30-day Postoperative Outcomes Research Articles

Robotic colorectal procedures: does operative start time impact short-term outcome?

Previous publications revealed more complications in afternoon versus morning surgeries. With much attention given to robotic surgery outcomes, we sought to evaluate whether morning versus afternoon start time matters. In a retrospective review of a prospective database, 210 robotic colorectal surgeries were grouped into 97 morning versus 113 afternoon cases. Preoperative risk factors, intraoperative events, and 30-day postoperative outcomes were compared. An independent samples t-test, Fisher's exact test, and linear regression were used for categorical and continuous variables. Morning patients were significantly younger than afternoon patients (59.5 vs. 65.5, p = 0.004), but there were no significant differences in gender, mean BMI, Charlson Comorbidity Index score, total operative time, console time, estimated blood loss, indications for surgery, and resection type. Morning patients had a significantly shorter mean length of stay (6.0 vs. 8.0days, p = 0.021), but no significant differences in overall postoperative complications (0.30 vs. 0.30, p = 0.715), wound infection (5.2% vs. 7.1%, p = 0.564), anastomotic leak (0% vs. 2.7%, p = 0.251), ileus/small bowel obstruction (29.9% vs. 22.1%, p = 0.199), and 30-day readmission (8.2% vs. 7.1%, p = 1.000). When analyzing time of day as a continuous variable, we found no significant associations with intra- or postoperative complications. We found no correlation between surgery start time and intra- or postoperative outcomes. This can be partly attributed to these cases being non-emergent and performed primarily by two experienced surgeons with highly trained operating room robotic staff in a large volume tertiary center. This, along with decreased fatigue attributed to superior ergonomics of robotic surgery, may have mitigated previously reported differences between morning and afternoon procedures.

Use of intraoperative MRI for resection of intracranial tumors: A nationwide analysis of short-term outcomes

ObjectiveRecent evidence supports the use of intraoperative MRI (iMRI) during resection of intracranial tumors due to its demonstrated efficacy and clinical benefit. Though many single-center investigations have been conducted, larger nationwide outcomes have yet to be characterized. MethodsWe used the American College of Surgeons National Surgical Quality Improvement Program database to examine baseline characteristics and 30-day postoperative outcomes among patients undergoing craniotomy for tumor resection with and without iMRI. Comparisons between outcomes were accomplished after propensity matching using chi-square tests for categorical variables and Welch two-sample t-tests for continuous variables. ResultsA total of 38,003 patients met inclusion criteria. Of this population, 54 (0.1%) received iMRI, while 37,949 (99.9%) did not receive iMRI. After propensity score matching, the resulting groups consisted of an iMRI group (n = 54) and a matched non-iMRI group (n = 54). Procedures involving iMRI were associated with significantly increased operation length compared to those without (p < 0.01). Length of hospital stay was higher in patients without iMRI, with this difference trending towards significance (p = 0.05) in the unmatched comparison. Patients undergoing craniotomy without iMRI had a higher rate of readmission (p = 0.04). There was no significant difference in occurrence of other adverse events between the two patient groups. ConclusionDespite increasing operative length, iMRI is not associated with higher infection rate and may have a clinical benefit associated with reducing readmissions and a trend towards reducing inpatient length of stay. Additional nationwide analyses including more iMRI patients would provide further insight into the strength of these findings.

Racial disparities in outcomes of arthroscopic rotator cuff repair: A propensity score matched analysis using multiple national data sets

BackgroundDisparities in access, utilization and outcomes exist throughout the healthcare system for minority groups, including racial and ethnic minorities; these disparities have wide-reaching implications for individuals as well as the healthcare system as a whole. This study will examine the impact of race on short and medium term outcomes for patients undergoing rotator cuff repair (RCR) using matched cohorts. MethodsPatients undergoing arthroscopic rotator cuff repair from 2016 to 2018 were extracted from two national databases: the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and TriNetX Research Network. Using the ACS-NSQIP database, univariate analysis was performed to identify differences in comorbidities between white and minority patients. Patients were propensity score matched based on significant differences between groups and 30-day postoperative outcomes were assessed. These comorbidities were then used to propensity score match white and minority patients in the TriNetX database and two-year postoperative outcomes were evaluated. ResultsFollowing propensity score matching, 3716 patients remained in each group from the ACS-NSQIP database and 4185 patients remained in each group from the TriNetX database. The OR time for minority patients was longer than white patient in the ACS-NSQIP database (92.2 vs. 87.6 min, p < .001). There was no difference in medium-term outcomes for repeat RCR, infection or frozen shoulder between white and minority patients in the TriNetX database. ConclusionAfter propensity score matching the only significant short-term outcome between white and minority patients undergoing RCR was a difference in OR time; there were no differences in medium-term outcomes. This may indicate that the source of racial disparities is one of access to healthcare rather than an innate difference in the patients’ outcomes. Further study is needed to elucidate this issue.

