Clavien-Dindo System Research Articles

First Canadian experience with robotic laparoendoscopic single-site vs. standard laparoscopic living-donor nephrectomy: A prospective comparative study.

We aimed to compare the outcomes of robotic laparoendoscopic single-site living donor nephrectomy (R-LESS LDN) vs. standard laparoscopic living donor nephrectomy (LLDN). Between October 2013 and November 2015, 39 patients were allocated to either standard LLDN (n=25) or R-LESS LDN (n=14). Patient demographics, perioperative outcomes, analgesic requirement, visual analogue scale of pain at postoperative days 1, 3, 7, and 30, and a health-related quality of life and body image questionnaire were prospectively collected. There were no significant differences in demographics and intraoperative outcomes between the two cohorts. The R-LESS LDN cohort had lower analgesic requirement (p=0.002) and lower visual pain scores on days 1 and 3 (p=0.001). Additionally, body image and satisfaction scores in the R-LESS group were also superior compared to the LLDN cohort (p=0.008). There was no significant difference in the postoperative complications according to the Clavien-Dindo system. Recipient graft functional outcomes were equivalent. This is the first evidence that R-LESS LDN is safe and associated with comparable surgical and early functional outcomes compared to LLDN, while pain, donor body image, and satisfaction scores were improved compared to LLDN.

Use of Clavien-Dindo classification in evaluating complications following pancreaticoduodenectomy in 1,056 cases: A retrospective analysis from one single institution.

The Clavien-Dindo (C-D) classification is a simple and feasible grading system of postoperative complications. The aim of the present study was to apply this system to retrospectively classify all types of post-pancreaticoduodenectomy (PD) complications (PPCs) and to systematically identify associated risk factors. Between January 2009 and December 2014, the C-D classification was applied to retrospectively classify PPCs for 1,056 patients who had undergone PD at the West China Hospital. Univariate and multivariate analyses were performed to link perioperative parameters and mortality with the severity of PPCs, which were subdivided into overall PPCs (Grade I-V), severe PPCs (Grade III-V) and mortality (Grade V). The number of patients with Clavien-Dindo grade I, II, IIIa, IIIb, IVa, IVb and V complications was 185 (17.5%), 128 (12.1%), 50 (4.7%), 25 (2.4%), 35 (3.3%), 19 (1.8%) and 33 (3.1%), respectively. A total of 475 (45.0%) patients experienced overall PPCs; 168 (15.9%) patients experienced severe PPCs; and 33 patients succumbed to mortality following PD. The following risk factors were identified following PD: Preoperative hypoproteinemia was correlated with all three subdivisions; obstructive jaundice was associated with severe PPCs and mortality; and older age was revealed to be an independent risk factor of mortality. A large retrospective study was performed in the present study and PD was correlated with a high occurrence of PPCs. The Clavien-Dindo system represents a broad applicable and feasible approach to evaluating PPCs in patients following PD. The independent risk factors of PPCs that were identified in the present study require further validation using the Clavien-Dindo classification in additional prospective studies.

Perioperative outcomes of zero ischemia radiofrequency ablation-assisted tumor enucleation for renal cell carcinoma: results of 182 patients

BackgroundTo evaluate the perioperative outcomes of zero ischemia radiofrequency ablation-assisted tumor enucleation.MethodsPatients undergoing zero ischemia radiofrequency ablation-assisted tumor enucleation were retrospectively identified from July 2008 to March 2013. The tumor was enucleated after RFA treatment. R.E.N.A.L., PADUA and centrality index (C-index) score systems were used to assess each tumor case. We analyzed the correlation of perioperative outcomes with these scores. Postoperative complications were graded with Clavien-Dindo system. Multivariate logistic regression analyses were used to assess risk of complications.ResultsAmong 182 patients assessed, median tumor size, estimated blood loss, hospital stay and operative time were 3.2 cm (IQR 2.8–3.4), 80 ml (IQR 50–120), 7 days (IQR 6–8) and 100 min (IQR 90–120), respectively. All three scoring systems were strongly correlated with estimated blood loss, hospital stay and operative time. We found 3 (1.6%) intraoperative and 23 (12.6%, 13 [7.1%] Grade 1 and 10 [5.5%] Grade 2 & 3a) postoperative complications. The median follow-up was 55.5 months (IQR 45–70). Additionally, the complexities of R.E.N.A.L., PADUA and C-index scores were significantly correlated with complication grades (P < 0.001; P < 0.001; P < 0.001; respectively). As the representative, R.E.N.A.L. score was an independent predictive factor for postoperative complications and patients with a high complexity had an over 24-fold higher risk compared to those with a low complexity (OR 24.360, 95% CI 4.412–134.493, P < 0.001).ConclusionsZero ischemia radiofrequency ablation-assisted tumor enucleation is considered an effective nephron-sparing treatment. Scoring systems could be useful for predicting perioperative outcomes of radiofrequency ablation-assisted tumor enucleation.

Complications following lengthening of spinal growing implants: is postoperative admission necessary?

