Differences In 30-day Outcomes Research Articles

Sentinel Lymph Node Biopsy Versus Axillary Lymphadenectomy in Patients Treated with Lumpectomy: An Analysis of Short-Term Outcomes

Sentinel lymph node biopsy (SLNB) has been shown to reduce many of the long-term complications associated with a traditional axillary lymph node dissection (ALND); however, short-term outcomes have yet to be characterized. This study was designed to identify trends and differences in 30-day outcomes of partial mastectomy with concurrent SLNB or complete ALND to more effectively determine which patients may be at risk for perioperative complications. A retrospective review of the National Surgical Quality Improvement Program database from 2010 to 2011 was performed to identify all female patients undergoing partial mastectomy with concurrent ALND or SLNB. Logistic regression analysis was used to investigate the relationship between surgical management of the axilla and 30-day complications and readmissions. Of the 6,841 patients identified, 1,877 (27.4 %) received a complete ALND. Overall, the ALND cohort demonstrated significantly more readmissions and reoperations, as well as longer operative times and fewer outpatient procedures. No difference was detected in postoperative complications between the two groups. However, after adjusting for potential confounders, ALND did not predict increased risk of 30-day morbidity or unplanned 30-day readmission compared with SLNB in patients undergoing partial mastectomy. After adjusting for potential confounders, ALND does not significantly increase the risk of 30-day postoperative overall morbidity or readmission compared with SLNB. Improvement of postoperative outcomes should focus on management of high-risk patients and perioperative complications regardless of surgical management of the axilla.

Relation Between Six-Minute Walk Test Performance and Outcomes After Transcatheter Aortic Valve Implantation (from the PARTNER Trial)

Functional capacity as assessed by 6-minute walk test distance (6MWTD) has been shown to predict outcomes in selected cohorts with cardiovascular disease. To evaluate the association between 6MWTD and outcomes after transcatheter aortic valve implantation (TAVI) among participants in the Placement of AoRTic TraNscathetER valve (PARTNER) trial, TAVI recipients (n = 484) were stratified into 3 groups according to baseline 6MWTD: unable to walk (n = 218), slow walkers (n = 133), in whom 6MWTD was below the median (128.5 meters), and fast walkers (n = 133) with 6MWTD >128.5 meters. After TAVI, among fast walkers, follow-up 6MWTD decreased by 44 ± 148 meters at 12 months (p <0.02 compared with baseline). In contrast, among slow walkers, 6MWTD improved after TAVI by 58 ± 126 meters (p <0.001 compared with baseline). Similarly, among those unable to walk, 6MWTD distance increased by 66 ± 109 meters (p <0.001 compared with baseline). There were no differences in 30-day outcomes among 6MWTD groups. At 2 years, the rate of death from any cause was 42.5% in those unable to walk, 31.2% in slow walkers, and 28.8% in fast walkers (p = 0.02), driven primarily by differences in noncardiac death. In conclusion, among high-risk older adults undergoing TAVI, baseline 6MWTD does not predict procedural outcomes but does predict long-term mortality. Nonetheless, patients with poor baseline functional status exhibit the greatest improvement in 6MWTD. Additional work is required to identify those with poor functional status who stand to benefit the most from TAVI.

No Major Differences in 30-Day Outcomes in High-Risk Patients Randomized to Off-Pump Versus On-Pump Coronary Bypass Surgery: The Best Bypass Surgery Trial

No Major Differences in 30-Day Outcomes in High-Risk Patients Randomized to Off-Pump Versus On-Pump Coronary Bypass Surgery: The Best Bypass Surgery Trial

No Major Differences in 30-Day Outcomes in High-Risk Patients Randomized to Off-Pump Versus On-Pump Coronary Bypass Surgery: The Best Bypass Surgery Trial

No Major Differences in 30-Day Outcomes in High-Risk Patients Randomized to Off-Pump Versus On-Pump Coronary Bypass Surgery: The Best Bypass Surgery Trial

Response to Letters Regarding Article, “No Major Differences in 30-Day Outcomes in High-Risk Patients Randomized to Off-Pump Versus On-Pump Coronary Bypass Surgery: The Best Bypass Surgery Trial”

Response to Letters Regarding Article, “No Major Differences in 30-Day Outcomes in High-Risk Patients Randomized to Off-Pump Versus On-Pump Coronary Bypass Surgery: The Best Bypass Surgery Trial”

