Comprehensive Complication Index Research Articles

Comprehensive complication index as a prognostic factor in minimally invasive esophagectomy for esophageal squamous cell carcinoma.

Postoperative complications affect long-term prognosis in patients with esophageal squamous cell carcinoma (ESCC). Although a comprehensive estimator can predict long-term prognosis, the Clavien-Dindo classification system, a widely used approach to evaluate complications, assesses each complication individually. We aimed to clarify the utility of the comprehensive complication index (CCI) on predicting the overall survival (OS) of patients with ESCC following minimally invasive esophagectomy (MIE). This was a retrospective study of patients undergoing MIE for ESCC in the prone position between January 2011 and December 2018. Multivariate analyses using the Cox proportional hazards model were performed to determine independent risk factors for OS. The study cohort included 229 patients who were categorized into patients with CCI values of ≥ 33.7 (CCI high) and < 33.7 (CCI low) by receiver-operating characteristic (ROC) curve analysis. There were no significant differences between the two groups according to clinicopathological factors, such as sex, age, tumor location, tumor depth, lymph node metastasis, and neoadjuvant chemotherapy. The intraoperative transfusion rate in the CCI high group was significantly higher than in the CCI low group. The 5year OS rate was significantly lower in the CCI high group than in the CCI low group (49.5% vs. 65.7%, p = 0.030). By multivariate analyses, age, tumor depth, lymph node metastasis, and the CCI were independent predictors of OS. Comprehensive assessment of postoperative complications using the CCI was useful in predicting OS of patients undergoing MIE for the ESCC.

Classification of intraoperative adverse events in visceral surgery

BackgroundIntraoperative adverse events (iAEs) are frequent in visceral surgery, but severity and related postoperative outcome are poorly investigated. A novel classification of intraoperative adverse events, ClassIntra, includes surgical and anesthesiologic intraoperative adverse events using 5 severity grades and showed a high criterion and construct validity across all surgical disciplines. ClassIntra was studied for reproducibility in a prespecified group of patients undergoing visceral surgery. MethodsiAEs were recorded in all patients enrolled in the ClassIntra validation study (NCT03009929). Postoperative complications were assessed daily according to the Clavien-Dindo classification. Results of the visceral group were compared with those of the non-visceral group and the full cohort. The risk-adjusted association between most severe intra and postoperative complications was investigated in a multivariable proportional odds model. Second, risk-adjusted association between ClassIntra grade and Comprehensive Complication Index, and postoperative length of stay was investigated. ResultsIn total, 1,270 out of 2,520 patients (50%) underwent visceral surgery. Compared with the nonvisceral group and full cohort, more intraoperative (337/1270 [27%] vs 273/1250 [22%] vs 610/2520 [24%] patients) and postoperative complications (457/1270 [36%] vs 381/1250 [30%] vs 838/2520 [33%] patients) occurred. The risk for a more severe postoperative complication increased with each ClassIntra grade (odds ratio [95% confidence interval] I vs 0 1.10 [0.73 to 1.66], II vs 0 1.69 [1.10 to 2.60], III vs 0 2.31 [1.21 to 4.41], IV vs 0 2.35 [0.69 to 8.06]). Accordingly, CCI and postoperative length of stay increased with each ClassIntra grade in the visceral group, comparable with the nonvisceral and full cohort. ConclusionConsistent results for the association of intraoperative adverse events and patient outcomes render ClassIntra a valuable instrument in visceral surgery.

Improved clinical outcomes of outpatient enhanced recovery hip and knee replacements in comparison to standard inpatient procedures: A study of patients who experienced both

