30-day Major Complications Research Articles

Modifying Interhospital Hepatopancreatobiliary Transfers Based on Predictive Analytics: Moving from a Center of Excellence to a Health-Care System of Excellence

Regionalization of complex surgical care has increased interhospital transfers to quaternary centers within large health-care systems. Risk-based patient selection is imperative to improve resource allocation without compromising care. This study aimed to develop predictive models for identifying low-risk patients for transfer to a fully integrated satellite hepatopancreatobiliary (HPB) service in the northeast region of the health-care system. HPB transfers to the quaternary center over 15 months from hospitals in proximity to the satellite HPB center. A predictive tool was developed based on simple pretransfer variables and outcomes for 30-day major complications (Clavien grade ≥ 3), readmission, and mortality. Thresholds for "low risk" were set at different SDs below mean for each model. Predictive models were developed from 51 eligible northeast region patient transfers for major complications (Brier score 0.1948, receiver operator characteristic (ROC) 0.7123, P = 0.0009), readmission (Brier score 0.0615, ROC 0.7368, P = 0.0020), and mortality (Brier score 0.0943, ROC 0.7989, P = 0.0023). Thresholds set from 2 SD below the mean for all models identified 2 as "low risk." Adjusting the threshold for the serious complication model to only 1 SD below the mean increased the "low-risk" cohort to five patients. These models demonstrate an easy-to-use tool to assist surgeons in identifying low-risk patients for diversion to a fully integrated satellite center. Improved interhospital transfers within a region could begin a transition from centers of excellence toward health-care systems of excellence.

Utility of the Surgical Apgar Score in pancreatic cancer and modification

ObjectivesThe Surgical Apgar Score (SAS) can predict the incidence of complications in different surgical fields. However, it is rarely studied in pancreatic cancer. The aim of the present study was to assess the predictive value of the SAS in pancreatic ductal adenocarcinoma (PDAC), and then propose a modified SAS which was more suitable for pancreatic cancer patients. Materials and methodsA prospective cohort study of 160 PDAC patients was concluded. The primary endpoint was 30-day major complications. The SAS was calculated as described. The overall discriminatory power of the score was analyzed using receiver operating characteristic curves and the area under the curve (AUC) with respect to major complications or death. ResultsIt showed a significant predictive value of SAS in major complications or death in PDAC (p = 0.020, AUC = 0.606), especially in complication of pneumonia (p = 0.022) and pleural effusion (p = 0.023). In addition, the SAS exert significant predictive value in distal pancreatectomy group, but it has a weak predictive value for pancreaticoduodenectomy group. On multivariable analyses, occurrence of major postoperative complications was associated with lowest mean arterial pressure, estimated blood loss and operative time. Interestingly, as a characteristic of SAS, lowest heart rate was not involved. The modified SAS we proposed including lowest mean arterial pressure, estimated blood loss and operative time increased AUC from 0.606 to 0.743. ConclusionsThe SAS can be a simple, rapid scoring system that effectively predicts major postoperative complications. Besides, the modified SAS we proposed in this study, which included lowest mean arterial pressure, estimated blood loss and operative time, exert a better predictive value in PDAC patients.

Clinically Meaningful Laboratory Protocols Reduce Hospital Charges Based on Institutional and ACS-NSQIP® Risk Calculators in Hepatopancreatobiliary Surgery

Postoperative laboratory testing is an underrecognized but substantial contributor to health-care costs. We aimed to develop and validate a clinically meaningful laboratory (CML) protocol with individual risk stratification using generalizable and institution-specific predictive analytics to reduce laboratory testing and maximize cost savings for low-risk patients. An institutionally based risk model was developed for pancreaticoduodenectomy and hepatectomy, and an ACS-NSQIP®-based model was developed for distal pancreatectomy. Patients were stratified in each model to the CML by individual risk of major complications, readmission, or death. Clinical outcomes and estimated cost savings were compared with those of a historical cohort with standard of care. Over 34 months, 394 patients stratified to the CML for pancreaticoduodenectomy or hepatectomy saved an estimated $803,391 (44.4%). Over 13 months, 52 patients stratified to the CML for distal pancreatectomy saved an estimated $81,259 (30.5%). Clinical outcomes for 30-day major complications, readmission, and mortality were unchanged after implementation of either model. Predictive analytics can target low-risk patients to reduce laboratory testing and improve cost savings, regardless of whether an institutional or a generalized risk model is implemented. Broader application is important in patient-centered health care and should transition from predictive to prescriptive analytics to guide individual care in real time.

