Clavien-Dindo Classification Of Surgical Complications Research Articles

Perioperative efficacy of laparoscopic duodenal-preserving pancreatic head resection

Objective: To compare the perioperative outcomes of laparoscopic duodenal-preserving pancreatic head resection(LDPPHR) with laparoscopic pancreaticoduodenectomy(LPD) in the treatment of borderline and benign diseases of the pancreatic head. Methods: This is a retrospective cohort study. Perioperative data from 87 patients with non-malignant pancreatic head diseases who underwent LDPPHR or LPD were retrospectively collected in the Department of Biliary-Pancreatic Surgery,Tongji Hospital,Tongji Medical College,Huazhong University of Science and Technology from January 2020 to December 2022. There were 49 male and 38 female patients with an age of 57.0(16.5) years (range: 20 to 75 years). Forty patients underwent LDPPHR and 47 patients underwent LPD. Quantitative data following a normal distribution were compared using Student's t-test, while quantitative data not following a normal distribution were compared using the Mann-Whitney U test. Comparisons of categorical or ordinal variables were made using χ2 test or Fisher's exact test. Logistic regression analysis was used to estimate the risk factors associated with the rate of complications. Results: There were no statistically significant differences between the LDPPHR group and the LPD group in terms of reoperation rate,total hospital stay duration,postoperative hospital stay duration,90-day mortality rate,30-day and 90-day readmission rates,and 2-year tumor recurrence rate (all P>0.05). The complication rate was higher in the LDPPHR group compared to the LPD group(32 cases (80.0%) vs. 24 cases (51.1%),χ2=7.89,P=0.005),but there was no difference in the rate of Clavien-Dindo classification of surgical complications≥Ⅲ between the two groups(4 cases (10.0%) vs. 6 cases (12.8%), χ2<0.01, P=0.947). Additionally,the rate of delayed gastric emptying (DGE) was higher in the LDPPHR group compared to the LPD group (χ2=10.79,P=0.001),but there was no statistically significant difference in the rate of B,C grade DGE between the two groups (χ2=0.48, P=0.487). There were no statistically significant differences in the rates of postoperative pancreatic fistula,bile leakage,post-pancreatectomy hemorrhage,intra-abdominal infection,and pulmonary infection between the two groups (all P>0.05). The results of the univariate logistic regression analysis showed that LDPPHR (compared to LPD, OR=3.83, 95%CI: 1.46 to 10.04, Z=2.73,P=0.006) and preoperative biliary stent placement (compared to non-use of biliary stent, OR=5.30, 95%CI: 1.13 to 25.00, Z=2.11, P=0.035) were risk factors for the complication rate,but neither was an independent risk factor for complication rate (all P>0.05). Conclusion: The preliminary results suggest that LDPPHR can achieve perioperative safety and effectiveness comparable to LPD.

The comparison between endoscopic and surgical treatment of delayed iatrogenic bile duct injury by propensity score matching

Objective: To compare the safety and clinical efficacy of endoscopic and surgical treatment of patients with delayed iatrogenic bile duct injury (DBDI) with severity (SG) grade 1 to 2. Methods: The clinical data of 129 patients with SG grade 1 to 2 DBDI who received endoscopic or surgical treatment in the First Hospital of Lanzhou University from November 2007 to November 2021 were retrospectively collected. There were 46 males and 83 females,aged (M(IQR)) 54(22)years(range: 21 to 82 years). The baseline data of the two groups were matched 1∶1 by propensity score matching(caliper value was 0.2). Independent sample t test,rank sum test,χ2 test or Fisher exact probability test were used to analyze the data of the two matched groups. Results: There were 48 patients in each of the endoscopic treatment and surgical groups after matching,and there was no difference in general information between the two groups(both P>0.05). The bile duct injury-repair interval and intraoperative anesthesia complications were not statistically significant between the two groups after matching(all P>0.05). Compared with the surgical group, patients in the endoscopic treatment group had significantly shorter operative time(50 (30) minutes vs. 185 (100) minutes, Z=7.675,P<0.01) and postoperative hospital stay(5 (5) days vs. 12 (7) days, Z=5.848, P<0.01).For safety,there was no statistical difference in the incidence of immediate postoperative complications between the two groups with Clavien-Dindo classification of surgical complications<Ⅲ;the incidence of serious postoperative complications (Clavien-Dindo classification of surgical complications≥Ⅲ) was significantly higher in the surgical group than in the endoscopic treatment group(P=0.012). The incidence of long-term postoperative complications was not statistically different between the two groups(28.1% vs. 20.7%,P=0.562). In terms of efficacy,the postoperative liver function indexes of patients in both groups improved significantly compared with the preoperative period and returned to normal or near normal levels; the postoperative infection indexes of both groups showed an increasing trend,but were within the normal range. Of the 96 patients in both groups,61 obtained follow-up,and the follow-up time was (89.4±48.0)months(range: 3 to 165 months),and there was no statistical difference between the two groups(P=0.079). The probability of excellent long-term follow-up (78.1% vs. 86.2%) was not statistically different between the two groups(P=0.412).In patients with Strasberg-Bismuth type E1,the probability of excellent long-term follow-up was higher in the endoscopic treatment group compared with the surgical group(13/14 vs. 2/5,P=0.037). Conclusions: For DBDI patients with SG grade 1 to 2 and bile duct continuity,endoscopy can be used as the first deterministic treatment. The advantages of endoscopic therapy compared to surgery are the lower incidence of postoperative serious complications,and the shorter duration of surgery and postoperative hospital stay.

