High-volume Surgical Centers Research Articles

Factors Affecting Implant Length in Primary Inflatable Penile Prosthesis Placement

ObjectivesTo evaluate predictors of implant length for men undergoing primary IPP placement. MethodsA multicenter, retrospective cohort study was performed for men undergoing primary IPP placement at 16 high-volume surgical centers. Patient demographics, comorbidities, operative approach, and implanted cylinder and rear tip extender length were recorded. Associations between potential preoperative and intraoperative predictors of total device length were tested using non-parametric correlation and Kruskal-Wallis tests, followed by multiple regression. ResultsOf 3,951 men undergoing primary IPP placement from July 2016 – July 2021, the median implant length was 20 cm (IQR: 19 – 22). Shorter implant length was associated with increasing age in years (β = -0.01, p=0.009), Asian ethnicity (β = -2.34, p=0.008), history of radical prostatectomy (β = -0.35, p=0.001), and use of an infrapubic surgical approach (β = -1.02, p<0.001). Black or African American ethnicity was associated with the implantation of longer devices (β = 0.35, p<0.001). No significant associations were recorded with BMI, history of intracavernosal injections, diabetes mellitus, tobacco use, radiation therapy, Peyronie’s disease, priapism, or cavernosal dilation technique. ConclusionsThe length of an implanted penile prosthesis was found to be associated with preoperative and intraoperative factors including history of radical prostatectomy and operative approach. The knowledge of these associations may assist in the preoperative counseling of patients receiving IPP and help create accurate postoperative expectations.

Trends in Elbow Ulnar Collateral Ligament Repairs and Reconstructions and an Analysis Between Low- and High-Volume Surgical Centers: A 10-Year Study in New York State.

Elbow ulnar collateral ligament (UCL) reconstruction (UCLR) is the gold standard for operative treatment of UCL tears, with renewed interest in UCL repairs. To (1) assess trends in rates of UCLR and UCL repair and (2) identify predictors of complications by demographic, socioeconomic, or surgical center volume factors. Descriptive epidemiology study. Patients who underwent UCLR or UCL repair at New York State health care facilities between 2010 and 2019 were retrospectively identified; concomitant ulnar nerve procedures among the cohort were also identified. Surgical center volumes were classified as low (<99th percentile) or high (≥99th percentile). Patient information, neighborhood socioeconomic status quantified using the Area Deprivation Index, and complications within 90 days were recorded. Poisson regression analysis was used to compare trends in UCLR versus UCL repair. Multivariable regression was used to determine whether center volume, demographic, or socioeconomic variables were independent predictors of complications. A total of 1448 UCL surgeries were performed, with 388 (26.8%) concomitant ulnar nerve procedures. UCLR (1084 procedures; 74.9%) was performed more commonly than UCL repair (364 procedures; 25.1%), with patients undergoing UCL repair more likely to be older, female, and not privately ensured and having undergone a concomitant ulnar nerve procedure (all P < .001). With each year, there was an increased incidence rate ratio for UCL repair versus UCLR (β = 1.12 [95% CI, 1.02-1.23]; P = .022). The authors identified 2 high-volume centers (720 UCL procedures; 49.7%) and 131 low-volume centers (728 UCL procedures; 50.3%). Patients undergoing UCL procedures at high-volume centers were more likely to be younger and male and receive workers' compensation (all P < .001). UCL repair and ulnar nerve-related procedures were both more commonly performed at low-volume centers (P < .001). There were no significant differences in 3-month infection, ulnar neuritis, instability, arthrofibrosis, heterotopic ossification, or all-cause complication rates between low- and high-volume centers. The only significant predictor for all-cause complication was Medicaid insurance (OR, 2.91 [95% CI, 1.20-6.33]; P = .011). A rising incidence of UCL repair compared with UCLR was found in New York State, especially among female patients, older patients, and nonprivate payers. There were no differences in 3-month complication rates between high- and low-volume centers, and Medicaid insurance status was a predictor for overall complications within 90 days of operation.

Comparison of Transcatheter Edge-to-Edge Mitral Valve Repair for Primary Mitral Regurgitation Outcomes to Hospital Volumes of Surgical Mitral Valve Repair.

