Difference In Postoperative Mortality Research Articles

Single-stage versus two-stage surgery of pulmonary and hepatic hydatid cysts

IntroductionConcomitant lung and liver hydatid cyst is a rare condition. Most surgeons agree that both sites should be resected in one-time surgery.AimWe present a case series of hepatic and pulmonary hydatid cyst treated in one-stage surgery (OSS) compared with patients who underwent two-stage surgery (TSS).Material and methodsThis retrospective study included 47 patients separated into two groups (33 TSS and 14 OSS) between 2008 and 2019. Data on clinical symptoms, sites, radiological features, techniques, postoperative complications, mean hospital stay and outcome were analyzed separately for TSS and OSS procedures.ResultsA total of 33 patients who underwent TSS (70.2%) were compared to 14 patients operated on by OSS (29.8%). No significant differences were found between groups for age (45.3 vs. 42.7, p = 0.45), sex (male: 57.6% vs. 64.2%) and socio-geographic status (urban: 72.7% vs. 78.6%). But there were more postoperative complications (24.3% vs. 14.3%, p = 0.036) in the TSS group, and operative duration (154 minutes vs. 122 minutes, p = 0.047), postoperative hospital stay (13.8 days vs. 8.7 days, p = 0.022), and interruption of activities and work (56 days vs. 31 days, p = 0.045) were longer in the TSS group. There was no difference in postoperative mortality between the 2 groups.ConclusionsSingle-stage surgical management by trans-thoraco-phrenotomy can be recommended to treat dual-seat hepatic and pulmonary hydatid disease with fewer complications and a rapid return to work. This technique is easier and safer for right lung and liver dome hydatid cysts.

Association Between Perioperative Glycemic Control Strategy and Mortality in Patients With Diabetes Undergoing Cardiac Surgery: A Systematic Review and Meta-Analysis.

ObjectiveTo analyze association between different perioperative glycemic control strategies and postoperative outcomes in patients with diabetes undergoing cardiac surgery.MethodsMEDLINE, Cochrane Library, Web of Science, EMBASE, Wanfang Data, China National Knowledge Infrastructure (CNKI) and China Biology Medicine (CBM) databases were searched from inception to January 31, 2019. Two researchers independently screened the literature, extracted data, and evaluated the risk of bias of included studies, and consensus was reached by discussion with a third researcher.ResultsSix RCTs were included in the meta-analysis. We analyzed the effect of liberal (>180 mg/dl or 10.0 mmol/L), moderate (140–180 mg/dl or 7.8–10.0 mmol/L) and strict (<140 mg/dl or 7.8 mmol/L) glycemic control strategies in patients with diabetes undergoing cardiac surgery. The pooled results showed that strict glycemic control strategy was associated with a significant reduction in the risk of atrial fibrillation [OR = 0.48, 95%CI (0.32, 0.72), P < 0.001] and sternal wound infection [OR = 0.28, 95%CI (0.14, 0.54), P < 0.001], while there was no significant differences in postoperative mortality, stroke, and hypoglycemic episodes when compared with moderate control. In addition, there is no significant difference between moderate and liberal glycemic control strategies in postoperative mortality. However, moderate control was beneficial in reducing atrial fibrillation [OR = 0.28, 95%CI (0.13, 0.60), P = 0.001] compared with the liberal glycemic control strategy.ConclusionsThis meta-analysis showed when compared with moderate glycemic control strategy in patients with diabetes undergoing cardiac surgery, maintained strict glycemic control was associated with lower risk of atrial fibrillation and sternal wound infection. No benefit was found with liberal glycemic control strategy, so it could be a poor glycemic control strategy.

