High-complexity Surgery Research Articles

Women in thoracic, cardiac and vascular surgery claim for a change in the working situation: an Italian national survey.

Women's participation in the surgical workforce has increased. The aim of the study is to acquire objective data regarding practice, training, satisfaction, and discrimination of women surgeons working in cardiothoracic and vascular surgery in Italy. An 83-item questionnaire was distributed through social media and sent to e-mails of women surgeons from November through December 2020. A sub-analysis on women working in cardiac, thoracic, and vascular surgery was performed. Overall, 222 respondents were included (48 cardiac, 62 thoracic, and 112 vascular surgeons). Thirty-six percent partially abandoned surgical activities in favor of other professional activities, not including the operating room. On average, our respondents took part in 33% of all surgical cases performed in their units; however, of 12 high complexity surgeries per month, less than one is performed by them. Only 7 female participants who answered the questionnaire were in leadership positions. Many respondents struggle with lack of mentorship and missing opportunities in operating room. A high percentage of women experienced discrimination due to their gender in their professional life, and 59% claimed to have been subject to sexual harassment. In Italy, women thoracic, cardiac, and vascular surgeons face lack of mentorship, opportunities in the operating room, and gender-related issues including some episodes of sexual harassment. Diversity, equity, and inclusion should become strategic priorities in all institutions. Among our respondents, surgical exposure is limited, which may deter a surgical career and play a crucial role in surgeons' dissatisfaction, that also include poor work-life-balance, and a large amount of administrative work. Surgical societies may address these issues by providing structured mentorship programs and networking opportunities. Societies' contributions might substantially impact supporting and retaining women at different stages of their careers.

Next Steps Toward Reducing Surgical Morbidity After Complex Cytoreductive Surgery in Fit Surgical Patients

Objective: Using a triage algorithm for primary cytoreductive surgery (PCS) reduces perioperative mortality, however, nonlethal complications are common. This study identified procedures associated with postoperative complications in triage-appropriate women, with the aim of guiding the next steps to foster surgical quality improvement. Materials and Methods: Consecutive triage-appropriate women with stage IIIC/IV ovarian cancer undergoing PCS, from January 2012 to April 2018, were included. The expanded Accordion scale was used to grade complications. Adjusted risk ratios (RRs) were calculated to quantify the association between concomitant procedures and risk of 30-day grade 3+ (G3+) complications by fitting Poisson regression models adjusted for performance status and age. Population-attributable risk (PAR) was calculated based on the adjusted RRs and prevalence of each procedure. Results: Of 214 women, 82.7% had intermediate- or high-complexity surgery, 68.7% had complete gross resection, 3.7% had residual disease >1 cm, and 18.7% experienced G3+ complications. In univariate analysis, operative time, surgical complexity, splenectomy, and bowel resection (any and extent of) were associated with G3+ complications. Operative time, bowel resection (any, extent of, and large) were associated with G4+ complications. In the adjusted analysis for G4+ complications, bowel resection (any, extent of, and large) had statistically significant PAR values of 60.7%, 54.7%, and 50.8%, respectively. PAR values associated with G3+ complications were 27.4% and 26.8% for any and multiple bowel resections, respectively. Conclusions: Bowel resection, upper abdominal procedures, and longer operative times are essential for PCS, but each contributes to the relatively constant rates of postoperative morbidity despite triage to prevent frail patients from undergoing PCS. Surgical-improvement research should focus on improving the safety of these procedures. (J GYNECOL SURG 20XX:000)

Coronary Artery Bypass Surgery Among Medicare Beneficiaries in Health Professional Shortage Areas.

Health professional shortage areas (HPSAs) were created by the Health Resources and Services Administration to identify communities with a shortage of clinical providers. For medical conditions, these designations are associated with worse outcomes. However, far less is known about patients undergoing high-complexity surgical procedures, such as coronary artery bypass grafting (CABG). The aim was to compare postoperative surgical outcomes of high-complexity surgery in beneficiaries living in HPSA versus non-HPSA designated areas. This study is a retrospective cohort review of Medicare beneficiaries who underwent CABG between 2014 and 2018. The authors compared risk-adjusted 30-day mortality, complication, reoperation, and readmission rates for beneficiaries living in a designated HPSA versus non-HPSA using a multivariable logistic regression model accounting for patient (eg, age, sex, comorbidities, surgery year) and hospital characteristics (eg, patient-to-nurse ratio, teaching status). Patient travel burden was measured based on the time and distance required to travel from the beneficiary's home zip code to the hospital zip code. Of the 370,532 Medicare beneficiaries who underwent CABG, 30,881 (8.3%) lived in a HPSA. Beneficiaries in HPSAs were found to experience comparable 30-day mortality (3.50% vs. 3.65%, P <0.001), complication (32.67% vs. 33.54%, P <0.001), reoperation (1.58% vs. 1.66%, P <0.001), and readmission (14.72% vs. 14.86%, P <0.001) rates. Beneficiaries experienced greater mean travel times (91.2 vs. 64.0 minutes, P <0.001) and mean travel distances (85.0 vs. 59.3 miles, P <0.001). Medicare beneficiaries living in designated HPSA experienced comparable surgical outcomes after CABG surgery but a significantly greater travel burden. The greater travel burden experienced by patients living in designated shortage areas to obtain comparable surgical care for complex procedures demonstrates important tradeoffs between access and quality.

