30-day Complications Research Articles

Complications and Healthcare Cost of Total Hip Arthroplasty in Patients with Depressive Disorder.

The purpose of this study was to determine whether the rates of (1) in-hospital lengths of stay (LOS), (2) readmissions, (3) medical complications, and (4) costs of care are higher for patients with depressive disorder (DD) undergoing primary total hip arthroplasty (THA) for treatment of femoral neck fractures (FNFs). A retrospective query of a national administrative claims database for patients undergoing primary THA from 2006 to 2014 was conducted. Patients with DD undergoing THA for treatment of FNF were 1:5 ratio propensity score matched to a cohort (DD=6,758, controls=33,708). Primary endpoints included LOS, 90-day medical complications, 90-day readmissions, and healthcare reimbursements. A P-value less than 0.05 was considered statistically significant. Longer LOS were observed for patients with DD compared to those without DD (5.6 days vs. 5.4 days, P<0.001). Similar readmission rates (29.9% vs. 25.0%, odds ratio [OR] 1.03, P=0.281) were observed between groups. The odds of 90-day medical complications were higher for patients with DD compared to control subjects (60.6% vs. 21.4%, OR 1.57, P<0.0001). Within the 90-day episode of care interval, patients with a history of DD incurred significantly higher healthcare expenditures ($21,382 vs. $19,781, P<0.001). Our findings showed longer LOS, higher odds of 90-day medical complications, and higher healthcare expenditures within the 90-day episode of care following a primary THA for treatment of FNF for patients with DD compared to the matched cohort. Thus, accordingly, patients with DD should receive counseling prior to undergoing surgery.

Postoperative Delirium Following Posterior Lumbar Spinal Fusion: Epidemiology, Risk Factors, and Associated Complications

Postoperative delirium (POD) is frequently reported in the elderly after major surgery. Several risk factors have been identified, including age, surgical complexity, and comorbidities. Posterior lumbar fusion patients were identified using PearlDiver and filtered into two cohorts based on the presence or absence of POD within 7days of surgery. Epidemiological analyses were performed to examine trends in POD by age and year. Comparative analyses were performed on patient demographics and baseline cognitive status. After matching by age, sex, and comorbidities, electrolyte disturbances and 90-day postoperative complications were analyzed. Among 476,482 no POD and 2591 POD patients, the mean age was 60.90years, 57.6% were female, and the mean Charlson comorbidity index was 1.78. POD patients frequently had baseline cognitive impairment (P < 0.001). Incidence of POD decreased from 0.7% in 2010 to 0.4% in 2022 (P < 0.001) and increased with increasing patient age (P<0.001). POD patients had higher length of stay (12 vs. 6days, P < 0.001) and 90-day costs ($20,605 vs. $17,849, P<0.001). After matching, POD patients had higher hypernatremia (5.8% vs. 3.5%, P= 0.001) and hypocalcemia (5.0% vs. 3.5%, P= 0.026). POD patients had higher 90-day postoperative complications (P < 0.05) than no POD patients. Nearly 0.5% of patients who underwent posterior spinal fusion between 2010 and 2022 developed delirium, although incidence rates have decreased over time. POD was common in elderly patients with electrolyte disturbances who underwent multilevel fusions. Patients suffering from POD had higher rates of 90-day postoperative complications. Ongoing efforts to deliver interventions to mitigate the consequences of POD among spine surgery patients are warranted.

Does Use of GLP-1 Agonists Increase Postoperative Complications in Patients Undergoing Shoulder Arthroplasty?

Amidst the rising prevalence of type 2 diabetes mellitus (T2DM) and obesity among individuals undergoing total shoulder arthroplasty (TSA), the impact of glucagon-like-peptide-1 (GLP-1) therapy on surgical outcomes merits thorough investigation. Though it is known that GLP-1 therapy poses an interesting challenge for anesthesia during the perioperative period, little is known regarding the effects of these medications on surgical outcomes. This study aimed to evaluate the influence of GLP-1 on postoperative outcomes and length of stay (LOS) in T2DM patients undergoing TSA. A retrospective cohort analysis was performed using a national database to identify primary TSA patients aged 18 and above with T2DM prescribed GLP-1 therapy at the time of surgery. Exclusion criteria included revision surgery, TSA for fracture, type 1 diabetes, steroid-induced diabetes, and contraindications for GLP-1 therapy. A control group of T2DM TSA patients not on GLP-1 therapy was used, and a 1:4 propensity-score match was performed. Incidence rates and odds ratios (OR) via multivariable logistic regression were calculated. The primary outcomes were 90-day major medical complications and LOS. Secondary outcomes included 2-year joint-related complications. In the 90-day follow-up cohort, 64,567 patients met inclusion criteria, with 8,481 (13.1%) on GLP-1 therapy. No significant increase in 90-day major complications, including DVT, cardiac arrest, myocardial infarction, cerebrovascular accident, pneumonia, pulmonary embolism, urinary tract infection, surgical site infection, hypoglycemic event, sepsis, or readmission, was found between GLP-1 and non-GLP-1 cohorts after multivariable logistic regression. In the 2-year follow-up cohort, 47,814 patients were included, with 5,969 (12.5%) on GLP-1 therapy. Similarly, 2-year joint-related complications, including all-cause revision, prosthetic joint infection, periprosthetic fracture, and aseptic revision, showed no significant differences between the GLP-1 and non-GLP-1 cohorts. No significant difference was observed in LOS in the 90-day cohort. This study provides a comprehensive analysis of GLP-1 therapy's impact on TSA outcomes, revealing no significant change in postoperative complications or LOS. The lack of increased postoperative risk underscores the potential of GLP-1 therapy in managing T2DM without adverse effects on TSA recovery. These insights contribute to understanding postoperative management in orthopedic surgery, indicating that we did not note any increased risk with GLP-1 use perioperatively in TSA patients, unlike in other populations like the TKA patients. Future research should focus on prospective analyses to further elucidate the role of GLP-1 therapy in surgical outcomes, aiming to enhance patient care and optimize postoperative strategies for T2DM patients undergoing TSA.

