Differences In Perioperative Morbidity Research Articles

Application of bridging mesh repair in giant ventral incisional hernia.

Achieving ideal abdominal wall reconstruction in giant ventral incisional hernia has been a challenging for surgeons. This study aimed to verify the safety and efficacy of bridging repair by comparing it with primary fascial closure (PFC) repair in the treatment of giant ventral incisional hernia. We retrospectively analyzed the clinical data of 92 patients with giant ventral incisional hernia who underwent mesh repair at our medical institution from January 1, 2014 to December 31, 2020. Patients were divided into 2 groups: the bridging repair group with 40 patients in whom repair was completed using the bridging technique and the PFC group with 52 patients in whom primary fascial closure was achieved and all patients underwent mesh reinforcement during the operation. The main outcome measures were recurrence rate and morbidity, especially intra-abdominal hypertension (IAH). Follow-up time of both groups lasted at least 24months after surgery. After a median of 46months and 65months of follow-up, respectively, in the two groups, bridging repair did not increase the long-term recurrence rate (2.56%) in the larger defect area group compared to the PFC group (1.96%). There were no significant differences in perioperative morbidity, IAH, incidence of postoperative chronic pain, and sensory impairment of the abdominal wall between both groups. The application of bridging surgery in the treatment of complex giant ventral incisional hernias is safe and effective and does not significantly increase the postoperative recurrence rate.

So Now We Know—Reflections on the Extent of Resection for Stage I Lung Cancer

Lobectomy has been the standard treatment for stage I lung cancer in healthy patients, largely based on a randomized trial published in 1995. Nevertheless, research has continued regarding the role of sublobar resection. Three additional randomized trials addressing resection extent in healthy patients have recently been published. These 4 trials involve differences in design, eligibility, interventions, and intraoperative processes. Patients were ineligible if intraoperative assessment demonstrated stage > IA or inadequate resection margins. All trials consistently show no differences in perioperative morbidity, mortality, and postoperative changes in lung function between sublobar resection and lobectomy—consistent with other nonrandomized evidence. Long-term outcomes are generally encouraging of lesser resection, but some inconsistencies are apparent. The 2 larger recent trials demonstrated no overall survival difference while the others suggested better survival after lobectomy versus sublobar resection. Recurrence-free survival was found to be the same after lobectomy versus sublobar resection in 3 trials, despite higher locoregional recurrences after sublobar resection. The low 5-year recurrence-free survival (64%, regardless of resection extent) in 1 recent trial highlights the need for further optimization. Thus, there is high-level evidence that sublobar resection is a reasonable alternative to lobectomy in healthy patients. However, variability in long-term results suggests that aspects of patients, tumors and interventions need to be better understood. Therefore, we propose to apply sublobar resection cautiously; especially because there are no short-term benefits. Sublobar resection requires careful attention to intraoperative details (nodes, margins), and may be best suited for less aggressive (eg, ground glass, slow growing) tumors.

Perioperative outcome and long-term survival for intrahepatic cholangiocarcinoma after portal vein embolization and subsequent resection: A propensity-matched study

IntroductionIn view of the high therapeutic value of surgical resection for intrahepatic cholangiocarcinomas (ICC), our study addresses the question of clinical management and outcome in case of borderline resectability requiring hypertrophy induction of the future liver remnant prior to resection. MethodsClinical data was collected of all primary ICC cases receiving major liver resection with or without prior portal vein embolization (PVE) from a single high-volume center. PVE was performed via a percutaneous transhepatic access. Propensity score matching was performed. Perioperative morbidity was assessed as well as long-term survival with a minimum follow-up of 36 months. ResultsNo significant difference in perioperative morbidity was seen between the PVE and the control group. For the PVE group, median OS was 28 months vs. 37 months for the control group (p = 0.418), median DFS 18 and 14 months (p = 0.703). Disease progression during hypertrophy was observed in 38% of cases. Here, OS and DFS was reduced to 18 months (p = 0.479) and 6 months (p = 0.013), respectively. In case of positive N-status or multifocal tumor (MF+) OS was also reduced (18 vs. 26 months, p = 0.033; MF+: 9 vs. 36months p = 0.013). ConclusionOur results suggest that the surgical therapy in case of borderline resectability offers acceptable results with non-inferior OS rates compared to cases without preoperative hypertrophy induction and comparable oncological features. In the presence of additional risk factors (multifocal tumor, lymph node metastasis, PD during hypertrophy) the OS is notably reduced.

