Higher Rate Of Major Complications Research Articles

Corrélation entre l’utilisation d’une tige remplissante et le syndrome d’implantation du ciment chez les personnes âgées ostéoporotiques souffrant d’une fracture du col du fémur traitée par arthroplastie de hanche cimentée : une étude cas-témoin rétrospective chez 128 patients

BackgroundBone cement implantation syndrome (BCIS) is a serious and potentially fatal complication especially in patients with osteoporotic femoral neck fracture (OFNF) undergoing cemented hip arthroplasty (CHA). Recent studies showed that the shape-closed femoral stem profile could lead to a significant increase of the intramedullary pressure during cementation and prosthesis insertion. This study aimed to 1) correlate the use of shaped-closed femoral stem and other perioperative risk factors with severe grade of BCIS (grade 2 or 3: BCIS gr2/3, and 2) identify the prevalence of BCIS in the elderly patients with OFNF and treated with CHA. HypothesisLarge wedge-shaped (or “shape-closed”) femoral stem design would significantly associate with BCIS gr2/3 in the elderly patients who sustained OFNF and underwent CHA. Patients and methodsA total of 128 OFNF patients, who aged over 75 years and underwent CHA were retrospectively reviewed and then allocated into 2 groups: SC Group (use shape-closed femoral stem, n=40) and FC Group (use force-closed femoral stem, n=88). BCIS was grading in all patients according to Donaldson classification. Perioperative data between the patients with BCIS-gr2/3 and those with BCIS grade 0 or 1 (BCIS-gr0/1) were compared. Multiple logistic regression analysis was used to identify predictive factors for BCIS-gr2/3. ResultsThe prevalence of overall BCIS and BCIS-gr2/3 was 32.8 % (n=42) and 6.2 % (n=8), respectively. The total in-hospital and 1-year mortality rates were 2.3 % and 4.7 %, respectively. The major perioperative complication in patients with BCIS-gr2/3 was significantly higher compared to those in patients with BCIS-gr0/1 (62.5 % vs. 10.0 %, p=0.001). Multivariate analysis showed that age >90 years (OR 9.4, 95 % CI: 1.4-62.9, p=0.02), preinjury Parker mobility score <4 (OR=48.8; 95 % 2.7-897.2, p=0.008) and shape-closed femoral stem used (OR=19.1; 95 %CI, 1.8–204.5, p=0.01) were the significant independent predictors for BCIS-gr2/3 in these patients. ConclusionBCIS in OFNF patients undergoing CHA is common and associates with a high major perioperative complication rate. Our initial hypothesis is validated as the patients at risk for BCIS-gr2/3 are those whose CHA procedures use a shape-closed femoral stem design and with extreme age, and having poor preinjury ambulatory status. Therefore, we recommended using cementless stem as the first option in OFNF. However, if CHA is needed, strict guideline for cement insertion should be followed with force-closed stem application to avoid the risk of BCIS-gr2/3. Level of evidenceIII; Retrospective case-control study.

Surgical Outcome After Pancreatoduodenectomy for Duodenal Adenocarcinoma Compared with Other Periampullary Cancers: A Nationwide Audit Study

BackgroundSurgical outcome after pancreatoduodenectomy for duodenal adenocarcinoma could differ from pancreatoduodenectomy for other cancers, but large multicenter series are lacking. This study aimed to determine surgical outcome in patients after pancreatoduodenectomy for duodenal adenocarcinoma, compared with other periampullary cancers, in a nationwide multicenter cohort.MethodsAfter pancreatoduodenectomy for cancer between 2014 and 2019, consecutive patients were included from the nationwide, mandatory Dutch Pancreatic Cancer Audit. Patients were stratified by diagnosis. Baseline, treatment characteristics, and postoperative outcome were compared between groups. The association between diagnosis and major complications (Clavien–Dindo grade III or higher) was assessed via multivariable regression analysis.ResultsOverall, 3113 patients, after pancreatoduodenectomy for cancer, were included in this study: 264 (8.5%) patients with duodenal adenocarcinomas and 2849 (91.5%) with other cancers. After pancreatoduodenectomy for duodenal adenocarcinoma, patients had higher rates of major complications (42.8% vs. 28.6%; p < 0.001), postoperative pancreatic fistula (International Study Group of Pancreatic Surgery [ISGPS] grade B/C; 23.1% vs. 13.4%; p < 0.001), complication-related intensive care admission (14.3% vs. 10.3%; p = 0.046), re-interventions (39.8% vs. 26.6%; p < 0.001), in-hospital mortality (5.7% vs. 3.1%; p = 0.025), and longer hospital stay (15 days vs. 11 days; p < 0.001) compared with pancreatoduodenectomy for other cancers. In multivariable analysis, duodenal adenocarcinoma was independently associated with major complications (odds ratio 1.14, 95% confidence interval 1.03–1.27; p = 0.011).ConclusionPancreatoduodenectomy for duodenal adenocarcinoma is associated with higher rates of major complications, pancreatic fistula, re-interventions, and in-hospital mortality compared with patients undergoing pancreatoduodenectomy for other cancers. These findings should be considered in patient counseling and postoperative management.