Efficacy and outcomes of per oral plication of the (neo)esophagus (POPE) for impaired emptying in achalasia and post-esophagectomy patients.

Per-oral plication of the (neo)esophagus (POPE) is an endoscopic procedure used to improve emptying of the defunctionalized esophagus or gastric conduit, with the hope of improving symptoms andquality of life. As this procedure has only been performed in the United States for the past 4years, safety and efficacy have not been well established. This is a retrospective case series for patients who underwent POPE from a single institution between 2019 and 2023. Data collected included demographics, preoperative diagnoses and treatments, imaging, endoscopic data,operative intervention, 90-day complications, andresponse to treatment. Quality of life and patient satisfaction data were collected by phone survey. Seventeen cases were identified, encompassing 13 primary procedures and 4 repeat POPEs (re-POPE). Eight patients had end-stage achalasia and 5 had impaired gastric emptying after esophagectomy with gastric conduits. Median age was 65years and median ASA was 3, with 38.5% female patients. POPE was performed with 2-6 plication sutures in an average of 75min. The majority of patients discharged home the same day. For the 17 procedures, there were 4 complications. Two patients required antibiotics for pneumonia, while 4 required procedural intervention. There were no deaths. Preoperative symptoms improved or resolved at initial follow up in 82.3% of patients. Four patients experienced symptom recurrence and required re-POPE, 1 with achalasia and 3 with gastric conduits. Although all achalasia patients had an "end-stage esophagus," none have required esophagectomy since the introduction of POPE. POPE is an endoscopicprocedure that is efficacious in relieving emptying difficulties for the end-stage esophagus andgastric conduit. It may obviate the need for esophagectomy or conduit replacement. Also, it can be repeated in select patients. While the risk profile of complications is favorable compared to alternative operations, patients with gastric conduits are at higher risk.

Sleeve gastrectomy prior to primary total hip and total knee arthroplasty is associated with increased risk of early complications

AimsThe purpose of this study was to determine the association between prior sleeve gastrectomy in patients undergoing primary total hip and knee arthroplasty, and 90-day complications, incidence of revision arthroplasty, and patient-reported outcome scores at final follow-up.MethodsThis is a retrospective, single-centre analysis. Patients undergoing primary hip or knee arthroplasty with a prior sleeve gastrectomy were eligible for inclusion (n = 80 patients). A morbidly obese control group was established from the same institutional registry using a 1:2 match, for cases:controls with arthroplasty based on propensity score using age, sex, pre-sleeve gastrectomy BMI, Current Procedural Terminology code to identify anatomical location, and presurgical haemoglobin A1C. Outcomes included 90-day complications, incidence of revision arthroplasty, and patient-reported outcome scores at final follow-up. Multivariable logistic regressions evaluated associations of underlying preoperative demographic and treatment characteristics with outcomes.ResultsComplications within 90 days of surgery were increased in the sleeve gastrectomy group relative to the obese control group after controlling for underlying preoperative demographic characteristics (odds ratio (OR) 4.00 (95% CI 1.14 to 13.9); p = 0.030). Postoperative revisions were similar in the sleeve gastrectomy group relative to the obese control group after controlling for underlying preoperative demographic characteristics (OR 17.8 (95% CI 0.64 to 494.3); p = 0.090). Patient-Reported Outcomes Measurement Information System (PROMIS) depression decreased by a greater amount from pre- to postoperative in the obese controls relative to the sleeve gastrectomy group (OR 4.04 (95% CI 0.06 to 8.02); p = 0.047). PROMIS pain interference and physical function change from pre- to postoperative was not associated with sleeve gastrectomy status.ConclusionWe found a higher rate of complications at 90 days in patients who underwent sleeve gastrectomy prior to primary hip or knee arthroplasty relative to a matched, obese control population. Prosthetic revision rates were similar between the two groups, while improvements in PROMIS depression scores were larger in the obese cohort. This study suggests that sleeve gastrectomy to achieve preoperative weight loss prior to arthroplasty surgery may not mitigate early complication risks in obese patient populations.Cite this article: Bone Joint J 2024;106-B(9):935–941.