Transcatheter edge-to-edge mitral valve (MV) repair (TEER) is an effective treatment for patients with primary mitral regurgitation at prohibitive risk for surgical MV repair (MVr). High-volume MVr centers and high-volume TEER centers have better outcomes than low-volume centers, respectively. However, whether MVr volume predicts TEER outcomes remains unknown. We hypothesized that high-volume MV surgical centers would have superior risk-adjusted outcomes for TEER than low-volume centers. We combined data from the American College of Cardiology/Society of Thoracic Surgeons Transcatheter Valve Therapy registry and the Society of Thoracic Surgeons adult cardiac surgery database. MVr was defined as leaflet resection or artificial chords with or without annuloplasty and was evaluated as a continuous variable and as predefined categories (<25, 25-49, and ≥50 MV repairs/year). A generalized linear mixed model was used to evaluate risk-adjusted in-hospital/30-day mortality, 30-day heart failure readmission, and TEER success (mitral regurgitation ≤2+ and gradient <5 mm Hg). The study comprised 41 834 patients from 500 sites of which 332 (66.4%) were low, 102 (20.4%) intermediate, and 66 (13.2%) high-volume surgical centers (P<0.001). TEER success was 54.6% and was not statistically significantly different across MV surgical site volumes (P=0.4271). TEER mortality at 30 days was 3.5% with no significant difference across MVr volume on unadjusted (P=0.141) or adjusted (P=0.071) analysis of volume as a continuous variable. One-year mortality was 15.0% and was lower for higher MVr volume centers when adjusted for clinical and demographic variables (P=0.027). Heart failure readmission at 1 year was 9.4% and was statistically significantly lower in high-volume centers on both unadjusted (P=0.017) or adjusted (P=0.015) analysis. TEER can be safely performed in centers with low volumes of MV repair. However, 1-year mortality and heart failure readmission are superior at centers with higher MVr volume.

Analyzing the Impact of Oncological Data at Different Time Points and Tumor Biomarkers on Artificial Intelligence Predictions for Five-Year Survival in Esophageal Cancer

AIM: In this study, we use Artificial Intelligence (AI), including Machine (ML) and Deep Learning (DL), to predict the long-term survival of resectable esophageal cancer (EC) patients in a high-volume surgical center. Our objective is to evaluate the predictive efficacy of AI methods for survival prognosis across different time points of oncological treatment. This involves comparing models trained with clinical data, integrating either Tumor, Node, Metastasis (TNM) classification or tumor biomarker analysis, for long-term survival predictions. METHODS: In this retrospective study, 1002 patients diagnosed with EC between 1996 and 2021 were analyzed. The original dataset comprised 55 pre- and postoperative patient characteristics and 55 immunohistochemically evaluated biomarkers following surgical intervention. To predict the five-year survival status, four AI methods (Random Forest RF, XG Boost XG, Artificial Neural Network ANN, TabNet TN) and Logistic Regression (LR) were employed. The models were trained using three predefined subsets of the training dataset as follows: (I) the baseline dataset (BL) consisting of pre-, intra-, and postoperative data, including the TNM but excluding tumor biomarkers, (II) clinical data accessible at the time of the initial diagnostic workup (primary staging dataset, PS), and (III) the PS dataset including tumor biomarkers from tissue microarrays (PS + biomarkers), excluding TNM status. We used permutation feature importance for feature selection to identify only important variables for AI-driven reduced datasets and subsequent model retraining. RESULTS: Model training on the BL dataset demonstrated similar predictive performances for all models (Accuracy, ACC: 0.73/0.74/0.76/0.75/0.73; AUC: 0.78/0.82/0.83/0.80/0.79 RF/XG/ANN/TN/LR, respectively). The predictive performance and generalizability declined when the models were trained with the PS dataset. Surprisingly, the inclusion of biomarkers in the PS dataset for model training led to improved predictions (PS dataset vs. PS dataset + biomarkers; ACC: 0.70 vs. 0.77/0.73 vs. 0.79/0.71 vs. 0.75/0.69 vs. 0.72/0.63 vs. 0.66; AUC: 0.77 vs. 0.83/0.80 vs. 0.85/0.76 vs. 0.86/0.70 vs. 0.76/0.70 vs. 0.69 RF/XG/ANN/TN/LR, respectively). The AI models outperformed LR when trained with the PS datasets. The important features shared after AI-driven feature selection in all models trained with the BL dataset included histopathological lymph node status (pN), histopathological tumor size (pT), clinical tumor size (cT), age at the time of surgery, and postoperative tracheostomy. Following training with the PS dataset with biomarkers, the important predictive features included patient age at the time of surgery, TP-53 gene mutation, Mesothelin expression, thymidine phosphorylase (TYMP) expression, NANOG homebox protein expression, and indoleamine 2,3-dioxygenase (IDO) expressed on tumor-infiltrating lymphocytes, as well as tumor-infiltrating Mast- and Natural killer cells. CONCLUSION: Different AI methods similarly predict the long-term survival status of patients with EC and outperform LR, the state-of-the-art classification model. Survival status can be predicted with similar predictive performance with patient data at an early stage of treatment when utilizing additional biomarker analysis. This suggests that individual survival predictions can be made early in cancer treatment by utilizing biomarkers, reducing the necessity for the pathological TNM status post-surgery. This study identifies important features for survival predictions that vary depending on the timing of oncological treatment.

