Clavien-Dindo System Research Articles

A Role for the Early Warning Score in Early Identification of Critical Postoperative Complications.

We examined whether an early warning score (EWS) could predict inpatient complications in surgical patients. Abnormal vitals often precede in-hospital mortality. The EWS calculated using vital signs has been developed to identify patients at risk for mortality. Inpatient general surgery procedures with National Surgical Quality Improvement Project data from 2013 to 2014 were matched with enterprise data on vital signs and neurologic status to calculate the EWS for each postoperative vital set measured on the ward. Outcomes of major complications, unplanned intensive care unit transfer, and medical emergency team activation were classified using the Clavien-Dindo system as grade I to V. Relationship with EWS and timing of complication was assessed using Kruskal-Wallis test and linear regression accounting for clustering with generalized estimating equation. Among 552 patients admitted to the ward postsurgery, 68 (12.3%) developed at least one grade I to III complication and 37 (6.7%) developed a grade IV/V complication. The mean maximum EWS was significantly higher preceding grade IV/V complications (10.1) compared with grade I to III complications (6.4) or across the hospital stay in patients without complications (5.4; P < 0.01). EWS significantly increased in the 3 days preceding grade IV/V complications (P < 0.001) and declined in patients without complications in the 3 days before discharge (P < 0.001). A threshold EWS of 8 predicted occurrence of grade IV/V complications with 81% sensitivity and 84% specificity. Critical postoperative complications can be preceded by rising EWS. Interventional studies are needed to evaluate whether EWS can reduce the severity of postoperative complications and mortality for surgical patients through early identification and intervention.

Modified urethrovesical anastomosis during robot-assisted simple prostatectomy: Technique and results.

BackgroundDespite significant developments in transurethral surgery for benign prostatic hyperplasia, simple prostatectomy remains an excellent option for patients with severely enlarged glands. The objective is to describe our results of robot-assisted simple prostatectomy (RASP) with a modified urethrovesical anastomosis (UVA).MethodsFrom May 2011 to February 2014, RASP with UVA was performed in 34 patients by a single surgeon (O.C.) using the da Vinci S-HD surgical system. The UVA was performed between the bladder neck and urethral margin using the Van Velthoven technique. Demographic, perioperative, and outcome data were recorded. Complications were recorded with the Clavien–Dindo system.ResultsThe mean (standard deviation) age was 68 years (62–74 years). The median preoperative prostate volume (interquartile range) was 117 cc (99–146 cc). Operative time was 96 minutes (78–126 minutes), estimate blood loss was 200 mL (100–300 mL), and two (5.8%) patients required a blood transfusion. No conversion to open surgery was needed. The median specimen weight on pathological examination was 76 g (58–100 g). The average hospital stay was 2.2 days (1–4 days) and average Foley catheter time was 4.6 days (4–6 days). No intraoperative complications were recorded. There were seven (20.5%) postoperative complications, most of them Clavien less than or equal to Grade II.ConclusionThe results of our study show that RASP with UVA is a feasible, secure, and reproducible procedure with low morbidity. Additional series with larger patient cohorts are needed to validate this approach.

Laparoscopic vs open pancreaticoduodenectomy: A comparative study

Background: Laparoscopic pancreaticoduodenectomy (LPD) is a complex procedure and comparative data on its feasibility and outcomes are still emerging. We review our experience of LPD and compare the early outcomes with open pancreaticoduodenectomy (OPD). Method: All patients who underwent (OPD) and (LPD) for periampullary carcinoma between Jan2011 to August2014 were retrospectively analysed from a prospectively maintained database. Preoperative data &, postoperative complications including pancreatic leak, delayed gastric emptying (DGE) and post-pancreatectomy hemorrhage (PPH) defined by ISGPS and graded as per Clavien Dindo system and histopathological variables were compared. Result: Of 154 patients, the study cohort, 38 underwent LPD and 116 OPD. There was no difference in patient demographics, AASA (p = 0.06), ECOG status (p = 0.30) and co-morbidities. Mean operating time in LPD was 480+/−132 & in OPD 402+/−78 minutes and it was statistically significant (p < ≤ 0.001). Mean blood loss was 246.6+/−84.5ml in LPD & 282+/−127ml in OPD (p = 0.21). Five (13.2%) in LPD and 15 (13.04%) in OPD developed clinically significant (≥grade B) pancreatic fistula (p = 1.0). DGE (grade B&C) was observed in 14.8% in OPD and 18.4% in LPD (p = 0.61). Median hospital stay in OPD was 11days and in LPD 11.5 days (p = 0.05). Complications were similar in both the groups (p = 0.78). Oncological outcomes including tumour margin status, number of lymphnodes retrieved, lymphnode ratio were equal in both the groups (p = 0.72;p = 0.21;p = 0.55), with mean number of lymph nodes retrieved in OPD and LPD being 10.67 and 9.42 respectively. Conclusion: LPD is a comparable in safety, feasibility and early oncological outcomes to OPD.