OBJECTIVE The aim of this study was to evaluate the effect of postoperative admission status on 30-day perioperative complications in patients with growing spinal instrumentation undergoing surgical lengthening. METHODS This retrospective case-control study of records from the 2014-2015 National Surgical Quality Improvement Program-Pediatric database was performed to identify surgical lengthening procedures of spinal implants in patients with growing instrumentation by Current Procedural Terminology code. The 30-day postoperative complications were classified according to the Clavien-Dindo system. Patients were subdivided according to their postsurgical admission status. Admission status, American Society of Anesthesiologists (ASA) Physical Status classification, tracheostomy, neuromuscular diagnosis, ventilator dependence, and nutritional support were considered as possible risk factors in univariate and multivariate logistic regression analyses. RESULTS A total of 796 patients were identified (mean age 9.09 ± 3.44 years; 54% of patients were female), of whom 73% underwent lengthening on an inpatient basis. Patients with a tracheostomy or ventilator dependence were more likely to be admitted postoperatively. The overall rate of major complications was 3.5% and did not differ based on admission status (2.8% inpatient vs 3.8% outpatient, p = 0.517). On univariate analysis, ventilator dependence (9.5% vs 2.7%, p = 0.002), need for nutritional support (7.1% vs 2.5%, p = 0.006), and ASA class > II (4.8% vs 1.3%, p = 0.04) placed patients at a higher risk for any postoperative complications. Multivariate analysis identified only ventilator dependence as an independent risk factor for any perioperative complication. CONCLUSIONS Postoperative admission status did not affect the rate of 30-day perioperative complications, readmission, or rate of unplanned operations following lengthening of growing spinal instrumentation. Outpatient lengthening appears to be safe; however, consideration for postoperative admission should be given for those who are ventilator dependent.

Single-Center Experience of Tracheobronchoplasty for Tracheobronchomalacia: Perioperative Outcomes

We present trends in practice as our experience has grown and report the postoperative morbidity and its associated factors after tracheobronchoplasty. A retrospective cohort study was conducted of 161 patients who underwent tracheobronchoplasty from October 2002 to September 2016. The main outcome was development of a postoperative complication within 30 days of the operation. Postoperative complication events were graded using the Clavien-Dindo system. The study patients were divided into two consecutive cohorts to examine trends in systems of care. Postoperative morbidity was examined using a log-binomial regression model. The cohort consisted of 103 women (64%), with a median age of 58 years (interquartile range, 52 to 66 years). Postoperative morbidity occurred in 75 patients (47%). Severe complications (Clavien-Dindo grade ≥IIIa) occurred in 38 patients (24%), most of which were respiratory in nature, including 27 (17%) with respiratory failure. Median intensive care unit length of stay was 4 days (interquartile range, 3 to 5 days), with a total length of stay of 8 days (interquartile range, 6 to 11 days). In-hospital mortality occurred in 2 patients (1%). Discharge was directly to home in 68% of patients (37% without assistance and 31% with visiting nurse follow-up) and to a rehabilitation facility in 31%. After adjusting for age, sex, race, operative time, and intraoperative blood loss, forced expiratory volume in 1 second was an independent predictor (odds ratio, 0.97; 95% confidence interval, 0.95 to 0.99; p= 0.01) for postoperative morbidity. Despite an arduous hospital course withsignificant risk of severe complication, patients undergoing tracheobronchoplasty for severe tracheobronchomalacia have low risk of mortality and most are discharged directly tohome.

PD61-07 COMPARATIVE ANALYSIS OF PERIOPERATIVE OUTCOMES FOR PATIENTS WITH 4-7CM RCC TREATED WITH EITHER MICROWAVE ABLATION, PARTIAL NEPHRECTOMY OR RADICAL NEPHRECTOMY

