Perioperative 30-day Mortality Research Articles

Anesthesia-related and perioperative mortality: An audit of 8493 cases at a tertiary pediatric teaching hospital in South Africa.

This study aimed to quantify the incidence of anesthesia-related and perioperative mortality at a large tertiary pediatric hospital in South Africa. This study included all children aged <18years who died prior to discharge from hospital and within 30days of their last anesthetic at the Red Cross War Memorial Children's Hospital between January 1, 2015 to December 31, 2015. A panel of three senior anesthetists reviewed each death to reach a consensus as to whether: (i) anesthesia caused the death; (ii) anesthesia may have contributed to or influenced the timing of death; or (iii) anesthesia was entirely unrelated to the death. There were 47 deaths within 30days of anesthesia prior to discharge from hospital during this 12-month period. The in-hospital mortality within 24h of administration of anesthesia was 16.5 per 10000 cases (95% confidence intervals [CI]=7.8-25.1) and within 30days of administration of anesthesia was 55.3 per 10000 cases (95% CI=39.5-71.2). Age under 1year (OR 4.5; 95% CI=2.5-8.0, P=.012) and cardiac surgery and interventional cardiology procedures (OR 2.5; 95% CI=1.2-5.2, P<.01) were both independent predictors of increased risk of perioperative mortality. The overall 24-h and 30-day anesthesia-related and in-hospital perioperative mortality rates in our study are comparable with other similar studies from tertiary pediatric centers.

Influence of tumor size on outcomes following pelvic exenteration.

Pelvic exenteration (PE) is often the only curative option for locally advanced or recurrent pelvic malignancies. Despite radical surgery, recurrence risk and morbidity remain high. In this study, we sought to determine tumor size effect on perioperative outcomes and subsequent survival in patients undergoing PE. Retrospective chart review was performed for female patients who underwent PE at two comprehensive cancer centers from 2000 to 2015. Demographics, complications and outcomes were recorded. Statistical analyses were performed using chi-square, student's t-test, logistic regression, non-parametric tests, log-rank test, and Cox proportional hazards. Of 151 women who underwent PE, 144 had available pathologic tumor size. Gynecologic oncology, surgical oncology, and urology performed 84, 29, and 31 exenterations, respectively. Tumor dimensions ranged from 0 to 25.5cm. Perioperative complications, 30-day mortality, reoperation, and readmission rates were not associated with tumor size. Obesity and prior radiation increased risk for major perioperative complication while anterior exenterations decreased risk. Larger tumors were more likely to undergo total pelvic exenteration (OR 1.14; 95%CI 1.03-1.27), have positive margins (OR 1.11; 95%CI 1.02-1.22), and recur (65%, 42% and 20% for tumors >4cm, ≤4cm and no residual tumor respectively, p=0.016). Tumor size >4cm and positive margins were associated with worse overall survival amongst gynecologic oncology patients. Tumor size was not associated with perioperative morbidity. Larger tumors were associated with positive margins, more extensive resection, and worse survival in gynecologic oncology patients. Larger studies are needed to further understand tumor size impact on PE outcomes within specific tumor types.

Association of Postoperative High-Sensitivity Troponin Levels With Myocardial Injury and 30-Day Mortality Among Patients Undergoing Noncardiac Surgery