MP14-16 INCREASED PROSTATE SIZE AND HISTORY OF PREOPERATIVE VOIDING DYSFUNCTION ASSOCIATED WITH GREATER URINARY TOXICITY AFTER POST-PROSTATECTOMY ADJUVANT OR SALVAGE RADIATION

You have accessJournal of UrologyProstate Cancer: Localized: Radiation Therapy1 Apr 2016MP14-16 INCREASED PROSTATE SIZE AND HISTORY OF PREOPERATIVE VOIDING DYSFUNCTION ASSOCIATED WITH GREATER URINARY TOXICITY AFTER POST-PROSTATECTOMY ADJUVANT OR SALVAGE RADIATION Juan Guzman and Ricardo Sanchez-Ortiz Juan GuzmanJuan Guzman More articles by this author and Ricardo Sanchez-OrtizRicardo Sanchez-Ortiz More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2519AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Animal models using the rabbit bladder have shown that outlet obstruction is associated with bladder fibrosis and diminished aerobic metabolism. Given that genitourinary toxicity in men undergoing radiation therapy (RT) after radical prostatectomy (RP) is related to ischemia, we set out to correlate the relationship between clinical factors affecting bladder circulation and urinary complications after RT. METHODS Patients with a history of postoperative (postop) RT were identified from a database of 542 consecutive men who underwent RP by a single surgeon. Indications included positive margins, pT3, or a serum PSA ≥ 0.2. All were continent and waited ≥ 6 months before RT. Of 508 patients with ≥ 6 months (mo.) follow-up, 50 received adjuvant (3.3%, 17/508) or salvage (6.5%, 33/508) intensity modulated RT (median dose of 69 Gy), with 15.1% (5/33) receiving androgen ablation in the salvage group. Urinary complications were classified using the Clavien-Dindo system. SPSS was used for statistical analysis. RESULTS After a median follow-up of 37.9 mo., transient incontinence developed in 1 patient (2%) (Clavien-Dindo grade II), and permanent incontinence in 3 men (6%), one managed medically (grade II), and the others with a sling and an artificial sphincter, respectively (grade III). Three patients (6%) developed bladder neck scars requiring incision. No urothelial malignancies were identified. Twenty percent of patients (10/50) developed hematuria requiring fulguration (grade III) (5 salvage and 5 adjuvant RT) followed by hyperbaric oxygen therapy in 3 patients. Patients with hematuria had higher preop International Prostate Symptom Scores (IPSS) (15.5 vs. 6.5, p<0.01) and larger prostates (51.7 vs. 39.3 g, p<0.01) compared with those without. Seventy five percent of patients with prostates ≥ 60 g developed hematuria compared with 9.5% of those with smaller glands (p<0.001). Diabetic patients showed a trend for hematuria (25% vs. 19.5%) and incontinence (12.5% vs. 7.3%) but this was not significant (only 8/50 radiated patients had DM). Urinary complications did not correlate with age, surgery type (80% robotic), salvage vs. adjuvant RT, body-mass index, smoking, hyperlipidemia, or hypertension. CONCLUSIONS Our data show that grade III urinary complications may develop in up to 30% of patients treated with RT after RP. Gross hematuria was 3 times more common (20%) than incontinence (6%) or strictures (6%) and predominantly affected men with preop voiding dysfunction or large prostates (≥ 60 g). The association between preoperative gland size and complications of RT in the postprostatectomy setting warrants validation with a larger cohort of patients. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e150 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Juan Guzman More articles by this author Ricardo Sanchez-Ortiz More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP22-12 THE RELATIONSHIP BETWEEN OPERATIVE TIMES AND COMPLICATION RATES IN PERCUTANEOUS NEPHROSTOLITHOTOMY PROCEDURES

