Concomitant Major Procedures Research Articles

Gynecologic Surgical Subspecialty Training Decreases Surgical Complications in Benign Minimally Invasive Hysterectomy

Study ObjectiveTo evaluate the impact of gynecologic subspecialty training on surgical outcomes in benign minimally invasive hysterectomies (MIH) while accounting for surgeon volume. DesignRetrospective cohort study of patients who underwent a MIH between 2014 and 2017. SettingSingle community hospital system. PatientsPatients were identified via CPT (Current Procedural Terminology) codes for MIH: vaginal, laparoscopic or robotic. Exclusion criteria included a gynecologic cancer diagnosis or concomitant major procedure at the time of hysterectomy. One thousand six hundred and thirty-one patients underwent a benign MIH performed by a gynecologic generalist or a subspecialist in Minimally-Invasive Gynecologic Surgery (MIGS), Urogynecology and Pelvic Reconstructive Surgery (URPS), or Gynecologic Oncology. 125 hysterectomies were vaginal, 539 were conventional laparoscopic, and 967 were robotic. InterventionsN/A Measurements and Main ResultsSurgical outcomes including intraoperative complications, operative outcomes, and postoperative readmissions and reoperations, were compared between generalists and subspecialists and stratified by surgeon volume status, with “high-volume” defined as performing 12 or more hysterectomies annually. Odds ratios for the primary outcome, Clavien-Dindo Grade III complications (which included visceral injuries, conversions, and reoperations within 90 days), were calculated to evaluate the impact of subspecialty training while accounting for surgeon volume status. 855/1631 (52.4%) MIH were performed by generalists and 776/1631 (47.6%) by subspecialists. High-volume generalists performed 618/1631 (37.9%) of MIH, 14.5% (237/1631) were performed by low-volume generalists. All subspecialists were high-volume surgeons; 38.1% of generalists were high-volume.The odds of a Clavien-Dindo Grade III complication was 0.39 (0.25-0.62) for hysterectomies performed by subspecialists compared to high-volume generalists after adjusting for potential confounding variables (p < .001). Subspecialists and high-volume surgeons had significantly lower incidence of visceral injuries, transfusions, blood loss over 500 mL, and conversions compared to generalists and low-volume surgeons, respectively. ConclusionBoth subspecialty training and high surgeon volume status are associated with a lower risk of surgical complications in benign MIH. Subspecialty training is associated with a reduction in surgical complications even after accounting for surgeon volume.

Performance evaluation of a North American center using the established global benchmark for laparoscopic liver resections: A retrospective study

BackgroundThe global benchmark cut-offs were set for laparoscopic liver resection procedures: left lateral sectionectomy, left hepatectomy, and right hepatectomy. We aimed to compare the performance of our North American center with the established global benchmarks. MethodsThis is a single-center study of adults who underwent laparoscopic liver resection between 2010 to 2022 at the Toronto General Hospital. Fourteen benchmarking outcomes were assessed: operation time, intraoperative blood transfusion, estimated blood loss, blood loss ≥500 mL, blood loss ≥1000mL, open-conversion, postoperative length of stay, return to operation, postoperative morbidity, postoperative major-morbidity, 30-day mortality, 90-day mortality, R1 resection, and failure to rescue. Low-risk benchmark cases were defined as follows: patients aged 18 to 70 years, American Society of Anesthesiologist score ≤ 2, tumor size <10 cm, and Child–Pugh score ≤A. Cases involving bilio-enteric anastomosis, hilar dissection, or concomitant major procedures were excluded from the low-risk category. Cases that did not meet the criteria for low-risk selection were considered high-risk cases. ResultsA total of 178 laparoscopic liver resection cases were analyzed (109 left lateral sectionectomies, 45 left hepatectomies, 24 right hepatectomies). Forty-four (25%) cases qualified as low-risk cases (23 left lateral sectionectomies, 16 left hepatectomies, 5 right hepatectomies). The postoperative major morbidity and 90-day mortality after left lateral sectionectomy, left hepatectomy, and right hepatectomy for the low-risk cases were 0%, 0%, and 0%, and 0%, 0%, and 0%, respectively. For the high-risk cases post-2017, the outcomes in the same order were 0%, 0%, and 12%; 0%, 0%, and 0%, respectively. For the high-risk cases operated pre2017, the outcomes in the same order were 9%∗, 16%∗, and 18%; 2%∗, 0%, and 9%∗ (asterisks indicate not meeting the global cut-off), respectively. ConclusionA North American center was able to achieve outcomes comparable to the established global benchmark for laparoscopic liver resection.