Limited Lymph Node Resection Does Not Decrease Postoperative Mortality After Esophagectomy in Octogenarians With Thoracic Esophageal Cancer

BackgroundOctogenarians with esophageal cancer typically have a poor physical condition, reduced physiological reserves, and high postoperative mortality (POM). Extensive lymph node dissection increases surgical trauma and postoperative complications. The purpose of this study was to examine the associations between the number of dissected lymph nodes and short-term and long-term postoperative outcomes in octogenarians with thoracic esophageal cancer. MethodsWe examined the data of patients from the Surveillance, Epidemiology, and End Results database. We divided the patients into two groups in accordance with the number of lymph nodes dissected: patients with <15 examined lymph nodes (eLNs) and patients with ≥15 eLNs. Mortality was quantified at 30, 60, and 90 d after surgery. Univariable and multivariable logistic regression analyses were performed to identify predictors of 90-day mortality. Kaplan–Meier analysis and the log-rank test were used to analyze the overall survival and cause-specific survival of the patients. ResultsA total of 208 octogenarians with thoracic esophageal cancer were included in the analysis. The 30-day POM rates were 10.3% and 6.9%, the 60-day POM rates were 16.9% and 13.9%, and the 90-day POM rates were 21.3% and 19.4% for patients with <15 eLNs and ≥15 eLNs, respectively. However, the differences in POM between the two groups were statistically nonsignificant (all P > 0.05). In accordance with the multivariable logistic regression analysis, age and marital status were significantly associated with 90-day POM. Furthermore, no significant difference was found between the groups in terms of long-term survival. The 5-year overall survival rates were 29% and 26.8% (P = 0.719) and the 5-year cause-specific survival rates were 43.2% and 34.1% (P = 0.446) in patients with <15 eLNs and ≥15 eLNs, respectively. ConclusionsWe have demonstrated that octogenarians undergoing esophagectomy are associated with an unacceptably high POM, and less extensive lymph node resection does not decrease POM. Octogenarians may not benefit from esophagectomy with lymphadenectomy. Additional studies need to be conducted to further guide clinicians performing highly selective esophagectomy.

Short-Term Risk of Bilateral Internal Mammary Artery Grafting in Diabetic Patients

This study compares the morbidity and mortality at 30 days following the use of bilateral internal mammary arteries (BIMA) vs a single internal mammary artery (SIMA) at the time of coronary artery bypass grafting (CABG) in patients with a preoperative HbA1c. Patients undergoing CABG from January 2008 to December 2016 reported to the Society of Thoracic Surgeons database were retrospectively reviewed. The patients were divided into 2 groups: use of BIMA or use of SIMA and propensity matched. To assess the effect of preoperative HbA1c, both groups were further divided into 5 subgroups: patients without diabetes mellitus (DM), or patients with DM and a preoperative HbA1c level in one of four groups (< 7%, 7-9%, 9-11%, or >11%). The postoperative outcomes in both the BIMA and SIMA groups were compared. There were 700,504 and 28,115 patients with measured preoperative HbA1c levels in the SIMA and BIMA groups, respectively. Propensity score matching identified 23,635 comparable patients in each group for analysis. There was no difference in postoperative mortality between the BIMA and SIMA groups (1.3% vs 1.2%). The incidences of sternal wound infection (SWI) in patients undergoing placement of BIMA vs SIMA were: 0.8% vs 0.4% with no DM (P < 0.0001), 1.9% vs 1.0% with HbA1c < 7% (P < 0.001), 2.4% vs 1.2% with HbA1c 7-9% (P < 0.001), 2.8% vs 1.4% with HbA1c 9-11% (P = 0.02), 4.1% vs 1.5% with HbA1c > 11% (P = 0.01). Based on the incidence of SWI, BIMA is a reasonable approach with an HbA1c<7%.

Laparoscopic hepatectomy is safe and effective for the management of patients with colorectal cancer liver metastases in a population-based analysis in Ontario, Canada. A retrospective cohort study.