You have accessJournal of UrologyStone Disease: Surgical Therapy I1 Apr 2016MP22-12 THE RELATIONSHIP BETWEEN OPERATIVE TIMES AND COMPLICATION RATES IN PERCUTANEOUS NEPHROSTOLITHOTOMY PROCEDURES Julie Stein, Kaitlan Cobb, John Michael DiBianco, and Patrick Mufarrij Julie SteinJulie Stein More articles by this author , Kaitlan CobbKaitlan Cobb More articles by this author , John Michael DiBiancoJohn Michael DiBianco More articles by this author , and Patrick MufarrijPatrick Mufarrij More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.700AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Prolonged operative time has long been associated with postoperative complications. Percutaneous nephrostolithotomy (PCNL) is a common approach for the treatment of complex stone disease, often requiring lengthy operative times and/or multiple surgical stages. Complications of PCNL, including hemorrhage, injury to adjacent organs/structures, and infection, have been reported to occur at higher rates in procedures that have had prolonged operative times. Additionally, some of these complications may limit the duration of PCNL procedures, thereby decreasing stone-free rates or requiring more surgical stages. We aimed to investigate the relationship between operative times and postoperative complications as classified by the Clavien-Dindo System of Surgical Complications. METHODS A retrospective review was performed on 66 patients who underwent PCNL by a single endourologist at George Washington University Hospital and Sibley Memorial Hospital in Washington, D.C. from October 2012 to December 2014. Data on basic patient demographics and characteristics, operative times, and complications were collected. Operative time was defined by surgery start time and stop time as recorded by the anesthesiologist. Complications were classified by the Clavien-Dindo system on a scale of 0 to 5. RESULTS Mean age of patients was 57.3 +/- 12.2 years. Overall complication rate was 14.9% with 0% Clavien I, 9.0% Clavien II, 0% Clavien III, 6.0% Clavien IV, and 0% Clavien V. Mean operative time was 232.0 +/- 72.7 minutes. A simple linear regression model revealed that operative time accounted for 6.1% of the variance in Clavien score (R2 = .061, p < 0.05). One-way Analysis of Variance (ANOVA) demonstrated that the presence of infection stones differed significantly between Clavien classes (F(2, 60) = 3.32, p = 0.043). Post-hoc analyses showed that infection stones were associated with a Clavien II complication (p = 0.05), but not with a Clavien IV complication (p > 0.05). CONCLUSIONS In our investigation, increased operative time of PCNL procedures was not associated with an increase in complications. The increase in mid-level complications observed in patients identified to have infection-based stones corroborates previous data on this particular group of stone patients. While, in general, it is advisable to minimize operative duration, this data does not suggest an increased complication risk with lengthier PCNL procedures. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e257-e258 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Julie Stein More articles by this author Kaitlan Cobb More articles by this author John Michael DiBianco More articles by this author Patrick Mufarrij More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Interaction of Postoperative Morbidity and Receipt of Adjuvant Therapy on Long-Term Survival After Resection for Gastric Adenocarcinoma: Results From the U.S. Gastric Cancer Collaborative.

Postoperative complications (POCs) can negatively impact survival after oncologic resection. POCs may also decrease the rate of adjuvant therapy completion. We evaluated the impact of complications on gastric cancer survival and analyzed the combined effect of complications and adjuvant therapy on survival. We analyzed 824 patients from 7 institutions of the U.S. Gastric Cancer Collaborative who underwent curative resection for gastric adenocarcinoma between 2000 and 2012. POC were graded using the modified Clavien-Dindo system. Survival probabilities were estimated using the method of Kaplan and Meier and analyzed using multivariate Cox regression. Median follow-up was 35months. The overall complication rate was 41%. The 5-year overall survival (OS) and recurrence-free survival (RFS) of patients who experienced complications were 27 and 23%, respectively, compared with 43 and 40% in patients who did not have complications (p<0.0001 for OS and RFS). On multivariate analysis, POC remained an independent predictor for decreased OS and RFS (HR 1.3, 95% CI 1.1-1.6, p=0.03 for OS; HR 1.3, 95% CI 1.01-1.6, p=0.03 for RFS). Patients who experienced POC were less likely to receive adjuvant therapy (OR 0.5, 95% CI 0.3-0.7, p<0.001). The interaction of complications and failure to receive adjuvant therapy significantly increased the hazard of death compared with patients who had neither complications nor adjuvant therapy (HR 2.3, 95% CI 1.6-3.2, p<0.001). Postoperative complications adversely affect long-term outcomes after gastrectomy for gastric cancer. Not receiving adjuvant therapy in the face of POC portends an especially poor prognosis following gastrectomy for gastric cancer.

Distal corporoplasty for distal cylinders extrusion after penile prosthesis implantation.

Distal extrusion of cylinders is a potential complication of the penile prosthesis implantation. Several methods have been proposed for repairing a distal penile erosion. We present our preliminary experience in "Distal corporoplasty" technique. We enrolled 18 consecutive patients whose underwent a distal corporoplasty with simultaneous reimplantation of an "AMS 700 inflatable penile prosthesis (LGX)" from January 2013 to November 2015 at our hospital. All procedures were performed by a single surgical team. Intraoperative and postoperative complications have been classified and reported according to Satava6 and Clavien-Dindo (CD) system.7 Mean values with standard deviations (±SD) were computed and reported for all items. Mean age of the patients was 53.61 (±11.90) years. Mean body max index (BMI) was 24.22 (±2.51). Mean operative time was 85.2 (±13.1) minutes. Blood losses were minimal. No intraoperative complications are reported according to Satava classification. Four out of 18 patients (22.22%) experienced postoperative complications according to CD system. All patients had sexual intercourse for the first time postsurgery after a mean of 59.11 ± 2.08 days. Mean follow-up was 22.11 (±9.95). Distal extrusion of cylinders is a potential complication of the penile prosthesis implantation. Distal corporoplasty was first described by Mulcahy. He reported a series of 14 patients with a follow-up of about 2 years with optimal functional outcomes. Moreover, distal corporoplasty resulted in shorter operative time, better function, less pain, and fewer recurrences than Gortex windsock repair.10 In our experience, distal corporoplasty is a simple and safe procedure in the treatment of distal cylinders extrusion when the prosthetic material is not exposed to the exterior.

