Adverse Perioperative Outcomes Research Articles

Advanced ovarian cancer and cytoreductive surgery: Independent validation of a risk-calculator for perioperative adverse events

ObjectiveTo independently validate a published risk-calculator for adverse perioperative outcomes in patients with epithelial ovarian cancer undergoing debulking surgery at a high-volume surgical center. MethodsUsing our institution's curated prospective ovarian cancer database, we identified patients with epithelial ovarian cancer who underwent a debulking procedure from 7/2015 to 5/2019, to be used as the validation cohort. Variables used in the published nomogram were collected. These included American Society of Anesthesiology classification, preoperative albumin, history of bleeding disorder, presence of ascites on preoperative imaging, designation of elective or emergent surgery, age of the patient, and a procedure score. Patients were included if they had information available for all the variables used in the nomogram, and 30-day follow-up within our institution. The primary outcome was Clavien-Dindo Class IV with specific conditions (postoperative sepsis, septic shock, cardiac arrest, myocardial infarction, pulmonary embolism, ventilation >48 h, or unplanned intubation) and 30-day mortality. The combination of these endpoints is called the combined complication rate. ResultsA total of 700 patients who underwent debulking surgery for epithelial ovarian cancer during the timeframe met inclusion criteria. The combined complication rate was 11.7%; 9.9% of patients were readmitted; 2.7% required reoperation. Sepsis was the most common primary endpoint complication (4.4%), followed by septic shock (1.4%). There was no 30-day mortality in our cohort. The nomogram performed well, with a c index of 0.715 (95% CI 0.66–0.768), which was comparable to the published nomogram. ConclusionsWe independently validated a complication nomogram at a high-volume surgical center. This nomogram performs well at predicting a lower likelihood of serious postoperative complications. An enhanced nomogram would help identify patients at higher risk for serious complications.

Larger patients shouldn't have fewer options: urethroplasty is safe in the obese.

ABSTRACTObjective To examine the impact of obesity on perioperative outcomes and urethral stricture recurrence after anterior urethroplasty.Material and Methods We reviewed our prospectively maintained single-surgeon database to identify men with anterior urethral strictures who had undergone anastomotic or augmentation urethroplasty between October 2012 and March 2018. In all, 210 patients were included for primary analysis of perioperative outcomes, while 193 patients with at least 12 months follow-up were included for secondary analysis of stricture recurrence. Patients grouped by BMI were compared using univariate and multivariate analyses for perioperative outcomes and log rank testing for recurrence-free survival.Results Overall, 41% (n=86) of patients were obese and 58.6% (n=123) had bulbar urethral strictures. Obese patients had significantly longer urethral strictures (mean=6.7cm±4.7) than nonobese patients (p <0.001). Though urethroplasty in obese patients was associated with increased estimated blood loss (EBL) relative to normal BMI patients on both univariate (p=0.003) and multivariate (p <0.001) analyses, there was no difference in operative time, length of stay, or complication rate between BMI groups. At a mean follow-up interval of 36.7 months, 15% (n=29) of patients had stricture recurrence, yet recurrence-free survival was not significantly different between groups (log rank p=0.299). Dorsal augmentation urethroplasty resulted in significantly fewer recurrences in obese patients compared to nonobese patients (p=0.036).Conclusion Despite the association with increased urethral stricture length and EBL, obesity is not predictive of adverse perioperative outcomes or stricture recurrence. Obese patients should be offered urethral reconstruction, but patient selection and preoperative counseling remain imperative.