Acute Kidney Injury After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy in a Portuguese Population.

Acute kidney injury (AKI) after cytoreductive surgery followed by the infusion of hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is associated with a higher rate of major complications, resulting in prolonged hospitalization and increased mortality. Our objective was to evaluate the incidence of AKI and further progression to chronic kidney disease (CKD) in patients submitted to this procedure and recognize the associated risk factors. This retrospective study collected demographic, tumor-related, intraoperative, and postoperative data from 182 patients who underwent CRS/HIPEC from January 2016 to December 2019. Renal impairment was defined according to Kidney Disease Improving Global Outcomes criteria for AKI. We conducted univariate and multiple logistic regression analyses to assess the association between variables of interest and AKI. Twenty-three patients (12.6%) developed AKI. In the AKI group, the risk for developing CKD was six times higher (odds ratio (OR) 6.48, confidence interval (CI) 1.601 - 26.255). Multivariate regression identified higher risk of developing AKI in patients who underwent HIPEC with cisplatin (OR 12.21, CI 1.26 - 109.70, P = 0.025), in each additional day spent in the intensive care unit (ICU) (OR 2.42, CI 1.07 - 5.45, P = 0.033), and an association for each unit increase in estimated glomerular filtration rate (eGFR) before HIPEC (OR 0.96, CI 0.94 - 0.98, P = 0.037) and AKI development. Patients who are at higher risk of AKI after CRS/HIPEC include those who performed cisplatin HIPEC regimen, had poorer preoperative renal function and had longer ICU stays. Early institution of preventive measures and frequent monitoring should be considered to minimize AKI risk and its associated morbidity, such as CKD progression.

Abstract 11152: Complications Associated With Transesophageal Echocardiography in Transcatheter Structural Cardiac Interventions in the United States: 2012-2022

Introduction: Transesophageal echocardiograms (TEEs) performed during structural cardiac interventions may have higher complications than those performed in the non-operative setting. However, there is limited data on complications associated with TEE in these procedures. The objective of this study was to evaluate the prevalence of major complications among these patients in the United States (US). Methods: A retrospective cohort study was conducted using an electronic health record database from large academic medical centers across the US for patients undergoing TEE during structural interventions from January 2012 to January 2022. Using the American Society of Echocardiography endorsed ICD-10 codes, patients undergoing TEE during a structural cardiac intervention, including transaortic, mitral or tricuspid valve repair, left atrial appendage occlusion, and paravalvular leak replacement were identified. The primary outcome was major complications within 72 hours of the procedure (composite of bleeding, esophageal and upper respiratory tract injury). Results: A total of 9,482 adult patients undergoing TEE for transcatheter structural cardiac interventions were identified. The median age was 71 years (IQR: 61 - 80 years), including 43% females and 19% non-white individuals. Of those, 7,158 (75%) of patients were on anticoagulation, and 6,272 (66%) were on antiplatelet therapy. In the study cohort, 246 (2.6%) patients had a major complication. Complication rates were higher in patients on anticoagulation or antiplatelet therapy compared to those who were not (2.9% vs. 0.84%, p&lt;0.001, OR: 3.57 [95% CI: 1.89- 6.74]). Patients aged ≥65 had higher rates of major complications compared with those &lt;65 (2.95% vs. 1.16%, p&lt;0.001). Complication rates were similar among males and females (2.7% vs 2.5%, p=0.50). Conclusions: Nearly 2.6% of patients undergoing TEE during transcatheter structural cardiac interventions have a major complication. Major complications are relatively more common among older patients and those on anticoagulant and antiplatelet therapy. With a shift of poor surgical candidates to less invasive procedures, the future of TEE-guided procedures relies on a heart team approach and a comprehensive risk discussion.