Predictors of Operative Mortality of 928 Intact Aortoiliac Aneurysms

The aim of this study is to identify preoperative and intraoperative factors associated with in-hospital mortality of intact abdominal aortoiliac aneurysm repair. In this observational study, prospectively collected information included demographics, risk factors, comorbidities, aneurysm characteristics (including special aneurysm presentation, i.e., inflammatory, mycotic/infected, aortocaval fistula), investigations, and operative variables. Receiver operating characteristic) curve analysis of the Glasgow aneurysm score (GAS) and the Vascular Study Group of New England (VSGNE) score was performed in the subgroup of bland aneurysms undergoing isolated elective repair. A total of 928 cases with intact aortoiliac aneurysms had an elective (n=882) or urgent (n=46) repair, associated with an in-hospital mortality of 1.7% and 8.7%, respectively (P=0.01). Open repair (n=514) was a predictor of higher mortality (3.3% vs. 0.5% for endovascular aneurysm repair [EVAR], n=414, odds ratio [OR] 7.1, P=0.003), and so was the pre-EVAR era (4.8% vs. 1.3% in the EVAR era, OR 4.0, P=0.004). Other significant predictors included the presence of abdominal/back pain (7.5% vs. 1.3%, OR=6.0, P=0.001), preoperative angiography (7% vs. 1.6%, OR=4.5, P=0.01), special aneurysm presentation (10.9% vs. 1.5%, OR=8.1, P<0.001), concomitant major procedures (19% vs. 1.7%, OR=14.0, P<0.001), serious intraoperative complications (9.1% vs. 1.5%, OR=6.6, P=0.001), median number of transfused units of blood intraoperatively (2 and 0 for cases with and without mortality, respectively, P<0.001), and procedure duration (270 and 150min for cases with and without mortality, respectively, P<0.001). Open repair (OR=4.5, P=0.05), special aneurysm presentation (OR=6.58, P=0.001), and concomitant major procedures (OR=14.3, P<0.001) were independent predictors of higher mortality. ROC curve analysis for the GAS (P=0.87) and VSGNE score (P=0.10) failed to demonstrate statistical significance in the subgroup of bland aneurysms undergoing isolated elective repair. Our study has demonstrated independent risk factors for mortality, which should be considered when contemplating aortoiliac aneurysm repair. We failed to externally validate the GAS and VSGNE score.

Novel Predictors of Peri-Operative Mortality in a Series Of 931 Consecutive Patients with Intact Aortoiliac Aneurysms Managed at a Single Centre

Introduction - The aim of our study was to identify preoperative and intraoperative factors associated with in-hospital mortality after repair of intact abdominal aortic or iliac aneurysms. Methods - This was a retrospective analysis of prospectively collected information on patients undergoing repair of intact aortoiliac aneurysms during a 28-year period. Recorded information included preoperative demographics, risk factors and co-morbidities, aneurysm characteristics, investigations and operative variables including special aneurysm presentation (inflammatory, mycotic/infected, aortocaval fistula) and procedure type (open vs. endovascular repair). Univariate and multivariate logistic regression analyses (with odds ratios, OR) were performed, the latter performed to develop a predictive model using the generated output. The area under the curve of the receiver operating characteristics (ROC) curve of our score, the Glasgow aneurysm score (GAS),1 and the Vascular Study Group of New England (VSGNE) score,2 was calculated. Results - During the study period we operated on 931 patients with intact aortoiliac aneurysms, on an elective (n=882) or urgent (n=49) basis, and an in-hospital mortality of 1.7% and 8.2%, respectively (p=0.015). Endovascular aneurysm repair (EVAR, n=414) was a predictor of lower mortality (0.5% vs. 3.3% for open repair, n=517, p=0.003). Other significant predictors included the presence of abdominal or back pain (7.5% vs 1.3% for no pain, p<0.001), preoperative angiography (6.9% vs 1.6% for no angiography, p=0.01), special aneurysm presentation (10.7% vs 1.5% for 875 ordinary atherosclerotic aneurysms, p<0.001), concomitant major procedures (19% vs 1.6% for the rest, p<0.001), serious intraoperative complications (9.1% vs 1.5% for no such complications, p<0.001), median number of transfused units of blood intraoperatively (2 and 0 for cases with and without mortality, respectively, p<0.001) and duration of the procedure (300min and 150min for cases with and without mortality, respectively, p<0.001). On multivariate analysis, EVAR was an independent predictor of lower mortality (OR=0.22, p=0.05) and special aneurysm presentation (OR=6.45, p=0.001) and concomitant major procedures (OR=14.3, p<0.001) were independent predictors of higher mortality. The area under the ROC curve, and p values for the GAS, VSGNE score and our score was 0.46, 0.62 and 0.81, and 0.59, 0.084 and 0.00003, respectively (Figure). The difference between the VSGNE and our score was significant (p=0.029). Repeat analysis for electively operated cases demonstrated an area under the ROC curve of 0.66 (p=0.029) and 0.80 (p=0.000069), respectively, for the VSGNE and our score, with the difference becoming non-significant. Conclusion - Our study in patients undergoing aortoiliac aneurysm repair has demonstrated novel risk factors for mortality and externally validated VSGNE in different healthcare settings.

