Accordion Severity Grading System Research Articles

Outcomes of secondary cytoreductive surgery in patients with platinum-sensitive recurrent ovarian cancer progressed after prior poly (adenosine diphosphate-ribose) polymerase inhibitors: A retrospective cohort study

ObjectiveTo evaluate the impact of previous poly (adenosine diphosphate-ribose) polymerase (PARP) inhibitor therapy on the effectiveness of secondary cytoreductive surgery (SCS) in patients with platinum-sensitive recurrent ovarian cancer (PSROC). MethodsWe identified patients with PSROC who underwent SCS at the Cancer Hospital, Chinese Academy of Medical Science, between January 2010 and December 2022. Postoperative complications within 30 days were categorized using the Accordion Severity Grading System. The Kaplan‒Meier method was used to estimate both overall survival (OS) and progression-free survival (PFS), and multivariate analysis was used to identify independent prognostic factors. ResultsOf the 265 patients included, 39 received prior PARP inhibitor therapy (Group A), and 226 did not (Group B). The rates of complete resection after SCS did not significantly differ between the two groups (79.5 % for Group A vs. 81.0 % for Group B; p = 0.766). As of December 2023, Group A exhibited a significantly shorter median PFS (14.2 months) than Group B (22.5 months; p = 0.002). Furthermore, the 3-year OS rate was lower in Group A (72.5 %) than in Group B (82.7 %; p = 0.015). The incidence of severe postoperative complications was comparable between Groups A and B (7.7 % vs. 1.8 %; p = 0.061). Multivariate analysis revealed that prior PARP inhibitor therapy significantly reduced the median PFS (hazard ratio (HR) = 4.434; p = 0.021) and OS (HR = 2.076; p = 0.010). ConclusionsSCS for PSROC demonstrated reduced efficacy in patients previously treated with PARP inhibitors compared to those without prior PARP inhibitor treatment.

Laparoscopic versus laparotomic surgical treatment in apparent stage I ovarian cancer: a multi-center retrospective cohort study

BackgroundLaparoscopic treatment shows non-inferior survival outcomes and better surgical outcomes in apparent stage I ovarian cancer (OC) in some studies but has not been well defined.MethodsWe conducted a retrospective study of patients with apparent stage I OC treated in two hospitals between 2012 and 2022. The surgical and oncologic outcomes were evaluated between patients receiving laparoscopic and laparotomic surgery.ResultsWe identified 37 patients with apparent stage I OC, including 15 (40.5%) serous carcinomas, 9 (24.3%) mucinous cancers, 3 (8.1%) endometroid cancers, 2 clear cell carcinomas, and 8 (21.6%) non-epithelial cancers. Sixteen patients received laparoscopic surgery and the other 21 patients underwent laparotomic surgery. The median age (44.5 vs. 49.0 years), mean mass size (10.5 vs. 11.3 cm), and median follow-up time (43.5 vs. 75.0 months) showed no statistically significant differences between patients in laparoscopic and laparotomic groups (all P > 0.05). All the patients underwent comprehensive surgical staging surgery, and the mean surgical time (213.5 vs. 203.3 min, P = 0.507), number of lymph nodes sampling (18.6 vs. 17.5, P = 0.359), proportion of upstaging (12.5% vs. 19.0%, P = 0.680), and postoperative complications (no Accordion Severity Grading System grade ≥ 3) were comparable between two surgical groups. Moreover, patients in the laparoscopic group had significantly less intraoperative blood loss (231.3 vs. 352.4 mL, P = 0.018), shorter interval between surgery and postoperative adjuvant chemotherapy (7.4 vs. 9.5 days, P = 0.004), shorter length of hospital stay (9.9 vs. 13.8 days, P < 0.001) than those treated with laparotomic surgery. During a median follow-up of 54.0 months, 9 (24.3%) relapsed and 1 (2.7%) died, with a 5-year recurrence-free survival (RFS) and disease-specific survival (DSS) rate of 70.6% and 100%, respectively. However, the 5-year RFS (93.3% vs. 58.8%, P = 0.084) and DSS (100% vs. 100%, P = 0.637) rates did not significantly differ between the two groups.ConclusionLaparoscopic surgical treatment had less intraoperative blood loss, earlier postoperative adjuvant chemotherapy administration, shorter hospitalization time, and non-inferior survival outcomes in apparent stage I OC when compared with laparotomic surgery.

Short-term results after robot-assisted surgery for primary rectal cancers requiring beyond total mesorectal excision in multiple compartments.