You have accessJournal of UrologyKidney Cancer: Localized: Ablative Therapy1 Apr 2018PD61-07 COMPARATIVE ANALYSIS OF PERIOPERATIVE OUTCOMES FOR PATIENTS WITH 4-7CM RCC TREATED WITH EITHER MICROWAVE ABLATION, PARTIAL NEPHRECTOMY OR RADICAL NEPHRECTOMY Daniel D. Shapiro, Shane A. Wells, Timothy J. Ziemlewicz, Meghan G. Lubner, J. Louis Hinshaw, Fred T. Lee, David F. Jarrard, Kyle A. Richards, Sara L. Best, Tracy M. Downs, Glenn O. Allen, Stephen Y. Nakada, and E. Jason Abel Daniel D. ShapiroDaniel D. Shapiro More articles by this author , Shane A. WellsShane A. Wells More articles by this author , Timothy J. ZiemlewiczTimothy J. Ziemlewicz More articles by this author , Meghan G. LubnerMeghan G. Lubner More articles by this author , J. Louis HinshawJ. Louis Hinshaw More articles by this author , Fred T. LeeFred T. Lee More articles by this author , David F. JarrardDavid F. Jarrard More articles by this author , Kyle A. RichardsKyle A. Richards More articles by this author , Sara L. BestSara L. Best More articles by this author , Tracy M. DownsTracy M. Downs More articles by this author , Glenn O. AllenGlenn O. Allen More articles by this author , Stephen Y. NakadaStephen Y. Nakada More articles by this author , and E. Jason AbelE. Jason Abel More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2831AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Although microwave ablation (MWA) may be used for RCC treatment in older patients with co-morbidities, the perioperative morbidity associated with MWA in larger tumors has not been described in detail. The purpose of this project was to evaluate perioperative outcomes (complications, hospital stay, transfusion rate, readmission rate) for patients with 4-7cm RCC tumors treated with either MWA or surgery. METHODS Comprehensive data was analyzed for consecutive RCC patients with tumors 4-7cm following treatment with MWA, partial nephrectomy (PN) or radical nephrectomy (RN). Patients with metastases or venous thrombus were excluded. Complications within 90 days were classified using the Clavien-Dindo system. Univariate and multivariate Cox analysis was performed to determine factors associated with perioperative outcomes. RESULTS An institutional database identified 42 MWA, 74 PN and 211 RN (n=327) treated from 2000-2017. Perioperative complications were identified in 9 (21%) MWA, 18 (24%) PN and 28 (13%) RN patients. Patients treated with MWA had higher Charlson co-morbidity scores (p<0.0001) and were older (p<0.0001) compared to patients treated surgically. After multivariate analysis, independent predictors of perioperative complications included treatment with PN (vs. MW or RN) HR 2.42 (95%CI 1.23 – 4.76) and prior abdominal surgery HR 2.27 (95%CI 1.21-4.26).Blood transfusion rate was not statistically different among treatments, (4.7% MWA, 8.1% PN, 4.7% RN; p=0.53). Perioperative mortality within 30 days was identified following in 0 MWA, 0 PN and 1/211 (0.5%) RN patients. Median hospital stay was shorter for MWA 1 day (IQR 1-1) vs. PN 4 days (IQR 3-6) or RN 4 days (IQR 3-4), p<0.001. No difference was identified in 30- day re-admission rate among treatments, 7.1% MWA vs, 1.4% PN vs. 2.8% RN, p=0.21. CONCLUSIONS Patients treated with microwave ablation for 4-7cm RCC tumors had shorter length of hospitalization with no differences in 30-day re-admission rate, overall complication rate, or perioperative mortality. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e1153-e1154 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Daniel D. Shapiro More articles by this author Shane A. Wells More articles by this author Timothy J. Ziemlewicz More articles by this author Meghan G. Lubner More articles by this author J. Louis Hinshaw More articles by this author Fred T. Lee More articles by this author David F. Jarrard More articles by this author Kyle A. Richards More articles by this author Sara L. Best More articles by this author Tracy M. Downs More articles by this author Glenn O. Allen More articles by this author Stephen Y. Nakada More articles by this author E. Jason Abel More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP28-05 COMPLICATIONS FOLLOWING 1053 PERCUTANEOUS CORE RENAL MASS BIOPSIES: RISK FACTORS AND SAFETY ASSESSMENT