Individual and institutional predisposing factors of MRSA surgical site infection and outcomes-a retrospective case-control-study in 14 European high-volume surgical centres.

To assess incidence rates of surgical site infections (SSI) by MRSA and to determine related factors and clinical outcome compared to MSSA, including country-specific, institutional and patient determinants. We performed a subgroup analysis of the Europe-wide SALT (NCT03353532) study population with MRSA SSI from 14 centres in France, Germany, Italy, Spain and the UK. An overall MRSA SSI incidence of 0.06% (n = 104) was found in 178 903 patients undergoing invasive surgery in 2016. Frequently observed comorbidities were chronic cardiovascular disease, diabetes and solid tumours. Compared to the overall MRSA SSI incidence, incidence rates were significantly higher in Spain (58 of 67 934 cases) and lower in Germany (16 of 46 443 cases; both P < 0.05). Centres with antibiotic stewardship (ABS) and infectious disease (ID) consultation programmes (n = 3/14) had lower MRSA rates (17 of 43 556 cases versus 61 of 83 048 cases, P < 0.05). In bivariate analyses, MRSA SSI patients were significantly older, had higher BMI and more comorbidities compared to MSSA (P < 0.05 each). Surgery performed between 6:00 and 12:00 pm led to higher MRSA proportions among S. aureus SSI (17 of 104 cases versus 62 of 640 cases, P < 0.05). This study shows low overall and country-specific incidence rates of MRSA SSI in Europe. We could show significant differences between countries as well as between centres with established ABS and ID consultation programmes were observed. The number of those programmes seems too small against this background.

Lateral UKA can be a safe solution in a young patients' population: a 10-year follow-up report.

This study aimed to assess the long-term survivorship and functional outcomes of fixed-bearing lateral unicompartmental knee arthroplasty (UKA) in a young patients' population with osteoarthritis limited to the lateral compartment. The study included a cohort of consecutive patients who underwent lateral UKA between January 2008 and December 2014 at a single high-volume surgical center. The surgical procedures were performed by experienced surgeons using a lateral parapatellar approach and fixed-bearing implants. Patient follow-up included a retrospective re-evaluation, clinical assessments, patient-reported outcome measures (PROMs), and X-ray analysis. A total of 40 lateral UKAs were analyzed, with 19 performed on the left and 21 on the right knee. The mean age of the patients at the time of surgery was 57.6 years, and the mean BMI was 24.8. At the final follow-up, 80% of patients achieved excellent outcomes (OKS > 41), and 20% had good outcomes (OKS: 34-41). No patients exhibited fair or poor outcomes. The mean FJS at the final follow-up was 82.8. The mean WOMAC was 10.5. Kaplan-Meier survival analysis revealed a survivorship rate of 93.1% at 10 years, considering revision for any reason as endpoint. Lateral UKA proved to be an effective treatment option for osteoarthritis affecting the lateral compartment of the knee. The study demonstrated a high survivorship rate and favorable functional outcomes at a mean follow-up of 132.7 months. These findings highlight the potential benefits of fixed-bearing lateral UKA in selected patients with lateral compartment knee pathology.

Partial Nephrectomy Drives the Association Between High-volume Centers and Decreased Mortality: A Surveillance, Epidemiology, and End Results-Medicare Analysis

To better understand the association between high-volume surgical kidney cancer centers and decreased mortality. To identify quality metrics that mediate this association. We designed a cohort of 14,044 patients who were diagnosed with kidney cancer between 2004 and 2013 and underwent a partial or radical nephrectomy using SEER-Medicare data. Hospitals were divided into quartiles based on their total nephrectomy volume for the study period. We investigated 6 quality metrics as potential mediators of the association between hospital volume and mortality using a mediation model. At the highest volume centers, survival was higher at 1-, 3-, 5-, and 10-year time intervals, respectively (91% vs 89%, 80% vs 76%, 70% vs 66%, 45% vs 38%, P<.001) compared to the lowest quartile nephrectomy centers. Receipt of partial nephrectomy for stage ≤T1a tumors explains 52.3% of the total association between hospital nephrectomy volume and mortality. Additionally, patients at the highest-volume centers were more likely to be younger (20% vs 26% 80≤ years old, P<.001), white (82% vs 78%, P<.001), reside in more densely populated counties (≥1 million residents, 62% vs 42%, P>.001), have a shorter mean length of stay (5.03 vs 5.88days, P<.001) when compared to those in the lowest-volume quartile. This analysis of SEER-Medicare data is the first to suggest that partial nephrectomy in the setting of T1a tumors mediates the association between hospital volume and mortality. Quality metrics that reduce mortality should be harnessed to develop more efficient and higher-quality health systems.