Little is known about the relationship between perioperative high-sensitivity troponin T (hsTnT) measurements and 30-day mortality and myocardial injury after noncardiac surgery (MINS). To determine the association between perioperative hsTnT measurements and 30-day mortality and potential diagnostic criteria for MINS (ie, myocardial injury due to ischemia associated with 30-day mortality). Prospective cohort study of patients aged 45 years or older who underwent inpatient noncardiac surgery and had a postoperative hsTnT measurement. Starting in October 2008, participants were recruited at 23 centers in 13 countries; follow-up finished in December 2013. Patients had hsTnT measurements 6 to 12 hours after surgery and daily for 3 days; 40.4% had a preoperative hsTnT measurement. A modified Mazumdar approach (an iterative process) was used to determine if there were hsTnT thresholds associated with risk of death and had an adjusted hazard ratio (HR) of 3.0 or higher and a risk of 30-day mortality of 3% or higher. To determine potential diagnostic criteria for MINS, regression analyses ascertained if postoperative hsTnT elevations required an ischemic feature (eg, ischemic symptom or electrocardiography finding) to be associated with 30-day mortality. Among 21 842 participants, the mean age was 63.1 (SD, 10.7) years and 49.1% were female. Death within 30 days after surgery occurred in 266 patients (1.2%; 95% CI, 1.1%-1.4%). Multivariable analysis demonstrated that compared with the reference group (peak hsTnT <5 ng/L), peak postoperative hsTnT levels of 20 to less than 65 ng/L, 65 to less than 1000 ng/L, and 1000 ng/L or higher had 30-day mortality rates of 3.0% (123/4049; 95% CI, 2.6%-3.6%), 9.1% (102/1118; 95% CI, 7.6%-11.0%), and 29.6% (16/54; 95% CI, 19.1%-42.8%), with corresponding adjusted HRs of 23.63 (95% CI, 10.32-54.09), 70.34 (95% CI, 30.60-161.71), and 227.01 (95% CI, 87.35-589.92), respectively. An absolute hsTnT change of 5 ng/L or higher was associated with an increased risk of 30-day mortality (adjusted HR, 4.69; 95% CI, 3.52-6.25). An elevated postoperative hsTnT (ie, 20 to <65 ng/L with an absolute change ≥5 ng/L or hsTnT ≥65 ng/L) without an ischemic feature was associated with 30-day mortality (adjusted HR, 3.20; 95% CI, 2.37-4.32). Among the 3904 patients (17.9%; 95% CI, 17.4%-18.4%) with MINS, 3633 (93.1%; 95% CI, 92.2%-93.8%) did not experience an ischemic symptom. Among patients undergoing noncardiac surgery, peak postoperative hsTnT during the first 3 days after surgery was significantly associated with 30-day mortality. Elevated postoperative hsTnT without an ischemic feature was also associated with 30-day mortality.

Thoracic endovascular aortic repair for traumatic type B aortic dissection: a 5-year experience from a single center.

The aim of this paper was to share our experience and demonstrate the feasibility, safety and efficacy of thoracic endovascular aortic repair (TEVAR) for traumatic type B aortic dissection (TTBAD). Between October 2010 and October 2015, 36 patients, who have been diagnosed as TTBAD, were included. A computed tomography angiography (CTA) scan was performed to confirm the diagnosis and to localize the aortic entry. The clinical data and outcomes of these patients were retrospectively reviewed and collected for further analysis. CTA scan follow-up was organized 1 week, 3 months, 6 months and yearly after the procedure. Thirty-six cases (48.7±15.8 years, 25 men) were included in this study. All the patients were successfully managed with TEVAR, and the perioperative mortality and 30-day mortality were zero. The mean hospitalization time was 14.6±8.4 days, with the mean intensive care unit (ICU) stay time being 44.4±62.4 hours. After TEVAR, no cardiocerebral events happened, but 6 patients suffered from pulmonary infection, 1 patient suffered from renal failure, and type I endoleak occurred in 1 patient. The postoperative courses of the other patients were uneventful. All the patients were followed-up for 13.1±12.6 months, and we could affirm the stability of the implants and good quality of life of the included patients. Treatment of TTBAD by TEVAR with implantation of stent graft is technical possible, besides, it is remarkably safe and effective.

Diagnosis of perioperative myocardial infarction after heart valve surgery with new cut-off point of high-sensitivity troponin T and new electrocardiogram or echocardiogram changes

ObjectiveCriteria for diagnosing myocardial infarction (MI) after heart valve surgery are not collected in the Third Universal Definition of MI. We aimed to define cut-offs for high-sensitivity cardiac troponin T (hs-cTnT) and creatine kinase-MB (CK-MB) for the diagnosis of perioperative MI after heart valve surgery according to perioperative MI determined by new alterations in electrocardiogram (ECG) and/or transthoracic echocardiogram (TTE). Secondary endpoints were incidence of perioperative MI, postoperative complications, 30-day mortality, and 2-year survival. MethodsHeart valve surgery was performed in 805 patients (June 2012-January 2016). hs-cTnT and CK-MB were measured at intensive care unit (ICU) admission and 8, 16, 24, 48, and 72 hours after surgery. Blind to outcomes, we analyzed ECGs and TTEs before and after surgery. Patients were divided into 2 groups: with ECG and/or TTE criteria after surgery (following the consensus statement) and without these changes. We conducted receiver operating characteristic analyses for hs-cTnT and CK-MB in the group with ECG and/or TTE criteria. ResultsECG and/or TTE criteria were observed in 88 patients. Receiver operating characteristic analyses in this group showed hs-cTnT levels of 732.3 pg/mL at ICU admission; 1008 pg/mL at 8 hours, 1057 pg/mL at 16 hours, and 958.3 pg/mL at 24 hours after surgery (P < .001) and CK-MB levels of 26.78 mg/dL at ICU admission, 54.88 mg/dL at 8 hours, 38.98 mg/dL at 16 hours, and 18.4 mg/dL at 24 hours after surgery (P < .001). ConclusionsCut-offs for hs-cTnT and CK-MB to diagnose perioperative MI after heart valve surgery are well above upper reference limit. These findings update the Third Universal Definition providing cut-offs to diagnose perioperative MI after heart valve surgery.