Long-Term Consequences of Acute Kidney Injury After Pediatric Cardiac Surgery: A Systematic Review

The objective of this study was to evaluate the available data on long-term kidney dysfunction, hypertension, and mortality after cardiac surgery-associated acute kidney injury (AKI) in the pediatric population. PubMed/MEDLINE, Embase, Scopus, and reference lists of relevant articles were searched for eligible studies published from inception through March 2022. Long-term outcomes after pediatric cardiac surgery complicated by AKI and those without were investigated. We identified 14 studies published between 2013 and 2022 that included a total of 6701 patients (AKI: 1376 patients; no AKI: 5325 patients). These studies used different well-established classifications to define AKI. All the studies suggested that AKI after heart surgery is common in the pediatric patient population and reported a potential link between cardiac surgery-associated AKI and important clinical outcomes. However, only 4 out of 11 studies found a strong association between (absence of recovery from) cardiac surgery-associated AKI and risk of developing chronic kidney disease, and 3 out of 5 studies found a significant increase in mortality rates for pediatric patients who developed AKI after cardiac surgery. Only 1 out of 4 studies found an association between AKI and hypertension at 12months postoperatively, but found no association at later follow-up times. Although there is a trend, evidence on the long-term consequences of cardiac surgery-associated AKI in the pediatric population is mixed. Genetic syndromes, preexisting kidney disease, univentricular or cyanotic heart conditions, and/or high-complexity surgery may be more important for the development of kidney dysfunction by adolescence and early adulthood. Regardless, these children may benefit from a long-term kidney follow-up.

Investigating the Impact of Ultra-Radical Surgery on Survival in Advanced Ovarian Cancer Using Population-Based Data in a Multicentre UK Study.

Simple SummaryOvarian cancer is treated by surgery to remove all visible cancer and chemotherapy. Cancer survival is highest when no cancer is left behind after surgery. Ultra-radical (URS) surgery or maximal effort cytoreduction surgery uses additional surgical procedures, e.g., splenectomy, diaphragm stripping, etc. to remove all visible cancer. The use of URS varies internationally with some cancer centres performing this routinely and others not. We conducted a multi-centre study investigating 1471 patients with advanced ovarian cancer (AOC) across three types of gynaecological cancer centres in the UK—those offering mainly low, intermediate or high complexity surgery and investigated survival from cancer in an operated and non-operated whole cohort of women with advanced ovarian cancer. We found that cancer survival was highest in the centres practicing more radical surgery, even after age and deprivation of patients was taken into consideration. Centres practicing mainly low complexity surgery should change practice. We investigated URS and impact on survival in whole patient cohorts with AOC treated within gynaecological cancer centres that participated in the previously presented SOCQER 2 study. National cancer registry datasets were used to identify FIGO Stage 3,4 and unknown stage patients from 11 cancer centres that had previously participated in the SOCQER2 study. Patient outcomes’ association with surgical ethos were evaluated using logistic regression and Cox proportional hazards. Centres were classified into three groups based on their surgical complexity scores (SCS); those practicing mainly low complexity, (5/11 centres with >70% low SCS procedures, 759 patients), mainly intermediate (3/11, 35–50% low SCS, 356 patients), or mainly high complexity surgery (3/11, >35% high SCS, 356 patients). Surgery rates were 43.2% vs. 58.4% vs. 60.9%. across mainly low, intermediate and high SCS centres, respectively, p < 0.001. Combined surgery and chemotherapy rates were 39.2% vs. 51.8% vs. 38.3% p < 0.000 across mainly low, intermediate and high complexity groups, respectively. Median survival was 23.1 (95% CI 19.0 to 27.2) vs. 22.0 (95% CI 17.6 to 26.3) vs. 17.9 months (95% CI 15.7 to 20.1), p = 0.043 in mainly high SCS, intermediate, and low SCS centres, respectively. In an age and deprivation adjusted model, compared to patients in the high SCS centres, patients in the low SCS group had an HR of 1.21 (95% CI 1.03 to 1.40) for death. Mainly high/intermediate SCS centres have significantly higher surgery rates and better survival at a population level. Centres that practice mainly low complexity surgery should change practice. This study provides support for the utilization of URS for patients with advanced OC.