Is laparoscopic surgery really effective for the treatment of colon and rectal cancer in very elderly over 80 years old? A prospective multicentric case–control assessment

To evaluate the effectiveness of laparoscopic surgery (LCS) for colon and rectal cancer in the very elderly over 80years old. We performed a prospective multicentric analysis comparing patients over 80 years (Group A) and patients between 60 and 69 years (Group B) undergoing LCS for cancer from January 2008 to December 2013. Colon and rectal cancers were analyzed separately. Comorbidity and complications were classified using the Charlson comorbidity index (CCI) and the Clavien-Dindo system, respectively. Oncological parameters included tumor-free margins, number of lymph nodes harvested and circumferential resection margin. Group A included 96 and 33 patients, and Group B 220 and 82 for colon and rectal cancers, respectively. Groups were similar except for ASA score and CCI, as expected. There was no significant difference in operative time [colon; rectum] (180[IQR 150-200] vs 180[150-210] min; NS-180[160-210] vs 180[165-240] min; NS), estimated blood loss (50[25-75] vs 50[25-120]mL; NS-50[0-150] vs 50[25-108.7]mL; NS) and conversion rate (2.1 vs 2.7%; NS-3.0 vs 2.4%; NS). Timing of first stool (3[2-3.25] vs 3[2-5] dd; NS-3[2-4] vs 3[2-5] dd; NS), length of stay (7[6-8] vs 7[6-8] dd; NS-8[8-9] vs 8[7-9] dd; NS) and readmission rate (1.0 vs 0.45%; NS-6.1 vs 1.2%; NS) were similar. Tumor-free margins were appropriate, and positivity of CRM is poor (6.1 vs 4.9; NS). We did not record significant differences in complications rate (47.9 vs 43.6%; NS-63.6 vs 52.4%; NS). Laparoscopic surgery is effective for the treatment of colorectal cancer even in the very elderly. Age is not a risk factor or a limitation for LCS.

The effect of postoperative morbidity on long-term survival after curative resection for extra-hepatic biliary tumors: A multi-institution analysis from the U.S. Extrahepatic Biliary Malignancy Consortium.

435 Background: Surgical resection is the cornerstone of curative therapy for extrahepatic biliary tumors (EHBTs) Postoperative complications (POCs) can negatively impact survival after oncologic resection. We evaluated the impact of POCs on survival after resection of EHBTs. Methods: We analyzed 914 patients from ten institutions of the U.S. Extrahepatic Biliary Malignancy Consortium who underwent curative resection for gallbladder adenocarcinoma (n=389), hilar (n=295) and distal (n=294) cholangiocarcinoma between 1998 and 2015. POCs were graded using the modified Clavien-Dindo system. Overall survival (OS) probabilities were estimated using the method of Kaplan and Meier and analyzed using multivariate Cox regression. Results: Median follow-up was 20 months. The median age was 66 years, and the overall complication rate was 54%. Complication rates were significantly higher in patients with distal or hilar cholangiocarcinoma (62%) when compared with gallbladder cancer (41%, p&lt;0.001). For all cancer types, patients who experienced POCs had lower 5-year OS when compared with those who did not (18% vs 28%, p&lt;0.001). On multivariate Cox regression, POC remained an independent predictor for decreased OS (HR 1.5, 95% CI 1.3-1.9, p&lt;0.001; Table). Among patients who experienced POCs, survival did not differ by greatest Clavien grade of complication experienced (p=0.89), however patients who had 2 or more POCs did have decreased long term survival when compared with patients with only a single POC (HR 1.5, 95% CI 1.2-1.8, p=0.001). Conclusions: POCs adversely affect long-term outcomes after curative resection for extra-hepatic biliary tumors. While any complication grade did not have a significant impact on long-term survival, increasing number of POCs did significantly worsen the prognosis for OS. [Table: see text]

The Impact of Body Mass Index on the Surgical Outcomes of Patients With Gastric Cancer: A 10-Year, Single-Institution Cohort Study.