Rectal cancers requiring beyond total mesorectal excision (bTME) are traditionally operated using an open approach, but the use of minimally invasive robot-assisted procedures is increasing. Introduction of minimal invasive surgery for complex cancer cases could be associated with compromised surgical margins or increased complication rates. Therefore, reporting results both clinical and oncological in large series is important. Since bTME procedure reports are heterogeneous, comparing results is often difficult. In this study, a magnetic resonance imaging (MRI) classification system was used to describe the bTME surgery according to pelvic compartments. Consecutive patients with primary rectal cancer operated with laparoscopic robot-assisted bTME were prospectively included for 2 years. All patients had tumors that threatened the mesorectal fascia, invaded adjacent organs, and/or involved metastatic pelvic lateral lymph nodes. Short-term clinical outcomes and oncological specimen quality were registered. Surgery was classified according to pelvic compartments resected. Clear resection margins (R0 resection) were achieved in 95 out of 105 patients (90.5%). About 26% had Accordion Severity Grading System of Surgical Complications grade 3-4 complications and 15% required re-operations. About 7% were converted to open surgery. The number of compartments resected ranged from one to the maximum seven, with 83% having two or three compartments resected. All 10 R1 resections occurred in the lateral and posterior compartments. The short-term clinical outcomes and oncological specimen quality after robot-assisted bTME surgery were comparable to previously published open bTME surgery. The description of surgical procedures using the Royal Marsden MRI compartment classification was feasible.

Evaluation of postoperative complications in the older population

Evaluation of the frequency and severity of postoperative complications is an integral part of establishing the clinical utility of a specific treatment. They define the possible consequences resulting from the chosen method of treatment, and thus the potential risks associated with this choice. Thanks to the analysis of complications, it is possible to evaluate patients’ safety, identify a problem in the course of surgery within a given hospital and surgical team or carry a financial analysis. Not only is the frequency of occurrence important, but so is the severity of complications. Therefore, in recent years we have seen the development of several new tools for assessing postoperative complications such as the Cla­vien-Dindo scale, the Accordion Severity Grading System, the Postoperative Morbidity Index or the Comprehensive Complication Index. Analysis of the above-mentioned scales may contribute to the development of clear algorithms for the management of older patients at increased risk of severe complications and higher mortality, which subsequently may lead to increased efficacy and safer treatment in this population.

Anxiety and depression in older adult patients undergoing elective liver surgery in allopatry medical treatment

Allopatry medical treatment is common in China. However, allopatry medical therapy can result in many problems, including a negative psychological impact on patients. Patients undergoing liver surgery often experience anxiety and depression. To understand the psychological status of older adult patients undergoing surgery better, this study was designed to investigate the incidence of anxiety and depression in older adult patients undergoing elective liver surgery and to analyze factors associated with it in allopatry medical therapy. A total of 173 older adult patients undergoing elective liver surgery were included in the study. Patients were evaluated using the hospital anxiety and depression scale (HADS). The contributing factors affecting the psychological state of older adult patients undergoing elective surgery were analyzed using a linear regression method. The HADS-A (hospital anxiety and depression scale-anxiety). The correlation (scale) score of the older adult patients undergoing elective liver surgery was (8.69 ± 2.38), including 53 asymptomatic patients, 86 suspicious patients, and 34 symptomatic patients. The HADS-D (hospital anxiety and depression scale-depression) score was (8.31 ± 2.90), including 83 asymptomatic patients, 56 suspicious patients, and 34 symptomatic patients. Multivariate analysis showed that residence and complication grade (Clavien–Dindo Classification of Surgical Complications or Accordion Severity Grading System) significantly correlated with the anxiety level of patients undergoing elective surgery. Residence, a requirement of blood transfusion, total transfusion volume, and Accordion complication grade showed a significant correlation with depression in patients undergoing elective surgery. Anxiety and depression in older adult patients undergoing elective liver surgery were common. Regional differences (local patients vs non local patients) and the severity of complications were the risk factors for anxiety and depression in older adult patients undergoing elective liver surgery. Reducing both regional differences and the severity of complications would be beneficial to alleviate the risk of anxiety and depression in older adult patients undergoing elective liver surgery and thus promote their physical and mental health.