Into the future: A pilot study combining imaging with molecular profiling to predict resectability in ovarian cancer

ObjectiveWe sought to determine the predictive value of combining tumor molecular subtype and computerized tomography (CT) imaging for surgical outcomes after primary cytoreductive surgery in advanced stage high-grade serous ovarian cancer (HGSOC) patients. MethodsWe identified 129 HGSOC patients who underwent pre-operative CT imaging and post-operative tumor mRNA profiling. A continuous CT-score indicative of overall disease burden was defined based on six imaging measurements of anatomic involvement. Molecular subtypes were derived from mRNA profiling of chemo-naïve tumors and classified as mesenchymal (MES) subtype (36%) or non-MES subtype (64%). Fischer exact tests and multivariate logistic regression examined residual disease and surgical complexity. ResultsWomen with higher CT-scores were more likely to have MES subtype tumors (p = 0.014). MES subtypes and a high CT-score were independently predictive of macroscopic disease and high surgical complexity. In multivariate models adjusting for age, stage and American Society of Anesthesiologists (ASA) score, patients with a MES subtype and high CT-score had significantly elevated risk of macroscopic disease (OR = 26.7, 95% CI = [6.42, 187]) and were more likely to undergo high complexity surgery (OR = 9.53, 95% CI = [2.76, 40.6], compared to patients with non-MES tumor and low CT-score. ConclusionPreoperative CT imaging combined with tumor molecular subtyping can identify a subset of women unlikely to have resectable disease and likely to require high complexity surgery. Along with other clinical factors, these may refine predictive scores for resection and assist treatment planning. Investigating methods for pre-surgical molecular subtyping is an important next step.

Transformational Leadership, Team Processes, and Surgery Outcomes

Existing research on transformational leadership is restricted by methodological and contextual limitations. Consequently, whether evidence for transformational leadership’s effectiveness in traditional work environments generalizes to extreme contexts remains to be seen. We develop and test novel theory founded in Hannah et al.’s (2009) extreme context framework and situation strength theorizing (Mischel, 1978) to understand leadership in the operating room – an extreme context. Specifically, we sought to understand why transformational leadership might not always be enough for improving team and individual outcomes. We suggest that in weak situations, where the appropriate course of action is unclear (e.g., high complexity surgeries), transformational leadership interacts with directive leadership to predict team processes and patient outcomes. We combine observations of transformational, directive leadership, and surgical errors across 150 surgeries with team reports of psychological safety, collective efficacy, and surgical complexity, as well as objective reports of patient outcomes to advance theory on transformational leadership and extreme contexts. Findings demonstrate that when surgical complexity is high both transformational leadership and controlling leadership influence patient outcomes through team-level psychological safety. Importantly, the effects of leadership were not significant in medium or low complexity surgeries. Limitations, strengths, and both theoretical and practical contributions are discussed.

Triage, then what? Next steps toward reducing surgical morbidity after complex cytoreductive surgery in fit surgical patients (461)