Ureteroscopy for stone disease in pediatric patients with neurogenic bladder: A single institution case-control study

Ureteroscopy (URS) for urolithiasis in pediatric patients may be particularly challenging for patients with co-morbidities that increase the risk for stone formation and recurrence. Patients with neurogenic bladders (NGB) and/or patients that are non-ambulatory are reported to have higher rates of additional comorbidities and a particularly increased risk of developing urolithiasis, and higher rates of infections and post-operative complications. To report outcomes of URS for stone disease in pediatric patients with NGB and/or non-ambulatory status and compare these outcomes to patients without these co-morbidities. An IRB-approved prospective single institutional registry was used to retrospectively identify all patients under 18 years of age who underwent URS for stone disease between July 2012 and July 2021, excluding bladder stones. Patients were categorized in two groups: patient with NGB with or without non-ambulatory status versus all other patients (control). Baseline demographics, pre-operative radiologic imaging, intra-operative details, and post-operative outcomes including 30-day complications were aggregated and compared between the two groups. 275 URS in 198 patients were performed during the study period, and 49 (18%) of these were performed on patients with NGB. Pre-operative imaging showed significantly higher number of stones (3 vs 2, p=0.003) and larger total stone burden in patients with NGB than those without NGB (15mm vs 9mm, p=0.009). Patients with NGB had a significantly longer length of procedure (86 vs 60min, p=0.002), increased need for staged procedures, increased length of stay (1 vs 0 days, p<0.001), and increased use of an extended duration of antibiotics prior to the procedure (<0.001). There was no difference in need for passive dilation, stent placement, or other intra-operative parameters. There was no statistical difference in the incidence of 30-day complications between the two groups post-operatively. However, there was a higher incidence of febrile UTIs (8.2% vs 1.3%, p=0.021) in patients with NGB and a lower incidence of pain related complications (0 % vs 9.3%, p=0.032). Patients with NGB had a higher incidence of requiring ipsilateral URS for recurrent stone disease within a year of surgery (34.6% vs 18.9%, p=0.01). The results show that URS for urolithiasis can be done safely and effectively in pediatric patients with neurogenic bladders. The increased risk of infectious complications within 30 days of surgery warrants careful pre- and post-operative antibiotic care plan for this patient population.

Outcomes of fixed versus mobile-bearing medial unicompartmental knee arthroplasty.

The optimal bearing surface design for medial unicompartmental knee arthroplasty (UKA) remains controversial. The aim of this study was to compare outcomes of fixed-bearing (FB) and mobile-bearing (MB) UKAs from a single high-volume institution. Prospectively collected data were reviewed for all primary cemented medial UKAs performed by seven surgeons from January 2006 to December 2022. A total of 2,999 UKAs were identified, including 2,315 FB and 684 MB cases. The primary outcome measure was implant survival. Secondary outcomes included 90-day and cumulative complications, reoperations, component revisions, conversion arthroplasties, range of motion, and patient-reported outcome measures. Overall mean age at surgery was 65.7 years (32.9 to 94.3), 53.1% (1,593/2,999) of UKAs were implanted in female patients, and demographics between groups were similar (p > 0.05). The mean follow-up for all UKAs was 3.7 years (0.0 to 15.6). Using revision for any reason as an endpoint, five-year survival for FB UKAs was 97.2% (95% CI 96.4 to 98.1) compared to 96.0% for MB (95% CI 94.1 to 97.9; p = 0.008). The FB group experienced fewer component revisions (14/2,315, 0.6% vs 12/684, 1.8%; p < 0.001) and conversion arthroplasties (38/2315, 1.6% vs 24/684, 3.5%; p < 0.001). A greater number of MB UKAs underwent revision due to osteoarthritis progression (FB = 21/2,315, 0.9% vs MB = 16/684, 2.3%; p = 0.003). In the MB group, 12 (1.8%) subjects experienced bearing dislocations which required revision surgery. There were 15 early periprosthetic tibia fractures (0.6%) in the FB group compared to 0 for MB (p = 0.035). In similar patient populations, FB UKAs demonstrated slightly higher survival than a commonly used MB design. Adverse event profiles differed by bearing type, with an increased risk of bearing dislocation and OA progression with MB designs, and early periprosthetic tibia fractures for FB designs.

Does a delay to surgery for preoperative echocardiogram affect outcomes in patients with hip fracture?

