Differences In Perioperative Outcomes Research Articles

No Difference in Perioperative Outcomes Following Colorectal Cancer Resection Between Flagship and Non-Flagship Hospitals in New York State.

Hospitals are rapidly consolidating to create large healthcare systems. Whether outcomes following colorectal cancer resection at flagship hospitals differ from those at non-flagship hospitals is unknown. A 6-year retrospective analysis of an all-payor New York State (NYS) hospital database was conducted. All adult patients with a colorectal resection for primary resectable colorectal cancer were included. Within each system, the hospital with the most colorectal resections was designated the "flagship" hospital. Thirty-day outcomes at flagship facilities were compared to affiliated, non-flagship hospitals following colorectal resection while matching for patient-level differences. In total, 28 400 patients were included across 31 healthcare systems in NYS. There were no differences in mortality (0.9% vs. 1.1%), 30-day readmissions (10.5% vs. 11.9%), or postoperative outcomes between matched patients treated at flagship versus non-flagship facilities (p > 0.05). There are no differences in perioperative outcomes between flagship and non-flagship hospitals in a given system in NYS. Patients with resectable non-metastatic colorectal cancer may not need to undergo oncologic resection at flagship hospitals to receive high-quality perioperative care.

Long-term perioperative antibiotic prophylaxis after urethral reconstruction does not improve clinical outcomes and increases incidence of MDR organisms

PurposeTo analyze the impact of long-term postoperative antibiotic prophylaxis following urethral reconstruction on perioperative outcomes, postoperative urine cultures, and the emergence of multidrug-resistant bacteria.MethodsIn this retrospective review of patients undergoing urethral reconstruction with a single surgeon from 2019 to 2023, patients either received long-term prophylactic postoperative antibiotics for 3–4 weeks while indwelling catheters were in place or they did not receive prophylactic antibiotics. Preoperative and postoperative urine cultures were obtained on all patients. The primary outcome measure was the association of prophylactic antibiotics with the presence of multidrug-resistant bacteria in postoperative urine cultures. Secondary outcomes included differences in perioperative outcomes.ResultsOf 166 patients undergoing urethral reconstruction, 147 met all inclusion criteria. Of these, 84 received antibiotic prophylaxis and 63 did not. The number of multidrug-resistant organisms in postoperative urine cultures was significantly different between cohorts indicating a harmful effect of antibiotic prophylaxis (P <.01). There were no significant differences in perioperative outcomes including positive urine cultures, clinical urinary tract infections, wound complications, or recurrence.ConclusionThese data show that the administration of postoperative prophylactic antibiotics does not influence perioperative outcomes but does heighten the risk of encountering multidrug-resistant bacteria. This novel finding should discourage the routine use of antibiotic prophylaxis in patients undergoing urethral reconstruction.

Endovascular abdominal aortic aneurysm repair (EVAR) outcomes of unibody and single/double docking limb endografts in Medicare beneficiaries between 2012 and 2018.

The evaluation of perioperative and long term outcomes for endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAA) using anatomic (unibody) and proximal neck fixated (docking limbs) endografts across consecutive time cohorts. This study compares the outcomes of EVAR in Medicare patients stratified by mode of fixation. All patients who underwent EVAR between 2012 and 2018 were identified in the Medicare database. Anatomic fixation (AF) and proximal fixation (PF) grafts were differentiated using Current Procedural Terminology (CPT) codes. The AF population was divided into three-time cohorts based on iterative changes in graft design: Cohort 1: (01/01/2012-20/07/2014); Cohort 2: (21/07/2014-09/05/2016); and Cohort 3: (10/05/2016-31/12/2017). The PF cohort was similarly divided into these three periods. Outcomes were evaluated through 31/12/2020 and included all-cause mortality, aortic rupture, and aortic-related reintervention. 32,031 patients underwent EVAR during the study period; 4729 were AF and 27,302 were PF. There were more women (p < .001) and patients with peripheral vascular disease (PVD) (p < .001) in the AF group. There were no group differences in perioperative outcomes. In Cohort 1, there was a higher rate of reintervention (11.9% vs 7.6%; p < .001) and aortic rupture (5.3% vs 4.0%; p = .019) in the AF group compared to the PF group. In Cohort 2, reintervention, aortic rupture, and reintervention rates were similar between the two groups (p = NS). In Cohort 3, the reintervention and aortic rupture rates were similar between the two groups (p = NS). The higher rates of aortic rupture and reintervention seen in the AF group in Cohort 1 when compared with the PF group did not persist in Cohorts 2 and 3. This suggests that improvements in graft design may have led to durability which is similar to that of PF grafts. However, late aneurysm related complications are inherent risks after EVAR and long-term surveillance remains necessary.