This study aimed to investigate the impact of body mass index (BMI) on the short-term and long-term results of a large cohort of gastric cancer (GC) patients undergoing gastrectomy.Recently, the “obesity paradox” has been proposed, referring to the paradoxically “better” outcomes of overweight and obese patients compared with nonoverweight patients. The associations between BMI and surgical outcomes among patients with GC remain controversial.A single-institution cohort of 1249 GC patients undergoing gastrectomy between 2000 and 2010 were categorized to low-BMI (<18.49 kg/m2), normal-BMI (18.50–24.99 kg/m2), and high-BMI (≥25.00 kg/m2) groups. The postoperative complications were classified according to the Clavien-Dindo system, and their severity was assessed by using the Comprehensive Complication Index (CCI). The impact of BMI on the postoperative complications and overall survival was analyzed.There were 908, 158, and 182 patients in the normal-BMI, low-BMI, and high-BMI groups, respectively. The overall morbidity in the high-BMI group (24.7%) was higher than that in either the low-BMI or the normal-BMI group (20.9% and 15.5%, respectively; P = 0.006), but the mean CCI in the low-BMI group was significantly higher (8.32 ± 19.97) than the mean CCI in the normal-BMI and high-BMI groups (3.76 ± 11.98 and 5.58 ± 13.07, respectively; P < 0.001). The Kaplan–Meier curve and the log-rank test demonstrated that the low-BMI group exhibited the worst survival outcomes compared with the normal-BMI group, whereas the high-BMI group exhibited the best survival outcomes (P < 0.001). In multivariate analysis, BMI was identified as an independent prognostic factor. In the stage-specific subgroup analysis, a low BMI was associated with poorer survival in the cases of stage III–IV diseases.Low BMI was associated with more severe postoperative complications and poorer prognosis. Despite a higher risk of mild postoperative complications, the high-BMI patients exhibited paradoxically “superior” survival outcomes compared with the normal-BMI patients. These findings confirm the “obesity paradox” in GC patients undergoing gastrectomy.

A multicenter study of 30 days complications after deceased donor liver transplantation in the model for end-stage liver disease score era.

Knowledge of risk factors for posttransplant complications is likely to improve patient outcomes. Few large studies of all early postoperative complications after deceased donor liver transplantation (DDLT) exist. Therefore, we conducted a retrospective, cohort study of 30-day complications, their risk factors, and the impact on outcomes after DDLT. Three centers contributed data for 450 DDLTs performed from January 2005 through December 2009. Data included donor, recipient, transplant, and outcome variables. All 30-day postoperative complications were graded by the Clavien-Dindo system. Complications per patient and severe (≥ grade III) complications were primary outcomes. Death within 30 days, complication occurrence, length of stay (LOS), and graft and patient survival were secondary outcomes. Multivariate associations of risk factors with complications and complications with LOS, graft survival, and patient survival were examined. Mean number of complications/patient was 3.3 ± 3.9. At least 1 complication occurred in 79.3%, and severe complications occurred in 62.8% of recipients. Mean LOS was 16.2 ± 22.9 days. Graft and patient survival rates were 84% and 86%, respectively, at 1 year and 74% and 76%, respectively, at 3 years. Hospitalization, critical care, ventilatory support, and renal replacement therapy before transplant and transfusions during transplant were the significant predictors of complications (not the Model for End-Stage Liver Disease score). Both number and severity of complications had a significant impact on LOS and graft and patient survival. Structured reporting of risk-adjusted complications rates after DDLT is likely to improve patient care and transplant center benchmarking. Despite the accomplished reductions in transfusions during DDLT, opportunities exist for further reductions. With increasing transplantation of sicker patients, reduction in complications would require multidisciplinary efforts and institutional commitment. Pretransplant risk characteristics for complications must factor in during payer contracting.

A Single-centre Early Phase Randomised Controlled Three-arm Trial of Open, Robotic, and Laparoscopic Radical Cystectomy (CORAL)

BackgroundLaparoscopic radical cystectomy (LRC) and robot-assisted radical cystectomy (RARC) are increasingly popular, but high-level evidence for these techniques remains lacking. ObjectiveTo compare the outcomes of patients undergoing open radical cystectomy (ORC), RARC, and LRC. Design, setting, and participantsFrom March 2009 to July 2012, 164 patients requiring radical cystectomy for muscle-invasive bladder cancer or high-risk non–muscle-invasive bladder cancer were invited to participate, with an aim of recruiting 47 patients into each arm. Overall, 93 were suitable for trial inclusion; 60 (65%) agreed and 33 (35%) declined. InterventionORC, RARC, or LRC with extracorporeal urinary diversion. Outcome measurements and statistical analysisPrimary end points were 30- and 90-d complication rates. Secondary end points were perioperative clinical, pathologic, and oncologic outcomes, and quality of life (QoL). The Fisher exact test and analysis of variance were used for statistical analyses. Results and limitationsThe 30-d complication rates (classified by the Clavien-Dindo system) varied significantly between the three arms (ORC: 70%; RARC: 55%; LRC: 26%; p=0.024). ORC complication rates were significantly higher than LRC (p<0.01). The 90-d complication rates did not differ significantly between the three arms (ORC: 70%; RARC: 55%; LRC 32%; p=0.068). Mean operative time was significantly longer in RARC compared with ORC or LRC. ORC resulted in a slower return to oral solids than RARC or LRC. There were no significant differences in QoL measures. Major limitations are the small sample size and potential surgeon bias. ConclusionsThe 30-d complication rates varied by type of surgery and were significantly higher in the ORC arm than the LRC arm. There was no significant difference in 90-d Clavien-graded complication rates between the three arms. Patient summaryWe compared patients having open, robotic, or laparoscopic bladder removal surgery for bladder cancer and found no difference in Clavien-graded complication rates at 90 d.