BackgroundThe benefits of combining enhanced recovery after surgery (ERAS) interventions with an outpatient program for total hip/knee arthroplasty (THA/TKA) are uncertain. This study's main objective was to evaluate adverse events with an ERAS-outpatient compared to standard-inpatient care and secondary objectives were to compare pain, functional recovery, PROMs and satisfaction. HypothesisThe ERAS-outpatient program would result in reduced adverse events compared to standard-inpatient care. MethodsAn ambidirectional single subject cohort study was conducted on 48 consecutive patients who experienced both a standard-inpatient and an ERAS-outpatient THA/TKA (contralaterally). Adverse event rate according to the Clavien-Dindo scale, the Comprehensive Complications Index (CCI) and the number of unplanned episodes of care were assessed. Postoperative pain on a numeric rating scale, opioid consumption in morphine milligram equivalents, functional recovery, patient reported outcome measures (PROMs) (WOMAC, KOOS, HOOS, Forgotten Joint Score and Patient Joint Perception) and patients’ satisfaction were also evaluated. ResultsFollowing the ERAS-outpatient surgery, complication rates were reduced by more than 50% (2.1 vs. 4.4, p<0.001), CCI was significantly lower (12.3 vs. 19.1, p<0.001), and similar unplanned episodes of care were observed (p>0.999). In the first 8 postoperative hours, perceived pain was similar (p>0.805) while opioid consumption was significantly reduced (9.3 vs. 26.5, p<0.001). Patients walked, climbed stairs, showered, performed activities of daily living, practised sports, went back to work sooner (p<0.001), but PROMs were similar between groups at the last follow-up (p>0.188). Patients were more satisfied of the ERAS-outpatient pathway and recommended it significantly more (p<0.002). ConclusionCompared to the conventional inpatient care, the ERAS-outpatient program proved to be safer, enable faster functional recovery, and improve patients’ satisfaction which highlight the importance of following ERAS principles when implementing an outpatient THA/TKA program. Level of evidenceIII; Ambidirectional Cohort study.

Clinical effect of rectus sheath block compared to intrathecal morphine injection for minimally invasive colorectal cancer surgery: a propensity score-matched study.

To evaluate the postoperative outcomes of a multimodal perioperative pain management protocol with rectus sheath blocks (RSBs) or intrathecal morphine (ITM) injection for minimally invasive colorectal cancer surgery. A total of 112 patients underwent minimally invasive colorectal surgery. Forty-one patients underwent RSB (group 1), whereas 71 patients underwent ITM (group 2) in addition to multimodal pain management using enhanced recovery after the surgery protocol. To adjust for the baseline differences and selection bias, baseline characteristics and postoperative outcomes were compared using propensity score matching. Forty patients were evaluated in each group. There was no significant difference in the length of hospital stay between the two groups. According to the Comprehensive Complication Index (CCI) score, the postoperative complication rate was significantly lower in the RSB group (3.0 ± 7.8) than in the ITM group (8.1 ± 10.9; p = 0.016). During the first 24h after surgery, the median postoperative visual analog scale score was significantly higher in the RSB group than in the ITM group (2.0 ± 1.1 vs. 1.5 ± 1.2; p = 0.048). Postoperative morphine use was also significantly higher in the RSB group than in the ITM group in the first 24h (23.7 ± 19.8 vs 11.6 ± 15.6%; p = 0.003) and 48h (16.9 ± 24.8 vs. 7.5 ± 11.9; p = 0.036) after surgery. Significant urinary retention occurred after the in the RSB and ITM groups (5% vs. 45%; p < 0.001). Although the RSB group had higher morphine use during the first 48h after surgery, the length of hospital stay remained the same and the complications were less in terms of the CCI score. Thus, transperitoneal RSB is a safe and feasible approach for postoperative pain management following minimally invasive procedures.

A1027 - The comprehensive complication index as a tool for reporting the burden of complications after percutaneous nephrolithotomy: Is it time to leave the Clavien-Dindo classification behind?

A1027 - The comprehensive complication index as a tool for reporting the burden of complications after percutaneous nephrolithotomy: Is it time to leave the Clavien-Dindo classification behind?

Initial radiologic appearance rather than management strategy predicts the outcomes of sleeve gastrectomy leaks.