Evaluation of the usefulness of the Clavien-Dindo classification of surgical complications

The Clavien-Dindo (CD) classification is widely used in the reporting of surgical complications in scientific literature. It groups complications based on the level of intervention required to resolve them, and benefits from simplicity and ease of use, both of which contribute its to high inter-rater reliability. It has been validated for use in many specialties due to strong correlation with key outcome measures including length of stay, postsurgical quality of life and case-related renumeration. Limitations of the classification include concerns over differentiating grade III and IV complications and not classifying intraoperative complications. The Comprehensive Complication Index is an adaptation of the CD classification which generates a morbidity score from 0 to 100. It has been proposed as a more effective method of assessing the morbidity burden of surgical procedures. However, it remains less popular as calculations of morbidity are complicated and time-consuming. In recent years there have been suggestions of adaptations to the CD classification such as the Clavien-Dindo-Sink classification, while in some specialties, completely new classifications have been proposed due to evidence the CD classification is not reliable. Similarly, the Surgical Expertise and Validity Evaluation project aims to determine benchmarks against which surgeons may compare their own practice.

Comparison of the Y-pouch orthotopic neobladder and the Studer technique after radical cystectomy: surgical and functional outcomes from a single-center series

BackgroundTo explore a method of constructing an orthotopic ileal neobladder (ONB) in the Y-pouch configuration. We describe the steps followed to create the Y-pouch ileal orthotopic neobladder (ONB) and compared the perioperative, functional, and urodynamics outcomes with the Studer neobladder technique.MethodsA retrospective cohort study of 90 bladder cancer patients, who received open radical cystectomy with the ONB performed at a hospital from June 2009 to May 2020. These patients were divided into two groups—the Y-pouch and the Studer neobladder groups. Perioperative, functional outcome, complication, renal function data outcomes, and pressure–volume study were used to evaluate the treatment outcomes after a radical cystectomy.ResultsNinety patients (54 Studer and 36 Y-pouch neobladder) were enrolled. The median patient age was 62.6 (± 11) years. The mean operative time for the Studer technique was 290 (242.5–350) min, and the Y-pouch technique was 300 (271.2–335) min) (p = 0.826). At 30 days postoperatively, the Clavien-Dindo classification of surgical complications revealed grade-2 urinary infections in two patients (5.6%) and six patients (11.1%) for the Y-pouch and Studer techniques, respectively. Intermediate complications (30–90 days) were reported in 4 (11.1%) and 18 patients (44.4%) in the Y-pouch and the Studer techniques, respectively (p = 0.062). In the urodynamics study (UDS), the Y-pouch group had a mean postvoid residual volume of 20 mL and Studer of 40 ml (p = 0.06). A mean capacity of 462 (380–600) mL compares to the Studer neobladder group with 495 (400–628) mL. The average mean compliance of the Studer group was 35.5 (28–52) ml/cm H2O and 33 (30–43) ml/cm H2O for Y pouch, and most patients had > 30 ml/cm H2O compliance (80/90 patients).ConclusionsThe Y-pouch neobladder technique in an RC with an orthotopic neobladder provides perioperative and functional outcomes compared to those of the Studer orthotopic neobladder resulting in similar intermediate-term. Therefore, the Y-pouch ileal neobladder is both feasible and safe to be used as a standard neobladder technique for urinary diversion in patients with bladder cancer undergoing radical cystectomy and needs confirmation with long-term results.