You have accessJournal of UrologyKidney Cancer: Epidemiology & Evaluation/Staging I1 Apr 2018MP28-05 COMPLICATIONS FOLLOWING 1053 PERCUTANEOUS CORE RENAL MASS BIOPSIES: RISK FACTORS AND SAFETY ASSESSMENT Natasza Posielski, Anthony Bui, Shane A. Wells, Sara L. Best, Lori Mankowski Gettle, Timothy J. Ziemlewicz, Meghan G. Lubner, J. Louis Hinshaw, Fred T. Lee, Stephen Y Nakada, and E. Jason Abel Natasza PosielskiNatasza Posielski More articles by this author , Anthony BuiAnthony Bui More articles by this author , Shane A. WellsShane A. Wells More articles by this author , Sara L. BestSara L. Best More articles by this author , Lori Mankowski GettleLori Mankowski Gettle More articles by this author , Timothy J. ZiemlewiczTimothy J. Ziemlewicz More articles by this author , Meghan G. LubnerMeghan G. Lubner More articles by this author , J. Louis HinshawJ. Louis Hinshaw More articles by this author , Fred T. LeeFred T. Lee More articles by this author , Stephen Y NakadaStephen Y Nakada More articles by this author , and E. Jason AbelE. Jason Abel More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.905AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Percutaneous renal mass biopsy (RMB) is an effective diagnostic tool. Although morbidity of RMB is generally minimal, few studies have investigated risk factors and safety for complications. The purpose of this project is to evaluate patient, tumor, and technical factors associated with procedural complications following RMB. METHODS Consecutive patients treated with percutaneous core RMB from 2003-2017 were identified. Institutional protocol allows RMB with INR ≤ 2.0, platelets > 25,000 and continuation of aspirin (ASA) therapy. Complications ≤30 days were graded using the Clavien-Dindo system. Logistic regression evaluated associations between complications and: age, gender, body mass index (BMI), Charlson Comorbidity Index (CCI), smoking status, pre-procedure labs (platelets, INR, hemoglobin), ASA, blood pressure during procedure, tumor diameter, Nephrometry score, biopsy needle size, US vs. CT guidance, number of needle passes, presence of trainees, and radiologist′s prior experience. RESULTS Of 1053 patients, 23 (2.2%) patients had procedural complications including: symptomatic hematomas 6(0.6%), gross hematuria 8 (0.8%), severe pain 4 (0.4%), UTI 4 (0.4%) and one patient each with hypotension, pseudoaneurysm and urinary retention. Major complications (≥Clavien 3a) were identified in 5 (0.5%) patients and 11 (1.0%) were admitted to the hospital. No patients had tumor seeding from biopsy. Age, BMI, gender, CCI, smoking status, platelet count, INR, hemoglobin, and blood pressure were not associated with complications (p=0.48, 0.09, 0.10, 0.33, 0.47, 0.16, 0.41, 0.46, 0.30). No associations were identified with complications and tumor diameter, Nephrometry score, needle size, type of radiologic guidance, or number of needle passes (0.30, 0.18, 1.0, 0.27, 0.10). RMB was performed in 401 (38%) patients on ASA and 51 (4.8%) with INR > upper limit normal. Risk was not increased in patients on ASA or for patients with INR 1.3-2.0, p=0.23 and 0.41, respectively. Trainee presence did not increase complication rate, p=0.24. Twelve radiologists performed at least 50 RMB, median 83 (range 54-136). Complications rates ranged from 0-2.3%, but no difference was identified between the most and least experienced radiologists, p=0.21. Risk was not increased during radiologist′s first 50 cases, p=0.23. CONCLUSIONS Renal mass biopsy is safe for patients with platelets > 25,000 or INR 1.3-2.0 and ASA did not increase complication risk. Number of needle passes, BMI, co-morbidities and radiologist experience were also not associated with complications. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e358 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Natasza Posielski More articles by this author Anthony Bui More articles by this author Shane A. Wells More articles by this author Sara L. Best More articles by this author Lori Mankowski Gettle More articles by this author Timothy J. Ziemlewicz More articles by this author Meghan G. Lubner More articles by this author J. Louis Hinshaw More articles by this author Fred T. Lee More articles by this author Stephen Y Nakada More articles by this author E. Jason Abel More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP80-01 TRANSPERINEAL PROCEDURES (BIOPSY AND CRYOABLATION) UNDER LOCAL ANESTHESIA: OUR EXPERIENCE AFTER 1,015 PROCEDURES

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Quality Improvement & Patient Safety III1 Apr 2018MP80-01 TRANSPERINEAL PROCEDURES (BIOPSY AND CRYOABLATION) UNDER LOCAL ANESTHESIA: OUR EXPERIENCE AFTER 1,015 PROCEDURES Fernando Bianco, Jose Antonio Grandez, Sergio Lozano-Kaplun, Marilin Nicholson, Ariel Kaufman, and Gloria Egui-Benatouil Fernando BiancoFernando Bianco More articles by this author , Jose Antonio GrandezJose Antonio Grandez More articles by this author , Sergio Lozano-KaplunSergio Lozano-Kaplun More articles by this author , Marilin NicholsonMarilin Nicholson More articles by this author , Ariel KaufmanAriel Kaufman More articles by this author , and Gloria Egui-BenatouilGloria Egui-Benatouil More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2689AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The perineal area has been evasive to office based approaches given its sensitivity, difficult access requiring lithotomy or exacerbated lithotomy positioning. Indeed, general or spinal anesthesia is commonly required for a prostate biopsy if performed thru the perineum. The emergence of MRI-Ultrasound (MR/US) fusion biopsies has led to an increased precision in the diagnosis of prostate cancer. However, this fusion technology is mostly implemented using the transrectal technique. Herein, we present our method to block the perineum making it feasible to perform procedures (Prostate Biopsy and Cryoablation) safely in the office setting under local anesthesia METHODS This study evaluated consecutive men who presented to our office for a transperineal procedure, either MR/US Fusion Biopsy or Cryoablation performed using a novel perineal block. The procedures were performed between August 2014 and September 2017. The information was collected prospectively using the Focalyx App (ISO, Android). For this report we queried diagnostic and treatment information such as: age, PSA, DRE findings, clinical stage, WHO Modified Gleason scores, co-morbidities, biopsy and treatment duration, Pain - measured with wonker baker pain faces scale - and clavien-dindo system 30 day outcomes post procedure outcomes. RESULTS A total of 1,015 procedures were performed, 626 were Transperineal Biopsies (TBX) and 389 Transperineal Cryoablations (TPC). There was a statistically significant difference in the mean times of the procedures 22' and 60' for TBX and TPC, respectively. However, pain measures were similar as the median and mean pain referred after TBX were 2 and 2.5 with respective pain measures for TPC of 2 and 1.7. A total of 33 (3%) adverse events within 30 days were recorded, 18 (2.8%) after TBX and 15 after TPC (3.9%). There was one episode of UTI after TBX requiring admission due to presumptive sepsis, however, blood cultures were negative. In the TPC group 4 of the 11 patients with urinary retention greater than 3 weeks required a TURP. There was one patient (TPC) who developed a vasovagal episode and sustained a fall requiring hospital admission CONCLUSIONS Our study shows that transperineal procedures performed under local anesthesia are well tolerated and harbor low rates (<4%) of adverse events. This novel block provides the urologist to access the perineum safely in the office setting © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e1089 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Fernando Bianco More articles by this author Jose Antonio Grandez More articles by this author Sergio Lozano-Kaplun More articles by this author Marilin Nicholson More articles by this author Ariel Kaufman More articles by this author Gloria Egui-Benatouil More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