The Impact of Smoking on Sacrocolpopexy Perioperative Outcomes: An Observational Study.

Tobacco smoke is a modifiable risk factor that surgeons discuss with patients prior to undergoing sacrocolpopexy or mesh revision surgery. The aim of the study was to investigate the effect of smoking on perioperative outcomes after sacrocolpopexy for pelvic organ prolapse and mesh revision repair. This was a retrospective cohort study of data obtained from the National Surgical Quality Improvement Project's database. Women who underwent surgery for pelvic organ prolapse via abdominal sacrocolpopexy (ASCP) or minimally invasive sacrocolpopexy (MISCP) or prolapse mesh revision surgery from 2011 to 2021 were identified and compared based on current tobacco use. Demographic, medical, and surgical history, as well as intraoperative and 30-day perioperative outcomes, were compared. Multivariate analysis was performed. Overall, 21,980 women underwent MISCP (8.60% smokers) and 3,775 underwent ASCP (8.74% smokers). Postoperative wound infections were more common after sacrocolpopexy in patients who smoked. Readmission after MISCP was more common in smokers. The composite perioperative morbidity score was different between smokers and nonsmokers for MISCP (P = 0.001) and ASCP (P = 0.002). Multivariate analyses of MISCP outcomes found an association between smoking and wound infection, readmission, and composite score. Multivariate analyses of ASCP outcomes found an association between smoking and wound infection. Overall 2,160 patients underwent mesh removal by any modality (16.57% smokers), and no difference in perioperative outcomes between smokers and nonsmokers for mesh removal was found. An association was found between tobacco smoking and wound infection as well as other postoperative complications. Tobacco use prior to a mesh excision procedure does not appear to increase perioperative outcomes.

Cutaneous ureterostomy following robot-assisted radical cystectomy: a multicenter comparative study of transperitoneal versus retroperitoneal techniques

BackgroundThe aim of this study was to evaluate the differences in perioperative outcomes between transperitoneal and retroperitoneal techniques in cutaneous ureterostomy (CUS).MethodsBetween 2018 and 2023, 55 patients underwent CUS following robot-assisted radical cystectomy. Among the 55 patients, we compared 33 patients who underwent transperitoneal CUS (t-CUS) and 22 who underwent retroperitoneal CUS (r-CUS).ResultsCompared with the r-CUS group, the t-CUS group had significantly shorter operative times (p < 0.001); significantly less estimated blood loss (p < 0.001); and significantly lower incidence of complications (Clavien–Dindo classification grade ≤ 2) within 30 days (p = 0.005). Unexpectedly, the incidence of ileus within 30 days was lower, though the difference was not statistically significant (p = 0.064). During the median follow-up period of 24.3 months, no ileus was observed in either group after 30 days postoperatively. There was no significant difference in the stent-free rate between the groups (p = 0.449). There were also no significant differences in the rates of change in estimated glomerular filtration rate from preoperatively at 3, 6, 12, and 24 months postoperatively between the groups (p = 0.590, p = 0.627, p = 0.741, and p = 0.778, respectively).ConclusionsCompared with r-CUS, t-CUS was associated with a shorter operative time and lower incidence of perioperative complications, including gastrointestinal complications. We believe that t-CUS can be performed safely and effectively.

Insights into sex differences in perioperative outcomes of non-small cell lung cancer patients.