The optimal treatment of patients with mild and moderate acute cholecystitis: time for a revision of the Tokyo Guidelines.

According to the Tokyo Guidelines, severity of acute cholecystitis is divided into three grades based on the degree of inflammation and the presence of organ dysfunction. These guidelines recommend grade I (mild) acute cholecystitis to be treated with early laparoscopic cholecystectomy and grade II (moderate) acute cholecystitis with delayed cholecystectomy. Yet, several studies have shown that, for acute cholecystitis in general, early cholecystectomy is superior to delayed cholecystectomy in terms of complication rate, duration of hospital stay and costs. The aim of this study was to determine the clinical outcomes of emergency cholecystectomy in patients with grade II acute cholecystitis. Based on our findings, we propose a revision of the Tokyo Guidelines. We performed a retrospective observational cohort study of 589 consecutive patients undergoing emergency cholecystectomy for acute calculous cholecystitis in a large teaching hospital between January 2002 and January 2015. Patients were classified according to the severity assessment criteria of the Tokyo Guidelines. Patients with grade I and grade II acute cholecystitis were compared for perioperative outcomes. Emergency cholecystectomy was performed in 270 patients with grade I acute cholecystitis and 187 patients with grade II acute cholecystitis. There was no difference in conversion rate (6 vs. 6%, p=0.985) and operating time (60min [25-255] vs. 70min [30-255], p=0.421). Also the perioperative complication rate (7 vs. 9%, p=0.517), 30-day mortality (1 vs. 1%, p=0.648) and length of hospital stay (4days [1-42] vs. 4days [1-62], p=0.327) were similar between grade I and grade II acute cholecystitis. The clinical outcomes of emergency cholecystectomy did not differ between patients with grade I and grade II acute cholecystitis. The findings support a revision of the Tokyo Guidelines with respect to the recommendation of performing emergency cholecystectomy in both grade I and grade II acute cholecystitis.

Impact of Surgeon Volume on Outcomes of Older Stage I Lung Cancer Patients Treated via Video-assisted Thoracoscopic Surgery

Surgeon procedure volume influences outcomes of patients undergoing cancer operations. Limited data are available, however, on the volume-outcome relationship for video-assisted thoracoscopic surgery (VATS) in the treatment of non-small cell lung cancer (NSCLC). In this study, we used population-based data to evaluate the extent to which surgeon volume is associated with postoperative and long-term oncological outcomes following VATS resection for older patients with early-stage NSCLC. Stage I NSCLC patients >65 years treated with VATS wedge, segmentectomy, or lobectomy between 2000 and 2010 were identified from the Surveillance, Epidemiology, and End Results registry linked to Medicare. Surgeon volume was grouped into tertiles (low, intermediate, and high). Outcomes included perioperative complications, intensive care unit admission, extended length of stay, perioperative (30-day) mortality, and long-term overall and lung cancer-specific survival. We used propensity score methods to compare adjusted survival of patients by surgical volume group. A total of 2295 study patients were identified. Patients treated by high-volume surgeons had decreased intensive care unit admissions (hazard ratio [HR]: 0.46, 95% CI: 0.41-0.51) and postoperative length of stay (HR: 0.75, 95% CI: 0.61-0.92). Adjusted analyses showed that overall (HR: 0.73, 95% CI: 0.62-0.87) and lung cancer-specific (HR: 0.76, 95% CI: 0.58-0.99) survival was better for patients treated by high-volume surgeons. Elderly stage I NSCLC patients undergoing VATS by high-volume surgeons have reduced postoperative complications and improved survival. Organization of care favoring referrals of VATS candidates to high-volume providers may help improve the outcomes of patients with early-stage lung cancer.