A single-team experience with robotic pancreatic surgery in 1010 cases

To assess the safety and advantages of robotic pancreatic surgery (RPS) based on the single-team experience with 1010 cases. The clinical data of 1010 cases of RPS performed by a single team from November, 2011 to September, 2017 in our hospital were collected prospectively and analyzed. In most of cases the surgeries were performed using the third-generation da Vinci robotic surgical system. The 1010 cases receiving RPS included 417 cases of robotic pancreatoduodenectomy (RPD), 428 cases of robotic distal pancreatectomy, 60 cases of robotic central pancreatectomy, 53 cases of robotic pancreatic tumor enucleation, 3 cases of Appleby procedure, and 49 cases of other operations (including 4 cases of innovative robotic retroperitoneal laparoscopic surgery, 4 cases of robotic pancreatic tumor enucleation combined with main pancreatic duct bridging repair, 1 case of single incision robotic pancreatic tumor enucleation, and 2 cases of robotic central pancreatectomy combined with end-to-end anastomosis reconstruction). The median operative time was 210 min (30-720 min) with a median intraoperative blood loss of 80 mL (10-2000 mL), a conversion rate of 4.06% (41/1010), a blood transfusion rate of 6.7% (68/1010), a mean post-operative stay of 10.87∓6.70 days, a complication rate (beyond grade III according to Clavien-Dindo scoring system) of 8.0% (81/1010), and a pancreatic fistula rate (beyond) grade B of 9.21% (93/1010). The mortality rate of the patients was 0.69% (7/1010) in 30 days and 1.31% (12//934) in 90 days. The application of RPS in total pancreatectomy increased steadily from the rate of 10.44% in 2012 to 72.06% in 2017. This represents to our knowledge the world largest series of robotic pancreatic resections. RPS is expected to gradually replace open procedure and laparoscopic procedure to become the primary choice of approach for pancreatectomy. After the learning curve, RPS procedure including distal pancreatectomy, robotic Appleby procedure and other operations can be safely performed, and the experiences from other centers can be beneficial to reduce severe complications in the early stage of learning.

Risk factors for complications in cochlear implant surgery.

The objective of this study was to achieve uniform reporting of complications and failures in cochlear implantation, to analyze complications and failures and to identify risk factors for complications in a series of over 1300 cochlear implantations. In a retrospective chart review and observational study, data from all cochlear implantations from 1987 to 2015 were entered in a custom-made database. Complications were classified using the contracted form of the Clavien-Dindo system and risk factors were identified by statistical analysis. A complication rate of 18.4% and a device failure rate of 2.9% were found. There was a higher rate of hematoma in patients with a clotting disorder and when a subtotal petrosectomy was performed, a higher rate of wound infections in patients who were not vaccinated against Streptococcus pneumoniae and a higher rate of meningitis in patients with an inner ear malformation. The use of a strict definition of a medical complication and device failure-in combination with the Clavien-Dindo classification system-enables uniform and objective registration of adverse events and prevents any tendency to downgrade complications. Complication and failure rates in this series are comparable to those reported in the literature. These results stress the need for pneumococcal vaccination, which may prevent general wound infections, but is especially important for patients with inner ear malformation, who have an increased risk of (postoperative) meningitis.

Multi-institutional Outcomes for Simultaneous and Staged Urinary and Fecal Diversions in Patients Without Cancer

To compare the morbidity and postoperative recovery between patients treated with urinary diversion after colostomy with patients undergoing simultaneous double diversion (DD). A multi-institutional retrospective review was performed in patients treated with urinary diversion after colostomy or simultaneous DD between 2007 and 2014 for noncancerous indications. The Clavien-Dindo system was used to classify complications occurring within 90 days of surgery, and high-grade adverse events (HGAE) were classified grade 3 or higher. A total of 46 patients were identified with fecal and urinary diversions (19 in the after colostomy (AC) group, 27 in the DD group). Common indications for urinary diversion were neurogenic bladder (54%) and urinary fistula (44%). Mean hospital stay and return of bowel function after surgery for entire cohort was 13 and 7 days, respectively, with no differences between AC and DD groups. Almost 50% of patients in the cohort experienced an HGAE but there was no difference in HGAE incidence (8/19 AC, 13/27 DD; P = .69) or complication type between the groups. Increased operative time (5% risk per every 15 minutes over 7 hours, P = .03) was the only independent variable associated with increased risk of HGAE. DD was not independently associated with increased risk of HGAE compared with staged urinary diversion. Morbidity and postoperative recovery appeared similar whether urinary diversion is performed after colostomy or during a DD.

A retrospective analysis of complications of laparoscopic left donor nephrectomy using the Kocak's modification of Clavien-Dindo system.

