Classification Of Surgical Complications Research Articles

"A randomized, double-blind study of the effects of omega-3 fatty acids (Omegaven) on outcome after major liver resection".

BackgroundThe body is dependent on the exogenous supply of omega-3 polyunsaturated fatty acids (n3-PUFA). These essential fatty acids are key players in regulating metabolic signaling but also exert anti-inflammatory and anti-carcinogenic properties. The liver is a major metabolic organ involved in fatty acid metabolism. Under experimental conditions, n3-PUFA exert beneficial effect on hepatic steatosis, regeneration and inflammatory insults such as ischemic injury after surgery. Some of these effects have also been observed in human subjects. However, it is unclear whether perioperative administration of n3-PUFA is sufficient to protect the liver from ischemic injury. Therefore, we designed a randomized controlled trial (RCT) assessing n3-PUFA (pre-) conditioning strategies in patients scheduled for liver surgery.Methods/DesignThe Omegaven™ trial is a multi-centric, double-blind, randomized, placebo- controlled trial applying two single doses of Omegaven™ or placebo on 258 patients undergoing major liver resection. Primary endpoints are morbidity and mortality one month after hospital discharge, defined by the Clavien- Dindo classification of surgical complications (Ann Surg 240(2):205–13, 2004) as well as the Comprehensive Complication Index (CCI) (Ann Surg 258(1):1–7, 2013). Secondary outcome variables include length of Intensive Care Unit (ICU) and hospital stay, postoperative liver function tests, fatty acid and eicosanoid concentration, inflammatory markers in serum and in liver tissue. An interim analysis is scheduled after the first 30 patients per randomization group.DiscussionLong-term administration of n3-PUFA have a beneficial effect on metabolism and hepatic injury. Patients often require surgery without much delay, thus long-term n3-PUFA uptake is not possible. Also, lack of compliance may lead to incomplete n3-PUFA substitution. Hence, perioperative Omegaven™ may provide an easy and controllable way to ensure hepaative application of tic protection.Trial registrationClinicalTrial.gov: ID: NCT01884948, registered June 14, 2013; Institution Ethical Board Approval: KEK-ZH-Nr. 2010–0038; Swissmedic Notification: 2012DR3215.

PWE-401 Nurse-led audit of post-operative morbidity following colorectal resection: making the most of existing resources

Introduction: Colorectal and stoma care nurses have been auditing their specialist services for years, but have contributed less frequently to colorectal surgical service-wide audit measuring clinical outcomes relating to surgical as well as nursing care. Nurse-led follow-up provides the ideal platform to measure key indicators of quality care and identify areas for both service improvement and future research activity. Method: A nurse-led follow-up clinic at 30 days following patient discharge was used to audit 142 consecutive patients undergoing elective (n= 98) or emergency (n=44) colorectal resection over a three month period. Audit data were recorded at two time-points, discharge from hospital and at clinic, with audit templates developed using validated tools designed to measure general post-operative morbidity (Grocott et al, 2007; Dindo et al, 2004) and modified to include a focus on colorectal surgery-specific complications. Audit templates were tested during two clinics prior to full data collection to ensure they included all required variables. Results: A wide range of anticipated and unanticipated findings were identified relating to both inpatient and early post- discharge morbidity. Findings were presented to the whole colorectal team, including upper GI and colorectal surgeons and their teams, specialist nurses, theatre-based and ward-based nursing staff. Areas of clinical practice identified by the audit as requiring improvement were identified and discussed, with immediate changes to surgical practice agreed by the whole team. Nurse-led follow-up for all colorectal patients was established as a potential goal for future service improvement. Conclusion: This nurse-led audit enabled the whole colorectal team to scrutinise their clinical practice by comprehensively examining patient outcomes at two time-points following colorectal resection. Nurse-led follow-up using an auditable documentation template facilitates the recognition and reporting of a wide range of post-operative complications and provides valuable support for patients, particularly those who do not have routine access to specialist nursing services.