P-078 IMPLEMENTATION OF THE HOSPITAL-AT-HOME UNIT IN THE POSTOPERATIVE COMPLEX ABDOMINAL WALL

Abstract Abreviations EHS: European Hernia Society Aim Show the results of the application of a new service in our hospital, Hospital-at-Home, in the postoperative period of incisional hernias and complex abdominal wall. Material and Methods Retrospective analysis of operated patients in our center in 30 month period (July 2020 - December 2022) with complex abdominal wall. Patients who accept home follow-up with Hospital-at-Home unit and who corresponded to the geographical area. Patients with incisional midline hernia are included: more than two locations -M- in the classification of the EHS or width greater than 4 cm (W2). Lateral incisional hernias with more than two locations -L- are also included in the EHS classification and complex parastomal hernias. Results 25 patients, 17 men and 8 women, underwent both elective and urgent incisional hernia surgery. The surgical techniques used were retromuscular mesh repair, posterior component separation and onlay technique (emergency cases). Mean hospital stay was 4.5 days. Later the patients were visited by Hospitalization at Home. There were 2 surgical wound infections treated with intravenous antibiotics and a need for reoperation (Grade II and IIIa of Clavien-Dindo classification of surgical complications. Recurrent incisional hernia was observed in 1 patient. Conclusions Benefits of Hospitalization at Home by improving the degree of patient satisfaction, reducing the hospital stay and not worsening the clinical safety of the patient with complications.

Evaluation of the usefulness of the Clavien-Dindo classification of surgical complications

The Clavien-Dindo (CD) classification is widely used in the reporting of surgical complications in scientific literature. It groups complications based on the level of intervention required to resolve them, and benefits from simplicity and ease of use, both of which contribute its to high inter-rater reliability. It has been validated for use in many specialties due to strong correlation with key outcome measures including length of stay, postsurgical quality of life and case-related renumeration. Limitations of the classification include concerns over differentiating grade III and IV complications and not classifying intraoperative complications. The Comprehensive Complication Index is an adaptation of the CD classification which generates a morbidity score from 0 to 100. It has been proposed as a more effective method of assessing the morbidity burden of surgical procedures. However, it remains less popular as calculations of morbidity are complicated and time-consuming. In recent years there have been suggestions of adaptations to the CD classification such as the Clavien-Dindo-Sink classification, while in some specialties, completely new classifications have been proposed due to evidence the CD classification is not reliable. Similarly, the Surgical Expertise and Validity Evaluation project aims to determine benchmarks against which surgeons may compare their own practice.

USE OF A MODIFIED CLAVIEN-DINDO CLASSIFICATION SYSTEM FOR ORTHOPAEDIC COMPLICATIONS IN A LEVEL 1 TRAUMA CENTRE

Complications are an inevitable part of orthopaedic surgery, how one defines complications can have an impact on the ability to learn from them. A group of general surgeons headed by Clavien and Dindo et al.1 have previously published their classification system for surgical complications based on the type of therapy required to correct the complication.Our aim was to evaluate a modification of this classification system and its use over a 12-month period at our institution via our departmental audits, our hypothesis being that this would direct appropriate discussion around our complications and hence learning and institutional change.A modified Clavien-Dindo Classification was prospectively applied to all complications recorded in the Orthopaedic departmental quarterly audits at our institution for a 12-month period (4 audits). The audit discussion was recorded and analysed and compared with the quarterly complication audits for the preceding 12-month period.The modified Clavien-Dindo classification for surgical complications was applicable and reproducible to Orthopaedic complications in our level 1 trauma centre. It is a transparent system, objective in its interpretation and avoids the tendency to down-grade serious complications. It was easy to apply and directed discussion appropriately at our quarterly audit meetings on complications where there was a preventable outcome or important learning point. In particular modifications to VTE and Death classes allowed the unit to focus discussion on cases where complication was preventable or unexpected.The modified Clavien-Dindo classification system is an easy to use and reproducible classification system for Orthopaedic complications in our unit it directed audit discussion towards cases where complications were preventable or had a learning point.

A RADIOTERAPIA E QUIMIOTERAPIA NEOADJUVANTES PARA PACIENTES COM CÂNCER DE ESÔFAGO E JUNÇÃO GASTRO-ESOFÁGICA AFETAM OS RESULTADOS PÓS-OPERATÓRIOS? UM ESTUDO USANDO O SISTEMA DE REGRESSÃO TUMORAL DE BECKER E REGRESSÃO DE LINFONODOS