<b>Objectives:</b> In advanced ovarian cancer (OC), the use of a validated triage algorithm based on patient/disease factors results in significantly fewer poor outcomes, including mortality, after primary cytoreductive surgery (PCS). However, the rate of complications remains high even for triage-appropriate women, suggesting an opportunity for process improvement. To steer surgical innovation research, we sought to identify procedures that are most associated with postoperative complications in surgically fit OC patients. <b>Methods:</b> Triage-appropriate stage IIIC/IV women with OC undergoing PCS from January 2, 2012, to April 30, 2018, were identified from a prospectively maintained database. Women were considered triage- appropriate if none of the following high-risk criteria was present: <i>(i)</i> Albumin <3.5 g/dl, <i>(ii)</i> age ≥80 years, or <i>(iii)</i> age 75-79 and at least one of the following: ECOG performance status >1, stage IV disease, or complex surgery required (more than hysterectomy, salpingo- oophorectomy, and omentectomy). Characteristics were compared between patients with and without 30-day Accordion Grade 3+ complications. We calculated risk ratios (RR) using Poisson regression models with robust error variance and population attributable fractions (PAF). The PAF is defined as the reduction in the complication rate that could be expected if exposure to that specific procedure was eliminated and is a useful tool for analyzing impact and steering quality improvement. <b>Results:</b> Among 214 included women, 177 (82.7%) had intermediate/ high complexity surgery. Complete gross resection was achieved in 68.7%, and only 3.7% had residual disease >1 cm. Overall, 40 women (18.7%) experienced a grade (G) 3+ complication. The following factors were significantly associated with G3+ complications in univariate analysis: stage IV, surgical complexity, operative time, bowel resection/extent of bowel resection, and splenectomy. Additionally, operative time and bowel resection/extent of bowel resection were associated with G4+ complications (relative to none/G1/G2). Table 1 summarizes the association between specific procedures and the occurrence of a G3+ complication, and PAF analysis, adjusted for ASA score and stage. We observed that multiple bowel resections had the highest PAF (25.6; 95% CI: 4.0-47.2). Diaphragm stripping/resection and splenectomy had a PAF of 25.9 (95% CI:-3.8-55.6) and 12.1 (95% CI: -4.8-29.0), respectively, though not statistically significant. <b>Conclusions:</b> Bowel resection, diaphragm procedures, and splenectomy are essential to successful PCS in OC. Each is a potential source of significant complications, even after triage, to eliminate high-risk patient factors. For example, 25% of all G3+ complications occur in patients with multiple bowel resections. Focusing our surgical improvement research on these procedures will likely have the highest yield in further reducing morbidity associated with cytoreductive surgery for our patients.

Frailty associated with failure to recover from grade 3 complications after surgery for advanced ovarian cancer (560)

<b>Objectives:</b> Frailty is characterized by vulnerability to stressors and lack of reserve. Frailty is emerging as an important predictor of tolerance to treatment in gynecologic malignancy and is associated with poor outcomes in advanced ovarian cancer (OC). An important stressor is the experience of severe complications at debulking surgery. We aimed to assess the impact of frailty on short-term survival after surgical cytoreduction and a severe complication in advanced OC. <b>Methods:</b> Patients with stage IIIC/IV OC who underwent curativeintent primary debulking surgery (PDS) from January 2, 2003, to April 30, 2018 at a single institution were identified from a prospectively maintained surgical database of OC patients. Patient's clinical, surgical, and outcomes data were collected from the medical record. Frailty was defined by a frailty index (FI). The FI included 30 items scored at 0, 0.5, or 1 and was calculated by summing across all the item scores and dividing by the total (range: 0-1). Those without frailty index or lack of follow-up data were excluded. Surgical complications were collected for 30 days post-surgery and graded by the modified Accordion scale. All patients who experienced a grade 3 complication were included. Cox regression models were fit to evaluate associations with death within six months after surgery. <b>Results:</b> Of the 922 patients who had PDS in this time period, 142 met the inclusion criteria. The average age of the cohort was 64.6 years, and the majority had serous histology (92.3%), stage IIIC disease (64.1%), and grade 3 disease (97.9%). Nearly half underwent high complexity surgery (47.2%), and most had resection to no gross residual disease (40.1%) or ≤1 cm of disease (43.7%). FI was ≥0.15 in 36 (25.4%) patients. There were 27 (19%) deaths within the first six months after PDS. Univariate factors associated with death by six months after surgery included age (HR: 1.6 per 10-year increase, 95% CI: 1.1-2.4), ASA score >3 (HR: 4.8, 95% CI: 1.6-13.8), body mass index (HR: 1.3 per 5 kg/m² increase, 95% CI: 1.0-1.6), FI >0.15 (HR: 2.5, 95% CI: 1.3-5.4, Figure), and residual disease (HR: 4.2, 95% CI: 1.8-12.1 for > 1 cm disease compared to no gross residual disease). <b>Conclusions:</b> Since surgical complications are non-avoidable, it is important to identify the patients who will not be able to recover from a complication. Identifying frailty prior to surgery is important to determine patients who may be better suited for neoadjuvant chemotherapy and prehabilitation efforts.