PTU-271 Hidden morbidity following colorectal resection: postoperative evaluation

Introduction The implementation and evaluation of Enhanced Recovery after Surgery programmes over the past 15 years has ensured the accurate reporting of inpatient morbidity post colorectal resection. However, there is a paucity of audit or research examining post-operative morbidity in the early discharge period. Method 142 consecutive patients undergoing elective (n = 98) or emergency (n = 44) colorectal resection over a three-month period were invited to attend a nurse-led outpatient clinic at 30 days post-discharge. Audit data were collected at two time-points, discharge from hospital and at clinic. Audit templates were developed using the Postoperative Morbidity Survey, 1 Clavien-Dindo classification criteria 2 and modified to include additional colorectal surgery-specific outcomes. Results were recorded and analysed using SPSS. Results Unanticipated findings relating to post-discharge morbidity identified through the audit included: 35% (n = 32) of infection-free inpatients developed surgical site infections following discharge. 34% (n = 47) of all patients had significant urinary symptoms when seen in clinic. Dietary implications at 30 days post-discharge included an appetite of half or less than usual intake in 27% of patients (n = 37) and moderate to major changes in dietary intake compared to their pre-operative diet in 30% (n = 42). 27% (n = 38) of patients had an ileostomy; of those without an ileostomy, 20% (n = 21) had four or more daily bowel movements, with 22% (n = 23) describing their stool consistency as watery, loose or unsettled. 45% (n = 46) of those without an ileostomy reported one or more problematic bowel symptom related to their surgical experience at 30 days post-discharge. Conclusion These audit findings suggest that individuals undergoing colorectal resection experience significant levels of post-discharge morbidity, extending the burden on them and the services required to support them for longer than may have been previously anticipated. Nurse-led follow-up using auditable documentation templates facilitates the recognition and reporting of complications following discharge and provides valuable support for patients. Disclosure of interest None Declared. References Grocott MPW, et al . The Postoperative Morbidity Survey was validated and used to describe morbidity after pelvic surgery. J Clin Epidemiol 2007;60:919–928 Dindo D, et al . Classification of Surgical Complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205–213

PTH-253 Pre-operative weight loss in patients undergoing colorectal surgery

Introduction Malnutrition is associated with poorer post-operative outcomes in patients undergoing surgery. Weight loss and nutritional problems are a common occurrence in cancer and IBD (Irritable Bowel Disease). This study examines the effect of weight loss and complications in a lower gastrointestinal (LGI) surgical population. Method A prospective observational study was undertaken in patients admitted to a GI Unit at St Thomas’ Hospital (October to December 2014) for emergency and elective surgery. Data on unintentional weight loss (6 months prior to admission), LOS (length of stay), and complication occurrence was collated. Results Data on 48 patients was collected; presented in [Table 1][1]: ![Abstract PTH-253 Table 1][2] Abstract PTH-253 Table 1 Conclusion Pre-operative weight loss was associated with increased LOS and complication occurrence in patients undergoing LGI surgery. Early detection and treatment of malnutrition is an essential consideration in the pre-operative optimisation of patients undergoing LGI surgery. Planned elective admissions should have services in place to address nutritional status prior to surgery. Further prospective randomised studies would help elucidate optimal pre-operative nutritional interventions. Disclosure of interest None Declared. Reference 1. Dindo D, Demartines N, Clavien PA. The Clavien-Dindo Classification of Surgical Complications. Ann Surg. 2004;244:931–937 [1]: #F1 [2]: pending:yes

Critical Analysis of Patient-reported Complaints and Complications After Urethroplasty for Bulbar Urethral Stricture Disease

To evaluate the full spectrum of postoperative complications and patient-reported complaints after urethroplasty for bulbar urethral stricture disease. We performed a retrospective review of our institutional database for all patients who underwent urethroplasty from January 1, 2002 to December 1, 2012. We recorded all postoperative complications and patient-reported complaints and grouped them by the Clavien-Dindo classification of surgical complications and into the following categories: perioperative, infectious, anatomic, sexual dysfunction, and voiding related. The Fisher exact test was used to calculate statistical differences among repair types and etiology. Three hundred twenty-five men underwent urethroplasty by 2 surgeons (G.D.W. and A.C.P.) during the period reviewed. Two hundred ninety-two of 325 men (90%) had sufficient follow-up data available. One hundred eleven of 292 men (38%) reported a total of 146 postoperative complications or complaints. Forty-seven of 111 men (42%) were classified as having a perioperative complication, 17 of 111 (15.3%) as infectious, 8 of 111 (7.2%) as anatomic, 29 of 111 (26.1%) as sexual dysfunction, and 32 of 111 (28.8%) as voiding related. The majority of complications were classified as Clavien grade I (87 of 146, 60%). Forty-seven of 146 men (32%) were classified as having Clavien grade II, 9 of 146 (6%) as grade III, and 3 of 146 (2%) as grade IV. There were no grade V complications. Patients with iatrogenic etiology had a higher rate of infectious-related complications when compared with idiopathic or traumatic (17.5% vs 3.7%, 4.8%, respectively; P = .008). Urethroplasty continues to have excellent outcomes with acceptable complication rates, the majority of which are self-reported complaints about voiding, scrotal and/or perineal neuralgia, and sexual dysfunction and appear to have minimal long-term sequelae.