Cost comparison of robotic-assisted laparoscopic hysterectomy versus standard laparoscopic hysterectomy.

The aim of the study was to assess if the cost of robotic-assisted total laparoscopic hysterectomy is similar to the cost of standard laparoscopic hysterectomy when performed by surgeons past their initial learning curve. A retrospective chart review of all hysterectomies was performed for benign indications without concomitant major procedures at Orange Coast Memorial Medical Center (OCMMC) and Saddleback Memorial Medical Center between January 1, 2013 and September 30, 2013. Robotic-assisted total laparoscopic hysterectomies (RTLH) and standard laparoscopic hysterectomies (LAVH and TLH) were compared. Data analyzed included only those hysterectomies performed by surgeons past their initial learning curve (minimum of 30 previous robotic cases). The primary outcome was the direct total cost of patient's hospitalization related to hysterectomy. The secondary outcomes were estimated blood loss, surgery time, and days in hospital post-surgery. A multiple linear regression model was applied to evaluate the difference between RTLH and LAVH/TLH in hospital cost, blood loss, and surgery time, while adjusting for hospital, patient's age, body mass index (BMI), whether or not the patient had previous abdominal/pelvic surgery, and uterine weight. The χ (2) test was applied to examine the association between hospital stay and surgery type. There were 93 hysterectomies (5 LAVH, 88 RTLH) performed at OCMMC and 90 hysterectomies (6 LAVH, 17 TLH, 67 RTLH) performed at Saddleback Memorial Medical Center. The hospitalization total cost result showed that, after adjusting for hospital, age, BMI, previous abdominal/pelvic surgery, and uterine weight, RTLH was not significantly more expensive than LAVH/TLH (mean diff.=$283.1, 95% CI=[-569.6, 1135.9]; p=0.51) at the 2 study hospitals. However, the cost at OCMMC was significantly higher than Saddleback Memorial Medical Center (mean diff.=$2008.7, 95% CI=[1380.6, 2636.7]; p<0.0001); and the cost increased significantly with uterine weight (β=3.8, 95% CI=[2.3, 5.3]; p<0.0001). Further analysis showed significantly less blood loss (mean diff.=-78.5ml, 95% CI=[-116.8, -40.3]; p<0.0001) and shorter surgery time (mean diff.=-21.9min., 95% CI=[-39.6, -4.2]; p=0.016) for RTLH versus LAVH/TLH. There was no significant association between hospital stay and surgery type (p=0.43). After adjusting for patient-level covariates, there was no statistically significant cost difference of performing robotically assisted laparoscopic hysterectomy versus standard laparoscopic hysterectomy when performed by surgeons past their initial learning curve at two community hospitals.

Autologous Versus Allogeneic Transfusions: No Difference in Perioperative Outcome After Partial Hepatectomy

Blood transfusion is often necessary in patients undergoing liver resection. Because of the risks associated with allogeneic blood products, preoperative autologous blood donation has been advocated, but its benefit with respect to perioperative outcome remains unclear. This study compares perioperative outcome in patients transfused only with autologous blood to a matched cohort receiving only allogeneic blood. All patients subjected to hepatic resection and given only perioperative autologous red cell transfusions were identified from a prospective database of 2,123 patients and reviewed retrospectively. This group was matched to patients transfused only with a comparable number of allogeneic red cell units and to a control group that received no blood products. All patients in the autologous or allogeneic group received either 1 or 2 U. Matching was based on age, comorbidity, extent of hepatic resection, and estimated blood loss. Matched pair analysis was performed using the paired t test, McNemar and Stuart–Maxwell tests. From December 1991 to May 2003, 124 patients undergoing hepatic resection received perioperative autologous blood only, for which optimal matching was possible in 104. The groups were similar with respect to age, comorbidities, and blood loss; the proportions receiving preoperative chemotherapy, requiring a major resection (≥3 segments) or a complex procedure (concomitant major procedure in addition to the principal hepatic resection) were also similar. There were no differences between the autologous and allogeneic groups in length of hospitalization, complications, and operative mortality. In patients undergoing hepatic resection, autologous blood transfusion did not demonstrably improve perioperative outcome when compared to a matched cohort of patients receiving a similar number of allogeneic units.