Laparoscopic hepatectomy (LH) has been deemed safe, and, in the case of minor hepatectomy, the standard of care. Short-, long-term outcomes and costs of LH compared with open hepatectomy (OH) in patients with colorectal cancer liver metastases have not been well described at the population level. Patients diagnosed with colorectal cancer undergoing hepatectomy were included in this population-based retrospective cohort study from 2006- to 2014. Postoperative complications (per Clavien-Dindo) and survival were analyzed using a linear mixed model and Cox-Proportional hazards model respectively. Costs of surgery and the 90-day postoperative period were considered in 2018 Canadian dollars and compared from the perspective of a third-party payer. Over a median follow-up of 56 months, 95% confidence interval (CI): 51 to 68), there were 2991 hepatectomies (OH: 2551 (85%) and LH: 440 (15%)). LH compared to OH was more common for patients >70 years-old (30% vs. 22%, p=0.004) and for minor hepatectomy (52% vs. 32%, p<0.001) respectively. By multivariable analyses, OH was associated with similar 90-day mortality (Odds Ratio (OR) 1.05, 95% CI: 0.56-1.97), and overall survival (Hazard Ratio (HR) 1.08, 95% CI: 0.90-1.29), but higher rates of major postoperative complications (OR 1.34, 95% CI: 1.03-1.76), higher cost (median difference $6,163, 95% CI: $3229 to $9096), and longer length of hospital stay (LOS) (mean difference 3.04 days, 95% CI: 2.7 to 3.91). LH was associated with lower postoperative complications, shorter LOS, which translated into lower costs to the healthcare system, without differences in postoperative mortality and survival.

Long-term Outcomes After Reoperative Coronary Artery Bypass Grafting

Reoperative coronary artery bypass grafting (CABG) surgery has an established increasedoperative risk with worse perioperative morbidity and mortality. However, contemporary propensity-matched outcomes are limited in the existing literature. All patients who underwent CABG from 2011 to 2017 at the University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania were included. Propensity matching yielded risk-adjusted patient populations. Cox regression analysis was performed to identify independent predictors of 30-day, 1-year, and 5-year mortality and readmission. The total population consisted of 7615 patients who underwent CABG; 7265 of these patients had first-time CABG, and 350 patients had reoperative CABG. After propensity score matching, blood product transfusion (45.5% vs 56.4%; P= .002) and delayed sternal closure (0.2% vs 2.5%; P < .001) remained significantly higher for reoperative CABG. There was no difference in 30-day (5.3% vs 7.5%; P= .19) or 1-year (12.1% vs 14.8%; P= .23) mortality for first-time vs reoperative CABG. Five-year mortality was significantly higher for the reoperative cohort (28.5% vs 38.3%; P= .03). There was no difference in 30-day, 1-year, or 5-year hospital readmissions. On Cox multivariable regression analysis, reoperative CABG was not a predictor of mortality or readmission at 30 days, 1 year, or 5 years. After propensity score matching, there was no difference in postoperative mortality or readmission for reoperative CABG up to 1-year. This trend continued for 5-year readmissions; however, 5-year mortality was higher for the reoperative cohort. Risk adjustment did not identify reoperative CABG as a risk factor for long-term mortality.

Fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery.

Fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery.

Hepatic Resection With Thrombectomy in the Treatment of Hepatocellular Carcinoma Associated With Macrovascular Invasion

IntroductionMacrovascular invasion (MVI) in patients with hepatocellular carcinoma (HCC) is a very poor prognostic factor. Treatment in such cases is still a matter of debate. The goal of this study is to assess short- and long-term results of liver resection and thrombectomy in a series of patients with HCC and MVI. MethodsRetrospective cohort study of patients who underwent liver resection for HCC in the period 2007–2015 (n = 120). Of all the patients, 108 did not have MVI, while 12 presented with MVI: 1 patient in the common portal vein (Vp4), 8 patients in first-order portal branches (Vp3), 1 patient in a sectorial branch (Vp2), 1 patient in a segmental branch (Vp1); another patient presented with tumor thrombus in a main hepatic venous branch in the confluence with the vena cava (Vv2). ResultsPatients with MVI needed major hepatic resection more frequently than patients without MVI (83.3% vs 25.9%, P < .0001), with no differences in postoperative mortality or severe morbidity. Patients with MVI required a longer operative time and developed more frequently postoperative ascites (33.3% vs 9.3%, P = .034).Global survival at 1, 3 and 5 years was 66.7%, 33.3% and 22.2% in patients with IMV, and 90.7%, 72.4% and 52.2% in patients without IMV (P = .009), respectively. ConclusionsHepatectomy associated with thrombectomy might be justified in a selected group of patients with HCC and MVI, offering a potential benefit in survival with acceptable morbidity.

