Higher Comprehensive Complication Index Research Articles

Robotic and Laparoscopic Adrenalectomy for Pheochromocytoma: An International Multicenter Study

Background and objectiveRobotic adrenalectomy (RA) has attracted interest as an alternative to laparoscopic adrenalectomy (LA) for patients with pheochromocytoma, although its beneficial effects are uncertain. Our aim was to compare RA and LA outcomes for these patients. MethodsData for patients who underwent RA or LA for pheochromocytoma in 46 international centers between 2012 and 2022 were reviewed. We analyzed baseline characteristics and postoperative complications at discharge, 90 d, and 1 yr. We conducted propensity score matching (PSM; 1:1 ratio) and multivariable analyses to evaluate outcomes and risk factors for the occurrence of complications and higher Comprehensive Complication Index (CCI). Key findings and limitationsOf 1755 patients, 1613 (91.9%) underwent LA and 142 (8.1%) underwent RA. Estimated blood loss, conversion rate, complication rate, and CCI at discharge, 90 d, and 1 yr were similar between the groups. However, RA was associated with a longer operative time in comparison to LA (100 vs 123 min; p < 0.001), but not after PSM (p = 0.120). Multivariable analysis revealed that Charlson comorbidity index (odds ratio [OR] 1.17, 95% confidence interval [CI] 1.07–1.29; p = 0.001), and tumor size per 1-cm increment (OR 1.13, 95% CI 1.07–1.21; p < 0.001) were independently associated with the incidence of complications, but there was no significant difference in complication rates between the LA and RA groups (OR 1.09, 95% CI 0.63–1.87; p = 0.767). After PSM, RA was associated with a lower rate of severe (grade ≥3a) complications in comparison to LA (p = 0.023). Conclusions and clinical implicationsRA is a safe alternative to LA and yields similar outcomes for patients with pheochromocytoma. RA may be associated with a lower likelihood of severe complications. Further studies are warranted to determine the role of robotic surgery in pheochromocytoma. Patient summaryPheochromocytoma is a rare tumor in the adrenal gland and the gold-standard treatment is surgical removal. We assessed patient outcomes after robot-assisted surgery compared with laparoscopic surgery and found that outcomes are similar, but the rate of severe complications may be lower if a surgical robot is used.

Preoperative anaemia in distal pancreatectomy: a propensity-score matched analysis

BackgroundPreoperative anaemia is a prevalent morbidity predictor that adversely affects short- and long-term outcomes of patients undergoing surgery. This analysis aimed to investigate preoperative anaemia and its detrimental effects on patients after distal pancreatectomy.Material and methodsThe present study was a propensity-score match analysis of 286 consecutive patients undergoing distal pancreatectomy. Patients were screened for preoperative anaemia and classified according to WHO recommendations. The primary outcome measure was overall morbidity. The secondary endpoints were in-hospital mortality and rehospitalization.ResultsThe preoperative anaemia rate before matching was 34.3% (98 patients), and after matching a total of 127 patients (non-anaemic 42 vs. anaemic 85) were included. Anaemic patients had significantly more postoperative major complications (54.1% vs. 23.8%; p < 0.01), a higher comprehensive complication index (26.2 vs. 4.3; p < 0.01), and higher in-hospital mortality rate (14.1% vs. 2.4%; p = 0.04).Multivariate regression analysis confirmed these findings and identified preoperative anaemia as a strong independent risk factor for postoperative major morbidity (OR 4.047; 95% CI: 1.587–10.320; p < 0.01).ConclusionThe current propensity-score matched analysis strongly considered preoperative anaemia as a risk factor for major complications following distal pancreatectomy. Therefore, an intense preoperative anaemia workup should be increasingly prioritised.

Clinical outcomes and costs of retromuscular and intraperitoneal onlay mesh techniques in robotic incisional hernia repair.