P2.04-039 Long-Term Risk of Recurrence in Benign Pleural Solitary Fibrous Tumors: A Single Institution Review: Topic: Esophageal Cancer and Other Malignancies

Solitary fibrous tumor (SFT) is a rare tumor of submesothelial origin that can occur in the abdomen, extremities, trunk, head, neck and pleura. Pleural SFTs are defined as benign or malignant based on the number of mitoses and the presence of pleomorphism, hemorrhage, or necrosis. There is limited data in the literature regarding the recurrence risk of benign pleural SFT and the need for long-term follow up in these patients. A single institution retrospective chart review was performed on all surgically resected primary pleural SFTs between 1992 and 2015. Preoperative clinical information, pathologic tumor characteristics, and long-term recurrence and survival data were collected. There were 29 primary pleural SFTs resected between 1992 and 2015. Patients had a mean age of 60 years and there were 16 men (55%) and 13 women (45%). Fourteen (48%) presented with symptoms, including two patients with paraneoplastic syndromes, and the other 15 tumors (52%) were found incidentally on imaging. There were six giant SFTs defined as size greater than 15 cm, with two of six giant SFTs undergoing preoperative embolization to aid surgical resection. Otherwise, there were no neoadjuvant or adjuvant treatments in any patient. There was no perioperative 30-day mortality (0%). Mean follow up time was 77 months, during which 4 (14%) patients recurred and 21 of 29 patients (72%) were alive at last follow up. Three of the 8 deaths occurred in patients with recurrent disease. Among the 19 benign pleural SFTs, 2 (11%) recurred at 5 and 9 years postoperatively and 2 of the 6 malignant SFTs (33%) recurred at 4 and 15 years postoperatively. Margin status was known in 25 cases, of which 21 (84%) were negative and 4 (16%) were positive. There were no recurrences in patients with known negative margins. This study represents one of the largest contemporary single institution reviews of outcomes of pleural SFT. While benign pleural SFTs were less likely to recur than malignant pleural SFTs, benign pleural SFTs with positive or unknown margin status remain at risk for recurrence up to a decade following resection and require ongoing long-term follow up and surveillance imaging.

Open Surgical Repair Remains the Gold Standard for Treating Aortic Arch Pathology

Endovascular arch repair technology is driven in large part by the assumption that open arch operations are high-risk. We wanted to evaluate the clinical results of open arch reconstruction in the modern era in a large group practice. From October 2003 to June 2014, 567 patients underwent aortic arch operations: hemiarch repair was performed in 429 patients (75.7%; group A), total arch repair in 129 (22.7%; group B), and patch repair in the remaining 9 (1.6%). The procedure was an emergency in 88 patients (20.5%) in group A and in 41 patients (31%) in group B. Redo sternotomy after a previous aortic operation was performed in 35 patients (8.2%) in group A and in 28 patients (22%) in group B. Permanent neurologic deficits were diagnosed in 12 patients (2.8%) in group A and in 3 patients (2.4%) in group B. No spinal cord injuries occurred. Mortality at 30days was 4% (17 patients) in group A and 5.4% (7 patients) in group B. Patients in group A were younger than in groupB (mean age, 61.3 vs 63.6 years; p= 0.06). Older age (odds ratio, 1.05; 95% confidence interval, 1.01 to 1.09; p=0.0087) and extracorporeal circulation time (odds ratio, 1.01; 95% confidence interval, 1 to 1.01; p<0.001) were predictors of perioperative 30-day mortality. Age (odds ratio, 1.05; 95% confidence interval, 1.01 to 1.08; p= 0.006) was the only predictor for neurologic dysfunction. Survivalat 2, 6, and 8 years was 90%, 80%, and 69%, respectively, for group A, and 85%, 70% and 62%, respectively, for group B. These results set a standard against which endovascular technology needs to be compared.

Complications of biliary-enteric anastomoses.

INTRODUCTION Biliary-enteric anastomoses are performed for a range of indications and may result in early and late complications. The aim of this study was to assess the risk factors and management of anastomotic leak and stricture following biliary-enteric anastomosis. METHODS A retrospective analysis of the medical records of patients who underwent biliary-enteric anastomoses in a tertiary referral centre between 2000 and 2010 was performed. RESULTS Four hundred and sixty-two biliary-enteric anastomoses were performed. Of these, 347 (75%) were performed for malignant disease. Roux-en-Y hepaticojejunostomy or choledocho-jejunostomy were performed in 440 (95%) patients. Perioperative 30-day mortality was 6.5% (n=30). Seventeen patients had early bile leaks (3.7%) and 17 had late strictures (3.7%) at a median of 12 months. On univariable logistic regression analysis, younger age was a significant risk factor for biliary anastomotic leak. However, on multivariable analysis only biliary reconstruction following biliary injury (odds ratio [OR]=6.84; p=0.002) and anastomosis above the biliary confluence (OR=4.62; p=0.03) were significant. Younger age and biliary reconstruction following injury appeared to be significant risk factors for biliary strictures but multivariable analysis showed that only younger age was significant. CONCLUSIONS Biliary-enteric anastomoses have a low incidence of early and late complications. Biliary reconstruction following injury and a high anastomosis (above the confluence) are significant risk factors for anastomotic leak. Younger patients are significantly more likely to develop an anastomotic stricture over the longer term.