Is staple line oversewing in patients on chronic anticoagulation during laparoscopic sleeve gastrectomy necessary? Propensity score matching analysis using the 2015-2018 MBSAQIP.

There is an increased incidence of post-operative bleeding in patients on chronic anticoagulation (CAC). This incited some surgeons to oversew the sleeve staple line as a potentially preventive measure for post-operative bleeding. However, there is no clear evidence to assess theeffectiveness of staple line oversewing during laparoscopic sleeve gastrectomy (LSG) in patients with CAC. Using the 2015-2018 metabolic and bariatric surgery accreditation and quality improvement program database, patients between ages 18 and 65 who underwent LSG were included. To investigate the role of CAC, we performed 1:1 propensity score matching (PSM) between the CAC and non-CAC patients. Then, to explore the impact of oversewing, we focused on the CAC patients and divided them into 2 subgroups: oversewing versus non-oversewing. PSM was also performed to compare both subgroups. To avoid confounders, both PSM analyses were performed using 22 preoperative characteristics. 30-day postoperative outcomes including bleeding and blood transfusion requirement were assessed. 402,826 patients underwent LSG. 9148 patients (2.3%) were on CAC. In the CAC cohort (8843 matched cases), the anticoagulated patients showed significant increase in postoperative bleeding (1.2% vs. 0.5%; P < 0.001), blood transfusion requirements (1.7% vs. 0.7%; P < 0.001), unplanned ICU admissions (2.0% vs. 1.3%; P = 0.001), interventions (2.0% vs. 1.5%; P = 0.015), and readmissions (6.2% vs. 4.7%; P < 0.001). 1939 (21.2%) patients on CAC underwent oversewing during the LSG. The operative time was significantly longer in these patients (87.11 ± 40 vs. 76.19 ± 37; P < 0.001). Patients who underwent oversewing showed similar results in 30-day outcomes as those who did not, with no statistical difference, including postoperative bleeding (1.0% vs. 0.9%; P = 0.8) and blood transfusion requirements (1.4% vs. 1.8%; P = 0.9). Incidences of post-operative bleeding and blood transfusion requirements are higher in patients on CAC during the LSG. Oversewing the sleeve staple line leads to longer operative times without additional benefit in 30-day outcomes.

Early Postoperative Bleeding After Laparoscopic Roux-En-Y Gastric Bypass: a Single Center Analysis.

Early postoperative bleeding is a common complication after laparoscopic Roux-en-Y gastric bypass (LRYGB) and is associated with significant morbidity. We aimed to identify predictors of early postoperative bleeding after LRYGB and characterize hemorrhagic events and 30-day postoperative outcomes. We conducted a retrospective cohort study regarding all patients submitted to LRYGB in 2019 at a high-volume obesity center. Early postoperative bleeding was defined as any clinically significant evidence of hemorrhage in the early postoperative period. Demographic, preoperative, and intraoperative factors were evaluated for associations with postoperative bleeding. Postoperative outcomes were compared between patients with and without hemorrhage. Of 340 patients submitted to LRYGB, 14 (4.1%) had early postoperative bleeding. Patients with bleeding had an increased preoperative left hepatic lobe diameter (8.4 vs. 7.3cm, p = 0.048). Prior cholecystectomy (28.6 vs. 14.5%) and previous bariatric surgery (35.7 vs. 23.9%) tended to be more prevalent among these patients. Bleeding occurred at a median time of 31.2 [IQR 19.7-38.5] h. Thirteen patients presented with intraluminal bleeding and one with extraluminal bleeding. Melena was the most common symptom. All hemorrhages were clinically diagnosed, and 92.9% were managed conservatively. Postoperative bleeding was associated with longer hospital stay (3.5 vs. 2.0days), higher reintervention (7.1 vs. 0%), and readmission (14.3 vs. 0%), all p < 0.05. Bleeding was the most frequent early complication after LRYGB. Patients with hepatomegaly and prior surgeries may have technically challenging LRYGB and should be carefully assessed. Perioperative strategies should be encouraged in high-risk patients to prevent bleeding.