The effect of neoadjuvant chemoradiotherapy (nCRT) in patients with locally advanced esophageal cancer can be determined by assessing the Becker tumor regression grade in the primary tumor, as well as in lymph nodes. The aim of this study was to investigate the anatomopathological changes caused by neoadjuvant chemoradiotherapy and their impact on clinical parameters. Specifically, we analyzed the Becker tumor regression grade, lymph node status, and regression changes and evaluated their association with the Clavien-Dindo classification of surgical complications and overall patient survival. This is a retrospective and observational study including 139 patients diagnosed with adenocarcinoma or squamous cell carcinoma of the esophagus and treated with either neoadjuvant chemoradiotherapy followed by surgery or surgery alone. For the 94 patients who underwent neoadjuvant chemoradiotherapy, we evaluated tumor regression by Becker tumor regression grade in primary tumors. We also analyzed lymph node status and regression changes on lymph nodes with or without metastases. Overall survival analysis was performed using Kaplan-Meier curves. Becker tumor regression grade is associated with lower lymphatic permeation (p<0.01) and vascular invasion (p<0.001), but not with lymph node regression rate (p=0.10). Clavien-Dindo classification was associated neither with lymph node regression rate (odds ratio=0.784, p=0.795) nor with tumor regression grade (p=0.68). Patients who presented with lymphatic permeation and vascular invasion had statistically significantly lower median survival (17 vs. 30 months, p=0.006 for lymphatic permeation, and 14 vs. 29 months, p=0.024 for vascular invasion). In our series, we were unable to demonstrate an association between Becker tumor regression grade and lymph node regression rate with any postoperative complications. Patients with lower lymphatic permeation and vascular invasion have higher overall survival, correlating with a better response in the Becker tumor regression grade system.

Short-term Outcome of Danish Kidney Donors: Postoperative Complications and Labor Affiliation

BackgroundLiving kidney donation is safe and effective, but disincentives to donation include risk of short- and long-term complications, which need to be addressed in order to ensure care of live kidney donors. MethodsFrom January 1, 2016 to December 31, 2019, 123 living kidney donors (LKDs) underwent LKD nephrectomy at Aarhus University Hospital, Aarhus, Denmark. Data from The Scandiatransplant registry and patient records were reviewed in order to identify short-term postoperative complications within 90 days after donation, as well as affiliation to the labor market and health data at follow-up. The Clavien-Dindo classification of surgical complications with modifications by Kocak et al was used to categorize minor and major complications. ResultsThere were available data for 119 of 123 LKDs. Of these, 25 (21%) developed minor complications and 4 (3%) developed major complications. Ninety LKDs (76%) had an uneventful course without any complications. The most common complications were pain and nausea that required additional medical treatment. Seventy-two of the 82 LKDs working before donation had returned to work within 3 months after donor nephrectomy. No one retired or became disabled as a result of being a live kidney donor. ConclusionsShort-term follow up of the LKDs showed that most donors experienced an uneventful course and that the frequency of major complications was low. Donation did not seem to impact the ability to resume work. At the 90-day follow-up the majority of donors with both minor and major complications resumed work and reported full convalescence at the same level as donors without any complications. Nine of the LKDs (8%), all women, were out of work for >3 months with the main reason being fatigue.

Impact of resident involvement on patient outcomes in laparoscopic cholecystectomy of different degrees of complexity: analysis of 2331 cases.

Resident involvement in the operating room is a vital component of their medical education. Laparoscopic cholecystectomy (LC) represents the paradigmatic minimally invasive training procedure, both due to its prevalence and its different forms of complexity. We aim to evaluate whether the supervised participation of residents as operative surgeons in LC of different degrees of complexity affects postoperative outcomes in a university hospital. This is a retrospective, single-center study that included all consecutive adult (> 18years old) patients operated for a LC between January 1, 2012 and December 31, 2017. Each surgical procedure was recorded according to the level of complexity that we established in three types of categorization (level 1: elective surgery; level 2: cholecystitis; level 3: biliary instrumentation). Patients were clinically monitored at an outpatient clinic 7 and 30-day postoperative. Postoperative outcomes of patients operated by supervised residents (SR) and trained surgeons (TS) were compared. Postoperative complications were graded according to the Clavien-Dindo classification of surgical complications. A total of 2331 patients underwent LC during the study period, of whom 1573 patients (67.5%) were operated by SR and 758 patients (32.5%) by TS. There were no significant differences among age, sex, and BMI between patients operated in both groups, with the exception of ASA (P = 0.0001). Intraoperative cholangiography was performed in 100% of the patients, without bile duct injuries. There were no deaths in the 30 postoperative days. The overall complication rate was 5.70% (133 patients), with no significant differences when comparing LC performed by SR and TS (5.09 vs. 6.99%; P = 0.063). The severity rates of complications were similar in both groups (P = 0.379). Patient readmission showed a statistical difference comparing SR vs TS (0.76% vs. 2.2%; P = 0.010). The postoperative complications rate according to the complexity level of LC was not significant in level 1 and 2 for both groups. However in complexity level 3 the TS group experienced a greater rate of complications compared to the SR group (18.12% vs. 9.38%; P = 0.058). In the multivariate analysis, the participation of the residents as operating surgeons was not independently associated with an increased risk of complications (OR 1.22, 95% CI 0.84-1.77; P = 0.275), neither other risk factors like age ≥ 65years, BMI, complexity level 2-3, or ASA ≥ 3-4. The association of another surgical procedure with the LC was an independent factor of morbidity (OR 3.85, 95% CI 2.54-5.85; P = 0.000). Resident involvement in LC with different degrees of complexity did not affect postoperative outcomes. The participation of a resident as operating surgeon is not an independent risk factor and may be considered ethical, safe, and reliable whenever implemented in the background of a residency-training program with continuous supervision and national accreditation. The sum of other procedures not related to a LC should be taken as a risk factor of morbidity.