Delay to surgery >24 hours has been shown to correlate with mortality rates in patients with hip fracture when left untreated. Many of these patients have multiple comorbidities, including aortic stenosis (AS), and undergo workup for operative clearance, which may delay time to surgery. The purpose of this study was to examine whether preoperative echocardiogram workup affects time to surgery, complications, and mortality after operative fixation for hip fracture. Our institutional hip fracture registry was retrospectively reviewed for inclusion over a 3-year period. Patients who had a preoperative echocardiogram (yECHO) for operative clearance were compared with those who did not (nECHO). Demographic data, time to surgery, overall complication rate, and mortality at 30 days, 90 days, and 1 year were collected. Two cohorts consisted of 136 yECHO patients (45.8%) and 161 nECHO patients (54.2%). Thirty-two yECHO patients (23.5%) had AS. Patients in the yECHO cohort were more likely to have a complication for any cause compared with nECHO patients (25.7% vs. 10.6%, P = 0.01) and have a higher mortality rate at 1 year (38.9% vs. 17.4%, P = 0.001). There was no association found between AS and all-cause complication (P = 0.54) or 30-day (P = 0.13) or 90-day mortality rates (P = 0.79). However, patients with AS had a significantly higher mortality rate at 1 year (45.8% vs. 25.1%, P = 0.03). This study reinforces the benefits of ensuring less than a 24-hour time to surgery in the setting of a hip fracture and identifies an area of preoperative management that can be further optimized to prevent unnecessary prolongation in time to surgery. Patients with known aortic stenosis are not associated with increased 30-day or 90-day mortality or all-cause complications. Surgical delays in the yECHO cohort were attributed to preoperative medical assessments, including echocardiograms and the management of comorbidities. Therefore, the selective utilization of preoperative echocardiograms is needed and should be reserved to ensure they have a definitive role in guiding the perioperative care of patients with hip fracture. III.

Chronic Anticoagulation in Patients Who Have Atrial Fibrillation Undergoing Outpatient Total Knee Arthroplasty: A Retrospective Matched Cohort Study

BackgroundPatients who have atrial fibrillation frequently require long-term anticoagulation with warfarin or a direct-acting oral anticoagulant (DOAC), such as apixaban or rivaroxaban, to avoid vascular complications. However, the impact of anticoagulant use on postoperative complications following total knee arthroplasty (TKA) in an outpatient setting has not been thoroughly elucidated. The purpose of this study was to examine the impact of anticoagulant use on early postoperative complications among atrial fibrillation patients undergoing outpatient TKA. MethodsAn insurance claims database was queried to identify all patients who underwent outpatient TKA between January 2010 and April 2022. There were two cohorts of patients, with associated 1:1 matched controls, who had atrial fibrillation and filled a prescription of either warfarin (N = 4,396) or DOAC (N = 5,383) for at least 30 days. The mean age was 70 years (range, 51 to 84), and 47.9% were women in the warfarin cohort, while the mean age was 70 years and 49.2% were women in the DOAC cohort. Postoperative 30-day medical and 90-day surgical complications were subsequently compared. ResultsPatients on warfarin had a higher incidence of pulmonary embolism (1.1 versus 0.2%, P < 0.001) and a lower incidence of TKA revision (0.1 versus 0.4%, P = 0.003) than matched controls. Similarly, patients on DOACs exhibited a higher incidence of pneumonia (1.4 versus 0.6%, P < 0.001) and myocardial infarction (3.2 versus 1.5%, P < 0.001) and a lower incidence of wound dehiscence (0.1 versus 0.5%, P < 0.001), joint infection (0.4 versus 0.9%, P = 0.002), and TKA revision (0.1 versus 0.4%, P = 0.002) than matched controls. ConclusionsAtrial fibrillation patients on long-term anticoagulants undergoing outpatient TKA experience higher rates of medical complications and lower rates of surgical complications than matched controls. Thus, patients on long-term anticoagulants may be considered for outpatient TKA but should be counseled appropriately on associated medical risks.

Rheumatoid arthritis is associated with higher 90-day systemic complications compared to osteoarthritis after total shoulder arthroplasty: a cohort study.

Total shoulder arthroplasty (TSA) in patients with rheumatoid arthritis (RA) can present unique challenges. The aim of this study was to compare both systemic and joint-related postoperative complications in patients undergoing primary TSA with RA versus those with primary osteoarthritis (OA). Using the TriNetX database, Current Procedural Terminology and International Classification of Diseases, 10th edition codes were used to identify patients who underwent primary TSA. Patients were categorized into two cohorts: RA and OA. After 1:1 propensity score matching, postoperative systemic complications within 90 days following primary TSA and joint-related complications within 5 years following anatomic TSA (aTSA) and reverse shoulder arthroplasty (RSA) were compared. After propensity score matching, the RA and OA cohorts each consisted of 8,523 patients. Within 90 days postoperation, RA patients had a significantly higher risk of total complications, deep surgical site infection, wound dehiscence, pneumonia, myocardial infarction, acute renal failure, urinary tract infection, mortality, and readmission compared to the OA cohort. RA patients had a significantly greater risk of periprosthetic joint infection and prosthetic dislocation within 5 years following aTSA and RSA, and a greater risk of scapular fractures following RSA. Among RA patients, RSA had a significantly higher risk of prosthetic dislocation, scapular fractures, and revision compared to aTSA. Following TSA, RA patients should be considered at higher risk of systemic and joint-related complications compared to patients with primary OA. Knowledge of the risk profile of RA patients undergoing TSA is essential for appropriate patient counseling and education. Level of evidence: III.