Introduction:Kocak described a modification of Clavien-Dindo classification system (CDCS) for reporting procedure-related complications in laparoscopic donor nephrectomy (LDN). We used the Kocak modification in grading and reporting the severity of complications in patients who underwent LDN and in evaluating various parameters that predict them.Methods:In all, 1430 patients who underwent left LDN from 2000 to 2016 were included in this study. All data was retrospectively collected and analyzed for complications occurring in the postoperative period. All complications were classified according to the four grades of Kocak-modified CDCS.Results:124 patients (8.6%) suffered a total of 235 postoperative complications. Most of the complications were Grade I and Grade II (Grade I: 79.5% [n = 187] and Grade II 16.2% [n = 38]), 2.5% of the complications were Grade III (n = 6) and Kocak Grade IVa complications occurred in three patients. There was one death (Grade IVb: 0.4%, overall mortality rate: 0.06%). The incidence of complications was significantly greater for male patients, those with body mass index ≥25 kg/m2, and if the operating surgeon had ≤ 1 year of experience in performing LDN surgery.Conclusion:LDN is a safe procedure with low morbidity. The rate of complications is 8.6% and most of these complications are of low grade. The use of a standardized system for reporting the complications of LDN allows appropriate comparison between reported data.

The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer

ObjectiveThe adoption of Enhanced Recovery After Surgery programs in thoracic surgery is relatively recent with limited outcome data. This study aimed to determine the impact of an Enhanced Recovery After Surgery pathway on morbidity and length of stay in patients undergoing lung resection for primary lung cancer. MethodsThis prospective cohort study collected data on consecutive patients undergoing lung resection for primary lung cancer between April 2012 and June 2014 at a regional referral center in the United Kingdom. All patients followed a standardized, 15-element Enhanced Recovery After Surgery protocol. Key data fields included protocol compliance with individual elements, pathophysiology, and operative factors. Thirty-day morbidity was taken as the primary outcome measure and classified a priori according to the Clavien-Dindo system. Logistic regression models were devised to identify independent risk factors for morbidity and length of stay. ResultsA total of 422 consecutive patients underwent lung resection over a 2-year period, of whom 302 (71.6%) underwent video-assisted thoracoscopic surgery. Lobectomy was performed in 297 patients (70.4%). Complications were experienced by 159 patients (37.6%). The median length of stay was 5 days (range, 1-67), and 6 patients (1.4%) died within 30 days of surgery. There was a significant inverse relationship between protocol compliance and morbidity after adjustment for confounding factors (odds ratio, 0.72; 95% confidence interval, 0.57-0.91; P < .01). Age, lobectomy or pneumonectomy, more than 1 resection, and delayed mobilization were independent predictors of morbidity. Age, lack of preoperative carbohydrate drinks, planned high dependency unit/intensive therapy unit admission, delayed mobilization, and open approach were independent predictors of delayed discharge (length of stay >5 days). ConclusionsIncreased compliance with an Enhanced Recovery After Surgery pathway is associated with improved clinical outcomes after resection for primary lung cancer. Several elements, including early mobilization, appear to be more influential than others.

Intracorporeal robot-assisted radical cystectomy, together with an enhanced recovery programme, improves postoperative outcomes by aggregating marginal gains.

To assess the cumulative effect of an enhanced recovery after surgery (ERAS) pathway and minimally invasive robot-assisted radical cystectomy with intracorporeal urinary diversion (iRARC) in comparison with open radical cystectomy (ORC) on length of hospital stay (LOS) and peri-operative outcomes. Between February 2009 and October 2017, 304 radical cystectomy cases were performed at a single institution (ORC, n = 54; robot-assisted radical cystectomy [RARC], n = 250). Data were prospectively collected. We identified 45 consecutive ORC cases performed without ERAS before the commencement of the RARC programme (Cohort A), 50 consecutive iRARC cases performed without ERAS (Cohort B) and 40 iRARC cases with ERAS (Cohort C). The primary outcome measure was LOS, while secondary outcome measures included peri-operative 90-day complications and readmission rate. Complications were accessed using the Clavien-Dindo system. Patients in all cohorts were evenly matched with regard to age, sex, body mass index, neoadjuvant treatment, tumour stage, lymph node yield, previous pelvic radiotherapy and surgery, peri-operative anaemia, as well as physiological state. Patients who underwent iRARC with ERAS had a significantly higher American Society of Anesthesiologists score (III-IV) and were more likely to receive neobladder reconstruction. The median (interquartile range) LOS was shorter in the iRARC with ERAS group (7 [6-10]) days than in the iRARC without ERAS group (11 [8-15]) days and the ORC group (17 [14-21] days). In a propensity score-matched cohort of patients who underwent iRARC, patients who followed the ERAS pathway had significantly lower 90-day readmission rates. Additionally, implementing ERAS in an iRARC cohort resulted in a significantly lower 90-day all (P < 0.001) and gastrointestinal-related complications (P = 0.001). The ERAS pathway and younger patients were independently associated with an LOS of ≤10days on multinomial logistic regression. A comprehensive ERAS programme can significantly reduce LOS in patients undergoing iRARC without increasing 90-day readmission rates. An ERAS programme can augment the benefits of iRARC in improving peri-operative outcomes. In studies comparing ORC and RARC, the presence or absence of an ERAS programme will be a confounding factor and only level 1 evidence can be interpreted reliably.