The appreciation of sex differences is substantial for precise cancer management. Surgery is the main treatment for non-small cell lung cancer (NSCLC). We aimed to identify sex differences on perioperative outcomes in NSCLC patients and to uncover the origins of sex effect in outcomes using a Chinese cohort. We retrospectively enrolled patients undergoing NSCLC surgery in the Western China Lung Cancer Database from January 2014 to April 2021. We compared baseline characteristics and perioperative outcomes between male and female. Multivariable analyses were performed. We conducted causal mediation analysis to identify drivers to sex differences in perioperative outcomes. Altogether, data of 10,181 patients (5,738 women and 4,443 men) were analyzed. Women had lower incidence of complications (5.05% vs. 12.15%), shorter postoperative length of stays (4.92 vs. 6.41 days), and less hospitalization cost (50,713.69 vs. 54,580.85, Chinese Yuan). Multivariable regression analysis identified sex as an independent factor of perioperative complications [odds ratio (OR), 1.843, 95% confidence interval (CI): 1.476-2.294], as well as of postoperative length of hospital stays (beta 0.123, 95% CI: 0.099-0.148), and hospitalization cost (beta 0.026, 95% CI: 0.026-0.026). Mediation analysis revealed that age, body mass index, prevalence of chronic obstructive pulmonary disease, predicted diffusion capacity for carbon monoxide, tumor size, pleural adhesion, and surgery duration were identified as mediators for sex differences in outcomes, while smoking status, surgery type, and resection extent were not. Female NSCLC patients demonstrated lower incidence of complications, shorter postoperative length of stays, and less hospitalization cost after surgery. Those differences between men and women could be explained by their inherent biological differences and baseline health status. Perioperative management strategies for NSCLC should prioritize recognizing the potentially poorer outcomes among male patients and implementing tailored precautions accordingly.

Comparison of Open and Endovascular Repair of Complex Abdominal Aortic Aneurysms

To compare perioperative and 5-year outcomes following endovascular (FEVAR) and open repair (OAR) of complex abdominal aortic aneurysms (cAAA) in males and females separately, given the known sex related differences in perioperative outcomes. We studied all elective cAAA repairs between 2014-2019 in the Vascular Implant Surveillance and Interventional Outcomes Network (VISION) registry. We stratified patients based on sex. We calculated propensity scores for assignment to either OAR or FEVAR. Covariates including age, race, diameter, baseline comorbidities, proximal extent of repair, annual center volumes, and annual surgeon volumes were introduced into the model for estimating propensity scores. Within matched cohorts, perioperative outcomes and 5-year outcomes (mortality, reinterventions, and ruptures) were evaluated using multivariable logistic and Cox regression models. We identified 2,825 patients of whom 29% were female. Within both the sexes, OAR was more commonly performed (OAR vs FEVAR: males: 53% vs 47%; females: 63% vs 37%). After matching, among males (n=1326), FEVAR was associated with lower perioperative mortality (FEVAR vs OAR: 2.3% vs 5.1%; p<.001). However, FEVAR was associated with comparable 5-year mortality (38% vs 28%; hazard ratio (HR) 1.2 [0.92-1.4]; p=.22) and a higher hazard of 5-year reintervention (19% vs 3.7%; aHR: 4.5 [2.6-7.6], p<.001). Among females (n=456), FEVAR and OAR showed similar perioperative mortality (8.3% vs 7.0%; p=.73). At 5 years, FEVAR was associated with higher hazards of mortality (43% vs 32%; aHR: 1.5 [1.03-2.2], p=.034) and reintervention (20% vs 3.0%; aHR: 4.8 [2.1-11], p<.001) compared with OAR. Among males, FEVAR was associated with favorable perioperative outcomes compared with OAR, though these advantages attenuate over time. However, among females, FEVAR was associated with similar perioperative outcomes, eventually leading to higher reinterventions and possibly higher mortality within 5 years. Future efforts should focus on determining the factors associated with these sex disparities to improve outcomes following FEVAR in females. Based on current evidence, females undergoing elective cAAA repair should be selected with due caution, especially for endovascular repair.

Intercostal nerve cryoablation in lung transplantation: A single-center, propensity score–matched analysis

BackgroundAchieving adequate pain control after lung transplantation is an essential milestone in a patient's recovery. We compared postoperative opioid use, clinical outcomes, and respiratory function in lung transplant recipients treated with intercostal nerve cryoablation (INC) compared to those receiving standard pain management. MethodsWe reviewed all adult lung transplants performed at our center between January 2016 and December 2022. We excluded cases performed through median sternotomy and patients with prior thoracotomies, multiorgan transplants, and redo transplants. We performed a propensity score–matched analysis, comparing patients who received INC versus those who received standard pain management. The primary outcome was cumulative postoperative opioid use in morphine milligram equivalents (MME) by postoperative day (POD) 14. Secondary outcomes included opioid use on POD5 and POD10, perioperative outcomes, 1-year survival, and longitudinal measurement of respiratory function. ResultsPropensity score matching resulted in 85 patients in each group. Compared to the standard pain management group, the INC group had a lower cumulative opioid use by POD14 (509 MME vs 864 MME; P = .032). In addition, the INC group had less opioid use at POD5, POD10, and POD14; no difference in perioperative outcomes; and similar 1-year survival. The INC group had better respiratory function at 6 and 12 months post-transplant compared to the standard pain management group. ConclusionsIn our single-center analysis, INC was associated with less opioid use and improved respiratory function after lung transplant. This report adds to the growing literature supporting the use of INC in multimodal pain management strategies and enhanced recovery protocols in lung transplant.