Quality of pancreatic surgery in terms of the burden of complication using the accordion severity grading system and postoperative morbidity index

Quality of pancreatic surgery in terms of the burden of complication using the accordion severity grading system and postoperative morbidity index

The clinical and economic impact of surgical site infections after distal pancreatectomy

BackgroundThe present study aimed to evaluate surgical site infections’ clinical and economic impact after distal pancreatectomy. MethodsThe study was a prospective, monocentric, observational study, including all adult patients who underwent distal pancreatectomy. According to the American Centers for Disease Control and Prevention definition, the surgical site infection assessment was prospectively performed by trained personnel. The Accordion Severity Grading System was used to evaluate the clinical burden of surgical site infection. The hospitalization’s total costs were calculated using the hospital expenditure report, excluding the intraoperative costs. ResultsDuring the study period, 414 distal pancreatectomies were performed. The overall incidence of surgical site infection was 26% (106 patients). Surgical site infections were associated with a higher body mass index (P = .022, odds ratio 1.2), positive preoperative rectal swab for multidrug resistant bacteria (P = .010, odds ratio 4.2), and increased operative time (P = .037, odds ratio 1.1). Using the Accordion Severity Grading System, surgical site infections contributed significantly to the total clinical burden (25.5%) and prolonged hospitalization (P < .001). Furthermore, surgical site infection doubled the costs (12.915 vs 6.888 euros, P < .001). ConclusionSurgical site infection has a high clinical burden, negatively impacting the postoperative course. The costs and length of stay proportionally increased with the surgical site infection severity, doubling the hospitalization expenses.

Suprafascial plane endoscopy versus open carpal tunnel release for idiopathic carpal tunnel syndrome: Use of the Accordion Severity Grading System

This study aimed to assess the safety and effectiveness of modified endoscopic technique with a single portal from an external carpal tunnel approach for surgical operations in a suprafascial plane superficial to the transverse carpal ligament. Reversible nerve injury risk is threefold greater with a conventional endoscopic method than with open carpal tunnel release (OCTR), and this suprafascial plane endoscopic release (SPER) should circumvent the problem of hardware in the carpal tunnel encountered with the conventional endoscopic method and liable to cause iatrogenic damage to the median nerve. However, the surgical consequences of the new technique have not been studied. To fill this gap, a retrospective therapeutic study was conducted to compare negative outcomes versus open surgery. The Accordion Severity Grading System was used to grade complications from 0 to 3 according to necessity of treatment. Sequela and failure rates were also compared between the SPER and OCTR groups. Eighty-eight cases in 72 patients with idiopathic carpal tunnel syndrome (ICTS) met the inclusion criteria. SPER was performed in 28 hands in 27 patients, and OCTR in 60 hands in 49 patients. The results showed no significant difference in complication, sequela, or failure rates between groups (p > 0.05). Suprafascial plane endoscopic release, has certain advantages over the open method and was validated as a safe and effective method of treating ICTS.

Perioperative goal-directed therapy in high-risk abdominal surgery. A multicenter randomized controlled superiority trial

Study objectiveThe potential of perioperative goal-directed therapy (PGDT) to improve outcome after high-risk abdominal surgery remains subject of debate. In particular, there is a need for large, multicenter trials focusing on relevant patient outcomes to confirm the evidence found in small, single center studies including minor complications in their composite endpoints. The present study therefore aims to investigate the effect of an arterial waveform analysis based PGDT algorithm on the incidence of major complications including mortality after high-risk abdominal surgery. DesignProspective randomized controlled multicenter trial. SettingOperating theatres and Post-Anesthesia/Intensive Care units (PACU/ICU) of four tertiary hospitals in The Netherlands. PatientsA total number of 482 patients undergoing elective, abdominal surgery that is considered high-risk due to the extent of the procedure and/or patient comorbidities. InterventionsHemodynamic therapy using an age-specific PGDT algorithm including cardiac index (CI) and stroke volume variation (SVV) measurements during a 24-h perioperative period starting at induction of anesthesia. MeasurementsThe average number of major complications (including mortality) within 30 days after surgery, the number of minor complications, hospital and PACU/ICU length of stay (LOS), amounts of fluids and vasoactive medications used. Complications were graded using the Accordion severity grading system. ResultsThe average number of major complications per patient was 0.79 (PGDT group) versus 0.69 (control group) (p = 0.195). There were no statistically significant differences in the number of minor complications, hospital LOS, PACU/ICU LOS, or grading of complications. Patients in the PGDT group received more fluids intraoperatively, more dobutamine intra- and postoperatively, while patients in the control group received more phenylephrine during the operation. ConclusionsPGDT based on a CI and SVV driven algorithm did not result in improved outcomes after high-risk abdominal surgery. Clinical trial registrationNetherlands Trial Registry: NTR3380.