Infective endocarditis in octogenarians: a retrospective study in a single, high-volume surgical centre

Abstract Funding Acknowledgements Type of funding sources: None. Background Infective endocarditis (IE) is a severe disease associated with high morbidity and mortality. Little is known about the best management of elderly patients with IE. In these patients, surgery may be challenging. Our study aimed to describe IE’s features in octogenarians and to identify the independent predictors of mortality, focusing on the prognostic impact of disability. Methods We retrospectively analyzed 551 consecutive patients admitted to a single surgical centre with a definite diagnosis of non-device-related infective endocarditis; of these, 97 (17.6%) were older than 80 years. Results In patients under eighty, males were mostly involved with a sex ratio exceeding 2:1. This ratio was inverted in older people, where the female gender represented 53.6% of the total. Enterococci (29.8 vs 17.4%, p = 0.005) were significantly more frequent than in younger people. Comorbidities were more frequent in elderly patients; consequently, EUROSCORE II was higher (median ± IQR 16.4 ± 21.1 vs 5.0 ± 10.3, p = 0.001). In octogenarians, IE was more frequently left-sided (97.9 vs 89.8%, p = 0.011). Octogenarians were more often excluded from surgery despite indication (23.7 vs 8.1%, p = 0.001) and had higher three-year mortality (45.3 vs 30.6%, p = 0.005) than younger patients. In elderly patients, age did not independently predict mortality, while exclusion from surgery and a high grade of disability did. Conclusions Octogenarians with IE have specific clinical and microbiological characteristics. Older patients are more often excluded from surgery, and the overall prognosis is poor. Age per se should not be a reason to deny surgery, while disability predicts futility.

A cost analysis of MR-guided laser interstitial thermal therapy for adult refractory epilepsy.

MR-guided laser interstitial thermal therapy (LITT) is used increasingly for refractory epilepsy. The goal of this investigation is to directly compare cost and short-term adverse outcomes for adult refractory epilepsy treated with temporal lobectomy and LITT, as well as to identify risk factors for increased costs and adverse outcomes. The National Inpatient Sample (NIS) was queried for patients who received LITT between 2012 and 2019. Patients with adult refractory epilepsy were identified. Multivariable mixed-effects models were used to analyze predictors of cost, length of stay (LOS), and complications. LITT was associated with reduced LOS and overall cost relative to temporal lobectomy, with a statistical trend toward lower incidence of postoperative complications. High-volume surgical epilepsy centers had lower LOS overall. Longer LOS was a significant driver of increased cost for LITT, and higher comorbidity was associated with non-routine discharge. LITT is an affordable alternative to temporal lobectomy for adult refractory epilepsy with an insignificant reduction in inpatient complications. Patients may benefit from expanded access to this treatment modality for both its reduced LOS and lower cost.

Multidisciplinary Breast Cancer Clinic: A Novel Approach to Decrease Time to Intervention.

Multidisciplinary clinics (MDCs) were created at high-volume surgical oncology centers to optimize breast cancer care, in which patients are seen by multiple subspecialists at one visit. We aim to evaluate our experience with this novel approach. We examined 492 patients with newly diagnosed invasive breast cancer from January 1, 2020, to September 1, 2022. Patients seen at our MDC had a decreased time to intervention across all measured intervals: 3days faster (10 vs 13days) from biopsy to clinic visit [t Sat 2.09 > t critical two tail 1.99], 5days faster (23 vs 28days) from diagnosis to initiation of neoadjuvant chemotherapy [t Sat 5.12 > t critical two tail 2.019], and 21days faster (24 vs 45days) from surgery clinic visit to operation [t Sat 5.12 > t critical two tail 2.019]. Although early in our experience, we have initiated a strategy for improved breast cancer care.