Late rupture of abdominal aortic aneurysm after endovascular repair

ObjectiveThe purpose of this study was to compare findings at presentation and surgical outcomes in patients in whom abdominal aortic aneurysms (AAAs) ruptured after endovascular repair and in patients in whom AAAs ruptured before any treatment during a defined period at a single center. MethodsThis is a retrospective analysis of consecutive patients who presented to Royal Prince Alfred Hospital with ruptured AAA from September 2003 to September 2014. Medical records of each patient were reviewed to retrieve demographics, findings at presentation, and surgical outcome. Comparison of the outcomes between those occurring after endovascular repair (group 1) and those occurring without previous endovascular treatment (group 2) was made using the data collected and combining the results obtained by a previous study that analyzed the same findings between 1992 and 2003 from the same center to provide a total 22-year experience (1992-2014) at a single quaternary referral center. ResultsFrom May 1992 to September 2014, there were 1921 elective repairs of intact infrarenal AAAs, with 1288 endovascular and 633 open repairs. During 22 years, 40 of the 1288 patients (3.1%) who underwent endovascular repair for AAA had rupture. The proportion of patients with hypotension at presentation in group 1 (13/40) was significantly less than in group 2 (108/138; P < .01). The difference in perioperative 30-day mortality rate in group 1 (8/40 [20%]) compared with group 2 (68/138 [49%]) was significant (P < .01). ConclusionsThis study confirmed that endovascular AAA repair does not prevent rupture in all patients. The data suggest that rupture, when it does occur, may not be accompanied by such major hemodynamic changes and higher mortality rate as with rupture of an untreated AAA. Strict surveillance and follow-up are required, especially in patients with relatively large initial AAA diameter or presence of endoleak and graft migration, to reduce the rate of ruptures after endovascular repair. Complete prevention will remain challenging because rupture may occur without any predisposing abnormalities. With the advent of new-generation devices, continuous larger long-term studies are required to document reduction in rupture rates after endovascular aneurysm repair.

Predictors of 30-day perioperative morbidity and mortality of unruptured intracranial aneurysm surgery

IntroductionLarge-scale studies examining the incidence and predictors of perioperative complications after surgical clipping of unruptured intracranial aneurysms (UIA) using nationally representative prospectively collected data are lacking in the literature. MethodsUsing the American College of Surgeons’ National Surgical Quality Improvement Program (ACS-NSQIP) dataset, we conducted a retrospective analysis of the complications experienced by patients that underwent surgical management of a UIA between the years of 2007 and 2013. The primary outcomes of interest were mortality within the 30-day perioperative period and adverse discharge disposition to a location other than home. Predictors of morbidity and mortality were elucidated using multivariable logistic regression analyses controlling for available patient demographic, comorbidity, and operative characteristics. Results662 patients were identified in the ACS-NSQIP dataset for operative management of an unruptured aneurysm. The observed rates of 30-day mortality and adverse discharge disposition were 2.27% and 19.47%, respectively. A hundred and eight (16.31%) patients developed at least one major complication. On multivariable analysis, death within 30days was significantly associated with increased operative time (OR 1.005 per minute, 95% CI 1.002–1.008) and chronic preoperative corticosteroid use (OR 28.4, 95% CI 1.68–480.42), whereas major complication development was associated with increased operative time (OR 1.004 per minute, 95% CI 1.002–1.006), age (OR 1.017 per year, 95% CI 1–1.034), preoperative dependency (OR 3.3, 95% CI 1.16–9.40) and diabetes mellitus (OR 2.89, 95% CI 1.45–5.75). Lastly, increasing age (OR 1.017 per year, 95% CI 1–1.034) as well as ASA Class 3 (OR 1.73, 95% CI 1.08–2.77) and 4 (OR 2.28, 95% CI 1.1–4.72) were independent predictors of discharge to a location other than home. ConclusionOur study yields morbidity and mortality benchmarks for UIA surgery in a representative, national surgical registry. It will hopefully aid in recognizing those patients at greater risk for postoperative complications following surgical management, leading to appropriate changes in treatment strategies for this selected group of patients.