Accordion: A Useful and Workable Classification of Complications After Breast Reconstructive Surgery.

Background: The aim of this study was to evaluate whether Accordion Severity Grading System can serve as a tool for classification, and severity assessment in reporting postoperative complications after breast reconstructive surgery. Methods: A retrospective analysis covered 88 breast reconstruction surgeries following mastectomy and prophylactic breast amputation with simultaneous reconstruction conducted from January 2015 to December 2017. All registered postoperative complications were evaluated using the Accordion Severity Grading System. The time horizon selected was 6 weeks after surgery. Results: Eighty-two adverse events which met the criteria for complications according to the Accordion classification were observed in 53.4% (n = 47) of the patients. The highest percentage of complications was observed in the group where reconstruction involved using autologous tissues (pedicled transverse rectus abdominis myocutaneous), which were associated with 77.4% risk of complications. In patients with combined methods (latissimus dorsi + prosthesis), complications occurred in half of the cases (51.4%). In patients who underwent reconstructive procedures with artificial materials (expander/prosthesis), complications occurred in 20% of cases. A high γ correlation coefficient of 0.7 (P < .001) was observed between the Accordion degree assigned to the patient and the length of hospital stay. A moderately strong correlation was found between the degree of Accordion system and rehospitalization rate (r = 0.54; P < .0001) and cost of hospital care (r = 0.65; P < .001). Discussion: Based upon the presented study, Accordion Severity Grading System is a workable, intuitive and universal scale for classifying and assessing the severity of postoperative complications and may be recommended for documenting complications in breast reconstructive procedures.

Cumulative operative time and postoperative complication risk in synchronous resections of colorectal liver metastases and primary tumors

Presenter: Allison N Martin MD, MPH | The University of Texas MD Anderson Cancer Center Background: Selection of patients for synchronous resection of colorectal liver metastases (CLM) and primary colorectal cancers (CRC) is complex due to inherent complication rates. We sought to identify perioperative factors associated with postoperative morbidity after synchronous resection. Methods: Using a prospectively maintained quality improvement database, adult patients undergoing synchronous CLM and CRC resection from 1/1/2017-7/1/2020 were included, and 90-day postoperative outcomes were collected. The primary outcome of this study was to estimate effects of clinical covariates on the occurrence of grade 2 or worse (grade ≥2) complications as defined by the Accordion Severity Grading System. Univariate and sequential multivariable logistic regression models were used to estimate the impact of colorectal resection type, Kawaguchi-Gayet complexity grade of hepatectomy and perioperative risk factors on outcomes, including 90-day postoperative complications. Results: A total of 120 patients underwent synchronous CLM and CRC resection during this study period. Most patients (62%) underwent a low-complexity hepatectomy (Kawaguchi-Gayet 1 [KG1]), and the most common CRC resections were right colectomy (n=37, 31%) and proctectomy (n=40, 33%). The most common synchronous resection was a KG1 CLM resection with proctectomy (n=30, 25%). Nearly 40% (n=46) of patients experienced grade ≥2 complications, and 12% (n=14) experienced grade ≥3 complications. Grade ≥2 complication was associated with longer length of stay (median LOS 7.5 vs. 4 days, p506 minutes) had higher rates of grade ≥2 complications (37% vs. 15%, p=0.04) and were associated with a greater than 4-fold increased risk of grade ≥2 morbidity (OR 4.3, 95% CI 1.41-13.1, p=0.01). As an intraoperative surrogate for complexity of hepatectomy, Pringle inflow occlusion time above the median (33 minutes) was not significantly associated with increased risk of grade ≥2 morbidity (p=0.26). In multivariable analysis, increasing operative time was independently associated with grade ≥2 complications, especially for those resections in the highest quartile (OR 7.28, 95% CI 1.73-30.6, p=0.007; Table 1). Conclusion: In patients preoperatively selected for synchronous CLM and CRC resection, prolonged operative time is independently associated with grade ≥2 complications. Surgical teams should consider preoperative initiatives to address factors related to total operative time, including team dynamics, communication, and case selection, to accurately predict and reduce cumulative operative time as a strategy to mitigate complication risk. Operative time may also inform intraoperative decisions after the hepatectomy to continue with or delay the colorectal resection.

Critical evaluation of quality of hepatopancreatic surgery in a medium-volume center in Finland using the Accordion Severity Grading System and the Postoperative Morbidity Index.