This study aims to compare clinical outcomes and financial cost of intraperitoneal onlay mesh (IPOM) versus retromuscular (RM) repairs in robotic incisional hernia repairs (rIHR). Patients who underwent either IPOM or RM elective rIHR from 2012 to 2022 were included. Demographics, operative details, postoperative outcomes, and hospital costs were directly compared. Sixty-nine IPOM and 55 RM were included. Age and body mass index (BMI) did not differ between both groups (IPOM vs RM: 59.3 ± 11.2years vs. 57.5 ± 14years, p = 0.423; BMI 34.1 ± 6.3 vs. BMI 33.2 ± 6.9, p = 0.435, respectively). Comorbidities and hernia characteristics were comparable. Extensive lysis of adhesions (> 30min) was required more often in IPOM (18 vs. 6 in RM, p = 0.034). Defect closure was achieved in 100% of RM vs. 81.2% in IPOM (p < 0.001). Median (interquartile range) postoperative pain score was higher in RM than in IPOM [5(3-7) vs. 4(3-5), respectively, p = 0.006]. Median length of stay (0day) and same-day discharge rate did not differ between groups (p = 0.598, p = 0.669, respectively). Six (8.7%) patients in the IPOM group versus one (1.8%) patient in the RM group were readmitted to hospital within 30 days postoperatively (p = 0.099). Perioperative complications were higher in IPOM (p = 0.011; 34.8% vs. 14.5% in RM) with higher Comprehensive Complication Index® morbidity scores [0(0-12.2) vs 0(0-0) in RM, p = 0.008)], Clavien-Dindo grade-II complications (8 vs 0 in RM, p = 0.009), and surgical site events (17 vs. 5 in RM, p = 0.024). Within a follow-up period of 57(± 28) months, recurrence rates were similar between both groups. Hospital costs did not differ between groups [IPOM: $9978 (7031-12,926) vs. RM: $8961(6701-11,222), p = 0.300]. Although postoperative complication costs were higher in IPOM ($2436 vs RM: $161, p = 0.020), total costs were comparable [IPOM: $12,415(8700-16,130) vs. RM: $9123(6789-11,457), p = 0.080]. Despite retromuscular repairs having lower postoperative complications than intraperitoneal onlay mesh repairs, both techniques offered encouraging results in robotic incisional hernia repair at a comparable total cost.

A comparative analysis of Charlson's weighted index of comorbidity and perforated peptic ulcer scores in predicting postoperative mortality and high comprehensive complication index.

Limited data exists on Charlson's weighted index of comorbidity (WIC) predictability for postoperative outcomes following perforated peptic ulcer (PPU) surgery. This study assesses the utility of WIC and other predictive scores in forecasting both postoperative mortality and morbidity in PPU. Patients with PPUs operated between 2018 and 2021 in a Malaysian tertiary referral center were included. Clinical data were retrospectively analyzed for association with mortality and morbidity measured with the Comprehensive Complication Index (CCI). Predictability of WIC and other predictors were examined using area under receiver-operator characteristic (ROC) curve (AUC). Among 110 patients included, 18 died (16.4%) and 36 (32.7%) had significant morbidity postoperatively (High CCI, ≥26.2). Both mortality and high CCI were associated with age >65years, female sex, comorbidities (diabetes mellitus, hypertension, and renal disease), and American Society of Anesthesiologist score >2. Most patients who died had renal dysfunction, metabolic acidosis, lactate >2mmol/L upon presentation preoperatively. While surgery >24h after presentation correlated with mortality and high CCI, the benefit of earlier surgery <6h or <12h was not demonstrated. WIC (AUC, 0.89; 95% CI, 0.81-0.99) showed similar predictability to Peptic Ulcer Perforation (PULP) (AUC, 0.97; 95% CI, 0.93-1.00) for mortality. PULP effectively predicted high CCI (AUC, 0.83; 95% CI, 0.73-0.93; p<0.001). WIC is valuable in predicting mortality, highlighting the importance of comorbidity in risk assessment. PULP score was effective in predicting both mortality and high CCI. Early identification of patients with high perioperative risk will facilitate patients' triage for escalated care, leading to a better outcome.

Biliary complications after adult-to-adult living-donor liver transplantation: An international multicenter study of 3633 cases

In living-donor liver transplantation, biliary complications including bile leaks and biliary anastomotic strictures remain significant challenges, with incidences varying across different centers. This multicentric retrospective study (2016-2020) included 3633 adult patients from 18 centers and aimed to identify risk factors for these biliary complications and their impact on patient survival. Incidences of bile leaks and biliary strictures were 11.4% and 20.6%, respectively. Key risk factors for bile leaks included multiple bile duct anastomoses (odds ratio, [OR] 1.8), Roux-en-Y hepaticojejunostomy (OR, 1.4), and a history of major abdominal surgery (OR, 1.4). For biliary anastomotic strictures, risk factors were ABO incompatibility (OR, 1.4), blood loss >1 L (OR, 1.4), and previous abdominal surgery (OR, 1.7). Patients experiencing biliary complications had extended hospital stays, increased incidence of major complications, and higher comprehensive complication index scores. The impact on graft survival became evident after accounting for immortal time bias using time-dependent covariate survival analysis. Bile leaks and biliary anastomotic strictures were associated with adjusted hazard ratios of 1.7 and 1.8 for graft survival, respectively. The study underscores the importance of minimizing these risks through careful donor selection and preoperative planning, as biliary complications significantly affect graft survival, despite the availability of effective treatments.

