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Non-ST-elevation myocardial infarction (NSTEMI) and unstable angina pectoris are frequent causes of hospital admission in the elderly. However, clinical trials targeting this population are scarce, and these patients are less likely to receive treatment according to guidelines. We aimed to investigate whether this population would benefit from an early invasive strategy versus a conservative strategy. In this open-label randomised controlled multicentre trial, patients aged 80 years or older with NSTEMI or unstable angina admitted to 16 hospitals in the South-East Health Region of Norway were randomly assigned to an invasive strategy (including early coronary angiography with immediate assessment for percutaneous coronary intervention, coronary artery bypass graft, and optimum medical treatment) or to a conservative strategy (optimum medical treatment alone). A permuted block randomisation was generated by the Centre for Biostatistics and Epidemiology with stratification on the inclusion hospitals in opaque concealed envelopes, and sealed envelopes with consecutive inclusion numbers were made. The primary outcome was a composite of myocardial infarction, need for urgent revascularisation, stroke, and death and was assessed between Dec 10, 2010, and Nov 18, 2014. An intention-to-treat analysis was used. This study is registered with ClinicalTrials.gov, number NCT01255540. During a median follow-up of 1·53 years of participants recruited between Dec 10, 2010, and Feb 21, 2014, the primary outcome occurred in 93 (40·6%) of 229 patients assigned to the invasive group and 140 (61·4%) of 228 patients assigned to the conservative group (hazard ratio [HR] 0·53 [95% CI 0·41–0·69], p=0·0001). Five patients dropped out of the invasive group and one from the conservative group. HRs for the four components of the primary composite endpoint were 0·52 (0·35–0·76; p=0·0010) for myocardial infarction, 0·19 (0·07–0·52; p=0·0010) for the need for urgent revascularisation, 0·60 (0·25–1·46; p=0·2650) for stroke, and 0·89 (0·62–1·28; p=0·5340) for death from any cause. The invasive group had four (1·7%) major and 23 (10·0%) minor bleeding complications whereas the conservative group had four (1·8%) major and 16 (7·0%) minor bleeding complications. In patients aged 80 years or more with NSTEMI or unstable angina, an invasive strategy is superior to a conservative strategy in the reduction of composite events. Efficacy of the invasive strategy was diluted with increasing age (after adjustment for creatinine and effect modification). The two strategies did not differ in terms of bleeding complications. Norwegian Health Association (ExtraStiftelsen) and Inger and John Fredriksen Heart Foundation.

To evaluate the associations of neurosurgical start and duration with surgical outcomes. This retrospective study analysed elective neurosurgery data from January 1, 2017, to December 30, 2021. Unplanned reoperation and postoperative mortality during hospitalization were the outcomes. We divided the surgical start time, duration and completion time into categories (Q1: 8–13:00; Q2:13–17:00; and Q3: others), (Q1: less than 5 h; Q2: 5–10 h; and Q3: others), and (Q1: 08–18:00; and Q2: others). Generalized linear mixed models were used to explore associations between surgical time subgroups and outcomes. Interaction analyses were performed to evaluate surgical outcomes and subgroup interaction associations. In total, 16,549 patients were analysed, and 611 patients had adverse outcomes. Compared with earlier start times and shorter durations, later start times and longer durations were associated with 200 and 600% greater risks, respectively. Compared with earlier and longer-duration surgeries, earlier and longer-duration surgeries were associated with a lower risk of adverse events. These data indicate that a later surgical time and longer duration are associated with more adverse surgical results. Furthermore, the association between the duration of the operation and surgical outcomes might be modulated by the surgical start time.