Long-term health-related quality of life after pancreatic resection for malignancy in patients with and without severe postoperative complications

BackgroundSurgery for pancreatic cancer yields significant morbidity and mortality risks and survival is limited. Therefore, the influence of complications on quality of life (QoL) after pancreatic surgery is important. This study compares QoL in patients with and without severe complications after surgery for pancreatic (pre-)malignancy. MethodsThis prospective cohort study scored complications after pancreatic surgery according to the Clavien–Dindo system and the definitions of the International Study Group of Pancreatic Surgery. QoL was measured by the RAND36 questionnaire, the European Organization for Research and Treatment of Cancer core questionnaire (QLQ-C30) and the pancreas specific QLQ-PAN26. QoL in patients with severe complications was compared with QoL in patients with no or mild complications over a period of 12 months. Analysis was performed with linear mixed models for repeated measurements. ResultsBetween March 2012 and July 2016, 137 patients were included. Sixty-eight patients (50%) had at least 1 severe complication. There were no statistically significant and clinically relevant differences between both groups in QoL up to 12 months after surgery. ConclusionIn this study, no differences in QoL between patients with and without severe postoperative complications were encountered during the first 12 months after surgery for pancreatic (pre-)malignancy. Trial registrationhttp://www.clinicaltrials.gov Identifier: NCT02175992.

Extended Case Duration and Hypotension Are Associated With Higher-grade Postoperative Complications After Urinary Diversion for Non-oncological Disease

To report survival for patients who undergo urinary diversion for benign indications and to identify risk factors for morbidity at 90 days. This is a retrospective review of consecutive urinary diversions with or without cystectomy for non-oncological indications at a single institution. The indication for diversion was intractable incontinence, upper tract deterioration, urinary fistula, and unmanageable bladder pain. Patients were categorized according to their most severe complication within 90 days of surgery, using the Clavien-Dindo system. Multivariable analysis was performed to identify factors associated with high-grade complications. Survival analysis was performed. Between 2007 and 2014, 141 patients underwent urinary diversion for non-oncological indications. The postoperative rate of high-grade adverse events (class III or greater) was 28%. Risk factors for class III or greater complications at 90 days included prolonged intraoperative mean arterial pressure below 75% of baseline, operative duration greater than 343 minutes, and postoperative vasopressor requirement. Kaplan-Meier survival analysis demonstrated a 1- and 5-year survival of 88.4% and 77.2%, respectively. The long-term survival of patients who experienced higher-grade complications was not statistically different from the survival of the rest of the group. The study was limited by a retrospective design and sample size in identifying additional variables associated with increased risk of long-term mortality. Urinary diversion for non-oncological conditions has a good 5-year survival in this cohort. Extended case duration and hemodynamic instability during or immediately after urinary diversion are associated with a high-grade complication within 90 days of the procedure.

Management of Low Colorectal Anastomotic Leakage in the Laparoscopic Era: More Than a Decade of Experience.

Anastomotic leak after colorectal surgery increases postoperative mortality, cancer recurrence, permanent stoma formation, and poor bowel function. Anastomosis between the colon and rectum is a particularly high risk. Traditional management mandates laparotomy, disassembly of the anastomosis, and formation of an often-permanent stoma. After laparoscopic colorectal surgery it may be possible to manage anastomotic failure with laparoscopy, thus avoiding laparotomy. The purpose of this study was to determine the feasibility of the laparoscopic management of failed low colorectal anastomoses. This was a single-institute case series. A total of 555 laparoscopic patients undergoing anterior resection with primary anastomosis within 10 cm of the anus in the period 2000-2012 were included. Anastomotic failure, defined as any clinical or radiological demonstrable defect in the anastomosis; complications using the Clavien-Dindo system; mortality within 30 days; and patient demographics and risk factors, as defined by the Charlson index, were measured. Leakage occurred in 44 (7.9%) of 555 patients, 16 patients with a diverting ileostomy and 28 with no diverting ileostomy. Leakage was more common in those with anastomoses <5 cm form the anus, male patients, and those with a colonic J-pouch and rectal cancer. Diverting ileostomy was not protective of anastomotic leakage. In those patients with anastomotic leakage and a primary diverting ileostomy, recourse to the peritoneal cavity was required in 4 of 16 patients versus 24 of 28 without a diverting ileostomy (p = 0.0002). In 74% of those cases, access to the peritoneal cavity was achieved through laparoscopy. Permanent stoma rates were very low, including 14 (2.5%) of 555 total patients or 8 (18.0%) of 44 patients with anastomotic leakage. Thirty-day mortality was rare (0.6%). This study was limited by the lack of a cohort of open cases for comparison. Laparoscopic anterior resection is associated with low levels of complications, including anastomotic leak, postoperative mortality, and permanent stoma formation. Anastomotic leakage can be managed with laparoscopy in the majority of cases. See Video Abstract at http://links.lww.com/DCR/A353.

