30-day Major Complications Research Articles

Are Patient Outcomes Affected by Surgeon Experience With Total Hip Arthroplasty in Morbidly Obese Patients?

Surgeons with high volume (HV) of total hip arthroplasty (THA) have seen better outcomes than low volume (LV) surgeons. However, literature regarding surgeon volume and outcomes in morbidly obese THA patients is scarce. This study examines the association between surgeon volume with THA in morbidly obese patients (body mass index ≥40) and their clinical outcomes. We retrospectively reviewed all morbidly obese patients who underwent primary THA at our institution between March 2012 and July 2020 with 2 years of follow-up. Clinical outcomes were compared between the HV (HVa, top quartile of surgeons with the highest overall yearly THA volume) and LV (LVa) surgeons. Similar analysis was run comparing HV of morbidly obese THA (HVo, top quartile of surgeons with the highest yearly morbidly obese THA volume) and LV of morbidly obese THA (LVo) surgeons. Six hundred and forty-three patients and 33 surgeons were included. HVa surgeons had significantly shorter length of stay and increased home discharge. HVa and HVo surgeons had significantly shorter operative times. There were no significant differences in overall 90-day major and minor complications or clinical differences in patient-reported outcomes. Revision rates and freedom from revisions did not differ between groups at 2-year follow-up. HVa surgeons had significantly lower length of stay and operative times and increased discharge to home. There was no significant decrease in complications or revisions in either comparison model. Complications, revision rates, and patient satisfaction in morbidly obese patients who undergo THA may be independent of surgeon volume.

Resident involvement in hand and upper extremity surgery: An analysis of 30-day complications

BackgroundRotations in hand and upper extremity surgery are a core component of the Orthopaedic and Plastic Surgery resident training curriculums. This study compares short-term outcomes in hand and upper extremity procedures with and without resident involvement. MethodsThe National Surgical Quality Improvement Program database was queried from years 2005–2012 for all procedures distal to the shoulder. Patients were stratified based on whether a resident scrubbed for the procedure. Outcome measures were 30-day mortality, reoperation rate, minor complications, major complications, and length of stay (LOS). Chi-squared tests were used to determine significant variables. Significant variables were included in a binomial multivariate logistic regression model. ResultsA total of 7697 patients were included in the study. Of those, 4509 (59 %) had no resident, and 3188 (41 %) had a resident. Patients with resident involvement were less likely to be Caucasian, ASA classification 3 or higher, and outpatient. Cohorts were similar with respect to age, sex, and emergent status. Operative time was 15 min longer in resident cases. Work relative value units were higher in resident cases. In the multivariate logistic regression model, resident involvement had no statistically significant impact on LOS, mortality, reoperation rate, minor complications, or major complications. Subgroup analysis showed increased odds of superficial surgical site infections in resident cases, although this was statistically insignificant (OR 1.35, p = 0.24). ConclusionsHand and upper extremity procedures with resident involvement do not have any increase in overall adverse short-term outcomes. In appropriately selected cases, residents can participate without compromising patient safety.

Safety and efficacy of intraperitoneal drain placement after emergency colorectal surgery: An international, prospective cohort study.

Intraperitoneal drains are often placed during emergency colorectal surgery. However, there is a lack of evidence supporting their use. This study aimed to describe the efficacy and safety of intraperitoneal drain placement after emergency colorectal surgery. COMPlicAted intra-abdominal collectionS after colorectal Surgery (COMPASS) is a prospective, international, cohort study into which consecutive adult patients undergoing emergency colorectal surgery were enrolled (from 3 February 2020 to 8 March 2020). The primary outcome was the rate of intraperitoneal drain placement. Secondary outcomes included rate and time-to-diagnosis of postoperative intraperitoneal collections, rate of surgical site infections (SSIs), time to discharge and 30-day major postoperative complications (Clavien-Dindo III-V). Multivariable logistic and Cox proportional hazards regressions were used to estimate the independent association of the outcomes with drain placement. Some 725 patients (median age 68.0 years; 349 [48.1%] women) from 22 countries were included. The drain insertion rate was 53.7% (389 patients). Following multivariable adjustment, drains were not significantly associated with reduced rates (odds ratio [OR] = 1.56, 95% CI: 0.48-5.02, p = 0.457) or earlier detection (hazard ratio [HR] = 1.07, 95% CI: 0.61-1.90, p = 0.805) of collections. Drains were not significantly associated with worse major postoperative complications (OR = 1.26, 95% CI: 0.67-2.36, p = 0.478), delayed hospital discharge (HR = 1.11, 95% CI: 0.91-1.36, p = 0.303) or increased risk of SSIs (OR = 1.61, 95% CI: 0.87-2.99, p = 0.128). This is the first study investigating placement of intraperitoneal drains following emergency colorectal surgery. The safety and clinical benefit of drains remain uncertain. Equipoise exists for randomized trials to define the safety and efficacy of drains in emergency colorectal surgery.