Surgical flap delay to allow primary transabdominal transplantation of extended rectus abdominis myocutaneous flaps in increasingly complex pelvic wound reconstructions

Primary intra- or transabdominal transplantation of an extended rectus abdominis myocutaneous (ERAM) flap may help prevent surgical complications of pelvic resections. Surgical delay of the ERAM flap may help prevent intra-abdominal (partial) flap loss after transplantation in highly complex situations including previous irradiation. We report on the outcome of this approach and the risk-factors associated with an eventful outcome. From 2012 to 2020, 105 delayed ERAM flaps were consecutively applied immediately following extended pelvic resections after chemoradiation or hyperthermic intraperitoneal chemotherapy. We addressed the increased reconstructive demands by designing the flap in line with the 10th rib and delaying the flap’s skin island. All post-operative complications were assessed in light of patient-related or procedure-related potential risk-factors. Major complications occurred in 39 patients. These were correlated with surgery for residual or recurrent malignancy (p < 0.01), with tip necrosis after flap delay (p = 0.02), and with the use of a mesh to close the abdominal donor site (p < 0.01). (Partial) flap loss occurred in 4 cases. We observed a comparably high rate of major complications after ERAM transplantations for increasingly extending indications of perineal-pelvic resections. We consider this to be attributable to poorer patients’ conditions and disease processes, rather than to flap viability. Delay of the flap allowed for the use of large and voluminous flaps with comparably little (partial) flap loss.

Not to Rush-Laboratory Parameters and Procedural Complications in Patients Undergoing Left Atrial Appendage Closure.

Background: As a preventive procedure, minimizing periprocedural risk is crucially important during left atrial appendage closure (LAAC). Methods: We included consecutive patients receiving LAAC at nine centres and assessed the relationship between baseline characteristics and the acute procedural outcome. Major procedural complications were defined as all complications requiring immediate invasive intervention or causing irreversible damage. Logistic regression was performed and included age and left-ventricular function. Furthermore, the association between acute complications and long-term outcomes was evaluated. Results: A total of 405 consecutive patients with a median age of 75 years (37% female) were included. 47% had a history of stroke. Median CHA2DS2-VASc score was 4 (interquartile range, 3−5) and the median HAS-BLED score was 3 (2−4). Major procedural complications occurred in 7% of cases. Low haemoglobin (OR 0.8, 95% CI 0.65−0.99 per g/dL, p = 0.040) and end-stage kidney disease (OR 13.0, CI 2.5−68.5, p = 0.002) remained significant in multivariate analysis. Anaemia (haemoglobin < 12 and < 13 g/dL in female and male patients) increased the risk of complications 2.2-fold. Conclusions: The major complication rate was low in this high-risk patient population undergoing LAAC. End-stage kidney disease and low baseline haemoglobin were independently associated with a higher major complication rate.

Complications after neoadjuvant chemotherapy and radical cystectomy for patients with bladder cancer: A propensity score matched analysis.

Neoadjuvant chemotherapy (NAC) in combination with radical cystectomy (RC) is the standard of care for muscle-invasive bladder cancer (MIBC). We investigated the impact of NAC on postoperative complications after RC in patients with bladder cancer (BCa). Using the recently available American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Targeted Cystectomy database, we identified adult (>18 years old) patients who underwent RC for the treatment of BCa. Patients were then dichotomized based on whether they received NAC. We performed a 1:1 propensity score matched (PSM) analysis based on demographic and perioperative covariates. Postoperative outcomes were then compared between the two matched groups. A multivariable analysis was also performed to identify if NAC was associated with any complication. We identified 1582 eligible patients: 913 (57.7%) in the group that did not receive NAC and 669 (42.3%) in the group that did receive NAC. Before PSM, patients in the NAC group were younger, had lower American Society of Anesthesiology (ASA) scores, had higher rates of preoperative anemia, and were more likely to undergo continent urinary diversion. Similarly, before PSM patients in the NAC group had significantly higher rates of major complications, sepsis, urinary leak/fistula, and intraoperative/postoperative blood transfusion compared to the group that did not receive NAC; however, after 1:1 PSM, we did not find any significant difference postoperative complication rates. Multivariable analysis confirmed that NAC was not associated with any complications. We demonstrated that NAC does not impact 30-day postoperative complications in patients undergoing RC for BCa.

Impact of sarcopenia on the surgical outcomes in patients with hepatolithiasis: A multicenter 10-year experience