MP37-15 A MULTICENTER RETROSPECTIVE STUDY ASSESSING RISK OF COMPLICATIONS IN HYDROCELE SURGERY

You have accessJournal of UrologyCME1 May 2022MP37-15 A MULTICENTER RETROSPECTIVE STUDY ASSESSING RISK OF COMPLICATIONS IN HYDROCELE SURGERY Lauri Mäki-Lohiluoma, Tuomas P. Kilpeläinen, Petrus Järvinen, Henna K. Söderström, Kari A.O. Tikkinen, and Jukka Sairanen Lauri Mäki-LohiluomaLauri Mäki-Lohiluoma More articles by this author , Tuomas P. KilpeläinenTuomas P. Kilpeläinen More articles by this author , Petrus JärvinenPetrus Järvinen More articles by this author , Henna K. SöderströmHenna K. Söderström More articles by this author , Kari A.O. TikkinenKari A.O. Tikkinen More articles by this author , and Jukka SairanenJukka Sairanen More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002591.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Despite being one of the most common urologic procedures, the risk estimates for complications after hydrocele surgery (hydrocelectomy) are uncertain. Decision making between hydrocelectomy and aspiration-sclerotherapy involves balancing risk of complications with risk of recurrence, a trade-off that critically depends on the complication risks of hydrocele surgery. We conducted a multicenter study to examine the 90-day risks of complications of hydrocele surgery in a large, contemporary sample. METHODS: We retrospectively reviewed all hydrocele operations conducted in all five Helsinki (Finland) metropolitan area public hospitals between January 2010 and December 2018. We evaluated following outcomes during period of 90 days post-surgery: 1) Hydrocele surgery complications classified according to the Clavien-Dindo classification of surgical complications and 2) reoperations due to a surgical complication. We applicated the Clavien-Dindo classification to hydrocele surgery as illustrated in table 1. We recorded the length of stay for those patients readmitted to the ward. RESULTS: We identified 867 hydrocele operations (38 (4.3%) bilateral). A total of 219 (25.3%) patients had hydrocele surgery complications within 90 days post-surgery. Of these, 76 (8.8% of all; 35% of those who had complications) had Clavien-Dindo classified grade I complications, 80 (9.2%; 37%) grade II, 61 (7.0%; 28%) grade III, 2 (0.2%; 0.9%) grade IV and none grade V complications (Table 1). A total of 47 (5.4% of all; 21% of those who had complications) patients required immediate re-operation due to complications. Vast majority, 42 of the reoperations were due to bleeding. Many reoperated patients had multiple complications; i.e infected hematoma, hematoma and wound dehiscence. In total 51 (5.9%) patients were readmitted to the ward because of postoperative complications. One patient (0,1%) needed intensive care for 4 days. The median length of stay at the ward because of postoperative complications was 4days (range 1-24 days, IQR 5). The retrospective design of the study limits accuracy of the estimates. CONCLUSIONS: Complications after hydrocele surgery are common and warrant further research of this condition. These estimates can be useful for shared decision making between clinicians and patients. Source of Funding: The Sigrid Jusélius Foundation, and Competitive Research Funding of the Helsinki University Hospital (TYH2020248) © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e615 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Lauri Mäki-Lohiluoma More articles by this author Tuomas P. Kilpeläinen More articles by this author Petrus Järvinen More articles by this author Henna K. Söderström More articles by this author Kari A.O. Tikkinen More articles by this author Jukka Sairanen More articles by this author Expand All Advertisement PDF DownloadLoading ...

Timing of Closure of a Protective Loop-Ileostomy Can Be Crucial for Restoration of a Functional Digestion.