Is mandatory routine caudate lobe resection indicated in hilar cholangiocarcinoma ?

Presenter: Lavanya Yohanathan MD | Mayo Clinic, Rochester Background: Necessity for routine resection of caudate lobe as part of liver resection in hilar cholangiocarcinoma (CCA) is controversial. The caudate lobe is an anatomic component of resectability where careful preoperative planning with assessment of imaging should factor into whether resection is indicated. We sought to evaluate if hepatectomy with caudate resection compared to those without caudate resection affected overall survival Methods: We reviewed data for all patients undergoing hilar cholangiocarcinoma (HCCA) resection between 1993-2017. Operative notes were reviewed to evaluate whether caudate lobe resection was undertaken. Extent of liver resection was recorded. Frozen section and final pathology status for was reviewed. Overall survival was the primary outcome. Progression free survival and recurrence pattern were secondary outcomes. Results: 178 patients underwent hepatic and bile duct resection with regional lymphadenectomy and Roux Y hepaticojejunostomy for HCCA. Of 178 patients, 100 (56%) patients underwent caudate resection (CR) whereas 78(44%) patients did not have their caudate lobes (NCR) resected. There was no significant difference in patient demographics or tumor characteristics. 88% of patients underwent a preoperative biopsy and the mean CA 19-9 level amongst both groups was 26.5 (17.7-38.2). Majority of these tumors were poorly differentiated (NCR:50%, CR:42.4%) followed by moderately differentiated (NCR, CR: 42.4%). Of 178 pts, 87 pts (48.9%) had a left hepatectomy, of which 81 pts had caudate lobe resection. 84 pts (47.2%) underwent a right hepatectomy ,4 pts (2.2%) had a right trisegmentectomy, of which 17 and 2 patients had their caudate lobe resected respectively. Liver margins were negative in 95% of pts in NCR group and 97% in the CR group (p=0.36). Lymph node metastases were present in 43% of pts in the NCR group and 32% in CR group (p=0.14). There was no significant difference in postoperative mortality (p=0.78). Higher rates of postoperative bile leak occurred in the NCR group 37.7% versus the CR group 21% (p=0.02) necessitating higher rates of percutaneous drain placement in the NCR group (36% vs.18%, p=0.005). Biliary fistula occurred in 17.6% of patients in NCR group compared to 7.2% in the CR group (p=0.11). Median overall survival was 28.4 and 44 months in the NCR and CR groups respectively (p=0.28). A higher proportion of patients in the NCR group received adjuvant chemotherapy (40%) and postoperative radiation (21%) when compared to CR group where 34% of pts received adjuvant chemotherapy and 13% postoperative radiation. Most frequent recurrence was within the liver and hepaticojejunostomy site. Peritoneal and extrahepatic recurrences were fewer. Intrahepatic recurrence occurred in 6/22(27%) in the NCR group and 18/35% (51%) in CR group (p=0.13). Median progression free survival was 19.8 and 33.7 months in the NCR and CR groups (p=0.34) Conclusion: Routine caudate lobe resection does not confer survival advantage in patients undergoing liver resection, regional lymphadenectomy and Roux Y reconstruction for hilar cholangiocarcinoma. Nodal status had no impact on survival related to CLR. The decision to resect caudate lobe should be based on radiological imaging, tumor characteristics, and pathologic evaluation with the ultimate goal of achieving a R0 resection.

O148 SHORT-TERM RESULTS OF A RANDOMIZED CONTROLLED TRIAL OF STANDARD VS. PROLONGED TIME TO SURGERY AFTER NEOADJUVANT CHEMORADIATION FOR CANCER