Assessment of mechanical bowel preparation prior to nephrectomy in the minimally invasive surgery era: insights from a national database analysis in the United States.

This study was performed to evaluate the association between mechanical bowel preparation (MBP) and perioperative outcomes following nephrectomy in the minimally invasive surgery (MIS) era. All partial and radical nephrectomies between 2019 and 2021 from the National Surgical Quality Improvement Program database were evaluated. Thirty-day perioperative outcomes were compared between groups where MBP was performed vs. not, in both the MIS and open surgery (OS) cohorts. A propensity score matching technique was utilized within MIS cases to control for covariates. The chi-square and t tests were used to determine significance. A total of 11,869 cases met the inclusion criteria and were included in the analysis. Of these, 8,204 (69.1%; comprising 65.3% robotic and 34.7% laparoscopic) underwent MIS, while 3,655 (30.9%) underwent OS. The rate of MBP was higher in the MIS group (16.0% vs. 10.0%, p < 0.001). Within the MIS group, MBP was associated with reduced rates of postoperative ileus (0.9% vs. 1.9%, p = 0.02), while other complications were comparable. Propensity score matching showed no association between MBP and postoperative ileus. However, a lower rate of 30-day readmission in the MBP group became statistically significant (4.4% vs. 6.4%, p = 0.01). Conversely, patients in the MBP group also demonstrated higher rates of pneumonia (1.29% vs. 0.46%, p = 0.002) and pulmonary embolism (0.6% vs. 0%, p < 0.001) after matching. MBP practice prior to nephrectomy is infrequent in both OS and MIS cases, with minor differences in perioperative outcomes for patients undergoing MIS. Routine MBP should continue to be excluded from the standard of care for nephrectomy in the MIS era.

Retroperitoneal cutaneous ureterostomy following radical cystectomy: A multicenter comparative study of robotic versus open surgery.

The aim of this study was to evaluate the differences in perioperative outcomes of cutaneous ureterostomy (CUS) between open surgery (open radical cystectomy, ORC) and robot-assisted surgery (robot-assisted radical cystectomy, RARC), including the stent-free rate, readmission rates due to urinary tract infection (UTI), and changes in renal function. Between 2005 and 2023, a total of 37 patients underwent CUS following ORC, while 24 patients underwent CUS following RARC. Perioperative outcomes were compared between these two groups. The patients in the RARC group were significantly older (p = 0.007) and had a significantly higher proportion of high-risk cases with ASA-PS ≥3 (p = 0.002). In addition, RARC was associated with a significantly lower estimated blood loss (p < 0.001) and a reduced transfusion rate (p = 0.003). Postoperative complication rates and the stent-free rate were comparable between the ORC and RARC groups. Throughout a median follow-up period of 2.6 years, rates of readmission due to UTI did not differ significantly between the two groups. Moreover, there were no differences in the change in estimated glomerular filtration rate before and after surgery and the 3-year survival rates were similar across both groups. CUS following RARC appears to offer a safer alternative compared with CUS following ORC, and the stent-free rates are comparable. The significantly lower estimated blood loss and transfusion rate associated with RARC are particularly favorable for elderly patients, those who are frail, and individuals with multiple comorbidities.