The relationship between cardiac muscularis propria and clinical outcomes of peroral endoscopic myotomy in achalasia

Background and aimAchalasia patients usually present lower esophageal sphincter thickening, which can impact the expansibility of cardia. We aimed to investigate the effect of cardiac muscularis propria (MP) on perioperative adverse events (AEs) and treatment outcomes of patients treated with peroral endoscopic myotomy (POEM). MethodsWe retrospectively reviewed 114 patients with achalasia undergoing pre-POEM endoscopic ultrasonography (EUS) between May 2013 and November 2019. Cardiac MP thickness was measured using EUS. POEM failure was defined as Eckardt score >3. Risk factors for perioperative AEs and POEM failure were identified. ResultsPatients were divided into the thin (n = 52) and the thick group (n = 62) based on the median of cardiac MP thickness (3.0 mm). Perioperative AEs rate of the thin group seemed to be slightly higher than that of the thick group (11.5% vs. 4.8%, P = 0.30). During a median follow-up of 30 months (range 1–77), 100 patients completed follow-up, 16 (16%) of which occurred clinical failure. The clinical outcomes of patients in the thin group were significantly poorer than those patients in the thick group (P = 0.006). Cardiac MP thickness was an independent risk factor for POEM failure (hazard ratio 3.9, P = 0.02; Cox regression), but not the risk factor for perioperative AEs (odds ratio 2.6, P = 0.2; logistic regression). ConclusionCardiac MP thickness could be a novel predictive factor for POEM failure in patients with achalasia.

Kidney transplantation in valvular heart disease and pulmonary hypertension: Consensus in waiting.

Kidney transplantation induces a lesser anesthetic, surgical, and physiological alterations than other solid organ transplantation. Concomitant valvular pathologies expose these patients to poor postoperative outcome. There is a critical gap in knowledge and lack of coherence in the guidelines related to the management in patients with end-stage renal disease with valvular heart disease. The individualized diagnostic and management plan should be based on the assessment of perioperative outcomes. Similarly, pulmonary hypertension in end-stage renal disease poses a unique challenge, it can manifest in isolation or may be associated with other cardiac lesions, namely left-sided valvular heart disease and left ventricular systolic and diastolic dysfunction. Quantification and stratification according to etiology are needed in pulmonary hypertension to ensure an adequate management plan to minimize the adverse perioperative outcomes. Lack of randomized controlled trials has imposed hindrance in proposing a unified approach to clinical decision-making in these scenarios. In this review, we have described the magnitude of the problems, pathophysiologic interactions, impact on clinical outcomes and have also proposed a management algorithm for both the scenarios.

Overlapping Urological Surgeries at a Tertiary Academic Center

To evaluate whether the practice of procedure-time overlapping surgery (OS) is associated with inferior outcomes compared to nonoverlapping surgery (NOS) in urology, to address the paucity of data surrounding urologic surgeries to support or refute this practice. We performed a retrospective review of all urological surgeries at a single tertiary-level academic center, Emory University Hospital, from July 2016 to July 2018. Patients who received OS were matched 1:2 to patients who had NOS. The primary outcomes were perioperative and postoperative complications and mortality. We reviewed 8535 urological surgeries. In-room time overlap was seen in 50.5% of cases and procedure-time overlap in 7.4%. Eleven out of the 13 attending urologists performed OS. The average time in the operating room was greater for OS by an average of 14 minutes. The average operative time was greater for OS than NOS by 11 minutes, but this did not reach statistical significance. There was no significant difference between the cohorts for rate of blood transfusions, ICU stay, need for postoperative invasive procedures, length of postoperative hospital stay, discharge location, Emergency Room visits, hospital readmission rate, 30 and 90-day rates of postoperative complications, and mortality. Procedure-time overlapping surgeries constituted a minority of urological cases. OS were associated with greater in-room time. We found no increased risk of perioperative or postoperative adverse outcomes in OS compared to matched NOS.

National trends and outcomes of morbidly obese women who underwent inpatient hysterectomy for benign gynecological disease in the USA