A Comparative Effectiveness Analysis of the Implementation of Surgical Safety Checklists in a Tertiary Care Hospital.

The appropriately coached implementation of surgical safety checklists (SSCs) reduces the incidence of perioperative complications and 30-day mortality of patients undergoing surgery. The association of the introduction of SSCs with 90-day mortality remains unclear. To assess the association between the implementation of SSCs and all-cause 90- and 30-day mortality rates. Evaluation of the outcomes of surgical procedures performed during the 6 months before (January 1 to June 30, 2010) and after (January 1 to June 30, 2013) the introduction of SSCs by retrospective analysis of administrative databases. The study was conducted in a public, regional, university-affiliated hospital in Italy. Data were collected from October 23, 2013, to November 12, 2014, including 90-day all-cause mortality, 30-day all-cause mortality, length of hospital stay, and 30-day readmission rate among patients undergoing noncardiac surgery. Patients undergoing surgery during the 6-month periods before and after the implementation of SSCs were compared. Data were analyzed from September 17, 2014, to July 31, 2015. Risk-adjusted rates of 90- and 30-day mortality, readmission rate, and length of stay. The total study sample of 10 741 patients included 5444 preintervention and 5297 postintervention patients (5093 [47.4%] male and 5648 [52.6%] female patients; mean [SD] age, 53.0 [23.0] years). Ninety-day all-cause mortality was 2.4% (129 patients) before compared with 2.2% (118 patients) after the SSC implementation, for an adjusted odds ratio (AOR) of 0.73 (95% CI, 0.56-0.96; P = .02). Thirty-day all-cause mortality was 1.36% (74 patients) before compared with 1.32% (70 patients) after the SSC implementation, for an AOR of 0.79 (95% CI, 0.56-1.11; P = .17). Thirty-day readmission occurred in 797 patients (14.6%) in the preimplementation group vs 766 patients (14.5%) in the postimplementation group, for an AOR of 0.90 (95% CI, 0.81-1.01; P = .79). The adjusted length of stay was 10.4 (95% CI, 10.3-10.6) days in the preimplementation group compared with 9.6 (95% CI, 9.4-9.7) days in the postimplementation group (P < .001). The data cannot prove causality owing to the study design. The implementation of SSCs was associated with a 27% reduction of the adjusted risk for all-cause death within 90 days but not within 30 days. The adjusted length of stay was reduced after implementation of SSCs.

Kidney Transplant Outcomes in the Super Obese: A National Study From the UNOS Dataset.

We evaluated outcomes of super-obese patients (BMI>50) undergoing kidney transplantation in the US. We performed a review of 190 super-obese patients undergoing kidney transplantation from 1988 through 2013 using the UNOS dataset. Super-obese patients had a mean age of 45.7years (21-75years) and 111 (58.4%) were female. The mean BMI of the super-obese group was 56 (range 50.0-74.2). A subgroup analysis demonstrated that patients with BMI>50 had worse survival compared to any other BMI class. The 30-day perioperative mortality and length of stay was 3.7% and 10.09days compared to 0.8% and 7.34days in nonsuper-obese group. On multivariable analysis, BMI>50 was an independent predictor of 30-day mortality, with a 4.6-fold increased risk of perioperative death. BMI>50 increased the risk of delayed graft function and the length of stay by twofold. The multivariable analysis of survival showed a 78% increased risk of death in this group. Overall patient survival for super-obese transplant recipients at 1, 3, and 5years was 88, 82, and 76%, compared to 96, 91, 86% on patients transplanted with BMI<50. A propensity score adjusted analysis further demonstrates significant worse survival rates in super-obese patients undergoing kidney transplantation. Super-obese patients had prolonged LOS and worse DGF rates. Perioperative mortality was increased 4.6-fold compared to patients with BMI<50. In a subgroup analysis, super-obese patients who underwent kidney transplantation had significantly worse graft and patient survival compared to underweight, normal weight, and obesity class I, II, and III (BMI 40-50) patients.

Could hybrid minimally invasive esophagectomy improve the treatment results of esophageal cancer?