There is No Increased Pulmonary Risk Following Total Hip Arthroplasty in Patients Who Have Obstructive Sleep Apnea Without Underlying Lung Disease

BackgroundObstructive sleep apnea (OSA) is a frequent comorbidity. The current study evaluated whether there is a difference in the perioperative outcome after total hip arthroplasty (THA) in patients who had a low to moderate risk for OSA and high risk for OSA, respectively. MethodsAfter excluding patients who had concomitant lung disease (chronic obstructive pulmonary disease, asthma, or lung fibrosis) and those missing a STOP-Bang Score, 1,141 THA patients who had OSA were included in this retrospective study. Patients at low to moderate risk for OSA (STOP-Bang Score 0 to 4) and patients at high risk for OSA (STOP-Bang Score 5 to 8) were compared, and SpO2 (oxygen saturation) drops < 90% as well as readmission rates were compared between patients who did and did not use continuous positive airway pressure (CPAP). ResultsThere was no difference in the risk of SpO2 drop below 90% (1 versus 0%, P = 0.398) and readmission rate (2 versus 2%, P = 0.662) between patients who had low to moderate OSA risk (327 THA) and high OSA risk (814 THAs). There was no difference in SpO2 (P > 0.999) and a decrease in oxygen flow rate from the postanesthesia care unit to the morning of the first postoperative day. A CPAP device was used by 41% (467 of 1,141) of patients. There were no differences in SpO2 drop < 90% (0 versus 0%, P = 0.731) and readmission rate (2 versus 2%, P = 0.612) between patients who did and did not use a CPAP machine. ConclusionsThe current study showed no difference in perioperative outcomes between OSA patients undergoing THA who had a low STOP-Bang Score and patients who had a high STOP-Bang Score, regardless of the use of a CPAP machine. These data suggest that an elevated Stop-Bang Score does not indicate an increased perioperative risk for OSA patients when deciding on outpatient discharge.

Aortic valve performance after remodelling versus reimplantation in a propensity-matched comparison.

Both aortic root remodelling and aortic valve (AV) reimplantation have been used for valve-sparing root replacement in patients with aortic root aneurysm with or without aortic regurgitation. There is no clear evidence to support one technique over the another. This study aimed to compare remodelling with basal ring annuloplasty versus reimplantation on a multicentre level with the use of propensity-score matching. This was a retrospective international multicentre study of patients undergoing remodelling or reimplantation between 2010 and 2021. Twenty-three preoperative covariates (including root dimensions and valve characteristics) were used for propensity-score matching. Perioperative outcomes were analysed along with longer-term freedom from AV reoperation/reintervention and other major valve-related events. Throughout the study period, 297 patients underwent remodelling and 281 had reimplantation. Using propensity-score matching, 112 pairs were selected and further compared. We did not find a statistically significant difference in perioperative outcomes between the matched groups. Patients after remodelling had significantly higher reintervention risk than after reimplantation over the median follow-up of 6 years (P = 0.016). The remodelling technique (P = 0.02), need for decalcification (P = 0.03) and degree of immediate postoperative AV regurgitation (P < 0.001) were defined as independent risk factors for later AV reintervention. After exclusion of patients with worse than mild AV regurgitation immediately after repair, both techniques functioned comparably (P = 0.089). AV reimplantation was associated with better valve function in longer-term postoperatively than remodelling. If optimal immediate repair outcome was achieved, both techniques provided comparable AV function.

A propensity-score-matched comparison of standard and extended pelvic lymph node dissection in robot-assisted laparoscopic radical cystectomy.

To compare the difference in perioperative outcomes between standard pelvic lymph node dissection (sPLND) and extended pelvic lymph node dissection (ePLND) in robot-assisted radical cystectomy (RARC) and evaluate the survival outcomes. The clinical data were retrospectively collected from patients who underwent RARC between January 2016 and December 2020 in Nanjing Drum Hospital. The patients were divided into sPLND and ePLND group according to the extent of pelvic lymph node dissection. Finally, 80 pairs of patients obtained for two groups by propensity score matching (PSM) and their perioperative and survival outcomes were analyzed. The median number of dissected lymph nodes (LN) after PSM was 13 in sPLND group and 16 in ePLND group (P = 0.004). Perioperative complications were similar between 2 groups. After PSM, ePLND improved 5-year RFS and OS in all patients (85.74 vs. 61.94%, P = 0.004; 82.80 vs. 67.50%, P = 0.033), patients with ≥ T3 disease (73.66 vs. 23.86%; P = 0.007; 68.20 vs. 36.20%; P = 0.032) and patients with LN metastasis (67.70 vs. 7.33%; P = 0.004; 60.60 vs. 16.67%; P = 0.045) compared to sPLND. Extended PLND significantly increased lymph node yield without increasing complication and improved RFS and OS compared to sPLND.