Abstract BACKGROUND Reoperation has been increasingly utilized as a metric evaluating quality of care. OBJECTIVE To evaluate the rate of, reasons for, and predictors of unplanned reoperation after craniotomy for tumor in a nationally accrued population. METHODS Patients who underwent cranial tumor resection were extracted from the prospective National Surgical Quality Improvement Program registry (2012-2014). Multivariate logistic regression examined predictors of unplanned cranial reoperation. Predictors screened included patient age, sex, tumor location and histology, functional status, comorbidities, preoperative laboratory values, operative urgency, and time. RESULTS Of the 11 462 patients included, 3.1% (n = 350) underwent an unplanned cranial reoperation. The most common reasons for cranial reoperation were intracranial hematoma evacuation (22.5%), superficial or intracranial surgical site infections (11.9%), re-resection of tumor (8.4%), decompressive craniectomy (6.1%), and repair of cerebrospinal fluid leakage (5.6%). The strongest predictor of any cranial reoperation was preoperative thrombocytopenia (less than 100 000/μL, odds ratio [OR] = 2.51, 95% confidence interval [CI]: 1.23-5.10, P = .01). Thrombocytopenia, hypertension, emergent surgery, and longer operative time were predictors of reoperation for hematoma (P ≤ .004), while dependent functional status, morbid obesity, leukocytosis, and longer operative time were predictors of reoperation for infection (P < .05). Although any unplanned cranial reoperation was not associated with differential odds of mortality (OR = 1.68, 95% CI: 0.94-3.00, P = .08), hematoma evacuation was significantly associated with thirty-day death (P = .04). CONCLUSION In this national analysis, unplanned cranial reoperation was primarily associated with operative indices, rather than preoperative characteristics, suggesting that reoperation may have some utility as a quality indicator. However, hypertension and thrombocytopenia were potentially modifiable predictors of reoperation.

Background Hartmann's procedure is a commonly performed operation for complicated left colon diverticulitis or malignancy. The timing for reversal of Hartmann's is not well defined as it is technically challenging and carries a high complication rate. Methods This study is a retrospective audit of all patients who underwent Hartmann's procedure between 2008 and 2014. Reversal of Hartmann's rate, timing, American Society of Anesthesiologists grade, length of stay and complications (Clavien-Dindo) including 30-day mortality were recorded. Results Hartmann's procedure (n = 228) indications were complicated diverticular disease 44% (n = 100), malignancy 32% (n = 74) and other causes 24%, (n = 56). Reversal of Hartmann's rate was 47% (n = 108). Median age of patients was 58 years (range 21-84 years), American Society of Anesthesiologists grade 2 (range 1-4), length of stay was eight days (range 2-42 days). Median time to reversal of Hartmann's was 11 months (range 4-96 months). The overall complication rate from reversal of Hartmann's was 21%; 3.7% had a major complication of IIIa or above including three anastomotic leaks and one deep wound dehiscence. Failure of reversal and permanent stoma was less than 1% (n = 2). Thirty-day mortality following Hartmann's procedure was 7% (n = 15). Where Hartmann's procedure wass not reversed, for 30% (n = 31) this was the patient's choice and 70% (n = 74) were either high risk or unfit. Conclusions Hartmann's procedure is reversed less frequently than thought and consented for. Only 46% of Hartmann's procedures were stoma free at the end of the audit period. The anastomotic complication rate of 1% is also low for reversal of Hartmann's procedure in this study.

The aim of this study is to evaluate the sex-related differences on the risks of perioperative and late outcomes for adult acute aortic dissection (AAD) patients following surgical management. By using Taiwan National Health Insurance Research Database, totally 1,410 female and 3,432 male patients were identified to first-ever receive type A AAD open surgery or type B AAD stenting treatment from 2004 to 2013. We assessed the sex-related difference on outcomes, including in-hospital mortality, all-cause mortality, aortic death, redo aortic surgery, ischemic stroke, and depression during the follow-up period. The analysis was done separately for type A and type B surgeries. On average, female patients diagnosed with AAD were older than males. There was no significant sex difference of in-hospital mortality or all-cause mortality for both type A open and type B stent surgeries. The risk of redo aortic surgery was significantly greater in males than females (7.8% vs. 4%; unadjusted subdistribution hazard ratio [SHR] 0.51, 95% CI 0.38-0.69) for type A open surgery, but not for type B stent surgery. Noticeably, the risk of newly-diagnosed depression was significantly greater in females than males (8% vs. 5.1%; unadjusted SHR 1.6, 95% CI 1.24-2.06) for type A open surgery, but not for type B stent surgery. No significant sex-related difference was found for the in-hospital mortality or accumulative all-cause mortality. However, there were more redo aortic surgeries for males and more postoperative depression for females in type A AAD population.