Risk Factors for a High Comprehensive Complication Index after Splenectomy Plus Pericardial Devascularization for Portal Hypertension.

Mathematical integration of all complications from the Clavien-Dindo classification into one number called the comprehensive complication index provides a novel method to capture morbidity. This objective of this study was to compare the evaluations of complications between the novel comprehensive complication index and Clavien-Dindo classification for portal hypertension patients who underwent splenectomy plus pericardial devascularization. Patients treated with either splenectomy plus simplified pericardial devascularization or splenectomy plus traditional pericardial devascularization were included retrospectively. Correlation and logistic regression analyses of the postoperative hospital stay and total hospitalization expense were compared between the comprehensive complication index and Clavien-Dindo classification. The cumulative sum-comprehensive complication index was generated and compared between operation types. The Child-Pugh classification at admission, spleen thickness, and intraoperative blood loss were risk factors for high comprehensive complication index. Comprehensive complication index showed a stronger relationship with the postoperative hospital stay and total hospitalization expense than the Clavien-Dindo classification. Logistic regression analysis of the postoperative hospital stay demonstrated that the R2 values for the comprehensive complication index and Clavien-Dindo classification were 0.15 and 0.14, respectively. The cumulative sum-comprehensive complication index graph showed a steady dynamic decrease in the cumulative sum score for the individual operation type, with splenectomy plus simplified pericardial devascularization revealing a more notable decrease than splenectomy plus traditional pericardial devascularization. Comprehensive complication index is an excellent method to assess postoperative morbidity in portal hypertension patients. The cumulative sum-comprehensive complication index chart can better dynamically monitor and compare different operation types. Splenectomy plus simplified pericardial devascularization is better than splenectomy plus traditional pericardial devascularization at decreasing cumulative sum-comprehensive complication index.

41. HIGH COMPREHENSIVE COMPLICATION INDEX AFTER MINIMALLY INVASIVE ESOPHAGECTOMY ASSOCIATED WITH POOR SHORT-TERM AND LONG-TERM OUTCOME: A PROPENSITY SCORE MATCHING ANALYSIS

Abstract Introduction The comprehensive complication index (CCI) is a new index to comprehensively and systematically evaluate complication severity. The objective of this study was to evaluate the predictive ability of CCI on short—and long-term overall survival(OS) in patients with esophageal squamous cell carcinoma (ESCC) undergoing minimally invasive esophagectomy (MIE) based on a propensity Score Matching (PSM) analysis. Methods A total of 356 patients treated with radical MIE from 2013 to 2017 were included, and the primary outcome was OS, and the secondary outcomes were postoperative hospital stay and hospital costs. Firstly, the optimla cut-off value of CCI was determined by X-tile. PSM was used to balance the baseline characteristics. Second, we compared postoperative hospital stay and hospital costs between high- and low-CCI group. Third, the Kaplan–Meier survival curve was used to analyze survival difference. Fourth, univariate and multivariate Cox analysis was used to explore the independent risk factors of OS. Results The CCI &amp;gt; 24.2 was defined as high-CCI group and CCI≦24.2 was defined as low-CCI group. The high-CCI group had more hospital costs and longer hospital stay than the low-CCI group both before and after PSM (p &amp;lt; 0.001). The K-M analysis indicated that patients with high CCI had worse prognosis both before and after PSM (before matching: P &amp;lt; 0.001; after matching: P = 0.04). CCI was determined as independent prognostic factor both before and after PSM (before PSM, P = 0.002; after PSM, P = 0.025). Conclusion The CCI could quantify postoperative complications after esophagectomy. High CCI is associated with longer hospital stay and hospitalization costs, and is an independent risk factor for poor OS.