Renal Autotransplantation: 27-Year Experience at 2 Institutions

Renal autotransplantation is an infrequently performed procedure. It has been used to manage complex ureteral disease, vascular anomalies and chronic kidney pain. We reviewed our 27-year experience with this procedure. This is a retrospective, observational study of 51 consecutive patients who underwent renal autotransplantation, including 29 at Oregon Health and Science University between 1986 and 2013, and 22 at Virginia Mason Medical Center between 2007 and 2012. Demographics, indications, operative details and followup data were collected. Early (30 days or less) and late (greater than 30 days) complications were graded according to the Clavien-Dindo system. Factors associated with complications and pain recurrence were evaluated using a logistic regression model. The 51 patients underwent a total of 54 renal autotransplants. Median followup was 21.5 months. The most common indications were loin pain hematuria syndrome/chronic kidney pain in 31.5% of cases, ureteral stricture in 20.4% and vascular anomalies in 18.5%. Autotransplantation of a solitary kidney was performed in 5 patients. Laparoscopic nephrectomy was performed in 23.5% of cases. Median operative time was 402 minutes and median length of stay was 6days. No significant difference was found between preoperative and postoperative plasma creatinine (p = 0.74). Early, high grade complications (grade IIIa or greater) developed in 14.8% of patients and 12.9% experienced late complications of any grade. Two graft losses occurred. Longer cold ischemia time was associated with complications (p = 0.049). Of patients who underwent autotransplantation for chronic kidney pain 35% experienced recurrence and 2underwent transplant nephrectomy. No predictors of pain recurrence were identified. The most common indications for renal autotransplantation were loin pain hematuria syndrome/chronic kidney pain, ureteral stricture and vascular anomalies in descending order. Kidney function was preserved postoperatively and 2 graft losses occurred. At a median followup of 13 months pain resolved in 65% of patients who underwent the procedure. Complication rates compared favorably with those of other major urological operations and cold ischemia time was the only predictor of postoperative complications.

PWE-079 Clinical assessment of operative fitness can identify patients at risk of complications after hepatectomy for malignant disease, but does not correlate with long-term survival

<h3>Introduction</h3> Liver resection is associated with significant morbidity and mortality, and accurate pre-operative assessment of risk is an important part of the pre-operative consultation. Numerous scoring systems exist to assess operative risk, which are rarely used in routine practice. All patients, however, are assessed in out-patient clinic and a subjective assessment of risk is made. Patients thought to be at higher risk of operative complications in our hospital are referred for CPX testing. We wished to establish if clinicians are able to predict patients at greater risk of complications after liver resection. <h3>Method</h3> Prospectively collected data on patients undergoing hepatectomy were retrieved from the HPB unit database. From February 2008 to November 2013 patients subjectively anticipated to be at high-risk were selectively referred for CPX. The study group excluded patients with chronic liver disease and biliary obstruction. Operative complications were classified according to the Clavien-Dindo system. Outcomes between the group referred for CPX was compared with control group. <h3>Results</h3> During the study period 405 resections were performed on 368 individuals. CPX testing was carried out prior to 101 resections. Median age was 72 and 64 in CPX and non-CPX groups, respectively (P &lt; 0.001). Men accounted for 68% and 46% of CPX and non-CPX patients respectively (P &lt; 0.001). There was no difference in the underlying diagnosis or number of resected liver segments between groups. CPX and non-CPX patients suffered 19 (18.8%) and 28 (9.2%) grade 4–5 complications, respectively (P = 0.009). No difference was seen for grade 3 complications. There was no difference in long-term survival between CPX and non-CPX groups (P = 0.63). <h3>Conclusion</h3> This study represents the only attempt to assess clinicians’ ability to identify patients at greater risk of complications following hepatectomy. The confirmation that patients identified in this way have approximately 100% greater risk of grade 4–5 complications demonstrates the value of pre-operative counselling by experienced clinicians. Interestingly, patients identified to be lower operative risk do not have improved long-term survival, suggesting disease recurrence and progression are more important determinants of long-term outcome. <h3>Disclosure of interest</h3> None Declared.

PWE-080 Is cardiopulmonary exercise testing prior to hepatectomy useful?