Nonmodifiable factors and complications contribute to length of stay in robot-assisted partial nephrectomy.

Introduction/Objective: Robotic-assisted partial nephrectomy (RPN) offers a mean length of stay (LOS) of 2 to 3 days. The purpose of this study is to determine the impact of modifiable and nonmodifiable risk factors on hospital LOS after RPN.Patients and Methods: We retrospectively reviewed our prospectively maintained database to identify all patients undergoing RPN for localized tumors at five US centers from 2007 to 2013. Patient and tumor characteristics were compared among hospital LOS groups. Associated factors were modeled using univariate and multivariate cumulative logistic regression to determine factors predictive of hospital LOS.Results: One thousand five hundred thirty-two patients were grouped into LOS 1 to 3 days (1298, 84.1%), LOS=4 days (133, 8.6%), and LOS >4 days (110, 7.2%). Patient demographics were similar between groups. Patients in the LOS=4 and LOS >4 day groups were more likely to have a higher Charlson comorbidity index score (mean 2.2, 3.1 and 3.8; p<0.001), higher nephrometry score (mean 7.1, 7.6, 7.8; p=0.0002), and larger tumors (mean 2.9, 3.6 and 3.5 cm; p<0.0001) than those in the LOS 1 to 3 day group. Significant differences in complication rates were observed when comparing LOS 1–3 (116, 8.9%), LOS=4 (40, 30%), and LOS >4 (59, 54%). According to the Clavien–Dindo classification of surgical complications, 11 grade 3 and 11 grade 4 complications occurred in patients with an LOS of 4 or more days (p<0.0001). Postoperative transfusion, deep vein thrombosis, pulmonary embolism, atrial fibrillation, dyspnea/atelectasis, ileus, and acute renal failure each significantly predicted a hospital LOS >4 days (p<0.001).Conclusion: 15.8% of patients undergoing RPN have an LOS of 4 days or more. Longer LOS was independently associated with higher Charlson index, nephrometry score (nonmodifiable factors), and perioperative complications (potentially modifiable). These data may be useful in perioperative counseling and payer precertification.

Implementation and preliminary validation of a new score that predicts post-operative complications.

An accurate pre-operative risk assessment could reduce morbidity and mortality for high-risk surgical patients. The aim of the study was to implement and preliminary validate a new score that could predict the occurrence of post-operative complications (PoCs): the Anesthesiological and Surgical Postoperative Risk Assessment (ASPRA) score. The ASPRA score was created through a literature's review; a score of 1-3 was given to each identified risk factor, according to its statistical correlation with PoC. ASPRA was retrospectively applied to a derivation set of 176 surgical patients. A receiver operating characteristic (ROC) analysis evaluated the discriminating ability of the score and cutoff value in predicting the occurrence of PoCs, according to the Clavien-Dindo classification of surgical complications. The statistical validation of the score and related cutoff values was prospectively ran within a validation set of 1928 surgical patients. Through ROC analysis, an ASPRA score of 7 was chosen as the cutoff value in the derivation set. In the validation set, 65.3% of patients presented a PoC (Clavien ≥ 1). In this group, ROC analysis showed an area under the curve (AUC) of 0.72, and although potentially related to the high rate of complications a high positive predictive value of 87.0% has been observed. No significant differences were found in ROC-AUC, sensitivity, specificity, or positive or negative predictive value between the derivation and validation sets (P > 0.05). The new ASPRA score has a high positive predictive value to predict the occurrence of PoCs. Further prospective studies are required to confirm these results.

Estimation of mortality and morbidity risk of radical cystectomy using POSSUM and the Portsmouth predictor equation.