The US population has witnessed an epidemic expansion of obesity in the past several decades; nearly 50% of the population is projected to be obese by 2030 and 25% morbidly obese. This study examined trends, characteristics and outcomes of morbidly obese women who underwent benign hysterectomy. This is a population-based retrospective observational study querying the National Inpatient Sample from January 2012 to September 2015. The study population included 509395 women who underwent hysterectomy for benign gynecological disease: 430865 (84.6%) non-obese women, 50435 (9.9%) women with class I-II obesity and 28095 (5.5%) women with class III obesity. Main outcome measures were (i) cohort-level trends of obesity and perioperative complications assessed by piecewise linear regression with log transformation and (ii) patient-level perioperative complication risk by body habitus assessed with a generalized estimating equation after using a multiple-group generalized boosted model. The rate of class III obesity increased by 40.4%, higher than the rate of class I-II obesity (22.2%) (both, P<.001). In parallel, cohort-level rates of perioperative complication and prolonged hospitalization for ≥7days increased by 19.4% and 54%, respectively (P<.001). In a weighted model, class I-II obesity (16.4% vs 14.6%, odds ratio 1.15, 95% confidence interval 1.08-1.21) and class III obesity (19.2% vs 14.6%, odds ratio 1.39, 95% confidence interval 1.28-1.51) had a significantly increased risk of perioperative complications compared with non-obesity. Larger body habitus was associated with higher total charge (median, $35180, $36094 and $39382; all values cited in US dollars) and prolonged admission rate for ≥7days (2.9%, 3.1% and 3.9%) (both, P<.001). The rate of obesity, particularly morbid obesity, has significantly increased among women undergoing benign hysterectomy in the USA. Morbidly obese women had adverse perioperative outcomes, and the increasing number of morbidly obese women resulted in both an increased perioperative morbidity and total charges as a cohort. National and society-based approaches are necessary to reduce the obesity rate and hysterectomy morbidity.

A Risk Model of Admitting Patients With Silent SARS-CoV-2 Infection to Surgery and Development of Severe Postoperative Outcomes and Death: Projections Over 24 Months for 5 Geographical Regions.

Objective:To model the risk of admitting silent COVID-19-infected patients to surgery with subsequent risk of severe pulmonary complications and mortality.Summary Background Data:With millions of operations cancelled during the COVID-19 pandemic, pressure is mounting to reopen and increase surgical activity. The risk of admitting patients who have silent SARS-Cov-2 infection to surgery is not well investigated, but surgery on patients with COVID-19 is associated with poor outcomes. We aimed to model the risk of operating on nonsymptomatic infected individuals and associated risk of perioperative adverse outcomes and death.Methods:We developed 2 sets of models to evaluate the risk of admitting silent COVID-19-infected patients to surgery. A static model let the underlying infection rate (R rate) and the gross population-rate of surgery vary. In a stochastic model, the dynamics of the COVID-19 prevalence and a fixed population-rate of surgery was considered. We generated uncertainty intervals (UIs) for our estimates by running low and high scenarios using the lower and upper 90% uncertainty limits. The modelling was applied for high-income regions (eg, United Kingdom (UK), USA (US) and European Union without UK (EU27), and for the World (WORLD) based on the WHO standard population.Results:Both models provided concerning rates of perioperative risk over a 24-months period. For the US, the modelled rates were 92,000 (UI 68,000–124,000) pulmonary complications and almost 30,000 deaths (UI 22,000–40·000), respectively; for Europe, some 131,000 patients (UI 97,000–178,000) with pulmonary complications and close to 47,000 deaths (UI 34,000–63,000) were modelled. For the UK, the model suggested a median daily number of operations on silently infected ranging between 25 and 90, accumulating about 18,700 (UI 13,700–25,300) perioperative pulmonary complications and 6400 (UI 4600–8600) deaths. In high-income regions combined, we estimated around 259,000 (UI 191,000–351,000) pulmonary complications and 89,000 deaths (UI 65,000–120,000). For the WORLD, even low surgery rates estimated a global number of 1.2 million pulmonary complications and 350,000 deaths.Conclusions:The model highlights a considerable risk of admitting patients with silent COVID-19 to surgery with an associated risk for adverse perioperative outcomes and deaths. Strategies to avoid excessive complications and deaths after surgery during the pandemic are needed.