Introduction Liver resection is a major operation with significant morbidity and mortality, and accurate pre-operative assessment of risk is important. Cardiopulmonary exercise testing (CPX) is used increasingly before major abdominal surgery, although its usefulness prior to hepatectomy is unclear. We wished to evaluate the role of CPX testing prior to liver resection. Method Prospectively collected data were extracted from the HPB unit database. The study group excluded patients with chronic liver disease and biliary obstruction. CPX testing was introduced in February 2008, initially selectively but after November 2013 was used in all patients undergoing liver resection. Standard CPX and operative parameters were retrieved. Operative complications were classified according to the Clavien-Dindo system and grade 3–5 complications considered significant. Multi-variate methods were used to assess potential associations between pre-operative CPX parameters and operative complications. Results Pre-operative CPX was performed on 183 occasions. Grade 3, 4 and 5 complications were suffered by 17, 38 and 3% of patients, respectively. A weak association was noted between increasing ventilatory equivalents for CO2(VE/CO2), the risk of Grade 3–5 complications (Odds ratio = 1.11, p = 0.015) and length of post-operative stay (p = 0.004). No association was noted between any other CPX variable and operative outcome. Conclusion With the exception of VE/CO2,CPX test parameters did not predict the development of post-operative complications. It is likely that the majority of complications suffered after liver resection relate to technical aspects of the operation and are not associated with cardio-respiratory function. Disclosure of interest None Declared.

Clinical assessment before hepatectomy identifies high-risk patients

BackgroundLiver resection is associated with significant morbidity, and assessment of risk is an important part of preoperative consultations. Objective methods exist to assess operative risk, including cardiopulmonary exercise testing (CPX). Subjective assessment is also made in clinic, and patients perceived to be high-risk are referred for CPX at our institution. This article addresses clinicians' ability to identify patients with a higher risk of surgical complications after hepatectomy, using selection for CPX as a surrogate marker for increased operative risk. Materials and methodsProspectively collected data on patients undergoing hepatectomy between February 2008 and November 2013 were retrieved and the cohort divided according to CPX referral. Complications were classified using the Clavien–Dindo system. ResultsCPX testing was carried out before 101 of 405 liver resections during the study period. The median age was 72 and 64 in CPX and non-CPX groups, respectively (P < 0.001). The resection size was similar between the groups. No difference was noted for grade III complications between CPX and non-CPX tested-groups; however, 19 (18.8%) and 28 (9.2%) patients suffered grade IV–V complications, respectively (P = 0.009). There was no difference in long-term survival between groups (P = 0.63). ConclusionsThis study attempts to assess clinicians' ability to identify patients at greater risk of complications after hepatectomy. The confirmation that patients identified in this way are at greater risk of grade IV–V complications demonstrates the value of preoperative counseling. High-risk patients do not have worse long-term outcomes suggesting survival is determined by other factors, particularly disease recurrence.

Resection versus ablation in hepatitis B virus−related hepatocellular carcinoma patients with portal hypertension: A propensity score matching study

With recent improvements in operative techniques, many studies have reported that resection is safe for hepatocellular carcinoma (HCC) patients with portal hypertension (PHT). However, no direct evidence exists to compare resection with ablation in patients with hepatitis B virus (HBV)-related PHT. Of 259 HBV-related PHT patients who met the Milan criteria, 123 patients underwent resection and 136 underwent ablation as a primary treatment. Complications were graded with the Clavien-Dindo system, and oncologic outcomes were analyzed with a propensity score matching (PSM) method. Compared with the ablation group, the resection group showed larger tumors, greater white blood cell counts, greater platelet counts, lower γ-glutamyltransferase levels, and lower model of end stage liver disease scores (all P < .05). Although more frequent complications occurred in the resection group (P < .001), the difference was significant for the Grade I complications but not for Grade II-V complications. The recurrence-free survival (RFS) and overall survival (OS) rates were greater in the resection group than in the ablation group (P = .001 and P = .010, respectively). After one-to-one PSM, 77 resection patients and 77 ablation patients were selected for further analyses. The advantages of resection over ablation were still observed in RFS (P = .002) and OS (P = .012). Grade I-V complications were comparable between the 2 groups (all P > .100). Resection is safe and confers a survival advantage over ablation in HBV-related PHT patients. Resection may be recommended as an optimal treatment for these patients.