Preoperative anemia and 30-day postoperative outcomes among women undergoing laparoscopic myomectomy

More than half of women with symptomatic uterine fibroids experience heavy or prolonged menstrual bleeding. This contributes to chronic anemia among reproductive aged women. Although hysterectomy provides definitive surgical treatment, laparoscopic myomectomy is considered standard of care for the surgical management of symptomatic fibroids for women desiring uterine-sparing treatment. Preoperative anemia has been associated with increased risk of postoperative morbidity and mortality in gynecologic surgery. Current research on preoperative anemia in the benign gynecologic literature has primarily focused on hysterectomy, and little has been published regarding the risk profile for patients desiring myomectomy. The purpose of this study was to determine if preoperative anemia was associated with increased risk for 30-day postoperative morbidity or mortality following laparoscopic myomectomy. The aim was to provide clinical insight for gynecologic surgeons weighing the decision of whether to proceed with laparoscopic myomectomy for an anemic patient versus delaying surgery to focus on medical management and optimization. This retrospective population-based cohort study evaluated adult women who underwent laparoscopic myomectomy from 2014-2019. Data was collected from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). The exposure of interest was preoperative anemia, defined at hematocrit value less than 36% documented within 14-days prior to surgery. The primary outcome of interest was the occurrence of any minor or major postoperative complication as characterized by the standardized Clavien-Dindo classification utilizing bivariate and multivariable analysis. A total of 2097 cases were included for analysis; 26.66% of these women were anemic with an average preoperative hematocrit of 32.59% (±3.19%). There was a significant difference in the distribution of race/ethnicity, with most anemic patients self-identifying as “Black” (50.09%, p-value <0.001). Anemic patients were more likely to receive perioperative blood transfusion (4.29% versus 1.56%, p-value <0.01), had higher readmission rates (2.98% versus 1.16%, p-value 0.01), and were more likely to have “any” minor complication (7.16% versus 3.84%, p-value <0.01). After multivariate analysis adjusted for potential confounders, anemic patients had increased risk of experiencing a minor postoperative complication following laparoscopic myomectomy, with adjusted odds ratio of 1.71 (95% CI 1.10-2.66, p-value 0.02). However, there was no significant risk of any major postoperative complications. Preoperative anemia was common among women undergoing laparoscopic myomectomy. Anemia was not associated with increased risk for major postoperative complications within 30-days for this specific patient population.

Peri-operative outcomes between primary and replacement artificial urinary sphincter surgery: An ACS-NSQIP analysis.

To evaluate differences in perioperative clinical outcomes in men undergoing artificial urinary sphincter (AUS) implantation in primary versus replacement settings. Secondarily, we aimed to identify patient-related factors contributing to complications associated with AUS placement. A review of the American College of Surgeons-National Surgical Quality Improvement Program was performed between 2010 and 2018 identifying males undergoing AUS implantation. Subjects were further subdivided into primary implantation or removal/replacement of AUS simultaneously via current procedural terminology codes 53445 and 53447, respectively. 30-Day postoperative outcomes were compared between cohorts using t-test and Fisher's exact test. The relationship between patient factors and complications was evaluated using logistic regression. A total of 1,892 patients were identified: 1,445 primary AUS placement and 447 AUS replacement procedures. Patients undergoing AUS replacement were statistically older than those undergoing primary implantation (71.4 vs 69.7 years, P < .001). AUS replacement procedures were associated with an increased rate of superficial surgical site infection (SSI) compared to primary procedures (1.3% vs 0.4%, P ¼ .042). There were no differences identified between cohorts for deep SSI, cardiopulmonary complications, reoperation, operative time, or length of stay. Logistic regression demonstrated that higher body mass index was found to be independent risk factors for any complications, and diabetes mellitus was associated with increased risk of AUS-related readmission. Within the perioperative period, patients undergoing replacement AUS have an increased risk of superficial SSI compared to primary AUS implantation. These findings can assist with appropriate perioperative counseling of patients undergoing primary and replacement AUS implantations.

Preoperative MELD score predicts adverse outcomes following gastrectomy: An ACS NSQIP analysis

BackgroundThe Model End-Stage Liver Disease (MELD) has been widely used to predict the mortality and morbidity of various surgical procedures. We aimed to assess the impact of preoperative MELD score on adverse 30-day postoperative outcomes following gastrectomy. MethodsPatients who underwent elective, non-emergent gastrectomy were identified from the ACS NSQIP 2014–2019 database. Patients were categorized according to a calculated MELD score. The primary outcomes of this study were the 30-day overall complications and major complication rates following gastrectomy. ResultsCompared to MELD <11, patients with MELD ≥11 had significantly higher rates of mortality, any complication, and major complication. MELD score ≥11 was significantly associated with any complication (OR 1.73, p = 0.011) and major complications (1.85, p = 0.014) on multivariate analysis. ConclusionsMELD score ≥11 was associated with poorer outcomes in patients undergoing gastrectomy compared to lower MELD scores.