Colorectal Endoscopic Stenting Trial (CReST) for obstructing left-sided colorectal cancer: randomized clinical trial.

Colorectal cancer often presents with obstruction needing urgent, potentially life-saving decompression. The comparative efficacy and safety of endoluminal stenting versus emergency surgery as initial treatment for such patients is uncertain. Patients with left-sided colonic obstruction and radiological features of carcinoma were randomized to endoluminal stenting using a combined endoscopic/fluoroscopic technique followed by elective surgery 1-4 weeks later, or surgical decompression with or without tumour resection. Treatment allocation was via a central randomization service using a minimization procedure stratified by curative intent, primary tumour site, and severity score (Acute Physiology And Chronic Health Evaluation). Co-primary outcome measures were duration of hospital stay and 30-day mortality. Secondary outcomes were stoma formation, stenting completion and complication rates, perioperative morbidity, 6-month survival, 3-year recurrence, resource use, adherence to chemotherapy, and quality of life. Analyses were undertaken by intention to treat. Between 23 April 2009 and 22 December 2014, 245 patients from 39 hospitals were randomized. Stenting was attempted in 119 of 123 allocated patients (96.7 per cent), achieving relief of obstruction in 98 of 119 (82.4 per cent). For the 89 per cent treated with curative intent, there were no significant differences in 30-day postoperative mortality (3.6 per cent (4 of 110) versus 5.6 per cent (6 of 107); P = 0.48), or duration of hospital stay (median 19 (i.q.r. 11-34) versus 18 (10-28) days; P = 0.94) between stenting followed by delayed elective surgery and emergency surgery. Among patients undergoing potentially curative treatment, stoma formation occurred less frequently in those allocated to stenting than those allocated to immediate surgery (47 of 99 (47.5 per cent) versus 72 of 106 (67.9 per cent); P = 0.003). There were no significant differences in perioperative morbidity, critical care use, quality of life, 3-year recurrence or mortality between treatment groups. Stenting as a bridge to surgery reduces stoma formation without detrimental effects. Registration number: ISRCTN13846816 (http://www.controlled-trials.com).

Pancreaticoduodenectomy Is the Best Surgical Procedure for Zollinger-Ellison Syndrome Associated with Multiple Endocrine Neoplasia Type 1.

Simple SummaryApproximately 30% of patients with multiple endocrine neoplasia type 1 (MEN1) develop the Zollinger–Ellison syndrome (ZES), caused by solitary or multiple duodenal gastrinomas. Its management, especially regarding indication, timing, and type of surgery, is highly controversial. Therefore, the present study evaluated the long-term outcomes of pancreaticoduodenectomy (PD) versus non-PD resections in MEN1-ZES with regard to biochemical cure and quality of life. We found in a series of 35 patients that initial PD is the superior surgical procedure for MEN1-ZES, leading to long-term cure in about 80% of patients, fewer duodenopancreatic reoperations and an acceptable quality of life. Based on the results of this study, MEN1-ZES should be considered a surgically curable disease.Aim: The aim of this research was to evaluate the long-term outcome of pancreaticoduodenectomy (PD) versus other duodenopancreatic resections (non-PD) for the surgical treatment of the Zollinger–Ellison syndrome (ZES) in patients with multiple endocrine neoplasia type 1 (MEN1). Methods: Prospectively recorded patients with biochemically confirmed MEN1-ZES who underwent duodenopancreatic surgery were retrospectively analyzed in terms of clinical characteristics, complications, cure rate, and long-term morbidity, including quality of life assessment (EORTC QLQ-C30). Results: 35 patients (16 female, 19 male) with MEN1-ZES due to duodenopancreatic gastrinomas with a median age of 42 (range 30–74) years were included. At the time of diagnosis, 28 (80%) gastrinomas were malignant, but distant metastases were only present in one (3%) patient. Eleven patients (31.4%) underwent pancreatoduodenectomy (PD) as the initial procedure, whereas 24 patients underwent non-PD resections involving duodenotomy with gastrinoma excision, enucleation of the pNEN from the head of the pancreas, and peripancreatic lymphadenectomy, either with or without distal pancreatectomy (i.e., either Thompson procedure, n = 12, or DUODX, n = 12). There was no significant difference in perioperative morbidity and mortality between the two groups (p ≥ 0.05). One (9%) patient of the PD group required reoperation for recurrent or metastatic ZES compared to eight (22.8%) patients of the non-PD resection groups. After a median follow-up time of 134 months (range 6–480) nine of 11 (82%) patients in the PD group, two of 12 (16%) patients in the Thompson procedure group, and three of 12 (25%) patients in the DUODX group had normal serum gastrin levels. In addition, the global health QoLScore was better in the PD group (76.9) compared to the Thompson procedure (57.4) and DUODX (59.5) groups. Conclusions: Initial PD seems to be the superior surgical procedure for MEN1-ZES, resulting in a long-term cure rate of about 80%, fewer duodenopancreatic reoperations, and an acceptable quality of life.