IntroductionThe Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM) and the Portsmouth predictor equation (P-POSSUM) are simple scoring systems used to estimate the risk of complications and death postoperatively. We investigated the use of these scores to predict the postoperative risk in patients undergoing radical cystectomy (RC).Material and methodsIn this retrospective study, we enrolled 280 patients who underwent RC for invasive bladder cancer between January 2003 and December 2011. Morbidity and mortality were predicted using the POSSUM and P-POSSUM equations. We further assessed the ability of the POSSUM and P-POSSUM to predict the mortality and morbidity risk in RC patients with a Clavien–Dindo classification of surgical complications of grade II or higher.ResultsThe observed morbidity and mortality rates were 58.9% (165 patients) and 1.8% (5 patients), respectively. Predicted morbidity using POSSUM was 49.2% (138 patients) compared to the 58.9% (165 patients) observed (P <0.0001). Compared to the observed death rate of 1.8% (5 patients), predicted mortality using POSSUM and P-POSSUM was 12.1% (34 patients) and 3.9% (11 patients), respectively (P <0.0001 and P = 0.205). The mortality risk estimated by P-POSSUM was not significantly different from the observed mortality rate.ConclusionsThe results of this study supported the efficacy of POSSUM combined with P-POSSUM to predict morbidity and mortality in patients undergoing RC. Further prospective studies are needed to better determine the usefulness of POSSUM and P-POSSUM for a comparative audit in urological patients undergoing RC.

Complications after laparotomy for trauma: a retrospective analysis in a level I trauma centre.

Laparotomy is a potential life-saving procedure after traumatic abdominal injury. There is limited literature about morbidity and mortality rates after trauma laparotomy. The primary aim of this study is to describe the complications which may occur due to laparotomy for trauma. Retrospective evaluated single-centre study with data registry up to 1 year after initial laparotomy for trauma was performed in a level 1 trauma centre in The Netherlands. Between January 2000 and January 2011, a total of 2390 severely injured trauma patients (ISS ≥ 16) were transported to the VUMC. Patient demographics; mechanism of injury; injury patterns defined by Abbreviated Injury Scale (AIS), Injury Severity Score (ISS) and Revised Trauma Score (RTS); surgical interventions and findings; and morbidity and mortality were documented. A total of 92 trauma patients who underwent a trauma laparotomy met the inclusion criteria. Of these patients, 71 % were male. Median age was 37 years. Median ISS was 27. Mechanisms of injury comprised of car accidents (20 %), fall from height (17 %), motorcycle accidents (12 %), pedestrian/cyclist hit by a vehicle (9 %) and other in three patients (5 %). Penetrating injuries accounted for 37 % of the injuries, consisting of stab wounds (21 %) and gunshot wounds (16 %). Complications classified by the Clavien-Dindo Classification of Surgical Complications showed grade I complications in 21 patients (23 %), grade II in 36 patients (39 %), grade III in 21 patients (23 %), grade IV in 2 patients (2 %) and grade V in 16 patients (17 %). Laparotomy for trauma has a high complication rate resulting in significant morbidity and mortality. Most events occur in the early postoperative period. Further prospective research needs to be conducted in order to identify possibilities to improve care in the future.

Trends and results in treatment of gastric cancer over last two decades at single East European centre: a cohort study.

BackgroundA steady decline in gastric cancer mortality rate over the last few decades is observed in Western Europe. However it is still not clear if this trend applies to Eastern Europe where high incidence rate of gastric cancer is observed.MethodsThis was a retrospective non-randomized, single center, cohort study. During the study period 557 consecutive patients diagnosed with gastric cancer in which curative operation was performed met the inclusion criteria. The study population was divided into two groups according to two equal time periods: 01-01-1994 – 31-12-2000 (Group I – 273 patients) and 01-01-2001 – 31-12-2007 (Group II – 284 patients). Primary (five-year survival rate) and secondary (postoperative complications, 30-day mortality rate and length of hospital stay) endpoints were evaluated and compared.ResultsRate of postoperative complications was similar between the groups, except for Grade III (Clavien-Dindo grading system for the classification of surgical complications) complications that were observed at significantly lower rates in Group II (26 (9.5%) vs. 11 (3.9%), p = 0.02). Length of hospital stay was significantly (p = 0.001) shorter (22.6 ± 28.9 vs. 16.2 ± 17.01 days) and 30-day mortality was significantly (p = 0.02) lower (15 (5.5%) vs. 4 (1.4%)) in Group II. Similar rates of gastric cancer related mortality were observed in both groups (92.3% vs. 90.7%). However survival analysis revealed significantly (p = 0.02) better overall 5-year survival rate in Group II (35.6%, 101 of 284) than in Group I (23.4%, 64 of 273). There was no difference in 5-year survival rate when comparing different TNM stages.ConclusionsGastric cancer treatment results remain poor despite decreasing early postoperative mortality rates, shortening hospital stay and improved overall survival over the time. Prognosis of treatment of gastric cancer depends mainly on the stage of the disease. Absence of screening programs and lack of clinical symptoms in early stages of gastric cancer lead to circumstances when most of the patients presenting with advanced stage of the disease can expect a median survival of less than 30 months even after surgery with curative intent.