Initial radiologic appearance rather than management strategy predicts the outcomes of sleeve gastrectomy leaks. Multiple modalities have been advocated for the treatment of sleeve gastrectomy leak, and there remains no consensus on the best treatment paradigm. For more than 10 years, we have variably attempted luminal occlusive therapies and repeated endoscopic debridement as treatment options. By evaluating the outcomes from these approaches, we aimed to determine whether the first management strategy is superior to the second in terms of outcomes. Patients were analyzed by group (luminal occlusive therapy versus repeated endoscopic debridement). Leaks were then stratified by radiologic appearance on computed tomography, defined as phlegmon, collection, contrast medium leak, or fistula. The primary outcome was length of stay (LOS). Secondary outcomes were comprehensive complication index and the need for resection. There were 54 patients, with 22 in the luminal occlusion group and 32 in the repeated debridement group. There was no difference in LOS (59.8 ± 41.6 versus 46.5 ± 51.2 days, P = .179) and no difference in the requirement for resection (4 versus 3 resections, p = .425). Subset analysis suggested that patients who underwent operative versus conservative management (P = .006) had a longer LOS. Excluding management strategy, radiologic appearance on admission significantly predicted LOS (P = .0053). Patients presenting with fistula (84 ± 25.4 days) and contrast medium leak (64.1 ± 40 days) had a significantly longer LOS than those diagnosed with phlegmon (13.5 ± 5.5 days). Radiologic appearance was predictive of complication severity (P < .0001) and salvage resection (P = .008). There was no significant difference in outcomes between patients treated with intraluminal occlusion or repeated debridement. Initial radiologic appearance was predictive of LOS and complication severity. This highlights the need for routine use of a validated classification system in studies reporting outcomes and treatment of sleeve leaks.

A0006 - Application of the comprehensive complication index to a cost-prediction model for radical cystectomy: Preliminary analysis

A0006 - Application of the comprehensive complication index to a cost-prediction model for radical cystectomy: Preliminary analysis

Minimally invasive treatment of colorectal liver metastases: does robotic surgery provide any technical advantages over laparoscopy? A multicenter analysis from the IGoMILS (Italian Group of Minimally Invasive Liver Surgery) registry.

Surgery has been the mainstay treatment for colorectal liver metastases (CRLM). Although the benefits of a laparoscopic approach have been evidenced by several comparative studies, the comparison between robotic and laparoscopic liver surgery has not been elucidated. Thus, in this study, we aim to analyze the short-term outcomes of a multicenter population that underwent robotic versus laparoscopic liver resection for CRLM. Consecutive patients with CRLM who were enrolled in the IGoMILS registry between November 2014 and June 2019 were retrospectively evaluated to compare robot-assisted procedures with laparoscopic procedures. Primary outcomes were postoperative morbidity and mortality, while secondary outcomes were length of hospital stay, operative time, and histological features of the surgical specimen. The effect size of surgical technique on resection margins was quantified using Hedges' g. In total, 1030 patients underwent minimally invasive liver surgery (MILS) for CRLM; of these, 77 (7.5%) underwent a robot-assisted approach (R-MILS), whereas 953 (92.5%) underwent a laparoscopic approach (L-MILS). Laparoscopy and robot-assisted surgery were comparable in terms of postoperative outcomes: specifically, complication rates, Comprehensive Complication Index (CCI®), intraoperative blood loss, conversion rate, operative time, and length of hospital stay did not differ significantly between the two groups. R-MILS showed a reduced rate of R1 resection margins (19.9 vs. 28.8%, p = 0.025) and wider surgical margins compared with L-MILS (8 vs. 3mm, p < 0.001). The effect size of robot-assisted surgery was increased for posterosuperior lesions (g = 0.78) and difficult procedures (g = 1.92). As per our findings, it was determined that robot-assisted liver surgery offers some technical advantages over conventional laparoscopy, maintaining the benefits of minimally invasive surgery on short-term outcomes.

Prehabilitation in patients undergoing colorectal surgery fails to confer reduction in overall morbidity: results of a single-center, blinded, randomized controlled trial.

Currently, there are solely weak recommendations in the enhanced recovery after surgery (ERAS) protocol regarding the role of preoperative physical activity and prehabilitation in patients undergoing colorectal surgery. Studies in heterogenous groups showed contradictory results regarding the impact of prehabilitation on the reduction of postoperative complications. The aim of this study was to assess the impact of prehabilitation on postoperative complications in patients undergoing colorectal surgery within an ERAS protocol. Between July 2016 and June 2019, a single-center, blinded, randomized controlled trial designed to test whether physiotherapeutic prehabilitation vs. normal physical activities prior to colorectal surgery may decrease morbidity within a stringent ERAS protocol was carried out. The primary endpoint was postoperative complications assessed by Comprehensive Complications Index (CCI®). Primary and secondary endpoints for both groups were analyzed and compared. A total of 107 patients (54 in the prehabilitation enhanced recovery after colorectal surgery [pERACS] group and 53 in the control group) were included in the study and randomized. Dropout rate was 4.5% (n = 5). Baseline characteristics were comparable between the pERACS and control groups. The percentage of colorectal adenocarcinoma was low in both groups (pERACS 32% vs. control 23%, p = 0.384). Almost all patients underwent minimally invasive surgery in both groups (96% vs. 98%, p = 1.000). There was no between-group difference in the primary outcome, as the mean CCI at 30-day postoperative in the pERACS group was 18 (SD 0-43) compared to 15 (SD 0-49) in the control group (p = 0.059). Secondary outcome as complications assessed according to Clavien-Dindo, length of hospital stay, reoperation rate, and mortality showed no difference between both groups. Routine physiotherapeutic prehabilitation has no additional benefit for patients undergoing colorectal surgery within an ERAS protocol. ClinicalTrial.gov: ID: NCT02746731; Institution Ethical Board Approval: KEK-ZH Nr. 2016-00,229.