What are the implications of radiologically abnormal cardiophrenic lymph nodes in advanced ovarian cancer? An analysis of tumour burden, surgical complexity, same-site recurrence and overall survival

IntroductionOur paper evaluates the relationship between radiologically abnormal cardiophrenic lymph nodes (CPLN) in advanced ovarian cancer and pattern of disease distribution, tumour burden, surgical complexity, rates of cytoreduction and same-site recurrence. Impact of suspicious CPLN and CPLN dissection on overall survival also determined. Materials and methodsRetrospective review of index CT imaging for 151 consecutive patients treated for stage III/IV ovarian malignancy in a large UK cancer centre to identify radiologically abnormal CPLN. Corresponding surgical, histo-pathological and survival data analysed. Results42.6% of patients had radiologically ‘positive’ CPLN on index CT. Radiological identification of CPLN involvement demonstrated a sensitivity of 82% within our centre. Patients with cardiophrenic lymphadenopathy on pre-operative CT had significantly more co-existing ascites (p = 0.003), omental (p = 0.01) and diaphragmatic disease (p < 0.0001). At primary debulking (PDS), suspicious CPLN were associated with significantly higher surgical complexity scores, without feasibility of complete cytoreduction being impacted. Cardiophrenic involvement at initial diagnosis was associated with same-site relapse at recurrence (p = 0.001). No significant difference in overall survival was demonstrated according to CPLN status following either PDS or delayed debulking (DDS). CPLN dissection did not improve patient outcomes. ConclusionRadiological identification of abnormal CPLN is reliable. Suspicious CPLN appear to represent a surrogate marker of tumour volume – in particular, heralding upper abdominal disease – and should prompt anticipation of high complexity surgery and referral to an appropriate centre. Patients with prior CPLN involvement are more likely to develop same-site recurrence at relapse. Our survival data suggests cardiophrenic LN disease does not worsen patient prognosis and that the therapeutic benefit of CPLN dissection remains unclear.

Screening complications in the postoperative period of orthopedic surgeries by video arthroscopy

To analyze the prevalence and characteristics of late postoperative complications of orthopedic surgeries by video arthroscopy. This was a descriptive cross-sectional study that evaluated, through its own instrument, local and systemic postoperative complications of patients undergoing orthopedic surgeries by video arthroscopy. The study included 270 patients, who were evaluated on days 30(without prosthesis) and 90(with prosthesis placement) of the postoperative period, by telephone service. The selection of participants occurred sequentially and population-based, within the data collection period, from February to July 2020, in a large hospital for medium and high complexity surgeries. Of the 270 procedures performed in the period, 4.4% (n = 12) presented late postoperative infection. The most frequent complications were erythema (83%), edema (75%) and secretion (67%) in the surgical wound. Most used antibiotic therapy (92%) and anti-inflammatory drugs (67%). Hospital readmission was not necessary concerning the complications. Only 50% required medical evaluation before the scheduled time. The need for practices that ensure the quality of perioperative care and improve the active search to assess surgical outcomes is reinforced.

Brazil's health system functionality amidst of the COVID-19 pandemic: An analysis of resilience

BackgroundAs of December 31, 2020, Brazil had the second-highest burden of COVID-19 worldwide. Given the absence of federal government coordination, it was up to the local governments to maintain healthcare provision for non-COVID health issues. In this descriptive study, we aimed to discuss the SUS functionality and resilience, describing the impact of the pandemic on non-COVID health services delivery while considering the regional inequalities of the allocation of financing health system, health infrastructure and health workforce.MethodsWe used input-output framework based on the World Health Organization (WHO) Health System Building Blocks to estimate health system functionality and resilience. An ecological assessment was designed to calculated mean relative changes to compare the first year of the pandemic in Brazil with the previous one. All data used in this study were anonymized and made available by the Brazilian Ministry of Health. Input indicators were categorized in health system financing (federal funding received as well as expenditure of both state and city governments), health system's infrastructure (hospital beds) and health workforce (healthcare workers positions). Output indicators were categorized into nine different groups of service delivery procedures. To explore the relationship between the variation in procedures with socioeconomic conditions, we used the Socioeconomic Vulnerability Index (SVI).FindingsState governments had a 38·6% increase in federal transfers, while municipal governments had a 33·9% increase. The increase of ICU beds reached its peak in the third quarter of 2020, averaging 72·1% by the end of the year. The country also saw an increase in jobs for registered nurses (13·6%), nurse assistants (8·5%), physiotherapists (7·9%), and medical doctors (4·9%). All procedures underwent expressive reduction: Screenings (−42·6%); Diagnostic procedures (−28·9%); Physician appointments (−42·5%); Low and medium complexity surgeries (−59·7%); High complexity surgeries (−27·9%); Transplants (−44·7%); Treatments and clinical procedures due to injuries of external causes (−19·1%); Irrepressible procedures (−8·5%); and Childbirths (−12·6%). The most significant drop in procedures happened in the first quarter of the pandemic, followed by progressive increase; most regions had not yet recovered by the end of 2020. State-level changes in numbers of procedures point towards a negative trend with SVI.InterpretationThe Brazilian Government did not consider that socioeconomically vulnerable states were at a higher risk of being impacted by the overburden of the health system caused by the COVID-19, which resulted in poorer health system functionality for those vulnerable states. The lack of proper planning to improve health system resilience resulted in the decrease of a quarter of the amount of healthcare procedures increasing the already existing health disparities in the country.FundingMCTIC/CNPQ/FNDCT/MS/SCTIE/DECIT No 07/2020.