Early postoperative outcomes following bariatric surgery in the United States: Are racial disparities improving?

BackgroundBariatric surgery offers effective treatment for morbid obesity and associated medical comorbidities, with excellent short- and long-term outcomes. Although it has been well documented that racial minority bariatric patients have worse outcomes than White patients, it remains unclear whether this recognition has led to improvement. Herein, we assess recent trends in bariatric surgery among Black and White patients and compare early postoperative outcomes by race.MethodsPrimary sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) patients from 2015 to 2021 reported to the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program were studied. Bariatric patients were stratified by race (Black and White) and perioperative outcomes were compared between matched Black and White patients. Primary outcome was 30-day mortality. Secondary outcomes included hospital readmissions, hospital length of stay (LOS), reoperation, and postoperative complications.ResultsOverall, there were 193,071 Black and 645,224 White primary bariatric patients, with a higher volume of SG and RGYB performed among White patients. A total of 219,566 Black and White bariatric patients were matched and included in the case–control. Black patients were found to have higher rates of 30-day mortality (0.02% vs. 0.01%; p = 0.03) and readmissions (3.68% vs. 2.65%; p < 0.001). There were no significant differences in LOS, reoperations, or overall postoperative complications. However, there was a higher postoperative pulmonary thromboembolism rate (0.16% vs 0.08%; p < 0.001).). The differences in perioperative outcomes stratified by race persisted over the study period (Fig. 1).ConclusionBlack bariatric surgery patients continue to have worse perioperative outcomes compared with their White counterparts. Further work must be done to determine contributing factors in order to effect improvement in outcomes in bariatric surgical care for racial minority patients.

Is fluorometric sentinel lymph node biopsy in endometrial cancer necessary?

In this study, we collected perioperative and postoperative follow-up data from patients with endometrial cancer (EC) at different stages to evaluate the role of sentinel lymph node biopsy (SLNB) in endometrial cancer surgery. A total of 186 endometrial cancer patients undergoing radical hysterectomy from January 2018 to April 2022 were retrospectively analyzed. Patients were classified into four groups. Group A comprised patients diagnosed with stage IA grade 1 and 2 endometrioid EC who underwent SLNB. Group B comprised patients with stage IA grade 1 and 2 endometrioid EC who did not undergo SLNB. Group C comprised patients with higher-grade endometrioid EC, wherein systematic lymph node dissection was performed based on SLNB results. Group D comprised patients with higher-grade endometrioid EC who did not undergo SLNB and instead underwent direct systematic lymph node dissection. Clinical, pathological data, and follow-up information for all patients were collected. In Group A and B, SLNB was performed on 36 out of 67 patients with IA stage 1 and 2 endometrial cancer, yielding a SLN positivity rate of 5.6%. There were no significant differences observed between the two groups regarding perioperative outcomes and postoperative follow-up. Conversely, among 119 patients with higher-grade endometrial cancer, 52 underwent SLNB, with 20 patients exhibiting SLN positivity, resulting in a SLN positivity rate of 38.4%. However, the decision to undergo SLNB did not yield significant differences in perioperative outcomes and postoperative follow-up among these patients. For stage IA grade 1 and 2 endometrioid EC, the incidence of lymph node positivity is low, omitting SLNB in this subpopulation is a feasible option. In other stages of endometrioid EC, there is no significant difference in perioperative and postoperative follow-up data between patients undergoing routine systematic lymphadenectomy and those undergoing systematic lymphadenectomy based on SLNB results. Therefore, if SLNB is not available, the standard procedure of PLND remains an option to obtain information about lymph node status, despite the surgical complications associated with this procedure.

Clinical relevance of the 3-cm threshold in sigmoid diverticulitis with abscess: consensus or quandary?