Assessing differences in surgical outcomes following emergency abdominal exploration for complications of elective surgery and high-risk primary emergencies

Irrespective of its etiology, emergency surgical abdominal exploration (EAE) is considered a high-risk procedure with mortality rates exceeding 20%. The aim of this study was to evaluate differences in outcomes in patients who required EAE due to complications of complex elective abdominal procedures and those who required EAE due to high-risk primary abdominal emergencies. Patients undergoing EAE for acute surgical complications of complex abdominal elective surgical procedures (N = 293; Elective group) and patients undergoing EAE for high-risk primary abdominal emergencies (N = 776; Emergency group) from 2012 to 2019 at our institution were retrospectively assessed for morbidity and mortality. Postoperative complications occurred in 196 patients (66.94%) in the elective group and 585 patients (75.4%) in the emergency group. The relatively low complication burden in the elective group was also evidenced by a significantly lower comprehensive complication index score (54.00 ± 37.36 vs. 59.25 ± 37.08, p = 0.040). The in-hospital mortality rates were 31% (91 of 293) and 38% (295 of 776) in the elective and emergency groups, respectively. This difference between the two groups was statistically significant (p = 0.035). In multivariate analysis, age, peripheral artery disease, pneumonia, thromboembolic events, ICU stay, ventilator dependence, acute kidney failure and liver failure were independent predictors of mortality. Our data show that patients undergoing EAE due to acute complications of major elective surgery tolerate the procedure relatively well compared with patients undergoing EAE due to primary high-risk abdominal emergencies.

CONUT Score Predicts Early Morbidity After Liver Transplantation: A Collaborative Study.

Introduction: Liver transplantation (LT) is burdened by the risk of post-operative morbidity. Identifying patients at higher risk of developing complications can help allocate resources in the perioperative phase. Controlling Nutritional Status (CONUT) score, based on lymphocyte count, serum albumin, and cholesterol levels, has been applied to various surgical specialties, proving reliable in predicting complications and prognosis. Our study aims to investigate the role of the CONUT score in predicting the development of early complications (within 90 days) after LT.Methods: This is a retrospective analysis of 209 patients with a calculable CONUT score within 2 months before LT. The ability of the CONUT score to predict severe complications, defined as a Comprehensive Complication Index (CCI) ≥42.1, was examined. Inverse Probability Treatment Weighting was used to balance the study population against potential confounders.Results: Patients with a CCI ≥42.1 had higher CONUT score values (median: 7 vs. 5, P-value < 0.0001). The CONUT score showed a good diagnostic ability regarding post-LT morbidity, with an AUC = 0.72 (95.0%CI = 0.64–0.79; P-value < 0.0001). The CONUT score was the only independent risk factor identified for a complicated post-LT course, with an odds ratio = 1.39 (P-value < 0.0001). The 90-day survival rate was 98.8% and 87.5% for patients with a CONUT score <8 and ≥8, respectively.Conclusions: Pre-operative CONUT score is a helpful tool to identify patients at increased post-LT morbidity risk. Further refinements in the score composition, specific to the LT population, could be obtained with prospective studies.