P557 Robotic surgery significantly improves outcomes for patients with inflammatory bowel disease

Abstract Background Patients with Inflammatory Bowel Disease (IBD) have a high likelihood of both surgical treatment at a young age and repetitive operative interventions. Therefore, development of novel surgical techniques to minimize operative trauma are crucial for this group of patients. Robotic Surgery represents the newest minimally invasive technology available to reduce the impact of surgery, but has mostly been used for colorectal cancer rather than for benign conditions. The purpose of this study was to assess the feasibility and clinical outcomes of robotic surgery for patients with IBD. Methods This is a single-institution prospective study evaluating all IBD patients undergoing robotic surgery between October 2020 to November 2021 at our trust. Demographic data, perioperative and 30-day postoperative outcomes were assessed. The feasibility of the techniques and clinical outcomes were documented and data were analysed. Results A total of ninety robotic cases were performed from October 2020 to November 2021. Of these, 20 were IBD (75% Crohn’s disease). The M:F ratio was 1:1; median age was 41 (18–79) years, BMI of 25 (16–37) kg/m2. Eighty-four per cent of patients were treated with a biologic agent in the preceding 60 days. The 2 most commonly performed procedures were Right Hemicolectomy with intracorporeal anastomosis (44%) and subtotal colectomy with end ileostomy (22%). There were no conversions to open surgery. Return of gut function, as defined by tolerating oral diet and passing flatus, was noted within 48 hours in 85% of the patients (n=17). There was minimal blood loss and all patients were discharged on their baseline Hb with no need for iron replacement therapy or blood transfusion. The median length of hospital stay was 4.5 days (3–10). There was no reported mortality. The 30-day readmission rate was 5% (n=1). Conclusion Robotic surgery for patients with IBD is feasible, safe and improves clinical and surgical outcomes. This novel approach ensures that surgery remains minimally invasive, leading to a significant reduction in length of hospital stay, a rapid postoperative recovery and an earlier return of gut function.

Minimally invasive versus open duodenal switch: a nationwide retrospective analysis.

This study aims to characterize the variability in clinical outcomes between open, laparoscopic, and robotic Duodenal Switch(DS). From the Metabolic and Bariatric Surgery and Accreditation Quality Improvement Program, patients who underwent DS (2015-2018) were identified. Open DS was compared to laparoscopic and robotic approaches with for patients factors, perioperative characteristics, and 30-day postoperative outcomes. Logistic regression estimates were used to characterize variables associated with surgical site infections, bleeding, reoperation, readmission, and early discharge (hospital stay of ≤ one day). Of 7649 cases, 411 (5.4%) were open, 5722 (74.8%) were laparoscopic, and 1515 (19.8%) were robotic DS. Open DS patients were more often older (≥ 65years:4.7% vs. 4.3% vs. 2.1%, p < 0.01) and had lower body mass index (< 40kg/m2:16.3% vs. 10.5% vs. 9.9%, p < 0.01). The co-morbidities were mainly comparable between the three groups. Open DS was more often without skilled assistance (35.3% vs. 12.1% vs. 5.3%, p < 0.01), revisional (41.4% vs. 20.5% vs. 21.3%, p < 0.01), and performed concurrently with other operations. Robotic DS surgery was more often longer (≥ 140min:64.4% vs. 39.2% vs. 86.9%, p < 0.01). Post-operatively, open DS was associated with higher rates of surgical site infection (7.1% vs. 2% vs. 2.8%, p < 0.01), bleeding (2.4% vs. 0.7% vs. 0.9%, p = 0.001), reoperation (6.6% vs. 3.6% vs. 4.4%, p = 0.01), and readmission (12.4% vs. 6.8% vs. 8.3%, p = < 0.01). Patients undergoing robotic DS were more often discharged early (0.5% vs. 1% vs. 7.8%, p < 0.01). In the regression analyses, minimally invasive DS was associated with lower odds for wound infections (OR = 0.3,CI = [0.2-0.5]), bleeding (OR = 0.4,CI = [0.2-0.8]), and readmission (OR = 0.6,CI = [0.4-0.8]), as well as greater likelihood of early discharge (OR = 5.6 CI = [1.3-23.0]). Open DS is associated with greater risk for complications and excessive resource utilization when compared to minimally invasive approaches. Laparoscopic and robotic techniques should be prioritized in performing DS, despite the complexity of the procedure.