Free flap reconstruction for head and neck cancer can be safely performed in both young and elderly patients after careful patient selection.

Surgical treatment of head and neck cancer often results in complex defects requiring reconstruction with microvascular free tissue transfer. However, in elderly patients, curative treatment with radical surgery and free flap reconstruction is often withheld. The objective of this study is to assess the outcomes of free flap surgery in elderly patients, using a standard surgical complication classification system. A retrospective review was conducted of patients who underwent primary free flap reconstruction following major surgery for head and neck cancer between 1995 and 2010. Complications were assessed using the Clavien Dindo classification system, and grades III-V were classified as major complications. Comorbidity was classified according to the adult comorbidity evaluation index 27. A comparison was done between patients <70 and ≥70 years. Two hundred-two patients were included in this study. Multivariate analysis showed that only disease stage was a significant predictor of recipient site complications, and comorbidity was the only significant predictor of medical complications. Age was not a predictor of complications. There were no significant differences in disease specific or overall survival between young and elderly patients. Optimal patient selection for free flap surgery is essential. This requires thorough pre-operative assessment, including analysis of comorbidity in both young and elderly patients. Patients' biological age, and not chronological age, should be individually determined to assess feasibility of major surgery. Patients should not be denied surgery based on age alone.

Adopting Clavien – Dindo classification of surgical complications in 438 cases of vaginal native tissue repair for pelvic organ prolapse

Objective: To analyze safety of vaginal native tissue prolapse repair using Clavien-Dindo (CD) classification of surgical complications.

Prospective Randomized Comparison of Transperitoneal vs Retroperitoneal Laparoscopic Simple Nephrectomy

To compare the results of transperitoneal laparoscopic vs retroperitoneoscopic simple nephrectomy for benign renal diseases in a prospective randomized design. In this study between January 2009 and August 2013, 31 patients underwent transperitoneal laparoscopic nephrectomy and 31 retroperitoneoscopic nephrectomy after randomization. The 2 groups were compared for the visual pain score on the first and second postoperative days as the primary end point of the study. Complications were recorded and graded using Dindo-modified Clavien classification of surgical complications. Secondary objectives were to compare each of the operative techniques in terms of duration of surgery, complication rates, and postoperative convalescence. Statistical analysis was performed with SPSS version 16.0 with P<.05 considered statistically significant. The difference in the visual pain score (4.9 vs 2.7 on day 1; 3.2 vs 1.1 on day 2) and the tramadol requirements (167.3 vs 132.8mg) were statistically significant and more in the transperitoneal laparoscopic nephrectomy. The hospital stay and convalescence were significantly lower in retroperitoneoscopic group. Three patients in transperitoneal laparoscopic nephrectomy group and 2 patients in retroperitoneoscopic group required conversion. Mean time to normal activities wassignificantly less in retroperitoneal laparoscopic nephrectomy group (16.7±3.5 vs 9.34±4.9days; P=.0001). Although both transperitoneal laparoscopic and retroperitoneoscopic simple nephrectomy are feasible options for nonfunctioning kidneys due to benign renal diseases in adults, retroperitoneal laparoscopic nephrectomy is associated with significantly less pain, less analgesic requirement, shorter hospital stay, and short convalescence as compared with transperitoneal laparoscopic approach.

Preoperative model for end-stage liver disease score as a predictor for posthemihepatectomy complications.