Thirty-Day Major and Minor Complications Following Total Hip Arthroplasty—A Comparison of the Direct Anterior, Lateral, and Posterior Approaches

BackgroundThe choice of surgical approach during total hip arthroplasty (THA) remains highly controversial. The aim of the present study was to compare 30-day major and minor complications, following primary THA between the direct anterior, lateral, and posterior approaches. MethodsOur hospital performs primary THAs using all 3 aforementioned approaches based on surgeon preference. Patients who underwent primary THA from August 2010 to August 2017 were identified using our institution’s total joint registry, and their data were combined with prospectively collected data from the National Surgical Quality Improvement Program database (which evaluates a random sample of approximately 20% of all surgical patients in our hospital). Baseline characteristics, operative variables, and postoperative complications were then compared between the three groups. ResultsThe analysis comprised 1967 primary THAs (1913 patients), whereby 56%, 29%, and 15% were performed through a posterior, lateral, and direct anterior approach, respectively. Thirty-day major and minor complications occurred in 3.9% and 9.4% of surgeries, respectively. After adjusting for baseline patient characteristics, there was no significant difference in major or minor perioperative complications between the 3 approaches. ConclusionsThis study compared perioperative complications between the 3 most commonly used approaches for THA utilizing a synthesis of our institutional total joint registry and high-quality National Surgical Quality Improvement Program data. Thirty-day major and minor complications were similar regardless of the surgical approach employed, which may help surgeons and patients simplify the multiple considerations taken into account when deciding on surgical approach for primary THA. Level of EvidenceTherapeutic, Level III.

Concurrent Laparoscopic Ventral Hernia Repair with Bariatric Surgery: a Propensity-Matched Analysis

BackgroundVentral hernias are a common finding during bariatric surgery; however, the risks and benefits of repair during surgery remain unclear. Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, we examined the short-term outcomes of patients undergoing bariatric surgery with concurrent ventral hernia repair (VHR) versus bariatric surgery alone. MethodsPatients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) were included. A propensity-matched analysis was performed between laparoscopic bariatric surgery with and without concurrent VHR. The primary outcome was the 30-day major complication rate which includes but is not limited to 30-day reoperation, deep surgical site infection, and sepsis. Secondary outcomes included operative time, length of hospital stay, 30-day readmission, and 30-day mortality. ResultsA total of 430,225 patients were included, of which 4690 (1.1%) received concomitant VHR. With one-to-one propensity score matching, 4648 pairs were selected. Concurrent VHR was associated with a higher major complication rate (5.8 vs 3.8%, p < 0.001) but no significant difference in mortality (0.3 vs 0.2%, p = 0.531). Both LSG with VHR (3.2 vs 2.4%, p = 0.007) and RYGB with VHR (9.3 vs 5.7%, p < 0.001) were associated with an increase in major complications. ConclusionsPatients undergoing VHR during bariatric surgery do not experience higher mortality. However, these patients have an elevated risk of major complications with this risk being higher among patients undergoing VHR and LRYGB. Bariatric surgeons should consider these risks when choosing to perform VHR at the time of bariatric surgery.

Variation in Hospital Door-to-Intervention Time for Ruptured AAAs and Its Association with Outcomes

A ruptured abdominal aortic aneurysm (rAAA) is a life-threatening condition that carries a high mortality rate. Recent guidelines have recommended a goal "door-to-intervention" time of ≤90minutes despite a paucity of evidence to support this goal. The aim of this study was to analyze recent trends in door-to-intervention time for rAAAs and determine the effect of the 90-minute door-to-intervention benchmark on postoperative complications. A retrospective analysis of all patients who underwent open aortic repair (OAR) or endovascular aneurysm repair (EVAR) of a rAAA in the Vascular Quality Initiative database (2003-2018) was performed. Variation in door-to-intervention time was analyzed at the patient and hospital level. Patients were dichotomized into ≤90 or >90minute door-to-intervention time cohorts. Hierarchical modeling controlling for the hospital random effect and multivariate logistic models was used to analyze the association on 30-day mortality and major in-hospital complications. A total of 3,630 operative cases for rAAA were identified (1696 OAR and 1934 EVAR). For the OAR cohort, 1035 patients (61%) had a door-to-intervention time of ≤90minutes. However, at the hospital level, a minority of hospitals (49%) reliably achieved the OAR goal door-to-intervention time. For OARs, there was no difference in 30-day risk-adjusted major complications or mortality between the ≤90- and>90-minute cohorts. For EVAR, 1014 patients (53.8%) had a door-to-intervention time of ≤90minutes and a minority of hospitals (40%) upheld the recommended ≤90minute door-to-intervention threshold. In the EVAR group, patients with a ≤90minute door-to-intervention time had higher rates of postoperative myocardial infarction (12.0% vs. 8.5%; P<0.05) but no difference in 30-day risk-adjusted mortality. A low percentage of rAAAs are being treated within the recommended door-to-intervention time. Despite this deficiency, the ≤90-minute benchmark has minimal impact on postoperative morbidity and mortality. Based on these findings, alternative quality metrics should be identified to improve the clinical care of patients with rAAA.