Prophylactic retrorectus mesh versus no mesh in midline emergency laparotomy closure for prevention of incisional hernia (PREEMER): study protocol for a multicentre, double-blinded, randomized controlled trial

BackgroundDespite the fact that emergency midline laparotomy is a risk factor for an incisional hernia, active research on hernia prevention in emergency settings is lacking. Different kinds of meshes and mesh positions have been studied in elective abdominal surgery, but no randomized controlled trials in emergency settings have been published thus far.MethodThe PREEMER trial (registration number NCT04311788) is a multicentre, patient- and assessor-blinded, randomized controlled trial to be conducted in six hospitals in Finland. A total of 244 patients will be randomized at a 1 : 1 ratio to either the retrorectus mesh group, featuring a self-gripping prophylactic mesh, or to the no mesh (control) group, both closed by small-stitch 4 : 1 closure with continuous slowly absorbable monofilament suturing. The primary outcome of the PREEMER trial is the incidence of incisional hernia 2 years after surgery, which will be detected clinically and/or radiologically. Secondary outcomes are the Comprehensive Complication Index score, incidence of surgical-site infections and fascial dehiscence within 30 days of surgery; the incisional hernia repair rate and mesh- or hernia-related reoperations within the 2- and 5-year follow-ups; the incidence of incisional hernia within the 5-year follow-up; and quality of life measured by RAND-36, the Activities Assessment Scale and the PROMIS questionnaire within 30 days and 2 and 5 years from surgery. Additionally, health–economic explorative measures will be explored.ConclusionThe PREEMER trial will provide level 1 evidence on incisional hernia prevention in an emergency setting.Registration numberNCT04311788 (http://www.clinicaltrials.gov). Registered 7 March 2020.

Opioid-free versus opioid-based anesthesia in pancreatic surgery

BackgroundOpioid-free anesthesia (OFA) is associated with significantly reduced cumulative postoperative morphine consumption in comparison with opioid-based anesthesia (OBA). Whether OFA is feasible and may improve outcomes in pancreatic surgery remains unclear.MethodsPerioperative data from 77 consecutive patients who underwent pancreatic resection were included and retrospectively reviewed. Patients received either an OBA with intraoperative remifentanil (n = 42) or an OFA (n = 35). OFA included a combination of continuous infusions of dexmedetomidine, lidocaine, and esketamine. In OBA, patients also received a single bolus of intrathecal morphine. All patients received intraoperative propofol, sevoflurane, dexamethasone, diclofenac, neuromuscular blockade. Postoperative pain management was achieved by continuous wound infiltration and patient-controlled morphine. The primary outcome was postoperative pain (Numerical Rating Scale, NRS). Opioid consumption within 48 h after extubation, length of stay, adverse events within 90 days, and 30-day mortality were included as secondary outcomes. Episodes of bradycardia and hypotension requiring rescue medication were considered as safety outcomes.ResultsCompared to OBA, NRS (3 [2–4] vs 0 [0–2], P < 0.001) and opioid consumption (36 [24–52] vs 10 [2–24], P = 0.005) were both less in the OFA group. Length of stay was shorter by 4 days with OFA (14 [7–46] vs 10 [6–16], P < 0.001). OFA (P = 0.03), with postoperative pancreatic fistula (P = 0.0002) and delayed gastric emptying (P < 0.0001) were identified as only independent factors for length of stay. The comprehensive complication index (CCI) was the lowest with OFA (24.9 ± 25.5 vs 14.1 ± 23.4, P = 0.03). There were no differences in demographics, operative time, blood loss, bradycardia, vasopressors administration or time to extubation among groups.ConclusionsIn this series, OFA during pancreatic resection is feasible and independently associated with a better outcome, in particular pain outcomes. The lower rate of postoperative complications may justify future randomized trials to test the hypothesis that OFA may improve outcomes and shorten length of stay.

The Japanese Difficulty Scoring System Correlates with Postoperative Outcome Assessed by the Comprehensive Complication Index in Patients Undergoing Minimally Invasive Liver Resection