Outcomes analysis of microsurgical physiologic lymphatic procedures for the upper extremity from the United States National Surgical Quality Improvement Program.

Physiologic microsurgical procedures to treat lymphedema include vascularized lymph node transfer (VLNT) and lymphovenous bypass (LVB). The purpose of this study was to assess 30-day outcomes of VLNT and LVB using the National Surgical Quality Improvement Program (NSQIP) database. NSQIP was queried (2012-2018) for lymphatic procedures for upper extremity lymphedema after mastectomy. Prophylactic lymphatic procedures and those for lower extremity lymphedema were excluded. Outcomes were assessed for three groups: LVB, VLNT, and patients who had procedures simultaneously (VLNA+LVB). Primary outcomes measured were operative time, 30-day morbidities, and hospital length of stay. The study included 199 patients who had LVB (n=43), VLNT (n=145), or VLNT+LVB (n=11). There was no difference in co-morbidities between the groups (p=0.26). 30-day complication rates including unplanned reoperation (6.9% VLNT vs. 2.3% LVB) and readmission (0.69% VLNT vs. none in LVB) were not statistically significant (p=0.54). Surgical site infection, wound complications, deep vein thromboembolism, and cardiac arrest was also similar among the three groups. Postoperative length of stay for VLNT (2.5 days± 2.3), LVB (1.9 days± 1.9), and VLNT+LVB (2.8 days± 0.3) did not differ significantly (p=0.20). Operative time for LVB (305.4min± 186.7), VLNT (254 min± 164.4), and VLNT+LVB (295.3min± 43.2) was not significantly different (p=0.21). Our analysis of the NSQIP data revealed that VLNT and LVB are procedures with no significant difference in perioperative morbidity. Our results support that choice of VLNT versus LVB can be justifiably made per the surgeon's preference and experience as the operations have similar complication rates.

Clinical Impact of Preoperative Relief of Jaundice Following Endoscopic Retrograde Cholangiopancreatography on Determining Optimal Timing of Laparoscopic Cholecystectomy in Patients with Cholangitis.

Background: About 10% of patients with gallbladder (GB) stones also have concurrent common bile duct (CBD) stones. Laparoscopic cholecystectomy (LC) after removal of CBD stones using endoscopic retrograde cholangiopancreatography (ERCP) is the most widely used method for treating coexisting gallbladder and common bile duct stones. We evaluated the optimal timing of LC after ERCP according to clinical factors, focusing on preoperative relief of jaundice. Methods: A total of 281 patients who underwent elective LC after ERCP because of choledocholithiasis and cholecystolithiasis from January 2010 to April 2018 were retrospectively reviewed. We compared the hospital stay, perioperative morbidity, and rate of surgical conversion to open cholecystectomy according to the relief of jaundice before surgery. These enrolled patients were divided into two groups: relief of jaundice before surgery (group 1, n = 125) or not (group 2, n = 156). Results: The initial total bilirubin level was higher in group 1; however, there were no significant differences in the other baseline characteristics including age, sex, American Society of Anesthesiologists score, previous surgical history, white blood cell count, C-reactive protein, and operative time between the two groups. There was also no significant difference in postoperative hospital stay between the two groups (4.5 ± 3.3 vs. 5.5 ± 5.6 days, p = 0.087). However, after ERCP, the waiting time until LC was significantly longer in group 1 (5.0 ± 4.9 vs. 3.5 ± 2.4 days, p < 0.001). There were no statistical differences in the conversion rate (3.2% vs. 3.8%, p = 0.518) or perioperative morbidity (4.0% vs. 5.8%, p = 0.348), either. Conclusions: LC would not be delayed until the relief of jaundice after ERCP since there were no significant differences in perioperative morbidity or surgical conversion rate to open cholecystectomy. Early LC after ERCP may be feasible and safe in patients with cholangitis and cholecystolithiasis.