Practice patterns and complications of hysterectomy for invasive cervical cancer after the Laparoscopic Approach to Cervical Cancer trial

After the publication of the Laparoscopic Approach to Cervical Cancer trial, the standard surgical approach for early-stage cervical cancer is open radical hysterectomy. Only limited data were available regarding whether the change to open abdominal hysterectomy observed after the Laparoscopic Approach to Cervical Cancer trial led to an increase in postoperative complication rates as a consequence of the decrease in the use of the minimally invasive approach. This study aimed to analyze whether there was a correlation between the publication of the Laparoscopic Approach to Cervical Cancer trial and an increase in the 30-day complications associated with surgical treatment of invasive cervical cancer. Data from the American College of Surgeons National Surgical Quality Improvement Program were used to compare the results in the pre-Laparoscopic Approach to Cervical Cancer period (January 2016 to December 2017) vs the results in the post-Laparoscopic Approach to Cervical Cancer period (January 2019 to December 2020). The rates of each surgical approach (open abdominal or minimally invasive) hysterectomy for invasive cervical cancer during the 2 periods were assessed. Subsequently, 30-day major complication, minor complication, unplanned hospital readmission, and intra- or postoperative transfusion rates before and after the publication of the Laparoscopic Approach to Cervical Cancer trial were compared. Overall, 3024 patients undergoing either open abdominal hysterectomy or minimally invasive hysterectomy for invasive cervical cancer were included in the study. Of the patients, 1515 (50.1%) were treated in the pre-Laparoscopic Approach to Cervical Cancer period, and 1509 (49.9%) were treated in the post-Laparoscopic Approach to Cervical Cancer period. The rate of minimally invasive approaches decreased significantly from 75.6% (1145/1515) in the pre-Laparoscopic Approach to Cervical Cancer period to 41.1% (620/1509) in the post-Laparoscopic Approach to Cervical Cancer period, whereas the rate of open abdominal approach increased from 24.4% (370/1515) in the pre-Laparoscopic Approach to Cervical Cancer period to 58.9% (889/1509) in the post-Laparoscopic Approach to Cervical Cancer period (P<.001). The overall 30-day major complications remained stable between the pre-Laparoscopic Approach to Cervical Cancer period (85/1515 [5.6%]) and the post-Laparoscopic Approach to Cervical Cancer period (74/1509 [4.9%]) (adjusted odds ratio, 0.85; 95% confidence interval, 0.61-1.17). The overall 30-day minor complications were similar in the pre-Laparoscopic Approach to Cervical Cancer period (103/1515 [6.8%]) vs the post-Laparoscopic Approach to Cervical Cancer period (120/1509 [8.0%]) (adjusted odds ratio, 1.17; 95% confidence interval, 0.89-1.55). The unplanned hospital readmission rate remained stable during the pre-Laparoscopic Approach to Cervical Cancer period (7.9% per 30 person-days) and during the post-Laparoscopic Approach to Cervical Cancer period (6.3% per 30 person-days) (adjusted hazard ratio, 0.78; 95% confidence interval, 0.58-1.04)]. The intra- and postoperative transfusion rates increased significantly from 3.8% (58/1515) in the pre-Laparoscopic Approach to Cervical Cancer period to 6.7% (101/1509) in the post-Laparoscopic Approach to Cervical Cancer period (adjusted odds ratio, 1.79; 95% confidence interval, 1.27-2.53). This study observed a significant shift in the surgical approach for invasive cervical cancer after the publication of the Laparoscopic Approach to Cervical Cancer trial, with a reduction in the minimally invasive abdominal approach and an increase in the open abdominal approach. The change in surgical approach was not associated with an increase in the rate of 30-day major or minor complications and unplanned hospital readmission, although it was associated with an increase in the transfusion rate.

Incidence, risk factors, and outcomes of venous thromboembolism in patients undergoing surgery for retroperitoneal tumors: A propensity-matched retrospective cohort study.

Venous thromboembolism (VTE) is a common postoperative complication; however, incidence and risk stratification of postoperative VTE in patients with retroperitoneal tumor remains unclear. We aim to quantify incidence, identify risk factors, and determine outcomes of VTE in patients undergoing retroperitoneal tumor surgery. We retrospectively reviewed characteristics, perioperative outcomes, and overall survival (OS) of patients (VTE and non-VTE) who underwent retroperitoneal tumor surgery between 2015 and 2020. Perioperative and oncologic outcomes were compared using propensity-matching and Cox analyses. Of 1223 patients with retroperitoneal tumor surgery, 2.1% had VTE. Age (odds ratio [OR] 1.140, 95% confidence interval [CI] 1.053-1.239, P=0.004), recurrence (OR 1.851, 95% CI 1.241-2.761, P=0.003), and vascular resection (OR 2.036, 95% CI 1.054-3.934, P=0.034) were independent risk factors, with significant between-group differences regarding age, recurrence, sarcoma, organ resection, vascular resection, and operation time. No between-group differences in 30-day all-cause mortality (8% vs. 4%, OR 0.657, 95% CI 0.375-1.151, P=0.427) and major complications (12% vs. 8%, OR 0.775, 95% CI 0.483-1.244, P=0.572) were observed. Mean hospitalization duration (20.1 vs. 22.9d, OR 1.153, 95% CI 1.022-1.386, P=0.033) and ICU stay (3.2 vs. 5.5d, OR 1.193, 95% CI 1.034-1.347, P=0.012) were shorter in non-VTE versus VTE, respectively, with inferior OS (hazard ratio [HR] 2.090, 95% CI 1.014-4.308, P=0.046) in VTE. Age, recurrence, and vascular resection are positively associated with VTE, which is associated with inferior OS.