Surgery-related disseminated intravascular coagulation predicts postoperative complications

PurposeThe rate of postoperative morbidity, including infectious complications, is still high after major hepatobiliary pancreatic (HBP) surgery. Although surgery-related disseminated intravascular coagulation (DIC) occurs in some cases, its significance has not been elucidated in HBP surgery. This study aimed to evaluate the influence of surgery-related DIC on the complication severity after HBP surgery.MethodsWe analyzed the records of 100 patients with hepatectomy in two or more segments, hepatectomy with biliary tract reconstruction, and pancreaticoduodenectomy. The baseline characteristics and complications were compared between patients with and without surgery-related DIC on postoperative day 1 (POD1) after HBP surgery between 2010 and 2018. Complication severity was assessed using the Comprehensive Complication Index (CCI).ResultsThe DIC group (surgery-related DIC on POD1) had predictive factors, such as larger bleeding volume and higher liver enzyme levels. The DIC group exhibited significantly elevated rates of surgical site infection, sepsis, prolonged intensive care unit stay, more frequent blood transfusions, and higher CCI. Furthermore, compared with and without adjustment of DIC, odds ratio (OR) of AST level and operation time for the risk of high CCI decreased (OR of AST level: 1.25 to 1.19 and OR of operation time: 1.30 to 1.23) and the significant differences had vanished.ConclusionsSurgery-related DIC on POD1 could be a partial mediator between AST level, operation time and higher CCI. The prevention or proper management of surgery-related DIC on POD1 can be an important target to reduce the severity of postoperative complications.

Comprehensive Complication Index to Monitor Morbidity and Mortality After Liver Transplantation in Primary Sclerosing Cholangitis.

The objective of this study was to investigate the short-term and long-term morbidity after liver transplantation (LTx) in patients with primary sclerosing cholangitis (PSC). PSC is a common indication for LTx in Scandinavia. Recently, research has focused on long-term survival and morbidity. The Comprehensive Complication Index (CCI) precisely describes postsurgical complications, by considering both number and severity. Two patient groups were compared: those with classical PSC symptoms (n=148) and those with increased risk of cholangiocarcinoma (n=51, premalignant group). Two CCI scores were calculated, at 1-year post-LTx and a cumulative overall score at the latest follow-up. In addition, we investigated factors potentially related to high CCI. The 1-year median CCI were 29.6 and 26.2 in the classical and premalignant groups, respectively ( P =0.308). The median overall CCI were 43.2 and 46.8 ( P =0.765), respectively. Patient survival was significantly lower in patients with 1-year CCI>42. The most common complications associated with low survival were cholangitis, infections, and hypertension. One-year and overall CCI were similar between sexes and different types of biliary anastomosis. Patients with pre-LTx Model for End-stage Liver Disease scores >20 had higher 1-year and overall CCI (36.2 and 52.6, respectively) than those with lower Model for End-stage Liver Disease scores. Both low (<22) and high (>25kg/m 2 ) body mass indices were associated with high overall 1-year and overall CCI (50.9 and 41.8, respectively), but median body mass indices were associated with significantly lower 1-year and overall CCI (38.4, P =0.023). The previously determined 1-year CCI cutoff of 42 could significantly predict survival post-LTx. Mortality and morbidity were not significantly different between the PSC groups analyzed.

Development of sarcopenia-based nomograms predicting postoperative complications of benign liver diseases undergoing hepatectomy: A multicenter cohort study.

Sarcopenia has a remarkable negative impact on patients with liver diseases. We aimed to evaluate the impact of preoperative sarcopenia on the short-term outcomes after hepatectomy in patients with benign liver diseases. A total of 558 patients with benign liver diseases undergoing hepatectomy were prospectively reviewed. Both the muscle mass and strength were measured to define sarcopenia. Postoperative outcomes including complications, major complications and comprehensive complication index (CCI) were compared among four subgroups classified by muscle mass and strength. Predictors of complications, major complications and high CCI were identified by univariate and multivariate logistic regression analysis. Nomograms based on predictors were constructed and calibration cures were performed to verify the performance. 120 patients were involved for analysis after exclusion. 33 patients were men (27.5%) and the median age was 54.0 years. The median grip strength was 26.5 kg and the median skeletal muscle index (SMI) was 44.4 cm2/m2. Forty-six patients (38.3%) had complications, 19 patients (15.8%) had major complications and 27 patients (22.5%) had a CCI ≥ 26.2. Age (p = 0.005), SMI (p = 0.005), grip strength (p = 0.018), surgical approach (p = 0.036), and operation time (p = 0.049) were predictors of overall complications. Child-Pugh score (p = 0.037), grip strength (p = 0.004) and surgical approach (p = 0.006) were predictors of major complications. SMI (p = 0.047), grip strength (p < 0.001) and surgical approach (p = 0.014) were predictors of high CCI. Among the four subgroups, patients with reduced muscle mass and strength showed the worst short-term outcomes. The nomograms for complications and major complications were validated by calibration curves and showed satisfactory performance. Sarcopenia has an adverse impact on the short-term outcomes after hepatectomy in patients with benign liver diseases and valuable sarcopenia-based nomograms were constructed to predict postoperative complications and major complications.