Cytomegalovirus mismatch after heart transplantation: Impact of antiviral prophylaxis and intravenous hyperimmune globulin.

ObjectiveCytomegalovirus (CMV) infections are correlated with complications following heart transplantation (HTx) and impaired outcome. The impact of a serologic mismatch between donor and recipient and the necessity of prophylactic virostatic medication is still a matter of concern.MethodsWe retrospectively reviewed all patients that underwent HTx between 2010 and 2020 in our department. The recipients (n = 176) could be categorized into four risk groups depending on their serologic CMV matching (D+/R − = donor CMV‐IgG positive and recipient CMV‐IgG negative, n = 32; D − /R+, n = 51; D − /R − , n = 35; D+/R+, n = 58). All patients followed the same protocol of CMV prophylaxis with application of ganciclovir/valganciclovir and intravenous CMV hyperimmune globulin.RESULTSIncidence of postoperative morbidity such as primary graft dysfunction, neurological events, infections, and graft rejection were comparable between all groups (p > .05). However, the incidence of postoperative acute kidney injury with hemodialysis was by trend increased in the D−/R+ group (72.0%) compared to the other groups. In‐hospital CMV‐DNAemia was observed in serologic positive recipients only (D+/R−: 0.0%, D−/R+: 25.0%, D−/R−: 0.0%, D+/R+: 13.3%, p < .01). During the first year, a total of 18 patients developed CMV‐DNAemia (D+/R−: 31.6%, D−/R+: 31.9%, D−/R−: 3.4%, D+/R+: 11.1%, p = .03).ConclusionsSeropositive recipients carry an important risk for CMV‐DNAemia. However, we did not observe differences in perioperative morbidity and mortality regarding CMV matching, which might be related to regularly administer prophylactic virostatics and additional CMV‐IVIG for risk constellations. For high‐risk constellation, long‐term application of CMV‐IVIG during the first year after transplant may be beneficial.

Impact of Cytomegalovirus Mismatch on Outcome after Heart Transplantation

Purpose Cytomegalovirus (CMV) is correlated with a number of complications following heart transplantation (HTx). The impact of a serologic mismatch between donor and recipient is still controversially discussed. Especially the necessity of prophylactic virostatic medication is a matter of concern. Therefore, we aimed to analyse the impact of preoperative CMV matching on perioperative morbidity and mortality after HTx. Methods We retrospectively reviewed all 178 patients, which underwent HTx between 2010 and 2020 in our department. Patients were divided with regard to their pretransplant CMV matching. The recipients could be categorized into 4 groups depending on their serologic CMV matching (Group 1: donor and recipient CMV-IgG positive (=D+/R+), n=52; Group 2: (D+/R-), n=31; Group 3: (D-/R+), n=49; Group 4: (D-/R-), n=34). The remaining patients were excluded due to missing information about the donors CMV status. Patients and donors were comparable concerning co-morbidities and risk factors for impaired posttransplant outcome. Results Incidence of primary graft dysfunction (PGD), perioperative neurological events, bleeding complications, severe infections and early graft rejection (>1R) were comparable between all groups (p>0.05). In contrast, the incidence of postoperative acute kidney injury with need for hemodialysis was significantly increased in Group 3 (73.9%) compared to the other groups (57.7% in Group 1, 40.0% in Group 2 and 52.9% in Group 4, p=0.03). Posttransplant CMV viremia was observed in serologic positive recipients only (Group 1: 13.3%, Group 2: 0.0%, Group 3: 25.0%, Group 4: 0.0%, p Conclusion Except for kidney function, we did not observe any differences in perioperative morbidity and mortality regarding CMV matching in our cohort. Seropositive recipients carry the most important risk factor of posttransplant CMV viremia. In contrast, the so-called “high-risk” CMV configuration (D+/R-) showed no impairments of postoperative outcome compared to “low-risk” (D-/R-), which may be related to positive effects of regularly administered prophylactic virostatic medication in the “high-risk” cohort.