PurposeDiverticular abscess is a common manifestation of acute complicated diverticulitis. We aimed to analyze the clinical course of patients with diverticular abscess initially treated conservatively.MethodsAll patients with diverticular abscess undergoing elective or urgent/emergency surgery from October 2004 to October 2022 were identified from our institutional database. Depending on the abscess size, patients were divided into group A (≤ 3 cm) and group B (> 3 cm). Conservative treatment failure was defined as clinical deterioration, persistent or recurrent abscess, or urgent/emergency surgery. Baseline characteristics and short-term perioperative outcomes were recorded and compared between both groups. Uni- and multivariate analyses were conducted to identify determinants of conservative treatment failure and overall ostomy formation.ResultsA total of 105 patients were enrolled into group A (n = 73) and group B (n = 32). Uni- and multivariate analyses revealed abscess size as the only significant factor of conservative therapy failure [OR 9.904; p < 0.0001], while overall ostomy formation was significantly affected by an increased body mass index (BMI) [OR 1.366; p = 0.026]. There were no significant differences in perioperative outcome with the exception of a longer total hospital stay in patients managed with abscess drainage compared to antibiotics alone prior surgery in group B (p = 0.045).ConclusionAbscess diameter > 3 cm is not just an arbitrary chosen cut-off value for drainage placement but has a prognostic impact on medical treatment failure in patients with complicated acute diverticulitis. In this subgroup, the choice between primary drainage and antibiotics does not appear to influence outcome at the cost of prolonged hospital stay after drainage insertion.

Is Stent-Free Ureteroenteric Anastomosis Associated With Lower Ureteroenteric Strictures After Robot-Assisted Radical Cystectomy and Ileal Conduit?

We aimed to investigate the differences in perioperative outcomes, especially ureteroenteric strictures, between patients who underwent a stented ureteroenteric anastomosis at the time of robot-assisted radical cystectomy (RARC) and ileal conduit vs those who did not. A retrospective review of our RARC database was performed (2009-2023). Patients were divided into those who received stented ureteroenteric anastomosis vs those who did not. Propensity score matching was performed in the ratio of 3 (stented ureteroenteric anastomosis) to 1 (stent-free) in terms of age, gender, BMI, race, American Society of Anesthesiologists score, neoadjuvant chemotherapy, Charlson Comorbidity Index, prior radiation therapy, previous abdominal surgery history, clinical T3/clinical T4 stage, preoperative metastasis, and preoperative hydronephrosis. A cumulative incidence curve was used to depict ureteroenteric strictures and a Cox regression model was used to identify variables associated with ureteroenteric strictures. Four hundred eighty-eight patients underwent RARC, 366 individuals underwent a stented ureteroenteric anastomosis, and 122 patients underwent a stent-free approach. There was no significant difference in 90-day overall complications, high-grade complications, readmissions, UTIs, leakage, and ileus (P > .05). Ureteroenteric strictures occurred at a rate of 13% and 18% at 1 and 2 years, respectively in the stented group, vs 7% and 10% in the stent-free group (P = .05). Stent placement was significantly associated with ureteroenteric strictures. Stent-free ureteroenteric anastomosis was associated with fewer strictures following RARC and ileal conduit.

Sex Related Differences in Perioperative Outcomes after Complex Endovascular Aortic Aneurysm Repair

Prior studies suggest female sex is associated with worse outcomes after complex endovascular aortic aneurysm repair (EVAR) due to anatomic differences. Therefore, we aimed to compare 30-day perioperative and long-term outcomes after complex EVAR by sex. A single-center retrospective review of consecutive elective and emergent complex EVAR with company-manufactured devices, laser fenestration, snorkel/periscope, or octopus technique was performed from 2012-2023. The primary outcome was a composite endpoint of any major adverse event (MAE), new-onset dialysis, or death within 30days. Secondary 30-day technical and long-term outcomes were also assessed. 293 patients (57 females, 19%), mean age 74years, underwent complex EVAR with commercially available Zenith fenestrated endovascular graft (71%), p-Branch (2%), laser fenestration (8%), snorkel/periscope (16%), or octopus (2%) techniques. Females had significantly different aneurysm-related anatomic characteristics compared to males, including smaller aneurysm diameters (58±7.2 vs. 64±13.2mm, P<0.001), more involved aneurysm extent (21.7% vs. 9.8% thoracoabdominal, P=0.04), increased renal artery calcification (43.9% vs. 27.1%, P=0.01), and smaller iliac (7.6±1.3 vs. 8.9±1.8mm, P<0.01). Operative outcomes were similar; however, females had a greater need for adjunctive access conduits (21.1% vs. 10.6%, P=0.04), lower technical success (91.2% vs. 98.3%, P=0.02), and longer median [interquartile range] length of stay (3.0 [4.0] vs. 2.0 [2.5] days, P<0.001). The composite 30-day outcome of any MAE, new dialysis, or death was not significantly different (15.8% females vs. 11.4% males, P=0.37). Technical endpoints including 30-day rates of target artery occlusion and type 1 or 3 endoleak were also similar between groups. At mean follow-up of nearly 3years, females had significantly lower rate of renal function decline (16.0% vs. 41.9%, P<0.001), but no differences were found in long-term all-cause mortality, aneurysm sac regression, reintervention, or total follow-up imaging studies between groups. Females undergoing complex EVAR had challenging anatomy with higher intraoperative target artery occlusion, conduit use, and longer length of stay. However, 30-day and long-term outcomes were similar, suggesting females can undergo complex EVAR with high technical success and comparable perioperative outcomes to males. Females appeared to have protection from long-term renal function decline, which will be important for future study.