Letter by Miceli et al Regarding Article, “No Major Differences in 30-Day Outcomes in High-Risk Patients Randomized to Off-Pump Versus On-Pump Coronary Bypass Surgery: The Best Bypass Surgery Trial”

HomeCirculationVol. 122, No. 17Letter by Miceli et al Regarding Article, “No Major Differences in 30-Day Outcomes in High-Risk Patients Randomized to Off-Pump Versus On-Pump Coronary Bypass Surgery: The Best Bypass Surgery Trial” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Miceli et al Regarding Article, “No Major Differences in 30-Day Outcomes in High-Risk Patients Randomized to Off-Pump Versus On-Pump Coronary Bypass Surgery: The Best Bypass Surgery Trial” Antonio Miceli, MD, Mattia Glauber, MD and Gianni D. Angelini, MD, MCh, FRCS Antonio MiceliAntonio Miceli Search for more papers by this author , Mattia GlauberMattia Glauber Search for more papers by this author and Gianni D. AngeliniGianni D. Angelini Search for more papers by this author Originally published26 Oct 2010https://doi.org/10.1161/CIRCULATIONAHA.110.944520Circulation. 2010;122:e497To the Editor:The results of the Best Bypass Surgery Trial (BBS), performed on 341 high-risk patients (European system for cardiac operative risk evaluation [EuroSCORE] >5) undergoing coronary artery bypass grafting with (on-pump coronary artery bypass graft surgery) or without (off-pump coronary artery bypass graft surgery) cardiopulmonary bypass, report no significant differences in the composite of adverse cardiac and cerebrovascular events or in any of the following outcomes: All-cause mortality, acute myocardial infarction, cardiac arrest, low cardiac output/cardiogenic shock, stroke, and coronary reintervention.1 However, in our opinion, the definition of high-risk patient should be interpreted carefully. Although the EuroSCORE identifies patients with a score >6 as high risk,2 the score is based on 18 independent variables, many of which were not considered in the study. Risk factors such as previous cardiac surgery, critical preoperative state, emergency operation, and poor left ventricular dysfunction were excluded. Furthermore, active endocarditis, pulmonary hypertension, other than isolated coronary artery bypass surgery, surgery on the thoracic aorta, and postinfarction septal rupture were not considered in the study because of the nature of the study. Chronic pulmonary disease and neurological dysfunction were not defined according to EuroSCORE, and there is no information on patients with unstable angina. Finally, it has been shown that the ability of the EuroSCORE to predict mortality is reduced in high-risk patients.3 Indeed, Puskas et al,4 using the Society of Thoracic Surgeons' predicted risk of mortality on 14 776 patients undergoing coronary surgery, showed that off-pump coronary artery bypass graft surgery disproportionately benefited high-risk patients.Antonio Miceli, MDMattia Glauber, MD Fondazione G. Monasterio CNR-Regione Toscana Massa, ItalyGianni D. Angelini, MD, MCh, FRCS Bristol Heart Institute University of Bristol Bristol, United KingdomDisclosuresNone.

Letter by Pocar et al Regarding Article, “No Major Differences in 30-Day Outcomes in High-Risk Patients Randomized to Off-Pump Versus On-Pump Coronary Bypass Surgery: The Best Bypass Surgery Trial”

To the Editor: We congratulate Moller et al for outlining no major differences in short-term outcomes after off-pump versus conventional coronary bypass surgery in patients with European System for Cardiac Operative Risk Evaluation (EuroSCORE) ≥5.1 Mean additive EuroSCORE was 6.9, but no patient with ejection fraction <30% was enrolled, suggesting the prevalence of extracardiac risk factors in determining a higher risk profile. Although the …

No Major Differences in 30-Day Outcomes in High-Risk Patients Randomized to Off-Pump Versus On-Pump Coronary Bypass Surgery