Hepatopancreatobiliary surgery is prone to complications. Methods are needed to monitor surgical outcomes and enable comparison between institutions. Complications were collected prospectively and reviewed using the modified Accordion Severity Grading System (MASGS) and the Postoperative Morbidity Index (PMI). This study included 527 consecutive patients receiving either pancreatic or liver resection in 2000-2017 in Central Finland Central Hospital. The PMI was 0.177 for all patients, and 0.192, 0.094, 0.285, and 0.129 for patients receiving major pancreatic (n=218), minor pancreatic (n=93), major liver (n=73), and minor liver (n=143) resection, respectively. The rates of postoperative pancreatic fistula (POPF) after pancreaticoduodenectomies (n=200) were 6.5% for grade B and 5.5% for grade C; rates for biliary leak were 1.0% (grade A), 2.5% (grade B), and 0.5% (grade C). Similarly, the rates for delayed gastric emptying (DGE) were 2.8% (grade A), 15.6% (grade B), and 3.7% (grade C). Postoperative hepatic dysfunction occurred in 2.3%, major surgical site bleeding in 2.3%, and biloma in 7.9% of patients after liver resection. Ninety-day mortality rates were 3.7% and 1.1% in major and minor pancreatic resections, and 8.2% and 0.7% in major and minor liver resections. Major complications occurred in 13.3% and 3.3% in pancreatic, and 19.2% and 6.3% in liver resections, respectively. Major pancreatic and hepatic surgery are associated with significant morbidity and burden in our center, comparable with previous population-based studies. PMI is an informative way to monitor surgical outcomes and enable comparison between institutions.

Severity of Postoperative Complications From the Perspective of the Patient.

Background:Although provider-derived surgical complication severity grading systems exist, little is known about the patient perspective.Objective:To assess patient-rated complication severity and determine concordance with existing grading systems.Methods:A survey asked general surgery patients to rate the severity of 21 hypothetical postoperative events representing grades 1 to 5 complications from the Accordion Severity Grading System. Concordance with the Accordion scale was examined. Separately, descriptive ratings of 18 brief postoperative events were ranked.Results:One hundred sixty-eight patients returned a mailed survey following their discharge from a general surgery service. Patients rated grade 4 complications highest. Grade 1 complications were rated similarly to grade 5 and higher than grades 2 and 3 (P ≤ .01). Patients rated one event not considered an Accordion scale complication higher than all but grade 4 complications (P < .001). The brief events also did not follow the Accordion scale, other than the grade 6 complication ranking highest.Conclusion:Patient-rated complication severity is discordant with provider-derived grading systems, suggesting the need to explore important differences between patient and provider perspectives.

Decoding Grade B Pancreatic Fistula: A Clinical and Economical Analysis and Subclassification Proposal.

The aim of this study was to describe characteristics and management approaches for grade B pancreatic fistula (B-POPF) and investigate whether it segregates into distinct subclasses. The 2016 ISGPS refined definition of B-POPF is predicated on various postoperative management approaches, ranging from prolonged drainage to interventional procedures, but the spectrum of clinical severity within this entity is yet undefined. Pancreatectomies performed at 2 institutions from 2007 to 2016 were reviewed to identify B-POPFs and their treatment strategies. Subclassification of B-POPFs into 3 classes was modeled after the Fistula Accordion Severity Grading System (B1: prolonged drainage only; B2: pharmacologic management; B3: interventional procedures). Clinical and economic outcomes, unique from the ISGPS definition qualifiers, were analyzed across subclasses. B-POPF developed in 320 of 1949 patients (16.4%), and commonly required antibiotics (70.3%), prolonged drainage (67.8%), and enteral/parenteral nutrition (54.7%). Percutaneous drainage occurred in 79 patients (24.7%), always in combination with other strategies. Management of B-POPFs was widely heterogeneous with a median of 2 approaches/patient (range 1 to 6) and 38 various strategy combinations used. Subclasses B1-3 comprised 19.1%, 52.2%, and 28.8% of B-POPFs, respectively, and were associated with progressively worse clinical and economic outcomes. These results were confirmed by multivariable analysis adjusted for clinical and operative factors. Notably, distribution of the B-POPF subclasses was influenced by institution and type of resection (P < 0.001), while clinical/demographic predictors proved elusive. B-POPF is a heterogeneous entity, where 3 distinct subclasses with increasing clinical and economic burden can be identified. This classification framework has potential implications for accurate reporting, comparative research, and performance evaluation.