Effects of Chronic Corticosteroid and Immunosuppressant Use in Patients Undergoing Bariatric Surgery.

Chronic immunosuppression can put surgical patients at additional risk for complications, particularly infection. This is not a contraindication for patients undergoing bariatric surgery. However, with the increasing prevalence of bariatric surgery, it is important to characterize the additional risks for immunosuppressed patients. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry was used to identify immunosuppressed patients who had undergone bariatric surgery. Patients undergoing primary bariatric surgery (laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy) at an accredited institution between 2015 and 2017 were included. A multivariable regression analysis was performed, controlling for age, sex, procedure, and several other comorbidities. Overall 30-day incidence of major complications was the primary outcome. A secondary analysis compared outcomes amongst immunosuppressed patients by procedure type using a propensity-matched analysis. Propensity matching was performed based on preoperative comorbidities and bariatric procedure. A total of 430,936 patients were included in the study. Of these, 7214 (1.7%) were chronically immunosuppressed. Our multivariable regression analysis found statistically higher odds of 30-day major complications (OR 1.39, 95% CI 1.25-1.55; p < 0.001), bleed (OR 1.49, 95% CI 1.24-1.80; p < 0.001) and anastomotic leak (OR 1.38, 95% CI 1.02-1.87; p = 0.037) amongst immunosuppressed patients. However, there was no difference between 30-day mortality (OR 1.15, 95% CI 0.64-2.07; p = 0.644). Our secondary analysis found higher rates of 30-day major complications for immunosuppressed patients undergoing gastric bypass (9.6% vs. 5.0%; p < 0.001). Immunosuppressed patients are at higher risk of major complications when undergoing bariatric surgery, especially gastric bypass.

Cytoreductive Surgery With or Without Hyperthermic Intraperitoneal Chemotherapy for Gastric Cancer With Peritoneal Metastases (CYTO-CHIP study): A Propensity Score Analysis.

Gastric cancer (GC) with peritoneal metastases (PMs) is a poor prognostic evolution. Cytoreductive surgery (CRS) yields promising results, but the impact of hyperthermic intraperitoneal chemotherapy (HIPEC) remains controversial. Here we aimed to compare outcomes between CRS-HIPEC versus CRS alone (CRSa) among patients with PMs from GC. From prospective databases, we identified 277 patients with PMs from GC who were treated with complete CRS with curative intent (no residual nodules > 2.5 mm) at 19 French centers from 1989 to 2014. Of these patients, 180 underwent CRS-HIPEC and 97 CRSa. Tumor burden was assessed using the peritoneal cancer index. A Cox proportional hazards regression model with inverse probability of treatment weighting (IPTW) based on propensity score was used to assess the effect of HIPEC and account for confounding factors. After IPTW adjustment, the groups were similar, except that median peritoneal cancer index remained higher in the CRS-HIPEC group (6 v 2; P = .003). CRS-HIPEC improved overall survival (OS) in both crude and IPTW models. Upon IPTW analysis, in CRS-HIPEC and CRSa groups, median OS was 18.8 versus 12.1 months, 3- and 5-year OS rates were 26.21% and 19.87% versus 10.82% and 6.43% (adjusted hazard ratio, 0.60; 95% CI, 0.42 to 0.86; P = .005), and 3- and 5-year recurrence-free survival rates were 20.40% and 17.05% versus 5.87% and 3.76% (P = .001), respectively; the groups did not differ regarding 90-day mortality (7.4% v 10.1%, respectively; P = .820) or major complication rate (53.7% v 55.3%, respectively; P = .496). Compared with CRSa, CRS-HIPEC improved OS and recurrence-free survival, without additional morbidity or mortality. When complete CRS is possible, CRS-HIPEC may be considered a valuable therapy for strictly selected patients with limited PMs from GC.

Effect of Intraoperative Goal-directed Balanced Crystalloid versus Colloid Administration on Major Postoperative Morbidity: A Randomized Trial.