Predictors for complication in renal cancer surgery: a national register study.

Nationwide register data provide unique opportunities for real-world assessment of complications from different surgical methods. This study aimed to assess incidence of, and predictors for, post-operative complications and to evaluate 90-day mortality following different surgical procedures and thermal ablation for renal cell carcinoma (RCC). All patients undergoing surgical treatment and thermal ablation for RCC in Sweden during 2015-2019 were identified from the National Swedish Kidney Cancer Register. Frequencies and types of post-operative complications were analysed. Logistic regression models were used to identify predictors for 90-day major (Clavien-Dindo grades III-V) complications, including death. The overall complication rate was 24% (1295/5505), of which 495 (8.7%) were major complications. Most complications occurred following open surgery, of which bleeding and infection were the most common. Twice as many complications were observed in patients undergoing open surgery compared to minimally invasive surgery (20% vs. 10%, P < 0.001). Statistically significant predictors for major complications irrespective of surgical category and technique were American society of anesthiologists (ASA) score, tumour diameter and serum creatinine. Separating radical and partial nephrectomy, surgical technique remained a significant risk factor for major complications. Most complications occurred within the first 20 days. The overall 90-day readmission rate was 6.2%, and 30- and 90-day mortality rates were 0.47% and 1.5%, respectively. In conclusion, bleeding and infection were the most common major complications after RCC surgery. Twice as many patients undergoing open surgery suffer a major post-operative complication as compared to patients subjected to minimally invasive surgery. General predictors for major complications were ASA score, tumour size, kidney function and surgical technique.

Low Skeletal Muscle as a Risk Factor for Worse Survival in Nonmetastatic Renal Cell Carcinoma with Venous Tumor Thrombus.

Renal cell carcinoma (RCC) with tumor thrombosis often requires nephrectomy and tumor thrombectomy. As an extensive and potentially morbid operation, patient preoperative functional reserve and body composition is an important consideration. Sarcopenia is a risk factor for increased postoperative complications, systemic therapy toxicity, and death solid organ tumors, including RCC. The influence of sarcopenia in RCC patients with tumor thrombus is not well defined. This study evaluates the prognostic ability of sarcopenia regarding surgical outcomes and complications in patients undergoing surgery for RCC with tumor thrombus. We retrospectively analyzed patients with nonmetastatic RCC and tumor thrombus undergoing radical nephrectomy and tumor thrombectomy. Skeletal muscle index (SMI; cm2/m2) was measured on preoperative CT/MRI. Sarcopenia was defined using body mass index- and sex-stratified thresholds optimally fit via a receiver-operating characteristic analysis for survival. Associations between preoperative sarcopenia and overall (OS), cancer-specific survival (CSS), and 90-day major complications were determined using multivariable analysis. 115 patients were analyzed, with median (IQR) age and body mass index of 69 (56-72) and 28.6 kg/m2 (23.6-32.9), respectively. 96 (83.4%) of the cohort had ccRCC. Sarcopenia was associated with shorter median OS (P=.0017) and CSS (P = .0019) in Kaplan-Meier analysis. In multivariable analysis, preoperative sarcopenia was prognostic of shorter OS (HR = 3.38, 95% confidence interval [CI] 1.61-7.09) and CSS (HR=5.15, 95% CI 1.46-18.18). Notably, 1 unit increases in SMI were associated with improved OS (HR = 0.97, 95% CI 0.94-0.999) but not CSS (HR=0.95, 95% CI 0.90-1.01). No significant relationship between preoperative sarcopenia and 90-day major surgical complications was observed in this cohort (HR=2.04, 95% CI 0.65-6.42). Preoperative sarcopenia was associated with decreased OS and CSS in patients surgically managed for nonmetastatic RCC and VTT, however, was not predictive of 90-day major postoperative complications. Body composition analysis has prognostic utility for patients with nonmetastatic RCC and venous tumor thrombus undergoing surgery.

The short- and long-term outcome after the surgical management of common bile duct stones in a tertiary referral hospital

BackgroundThe removal of common bile duct stones by endoscopic retrograde cholangiopancreatography (ERCP) shows excellent results with low complication rates and is therefore considered a gold standard. However, in case of stones non-removable by ERCP, surgical extraction is needed. The surgical approach is still controversial and clinical guidelines are missing. This study aims to analyze the outcomes of patients treated with choledochotomy or hepaticojejunostomy for common bile duct stones.MethodsAll patients who underwent choledochotomy or hepaticojejunostomy for common bile duct stones at a tertiary referral hospital over 11 years were included. The analyzed data contains basic demographics, diagnostics, surgical parameters, length of hospitalization, and morbidity and mortality.ResultsOver the study period, 4375 patients underwent cholecystectomy, and 655 received an ERCP with stone extraction, with 48 of these patients receiving subsequent surgical treatment. ERCP was attempted in 23/30 (77%) of the choledochotomy patients pre/intraoperatively and 11/18 (56%) in hepaticojejunostomy patients. The 30-day major complication rate (Clavien-Dindo > II) was 1/30 (3%) in the choledochotomy group and 2/18 (11%) in the hepaticojejunostomy group. Complications after 30 days occurred in 3/30 (10%) patients and 2/18 (11%), respectively, and no mortality occurred.ConclusionERCP should still be considered the gold standard, although due to low short- and long-term morbidity rates, choledochotomy and hepaticojejunostomy represent effective surgical solutions for common bile duct stones.