Predictive Value of Body Composition Parameters for Postoperative Complications in Patients Who Received Pancreaticoduodenectomy

Introduction: Sarcopenia and visceral obesity have been identified as risk factors for postoperative complications following hepatobiliary and colon surgery. However, the correlation between body composition parameters and morbidity following pancreatectomy remains unclear. This study aimed to assess the predictive value of body composition parameters measured from preoperative CT images for postoperative complications following pancreaticoduodenectomy (PD). Methods: A retrospective study of patients who underwent PD between January 2018 and January 2021 was performed. Areas of subcutaneous adipose tissue, visceral adipose tissue, total abdominal muscle area, and mean muscle radio-attenuation were measured from preoperative CT images. Postoperative complications were categorized according to the Clavien-Dindo classification, and comprehensive complication index (CCI) scores were calculated. Logistic regression analysis was performed to identify factors associated with clinically relevant postoperative pancreatic fistula (CR-POPF) and high CCI score (≥26.2). Results: From the data collected on 129 study patients, sarcopenia, visceral obesity, and myosteatosis were detected in 47 (36.4%), 38 (29.4%), and 50 (38.7%) patients, respectively. CR-POPF developed in 51 (39.5%) patients, the overall median CCI score was 30.8 (22.6–36.2), and high CCI scores were identified in 70 (54.3%) patients. Multivariate analysis indicated sarcopenia and visceral obesity were independent risk variables for CR-POPF. Preoperative sarcopenia, visceral obesity, age, preoperative biliary drainage, and a positive culture of postoperative drainage were predictors of high CCI scores. Conclusion: Sarcopenia and visceral obesity were significant predictors of CR-POPF and high CCI score. Preoperative body composition assessment by CT images may help identify high-risk patients who undergo PD.

Impact of Abdominal Aortic Calcification After Major Hepatobiliary Pancreatic Surgery: A Retrospective Cohort Study.

The rate of postoperative morbidity after major hepatobiliary pancreatic (HBP) surgery is estimated to be high. We hypothesized that the frailty and insufficient blood supply of organs caused by arteriosclerosis may lead to increased severity of postoperative complications. The aim of this study was to clarify the relationship between abdominal aortic calcification (AAC) and severity of major HBP surgery postoperative complications. A total of 322 major HBP surgeries were performed in Hiroshima University Hospital, Japan from January 2010 to March 2018. The records of 214 patients were retrospectively analyzed to include those with hepatectomy in two or more segments. These included donor hepatectomy, hepatectomy with biliary tract reconstruction, and pancreaticoduodenectomy. We compared the baseline AAC levels (cut-off; 1,000 mm3) with their corresponding levels after HBP surgery complications developed. The complication severity was assessed using the Comprehensive Complication Index (CCI). The high-AAC (N=71) group had significantly increased incidence rates of surgical site infections and a higher CCI, even after propensity matching. Multivariate analysis revealed that a higher AAC was an independent risk factor of severe postoperative complications (CCI ≥40) (OR=10.21, p<0.01). An increased AAC has a corresponding increase in postoperative complication severity after major HBP surgery. Careful anastomosis and infection control are required to prevent the progression of severe postoperative complications among high-AAC patients.

Postoperative complications predict poor outcomes only in patients with a low modified clinical score after resection of colorectal liver metastases: a retrospective cohort study

The aim was to identify the optimal criteria of postoperative complications (POCs) for predicting oncological outcomes after hepatectomy for colorectal liver metastases (CRLMs) and to investigate the variable prognostic implications of POCs according to the modified clinical score (M-CS). We identified 751 patients who underwent curative hepatic resection for CRLM between 2007 and 2018. Patients were categorized based on the M-CS. The impact of the severity [≥ Clavien–Dindo grade (C–D) III or comprehensive complication index (CCI) ≥ 26.2] or type [any infectious complications of POC (Inf-poc)] of POC on overall survival (OS) and recurrence-free survival (RFS) was assessed by univariate and multivariable analyses in different groups. Patients with a major or infectious complication were not associated with either RFS or OS in multivariable analysis of the whole cohort. However, patients with a high CCI had a worse OS (HR 1.51, P = 0.004). Among patients with low M-CS, patients with high CCI had worse OS (HR 1.49, P = 0.035) and RFS (HR 1.32, P = 0.048) than those without high CCI. In contrast, the survival disadvantage of a high CCI was not present in patients with a high M-CS. Compared to Inf-poc or major complications, a high CCI decreased long-term OS in patients treated with hepatectomy for CRLM. High CCI has a variable prognostic impact after hepatic resection for CRLM depending on the M-CS. POC is not a decisive factor to justify the use of hepatectomy for CRLM in patients with high M-CS.