BackgroundAs diagnostic techniques advance and surgical outcomes improve, the rate of utilization of liver hemihepatectomy for various indications will continue to increase.ObjectivesTo explore the preoperative predictors of liver hemihepatectomy postoperative complications.Patients and methodsThis study included retrospective analysis of the clinical data of patients who underwent either liver hemihepatectomy or extended hemihepatectomy at Georg August University Hospital-Goettingen for the period 2002–2012. The outcomes were either postoperative complications or death of the patient (within 3 months from the end of the operation). Modified classification of surgical complications was adopted in the current study. The preoperative model for end-stage liver disease (MELD) score, aspartate aminotransferase, creatinine, international normalized ratio, and bilirubin in addition to the demographic characteristics of the patients and intraoperative blood loss were analyzed as predictive for postliver hemihepatectomy complications.ResultsThe study included 144 patients who underwent liver hemiheptectomy or extended hemihepatectomy through the study period (2002–2012). Postoperative complications were reported among patients out of 144 (52.1%). The most frequent complications were pleural effusion (26.7%), biliary leakage (21.3%), wound dehiscence (13.3%), ascites, and intra-abdominal abscess (6.7%). Death was reported among six patients of those who developed complications (8%). There were four cases of hepatic cirrhosis (one macroscopic and three microscopic). Two of the microscopic cases had no postoperative complications (grade 1), whereas one case had grade 3a and the macroscopic case had postoperative complication grade 1. Their MELD scores ranged between 6 and 10 preoperatively. The association between preoperative MELD score and development of posthemihepatetomy was statistically significant, P=0.002. Death was reported in six cases, yielding a mortality rate of 4.17%. MELD score preoperatively was the only significant predictor for postoperative complications.ConclusionThe rate of complications following hemihepatectomy remains high, with 52.1% of the patients in the current study having at least one complication as all of our patients underwent either hemihepatectomy or extended hemihepatectomy. A 4.17% mortality rate has been reported. A higher preoperative MELD score is the only significant predictor for the development of posthemihepatectomy complications.

Results of treatment of patients with gallstone disease and ductal calculi by single-stage laparoscopic cholecystectomy and bile duct exploration.

IntroductionCholedocholithiasis is the most common cause of obstructive jaundice. Common bile duct stones are observed in 10–14% of patients diagnosed with gall bladder stones. In the case of gall bladder and common bile duct stones the procedure involves not only performing cholecystectomy but also removing the stones from bile ducts.AimTo compare the results of the treatment of patients with gallstone disease and ductal calculi by one-stage laparoscopic cholecystectomy and common bile duct exploration with two other methods: one-stage open cholecystectomy and common bile duct exploration, and a two-stage procedure involving endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy.Material and methodsBetween 2004 and 2011 three groups of 100 patients were treated for obstructive jaundice caused by choledocholithiasis. The first group of 42 patients underwent ERCP followed by laparoscopic cholecystectomy. The second group of 23 patients underwent open cholecystectomy and common bile duct exploration, whereas the third group of 35 patients underwent laparoscopic cholecystectomy with common bile duct exploration. The data were analysed prospectively. The methods were compared according to complete execution, bile duct clearance and complication rate. Complications were analysed according to Clavien’s Classification of Surgical Complications. The results were compared using the ANOVA statistical test and Student’s t-test in Statistica. Value of p was calculated statistically. A p-value less than 0.05 (p < 0.05) signified that groups differed statistically, whereas a p-value more than 0.05 (p > 0.05) suggested no statistically significant differences between the groups.ResultsThe procedure could not be performed in 11.9% of patients in the first group and in 14.3% of patients in the third group. Residual stones were found in 13.5% of the patients in the first group, in 4.3% of the patients in the second group and in 6.7% of the patients in the third group. According to Clavien’s classification of complications grade II and III, we can assign the range in the first group at 21.6% for grade II and 0% for grade III, in the second group at 21.4% and 3.6% and in the third group at 6.7% and 3.3% respectively.ConclusionsThe use of all three methods of treatment gives similar results. One-stage laparoscopic cholecystectomy with common bile duct exploration is after all the least invasive, safer and more effective procedure.