Morbid obesity is a life threatening condition. Currently, surgery represents the only effective and durable therapeutic option to treat it. The first aim of the study was to estimate and compare the major surgical complications and the 30-day rate of mortality between laparoscopic and open Roux-en-Y gastric bypass (LRYGB and RYGB). The second aim was to evaluate the change in outcomes, complications, and deaths, with increased experience over the time period of the review. A random effect of the meta-analysis and meta-regression was used to evaluate surgical complications (i.e., reoperation, stenosis, bleeding, surgical site infection, fistula, internal hernia, and incisional ventral hernia) and the rate of mortality after LRYGB and RYGB over time. A search of literature from 2000 to 2014 led to the selection of 17 papers. When looking at surgical techniques separately, we observed a higher rate of mortality for open surgery (death rate 0.82 %, 95 % CI = 0.49–1.23) compared to laparoscopic surgery (death rate 0.22 %, 95 % CI = 0.09–0.40). This difference resulted highly significant when the two techniques were formally compared ( p  < 0.001). The improving of surgery technique resulted in a mean rate of mortality reduction of 0.069 %. Laparoscopy represents the approach of choice for bariatric surgery. Contemporary reports of LRYGB show low mortality rates and progressive decline in postoperative complications. Laparoscopic bariatric surgery requires advanced laparoscopic skills, and probably an extended learning curve is not accounted for by current mortality statistics.

Background The high prevalence of caesarean section (CS) is a global concern. Relaparotomy is needed when conservative managements are not effective in CS complications. This study aimed to systematically review and meta-analyze the mortality rate and risk factors of relaparotomy after CS. Methods Based on a pre-registered protocol, we searched 11 databases. The MOOSE guideline was followed, and the reporting was in accordance with the PRISMA statement. A Freeman-Tukey double arcsine transformation was used to transform the raw data, and a random-effects meta-analytic model was applied. The quality of the evidence was evaluated by Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results The qualities of the pooled results were assessed to be “very low” based on the inclusion of observational studies. A total of 40 studies were retrieved. The mortality rate in patients after relaparotomy was 7.24% (95%CI 4.10-11.03%). Significant gap existed between high-resources and low-resources countries. In developed areas this rate was 0.56% and in places of low resources this rate was 16.90%. Higher CS rate correlated with higher mortality. Over 70% of the relaparotomies followed emergent CS. Risk factors associated with relaparotomy included higher maternal age, CS performed in the second stage of labor, twin pregnancy, preterm birth (OR 2.72, 95%CI 1.87–3.95) and preeclampsia (OR 3.24, 95%CI 1.47–7.14). Conclusion Our findings demonstrated the high mortality rate in patients who had relaparotomy after CS. Interpretation of the results should be with caution due to GRADE evidence level. During a time when there is an imbalance in medical resources in different countries, interventions to reduce CS rate, good prenatal care and intensified post-operative management are important. Trial registration PROSPEROCRD42021265325.

Background The treatment of acetabular fractures ranges from non-operative with no restrictions in mobilisation to some of the more complex operative treatments in orthopaedics. Treatment strategies are developing, and outcomes need to be studied continuously. The study’s primary aim was to assess the rate of secondary treatment in patients with acetabular fractures treated non-operatively or operatively. A secondary aim was to study mortality. Methods Data were retrieved from the Swedish Fracture Register and cross-referenced with the Swedish Arthroplasty Register for all patients aged ≥ 18 years with an acetabular fracture between 2014 and 2023. Patients were divided into three primary treatment groups: non-operative treatment, open reduction and internal fixation (ORIF), and total hip arthroplasty (THA) with/without combined ORIF (THA/combined hip procedure, CHP). The study examined mortality rates within each treatment group. Results Of the 3318 patients included in the study, 74% were treated non-operatively, 18% with ORIF, and 8% with THA/CHP. 4% of non-operatively treated patients and 17% of patients treated with ORIF had been converted to THA at 5 years, 12% of patients with THA as primary treatment had been revised. Patients who underwent THA as their initial treatment were more likely to undergo secondary treatment early. However, in those initially treated with ORIF the prevalence of secondary treatment increased after the first year. The non-operatively treated group had the highest mortality rate (19% at 1 year), followed by the THA group (14% at 1 year). Conclusions This observational nationwide register study on acetabular fractures shows that surgically treated patients have a relatively high reoperation rate. Younger patients are predominately treated with ORIF and display low mortality rates. Older patients with complex fracture patterns may benefit from primary treatment with THA/CHP being more frequently performed compared to prevailing practice.