Metabolic Syndrome Increases Risk of Readmission and Complications in Operative Fixation of Pilon Fractures.

Background Studies demonstrate that metabolic syndrome (MetS) negatively impacts surgical outcomes. This study sought to identify how metabolic syndrome affects outcomes after open reduction and internal fixation (ORIF) of traumatic pilon fractures. Methods Patients who underwent ORIF for pilon fractures from 2012 to 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patients with MetS were compared to non-MetS patients for rates of adverse events, prolonged stay, readmission, discharge location, and operative time in the 30-day postoperative period. All statistical analyses were conducted using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Paired student t-tests were used to assess continuous variables. Pearson's Chi-square and odds ratios were used for categorical variables. Results A total of 1,915 patients met this study's inclusion criteria, and 127 MetS patients were identified in the cohort. The MetS cohort was older (62.7 vs49.5 years old, p-value <0.01), with a greater proportion of female patients (59.1% vs 50.2%, p=0.054). MetS patients experienced significantly higher rates of infectious complications (7.9% vs 3.9% OR 2.75 (CI 1.36-5.53), p=0.008), major adverse events (11% vs 4.3%, OR 2.79 (CI 1.53-5.09) p=0.002), and readmissions. MetS patients also had longer lengths of stay (7 days vs 3.8 days, p-value<0.001), and were more likely to be discharged to a non-home location (51.2% vs 19.5%, p-value<0.01, OR 4.32 (CI=3.0-6.24) p<0.001). Conclusion Patients with MetS have an increased risk of 30-day major complications, infection, readmissions, discharge to a non-home location, and prolonged operative time, and therefore warrant additional consideration for perioperative monitoring.

Short-Term Prognostic Value of the Culprit-SYNTAX Score in Patients with Acute Myocardial Infarction.

The SYNergy between Percutaneous Coronary Intervention with TAXus and Cardiac Surgery (SYNTAX) score is a scoring system that helps to decide on surgery or percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (MI), and studies are showing the prognostic value of this scoring system in both AMI and coronary artery disease patients undergoing PCI. In acute coronary syndrome (ACS) patients, the infarct-related artery and the complexity of the lesions are also important in terms of mortality and morbidity. Our study aimed to determine the prognostic value of the culprit vessel's SYNTAX score (cul-SS) in patients presenting with MI. In our study, 1284 patients presenting with MI were analyzed retrospectively. The SYNTAX scores and cul-SS of the patients were calculated. In-hospital and 30-day deaths and major complications were accepted as primary outcomes. The SYNTAX scores and cul-SS were compared in terms of predicting primary outcomes. Major complications were observed in 36 (2.8%) patients, death in 42 (3.3%) patients, and stent thrombosis in 24 (1.9%) patients. The area under the curves for SYNTAX and cul-SS for predicting primary outcomes is 0.64 and 0.68 (p = 0.026), respectively. Cul-SS was as successful as the SYNTAX score in predicting stent thrombosis and was superior in predicting short-term death and major complications.

Risk Factors for Major Complications Following Minimally Invasive Surgeries for Endometriosis in the United States

To study the rate and risk factors for short-term postoperative complications of patients undergoing minimally invasive surgery (MIS) for endometriosis in the United States. Retrospective cohort study. American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2020. Patients with endometriosis diagnosis. Laparoscopic surgery for endometriosis. We compared women with and without 30-day postoperative major complications, defined according to the Clavien-Dindo classification. A total of 28 697 women underwent MIS during the study period, of which 2.6% had major postoperative complications. Organ space surgical site infection and reoperation were the most common complications (47.0% and 39.8%, respectively). In multivariable regression analysis, African American race (adjusted odds ratio [aOR] 95% confidence interval [CI] 1.61 [1.29-2.01], p <.001), hypertension (aOR 95% CI 1.23 [1.01-1.50], p=.036), bleeding disorders (aOR 95% CI 1.96 [1.03-3.74], p=.041), bowel procedures (aOR 95% CI 1.93 [1.37-2.72], p <.001) and hysterectomy (aOR 95% CI 2.09 [1.67-2.63], p <.001) were independently associated with increased risk of major complications. In multivariable regression analysis of laparoscopies without bowel procedures, African American race, bleeding disorders, and hysterectomy were independently associated with increased major complication risk. Among cases with bowel procedures, African American race and colectomy were independently associated with increased major complication risk. In multivariable regression analysis of women who underwent hysterectomy, African American race, bleeding disorders, and lysis of adhesions were independently associated with increased major complications risk. Among women who underwent uterine-sparing surgery, African American race, hypertension, preoperative blood transfusion, and bowel procedures were independently associated with increased major complications risk. Among women undergoing MIS for endometriosis, African American race, hypertension, bleeding disorders, and bowel surgery or hysterectomy are risk factors for major complications. African American race is a risk factor for major complications among women undergoing surgeries with and without bowel procedures or hysterectomy.