Perioperative outcomes and survival after neoadjuvant immunochemotherapy for locally advanced esophageal squamous cell carcinoma

ObjectiveThis study aimed to compare the difference in perioperative outcomes and prognosis between neoadjuvant immunochemotherapy and neoadjuvant chemoradiotherapy for locally advanced esophageal squamous cell carcinoma. MethodsThe patients with locally advanced esophageal squamous cell carcinoma receiving neoadjuvant immunochemotherapy or neoadjuvant chemoradiotherapy were identified from a prospectively maintained database at Zhongshan Hospital of Fudan University between January 2018 and March 2022. Propensity score matching was performed to balance the 2 groups. ResultsA total of 124 patient pairs were enrolled in the final analysis. The complete pathological response rate (20.2% vs 29.0%, P = .140) was similar in the 2 groups, whereas the lower major pathological response rate (44.4% vs 61.3%, P = .011) was observed in the neoadjuvant immunochemotherapy group. Neoadjuvant immunochemotherapy was associated with a lower rate of adverse events (42.7% vs 55.6%, P = .047) without additional postoperative complications (38.7% vs 35.5%, P = .693). The neoadjuvant immunochemotherapy group had lower distant metastasis (6.5% vs 16.1%, P = .027) and overall recurrence (11.3% vs 23.4%, P = .019) in the postoperative 1 year. Also, neoadjuvant immunochemotherapy was associated with better progression-free survival (hazard ratio, 0.50; 95% CI, 0.32-0.77; P = .002). Cox proportional hazard analysis showed that neoadjuvant immunochemotherapy (univariable: hazard ratio, 0.55; 95% CI, 0.37-0.82; P = .003; multivariable: hazard ratio, 0.44; 95% CI, 0.29-0.65; P < .001) was one of the independent prognostic factors for progression-free survival. The 2 groups had similar overall survival (hazard ratio, 0.62; 95% CI, 0.36-1.09; P = .094) at the latest follow-up. ConclusionsThis retrospective study showed that neoadjuvant immunochemotherapy was safe and effective for patients with locally advanced esophageal squamous cell carcinoma. Further verification is needed in randomized controlled trials.

Laparoscopic totally extraperitoneal hernia repair in patients with a history of previous abdominopelvic surgery

A retrospective cohort study of patients undergoing laparoscopic inguinal hernia repair compared short- and long-term outcomes between individuals with or without history of previous abdominopelvic surgery, aiming to determine the feasibility of totally extraperitoneal (TEP) repair within this population. All patients who underwent elective TEP inguinal hernia repair by one consultant surgeon across three London hospitals from January 2017 to May 2023 were retrospectively analysed to assess perioperative outcomes. Two hundred sixty-two patients were identified, of whom two hundred forty-three (93%) underwent laparoscopic TEP repair. The most frequent complications were haematoma (6.2%) and seroma (4.1%). Recurrence occurred in four cases (1.6% of operations, 1.1% of hernias). One hundred eighty-four patients (76%) underwent day-case surgery. There were no mesh infections or explanations, vascular or visceral injuries, port-site hernias, damage to testicle, or persisting numbness. There were no requirements for blood transfusion, returns to theatre, or readmissions within 30 days. There was one conversion to open and one death within 60 days of surgery. Eighty-three (34%) had a history of previous AP surgery. There was no significant difference in perioperative outcomes between the AP and non-AP arms. This finding carried true for subgroup analysis of 44 patients whose AP surgical history did not include previous inguinal hernia repair and for those undergoing repair of recurrent hernia. In expert hands, laparoscopic TEP repair is associated with excellent outcomes and low rates of long-term complications, and thus should be considered as standard for patients regardless of a history of AP surgery.