Complications and Month of Surgery: Does Scheduling Make a Difference?

Objective: This study evaluated if there were differences in perioperative morbidity associated with elective surgery based on the month in which surgery was performed. An electronic medical record...

Racial disparities in surgical outcomes of patients undergoing debulking surgery for ovarian cancer

Objective: While racial disparities in ovarian cancer survival have been well documented, disparities in short-term outcomes are less studied. We aimed to identify racial differences in perioperative morbidity among white and black women following debulking surgery for ovarian cancer.

Technical Report and Surgical Outcomes of Needlescopic Totally Extraperitoneal Inguinal Hernia Repair: A Single-center, Retrospective Cohort Study.

Technical difficulties in totally extraperitoneal inguinal hernia repair (TEP) may be strongly associated with poor operability in a limited operative field. Needlescopic instruments could be helpful in a limited space, and the aim of this study was to evaluate the clinical efficacy of needlescopic TEP. The study population constituted 150 consecutive patients undergoing needlescopic TEP, and we compared these patients with 151 consecutive patients who underwent conventional TEP regarding patients' demographic features and operative outcomes. Inclusion criteria were: (1) being treated by an experienced surgeon and (2) replying to our questionnaire regarding postoperative outcomes. The mean skin opening to closing times for unilateral and bilateral repairs were, respectively, 95.3±30.1 and 130.2±48.7 minutes for conventional TEP and 75.7±24.5 and 114.5±46.3 minutes for needlescopic TEP. The difference for unilateral repairs between the 2 surgical groups was significant (P=0.01). Conversion rates, postoperative hospital stays, and perioperative morbidity rates showed no significant differences between the 2 groups. Needlescopic TEP is a useful procedure that decreases operative duration with no significant differences in perioperative morbidity compared with conventional TEP.

Operative Results and Perioperative Morbidity After Intensified Neoadjuvant Chemotherapy with FLOT for Gastroesophageal Adenocarcinoma Impact of Intensified Neoadjuvant Treatment

BackgroundPerioperative treatment is the standard of care in Western Europe for locally advanced gastric cancer (GC) and adenocarcinoma of the gastroesophageal junction (GEJ). Intensified neoadjuvant treatment within the NeoFLOT trial proved to be safe and effective. Yet, the influence of such intensification with 6 cycles of FLOT in the neoadjuvant setting has not been analyzed regarding its possible impact on perioperative results. Materials and MethodsA total of 537 patients were enrolled in this study; of whom, 132 had followed a standard neoadjuvant protocol (CTx), 356 had not received any neoadjuvant treatment (NoCTx), and 49 patients had undergone an intensified chemotherapy within the NeoFLOT trial (IntCTx) with 6 cycles of FLOT (5-FU, leucovorin, oxaliplatin, docetaxel) every 2 weeks. ResultsOur results reveal no significant difference in perioperative morbidity or mortality with regard to the neoadjuvant treatment. Postoperative bleeding and hematoma occurred less frequently in the IntCTx group compared to the NoCTx and the CTx groups (2.0% vs. 5.33% vs. 5.1%). Postoperative lymph fistulas were slightly more frequent in the IntCTx group (4.1% vs. 0.3% vs. 1.6%). Patients treated within the NeoFLOT trial had a higher risk for blood transfusions (OR 5.5; 95%-KI, 2.49–12.19), whereas patients without neoadjuvant therapy had the longest ICU stay (mean 8.3 vs. CTx 4.5 vs. IntCTx 6.7 days). ConclusionThe results of the current study indicate that also an intensification of neoadjuvant chemotherapy with 6 preoperative cycles of FLOT does not significantly increase perioperative complications. Thus, prolonged neoadjuvant chemotherapy with FLOT is safe for patients with locally advanced GC or GEJ tumors.