Perioperative safety and outcomes following radical prostatectomy in setting of locally advanced, node positive, and metastatic prostate cancer.

e17108 Background: Historically, definitive surgical management with radical prostatectomy (RP) has only been considered an option for the treatment of localized prostate cancer (PCa). However, recent data may suggest a role for RP in advanced PCa treatment. Currently, there is limited data on the safety and perioperative outcomes of RP in this setting. Here, we aim to compare the perioperative outcomes of RP for locally advanced, node positive, and metastatic PCa using the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) new procedure targeted database. Methods: RP procedures performed between 2019-2020 were identified. Patients were stratified to compare the effect of locally advanced disease (T3-4), node-positivity (N+), and metastasis (M+) against patients with localized (T1-2 N0 M0) PCa. Baseline demographics and 30-day outcomes, including operative time, hospital length-of-stay, 30-day mortality, readmissions, reoperations, major complications, minor complications, and surgery-specific complications, were compared between groups. Results: Pathologic staging data was available for 9,276 RPs. Baseline demographics were comparable. There was a slightly higher rate of minor-complications in the locally-advanced cohort, but no significant difference in major-complications, 30-day-mortality, readmissions, or rectal injuries. In comparison, while node-positivity was associated with longer operative time, LOS, and incidence of 30-day renal failure, it was not associated with a higher rate of any major, minor or surgery-specific complication. Similarly, RP for metastatic cases appeared to be comparably safe to those with M0 disease, although they were associated with a slightly higher rate of bleeding, prolonged-NG-tube use, and ureteral obstruction. Conclusions: RP for patients with locally advanced, node positive, and metastatic prostate cancer appears to be safe, and is not associated with significantly higher rates of 30-day mortality or major complications compared to localized prostate cancer. Given the previously demonstrated survival benefit in treating the primary tumor in advanced disease with radiation therapy, there may be a role for the RP in treating advanced PCa. Further studies are needed to better characterize the risks and benefits of surgery in these patients.

Impact of transradial versus transfemoral access for preprocedural coronary angiography on TAVR-associated complications.

Vascular injury and bleeding complications remain frequent after transcatheter aortic valve replacement (TAVR). Whether the access-site of preprocedural coronary angiography (CAG) affects TAVR-related complications is not known. The aim of this study was to evaluate the impact of transradial (TRA) versus transfemoral access (TFA) for preprocedural CAG on outcomes in patients undergoing subsequent TAVR. The study cohort included 1002 patients undergoing transfemoral TAVR, of whom 39.4% (395/1002) had undergone radial and 60.6% (607/1002) femoral access for pre-TAVR CAG. The primary endpoint was a composite of 30-day mortality and major vascular complications after TAVR. Key secondary endpoints included VARC-3-defined complications. The primary endpoint occurred less frequently in patients with prior TRA (3.3%) as compared to patients with prior TFA (6.3%, p=0.04), which was mainly driven by significantly lower rates of major vascular complications (0.8% vs 2.5%, p=0.05). Moreover, incidences of periprocedural access-related vascular injury and unplanned endovascular interventions were lower in TRA patients (13.2% vs 18.0%, p=0.05). The rate of major bleeding tended to be lower in the TRA (1.5%) as compared to the TFA group (3.5%) but was not significantly different (p=0.07). Moreover, the rate of life-threatening bleeding was comparable between both groups (0.5% vs 0.8%, p=0.71). Transradial access for preprocedural CAG was associated with significantly lower rates of vascular complications following subsequent TAVR as compared to transfemoral access. However, despite the tendency to lower major bleedings with transradial access, no significant association was detectable between the access-site of coronary angiography and TAVR-related bleeding complications.

The impact of neoadjuvant chemotherapy on 30-day radical cystectomy outcomes.

4594 Background: Neoadjuvant chemotherapy (NAC), often a cisplatin-based regimen, is recommended before radical cystectomy (RC), as studies have shown a modest survival benefit. However, NAC may confer toxicity and augment preoperative frailty, affecting perioperative outcomes. We investigated the relationship between NAC and 30-day RC outcomes using the National Surgical Quality Improvement Program (NSQIP). Methods: RCs performed between 2019-2020 were identified in NSQIP and the corresponding cystectomy-targeted database. Baseline demographics, comorbidities, and operative parameters were compared via Pearson’s chi-square and t-tests between patients who received NAC before RC and RC alone (RCA) groups. Patient frailty was compared using the NSQIP frailty index (mFI-5), a validated 5-item score including points for diabetes, functional status, chronic obstructive pulmonary disease, heart failure, and hypertension. Multivariable logistic regression was used to compare outcomes, adjusting for age, race, robotic or open approach, urinary diversion type, comorbidities, ASA classification, and functional status. Minor complications included superficial SSI, pneumonia, UTI, bleeding requiring transfusion, AKI, or C. diff infection. Major 30-day complications included sepsis, DVT, stroke, reintubation, renal failure, MI, PE, septic shock, wound dehiscence, deep wound infection, cardiac arrest, readmission, reoperation, or mortality. All statistical tests were two tailed, p&lt;0.05 considered significant. Results: 4,482 RCs were identified. Of these, 1889 (42%) patients received NAC. Compared to RCA, NAC patients were younger (66.9 years vs 70.4 years, p&lt;0.001), had higher rates of white race, being functionally independent, preoperative weight loss, and cigarette use. NAC also had lower ASA class, fewer comorbidities, and lower frailty (mFI-5 0.8 vs 0.9, p&lt;0.001). Compared to RCA, NAC patients had more robotic cystectomies (23% vs 19%, p=0.0003), received more continent diversions, had a shorter length of stay (7.1 vs 7.8 days, p&lt;0.001), and more commonly had pT0 tumors compared to RCA (18.4% vs 5.9%, p&lt;0.001). On MVA, NAC patients had higher rates of minor complications, most notably increased bleeding requiring transfusion [OR 1.8; 95%CI 1.6-2.1; p&lt;0.001]. There was no difference in major complications between NAC and RCA, except NAC was associated with higher rates of sepsis [OR 1.4; 95%CI 1.1-1.8; p=0.003]. There was no difference in 30-day need for reoperation, readmission, or mortality. Conclusions: In the largest study to date on this topic, we found that NAC for RC is often given to younger, healthier patients, and is not associated with higher rates of major complications or mortality. NAC is associated with higher rates of bleeding and sepsis, which may be related to the immunosuppressive effects of chemotherapeutics. Providers should discuss with patients the benefits and risks of NAC before RC.