303 Eras protocols in gynaecological oncology. Should we include epidural analgesia?

Introduction: Enhanced recovery after surgery (ERAS) pathways aim to improve the perioperative practice ending in a shorter length of stay with less postoperative complications. Although thoracic epidural analgesia (TEA) is included in ERAS guidelines of other specialties, it is not included in ERAS guidelines in gynaecological oncology. We aim to provide further information in the use of TEA in ERAS protocols in gynaecological oncology. Methods: A retrospective analysis of a prospectively maintained database of patients who underwent intermediate to high complexity surgery from January 2020 to March 2021 due to gynecological malignancy. The ERAS protocol was followed and patients with compliance rates >75% who received postoperative (PO) analgesia through thoracic epidural catheter as part of multimodal analgesia (TEA group) versus those who did not (non-TEA group) were compared. Mobilization, length of stay (LOS), and postoperative pain were considered the primary outcomes of the study. Results: A total of 130 patients (87 in TEA group versus 43 in non-TEA group). Mean visual analog scale (VAS) pain scores at both the day of surgery and PO day 1, were significantly lower in TEA group compared to non-TEA (3.74 vs 4.67, p<0.0001 and 3.30 vs 4.14, p<0.0001, respectively). Mobilization rates were significantly higher in TEA group versus non-TEA (93% vs 62%, p<0.0001). Mean opioid use was significantly higher in non-TEA group (p<0.0001), while nausea rates were significantly reduced in TEA patients (p=0.021). No difference in LOS was observed among the two groups (4.18 vs 4.40, p=0.995) same as in complication rates. Conclusions: Although TEA is not included in ERAS protocols in gynaecological oncology, in experienced hands, it would be a beneficial tool related to decreased need of opioid use and nausea rates with no impact to hospital stay and PO complications, aiming to improve the perioperative quality of patient’s care.

A ureteral stricture disease score and classification system: correlation with upper urinary tract reconstructive surgery complexity.

BackgroundTo develop an original and standardized ureteral stricture disease (USD) score and classification system for quantifying ureter stricture characteristics, assessing complexity of the minimally invasive upper urinary tract reconstructive (UUTR) surgical procedure, formulating preoperative plans, and offering objective comparisons of surgical techniques between different institutions and surgeons.MethodsWe retrospectively reviewed a test set of 64 patients and a validation set of 170 patients who underwent minimally invasive UUTR surgery from January 2018 to January 2021. Three factors were selected to be included in the USD score and classification system: (I) stricture etiology (E, 1–2 points); (II) stricture segment (S, 0–3 points); and (III) length of stricture (L, 1–5 points). The UUTR surgery involves low-complex surgeries (cystoscopy with ureteral dilation and stent placement, ureteropyeloplasty, end to end repair, ureteral reimplantation) and high-complex surgeries (onlay repair (buccal mucosae, lingual mucosae, appendix mucosae), Boari flap repair and ileal ureter replacement). Estimated blood loss and operative time were used as surrogate indicators of surgical complexity.ResultsThe interrater reliability of the USD score and classification system was 0.908. A linear relationship between the USD score and estimated blood loss was observed (rs =0.676, P<0.001). The USD score was also correlated with operative time (rs =0.638, P<0.001). A significant difference in USD scores was found between the high and low complexity surgery groups (4 vs. 7, P<0.001). Variability of UUTR surgery is based on USD classification system, but with regularity to conform to.ConclusionsThe USD score and classification system is a concise, easily applicable, and validated scale to delineate the clinically significant features of ureter stricture that correlate with the complexity of the UUTR surgical procedure. The use of this score and classification system can facilitate preoperative plan and comparison of USD treatments in clinical practice and urological literature. Research with large sample is needed to further examine and modify the use of the system.