IntroductionProtective loop-ileostomy is one of the most common interventions in abdominal surgery to provide an alternative intestinal outlet until sufficient healing of a distal anastomosis has occurred. However, closure of a loop-ileostomy is also associated with complications. Thus, knowledge of the optimal time interval between primary and secondary surgery is crucial.MethodsData from 409 patients were retrospectively analyzed regarding complications and risk factors in closure-associated morbidity and mortality. A modified Clavien-Dindo classification of surgical complications was used to evaluate the severity of complications.ResultsA total of 96 (23.5%) patients suffered from postoperative complications after the closure of the loop-ileostomy. Early closure within 150 days from enterostomy (n = 229) was associated with less complications (p < 0.001**). Looking at the severity of complications, there were significantly more (p = 0.014*) mild postoperative complications in the late closure group (>150 days). Dysfunctional digestive problems—either (sub-) ileus (p = 0.004*), diarrhea or stool incontinence (p = 0.003*)—were the most frequent complications associated with late closure. Finally, we could validate in a multivariate analysis that “time to closure” (p = 0.002*) is independently associated with the development of complications after closure of a protective loop-ileostomy.ConclusionLate closure (>150 days) of a loop-ileostomy is an independent risk factor in post-closure complications in a multivariate analysis. Nevertheless, circumstances of disease and therapy need to be considered when scheduling the closure procedure.

Restoration of elective spine surgery during the first wave of COVID-19 : a UK-wide British Association of Spine Surgeons (BASS) prospective, multicentre, observational study.

AimsWith resumption of elective spine surgery services in the UK following the first wave of the COVID-19 pandemic, we conducted a multicentre British Association of Spine Surgeons (BASS) collaborative study to examine the complications and deaths due to COVID-19 at the recovery phase of the pandemic. The aim was to analyze the safety of elective spinal surgery during the pandemic.MethodsA prospective observational study was conducted from eight spinal centres for the first month of operating following restoration of elective spine surgery in each individual unit. Primary outcome measure was the 30-day postoperative COVID-19 infection rate. Secondary outcomes analyzed were the 30-day mortality rate, surgical adverse events, medical complications, and length of inpatient stay.ResultsIn all, 257 patients (128 males) with a median age of 54 years (2 to 88) formed the study cohort. The mean number of procedures performed from each unit was 32 (16 to 101), with 118 procedures (46%) done as category three prioritization level. The majority of patients (87%) were low-medium “risk stratification” category and the mean length of hospital stay was 5.2 days. None of the patients were diagnosed with COVID-19 infection, nor was there any mortality related to COVID-19 during the 30-day follow-up period, with 25 patients (10%) having been tested for symptoms. Overall, 32 patients (12%) developed a total of 34 complications, with the majority (19/34) being grade 1 to 2 Clavien-Dindo classification of surgical complications. No patient required postoperative care in an intensive care setting for any unexpected complication.ConclusionThis study shows that safe and effective planned spinal surgical services can be restored avoiding viral transmission, with diligent adherence to national guidelines and COVID-19-secure pathways tailored according to the resources of the individual spinal units.Cite this article: Bone Jt Open 2021;2(12):1096–1101.

Neoadjuvant chemoradiotherapy with sequential ipilimumab and nivolumab in rectal cancer (CHINOREC): A prospective randomized, open-label, multicenter, phase II clinical trial.

TPS3623 Background: Immune checkpoint inhibitors (ICI), such as ipilimumab (anti-cytotoxic T-lymphocyte-associated protein 4) or nivolumab (anti-programmed cell death protein 1) have been proven to be an effective strategy in solid cancers. However, ICI seem not to be effective in microsatellite stable (MSS) cancers. As they might lack an immunogenic priming, radiotherapy (RT) is capable to induce an immunogenic cell death (ICD) and subsequently an immunogenic tumor immune microenvironment (TIME). Thus, RT might restore the susceptibility of MSS tumors to ICI and consequently leading to an effective anti-tumor immune response. Methods: This is a prospective, randomized, open-label, multicenter, phase II investigator-initiated clinical trial (IIT), including patients with locally advanced rectal cancer (LARC). Patients receive either neoadjuvant chemoradiotherapy (CRT) alone (50 Gy in 2 Gy fractions over 25 working days + capecitabine 1650 mg/m2/d PO) or in combination with ipilimumab (1 mg/kg IV on day 7) and nivolumab (3 mg/kg IV on day 14, 28 and 42). Patients will undergo surgery within 10-12 weeks post CRT. The primary endpoint is incidence of treatment-emergent adverse events (AEs) assessed by the Clavien-Dindo classification of surgical complications and the common terminology criteria of adverse events (CTCAE). Secondary objectives are radiographic and pathological therapy response. Serial liquid (plasma, serum and peripheral blood mononuclear cells) and tissue biopsies will be taken before, during and after neoadjuvant treatment. Genomic, transcriptomic, epigenomic and proteomic pattern of liquid and tissue biopsies, as well as the immune cell infiltrate of resected specimen, will be correlated with therapy response and clinical outcome. Currently 8 of planned 80 patients have been enrolled. Registration numbers: NCT no. NCT04124601, EudraCT no. 2019-003865-17. Clinical trial information: NCT04124601.