Improvement in Perioperative Outcome After Hepatic Resection

Objective To assess the nature of changes in the field of hepatic resectional surgery and their impact on perioperative outcome. Methods Demographics, extent of resection, concomitant major procedures, operative and transfusion data, complications, and hospital stay were analyzed for 1,803 consecutive patients undergoing hepatic resection from December 1991 to September 2001 at Memorial Sloan-Kettering Cancer Center. Factors associated with morbidity and mortality and trends in operative and perioperative variables over the period of study were analyzed. Results Malignant disease was the most common diagnosis (1,642 patients, 91%); of these cases, metastatic colorectal cancer accounted for 62% (n = 1,021). Three hundred seventy-five resections (21%) were performed for primary hepatic or biliary cancers and 161 (9%) for benign disease. Anatomical resections were performed in 1,568 patients (87%) and included 544 extended hepatectomies, 483 hepatectomies, and 526 segmental resections. Sixty-two percent of patients had three or more segments resected, 42% had bilobar resections, and 37% had concomitant additional major procedures. The median blood loss was 600 mL and 49% of patients were transfused at any time during the index admission. Median hospital stay was 8 days, morbidity was 45%, and operative mortality was 3.1%. Over the study period, there was a significant increase in the use of parenchymal-sparing segmental resections and a decrease in the number of hepatic segments resected. In parallel with this, there was a significant decline in blood loss, the use of blood products, and hospital stay. Despite an increase in concomitant major procedures, operative mortality decreased from approximately 4% in the first 5 years of the study to 1.3% in the last 2 years, with 0 operative deaths in the last 184 consecutive cases. On multivariate analysis, the number of hepatic segments resected and operative blood loss were the only independent predictors of both perioperative morbidity and mortality. Conclusions Over the past decade, the use of parenchymal-sparing segmental resections has increased significantly. The number of hepatic segments resected and operative blood loss were the only predictors of both perioperative morbidity and mortality, and reductions in both are largely responsible for the decrease in perioperative mortality, which has occurred despite an increase in concomitant major procedures.

Improvement in perioperative outcome after hepatic resection: analysis of 1,803 consecutive cases over the past decade.

To assess the nature of changes in the field of hepatic resectional surgery and their impact on perioperative outcome. Demographics, extent of resection, concomitant major procedures, operative and transfusion data, complications, and hospital stay were analyzed for 1,803 consecutive patients undergoing hepatic resection from December 1991 to September 2001 at Memorial Sloan-Kettering Cancer Center. Factors associated with morbidity and mortality and trends in operative and perioperative variables over the period of study were analyzed. Malignant disease was the most common diagnosis (1,642 patients, 91%); of these cases, metastatic colorectal cancer accounted for 62% (n = 1,021). Three hundred seventy-five resections (21%) were performed for primary hepatic or biliary cancers and 161 (9%) for benign disease. Anatomical resections were performed in 1,568 patients (87%) and included 544 extended hepatectomies, 483 hepatectomies, and 526 segmental resections. Sixty-two percent of patients had three or more segments resected, 42% had bilobar resections, and 37% had concomitant additional major procedures. The median blood loss was 600 mL and 49% of patients were transfused at any time during the index admission. Median hospital stay was 8 days, morbidity was 45%, and operative mortality was 3.1%. Over the study period, there was a significant increase in the use of parenchymal-sparing segmental resections and a decrease in the number of hepatic segments resected. In parallel with this, there was a significant decline in blood loss, the use of blood products, and hospital stay. Despite an increase in concomitant major procedures, operative mortality decreased from approximately 4% in the first 5 years of the study to 1.3% in the last 2 years, with 0 operative deaths in the last 184 consecutive cases. On multivariate analysis, the number of hepatic segments resected and operative blood loss were the only independent predictors of both perioperative morbidity and mortality. Over the past decade, the use of parenchymal-sparing segmental resections has increased significantly. The number of hepatic segments resected and operative blood loss were the only predictors of both perioperative morbidity and mortality, and reductions in both are largely responsible for the decrease in perioperative mortality, which has occurred despite an increase in concomitant major procedures.