Assessment of Safety and Applicability of Laparoscopic vs Open Non Anatomical Resection of Hepatocellular Carcinoma in Cirrhotic Patients

Abstract Background Laparoscopic liver resection (LLR) has been progressively developed along the past two decades. Liver surgery was one of the last frontiers reached by minimally invasive surgery. Surgical technique and equipment evolved to overcome technical limitations, making laparoscopic liver resections (LLR) safe and feasible. Surgeons developed skills in a stepwise approach, beginning with low complexity operations for benign diseases and reaching high-complexity surgeries for malignant cases and living donor organ harvesting. Objective s: The aim of the study is to compare short term results of laparoscopic versus open hepatectomy regarding to intra operative details and post-operative management and complications for achieving a safe hepatic resection for treatment of HCC in cirrhotic patients. Patients and Methods In this prospective study, a comparison between laparoscopic resection and open resection was done to compare short-term results between laparoscopic and open liver resection. This study was conducted on 30 patients with hepatocellular carcinoma. 15 patients (50%) were treated by laparoscopic liver resection (Group A) while the other 15 patients (50%) were treated by open liver resection (Group B). Results Regarding the demographic data, the presence of past history of medical condition and the preoperative laboratory results, no statistical significance was found. The mean operative time has statistically significant difference between the 2 groups, with decreased operative time in the laparoscopic group (P &amp;lt; 0.001). The mean blood loss has no statistically significant difference relations between the 2 groups, (P = 0.866) with conversion rate of (13.3%) happened in two cases. Conclusion Laparoscopic liver resection is a safe and feasible treatment option for HCC in cirrhotic patient needing minor resection at laparoscopic segments (II, III, IVa,V,VI). Laparoscopic liver resection for HCC has superior short- term and comparable oncological outcomes to open liver resection. LLR should be performed for carefully selected patients and by an expert surgical team.

ERAS® as a public health policy: Implementation in the Alberta Health System

Enhanced Recovery After Surgery (ERAS®) was implemented across Alberta Health Services, a single payer publicly funded provincial health system starting in 2013. Implementation across multiple provincial sites in colorectal surgery reduced postoperative complications by 12% and median length of stay by one day. Subsequent implementation in gynecologic oncology reduced postoperative complications by 17% and length of stay by 2 days in high complexity surgery. Implementation has had an estimated net savings in the province of $7.22 million Canadian dollars (CAD) over 5 years with a return on investment of $1.05 to $7.31 for every dollar invested in the project. Patient involvement enabled success of the program, with support, education, and mitigation of patient stress identified as key components for success. Provider knowledge and motivation were essential to ensure ongoing compliance with ERAS guidelines. Provider education, and demonstration of improvement in patient outcomes using audit is one method to ensure continued motivation from care providers. Systemlevel leadership is essential to provide consistent messaging and support for initiatives, while providerlevel leadership in the form of physician champions and nurse coordinators ensures compliance and appropriate integration of ERAS into daily practice. Implementation of ERAS across a unified health care system has improved patient outcomes while saving resources. Further research into expansion of the program to community hospitals and all surgical domains is underway.

Impact of the Strategies Adopted to Face the COVID-19 Pandemic in a Brazilian Reference Institute for High Complexity Surgery in Orthopedics and Traumatology.

COVID-19 pandemics required substantial reorganization and adaptation of healthcare services all over the world. This study aims to analyze the effect of operational strategies implemented in Brazil to manage the extra strain placed on healthcare services by the COVID-19 pandemic of 2020. In particular, this investigation examines the strategy to convert an institute specialized in elective orthopedic procedures of high complexity into a trauma unit for all musculoskeletal trauma patients of an entire federative unit. A retrospective study was conducted comparing hospital variables at the peak period of the pandemic (from March 16, 2020 to June 30, 2020) with the same period in 2019 as a comparative baseline. The variables analyzed included number of professionals away from work, surgeries performed, outpatient care, transfers, length of stay, number of patients diagnosed with COVID-19 and patient mortality. During the COVID-19 peak period, there was a 48.5% reduction in surgical productivity and 72.4% reduction in outpatient care compared with the same period in 2019. The number of transfers increased substantially (124.5%), while 94 confirmed cases and 77 suspected cases of COVID-19 were reported. The mortality rate increased by 245%. The present study highlighted the effect of COVID-19 on a tertiary orthopedic hospital. Despite the dramatic changes in hospital operations, due to the implementation of protocols to manage the pandemic, the results demonstrated the feasibility and efficiency of such protocols in prioritizing quality and safety for patients and the healthcare workforce.