Introduction: The Japanese difficulty score (JDS) was developed to standardize the difficulty grading of laparoscopic hepatectomy. The JDS has not consistently correlated well with postoperative outcomes such as Clavien-Dindo complications. This study aims to determine if the JDS correlates with complications as classified by the more inclusive comprehensive complication index (CCI). Methods: A single institutional database was retrospectively queried for all purely minimally-invasive (MIS) hepatectomies performed between January 2008 and December 2019Patient charts were reviewed and data was collected. Patients were grouped into “Low” (<4), “Intermediate” (4-6), and “High” (7+) difficulty based on JDS. Complications were graded using CCI. Statistical comparisons were made using ANOVA or χ2 test, as appropriate. IRB approval was obtained. Results: 413 pure MIS resections were performed. There were 75 (18.2%) Low, 207 (50.1%) Intermediate, and 131 (31.7%) High difficulty MIS hepatectomies. There were no demographic differences. High difficulty was associated with longer operative time (p<0.001), higher mean EBL (p<0.001), and were more likely to require blood transfusion (p<0.001). Mean length of stay (LOS) was longer for more difficult resections (p<0.001). There was no difference between groups in Clavien-Dindo complications or 30-day readmissions. The CCI was significantly higher (Low 7.0, Intermediate 9.5, High 15.8; p=0.006) for more difficult resections. Post-hepatectomy liver failure (PHLF) occurred more frequently with higher JDS (p=0.0023). Conclusions: MIS liver resections with higher JDS were associated with increased operative times, EBL, blood transfusions, LOS, PHLF and overall complications as indicated by the CCI, despite no difference between groups in Clavien-Dindo complications.

Using Machine Learning to Predict Post-Hepatectomy Liver Failure and Postoperative Complications in an International Cohort of Major Hepatectomies

Introduction: Post-hepatectomy liver failure (PHLF) is the most important determinant of mortality following liver resection. Innovative tools are needed to identify patients at elevated risk of PHLF and postoperative morbidity. Methods: Patients who underwent major hepatectomy between 2010-2020 at twelve international centers were identified. Preoperative, intraoperative, and postoperative data were extracted from the medical record. Two stacked generalization schemes were built using weighted logistic regression, weighted elastic net logistic regression, balanced random forest, and boosting with random under-sampling as base estimators to predict development of PHLF (ISGLS grades B and C) and a Comprehensive Complication Index (CCI) >40. Model performance was assessed using the area under the curve (AUC). After fitting the models, we inspected the variable importance measures to identify variables that are most predictive of outcomes. Results: Among 2,191 patients analyzed (n = 1826 training; n = 365 testing), 162 (7.6%) developed clinically significant PHLF and 160 (7.3%) had a CCI>40. The final predictive models included the following clinical features: preoperative hemoglobin, number of segments resected, body mass index, alcohol- and chemotherapy-associated liver impairment, and the Charlson Comorbidity Index. The stacked generalization for development of ISGLS grades B and C had an AUC of 0.77 (95% CI: 0.68-0.85) in the hold-out testing set. The stacked generalization for development of CCI>40 had an AUC of 0.75 (95% CI: 0.67-0.83). Conclusions: Machine learning algorithms based on preoperative and intraoperative variables can be utilized to predict surgical outcomes following major hepatectomy. Further validation of these models is warranted. Tabled 1FP01-6 Table 1. Comparison of predictive performance of machine learning models5-fold Cross validationHold-out testModelsAUCAUCISGLSB & CWeightedlogistic regression0.80 (0.02)0.77 (0.04)Elastic net0.79 (0.02)0.77 (0.04)Balanced0.80 (0.05)0.79 (0.04)Random forest0.78 (0.05)0.78 (0.04)RUS Boost0.80 (0.03)0.77 (0.04)StackingCCI> 40Weightedlogistic regression0.72 (0.04)0.75 (0.04)Elastic net0.72 (0.03)0.75 (0.04)Balanced0.74 (0.03)0.78 (0.04)Random forest0.74 (0.03)0.68 (0.05)RUS Boost0.72 (0.04)0.75 (0.04)StackingEach predictive model training was validated using 5-fold cross validation on training set in addition to bootstrap sampling (B=1000) of holdout test set with replacement. The performances were evaluated using the area under the curve; mean (SD).AUC: area under the curve, RUS: random under-sampled, ISGLS: International Study Group of Liver Surgery, CCI: comprehensive complication index Open table in a new tab Each predictive model training was validated using 5-fold cross validation on training set in addition to bootstrap sampling (B=1000) of holdout test set with replacement. The performances were evaluated using the area under the curve; mean (SD). AUC: area under the curve, RUS: random under-sampled, ISGLS: International Study Group of Liver Surgery, CCI: comprehensive complication index

Risk factors associated with postoperative complications and prolonged postoperative length of stay after laparoscopic liver resection.