En bloc resection for nonmuscle invasive bladder cancer: review of the recent literature.

Conventional transurethral resection of bladder tumor (cTURBT) is the standard approach to the diagnosis and treatment of nonmuscle invasive bladder cancer. However, it suffers from inherent limitations such as insufficient assessment of resection depth and the need for intravesical tumor fragmentation that hampers histopathological evaluation. We summarize recent clinical data on en bloc resection of bladder tumor (ERBT), a method that promises to overcome these limitations. The PubMed/Medline databases were searched for reports on ERBT focusing on trends in the last 2 years. ERBT provides greater resection quality, making up to 95% of detrusor muscle available for pathological evaluation. ERBT also allows detection of the muscularis mucosae thus facilitating T1 substaging. Available data demonstrate no significant difference in perioperative morbidity. No conclusions can be drawn on the impact of either modality on tumor recurrence and progression, as the available data is too underpowered. ERBT is gaining acceptances as there is increasing evidence that it improves the quality of resected specimens. There seems to be no difference in perioperative morbidity between ERBT and cTURBT. The impact of ERBT on important endpoints such as recurrence and progression remains to be fully elucidated in further studies.

Revision of Pancreatic Neck Margins Based on Intraoperative Frozen Section Analysis Is Associated With Improved Survival in Patients Undergoing Pancreatectomy for Ductal Adenocarcinoma.

To test the hypothesis that complete, tumor-free resection at the pancreatic neck, achieved either en-bloc or non-en-bloc (ie, revision based on intraoperative frozen section [FS] analysis), is associated with improved survival as compared with incomplete resection (IR) in pancreatic ductal adenocarcinoma. Given the likely systemic nature of pancreatic ductal adenocarcinoma, the oncologic benefit of achieving a histologically complete local resection, particularly through revision of a positive intraoperative FS at the pancreatic neck, remains controversial. Clinicopathologic and treatment data were reviewed for 986 consecutive patients with ductal adenocarcinoma at the head, neck, or uncinate process of the pancreas who underwent open pancreatectomy as well as intraoperative FS analysis between 1998 and 2012 at Massachusetts General Hospital and between 1998 and 2013 at the University of Verona. Overall survival (OS) and perioperative morbidity and mortality were compared across 3 groups: complete resection achieved en-bloc (CR-EB), complete resection achieved non-en-bloc (CR-NEB), and IR. The CR-EB cohort comprised 749 (76%) patients, CR-NEB 159 patients (16%), and IR 78 patients (8%). Other than a higher incidence of vascular resection among CR-NEB and IR patients, no demographic, pathologic (eg, tumor grade, lymph node positivity, superior mesenteric artery involvement), or treatment factors (eg, neoadjuvant and adjuvant therapy use) differed between the groups. Median OS was significantly higher in patients with CR-EB (28 mo, P = 0.01) and CR-NEB resections (24 mo, P = 0.02) as compared with patients with IR resections (19 mo). After adjusting for clinicopathologic and treatment characteristics, CR-EB and CR-NEB margin status were found to be independent predictors of improved OS (relative to IR, CR-EB hazard ratio [HR] 0.65, 95% confidence interval [CI] 0.49-0.86; CR-NEB HR 0.69, 95% CI 0.50-0.96). There were no intergroup differences in perioperative morbidity and mortality, including rates of pancreatic fistula. For patients with ductal adenocarcinoma at the head, neck, or uncinate process of the pancreas undergoing pancreatectomy, complete tumor extirpation via either en-bloc or non-en-bloc complete resection based on FS analysis is associated with improved OS, without an associated increased perioperative morbidity or mortality.

Caring for Patients With Uterine Cancer in Rural and Public Hospitals in New York State.