Robot-assisted versus laparoscopic approach to concurrent bariatric surgery and hiatal hernia repair: propensity score matching analysis using the 2015–2018 MBSAQIP

Up to 37% of class three obesity patients have a Hiatal Hernia (HH). Most of the existent HHs get repaired at the time of bariatric surgery. Although the robotic platform might offer potential technical advantages over traditional laparoscopy, the clinical outcomes of the concurrent bariatric surgery and HH repair comparing robotic vs laparoscopic approaches have not been reported. Using the 2015-2018 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, patients between 18 and 65year old who underwent Sleeve gastrectomy (SG) or Roux en-Y Gastric Bypass (RYGB) with concurrent HH repair were identified. Demographic, operative, and 30-day postoperative outcomes data were compared between laparoscopic and robotic groups. To adjust for potential confounders, 1:1 propensity score matching was performed using 22 preoperative characteristics. 75,034 patients underwent SG (n = 61,458) or RYGB (n = 13,576) with concurrent HH repair. The operative time was significantly longer in the Robotic-assisted compared to the laparoscopic approach both for SG (102.31 ± 44 vs. 75.27 ± 37; P < 0.001) and for RYGB (163.48 ± 65 vs. 132.87 ± 57; P < 0.001). In the SG cohort (4639 matched cases), the robotic approach showed similar results in 30day outcomes as in the laparoscopic approach, with no statistical difference. Conversely, for the RYGB cohort (1502 matched cases), the robotic approach showed significantly fewer requirements for blood transfusions (0.3% vs. 1.7%; P = 0.001), fewer anastomotic leaks (0.2% vs. 0.8%; P = 0.035), and less postoperative bleeding (0.4% vs. 1.1%; P = 0.049). Robotic concurrent bariatric surgery and HH repair leads to similar overall clinical outcomes as the laparoscopic approach despite longer operative times. Furthermore, the robotic approach is associated with reduced blood transfusion and anastomotic leak incidence in the RYGB group.

Short- and long-term predictive power of the preoperative Geriatric Assessment components in older cancer patients undergoing high-risk abdominal surgery

IntroductionThe pathological stage of the cancer and presence of postoperative complications are the most important predictors of survival in older oncologic patients. Therefore, determining biological age, and risks connected with it, should be the key factor in the preoperative assessment. It may be accomplished by using a Geriatric Assessment (GA). However, it is not established which components are most useful for predicting short- and long-term postoperative outcomes in cancer patients undergoing high-risk abdominal surgery. Materials and methodsA total of 334 consecutive cancer patients aged ≥70 years underwent elective abdominal surgery and were followed-up prospectively for 12 months. The preoperative GA consisted of eight domains: functional, physical activity, comorbidity, polypharmacotherapy, nutritional, cognition, mood, and social support. Logistic regression analyses were used to analyse the predictive ability. ResultsAll components of GA were independent risk factors of 30-day major morbidity apart from ADL, BOMC, Polypharmacy (OR 0.6–1.3; p < 0.001). However, ADL, TUG, the polypharmacy and the MOS-SSS turned out to be significant predictors of 30-day mortality (OR 0.72–1.46; p < 0.001). In turn, only ADL, CDT and MOS-SSS were valid predictors of 12-months mortality (OR 0.46–0.85; p < 0.001). Frailty (surrogate of the biological age), not the chronological age, were also independent predictors of all outcomes (OR 4.71–8.56 p < 0.001). ConclusionNot the chronological age but components of GA and frailty are significant predictors of both 30-day postoperative outcome and 12-months mortality in older cancer patients undergoing high-risk abdominal surgery.

A Retrospective Study of the Relationship Between Blood Transfusion and 30-Day Postoperative Outcomes in Patients Undergoing Isolated Off-Pump Coronary Artery Bypass Grafting.