Renal Cell Carcinoma with Venous Extension: Safety of Laparoscopic Surgery for Thrombus Levels I-IIIa.

Background: Novel studies are helping to consider minimally invasive surgery for treating patients with renal cell carcinoma and venous tumor thrombus. Evidence regarding its feasibility and safety is still sparse and does not include a subclassification for level III thrombi. We aim to compare the safety of laparoscopic vs open surgery in patients with levels I-IIIa thrombus. Materials and Methods: This is a cross-sectional comparative study using single-institutional data on adult patients treated surgically between June 2008 and June 2022. Participants were categorized into open and laparoscopic surgery groups. Primary outcome was difference in the incidence of 30-day major postoperative complications (Clavien-Dindo III-V) between groups. Secondary outcomes were differences in operative time, length of hospital stay, intraoperative blood transfusions, delta hemoglobin level, 30-day minor complications (Clavien-Dindo I-II), estimated overall survival, and progression-free survival between groups. A logistic regression model was performed including adjustment for confounding variables. Results: Overall, 15 patients in the laparoscopic group and 25 patients in the open group were included. Major complications occurred in 24.0% of patients within the open group and 6.7% of patients were treated laparoscopically (p = 0.120). Minor complications arose in 32.0% of patients treated with open surgery and in 13.3% of patients treated in the laparoscopic group (p = 0.162). Although not significant, there was a higher perioperative death rate within open surgery cases. The laparoscopic approach presented a crude odds ratio for major complications of 0.22 (95% confidence interval 0.02-2.1, p = 0.191) compared with open surgery. No differences were found between groups regarding oncologic outcomes. Conclusion: Laparoscopic approach for patients with venous thrombus levels I-IIIa seems to be as safe as open surgery.

Comparison of Safety and Effectiveness of Bivalirudin Between Diabetic and Nondiabetic Acute Coronary Syndrome Patients Undergoing Percutaneous Coronary Intervention

Background: Recurrent thrombotic events remain significantly high in spite of the currently recommended dual antiplatelet (DAPT) and conventional antithrombotic heparin (± GPI/ glycoprotein IIb/IIIa inhibitor) in diabetic ACS patients after PCI compared with non-diabetic even this drug eluting stent (DES) era. Therefore, more potent antithrombotic therapies are warranted for this group of high-risk patients.Comparison of safety and efficacy of newer anticoagulant bivalirudin between diabetic and non-diabetic ACS patients undergoing PCI using bivalirudin versus heparin (± GPI) is less well defined in Bangladeshi population. Objective: To determine and compare the incidence of 30-day major adverse cardiac events (MACEs), stent thrombosis and hemorrhagic complications between diabetic and non-diabetic ACS patients undergoing PCI. Impact of antithrombotic strategy (bivalirudin vs. heparin ± GPI) on the 30- day post PCI clinical outcome was also evaluated and compared between diabetic and non-diabetic subgroup. Methods: In this randomized controlled study, 500 ACS patients aged 18-75 years (200diabetic and 300 non-diabetics) who underwent PCI from November 2018 to October 2019 at the department of cardiology, BSMMU, were randomly assigned, in an open-label fashion to treatment with bivalirudin alone, heparin alone, or heparin plus eptifibatide (GPI) in a 1:1:1 ratio. Among them, 200 patients received Bivalirudin with a loading dose of 0.75 mg/kg, followed by an infusion of 1.75 mg/kg/h for up to 4 hours, 153 patients received UFH with a bolus of 70-100 U/kg (targeted ACT: 200-250 s) and 147 patients got heparin plus eptifibatide as 60 IU/kg heparin along with 180 μg/kg eptifibatide i.v. boluses, followed by a 2 μg /kg /min eptifibatide infusion for 18 hr consistent with current guidelines.Other pre- and post-procedural medications got under current guidelines. Both diabetic and non-diabetic subjects were subdivided into bivalirudin and control group (heparin ± GPI). In diabetic cohort, 100 patients were in bivalirudin and 100 patients were in control group. Among non -diabetic patients, 100 were in bivalirudin and 200 were in control group. The outcome measures were 30-day hemorrhagic complications, stent thrombosis, and MACCEs [death, MI, target lesion revascularization (TLR), and stroke] according to diabetic status. The diabetic and non-diabetic subgroup was also analyzed for the same outcome measure according to antithrombotic strategy. Peri and post PCI clinical follow-up comprised checking office visits and telephone contacts. Results: According to diabetic status, net adverse clinical events (NACEs) were significantly higher in diabetic in comparison to non-diabetic (diabetic vs. non-diabetic, 15% vs. 7.6 %, P=0.008) and was associated with higher incidence of MACCEs (10.5% vs. 4.0%, P=0.004), cardiac death (4 % vs. 1 %, P=0.02) and BARC 2,3,5 grade bleeding events (9% vs. 4 %, P=0.02). In diabetic cohort, incidence of 30-day NACEs was significantly lower in bivalirudin than control group(bivalirudin vs. UFH ± GPI, 6 % vs. 24 %, P=0.004) and was associated with lower incidence of MACCEs (2% vs. 8.5%, P=0.03) and bleeding events (3 % vs. 15 %, P=0.003) whereas incidence of stent thrombosis (2 % vs. 3%, P =0.651) was comparable between the bivalirudin and control groups. There was a significant advantage in favor of bivalirudin treatment among insulin-treated patients with regard to cardiac death at 30-day (bivalirudin vs. control group, 0% vs. 16.6%, p = 0.03) compared with non-insulin treat diabetic patients. However, subgroup analysis of the nondiabetic patients showed that there was no significant difference in the incidence of 30-Day NACEs (4% vs. 9.5%, P=0.09) according anticoagulant status. Multivariate analysis showed that bivalirudin (HR: 0. 202, 95% CI: 0.078 – 0.519, P=0.009) was independent protective factor of 30-day NACEs for diabetic patients. Conclusion: Bivalirudin monotherapy is safer and more efficacious for diabetic ACS patients compared with non-diabetic ACS patients undergoing PCI. J Dhaka Med Coll. 2022; 31(1) : 126-136