BackgroundThe impact of sarcopenia on the surgical outcomes of hepatectomy for hepatolithiasis has not been investigated. The present study elucidated the effect of sarcopenia on short-term outcomes after hemihepatectomy for hepatolithiasis and investigated the benefit of different surgical approaches to hepatectomy in patients with sarcopenia. MethodsPatients who underwent hemihepatectomy for hepatolithiasis at Fujian Provincial Hospital and 5 other medical centers from 2010 to 2020 were enrolled. The sarcopenic obesity subgroup had sarcopenia coexisting with obesity, and the sarcopenic nonobesity subgroup had sarcopenia without obesity. We analyzed the postoperative outcomes of the sarcopenia group, sarcopenic obesity subgroup and sarcopenic nonobesity subgroup and the corresponding benefits of different surgical approaches. ResultsPatients with sarcopenia (n = 481) had worse surgical outcomes than nonsarcopenia, such as longer postoperative hospital duration of stay, longer time to oral intake, longer time to bowel movement, and longer time to off-bed activities. In postoperative short-term outcomes, we also found that sarcopenia had higher rates of major complications, bile leakage, and intensive care unit occupancy than the nonsarcopenic group. Subgroup analysis showed that sarcopenic obesity subgroup (n = 182) had the worst results in intraoperative outcomes and postoperative short-term outcomes. Multivariate analysis identified sarcopenic obesity as a significant risk factor for postoperative hospital duration of stay (hazard ratio = 2.994, P < .001). Furthermore, the sarcopenic obesity and sarcopenic nonobesity (n = 299) subgroups benefited from laparoscopic surgery compared with open surgery, including postoperative recovery and major complications (all P < .05). However, sarcopenic nonobesity subgroup had more significant benefits of laparoscopy than the sarcopenic obesity subgroup. The learning curve for laparoscopic hemihepatectomy for the sarcopenic obesity subgroup had a plateau, and the surgical outcomes of the sarcopenic obesity subgroup were closer to the sarcopenic nonobesity subgroup after the plateau. ConclusionSarcopenia is associated with more adverse events after hepatectomy and patients with sarcopenic obesity have a higher incidence of adverse events. Patients with sarcopenia could benefit from laparoscopy. Compared with the sarcopenic obesity patients, the sarcopenic nonobesity patients benefited more from laparoscopy. Although the sarcopenic obesity patients had more complications and slower postoperative recovery than the sarcopenic nonobesity patients, laparoscopic also could improve their short-term outcomes, but a longer learning curve was required.

Correlation between shape-closed femoral stem design and bone cement implantation syndrome in osteoporotic elderly femoral neck fracture undergoing cemented hip arthroplasty: A retrospective case-control study in 128 patients

BackgroundBone cement implantation syndrome (BCIS) is a serious and potentially fatal complication especially in patients with osteoporotic femoral neck fracture (OFNF) undergoing cemented hip arthroplasty (CHA). Recent studies showed that the shape-closed femoral stem profile could lead to a significant increase of the intramedullary pressure during cementation and prosthesis insertion. This study aimed to (1) correlate the use of shaped-closed femoral stem and other perioperative risk factors with severe grade of BCIS grade 2 or 3: BCIS gr2/3, and (2) identify the prevalence of BCIS in the elderly patients with OFNF and treated with CHA. HypothesisLarge wedge-shaped (or “shape-closed”) femoral stem design would significantly associate with BCIS gr2/3 in the elderly patients who sustained OFNF and underwent CHA. Patients and methodsA total of 128 OFNF patients, who aged over 75years and underwent CHA were retrospectively reviewed and then allocated into 2 groups: SC Group (use shape-closed femoral stem, n=40) and FC Group (use force-closed femoral stem, n=88). BCIS was grading in all patients according to Donaldson classification. Perioperative data between the patients with BCIS-gr2/3 and those with BCIS grade 0 or 1 (BCIS-gr0/1) were compared. Multiple logistic regression analysis was used to identify predictive factors for BCIS-gr2/3. ResultsThe prevalence of overall BCIS and BCIS-gr2/3 was 32.8% (n=42) and 6.2% (n=8), respectively. The total in-hospital and 1-year mortality rates were 2.3% and 4.7%, respectively. The major perioperative complication in patients with BCIS-gr2/3 was significantly higher compared to those in patients with BCIS-gr0/1 (62.5% vs. 10.0%, p=0.001). Multivariate analysis showed that age>90years (OR=9.4, 95% CI: 1.4–62.9, p=0.02), preinjury Parker mobility score<4 (OR=48.8; 95% CI: 2.7–897.2, p=0.008) and shape-closed femoral stem used (OR=19.1; 95% CI: 1.8–204.5, p=0.01) were the significant independent predictors for BCIS-gr2/3 in these patients. ConclusionBCIS in OFNF patients undergoing CHA is common and associates with a high major perioperative complication rate. Our initial hypothesis is validated as the patients at risk for BCIS-gr2/3 are those whose CHA procedures use a shape-closed femoral stem design and with extreme age, and having poor preinjury ambulatory status. Therefore, we recommended using cementless stem as the first option in OFNF. However, if CHA is needed, strict guideline for cement insertion should be followed with force-closed stem application to avoid the risk of BCIS-gr2/3. Level of evidenceIII; retrospective case-control study.

Robotic approach mitigates the effect of major complications on survival after pancreaticoduodenectomy for periampullary cancer.