Associations between malignancy and cardiovascular complications following emergency laparotomy – A retrospective cohort study

BackgroundSystemic inflammation in patients with malignant disease has been associated with increased risk of cardiovascular events. The pro-inflammatory perturbations following surgical trauma may further promote adverse perioperative cardiovascular events and increase the risk of patients with cancer undergoing major surgery. Our objective was to estimate the association between malignant disease and postoperative cardiovascular complications. Secondarily, we aimed to identify risk factors for postoperative cardiovascular complications. MethodsWe conducted a retrospective cohort study of all patients ≥18 years undergoing emergency laparotomy between 2010 and 2016 at Department of Surgery, Zealand University Hospital, Denmark. Complications were graded according to Clavien-Dindo classification of surgical complications. Multivariate logistic regression analysis was performed to estimate association between malignant disease and cardiovascular complications within 30 days of emergency laparotomy and to identify other risk factors for postoperative cardiovascular complications after emergency laparotomy. ResultsWe identified 1188 patients ≥18 years undergoing emergency laparotomy between 2010 and 2016, in which 254 (21%) had malignant disease. Within 30 days of emergency laparotomy, 89 (9.5%) of patients without malignancy died, as compared with 45 (18%) of patients with malignancy (p < 0.001). Cardiovascular death occurred in 17 (1.8%) and 5 (2.0%) patients in the non-malignant and malignant group, respectively. Severe cardiovascular complication graded CD 3–5 occurred in 93 (8%) of all patients within 30 days of emergency laparotomy. We found no association between malignancy and postoperative cardiovascular complications in patients undergoing emergency surgery (OR 0.8, 95% CI; 0.4, 1.5). Increasing age and ASA physical status classification system (ASA) score ≥ III were the only independent risk factors of cardiovascular complications graded CD 3–5. ConclusionsMalignancy was not associated with postoperative cardiovascular complications after emergency laparotomy. Risk factors for major cardiovascular complications after emergency abdominal surgery were age and ASA score ≥ III.

Open fetal myelomeningocele repair at a university hospital: surgery and pregnancy outcomes.

Myelomeningocele (MMC) is an open neural tube defect that causes great morbidity. Prenatal open repair is the standard treatment; however, there are many complications related to the procedure. This study reports preliminary findings of open in utero repair of MMC in a public tertiary hospital in Brazil and describes factors that could be associated with increased surgical morbidity. Thirty-nine patients underwent open in utero repair of MMC from October 2015 to August 2019. The Clavien-Dindo classification of surgical complications and a classification system with the preterm definitions of the World Health Organization were used, respectively, for maternal and fetal complications. A total of 28 mothers (71.8%) and 31 fetuses (79.5%) experienced at least one minor to major complication. Three mothers (7.7%) had a severe grade 4 complication. Fetal complications grades 3 to 5 occurred in 13 fetuses (33.3%). Gestational age at surgery and at birth were 24.88 ± 1.16weeks and 33.23 ± 3.68weeks, respectively. Preterm delivery occurred in 30 patients (76.9%), membrane rupture in 18 patients (46.2%) and chorioamnionitis in 13 patients (33.3%). Open fetal surgery for MMC was performed at a Brazilian public tertiary care center, resulting in three grade 4 maternal complications. Relevant fetal complications were also present. The use of a standard classification system for complications renders studies more comparable and data more useful for counseling patients. Adjustments of perioperative procedures and long-term follow-up are needed to determine the real benefit of open in utero repair of MMC at our hospital.