Robot-assisted Simple Prostatectomy for Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Enlargement: Surgical Technique and Outcomes in a High-volume Robotic Centre

BackgroundRobot-assisted simple prostatectomy (RASP) is a minimally invasive procedure for treatment of patients with lower urinary tract symptoms (LUTS) due to large benign prostatic enlargement (BPE). ObjectiveTo present the perioperative and short-term functional outcomes of RASP in a large series of patients with LUTS due to BPE treated in a high-volume referral center. Design, setting, and participantsWe retrospectively collected data for 67 consecutive patients who underwent RASP from October 2008 to August 2014. Surgical procedureRASP was performed using a Da Vinci S or Si system with a transvesical approach. MeasurementsComplications were graded according to the Clavien-Dindo system. Continuous variables are reported as median and interquartile range (IQR). Comparison of preoperative and postoperative outcomes was assessed by Wilcoxon test. A two-sided value of p<0.05 was considered statistically significant. Results and limitationsThe median preoperative prostate volume was 129ml (IQR 104–180). For the 45 patients who did not have an indwelling catheter, the median preoperative International Prostate Symptom Score (IPSS) was 25 (20.5–28), the median maximum flow rate (Qmax) was 7ml/s (IQR 5–11), and the median post-void residual volume (PVRV) was 73ml (IQR 40–116). The median operative time was 97min (IQR 80–127) and the median estimated blood loss was 200ml (IQR 115–360). The postoperative complication rate was 30%, including three cases (4.5%) with grade 3b complications (major bleeding requiring cystoscopy and coagulation). The median catheterization time was 3 d (IQR 2–4) and the median length of stay was 4 d (IQR 3–5). The median follow-up was 6 mo (IQR 2–12). At follow-up, the median IPSS was 3 (IQR 0–8), the median Qmax was 23ml/s (IQR 16–35), and the median PVRV was 0ml (IQR 0–36) (all p<0.001 vs baseline values). The retrospective design is the major study limitation. ConclusionsOur data indicate good perioperative outcomes, an acceptable risk profile, and excellent improvements in patient symptoms and flow scores at short-term follow-up following RASP. Patient summaryWe analyzed the perioperative and functional outcomes of robot-assisted simple prostatectomy in the treatment of male patients with lower urinary tract symptoms due to large prostatic adenoma. The procedure was associated with a relatively low risk of complications and excellent functional outcomes, including considerable improvements in symptoms and flow performance. We can conclude that the procedure is a valuable option in the treatment of such patients. However, comparative studies evaluating the efficacy of the procedure in comparison with endoscopic treatment of large prostatic adenomas are needed.

Evaluation of Clavien-Dindo classification in patients undergoing total gastrectomy for gastric cancer.

The Clavien-Dindo classification for postoperative complications has been established as a standardized system and applied in many fields of surgery. The aim of our study was to assess the complications after total gastrectomy using the Clavien-Dindo classification and identify risk factors related to them. Four hundred and fifteen patients who underwent total gastrectomy for gastric cancer between April 2009 and September 2014 were enrolled in this study. Postoperative complications were graded, and possible risk factors related to complications were analyzed. The overall complication rate was 13.3 %, with the severe complications classified as grade III or above accounting for 3.1 %. Age of 65 years old or more, higher TNM staging, and open surgery were identified as independent risk factors for overall complications. Age of 65 years old or more, ASA score of 3 or more, multiorgan resection, and retrieved lymph nodes of 30 or more were identified as independent risk factors for severe complications. The Clavien-Dindo system has a broad applicability and facilitates the assessment on the incidence and severity of complications. Large-scaled, prospective clinical trials using the classification are necessary to evaluate the postoperative complications of total gastrectomy for gastric cancer.

The application of PADUA scoring system for predicting complications of laparoscopic renal cryoablation.

To evaluate the clinical application of preoperative aspects and dimensions used for anatomical (PADUA) scoring system in predicting perioperative surgical outcomes in patients undergoing laparoscopic cryoablation (LCA). A total of 95 consecutive renal tumors treated with LCA between January 2007 and April 2013 were collected. Renal tumors were categorized into low- (6-7), moderate- (8-9), and high-complexity (10-13) groups according to PADUA indices. Demographics, perioperative variables, and complication rates were compared among three groups. Surgical conversion, blood loss >100 mL, tumor fracture, and incomplete ablation were regarded as intraoperative complications (IOCs). All postoperative complications (POCs) were graded using the Clavien-Dindo system. The risk for complications was assessed by univariate and multivariate logistic regression analyses. The estimated blood loss during LCA was associated with PADUA score. There were 17 (17.9%) IOCs and 20 (21.1%) POCs. Blood loss (>100 mL) was the most common IOC, which occurred in 10 (10.5%) patients. For POC, there were 15 (15.8%) minor complications (Clavien 1-2) and 5 (5.3%) major complications (Clavien 3a). Higher grade of PADUA scores was significantly correlated with the increase incidence of IOC and POC. The PADUA score was an independent predictive factor for POC, and the patients with moderate and high PADUA scores had an over sixfold and 17-fold higher risk compared to the patients with low scores, respectively. Our findings demonstrated, for the first time, the PADUA scoring system is an efficient assessment tool for predicting the perioperative complications in patients undergoing laparoscopic renal cryoablation.