Major complications (MCs) after pancreaticoduodenectomy (PD) are a known independent predictor of worse oncologic outcomes. There are limited data on the effect of major complications on long-term outcomes after robotic PD (RPD). The aim of this study is to compare the effect of MC on overall (OS) and disease-free survival (DFS) after RPD and open PD (OPD). This is a single-center, retrospective review of a prospectively maintained database of all patients undergoing PD for periampullary cancer including ampullary adenocarcinoma, distal cholangiocarcinoma, and duodenal carcinoma. Univariate analysis was performed on all clinical, pathologic, and treatment factors. MCs were defined as Clavien-Dindo ≥ grade 3. Kaplan-Maier survival analysis was performed with log-rank test for group comparison. Multivariable Cox regression analysis was used to identify factors associated with overall survival (OS) in both the OPD and RPD groups. A total of 190 patients with ampullary carcinoma (n = 98), cholangiocarcinoma (n = 55), and duodenal adenocarcinoma (n = 37) were examined over the study period with 61.1% (n = 116) undergoing RPD and 38.9% (n = 74) undergoing OPD. There was no significant difference in patient demographics between the RPD and OPD cohorts. Furthermore, R0 resection rates, tumor size, and lymph node involvement were similar between the RPD and OPD cohorts. OPD had higher rate of MC (40.5% vs 28.3% in RPD, p = 0.011) including clinically relevant pancreatic fistula (25.7% vs 8.6%, p = 0.001) and wound infection (34.5% vs 13.8%, p < 0.001). MCs were associated with a lower OS in the OPD cohort (HR = 2.18, 95%CI 1.0-4.55, p = 0.038). MCs were not associated with OS in the RPD cohort (HR = 1.55, 95%CI 0.87-2.76, p = 0.14). MCs are associated with worse patient outcomes after OPD but not after RPD. Robotic approach mitigates and possibly abrogates the negative effects of MCs on patient outcomes after PD for malignancy and is associated with improved adjuvant chemotherapy completion rates.

Prognostic value of cachexia index in patients with colorectal cancer: A retrospective study.

BackgroundCurrent diagnostic criteria for cancer cachexia are inconsistent, and arguments still exist about the impact of cachexia on the survival of patients with colorectal cancer. In this study, we aim to investigate the prognostic value of a novel cachexia indicator, the cachexia index (CXI), in patients with colorectal cancer.MethodsThe CXI was calculated as skeletal muscle index (SMI) × serum albumin/neutrophil-lymphocyte ratio. The cut-off value of CXI was determined by the receiver operating characteristic (ROC) curves and Youden’s index. The major outcomes were major complications, overall survival (OS), and recurrence-free survival (RFS).ResultsA total of 379 patients (234 men and 145 women) were included. The ROC curves indicated that CXI had a significantly diagnostic capacity for the detection of major complications. Based on Youden’s index, there were 231 and 148 patients in the low and high CXI groups, respectively. Patients in the low CXI group had significantly older age, lower BMI, and a higher percentage of cachexia and TNM stage II+III. Besides, Patients in low CXI group were associated with a significantly higher rate of major complications, blood transfusion, and longer length of stay. Logistic regression analysis indicated that low CXI, cachexia, and coronary heart disease were independent risk factors for the major complications. Kaplan Meier survival curves indicated that patients with high CXI had a significantly more favorable OS than those with low CXI, while no significant difference was found in RFS between the two groups. Besides, there were no significant differences in OS or RFS between patients with and without cachexia. The univariate and multivariate Cox regression analysis indicated that older age, low CXI, and coronary heart disease instead of cachexia were associated with a decreased OS.ConclusionCXI was better than cachexia in predicting OS and could be a useful prognostic indicator in patients with colorectal cancer, and greater attention should be paid to patients with low CXI.

Contemporary outcomes of pancreaticoduodenectomy for benign and precancerous cystic lesions.

The decision to undertake pancreaticoduodenectomy for benign and precancerous lesions has historically relied on outcomes data from operations for cancer. We aimed to describe risks for these specific patients and identify the highest risk groups. The ACS-NSQIP pancreatic targeted data was queried for pancreaticoduodenectomies for benign and pre-cancerous neoplasms from 2014 to 2018. Baseline characteristics, operative techniques and outcomes were examined. Multivariate regression was performed to identify predictors of major complications. 748 patients underwent pancreaticoduodenectomy for (n=541,72.3%) IPMN, (n=87,11.6%) MCN, (n=78,10.4%) serous cystadenoma, and (n=42,5.6%) solid pseudopapillary neoplasm. Median LOS was 8 days. Major complications (n=135,18.0%), non-home discharges (n=83,11.1%) and readmissions (n=153,20.5%) occurred frequently. In patients≥80 years of age (n=37), major complications (n=11,29.7%) and non-home discharge (n=9,24.3%) were quite common. 5-item modified frailty index≥0.4 (OR 1.84,95%CI 1.06-3.19,p=0.030), Male sex (OR 1.729,95%CI 1.152-2.595,p=0.008), Age≥65 (OR 1.63,95%CI 1.05-2.54,p=0.29) and African-American race (OR 2.50,95%CI 1.22-5.16,p=0.013) were independent predictors of major morbidity. Pancreaticoduodenectomies in this setting have high rates of major complications. Morbidity extends beyond the index hospitalization, with frequent readmission and non-home discharge. Patient specific factors, rather than technical or disease factors predicted outcomes. In certain patients, particularly those older than 80, the morbidity of this operation may exceed the cancer prevention benefits.