To evaluate perioperative outcomes for women with uterine cancer undergoing hysterectomy at rural and public hospitals in New York State. The New York Statewide Planning And Research Cooperative System database was used to identify women with uterine cancer who underwent hysterectomy from 2000 to 2015. Perioperative complications, inpatient mortality, and resource utilization were compared at rural, public and private hospitals. Multilevel mixed effect log-linear models were developed to evaluate the association between hospital type and outcomes of interest. Patient characteristics, hospital and surgeon clustering were accounted for within the model. Over the years studied, there were 193 hospitals that cared for 46,298 women with uterine cancer. Of these, 9.8% were public, 15.0% were rural, and 75.1% were private metropolitan. They cared for 11.0%, 2.2% and 86.8% of patients, respectively. The proportion of patients cared for at rural hospitals decreased significantly from 5.2% in 2000 to 0.6% in 2014 (P<.001). There was no change in the volume of patients cared for at public hospitals (11.3 to 10.3%, P>.05). In a multivariable model adjusting for patient risk, there were no significant differences in perioperative morbidity, transfusion and length of stay across the three hospital types (P>.05). Compared with private hospitals, treatment at a rural hospital was associated with increased inpatient mortality (adjusted risk ratio 4.03, 95% CI 1.02-15.97). In New York State, operative uterine cancer care is shifting away from rural hospitals. Public hospitals have similar risk-adjusted outcomes compared with private metropolitan facilities.

Clinical Course in Chronic Subdural Hematoma Patients Aged 18-49 Compared to Patients 50 Years and Above: A Multicenter Study and Meta-Analysis.

Objective: Chronic Subdural Hematoma (cSDH) is primarily a disease of elderly, and is rare in patients <50 years, and this may in part be related to the increased brain atrophy from 50 years of age. This fact may also influence clinical presentation and outcome. The aim of this study was to study the clinical course with emphasis on clinical presentation of cSDH patients in the young (<50 years).Methods: A retrospective review of a population-based cohort of 1,252 patients operated for cSDH from three Scandinavian neurosurgical centers was conducted. The primary end-point was difference in clinical presentation between the patients <50 y/o and the remaining patients (≥50 y/o group). The secondary end-points were differences in perioperative morbidity, recurrence and mortality between the two groups. In addition, a meta-analysis was performed comparing clinical patterns of cSDH in the two age groups.Results: Fifty-two patients (4.2%) were younger than 50 years. Younger patients were more likely to present with headache (86.5% vs. 37.9%, p < 0.001) and vomiting (25% vs. 5.2%, p < 0.001) than the patients ≥50 y/o, while the ≥50 y/o group more often presented with limb weakness (17.3% vs. 44.8%, p < 0.001), speech impairment (5.8% vs. 26.2%, p = 0.001) and gait disturbance or falls (23.1% vs. 50.7%, p < 0.001). There was no difference between the two groups in recurrence, overall complication rate and mortality within 90 days. Our meta-analysis confirmed that younger patients are more likely to present with headache (p = 0.015) while the hemispheric symptoms are more likely in patients ≥50 y/o (p < 0.001).Conclusion: Younger patients with cSDH present more often with signs of increased intracranial pressure, while those ≥50 y/o more often present with hemispheric symptoms. No difference exists between the two groups in terms of recurrence, morbidity, and short-term mortality. Knowledge of variations in clinical presentation is important for correct and timely diagnosis in younger cSDH patients.

Surgical outcomes in octogenarians with left-sided pancreatic ductal adenocarcinoma: a multi-institutional analysis