Effects of Pharmacologic Venous Thromboembolism (VTE) Prophylaxis in Benign Minimally Invasive Hysterectomy

Study Objective To evaluate if the addition of pharmacologic prophylaxis (heparin, low molecular weight heparin) for VTE is associated with adverse perioperative outcomes in minimally invasive surgery (MIS) hysterectomy for benign indications compared to mechanical prophylaxis alone. Design Retrospective cohort study. Setting Michigan Surgical Quality Collaborative (MSQC). Patients or Participants Patients who underwent a benign MIS hysterectomy (i.e. laparoscopic, vaginal, laparoscopic-assisted vaginal, or robotic-assisted laparoscopy) performed between July 2012 and June 2015 and received mechanical prophylaxis for thromboembolism. Interventions Patients were divided into cohorts who received mechanical prophylaxis alone (MPpx) or mechanical + pharmacologic prophylaxis (M+Pppx). Propensity score matching was used to minimize confounding due to differences in age, race, body mass index>40, hypertension, congestive heart failure, smoking, functional status, preoperative transfusion, preoperative anemia or thrombocytopenia, length of stay, and hospital teaching status. Outcomes evaluated in the propensity-matched cohorts were estimated blood loss, intraoperative time, postoperative blood transfusion, postoperative VTE, surgical site infection, reoperation, and readmission. Measurements and Main Results There were 1944 matched pairs of patients in the Mppx and M+Pppx cohorts. Intraoperative time was 21 minutes longer (168 minutes ± 63 min vs 189 ± 75 mins, p Conclusion Further research is needed into the addition of pharmacologicprophylaxis to mechanical prophylaxis and its association with longer operative time for benign minimally invasive hysterectomy. Given extremely low rates of VTE in both groups and no difference detected in other significant peri-operative outcomes using a large database, it seems reasonable to question routine use of pharmacologic prophylaxis in these patients.

Use of intraoperative navigation for posterior spinal fusion in adolescent idiopathic scoliosis surgery is safe to consider.

The use of image-guided stereotactic navigation is increasing in use in treating AIS; however, no studies have investigated perioperative outcomes and short-term adverse events compared with non-navigated procedures. The aim of the present study is to use a large national pediatric database to assess the rate of utilization of intraoperative navigation in pediatric patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis (AIS) and to compare thirty-day outcomes of navigated vs. non-navigated surgery. The NSQIP-Pediatric database was queried for cases of posterior fusion for AIS. Patients were stratified by whether or not a concurrent code for stereotactic navigation was used (CPT 61,783). Year of procedure, demographics, comorbidities, operative variables and perioperative adverse outcomes were abstracted and assessed using univariate and multivariate analysis. Overall, 12,739 non-navigated patients and 340 navigated patients were identified. The use of navigation increased from 0.5% of cases in 2012 to 5.2% of cases in 2018. Demographics, comorbidities, and number of levels fused did not differ between navigated and non-navigated patients. Navigated cases were on average 41min longer than non-navigated cases (268.6 vs. 309.6min p < 0.001), with 9.84% more cases requiring transfusion (65.0% vs 75.6%, p < 0.001). Hospital stay for navigated cases was an average of 0.4days shorter (3.9days vs 4.3days, p = 0.001). On multivariate analysis, navigated cases had higher odds of prolonged surgery (OR = 2.13, p < 0.001) and lower odds of prolonged length of stay (OR = 0.28, p < 0.001). Although the use of navigation for AIS posterior fusion was associated with longer operative time, post-operative hospital stay was shorter and other perioperative adverse outcomes were not significantly different between groups.

Characteristics and outcomes of women with gynecologic cancers undergoing heated intraperitoneal or intrathoracic chemotherapy

Objective: Heated intraperitoneal (HIPEC) and intrathoracic chemotherapy (HITEC) can be used to treat peritoneal dissemination of gynecologic cancers following cytoreductive surgery. The aim of this study was to investigate patient characteristics, disease outcomes, and perioperative adverse outcomes in women with gynecologic cancer receiving surgical debulking with HIPEC or HITEC.

Comparison of outcomes with utilization of hyperthermic intraperitoneal chemotherapy with paclitaxel and cisplatin versus cisplatin alone at interval debulking surgery in women with epithelial ovarian cancer

Objective: The aim of this study was to investigate perioperative adverse outcomes in women with epithelial ovarian cancer (EOC) receiving interval debulking surgery (IDS) with hyperthermic intraperitoneal chemotherapy (HIPEC) with paclitaxel/cisplatin versus single-agent cisplatin.