AimTo assess the effectiveness of hybrid minimally invasive esophagectomy (hMIE) in comparison with open esophagectomy (OE) in esophageal cancer treatment. MethodsThe single center prospective nonrandom cohort study included a total of 88 patients in convenience sample, who underwent the Ivor-Lewis procedure with a curative intention for the middle- and lower-third esophageal cancer between January 2009 and February 2015. All patients were operated by the one surgical team. Out of 88 patients, 44 underwent OE and 44 hMIE laparoscopic approach (laparoscopic gastric mobilization). Primary endpoints were significant early postoperative complications, including major postoperative pulmonary complications (MPPCs). Secondary endpoints were perioperative characteristics, 30-day mortality and oncological outcomes. ResultsThe total number of complications was 21 in the OE group vs. 13 in the hMIE group (p > 0.05). Higher prevalence of major postoperative pulmonary complications (MPPCs) was observed in the OE group compared to the hMIE group.Mean intensive care unit (ICU) stay was 3.8 (1–21) days; there was a statistically significant difference in favor of the hMIE group. Mean number of harvested lymph nodes was 26.3 in the OE group compared to 31.9 in the hMIE group (p < 0.05). There was no statistically significant difference regarding 30-day mortality between the groups. Overall median survival rate was 807 days; 824 days in the OE group vs. 778 days in the hMIE group (p > 0.05). ConclusionPerioperative and oncologic results after hMIE are not inferior but are even better in some aspects of treatment when compared to OE.

A prospective comparison of mid-term outcomes in patients treated with heart transplantation with advanced age donors versus left ventricular assist device implantation.

In Europe, the age of heart donors is constantly increasing. Ageing of heart donors limits the probability of success of heart transplantation (HTx). The aim of this study is to compare the outcome of patients with advanced heart failure (HF) treated with a continuous-flow left ventricular assist device (CF-LVAD) with indication as bridge to transplantation (BTT) or bridge to candidacy (BTC) versus recipients of HTx with the donor's age above 55 years (HTx with donors >55 years). we prospectively evaluated 301 consecutive patients with advanced HF treated with a CF-LVAD (n = 83) or HTx without prior bridging (n = 218) in our hospital from January 2006 to January 2015. We compared the outcome of CF-LVAD-BTT (n = 37) versus HTx with donors >55 years (n = 45) and the outcome of CF-LVAD-BTT plus BTC (n = 62) versus HTx with donors >55 years at the 1- and 2-year follow-up. Survival was evaluated according to the first operation. The perioperative (30-day) mortality rate was 0% in the LVAD-BTT group vs 20% (n = 9) in the HTx group with donors >55 years (P = 0.003). Perioperative mortality occurred in 5% of the LVAD-BTT/BTC patients (n = 3) and in 20% of the HTx with donors >55 year group (P = 0.026). Kaplan-Meier curves estimated a 2-year survival rate of 94.6% in CF-LVAD-BTT vs 68.9% in HTx with donors >55 years [age- and sex-adjusted hazard ratio (HR) 0.25; 95% confidence interval (CI) 0.08-0.81; P = 0.02 in favour of CF-LVAD]. Considering the post-HTx outcome, a trend in favour of CF-LVAD-BTT was also observed (age- and sex-adjusted HR 0.45; 95% CI 0.17-1.16; P = 0.09 in favour of CF-LVAD), whereas CF-LVAD-BTT/BTC showed a similar survival at 2 years compared with HTx with donors >55 years, both censoring the follow-up at the time of HTx and considering the post-HTx outcome. Early and mid-term outcomes of patients treated with a CF-LVAD with BTT indication seem better than HTx with old donors. It must be emphasized that up to 19% of patients in the CF-LVAD/BTT group underwent transplantation in an urgent condition due to complications related to the LVAD. At the 2-year follow-up, CF-LVAD with BTT and BTC indications have similar outcome than HTx using old heart donors. These results must be confirmed in a larger and multicentre population and extending the follow-up.

520 Perioperative 30-day mortality rates are dependent on hospital surgical volume - results from a Norwegian population based study on surgical treatment for renal cell carcinoma

520 Perioperative 30-day mortality rates are dependent on hospital surgical volume - results from a Norwegian population based study on surgical treatment for renal cell carcinoma

Minimally invasive approach for aortic arch surgery employing the frozen elephant trunk technique.