Crystalloid solutions leave the circulation quickly, whereas colloids remain for hours, thus promoting hemodynamic stability. However, colloids are expensive and promote renal toxicity in critical care patients. This study tested the hypothesis that goal-directed colloid administration during elective abdominal surgery decreases 30-day major complications more than goal-directed crystalloid administration. In this parallel-arm double-blinded multicenter randomized trial, adults having moderate- to high-risk open and laparoscopically assisted abdominal surgery with general anesthesia were randomly assigned to Doppler-guided intraoperative volume replacement with 6% hydroxyethyl starch 130/0.4 (n = 523) or lactated Ringer's solution (n = 534). The primary outcome was a composite of serious postoperative cardiac, pulmonary, infectious, gastrointestinal, renal, and coagulation complications that were assessed with a generalized estimating equation multivariate model. The primary safety outcome was a change in serum creatinine concentration up to 6 months postoperatively, compared to baseline concentrations. A total of 1,057 patients were included in the analysis. Patients assigned to crystalloid received a median [quartile 1, quartile 3] amount of 3.2 l [2.3, 4.4] of crystalloid, and patients assigned to colloid received 1.0 l [0.5, 1.5] of colloid and 1.8 l [1.2, 2.4] of crystalloid. The estimated intention-to-treat common effect relative risk for the primary composite was 0.90 for colloids versus crystalloids (95% CI: 0.65 to 1.23, P = 0.51), and 18% (91 of 523) of colloid patients and 20% (103 of 534) of crystalloid patients incurred at least one component of the primary outcome composite. There was no evidence of renal toxicity at any time. Doppler-guided intraoperative hydroxyethyl starch administration did not significantly reduce a composite of serious complications. However, there was also no indication of renal or other toxicity.

PD57-08 LARGE SINGLE-INSTITUTION COMPARISON OF PERIOPERATIVE OUTCOMES AND COMPLICATIONS BETWEEN OPEN RADICAL CYSTECTOMY, INTRACORPOREAL ROBOTIC-ASSISTED RADICAL CYSTECTOMY, AND ROBOTIC CYSTECTOMY WITH EXTRACORPOREAL URINARY DIVERSION

You have accessJournal of UrologyBladder Cancer: Invasive VI (PD57)1 Apr 2019PD57-08 LARGE SINGLE-INSTITUTION COMPARISON OF PERIOPERATIVE OUTCOMES AND COMPLICATIONS BETWEEN OPEN RADICAL CYSTECTOMY, INTRACORPOREAL ROBOTIC-ASSISTED RADICAL CYSTECTOMY, AND ROBOTIC CYSTECTOMY WITH EXTRACORPOREAL URINARY DIVERSION JJ Zhang*, Kyle Ericson, Lewis Thomas, Alice Crane, Abhinav Khanna, Jacob Knorr, Michele Fascelli, Anna Zampini, Georges-Pascal Haber, and Byron Lee JJ Zhang*JJ Zhang* More articles by this author , Kyle EricsonKyle Ericson More articles by this author , Lewis ThomasLewis Thomas More articles by this author , Alice CraneAlice Crane More articles by this author , Abhinav KhannaAbhinav Khanna More articles by this author , Jacob KnorrJacob Knorr More articles by this author , Michele FascelliMichele Fascelli More articles by this author , Anna ZampiniAnna Zampini More articles by this author , Georges-Pascal HaberGeorges-Pascal Haber More articles by this author , and Byron LeeByron Lee More articles by this author View All Author Informationhttps://doi.org/10.1097/01.JU.0000557164.66800.5dAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVES: Surgical approach in radical cystectomy includes open radical cystectomy (ORC) and robotic-assisted radical cystectomy (RARC) with either intracorporeal urinary diversion (ICUD) or extracorporeal urinary diversion (ECUD). Multi-institutional studies have compared ORC to RARC or ICUD to ECUD, but comparison of all three surgical options have not been published from a single institution. The objective is to compare intraoperative outcomes, perioperative outcomes, and complication rates between open, intracorporeal, and extracorporeal diversions at a single high-volume tertiary care center. METHODS: A retrospective review was conducted of 641 patients who underwent radical cystectomy with urinary diversion at a single high-volume hospital between 2011-2018. Intraoperative outcomes, perioperative outcomes, and 90-day major complications (Clavien-Dindo classification III-V) were compared between ORC, ICUD and ECUD. Statistical analyses were performed using Pearson’s chi squared test for categorical variables and one-way ANOVA or Kruskal-Wallis for continuous variables with significance defined as p<0.05. RESULTS: 641 patients underwent radical cystectomy with urinary diversion: 231 ORC, 185 ICUD, and 225 ECUD. Estimated mean operative time was highest for ECUD (437.4 min) compared to ICUD (409.7 min) and ORC (334.8 min), p<0.0001. Median estimated blood loss (EBL) was significantly lower for ICUD (300cc) compared to ECUD (400cc) and ORC (750cc), p <0.0001. Comparing postoperative outcomes, patients undergoing ICUD had shorter hospitalization compared to ICUD and open cystectomy (7.9 v 9.5 v. 10.5 days), p<0.0001. Although there was no significant difference in rate of ileus by surgical approach, ICUD was significantly associated with lower TPN requirement rates (7.6%) compared to ECUD (12.0%) and ORC (19.5%), p=0.001. Comparing complication rates, ICUD was significantly associated with lower 90-day major complication rate compared to ECUD and ORC (14.6% v 26.2% v 27.3%, p=0.04). There was no significant difference in 90-day readmission between the three approaches. CONCLUSIONS: In our large single-institution experience, robotic intracorporeal urinary diversion demonstrated benefits of lower EBL, shorter hospital stay, lower TPN requirements, and lower major complication rates compared to both robotic extracorporeal diversion and open radical cystectomy. Source of Funding: None Cleveland, OH© 2019 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 201Issue Supplement 4April 2019Page: e1026-e1026 Advertisement Copyright & Permissions© 2019 by American Urological Association Education and Research, Inc.MetricsAuthor Information JJ Zhang* More articles by this author Kyle Ericson More articles by this author Lewis Thomas More articles by this author Alice Crane More articles by this author Abhinav Khanna More articles by this author Jacob Knorr More articles by this author Michele Fascelli More articles by this author Anna Zampini More articles by this author Georges-Pascal Haber More articles by this author Byron Lee More articles by this author Expand All Advertisement PDF downloadLoading ...