The objective of this single-center study it to retrospectively analyze the relationship between transfusion and 30-day postoperative outcomes in patients undergoing isolated off-pump coronary artery bypass grafting. Perioperative data of 2,178 patients who underwent isolated off-pump coronary artery bypass grafting from 2018 to 2019 were collected. A 1:1 propensity score matching was performed to control for potential biases between patients who received blood transfusion and those who did not. After propensity score matching, we analyzed the clinical outcomes of transfusion and non-transfusion patients. Postoperative complications and the survival of patients within 30 days after surgery in both groups were analyzed. Kaplan-Meier survival curve and log-rank test were used for survival analysis. The total blood transfusion rate of all patients was 29%, including red blood cell (27.6%), plasma (7.3%), and platelet (1.9%). Four hundred and forty patients in each group were compared after propensity score matching. There were no significant differences in the incidence of stroke, myocardial infarction, atrial fibrillation, acute kidney function injury, and sternal wound infection of both groups (P&gt;0.05). However, higher incidence of postoperative pulmonary infection and more mechanical ventilation time and days of stay in the intensive care unit and postoperative in-hospital stay were associated with blood transfusion (P&lt;0.05). The 30-day cumulative survival rate of the transfusion group was lower than that of the control group (P&lt;0.05). Perioperative blood transfusion increases the risks of postoperative pulmonary infection and short-term mortality in off-pump coronary artery bypass grafting patients.

Ambulatory Cholecystectomy in the COVID-19 Era: Safety of a Major Outpatient Surgery Program in Pandemic

Since the Coronavirus disease 2019 (COVID-19) pandemic, elective surgery decreased substantially. On the other hand, a delay in the treatment of cholelithiasis in Chile leads to a significant morbidity, making surgical intervention essential. In this scenario, we performed the present study with the aim of defining if a major ambulatory surgery program is safe in the COVID-19 era. We included patients operated of ambulatory laparoscopic cholecystectomy between August 2020 and February 2021 in a hospital center in Santiago de Chile, during the peak of the COVID-19 pandemic, with an average PCR positivity rate of 6% and an ICU bed occupancy rate >80% in that period. Prospective data were collected to include baseline demographics, operative procedure and 30-day post-operative outcomes. A total of 109 cholecystectomies were performed, with a majority ASA I-II (American Society of Anaesthesiologists), in patients with cholelithiasis. 98.2% were completed laparoscopically, with a 17,4% rate for vesicular perforation. Thirty day follow-up revealed a complication rate of 44%, with 16,5% of patient having diarrhea and 17,4% abdominal pain. Only 2 patients (1.8%) developed COVID-19 symptoms postoperatively. 15.6% of patients attended the emergency department in the 30-day postoperative period. Early discharge was feasible in all patients. Our study demonstrates that an ambulatory cholecystectomy program during the COVID-19 pandemic can be carried out safely and effectively. Complications evidenced are in agreement with the reported literature, with a caveat of careful patient selection. We demonstrated that ambulatory surgery is feasible during pandemic, with a low incidence of COVID-19 infection, and without mortality.

Clinical Course of Patients with Post-operative Pancreatic Fistulas: Does Time Heal All Wounds?

Introduction: Management of clinically significant post-operative pancreatic fistulas (cs-POPF) can vary depending on institutional and surgeon preferences. Objective data regarding number of interventions, type and time to complete resolution for POPFs are sparse. Methods: The authors conducted a retrospective analysis of patients who developed a CS-POPF (Grades B,C) after Whipple over a 10-year period (2010-2019). 30-day postoperative outcomes, including symptoms and complications, were evaluated. Data regarding re-admissions and interventions performed until the resolution of POPF were compiled. Results: 1155 patients underwent Whipple during this period and 92 patients were recognized to have cs- POPFs. Average age of patients was 62 years (±11) and average BMI was 29 (±5) kg/m2. Mean blood loss was 354mL (±435). 60 patients had an ISGPS Grade B fistula and 32 had Grade C fistula. 32% of patients needed a second admission within 30 days of discharge. 78 patients needed an IR guided drain and 77 had a long-term central line placed. 33 patients needed a re-operation with washout and placement of new surgical drains being the most common. At last follow-up 8 patients (9%) had died with an unresolved POPF. 80 patients had documented resolution of their POPF with mean resolution time being 59 days. Conclusions: Patient who develop a cs-POPF have a prolonged clinical course. Operative interventions were needed in one third of patients. IR guided drainage was the mainstay of interventions. Complete resolution of cs-POPF can take up to 2 months. These objective data can guide expectations surrounding this devastating complication.