D153. Improving Operating Room Efficiency Through Reducing First Start Delays in an Academic Center

PURPOSE: Delays in operating room (OR) first case start times can cause additional costs for hospitals, healthcare team frustration and delay patient care. Here, we present our findings on a novel process improvement strategy and its effects on improving first case start times at an academic medical center. METHODS: First case in room start times were recorded for operating rooms at an academic medical center. Three interventions - automatic pre-operative orders, dot phrases to permit re-creation of unavailable consent forms, and improved H&P linking to the surgical encounter - were implemented to target documentation-related delays. Monthly percentages of first case on-time starts (FCOTS) and time saved were compared to the “pre-intervention” time period. Total cost savings from reduced operating room time was also estimated. RESULTS: During the first 3-months after implementation of the interventions, the percentage of FCOTS improved from an average of 36.7% to 52.7%. Total time savings across all operating rooms over the same time period was found to be 55.63 hours, which is estimated to have saved a total of $121,834.52 over the three-month interventional period. CONCLUSION: By implementing multiple quality improvement interventions, delays to first start in room OR cases can be meaningfully reduced. In high volume surgical centers and hospitals, these incremental changes can lead to substantial cost savings in both direct and indirect costs. Understanding the root causes of OR delays and designing quality improvement protocols to target those root causes can ultimately be a significant driver to reduce healthcare costs.

Application of Retrocolic Approach with Uncinate Process Priority in Laparoscopic Pancreaticoduodenectomy

Background: Pancreaticoduodenectomy (PD) is a complex operative procedure, which remains the primary curative treatment for pancreatic, distal bile duct, and periampullary cancers. In recent years, with the continuous development of laparoscopic technology and equipment, laparoscopic pancreaticoduodenectomy (LPD) has been performed gradually in many high-volume surgical centers. However, it is still challenging even for experienced pancreatic surgeons to perform LPD, at the same time, with the accumulation of surgical experience, different surgical approaches are also constantly discussed. Methods: We retrospectively analyzed the clinical data of 323 patients who received LPD at a single institution. Among them, 200 patients received operations with retrocolic approach, 123 patients were treated with traditional approach. In this study, we analyzed perioperative data and compared survival time for patients with pancreatic cancers in two groups. Result: Compared with traditional approach, retrocolic approach with uncinate process priority has a shorter operative time (94.25 ± 6.46 minutes versus 116.43 ± .4.78 minutes, P = .009) and less intraoperative blood loss (80 mL versus 150 mL, P = .562). However, there is no statistical significance in the incidence of postoperative complications (≥ Clavien-Dindo [CD] III) (65 [32.5%] versus 45 [36.58%], P = .871), R0 resection rates (41 versus 38, P = .826), and the number of lymph nodes harvested (16.64 ± 5.93 versus 15.37 ± 4.65, P = .785) between two groups. Meanwhile, the median survival time of patients with pancreatic cancers in posterior approach group was longer than those in traditional approach group (30.34 months versus 28.54 months, P > .05); however, there was no statistical significance between them. Conclusion: Retrocolic approach with uncinate process priority is a feasible method for pancreatic cancer, which could reduce operating time and intraoperative bleeding, meanwhile, not increase the incidence of postoperative complications. Retrocolic approach with uncinate process priority can be generalized to larger group sizes.

Urethral-Sparing Robot-Assisted Simple Prostatectomy: Case Series of the Initial Experience of a Brazilian Surgical Center

Benign prostatic hyperplasia (BPH) is a common condition among older men that causes lower urinary tract symptoms. Although pharmacological treatments are available, surgery is often required. The development of surgical techniques has progressed, with robotic simple prostatectomy (RASP) being one of the minimally invasive techniques for larger prostates. However, ejaculatory dysfunction remains a common postoperative problem of BPH surgery, significantly impacting patients' quality of life. In 1990, Dixon et al. were the first to describe the urethral-sparing approach, which maintained anterograde ejaculation. Recently, Wang et al. performed the first urethral-sparing RASP (USRASP). We present a case series from the initial experience of US-RASP in a high-volume Brazilian surgical center with an experienced robotic surgeon. Three patients underwent US-RASP at our center in 2022 were included. The mean age and prostate volume were, respectively, 67.7 years (42-89) and 88.9ml (85.6-92). None of the patients had a median lobe. Total preservation of the urethra was achieved in all patients, with no US-RASP failures and conversion to standard RASP. The average operative time of US-RASP was 98min (86-118). There were no intraoperative complications. Two of the three patients maintained anterograde ejaculation (66.7%), but with reduced volume. There were no postoperative complications and the patients are still being followed up to assess the long-term results. Therefore, our results suggest that USRASP can be implemented with good rates of preservation of the urethra and anterograde ejaculation, since performed by an experienced robotic surgeon.

Obstructive sleep apnea predicts pathologic response to neoadjuvant therapy in resected pancreatic ductal adenocarcinoma.

Obstructive sleep apnea predicts pathologic response to neoadjuvant therapy in resected pancreatic ductal adenocarcinoma.