Value of Model for End-Stage Liver Disease-Serum Sodium Scores in Predicting Complication Severity Grades After Liver Transplantation for Acute-on-chronic Liver Failure

BackgroundPreoperative evaluation is extremely important for patients undergoing liver transplantation (LT) for acute-on-chronic liver failure (ACLF). It is unclear that whether preoperative Model for End-Stage Liver Disease-Serum Sodium (MELD-Na) score has a decisive effect on the complication grade after LF for ACLF. This study is aimed to explore the value of preoperative MELD-Na scores in predicting complication severity grades post LT for ACLF. MethodsOne hundred fifty-nine patients enrolled in the study who underwent LT for ACLF between August 1, 2004, and September 1, 2014, were retrospectively analyzed. The Accordion Severity Grading system was adopted to classify the complication severity grade post LT: Grade 1 (mild), grade 2 (moderate), grades 3–5 (severe), and grade 6 (death). The area under the curve was calculated by plotting the receiver operating characteristic curve for evaluating the diagnostic accuracy of MELD-Na score for severe grade and mortality after LT. The correlation between MELD-Na score with complication severity grade post LT was demonstrated by Spearman correlation and multivariate analysis. The MELD-Na based nomogram was constructed to predict short-term mortality (grade 6). ResultsThe incidences of postoperative complications at all grade levels were: grade 2: 43 patients (27.0%, MELD-Na 27.3 ± 7.4), grade 3: 41 patients (25.8%, MELD-Na 32.7 ± 12.4), grade 4: 31 patients (19.5%, MELD-Na 34.3 ± 12.1), grade 5: 9 patients (5.7%, MELD-Na 30.7 ± 12.3), grade 6: 35 patients (22%, MELD-Na 37.1 ± 10.4). There was no grade 1 patient. The area under the curve of the MELD-Na scores for severe and death group were 0.631 (P < .05, 95% confidence interval [CI], 0.533–0.728) and 0.670 (P < .05, 95% CI, 0.574–0.766) respectively. The MELD-Na score was significantly correlated with the Accordion Severity Grade (rho 0.297, P < .01) by Spearman correlation analysis. Multivariate analysis confirmed that a MELD-Na score ≥ 25 was the only risk factor for postoperative severe grade complications (P < .05, odds ratio = 4.35) and that MELD-Na ≥ 35 was one risk factor for postoperative mortality (P < .01, hazard ratio = 4.72). MELD-Na ≥ 35 combined with other parameters (female, age, systematic infection, and intraoperative placement of the T-tube) in a constructed nomogram model had a good calibration curve with C-concordance of 0.790. ConclusionsMELD-Na scores are significantly correlated with Accordion Severity Grades. It can effectively predict the complication severity grade after LT for ACLF.

Resection of complex pancreatic injuries: Benchmarking postoperative morbidity using the Accordion Severity Grading System

Background: This study benchmarked the severity of complications using the Accordion Severity Grading System (ASGS) in patients undergoing resection for severe pancreatic injuries. Methods: A prospective database of 461 patients with pancreatic injuries treated from 1990 to 2015 was reviewed. 130 patients with AAST grade 3, 4 or 5 pancreatic injuries underwent resection (pancreatoduodenectomy (PD) n=20, distal pancreatectomy n=110), including 30 who had damage control laparotomy (DCL) and later definitive surgery. Uni- and multivariate logistic regression analysis was applied. Results: Overall 238 complications occurred in 95 (73%) patients of which 73% were ASGS grades 3-6. 19 patients (14.6%) died. Patients more likely to have complications after pancreatic resection were older, had RTS <7.8, were shocked on admission, had grade 5 pancreatic injuries with vascular and duodenal injuries, required a DCL, received a larger blood transfusion, had a PD and repeat laparotomies. Applying univariate logistic regression analysis, mechanism of injury, RTS <7.8, shock on admission, DCL, increasing AAST grade and type of pancreatic resection were significant variables for complications. Multivariate logistic regression analysis however showed that only age and type of pancreatic resection (PD) were significant. Conclusion: ASGS-assessed morbidity after pancreatic resection for trauma was high. This detailed outcome analysis serves as a reference for future institutional comparisons.

