hospital electronic records [HER] were used to abstract baseline data. Volumetric assessments of segments 2-3 were made on cross-sectional imaging before and after embolisation and corrected for body surface area. Survival was assessed from the HER. Results: Of 105 patients undergoing PVE, 60 met the inclusion criteria. 38 underwent RPVE and 22 underwent RPVE+4. 45 patients had undergone a mean of 5.5 cycles of prior chemotherapy. 13 patients had FRL metastases at PVE and 14 had already undergone subsegmental metastasectomy from the FRL. Assessments of hypertrophy were made at 43.2 AE 28.0 days (mean AE SD) after PVE. RPVE+4 resulted in a significantly greater increase in corrected FRL than RPVE alone (97.0 cm 2 /m 2 vs 62.9 cm 2 / m 2 ; p=0.008). Multivariate analysis indicated that only RPVE+4 and the presence of left lobe metastases were significantly associated with increased FRL post embolisation. Median survival post PVE was 2.4 years. Conclusion: RPVE+4 results in greater FRL hypertrophy than RPVE alone in patients with CLRM.
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