BackgroundUnplanned postoperative reintubation (UPR) is a marker for severe adverse outcomes following general and vascular surgery.Study designA retrospective analysis of 8809 adult patients, aged 18 years and older, who underwent major general and vascular surgery at a large single-center urban hospital was conducted from January 2013 to September 2016. Patients were grouped into those who experienced UPR and those who did not. Univariate and multivariate regression analyses were used to identify predictors of UPR, and association of UPR with adverse postoperative outcomes. All regression models had Hosmer-Lemeshow P > 0.05, and C-statistic >0.75, indicating excellent goodness-of-fit and discrimination.ResultsOf the 8809 patients included, 138 (1.6%) experienced UPR. There was no statistical difference in incidence of UPR between general and vascular surgery patients (p = 0.53). Independent predictors of UPR advanced age (OR 5.1, 95%CI 3.5–7.5, p < 0.01), higher ASA status (OR 7.9, 95%CI 5.6–11.1, p < 0.01), CHF (OR 7.0, 95%CI 3.6–13.9, p = 0.02), acute renal failure or dialysis (OR 3.1, 95%CI 1.8–5.7, p = 0.01), weight loss (OR 5.2, 95%CI 2.8–9.6, p = 0.01), systemic sepsis (OR 4.8, 95%CI 3.4–6.9, p < 0.01), elevated preoperative creatinine (OR 4.2, 95%CI 3.0–5.9, p = 0.01), hypoalbuminemia (OR 5.3, 95% CI 3.8–7.5, p = 0.01), and anemia (OR 4.0, 95%CI 2.8–5.9, p < 0.01). Following surgery, UPR was associated with increased mortality (OR 3.8, 95%CI 2.7–5.2, p < 0.01), pulmonary complications (OR 1.8, 95%CI 1.7–2.0, p < 0.01), renal complications (OR 2.6, 95%CI 1.7–3.5, p < 0.01), cardiac complications (OR 4.6, 95%CI 2.0–6.7, p < 0.01), postoperative RBC transfusion (OR 5.7, 95%CI 3.8–8.6,p < 0.01), and prolonged hospitalization (OR 1.8, 95%CI 1.5–2.4, p < 0.01).ConclusionUPR is significantly associated with postoperative morbidity and mortality. Perioperative management aimed at decreasing incidences of UPR after noncardiac surgery should target preoperative anemia in addition to previously identified predictors.

Introduction: Rotator cuff tear surgical repair techniques have significantly progressed. However, tendon retear following primary repair persistently occurs at high rates. Rehabilitation protocols, surgical fixation techniques, biologic therapy with scaffolds, platelet-rich plasma, and even stem cell applications are under study to promote adequate tendon healing. Methods: A nonsystematic query of the PubMed database was conducted in July 2016 utilizing the search terms ''rotator cuff repair,'' ''tear,'' ''rehabilitation,'' ''scaffold,'' ''platelet-rich plasma,'' and ''stem cell'' to identify, analyze, and summarize relevant studies. Conclusion: Individualized rehabilitation protocols may be the best approach for small to medium sized tears. Surgical fixation will continue to be debated as modifications to single-row technique and increases in suture number have improved tensile strength. Double-row repairs have been associated with higher costs. Transosseous equivalent technique exhibits comparable subjective and objective outcomes to single-and double-row repair at two-year follow-up. Biocompatible scaffold augmentation has showed inconsistent short-term results. Platelet-rich plasma has lacked uniformity in treatment preparation, administration, and outcome measurement with mixed results. Few human studies have suggested decreased retear rates and improved repair maintenance following bone marrow-derived mesenchymal stem cell augmentation. This review reiterated the necessity of additional high-quality, large-sample studies to develop any final verdict regarding efficacy.

BackgroundCardiac events (CE) following surgery have been associated with morbidity and mortality. Defining risk factors that contribute to CE is essential to improve surgical outcomes.Study designThis was a retrospective study at a large urban teaching hospital for surgery performed from 2013 to 2015. Adult patients (≥18 years) that underwent general and vascular surgery were analyzed. Patients were grouped into those who experienced postoperative CE and those who did not. Univariate and multivariate regression analyses were used to identify predictors of postoperative CE, and association of CE with adverse postoperative outcomes. Separate subgroup analyses were also conducted for general and vascular surgery patients to assess predictors of CE.ResultsOut of 8441 patients, 157 (1.9%) experienced CE after major general and vascular surgery. Underlying predictors for CE included age >65 years(OR 4.9, 95%CI 3.4–6.9,p < 0.01), ASA >3(OR 12.0, 95%CI 8.5–16.9,p < 0.01), emergency surgery(OR 3.7, 95%CI 2.7–5.1,p = 0.01), CHF(OR 11.2, 95%CI 6.4–16.7,p = 0.02), COPD(OR 3.9, 95%CI 2.4–6.4,p = 0.04), acute renal failure or dialysis(OR 8.0, 95%CI 5.2–12.1,p = 0.04), weight loss(OR 3.3, 95%CI 1.7–6.7,p < 0.01), preoperative creatinine >1.2 mg/dL(OR 5.1, 95%CI 3.7–7.1,p = 0.01), hematocrit <34%(OR 4.0, 95%CI 2.8–5.7,p < 0.01), and operative time >240 min(OR 2.0, 95%CI 1.3–3.3,p = 0.02). Following surgery, CE was associated with increased mortality(OR 3.5, 95%CI 1.2–6.5,p < 0.01), pulmonary complications(OR 5.0, 95%CI 3.1–8.9,p < 0.01), renal complications(OR 2.3, 95%CI 1.9–4.5,p < 0.01), neurologic complications(OR 2.5, 95%CI 1.4–5.2,p < 0.01), systemic sepsis(OR 2.2, 95%CI 1.7–4.0,p < 0.01), postoperative RBC transfusion(OR 4.4, 95%CI 2.7–6.5,p < 0.01), unplanned return to operating room(OR 4.0, 95%CI 2.3–6.9,p < 0.01), and prolonged hospitalization (OR 5.5, 95%CI 3.1–8.8,p = 0.03). There was no statistical difference in incidence of CE between general and vascular surgery patients (p = 0.44); however, predictors of CE differed between the two surgical groups.ConclusionPostoperative CE are associated with significant morbidity and mortality. Identified predictors of CE should allow for adequate risk stratification and optimization of perioperative surgical management.