Analysis of surgical outcomes in 102 patients with renal cell carcinoma with venous tumor thrombus: A retrospective observational single-center study.

The aim of the study was to assess short- and long-term results following radical nephrectomy with renal vein and inferior vena cava thrombectomy in patients with renal cell cancer with venous thrombus and to investigate impact of various demographical, clinical and histological factors on overall survival (OS). The medical records of 102 adult patients with renal cell cancer with venous thrombus admitted for surgery in Department of General, Vascular and Transplant Surgery from 2012 to 2019 were retrospectively analyzed. The tumor was more frequently located on the right side compared to the left one (55 vs. 47). According to Neves Zincke classification, the levels of venous thrombus were as follows: 1 to 48 (47%), 2 to 47 (46%), 3 to 6 (6%), and 4 to 1 (1%). Postoperative complications were noted in 16 (15.7%) patients. One (3%) patient (Neves Zincke 2) died of intraoperative pulmonary embolism during hospitalization. Clear cell carcinoma was the most common pathological type reported in 92 (90.2%) patients. Thirty nine (38.2%) patients were alive at the time of last follow-up. The median OS was 21.50 (0–101.17) months. The 1-year OS was 75.5%. Significantly better OS (median 38.03 months) was noted in patients with RCC Neves Zincke 1 compared to OS (median 14.79 months) in patients with Neves Zincke 2-4 VT (P = .008). Higher tumor staging (T3 vs. T4) (P = .038), nodal staging (N0 vs. N1) (P = .0008), Fuhrman histological grading (G1-2 vs. G3-4) (P = .033) were associated with a shorter OS. Patients with renal cell cancer with venous thrombus, with an acceptable perioperative risk, should be treated surgically, because radical nephrectomy with thrombectomy performed in a high volume surgical center is a safe procedure. Neves Zincke 2-4 venous thrombus, higher tumor and nodal staging, as well higher Fuhrman histological grading are associated with a shorter OS.

Triage and outcomes for a whole cohort of patients presenting for major emergency abdominal surgery including the No-LAP population: a prospective single-center observational study.

PurposeThis study aimed to characterize 252 consecutive patients with an indication for major emergency abdominal surgery including patients not proceeding to surgery (No-Lap). Patients who do not proceed to major emergency abdominal surgery and their clinical outcomes are not well characterized in the existing literature. Triage criteria may vary between centers, potentially impacting reported outcomes.MethodsA single-center prospective observational study in a high-volume Danish surgical center including 252 patients presenting with an indication for major emergent abdominal surgery was conducted from the 15th of October 2020 to the 15th of August 2021. The primary outcome was to estimate the prevalence of No-Lap patients.ResultsOverall, 21 patients (8.3%) of our total study cohort did not proceed to surgery. These patients were significantly older, more comorbid with higher ASA scores, poorer performance status, and were more likely to have bowel ischemia. Poor functional performance and surgeons’ consideration of futile intervention were the main reasons for deferring surgery in all 21 patients. Overall, 30-day mortality was 95% for the No-LAP cohort, 9% for the LAP cohort, and 16% for the whole cohort, respectively.ConclusionsThe No-LAP group selection process could be one of the main determinants of reported postoperative outcomes. Prospective international multi-center studies to characterize the entire cohort of patients eligible for emergency laparotomy including the No-LAP population are needed, as large variations in triage criteria and culture seem to exist.Trial registration Retrospectively registered.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00068-022-02052-4.

Prothrombin Complex Concentrate vs Plasma for Post–Cardiopulmonary Bypass Coagulopathy and Bleeding