Resection of complex pancreatic injuries: benchmarking postoperative morbidity using the accordion severity grading system

Background: This study benchmarked the severity of complications using the Accordion Severity Grading System (ASGS) in patients undergoing resection for severe pancreatic injuries. Methods: A prospective database of 461 patients with pancreatic injuries treated from 1990 to 2015 was reviewed. 130 patients with AAST grade 3, 4 or 5 pancreatic injuries underwent resection (pancreatoduodenectomy (PD) n=20, distal pancreatectomy n=110), including 30 who had damage control laparotomy (DCL) and later definitive surgery. Uni- and multivariate logistic regression analysis was applied. Results: Overall 238 complications occurred in 95 (73%) patients of which 73% were ASGS grades 3-6. 19 patients (14.6%) died. Patients more likely to have complications after pancreatic resection were older, had RTS <7.8, were shocked on admission, had grade 5 pancreatic injuries with vascular and duodenal injuries, required a DCL, received a larger blood transfusion, had a PD and repeat laparotomies. Applying univariate logistic regression analysis, mechanism of injury, RTS <7.8, shock on admission, DCL, increasing AAST grade and type of pancreatic resection were significant variables for complications. Multivariate logistic regression analysis however showed that only age and type of pancreatic resection (PD) were significant. Conclusion: ASGS-assessed morbidity after pancreatic resection for trauma was high. This detailed outcome analysis serves as a reference for future institutional comparisons.

Timed Stair-Climbing as a Surrogate Marker for Sarcopenia Measurements in Predicting Surgical Outcomes

BackgroundEstimating sarcopenia by measuring psoas muscle density (PMD) has been advocated as a method to accurately predict post-operative morbidity. The aim of the present study was to determine whether the Timed Stair Climb (TSC) could be used to replace PMD measurements in predicting morbidity. MethodsPatients were prospectively enrolled from March 2014–2015 and were eligible if they were undergoing an abdominal operation. PMD was measured using pre-operative CT scans obtained within 90 days of surgery. Ninety-day complications were assessed using the Accordion Severity Grading System. Multivariable analysis was performed to identify risk factors associated with operative morbidity. ResultsOf the patients, 298 were enrolled and completed TSC prior to undergoing an operation. Using the According Grading System, a grade 2 or higher complication occurred in 72 (24. 2%) patients with 8 (2.7%) deaths. There was an indirect relationship between PMD and TSC (P < 0.0001) and a direct relationship between TSC and complications (P = 0.04). On multivariable analysis decreasing PMD (P = 0.018) and increasing TSC (P = 0.026) were predictive of post-operative morbidity. Receiver operating characteristic curves demonstrated that the TSC was superior to both the ACS NSQIP Risk Calculator and PMD in predicting outcomes (TSC vs. PMD, P = 0.012; PMD vs. ACS NSQIP, P = 0.013; TSC vs. ACS NSQIP, P < 0.0001). ConclusionTSC, PMD, and the ACS NSQIP calculator are all useful tools; however, the TSC is superior in predicting post-operative morbidity.

Decoding grade B pancreatic fistula: a clinical and economical analysis and sub-classification proposal