604. REAL-WORLD MANAGEMENT AND OUTCOMES OF PATIENTS WITH NON METASTATIC ESOPHAGEAL SQUAMOUS CELL CARCINOMA IN THE FREGAT DATABASE

Abstract Background International guidelines for locally advanced esophageal squamous cell carcinoma (ESCC) recommend both neoadjuvant chemoradiotherapy (nCRT) followed by planned surgery (P-surg) or definitive chemoradiotherapy (dCRT) with salvage surgery (S-surg). However, the optimal treatment remains unknown, and the ongoing pragmatic NEEDS randomized trial is assessing the efficacy of an organ-preserving strategy after dCRT (Nilsson, Front Oncol 2022). Real-world data on the management of non-metastatic ESCC is limited. This study aims to describe the treatment strategies and prognosis of patients with non-metastatic ESCC in a real-world setting. Methods We conducted a retrospective cohort study of patient treated for non-metastatic ESCC between 2014 and 2022. Data were extracted from the FREGAT database. For the entire population, different treatment strategies were described. We compared patients who received nCRT with those who received dCRT under real-life conditions (“Real-life” population) and according to the NEEDS randomized trial criteria (“NEEDS-like” population). Five-year overall survival (OS) and relapse-free survival (RFS) were compared between nCRT and dCRT patients using a Cox proportional hazard model adjusting for major confounders. In operated patients, the impact of surgery on OS and RFS was assessed using a time-dependent Cox proportional hazard model. Postoperative outcomes were compared between P-surg and S-surg using Fisher’s exact test. Results From 971 patients diagnosed with non-metastatic ESCC, 867 (89.3%) received a curative treatment including dCRT (41.0%), nCRT (28.0%), primary esophagectomy (9.8%), neoadjuvant chemotherapy (3.4%), or endoscopic resection (1.0%). Fifty-nine patients (6,1%) received supportive care or chemotherapy alone. Forty-five patients (4.6%) died during or before treatment. In the “real-life” population (n=659), 269 patients received nCRT and 390 patients received dCRT. A total of 229 patients (93.5%) in nCRT group underwent P-surg and S-surg was performed in 44 patients (11.3%) in dCRT group. After adjustment, dCRT was associated with a significantly poorer 5-year OS and RFS (respectively HR=1.83, 95%CI 1.44-2.33; HR=1.98, 95%CI 1.57-2.49). A complete clinical response (cCR) was observed in 21.6% and 29.5% of the nCRT and dCRT groups, respectively. Among cCR undergoing resection, 35.8% had residual disease on pathological specimen. Time between CRT and surgery was 58 days (IQR44-72) vs. 109 days (IQR71-278) for P-surge and S-Surg respectively. The 90-day mortality, major morbidity (Clavien-Dindo III/IV) and pulmonary complication rates were similar in both groups, except for a higher risk of anastomotic leakage after S-surg (p=0.05). In the “NEEDS-like” population (n=598), findings were consistent and comparable to those observed in the “real-life” population. Conclusion Among non-mestastatic ESCC included in the FREGAT database, 10.6% had a non-curative approach or died prematurely. Most patients underwent dCRT, with S-surg rate of only 11.3%. Neoadjuvant CRT followed by P-surg was associated with the best outcome in terms of OS and RFS in both “rela life” and “Needs-like” populations. In operated patients, postoperative outcomes were similar after nCRT and dCRT, except for a higher incidence of anastomotic leakage after S-surg. This study highlighted the therapeutic strategies used and their results in real-life conditions for non-metastatic ESCC inside the FREGAT database. The treatment option of nCRT followed by P-surg appears to remain the optimal curative treatment regimen.