Post-cardiopulmonary bypass (CPB) coagulopathy and bleeding are among the most common reasons for blood product transfusion in surgical practices. Current retrospective data suggest lower transfusion rates and blood loss in patients receiving prothrombin complex concentrate (PCC) compared with plasma after cardiac surgery. To analyze perioperative bleeding and transfusion outcomes in patients undergoing cardiac surgery who develop microvascular bleeding and receive treatment with either PCC or plasma. A single-institution, prospective, randomized clinical trial performed at a high-volume cardiac surgical center. Patients were aged 18 years or older and undergoing cardiac surgery with CPB. Patients undergoing complex cardiac surgical procedures (eg, aortic replacement surgery, multiple procedures, or repeated sternotomy) were preferentially targeted for enrollment. During the study period, 756 patients were approached for enrollment, and 553 patients were randomized. Of the 553 randomized patients, 100 patients met criteria for study intervention. Patients with excessive microvascular bleeding, a prothombin time (PT) greater than 16.6 seconds, and an international normalized ratio (INR) greater than 1.6 were randomized to receive treatment with either PCC or plasma. The PCC dose was 15 IU/kg or closest standardized dose; the plasma dose was a suggested volume of 10 to 15 mL/kg rounded to the nearest unit. The primary outcome was postoperative bleeding (chest tube output) from the initial postsurgical intensive care unit admission through midnight on postoperative day 1. Secondary outcomes were PT/INR, rates of intraoperative red blood cell (RBC) transfusion after treatment, avoidance of allogeneic transfusion from the intraoperative period to the end of postoperative day 1, postoperative bleeding, and adverse events. One hundred patients (mean [SD] age, 66.8 [13.7] years; 61 [61.0%] male; and 1 [1.0%] Black, 1 [1.0%] Hispanic, and 98 [98.0%] White) received the study intervention (49 plasma and 51 PCC). There was no significant difference in chest tube output between the plasma and PCC groups (median [IQR], 1022 [799-1575] mL vs 937 [708-1443] mL). After treatment, patients in the PCC arm had a greater improvement in PT (effect estimate, -1.37 seconds [95% CI, -1.91 to -0.84]; P < .001) and INR (effect estimate, -0.12 [95% CI, -0.16 to -0.07]; P < .001). Fewer patients in the PCC group required intraoperative RBC transfusion after treatment (7 of 51 patients [13.7%] vs 15 of 49 patients [30.6%]; P = .04); total intraoperative transfusion rates were not significantly different between groups. Seven (13.7%) of 51 patients receiving PCCs avoided allogeneic transfusion from the intraoperative period to the end of postoperative day 1 vs none of those receiving plasma. There were no significant differences in postoperative bleeding, transfusions, or adverse events. The results of this study suggest a similar overall safety and efficacy profile for PCCs compared with plasma in this clinical context, with fewer posttreatment intraoperative RBC transfusions, improved PT/INR correction, and higher likelihood of allogeneic transfusion avoidance in patients receiving PCCs. ClinicalTrials.gov Identifier: NCT02557672.

Socioeconomic Predictors of Access to Care for Patients with Operatively Managed Pancreatic Cancer in New York State

PurposeWe evaluated how race and socioeconomic factors impact access to high-volume surgical centers, treatment initiation, and postoperative care for pancreatic cancer in a state with robust safety net insurance coverage and healthcare infrastructure. MethodsThe New York Statewide Planning and Research Cooperative System was analyzed. Patients with pancreatic cancer resected from 2007 to 2017 were identified by ICD and CPT codes. Primary outcomes included surgery at low-volume facilities (<20 pancreatectomies/year), time to therapy initiation, and time to postoperative surveillance imaging (within 60–180 days after surgery). ResultsIn total, 3312 patients underwent pancreatectomy across 124 facilities. Median age was 67 years (IQR 59, 75) and 55% of patients were male. Most (72.7%) had surgery at high-volume centers. On multivariable analysis, odds ratios for surgery at low-volume centers were increased for Black race (2.21 (95% CI 1.69–2.88)), Asian race (1.64 (95% CI 1.09–2.43)), Hispanic ethnicity (1.68 (95% CI 1.24–2.28)), Medicaid insurance (2.52 (95% CI 1.79–3.56)), no insurance (2.24 (95% CI 1.38–3.61)), lowest income quartile (3.31 (95% CI 2.14–5.32)), and rural zip code (2.49 (95% CI 1.69–3.65)). Patients treated at low-volume centers waited longer to initiate treatment (hazard ratio (HR) 0.91 (95% CI 0.81–1.01)). Black patients underwent the least surveillance imaging (50.4%; p <0.0001), while Asian (HR 2.04, 95% CI 1.40–2.98)) and Hispanic patients (HR 1.36 (95% CI 1.00–1.84)) were more likely to have surveillance imaging. ConclusionsRace independently affected access to high-volume facilities and surveillance imaging. When considered in light of other accumulating evidence, future efforts might investigate the perceptions and logistical considerations noted by providers and patients alike to identify the etiology of these disparities and then institute corrective measures.