Abstract Aim The aim of this study was to clarify if prolonged time to surgery (TTS) improves postoperative outcomes in the curative intended treatment of an junctional cancer. Background &amp; Methods sophagectomy is conventionally performed 4-6 weeks after completed neoadjuvant chemoradiotherapy (nCRT). However, studies have shown that prolonged TTS might be favourable. A randomized multicentre clinical trial was performed with allocation to 4-6 or 10-12 weeks between finished nCRT and surgery. All patients received nCRT according to CROSS. Primary outcome of thstudy was postoperative. Smortality, need for intensive care, and length of hospital stay. Results The study randomized 248 patients, 202have to date undergone esophagectomy 98 patients were allocated to prolonged TTS, and the groups were well matched concerning baseline characteristics. Postoperative complications were reported in 106 patients (52.5%).There was no difference in postoperative Clavien-Dindo score.In the standardgroup 17 (16.4%) patients had anastomotic leak compared to 19 (19.4%) in the prolongedgroup (P=0.572). Conduit necrosis was reported in 9 (4.5%) patients, esophago-bronchial fistula in 1 (0.5%) patient,chyle leak in 5 (2.5%) neumoni in 54 (26.7%) patients and respiratory insufficiency in 36 (17.8%) patients without significant difference . In the standard group 5 (4.8%) patients had postoperative mortality due to a complication, compared to 2 (2.0%) patients in the prolonged group (P=0.446). Median length of hospital stay was 14 days in the standard group and 17.5 days in the prolonged group (P=0.040). Conclusion In this we found no significant differences in postoperative mortality comparing standard to prolonged TTS after nCRT. Although, an observandum is that the median length of hospital stay was significantly longer in the prolonged group. We need to compare response and survival to properly evaluate prolonged TTS, but these results suggest that timing is not cardinal in short-term postoperative outcomes.

Prospective randomized placebo-controlled double-blind clinical study of adjuvant dexamethasone with surgery for chronic subdural haematoma with post-operative subdural drainage: Interim analysis

Most chronic subdural haematomas (CSDH) are successfully treated neurosurgically. However, operative recurrences occur with a frequency 3–30%, consume resources and potentially prolong length-of stay (LOS). The only adjuvant factor proven to significantly decrease CSDH recurrence rate (RR) is post-operative subdural drainage. Corticosteroids have been used to conservatively manage CSDH. One non-randomised study also compared dexamethasone (DX) as an adjunct to surgery without post-operative drainage: whilst a null effect was observed, the ‘surgery-alone’ group consisted of only n = 13. We present an interim analysis of the first registered prospective randomised placebo-controlled trial (PRPCT) of adjuvant DX on RR and outcome after CSDH surgery with post-operative drainage. Participants were randomised to either placebo or a reducing DX regime over 2 weeks, with CSDH evacuation and post-operative drainage. Post-operative mortality (POMT) and RR were determined at 30 days and 6 months; modified Rankin Score (mRS) at discharge and 6 months. Post-operative morbidity (POMB) and adverse events (AEs) were determined at 30 days. Interim analysis at approximately 50% estimated sample size was performed (n = 47). Recurrences were not observed with DX: only with placebo (0/23 [0%] v 5/24 [20.83%], P = 0.049). There was no significant between-group differences in POMT, POMB, LOS, mRS or AEs. ConclusionsIn this first registered PRPCT, interim analysis suggested that adjuvant DX with post-operative drainage is both safe and may significantly decrease recurrences. A 12.5% point between-groups difference may be reasonable to power a final sample size of approximately n = 89. Future studies could consider adjuvant DX for longer than the arbitrarily-chosen 2 weeks.

Resección hepática con trombectomía en el tratamiento del carcinoma hepatocelular con invasión vascular macroscópica

IntroductionMacrovascular invasion (MVI) in patients with hepatocellular carcinoma (HCC) is a very poor prognostic factor. Treatment in such cases is still a matter of debate. The goal of this study is to assess short- and long-term results of liver resection and thrombectomy in a series of patients with HCC and MVI. MethodsRetrospective cohort study of patients who underwent liver resection for HCC in the period 2007-2015 (n=120). Of all the patients, 108 did not have MVI, while 12 presented with MVI: 1patient in the common portal vein (Vp4), 8patients in first-order portal branches (Vp3), 1patient in a sectorial branch (Vp2), 1patient in a segmental branch (Vp1); another patient presented with tumor thrombus in a main hepatic venous branch in the confluence with the vena cava (Vv2). ResultsPatients with MVI needed major hepatic resection more frequently than patients without MVI (83.3% vs 25.9%, P<.0001), with no differences in postoperative mortality or severe morbidity. Patients with MVI required a longer operative time and developed more frequently postoperative ascites (33.3% vs 9.3%, P=.034).Global survival at 1, 3 and 5years was 66.7%, 33.3% and 22.2% in patients with IMV, and 90.7%, 72.4% and 52.2% in patients without IMV (P=.009), respectively. ConclusionsHepatectomy associated with thrombectomy might be justified in a selected group of patients with HCC and MVI, offering a potential benefit in survival with acceptable morbidity.