Safety and efficacy of outpatient versus inpatient adult brachial plexus surgery

PurposeOutpatient orthopedic surgery is becoming more common as a method of providing safe and cost-effective medical care. The purpose of this study was to compare outcomes between adult patients undergoing outpatient versus inpatient brachial plexus surgery. MethodsA single institution database was queried for patients with brachial plexus injuries undergoing brachial plexus exploration with or without concomitant reconstructive procedures from 2010 to 2022. Outcome measures included 90-day major and minor complications, as well as longer term pain scores and reoperation rates. Multivariate analysis was performed to compare outcomes between the cohorts. ResultsIn a group of 51 adult patients, 36 (70.6 %) were admitted for at least one night following surgery and 15 (29.4 %) underwent outpatient surgery. The cohorts were similar with respect to demographics. When compared to brachial plexus procedures performed between 2010 and 2016, those performed between 2017 and 2022 were 67 % more likely to be outpatient (OR 0.33; p = 0.11). The overall major complication rate during the 90-day episode of care was 11.8 % (n = 6), all of which occurred in the inpatient cohort. There was no significant difference in minor complication rate. 90-day reoperation rate due to complications was 2.8 % in the inpatient cohort and 0.0 % in the outpatient cohort. ConclusionNo prior study has assessed the safety of brachial plexus exploration and reconstruction in an outpatient setting. This study demonstrates that outpatient brachial plexus surgery is a safe option for properly selected patients. Procedures were more often performed outpatient in recent years, reflecting a continuing evolution of our practice.

Peak Procedural ACT Is Associated With All-Cause Mortality After Femoral Access PCI

BackgroundA minimum threshold activated clotting time (ACT) to guide heparin dosing during percutaneous coronary intervention (PCI) is associated with lower ischemic complications. However, data are variable regarding the risk of high ACT levels. The aim of this study was to assess the impact of peak procedural ACT on complications and mortality for transfemoral and transradial access PCI. MethodsThe UC San Diego Health National Cardiovascular Data Registry CathPCI Registry was used to obtain data on patients who underwent native vessel PCI from January 2007 to September 2022. Coronary artery bypass graft patients and those who received bivalirudin were excluded. Complications and all-cause mortality at 30 days and 1-year post-PCI were assessed by ACT tertile. ResultsA total of 2473 patients (age 65 ± 12 years; 74% male) undergoing PCI with 53% femoral and 47% radial access were included. The majority (82%) had 1-vessel coronary artery disease with heterogeneous clinical presentations (21.8% ST-elevation myocardial infarction, 25.4% non–ST-elevation myocardial infarction, 4.9% unstable angina, 33.8% stable angina, 3.4% atypical chest pain, 10.7% other indication for PCI). With femoral access, patients in the third tertile (ACT ≥ 275) had significantly higher all-cause mortality at 30 days (5.3% vs 2.7% vs 0.9%; P < .001), 6 months (6.3% vs 4.0% vs 2.0%; P = .007), and 1 year (9.0% vs 6.0% vs 2.7%; P < .001) compared to the second (ACT 228-275) and first tertile (ACT ≤ 228), respectively. A 30-day landmark analysis revealed that there was no difference in all-cause mortality beyond 30 days (3.9% vs 3.4% vs 1.8%; P = .176). There were increased bleeding complications in the highest tertile (12.8% vs 9.8% vs 7.5%; P = .034) and a higher need for blood products (10.4% vs 6.7% vs 5.4%; P = .014). There was no difference in ischemic major adverse cardiovascular events specifically periprocedural myocardial infarction or stroke between tertiles. There was no difference in clinical outcomes by peak ACT for patients who had radial access. ConclusionsHigher ACT with transfemoral access PCI was associated with increased 30-day mortality, bleeding complications, and need for blood products post-PCI.

Using machine learning to identify risk factors for short-term complications following thumb carpometacarpal arthroplasty

BackgroundThumb carpometacarpal (CMC) joint osteoarthritis is among the most common degenerative hand diseases. Thumb CMC arthroplasty, or trapeziectomy with or without tendon augmentation, is the most frequently performed surgical treatment and has a strong safety profile. Though adverse outcomes are infrequent, the ability to predict risk for complications has substantial clinical benefits. In the present study, we evaluated a well-known surgical database with machine learning (ML) techniques to predict short-term complications and reoperations after thumb CMC arthroplasty. MethodsA retrospective study was conducted using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) years 2005–2020. Outcomes were 30-day wound and medical complications and 30-day return to the operating room. We used three ML algorithms — a Random Forest (RF), Elastic-Net Regression (ENet), and Extreme Gradient Boosted Tree (XGBoost), and a deep learning Neural Network (NN). Feature importance analysis was performed in the highest performing model for each outcome to identify predictors with the greatest contributions. ResultsWe included a total of 7711 cases. The RF was the best performing algorithm for all outcomes, with an AUC score of 0.61±0.03 for reoperations, 0.55±0.04 for medical complications, and 0.59±0.03 for wound complications. On feature importance analysis, procedure duration was the highest weighted predictor for reoperations. In all outcomes, procedure duration, older age, and female sex were consistently among the top five predictors. ConclusionsWe successfully developed ML algorithms to predict reoperations, wound complications, and medical complications. RF models had the highest performance in all outcomes.