INTRODUCTION:There are limited data on the incidence, predictors, and time to future liver abnormalities in patients with intrahepatic cholestasis of pregnancy (ICP). METHODS:Single-center retrospective study of pregnant women with and without ICP who delivered from 2005 to 2009 evaluating incidence and time to future liver abnormalities. Women returning for care with liver function tests at a minimum of 6 months postpartum were included. Liver disease diagnoses and liver functions test abnormalities were compared. Time to development of alanine aminotransferase (ALT) >25 U/L, alkaline phosphatase (ALP) >140 U/L, and diagnosis of liver disease (through imaging or clinical evaluation) were compared between women with and without ICP using Kaplan-Meier methods and Cox regression models. RESULTS:A total of 255 women with ICP and 131 age-matched control subjects with delivery during the same period were identified. Subjects in both groups were similar in follow-up time, age at pregnancy, prepregnancy body mass index, and ethnicity (≥75% were Hispanic in both groups). On univariate analyses, ICP was associated with increased incidence of ALT >25 U/L P < 0.01 ALP >140 U/L (P < 0.01) and liver disease (P = 0.03). Adjusting for metabolic factors, ICP diagnosis was associated with risk of future liver abnormalities: postpartum ALT >25 U/L (hazard ratio [HR] 1.9, P < 0.01), ALP >140 U/L (HR 3.4, P < 0.01), and liver disease (HR 1.5, P = 0.05).

Background Cardiac events following thoracic endovascular aortic repair (TEVAR) have been associated with significant morbidity and mortality. However, predictors of post-TEVAR cardiac events in descending thoracic aortic aneurysm or dissection are poorly understood. Methods A retrospective analysis of completed TEVAR procedures performed from 2010 to 2016 was conducted using the ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) participant user file database. Adult patients (≥18 years) who underwent TEVAR for descending thoracic aortic aneurysm or dissection were identified and 30-day outcomes were examined. An initial univariate analysis was performed to determine associations between all patient variables and cardiac events, defined as myocardial infarction or cardiac arrest that occurred ≤30 days of surgery. Multivariate logistic regression was subsequently performed to identify independent risk factors for cardiac events following TEVAR. Results The study identified 150 out of 2,905 (5.2%) patients who underwent TEVAR for descending thoracic aortic aneurysm or dissection who developed cardiac events. No significant difference in incidence of cardiac events was noted among patients presenting with aortic aneurysm or dissection (p = 0.339). The overall 30-day mortality rate for all patients was 9.1%. Independent preoperative predictors of post-TEVAR cardiac events included emergency procedure (odds ratio [OR] 2.80, 95% confidence interval [CI] 1.9–4.1, p < 0.01); American Society of Anesthesiologists score >3 (OR 1.71, 95% CI 1.1–2.6, p = 0.01), ventilator dependence (OR 2.33, 95% CI 1.3–4.2, p < 0.01), renal failure (OR 2.53, 95% CI 1.50–4.3, p < 0.01), blood transfusion (OR 1.84, 95% CI 1.1–3.2, p = 0.03), and preoperative leukocytosis (OR 2.45, 1.6–3.8, p < 0.01). After TEVAR, unplanned reintubation (OR 5.52, 95% CI 3.5–8.8, p < 0.01), prolonged mechanical ventilation (OR 1.94, 95% CI 1.2–3.2, p = 0.011), and postoperative blood transfusion (OR 4.02, 95% CI 2.70–6.0, p < 0.01) were independent predictors of cardiac events. Cardiac events greatly increased mortality (60.7 vs. 5.5%), total length of hospital stay (13.2 ± 14.7 days vs. 8.3 ± 9.3 days), and readmission rates (19.3 vs. 8.2%, p < 0.01). Conclusions Cardiac events following TEVAR are associated with significant mortality. Patients with these risk factors should be appropriately monitored to improve outcomes.