Fixed-dose ultrasound-accelerated thrombolysis for acute pulmonary embolism: short- and long-term outcome data from a single-center study

Abstract Funding Acknowledgements Type of funding sources: None. Background Data on clinical outcomes after fixed-dosed ultrasound-accelerated thrombolysis (USAT) for acute pulmonary embolism (PE) is still limited, particularly concerning safety and long-term course. Methods We studied patients with acute PE treated with USAT at a University Hospital between 2018 and 2022. Patients were candidates to USAT if acute PE fulfilled the criteria of high-risk or intermediate-high risk (plus additional markers of clinical severity or early deterioration) as per European guidelines. USAT was given at a standard regimen of 10 mg alteplase/catheter over 15 hours. Early outcomes included: mean pulmonary arterial pressure (mPAP) before and after treatment, National Early Warning Score (NEWS) during USAT; 30-day all-cause death, 30-day hemodynamic decompensation, 30-day PE recurrence, and 30-day major bleeding complications (ISTH definition). Late outcomes were: confirmed CTEPH, persistent post-PE dyspnea, and "post-PE impairment" (PPEI), as defined by the combination of dyspnea with sPAP&amp;gt;35 mm Hg, TAPSE &amp;lt;1.6cm, or RV/RA gradient &amp;gt;36 mmHg, death. Results We included 161 patients: the mean age was 67.8 (SD 14.6) years and 96 were men. All had acute bilateral PE and were treated with two catheters for a median alteplase dose of 20 mg. All patients received anti-Xa activity-adjusted unfractionated heparin, except one, who received argatroban. mPAP decreased from a mean of 35.6 (SD 9.8) to 25.6 (SD 8.2) mmHg after a 15-hour course of treatment (absolute difference 10.2 mmHg; SD 8.1). The NEWS decreased from a median of 5 (Q1-Q3: 4-6) points before USAT to 3 (Q1-Q3: 2-4) points after USAT. No hemodynamic decompensations were recorded within 30 days of hospitalization. One (0.6%) recurrence of PE within 30 days occurred. Two major bleeding (1.2%), of which one (0.6%) was intracranial and fatal, were observed. No other deaths were recorded within 30 days of acute PE. Of 125 patients followed at our center and included in the long-term analysis (median follow-up time 104, Q1-Q3 91-200, days), CTEPH was diagnosed in 2 (1.6%) patients. In one patient, CTEPH was most probably pre-existing, namely present already at the time of "acute" PE, based on hemodynamic and radiological findings. CTEPH was incident in the other patient. 24 (19.2%) patients reported persistent dyspnea, of whom 5 (4.0%) fulfilled the PPEI criteria. Death was recorded in 8 (6.4%) patients after a median of 591 (Q1-Q3; 517-710) days and no event was PE-related. One (0.8%) recurrent PE occurred. Conclusions USAT rapidly reduced the mean pulmonary arterial pressure in selected intermediate-high and high-risk acute PE with a good safety profile. Only 4.0% patients had residual symptoms and right ventricular dysfunction over long-term follow-up. This data reassures USAT being an effective and safe option for acute PE also in terms of long-term outcomes.