Bariatric Surgery In Obese Patients With Ventricular Assist Devices: A Single Center Experience

Background Sleeve gastrectomy (SG) may be a useful intervention to help obese patients with ventricular assist devices (VADs) to improve their candidacy for heart transplantation (HT). However, much remains unknown about perioperative adverse events, weight changes and long-term outcomes. Methods Medical histories of all patients who underwent any bariatric surgery during VAD support in our large VAD/HT center were reviewed. Continuous variables were expressed in means (± standard deviations) or medians (p25-p75) and categorical variables were represented in percentages. The differences between body mass indices (BMIs) at different timepoints were analyzed with paired t-test and Spearman's correlations. P-values ≤ 0.05 were considered statistically significant. Results Between July 2016 and January 2020, eight patients with VADs underwent SG (age 43.8 [± 13.9] years old, 50% males). Mean time between VAD implantation and SG was 29.4 (± 16) months. There was a significant increase in BMI from VAD implantation (37.8 [± 6.7] kg/m2) to the time of SG (42.7 [± 4.5] kg/m2), p = 0.02). Other baseline, perioperative, and postoperative data can be found in Table 1. As early as 3-month after SG, BMIs had significantly decreased to 36.8 (± 4.2) kg/m2, (p Conclusions In this cohort, SG was an effective and safe means to help VAD patients to lose significant amount of weight in a short period of time, reversing the previous trend of weight gain after VAD implantation. Most of the patients did not require ICU admission or blood transfusion. Sleeve gastrectomy should be considered in morbidly obese VAD patients to improve their candidacy for HT.

Improving surgical safety checklist completion using distributed responsibility of checklist item completion among operating room team members: A quality improvement project

Background. Surgical safety checklists are a standard of care for safe operating room practice, but their use has not been associated with reductions in adverse perioperative outcomes in some settings. Non-adherence and partial checklist completion may contribute to this lack of effect.&#x0D; Objective. To examine whether a surgical safety checklist using distributed responsibility of checklist item completion, by allocation of questions and responses among operating room staff, increases surgical safety checklist compliance.&#x0D; Methods. With Quality and Risk Management approval, a multicomponent strategy consisting of novel surgical safety checklist focused on distributed responsibility of checklist item completion was evaluated in orthopaedic operating rooms at The Hospital for Sick Children, Toronto, from July to August 2016 using a before-and-after study design. The intervention consisted of a wall-mounted reusable checklist with questions and responses designated to specific operating room team members. Team training was provided beforehand, operating room team leaders were identified to promote the intervention, and revisions to the checklist content and process were implemented based on feedback on feasibility and clinical sensibility.&#x0D; Results. A total of 45 and 59 children were included in pre-intervention and intervention groups, respectively. Overall, 87% (1,354/1,560) of checklist items were observed. Checklist item completion was significantly increased in the post-intervention group (77% [615/802]) compared with the pre-intervention group (27% [150/522]) (P&lt;0.001).&#x0D; Conclusions. These findings suggest that a multicomponent strategy of designating responsibility for item completion among operating room team members and using a memory aid can improve compliance with surgical safety checklist item completion.

P59. Chronic preoperative opioid use is associated with higher perioperative resource utilization and adverse outcomes in adult spinal deformity patients