Potential value and limitations of different clinical scoring systems in the assessment of short- and long-term outcome following orthotopic liver transplantation.

BackgroundIn an attempt to further improve liver allograft utilization and outcome in orthotopic liver transplantation (OLT), a variety of clinical scoring systems have been developed. Here we aimed to comparatively investigate the association of the Balance-of-Risk (BAR), Survival-Outcomes-Following-Liver-Transplant (SOFT), Preallocation-Survival-Outcomes-Following-Liver-Transplant (pSOFT), Donor-Risk-Index (DRI), and the Eurotransplant-Donor-Risk-Index (ET-DRI) scores with short- and long-term outcome following OLT.MethodsWe included 338 consecutive patients, who underwent OLT in our institution between May 2010 and November 2017. For each prognostic model, the optimal cutoff values were determined with the help of the Youden-index and their diagnostic accuracy for 90-day post OLT-mortality and major postoperative complications was measured by the area under the receiver operating characteristic curve (AUROC). Patient- and graft survival were analyzed using the Kaplan-Meier method and the log-rank test. Morbidity was assessed using the Clavien-Dindo classification and the Comprehensive-Complication-Index.ResultsBAR, SOFT, and pSOFT performed well above the conventional AUROC-threshold of 0.70 with good prediction of early mortality. Only BAR showed AUC>0.70 for both mortality and major morbidity. With the cutoffs of 14, 31, and 22 respectively for BAR, SOFT, and pSOFT, subgroup analysis showed significant differences (p<0.001) in morbidity and mortality, length of intensive care- and hospital-stay and early allograft dysfunction rates. Five-years patient survival was inferior in the high BAR, pSOFT, and SOFT groups.ConclusionsOut of all scores tested, the BAR-score had the best value in predicting both 90-day morbidity and mortality after OLT showing the highest AUCs. The pSOFT and SOFT scores demonstrated an acceptable accuracy in predicting 90-day morbidity and mortality. The used BAR, SOFT, and pSOFT cutoffs allowed the identification of patients at risk in terms of five-year patient survival. The DRI and ET-DRI scores have failed to predict recipient outcomes in the present setting.

Can Elective Spine Surgery Be Performed Safely Among Nonagenarians?: Analysis of a National Inpatient Database in Japan.