Effect of thoracic epidural anesthesia on postoperative outcome in major liver surgery: a retrospective cohort study

PurposePostoperative complications after major liver surgery are common. Thoracic epidural anesthesia may provide beneficial effects on postoperative outcome. We strove to compare postoperative outcomes in major liver surgery patients with and without thoracic epidural anesthesia.MethodsThis was a retrospective cohort study in a single university medical center. Patients undergoing elective major liver surgery between April 2012 and December 2016 were eligible for inclusion. We divided patients into two groups according to whether or not they had thoracic epidural anesthesia for major liver surgery. The primary outcome was postoperative hospital length of stay, i.e., from day of surgery until hospital discharge. Secondary outcomes included 30-day postoperative mortality and major postoperative complications. Additionally, we investigated the effect of thoracic epidural anesthesia on perioperative analgesia doses and the safety of thoracic epidural anesthesia.ResultsOf 328 patients included in this study, 177 (54.3%) received thoracic epidural anesthesia. There were no clinically important differences in postoperative hospital length of stay (11.0 [7.00–17.0] vs. 9.00 [7.00–14.0] days, p = 0.316, primary outcome), death (0.0 vs. 2.7%, p = 0.995), or the incidence of postoperative renal failure (0.6 vs. 0.0%, p = 0.99), sepsis (0.0 vs. 1.3%, p = 0.21), or pulmonary embolism (0.6 vs. 1.4%, p = 0.59) between patients with or without thoracic epidural anesthesia. Perioperative analgesia doses — including the intraoperative sufentanil dose (0.228 [0.170–0.332] vs. 0.405 [0.315–0.565] μg·kg−1·h−1, p < 0.0001) — were lower in patients with thoracic epidural anesthesia. No major thoracic epidural anesthesia-associated infections or bleedings occurred.ConclusionThis retrospective analysis suggests that thoracic epidural anesthesia does not reduce postoperative hospital length of stay in patients undergoing major liver surgery — but it may reduce perioperative analgesia doses. Thoracic epidural anesthesia was safe in this cohort of patients undergoing major liver surgery. These findings need to be confirmed in robust clinical trials.

Outcomes After Supratentorial Craniotomy for Primary Malignant Brain Tumor Resection in Adult Patients: A National Surgical Quality Improvement Program Analysis

The rate of complications remains significant after craniotomy for supratentorial primary malignant brain tumors despite recent advances. The goal of this study is to characterize factors associated with these complications. Data were extracted from the National Surgical Quality Improvement Program database from 2016 to 2019. Patients who underwent a craniotomy for resection of supratentorial primary malignant brain tumors were included. Covariates included demographics/comorbidities, preoperative laboratory values, American Society of Anesthesiologists (ASA) classification, operative time, and postoperative complications. Multivariable logistic regression with backward and forward selection was used to evaluate independent predictors of death, prolonged hospitalization, postoperative stroke with neurologic deficit (CVA), and unplanned readmission. Predictive fit of the model was evaluated using the area under the receiver operating curve (AUC). Of 8965 included cases, the 30-day postoperative risks were 1.9% for CVA, 10.1% for unplanned readmission, 1.2% for prolonged hospitalization, and 2.4% for death. Age, ASA category, disseminated cancer, preoperative functional dependence, and postoperative respiratory complications were predictors of 30-day mortality (AUC, 0.83; P < 0.001). CVA was best predicted by increased operation time (P < 0.001), age, ASA category, and recent weight loss (AUC, 0.63; P= 0.009). Prolonged hospitalization was predicted by nonelective surgery status, time from admission to surgery, reintubation, and postoperative sepsis (AUC, 0.78; P < 0.001). Unplanned readmission was predicted by chronic steroid use, postoperative thrombotic complications after surgery, organ/space surgical site infection, deep vein thrombosis, postoperative systemic sepsis, and septic shock (AUC, 0.68; P < 0.001). Our study identifies predictors of major 30-day complications after craniotomy for this subset of patients with brain tumor.

Racial Disparities in General Surgery Outcomes

IntroductionWhile disparities in Black and Hispanic and Latino patients undergoing general surgeries are well described, most analyses leave out Asian, American Indian or Alaskan Native (AIAN), and native Hawaiian or Pacific Islander patients. This study identified general surgery outcomes for each racial group in the National Surgical Quality Improvement Program. MethodsNational Surgical Quality Improvement Program was queried to identify all procedures conducted by a general surgeon from 2017 to 2020 (n = 2,664,197). Multivariable regression models were used to investigate the impact of race and ethnicity on 30-day mortality, readmission, reoperation, major and minor medical complications, and non–home discharge destinations. Adjusted odds ratios (AOR) and 95% confidence intervals were calculated. ResultsCompared to non-Hispanic White patients, Black patients had higher odds of readmission and reoperation, and Hispanic and Latino patients had higher odds of major and minor complications. AIAN patients had higher odds of mortality (AOR: 1.003 (1.002-1.005), P < 0.001), major complication (AOR: 1.013 (1.006-1.020), P < 0.001), reoperation (AOR: 1.009, (1.005-1.013), P < 0.001), and non–home discharge destination (AOR: 1.006 (1.001-1.012), P = 0.025), while native Hawaiian or Pacific Islander patients had lower odds of readmission (AOR: 0.991 (0.983-0.999), P = 0.035) and non–home discharge destination (AOR: 0.983 (0.975-0.990), P < 0.001) compared to non–Hispanic White patients. Asian patients had lower odds of each adverse outcome. ConclusionsBlack, Hispanic and Latino, and AIAN patients are at higher odds for poor postoperative results than non–Hispanic White patients. AIANs had some of the highest odds of mortality, major complications, reoperation, and non–home discharge. Social health determinants and policy adjustments must be targeted to ensure optimal operative results for all patients.