Traumatic Lower Extremity Vascular Injuries and Limb Salvage in a Civilian Urban Trauma Center

Data on management of traumatic lower extreity arterial injuries comes largely from military experience and involves few civilian centers. This study reports on the experience of an urban trauma center and factors associated with limb loss. A retrospective review of lower extremity arterial injuries between 2013 and 2020 at an academic urban level 1 trauma center was completed. Patients with lower extremity revascularization were included in the final data analysis. Demographics, clinical variables, operative details, type of revascularization, as well as 30-day morbidity and postoperative outcomes were analyzed. The primary outcome of interest was 30-day limb loss. Secondary outcomes included postoperative complications and functional outcomes. Seventy-five patients were included in our analysis. Sixty-nine were male (92%), mean age 33 ± 15 years, 50 patients had penetrating trauma (67%), mean injury severity score was 15 ± 9. Thirty-day limb loss was reported in 8 (11%). Factors associated with limb loss included female sex (P=0.001), high body mass index (P=0.001), blunt injury (P=0.001), associated fractures (P=0.005), significant soft tissue injury (P=0.007), delayed repair after shunt placement (P=0.003), bypass revascularization (P=0.001), initial revascularization failure (P=0.019), and wound complications (P < 0.001). Fifty-five patients had at least one return to the operating room (ROR), including 24 patients (32%) for complications related to their revascularization. These included delayed compartment syndrome (n=7), revascularization failure (n=9), bleeding (n=3), and vascular surgical wound complications (n=5). Mean length of hospital stay (LOS) for the cohort was 24 ± 20 days with 3 ± 3 ROR, in contrast patients who ultimately required amputation had LOS of 57 ± 21 days with 8 ± 4 ROR. Fifty-seven patients (76%) followed in clinic for a median 36 [14-110] days, with only 32 (43%) at >30 days. Twenty-three reported ambulation without assistance, 9 neuromotor deficit including 1 patient that had delayed amputation. Patients with blunt trauma and associated fracture and/or extensive soft tissue injury are at risk of limb loss. These injuries are often associated with postoperative wound complications, requiring aggressive soft tissue care that substantially increases ROR and LOS; Expectations for limb salvage in these patients should be tempered when the other associated factors with limb loss mentioned above are also present. When limb salvage is achieved, regaining full limb function remains a challenge.

Open versus minimally invasive small bowel resection for Crohn's disease: a NSQIP retrospective review and analysis.

Many patients with Crohn's Disease will require surgical resection. While many studies have described outcomes following ileocecectomy, few have evaluated surgical resection of other portions of small bowel. We sought to compare open and minimally invasive surgery (MIS) approaches for small bowel resection excluding ileocecectomy of patients with Crohn's Disease using the National Surgical Quality Improvement Program (NSQIP) database. The NSQIP database was queried for patients with Crohn's disease or complications related to Crohn's disease who underwent segmental small bowel resection utilizing open or minimally invasive approaches between 2012 and 2018. Patients requiring ileocecectomy or diagnosed with ascites, disseminated cancer, pre-operative sepsis, ASA class 5, and patients requiring mechanical ventilation were excluded. The association of pre-operative variables including patient demographic information and comorbidities with surgical approach were examined using Fishers exact test. Intraoperative, and 30-day post-operative outcomes were compared between the groups using both univariate and multivariate logistical regression models. SAS was used for data analysis with p < 0.05 considered significant. After exclusions, we found 1697 patients with Crohn's disease who underwent segmental small bowel resection, 1252 of whom underwent open surgery and 445 of whom underwent MIS. After adjusting for possible confounders with multivariable analysis, patients who underwent MIS had a lower incidence of wound events (surgical site, organ space, or deep wound infection, or dehiscence), post-operative bleeding, need for return to the operating room, and shorter total hospital length of stay despite longer operative times compared with open surgery. This retrospective review of NSQIP shows that minimally invasive small bowel resection is associated with equivalent or improved morbidity over open surgery in select patients with small bowel Crohn's Disease. We show that in select patients minimally invasive small bowel resection can be safe and performed for patients with isolated small bowel Crohn's disease.

Regional or Neuraxial Anesthesia May Help Mitigate the Effects of Bone Cement Implantation Syndrome in Patients Undergoing Cemented Hip and Knee Arthroplasty for Oncologic Indications.