Retrospective cohort study. To compare morbidity and mortality between nonagenarians and other older adult patients who underwent elective spine surgery. There is a lack of information of the perioperative risks of nonagenarians undergoing spine surgery. Data of patients aged ≥65 years who underwent elective spine surgery from July 2010 to March 2013 were extracted from the Diagnosis Procedure Combination database, a nationwide administrative inpatient database in Japan. Clinical outcomes included mortality, occurrence of major complications (cardiac events, respiratory complications, pulmonary embolism, stroke, and acute renal failure), urinary tract infection, and postoperative delirium. These clinical outcomes in nonagenarians were compared with those in patients aged 65 to 79 years and octogenarians. A multivariate logistic regression model fitted with a generalized estimation equation was used to evaluate the influence of advanced age on 90-day mortality and postoperative major complications. Of 88,370 patients identified in the database, 418 were nonagenarians. Compared with patients aged 65 to 79 years and octogenarians, nonagenarians had the highest rates of 90-day mortality (0.2%, 0.3%, and 1.7%, respectively; P < 0.001) and at least one major complication (3.7%, 5.0%, and 7.4%, respectively; P < 0.001). Nonagenarians had the highest proportions of cardiac events, respiratory complications, urinary tract infections, and delirium. The multivariable logistic regression analyses revealed that nonagenarians had increased risks of both 90-day mortality (odds ratio, 8.65; 95% confidence interval, 3.62-20.6) and postoperative major complications (odds ratio, 2.32; 95% confidence interval, 1.61-3.36) compared with patients aged 65 to 79 years. Nonagenarians had increased morbidity and mortality following elective spine surgery compared with other older adult patients. Among the complications, cardiac events, respiratory complications, urinary tract infection, and delirium were more likely to occur in nonagenarians. 3.

Perioperative haemodynamic therapy for major gastrointestinal surgery: the effect of a Bayesian approach to interpreting the findings of a randomised controlled trial

ObjectiveThe traditional approach of null hypothesis testing dominates the design and analysis of randomised controlled trials. This study aimed to demonstrate how a simple Bayesian analysis could have been used...

Case Volume and Outcomes After TAVR With Balloon-Expandable Prostheses: Insights From TVT Registry

BackgroundGiven conflicting findings of previous studies, much remains to be understood regarding a volume-outcomes relationship (VOR) in transcatheter aortic valve replacement (TAVR). ObjectivesThe purpose of this study was: 1) to determine if, after the initial learning curve (LC), a VOR for balloon-expandable (BE) TAVR persisted; and 2) to determine if LCs and VORs differed across different device generations. MethodsData collected by the TVT registry for BE valve implants from November 2011 through January 2017 were included in this analysis (n = 61,949). Primary outcomes included 30-day all-cause mortality, stroke, and major vascular complications. For each center, all implants were ordered chronologically according to case sequence number (CS#). To determine where the learning curve terminated (LCT), a grid search analysis was applied across a range of CS# from 10 to 300 by increments of 1. After LCT, the VOR was assessed by examining case volume/month by center. This analysis was performed separately for: 1) all BE valve types; 2) Sapien 3 (S3) only; and 3) S3 in BE valve naïve sites. ResultsIn experience with all commercially available BE valve types, there was an initial LC that terminates around case #201. After the initial LC, a volume–outcomes relationship was no longer evident. In analysis limited to S3, there was no demonstrable LC or VOR. Likewise, there was no demonstrable LC or VOR with S3 for BE valve naïve sites. ConclusionsAfter a case experience of 200 cases, there was LCT; subsequent to initial learning, a VOR was no longer evident. In the S3-only analysis, there was no LC or no demonstrable VOR. With current-generation BE-TAVR, centers should expect to achieve consistently excellent outcomes even during early case experience.

Hypoalbuminemia Is Associated With Increased Postoperative Mortality and Complications in Hand Surgery.

Background: Malnutrition has been associated with increased perioperative morbidity and mortality in orthopedic surgery. This study was designed with the hypothesis that preoperative hypoalbuminemia, a marker for malnutrition, is associated with increased complications after hand surgery. Methods: A retrospective cohort study of 208 hand-specific Current Procedural Terminology codes was conducted with the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2013. In all, 629 patients with low serum albumin were compared with 4079 patients with normal serum albumin. The effect of hypoalbuminemia was tested for association with 30-day postoperative mortality, and major and minor complications. Results: Hypoalbuminemia was independently associated with emergency surgery, diabetes mellitus, dependent functional status, hypertension, end-stage renal disease, current smoking status, and anemia. Patients with hypoalbuminemia had a higher rate of mortality, minor complications, and major complications. Conclusions: Hypoalbuminemia is associated with an increased risk of postoperative morbidity and mortality in patients undergoing hand surgery. As such, increased focus on perioperative nutrition optimization may lead to improved outcomes for patients undergoing hand surgery.

Can Machine Learning Methods Produce Accurate and Easy-to-use Prediction Models of 30-day Complications and Mortality After Knee or Hip Arthroplasty?