IntroductionLaparoscopic liver resection (LLR) has expanded rapidly. Previously published studies are limited to small samples and selected patients. Comprehensive data that may significantly influence the incidence of perioperative complications and postoperative length of stay (PLOS) are lacking.AimTo characterize complications after LLR and to identify risk factors associated with postoperative complications and prolonged PLOS.Material and methodsThis study was carried out at a high-volume HPB centre and included all patients who underwent LLRs between 2015 and 2018. Postoperative complications were analysed in detail. Logistic regression was used to identify independent risk factors. The primary outcome was postoperative complications with a comprehensive complication index (CCI) ≥ 26.2. The second outcome was prolonged length of stay.ResultsWe identified 938 patients who underwent LLR. In the full cohort, 79 (8.4%) patients experienced major complications with a CCI ≥ 26.2, with postoperative mortality in 4 (0.4%) patients. On multivariate analysis, the diagnosis of primary (OR = 8.97, 95% CI: 2.54–43.74, p = 0.001) and metastatic liver tumours (OR = 5.74, 95% CI: 1.20–30.90, p = 0.028), infectious liver disease (OR = 24.04, 95% CI: 5.30–129.53, p < 0.001), difficult liver resection (OR = 2.77, 95% CI: 1.29–6.69, p = 0.014), and intraoperative bleeding > 1000 ml (OR = 9.29, 95% CI: 3.40–26.43, p < 0.001) were independent factors that increased the odds of major complications. The median PLOS after the operation was 5 days (range: 2–35 days). Factors that independently influenced prolonged PLOS on multivariate analysis were age over 70 years, metastatic liver tumour, difficult liver resection, liver cirrhosis, and right hepatectomy.ConclusionsLLR remains safe for most liver space-occupying lesions. Several preoperative and intraoperative factors associated with the risk of complications and prolonged PLOS were identified. These factors should be considered during patient selection and perioperative management.

Development and Validation of a Decision Tree and CCI-Based Risk-Scoring Model for Iatrogenic Bile Duct Injury after Cholecystectomy: A Nationwide Multicenter Study

Introduction: Iatrogenic bile duct injury (IBDI) is a serious and challenging surgical complication associated with high morbidity and mortality. IBDI management can be guided by artificial intelligence models. Methods: This is a retrospective multi-institution cohort study of patients diagnosed with IBDI after cholecystectomy conducted between January 1990 and July 2020. We implemented a decision tree analysis to determine the factors that contribute to successful primary repair and developed a risk-scoring model based on the Comprehensive Complication Index. Our models were developed with data from 15 hospitals (development cohort) and validated with data from 7 hospitals (validation cohort). Using two models, our study identified the factors associated with successful primary repair of IBDI and predicted the success of definitive repair based on patient risk levels. Results: Our decision tree model was 82.8% accurate in predicting the success of the primary repair (Figure). Non-type E IBDI (p <0.01), treatment in specialized centers (p <0.01), and surgical repair (p < 0.001) were associated with better prognosis. The risk-scoring model was 82.3% (79.0–85.3%, 95% confidence interval [CI]) and 71.7% (63.8–78.7%, 95% CI) accurate in predicting success in the development and validation cohorts, respectively. Surgical repair, successful primary repair and repair between 2 and 6 weeks were associated with better outcomes. Conclusions: Patients with IBDI including non-type E who were managed in specialized centers were more likely to achieve better outcomes. Our risk-scoring model helped predict complications and guide management.

Comparison of Hybrid Versus Synthetic Mesh in Robotic Rives-Stoppa Ventral Hernia Repair.

To estimate the average treatment effect on the treated (ATT) and to assess the clinical outcomes in two different types of mesh in robotic Rives-Stoppa (rRS) ventral hernia repair (VHR). A retrospective analysis of a robotic VHR database between February 1, 2013 and May 31, 2022. Patients who underwent a rRS VHR were included in this study and separated into two groups depending on the mesh used: SynecorTM Preperitoneal Biomaterial (SynecorTM Pre) and Bard™ Soft. Through propensity score and inverse-probability-treatment-weighting, the ATT was estimated for two scenarios; the first with the treated target having used the SynecorTM Pre, the second having used the Bard™ Soft mesh. Adjusted linear regression models, including lingering imbalanced variables, were used for both the primary outcome of the Comprehensive Complication Index (CCI®), and the secondary outcome of the hospital cost. A total of 186 patients who underwent rRS were separated into the two groups (SynecorTM Pre mesh, n = 85; Bard™ Soft mesh, n = 101). Adjusted linear regression models for the CCI showed no statistical difference between both groups (p > 0.05), whereas ATT on hospital cost was significantly higher (p < 0.001) in the SynecorTM Pre group in both scenarios [(95% confidence interval) = 3882 (2352, 5413) and -5185 (-8213, -2157), respectively]. Both mesh materials provided excellent outcomes with no difference in complications or recurrence rates. However, hospital cost was found to be higher in the hybrid mesh group. Long-term follow-up is needed to fully assess the performance of both mesh types in rRS.