Bone cement implantation syndrome (BCIS) occurs during and after cementation of implants and is associated with hypotension, hypoxia, and cardiovascular collapse. In this study, we aimed to identify risk factors and potential mitigating factors of BCIS in the oncologic adult cohort undergoing cemented arthroplasty. We retrospectively reviewed oncologic patients aged 18 years or older who underwent cemented arthroplasty of either the hip or knee from 2015 to 2020. All implants were stemmed. We classified BCIS into three separate categories: (1) grade 1: intraoperative moderate hypoxia (<94%) or drop in systolic blood pressure >20%; (2) grade 2: intraoperative severe hypoxia or drop in systolic blood pressure >40%; and (3) grade 3: cardiovascular collapse requiring cardiopulmonary resuscitation. Demographics, primary malignancy diagnosis, intraoperative factors including cement timing, development of BCIS, 30-day postoperative outcomes, and mortality up to 2 years postoperatively were evaluated. Bivariate analyses and multivariate logistic regression were performed. Sixty-seven patients met inclusion criteria. Of these, 31 patients (46%) developed BCIS. No difference was found in age (65.5 versus 60.9 years; P = 0.15) or body mass index (28.8 kg/m2 versus 29.3 kg/m2; P = 0.76), comorbidities, intraoperative factors, or postoperative surgical outcomes between those who developed BCIS and those who did not (all; P > 0.05). An association with the type of anesthesia administered and development of BCIS in patients receiving general anesthesia alone (17/24 patients, 71%), neuraxial and general (4/15 patients, 27%), and regional and general anesthesia (10/28 patients 36%, P = 0.01) was found. Compared With neuraxial and regional anesthesia, general anesthesia alone had 5.8 (P = 0.007) and 4.5 times (P = 0.006) greater odds of developing BCIS, respectively. No differences were noted in rates of BCIS between regional and neuraxial anesthesia (P = 0.81). Addition of regional or neuraxial anesthesia may be protective in reducing development of BCIS in the orthopaedic oncologic cohort undergoing hip and knee arthroplasty. III.

Association Between Procalcitonin and Post-hepatectomy Liver Failure in Hepatocellular Carcinoma Patients.

Objectives: Procalcitonin (PCT) has long been proved as an early diagnostic signal for postoperative outcomes. The purpose of this study is to explore the value of serum procalcitonin levels in predicting post-hepatectomy liver failure (PHLF), and further to declarethe relationship between postoperative PCT and short-term prognosis in patients after hepatectomy. Methods: Clinical data of patients with hepatocellular carcinoma (HCC) who underwent hepatectomy from June 1st, 2019 to September 31st, 2020 at Shanghai Eastern Hepatobiliary Surgery Hospital had been retrospectively analyzed. Logistic regression analysis was used to evaluate the risk factors related to PHLF. The Kaplan-Meier method was used to calculate the PHLF rate and 30-day survival after surgery. Results: A total of 885 patients with complete data were finally included in analysis, 311 of them with elevated serum PCT (≥1 ng/ml). Results of the logistic regression analysis suggested a significant association between PCT and PHLF [HR, 95%CI; 3.801 (1.825, 7.917), p < 0.001]. Other significant risk factors for PHLF included portal hypertension, portal blocking time (>30 min) and blood transfusion (>200 ml). Kaplan-Meier analysis also suggested a higher PHLF rate in elevated PCT patients [9.0% (95% CI, 7.3 to 12.8 VS. 1.9% (95% CI, 1.1–4.3)); p < 0.001]. For secondary outcomes, elevated PCT was also highly associated with postoperative sepsis, ICU admission, 30-day mortality and 3-month mortality. Conclusion: Elevated procalcitonin level in patients after hepatectomy is related to higher PHLF rate, with lower 30-day survival and poor short-term postoperative outcomes.

Can extant comorbidity indices identify patients who experience poor outcomes following total joint arthroplasty?

It is uncertain if generic comorbidity indices commonly used in orthopedics accurately predict outcomes after total hip (THA) or knee arthroplasty (TKA). The purpose of this study was to determine the predictive ability of such comorbidity indices for: (1) 30-day mortality; (2) 30-day rate of major and minor complications; (3) discharge disposition; and (4) extended length of stay (LOS). The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was retrospectively reviewed for all patients who underwent elective THA (n = 202,488) or TKA (n = 230,823) from 2011 to 2019. The American Society of Anesthesiologists (ASA) physical status classification system score, modified Charlson Comorbidity Index (mCCI), Elixhauser Comorbidity Measure (ECM), and 5-Factor Modified Frailty Index (mFI-5) were calculated for each patient. Logistic regression models predicting 30-day mortality, discharge disposition, LOS greater than 1 day, and 30-day major and minor complications were fit for each index. The ASA classification (C-statistic = 0.773 for THA and TKA) and mCCI (THA: c-statistic = 0.781; TKA: C-statistic = 0.771) were good models for predicting 30-day mortality. However, ASA and mCCI were not predictive of major and minor complications, discharge disposition, or LOS. The ECM and mFI-5 did not reliably predict any outcomes of interest. ASA and mCCI are good models for predicting 30-day mortality after THA and TKA. However, similar to ECM and mFI-5, these generic comorbidity risk-assessment tools do not adequately predict 30-day postoperative outcomes or in-hospital metrics. This highlights the need for an updated, data-driven approach for standardized comorbidity reporting and risk assessment in arthroplasty.