Background: Surgical resection for pancreatic ductal adenocarcinoma of the neck, body and tail (PDAC-NBT) accounts for 11.5% of all pancreatectomies. Of those, only 20% are performed on patients older than 80 years. This study characterizes this extremely small population of octogenarian patients with left-sided PDAC to establish their unique clinicopathologic, surgical, and treatment outcomes. Methods: Patients at five high-volume pancreatic centers with PDAC-NBT who underwent surgical resection with curative intent were retrospectively analyzed. Clinical, radiographic, pathologic, and treatment outcomes for the octogenarian cohort were compared to those of younger patients. Results: 370 patients were surgically treated between 2001 and 2016. Of those, 44 patients were greater than or equal to 81 years of age at diagnosis. Compared to patients aged less than 61 (n = 87), octogenarians exhibited no differences in presentation symptoms but exhibited significantly lower BMI (24.4 vs 29.2, p < 0.0001). Clinical characteristics were similar except that octogenarians presented with smaller tumors (3.4 cm vs 5.1 cm, p = 0.016) and were more likely to have elevated CA 19-9 (88% vs 52.9%, p = 0.020). The use of neoadjuvant therapy was similar between all age groups, but adjuvant chemotherapy was significantly under-utilized in octogenarians (36.6% vs 80.5%, p < 0.00001). Surgically, octogenarians had significantly shorter operative time (247 vs 300 minutes, p = 0.04), had fewer lymph nodes recovered (14.3 vs 22.2, p = 0.03) and were more likely to undergo a non-R0 resections (38.5% vs 18.5%, p = 0.02). Postoperatively, there were no differences in blood transfusions, complications, pancreatic fistulas, or hospital length of stay. Pathologically, no differences were found between tumor stage, lymph node ratio, perineural or lymphovascular invasion. Likewise, there were no significant survival differences attributable to age. Conclusion: Octogenarians with PDAC-NBT have significant differences in surgical and medical treatment metrics, including lower rates of R0 resection and adjuvant therapy. Despite this, there were no overall differences in perioperative morbidity, mortality, or survival. These data suggest that resection should be pursued in the appropriately selected octogenarian as outcomes are not associated with age-related clinicopathologic factors.

Safety of minimally invasive liver resections during live surgery: a propensity score based assessment

BackgroundConcerns regarding safety and outcomes of procedures performed during live events have been raised in the literature. Aim of the present investigation was to analyze the outcomes of laparoscopic liver resections performed during live events and conventional elective procedures. Methods60 laparoscopic liver resections performed during live events (Live group) were compared with 180 performed during conventional elective procedures (Control group) after propensity scores matching. The main endpoints were intraoperative and short-term postoperative outcomes. ResultsLive and Control group had comparable blood loss (300 vs 350 mL, p NS) and conversion rate (13.3% vs 14.4%, p NS), despite longer operation time for patients in the Live Group (280 ± 30 vs 210 ± 20 min, p = 0.032). There were no differences in perioperative morbidity and mortality: severe complications respectively occurred in 2 patients of the Live and in 7 patients of the Control group (p NS) with none directly related to intraoperative accidents. ConclusionsIn the setting of laparoscopic liver resections, live surgery does not negatively affect intra- and postoperative outcomes of patients if performed by expert surgeons: the creation of a specific expertise for the new generations of laparoscopic liver surgeons can be therefore pursued maintaining the primary endpoint of safety and oncological adequacy of procedures.

Laparoscopic versus open splenectomy for splenomegaly: the verdict is unclear.

The benefits of laparoscopic splenectomy (LS) over open splenectomy (OS) for normal-sized spleens have been well documented. However, the role of laparoscopy for moderate and massive splenomegaly is debated. A retrospective review of patients undergoing elective splenectomy at one institution from 1997 to 2017 was conducted. Moderate and massive splenomegaly was defined as splenic weight of 500-1000g and greater than 1000g, respectively. We performed a 1:2 matching of laparoscopic to open splenectomy to control for differences in splenic weight. Differences in perioperative morbidity (infection, thromboembolism, reoperation, readmission), intraoperative factors (blood loss, operative time), length of stay, and mortality were examined. A total of 491 elective splenectomies were identified. 268 cases were for splenic weights greater than 500g. After a 1:2 matching of LS:OS, we identified 22 LS and 44 matched OS for moderate splenomegaly. The LS group had longer mean operative times (178 vs. 107min, p < 0.01), with similar length of stay and blood loss. For massive splenomegaly, 26 LS were identified and matched to 52 OS. LS had longer mean operative times (171 vs. 112min, p < 0.01) and higher readmission rates (27% vs. 6%, p < 0.05). Other factors and outcomes did not differ between LS and OS for moderate or massive splenomegaly. The conversion rate for LS was higher for massive versus moderate splenomegaly, but was not statistically significant (35% vs. 14%, p = 0.09). LS for moderate and massive splenomegaly is associated with longer operative times. Other perioperative outcomes were comparable to OS, with no demonstrated benefits for LS. Although LS may be a feasible approach to moderate and massive splenomegaly, its benefits require further clarification in this patient population.