Low Rates of 30-Day Postoperative Complications After Meniscal Allograft Transplantation: A Retrospective Study Using the National Surgical Quality Improvement Program Database

PurposeThe purpose of this study is to determine the short-term (30-day) postoperative complication rates in patients undergoing meniscus allograft transplantation (MAT). MethodsAmerican College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for patients who had undergone MAT from 2014 to 2021 using Current Procedural Terminology (CPT) codes. Patients were excluded if they did not have sufficient demographic data – namely those without data for age, sex, BMI, preoperative functional status, ASA classification, operative time, and length of hospital stay. Post-operative complications within 30 days were identified and rates of complications were examined as the primary outcome of this study. As a secondary outcome, multivariate logistic regression was used to identify risk factors associated with the thirty-day incidence of post-operative complications. Subgroup analysis was performed to analyze differences in postoperative outcomes following isolated MAT versus MAT with concomitant ligament reconstruction/repair, cartilage preservation, or realignment osteotomy. ResultsA total of 396 meniscal transplants were identified, with mean age of 35.2 ± 14.9, mean body mass index (BMI) of 29.6 ± 6.7, mean length of stay of 0.5 ± 1.8 days. 11 patients experienced any adverse event (AAE), Specific complications included surgical site infections (5), deep vein thrombosis (DVT) (1), urinary tract infection (UTI) (3), and return to the operating room (OR) (2). On subgroup analysis, there was no significant difference between AAE rates in patients undergoing MAT with concomitant procedures compared to patients undergoing isolated MAT (7 vs 4, p=0.5). ConclusionPatients who underwent MAT had an overall complication rate of 2.8% in the short-term postoperative period (≤30 days). Patients undergoing MAT with concomitant ligament reconstruction/repair, cartilage preservation, and realignment osteotomy had similar rates of all postoperative complications when compared to patients undergoing isolated MAT. Level of EvidenceLevel IV, therapeutic case series.

Pilot robotic mastectomy in Singapore (PRoMiSing I) study: first safety and feasibility prospective cohort trial in South East Asia.

Robotic mastectomy has been performed worldwide since 2015. The advantages of the robotic approach in nipple-sparing mastectomy have been proven with better visualization and preservation of blood supply to the nipple-areolar complex, with a lower incidence of necrosis. It also allows smaller incisions for both mastectomy and immediate breast reconstruction. To date, no centers in Singapore and Southeast Asia offer robotic mastectomy. We believe that robotic mastectomy is a feasible and safe technique that our population can utilize. This study aimed to ascertain the surgical outcomes and perform a learning curve analysis in patients undergoing robotic mastectomy in a multi-ethnic South East Asian population. A single-arm prospective pilot study of eligible patients aged 21-70 years old with early breast cancer or high-risk patients indicated for risk-reducing mastectomy who were eligible and consented to robotic mastectomy were enrolled in this trial from December 22, 2022 to December 15, 2023. A total of 29 consecutive robotic mastectomies were performed. The mean total operative time was 95±10.2min. The average blood loss was 5.7±1.9ml, and the average length of stay was 1.05 days. The mean mastectomy specimen weight was 251g, and there was no conversion to conventional mastectomy in any case. Furthermore, there were no 30-day morbidity or complications in terms of wound infection requiring intervention, flap, and nipple-areolar complex necrosis, and postoperative hematoma/bleeding requiring intervention. This study contributes to the current evidence that robotic mastectomy is a safe and feasible option and could prove to be a great alternative to conventional mastectomy. Further prospective trials examining the long-term oncological outcomes of robotic mastectomy will be performed to establish the oncologic safety of this technique in breast cancer treatment.

Clinical characteristics and short-term outcomes in patients with cardiogenic shock undergoing mechanical circulatory support escalation from intra-aortic balloon pump to impella: From the J-PVAD registry.

An escalation strategy from intra-aortic balloon pump (IABP) to Impella (AbioMed, Danvers, MA, USA) is proposed in patients with cardiogenic shock (CS) refractory to IABP therapy, but its clinical data are lacking. This study aimed to elucidate the clinical characteristics and short-term outcomes in patients undergoing IABP-Impella escalation. From the Japanese nationwide registry of Impella (J-PVAD), a total of 2578 patients with CS receiving Impella support were classified into the IABP-Impella group (n = 189) or the Primary Impella group (n = 2389). We applied 1:3 propensity score (PS) matching, selecting 185 patients and 555 patients, respectively. Before matching, the IABP-Impella group presented longer shock-to-Impella time, worse laboratory data, and more frequent inotropes and pulmonary artery catheter use than the Primary Impella group. After matching, the baseline characteristics were well-balanced. Regarding the 30-day clinical outcomes in the PS-matched cohort, there were no significant differences in the rates of mortality and major complications (a composite of bleeding, hemolysis, infection, stroke, myocardial infarction, limb ischemia, and vascular injury) between the groups. However, The IABP-Impella group showed a significantly higher rate of infection (10.3 % vs. 5.6 %, p = 0.042) and additional mechanical circulatory support use (34.1 % vs. 23.8 %, p = 0.008) than the Primary Impella group. Compared to patients with primary Impella support, those undergoing IABP-Impella escalation showed similar 30-day mortality and major complications despite poorer clinical conditions before Impella support and a more complicated clinical course after Impella insertion.