Severe hypernatremia in children after surgical resection of hepatic echinococcosis: a rare and potentially fatal complication

BackgroundUsing effective scolicidal agents intraoperatively is essential to lessen the recurrence rate of hepatic echinococcosis. However, severe hypernatremia may occur after hypertonic saline (HS) has been applied as the scolicidal agent. The aim of this study is to report on pediatric patients with severe hypernatremia after hepatic echinococcus surgery.MethodsPatients who presented to West China Hospital between January 2010 and February 2017 were retrospectively analyzed. Children under 16 years with echinococcosis treated by resection were included in the study.ResultsA total of 26 children were enrolled in this study, including 16 boys and 10 girls with a median age of 8 (2–16). 24 (92.3 %) cases were cystic echinococcosis (CE) and two (7.7 %) were alveolar echinococcosis (AE). According to Clavien-Dindo classification of surgical complications, the complication rate of all 26 patients was 19.2 %, among which three cases belonged to Grade I, one to Grade III b and 1 to Grade IV. Two children encountered severe hypernatremia (sodium: 155.3 mmol/L and 190.0mmol/L). Data showed classic clinical features of severe hypernatremia: profound and persistent bradycardia, hypotension and coma. After treatment, they recovered well without any neurologic sequelae. All patients were followed up regularly for a median time of 38 months (range 4–89 months); the overall disease-free survival was 100.0 %.ConclusionsHS irrigation of intra-abdominal echinococcosis may cause acute hypernatremia and severe consequences. Diagnostic suspicion and early intervention are vital tools for avoiding morbidity and mortality.

Cohort profile: the St Vincent’s Melbourne Arthroplasty Outcomes (SMART) Registry, a pragmatic prospective database defining outcomes in total hip and knee replacement patients

PurposeThe St Vincent’s Melbourne Arthroplasty Outcomes (SMART) Registry is an institutional clinical registry housed at a tertiary referral hospital in Australia. The SMART Registry is a pragmatic prospective database, which...

“The outcomes of minilaparoscopic pyeloplasty in patients more than two Years: “A prospective case series study”

Background: To evaluate the efficacy of mini-laparoscopy in the management of ureteropelvic junction obstruction as regard: Functional and cosmetic results, complications, and patient’s overall satisfaction.Methods: a total of 28 patients were prospectively enrolled in this study at Zagazig university hospitals. All patients underwent preoperative laboratory evaluation and radiologic evaluation for assessment of pelvis antro-posterior diameter and maximal cortical thickness in mm using abdominal ultrasonography, and differential renal function, GFR and drainage using renal scintigraphy. All patient underwent transperitoneal minilaparoscopic pyeloplasty. Patients were evaluated postoperatively with documentation of any complication. Results: Of 33 patients recruited in this study, 25 patients with a mean age of 18.47 ± 8.03 years completed 6 months of follow-up. Mean operative time was 178.2 ± 34.9 minutes. pVAS score at discharge was 0.40 ± 0.21. There were highly statistically significant differences between both preoperative and postoperative ultrasonography and renal scintigraphy results. There is no major perioperative complication as per the Clavien-Dindo classification of surgical complications (grades IV–V). Total PSAQ score was 39.96 ± 2.44Conclusion: Minilaparoscopic pyeloplasty is a safe and feasible method for treatment of UPJO, as regards to the efficacy it shows excellent functional and cosmetic outcomes.

Revisiting the Surgical Management of Giant Hepatic Hemangiomas: Enucleation Versus Anatomical Resection?

Resection is rarely indicated in giant hepatic hemangiomas (HHs) that are symptomatic. Enucleation (EN), compared with anatomical resection (AR), is considered the better technique to resect them as EN has been reported to have lower morbidity while conserving the normal liver tissue. But no study has yet clearly established the superiority of EN over AR. In addition, the independent predictors of postoperative morbidity have not been established. All consecutive patients operated for HH at two specialized hepatobiliary centers were reviewed. Patient demographics, operative variables, and postoperative outcomes were analyzed and compared between two techniques. Postoperative complications were graded as per Clavien-Dindo classification of surgical complications. The aims of this study were to compare two techniques of HH resection with respect to postoperative outcomes and to identify the risk factors for 90-day major postoperative morbidity and mortality. A total of 64 patients, including 41 who underwent AR, 22who underwent EN, and 1 who underwent liver transplantation, were operated for hemangiomas during the study period. Ten patients (9 who were operated for hemangiomas of size ≤4cm and 1 who underwent transplantation) were excluded. Fifty-four patients, the majority being women (85%), with a median age of 48 years, were operated for giant HH. These patients were classified into two groups based on the technique of resection, namely, EN (22 patients) and AR (32 patients). Both groups were comparable in all aspects except that the number of liver segments resected was significantly more with AR. Postoperative outcomes were similar in both groups. Independent predictors of 90-day major complications including mortality were the use of total vascular exclusion (relative risk [RR]: 2.3, p=0.028) and duration of surgery >4.5h (RR: 2.3, p=0.025). Both techniques yield similar results with respect to 90-day postoperative morbidity and mortality. The choice of technique should be based on the location of tumor and simplicity of liver resection.