The impact of bloodstream infection in patients undergoing appendectomy due to acute appendicitis

Introduction: Current severity classification of appendicitis does not take into account the impact of bloodstream infection (BSI), despite the importance of BSI in critical care settings. Therefore, we examined whether BSI in emergency appendectomy indicated for acute appendicitis has a clinical impact. Methods: We retrospectively reviewed patients with acute appendicitis who underwent emergency surgery at our department between July 2015 and January 2020. Results: BSI was detected in 14 out of 154 patients (9%). Patients with BSI had a higher rate of major complications, readmission rate, and longer postoperative hospital stay, but there was no difference in the rate of complicated and uncomplicated appendicitis. Multivariate analysis showed age ≧ 58 years (Odds ratio [OR] 8.98 95% Confidence interval [CI] 2.07–39.0) and bilirubin ≧ 2.0 mg/dl (OR 8.79 95% CI 1.09–71.0) were associated with BSI. In 4 out of 8 cases (50%), the bacteria isolated in patients with BSI were not isolated in patients with intraabdominal infection (IAI). Conclusion: BSI in acute appendicitis had a clinical impact on postoperative outcomes, irrespective of complicated and uncomplicated appendicitis. Blood cultures should be considered for older patients, and patients with high bilirubin levels in emergency appendectomy for acute appendicitis.

138. Racial disparities in utilization of and short-term outcomes following cervical disc replacement vs anterior cervical discectomy and fusion

138. Racial disparities in utilization of and short-term outcomes following cervical disc replacement vs anterior cervical discectomy and fusion

Intraoperative Heparin Bolus and Postoperative Anticoagulation with Low Molecular Weight Heparin Increase Reliability of Microsurgical Free Flaps for Upper Extremity Reconstruction.

Microsurgery is an indispensable tool of upper extremity reconstruction addressing defect coverage and the restoration of function. Perioperative anticoagulation and antiplatelet therapy are controversially discussed with impact on microsurgical outcome, but without clear evidence. This study aims to evaluate the impact of perioperative anticoagulation and antiplatelet therapy in microsurgical upper extremity reconstruction. All eligible patients treated with microsurgical upper extremity reconstruction between January 2000 and July 2014 were included in a comparative analysis to define a superior anticoagulation and antiplatelet regime in a retrospective study. Endpoints were all major complications (e.g., total flap loss, arterial and venous thrombosis) as well as minor complication. A total of 183 eligible free flaps to the upper extremity were transferred in 169 patients. Altogether, 11 arterial (6.0%) and 9 venous (4.9%) thromboses, 11 total flap losses (6.0%), and 16 cases with hematoma (8.7%) were detected. In the subgroup analysis, patients who did not receive any heparin intraoperatively (n = 21; 11.5%) had a higher rate of major complications (p = 0.001), with total flap loss being the most frequent event (p = 0.004). A trend was shown for intraoperative bolus administration of 501 to 1,000 units unfractionated heparin (UFH) intravenously to have the lowest rate of major complications (p = 0.058). Intraoperative administration of acetylsalicylic acid (n = 13; 8.1%) did not have any influence on the rate of major complications. Postoperative anticoagulation with continuous UFH intravenously (n = 68; 37.2%) resulted in more frequent complications (p = 0.012), for example, an increased rate of total flap loss (p = 0.02) and arterial thrombosis (p = 0.02). The results of the present study favor administration of 501 to 1,000 units UFH intravenously as an intraoperative bolus (e.g., 750 units UFH intravenously). Postoperative low molecular weight heparin subcutaneous application in a prophylactic dose given once or twice a day was associated with less complications compared with continuous infusion of UFH, although continuously applied UFH may reflect an increased risk profile.

Impact of sarcopenia on outcomes of patients undergoing liver resection for hepatocellular carcinoma.