Existing universal and procedure-specific surgical risk prediction models of death and major complications after elective total joint arthroplasty (TJA) have limitations including poor transparency, poor to modest accuracy, and insufficient validation to establish performance across diverse settings. Thus, the need remains for accurate and validated prediction models for use in preoperative management, informed consent, shared decision-making, and risk adjustment for reimbursement. The purpose of this study was to use machine learning methods and large national databases to develop and validate (both internally and externally) parsimonious risk-prediction models for mortality and complications after TJA. Preoperative demographic and clinical variables from all 107,792 nonemergent primary THAs and TKAs in the 2013 to 2014 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) were evaluated as predictors of 30-day death and major complications. The NSQIP database was chosen for its high-quality data on important outcomes and rich characterization of preoperative demographic and clinical predictors for demographically and geographically diverse patients. Least absolute shrinkage and selection operator (LASSO) regression, a type of machine learning that optimizes accuracy and parsimony, was used for model development. Tenfold validation was used to produce C-statistics, a measure of how well models discriminate patients who experience an outcome from those who do not. External validation, which evaluates the generalizability of the models to new data sources and patient groups, was accomplished using data from the Veterans Affairs Surgical Quality Improvement Program (VASQIP). Models previously developed from VASQIP data were also externally validated using NSQIP data to examine the generalizability of their performance with a different group of patients outside the VASQIP context. The models, developed using LASSO regression with diverse clinical (for example, American Society of Anesthesiologists classification, comorbidities) and demographic (for example, age, gender) inputs, had good accuracy in terms of discriminating the likelihood a patient would experience, within 30 days of arthroplasty, a renal complication (C-statistic, 0.78; 95% confidence interval [CI], 0.76-0.80), death (0.73; 95% CI, 0.70-0.76), or a cardiac complication (0.73; 95% CI, 0.71-0.75) from one who would not. By contrast, the models demonstrated poor accuracy for venous thromboembolism (C-statistic, 0.61; 95% CI, 0.60-0.62) and any complication (C-statistic, 0.64; 95% CI, 0.63-0.65). External validation of the NSQIP- derived models using VASQIP data found them to be robust in terms of predictions about mortality and cardiac complications, but not for predicting renal complications. Models previously developed with VASQIP data had poor accuracy when externally validated with NSQIP data, suggesting they should not be used outside the context of the Veterans Health Administration. Moderately accurate predictive models of 30-day mortality and cardiac complications after elective primary TJA were developed as well as internally and externally validated. To our knowledge, these are the most accurate and rigorously validated TJA-specific prediction models currently available (http://med.stanford.edu/s-spire/Resources/clinical-tools-.html). Methods to improve these models, including the addition of nonstandard inputs such as natural language processing of preoperative clinical progress notes or radiographs, should be pursued as should the development and validation of models to predict longer term improvements in pain and function. Level III, diagnostic study.

Portal and mesenteric vein resection during pancreaticoduodenectomy and total pancreatectomy:

Background: The aim of this study was to identify the perioperative morbidity and long-term outcomes of venous resection (VR) duringpancreaticoduodenectomy (PD) and total pancreatectomy (TP) operations. Methods: We conducted a retrospective study of patients undergoing PD or TP between March 1995 and December 2014 at Mayo Clinic in Jacksonville, Florida. Preoperative, operative, and postoperative clinicopathological data were collected and analyzed. Results: Out of 601 patients who underwent PD and TP in this study, 104 (17.3%) underwent VR. The types of VR and reconstruction were: type I (lateral venorraphy) in 49 patients (47.1%), type II (patch graft) in 10 patients (9.6%), type III (primary anastomosis) in 27 patients (26%), and type IV (interposition venous graft) in 16 patients (15.4%). Two patients (1.9%) had no portomesenteric reconstruction. The 90-day major postoperative complications and mortality in patients with VR were 44.2% and 7.7%, respectively, versus 29.2% and 4.4%, respectively, in patients with standard resection. The 1-, 3-, 5-, and 7-year survival rates in VR with periampullaryadenocarcinoma were 55.1%, 27%, 21.9%, and 15.4%, respectively, while in patients with periampullaryadenocarcinoma without VR the survival rates were 78.4%, 45.6%, 34.6%, and 30.9%, respectively (P< 0.01). Conclusion: VR and reconstruction with PD can be performed safely with acceptable perioperative morbidity and long-term survival rates to achieve complete removal of the tumor.

30-day readmission after radical cystectomy: Identifying targets for improvement using the phases of surgical care.