Background The purpose of this study is to compare sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGBP) performed in Institutions participating in IFSO-European Chapter, Center of Excellence (COE) program. Methods Since the initiation of the program in January 2010, 6413 SGs and 10,622 RYGBPs performed as primary procedures by December 31, 2014, with at least 12-month follow-up, were retrospectively compared. Results There were steadily increasing numbers of patients underwent SG from 2010 to 2015. Early (<30 days) postoperative complication rate of 3.02 % for RYGBP was significantly higher than 2.12 % seen after SG ( p  = 0.0006). Only two patients, one in each group, died in the first 30 postoperative days (0.016 % mortality for SG vs 0.009 % for RYGBP–NS). From SG group, 103 patients, 1.61 %, and 206 patients, 1.94 %, from RYGBP group required readmission following hospital discharge in the first 30 days following bariatric surgery–NS. From the readmitted patients in the SG group, 75.72 % were reoperated vs 50.50 % in the RYGBP group ( p  < 0.0001). SG patients were heavier (BMI 44.93 vs 43.96 kg/m 2 , p  < 0.0001). However, significantly better % excess weight loss were seen following RYGBP in all postoperative years (60.36 vs 67.72 %, p  = 0.002 at fifth year). Better remission rates were seen for diabetes, arterial hypertension, dyslipidemia, and sleep apnea syndrome after RYGBP in the first postoperative year. Conclusions Both procedures were performed with very low complications, mortality, readmissions, and reoperations rate. Better weight loss was observed following RYGBP, the first five postoperative years.

Introduction While uptake of laparoscopic hepatectomy has improved, evidence on laparoscopic re-hepatectomy (LRH) for colorectal liver metastases (CRLMs) is limited and has never been compared to the open approach. We sought to define outcomes of LRH compared to open re-hepatectomy (ORH). Methods Patients undergoing re-hepatectomy for CRLM at 39 institutions (2006–2013) were identified. Primary outcomes were 30-day post-operative overall morbidity, mortality, and length of stay. Secondary outcomes were recurrence and survival at latest follow-up. LRHs were matched to ORHs (1:3) using a propensity score created by comparing pre-operative clinicopathologic factors (number and size of liver metastases and major hepatectomy). Results Of 376 re-hepatectomies included, 27 were LRH, including 1 (3.7%) conversion. The propensity-matched cohort included 108 patients. Neither median operative time (252 vs. 230 min; p  = 0.82) nor overall 30-day morbidity (48.1 vs. 38.3%; p  = 0.37) differed. Non-specific morbidity (including cardiac, respiratory, infectious, and renal events) decreased with LRH (11.1 vs. 30.9%, p  = 0.04), while surgical-specific morbidity, including liver insufficiency, was higher (44.4 vs. 22.2%, p  = 0.03). One ORH and 0 LRH suffered 30-day mortality. Median length of stay (9 vs. 12 days; p  = 0.60) was comparable. At latest follow-up, 26 (96.3%) LRH and 67 (82.7%) ORH patients were alive. Eight (29.6%) LRH and 36 (44.4%) ORH patients were alive without disease. Conclusion LRH for recurrent CRLM was associated with overall short-term outcomes comparable to ORH, but different morbidity profiles. While it may offer a safe and feasible approach, further insight is necessary to better define patient selection.