BackgroundPrevious studies have indicated that sarcopenia is associated with poor post‐operative outcomes in liver cancer patients, but the studies are limited by confounding from mixed diseases, retrospective data, and non‐standardized measurement methods. At present, there is no research with both muscle mass and strength as predictors for hepatocellular carcinoma (HCC) outcomes. We studied the impact of sarcopenia on post‐operative outcomes in HCC patients in a cohort study designed according to the European Working Group on Sarcopenia in Older People standards.MethodsA total of 781 consecutive patients admitted to our centre were registered from May 2020 to August 2021. All participants submitted questionnaires and underwent handgrip strength, chair stand test, physical performance, and computed tomographic evaluation. Then, they were divided into three groups according to muscle mass and strength: Group A (reduced muscle mass and strength), Group B (reduced muscle strength or reduced muscle mass), and Group C (normal muscle mass and strength). The baseline data and post‐operative outcomes were compared and analysed. The primary outcome variable in this study was the presence of a major post‐operative complication, and the secondary outcome was the 90‐day re‐admission rate.ResultsA total of 155 patients [median age, 60.00 (IQR, 51.00–66.00) years; 20 females (12.90%)] were included after strict exclusion. The mean (SD) BMI was 23.37 ± 0.23 kg/m2. The mean (SD) SMI of all participants was 47.05 ± 0.79 cm2/m2, and the mean (SD) handgrip strength was 32.84 ± 0.69 kg. Among them, 77 (49.68%) patients underwent laparoscopic hepatectomy, and 73 (47.10%) patients received major hepatectomy. Regarding the post‐operative results, Group A had a higher rate of major complications [40.91% (9 of 22) vs. 11.94% (8 of 67) in Group B and 6.06 (4 of 66) in Group C; P = 0.001], higher rate of blood transfusion (77.27% vs. 46.27% in Group B and 42.42% in Group C; P = 0.015), higher hospitalization expenses (P = 0.001), and longer hospital stay (P < 0.001). There was no difference in 90‐day re‐admission rates among the three groups. Sarcopenia (hazard ratio, 10.735; 95% CI, 2.547–45.244; P = 0.001) and open surgery (hazard ratio, 4.528; 95% CI, 1.425–14.387; P = 0.010) were independent risk factors associated with major complications.ConclusionsSarcopenia is associated with adverse outcomes after liver resection for HCC. It should be evaluated upon admission to classify high‐risk patients and reduce the risk of major complications.

Can revision of RYGB to sleeve gastrectomy be a solution to inadequate weight loss treatment?

We aimed to discuss the weight loss success of the revision of RYGB to sleeve gastrectomy (SG). Between January 2019 and June 2020, four patients' files were analyzed retrospectively. Post-RYGB mean minimal BMI was 27.4 ± 9.47 kg/m², before SG the mean BMI was 43.41 ± 4.16 kg/m2. Post-operative gastric fistula developed in two patients. The mean follow-up time after revision surgery was 17.25 ± 6.89 months, mean excess weight loss (EWL) was 74.77 ± 8.94%, and mean BMI was 32.65 ± 2.9 kg/m2. Despite high rate of major complications, revision of RYGB to SG is successful in weight loss and resolving certain complications of RYGB.

P-634 Safety of ART cycles with extremely high estradiol levels - A retrospective cohort study

Abstract Study question Are IVF treatments with extremely high peak estradiol levels during ovarian hyperstimulation associated with higher complication rates? Summary answer Extremely high estradiol levels were not associated with higher major complication rates, but patients were more likely to seek medical care following retrieval. What is known already The freeze-all policy and the increasing popularity of social oocyte freezing, have led to an increase in gonadotropin doses and number of oocytes retrieved and, as a direct effect, higher estradiol levels. Studies reporting major ART complications (OHSS, bleeding, infection, torsion, thromboembolic events) are based on heterogeneous patient populations without stratification by oocyte number or estradiol levels, except for a single study reporting an association between peak estradiol levels and the risk of ovarian torsion. Extreme estradiol levels, are associated with larger ovaries, repeated ovarian punctures, and possibly a thrombogenic effect. Therefore, higher complication rates can be expected. Study design, size, duration A retrospective cohort study including patients from two large medical centers treated between 2019-2021. Participants/materials, setting, methods A study group (239 patients) with extremely high peak estradiol levels (&amp;gt;20,000 pmol/L on the day of ovulation induction, or &amp;gt; 15,000 pmol/L on the previous day) and a control group (208 patients) with normal range estradiol levels (3000-12000pmol/L), treated at two large units were included. Patients were surveyed about complaints and medical care related to ovum pick up (OPU), and medical files were reviewed. Complication rates and the need for medical assistance were compared. Main results and the role of chance Several differences between the study and control group were observed as a consequence of the study design: Mean age was 33.01±5.14 vs. 34.57±4.52 (p = 0.01), Mean peak estradiol levels was 26645.34±8592.56 vs.7229.750±2329.20 (p &amp;lt; 0.001), mean number of oocytes were 27.55±13.46 vs. 11.63±5.77 (p &amp;lt; 0.001) for the study and control group respectivly. More patients in the control group underwent fertility preservation. Mean FSH levels and total gonadotropin dosage were higher in the control group. Major complications [3 (1.25%) in the study group vs. 1 (0.96%) in the control group] were similar between groups (p = 0.62). In the study group Two patients were diagnosed with ovarian torsion (0.83%), and one (0.41%) with early severe OHSS as a result of a positive BhCG related to an undiagnosed pregnancy prior to OPU. All three were admitted (1.25%). In the control group one patient was diagnosed with PID requiring inpatient IV antibiotic treatment (0.48%). One more patient was admitted with severe abdominal pain following OPU, for a total of 2 admissions (0.96%) (p = 1). 33 patients (13.8%) in the study group and 10 (4.8%) in the control group sought medical care after OPU, mostly due to abdominal pain, without further workup or hospitalization (p = 0.001). Limitations, reasons for caution A retrospective study with possible recall bias. Major adverse events are rare in IVF and may not be fully captured in the study population. Wider implications of the findings Based on our results, extremely high estradiol levels during ovarian hyperstimulation were not associated with thromboembolic events, higher major complication or hospitalization rates, thus may be considered safe. Nevertheless, patients may be informed of possible higher rates of discomfort, mostly abdominal pain. Larger studies are warranted to confirm our results. Trial registration number 0090-21-ASF