Off-pump coronary artery bypass grafting compared with coronary revascularization with cardiopulmonary bypass seems safe and results in about the same outcome in low-risk patients. Observational studies indicate that off-pump surgery may provide more benefit in high-risk patients. Our objective was to compare 30-day outcomes in high-risk patients randomized to coronary artery bypass grafting without or with cardiopulmonary bypass. We randomly assigned 341 patients with a EuroSCORE > or = 5 and 3-vessel coronary disease to undergo coronary artery bypass grafting without or with cardiopulmonary bypass. Patients were followed through the Danish National Patient Registry. The primary outcome was a composite of adverse cardiac and cerebrovascular events (ie, all-cause mortality, acute myocardial infarction, cardiac arrest with successful resuscitation, low cardiac output syndrome/cardiogenic shock, stroke, and coronary reintervention). An independent adjudication committee blinded to treatment allocation assessed the outcomes. Baseline characteristics were well balanced between groups. The mean number of grafts per patient did not differ significantly between groups (3.22 in off-pump group and 3.34 in on-pump group; P=0.11). Fewer grafts were performed to the lateral part of the left ventricle territory during off-pump surgery (0.97 versus 1.14 after on-pump surgery; P=0.01). No significant differences in the composite primary outcome (15% versus 17%; P=0.48) or the individual components were found at 30-day follow-up. Both off- and on-pump coronary artery bypass grafting can be performed in high-risk patients with low short-term complications. CLINICAL TRIAL REGISTRATION- clinicaltrials.gov. Identifier: NCT00120991.

Do outcomes differ after 3-Stage versus 2-Stage Ileal Pouch-Anal Anastomosis for chronic Ulcerative Colitis?

Given concerns of increased post-operative complications associated with anti-TNF-alpha antibody therapy, some surgeons are increasingly offering patients with chronic ulcerative colitis (CUC) a 3-stage approach to ileal pouch-anal anastomosis (IPAA). We aimed to assess outcomes after the 1st of 2-stages compared with the 2nd of 3-stages in a cohort of patients who underwent hand-assisted laparoscopic surgery (HALS). We identified all adult patients with CUC who underwent total proctocolectomy (TPC-IPAA, stage 1 of 2) and patients who underwent completion proctectomy (CP-IPAA, stage 2 of 3) at our institution from 2004 - 2009 using a prospectively maintained database. Univariate analysis assessed differences in 30-day outcomes after stage 1 of 2 as compared with stage 2 of 3. Data are frequency (proportion) or median. Over 5-years, 243 patients underwent HALS restorative proctocolectomy: TPC-IPAA (n= 212, 88%) or CP-IPAA (n= 30, 12%). At time of IPAA, patients in these two groups were not significantly different with respect to age, gender, BMI, medical comorbidities, and ASA classification. Two cases in TPC-IPAA had concurrent cancer, while none in the CP-IPAA did (p= 0.47). TPC-IPAA patients were less likely to have had prior abdominal (21% vs. 100%, p<0.0001) or intestinal surgery (1.4% vs. 100%, p<0.0001) compared to CP-IPAA. In regards to colitis medications, TPC-IPAA were more likely to be receiving 5-ASA (59% vs. 17%, p<0.0001), corticosteroids (75% vs. 23%, P<0.0001) or Immunomodulators (37% vs. 3.3%, p<0.0001); 13% of the TPCIPAA group, and none of the CP-IPAA group were receiving biologic therapy (p= 0.0006). In terms of severity of disease, according to the Montreal classification, TPC-IPAA had more severe disease than CP-IPAA (p<0.0001), while 23% and 13% were recently hospitalized (p= 0.2), 8% and 10% were recently transfused (p= 0.7), 12.8% and 30% were malnourished (p= 0.02), and 78.8% and 6.7% were had recently received either corticosteroids or biologic therapy (p<0.0001). In terms of surgical outcomes, 16 (7.5%) of TPC-IPAA were converted to laparotomy (most commonly for obesity, n= 4). Intra-operative complications occurred in TPC-IPAA was 8 (3.8%, most commonly for bleeding, n= 7), and after CP-IPAA none (0%, p= 0.14). TPC-IPAA had longer operative times (291 vs. 187, p<0.0001), and similar lengths of stay (5 vs. 5 days, p= 0.83) and readmissions (15.5% vs. 16.7%, p= 0.87). A total of 8% had re-operation after TPC-IPAA, and none after CP-IPAA (p= 0.03). Overall complications of any grade occurred in similar proportions (38% and 43%, p= 0.58). There were a total of 6 (2.8%) anastomotic leaks after TPC-IPAA, and none after CP-IPAA (p= 0.2). There were no mortalities in either group. Ileal pouch-anal anastomosis at the time of completion proctectomy, as compared with total proctocolectomy, is associated with shorter operative times, fewer intra-operative complications and reoperations, with similar rates of readmissions and overall complications. Further study in a larger cohort is needed to determine if a 3-stage approach to IPAA is associated with a lower anastomotic leak rate - the most important determinant of long-term pouch function and patient quality of life.