PD59-08 INTERNATIONAL MULTI-INSTITUTIONAL CHARACTERIZATION OF THE PERIOPERATIVE MORBIDITY OF METASTASECTOMY FOR RENAL CELL CARCINOMA

You have accessJournal of UrologyCME1 May 2022PD59-08 INTERNATIONAL MULTI-INSTITUTIONAL CHARACTERIZATION OF THE PERIOPERATIVE MORBIDITY OF METASTASECTOMY FOR RENAL CELL CARCINOMA Timothy Lyon, Eduard Roussel, Vidit Sharma, Gianpiero Carames, Christine Lohse, Stephen Boorjian, Houston Thompson, Steven Joniau, Maarten Albersen, Leuven Belgium, and Bradley Leibovich Timothy LyonTimothy Lyon More articles by this author , Eduard RousselEduard Roussel More articles by this author , Vidit SharmaVidit Sharma More articles by this author , Gianpiero CaramesGianpiero Carames More articles by this author , Christine LohseChristine Lohse More articles by this author , Stephen BoorjianStephen Boorjian More articles by this author , Houston ThompsonHouston Thompson More articles by this author , Steven JoniauSteven Joniau More articles by this author , Maarten AlbersenMaarten Albersen More articles by this author , Leuven BelgiumLeuven Belgium More articles by this author , and Bradley LeibovichBradley Leibovich More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002644.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Although complete surgical resection of metastatic renal cell carcinoma (mRCC) has been associated with improved cancer-specific survival, high-quality data on its perioperative morbidity are lacking. The existing population-based data are severely limited by reliance on billing claims to identify outcomes, which may overestimate events due to lack of code specificity. Therefore, the objective of this study was to evaluate 30-day complications after metastasectomy from two high-volume surgical centers. METHODS: Prospectively maintained nephrectomy registries at Mayo Clinic and UZ Leuven were queried to identify adults who underwent a metastasectomy for mRCC between 2006 and 2020. Records were retrospectively reviewed to identify a comprehensive list of over 40 possible complications within 30 days of surgery classified according to the Clavien-Dindo system, with grade III-V complications considered major. Associations of features with postoperative complications were evaluated using conditional logistic regression models with center as a stratification variable. RESULTS: A total of 740 metastasectomies in 522 patients were identified, including 543 contributed by Mayo Clinic and 197 by UZ Leuven. Among the 740 metastasectomies, 193 (26%; 95% CI 23-29%) had a 30-day complication and 62 (8%; 95% CI 7-11%) had a major complication, including eight (1%) perioperative deaths. Age, BMI, ASA score, metastasectomy concurrent with nephrectomy, multiple sites of metastasis, pancreatic metastasis, and size of metastasis were significantly associated with postoperative complications (Table 1). Similarly, age, multiple sites of metastasis, and pancreatic metastasis were significantly associated with major complications (Table 1). The addition of the indicator for complete metastasectomy and all two-way interactions with this feature was not statistically significant (p ≥ 0.2). CONCLUSIONS: In this multi-institutional cohort fewer than 10% of metastasectomies for mRCC resulted in a major complication within 30 days, which is considerably lower than reported in population-based data. Along with increasing age and comorbidity, patients with multiple sites of disease or those who harbor pancreatic metastases are at highest risk of postoperative morbidity. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e1021 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Timothy Lyon More articles by this author Eduard Roussel More articles by this author Vidit Sharma More articles by this author Gianpiero Carames More articles by this author Christine Lohse More articles by this author Stephen Boorjian More articles by this author Houston Thompson More articles by this author Steven Joniau More articles by this author Maarten Albersen More articles by this author Leuven Belgium More articles by this author Bradley Leibovich More articles by this author Expand All Advertisement PDF DownloadLoading ...

146: THE NEED OF CDH1 GERMLINE MUTATION SCREENING IN PATIENTS WITH GASTRIC CANCER IN THE WEST

Abstract Background and aim Although the international guidelines recommend the CDH1 germline mutations screening in patients at risk of carrying pathogenic mutations, few data exist about the compliance to systematic screening programs carried out in surgical centres. Methods In the present manuscript we report the results of CDH1 germline mutations screening, undertaken in patients with gastric cancer and their relatives at high volume surgical centre of Verona University from January 2011 to July 2020. In this study HDGC 2015 Guidelines criteria were used. Results During a 10 years period, we screened 72 subjects; among them, we found a pathogenic germline genetic alteration in 37 (51,4%). 15 patients underwent to surgery due to clinically detectable tumours or positive biopsies during endoscopic surveillance; of note the youngest case of early SRC tumours detected during endoscopy was aged 15 years old. 11 underwent prophylactic gastrectomy: 8 out of 11 (72,7%) presented neoplastic foci in the specimen. During surgical operation, 7 patients required an additional oesophageal resection due to the presence of gastric mucosa at the extemporary frozen section, despite the proximal section was made above the cardia. Conclusion Based on our experience, we can conclude that the CDH1 genetic screening should be absolutely offered to high-risk Western patients, in agreement with the international guidelines. Prophylactic total gastrectomy should be considered in selected cases also under 20 years of age.