Trans Oblique Ileal Conduit Technique Has a Low Risk of Parastomal Hernias

ObjectivesTo outline our surgical technique and outcomes of a ipsilateral "transoblique" ileal conduit performed during pelvic exenteration with a Vertical Rectus Abdominis Myocutaneous flap. We report hernia rates in a transrectus group as reference. MethodsWe identified patients from January 2007 to August 2020. The transoblique conduit is placed on the ipsilateral side as the VRAM, through the internal, external oblique, and transverse abdominis muscles. Stomal hernias were assessed radiologically. Transrectus patients were those undergoing radical cystectomy matched based on surgery date, age, and sex in a 3:1 ratio. We employed a Kaplan-Meier plot to visualize the duration between surgery and hernia. We calculated the hernia rate two years after surgery. Additionally, we present the 30-day postoperative complication rate. Results50 underwent transoblique conduits and we matched them to 190 transrectus patients. 67% were men with a median age of 62. 10/50 patients in the transoblique and 44/190 in the transrectus group developed a hernia, with a median follow-up of 2.2 years (IQR 0.8, 4.0). The two-year KM-estimated parastomal hernia rate was 14% (95% CI 1.6%, 25%) for the transoblique conduits, 21% (95% CI 15%, 28%) for the transrectus and 24% (95% CI 6.5%, 39%) for colostomies. Among the transoblique patients, 22 (44%) experienced at least one postoperative complication. ConclusionsA transoblique ileal conduit is safe in patients undergoing a right VRAM flap during a pelvic exenteration with a low parastomal hernia and complication rates.

Robotic-Assisted Radical Cystectomy: Single-Center Analysis of Factors Impacting Clavien ≥ II Complications.

Despite the advent of robotics and the decreasing rate of complications after radical cystectomy, several factors are renowned to impair the early outcomes of this procedure. The aim of this paper is to provide a multivariate analysis (MVA) of patient and surgical procedure-related variables likely to affect postoperative course and 30-day complication rate. Fifty-five robotic-assisted radical cystectomies (RARCs) performed at a single center from July 2021 to March 2023 were enrolled. Baseline demographics, comorbidities, and intraoperative and postoperative data were collected. Uni- and multivariate analyses were performed to evaluate the relationship with Clavien ≥ II complications arising within 30 days of surgery. A postoperative Clavien ≥ II complication was evident in 15 patients (28%), whereas Clavien ≥ III occurred only in 5 (9%). At MVA, the only independent predictor of Clavien ≥ II complications was a prior neoadjuvant chemotherapy (OR 5.6; 95% CI 1.22-25.3, p = 0.026). Recognized the small sample size, patients who received a prior NAC should deserve special care within the postoperative course.

Surgical management of peritoneal metastases from appendix and colon cancer in patients with inflammatory bowel disease

BackgroundInflammatory bowel disease (IBD) may compromise outcomes of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) for peritoneal metastases (PM) from appendix/colon cancer. We evaluated CRS/HIPEC outcomes in patients with concurrent IBD. MethodsA matched cohort study using a prospective institutional CRS/HIPEC database (1998–2023) included appendix/colon cancer patients with PM. We matched IBD patients to IBD-free controls in a 1:5 ratio with nearest-neighbor propensity score for sex, age, and peritoneal cancer index (PCI), and exact matching for prior CRS/HIPEC and primary tumor. Perioperative variables, including Clavien-Dindo 90-day complications, were compared. Kaplan-Meier overall (OS) and progression-free survival (PFS) were compared using stratified Cox regression. ResultsOf 605 CRS/HIPECs for appendix/colon cancer, 14 (2.3%) had concurrent Crohn’s disease (n = 6) or ulcerative colitis (n = 8). Seventy IBD-free controls were matched. Nine (64.7%) IBD patients had an appendix primary. Complete cytoreduction (CC-0/1) was achieved in 10 (71.4%) IBD and 57 (81.4%) IBD-free patients (p = 0.468). IBD vs IBD-free patients tended to have more grade-III/IV complications (35.7% [n = 5] vs 15.7% [n = 11], p = 0.082) and had a higher rate of severe nausea/vomiting (35.7% vs 4.3 %, p < 0.001) and diarrhea (28.6% vs 8.6%, p = 0.035). Rates of anastomotic leak (7.1% [n = 1] vs 1.4% [n = 1], p = 0.200) and intraabdominal infections (7.1% [n = 1] vs 2.9% [n = 2], p = 0.430) were similar for IBD vs IBD-free, respectively. IBD did not affect OS (HR [95% CI]: 1.1 [0.4, 2.9]) or PFS (HR [95% CI]: 1.2 [0.4, 3.9]). ConclusionIBD is associated with a higher rate of gastrointestinal complications after CRS/HIPEC for appendix/colon cancer; however, it does not affect OS or PFS.