BACKGROUND CONTEXT Prior to surgical consultation, spine patients are frequently started on opioid medications despite growing evidence discouraging this practice. Chronic opioid use has been reported in 15-30% of patients with degenerative pathology, but is poorly reported in the adult spinal deformity (ASD) population. PURPOSE This study quantifies the effect of preoperative opioid use on perioperative resource utilization and complications in ASD patients undergoing surgery. STUDY DESIGN/SETTING Retrospective review of prospectively collected data. PATIENT SAMPLE Single center study of consecutive ASD patients. OUTCOME MEASURES Postoperative APS consultation, opioid requirements, PCA use, lidocaine and ketamine infusions, length of stay, and perioperative complications. METHODS Single center study of consecutive ASD patients. Patients were enrolled in a registry where demographics, HRQLs, surgical metrics and complications were recorded prospectively. Opioid use and resource utilization were collected through chart reviews. The impact of opioid use on perioperative resource utilization and complications was examined using multivariate regression accounting for confounders, or univariate analysis as appropriate. RESULTS A total of 139 patients were included, and divided into two groups based on preoperative opioid use: opioid naive n=52, and chronic opioid n=87. Among chronic opioid users, average preoperative opioid use was 122.5 MED, with 43% on doses >90 MED. The chronic opioid were more frequently revisions (68.3% vs 50%, p=0.039). The groups were similar in regards to baseline demographics, magnitude of deformity and surgical invasiveness. The chronic opioid group had more frequent involvement of the acute pain service (48.2% vs 7.84%, p=0.0001), and more frequent postoperative use of ketamine (36.4% vs 7.84%, p=0.0001) and lidocaine (14.1% vs 0%, p=0.005) infusions. Preoperative MED correlated with PCA duration (r=0.29, p=0.0018). The chronic opioid group had higher postoperative opioid requirements (POD1 MED 388.6 vs 178.83, p=0.004 – POD7 MED 198.92 vs 86.23, p=0.0066), and had a higher incidence of perioperative complications (IRR 1.53, p=0.029). Patients in the chronic opioid group showed a trend towards more frequent non-routine discharge (home hospital /rehabilitation / skilled nursing facility) (30.4% vs 16.6%, p=0.07). CONCLUSIONS Sixty-three percent of ASD patients were on chronic opioid analgesia prior to surgery. Opioid use was associated with increased perioperative resource utilization, higher rates of adverse events, and more frequent nonroutine discharge. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

178. Minimally invasive surgery mitigates but does not eliminate adverse perioperative outcomes for frail TLIF

BACKGROUND CONTEXT Frailty is an increasingly recognized characteristic that has been validated across many studies as influencing operative risk. Utilization of frailty indices can allow for its identification of which spine patients may be too high risk for surgical intervention. This may be especially useful when it comes to surgeries that are minimally invasive and are supposed to have decrease perioperative outcomes. PURPOSE Identify MIS techniques effects in postoperative outcomes in TLIF patients. STUDY DESIGN/SETTING Retrospective review of a prospective database. PATIENT SAMPLE TLIF spine patients. OUTCOME MEASURES Complications, length of stay (LOS), estimated blood loss (EBL). METHODS Pts that underwent a lumbar spine procedure in a single-center Comprehensive Spine Quality Database. Pts were stratified based on procedural approach (Open [OP] and Minimally invasive Surgery [MIS]). Frailty was then calculated for each resultant group by using 30 variables with a validated method. Based on these scores, pts were categorized no frailty [NF]: 0.18. Groups were then controlled for surgical invasiveness. Chi-squared tests identified the relationship between complications and length of stay among various frailty states given surgical approach (OP vs MIS). These patients were propensity score matched for levels fused. Hospital acquired complications (HACs) were identified based on frailty groups through the use of chi-squared and t-tests for other surgical factors. A logistic regression analysis identified the association between frailty status and surgical, regarding postoperative (postop) outcomes. RESULTS A total of 1,300 TLIF spine patients were isolated (59yrs, 29.3kg/m2). After PSM for levels fused, there were 338 pts for both MIS and OP. MIS pts were older (56.1 vs 53.3; p CONCLUSIONS This study displays that when frailty status is taken into account, TLIF MIS patients benefit from this procedure type when analyzed against neurologic complications. However, these patients were seen to suffer more from postop complications but did not differ on any other specific complications or surgical variables. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

A cohort study investigating the relationship between patient reported outcome measures and pre-operative frailty in patients with operable, non-palliative colorectal cancer