Effect of malnutrition on postoperative results after pancreatic resection: An entropy balancing analysis

Malnutrition is a well-recognized risk factor for major surgery-related complications, but the impact of preoperative nutritional therapy is still debated due to a lack of high-level evidence. The study aims to evaluate the role of preoperative malnutrition in the postoperative course of patients who underwent pancreatic resection. This is a retrospective study involving 488 patients who underwent pancreatic resection. An entropy balance was applied to 134 patients at risk for moderate or severe malnutrition (M/S-MAL) to obtain a cohort equal to 354 patients, with the null or low risk of malnutrition (N/L-MAL). The reweighting scheme was made in two steps. In the 1st reweighting, the two cohorts were homogenized for confounding factors not modifiable. In the 2nd reweighting, the two cohorts were matched for modifiable factors by preoperative dietary support. The entropy balance was evaluated with the d-value. The postoperative results were reported as mean differences (MD) or odds ratio (OR) with a confidence interval at 95% (95 CI). The M/S-MAL included patients with lower values of BMI (d<0.750), hemoglobin (d=0.671), serum albumin (d=0.554), total protein (d=0.381). The M/S-MAL patients were more frequent ECOG 1-2 (d=0.418), with jaundice (d=0.445) or back pain (d=0.366). The pancreaticoduodenectomy (d=0.440) and vascular resection (d=0.620) in the M/S-MAL group were performed more frequently. The pancreatic remnant was more often hard (d=0.527), and the Wirsung duct dilated (d=0.459) in the N/L-MAL group. The rate of pancreatic ductal adenocarcinoma was higher in M/S-MAL (d=0.399). After 1st weighting, M/S-MAL patients have a high comprehensive complication index (CCI) (MD=5.5; 0.3 to 10.7), were more frequently discharged not at home (OR 2.3; 1.1 to 5.4) with a prolonged mean hospital stay (MD 6.1.1; 0.1 to 12.1, days), After 2nd weighting, the two groups have similar postoperative results. The correction of malnutrition could play an independent role in reducing the severity of complication, length of stay, and type of discharge in patients who underwent pancreatic resection.

Using the Comprehensive Complication Index to Rethink the ISGLS Criteria for Post-hepatectomy Liver Failure in an International Cohort of Major Hepatectomies.

To compare different criteria for post-hepatectomy liver failure (PHLF) and evaluate the association between International Study Group of Liver Surgery (ISGLS) PHLF and the Comprehensive Complication Index (CCI)" and 90-day mortality. PHLF is a serious complication following hepatic resection. Multiple criteria have been developed to characterize PHLF. Adults who underwent major hepatectomies at twelve international centers (2010-2020) were included. We identified patients who met criteria for PHLF based on three definitions: 1) ISGLS, 2) Balzan (INR > 1.7 and bilirubin > 2.92mg/dL) or 3) Mullen (peak bilirubin >7mg/dL). We compared the 90-day mortality and major morbidity predicted by each definition. We then used logistic regression to determine the odds of CCI>40 and 90-day mortality associated with ISGLS grades. Among 1646 included patients, 19 (1.1%) met Balzan, 68 (4.1%) met Mullen, and 444 (27.0%) met ISGLS criteria for PHLF. Of the three definitions, the ISGLS criteria best predicted 90-day mortality (AUC = 0.72; sensitivity 69.4%). Patients with ISGLS grades B&C were at increased odds of CCI > 40 (grade B OR 4.0; 95% CI: 2.2-7.2; grade C OR 137.0; 95% CI: 59.2-317.4). Patients with ISGLS grade C were at increased odds of 90-day mortality (OR 113.6; 95% CI: 55.6-232.1). Grade A was not associated with CCI> 40 or 90-day mortality. In this diverse international cohort of major hepatectomies, ISGLS grade A was not associated with 90-day mortality or high CCI, calling into question the current classification of patients in this group as having clinically significant PHLF.

Sarcopenia and major complications in patients undergoing oncologic colon surgery.