Postoperative readmissions following radical cystectomy (RC) have gained attention in the past decade. Postoperative and post-discharge complications play a role in readmission rates; however, our ability to predict readmissions remains poor. Using the National Surgical Quality Improvement Program database, we identified patients with bladder cancer undergoing RC from 2013-2015. Complications were defined as postoperative and post-discharge. Outcomes were 30-day readmission, post-discharge complications, and post-discharge major complications. Patient, operative, and complication factors were assessed using multivariable logistic regression. We identified 4457 patients who underwent RC; 9.2% of patients experienced a postoperative complication, 18.8% experienced a post-discharge complication, and 20.3% were readmitted. Overweight and obese body mass index (BMI), dependent functional status, chronic obstructive pulmonary disease (COPD), a continent diversion, and duration of operation were associated with post-discharge complications. Postoperative complications were not associated with post-discharge complications. Readmission was associated with Black race (odds ratio [OR] 1.5; 95% confidence interval [CI] 1.0-2.1), overweight (OR 1.5; 95% CI 1.2-1.8) and obese BMI (OR 1.5; 95% CI 1.2-1.9), diabetes (OR 1.2; 95% CI 1.0-1.5), COPD (OR 1.4; 95% CI 1.0-1.8), steroid use (OR 1.5; 95% CI 1.0-2.2), a continent diversion (OR 1.4; 95% CI 1.1-1.7), duration of operation (OR 1.1; 95% CI 1.1-1.2), and postoperative complications (OR 1.5; 95% CI 1.2-2.0). The majority of readmissions experienced a post-discharge complication. Factors that span the preoperative, intraoperative, postoperative, and post-discharge phases of care were identified to increase readmission risk. To improve readmission rates, interventions will have to target factors across the surgical experience.

Prediction of short-term surgical complications in women undergoing pelvic exenteration for gynecological malignancies

ObjectivePelvic exenteration (PE) is an extensive surgery associated with high rates of postoperative morbidity and mortality. The absence of well-defined preoperative selection criteria to identify patients eligible for PE prompted the assessment of pre-operative predictors of 30-day major surgical complications. MethodsDemographics and surgical characteristics of patients undergoing PE for gynecologic cancer in a single institution between 01/2004–12/2016 were reviewed. Postoperative complications within 30 days following surgery were graded using the Accordion grading system. Logistic regression was used to analyze potential risk factors for severe postoperative complications. ResultsA total of 138 patients were included in the cohort. Forty-five patients underwent total PE, 52 anterior PE, and 41 posterior PE. Among the 137 patients with follow-up, a severe postoperative complication was experienced by 37 patients (27.0%) and 3 patients (2.2%) experienced death within 90 days. The most frequent grade 3 complications were complications of urinary reconstruction (n = 15), wound dehiscence (n = 9), and abdominal abscess requiring intervention with drain or return to the operating room (n = 6). On multivariable analysis, independent predictors of severe postoperative complications were anterior or total PE (adjusted odds ratio (aOR): 11.66, 95% CI 2.56–53.18), pre-operative hemoglobin ≤10 mg/dl (aOR 2.70, 95% CI 1.02–7.14) and presence of 3+ comorbidities (aOR: 2.76, 95% CI 1.07–7.10). ConclusionsMajor complications after exenteration are common. Surgical complexity and patient selection play a considerable role in predicting complications. These data can be used to better risk stratify patients undergoing PE.

How Does Chemoradiotherapy Following Induction FOLFIRINOX Improve the Results in Resected Borderline or Locally Advanced Pancreatic Adenocarcinoma? An AGEO-FRENCH Multicentric Cohort.

Patients with borderline (BR) or locally advanced (LA) pancreatic adenocarcinoma (PAC) are often treated with induction FOLFIRINOX (FLX). However, the role of additional preoperative chemoradiotherapy (CRT) is controversial. The aim of this study is to evaluate its impact in patients who underwent resection after induction FLX. Retrospective analysis of prospective consecutive surgical BR or LA PAC patients after induction FLX in 23 French centers between November 2010 and December 2015, treated with or without preoperative additional CRT (FLX vs FLX + CRT groups). Two hundred three patients were included (106 BR, 97 LA PAC). Median number of FLX cycles was 6 (range 1-30); 50% (n = 102) of patients received additional CRT. Median duration between diagnosis and surgery was 5.4 and 8.7months (P = 0.001) in the FLX and FLX + CRT group, respectively. The 90-day mortality, major complications, and pancreatic fistula rates were 4.4%, 17.7%, and 5.4%, respectively. After 45.1months follow-up, overall survival (OS) and disease-free survival were 45.4months and 16.2months, respectively. Patients with additional CRT had higher R0 resection rate (89.2% vs 76.3%; P = 0.017), ypN0 rate (76.2% vs 48.5%; P < 0.001), and higher rate of pathologic major response (33.3% vs 12.9%; P = 0.001). In the FLX + CRT group, patients had lower rate of locoregional relapse (28.3% vs 50.7%; P = 0.004). Patients with additional CRT had longer OS than those receiving FLX alone (57.8 vs 35.5months; P = 0.007). Pathological results and survival data argue for interest in additional CRT. Prospective studies on an intention-to-treat basis are needed to confirm these results.