Implementation and Outcomes of an Enhanced Recovery after Surgery (ERAS) Programme in a Newly Established Unit of Pancreatic Surgery

Introduction: A prospective single centre cohort evaluation of a newly established pancreatic surgery programme following ERAS principles was performed. Method: All patients were managed with a perioperative ERAS protocol. Preoperative interventions included prehabilitation with physical exercise and respiratory physiotherapy, fragility assessment, detection and optimisation of anaemia, nutritional evaluation and supplementation of malnourished patients and intake of a complex clear carbohydrate-rich drink up to 2 hours before surgery in all patients. Intraoperative interventions were based on peridural catheterisation, non-opioid analgesia, antiemetics, and intraoperative removal of nasogastric tubes. Postoperative interventions consisted in early (<6 hours) oral diet, early scheduled mobilisation, respiratory physiotherapy, optimal control of pain and early drains and urinary catheters removal. The outcomes were compliance to the protocol, morbidity, mortality, postoperative LOS and readmission rate. Results: Between November 2017 and January 2020, 84 patients were included. Pancreatoduodenectomies 62 (73.8%), distal pancreatectomies 17 (20.2%), Beger procedures 3 (3.6%), total pancreatoduodenectomies 2 (2.4%), central pancreatectomies 1 (1.2%). 66 (78.6%) were open, 13 (15.3%) robotic, 2 (2.4%) laparoscopic and 4 (4.8%) were conversions either from laparoscopic or robotic procedures. Compliance of ERAS preoperative and intraoperative protocol items were both 100%, while compliance of ERAS postperative items was 81%. Major morbidity rate (Clavien>III) was 28.2%. Mean Comprehensive Complication Index Score (CCI) was 27.61. Mortality was 3.5%. Median postoperative LOS was 11 days (2-87). Readmission rate was 7,1%. Conclusion: ERAS can be implemented in a. newly established unit of pancreatic surgery without compromising patient safety and with similar outcomes to the reported in the literature.

Skeletal Muscle Loss after HPB Surgery and its Relation with Objectively Measured Postoperative Physical Activity and Nutritional Intake

Introduction: Although muscle loss is a well-known phenomenon in critical ill ICU-patients, little is known about muscle loss after major elective surgery and its association with in-hospital physical activity and nutritional intake. Methods: The MUSCLE POWER study is a prospective cohort study including patients undergoing major hepato-pancreato-biliary surgery. Postoperative muscle diameter was measured in six muscles (bilateral biceps, vastus intermedius, rectus femoris) by using ultrasound (Lumify, Philips) at baseline, three, seven and ten days after surgery. Physical activity and nutritional intake were objectively measured by Actigraph-device (wGT3X-BT) and a nutritional diary. Surgery-related muscle loss (SRML) was defined as >10% muscle loss in minimally one arm and one leg muscle. Results: Of the 111 included patients (67 (60%) men; mean age 66.11±11.65), 63 (57%) underwent pancreatic-, 43 (39%) liver- and 5 (4%) no-resection surgery. SRML after seven days was found in 41 (37%) patients. Patients with SRML had a higher median Comprehensive Complication Index (20.92 (8.66-27.61) versus 8.66 (0-25.86), p=0.029). Median activity in steps after four days was lower in patients with SRML (746 (358-1205) versus 1073 (519-2144) p=0.043). In pancreatic-surgery patients, significant lower protein intake per kilogram bodyweight was found in the SRML group at postoperative days two, three and five (p<0.05). In liver-surgery patients significant lower activity at postoperative days three and four was found (p<0.05) (Figure 1). Combination of lowest physical activity and lowest nutritional intake was highly related to SRML (p=0.004). Conclusion: Low postoperative physical activity and nutritional intake are associated with postoperative muscle loss.