MP3-20 RENAL AUTOTRANSPLANTATION: AN UNDERUTILIZED OPERATION FOR COMPLEX UPPER TRACT PATHOLOGY

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery II1 Apr 2014MP3-20 RENAL AUTOTRANSPLANTATION: AN UNDERUTILIZED OPERATION FOR COMPLEX UPPER TRACT PATHOLOGY Nikolai Sopko, Alvin Wee, John Rabets, Hannah Kerr, Stuart Flechner, and Vankatesh Krishnamurthi Nikolai SopkoNikolai Sopko More articles by this author , Alvin WeeAlvin Wee More articles by this author , John RabetsJohn Rabets More articles by this author , Hannah KerrHannah Kerr More articles by this author , Stuart FlechnerStuart Flechner More articles by this author , and Vankatesh KrishnamurthiVankatesh Krishnamurthi More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.199AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Review of current indications and treatment success of renal autotransplantation in patients with high rates of failed treatments and prior abdominal surgeries. METHODS We performed an IRB approved retrospective review of all patients who underwent renal autotransplantation at our institution, between January 2005 and August 2013. Complications were graded according to the Clavien Classification of Surgical Complications. RESULTS 61 patients underwent renal autotransplantation of 63 renal units (2 patients underwent bilateral autotransplantation). Indications included medical stone disease that was refractory to endoscopic management 23 (37%), proximal ureteral obstruction 18 (29%), renovascular disease 17 (27%), and loin pain-hematuria syndrome (LPHS) 5 (9%). Forty patients (63%) had prior open abdominal surgery with 16 (25%) having 3 or more operations. Median ASA score was 2 with 40% of patients with a score of 3. Operative approaches included a single midline intraperitoneal incision in 44 patients (70%), separate extraperitoneal (flank and lower quadrant) incisions in 17 patients (27%) and laparoscopic nephrectomy followed by an extraperitoneal lower quadrant incision in 2 patients (3%). Mean autograft nephrectomy time was 152 ± 79 minutes. Mean vascular anastomosis time was 50 ± 21 minutes. Median follow-up was 7 (IQR 2-23) months. Immediate technical success was achieved in 62 patients (98%). 2 grafts (3%), transplanted for stone disease and a proximal ureteral obstruction, failed and were removed on post-operative days 0 and 2, respectively. Resolution of the primary indication was noted in 53 (84%) patients. Chronic pain was associated with a worse outcome. Of the failed treatments, 2 had LPHS and 4 had stone disease with refractory pain despite resolution of obstruction. Median hospital stay was 8 (IQR 7-10) days with 2 readmissions within 30 days of discharge. 12 patients (19%) had Clavien Grade II, 2 (3%) had Clavien Grade III, and 1 had a Clavien Grade IV surgical complication. There were no deaths. All postoperative complications resolved without autograft compromise. CONCLUSIONS Renal autotransplantation can provide excellent outcomes for difficult to treat urologic and vascular conditions in a complex patient population. Utilization of 2 extraperitoneal incisions aids in cases of multiple prior abdominal surgeries and facilitates decreased nephrectomy and vascular anastomosis times. Patients undergoing autotransplantation for chronic pain have a greater chance of continued symptoms however the majority have resolution. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e41-e42 Peer Review Report Advertisement Copyright & Permissions© 2014MetricsAuthor Information Nikolai Sopko More articles by this author Alvin Wee More articles by this author John Rabets More articles by this author Hannah Kerr More articles by this author Stuart Flechner More articles by this author Vankatesh Krishnamurthi More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Bladder Neck Incision for Female Bladder Neck Obstruction: Long-term Outcomes

To evaluate the long-term outcomes of bladder neck incision (BNI) for primary bladder neck obstruction in women. Eighty-four women were diagnosed on the basis of videourodynamic study. BNI was performed for each patient, with incisions made at 2 different sites on the bladder neck. Follow-up data were available for 6-78 months (average, 27.4), postoperatively. Successful recovery after BNI without serious complications was achieved in 71 of 84 (84.5%) patients. During follow-up, the mean International Prostate Symptom Score decreased from 22.9 to 7.9 (P <.01). Quality of life decreased from 4.1 to 2.4 (P <.01). The maximum uroflow rate increased from 9.75 to 18.79 mL/s (P <.01). The postvoid residual decreased from 115.11 to 23.29 mL (P <.01). The maximal detrusor pressure at the maximum uroflow rate decreased from 69.61 to 20.48 cm H2O (P <.01). Several complications were identified after surgery, including hemorrhage, re-BNI, vesicovaginal fistula (VVF), stress urinary incontinence (SUI), and urethral stricture. All these complications were grade IIIa in the Clavien Classification of Surgical Complications. Three patients (3.6%) developed a VVF after BNI; these VVFs were repaired successfully. Four (4.7%) patients experienced SUI and recovered after transvaginal tension-free vaginal tape-obturator. Postoperative bleeding was identified in 3 patients (3.6%), and 1 received a blood transfusion. Three (3.6%) patients experienced urethral stricture after BNI and recovered after receiving intermittent urethral dilation. Primary bladder neck obstruction is uncommon and easily treatable when properly diagnosed by videourodynamic study, and BNI has a high success rate. Careful, sufficiently deep incisions at the 2- and 10-o'clock positions can ensure its success. Complications such as postoperative VVF or SUI can occur and must be actively managed.