The Impact of Venous Thromboembolism on Mortality and Morbidity During Nephrectomy for Renal Mass

To determine the morbidity, mortality, and costs associated with having concurrent venous thromboembolism (VTE) at the time of surgical resection of a renal mass. We identified 108,430 patients undergoing elective partial or radical nephrectomy for a renal mass from 2013 to 2017 using the Premier Healthcare database. The association of VTE with 90-day complication rates, mortality, ICU admission, readmission, and direct hospital costs (2019 US dollars) was determined with multivariable logistic regression and quantile regression models, respectively. Of the 108,430 patients who underwent elective partial or radical nephrectomy, 1.2% (n=1301) of patients were diagnosed with a preoperative VTE. Patients with preoperative VTE have higher rates of minor (odds ratio [OR] 1.47, 95% confidence inteval [CI] 1.34-1.62, P < .0001) and major complications (OR 2.53, 95% CI 2.23-2.86, P < .0001), mortality (OR 2.03, 95% CI 1.6-2.57, P < .0001), and readmissions (OR 1.73, 95% CI 1.57-1.90, P < .0001) compared to patients without preoperative VTE at the time of nephrectomy. Notably, the predicted probability for a major complication was significantly higher among patients with preoperative VTE who underwent either partial or radical nephrectomy, irrespective of the surgical approach utilized. Furthermore, rates of all types of complications except endocrine and soft tissue were significantly increased in patients undergoing nephrectomy with preoperative VTE compared to those without VTE. VTE at the time of nephrectomy is associated with significantly higher rates of major complications, increased mortality, and higher overall costs. Taken together, these findings have important implications for the counseling and management of renal masses in presence of VTE.

The effect of major postoperative complications on recurrence and long-term survival after cytoreductive surgery for ovarian cancer

ObjectiveTo assess the impact on survival of major postoperative complications and to identify the factors associated with these complications in patients with advanced ovarian cancer after cytoreductive surgery. MethodsWe designed a retrospective multicenter study collecting data from patients with IIIC-IV FIGO Stage ovarian cancer who had undergone either primary debulking surgery (PDS), early interval debulking surgery (IDS) after 3–4 cycles of neoadjuvant chemotherapy, or delayed debulking surgery (DDS) after 6 cycles, with minimal or no residual disease, from January 2008 to December 2015. Univariable and multivariable analyses were conducted to identify factors associated with major surgical complications (≥Grade 3). We assessed disease-free survival (DFS) and overall survival (OS) rates according to the occurrence of major postoperative complications. Results549 women were included. The overall rate of major surgical complications was 22.4%. Patients who underwent PDS had a higher rate of major complications (28.6%) than patients who underwent either early IDS (23.2%) or DDS (14.0%). Multivariable analysis revealed that extensive peritonectomy and surgical timing were associated with the occurrence of major complications. Median DFS and OS were 16.9 months (95%CI = [13.7–18.4]) and 48.0 months (95%CI = [37.2–73.1]) for the group of patients with major complications, and 20.1 months (95%CI = [18.6–22.4]) and 56.7 months (95%CI = [51.2–70.4]) for the group without major complications. Multivariable analysis revealed that major surgical complications were significantly associated with DFS, but not with OS. ConclusionsPatients who experienced major surgical complications had reduced DFS, compared with patients without major morbidity. Extensive peritonectomy and surgical timing were predictive factors of postoperative morbidity.