BackgroundSarcopenia is a surrogate marker for malnutrition and frailty, which has been linked to higher complication rates and prolonged length of stay (LOS) after surgery. The study aim was to assess the correlation between computed tomography (CT)‐based sarcopenia and short‐term clinical outcomes after oncologic colon surgery.MethodsThis retrospective study included consecutive patients operated between May 2014 and December 2019. Three radiological indices of sarcopenia were measured at the level of the third lumbar vertebra on preoperative CT scans: skeletal muscle area (SMA), skeletal muscle index (SMI) (both markers of muscle quantity), and skeletal muscle radiation attenuation (SMRA) (marker of muscle quality). Patients with major complications (grade ≥ 3b according to the Clavien classification) were compared with those without. Statistical correlation between sarcopenia indices, LOS, and comprehensive complication index (CCI) was tested with the Pearson correlation coefficient.ResultsA total of 325 patients were included. Mean age was 67 years [standard deviation (SD) 14.3], mean body mass index was 26.0 kg/m2 (SD 5.3), and 193 (59%) were male. Fifty patients (15.4%) had major complications, while 275 (84.6%) did not. Patients with major complications had more open surgery (52 vs. 21%, P < 0.01), intraoperative blood loss (257 vs. 102 mL, P = 0.035), and intraoperative complications (22 vs. 9%, P = 0.012). Patients with major complications had significantly increased CCI scores (53 vs. 6, P < 0.01), reoperations (74 vs. 0%, P < 0.01), and LOS (33 vs. 7, P < 0.01). SMA and SMI were comparable between both groups (126.0 vs. 125.2 cm2, P = 0.974, and 43.4 vs. 44.3 cm2/m2, P = 0.636, respectively), while SMRA was significantly lower in patients with major complications (33.6 vs. 37.3 HU, P = 0.018). A lower SMRA was correlated with prolonged LOS (r = −0.207, P < 0.01) and higher CCI (r = −0.144, P < 0.01), while the other sarcopenia indices had no influence on surgical outcomes.ConclusionsMuscle quality (SMRA) as a specific sarcopenia marker was lower in patients with major complications and seems to prevail over muscle quantity (SMA and SMI) in the prediction of adverse outcomes after oncologic colon surgery.

Clinical validation of implementing Enhanced Recovery After Surgery protocol in elderly colorectal cancer patients.

PurposeThe aim of this study was to evaluate the safety and feasibility of applying enhanced recovery after surgery (ERAS) protocol in elderly colorectal cancer patients.MethodsThe medical records of patients who underwent elective colorectal cancer surgery at our institution, from January 2017 to December 2017, were reviewed. Patients were divided into 2 groups: the young group (YG, patients aged 70 and under 70 years) and the old group (OG, patients over 70 years old). Perioperative outcomes and length of hospital stay were compared between both groups.ResultsIn total, 335 patients were enrolled; 237 were YG and 98 were OG. Despite the poorer baseline characteristics of OG, the perioperative outcomes were similar. Length of hospital stay was not different between the groups (YG, 5 days vs. OG, 5 days; P=0.320). When comparing the postoperative complications using the comprehensive complication index (CCI), there was no significant difference (YG, 8.0±13.2 vs. OG, 11.7±23.0; P=0.130). In regression analysis, old age (>70 years) was not a risk factor for high CCI in all patients. In multivariate analysis, C-reactive protein (CRP) level on postoperative day (POD) 3 to 4 was the only strong predictive factor for high CCI in elderly patients.ConclusionImplementing the ERAS protocol in patients aged >70 years is safe and feasible. High CRP (≥6.47 mg/dL) on POD 3 to 4 can be used as a safety index to postpone discharge in elderly patients.

Sarcopenia and surgical outcomes in patients undergoing oncologic colonic surgery

Abstract Objective Sarcopenia is a marker for malnutrition and frailty which could lead to higher complication rate and prolonged length of stay (LOS) after surgery. The study aim was to assess the correlation between sarcopenia and clinical outcomes in oncologic colonic surgery. Methods This retrospective study included consecutive patients operated between 2014 and 2019. Three radiological indices of sarcopenia were measured at the level of the third lumbar vertebra on preoperative CT scans: Skeletal Muscle Area (SMA), Skeletal Muscle Radiation Attenuation (SMRA), and Skeletal Muscle Index (SMI). Patients with major complications (&amp;gt; grade 3a) according to Clavien classification were compared to those without. Statistical correlation between sarcopenia indices, LOS and Comprehensive Complication Index (CCI) was tested by use of the Pearson correlation. Results A total of 325 patients were included, 50 (15.4%) with and 275 (84.6%) without major complications. SMA and SMI were comparable between both groups (respectively 126.0 vs 125.2 cm2, p = 0.974, and 43.4 vs 44.3 cm2/m2, p = 0.636), while SMRA was significantly lower in patients with major complications (33.6 vs 37.3 HU, p = 0.018). A lower SMRA was correlated with prolonged LOS (r=-0.207, p &amp;lt; 0.01) and higher CCI (r=-0.144, p &amp;lt; 0.01), while the other sarcopenia indices had no influence on surgical outcomes. Conclusion Preoperative SMRA or muscle quality appears to be a weak predictor for adverse outcomes after oncologic colectomy.