The gap in postoperative outcome between older and younger patients with stage I-III colorectal cancer has been bridged; results from the Netherlands cancer registry

Aim of the studyPrevious studies have shown that older patients benefited less than younger patients from surgical treatment for colorectal cancer (CRC). However, CRC care has advanced over time, and it is time to assess whether the difference in postoperative mortality between older and younger CRC patients is still present. MethodsPatients with primary stage I-III CRC diagnosed between 2005 and 2016 were selected from the Netherlands Cancer Registry (N = 111,778). Trends in postoperative mortality and 1-year postoperative relative survival (RS) were analysed, stratified according to age (<75 versus ≥75 years) and tumour location (colon versus rectum). One-year postoperative RS was analysed to correct for background mortality in the older population. ResultsBetween 2005 and 2016, 30-day postoperative mortality showed a stronger decrease for older patients (from 10.0% to 4.0% for colon cancer [p < 0.001] and from 8.3% to 2.7% for rectal cancer [p < 0.001]) compared with younger patients (from 2.0% to 0.9% for colon cancer [p < 0.001] and from 1.4% to 0.7% for rectal cancer [p = 0.01]). Between 2005 and 2016, also 1-year RS increased more for older patients (from 84.8% to 94.6% for colon cancer and from 86.1% to 97.2% for rectal cancer) compared with younger patients (from 94.0% to 97.8% for colon cancer and from 96.3% to 98.8% for rectal cancer). ConclusionBetween 2005 and 2016, differences in postoperative mortality between older and younger CRC patients decreased. One-year postoperative RS was almost equal for older and younger patients in 2015–2016. This information is crucial for shared decision-making on surgical treatment.

The Effect of Vitamin C on Clinical Outcome in Critically Ill Patients: A Systematic Review With Meta-Analysis of Randomized Controlled Trials.

The effects of vitamin C administration on clinical outcome in critically ill patients remain controversial. Online databases were searched up to October 1, 2018. We included randomized controlled trials on the use of vitamin C (any regimen) in adult critically ill patients versus placebo or no therapy. Risk ratio for dichotomous outcome and standardized mean difference for continuous outcome with 95% CI were calculated using random-effects model meta-analysis. Forty-four randomized studies, 16 performed in ICU setting (2,857 patients) and 28 in cardiac surgery (3,598 patients), published between 1995 and 2018, were included in the analysis. In ICU patients, vitamin C administration was not associated with a difference in mortality (risk ratio, 0.90; 95% CI, 0.74-1.10; p = 0.31), acute kidney injury, ICU or hospital length of stay compared with control. In cardiac surgery, vitamin C was associated to a reduction in postoperative atrial fibrillation (risk ratio, 0.64; 95% CI, 0.52-0.78; p < 0.0001), ICU stay (standardized mean difference, -0.28 d; 95% CI, -0.43 to -0.13 d; p = 0.0003), and hospital stay (standardized mean difference, -0.30 d; 95% CI, -0.49 to -0.10 d; p = 0.002). Furthermore, no differences in postoperative mortality, acute kidney injury, stroke, and ventricular arrhythmia were found. In a mixed population of ICU patients, vitamin C administration is associated with no significant effect on survival, length of ICU or hospital stay. In cardiac surgery, beneficial effects on postoperative atrial fibrillation, ICU or hospital length of stay remain unclear. However, the quality and quantity of evidence is still insufficient to draw firm conclusions, not supporting neither discouraging the systematic administration of vitamin C in these populations. Vitamin C remains an attractive intervention for future investigations aimed to improve clinical outcome.