Does hospital readmission following colorectal cancer resection and enhanced recovery after surgery affect long term survival?

Hospital readmission is undesirable for patients and care providers as this can affect short-term recovery and carries financial consequences. It is unknown if readmission has long-term implications. We aimed to investigate the impact of 30-day readmission on long-term overall survival (OS) following colorectal cancer resection within enhanced recovery after surgery (ERAS) care and explore the reasons for and the severity and details of readmission episodes. A dedicated, prospectively populated database was reviewed. All patients were managed within an established ERAS programme. Five-year OS was calculated using the Kaplan-Meier method. The number, reason for and severity of 30-day readmissions were classified according to the Clavien-Dindo (CD) system, along with total (initial and readmission) length of stay (LoS). Multivariate analysis was used to identify factors predicting readmission. A total of 1023 consecutive patients underwent colorectal cancer resection between 2002 and 2015. Of these, 166 (16%) were readmitted. Readmission alone did not have a significant impact on 5-year OS (59% vs 70%, P=0.092), but OS was worse in patients with longer total LoS (20 vs 14days, P=0.04). Of the readmissions, 121 (73%) were minor (CD I-II) and 27 (16%) required an intervention of which 16 (10%) were returned to theatre. Gut dysfunction 32 (19%) and wound complications 23 (14%) were the most frequent reasons for readmission. Prolonged initial LoS, rectal cancer and younger age predicted for hospital readmission. Readmission does not have a significant impact on 5-year OS. A broad range of conditions led to readmission, with the majority representing minor complications.

Contemporary Trends in Utilization and Perioperative Outcomes of Percutaneous Nephrolithotomy in the United States from 2003 to 2014.

To investigate the contemporary trends and perioperative outcomes of percutaneous nephrolithotomy (PCNL) by using a population-based cohort. Using the Premier Healthcare Database, we identified 225,321 patients in whom kidney/ureteral calculi were diagnosed and who underwent PCNL at 447 different hospitals across the United States from 2003 to 2014. Outcomes included 90-day postoperative complications (as classified by the Clavien-Dindo system), prolonged hospital length of stay, operating room time, blood transfusions, and direct hospital costs. Temporal trends were quantified by estimated annual percentage change (EAPC) by using least-squares linear regression analysis. Multivariable logistic regression was performed to identify predictors of outcomes. PCNL utilization rates initially increased from 6.7% (2003) to 8.9% (2008) (EAPC: +5.60%, p = 0.02), before plateauing at 9.0% (2008-2011), and finally declining to 7.2% in 2014 (EAPC: -4.37%, p = 0.02). Overall (Clavien ≥1) and major complication (Clavien ≥3) rates rose significantly (EAPC: +12.2% and +16.4%, respectively, both p < 0.001). Overall/major complication and blood transfusion rates were 23.1%/4.8% and 3.3%, respectively. Median operating room time and 90-day costs were 221 minutes (interquartile range [IQR] 4) and $12,734 (IQR $9419), respectively. Significant predictors of overall complications include higher Charlson comorbidity index (CCI) (CCI ≥2: odds ratio [OR] 2.08, p < 0.001) and more recent year of surgery (2007-2010: OR 3.20, 2011-2014: OR 4.39, both p < 0.001). Higher surgeon volume was significantly associated with decreased overall (OR 0.992, p < 0.001) and major (OR 0.991, p = 0.01) complications. Our contemporary analysis shows a decrease in the utilization of PCNL in recent years, along with an increase in complication rates. Numerous patient, hospital, and surgical characteristics affect complication rates.

Urinary Diversion With vs Without Bowel Anastomosis in Patients With an Existing Colostomy: A Multi-institutional Study

To describe the short-term outcomes with the bowel anastomosis (BA) approach vs the no-bowel anastomosis (NBA) approach in adult patients undergoing urinary diversion. A chart review was performed of adults undergoing urinary diversion from 2006 to 2015. Patients with a pre-existing colostomy were divided into NBA and BA groups. Postoperative complications were recorded per the Clavien-Dindo system. Variables were compared using the BA group as a control. A 2-tailed t test was used to compare means. A total of 43 patients were included: 33 in the BA group and 10 in the NBA. No significant differences were found between the 2 groups for the comorbidity index (P = .16), the body mass index (P = .54), or radiation history (P = .90). In the NBA and BA groups, the median blood loss was 250 and 300 mL (P = .11); the operative time was 550 and 480 minutes (P = .15); and the length of stay was 10 and 25 days (P = .38), respectively. The BA group had a higher rate of intraoperative (P = .04) and early (P = .02) overall complications. No significant difference was found in early bowel (P = .15) or ureteral obstruction (P = .08), in the overall stomal complications (P = .11), or in the rate of <90-day reoperation (P = .32). A lower rate of intraoperative and postoperative complications occurred in patients undergoing conversion of colostomy to a urinary diversion compared with patients with de novo urinary conduit creation. When possible, a BA should be avoided.