Classically, repair of extensive thoracic aortic pathologies including the aortic arch and descending aorta required two separate major surgical procedures via full sternotomy and a subsequent left lateral thoracotomy. We describe herein our preliminary institutional experience with minimally invasive single-stage extended thoracic aortic replacement employing the frozen elephant trunk (FET) technique via partial upper sternotomy (PUS) in 14 patients. Between December 2013 and January 2015, 14 consecutive patients with elective indications for FET underwent minimally invasive FET via PUS (PUS-FET) during moderate systemic hypothermia (28°C) and selective antegrade cerebral perfusion (ACP) using the E-vita Open® hybrid prosthesis (Jotec GmbH, Hechingen, Germany). The patients' mean age was 66 ± 6 years, and 9 patients (64%) were male. The arch vessels were reimplanted en bloc in all patients. Clinical data were prospectively entered into our institutional database. The surgical procedure was successful in all patients with no need for conversion to full sternotomy. An additional David procedure was performed in 1 patient, whereas 2 patients received a concomitant Bentall procedure. There was no perioperative death or 30-day mortality. The mean cardiopulmonary bypass time was 214 ± 35 min, and the myocardial ischaemic time was 125 ± 14 min. The ACP time was 54 ± 9 min, whereas the ventilation time reached 11 ± 4 h. Intensive care unit stay was 2 ± 3 days. Chest tube drainage within the first 24 h was 460 ± 130 ml. None of the 14 patients required re-exploration for bleeding. Patients were discharged after a hospital length of stay of 9 ± 2 days. No postoperative permanent neurological complication occurred. Two patients (14%) experienced temporary delirium with complete resolution of symptoms prior to discharge from the hospital. Our preliminary experience suggests that minimally invasive single-stage extended thoracic aortic replacement can safely and reproducibly be performed by employing the concept of PUS-FET.

Experience with cardiac surgery in a private tertiary hospital in Chennai, India

Background Major perioperative complications are not uncommon during cardiac surgery, which has been attributed to an increase in patients scheduled for complex and urgent cardiac surgeries on account of a surge of patients at the extremes of age. Patients and methods This was a cohort study of patients anesthetized for open heart surgery from March 2012 to May 2012 at the Frontier Lifeline Hospital, Chennai, India. Primary outcome measures were the pattern of presentation and complications following cardiac surgery. Secondary outcome measure was the 30-day perioperative mortality associated with cardiac surgery. Results A total of 291 patients underwent cardiac surgery. Their mean age was 34.71 ΁ 26.25 years (range 8.4 months to 81 years). Of them, 63.57% were adults and 66.32% were male. The most common indication for cardiac surgery was coronary artery disease [135 (46.39%) patients], followed by septal defect [60 (20.62%)] and valvular defect [40 (13.75%)]. In patients with coronary artery disease, triple-vessel disease occurred in 39.26% and double-vessel disease in 32.59%. Three patients underwent coronary artery bypass grafting plus mitral or aortic valve replacement, whereas off-pump coronary artery bypass grafting was performed in three (2.22%) patients. Sixty-three complications were observed in 291 patients (21.64%); the most common complication was significant pleural effusion in 13 patients (4.47%), followed by deep sternal wound infection in 10 (3.44%) and respiratory failure in seven patients (2.41%). Thirty days' perioperative mortality was seen in 17 patients (5.84%). Conclusion We have demonstrated that major complications are not uncommon after cardiac surgery. However; prompt and appropriate intervention reduces mortality.

Pulmonary metastasectomy for metastasized hepatocellular carcinoma after liver resection and liver transplantation: asingle center experience.

The role of surgery in the treatment of metastasized hepatocellular carcinoma (HCC) remains uncertain. We here report our single centre experience with pulmonary metastasectomy (PM) for metachronous HCC metastases to the lung following curative liver resection (LR) and liver transplantation (LT), respectively. Of 270 patients with HCC being treated by LR or LT at the University Hospital of Leipzig between January 1996 and July 2014, PM was performed in the follow up of 10 patients because of metachronous pulmonary HCC metastases. We retrospectively analyzed demographic and clinicopathological factors as well as the outcome after primary and secondary tumor treatment in these patients. Following LR/LT and metastasectomy, respectively, mean overall survival was 4.58 ± 0.84 years and 2.4 ± 0.69 years. Postoperative morbidity after primary and secondary tumor treatment was 30 % and 20 %, respectively. Perioperative 30-day mortality was 0 %. Univariate analysis suggest tumor grading (p < 0.05), and a disease free-intervall > 1 year (p = 0.02) as significant prognostic parameters for survival in our collective. PM can be performed safely with a reasonable morbidity even in immunosuppressed patients after LT. Further studies are needed toevaluate whether PM can increase long-term survival in selected patients with resectable metastases and represents an alternative or additive treatment modality to the protein kinase inhibitor sorafenib.