Appropriate triage allows aggressive primary debulking surgery with rates of morbidity and mortality comparable to interval surgery after chemotherapy

ObjectiveMorbidity and mortality (M/M) after primary debulking surgery (PDS) is often cited as a rationale for neoadjuvant chemotherapy and interval debulking surgery (IDS). We tested if using an evidence-based algorithm to identify patients fit for surgery would reduce M/M after PDS to that seen after IDS. MethodsWe included women who underwent PDS or IDS for advanced epithelial ovarian cancer (EOC) (1/2012–7/2016) guided by the use of a prospective triage algorithm. Outcomes were compared after applying inverse-probability of treatment weighting (IPTW) to adjust for covariate imbalance. ResultsOf 334 included patients, 232 (69.5%) underwent PDS and 102 (30.5%) were triaged to IDS. Relative to IDS group, PDS patients were younger (63.9 vs 67.5 years, P=0.01), were less likely to have low albumin (16.8% vs. 32.4%, P<0.001), had longer median operative times (315 vs 263 min, P <0.001), more high complexity surgeries and fewer low complexity surgeries (27.2% vs. 11.8% and 18.5% vs 36.3% respectively, P<0.001). The rates of the following outcomes were comparable for PDS and IDS, respectively: successful cytoreduction (complete, 62.5% vs 66.7%, P=0.47 and optimal, 95.3% vs 98.0%, P=0.36), 30-day grade 3+ complications (IPTW-adjusted 18.3% vs. 12.9%, P=0.22), 90-day mortality (IPTW-adjusted, 2.2% vs. 3.8%, P=0.42), length of hospitalization (P=0.29), and postoperative chemotherapy delivery (P=0.83). 3-year overall survival was higher for PDS group (IPTW-adjusted 64.1% vs. 42.6%, P=0.001). ConclusionsUse of our validated triage strategy allowed us to offer 70% of women with advanced EOC PDS surgery. Despite more complex surgery, M/M after this approach is low and comparable to IDS, with similar rates of complete resection and superior OS. Use of a validated triage system should be utilized when considering PDS vs neoadjuvant chemotherapy.

Aggressive surgery could overcome the extent of initial peritoneal dissemination for advanced ovarian, fallopian tube, and peritoneal carcinoma

We examined whether the extent of initial peritoneal dissemination affected the prognosis of patients with advanced ovarian, fallopian tube, and peritoneal carcinoma when initially disseminated lesions > 1 cm in diameter were removed, regardless of the timing of aggressive cytoreductive surgery. The extent of peritoneal dissemination was assessed by the peritoneal cancer index (PCI) at initial laparotomy in 186 consecutive patients with stage IIIC/IV. Sixty patients underwent primary debulking surgery and 109 patients underwent neoadjuvant chemotherapy followed by interval debulking surgery. Seventeen patients could not undergo debulking surgery because of disease progression during neoadjuvant chemotherapy. The median initial PCI were 17. Upper abdominal surgery and bowel resection were performed in 149 (80%) and 171 patients (92%), respectively. Residual disease ≤ 1 cm after surgery was achieved in 164 patients (89%). The initial PCI was not significantly associated with progression-free survival (PFS; p = 0.13) and overall survival (OS; p = 0.09). No residual disease and a high-complexity surgery significantly prolonged PFS (p < 0.01 and p = 0.02, respectively) and OS (p < 0.01 and p ≤ 0.01, respectively). The extent of initial peritoneal dissemination did not affect the prognosis when initially disseminated lesions > 1 cm were resected.

Modified fragility index and surgical complexity score are able to predict postoperative morbidity and mortality after cytoreductive surgery for advanced ovarian cancer

ObjectiveThe aim of this study was to assess the impact of surgical complexity on postoperative complications and mortality, according to patient's frailty (mFI) following surgery for ovarian cancer. MethodsPatients undergoing cytoreductive surgery for ovarian cancer from 2008 to 2018 were identified from our database. A surgical complexity score from 1 to 3 was used to assess the extent of surgery (simple to complex, respectively). mFI with 11 variables, based on mapping the Canadian Study of Health and Aging Frailty Index to the NSQIP comorbidities was evaluated. Data were analyzed using Fisher exact test, independent sample t-test, and logistic regression. ResultsOf 263 patients identified, 33% reported at least one postoperative complication and 6% had severe complications. BMI ≥ 30 (p = 0.04) increased mFI (p = 0.04) and high-complexity surgery (p < 0.001) were independent predictors of severe complications (G3-G5). Patients with high frailty index score (mFI ≥ 3) who underwent intermediate or high-complexity surgery were at higher risk of severe complications ranging from 29.4% to 50. ConclusionsThe combined evaluation of mFI and surgical complexity expected may identify patients at higher risk for severe morbidity allowing to stratify patients who are less likely to tolerate a surgical extensive treatment.