Association of a Home Monitoring Program With Interstage and Stage 2 Outcomes.

BackgroundIn shunt‐dependent, single‐ventricle patients, mortality remains high in the interstage period between discharge after neonatal surgery and stage 2 operation. We sought to evaluate the impact of our infant single‐ventricle management and monitoring program (ISVMP) on interstage mortality and stage 2 outcomes.Methods and ResultsThis retrospective single‐center cohort study compared patients enrolled in ISVMP at hospital discharge with historical controls. The relationship of ISVMP to interstage mortality was determined with a bivariate probit model for the joint modeling of both groups, using an instrumental variables approach. We included 166 ISVMP participants (December 1, 2010, to June 30, 2015) and 168 controls (January 1, 2007, to November 30, 2010). The groups did not differ by anatomy, gender, race, or genetic syndrome. Mortality was lower in the ISVMP group (5.4%) versus controls (13%). An ISVMP infant compared with a historical control had an average 29% lower predicted probability of interstage death (adjusted probability: −0.29; 95% CI, −0.52 to −0.057; P=0.015). On stratified analysis, mortality was lower in the hypoplastic left heart syndrome subgroup undergoing Norwood operation (4/84 [4.8%] versus 12/90 [14%], P=0.03) but not in those with initial palliation of shunt only (P=0.90). ISVMP participants were younger at the time of the stage 2 operation (138 versus 160 days, P<0.001), with no difference in postoperative mortality or length of stay.ConclusionsIn this single‐center study, we report significantly lower interstage mortality for participants with hypoplastic left heart syndrome enrolled in ISVMP. Younger age at stage 2 operation was not associated with postoperative mortality or longer length of stay.

Liver Transplantation from Voluntary Organ Donor System in China: A Comparison between DBD and DCD Liver Transplants.

Background In China, the cases of liver transplantation (LT) from donation after citizens' death have rose year by year since the citizen-based voluntary organ donor system was initiated in 2010. The objective of our research was to investigate the early postoperative and late long-term outcomes of LT from donation after brain death (DBD) and donation after circulatory death (DCD) according to the current organ donation system in China. Methods Sixty-two consecutive cases of LT from donation after citizens' death performed in our hospital between February 2012 and June 2017 were examined retrospectively for short- and long-term outcomes. These included 35 DCD LT and 27 DBD LT. Result Subsequent median follow-up time of 19 months and 1- and 3-year graft survival rates were comparative between the DBD group and the DCD group (81.5% and 66.7% versus 67.1% and 59.7%; P = 0.550), as were patient survival rates (85.2% and 68.7% versus 72.2% and 63.9%; P = 0.358). The duration of ICU stay of recipients was significantly shorter in the DBD group, in comparison with that of the DCD group (1 versus 3 days, P = 0.001). Severe complication incidence (≥grade III) after transplantation was identical among the DBD and DCD groups (48.1% versus 60%, P = 0.352). There was no significant difference in postoperative mortality between the DBD and DCD groups (3 of 27 cases versus 5 of 35 cases). Twenty-one grafts (33.8%) were lost and 18 recipients (29.0%) were dead till the time of follow-up. Malignancy recurrence was the most prevalent reason for patient death (38.8%). There was no significant difference in incidence of biliary stenosis between the DBD and DCD groups (5 of 27 cases versus 6 of 35 cases, P = 0.846). Conclusion Although the sample size was small to some extent, this single-center study first reported that LT from DCD donors showed similar short- and long-term outcomes with DBD donors and justified the widespread implementation of voluntary citizen-based deceased organ donation in China. However, the results should be verified with a multicenter larger study.

Long-term outcomes of multiple and single arterial off-pump coronary artery bypass grafting.