Surgical Outcomes in the Management of Isolated Nodal Recurrences: A Multicenter, International Retrospective Cohort

We report a multicenter international cohort representing what is toour knowledge the largest surgical experience with managing isolated retroperitoneal nodal recurrence of renal cell carcinoma, a unique subset of locoregional disease, yet to be described in detail. Patients with isolated nodal recurrence of pTanyN+M0 disease after nephrectomy were identified by retrospective chart review at 3 independent institutions. Progression-free survival was estimated by the Kaplan-Meier method and used to compare survival outcomes between primary T(1-2)N(any)M0 and T3N(any)M0 tumors as well as clear cell and nonclear cell histology renal cell carcinoma. A total of 22 patients met study inclusion criteria. Median time to localpostoperative recurrence was 31.5 months (IQR 12.9-43.3). After resection of isolated nodal recurrence 10 patients (46%) had a secondary recurrence at amedian of 11.2 months (IQR 8.1-18.4), of whom 2 (9%) died of the disease. Overall median progression-free survival was 12.7 months, including 24.8 months for T(1-2)N(any)M0 tumors, 9.9 months for T3N(any)M0 tumors, and13.4 and 17.6 months for clear and nonclear cell renal cell carcinoma, respectively. Surgical resection represents the best curative option for patients who present with isolated retroperitoneal lymph node recurrence of renal cell carcinoma. Durable postoperative progression-free survival is attainable in many patients regardless of histology or clinical TNM stage. In addition, our cohort showed a lower renal cell carcinoma related mortality rate than in previous series of local metastasis. As such, all patients free of precluding comorbidities should be considered candidates for complete surgical resection performed by an experienced genitourinary surgeon.

30-Day Hospital Readmission after Robotic Partial Nephrectomy—Are We Prepared for Medicare Readmission Reduction Program?

After CMS introduced the concept of the Hospital Readmissions Reduction Program, hospitals and health care centers became financially penalized for exceeding specific readmission rates. We retrospectively reviewed our institutional review board approved database of patients undergoing robotic partial nephrectomy at our institution and included in our analysis patients who were readmitted to any hospital as an inpatient stay within 30 days from discharge home after robotic partial nephrectomy. From March 2006 to March 2013 a total of 627 patients underwent robotic partial nephrectomy at our center and 28 (4.46%) were readmitted within 30 days of surgery. Postoperative bleeding was responsible for 8 (28.5%) readmissions. Pulmonary embolism was reported in 3 cases and retroperitoneal abscess was diagnosed in 2. Urinary leak requiring surgical intervention developed in 2 patients, pneumonia was diagnosed in 2 and 2 patients were readmitted for chest pain. Overall 9 (32.1%) patients presented with major complications requiring intervention. On multivariable analysis Charlson comorbidity index score was the only factor significantly associated with a higher 30-day readmission rate (p = 0.03). If the Charlson score was 5 or greater the chance of hospital readmission would be 2.7 times higher. Increased comorbidity, specifically a Charlson score of 5 or greater, was the only significant predictor of a higher incidence of 30-day readmission. This information can be useful in counseling patients regarding robotic partial nephrectomy and in determining baseline rates if CMS expands the number of conditions they evaluate for excess 30-day readmissions.

Prospective Randomized Comparison of Retroperitoneoscopic vs Open Pyeloplasty With Minimal Incision: Subjective and Objective Assessment in Adults

To determine the subjective and objective outcomes of retroperitoneoscopic vs open pyeloplasty with minimal incision in a prospective randomized comparison study. In this study between August 2011 to July 2013, 30 patients underwent retroperitoneal laparoscopic pyeloplasty and 30 open pyeloplasty with minimal incision (incision length <10 cm) after randomization. The 2 groups were compared for the visual pain score on the first and second postoperative days as the primary end point of the study. Complications were recorded and graded using Dindo-modified Clavien classification of surgical complications. Success rates were evaluated by improvement in pain score and objectively by diethylene triamine penta-acetic acid renal scan and other parameters. Statistical analysis was performed with SPSS version 16.0 (IBM) with P <.05 considered statistically significant. The difference in the visual pain score (5.6 vs 3.2 on day 1; 3.8 vs 1.5 on day 2) and the diclofenac requirements (333.3 vs 178.75 mg) were statistically significant and more in the open pyeloplasty. The hospital stay and convalescence were significantly lower in retroperitoneoscopic group. Success rate was found to be 96.67% with 1 failure in each group. Two patients in retroperitoneoscopic group required conversion. Both groups showed significant improvement in pain score and drainage pattern on diethylene triamine penta-acetic acid scan with decrease in hydronephrosis on ultrasound evaluation. Although subjective and objective outcomes are equivalent in both the groups, the retroperitoneoscopic approach is associated with significantly less pain, less analgesic requirement, shorter hospital stay and short convalescence in comparison with open pyeloplasty.