BackgroundFrailty refers to the reduction in homeostatic reserve resulting from an accumulation of physiological deficits over a lifetime. Frailty is common in older patients undergoing surgery and is an independent risk factor for post-operative mortality, morbidity and increased length of hospital stay. In frail individuals, stressors, such as surgery, can precipitate an acute deterioration in health, manifesting as delirium, falls, reduction in mobility or continence, rendering these individuals at an increased risk of adverse perioperative outcomes. However, little is known about how frailty affects the patient experience, functional ability and quality of life (QoL) after surgery. In addition, the distribution of frailty in this population is unknown.MethodsWe will conduct a multi-centre observational trial to investigate the relationship between patient reported outcome measures and preoperative frailty. We aim to recruit approximately two-hundred patients with operable, potentially curative colorectal cancer. Eligible patients will be identified at three hospital sites. QoL and functional ability (measured using EORTC QLQ-C30 and WHO-DAS 2.0 respectively) will be recorded at the pre-operative assessment clinic, and at 6 and 12 weeks postoperatively. Frailty scores including the Edmonton Frail Scale (EFS) and Rockwood clinical frailty scale (CFS) will be calculated both preoperatively, and at 12 weeks post-operatively. Secondary outcome measures including post-operative morbidity and mortality will be measured using Clavien Dindo classification and 90-day mortality.DiscussionThis observational feasibility study seeks to define the prevalence of frailty in older (> 65 years) colorectal cancer patients and understand how frailty impacts on patient reported outcome measures. This information will help to inform larger studies relating to treatment decision algorithms and promote shared decision making in this population.

Clinical significance of advanced lung cancer inflammation index, a nutritional and inflammation index, in gastric cancer patients after surgical resection: A propensity score matching analysis

The advanced lung cancer inflammation index (ALI) has recently been shown as a prognostic marker for several cancers. However, its predictive value for surgical and oncological outcomes in gastric cancer (GC) remains unclear. We retrospectively reviewed the preoperative ALI in 620GC patients receiving gastrectomy to elucidate the prognostic value for overall survival (OS) and disease-free survival (DFS) and to clarify its predictive value for perioperative risk of surgical site infection (SSI) in GC patients. Propensity score matching (PSM) analysis was also conducted to certify these potentials of preoperative ALI. Preoperative low ALI was significantly correlated with advanced tumor-node-metastasis stage classification. Patients with low ALI showed poorer OS (p<0.0001) and DFS (p<0.0001) compared to those with high ALI, and multivariate analysis showed that decreased ALI was an independent prognostic factor for OS [hazard ratios of 1.59; 95% confidence interval (CI) of 1.15-2.19, p=0.006]. Meanwhile, preoperative low ALI was also an independent risk factor for overall SSI [odds ratio (OR) of 2.04, 95% CI of 1.24-3.35, p=0.005] or organ-space SSI (OR of 2.69, 95% CI of 1.40-5.23, p=0.003). We further conducted PSM analysis and verified all of these findings in the PSM cohort. Quantification of preoperative ALI can identify patients with high risk of adverse perioperative and oncological outcomes in GC patients.

Obesity is associated with adverse short-term perioperative outcomes in patients treated with open and robot-assisted radical cystectomy for bladder cancer

BackgroundObese patients may be predisposed to adverse perioperative outcomes and it is uncertain whether robot-assisted radical cystectomy (RARC) benefits obese patients in comparison to open radical cystectomy (ORC). Thus, we tested the effect of obesity and surgical approach on perioperative outcomes and total hospital charges. MethodsWithin the National Inpatient Sample database (2008–2015), we identified obese (body mass index ≥30 kg/m2) vs. non-obese patients with non-metastatic bladder cancer treated with RARC or ORC. Estimated annual percent changes and weighted multivariable logistic and linear regression models adjusted for clustering as well as age, comorbidities, hospital volume, and respectively surgical approach, lengths of stay, and/or complications were used. ResultsOf all 11,594 patients (unweighted patient count), 1,119 (9.7%) were obese vs. 10,475 (90.3%) were not-obese. Obesity rate increased significantly over time (5.5%–13.3%, annual change: 11%, P = 0.001). RARC, as well as treatment in high volume hospitals was more prevalent in obese vs. non-obese patients (18.3 vs. 14.5% and 40.9 vs. 37.0%, both P < 0.01). In multivariable regression models, obesity independently predicted overall complications (odds ratio [OR] 1.23, confidence interval [CI]: 1.09–1.42), major complications (OR 1.63, CI: 1.41–1.87), longer hospital stay (OR 1.17, CI: 1.02–1.34) and higher total hospital charges ($+8,260, CI: 3951–12,570), all P < 0.01). In subgroup analyses in obese patients, RARC was not associated with overall (OR 1.15, P = 0.4) and major complications (OR 1.10, P = 0.6) or length of stay (OR 0.78, P = 0.1) compared with ORC but with higher hospital charges (+$16,794, P = 0.005). ConclusionObesity predisposes to higher rates of adverse perioperative outcomes at radical cystectomy. The benefit of RARC could not be validated in obese patients.