To compare the clinical outcomes between multiple arterial (MA) and single arterial (SA) off-pump coronary artery bypass grafting (OPCAB) when applied to left main coronary disease or three-vessel disease. A total of 537 patients with left main coronary disease or three-vessel disease underwent MA OPCAB (n=114) or SA OPCAB (n=423) in our center from January 2006 to December 2008. The propensity score matching (PSM) was used to obtain the risk-adjusted outcome. Both the perioperative and long-term results were analyzed. The median follow-up time was 117 months (interquartile range, 110 to 128 months). There was no statistical difference in postoperative mortality and the volume of drainage. The intensive care unit (ICU) length of stay (LOS) of the MA group was shorter than that of the SA group {1 [1-2] vs. 2 [1-3], P=0.001). In the long term, the mortality (5.7% vs. 17.5%, P=0.006), cardiac mortality (1.0% vs. 8.8%, P=0.008), fatal myocardial infarction (MI) rate (0.0% vs. 6.1%, P=0.015) and incidence of readmission for heart failure (19.8% vs. 37.7%, P=0.003) were lower in the MA group than in the SA group. The distributions of NYHA class (P<0.001) and CCS class (P<0.001) were better in the MA group than in the SA group. There was no significant difference in other outcomes. These results were consistent with the K-M curves of freedom from the adverse events. MA OPCAB was as safe as SA OPCAB, providing better perioperative recovery and better long-term clinical outcomes in the treatment of left main coronary disease or three-vessel disease.

Evidence-based Nurse Staffing: ICN's New Position Statement.

Evidence-based Nurse Staffing: ICN's New Position Statement.

Comparison of Neoadjuvant Chemotherapy Followed by Surgery to Upfront Surgery for Thymic Malignancy

The oncologic benefit of neoadjuvant chemotherapy in thymic malignancies remains unclear. Postoperative oncologic outcomes of curative resection after neoadjuvant chemotherapy were compared with those of upfront surgery. Based on records from a multicenter database, 1,486 patients with surgically resected thymic malignancies between 2000 and 2013 were included in thefinal study cohort. Of these, 110 patients (7.4%) underwent surgical resection after neoadjuvant chemotherapy, and 1,376 patients (92.6%) underwent upfront surgery. A propensity score-matched analysis was performed to minimize differences in preoperative and intraoperative variables. Postoperative outcomes and survivals were compared between the two groups. In the matched cohort, there were no significant differences in postoperative mortality (p value not calculated), postoperative complications (p= 0.405), and hospital length of stay (p= 0.821) between the two groups. However, the neoadjuvant chemotherapy group showed significantly higher transfusion rates (p= 0.003) and longer operation times (p < 0.001) than the upfront surgery group. Pathologically complete resection rates (p= 0.382) and tumor sizes (p= 0.286) were similar between the two groups. The 5-year overall survival rateswere 77.4% and 76.7%, respectively (p= 0.596). The 3-year recurrence-free survival rates were 62.9% and 71.5%, respectively (p= 0.070). Neoadjuvant chemotherapy, followed by resection, obtained similar resectability and long-term survival rates to those of upfront surgery. Therefore, the role of neoadjuvant chemotherapy should be refined in randomized controlled trials.

Pancreatectomy with arterial resection is superior to palliation in patients with borderline resectable or locally advanced pancreatic cancer

BackgroundFew studies have investigated the outcome of pancreatectomy associated with artery resection (PAR). MethodsRetrospective analysis of a cohort of operated borderline or locally advanced pancreatic cancer patients with surgically confirmed arterial involvement. Short and long-term outcome were analyzed and compared in patients who underwent PAR (Group 1) and palliative surgery (Group 2). ResultsOf 73 patients who underwent surgical exploration with intent of resection, 34 underwent PAR (±venous resection) (Group 1) and 39 underwent palliation (Group 2). 23 patients (67.7%) in Group 1 underwent combined artery-vein resection (AVR). Operation time was longer and blood loss higher in group 1 compared to group 2. There were no differences in post-operative mortality (2.9% vs 2.6%, p = 0.9) and post-operative surgical complications (38.2% vs 25.6%, p = 0.2). The 1, 3 and 5 years survival in Group 1 was superior to Group 2 (63.7%, 23.4% and Q3 23.4% vs 41.7%, 3.2% and 0, p = 0.003). ConclusionPAR seems to be safe and feasible in well selected patients and associated with an advantage of survival compared to palliation, in patients affected by locally advanced pancreatic cancer.