Background: The 2016 ISGPS refined definition of grade B fistula (B-POPF) is predicated on various post-operative management approaches, ranging from prolonged drainage to interventional procedures. However, the spectrum of clinical severity within this entity is yet undefined. Methods: Pancreatectomies performed at two institutions from 2007 to 2016 were reviewed to identify B-POPFs and their treatment strategies. Sub-classification of B-POPFs into three groups was modeled after the Fistula Accordion Severity Grading System (B1: prolonged drainage only; B2: antibiotics/artificial nutrition/somatostatin analogues/transfusions; B3: percutaneous/endoscopic/angiographic procedure). Clinical and economic outcomes, unique from the ISGPS definition qualifiers, were analyzed across subgroups. Results: B-POPF developed in 320/1949 patients (16.4%), and commonly required prolonged drainage (67.8%), antibiotics (70.3%) and artificial nutrition (54.7%). Percutaneous drainage occurred in 79 patients (24.7%) – always in combination with other strategies. Median number of strategies/patient was 2 (range 1–6). Subclasses B1-3 comprised 19.1%, 52.2% and 28.8% of B-POPFs, respectively, and were associated with progressively worse clinical and economic outcomes (Table 1). These results held true when analyzing pancreatoduodenectomies and distal pancreatectomies separately, and were confirmed by multivariable analysis adjusted for clinical and operative factors. Notably, distribution of the B-POPF subclasses was influenced by institution and type of resection (p < 0.001), while clinical/demographic predictors proved elusive. Conclusion: B-POPF is a heterogeneous entity, where three distinct classes with increasing clinical and economic burden can be identified. This classification framework has potential implications for accurate reporting, comparative research and performance evaluation.Table 1Clinical and economic outcome measures stratified by subtype of grade B fistulaOutcome measure n(%)Total Grade B 320 (100)B1 61 (19.1)B2 167 (52.2)B3 92 (28.8)p-valueTotal strategies used to treat the fistula; median (IQR)2 (1–3)12 (2–3)3 (3–4)<0.001Occurrence of non-fistulous complications244 (76.3)29 (47.5)135 (80.8)80 (87.0)<0.001Number of non-fistulous complications; median (IQR)1 (0–2)0 (0-1)1 (0–2)1 (1–3)0.008Total drain duration, days median (IQR)29 (22–39)26 (23-31)26 (19–36)36 (28–58)0.733ICU transfer38 (11.9)6 (9.8)14 (8.4)18 (19.6)0.025Duration of index stay, days median (IQR)18 (10–28)9 (7–13)21 (15–30)20 (9–33)<0.001Readmission84 (26.3)12 (19.7)31 (18.6)41 (44.6)<0.001Multiple readmissions15 (4.7)4 (6.6)1 (0.6)10 (10.9)0.001Fistula-related readmission67 (20.9)028 (16.8)39 (42.4)<0.001Duration of total stay, days median (IQR)21 (14–31)11 (8–14)24 (16–32)25 (19–38)<0.001PMI, mean ± SD0.325 ± 0.1570.221 ± 0.1630.313 ± 0.1390.417 ± 0.130<0.001Fistula ACB mean, ±SD0.274 ± 0.0810.110 ± 00.260 ± 00.370 ± 0<0.001Fistula as the highest graded complication254 (79.4)34 (55.7)141 (84.4)79 (85.9)<0.001Costs∗2.34521.3632.4602.892<0.001median (IQR)(1.637–3.318)(1.040–1.946)(1.801–3.268)(2.177–4.294)Cost variation∗∗+135%+36%+146%+189%–PMI, post-operative morbidity index; ACB, average complication burden.∗Costs data arc inflation-adjusted and expressed as a proportion to the cost of a non-complicated resection.**As compared to the patients experiencing no complications. Open table in a new tab PMI, post-operative morbidity index; ACB, average complication burden. ∗Costs data arc inflation-adjusted and expressed as a proportion to the cost of a non-complicated resection. **As compared to the patients experiencing no complications.

The value of MELD-Na score in predicting complication severity grades after orthotopic liver transplantation for severe hepatitis

Objective To study the value of preoperative MELD-Na score (Model for End-Stage Liver Disease-Sodium) in predicting complication severity grades after liver transplantation (LT) for severe hepatitis. Methods Patients who underwent LT for severe hepatitis between August 1, 2004, and September 1, 2014 were retrospectively studied. The Accordion severity grading system was used to classify the complication severity grades after LT. The grades were classified as grade 1 (mild), grade 2 (moderate), grade 3-5 (severe), and grade 6 (death). The area under the curve (AUC) was calculated by plotting the receiver operating characteristic curve (ROC) to evaluate the predictive accuracy of the MELD-Na score for the severe and mortality grades after LT. The correlation between the MELD-Na score with the complication severity grade after LT was studied by the Spearman correlation and by multivariate analysis. Results The incidences of postoperative complications for the 159 patients in this study were: grade 2 in 43 patients (27.0%, MELD-Na score 27.3±7.4), grade 3 in 41 patients (25.8%, MELD-Na score 32.7±12.4), grade 4 in 31 patients (19.5%, MELD-Na score 34.3±12.1), grade 5 in 9 patients (5.7%, MELD-Na score 30.7±12.3), grade 6 in 35 patients (22%, MELD-Na score 37.1±10.4). There was no grade 1 patient. The AUC of the MELD-Na score for the severe and death groups were 0.631 (P<0.05; 95%CI, 0.533~0.728) and 0.670 (P<0.05; 95%CI, 0.574~0.766) respectively. The MELD-Na score was significantly correlated with the Accordion severity grade (rho 0.297, P<0.01) on Spearman correlation analysis. Multivariate analysis showed that a MELD-Na score ≥25 was a risk factor of postoperative severe grade complication (P<0.05, OR=4.35), a MELD-Na score ≥35 was a risk factor of postoperative mortality (P<0.01, HR=4.72). Conclusion The MELD-Na score was significantly correlated with the Accordion severity grade, which efficaciously predicted the complication severity grades after liver transplantation. Key words: MELD-Na score; Severe hepatitis; Liver transplantation; Accordion severity grading system; Complication