Impact of Diabetes Mellitus on Outcomes of Patients With Knee Osteoarthritis Who Underwent Knee Arthroplasty: An Analysis of the Nationwide Inpatient Sample.

BackgroundKnee arthroplasty is one of the most common reasons for hospitalizations in the United States. Diabetes mellitus is thought to be associated with adverse perioperative outcomes. We sought to demonstrate the effect of comorbid diabetes on hospitalizations involving patients with knee osteoarthritis who had knee arthroplasty.Materials and methodsData was obtained from the Nationwide Inpatient Sample (NIS) for 2016 and 2017. ICD-10 codes were used to obtain a cohort of patient who were principally admitted for knee osteoarthritis who underwent knee arthroplasty. The patients were further divided according to diabetic status. The primary outcome compared inpatient mortality. Secondary outcomes included mean length of hospital stay, total hospital charges, presence of secondary diagnoses on discharge of acute kidney injury, surgical site infection, sepsis, thromboembolic events, non-ST segment elevation myocardial infarction (NSTEMI).ResultsPatients with diabetes mellitus had a lower adjusted odds ratio for mortality (aOR: 0.45 95% CI: 0.221 - 0.920, p = 0.029), with no significant difference in total hospital charges and length of hospital stay. Interestingly, patients with diabetes had lower odds of NSTEMI; 0.53 (95% CI: 0.369 - 0.750, p < 0.001) sepsis; 0.64 (95% CI: 0.449 - 0.924, p = 0.017) and DVT; 0.67 (95% CI: 0.546 - 0.822, p < 0.001).ConclusionUncomplicated diabetes mellitus is not associated with adverse outcomes in patients hospitalized with knee osteoarthritis who had knee arthroplasty.

Why women are not small men: sex-related differences in perioperative cardiopulmonary exercise testing

BackgroundThe use of preoperative cardiopulmonary exercise testing (CPET) to evaluate the risk of adverse perioperative outcomes is increasingly prevalent. CPET-derived information enables personalised perioperative care and enhances shared decision-making. Sex-related differences in physical fitness are reported in non-perioperative literature. However, little attention has been paid to sex-related differences in the context of perioperative CPET.AimWe explored differences in the physical fitness variables reported in a recently published multi-centre study investigating CPET before colorectal surgery. We also report the inclusion rate of females in published perioperative CPET cohorts that are shaping guidelines and clinical practice.MethodsWe performed a post hoc analysis of the trial data of 703 patients who underwent CPET prior to major elective colorectal surgery. We also summarised the female inclusion rate in peer-reviewed published reports of perioperative CPET.ResultsFitness assessed using commonly used perioperative CPET variables—oxygen consumption at anaerobic threshold (AT) and peak exercise—was significantly higher in males than in females both before and after correction for body weight. In studies contributing to the development of perioperative CPET, 68.5% of the participants were male.ConclusionTo our knowledge, this is the first study to describe differences between males and females in CPET variables used in a perioperative setting. Furthermore, there is a substantial difference between the inclusion rates of males and females in this field. These findings require validation in larger cohorts and may have significant implications for both sexes in the application of CPET in the perioperative setting.