Surgical Resection vs. Percutaneous Ablation for Single Hepatocellular Carcinoma: Exploring the Impact of Li-RADS Classification on Oncological Outcomes.

Simple SummaryLi-RADS classification has recently emerged as an accurate tool for hepatocellular carcinoma diagnosis in the setting of liver cirrhosis, but its prognostic value has never been investigated so far. Single HCC benefits from both surgical resection and percutaneous ablation, although several studies support the superiority of surgery in terms of oncological results. We retrospectively and blindly classified 140 treatment-naïve single HCC according to Li-RADS protocol, comparing the oncological outcomes of surgical resection and percutaneous ablation for each Li-RADS subclass. Our analysis highlighted better overall survival, recurrence free survival and lower incidence of local recurrence after surgical resection in Li-RADS-5 nodules, while Li-RADS-3/4 subclasses showed similar outcomes after the two treatments. These results confirm the superiority of surgical approach for single HCC and suggest a potential prognostic role of Li-RADS classification, supporting liver resection especially for Li-RADS-5 subclass.Background: Single hepatocellular carcinoma (HCC) benefits from surgical resection (SR) or US-guided percutaneous ablation (PA), although the best approach is still debated. We evaluated the impact of Li-RADS classification on the oncological outcomes of SR vs. PA as single HCC first-line treatment. Methods: We retrospectively and blindly classified treatment-naïve single HCC that underwent SR or PA between 2010 and 2016 according to Li-RADS protocol. Overall survival (OS), recurrence free survival (RFS) and local recurrence after SR and PA were compared for each Li-RADS subclass before and after propensity-score matching (PS-M). Results: Considering the general population, SR showed better 5-year OS (68.3% vs. 52.2%; p = 0.049) and RFS (42.5% vs. 29.8%; p = 0.002), with lower incidence of local recurrence (8.2% vs. 44.4%; p < 0.001), despite a significantly higher frequency of clinically-relevant complications (12.8% vs. 1.9%; p = 0.002) and a higher Comprehensive Complication Index (12.1 vs. 2.2; p < 0.001). Focusing on different Li-RADS subclasses, we highlighted better 5-year OS (67.1% vs. 46.2%; p = 0.035), RFS (45.0% vs. 27.0% RFS; p < 0.001) and lower incidence of local recurrence (9.7% vs. 48.6%; p < 0.001) after SR for Li-RADS-5 HCCs, while these outcomes did not differ for Li-RADS-3/4 subclasses; such results were confirmed after PS-M. Conclusions: Our analysis suggests a potential prognostic role of Li-RADS classification, supporting SR over PA especially for Li-RADS-5 single HCC.

Predictive factors of high comprehensive complication index in colorectal cancer patients using Enhanced Recovery After Surgery protocol: role as a safety net in early discharge.

PurposeThis study was performed to evaluate complications using comprehensive complication index (CCI) in colorectal cancer patients with implementation of the Enhanced Recovery After Surgery (ERAS) protocol, and to investigate the predictive factors associated with high morbidity rates. It can be used as a safety net in determining the timing of discharge.MethodsA total of 335 consecutive patients who underwent elective colorectal cancer surgery between January 2017 and December 2017 at a single tertiary center were enrolled. Postoperative complications were defined as occurring within 30 days after surgery. The predictive factor analysis for the high CCI group was also performed.ResultsIn total, 116 patients experienced postoperative complications. Wound-related complications and postoperative ileus were the most common. The mean CCI for overall colorectal cancer surgery was 9.1 ± 16.7. Patients featuring low CCI (<26.2) were 297 (88.7%) and high CCI were 38 (11.3%). In multivariable analysis, obstructive colorectal cancer (odds ratio, 3.278; 95% confidence interval, 1.217–8.829; P = 0.019) and CRP value on postoperative day (POD) 3–4 (odds ratio, 1.152; 95% confidence interval, 1.036–1.280; P < 0.010) were significant predictors for high CCI.ConclusionThe clinical usefulness of CCI in colorectal cancer patients with the ERAS protocol was verified, and it can be used for surgical quality control. More cautious care is needed and the timing of discharge should be carefully determined for patients with obstructive colorectal cancer or POD 3–4 CRP of ≥6.47 mg/dL.